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# 2018-02-19 - The Body Keeps The Score by Bessel Van Der Kolk
I have spent scant time studying psychology and trauma, so most of
this book was new territory for me. The most interesting themes:
* the deleterious effect of suppressing trauma and emotions.
* our natural need to feel separate from others (sense of self),
and in control (agency, or internal locus of control), even if
those feelings don't objectively reflect reality.
* the emphasis on curiosity and imagination for healing
* the value of acting (theater or "faking it") for creating virtual
memories to build up and restore parts of ourselves left void from
chronic omissions and unmet needs.
Below are my notes, almost entirely excerpts from the book.
# Chapter 1
Imagination is absolutely critical to the quality of our lives. Our
imagination enables us to leave our routine everyday existence by
fantasizing about travel, food, sex, falling in love, or having the
last word--all things that make life interesting. Imagination gives
us the opportunity to envision new possibilities--it is an essential
launchpad for making our hopes come true. It fires our creativity,
relieves our boredom, and enriches our most intimate relationships.
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 mental
flexibility. Without imagination there is no hope, no chance to
envision a better future, no place to go, no goal to reach.
They felt fully alive only when they were revisiting their traumatic
past.
In other words, for every soldier who serves in a war zone abroad,
there are ten children who are endangered in their own homes.
The brain-disease model overlooks four fundamental truths:
* 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;
* Language gives us the power to change ourselves and others by
communicating our experiences, helping us define what we know, and
finding a common sense of meaning;
* 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
* We can change social conditions to create environments in which
children and adults can feel safe and where they can thrive.
When we ignore these quintessential dimensions of humanity, we
deprive people of ways to heal from trauma and restore their
autonomy. Being a patient, rather than a participant in one's
healing process, separates suffering people from their community and
alienates them from an inner sense of self.
# Chapter 2
Their bodies register the threat but their conscious minds go on as
if nothing has happened... stress hormones keep sending signals to
the muscles to tense for action or immobilize in collapse. The
physical effects on the organs go unabated until they demand notice
when they are exposed as illness.
After trauma the world is experienced with a different nervous
system. The survivor's energy now becomes focused on suppressing
inner chaos, at the expense of spontaneous involvement in their life.
All are a product of the synchrony between the two branches of the
autonomic nervous system (ANS): the sympathetic (SNS), which acts as
the body's accelerator, and the parasympathetic (PNS), which serves
as its brake.
There is a simple way to experience these two systems for yourself.
Whenever you take a deep breath, you activate the SNS. The resulting
burst of adrenaline speeds up your heart, which explains why many
athletes take a few short, deep breaths before starting competition.
Exhaling, in turn, activates the PNS, which slows down the heart. If
you take a yoga or meditation class, your instructor will probably
urge you to pay particular attention to the exhalation, since deep,
long breaths out help calm you down. As we breathe, we continually
speed up and slow down the heart, and because of that the interval
between two successive heartbeats is never precisely the same. A
measurement called heart rate variability (HRV) can be used to test
the flexibility of this system, and good HRV--the more fluctuation
the better--is a sign that the brake and accelerator in your arousal
system are both functioning properly and in balance.
Three levels of safety:
* Social engagement -- VVC -- ventral vagal complex
* Fight or flight -- SNS -- sympathetic nervous system
* Freeze or collapse -- DVC -- dorsal vagal complex
Once this system (DVC) takes over, other people, and we ourselves,
cease to matter. Awareness is shut down, and we may no longer even
register physical pain.
# Chapter 5
It is especially challenging for traumatized people to discern when
they are actually safe and to be able to activate their defenses when
they are in danger.
But the polyvagal theory helped us to understand and explain why all
these disparate, unconventional techniques worked so well. ... All
rely on interpersonal rhythms, visceral awareness, and vocal and
facial states, reorganize their perception of danger, and increase
their capacity to manage relationships.
# Chapter 6
Traumatized people are prone to being disconnected from their bodies.
This may be related to the disappearance of medial prefontal
activation. Profound lack of self-awareness.
> What we witnessed here was a tragic adaptation: In an effort to
> shut off terrifying sensations, they also deadened their capacity
> to feel fully alive.
