The Body Keeps the Score

by Bessel van der Kolk MD

  Karlen’s research showed that dissociation is learned early: Later abuse or other traumas did not account for dissociative symptoms in young adults.40 Abuse and trauma accounted for many other problems, but not for chronic dissociation or aggression against self. The critical underlying issue was that these patients didn’t know how to feel safe. Lack of safety within the early caregiving relationship led to an impaired sense of inner reality, excessive clinging, and self-damaging behavior: Poverty, single parenthood, or maternal psychiatric symptoms did not predict these symptoms.

  This does not imply that child abuse is irrelevant41, but that the quality of early caregiving is critically important in preventing mental health problems, independent of other traumas.42 For that reason treatment needs to address not only the imprints of specific traumatic events but also the consequences of not having been mirrored, attuned to, and given consistent care and affection: dissociation and loss of self-regulation.

  RESTORING SYNCHRONY

  Early attachment patterns create the inner maps that chart our relationships throughout life, not only in terms of what we expect from others, but also in terms of how much comfort and pleasure we can experience in their presence. I doubt that the poet e. e. cummings could have written his joyous lines “i like my body when it is with your body. . . . muscles better and nerves more” if his earliest experiences had been frozen faces and hostile glances.43 Our relationship maps are implicit, etched into the emotional brain and not reversible simply by understanding how they were created. You may realize that your fear of intimacy has something to do with your mother’s postpartum depression or with the fact that she herself was molested as a child, but that alone is unlikely to open you to happy, trusting engagement with others.

  However, that realization may help you to start exploring other ways to connect in relationships—both for your own sake and in order to not pass on an insecure attachment to your own children. In part 5 I’ll discuss a number of approaches to healing damaged attunement systems through training in rhythmicity and reciprocity.44 Being in synch with oneself and with others requires the integration of our body-based senses—vision, hearing, touch, and balance. If this did not happen in infancy and early childhood, there is an increased chance of later sensory integration problems (to which trauma and neglect are by no means the only pathways).

  Being in synch means resonating through sounds and movements that connect, which are embedded in the daily sensory rhythms of cooking and cleaning, going to bed and waking up. Being in synch may mean sharing funny faces and hugs, expressing delight or disapproval at the right moments, tossing balls back and forth, or singing together. At the Trauma Center, we have developed programs to coach parents in connection and attunement, and my patients have told me about many other ways to get themselves in synch, ranging from choral singing and ballroom dancing to joining basketball teams, jazz bands and chamber music groups. All of these foster a sense of attunement and communal pleasure.

  CHAPTER 8

  TRAPPED IN RELATIONSHIPS: THE COST OF ABUSE AND NEGLECT

  The “night sea journey” is the journey into the parts of ourselves that are split off, disavowed, unknown, unwanted, cast out, and exiled to the various subterranean worlds of consciousness. . . . The goal of this journey is to reunite us with ourselves. Such a homecoming can be surprisingly painful, even brutal. In order to undertake it, we must first agree to exile nothing.

  —Stephen Cope

  Marilyn was a tall, athletic-looking woman in her midthirties who worked as an operating-room nurse in a nearby town. She told me that a few months earlier she’d started to play tennis at her sports club with a Boston fireman named Michael. She usually steered clear of men, she said, but she had gradually become comfortable enough with Michael to accept his invitations to go out for pizza after their matches. They’d talk about tennis, movies, their nephews and nieces—nothing too personal. Michael clearly enjoyed her company, but she told herself he didn’t really know her.

  One Saturday evening in August, after tennis and pizza, she invited him to stay over at her apartment. She described feeling “uptight and unreal” as soon as they were alone together. She remembered asking him to go slow but had very little sense of what had happened after that. After a few glasses of wine and a rerun of Law & Order, they apparently fell asleep together on top of her bed. At around two in the morning, Michael turned over in his sleep. When Marilyn felt his body touch hers, she exploded—pounding him with her fists, scratching and biting, screaming, “You bastard, you bastard!” Michael, startled awake, grabbed his belongings and fled. After he left, Marilyn sat on her bed for hours, stunned by what had happened. She felt deeply humiliated and hated herself for what she had done, and now she’d come to me for help in dealing with her terror of men and her inexplicable rage attacks.

  My work with veterans had prepared me to listen to painful stories like Marilyn’s without trying to jump in immediately to fix the problem. Therapy often starts with some inexplicable behavior: attacking a boyfriend in the middle of the night, feeling terrified when somebody looks you in the eye, finding yourself covered with blood after cutting yourself with a piece of glass, or deliberately vomiting up every meal. It takes time and patience to allow the reality behind such symptoms to reveal itself.

  TERROR AND NUMBNESS

  As we talked, Marilyn told me that Michael was the first man she’d taken home in more than five years, but this was not the first time she’d lost control when a man spent the night with her. She repeated that she always felt uptight and spaced out when she was alone with a man, and there had been other times when she’d “come to” in her apartment, cowering in a corner, unable to remember clearly what had happened.

