The Body Keeps the Score: Brain, Mind, and Body in the Healing of Trauma

by Bessel van der Kolk

Trauma, by definition, is unbearable and intolerable. Most rape victims, combat soldiers, and children who have been molested become so upset when they think about what they experienced that they try to push it out of their minds, trying to act as if nothing happened, and move on. It takes tremendous energy to keep functioning while carrying the memory of terror, and the shame of utter weakness and vulnerability.

While we all want to move beyond trauma, the part of our brain that is devoted to ensuring our survival (deep below our rational brain) is not very good at denial. Long after a traumatic experience is over, it may be reactivated at the slightest hint of danger and mobilize disturbed brain circuits and secrete massive amounts of stress hormones. This precipitates unpleasant emotions intense physical sensations, and impulsive and aggressive actions. These posttraumatic reactions feel incomprehensible and overwhelming. Feeling out of control, survivors of trauma often begin to fear that they are damaged to the core and beyond redemption.

When I began my psychiatry rotation, however, I was struck by the contrast between the incredible complexity of the mind and the ways that we human beings are connected and attached to one another, and how little psychiatrists knew about the origins of the problems they were treating. Would it be possible one day to know as much about brains, minds, and love as we do about the other systems that make up our organism?

We can now develop methods and experiences that utilize the brain’s own natural neuroplasticity to help survivors feel fully alive in the present and move on with their lives. 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 the trauma; 2) by taking medicines that shut down inappropriate alarm reactions, or by utilizing other technologies that change the way the brain organizes 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.

In other words, posttraumatic stress isn’t “all in one’s head,” as some people supposed, but has a physiological basis. Kardiner understood even then that the symptoms have their origin in the entire body’s response to the original trauma.

The lack of literature on the topic was a handicap, but my great teacher, Elvin Semrad, had taught us to be skeptical about textbooks. We had only one real textbook, he said: our patients. We should trust only what we could learn from them—and from our own experience. This sounds so simple, but even as Semrad pushed us to rely upon self-knowledge, he also warned us how difficult that process really is, since human beings are experts in wishful thinking and obscuring the truth. I remember him saying: “The greatest sources of our suffering are the lies we tell ourselves.”

It takes enormous trust and courage to allow yourself to remember. One of the hardest things for traumatized people is to confront their shame about the way they behaved during a traumatic episode,

Imagination is absolutely critical to the quality of our lives. Our imagination enables us to leave our routine everyday existence by fantasizing about travel, food, sex, falling in love, or having the last word—all the things that make life interesting. Imagination gives us the opportunity to envision new possibilities—it is an essential launchpad for making our hopes come true. It fires our creativity, relieves our boredom, alleviates our pain, enhances our pleasure, and enriches our most intimate relationships. When people are compulsively and constantly pulled back into the past, to the last time they felt intense involvement and deep emotions, they suffer from a failure of imagination, a loss of the mental flexibility. Without imagination there is no hope, no chance to envision a better future, no place to go, no goal to reach.

They felt a renewed sense of the comradeship that had been so vital to their war experience. They insisted that I had to be part of their newfound unit and gave me a Marine captain’s uniform for my birthday. In retrospect that gesture revealed part of the problem: You were either in or out—you either belonged to the unit or you were nobody. After trauma the world becomes sharply divided between those who know and those who don’t. People who have not shared the traumatic experience cannot be trusted, because they can’t understand it. Sadly, this often includes spouses, children, and co-workers.

In Boston winter snowstorms occasionally paralyze the public transit system, but to my amazement all of them showed up even during blizzards, some of them trudging several miles through the snow to reach the VA Clinic. For Christmas they gave me a 1940s GI-issue wristwatch. As had been the case with my group of Marines, I could not be their doctor unless they made me one of them.

For many people the war begins at home: Each year about three million children in the United States are reported as victims of child abuse and neglect.

We have discovered that helping victims of trauma find the words to describe what has happened to them is profoundly meaningful, but usually it is not enough. The act of telling the story doesn’t necessarily alter the automatic physical and hormonal responses of bodies that remain hypervigilant, prepared to be assaulted or violated at any time. 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. Our search to understand trauma has led us to think differently not only about the structure of the mind but also about the processes by which it heals.