> If the self-sensing system breaks down we need to find ways to
> reactivate it.
> 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.
Agency starts with what scientists call interoception, our awareness
of our subtle sensory, body-based feelings: the greater that
awareness, the greater our potential to control our lives. Knowing
what we feel is the first step to knowing why we feel that way.
Alexithymia - not registering feelings in the mind. Being out of
touch with one's feelings, contributes toward difficulty feeling
pleasure and having a sense of meaning.
Depersonalization - losing sense of self. Detachment from body.
> Trauma victims cannot recover until they become familiar with and
> befriend the sensations in their bodies. ... In order to change,
> people need to become aware of their sensations and the way that
> their bodies interact with the world around them. Physical
> self-awareness is the first step in releasing the tyranny of the
> past.
# Chapter 7
Associating intense sensations with safety, comfort, and mastery is
the foundation of self-regulation, self-soothing, and self nurture...
A secure attachment combined with the cultivation of competency
builds an "internal locus of control," the key factor in healthy
coping throughout life. Securely attached children learn what makes
them feel good; they discover what makes them (and others) feel bad,
and they acquire a sense of agency: that their actions can change how
they feel and how others respond. Securely attached kids learn the
difference between situations they can control and situations where
they need help. They learn that they can play an active role when
faced with difficult situations.
The need for attachment never lessens. Most human beings simply
cannot tolerate being disengaged from others for any length of time.
People who cannot connect through work, friendships, or family
usually find other ways of bonding, as through illness, lawsuits, or
family feuds. Anything is preferable to that godforsaken sense of
irrelevance and alienation.
# Chapter 8
Rage that has nowhere to go is directed against the self, in the form
of depression, self-hatred, and self-destructive actions.
In order to know who we are--to have an identity--we must know (or at
least feel that we know) what is and what was "real." We must
observe what we see around us and label it correctly; we must also be
able to trust our memories and be able to tell them apart from our
imagination. Losing the ability to make these distinctions is one
sign of what psychoanalyst William Niederland called "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.
# Chapter 9
In this chapter, and the next, I will discuss the chasm between
official diagnoses and what our patients actually suffer from and
discuss how my colleagues and I have tried to change the way patients
with chronic trauma histories are diagnosed.
... As he [Vincent Felitti] and his team started to inquire more
closely, they were shocked to discover that most of their morbidly
obese patients had been sexually abused as children. They also
uncovered a host of other family problems.
Little consideration is given to the possibility that many long-term
health risks might also be personally beneficial in the short-term.
We repeatedly hear from patients of the benefits of these "health
risks." The idea of the problem being a solution, while
understandable disturbing to many, is certainly in keeping with the
fact that opposing forces routinely coexist in biological systems.
... What one sees, the presenting problem, is often only the marker
for the real problem, which lies buried in time, concealed by patient
shame, secrecy, and sometimes amnesia--and frequently clinician
discomfort.
# Chapter 10
Epigenetics. "Major changes to our bodies can be made not just by
chemicals and toxins, but also in the way the social world talks to
the hard-wired world."
Social support is a biological necessity, not an option, and this
reality should be the backbone of all prevention and treatment.
Recognizing the profound effects of trauma and deprivation on child
development need not lead to blaming parents. We can assume that
parents do the best they can, but all parents need help to nurture
their kids. Nearly every industrialized nation, with the exception
of the United States, recognizes this and provides some form of
guaranteed support to families. James Heckman, winner of the 2000
Nobel Prize in Economics, has shown that quality early-childhood
programs that involve parents and promote basic skills in
disadvantaged children more than pay for themselves in improved
outcomes.
# Chapter 11
Most day-to-day experience passes immediately into oblivion. On
ordinary days we don't have much to report when we come home in the
evening. The mind works according to schemes or maps, and incidents
that fall outside the established pattern are most likely to capture
our attention. ... We remember insults and injuries best: The
adrenaline that we secrete to defend against potential threats helps
to engrave those incidents into our minds. ... As James McGaugh and
colleagues have shown, the more adrenaline you secrete, the more
precise your memory will be. But that is true only up to a certain
point.
Janet noted significant differences between ordinary and traumatic
memories. Traumatic memories are precipitated by specific triggers.
