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

by Bessel van der Kolk

Perhaps the most important finding in our study was that remembering the trauma with all its associated affects, does not, as Breuer and Freud claimed back in 1893, necessarily resolve it. Our research did not support the idea that language can substitute for action.

Nobody can “treat” a war, or abuse, rape, molestation, or any other horrendous event, for that matter; what has happened cannot be undone. But what can be dealt with are the imprints of the trauma on body, mind, and soul: the crushing sensations in your chest that you may label as anxiety or depression; the fear of losing control; always being on alert for danger or rejection; the self-loathing; the nightmares and flashbacks; the fog that keeps you from staying on task and from engaging fully in what you are doing; being unable to fully open your heart to another human being.

Trauma robs you of the feeling that you are in charge of yourself, of what I will call self-leadership

The challenge of recovery is to reestablish ownership of your body and your mind—of your self. This means feeling free to know what you know and to feel what you feel without becoming overwhelmed, enraged, ashamed, or collapsed. 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.

The emotions and physical sensations that were imprinted during the trauma are experienced not as memories but as disruptive physical reactions in the present.

In order to regain control over your self, you need to revisit the trauma: Sooner or later you need to confront what has happened to you, but only after you feel safe and will not be retraumatized by it. The first order of business is to find ways to cope with feeling overwhelmed by the sensations and emotions associated with the past.

Understanding why you feel a certain way does not change how you feel. But it can keep you from surrendering to intense reactions

The rational, analyzing part of the brain, centered on the dorsolateral prefrontal cortex, has no direct connections with the emotional brain, where most imprints of trauma reside, but the medial prefrontal cortex, the center of self-awareness, does.

Neuroscience research shows that the only way we can change the way we feel is by becoming aware of our inner experience and learning to befriend what is going on inside ourselves.

At the core of recovery is self-awareness. The most important phrases in trauma therapy are “Notice that” and “What happens next?” Traumatized people live with seemingly unbearable sensations: They feel heartbroken and suffer from intolerable sensations in the pit of their stomach or tightness in their chest. Yet avoiding feeling these sensations in our bodies increases our vulnerability to being overwhelmed by them.

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,

Learning to observe and tolerate your physical reactions is a prerequisite for safely revisiting the past.

“One way to think of this process of transformation is to think of mindfulness as a lens, taking the scattered and reactive energies of your mind and focusing them into a coherent source of energy for living, for problem solving, for healing.”

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

The training of competent trauma therapists involves learning about the impact of trauma, abuse, and neglect and mastering a variety of techniques that can help to (1) stabilize and calm patients down, (2) help to lay traumatic memories and reenactments to rest, and (3) reconnect patients with their fellow men and women. Ideally the therapist will also have been on the receiving end of whatever therapy he or she practices.

“People who are terrified need to get a sense of where their bodies are in space and of their boundaries. Firm and reassuring touch lets them know where those boundaries are: what’s outside them, where their bodies end. They discover that they don’t constantly have to wonder who and where they are. They discover that their body is solid and that they don’t have to be constantly on guard. Touch lets them know that they are safe.”

Helplessness and immobilization keep people from utilizing their stress hormones to defend themselves. When that happens, their hormones still are being pumped out, but the actions they’re supposed to fuel are thwarted. Eventually, the activation patterns that were meant to promote coping are turned back against the organism and now keep fueling inappropriate fight/flight and freeze responses. In order to return to proper functioning, this persistent emergency response must come to an end. The body needs to be restored to a baseline state of safety and relaxation from which it can mobilize to take action in response to real danger.

When people remember an ordinary event, they do not also relive the physical sensations, emotions, images, smells, or sounds associated with that event. In contrast, when people fully recall their traumas, they “have” the experience: They are engulfed by the sensory or emotional elements of the past.

During their training most psychologists are taught cognitive behavioral therapy. CBT was first developed to treat phobias such as fear of spiders, airplanes, or heights, to help patients compare their irrational fears with harmless realities. Patients are gradually desensitized from their irrational fears by bringing to mind what they are most afraid of, using their narratives and images (“imaginal exposure”), or they are placed in actual (but actually safe) anxiety-provoking situations (“in vivo exposure”), or they are exposed to virtual-reality, computer-simulated scenes, for example, in the case of combat-related PTSD, fighting in the streets of Fallujah. The idea behind cognitive behavioral treatment is that when patients are repeatedly exposed to the stimulus without bad things actually happening, they gradually will become less upset; the bad memories will have become associated with “corrective” information of being safe.33 CBT also tries to help patients deal with their tendency to avoid, as in “I don’t want to talk about it.”34 It sounds simple, but, as we have seen, reliving trauma reactivates the brain’s alarm system and knocks out critical brain areas necessary for integrating the past, making it likely that patients will relive rather than resolve the trauma.

Being traumatized is not just an issue of being stuck in the past; it is just as much a problem of not being fully alive in the present.

Over the past two decades the prevailing treatment taught to psychology students has been some form of systematic desensitization: helping patients become less reactive to certain emotions and sensations. But is this the correct goal? Maybe the issue is not desensitization but integration: putting the traumatic event into its proper place in the overall arc of one’s life.

