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

by Bessel van der Kolk

Research by the Centers for Disease Control and Prevention has shown that one in five Americans was sexually molested as a child; one in four was beaten by a parent to the point of a mark being left on their body; and one in three couples engages in physical violence. A quarter of us grew up with alcoholic relatives, and one out of eight witnessed their mother being beaten or hit.

Having been exposed to family violence as a child often makes it difficult to establish stable, trusting relationships as an adult.

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

Those new disciplines are neuroscience, the study of how the brain supports mental processes; developmental psychopathology, the study of the impact of adverse experiences on the development of mind and brain; and interpersonal neurobiology, the study of how our behavior influences the emotions, biology, and mind-sets of those around us.

We now know that trauma compromises the brain area that communicates the physical, embodied feeling of being alive.

We can now develop methods and experiences that utilize the brain’s own natural neuroplasticity to help survivors feel fully alive in the present and move on with their lives. 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.

The challenge is: How can people gain control over the residues of past trauma and return to being masters of their own ship?

But we will also see that the imprints from the past can be transformed by having physical experiences that directly contradict the helplessness, rage, and collapse that are part of trauma, and thereby regaining self-mastery.

That was a long time ago, but it’s wrong what they say about the past. . . . Looking back now, I realize I have been peeking into that deserted alley for the last twenty-six years.

Tom was upset by how difficult it was to feel any real affection for his wife, even though her letters had kept him alive in the madness of the jungle.

That morning I realized I would probably spend the rest of my professional life trying to unravel the mysteries of trauma.

How do horrific experiences cause people to become hopelessly stuck in the past? What happens in people’s minds and brains that keeps them frozen, trapped in a place they desperately wish to escape?

Kardiner noted that sufferers from traumatic neuroses develop a chronic vigilance for and sensitivity to threat.

even as Semrad pushed us to rely upon self-knowledge, he also warned us how difficult that process really is, since human beings are experts in wishful thinking and obscuring the truth.

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.

It takes enormous trust and courage to allow yourself to remember.

It’s hard enough to face the suffering that has been inflicted by others, but deep down many traumatized people are even more haunted by the shame they feel about what they themselves did or did not do under the circumstances.

Maybe the worst of Tom’s symptoms was that he felt emotionally numb. He desperately wanted to love his family, but he just couldn’t evoke any deep feelings for them.

When people are compulsively and constantly pulled back into the past, to the last time they felt intense involvement and deep emotions, they suffer from a failure of imagination, a loss of the mental flexibility. Without imagination there is no hope, no chance to envision a better future, no place to go, no goal to reach.

After trauma the world becomes sharply divided between those who know and those who don’t. People who have not shared the traumatic experience cannot be trusted, because they can’t understand it. Sadly, this often includes spouses, children, and co-workers.

One million of these cases are serious and credible enough to force local child protective services or the courts to take action.12 In other words, for every soldier who serves in a war zone abroad, there are ten children who are endangered in their own homes.

overwhelming experiences affect our innermost sensations and our relationship to our physical reality—the core of who we are.

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.

We now know that more than half the people who seek psychiatric care have been assaulted, abandoned, neglected, or even raped as children, or have witnessed violence in their families.

I was surprised and alarmed by the satisfaction I sometimes felt after I’d wrestled a patient to the floor so a nurse could give an injection, and I gradually realized how much of our professional training was geared to helping us stay in control in the face of terrifying and confusing realities.

This experience, and others like it, helped me formulate this rule for my students: If you do something to a patient that you would not do to your friends or children, consider whether you are unwittingly replicating a trauma from the patient’s past.

Semrad did not want our perceptions of reality to become obscured by the pseudocertainties of psychiatric diagnoses. I remember asking him once: “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.

He often said that people can never get better without knowing what they know and feeling what they feel.

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.

This study was one of many milestones on a road that gradually changed how medicine and psychiatry approached psychological problems: from infinitely variable expressions of intolerable feelings and relationships to a brain-disease model of discrete “disorders.”

Now a new paradigm was emerging: Anger, lust, pride, greed, avarice, and sloth—as well as all the other problems we humans have always struggled to manage—were recast as “disorders” that could be fixed by the administration of appropriate chemicals.

Antipsychotic drugs were a major factor in reducing the number of people living in mental hospitals in the United States, from over 500,000 in 1955 to fewer than 100,000 in 1996.7 For people today who did not know the world before the advent of these treatments, the change is almost unimaginable.

Almost all had in some way been trapped or immobilized, unable to take action to stave off the inevitable. Their fight/flight response had been thwarted, and the result was either extreme agitation or collapse.

traumatized people keep secreting large amounts of stress hormones long after the actual danger has passed,

Scared animals return home, regardless of whether home is safe or frightening. I thought about my patients with abusive families who kept going back to be hurt again. Are traumatized people condemned to seek refuge in what is familiar?

Many traumatized people seem to seek out experiences that would repel most of us,14 and patients often complain about a vague sense of emptiness and boredom when they are not angry, under duress, or involved in some dangerous activity.

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.

Normally attractors are meant to make us feel better. So, why are so many people attracted to dangerous or painful situations?

We then calculated that the amount of analgesia produced by watching fifteen minutes of a combat movie was equivalent to that produced by being injected with eight milligrams of morphine, about the same dose a person would receive in an emergency room for crushing chest pain.

Most treatment studies of PTSD find a significant placebo effect. People who screw up their courage to participate in a study for which they aren’t paid, in which they’re repeatedly poked with needles, and in which they have only a fifty-fifty chance of getting an active drug are intrinsically motivated to solve their problem.

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.

I have come to realize that psychiatric medications have a serious downside, as they may deflect attention from dealing with the underlying issues. The brain-disease model takes control over people’s fate out of their own hands and puts doctors and insurance companies in charge of fixing their problems.

Consider the case of antidepressants. If they were indeed as effective as we have been led to believe, depression should by now have become a minor issue in our society. Instead, even as antidepressant use continues to increase, it has not made a dent in hospital admissions for depression. The number of people treated for depression has tripled over the past two decades, and one in ten Americans now take antidepressants.

Half a million children in the United States currently take antipsychotic drugs. Children from low-income families are four times as likely as privately insured children to receive antipsychotic medicines.

One study, based on Medicaid data in thirteen states, found that 12.4 percent of children in foster care received antipsychotics, compared with 1.4 percent of Medicaid-eligible children in general.

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.”

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.