... When one element of a traumatic experience is triggered, other
elements are likely to automatically follow.
Ordinary memory is essentially social; it's a story that we tell for
a purpose... But there is nothing social about traumatic memory...
Janet coined the term "dissociation" to describe the splitting off
and isolation of memory imprints that he saw in his patients. He was
also prescient about the heavy cost of keeping these traumatic
memories at bay... He predicted that unless they became aware of the
split-off elements and integrated them into a story that had happened
in the past but was now over, they would experience a slow decline in
their personal and professional functioning. This phenomenon has now
been well documented in contemporary research.
# Chapter 12
This chapter includes an interesting story about English suppression
of the term "shell shock" in General Routine Order Number 2384 and in
the Southborough Report.
It also struck me that these soldiers seemed to keep a much tighter
lid on their anger and hostility than the younger veterans I'd worked
with. Culture shapes the expression of traumatic stress.
The essence of trauma is that it is overwhelming, unbelievable, and
unbearable. Each patient demands that we suspend our sense of what
is normal and accept that we are dealing with a dual reality: the
reality of a relatively secure and predictable present that lives
side-by-side with a ruinous, ever-present past.
"In our last month of therapy, I asked my psychiatrist why he did not
try to fix me as all the other therapists had attempted, yet failed.
He told me that he assumed, given what I had be [sic] able to
accomplish with my children and career, that I had sufficient
resiliency to heal myself, if he created a holding environment for me
to do so. This was an hour each week that became a refuge where I
could unravel the mystery of how I had become so damaged then
re-construct a sense of myself that was whole, not fragmented,
peaceful, not tormented. 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"
# Chapter 13
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. 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 focussed. 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.
The first order of business is to find ways to cope with feeling
overwhelmed by the sensations and emotions associated with the past.
Neuroscience research shows that the only way we can change the way
we feel is by becoming aware of our _inner_ experience and learning
to befriend what is going on inside ourselves.
... we have a host of inbuilt skills to keep us on an even keel.
In chapter 5 we saw how emotions are registered in the body. Some
80 percent of the fibers of the vagus nerve (which connects the
brain with many internal organs) are afferent; that is, they run
from the body into the 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. ... Mainstream Western psychiatric and psychological
healing traditions have paid scant attention to self-management.
In contrast to the Western reliance on drugs and verbal therapies,
other traditions from around the world rely on mindfulness,
movement, rhythms, and action. ... Aside from yoga, few of these
popular non-Western healing traditions have been systematically
studied for the treatment of PTSD.
Body awareness puts us in touch with our inner world... Simply by
noticing our annoyance, nervousness, or anxiety immediately helps us
shift our perspective and opens up new options other than our
automatic, habitual reactions. ... When we pay focussed attention to
our bodily sensations, we can recognize the ebb and flow of our
emotions and, with that, increase our control over them.
In order to change you need to open yourself to your inner
experience. The first step is to allow your mind to focus on your
sensations and notice how, in contrast to the timeless, ever-present
experience of trauma, physical sensations are transient and respond
to slight shifts in body position, changes in breathing, and shifts
in thinking. Once you pay attention to your physical sensations, the
next step is to label them... A further step is to observe the
interplay between your thoughts and your physical sensations.
Study after study shows that having a good support network
constitutes the single most powerful protection against becoming
traumatized. ... Our attachment bonds are our greatest protection
against threat. ... Traumatized human beings recover in the context
of relationships...
As we have seen, much of the wiring of our brain circuits is devoted
to being in tune with others. Recovery from trauma involves
(re)connecting with our fellow human beings. ... Most traumatized
individuals need an anchor and a great deal of coaching to do this
work.
Choosing a Professional Therapist: 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?
From the moment of our birth, our relationships are embodied in
responsive faces, gestures, and touch. ... When we play together, we
feel physically attuned and experience a sense of connection and joy.
... the most natural way that we humans calm down our distress is
by being touched, hugged, and rocked. Touch, the most elementary
tool we have to calm down, is proscribed from most therapeutic
practices.
... stress hormones are meant to give us strength and endurance to
respond to extraordinary conditions. Helplessness and
immobilization keep people from utilizing their stress hormones to
defend themselves. When that happens, their hormones are still
being pumped out, but the actions they're supposed to fuel are
thwarted.
