BOOK SUMMARY: THE BODY KEEPS THE SCORE
This was our first book for our now disbanded “Trauma Book Club”. We had a wonderful and relaxing time with the few who attended and plan to continue in future with book reviews. Bessel Van der Kolk, MD's “The Body Keeps the Score” remains one of the best books out there for both clinicians and clients. This book is a primer on trauma and the body and is invaluable to any of us in trauma focused work.
Book Summary
Bessel Van der Kolk is the preeminant neuroscientist most influencing our understanding of trauma as the cause of so many mental health issues. For that reason alone, the book is worth reading but there is so much more. This book has the most understandable explanation of the brain and trauma's impact on it of any we've read. Van der Kolk's extensive use of case examples from his therapy experiences powerfully expand this understanding. He uses simple terminology, such as calling the primitive brain the 'fire alarm', which can help our clients understand the brain impact of adverse experiences, particularly childhood abuse and neglect.
This book is a history of his career as a psychiatrist, researcher and therapist and as such, becomes a history of the mental health field over the last 30+ years. I (Bonnie) began practice over 40 years ago so remember many of the changes and their impact on our the field. I recall the same excitement he shares at being able to use medications early such as the early antidepressants to help people. I also agree about what we as a field have lost with the reductionist view of mental illness as a brain disease. This led to primarily treatment by drugs to fix a chemical imbalance, now debunked, but still a part of our culture. Here’s what he lists as losses from this paradigm shift (p. 38):
a) We have the capacity to heal each other that is equal to our capacity to destroy
b) Language does give us the power to change
c) We can regulate our own physiology [without drugs] through breathing, moving, touching.
d) We can change social conditions to help people feel safe and be able to thrive.
I learned more about the history of the DSM, its profit-rather than research-driven impetus, and why he was not successful in getting Child Developmental Trauma in the DSM V, after overwhelming research showing child mental illness has adverse experiences as its cause along with strong national support from child clinicians. Other child specialists share his helpful explanation of the loss of identity of self through trauma. Van der Kolk recognizes the value of language but emphasizes the greater importance of action that connects to the powerless, trapped, or frozen condition that is trauma's imprint on the brain.
More than all of this, however, we read about a man working and sharing from his heart, one who exemplifies a deep respect for suffering people and a commitment to healing the whole person in front of him. He is able to admit mistakes which often then result in further learning, showing himself curious and continually searching for new and better ways to assist others. He writes with openness about his own personal experiences with EMDR and other therapies, often leading to his next research and therapeutic interventions. We are all impressed with his passionate and heartfelt dedication to healing.
Part 1: The Rediscovery of Trauma
The title of this section is significant, underlying the knowledge about trauma and mental health being discovered by Janet and others in the late 1800's. Van der Kolk's early research on veterans is impactful, particularly the case example of the trauma-distorted perceptions found in Rorschach tests. Since EMDR deals with perception, this was a concrete example of how trauma distorts the brain's 'reality'. These early experiences later helped him to have a 'trauma lens' when he began working with survivors of incest. He saw their experiences very differently than the prevailing dismissive approach of the mental health field at the time. "Most human suffering relates to love and loss so the therapist's job is to help people acknowledge, experience, and bear the reality of life, with all its pleasures and heartbreak." (p. 26) He goes on to say that we can't get better until we 'know what we know and feel what we feel," recognizing the tremendous courage and strength it takes to remember.
Part 2: This is Your Brain on Trauma
Here he shares that our brain's adaptive response to stress leads to action and how trauma can overwhelm this healthy adaptive response. This supports Francine Shapiro's Adaptive Information Processing (AIP) theory of EMDR therapy that the brain moves toward health just like the rest of the body, unless blocked or hindered. His example of the child who survived 9/11 and drew a picture (p. 52), seen around the world, of people jumping from the Towers, shows the healthy result of taking action while being in the secure presence of caregivers.
In contrast, traumatized people often get stuck in powerlessness, either by being prevented or unable to take action. Robbie Adler-Tapia, EMDR author, trainer, and child welfare expert, told us in her specialty workshop, that the key Negative Cognition for children is powerlessness. Peter Levine, (Waking the Tiger) furthers our understanding of how trauma gets stuck in the body by clarifying how we differ from the animal kingdom in our response to stress. Animals who survive an attack by predators will get up, physically shake it off, and run away, something that is difficult for humans whose threats are not as obvious as a tiger nor frequently not as short lived as a predator attack. Action is key to healing as it shuts down the 'fight or flight' survival mechanism, signaling safety.