A 2010 report on 49,425 veterans with newly diagnosed PTSD from the Iraq and Afghanistan wars who sought care from the VA showed that fewer than one out of ten actually completed the recommended treatment.

Over the past decade the Departments of Defense and Veterans Affairs combined have spent over $4.5 billion on antidepressants, antipsychotics, and antianxiety drugs. A June 2010 internal report from the Defense Department’s Pharmacoeconomic Center at Fort Sam Houston in San Antonio showed that 213,972, or 20 percent of the 1.1 million active-duty troops surveyed, were taking some form of psychotropic drug: antidepressants, antipsychotics, sedative hypnotics, or other controlled substances.

However, drugs cannot “cure” trauma; they can only dampen the expressions of a disturbed physiology. And they do not teach the lasting lessons of self-regulation. They can help to control feelings and behavior, but always at a price—because they work by blocking the chemical systems that regulate engagement, motivation, pain, and pleasure.

The serotonin reuptake inhibitors (SSRIs) such as Prozac, Zoloft, Effexor, and Paxil have been most thoroughly studied, and they can make feelings less intense and life more manageable. Patients on SSRIs often feel calmer and more in control; feeling less overwhelmed often makes it easier to engage in therapy. Other patients feel blunted by SSRIs—they feel they’re “losing their edge.” I approach it as an empirical question: Let’s see what works, and only the patient can be the judge of that. On the other hand, if one SSRI does not work, it’s worth trying another, because they all have slightly different effects. It’s interesting that the SSRIs are widely used to treat depression, but in a study in which we compared Prozac with eye movement desensitization and reprocessing (EMDR) for patients with PTSD, many of whom were also depressed, EMDR proved to be a more effective antidepressant than Prozac.

Medicines that target the autonomic nervous system, like propranolol or clonidine, can help to decrease hyperarousal and reactivity to stress.55 This family of drugs works by blocking the physical effects of adrenaline, the fuel of arousal, and thus reduces nightmares, insomnia, and reactivity to trauma triggers.56 Blocking adrenaline can help to keep the rational brain online and make choices possible: “Is this really what I want to do?”

The most controversial medications are the so-called second-generation antipsychotic agents, such as Risperdal and Seroquel, the largest-selling psychiatric drugs in the United States ($14.6 billion in 2008). Low doses of these agents can be helpful in calming down combat veterans and women with PTSD related to childhood abuse.58 Using these drugs is sometimes justified, for example when patients feel completely out of control and unable to sleep or where other methods have failed.59 But it’s important to keep in mind that these medications work by blocking the dopamine system, the brain’s reward system, which also functions as the engine of pleasure and motivation.

Antipsychotic medications such as Risperdal, Abilify, or Seroquel can significantly dampen the emotional brain and thus make patients less skittish or enraged, but they also may interfere with being able to appreciate subtle signals of pleasure, danger, or satisfaction. They also cause weight gain, increase the chance of developing diabetes, and make patients physically inert, which is likely to further increase their sense of alienation. These drugs are widely used to treat abused children who are inappropriately diagnosed with bipolar disorder or mood dysregulation disorder. More than half a million children and adolescents in America are now taking antipsychotic drugs, which may calm them down but also interfere with learning age-appropriate skills and developing friendships with other children.

Columbia University study recently found that prescriptions of antipsychotic drugs for privately insured two- to five-year-olds had doubled between 2000 and 2007.61 Only 40 percent of them had received a proper mental health assessment.

Until it lost its patent, the pharmaceutical company Johnson & Johnson doled out LEGO blocks stamped with the word “Risperdal” for the waiting rooms of child psychiatrists. Children from low-income families are four times as likely as the privately insured to receive antipsychotic medicines. In one year alone Texas Medicaid spent $96 million on antipsychotic drugs for teenagers and children—including three unidentified infants who were given the drugs before their first birthdays.62 There have been no studies on the effects of psychotropic medications on the developing brain. Dissociation, self-mutilation, fragmented memories, and amnesia generally do not respond to any of these medications.

Between 2001 and 2011 the VA spent about $1.5 billion on Seroquel and Risperdal, while Defense spent about $90 million during the same period, even though a research paper published in 2001 showed that Risperdal was no more effective than a placebo in treating PTSD.64 Similarly, between 2001 and 2012 the VA spent $72.1 million and Defense spent $44.1 million on benzodiazepines65—medications that clinicians generally avoid prescribing to civilians with PTSD because of their addiction potential and lack of significant effectiveness for PTSD symptoms.

Why CBT? Because behavioral treatment can be broken down into concrete steps and “manualized” into uniform protocols, it is the favorite treatment of academic researchers, another group that could not be ignored.

Therapists have an undying faith in the capacity of talk to resolve trauma. That confidence dates back to 1893, when Freud (and his mentor, Breuer) wrote that trauma “immediately and permanently disappeared when we had succeeded in bringing clearly to light the memory of the event by which it was provoked and in arousing its accompanying affect, and when the patient had described that event in the greatest possible detail and had put the affect into words.”2 Unfortunately, it’s not so simple: Traumatic events are almost impossible to put into words. This is true for all of us, not just for people who suffer from PTSD.

