The Body Keeps the Score

by Bessel van der Kolk MD

  In my new job I was confronted on an almost daily basis with issues I thought I had left behind at the VA. My experience with combat veterans had so sensitized me to the impact of trauma that I now listened with a very different ear when depressed and anxious patients told me stories of molestation and family violence. I was particularly struck by how many female patients spoke of being sexually abused as children. This was puzzling, as the standard textbook of psychiatry at the time stated that incest was extremely rare in the United States, occurring about once in every million women.8 Given that there were then only about one hundred million women living in the United States, I wondered how forty seven, almost half of them, had found their way to my office in the basement of the hospital.

  Furthermore, the textbook said, “There is little agreement about the role of father-daughter incest as a source of serious subsequent psychopathology.” My patients with incest histories were hardly free of “subsequent psychopathology”—they were profoundly depressed, confused, and often engaged in bizarrely self-harmful behaviors, such as cutting themselves with razor blades. The textbook went on to practically endorse incest, explaining that “such incestuous activity diminishes the subject’s chance of psychosis and allows for a better adjustment to the external world.”9 In fact, as it turned out, incest had devastating effects on women’s well-being.

  In many ways these patients were not so different from the veterans I had just left behind at the VA. They also had nightmares and flashbacks. They also alternated between occasional bouts of explosive rage and long periods of being emotionally shut down. Most of them had great difficulty getting along with other people and had trouble maintaining meaningful relationships.

  As we now know, war is not the only calamity that leaves human lives in ruins. While about a quarter of the soldiers who serve in war zones are expected to develop serious posttraumatic problems,10 the majority of Americans experience a violent crime at some time during their lives, and more accurate reporting has revealed that twelve million women in the United States have been victims of rape. More than half of all rapes occur in girls below age fifteen.11 For many people the war begins at home: Each year about three million children in the United States are reported as victims of child abuse and neglect. One million of these cases are serious and credible enough to force local child protective services or the courts to take action.12 In other words, for every soldier who serves in a war zone abroad, there are ten children who are endangered in their own homes. This is particularly tragic, since it is very difficult for growing children to recover when the source of terror and pain is not enemy combatants but their own caretakers.

  A NEW UNDERSTANDING

  In the three decades since I met Tom, we have learned an enormous amount not only about the impact and manifestations of trauma but also about ways to help traumatized people find their way back. Since the early 1990s brain-imaging tools have started to show us what actually happens inside the brains of traumatized people. This has proven essential to understanding the damage inflicted by trauma and has guided us to formulate entirely new avenues of repair.

  We have also begun to understand how overwhelming experiences affect our innermost sensations and our relationship to our physical reality—the core of who we are. We have learned that trauma is not just an event that took place sometime in the past; it is also the imprint left by that experience on mind, brain, and body. This imprint has ongoing consequences for how the human organism manages to survive in the present.

  Trauma results in a fundamental reorganization of the way mind and brain manage perceptions. It changes not only how we think and what we think about, but also our very capacity to think. We have discovered that helping victims of trauma find the words to describe what has happened to them is profoundly meaningful, but usually it is not enough. The act of telling the story doesn’t necessarily alter the automatic physical and hormonal responses of bodies that remain hypervigilant, prepared to be assaulted or violated at any time. For real change to take place, the body needs to learn that the danger has passed and to live in the reality of the present. Our search to understand trauma has led us to think differently not only about the structure of the mind but also about the processes by which it heals.

  CHAPTER 2

  REVOLUTIONS IN UNDERSTANDING MIND AND BRAIN

  The greater the doubt, the greater the awakening; the smaller the doubt, the smaller the awakening. No doubt, no awakening.

  —C.-C. Chang, The Practice of Zen

  You live through that little piece of time that is yours, but that piece of time is not only your own life, it is the summing-up of all the other lives that are simultaneous with yours. . . . What you are is an expression of History.

  —Robert Penn Warren, World Enough and Time

  In the late 1960s, during a year off between my first and second years of medical school, I became an accidental witness to a profound transition in the medical approach to mental suffering. I had landed a plum job as an attendant on a research ward at the Massachusetts Mental Health Center, where I was in charge of organizing recreational activities for the patients. MMHC had long been considered one of the finest psychiatric hospitals in the country, a jewel in the crown of the Harvard Medical School teaching empire. The goal of the research on my ward was to determine whether psychotherapy or medication was the best way to treat young people who had suffered a first mental breakdown diagnosed as schizophrenia.

  The talking cure, an offshoot of Freudian psychoanalysis, was still the primary treatment for mental illness at MMHC. However, in the early 1950s a group of French scientists had discovered a new compound, chlorpromazine (sold under the brand name Thorazine), that could “tranquilize” patients and make them less agitated and delusional. That inspired hope that drugs could be developed to treat serious mental problems such as depression, panic, anxiety, and mania, as well as to manage some of the most disturbing symptoms of schizophrenia.

