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

by Bessel van der Kolk

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.

Paul Frewen at the University of Western Ontario did a series of brain scans of people with PTSD who suffered from alexithymia. One of the participants told him: “I don’t know what I feel, it’s like my head and body aren’t connected. I’m living in a tunnel, a fog, no matter what happens it’s the same reaction—numbness, nothing. Having a bubble bath and being burned or raped is the same feeling. My brain doesn’t feel.”

This failure to be in touch with their bodies contributes to their well-documented lack of self-protection and high rates of revictimization23 and also to their remarkable difficulties feeling pleasure, sensuality, and having a sense of meaning.

Trauma victims cannot recover until they become familiar with and befriend the sensations in their bodies. Being frightened means that you live in a body that is always on guard.

The bodies of child-abuse victims are tense and defensive until they find a way to relax and feel safe. In order to change, people need to become aware of their sensations and the way that their bodies interact with the world around them. Physical self-awareness is the first step in releasing the tyranny of the past.

my practice I begin the process by helping my patients to first notice and then describe the feelings in their bodies—not emotions such as anger or anxiety or fear but the physical sensations beneath the emotions: pressure, heat, muscular tension, tingling, caving in, feeling hollow, and so on. I also work on identifying the sensations associated with relaxation or pleasure. I help them become aware of their breath, their gestures and movements. I ask them to pay attention to subtle shifts in their bodies, such as tightness in their chests or gnawing in their bellies, when they talk about negative events that they claim did not bother them.

The most natural way for human beings to calm themselves when they are upset is by clinging to another person. This means that patients who have been physically or sexually violated face a dilemma: They desperately crave touch while simultaneously being terrified of body contact.

To have genuine relationships you have to be able to experience others as separate individuals, each with his or her particular motivations and intentions. While you need to be able to stand up for yourself, you also need to recognize that other people have their own agendas. Trauma can make all that hazy and gray.

how human beings may be induced to sacrifice everything they hold dear and true—including their sense of self—for the sake of being loved and approved of by someone in a position of authority.

As we grow up, we gradually learn to take care of ourselves, both physically and emotionally, but we get our first lessons in self-care from the way that we are cared for.

But when a neighbor stopped by and absorbed his mother’s interest with the latest gossip, the kids would run back and stay close, making sure he still had her attention. When infants and young children notice that their mothers are not fully engaged with them, they become nervous. When their mothers disappear from sight, they may cry and become inconsolable, but as soon as their mothers return, they quiet down and resume their play.

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.

If a mother cannot meet her baby’s impulses and needs, “the baby learns to become the mother’s idea of what the baby is.” Having to discount its inner sensations, and trying to adjust to its caregiver’s needs, means the child perceives that “something is wrong” with the way it is. Children who lack physical attunement are vulnerable to shutting down the direct feedback from their bodies, the seat of pleasure, purpose, and direction.

Abused kids are often very sensitive to changes in voices and faces, but they tend to respond to them as threats rather than as cues for staying in sync.

The first question I asked Jack was who he expected would visit him in jail on Christmas. “Nobody,” he told me. “Nobody ever pays attention to me.” It turned out that he had been caught during break-ins numerous times before. He knew the police, and they knew him. With delight in his voice, he told me that when the cops saw him standing in the middle of the living room, they yelled, “Oh my God, it’s Jack again, that little motherfucker.” Somebody recognized him; somebody knew his name. A little while later Jack confessed, “You know, that is what makes it worthwhile.” Kids will go to almost any length to feel seen and connected.

In one pattern, called “avoidant attachment,” the infants look like nothing really bothers them—they don’t cry when their mother goes away and they ignore her when she comes back. However, this does not mean that they are unaffected. In fact, their chronically increased heart rates show that they are in a constant state of hyperarousal. My colleagues and I call this pattern “dealing but not feeling.”12 Most mothers of avoidant infants seem to dislike touching their children. They have trouble snuggling and holding them, and they don’t use their facial expressions and voices to create pleasurable back-and-forth rhythms with their babies.

Anxious toddlers tend to grow into anxious adults, while avoidant toddlers are likely to become adults who are out of touch with their own feelings and those of others. (As in, “There’s nothing wrong with a good spanking. I got hit and it made me the success I am today.”)

Children in this situation have no one to turn to, and they are faced with an unsolvable dilemma; their mothers are simultaneously necessary for survival and a source of fear.17 They “can neither approach (the secure and ambivalent ‘strategies’), shift [their] attention (the avoidant ‘strategy’), nor flee.”18 If you observe such children in a nursery school or attachment laboratory, you see them look toward their parents when they enter the room and then quickly turn away. Unable to choose between seeking closeness and avoiding the parent, they may rock on their hands and knees, appear to go into a trance, freeze with their arms raised, or get up to greet their parent and then fall to the ground. Not knowing who is safe or whom they belong to, they may be intensely affectionate with strangers or may trust nobody. Main called this pattern “disorganized attachment.” Disorganized attachment is “fright without solution.”19

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.

Chronically failing to calm her baby down and establish an enjoyable face-to-face interaction, the mother is likely to come to perceive him as a difficult child who makes her feel like a failure, and give up on trying to comfort her child.

