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

by Bessel van der Kolk

Research by the Centers for Disease Control and Prevention has shown that one in five Americans was sexually molested as a child; one in four was beaten by a parent to the point of a mark being left on their body; and one in three couples engages in physical violence.

“The nucleus of the neurosis is a physioneurosis.”2 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.

Trauma results in a fundamental reorganization of the way mind and brain manage perceptions. It changes not only how we think and what we think about, but also our very capacity to think.

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.

Healing, he told us, depends on experiential knowledge: You can be fully in charge of your life only if you can acknowledge the reality of your body, in all its visceral dimensions.

Now that scientists were finding evidence that abnormal levels of norepinephrine were associated with depression, and of dopamine with schizophrenia, there was hope that we could develop drugs that target specific brain abnormalities.

After administering several courses of electric shock, the researchers opened the doors of the cages and then shocked the dogs again. A group of control dogs who had never been shocked before immediately ran away, but the dogs who had earlier been subjected to inescapable shock made no attempt to flee, even when the door was wide open—they just lay there, whimpering and defecating. The mere opportunity to escape does not necessarily make traumatized animals, or people, take the road to freedom.

Scared animals return home, regardless of whether home is safe or frightening.

One of the things that struck my colleague Mark Greenberg and me when we ran therapy groups for Vietnam combat veterans was how, despite their feelings of horror and grief, many of them seemed to come to life when they talked about their helicopter crashes and their dying comrades. (Former New York Times correspondent Chris Hedges, who covered a number of brutal conflicts, entitled his book War Is a Force That Gives Us Meaning.13) Many traumatized people seem to seek out experiences that would repel most of us,14 and patients often complain about a vague sense of emptiness and boredom when they are not angry, under duress, or involved in some dangerous activity.

Freud had a term for such traumatic reenactments: “the compulsion to repeat.” He and many of his followers believed that reenactments were an unconscious attempt to get control over a painful situation and that they eventually could lead to mastery and resolution. There is no evidence for that theory—repetition leads only to further pain and self-hatred. In fact, even reliving the trauma repeatedly in therapy may reinforce preoccupation and fixation.

titled “Pain in Men Wounded in Battle,” published in 1946. Having observed that 75 percent of severely wounded soldiers on the Italian front did not request morphine, a surgeon by the name of Henry K. Beecher speculated that “strong emotions can block pain.”

(1986), and while it ran we measured how long the veterans could keep their right hands in a bucket of ice water. We then repeated this process with a peaceful (and long-forgotten) movie clip. Seven of the eight veterans kept their hands in the painfully cold water 30 percent longer during Platoon. We then calculated that the amount of analgesia produced by watching fifteen minutes of a 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. We concluded that Beecher’s speculation that “strong emotions can block pain” was the result of the release of morphinelike substances manufactured in the brain. This suggested that for many traumatized people, reexposure to stress might provide a similar relief from anxiety.17 It was an interesting experiment, but it did not fully explain why Julia kept going back to her violent pimp.

Other researchers had shown that dominant male monkeys had much higher levels of brain serotonin than lower-ranking animals but that their serotonin levels dropped when they were prevented from maintaining eye contact with the monkeys they had once lorded over. In contrast, low-ranking monkeys who were given serotonin supplements emerged from the pack to assume leadership.

The social environment interacts with brain chemistry. Manipulating a monkey into a lower position in the dominance hierarchy made his serotonin drop, while chemically enhancing serotonin elevated the rank of former subordinates.

Half a million children in the United States currently take antipsychotic drugs. Children from low-income families are four times as likely as privately insured children to receive antipsychotic medicines. These medications often are used to make abused and neglected children more tractable.

Because drugs have become so profitable, major medical journals rarely publish studies on nondrug treatments of mental health problems.

Broca’s area is one of the speech centers of the brain, which is often affected in stroke patients when the blood supply to that region is cut off. Without a functioning Broca’s area, you cannot put your thoughts and feelings into words. Our scans showed that Broca’s area went offline whenever a flashback was triggered. In other words, we had visual proof that the effects of trauma are not necessarily different from—and can overlap with—the effects of physical lesions like strokes.