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. Ignoring inner reality also eats away at your sense of self, identity, and purpose.

Getting perspective on your terror and sharing it with others can reestablish the feeling that you are a member of the human race.

Helen’s discovery of language with the help of Anne Sullivan captures the essence of a therapeutic relationship: finding words where words were absent before and, as a result, being able to share your deepest pain and deepest feelings with another human being. This is one of the most profound experiences we can have, and such resonance, in which hitherto unspoken words can be discovered, uttered, and received, is fundamental to healing the isolation of trauma—especially if other people in our lives have ignored or silenced us.

Anyone who enters talk therapy, however, almost immediately confronts the limitations of language. This was true of my own psychoanalysis. While I talk easily and can tell interesting tales, I quickly realized how difficult it was to feel my feelings deeply and simultaneously report them to someone else.

Since then neuroscience research has 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 and 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.

Trauma stories lessen the isolation of trauma, and they provide an explanation for why people suffer the way they do.

trauma makes people feel like either some body else, or like no body. In order to overcome trauma, you need help to get back in touch with your body, with your Self.

Our sense of Self depends on being able to organize our memories into a coherent whole.

One day in 1987 psychologist Francine Shapiro was walking through a park, preoccupied with some painful memories, when she noticed that rapid eye movements produced a dramatic relief from her distress. How could a major treatment modality grow from such a brief experience? How is it possible that such a simple process had not been noted before? Initially skeptical about her observation she subjected her method to years of experimentation and research, gradually building it into a standardized procedure that could be taught and tested in controlled studies.

“You know, Bessel, maybe you need to learn to put your voyeuristic tendencies on hold. If it’s important for you to hear trauma stories, why don’t you go to a bar, put a couple of dollars on the table, and say to your neighbor, ‘I’ll buy you a drink if you tell me your trauma story.’ But you really need to know the difference between your desire to hear stories and your patient’s internal process of healing.”

left my EMDR training preoccupied with three issues that fascinate me to this day: EMDR loosens up something in the mind/brain that gives people rapid access to loosely associated memories and images from their past. This seems to help them put the traumatic experience into a larger context or perspective. People may be able to heal from trauma without talking about it. EMDR enables them to observe their experiences in a new way, without verbal give-and-take with another person. EMDR can help even if the patient and the therapist do not have a trusting relationship. This was particularly intriguing because trauma, understandably, rarely leaves people with an open, trusting heart.

Some psychologists have hypothesized that EMDR actually desensitizes people to the traumatic material and thus is related to exposure therapy. A more accurate description would be that it integrates the traumatic material. As our research showed, after EMDR people thought of the trauma as a coherent event in the past, instead of experiencing sensations and images divorced from any context.

As we’ve seen, traumatic memories persist as split-off, unmodified images, sensations, and feelings. To my mind the most remarkable feature of EMDR is its apparent capacity to activate a series of unsought and seemingly unrelated sensations, emotions, images, and thoughts in conjunction with the original memory. This way of reassembling old information into new packages may be just the way we integrate ordinary, nontraumatic day-to-day experiences.

The sleeping brain reshapes memory by increasing the imprint of emotionally relevant information while helping irrelevant material fade away.

Why is HRV important? When our autonomic nervous system is well balanced, we have a reasonable degree of control over our response to minor frustrations and disappointments, enabling us to calmly assess what is going on when we feel insulted or left out. Effective arousal modulation gives us control over our impulses and emotions: As long as we manage to stay calm, we can choose how we want to respond. Individuals with poorly modulated autonomic nervous systems are easily thrown off balance, both mentally and physically. Since the autonomic nervous system organizes arousal in both body and brain, poor HRV—that is, a lack of fluctuation in heart rate in response to breathing—not only has negative effects on thinking and feeling but also on how the body responds to stress. Lack of coherence between breathing and heart rate makes people vulnerable to a variety of physical illnesses, such as heart disease and cancer, in addition to mental problems such as depression and PTSD.

In our studies we keep seeing how difficult it is for traumatized people to feel completely relaxed and physically safe in their bodies. We measure our subjects’ HRV by placing tiny monitors on their arms during shavasana, the pose at the end of most classes during which practitioners lie face up, palms up, arms and legs relaxed. Instead of relaxation we picked up too much muscle activity to get a clear signal. Rather than going into a state of quiet repose, our students’ muscles often continue to prepare them to fight unseen enemies. A major challenge in recovering from trauma remains being able to achieve a state of total relaxation and safe surrender.

One of the clearest lessons from contemporary neuroscience is that our sense of ourselves is anchored in a vital connection with our bodies.14 We do not truly know ourselves unless we can feel and interpret our physical sensations; we need to register and act on these sensations to navigate safely through life.15 While numbing (or compensatory sensation seeking) may make life tolerable, the price you pay is that you lose awareness of what is going on inside your body and, with that, the sense of being fully, sensually alive.