I was often surprised by the dispassionate way patients’ symptoms were discussed and by how much time was spent on trying to manage their suicidal thoughts and self-destructive behaviors, rather than on understanding the possible causes of their despair and helplessness. I was also struck by how little attention was paid to their accomplishments and aspirations; whom they cared for, loved, or hated; what motivated and engaged them, what kept them stuck, and what made them feel at peace—the ecology of their lives.

But if the stories I’d heard in the wee hours were true, could it be that these “hallucinations” were in fact the fragmented memories of real experiences? Were hallucinations just the concoctions of sick brains? Could people make up physical sensations they had never experienced? Was there a clear line between creativity and pathological imagination? Between memory and imagination? These questions remain unanswered to this day, but research has shown that people who’ve been abused as children often feel sensations (such as abdominal pain) that have no obvious physical cause; they hear voices warning of danger or accusing them of heinous crimes.

In my role as recreation leader I noticed other things: As a group the patients were strikingly clumsy and physically uncoordinated. When we went camping, most of them stood helplessly by as I pitched the tents. We almost capsized once in a squall on the Charles River because they huddled rigidly in the lee, unable to grasp that they needed to shift position to balance the boat. In volleyball games the staff members invariably were much better coordinated than the patients. Another characteristic they shared was that even their most relaxed conversations seemed stilted, lacking the natural flow of gestures and facial expressions that are typical among friends. The relevance of these observations became clear only after I’d met the body-based therapists Peter Levine and Pat Ogden; in the later chapters I’ll have a lot to say about how trauma is held in people’s bodies.

Semrad taught us that 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,” he’d say, urging us to be honest with ourselves about every facet of our experience. He often said that people can never get better without knowing what they know and feeling what they feel.

This study was one of many milestones on a road that gradually changed how medicine and psychiatry approached psychological problems: from infinitely variable expressions of intolerable feelings and relationships to a brain-disease model of discrete “disorders.

Antipsychotic drugs were a major factor in reducing the number of people living in mental hospitals in the United States, from over 500,000 in 1955 to fewer than 100,000 in 1996.7 For people today who did not know the world before the advent of these treatments, the change is almost unimaginable. As a first-year medical student I visited Kankakee State Hospital in Illinois and saw a burly ward attendant hose down dozens of filthy, naked, incoherent patients in an unfurnished dayroom supplied with gutters for the runoff water. This memory now seems more like a nightmare than like something I witnessed with my own eyes.

Researchers’ need for a precise and systematic way to communicate their findings resulted in the development of the so-called Research Diagnostic Criteria, to which I contributed as a lowly research assistant. These eventually became the basis for the first systematic system to diagnose psychiatric problems, the American Psychiatric Association’s Diagnostic and Statistical Manual of Mental Disorders (DSM), which is commonly referred to as the “bible of psychiatry.” The foreword 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.8 As we will see, that modesty was tragically short-lived.

Gray’s data showed that the sensitivity of the amygdala depended, at least in part, on the amount of the neurotransmitter serotonin in that part of the brain. Animals with low serotonin levels were hyperreactive to stressful stimuli (like loud sounds), while higher levels of serotonin dampened their fear system, making them less likely to become aggressive or frozen in response to potential threats.18

The implications for traumatized people were obvious. Like Gray’s low-serotonin animals, they were hyperreactive, and their ability to cope socially was often compromised. If we could find ways to increase brain serotonin levels, perhaps we could address both problems simultaneously. At that same 1985 meeting I learned that drug companies were developing two new products to do precisely that, but since neither was yet available, I experimented briefly with the health-food-store supplement L-tryptophan, which is a chemical precursor of serotonin in the body. (The results were disappointing.) One of the drugs under investigation never made it to the market. The other was fluoxetine, which, under the brand name Prozac, became one of the most successful psychoactive drugs ever created.

On Friday I saw another patient to whom I’d given Prozac the previous Monday. She was a chronically depressed mother of two school-aged children, preoccupied with her failures as a mother and wife and overwhelmed by demands from the parents who had badly mistreated her as a child. After four days on Prozac she asked me if she could skip her appointment the following Monday, which was Presidents’ Day. “After all,” she explained, “I’ve never taken my kids skiing—my husband always does—and they are off that day. It would really be nice for them to have some good memories of us having fun together.” This was a patient who had always struggled merely to get through the day. After her appointment I called someone I knew at Eli Lilly and said, “You have a drug that helps people to be in the present, instead of being locked in the past.”

