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

by Bessel van der Kolk

Trauma results in a fundamental reorganization of the way mind and brain manage perceptions. It changes not only how we think and what we think about, but also our very capacity to think.

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.

You live through that little piece of time that is yours, but that piece of time is not only your own life, it is the summing-up of all the other lives that are simultaneous with yours. . . . What you are is an expression of History. —Robert Penn Warren, World Enough and Time

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.

Healing, he told us, depends on experiential knowledge: You can be fully in charge of your life only if you can acknowledge the reality of your body, in all its visceral dimensions.

Because drugs have become so profitable, major medical journals rarely publish studies on nondrug treatments of mental health problems.31 Practitioners who explore treatments are typically marginalized as “alternative.” Studies of nondrug treatments are rarely funded unless they involve so-called manualized protocols, where patients and therapists go through narrowly prescribed sequences that allow little fine-tuning to individual patients’ needs. Mainstream medicine is firmly committed to a better life through chemistry, and the fact that we can actually change our own physiology and inner equilibrium by means other than drugs is rarely considered.

The left and right sides of the brain also process the imprints of the past in dramatically different ways.2 The left brain remembers facts, statistics, and the vocabulary of events. We call on it to explain our experiences and put them in order. The right brain stores memories of sound, touch, smell, and the emotions they evoke. It reacts automatically to voices, facial features, and gestures and places experienced in the past. What it recalls feels like intuitive truth—the way things are.

When something reminds traumatized people of the past, their right brain reacts as if the traumatic event were happening in the present. But because their left brain is not working very well, they may not be aware that they are reexperiencing and reenacting the past—they are just furious, terrified, enraged, ashamed, or frozen. After the emotional storm passes, they may look for something or somebody to blame for it.

The stress hormones of traumatized people, in contrast, take much longer to return to baseline and spike quickly and disproportionately in response to mildly stressful stimuli.

For a hundred years or more, every textbook of psychology and psychotherapy has advised that some method of talking about distressing feelings can resolve them. However, as we’ve seen, the experience of trauma itself gets in the way of being able to do that. No matter how much insight and understanding we develop, the rational brain is basically impotent to talk the emotional brain out of its own reality.

Being traumatized means continuing to organize your life as if the trauma were still going on—unchanged and immutable—as every new encounter or event is contaminated by the past.

In PTSD the critical balance between the amygdala (smoke detector) and the MPFC (watchtower) shifts radically, which makes it much harder to control emotions and impulses.

Knowing the difference between top down and bottom up regulation is central for understanding and treating traumatic stress. Top-down regulation involves strengthening the capacity of the watchtower to monitor your body’s sensations. Mindfulness meditation and yoga can help with this. Bottom-up regulation involves recalibrating the autonomic nervous system, (which, as we have seen, originates in the brain stem).

I want to emphasize that emotion is not opposed to reason; our emotions assign value to experiences and thus are the foundation of reason.

Dissociation is the essence of trauma. The overwhelming experience is split off and fragmented, so that the emotions, sounds, images, thoughts, and physical sensations related to the trauma take on a life of their own. The sensory fragments of memory intrude into the present, where they are literally relived. As long as the trauma is not resolved, the stress hormones that the body secretes to protect itself keep circulating, and the defensive movements and emotional responses keep getting replayed.

Being anchored in the present while revisiting the trauma opens the possibility of deeply knowing that the terrible events belong to the past. For that to happen, the brain’s watchtower, cook, and timekeeper need to be online. Therapy won’t work as long as people keep being pulled back into the past.

“To be benevolent rather than malevolent is probably a true feature of our species.” 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. Numerous studies of disaster response around the globe have shown that social support is the most powerful protection against becoming overwhelmed by stress and trauma.

Sadly, our educational system, as well as many of the methods that profess to treat trauma, tend to bypass this emotional-engagement system and focus instead on recruiting the cognitive capacities of the mind. Despite the well-documented effects of anger, fear, and anxiety on the ability to reason, many programs continue to ignore the need to engage the safety system of the brain before trying to promote new ways of thinking. The last things that should be cut from school schedules are chorus, physical education, recess, and anything else involving movement, play, and joyful engagement. When children are oppositional, defensive, numbed out, or enraged, it’s also important to recognize that such “bad behavior” may repeat action patterns that were established to survive serious threats, even if they are intensely upsetting or off-putting.

But the polyvagal theory helped us understand and explain why all these disparate, unconventional techniques worked so well. It enabled us to become more conscious of combining top-down approaches (to activate social engagement) with bottom-up methods (to calm the physical tensions in the body). We were more open to the value of other age-old, nonpharmacological approaches to health that have long been practiced outside Western medicine, ranging from breath exercises (pranayama) and chanting to martial arts like qigong to drumming and group singing and dancing. All rely on interpersonal rhythms, visceral awareness, and vocal and facial communication, which help shift people out of fight/flight states, reorganize their perception of danger, and increase their capacity to manage relationships.

