Summary
Chapter 13—Healing from Trauma: Owning Your Self
The role of mental health professionals is to deal with the imprints of trauma on the body, mind, and soul. These imprints rob an individual of agency. Rather than promote a fixed sequence of steps that one must follow in chronological order, van der Kolk offers a series of overlapping goals. These include feeling calm and focused even when confronted with reminders of the past, being fully present and alive in the moment, and not keeping secrets from oneself. Van der Kolk often starts with "limbic system therapy" to help a traumatized individual cope with overwhelming sensations and emotions associated with the past. This involves restoring executive functioning, self-confidence, and the capacity for playfulness and creativity.
Van der Kolk offers self-management protocols and also highlights the importance of having a solid social support network. He insists that there is no one-size-fits-all therapeutic treatment. Patients may try yoga or martial arts, or have bodywork such as therapeutic massage done. Most psychologists are taught cognitive behavioral therapy (which addresses negative patterns of thought), but van der Kolk states that CBT might cause patients to relive rather than resolve the trauma. MDMA is being studied as a potential treatment for traumatized individuals who have been unresponsive to previous forms of therapy. While van der Kolk still prescribes a variety of psychotropic medications, he also states that they cannot "cure" trauma.
Chapter 14—Language: Miracle and Tyranny
Following the events at the World Trade Center on September, 2001, several organizations (including the NIH, Pfizer Pharmaceuticals, and the NYT Company Foundation) organized expert panels to recommend the best treatments for trauma. They settled on two: psychoanalytically oriented therapy and cognitive behavioral therapy. However, the vast majority of people turned to acupuncture, massage, yoga, and EMDR, according to a survey conducted a year later. As mentioned in previous chapters, human connections also play a primary role in healing. According to van der Kolk, "feeling listened to and understood changes our physiology."
There are two distinct forms of self-awareness: an autobiographical self that creates coherent narratives and one that registers the self from moment to moment, primarily in physical sensations. The latter registers how we feel about a situation deep inside, and it is this system that needs to be "accessed, befriended, and reconciled." Free writing is one way to channel one's true feelings. In 1986, the social psychologist and professor James Pennebaker at the University of Texas did a study in which his students were to write about a deeply personal experience that they'd found stressful or traumatic. The group assigned to write about the facts of what happened and their feelings and emotions about the event experienced the most benefits. Art, music, and dance are used by cultures around the world to treat trauma. Overall, van der Kolk emphasizes the importance of getting back in touch with one's body and self.
Chapter 15—Letting Go of the Past: EMDR
Van der Kolk used a procedure called eye movement desensitization and reprocessing (EMDR) to help a patient suffering from the trauma of having been attacked. The man's attackers took out his eye with a broken beer bottle. A different patient who had suffered from childhood sexual abuse experienced a breakthrough in her healing through EMDR sessions. EMDR originated in the late 1980s when a psychologist named Dr. Francine Shapiro noticed that rapid eye movements helped diminish her distressing thoughts. It has since become an evidence-based treatment for PTSD and other psychological conditions.
Deep sleep and REM sleep are essential to the process by which memories change over time. Individuals with PTSD commonly experience sleep disturbances, which then impacts their memories. The psychiatrist and sleep researcher Robert Stickgold studied how the sleeping brain consolidates memory by filtering information whose relevance is unclear when we are awake. Stickgold also suggests a link between EMDR and memory processing in dreams. Van der Kolk finishes the chapter by advocating for clinicians to try different methods, even if they may seem unconventional, in order to help their patients.
Chapter 16—Learning to Inhabit Your Body: Yoga
Van der Kolk uses yoga to help treat Annie, a teacher with a history of extreme abuse in her upbringing. Chronic anger and fear can manifest as constant muscle tension, spasms, back pain, migraines, fibromyalgia, and other forms of chronic pain. The physical, emotional, relational, and financial costs are numerous. When van der Kolk heard about heart rate variability (HRV) as a measure of the interplay between the sympathetic and parasympathetic systems, he and his colleagues recognized this as a tool to assess well-being in their patients. They found that people with PTSD have low HRV.
A yoga teacher named David Emerson began teaching at the Trauma Center, and van der Kolk and his colleagues studied the impact of yoga in treating patients with severe trauma histories. For Annie (and numerous other patients), yoga fostered a safe connection with her body (a vital step in her healing).
