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

by Bessel van der Kolk

People with PTSD have their floodgates wide open. Lacking a filter, they are on constant sensory overload. In order to cope, they try to shut themselves down and develop tunnel vision and hyperfocus. If they can’t shut down naturally, they may enlist drugs or alcohol to block out the world.

Being able to feel safe with other people is probably the single most important aspect of mental health; safe connections are fundamental to meaningful and satisfying lives.

Social support is not the same as merely being in the presence of others. The critical issue is reciprocity: being truly heard and seen by the people around us, feeling that we are held in someone else’s mind and heart.

Many traumatized people find themselves chronically out of sync with the people around them.

The body keeps the score:17 If the memory of trauma is encoded in the viscera, in heartbreaking and gut-wrenching emotions, in autoimmune disorders and skeletal/muscular problems, and if mind/brain/visceral communication is the royal road to emotion regulation, this demands a radical shift in our therapeutic assumptions.

Be patient toward all that is unsolved in your heart and try to love the questions themselves. . . . Live the questions now. Perhaps you will gradually, without noticing it, live along some distant day into the answer.

The disappearance of medial prefrontal activation could explain why so many traumatized people lose their sense of purpose and direction. I used to be surprised by how often my patients asked me for advice about the most ordinary things, and then by how rarely they followed it. Now I understood that 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, the basis of all emotions, were trying to tell them?

People who cannot comfortably notice what is going on inside become vulnerable to respond to any sensory shift either by shutting down or by going into a panic—they develop a fear of fear itself.

We now know that panic symptoms are maintained largely because the individual develops a fear of the bodily sensations associated with panic attacks. The attack may be triggered by something he or she knows is irrational, but fear of the sensations keeps them escalating into a full-body emergency.

just as bad, what is safe or nourishing. Self-regulation depends on having a friendly relationship with your body. Without it you have to rely on external regulation—from medication, drugs like alcohol, constant reassurance, or compulsive compliance with the wishes of others.

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.

Associating intense sensations with safety, comfort, and mastery is the foundation of self-regulation, self-soothing, and self-nurture, a theme to which I return throughout this book.

In contrast, children with histories of abuse and neglect learn that their terror, pleading, and crying do not register with their caregiver. Nothing they can do or say stops the beating or brings attention and help. In effect they’re being conditioned to give up when they face challenges later in life.

Children who don’t feel safe in infancy have trouble regulating their moods and emotional responses as they grow older. By kindergarten, many disorganized infants are either aggressive or spaced out and disengaged, and they go on to develop a range of psychiatric problems.23 They also show more physiological stress, as expressed in heart rate, heart rate variability,24 stress hormone responses, and lowered immune factors.25 Does this kind of biological dysregulation automatically reset to normal as a child matures or is moved to a safe environment? So far as we know, it does not. Parental abuse is not the only cause of disorganized attachment: Parents who are preoccupied with their own trauma, such as domestic abuse or rape or the recent death of a parent or sibling, may also be too emotionally unstable and inconsistent to offer much comfort and protection.

(Living with an irascible, withdrawn, or terrified spouse is likely to impose a major psychological burden on the partner, including depression.)

Disorganized attachment showed up in two different ways: One group of mothers seemed to be too preoccupied with their own issues to attend to their infants. They were often intrusive and hostile; they alternated between rejecting their infants and acting as if they expected them to respond to their needs.

Lyons-Ruth was particularly interested in the phenomenon of dissociation, which is manifested in feeling lost, overwhelmed, abandoned, and disconnected from the world and in seeing oneself as unloved, empty, helpless, trapped, and weighed down.

Infants who live in secure relationships learn to communicate not only their frustrations and distress but also their emerging selves—their interests, preferences, and goals.

Bowlby wrote: “What cannot be communicated to the [m]other cannot be communicated to the self.”38 If you cannot tolerate what you know or feel what you feel, the only option is denial and dissociation.

This does not imply that child abuse is irrelevant41, but that the quality of early caregiving is critically important in preventing mental health problems, independent of other traumas.

