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

by Bessel van der Kolk

But traumatic experiences do leave traces, whether on a large scale (on our histories and cultures) or close to home, on our families, with dark secrets being imperceptibly passed down through generations.

They also leave traces on our minds and emotions, on our capacity for joy and intimacy, and even on our biology and immune systems.

It takes tremendous energy to keep functioning while carrying the memory of terror, and the shame of utter weakness and vulnerability.

We now know that their behaviors are not the result of moral failings or signs of lack of willpower or bad character—they are caused by actual changes in the brain.

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. Which one of these is best for any particular survivor is an empirical question. Most people I have worked with require a combination.

Tom went through the motions of living a normal life, hoping that by faking it he would learn to become his old self again.

Trauma, whether it is the result of something done to you or something you yourself have done, almost always makes it difficult to engage in intimate relationships. After you have experienced something so unspeakable, how do you learn to trust yourself or anyone else again? Or, conversely, how can you surrender to an intimate relationship after you have been brutally violated?

The Rorschach tests also taught us that traumatized people look at the world in a fundamentally different way from other people.

After trauma the world becomes sharply divided between those who know and those who don’t.

I was particularly struck by how many female patients spoke of being sexually abused as children. This was puzzling, as the standard textbook of psychiatry at the time stated that incest was extremely rare in the United States, occurring about once in every million women.8 Given that there were then only about one hundred million women living in the United States, I wondered how forty seven, almost half of them, had found their way to my office in the basement of the hospital.

My patients with incest histories were hardly free of “subsequent psychopathology”—they were profoundly depressed, confused, and often engaged in bizarrely self-harmful behaviors, such as cutting themselves with razor blades.

This is particularly tragic, since it is very difficult for growing children to recover when the source of terror and pain is not enemy combatants but their own caretakers.

We have learned that trauma is not just an event that took place sometime in the past; it is also the imprint left by that experience on mind, brain, and body.

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.

“What would you call this patient—schizophrenic or schizoaffective?” He paused and stroked his chin, apparently in deep thought. “I think I’d call him Michael McIntyre,” he replied.

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.

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.

At this point, just as with drug addiction, we start to crave the activity and experience withdrawal when it’s not available. In the long run people become more preoccupied with the pain of withdrawal than the activity itself. This theory could explain why some people hire someone to beat them, or burn themselves with cigarettes. or why they are only attracted to people who hurt them. Fear and aversion, in some perverse way, can be transformed into pleasure.

This suggested that for many traumatized people, reexposure to stress might provide a similar relief from anxiety.

The drug revolution that started out with so much promise may in the end have done as much harm as good. The theory that mental illness is caused primarily by chemical imbalances in the brain that can be corrected by specific drugs has become broadly accepted, by the media and the public as well as by the medical profession.22 In many places drugs have displaced therapy and enabled patients to suppress their problems without addressing the underlying issues.

The SSRIs can be very helpful in making traumatized people less enslaved by their emotions, but they should only be considered adjuncts in their overall treatment.23

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 as 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.