Chapter 17—Putting the Pieces Together: Self-Leadership
Early in his career, van der Kolk treated a patient he calls Mary, who was diagnosed with dissociative identity disorder (DID). For true healing from trauma to occur, van der Kolk writes that we "need to revisit the parts of ourselves that developed the defensive habits that helped us survive." All major schools of psychology recognize the self as a mosaic of subpersonalities. Van der Kolk homes in on Internal Family Systems Therapy (IFS). Developed by Richard Schwartz, the IFS model proposes that the mind is made up of different parts that have their own levels of maturity, excitability, wisdom, and pain. Exiles, as they are known in IFS, are the parts that we deny and lock away inside. Managers proactively manage the individual's daily life, and can manifest as perfectionism or self-criticism. Firefighters react when an experience triggers an exiled emotion. Schwartz asserts that beneath these protective parts, there is a Self that is calm, wise, and compassionate. Overall, IFS provides a framework for understanding these different parts and referring to them in a non-pathologizing way.
Another patient named Joan sought help to manage her temper and deal with guilt about her extramarital affairs. Together, van der Kolk and Joan identified the different parts that were in charge at different times, all with the intention to protect her from the trauma of having been sexually abused as a young girl. Van der Kolk eventually treated both Joan and her husband, Brian. The last patient that van der Kolk describes in this chapter is an oncologist named Peter. As the son of two Holocaust survivors, Peter understood that his parents likely did the best they could in raising him, but he still felt neglect and emotional abuse. IFS helped him begin to heal his relationships, which had eroded as a result of his cruelty.
The rheumatologist Nancy Shadick facilitated studies that looked at whether IFS relieved the symptoms of patients with rheumatoid arthritis (RA). Nearly all of them had upbringings in which they were expected to be quiet and unobtrusive, which contributed to their RA. While the studies showed the efficacy of IFS and other practices like CBT and mindfulness, van der Kolk points out that they did not address whether increased psychological safety and comfort are reflected in a more robust immune system.
Chapter 18—Filling in the Holes: Creating Structures
This chapter concerns the treatment of the "inner void" of those who, as children, were made to feel unwanted, unseen, and unable to voice their truth. While at the founding conference of the US Association for Body Psychotherapy in June 1994, van der Kolk met a former dancer named Albert Pesso who conducted workshops in PBSP psychomotor therapy. This approach relies on role-playing and symbolic interactions to address past trauma or unmet needs and create new positive memories. During a private session with Pesso in which there were no other people around to role-play, van der Kolk positioned different furniture and objects as his parents, spouse, friends, and children. Upon looking at his projection of his internal landscape, van der Kolk was shocked to see that he had chosen two "hulking, dark, and threatening" objects to represent his parents. For both van der Kolk and his patients, engaging in scripted re-enactments and role-playing helped address unfulfilled needs.
Chapter 19—Rewiring the Brain: Neurofeedback
After his first year of medical school, van der Kolk worked as a part-time research assistant in Ernest Hartmann's sleep laboratory at Boston State Hospital. He prepared and monitored the study participants and analyzed their brain wave tracings. Hartmann's research contributed to the understanding of sleep processes. According to van der Kolk, EEGs (electroencephalograms) have untapped potential in terms of understanding psychiatric problems. A 2000 study conducted by professor and researcher Alexander McFarlane and his associates demonstrated that the brainwaves of traumatized patients did not help them pay attention to the task at hand by filtering out irrelevant information. In other words, the way that traumatized people process nontraumatic information profoundly shapes their daily information processing.
Van der Kolk learned about neurofeedback from the psychodynamic psychotherapist Sebern Fisher. Using real-time displays of brain activity (often an EEG), neurofeedback helps promote self-regulation of brain function. One extraordinary example of a patient benefiting from neurofeedback is the case of a young woman named Lisa. She suffered from dissociation and other symptoms as a result of severe childhood abuse. After Fisher administered several neurofeedback sessions, Lisa was able to integrate her trauma. Chronic childhood abuse and neglect disrupt the brain's ability to process sensory input. Neurofeedback holds immense promise as a treatment approach, especially for individuals who have tried other therapeutic methods to no avail.
Chapter 20—Finding Your Voice: Communal Rhythms and Theater
Many scientists, including Dr. van der Kolk, have been inspired by their own children's health issues to seek out new understandings of mind, brain, and therapy. When their adolescent son became ill with what van der Kolk calls chronic fatigue syndrome, Van der Kolk and his wife enrolled him in theater classes. Theater transformed his life through embodied self-expression and connection.