When patients can physically experience what it would have felt like
to fight back or run away, they relax, smile, and express a sense of
completion.
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.
Since that capacity to quietly observe oneself is a critical factor
in the integration of traumatic memories, it is likely that hypnosis,
in some form, will make a comeback.
# Chapter 14
Discovering your Self in language is always an epiphany...
Helen [Keller] later recalled that moment in The Story of My Life:
"Water! That word startled my soul, and it awoke, full of the spirit
of the morning. ... Until that day my mind had been like a darkened
chamber, waiting for words to enter and light the lamp, which is
thought. I learned a great many words that day."
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."
Language evolved primarily to share "things out there," not to
communicate our inner feelings, our interiority. (Again, the
language center of the brain is about as far removed from the center
for experiencing one's self as is geographically possible.)
We can get past the slipperiness of words by engaging the
self-observing, body-based self system, which speaks through
sensations, tone of voice, and body tensions. 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. When you write to yourself,
you don't have to worry about other people's judgment--you just
listen to your own thoughts and let their flow take over. Later,
when you reread what you wrote, you often discover surprising truths.
Such changes are called "switching" in clinical practice, and we see
them often in individuals with trauma histories. Patients activate
distinctly different emotional and physiological states as they move
from one topic to another. ... Some patients even appear to change
their personal identity...
Dealing with traumatic memories is, however, just the beginning of
treatment. Numerous studies have found that people with PTSD have
more general problems with focussed attention and with learning new
information.
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.
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_.
There is no question that language is essential: Our sense of Self
depends on being able to organize our memories into a coherent whole.
# Chapter 15
"On some level he felt that the tragic loss of his eye gave him
permission to abuse other people, but he also hated the angry,
vengeful person he had become."
EMDR = Eye Movement Desensitizing and Reprocessing
* EMDR loosens up something in the mind/brain that gives people
rapid access to loosely associated memories and images from the
past. This seems to help them put the traumatic experience into a
larger context or perspective.
* People may be able to heal from trauma without talking about it.
EMDR enables them to observe their experiences in a new way,
without verbal give-and-take with another person.
* EMDR can help even if the patient and the therapist do not have a
trusting relationship. This was particularly intriguing because
trauma, understandable, rarely leaves people with an open, trusting
heart.
EMDR is more effective for adult-onset trauma than childhood trauma.
Interestingly, in the first solid scientific study using EMDR in
combat veterans with PTSD, EMDR was expected to do so poorly that it
was included as the control condition for comparison with
biofeedback-assisted relaxation therapy. To the researchers'
surprise, 12 sessions of EMDR turned out to be the more effective
treatment. EMDR has since become one of the treatments for PTSD
sanctions by the Department of Veterans Affairs.
Seeing novel connections is the cardinal feature of creativity; as
we've seen, it's also essential to healing.
While we don't know precisely how EMDR works, the same is true of
Prozac. Prozac has an effect on seratonin, but whether its levels go
up or down, and in which brain cells, and why that makes people feel
less afraid, is still unclear. We likewise don't know precisely why
talking to a trusted friend gives such profound relief, and I am
surprised how few people seem eager to explore that question.
Clinicians have only one obligation: to do whatever they can to help
their patients get better. Because of this, clinical practice has
always been a hotbed for experimentation. ... 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.
# Chapter 16
All yoga programs consist of a combination of breath practices
(pranayama), stretches or postures (asanas), and meditation.
In our first yoga study we had a 50 percent dropout rate, the highest
of any study we'd ever done. When we interviewed the patients who'd
left, we learned that they had found the program too intense. Any
posture that involved the pelvis could precipitate intense panic or
even flashbacks to sexual assaults. Intense physical sensations
unleashed the demons from the past that had been so carefully kept in
check by numbing and inattention. This taught us to go slow [sic],
often at a snail's pace.
During the past few years brain researchers such as my colleagues
Sara Lazar and Britta Hoelzel at Harvard have shown that intensive
meditation has a positive effect on exactly those brain areas that
are critical for physiological self-regulation.
