The Body Keeps the Score, by Van Der Kolk - Book Summary

“We don't really want to know what soldiers go through in combat. We do not really want to know how many children are being molested and abused in our society or how many couples – almost a third, as it turns out – engage in violence at some point during their relationship. We want to think of families as safe havens in a heartless world and of our own country as populated by enlightened, civilized people. We prefer to believe that cruelty occurs only in faraway places.” pg. 11

“Trauma remains a much larger public health issue, arguably the greatest threat to our national well-being. Since 2001 far more Americans have died at the hands of their partners or other family members than in the wars in Iraq and Afghanistan. American women are twice as likely to suffer domestic violence as breast cancer.” pg. 350

What Trauma Is

PTSD is one of three types of trauma that Van Der Kolk writes about: the acute traumatic events we experience as adults that leave us dysregulated and suffering nightmares and flashbacks. Leaves us unable to connect or move forward. PTSD was the thing that tipped us off to more universal experiences of trauma. It is the only trauma disorder listed in the DSM. Despite how obviously terrible it is, in some ways, it is the easiest to understand and the easiest to treat. 

CPTSD was at least mentioned in my training and is sometimes diagnosed unofficially. But until I read this book, I did not really know what it was. Van Der Kolk also calls it Interpersonal Trauma. And this was my first great revelation. That trauma is often not acute, and not singular, and not obvious. That trauma is social. That the majority of trauma we experience happens in our relationships, in minute moments of interaction, again and again and again. It is a scolding, a moment of physical aggression, a sense of exclusion or rejection. Trauma, if it happens once, is easier to overcome. Trauma, when it happens constantly, is easy to minimize and brush off - this is also when it evolves into some of its worst manifestations.

“We voted nineteen to two to create a new trauma diagnosis for victims of interpersonal trauma. [Complex PTSD.] But much to our surprise the diagnosis that our work group had overwhelmingly approved did not appear in the final product. None of us had been consulted.” Pg. 145 wherein Van Der Kulk describes his assigned job on suggesting research-based revisions for the DSM.

The third kind of trauma Van Der Kolk mentioned is Developmental Trauma. Simply put, trauma that happens when we’re kids or teenagers. As kids or teenagers we are vulnerable, and prone to internalization. When we’re young we are in need of attention: unconditional care and validation. But trauma often replaces these things - moments that should have been loving become moments of cruelty. People that we should have been able to trust become the source of our fears. Childhood trauma isn’t just trauma, it’s the sabotage of that which should have protected us from trauma in the first place. 

“Even before DSM-5 was released the American Journal of Psychiatry published the results of validity tests of various new diagnoses which indicated that the DSM largely lacks what in the world of science is known as “reliability.”” pg. 166

“The lack of reliability and validity did not keep the DSM-V from meeting its deadline for publication, despite the near universal consensus that it represented no improvement over the previous diagnostic system. Could the fact that the APA had earned $100 million on the DSM-IV and is slated to take in a similar amount with the DSM-V … be the reason we have this new diagnostic system?” pg. 167

“In a statement release in June 2011, the British Psychological Society complained to the APA that the sources of psychological suffering in the DSM-V were identified as “located within individuals” and overlooked the “undeniable social causation of many such problems.”” pg. 167

In general, Trauma is a moment of hurt with lasting effects. It is a moment of intolerable suffering in the absence of another’s comfort or recognition. Trauma is invalidated pain. Which means, trauma is cultural - because how likely we are to feel validated has everything to do with the cultural-emotional atmosphere we are immersed in.

“Being validated by feeling heard and seen is a precondition for feeling safe.” pg. 303

“I wish I could separate trauma from politics, but as long as we continue to live in denial and treat only trauma while ignoring its origins we are bound to fail.” pg. 350 

Brain and Mind - Calming the Inner Child

“The challenge of recovery is to reestablish ownership of your body and your mind – of yourself. This means feeling free to know what you know and to feel what you feel.” Pg. 205

One of the most helpful take-away’s from Van Der Kolk’s book is the difference between the brain and the mind. The mind is our internal reality, it is the place where the self, and its story, are formed, edited, forgotten, remembered. The brain obviously creates the mind, but what I didn’t know before is the brain has different hurts and different processes for healing. Healing can have many avenues, but the more avenues we use the higher our chances for success. So attending to the brain might be important.