Trauma by nature drives us to the edge of comprehension, cutting us off from language based on common experience or an imaginable past.

The stress hormones of traumatized people, in contrast, take much longer to return to baseline and spike quickly and disproportionately in response to mildly stressful stimuli. The insidious effects of constantly elevated stress hormones include memory and attention problems, irritability, and sleep disorders. They also contribute to many long-term health issues, depending on which body system is most vulnerable

for some reason the normal response is blocked—for example, when people are held down, trapped, or otherwise prevented from taking effective action, be it in a war zone, a car accident, domestic violence, or a rape—the brain keeps secreting stress chemicals, and the brain’s electrical circuits continue to fire in vain.2 Long after the actual event has passed, the brain may keep sending signals to the body to escape a threat that no longer exists.

Being able to move and do something to protect oneself is a critical factor in determining whether or not a horrible experience

will leave long-lasting scars.

Our rational, cognitive brain is actually the youngest part of the brain and occupies only about 30 percent of the area inside our skull.

neurons that “fire together, wire together.”

If you feel safe and loved, your brain becomes specialized in exploration, play, and cooperation; if you are frightened and unwanted, it specializes in managing feelings of fear and abandonment.

These sensations converge in the thalamus, an area inside the limbic system that acts as the “cook” within the brain. The thalamus stirs all the input from our perceptions into a fully blended autobiographical soup, an integrated, coherent experience of “this is what is happening to me.”10 The sensations are then passed on in two directions—down to the amygdala, two small almond-shaped structures that lie deeper in the limbic, unconscious brain, and up to the frontal lobes, where they reach our conscious awareness. The neuroscientist Joseph LeDoux calls the pathway to the amygdala “the low road,” which is extremely fast, and that to the frontal cortex the “high road,” which takes several milliseconds longer in the midst of an overwhelmingly threatening experience. However, processing by the thalamus can break down. Sights, sounds, smells, and touch are encoded as isolated, dissociated fragments, and normal memory processing disintegrates. Time freezes, so that the present danger feels like it will last forever.

Because the amygdala processes the information it receives from the thalamus faster than the frontal lobes do, it decides whether incoming information is a threat to

However, neuroscience research shows that very few psychological problems are the result of defects in understanding; most originate in pressures from deeper regions in the brain that drive our perception and attention. When the alarm bell of the emotional brain keeps signaling that you are in danger, no amount of insight will silence it. I am reminded of the comedy in which a seven-time recidivist in an anger-management program extols the virtue of the techniques he’s learned: “They are great and work terrific—as long as you are not really angry.”

Emotions (from the Latin emovere—to move out) give shape and direction to whatever we do, and their primary expression is through the muscles of the face and body. These facial and physical movements

All are a product of the synchrony between the two branches of the autonomic nervous system (ANS): the sympathetic, which acts as the body’s accelerator, and the parasympathetic, which serves as its brake.6 These are the “reciprocals” Darwin

Whenever we feel threatened, we instinctively turn to the first level, social engagement. We call out for help, support, and comfort from the people around us. But if no one comes to our aid, or we’re in immediate danger, the organism reverts to a more primitive way to survive: fight or flight. We fight off our attacker, or we run to a safe place. However, if this fails—we can’t get away, we’re held down or trapped—the organism tries to preserve itself by shutting down and expending as little energy as possible. We are then in a state of freeze or collapse.

Immobilization is at the root of most traumas. When that occurs the DVC is likely to take over: Your heart slows down, your breathing becomes shallow, and, zombielike, you lose touch with yourself and your surroundings.

The lack of self-awareness in victims of chronic childhood trauma is sometimes so profound that they cannot recognize themselves in a mirror. Brain scans show that this is not the result of mere inattention: The structures in charge of self-recognition may be knocked out along with the structures related to self-experience.

us. They warn us that

Somatic symptoms for which no clear physical basis can be found are ubiquitous in traumatized children and adults. They can include chronic back and neck pain, fibromyalgia, migraines, digestive problems, spastic colon/irritable bowel syndrome, chronic fatigue, and some forms of asthma.16 Traumatized children have fifty times the rate of asthma as their nontraumatized peers.