# Chapter 17
How well we get along with ourselves depends largely on our internal
leadership skills--how well we listen to our different parts, make
sure they feel taken care of, and keep them from sabotaging one
another. Parts often come across as absolutes when in fact they
represent only one element in a complex constellation of thoughts,
emotions, and sensations.
Modern neuroscience has confirmed this notion of the mind as a kind
of society.
As Schwartz states: "If one accepts the basic idea that people have
an innate drive toward nurturing their own health, this implies that,
when people have chronic problems, something gets in the way of
accessing inner resources. Recognizing this, the role of therapists
is to collaborate rather than to teach, confront, or fill holes in
your psyche." The first step in this collaboration is to assure the
system that all parts are welcome and that all of them--even those
that are suicidal or destructive--were formed in an attempt to
protect the self-system, no matter how much they now seem to threaten
it.
* DID = dissociative identity disorder, formerly known as multiple
personality disorder
* IFS = internal family systems
* Exiles (IFS) = parts of ourselves we need to deny at all costs
* Managers (IFS) = critical/perfectionist parts
* Firefighters (IFS) = emergency responders
* Bending (IFS) = identifying with a single part of the Self
# Chapter 18
It is one thing to process memories of trauma, but it is an entirely
different matter to confront the inner void--the holes in the soul
that result from not having been wanted, not having been seen, and
not having been allowed to speak the truth.
Microtracking = tracking subtle shifts in body posture, facial
expression, tone of voice, and eye gaze, the nonverbal expressions of
emotion
Being validated by feeling heard and seen is a precondition for
feeling safe, which is critical when we explore the dangerous
territory of trauma and abandonment. A neuroimaging study has shown
that when people hear a statement that mirrors their inner state, the
right amygdala momentarily lights up, as if to underline the accuracy
of the reflection.
The more pain and deprivation we have experienced, the more likely we
are to interpret other people's actions as being directed against us
and less understanding we will be of their struggles, insecurities,
and concerns. If we cannot appreciate the complexity of their lives,
we may see anything that they do as confirmation that we are going to
get hurt and disappointed.
PBSP psychomotor therapy
Like the model mugging classes that I discussed in chapter 13, the
structures in psychomotor therapy hold out the possibility of forming
virtual memories that live side by side with the painful realities of
the past and provide sensory experiences of feeling seen, cradled,
and supported that can serve as antidotes to memories of hurt and
betrayal. In order to change, people need to become viscerally
familiar with realities that directly contradict the static feelings
of the frozen or panicked self of trauma, replacing them with
sensations rooted in safety, mastery, delight, and connection.
# Chapter 19
Neurofeedback
To my knowledge no other treatment has achieved such marked
improvement in executive functioning, which predicts how well a
person will function in relationships, in school performance, and at
work.
The connectome refers to the exquisitely interconnected network of
neurons (nerve cells) in your brain. Like the genome, the
microbiome, and other exciting 'ome' fields, the effort to map the
connectome and decipher the electrical signals that zap through it to
generate your thoughts, feelings, and behaviors has become possible
through development of powerful new tools and technologies.
# Chapter 20
Since time immemorial human beings have used communal rituals to cope
with their most powerful and terrifying feelings. Ancient Greek
theater, the oldest of which we have written records, seems to have
grown out of religious rites that involved dancing, singing, and
reenacting mythical stories.
Greek drama may have served as ritual reintegration for combat
veterans.
Collective movement and music create a larger context for our lives,
a meaning beyond our individual fate.
Despite their differences, all of these programs share a common
foundation: confrontation of the painful realities of life and
symbolic transformation through communal action.
# Epilogue
When i give presentations on trauma and trauma treatment,
participants sometimes ask me to leave out the politics and confine
myself to talking about neuroscience and therapy. I wish I could
separate trauma from politics, but as long as we continue to live in
denial and treat only trauma while ignoring its origins, we are bound
to fail.
author: Van der Kolk, Bessel A., 1943-
(HTM) detail: http://besselvanderkolk.net/the-body-keeps-the-score.html
LOC: RC552.P67 V358
tags: book,health,non-fiction
title: The Body Keeps The Score
# Tags
(DIR) book
(DIR) health
(DIR) non-fiction