Van der Kolk writes about witnessing the benefits of theater for veterans suffering from PTSD. He also recounts observing Archbishop Desmond Tutu use singing and dancing as he conducted public hearings for the Truth and Reconciliation Commission in South Africa in 1996. Though there is little research on how collective ceremonies affect the mind, brain, and manifestation of trauma, van der Kolk has directly observed and studied three programs that use theater as a therapeutic modality. These included Urban Improv in Boston, the Possibility Project in New York City, and Shakespeare & Company in Lenox, Massachusetts. Theater allows traumatized people to embody their emotions, give voice to them, and rhythmically engage with others.
Epilogue—Choices to be Made
Van der Kolk predicts that there will be breakthroughs in society-wide understandings about trauma. However, he also acknowledges how factors like budget cuts, elimination of food stamps, the opposition to universal healthcare, psychiatry's refusal to consider social conditions, the sale of weapons, and tolerance for incarceration undermine the awareness of trauma. Van der Kolk refuses to separate trauma from politics, and he stresses the importance of fostering environments where children can be curious and playful. This carries both individual and collective implications.
Analysis
While there is still a time and place for pharmaceuticals in van der Kolk's treatment approach, over the course of his career, he has widened the scope of his practice to include practices and treatments that Western psychiatric and psychological healing traditions consider "alternative." These include learning how to breathe, chant, and move in ways that train our arousal system by influencing the vagus nerve. Mindfulness is essential for safely revisiting the past. He also emphasizes the importance of social bonds when he says that "traumatized human beings recover in the context of relationships" (Chapter 13). Since humans evolved to be eusocial and interdependent, some mental health professionals choose to view trauma not just through an individual lens but also through wider cultural frameworks. However, van der Kolk also stresses the importance of a therapist homing in on the particulars of each patient and not obliterating individual differences. In his words, a patient should not be made to feel like "a list of symptoms on some diagnostic questionnaire" (Chapter 13).
Van der Kolk asserts that the inability to relate to others is a hallmark of mental unwellness. This can be seen back in Chapter 10 when he writes that "[h]umans are social animals, and mental problems involve not being able to get along with other people, not fitting in, not belonging, and in general not being able to get on the same wavelength." Restoring the capacity to form and maintain bonds does not necessarily have to take place between humans. Although he does not go into this in great detail in The Body Keeps the Score, animal-assisted therapy is another way to increase social interaction, among other benefits. This appears in the book when a teenager named Jennifer is entrusted with the responsibility of caring for a horse (Chapter 13). It is a critical first step to being able to relate to the staff at the Trauma Center and subsequently focus on her academic journey.
Rather than vilifying stress hormones, van der Kolk acknowledges both the purpose they serve and the way they can fuel inappropriate fight/flight and freeze responses. He is not the only one to communicate this to the public. Other scientists, clinicians, and writers have also conveyed nuanced information about complex topics related to stress and trauma. For instance, the neuroscientist and podcaster Andrew Huberman often discusses cortisol as a key hormone for energy, focus, and immune system function. Depending on the circumstances, cortisol levels can be both inappropriately elevated or inappropriately suppressed in traumatized individuals. Van der Kolk offers myriad approaches to dealing with this, but one example included a program that taught people how to actively fight off a simulated attack. This helped them transform "fear into positive fighting energy" (Chapter 13).
Van der Kolk extends this lack of vilification to understanding the root of many psychiatric problems as initial strategies for self-protection. In other words, when considered in the context of the traumatic experience, many of these self-destructive behaviors made sense at the time. Internal Family Systems (IFS) therapy is one therapeutic modality that explores how the protective parts of oneself may engage in strategies that were understandable in the context of the trauma, but that harm the individual in the present. Considering the thoughts, decisions, and behaviors of traumatized people with this perspective in mind can shed a compassionate light on understanding what drives them.
Van der Kolk indicates that not all therapies work for everyone due to a variety of factors. There could be a mismatch in therapeutic style, personality, communication, and compatibility. A mental health professional's impressive credentials don't necessarily indicate that they will be the right fit for a patient, and van der Kolk provides a personal example of this. During his EMDR training, van der Kolk's fellow student chose not to disclose any personal details. In response to van der Kolk's flustered annoyance, the fellow student told him that the EMDR session had resolved the matter, but that he (the fellow student) found van der Kolk unpleasant and insufferable. This experience turned out to be a pivotal moment for van der Kolk's approach because he learned how to prioritize his patient's internal process of healing over his own desire to hear stories. Overall, this shows that mental health professionals can evolve their practices at any point in their careers.