  Marilyn also said she felt as if she was just “going through the motions” of having a life. Except for when she was at the club playing tennis or at work in the operating room, she usually felt numb. A few years earlier she’d found that she could relieve her numbness by scratching herself with a razor blade, but she had become frightened when she found that she was cutting herself more and more deeply, and more and more often, to get relief. She had tried alcohol, too, but that reminded her of her dad and his out-of-control drinking, which made her feel disgusted with herself. So, instead, she played tennis fanatically, whenever she could. That made her feel alive.

  When I asked her about her past, Marilyn said she guessed that she “must have had” a happy childhood, but she could remember very little from before age twelve. She told me she’d been a timid adolescent, until she had a violent confrontation with her alcoholic father when she was sixteen and ran away from home. She worked her way through community college and went on to get a degree in nursing without any help from her parents. She felt ashamed that during this time she’d slept around, which she described as “looking for love in all the wrong places.”

  As I often did with new patients, I asked her to draw a family portrait, and when I saw her drawing (reproduced above), I decided to go slowly. Clearly Marilyn was harboring some terrible memories, but she could not allow herself to recognize what her own picture revealed. She had drawn a wild and terrified child, trapped in some kind of cage and threatened not only by three nightmarish figures—one with no eyes—but also by a huge erect penis protruding into her space. And yet this woman said she “must have had” a happy childhood.

  As the poet W. H. Auden wrote:

  Truth, like love and sleep, resents

  Approaches that are too intense.1

  I call this Auden’s rule, and in keeping with it I deliberately did not push Marilyn to tell me what she remembered. In fact, I’ve learned that it’s not important for me to know every detail of a patient’s trauma. What is critical is that the patients themselves learn to tolerate feeling what they feel and knowing what they know. This may take weeks or even years. I decided to start Marilyn’s treatment by inviting her to join an established therapy group where sh
e could find support and acceptance before facing the engine of her distrust, shame, and rage.

  As I expected, Marilyn arrived at the first group meeting looking terrified, much like the girl in her family portrait; she was withdrawn and did not reach out to anybody. I’d chosen this group for her because its members had always been helpful and accepting of new members who were too scared to talk. They knew from their own experience that unlocking secrets is a gradual process. But this time they surprised me, asking so many intrusive questions about Marilyn’s love life that I recalled her drawing of the little girl under assault. It was almost as though Marilyn had unwittingly enlisted the group to repeat her traumatic past. I intervened to help her set some boundaries about what she’d talk about, and she began to settle in.

  Three months later Marilyn told the group that she had stumbled and fallen a few times on the sidewalk between the subway and my office. She worried that her eyesight was beginning to fail: She’d also been missing a lot of tennis balls recently. I thought again about her drawing and the wild child with the huge, terrified eyes. Was this some sort of “conversion reaction,” in which patients express their conflicts by losing function in some part of their body? Many soldiers in both world wars had suffered paralysis that couldn’t be traced to physical injuries, and I had seen cases of “hysterical blindness” in Mexico and India

  Still, as a physician, I wasn’t about to conclude without further assessment that this was “all in her head.” I referred her to colleagues at the Massachusetts Eye and Ear Infirmary and asked them to do a very thorough workup. Several weeks later the tests came back. Marilyn had lupus erythematosus of her retina, an autoimmune disease that was eroding her vision, and she would need immediate treatment. I was appalled: Marilyn was the third person that year whom I’d suspected of having an incest history and who was then diagnosed with an autoimmune disease—a disease in which the body starts attacking itself.

  After making sure that Marilyn was getting the proper medical care, I consulted with two of my colleagues at Massachusetts General, psychiatrist Scott Wilson and Richard Kradin, who ran the immunology laboratory there. I told them Marilyn’s story, showed them the picture she’d drawn, and asked them to collaborate on a study. They generously volunteered their time and the considerable expense of a full immunology workup. We recruited twelve women with incest histories who were not taking any medications, plus twelve women who had never been traumatized and who also did not take meds—a surprisingly difficult control group to find. (Marilyn was not in the study; we generally do not ask our clinical patients to be part of our research efforts.)

  When the study was completed and the data analyzed, Rich reported that the group of incest survivors had abnormalities in their CD45 RA-to-RO ratio, compared with their nontraumatized peers. CD45 cells are the “memory cells” of the immune system. Some of them, called RA cells, have been activated by past exposure to toxins; they quickly respond to environmental threats they have encountered before. The RO cells, in contrast, are kept in reserve for new challenges; they are turned on to deal with threats the body has not met previously. The RA-to-RO ratio is the balance between cells that recognize known toxins and cells that wait for new information to activate. In patients with histories of incest, the proportion of RA cells that are ready to pounce is larger than normal. This makes the immune system oversensitive to threat, so that it is prone to mount a defense when none is needed, even when this means attacking the body’s own cells.