  As an attendant I had nothing to do with the research aspect of the ward and was never told what treatment any of the patients was receiving. They were all close to my age—college students from Harvard, MIT, and Boston University. Some had tried to kill themselves; others cut themselves with knives or razor blades; several had attacked their roommates or had otherwise terrified their parents or friends with their unpredictable, irrational behavior. My job was to keep them involved in normal activities for college students, such as eating at the local pizza parlor, camping in a nearby state forest, attending Red Sox games, and sailing on the Charles River.

  Totally new to the field, I sat in rapt attention during ward meetings, trying to decipher the patients’ complicated speech and logic. I also had to learn to deal with their irrational outbursts and terrified withdrawal. One morning I found a patient standing like a statue in her bedroom with one arm raised in a defensive gesture, her face frozen in fear. She remained there, immobile, for at least twelve hours. The doctors gave me the name for her condition, catatonia, but even the textbooks I consulted didn’t tell me what could be done about it. We just let it run its course.

  TRAUMA BEFORE DAWN

  I spent many nights and weekends on the unit, which exposed me to things the doctors never saw during their brief visits. When patients could not sleep, they often wandered in their tightly wrapped bathrobes into the darkened nursing station to talk. The quiet of the night seemed to help them open up, and they told me stories about having been hit, assaulted, or molested, often by their own parents, sometimes by relatives, classmates, or neighbors. They shared memories of lying in bed at night, helpless and terrified, hearing their mother being beaten by their father or a boyfriend, hearing their parents yell horrible threats at each other, hearing the sounds of furniture breaking. Others told me about fathers who came home drunk—hearing their footsteps on the landing and how they waited for them to come in, pull them out of bed, and punish them for some imagined offense. Several of the women recalle
d lying awake, motionless, waiting for the inevitable—a brother or father coming in to molest them.

  During morning rounds the young doctors presented their cases to their supervisors, a ritual that the ward attendants were allowed to observe in silence. They rarely mentioned stories like the ones I’d heard. However, many later studies have confirmed the relevance of those midnight confessions: We now know that more than half the people who seek psychiatric care have been assaulted, abandoned, neglected, or even raped as children, or have witnessed violence in their families.1 But such experiences seemed to be off the table during rounds. I was often surprised by the dispassionate way patients’ symptoms were discussed and by how much time was spent on trying to manage their suicidal thoughts and self-destructive behaviors, rather than on understanding the possible causes of their despair and helplessness. I was also struck by how little attention was paid to their accomplishments and aspirations; whom they cared for, loved, or hated; what motivated and engaged them, what kept them stuck, and what made them feel at peace—the ecology of their lives.

  A few years later, as a young doctor, I was confronted with an especially stark example of the medical model in action. I was then moonlighting at a Catholic hospital, doing physical examinations on women who’d been admitted to receive electroshock treatment for depression. Being my curious immigrant self, I’d look up from their charts to ask them about their lives. Many of them spilled out stories about painful marriages, difficult children, and guilt over abortions. As they spoke, they visibly brightened and often thanked me effusively for listening to them. Some of them wondered if they really still needed electroshock after having gotten so much off their chests. I always felt sad at the end of these meetings, knowing that the treatments that would be administered the following morning would erase all memory of our conversation. I did not last long in that job.

  On my days off from the ward at MMHC, I often went to the Countway Library of Medicine to learn more about the patients I was supposed to help. One Saturday afternoon I came across a treatise that is still revered today: Eugen Bleuler’s 1911 textbook Dementia Praecox. Bleuler’s observations were fascinating:

  Among schizophrenic body hallucinations, the sexual ones are by far the most frequent and the most important. All the raptures and joys of normal and abnormal sexual satisfaction are experienced by these patients, but even more frequently every obscene and disgusting practice which the most extravagant fantasy can conjure up. Male patients have their semen drawn off; painful erections are stimulated. The women patients are raped and injured in the most devilish ways. . . . In spite of the symbolic meaning of many such hallucinations, the majority of them correspond to real sensations.2

  This made me wonder: Our patients had hallucinations—the doctors routinely asked about them and noted them as signs of how disturbed the patients were. But if the stories I’d heard in the wee hours were true, could it be that these “hallucinations” were in fact the fragmented memories of real experiences? Were hallucinations just the concoctions of sick brains? Could people make up physical sensations they had never experienced? Was there a clear line between creativity and pathological imagination? Between memory and imagination? These questions remain unanswered to this day, but research has shown that people who’ve been abused as children often feel sensations (such as abdominal pain) that have no obvious physical cause; they hear voices warning of danger or accusing them of heinous crimes.

  There was no question that many patients on the ward engaged in violent, bizarre, and self-destructive behaviors, particularly when they felt frustrated, thwarted, or misunderstood. They threw temper tantrums, hurled plates, smashed windows, and cut themselves with shards of glass. At that time I had no idea why someone might react to a simple request (“Let me clean that goop out of your hair”) with rage or terror. I usually followed the lead of the experienced nurses, who signaled when to back off or, if that did not work, to restrain a patient. I was surprised and alarmed by the satisfaction I sometimes felt after I’d wrestled a patient to the floor so a nurse could give an injection, and I gradually realized how much of our professional training was geared to helping us stay in control in the face of terrifying and confusing realities.