Everyone in the study—even those who had received the placebo—improved, at least to some degree. Most treatment studies of PTSD find a significant placebo effect. People who screw up their courage to participate in a study for which they aren’t paid, in which they’re repeatedly poked with needles, and in which they have only a fifty-fifty chance of getting an active drug are intrinsically motivated to solve their problem. Maybe their reward is only the attention paid to them, the opportunity to respond to questions about how they feel and think. But maybe the mother’s kisses that soothe her child’s scrapes are “just” a placebo as well.

Surprisingly, however, the Prozac had no effect at all on the combat veterans at the VA—their PTSD symptoms were unchanged. These results have held true for most subsequent pharmacological studies on veterans: While a few have shown modest improvements, most have not benefited at all. I have never been able to explain this, and I cannot accept the most common explanation: that receiving a pension or disability benefits prevents people from getting better. After all, the amygdala knows nothing of pensions—it just detects threats.

As she emerged from the scanner, Marsha looked defeated, drawn out, and frozen. Her breathing was shallow, her eyes were opened wide, and her shoulders were hunched—the very image of vulnerability and defenselessness. We tried to comfort her, but I wondered if whatever we discovered would be worth the price of her distress.

After a few weeks he sent me the results, which you see above. I taped the scans up on the refrigerator in my kitchen, and for the next few months I stared at them every evening. It occurred to me that this was how early astronomers must have felt when they peered through a telescope at a new constellation.

All trauma is preverbal. Shakespeare captures this state of speechless terror in Macbeth, after the murdered king’s body is discovered: “Oh horror! horror! horror! Tongue nor heart cannot conceive nor name thee! Confusion now hath made his masterpiece!” Under extreme conditions people may scream obscenities, call for their mothers, howl in terror, or simply shut down. Victims of assaults and accidents sit mute and frozen in emergency rooms; traumatized children “lose their tongues” and refuse to speak. Photographs of combat soldiers show hollow-eyed men staring mutely into a void.

Deactivation of the left hemisphere has a direct impact on the capacity to organize experience into logical sequences and to translate our shifting feelings and perceptions into words. (Broca’s area, which blacks out during flashbacks, is on the left side.) Without sequencing we can’t identify cause and effect, grasp the long-term effects of our actions, or create coherent plans for the future. People who are very upset sometimes say they are “losing their minds.” In technical terms they are experiencing the loss of executive functioning.

When we returned home, Noam was still awake, and he showed me a picture that he had drawn at 9:00 a.m. on September 12. The drawing depicted what he had seen the day before: an airplane slamming into the tower, a ball of fire, firefighters, and people jumping from the tower’s windows. But at the bottom of the picture he had drawn something else: a black circle at the foot of the buildings. I had no idea what it was, so I asked him. “A trampoline,” he replied. What was a trampoline doing there? Noam explained, “So that the next time when people have to jump they will be safe.” I was stunned: This five-year-old boy, a witness to unspeakable mayhem and disaster just twenty-four hours before he made that drawing, had used his imagination to process what he had seen and begin to go on with his life.

During disasters young children usually take their cues from their parents. As long as their caregivers remain calm and responsive to their needs, they often survive terrible incidents without serious psychological scars.

After trauma the world is experienced with a different nervous system. The survivor’s energy now becomes focused on suppressing inner chaos, at the expense of spontaneous involvement in their lives. These attempts to maintain control over unbearable physiological reactions can result in a whole range of physical symptoms, including fibromyalgia, chronic fatigue, and other autoimmune diseases.

It is amazing how many psychological problems involve difficulties with sleep, appetite, touch, digestion, and arousal. Any effective treatment for trauma has to address these basic housekeeping functions of the body.

Whatever happens to a baby contributes to the emotional and perceptual map of the world that its developing brain creates. As my colleague Bruce Perry explains it, the brain is formed in a “use-dependent manner.”5 This is another way of describing neuroplasticity, the relatively recent discovery that neurons that “fire together, wire together.”