The Body Keeps the Score

by Bessel van der Kolk MD

  Generally the rational brain can override the emotional brain, as long as our fears don’t hijack us. (For example, your fear at being flagged down by the police can turn instantly to gratitude when the cop warns you that there’s an accident ahead.) But the moment we feel trapped, enraged, or rejected, we are vulnerable to activating old maps and to follow their directions. Change begins when we learn to “own” our emotional brains. That means learning to observe and tolerate the heartbreaking and gut-wrenching sensations that register misery and humiliation. Only after learning to bear what is going on inside can we start to befriend, rather than obliterate, the emotions that keep our maps fixed and immutable.

  LEARNING TO REMEMBER

  About a year into Marilyn’s group, another member, Mary, asked permission to talk about what had happened to her when she was thirteen years old. Mary worked as a prison guard, and she was involved in a sadomasochistic relationship with another woman. She wanted the group to know her background in the hope that they would become more tolerant of her extreme reactions, such as her tendency to shut down or blow up in response to the slightest provocation.

  Struggling to get the words out, Mary told us that one evening, when she was thirteen years old, she was raped by her older brother and a gang of his friends. The rape resulted in pregnancy, and her mother gave her an abortion at home, on the kitchen table. The group sensitively tuned in to what Mary was sharing and comforted her through her sobbing. I was profoundly moved by their empathy—they were consoling Mary in a way that they must have wished somebody had comforted them when they first confronted their traumas.

  When time ran out, Marilyn asked if she could take a few more minutes to talk about what she had experienced during the session. The group agreed, and she told us: “Hearing that story, I wonder if I may have been sexually abused myself.” My mouth must have dropped open. Based on her family drawing, I had always assumed that she was aware, at least on some level, that this was the case. She had reacted like an incest victim in her response to Michael, and she chronically behaved as if the world were a terrifying place.

  Yet even though she’d drawn a girl who was being sexually molested, she—or at least her cognitive, verbal self—had no idea what had actually happened to her. Her immune system, her muscles, and her fear system all had kept the score, but her conscious mind lacked a story that could communicate the experience. She reenacted her trauma in her life, but she had no narrative to refer to. As we will see in chapter 12, traumatic memory differs in complex ways from normal recall, and it involves many layers of mind and brain.

  Triggered by Mary’s story, and spurred on by the nightmares that followed, Marilyn began individual therapy with me in which she started to deal with her past. At first she experienced waves of intense, free-floating terror. She tried stopping for several weeks, but when she found she could no longer sleep and had to take time off from work, she continued our sessions. As she told me later: “My only criterion for whether a situation is harmful is feeling, ‘This is going to kill me if I don’t get out.’”

  I began to teach Marilyn calming techniques, such as focusing on breathing deeply—in and out, in and out, at six breaths a minute—while following the sensations of the breath in her body. This was combined with tapping acupressure points, which helped her not to become overwhelmed. We also worked on mindfulness: Learning to keep her mind alive while allowing her body to feel the feelings that she had come to dread slowly enabled Marilyn to stand back and observe her experience, rather than being immediately hijacked by her feelings. She had tried to dampen or abolish those feelings with alcohol and exercise, but now she began to feel safe enough to begin to remember what had happened to her as a girl. As she gained ownership over her physical sensations, she also began to be able to tell the difference between past and present: Now if she felt someone’s leg brush against her in the night, she might be able to recognize it as Michael’s leg, the leg of the handsome tennis partner she’d invited to her apartment. That leg did not belong to anyone else, and its touch didn’t mean someone was trying to molest her. Being still enabled her to know—fully, physically know—that she was a thirty-four-year-old woman and not a little girl.

  When Marilyn finally began to access her memories, they emerged as flashbacks of the wallpaper in her childhood bedroom. She realized that this was what she had focused on when her father raped her when she was eight years old. His molestation had scared her beyond her capacity to endure, so she had needed to push it out of her memory bank. After all, she had to keep living with this man, her father, who had assaulted her. Marilyn remembered having turned to her mother for protection, but when she ran to her and tried to hide herself by burying her face in her mother’s skirt, she was met with only a limp embrace. At times her mother remained silent; at others she cried or angrily scolded Marilyn for “making Daddy so angry.” The terrified child found no one to protect her, to offer strength or shelter.