“Agency” is the technical term for the feeling of being in charge of your life: knowing where you stand, knowing that you have a say in what happens to you, knowing that you have some ability to shape your circumstances.

The price for ignoring or distorting the body’s messages is being unable to detect what is truly dangerous or harmful for you and, 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.

alexithymia—Greek for not having words for feelings. Many traumatized children and adults simply cannot describe what they are feeling because they cannot identify what their physical sensations mean.

Children have a biological instinct to attach—they have no choice. Whether their parents or caregivers are loving and caring or distant, insensitive, rejecting, or abusive, children will develop a coping style based on their attempt to get at least some of their needs met.

securely attached infants are distressed when their mother leaves them, but they show delight when she returns, and after a brief check-in for reassurance, they settle down and resume their play.

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.

In another pattern, called “anxious” or “ambivalent” attachment, the infants constantly draw attention to themselves by crying, yelling, clinging, or screaming: They are “feeling but not dealing.”13

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

Our maps of the world are encoded in the emotional brain, and changing them means having to reorganize that part of the central nervous system, the subject of the treatment section of this book. Nonetheless, learning to recognize irrational thoughts and behavior can be a useful first step.

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.

“soul murder.” Erasing awareness and cultivating denial are often essential to survival, but the price is that you lose track of who you are, of what you are feeling, and of what and whom you can trust.

Traumatic Antecedents Questionnaire (TAQ).3

When does a hypothesis become a scientifically established fact?

How do we make sense of a story like Julian’s:

Part 4 - This is where the Audio book's missing chapter begins!

Through Pilates, I found a stronger physical core, as well as a community of women who willingly gave acceptance and social support that had been distant in my life since the trauma. This combination of core strengthening—psychological, social, and physical—created a sense of personal safety and mastery, relegating my memories to the distant past, allowing the present and future to emerge.”

Part 4 - This is where the Audio book's missing chapter ends!

Trauma robs you of the feeling that you are in charge of yourself, of what I will call self-leadership in the chapters to come.1 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.

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

Choosing a Professional Therapist 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.

There is no one “treatment of choice” for trauma, and any therapist who believes that his or her particular method is the only answer to your problems is suspect of being an ideologue rather than somebody who is interested in making sure that you get well. No therapist can possibly be familiar with every effective treatment, and he or she must be open to your exploring options other than the ones he or she offers. He or she also must be open to learning from you. Gender, race, and personal background are relevant only if they interfere with helping the patient feel safe and understood.

The critical question is this: Do you feel that your therapist is curious to find out who you are and what you, not some generic “PTSD patient,” need? Are you just a list of symptoms on some diagnostic questionnaire, or does your therapist take the time to find out why you do what you do and think what you think? Therapy is a collaborative process—a mutual exploration of your self.

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.

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.

eye movement desensitization and reprocessing (EMDR).

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.

EMDR, as well as the treatments discussed in subsequent chapters—internal family systems, yoga, neurofeedback, psychomotor therapy, and theater—focus not only on regulating the intense memories activated by trauma but also on restoring a sense of agency, engagement, and commitment through ownership of body and mind.

As you’ll recall from chapter 5, the autonomic nervous system is our brain’s most elementary survival system, its two branches regulating arousal throughout the body. Roughly speaking, the sympathetic nervous system (SNS) uses chemicals like adrenaline to fuel the body and brain to take action, while the parasympathetic nervous system (PNS) uses acetylcholine to help regulate basic body functions like digestion, wound healing, and sleep and dream cycles.

Heart rate variability measures the relative balance between the sympathetic and the parasympathetic systems. When we inhale, we stimulate the SNS, which results in an increase in heart rate. Exhalations stimulate the PNS, which decreases how fast the heart beats. In healthy individuals inhalations and exhalations produce steady, rhythmical fluctuations in heart rate: Good heart rate variability is a measure of basic well-being.

This being human is a guest house. Every morning is a new arrival. A joy, a depression, a meanness, some momentary awareness comes as an unexpected visitor. . . . Welcome and entertain them all. Treat each guest honorably. The dark thought, the shame, the malice, meet them at the door laughing, and invite them in. Be grateful for whoever comes, because each has been sent as a guide from beyond. —Rumi

Coping takes its toll. For many children it is safer to hate themselves than to risk their relationship with their caregivers by expressing anger or by running away. As a result, abused children are likely to grow up believing that they are fundamentally unlovable; that was the only way their young minds could explain why they were treated so badly. They survive by denying, ignoring, and splitting off large chunks of reality: They forget the abuse; they suppress their rage or despair; they numb their physical sensations.

Trying to control a child’s behavior while failing to address the underlying issue—the abuse—leads to treatments that are ineffective at best and harmful at worst. As they grow up, their parts do not spontaneously integrate into a coherent personality but continue to lead a relatively autonomous existence.

Cognitive behavioral therapies and mindfulness-based practices have also been shown to have a positive impact on pain, joint inflammation, physical disability, and depression.19 However, none of these studies has asked a crucial question: Are increased psychological safety and comfort reflected in a better-functioning immune system?