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

by Bessel van der Kolk

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The neuroscientist Joseph LeDoux and his colleagues have shown that the only way we can consciously access the emotional brain is through self-awareness, i.e. by activating the medial prefrontal cortex, the part of the brain that notices what is going on inside us and thus allows us to feel what we’re feeling.5 (The technical term for this is “interoception”—Latin for “looking inside.”)

BEFRIENDING THE EMOTIONAL BRAIN

This means that we can directly train our arousal system by the way we breathe, chant, and move, a principle that has been utilized since time immemorial in places like China and India, and in every religious practice that I know of, but that is suspiciously eyed as “alternative” in mainstream culture.

In research supported by the National Institutes of Health, my colleagues and I have shown that ten weeks of yoga practice markedly reduced the PTSD symptoms of patients who had failed to respond to any medication or to any other treatment.7

Learning how to breathe calmly and remaining in a state of relative physical relaxation, even while accessing painful and horrifying memories, is an essential tool for recovery.

When you deliberately take a few slow, deep breaths, you will notice the effects of the parasympathetic brake on your arousal (as explained in chapter 5). The more you stay focused on your breathing, the more you will benefit, particularly if you pay attention until the very end of the out breath and then wait a moment before you inhale again. As you continue to breathe and notice the air moving in and out of your lungs you may think about the role that oxygen plays in nourishing your body and bathing your tissues with the energy you need to feel alive and engaged.

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.

Simply noticing our annoyance, nervousness, or anxiety immediately helps us shift our perspective and opens up new options other than our automatic, habitual reactions.

It’s not surprising that so many trauma survivors are compulsive eaters and drinkers, fear making love, and avoid many social activities: Their sensory world is largely off limits.

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.” Practicing mindfulness calms down the sympathetic nervous system, so that you are less likely to be thrown into fight-or-flight.11

between your thoughts and your physical sensations. How are particular thoughts registered in your body? (Do thoughts like “My father loves me” or “my girlfriend dumped me” produce different sensations?) Becoming aware of how your body organizes particular emotions or memories opens up the possibility of releasing sensations and impulses you once blocked in order to survive.14 In chapter 20, on the benefits of theater, I’ll describe in more detail how this works.

Safety and terror are incompatible. When we are terrified, nothing calms us down like the reassuring voice or the firm embrace of someone we trust.

Frightened adults respond to the same comforts as terrified children: gentle holding and rocking and the assurance that somebody bigger and stronger is taking care of things, so you can safely go to sleep.

After an acute trauma, like an assault, accident, or natural disaster, survivors require the presence of familiar people, faces, and voices; physical contact; food; shelter and a safe place; and time to sleep.

Our attachment bonds are our greatest protection against threat.

Recovery from trauma involves (re)connecting with our fellow human beings. This is why trauma that has occurred within relationships is generally more difficult to treat than trauma resulting from traffic accidents or natural disasters.

Child abuse, molestation, and domestic violence all are inflicted by people who are supposed to love you. That knocks out the most important protection against being traumatized: being sheltered by the people you love.

If the people whom you naturally turn to for care and protection terrify or reject you, you learn to shut down and to ignore what you feel.

Managing your terror all by yourself gives rise to another set of problems: dissociation, despair, addictions, a chronic sense of panic, and relationships that are marked by alienation, disconnection, and explosions.

find out how rotten and disgusting I am and dump me as soon as you really get to know me.”

your heart is still broken because you were assaulted by someone you loved, you are likely to be preoccupied with not getting hurt again and fear opening up to someone new.

You need a guide who is not afraid of your terror and who can contain your darkest rage, someone who can safeguard the wholeness of you while you explore the fragmented experiences that you had to keep secret from yourself for so long.

Patients who have been brutalized by their caregivers as children often do not feel safe with anyone.

When we play together, we feel physically attuned and experience a sense of connection and joy. Improvisation exercises (such as those found at http://learnimprov.com/) also are a marvelous way to help people connect in joy and exploration. The moment you see a group of grim-faced people break out in a giggle, you know that the spell of misery has broken.

However, the most natural way that we humans calm down our distress is by being touched, hugged, and rocked. This helps with excessive arousal and makes us feel intact, safe, protected, and in charge.

Yet you can’t fully recover if you don’t feel safe in your skin. Therefore, I encourage all my patients to engage in some sort of bodywork, be it therapeutic massage, Feldenkrais, or craniosacral therapy.

“Then, with my first touch, I make firm, safe contact. Nothing forced or sharp. Nothing too fast. The touch is slow, easy for the client to follow, gently rhythmic. It can be as strong as a handshake. The first place I might touch is their hand and forearm, because that’s the safest place to touch anybody, the place where they can touch you back. “You have to meet their point of resistance—the place that has the most tension—and meet it with an equal amount of energy. That releases the frozen tension. You can’t hesitate; hesitation communicates a lack of trust in yourself. Slow movement, careful attuning to the client is different from hesitation. You have to meet them with tremendous confidence and empathy, let the pressure of your touch meet the tension they are holding in their bodies.”

“The body is physically restricted when emotions are bound up inside. People’s shoulders tighten; their facial muscles tense. They spend enormous energy on holding back their tears—or any sound or movement that might betray their inner state. When the physical tension is released, the feelings can be released. Movement helps breathing to become deeper, and as the tensions are released, expressive sounds can be discharged. The body becomes freer—breathing freer, being in flow. Touch makes it possible to live in a body that can move in response to being moved.