Our primitive brain, shared with other mammals, is geared toward survival. If our normal response is blocked (trapped, held down, prevented, frozen out) from action, our brain keeps secreting stress hormones. This limits our PFC activity–keeping our thinking brain off-line– while our amygdala and limbic system emotional (survival) brain remains in charge. Thus, "PTSD is the body continuing to defend against a threat that belongs in the past." (p. 60). Well said! "Knowing the difference between top down and bottom up regulation is central for understanding and treating traumatic stress." (p, 63) Van der Kolk states that top down regulation is strengthened with activities such as mindfulness meditation and yoga to 'recalibrate' the nervous system so the brain's 'watchtower' (PFC) more effectively monitors our body's reactions. Bottom up regulation happens through breath (one of the few body functions that is automatic and self regulatory), movement or touch. Therapeutic interventions need to do both as self regulation requires connection with the body.
He bluntly states that dissociation is the essence of trauma (p.66) because overwhelming adverse experiences cause a split-off and fragmentation of experiences. The survival brain, which he labeled the 'smoke detector,' loses the capacity to evaluate danger and safety in the environment. Lanius' research particularly shows how the body is lost through disconnection, explaining how severe early trauma leads to missing self awareness. When the brain shuts off this awareness to survive terrifying and overwhelming emotions, the person's capacity to feel fully alive is also deadened. A key to trauma treatment is helping clients to 'reactivate' a sense of self, 'the core of which is our physical body.' (p. 89) Recovering this requires a sense of agency, of being in charge of one's life. This is why mindfulness–knowing what you feel and understanding why–is so helpful in strengthening the PFC.
Van der Kolk also points out that this also lends support to Peter Levine's Somatic Therapy and Pat Ogden's Sensorimotor Psychotherapy approaches to the healing of trauma. In therapy, we need to a) draw out blocked sensory information b) help clients befriend, not suppress, body energies needing to be released and c) complete the self preserving physical actions that were thwarted when the survivor was restrained or immobilized by terror. (p. 96). Trauma survivors cannot recover 'until they become familiar with and befriend the sensations in their bodies." (p. 100) The wonderful thing about our brain is it does not know the difference between imagination and reality. Thus, we can assist our clients to imagine things as part of the change process. We do not rewrite history, but we can imagine present and future actions that will empower individuals who feel helpless and shameful due to their past adverse experiences.
Part 3: The Minds of Children
In this section, Bessel Van der Kolk covers the impact of adverse childhood experiences, notably child abuse and neglect, on the developing brain. Self regulation is learned from early caregivers through mirror neurons, empathy, and imitation. Early trauma changes the way the brain is wired and 'neither drugs nor conventional therapy' has show the necessary ability to change the brain. We have the evidence through neuroscience and most powerfully gathered by the author, to show that the majority of child mental health issues stem from trauma. Through his study of abused children and those who were not, he profoundly concludes "…for abused children, the whole world is filled with triggers." (p. 108) Think about children dealing with daily life while trying to manage these triggers, with elevated, hyper-alert physiology stemming from early caregiver deprivation, abuse or neglect and other adverse childhood experiences.
He advocated for and lost the battle to have the diagnosis of child Developmental Trauma Disorder replace most childhood diagnoses in the DSM V. He again bluntly states that the APA makes far too much money on the mandated use of the DSM to be open to change even with overwhelming research evidence, including the ACE Study. It made me think of Upton Sinclair's 1994 statement that I recently tweeted: “It is difficult to get a man to understand something, when his salary depends on his not understanding it.” (I, Candidate for Governor and How I Got Licked, 1994)
Diagnoses should lead us to interventions, and he asserts that our current child diagnoses describe behavioral and emotional symptoms that are the result of trauma. A similar disconnect comes with Shapiro's theoretical view that negative cognitions are a symptom of unprocessed memories, rather than the cause of dysfunction as cognitive approaches assert.
