8 Lessons from ‘The Body Keeps The Score’
Nuggets from this popular book on psychological trauma
What is psychological trauma? How does it effect us in ways we may not even realise? How does society succeed and fail in healing it?
If questions like these interest you, this 2014 book by Dr Bessel van der Kolk will be a compelling read. The author is a Dutch psychiatrist with lengthy experience of helping children and adults with trauma, primarily in the United States.
As the subtitle suggests (‘Mind, brain and body in the transformation of trauma’), the author embarks on a compelling journey into the psychological, neurological and physiological mechanisms of trauma. In doing so, he reveals that psychological trauma is never merely psychological; it involves the whole organism.
There’s also a practical focus on trauma therapies, with generous use of case studies — mostly first-hand accounts (this isn’t a textbook). The 360-odd pages contain plenty of useful insights, but I’ve found it helpful to condense and group my notes of The Body Keeps The Score into the following eight areas. I hope you find them useful too.
Lesson 1: Psychiatric drugs are big business.
The book references stunning statistics to reveal the widespread use of prescription drugs to address mental health issues in the United States. Using medication to alleviate symptoms in the short term often has a low chance of establishing long-term beneficial changes in the brain, and may negatively effect other areas of a person’s life. For example, antipsychotic drugs interfere with motivation, play and curiosity, and increase risk of obesity and diabetes.
According to van der Kolk, the US Department of Defence and the Department of Veterans Affairs spent over $4.5bn on antidepressants, antipsychotics and anti-anxiety drugs ‘over the past decade’ (the book was published in 2014). In 2010, 20% of active US troops (213,972 people) were taking psychotropic drugs. (In other words, one in five American combatants had a medically altered state of consciousness.)
Mainstream psychiatry prescribes drugs to children with apparently alarming ease.
‘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. […] In one year alone, Texas Medicaid spent $96m on antipsychotic drugs for children, including three unidentified infants who were given the drugs before their first birthdays.’
Lesson 2: Trauma is registered in your body (i.e. ‘the body keeps the score’).
Traumatised minds inhabit traumatised bodies. Due to the different modes of our autonomic nervous system, ‘After trauma, the world is experienced with a different nervous system that has an altered perception of risk and safety.’
The body registers trauma in the form of muscular tension resulting from stifled emotions, or from ‘fight of flight’ actions that were prevented in the moment of danger by an outside force, such as being physically trapped. PTSD patients may be exhausted by a permanently heightened state of arousal, unable to distinguish between dangerous and non-dangerous stimuli. We may even perform involuntary ‘re-enactments’ of events: for example, a patient may lose the use of his legs after passing out believing that he was about to lose them, despite not actually being injured at all.
Auto-immune disorders are more common among those who have been the victim of incest; their immune systems are hyper-alert to threat, even to the point of attacking the body’s own cells.
Lesson 3: Trauma alters the way the brain responds to the environment.
In perception and cognition, a traumatised mind is different from a ‘normal’ mind. ‘Trauma results in a fundamental reorganisation of the way mind and brain manage perceptions.’
Despite the potential of CBT, it is difficult to understand our way out of trauma.
‘Very few psychological problems are the result of defects in understanding; most originate in pressures from deeper regions in the brain that drive our perception and attention.’
In both PTSD and ADHD patients, it is common to find abnormally low activity in the prefrontal cortex, and therefore weakened ability to maintain rational control over the emotions generated by the limbic system.
Therapies that focus on music or drama, by engaging the whole body, can ‘circumvent the speechlessness that comes from terror.’
Lesson 4: Traumatic memory is unlike normal memory, and this is a problem.
We don’t always remember trauma clearly; it exists in our memory as fragments and sensations rather than a structured narrative. Traumatic events may also be repressed and/or difficult to access by the conscious mind, which may be re-traumatised by doing so.
This may make witness testimony from trauma victims difficult to understand or believe. In court, a victim may not be able to provide accurate testimony. Under stress, the language centre of the brain may shut down, or the witness may use cautious language to prevent their own emotional overload; this may come across as being evasive. How can a jury be expected to have an objective and nuanced understanding of this?
