The Body Keeps the Score
(Originally published December 2014)
Bessel van der Kolk is one of the world’s leading experts on trauma and trauma treatment, and continues to be a creative and provocative researcher and scholar in a subject that is finally receiving the attention it deserves in child welfare. Van der Kolk’s recent book, The Body Keeps the Score, should be required reading for professionals and advocates interested in bringing trauma informed practice to public child welfare agencies, courts, training programs and child and family treatment agencies.
Van der Kolk was a member of a group of trauma experts that developed the diagnosis of complex trauma in the early 1990s and lobbied unsuccessfully for its inclusion in the DSM-IV. His scorn for a diagnostic system that fails to distinguish acute trauma resulting from natural disasters or car accidents from chronic trauma perpetrated by caregivers is evident:
“This was a tragic exclusion (from DSM - IV). It meant that large numbers of patients could not be accurately diagnosed … You cannot develop a treatment for a condition that does not exist. Not having a diagnosis now confronts therapists with a serious dilemma: How do we treat people who are coping with the fall-out of abuse, betrayal and abandonment when we are forced to diagnose them with depression, panic disorder, bi-polar illness, or borderline personality, which do not really address what they are coping with?” And Van der Kolk continues “To this day, after twenty years and four subsequent re-visions, the DSM and the entire system based on it fail victims of child abuse and neglect – just as they ignored the plight of veterans before PTSD was introduced back in 1980.”
Remarkably, almost the same series of events have occurred in recent years after Van der Kolk and some of his colleagues in the National Child Traumatic Network articulated the diagnosis of Developmental Trauma Disorder to give traumatized abused and neglected children a single diagnosis rather than multiple diagnoses. In the proposal to the American Psychiatric Association they stated:
“Studies on the sequelae of childhood trauma in the context of caregiver abuse or neglect consistently demonstrate chronic and severe problems with emotion regulation, impulse control, attention and cognition, dissociation, interpersonal relationships, and self and relational schemas. In absence of a sensitive trauma specific diagnosis, such children are currently diagnosed with an average of 3-8 co-morbid disorders. The continued practice of applying multiple distinct co-morbid diagnoses to traumatized children has grave consequences: it defies parsimony, obscures etiological clarity, and runs the danger of relegating treatment and intervention to a small aspect of the child’s psychopathology rather than promoting a comprehensive treatment approach.”
Once again, however, the relevant DSM subcommittee rejected the proposal on the grounds that “no new diagnosis was required to fill a missing diagnostic niche,” a response which Van der Kolk views as clueless, but which most likely reflects an ongoing stubborn resistance to any new diagnosis that would subsume multiple more familiar diagnoses, a denial likely based as much on considerations of power and authority among mental health experts, along with ready access to funding streams, as on intellectual differences among scholars. Clearly, some well-placed clinicians have viewed developmental trauma disorder as a predatory diagnosis with the potential to undermine established treatment protocols and practices. Unfortunately, Van der Kolk does not address the interpersonal tensions and conflicts resulting from his evolving understanding of trauma with the same candor as Judith Herman in Trauma and Recovery.
Body Awareness and Mindfulness
For years, Van der kolk’s perspective on recovery from trauma has been divergent from many other therapists and researchers. In The Body Keeps the Score, Van der kolk is critical to the point of dismissive of cognitive behavioral treatment (which he asserts helps only about a third of trauma victims) and other talk therapies, and less concerned with developing a trauma narrative than most other trauma therapists. Van der kolk was an early user and proponent of Eye Movement Desensitization Reprocessing (EMDR) which, unlike some experts, he does not view as an idiosyncratic version of CBT.