The security of their attachment to their mothers predicted the amount of morphine that was required to control their pain—the more secure the attachment, the less painkiller was needed.

Emotional withdrawal had the most profound and long-lasting impact. Emotional distance and role reversal (in which mothers expected the kids to look after them) were specifically linked to aggressive behavior against self and others in the young adults.

But if we are abused or ignored in childhood, or grow up in a family where sexuality is treated with disgust, our inner map contains a different message.

the moment we feel trapped, enraged, or rejected, we are vulnerable to activating old maps and to follow their directions. Change begins when we learn to “own” our emotional brains. That means learning to observe and tolerate the heartbreaking and gut-wrenching sensations that register misery and humiliation. Only after learning to bear what is going on inside can we start to befriend, rather than obliterate, the emotions that keep our maps fixed and immutable.

the gravest and most costly public health issue in the United States: child abuse. He had calculated that its overall costs exceeded those of cancer or heart disease and 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.20 It would also have a dramatic effect on workplace performance and vastly decrease the need for incarceration.

Even more important, genes are not fixed; life events can trigger biochemical messages that turn them on or off by attaching methyl groups, a cluster of carbon and hydrogen atoms, to the outside of the gene (a process called methylation),

James Heckman, winner of the 2000 Nobel Prize in Economics, has shown that quality early-childhood programs that involve parents and promote basic skills in disadvantaged children more than pay for themselves in improved outcomes.

Economists have calculated that every dollar invested in high-quality home visitation, day care, and preschool programs results in seven dollars of savings on welfare payments, health-care costs, substance-abuse treatment, and incarceration, plus higher tax revenues due to better-paying jobs.

Seventy percent of prisoners in California spent time in foster care while growing up. The United States spends $84 billion per year to incarcerate people at approximately $44,000 per prisoner; the northern European countries a fraction of that amount. Instead, they invest in helping parents to raise their children in safe and predictable surroundings. Their academic test scores and crime rates seem to reflect the success of those investments.

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.

Ordinary memory is essentially social; it’s a story that we tell for a purpose: in Irène’s case, to enlist her doctor’s help and comfort; in Julian’s case, to recruit me to join his search for justice and revenge. But there is nothing social about traumatic memory. Julian’s rage at his girlfriend’s remark served no useful purpose. Reenactments are frozen in time, unchanging, and they are always lonely, humiliating, and alienating experiences.

Studies conducted during World War II in England showed that children who lived in London during the Blitz and were sent away to the countryside for protection against German bombing raids fared much worse than children who remained with their parents and endured nights in bomb shelters and frightening images of destroyed buildings and dead people.

EMDR proved to be a more effective antidepressant than Prozac.

shown that we possess two distinct forms of self-awareness: one that keeps track of the self across time and one that registers the self in the present moment. The first, our autobiographical self, creates connections among experiences and assembles them into a coherent story. This system is rooted in language. Our narratives change with the telling, as our perspective changes and as we incorporate new input. The other system, moment-to-moment self-awareness, is based primarily in physical sensations, but if we feel safe are not rushed, we can find words to communicate that experience as well. These two ways of knowing are localized in different parts of the brain that are largely disconnected from each other.10 Only the system devoted to self-awareness, which is based in the medial prefrontal cortex, can change the emotional brain. In the groups I used to lead for veterans, I could sometimes see these two systems working side by side. The soldiers told horrible tales of death and destruction, but I noticed that their bodies often simultaneously radiated a sense of pride and belonging. Similarly, many patients tell me about the happy families they grew up in while their bodies are slumped over and their voices sound anxious and uptight. One system 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. But the other system registers a different truth: how we experience the situation ...

stress is not an inherent property of events themselves—it is a function of how we label and react to them.