The Body Keeps The Score
Mind, Brain and Body in the Transformation of Trauma
By Bessel Van Der Kolk (Penguin Books Ltd, Paperback, 446pages)
“Our bodies are the texts that carry the memories and therefore remembering is no less than reincarnation” (Katie Cannon, p. 184).
The connection between trauma and the physical body is of great interest to me, and when I saw this book, I bought it without thinking twice. My heart sank when I realised that the reference list is about 50 pages long and I prepared myself for some dense academic reading. However, I was hooked right from page one. Although the book is full of facts, which are backed up by research, it is very accessible and hard to put down. Personal experiences and many case studies make this book so fascinating and readable.
The author, Bessel Van Der Kolk, is a psychiatrist and founder of a trauma centre in Boston. He has been working with victims of abuse, neglect, natural disasters, wars, accidents, human trafficking and assaults for over 30 years. We follow the journey of this remarkable man who tirelessly examines what works and for whom. His work centres on the question: “How can people gain control over residues of past trauma and return to being masters of their own ship?” (p. 3).
In the late sixties high hopes were put in newly developed pharmaceuticals and many doctors were mostly concerned about how to manage suicidal thoughts and self-destructive behaviour of mental health patients rather than listen to peoples stories. Although trained as a pharmacologist, Van Der Kolk saw the limitations of a purely chemical approach to help people with their post-traumatic responses. Today we know that half of the people who seek psychiatric care have been assaulted, abandoned, neglected or raped as children or have witnessed traumatic events. While drugs can improve traumatised peoples lives, the underlying issues often don’t get addressed. The brain-disease model takes control out of the patient’s hands and puts doctors in charge of fixing their problems.
As a young intern on a research ward of a mental health centre Van Der Kolk had the role of a recreation leader. During sports activities he noticed that the patients were clumsy and physically uncoordinated. They also lacked natural flow of gestures and facial expressions during conversations. These were his first observations how trauma is held in people’s bodies.
The development of brain-imaging techniques such as MRI, gave scientist the opportunity to visualize the brain as it is processing memories, sensations and emotions. Van Der Kolk was part of a team who studied brain activities of people during flashbacks. One of the participants was a mother, who killed her four-year old daughter in a car crash after running a red light. Although the accident happened 13 years ago, during a flashback her limbic system lit up. In particular the amygdala, which warns us of impending danger and activates the bodies stress response. Her heart rate, blood pressure and oxygen intake went up, the body was ready for fight or flight. At the same time there was a significant decrease of activity in one of the speech centres of the brain, which means that thoughts and feelings cannot be put into words. This area is often affected in stroke patients when the blood supply is cut off. The effects of trauma are similar to the effects of physical lesions caused by a stroke. Another area that lit up was in the visual cortex that registers images when they first enter the brain. The mother saw the accident as if it was actually happening. During flashbacks there was very little communication between the emotional brain and the rational brain, which explains that traumatised people may not realise that they are re-enacting the past.
Van Der Kolk uses the triune (three-part) brain to explain “the anatomy of survival” (p. 51). The oldest part is the reptilian brain, located in the brainstem. Above is the limbic system and he calls these two parts the emotional brain. The top layer of the brain is called the neocortex. We sense danger through our eyes, ears, nose and skin and these sensations converge in the thalamus (inside the limbic system), which acts as the “cook.” This blended “soup” of sensations is then extremely fast passed on to the amygdala and slightly slower to the frontal cortex. He calls the amygdala the “smoke detector” that picks up danger clues. It triggers stress hormones that get the body ready to response. Van Der Kolk likened the medial prefrontal cortex (located in frontal lobes) to a “watchtower.” This part of the brain makes judgements about the signal from the “smoke detector.” A balance between the amygdala and the prefrontal cortex is important for our relationships with other people. In a traumatised person there is reduced activity of the “watchtower” and they may become enraged by small frustrations, or freeze when somebody touches them.
Van Der Kolk tells the story of a couple that survived a horrific car crash physically unscathed. Both had become hypersensitive and irritable and, although both were sitting right next to each other, Stan suffered from terrible flashbacks while Ute became numb. Her mind went blank and the MRI scan showed decreased activity in nearly every area of the brain. While Stan was stuck in fight or flight, Ute had shut down. As a last resort the reptilian brain was activated. Often victims that are pinned down during a traumatic event or children that can’t escape from a terrifying caregiver react by shutting down. “Dissociation is the essence of trauma” (p. 66) and has huge implications for the body. It is often overlooked and treatment is more difficult.