When trauma occurs, and later when our trauma systems get activated, two things happen to the brain. First, the left-side brain, the rational-language side, gets way deactivated. Totally shuts down. This is why we have such a hard time talking about our traumas, and it’s also why trauma gets in the way of our ability to see the bigger picture. Details get lost, like ideas about other people’s motivations and intentions, the consequences of our own actions, and the reasons we do what we do. In trauma we only know what’s right in front of us and what we’re feeling. Everything else fades away.

The second thing that happens is the right-side brain, the emotional brain, gets way over-activated. We start feeling things much more intensely than we usually do. Our whole world becomes emotion and our reaction to that emotion. These processes were demonstrated again and again by Van Der Kolk with the backup of his neuro-research and years of experience.

Knowing how to apply this framework can be difficult, so I’ve learned to think about it like this: The language-rational brain is the parent-brain, and the emotional brain is the child-brain. When trauma happens we feel like kids: vulnerable, afraid, helpless, small. And when healing happens we feel like adults: rational, calm, communicative. The kid needs the adult. When the trauma system gets activated we get pulled into thinking and feeling like a much younger version of ourselves (often the age we were when the original trauma happened). And getting out of it again is a very difficult task. What we need is to reactivate the parent-brain and calm down the child-brain. 

It’s a two-pronged approach. First, we attend to the nervous system: any kind of self-care that’s going to slow your breathing and your heart-beat, stop the buzzing in your limbs, and calm the body. Second, we activate the parent. We ask ourselves, what would a good parent say to me right now? How might I comfort and validate myself? The idea is to provide the thing that was missing when the original trauma happened. And as I mentioned above, trauma is invalidated pain or unrecognised suffering. So, validate and recognise. With practice, intolerable feelings become tolerable. 

“If you were abused as a child you are likely to have a childlike part living inside you that is frozen in time, still holding fast to this kind of self-loathing and denial. Many adults who survive terrible experiences are caught in the same trap.” pg. 281

Treatment

The last few chapters of Van Der Kolk’s book are all on potential treatment approaches. He mentions that just one treatment is rarely enough for anyone, and a mix is usually necessary. So exploring your options is an important part of the process. A lot of these treatments aren’t recognized in main-stream psychotherapy, so I thought it’d be helpful to go through them here.

 EMDR: EMDR, Eye Movement Desensitization and Reprocessing, is a very well researched and somewhat mystifying treatment that’s used fairly commonly. The idea is that certain eye movements can access and unlock traumatic memory systems. Similarly, when we’re sleeping, rapid-eye movement phases of sleep are associated with dreaming, and dreaming is thought to be the brain's way of integrating memories into the larger self-narrative. So EMDR uses these built-in brain systems to access and integrate traumatic memories during our waking hours. It’s shown to be very successful.

“EMDR proved to be a more effective antidepressant than Prozac.” pg. 227

“To my mind the most remarkable feature of EMDR is its apparent capacity to activate a series of unsought and seemingly unrelated sensations, emotions, images, and thoughts in conjunction with the original memory. This way of reassembling old information into new packages may be just the way we integrate ordinary non-traumatic day-to-day experiences.” pg. 261 

Yoga: Yoga is obviously not for everyone, but Van Der Kolk makes a compelling argument about its benefits. All throughout the book he talks about the importance of attending to your body. The entire premise of his book is that trauma lives in the body and not just the mind or brain. And moving the body - particularly after experiencing a trauma where movement was taken away from you, for whatever reason, is crucial to healing. Yoga forces us to become mindful of physical experiences we have perhaps learned to shut out. Deep-breathing poses teach us to tolerate positions and sensations that are otherwise intolerable. Self-regulation is an unavoidable side-effect of regular yoga practice.

“Ten weeks of yoga practice markedly reduced to the PTSD symptoms of patients who had failed to respond to any medication or to any other treatment.” pg. 209 

FST: FST stands for Family Systems Therapy. It does not actually require the entire family, though. FST is a type of psychotherapy that takes a deep look at the all the different parts of a person and explores their different roles: the part that feels scared and child-like, the part the protects by being critical or self-deprecating, the part that jumps out and creates chaos in order to avoid terrible feelings. The part that has been exiled and buried because of the trauma it experienced. FST works to identify, name, negotiate with, forgive, and take care of each part in turn. It tries to create a central Self that manages these players in a cohesive way, instead of letting them all act independently from each other often to a detriment of the overall system.