If you have no internal sense of security, it is difficult to distinguish between safety and danger. If you feel chronically numbed out, potentially dangerous situations may make you feel alive. If you conclude that you must be a terrible person (because why else would your parents have you treated that way?), you start expecting other people to treat you horribly. You probably deserve it, and anyway, there is nothing you can do about it. When disorganized people carry self-perceptions like these, they are set up to be traumatized by subsequent experiences.33

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.

Another group of mothers seemed helpless and fearful. They often came across as sweet or fragile, but they didn’t know how to be the adult in the relationship and seemed to want their children to comfort them.

Karlen’s research provided me with one answer: Watching her videos, I could see the children becoming more and more inconsolable, sullen, or resistant to their misattuned mothers. At the same time, the mothers became increasingly frustrated, defeated, and helpless in their interactions. Once the mother comes to see the child not as her partner in an attuned relationship but as a frustrating, enraging, disconnected stranger, the stage is set for subsequent abuse.

Karlen’s research showed that dissociation is learned early: Later abuse or other traumas did not account for dissociative symptoms in young adults.40 Abuse and trauma accounted for many other problems, but not for chronic dissociation or aggression against self. The critical underlying issue was that these patients didn’t know how to feel safe. Lack of safety within the early caregiving relationship led to an impaired sense of inner reality, excessive clinging, and self-damaging behavior: Poverty, single parenthood, or maternal psychiatric symptoms did not predict these symptoms.

As a result, if we later hook up with somebody who treats us badly, we will be outraged. It won’t feel right: It’s not familiar; it’s not like home. 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. Our sense of our self is marked by contempt and humiliation, and we are more likely to think “he (or she) has my number” and fail to protest if we are mistreated.

She was glad that it was not really her—it was some other girl who was being molested.

Children sense—even if they are not explicitly threatened—that if they talked about their beatings or molestation to teachers they would be punished.

Children are also programmed to be fundamentally loyal to their caretakers, even if they are abused by them.

It took Marilyn a long time before she was ready to talk about her abuse: She was not ready to violate her loyalty to her family—deep inside she felt that she still needed them to protect her against her fears. The price of this loyalty is unbearable feelings of loneliness, despair, and the inevitable rage of helplessness. Rage that has nowhere to go is redirected against the self, in the form of depression, self-hatred, and self-destructive actions.

The mind works according to schemes or maps, and incidents that fall outside the established pattern are most likely to capture our attention.

We remember insults and injuries best: The adrenaline that we secrete to defend against potential threats helps to engrave those incidents into our minds.

As James McGaugh and colleagues have shown, the more adrenaline you secrete, the more precise your memory will be.

This treatise explained that, after having been traumatized, people automatically keep repeating certain actions, emotions, and sensations related to the trauma.

Janet was the first to point out the difference between “narrative memory”—the stories people tell about trauma—and traumatic memory itself.

Traumatized people simultaneously remember too little and too much.

Dissociation prevents the trauma from becoming integrated within the conglomerated, ever-shifting stores of autobiographical memory, in essence creating a dual memory system.

the problem with PTSD is dissociation, the goal of treatment would be association: integrating the cut-off elements of the trauma into the ongoing narrative of life, so that the brain can recognize that “that was then, and this is now.”

Even though psychoanalysis is today in eclipse, the “talking cure” has lived on, and psychologists have generally assumed that telling the trauma story in great detail will help people to leave it behind. That is also a basic premise of cognitive behavioral therapy (CBT), which today is taught in graduate psychology courses around the world.

Our bodies are the texts that carry the memories and therefore remembering is no less than reincarnation.

“I am aware that I, without realizing it, have lost my feelings—I don’t belong here anymore, I live in an alien world. I prefer to be left alone, not disturbed by anybody. They talk too much—I can’t relate to them—they are only busy with superficial things.”

Williams’s findings are supported by recent neuroscience research that shows that memories that are retrieved tend to return to the memory bank with modifications.22 As long as a memory is inaccessible, the mind is unable to change it. But as soon as a story starts being told, particularly if it is told repeatedly, it changes—the act of telling itself changes the tale.

There were two major differences between how people talked about memories of positive versus traumatic experiences: (1) how the memories were organized, and (2) their physical reactions to them. Weddings, births, and graduations were recalled as events from the past, stories with a beginning, a middle, and an end. Nobody said that there were periods when they’d completely forgotten any of these events. In contrast, the traumatic memories were disorganized. Our subjects remembered some details all too clearly (the smell of the rapist, the gash in the forehead of a dead child) but could not recall the sequence of events or other vital details (the first person who arrived to help, whether an ambulance or a police car took them to the hospital).

the reality of a relatively secure and predictable present that lives side by side with a ruinous, ever-present past. NANCY’S STORY

I don’t go to therapy to find out if I’m a freak I go and I find the one and only answer every week And when I talk about therapy, I know what people think That it only makes you selfish and in love with your shrink But, oh how I loved everybody else When I finally got to talk so much about myself

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.

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.

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.

As the previous parts of this book have shown, the engines of posttraumatic reactions are located in the emotional brain. In contrast with the rational brain, which expresses itself in thoughts, the emotional brain manifests itself in physical reactions: gut-wrenching sensations, heart pounding, breathing becoming fast and shallow, feelings of heartbreak, speaking with an uptight and reedy voice, and the characteristic body movements that signify collapse, rigidity, rage, or defensiveness.

However, the more frazzled we are, the more our rational brains take a backseat to our emotions.3