Van der kolk comments that “… my professional training, with its focus on understanding and insight, had largely ignored the relevance of the living, breathing body, the foundation of our selves.” He asserts that “many of my patients they could not feel whole areas of their bodies,” and were literally unable to identify objects that he put in their hands when their eyes were closed. According to Van der Kolk, trauma victims may often feel disconnected from their bodies, and numb to their internal states, or feel constantly anxious and on edge, profoundly unsafe in their physical being as well as in social relationships. This is because the brain systems that monitor (for the most part unconsciously) “housekeeping” functions in the body such as breathing, appetite elimination, sleeping and waking have been overwhelmed by the perception of threat(s) resulting from the brain’s response to traumatic events and their aftermath. The body is on alert, activated by stress hormones to the extent that physical health is eventually harmed, according to Van der Kolk, whose account of mental and emotional functioning has been greatly influenced by Antonio Damasio (see The Feeling of What Happens). Physiological dysregulation, in turn, leads to emotional dysregulation characterized by panic attacks, “meltdowns”, self-harm and other desperate survival strategies, according to Van der Kolk.
Given this perspective regarding the suffering of trauma victims, Van der Kolk has gravitated in his therapy toward practices developed in various spiritual traditions (especially Buddhism) to regulate internal states, for example mindfulness, meditation, yoga, physical practices like massage and dance, and scientific advances such as neuro-feedback. Feeling safe first means feeling connected to (i.e. aware of, sensitive to) the body and knowing how to calm down, in Van der Kolk’s view. He is extraordinarily focused on slow conscious breathing (6 breaths per minute with a pause between breaths) as a means to both physiological and emotion regulation.
The Importance of Social Relationships
The normal response of children to danger is to seek out others for reassurance or protection; a baby’s or toddler’s attachment pattern is a survival strategy. But what if children have been severely harmed, or neglected, or abandoned or repeatedly humiliated by caregivers? The survival strategies these children employ when they fear and distrust caregivers, e.g., numbing, dissociation, rage, social isolation, bullying are likely to puzzle or frighten caregivers, teachers and peers and undermine the potential for stable committed parenting, friendship and intimacy. This is the challenge confronting caregivers, i.e., birth parents, foster parents, adoptive parents, as well as parent educators, therapists and other professionals who work with abused and neglected children and youth. Arguably, a disrupted capacity for intimacy in early adulthood is a common pathway to intergenerational transmission of child maltreatment.
Van der Kolk emphasizes the importance of the experience of early nurturance in developing resilient responses to adversity. For the most part, Van der Kolk asserts, children who recover quickly from trauma have strong, secure, positive relationships with attuned caregivers, which provides a reliable source of emotional safety in dangerous conditions. But what if children lack nurturing parenting, and/or have experienced multiple unplanned moves in foster care?
Van der Kolk’s recommendations for facilitating recovery from early severe abuse and neglect are similar to those of Deborah Gray, Ann Gearity and other trauma experts:
“Since emotion regulation is the critical issue in managing the effects of trauma neglect, it would make an enormous difference if teachers, army sergeants, foster parents and mental health professionals were thoroughly schooled in emotion regulation techniques. Right now, this is mainly the domain of preschool and kindergarten teachers, who deal with immature brains and impulsive behavior on a daily basis …”
Van der Kolk has an important cautionary message about the over dependence on psychotropic drugs and verbal therapies to suppress and manage undesirable child behavior. He writes:
“Mainstream Western psychiatric and psychological healing traditions have paid scant attention to self- management … other traditions from around the world rely on mindfulness, movement, rhythm and actions.”
Van der Kolk goes on to mention yoga, tai chi, rhythmical drumming, martial arts, conscious breathing and meditation, but he adds “Aside from yoga, few of these popular non- Western healing traditions have been systematically studied for the treatment of PTSD.”
Agency: developing self- leadership
Despite his dismissive comments regarding “talk therapies”, some of Van der Kolk’s most interesting chapters in The Body Keeps the Score are about psychodynamic approaches to re-enabling the capacity for agency seemingly lost at the time of traumatic events and subsequently. Van der Kolk comments that “almost all (of his patients) 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.” The experience of trauma victims suggests that it is psychologically devastating to be immobilized at a time of severe threat to life and bodily integrity. The self-loathing that so many survivors suffer from may, in part, arise from an inability to forgive oneself for what seems an unforgiveable failure of nerve.