“Parts are not just feelings but distinct ways of being with their own beliefs, agendas, and roles in the overall ecology of our lives.” pg. 282

Theater: Theater can mean a lot of different things: working on confidence in improv, playing a role on a stage, or using volunteers and even pieces of furniture to recreate scenes from our past. Theater and other art-forms allow us to attend to our trauma memories at a distance, and with community support, without getting overwhelmed by the trauma system. To explore and experiment. It gives us opportunities to exercise imagination, something trauma takes away from us, and imagine what life might have been like if things were different. What would it have been like if the people who were supposed to take care of me actually did? It also helps us imagine a future that we might feel has been permanently taken from us. This way we can create new pseudo-memories or stories to live beside the originals in our minds.

“It’s often as terrifying for them to be the leader, to be trusted by someone vulnerable, as it is to be blindfolded and led.” pg. 339

Neuro-Feedback: I’d never heard of neuro-feedback until I read this book. Researchers have created computer programs which read signals in our brains and create graphics which respond to them. Imagine a computer screen showing a car on a road. When fear is experienced the car slows down, and when you feel calm the car speeds up. Then you try to win a race. The parameters of neuro-feedback can change according to the goals of the participants or program leaders. But regular practice shows success in literally training our brains to heal trauma.

Maybe none of these are your jam, but there are so many other options: dancing, singing, rhythmic movement, sports, tai-chi, self-defense, massage therapy, acupuncture, art-therapy. There’s a lot out there that can help us integrate our memories and get back in our bodies. Anything that helps you engage with life is a step in the right direction. And engagement is, in the end, all about experience and experimentation. So you don’t need to be looking for the perfect thing. Just try something.

Quotes

“Trauma compromises the brain area that communicates the physical, embodied feeling of being alive.” pg. 3

“There are fundamentally three Avenues: 1) top down, by talking, (re-) connecting with others, and allowing ourselves to know and understand what is going on with us, while processing the memories of trauma; 2) by taking medicines that shut down inappropriate alarm reactions, or by utilizing other technologies that changes the way the brain recognizes information, and 3) Bottom up: by allowing the body to have experiences that deeply and viscerally contradict the helplessness, rage, or collapse that result from trauma.” pg. 3

“For real change to take place, the body needs to learn that the danger has passed and to live in the reality of the present.” pg. 21

“Most human suffering is related to love and loss and that the job of therapists is to help people “acknowledge, experience, and bear” the reality of life– with all its pleasures and heartbreak. “The greatest sources of our suffering are the lies we tell ourselves.”” pg. 26-2.  In which Van Der Kolk quotes a teacher.

“The forward to the landmark 1980 DSM-III was appropriately modest and acknowledged that this diagnostic system was imprecise – so imprecise that it never should be used for forensic or insurance purposes. As we will see, that modesty was tragically short-lived.” pg. 29

“The mere opportunity to escape does not necessarily make traumatized animals, or people, take the road to freedom… Many traumatized people simply give up. Rather than risk experimenting with new options they stay stuck in the fear they know.” pg. 30

“For many traumatized people, re-exposure to stress might provide a … relief from anxiety… The amount of analgesia produced by watching 15 minutes of the combat movie was equivalent to that produced by being injected with eight milligrams of morphine, about the same dose a person would receive in an emergency room for crushing chest pain.” pg. 33

“The brain disease model overlooks four fundamental truths: (1) our capacity to destroy one another is matched by our capacity to heal one another. Restoring relationships and community is central to restoring well-being; (2) language gives us the power to change ourselves and others by communicating our experiences, helping us to define what we know, and finding a common sense of meaning; (3) we have the ability to regulate our own physiology, including some of the so-called involuntary functions of the body and brain, through such basic activities is breathing, moving, and touching; and (4) we can change social conditions to create environments in which children and adults can feel safe and where they can thrive.” pg. 38

“It is so much easier for them to talk about what has been done to them –  to tell a story of victimization and revenge –  then to notice, feel, and put into words the reality of their internal experience.” pg. 47

“The challenge of trauma treatment is not only dealing with the past but, even more, enhancing the quality of day-to-day experience. One reason that traumatic memories become dominant in PTSD is that it's so difficult to feel truly alive right now. When you can't be fully here, you go to the places where you did feel alive – even if those places are filled with horror and misery.” pg. 73