Telling the story is important; without stories, memory becomes frozen; and without memory you cannot imagine how things can be different. But as we saw in part 4, telling a story about the event does not guarantee that the traumatic memories will be laid to rest.

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?” Since I have started to integrate mindfulness and yoga into my practice, I use these medications less often, except occasionally to help patients sleep more restfully.

If you hide from yourself the fact that an uncle molested you when you were young, you are vulnerable to react to triggers like an animal in a thunderstorm: with a full-body response to the hormones that signal “danger.” Without language and context, your awareness may be limited to: “I’m scared.” Yet, determined to stay in control, you are likely to avoid anybody or anything that reminds you even vaguely of your trauma. You may also alternate between being inhibited and being uptight or reactive and explosive—all without knowing why.

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.

Symptoms of PTSD often include statements like “I feel dead inside,” “I will never be able to feel normal emotions again,” “I have permanently changed for the worse,” “I feel like an object, not like a person,” “I have no future,” and “I feel like I don’t know myself anymore.” The critical issue is allowing yourself to know what you know. That takes an enormous amount of courage. In What It Is Like to Go to War, Vietnam veteran Karl Marlantes grapples with his memories of belonging to a brilliantly effective Marine combat unit and confronts the

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.

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.

What happens inside when he tells me about that boy who never saw his father again? Where is it registered in his body? When you activate your gut feelings and listen to your heartbreak—when you follow the interoceptive pathways to your innermost recesses—things begin to change.

In the practice called free writing, you can use any object as your own personal Rorschach test for entering a stream of associations. Simply write the first thing that comes to your mind as you look at the object in front of you and then keep going without stopping, rereading, or crossing out. A wooden spoon on the counter may trigger memories of making tomato sauce with your grandmother—or of being beaten as a child. The teapot that’s been passed down for generations may take you meandering to the furthest reaches of your mind to the loved ones you’ve lost or family holidays that were a mix of love and conflict. Soon an image will emerge, then a memory, and then a paragraph to record it. Whatever shows up on the paper will be a manifestation of associations that are uniquely yours.

It is now widely accepted that stressful experiences—whether divorce or final exams or loneliness—have a negative effect on immune function,

For some patients tapping acupressure points is a good anchor.23 I ask others to feel the weight of their body in the chair or to plant their feet on the floor. I might ask a patient who is collapsing into silence to see what happens when he sits up straight. Some patients discover their own islands of safety—they begin to “get” that they can create body sensations to counterbalance feeling out of control. This sets the stage for trauma resolution: pendulating between states of exploration and safety, between language and body, between remembering the past and feeling alive in the present.

One of the ways the memory of helplessness is stored is as muscle tension or feelings of disintegration in the affected body areas: head, back, and limbs in accident victims, vagina and rectum in victims of sexual abuse.

The lives of many trauma survivors come to revolve around bracing against and neutralizing unwanted sensory experiences, and most people I see in my practice have become experts in such self-numbing. They may become serially obese or anorexic or addicted to exercise or work. At least half of all traumatized people try to dull their intolerable inner world with drugs or alcohol. The flip side of numbing is sensation seeking. Many people cut themselves to make the numbing go away, while others try bungee jumping or high-risk activities like prostitution and gambling. Any of these methods can give them a false and paradoxical feeling of control.

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.

All yoga programs consist of a combination of breath practices (pranayama), stretches or postures (asanas), and meditation. Different schools of yoga emphasize variations in intensity and focus within these core components. For example, variations in the speed and depth of breathing and use of the mouth, nostrils, and throat all produce different results, and some techniques have powerful effects on energy.12 In our classes we keep the approach simple. Many of our patients are barely aware of their breath, so learning to focus on the in and out breath, to notice whether the breath was fast or slow, and to count breaths in some poses can be a significant accomplishment.13

enemies. A major challenge in recovering from trauma remains being able to achieve a state of total relaxation and safe surrender.

‘Your body has things to say.’ I said back to myself, ‘I will try and listen.’”

“I’ve been doing yoga on my own in a room that overlooks the lake. I’m continuing to read the book you lent me [Stephen Cope’s wonderful Yoga and the Quest for the True Self]. It’s really interesting to think about how much I have been refusing to listen to my body, which is such an important part of who I am. Yesterday when I did yoga I thought about letting my body tell me the story it wants to tell and in the hip opening poses there was a lot of pain and sadness. I don’t think my mind is going to let really vivid images come up as long as I am away from home, which is good. I think now about how unbalanced I have been and about how hard I have tried to deny the past, which is a part of my true self. There is so much I can learn if I am open to it and then I won’t have to fight myself every minute of every day.”

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.

People who suffer from alexithymia tend to feel physically uncomfortable but cannot describe exactly what the problem is.

This is the result of numbing, which keeps them from anticipating and responding to the ordinary demands of their bodies in quiet, mindful ways. At the same time, it muffles the everyday sensory delights of experiences like music, touch, and light, which imbue life with value. Yoga turned out to be a terrific way to (re)gain a relationship with the interior world and with it a caring, loving, sensual relationship to the self.