  Our study showed that, on a deep level, the bodies of incest victims have trouble distinguishing between danger and safety. This means that the imprint of past trauma does not consist only of distorted perceptions of information coming from the outside; the organism itself also has a problem knowing how to feel safe. The past is impressed not only on their minds, and in misinterpretations of innocuous events (as when Marilyn attacked Michael because he accidentally touched her in her sleep), but also on the very core of their beings: in the safety of their bodies.2

  A TORN MAP OF THE WORLD

  How do people learn what is safe and what is not safe, what is inside and what is outside, what should be resisted and what can safely be taken in? The best way we can understand the impact of child abuse and neglect is to listen to what people like Marilyn can teach us. One of the things that became clear as I came to know her better was that she had her own unique view of how the world functions.

  As children, we start off at the center of our own universe, where we interpret everything that happens from an egocentric vantage point. If our parents or grandparents keep telling us we’re the cutest, most delicious thing in the world, we don’t question their judgment—we must be exactly that. And deep down, no matter what else we learn about ourselves, we will carry that sense with us: that we are basically adorable. As a result, if we later hook up with somebody who treats us badly, we will be outraged. It won’t feel right: It’s not familiar; it’s not like home. But if we are abused or ignored in childhood, or grow up in a family where sexuality is treated with disgust, our inner map contains a different message. Our sense of our self is marked by contempt and humiliation, and we are more likely to think “he (or she) has my number” and fail to protest if we are mistreated.

  Marilyn’s past shaped her view of every relationship. She was convinced that men didn’t give a damn about other people’s feelings and that they got away with whatever they wanted. Women couldn’t be trusted either. They were too weak to stand up for themselves, and they’d sell their bodies to get men to take care of them. If you were in trouble, they wouldn’t lift a finger to help you. This worldview manifested itself in the way Marilyn approached her colleagues at work: She was suspicious of the motives of anyone who was kind to her and called them on the slightest deviation from the nursing regulations. As for herself: She was a bad seed, a fundamentally toxic person who made bad things happen to those around her.

  When I first encountered patients like Marilyn, I used to challenge their thinking and try to help them see the world in a more positive, flexible way. One day a woman named Kathy set me straight. A group member had arrived late to a session because her car had broken down, and Kathy immediately blamed herself: “I saw how rickety your car was last week; I knew I should have offered you a ride.” Her self-criticism escalated to the point that, only a few minutes later, she was taking responsibility for her sexual abuse: “I brought it on myself: I was seven years old and I loved my daddy. I wanted him to love me, and I did what he wanted me to do. It was my own fault.” When I intervened to reassure her, saying, “Come on, you were just a little girl—it was your father’s responsibility to maintain the boundaries,” Kathy turned toward me. “You know, Bessel,” she said, “I know how important it is for you to be a good therapist, so when you make stupid comments like that, I usually thank you profusely. After all, I am an incest survivor—I was trained to take care of the needs of grown-up, insecure men. But after two years I trust you enough to tell you that those comments make me feel terrible. Yes, it’s true; I instinctively blame myself for everything bad that happens to the people around me. I know that isn’t rational, and I feel really dumb for feeling this way, but I do. When you try to talk me into being more reasonable I only feel even more lonely and isolated—and it confirms the feeling that nobody in the whole world will ever understand what it feels like to be me.”

  I genuinely thanked her for her feedback, and I’ve tried ever since not to tell my patients that they should not feel the way they do. Kathy taught me that my responsibility goes much deeper: I have to help them reconstruct their inner map of the world.

  As I discussed in the previous chapter, attachment researchers have shown that our earliest caregivers don’t only feed us, dress us, and comfort us when we are upset; they shape the way our rapidly growing brain perceives reality. Our interactions with our caregivers convey what is safe and what is dangerous: whom we can count on and who will let us down; what we ne
ed to do to get our needs met. This information is embodied in the warp and woof of our brain circuitry and forms the template of how we think of ourselves and the world around us. These inner maps are remarkably stable across time.

  This doesn’t mean, however, that our maps can’t be modified by experience. A deep love relationship, particularly during adolescence, when the brain once again goes through a period of exponential change, truly can transform us. So can the birth of a child, as our babies often teach us how to love. Adults who were abused or neglected as children can still learn the beauty of intimacy and mutual trust or have a deep spiritual experience that opens them to a larger universe. In contrast, previously uncontaminated childhood maps can become so distorted by an adult rape or assault that all roads are rerouted into terror or despair. These responses are not reasonable and therefore cannot be changed simply by reframing irrational beliefs. Our maps of the world are encoded in the emotional brain, and changing them means having to reorganize that part of the central nervous system, the subject of the treatment section of this book.

  Nonetheless, learning to recognize irrational thoughts and behavior can be a useful first step. People like Marilyn often discover that their assumptions are not the same as those of their friends. If they are lucky, their friends and colleagues will tell them in words, rather than in actions, that their distrust and self-hatred makes collaboration difficult. But that rarely happens, and Marilyn’s experience was typical: After she assaulted Michael, he had absolutely no interest in working things out, and she lost both his friendship and her favorite tennis partner. It is at this point that smart and courageous people like Marilyn, who maintain their curiosity and determination in the face of repeated defeats, start looking for help.