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

by Bessel van der Kolk

When people are forced to submit to overwhelming power, as is true for most abused children, women trapped in domestic violence, and incarcerated men and women, they often survive with resigned compliance. The best way to overcome ingrained patterns of submission is to restore a physical capacity to engage and defend.

People cannot put traumatic events behind until they are able to acknowledge what has happened and start to recognize the invisible demons they’re struggling with.

Telling the story is important; without stories, memory becomes frozen; and without memory you cannot imagine how things can be different.

On YouTube you can still watch the documentary Let There Be Light, by the great Hollywood director John Huston, which shows men undergoing hypnosis to treat “war neurosis.”

Research has shown that up to one hundred minutes of flooding (in which anxiety-provoking triggers are presented in an intense, sustained form) are required before decreases in anxiety are reported.36 Exposure sometimes helps to deal with fear and anxiety, but it has not been proven to help with guilt or other complex emotions.

CBT has not done so well for traumatized individuals, particularly those with histories of childhood abuse. Only about one in three participants with PTSD who finish research studies show some improvement.

In the largest published study of CBT for PTSD more than one-third of the patients dropped out; the rest had a significant number of adverse reactions. Most of the women in the study still suffered from full-blown PTSD after three months in the study, and only 15 percent no longer had major PTSD symptoms.

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.

desensitization to our own or to other people’s pain tends to lead to an overall blunting of emotional sensitivity.

By being able to observe the trauma from the calm, mindful state that IFS calls Self (a term I’ll discuss further in chapter 17), mind and brain are in a position to integrate the trauma into the overall fabric of life. This is very different from traditional desensitization techniques, which are about blunting a person’s response to past horrors. This is about association and integration—making a horrendous event that overwhelmed you in the past into a memory of something that happened a long time ago.

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.

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.

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.

A 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.

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.

The shadow may carry the best of the life we have not lived. Go into the basement, the attic, the refuse bin. Find gold there. Find an animal who has not been fed or watered. It is you!! This neglected, exiled animal, hungry for attention, is a part of your self.

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,

Silence about trauma also leads to death—the death of the soul. Silence reinforces the godforsaken isolation of trauma.

We may think we can control our grief, our terror, or our shame by remaining silent, but naming offers the possibility of a different kind of control.

If you’ve been hurt, you need to acknowledge and name what happened to you. I know that from personal experience: As long as I had no place where I could let myself know what it was like when my father locked me in the cellar of our house for various three-year-old offenses, I was chronically preoccupied with being exiled and abandoned. Only when I could talk about how that little boy felt, only when I could forgive him for having been as scared and submissive as he was, did I start to enjoy the pleasure of my own company.

Feeling listened to and understood changes our physiology; being able to articulate a complex feeling, and having our feelings recognized, lights up our limbic brain and creates an “aha moment.”

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.

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

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.”

Learning the names of things enabled the child not only to create an inner representation of the invisible and inaudible physical reality around her but also to find herself: Six months later she started to use the first-person “I.”

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. Communicating fully is the opposite of being traumatized.

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.

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

Being able to perceive visceral sensations is the very foundation of emotional awareness.

There are other ways to access your inner world of feelings. One of the most effective is through writing.

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.

Those who reported a traumatic sexual experience in childhood had been hospitalized an average of 1.7 days in the previous year—almost twice the rate of the others.

The group that had written about both the facts and the emotions related to their trauma clearly benefited the most: They had a 50 percent drop in doctor visits compared with the other two groups. Writing about their deepest thoughts and feelings about traumas had improved their mood and resulted in a more optimistic attitude and better physical health.

Those who allowed themselves to feel their emotions showed significant physiological changes, both immediate and long term. During their confessions blood pressure, heart rate, and other autonomic functions increased, but afterward their arousal fell to levels below where they had been at the start of the study. The drop in blood pressure could still be measured six weeks after the experiment ended.