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.

Also, a diagnostic label is likely to attach to people for the rest of their lives and have a profound influence on how they define themselves. I have met countless patients who told me that they “are” bipolar or borderline or that they “have” PTSD, as if they had been sentenced to remain in an underground dungeon for the rest of their lives, like the Count of Monte Cristo.

These monkeys grow up to be uptight: scared in new situations and lacking in curiosity. Regardless of their genetic predisposition, peer-raised monkeys overreact to minor stresses: Their cortisol increases much more in response to loud noises than does that of monkeys who were raised by their mothers.

Children who are fortunate enough to have an attuned and attentive parent are not going to develop this genetically related problem.11

V. The consensus, he wrote, was that no new diagnosis

almost thirty years, Alan Sroufe and his colleagues

Social support is a biological necessity, not an option, and this reality should be the backbone of all prevention and treatment.

For most people this involves (1) finding a way to become calm and focused, (2) learning to maintain that calm in response to images, thoughts, sounds, or physical sensations that remind you of the past, (3) finding a way to be fully alive in the present and engaged with the people around you, (4) not having to keep secrets from yourself, including secrets about the ways that you have managed to survive.

Recovery from trauma involves the restoration of executive functioning and, with it, self-confidence and the capacity for playfulness and creativity.

Apprehension about being hijacked by uncomfortable sensations keeps the body frozen and the mind shut.

Even though the trauma is a thing of the past, the emotional brain keeps generating sensations that make the sufferer feel scared and helpless.

In order to change you need to open yourself to your inner experience. The first step is to allow your mind to focus on your sensations and notice how, in contrast to the timeless, ever-present experience of trauma, physical sensations are transient and respond to slight shifts in body position, changes in breathing, and shifts in thinking. Once you pay attention to your physical sensations, the next step is to label them, as in “When I feel anxious, I feel a crushing sensation in my chest.” I may then say to a patient: “Focus on that sensation and see how it changes when you take a deep breath out, or when you tap your chest just below your collarbone, or when you allow yourself to cry.”

Study after study shows that having a good support network constitutes the single most powerful protection against becoming traumatized.

A trauma can be successfully processed only if all those brain structures are kept online.

He still regularly suffers from the sudden weakness in his limbs that requires him to sit or lie down. But, like his memories of childhood and Vietnam, these episodes do not dominate his existence. They are simply part of the ongoing, evolving story of his life.

As long as you keep secrets and suppress information, you are fundamentally at war with yourself. Hiding your core feelings takes an enormous amount of energy, it saps your motivation to pursue worthwhile goals, and it leaves you feeling bored and shut down. Meanwhile, stress hormones keep flooding your body, leading to headaches, muscle aches, problems with your bowels or sexual functions—and irrational behaviors that may embarrass you and hurt the people around you. Only after you identify the source of these responses can you start using your feelings as signals of problems that require your urgent attention.

When I got in touch with the most intimate, painful, or confusing moments of my life, I often found myself faced with a choice: I could either focus on reliving old scenes in my mind’s eye and let myself feel what I had felt back then, or I could tell my analyst logically and coherently what had transpired. When I chose the latter, I would quickly lose touch with myself and start to focus on his opinion of what I was telling him. The slightest hint of doubt or judgment would shut me down, and I would shift my attention to regaining his approval.

then asked her how she felt now about that little girl with newly diagnosed epilepsy who was left on her own. Instead of crying for her loneliness or being angry about the lack of support, she said fiercely: “She was stupid, whiny, and dependent. She should have stepped up to the plate and sucked it up.” That passion obviously came from the part of her that had valiantly tried to cope with her distress, and I acknowledged that it probably had helped her survive back then. I asked her to allow that frightened, abandoned girl to tell her what it had been like to be all alone, her illness compounded by family rejection. She started to sob and kept quiet for a long time until finally she said: “No, she did not deserve that. She should have been supported; somebody should have looked after her.” Then she shifted again and proudly told me about her accomplishments—how much she’d achieved despite that lack of support. Public story and inner experience finally met.