  Sylvia was a gorgeous nineteen-year-old Boston University student who usually sat alone in the corner of the ward, looking frightened to death and virtually mute, but whose reputation as the girlfriend of an important Boston mafioso gave her an aura of mystery. After she refused to eat for more than a week and rapidly started to lose weight, the doctors decided to force-feed her. It took three of us to hold her down, another to push the rubber feeding tube down her throat, and a nurse to pour the liquid nutrients into her stomach. Later, during a midnight confession, Sylvia spoke timidly and hesitantly about her childhood sexual abuse by her brother and uncle. I realized then our display of “caring” must have felt to her much like a gang rape. This experience, and others like it, helped me formulate this rule for my students: If you do something to a patient that you would not do to your friends or children, consider whether you are unwittingly replicating a trauma from the patient’s past.

  In my role as recreation leader I noticed other things: As a group the patients were strikingly clumsy and physically uncoordinated. When we went camping, most of them stood helplessly by as I pitched the tents. We almost capsized once in a squall on the Charles River because they huddled rigidly in the lee, unable to grasp that they needed to shift position to balance the boat. In volleyball games the staff members invariably were much better coordinated than the patients. Another characteristic they shared was that even their most relaxed conversations seemed stilted, lacking the natural flow of gestures and facial expressions that are typical among friends. The relevance of these observations became clear only after I’d met the body-based therapists Peter Levine and Pat Ogden; in the later chapters I’ll have a lot to say about how trauma is held in people’s bodies.

  MAKING SENSE OF SUFFERING

  After my year on the research ward I resumed medical school and then, as a newly minted MD, returned to MMHC to be trained as a psychiatrist, a program to which I was thrilled to be accepted. Many famous psychiatrists had trained there, including Eric Kandel, who later won the Nobel Prize in Physiology and Medicine. Allan Hobson discovered the brain cells responsible for the generation of dreams in a lab in the hospital basement while I trained there, and the first studies on the chemical underpinnings of depression were also conducted at MMHC. But for many of us residents, the greatest draw was the patients. We spent six hours each day with them and then met as a group with senior psychiatrists to share our observations, pose our questions, and compete to make the wittiest remarks.

  Our great teacher, Elvin Semrad, actively discouraged us from reading psychiatry textbooks during our first year. (This intellectual starvation diet may account for the fact that most of us later became voracious readers and prolific writers.) Semrad did not want our perceptions of reality to become obscured by the pseudocertainties of psychiatric diagnoses. I remember asking him once: “What would you call this patient—schizophrenic or schizoaffective?” He paused and stroked his chin, apparently in deep thought. “I think I’d call him Michael McIntyre,” he replied.

  Semrad taught us that most human suffering is related to love and loss and that the job of therapists is to help people “acknowledge, experience, and bear” the reality of life—with all its pleasures and heartbreak. “The greatest sources of our suffering are the lies we tell ourselves,” he’d say, urging us to be honest with ourselves about every facet of our experience. He often said that people can never get better without knowing what they know and feeling what they feel.

  I remember being surprised to hear this distinguished old Harvard professor confess how comforted he was to feel his wife’s bum against him as he fell asleep at night. By disclosing such simple human needs in himself he helped us recognize how basic they were to our lives. Failure to atten
d to them results in a stunted existence, no matter how lofty our thoughts and worldly accomplishments. Healing, he told us, depends on experiential knowledge: You can be fully in charge of your life only if you can acknowledge the reality of your body, in all its visceral dimensions.

  Our profession, however, was moving in a different direction. In 1968 the American Journal of Psychiatry had published the results of the study from the ward where I’d been an attendant. They showed unequivocally that schizophrenic patients who received drugs alone had a better outcome than those who talked three times a week with the best therapists in Boston.3 This study was one of many milestones on a road that gradually changed how medicine and psychiatry approached psychological problems: from infinitely variable expressions of intolerable feelings and relationships to a brain-disease model of discrete “disorders.”

  The way medicine approaches human suffering has always been determined by the technology available at any given time. Before the Enlightenment aberrations in behavior were ascribed to God, sin, magic, witches, and evil spirits. It was only in the nineteenth century that scientists in France and Germany began to investigate behavior as an adaptation to the complexities of the world. Now a new paradigm was emerging: Anger, lust, pride, greed, avarice, and sloth—as well as all the other problems we humans have always struggled to manage—were recast as “disorders” that could be fixed by the administration of appropriate chemicals.4 Many psychiatrists were relieved and delighted to become “real scientists,” just like their med school classmates who had laboratories, animal experiments, expensive equipment, and complicated diagnostic tests, and set aside the wooly-headed theories of philosophers like Freud and Jung. A major textbook of psychiatry went so far as to state: “The cause of mental illness is now considered an aberration of the brain, a chemical imbalance.”5