Again, those who wrote about personal traumas had fewer visits to the student health center, and their improved health correlated with improved immune function, as measured by the action of T lymphocytes (natural killer cells) and other immune markers in the blood. This effect was most obvious directly after the experiment, but it could still be detected six weeks later.

The capacity of art, music, and dance to circumvent the speechlessness that comes with terror may be one reason they are used as trauma treatments in cultures around the world.

Over the three following months members of all groups reported that they felt happier and healthier. However, only the expressive movement group that also wrote showed objective evidence: better physical health and an improved grade-point average. (The study did not evaluate specific PTSD symptoms.) Pennebaker and Krantz concluded: “The mere expression of the trauma is not sufficient. Health does appear to require translating experiences into language.”

Logically there is no reason why the English language could not perfectly well render the actuality of . . . warfare: it is rich in terms like blood, terror, agony, madness, shit, cruelty, murder, sell-out, pain and hoax, as well as phrases like legs blown off, intestines gushing out over his hands, screaming all night, bleeding to death from the rectum, and the like. . . . The problem was less one of “language” than of gentility and optimism. . . . The real reason [that soldiers fall silent] is that soldiers have discovered that no one is very interested in the bad news they have to report. What listener wants to be torn and shaken when he doesn’t have to be? We have made unspeakable mean indescribable: it really means nasty

Modern neuroscience solidly supports Freud’s notion that many of our conscious thoughts are complex rationalizations for the flood of instincts, reflexes, motives, and deep-seated memories that emanate from the unconscious.

As we have seen, trauma interferes with the proper functioning of brain areas that manage and interpret experience. A robust sense of self—one that allows a person to state confidently, “This is what I think and feel” and “This is what is going on with me”—depends on a healthy and dynamic interplay among these areas.

Only by getting in touch with your body, by connecting viscerally with your self, can you regain a sense of who you are, your priorities and values.

In other words 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.27 This requires well-functioning connections between the conscious brain and the self system of the body—connections that often are damaged by trauma. The full story can be told only after those structures are repaired and after the groundwork has been laid: after no body becomes some body.

Then he asked if I found it meaningful when people told me their trauma stories. Again, I had to agree with him. Then he said: “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.” I took Gerry’s admonition to heart and ever since have enjoyed repeating it to my students.

The group on Prozac did slightly better than the placebo group, but barely so. This is typical of most studies of drugs for PTSD: Simply showing up brings about a 30 percent to 42 percent improvement; when drugs work, they add an additional 5 percent to 15 percent. However, the patients on EMDR did substantially better than those on either Prozac or the placebo: After eight EMDR sessions one in four were completely cured (their PTSD scores had dropped to negligible levels), compared with one in ten of the Prozac group. But the real difference occurred over time: When we interviewed our subjects eight months later, 60 percent of those who had received EMDR scored as being completely cured.

At the end of eight weeks, almost half of the adult-onset group that received EMDR scored as completely cured, while only 9 percent of the child-abuse group showed such pronounced improvement. Eight months later the cure rate was 73 percent for the adult-onset group, compared with 25 percent for those with histories of child abuse.

Research had already shown that sleep, and dream sleep in particular, plays a major role in mood regulation. As the article in Dreaming pointed out, the eyes move rapidly back and forth in REM sleep, just as they do in EMDR. Increasing our time in REM sleep reduces depression, while the less REM sleep we get, the more likely we are to become depressed.

I am much comforted by considering the history of penicillin: Almost four decades passed between the discovery of its antibiotic properties by Alexander Fleming in 1928 and the final elucidation of its mechanisms in 1965.

Her rational mind told her this was nonsense, but this belief emanated from deep within her emotional, survival brain, from the basic wiring of her limbic system. It would not change until she felt safe enough within her body to mindfully go back into that experience and truly know how that little girl had felt and acted during the abuse.

Good heart rate variability is a measure of basic well-being.