A sense of isolation arises from the inability to express traumatic memory. (Alexithymia = not having words for feelings.) Finding the words to describe what has happened to us is therefore key to undoing the harm, and this may involve cultivating narrative memory of the traumatic event. ‘Communicating fully is the opposite of being traumatised.’
‘Telling the story is important; without stories, memory becomes frozen; and without memory you cannot imagine how things can be different.’
But in the case of extreme, lingering trauma, too stressful to recount, finding the words to describe it is only part of the issue. In such cases, ‘our body needs to learn that the danger has passed […]’. (See Lesson 2.)
Lesson 5: We need to shift the focus from symptoms to causes.
The DSM has evolved into ‘a veritable smorgasbord of possible labels’ that are not always helpful in determining effective treatment. Some diagnoses mistake clusters of symptoms with permanent disabilities, failing to identify the root cause, and the DSM tends to identify such clusters as diseases, rather than signs of the brain’s adaptation to past events. This brain-disease model ‘deprives people of ways to heal from trauma and restore their autonomy’. It is therefore ineffective at steering a path towards treatment which has long-lasting benefits. [I find this to be one of the book’s most useful and relevant insights.]
The author has campaigned unsuccessfully for a new diagnosis of Developmental Trauma Disorder to be included in the DSM (described in detail in Chapter 10 and the Appendix).
Lesson 6: We shouldn’t be too quick to dismiss whacky-sounding therapies.
The use of neurofeedback therapy has increased in recent years. A neurofeedback machine works by replicating brainwaves and echoing them back into the brain, rewarding patterns that correspond to self-regulation, of akind which are lacking in patients with symptoms of PTSD and ADHD. (Moving the feedback between different areas of the brain will change the way the patient feels moment-to-moment.)
Neurofeedback therapy can reportedly create rapid and long-lasting benefits, without the requirement for ongoing treatment or medication. The apparent rarity of negative side-effects, particularly major ones, is among the most promising aspects of the treatment.
Other techniques described in the book include Eye Movement Desensitization and Reprocessing (which enables a patient to revisit memories of trauma without being re-traumatised by them) and Internal Family Systems therapy(in which a patient enters into dialogue with inner voices).
Lesson 7: Trauma is political.
To rewire traumatised brains, ‘social support is a biological necessity, not an option’. Van der Kolk devotes the final chapter to this point, emphasising that issues relating to income, housing, education and employment all indirectly influence the onset of trauma and its ripple effect down the generations. ‘Hurt people hurt other people.’ We learn the role of community in restoring traumatised minds in Chapter 19, through accounts of theatre projects which enable participants to engage with others, name their emotions, and face the world.
The author also asserts that ‘all parents need help to nurture their kids’ (although the idea that this should come from the state, rather than more immediate family or community, is something I find controversial).
Also see Lesson 1.
However, the need for social support does not take responsibility away from the patient and therapist. Trauma patients must develop an ‘internal locus of control’, and effective therapy requires ‘deep, subjective resonance’ between therapist and patient… an observation which is also relevant to Lesson 8.
Lesson 8: The healing power of curiosity.
This last lesson is inferred from the book as a whole, not something it explicitly focuses on.
Practices which activate the ‘parasympathetic brake’ (i.e. chanting or breathing exercises) cultivate emotional self-awareness by requiring inward-focused curiosity as a starting point.
‘As I often tell my students, the two most important phrases in therapy, as in yoga, are “Notice that” and “What happens next?” Once you start approaching your body with curiosity rather than with fear, everything shifts.’
Interoception (self-awareness in the sense of ‘feeling what we’re feeling’) is enabled by the medial pre-frontal cortex, a region which is stimulated by meditation; this improves our ability to regulate our emotions, and change the way we feel.
Curiosity is also required from outside world. Therapists must be ‘emotionally available’ to their patients, who need to feel their therapist is specifically interested in what makes them different. This is particularly true for war veterans with PTSD, due to the isolation they feel from the rest of society — isolation stemming from the belief that those who have not suffered similarly can not be trusted, because they can not understand.
I recommend this book for anyone with even a passing interest in mental health. The topic of trauma is a potentially bottomless rabbit warren of further reading (van der Kolk’s list of citations is lengthy…), but I think most readers will find some enlightenment from a quick, surface-level read of the main chapters in The Body Keeps The Score.
This article is reposted from a blog post on my own website.