The brain gives us two options of effectively dealing with emotions and stress. Learning to regulate the balance between smoke detector and watchtower can be achieved “from the top down or from the bottom up” (p. 63). Top-down involves talking therapies and re-connecting with others to process memories of the trauma. Bottom-up regulation involves recalibrating the autonomic nervous system, which originates in the brain stem. The ANS can be accessed through breath, movement or touch.
When Stephen Porges developed the Polyvagal Theory (Polyvagal refers to the many branches of the vagus nerve) in 1994, the importance of social relationships gave a new insight into trauma. Being able to feel safe with other people is the most important sign of mental health. The social-engagement system involves mostly the vagus nerve. The vagus (wandering) nerve connects to many internal organs, including the stomach, heart and lungs. When the ventral vagal complex is running the show we are calm, centred and feel empathy with other people.
During a threat the first level of response is social engagement. We call out for help or assist others during a crisis. If the threat increases the older limbic brain takes over and gets the body ready for a fight or flight response. If there is no way out, an older vagal branch, the dorsal vagal complex gets activated for a freeze response. The Polyvagal Theory is vital for the understanding why more unconventional approaches in trauma treatment work so well.
Part three of the book examines trauma in children. Developmental trauma is a hidden epidemic and a study concluded that “eradicating child abuse in America would reduce the overall rate of depression by more than half, alcoholism by two-thirds, and suicide, IV drug use and domestic violence by three-quarters” (p. 148). Van Der Kolk discusses heartbreaking case studies and groundbreaking research. An immunology study on 12 women with incest history revealed that the ratio of RA or ‘memory cells’ (quickly respond to environmental threats they have encountered before) to RO cells (kept in reserve for new threats) was abnormal in comparison to a control group. All incest survivors had a higher proportion of RA cells, which means that their immune system is oversensitive to threat. The cells mount an attack when none is needed. Van Der Kolk noticed that a large number of women with incest history were diagnosed with an autoimmune disease. The traumatic experience of these women not only distorted their perception of threats coming from the outside; within their own bodies they had problems knowing how to feel safe.
The last part of the book describes the various ways to recovery, which involves restoring balance between the rational and emotional brains so that people can be in charge of their lives again. In the chapter ‘Befriending the Emotional Brain’, Van Der Kolk explains how we can access the limbic brain. Emotions are registered in the body, around 80% of the vagus nerve fibres are afferent, which means they carry information from the body to the brain. Age-old traditions like breathing exercises, chanting and movement reduced posttraumatic stress disorder symptoms in people who did not respond to medication or any other traditional treatments such as talking therapies. Van Der Kolk mentions chi kung, tai chi, aikido and capoeira as examples. These arts require physical movement, breathing and meditation. The effects of yoga for the treatment of posttraumatic stress disorder have been studied and an entire chapter describes research and efficacy.
Another way to access the autonomic nervous system is through touch.
Craniosacral therapy and therapeutic massage are recommended as complementary treatments. Mindful touch by a confident and sensitive therapist can be helpful for traumatised people to get to know and trust their bodies again. As another example of body-based therapies, the work of Peter Levine is mentioned. He developed techniques to help traumatised people to complete their actions that were suppressed during an event in order to survive. People realise that it is safe to move and they are able to defend and protect themselves.
Re-connecting with other people is another important step in the recovery of traumatised people. Many patients responded well to music, dancing and choral singing. By singing or moving in harmony with other people, we also become physically attuned “and experience a sense of connection and joy” (p. 215).
Van Der Kolk also had great success in the treatment of PTSD with a technique called eye movement desensitisation and reprocessing (EMDR). Interestingly, with EMDR, people may be able heal from trauma without talking about it. Another chapter is dedicated to neurofeedback, which he uses to help with hyperarousal, confusion and concentration problems of people who suffer from developmental trauma.
At the core of recovery is self-awareness and mindfulness. It recalibrates the smoke detector, the amygdala. People become less reactive to triggers. “Imprints from the past can be transformed by having physical experiences that directly contradict the helplessness, rage, and collapse that are part of trauma, and thereby regaining self-mastery” (p. 4).
Van Der Kolk comes to the conclusion that severely traumatised people require a combination of talk- and body-based therapy and sometimes medication to shut down inappropriate alarm reactions.
Recent research about the brain’s neuroplasticity is exciting and encouraging. People can change their behaviour, but only if they feel safe enough to experiment with new solutions.
(Review by Arno Gasteiger)