“Focusing on a shared history of trauma and victimization alleviates the searing sense of isolation, but usually at the price of having to deny their individual differences.” pg. 81

“ I was amazed to discover how many of my patients told me they could not feel whole areas of their bodies. Sometimes I'd ask them to close their eyes and tell me what I had put into their outstretched hands. Whether it was a car key, a quarter, or a can opener they often could not even guess what they were holding.” pg. 91

“Their relationship with their own inner reality was impaired. How could they make decisions, or put any plan into action, if they couldn't define what they wanted or, to be more precise, what the sensations in their bodies… were trying to tell them?” pg. 94

“The greater that awareness, the greater our potential to control our Lives. Knowing what we feel is the first step to knowing why we feel that way.” pg. 97-98

“Children with histories of abuse and neglect learn that their terror, pleading, and crying do not register with their caregiver… In effect they're being conditioned to give up when they face challenges later in life.” pg. 115

“On a deep level the bodies of insect victims have trouble distinguishing between danger and safety… This makes the immune system oversensitive to threat, so that it is prone to mount a defense when none is needed, even when this means attacking the body's own cells.” pg. 129

“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. It would also have a dramatic effect on workplace performance and vastly decrease the need for incarceration.” pg. 150

“Sexually abused girls… dropped out of high school at a higher rate… had more major illnesses and healthcare utilization…  showed abnormalities in their stress hormone responses, had an earlier onset of puberty, and accumulated a host of different, seemingly unrelated, psychiatric diagnoses.” pg. 164 

“With the passage of time, events had been bleached of their intense horror. In contrast, those who had been traumatized and subsequently developed PTSD did not modify their accounts; their memories were preserved essentially intact forty-five years after the war ended.” pg. 177

“The British general staff issued General Routine Order Number 2384 in June of 1917, which stated, “In no circumstances whatever will the expression ‘shell shock’ be used verbally or be recorded in any regimental or other casualty report, or any hospital or other medical document.”” pg. 187

“While World War I soldiers fail, have facial tics, and collapse with paralyzed bodies, the following generation talks and cringes… Their stomachs are upset, their hearts race, and they are overwhelmed by panic… Culture shapes the expression of traumatic stress.” pg. 189

“These vets communicated their distress via stomach cramps and chest pains rather than with nightmares and rage, from which, my research showed, they also suffered. Doctors shape how their patients communicate their distress… my sense was that neither the doctors nor their patients wanted to revisit the war.” pg. 190

“Because memory loss and delayed recall of traumatic experiences had never been documented in the laboratory, some cognitive scientists adamantly denied that these phenomena existed or that retrieved traumatic memories could be accurate. However, what doctors encounter in emergency rooms, or psychiatric wards, and on the battlefield is necessarily quite different from what scientists observe in their safe and well organized laboratories.” pg. 193

“In order to understand trauma, we have to overcome our natural reluctance to confront that reality and cultivate the courage to listen to the testimonies of survivors.” pg. 196-197

“Each patient demands that we suspend our sense of what is normal and accept that we are dealing with a dual reality: the reality of a relatively secure and predictable present that lives side by side with a ruinous, ever-present past.” pg. 197

“Nobody can “treat” a war, or abuse, rape, molestation, or any other horrendous event, for that matter; what has happened cannot be undone.” pg. 205

“Stress hormones are meant to give us the strength and endurance to respond to extraordinary conditions. People who actively do something to deal with a disaster [people who are able to]…  are at much lower risk of becoming traumatized.” pg. 219

“Yes, we can take drugs that blunt our emotions or we can learn to desensitize ourselves… desensitization to our own or to other people's pain tends to lead to an overall blunting of emotional sensitivity.” pg. 224

“One [part] creates a story for public consumption, and if we tell that story often enough, we are likely to start believing that it contains the whole truth.” pg. 238

“Trauma stories lessen the isolation of trauma, and they provide an explanation for why people suffer the way they do… Stories can also provide people with a target to blame. Blaming is a universal human trait that helps people feel good while feeling bad… “Hate makes the world go round.” But stories also obscure a more important issue, namely, that trauma radically changes people.” pg. 239

“Language evolved primarily to share “things out there”... Most of us are better at describing someone else that we are at describing ourselves.” pg. 239

“Many of our conscious thoughts are complex rationalizations for the flood of instincts, reflexes, motives, and deep-seated memories that emanate from the unconscious.” pg. 249