Some readers may remember the outstanding American movie, “Fearless” (1993), about the survivors of a plane crash in which most of the passengers died. One of the story lines in the movie is about a woman who survived the crash but condemns herself for not holding on to her baby who died when the plane hit the ground. No amount of empathy or compassion, or words of understanding, can relieve her self-condemnation until the main character (played by Jeff Bridges) places the young woman in the front seat of his car with instructions to hold on to an object about the size of her deceased child, and then accelerates the car until they hit a wall. Both the Jeff Bridges character, whose take away from the plane accident is that he cannot die, and the mother whose baby died in the crash are injured (though not severely); and their family members are horrified. Nevertheless, the young mother is released from a self-loathing that made it impossible for her to function or accept the love of her husband, extended family and friends. The Jeff Bridges character has a different challenge: he must relearn the fear of death.
Anyone who doubts whether severe life threatening neglect ( often combined with destitution) can be traumatic should read Marilynne Robinson’s extraordinary new novel, Lila, about a young woman who at age 3 or 4 lacked a name or identifiable caregiver and was in danger of starvation or death from exposure to the elements. Lila is rescued and mothered by a homeless woman who drifts from place to place. As a young adult, Lila is redeemed by the love of an elderly minister who must overcome her distrust and expectation of rejection. Lila is not redeemed from sin but from a deep sense of her worthlessness. Like many other trauma victims, she believes herself to be godforsaken, literally a non-entity in the eyes of others.
In the chapter, “Putting the Pieces Together: Self Leadership,” Van der kolk describes Internal Family Systems therapy (IFS), the goal of which is to integrate the fragmented parts of the self. Van der kolk states that “At the core of IFS is the notion that the mind of each of us is like a family in which the members have different levels of maturity, excitability, wisdom and pain.” And he continues, “In trauma, the self-system breaks down, and parts of the self become polarized and go to war with one another.”
Like other psychic families, IFS views the self as having three parts with distinct roles: “exiles” ( the toxic rejected parts of the person), “managers” ( critical and perfectionistic) and “firefighters” (emergency responders who act impulsively “whenever an emotion triggers an exiled emotion”). All three parts have an important role to play in protecting the self from “the full terror of annihilation.”
The goal of IFS as described by Van der kolk is to cultivate “mindful self- leadership” through compassion and curiosity regarding every aspect of the self and what trauma victims have done to survive. Non- judgmental curiosity is the therapeutic lynch pin of IFS; but the underlying belief is that the self that we aspire to does not have to be cultivated or developed. Van der kolk asserts that:
“Beneath the surface of the protective parts of trauma survivors there exists an undamaged essence, a Self that is confident, curious and calm, a Self that has been sheltered from destruction by the various protectors that have emerged in their efforts to ensure survival. Once those protectors trust that it is safe to separate, the Self will spontaneously emerge, and the parts can be enlisted in the healing process.”
Van der Kolk’s account of recovery from trauma has practical meaning for child welfare systems and for professionals who work with abused and neglected children:
Safety means not just physical safety but the experience of deep connection to and awareness of the body, so that the survivor’s body and brain are not always, or even usually, on alert. Activities that mobilize purposeful enjoyable physical movements have great therapeutic potential.
Emotion regulation begins with body awareness especially awareness of breathing, and, in young children, requires the willingness to turn to caregivers for help when they feel vulnerable.
The capacity to develop and sustain social support necessary for both protection and a sense of security begins with experiences of early nurturance, i.e., attunement, between caregivers and very young children. Managing behavior through consequences and damping down aggressive behavior with drugs is not a substitute for the experience of attuned caregiving.
A renewed capacity for personal agency is created by the acceptance of split-off parts of the self, a therapeutic process enabled by non-judgmental curiosity regarding the complex array of behaviors and internal processes deployed by victims to survive.
Damasio, Antonio, The Feeling of What Happens: Body and Emotion in the Making of Consciousness , Harcourt, Inc. 1999.
Fearless, starring Jeff Bridges, Isabella Rossellini and Rosie Perez; screenplay by Rafael Yglesias from his novel, directed by Peter Weir, 1993
Robinson, Marilynne, Lila, Farrar, Straus and Giroux, 2014.
Van der Kolk, Bessel, The Body Keeps the Score: Brain, Mind and Body in the Healing of Trauma, Viking, 2014.