Part 4: The Imprint of Trauma
Here is a very useful description of the normal vs. traumatic brain. Both have perceptions of experience stored in neuro networks but the key difference is in the level of arousal determined by how personally meaningful and emotional we felt during the experience. He goes back to very early research by Charcot and Pierre Janet's on the root of hysteria (now PTSD) characterized by intense emotional arousal. He discusses Freud's 'talking cure' involving an 'energetic reaction connected to the memory' being released' for resolution. (p. 182).
Dissociation is the splitting off and isolation of memory so the person remains ‘stuck in trauma time’. Shapiro outlines how unprocessed memories are the basis of pathology, preventing the brain from adaptively updating our neuropathways developed through distressing past adverse experiences. Processing, per Shapiro, is accelerated learning, leading to assimilation of new information, which cannot take place if a person is not in their ‘window of tolerance.’ It is both sad and encouraging to realize that these keys to mental health treatment have been there but are only recently being ‘rediscovered’ as Van der Kolk states. The advances in neuroscience and the neuroplasticity of the brain are significant leaps in our understanding of how to assist and heal others through mental health treatment interventions.
Most interesting are the results he summarizes of his own research into traumatic memories. They differ from positive memories in how they are organized and in their physical reactions. Positive memories have a beginning, a middle, and an end. Traumatic memories, however, are disorganized, fragmented, with blank periods, presenting as images, physical sensations and intense emotions (does this remind you of EMDR's Phase 3?). He learned that 'remembering the trauma with associated affects doesn't necessarily resolve it and language cannot substitute for action’. We have all experienced or witnessed deeper healing with actual or imaginative action completing what the client was unable to do in the past.
Part 5: Paths to Recovery
Van der Kolk's directive to an effective trauma therapy involves the following steps (not in order and overlapping) for clients to achieve (p. 203-204):
1) finding a way to become calm
2) learning to maintain that calm and focus when triggered with past thoughts, emotions, reminders, etc.
3) finding a way to be fully alive, in the present, and engaged with others
4) not having to keep secrets from self including the ways the person has managed to survive.
His position is clear that the trauma has to be revisited in more than the logical brain "The fundamental issue in resolving traumatic stress is to restore the proper balance between the rational and emotional part of the brain." (p. 205) Breathing for hyper-arousal, mindfulness to strengthen core of self awareness, relationships through good support networks and other ways of recovery through social connection are all important approaches. Thus he recommends clients choose a trauma therapist who is educated about the impact of child abuse and neglect and has a variety of techniques to stabilize and calm, help lay the trauma to rest, and reconnect people to others, not advocating just one treatment of choice.
This chapter continues with the variety of approaches on his 'menu' of healing, including the body as the bridge to language, putting words to nonverbal experiences, as well as yoga, EMDR, Schwartz's Internal Family Systems, Pesso's PBSP psychomotor therapy, neurofeedback, movement, theater, and dance. While we may not have the resources that Van der Kolk has, we can incorporate what we can as we continue to learn how to most effectively treat our clients.
We remain passionate about EMDR because of the powerful healing it provides. We know that the most effective EMDR treatment is provided by an innovative and attuned therapist willing to use all at his or her disposal to effect healing. Mindfulness has proven benefits and is particularly useful in the Preparation Phase of EMDR. Neurofeedback is foundational for resetting the brain to calmness and many EMDR therapists use HeartMath for this purpose. Trauma sensitive yoga works on reconnecting the body to address helplessness and awareness of body sensations needing release as critical for healing. Self leadership through integration of self through IFS, ego state therapy, structural dissociation or DNMS is foundational for our clients with dissociation and fragmentation. Adding movement, particularly for children with traumatic stress, is also powerful. The use of activity (rolling a ball, play) is as essential to healing as well as engagement. As my mentor and Director of EMDR Consulting, Roy Kiessling LISW would say, "if you can think it, do it' with creative ways of working with those who have had adverse childhood experiences. The multitude of specialty approaches and protocols came from just such innovation.
We strongly urge you to read the book, as there is so much that cannot be reflected here. This is just a taste of what Bessel Van der Kolk so clearly, powerfully, and eloquently teaches us in his book, The Body Keeps the Score.
Bonnie Mikelson, LISW
Director, EMDR & Beyond