  As Roland Summit wrote in his classic study The Child Sexual Abuse Accommodation Syndrome: “Initiation, intimidation, stigmatization, isolation, helplessness and self-blame depend on a terrifying reality of child sexual abuse. Any attempts by the child to divulge the secret will be countered by an adult conspiracy of silence and disbelief. ‘Don’t worry about things like that; that could never happen in our family.’ ‘How could you ever think of such a terrible thing?’ ‘Don’t let me ever hear you say anything like that again!’ The average child never asks and never tells.”3

  After forty years of doing this work I still regularly hear myself saying, “That’s unbelievable,” when patients tell me about their childhoods. They often are as incredulous as I am—how could parents inflict such torture and terror on their own child? Part of them continues to insist that they must have made the experience up or that they are exaggerating. All of them are ashamed about what happened to them, and they blame themselves—on some level they firmly believe that these terrible things were done to them because they are terrible people.

  Marilyn now began to explore how the powerless child had learned to shut down and comply with whatever was asked of her. She had done so by making herself disappear: The moment she heard her father’s footsteps in the corridor outside her bedroom, she would “put her head in the clouds.” Another patient of mine who had a similar experience made a drawing that depicts how that process works. When her father started to touch her, she made herself disappear; she floated up to the ceiling, looking down on some other little girl in the bed.4 She was glad that it was not really her—it was some other girl who was being molested.

  Looking at these heads separated from their bodies by an impenetrable fog really opened my eyes to the experience of dissociation, which is so common among incest victims. Marilyn herself later realized that, as an adult, she had continued to float up to the ceiling when she found herself in a sexual situation. In the period when she’d been more sexually active, a partner would occasionally tell her how amazing she’d been in bed—that he’d barely recognized her, that she’d even talked differently. Usually she did not remember what had happened, but at other times she’d become angry and aggressive. She had no sense of who she really was sexually, so she gradually withdrew from dating altogether—until Michael.

  HATING YOUR HOME

  Children have no choice who their parents are, nor can they understand that parents may simply be too depressed, enraged, or spaced out to be there for them or that their parents’ behavior may have little to do with them. Children have no choice but to organize themselves to survive within the families they have. Unlike adults, they have no other authorities to turn to for help—their parents are the authorities. They cannot rent an apartment or move in with someone else: Their very survival hinges on their caregivers.

  Children sense—even if it they are not explicitly threatened—that if they talked about their beatings or molestation to teachers they would be punished. Instead, they focus their e
nergy on not thinking about what has happened and not feeling the residues of terror and panic in their bodies. Because they cannot tolerate knowing what they have experienced, they also cannot understand that their anger, terror, or collapse has anything to do with that experience. They don’t talk; they act and deal with their feelings by being enraged, shut down, compliant, or defiant.

  Children are also programmed to be fundamentally loyal to their caretakers, even if they are abused by them. Terror increases the need for attachment, even if the source of comfort is also the source of terror. I have never met a child below the age of ten who was tortured at home (and who had broken bones and burned skin to show for it) who, if given the option, would not have chosen to stay with his or her family rather than being placed in a foster home. Of course, clinging to one’s abuser is not exclusive to childhood. Hostages have put up bail for their captors, expressed a wish to marry them, or had sexual relations with them; victims of domestic violence often cover up for their abusers. Judges often tell me how humiliated they feel when they try to protect victims of domestic violence by issuing restraining orders, only to find out that many of them secretly allow their partners to return.

  It took Marilyn a long time before she was ready to talk about her abuse: She was not ready to violate her loyalty to her family—deep inside she felt that she still needed them to protect her against her fears. The price of this loyalty is unbearable feelings of loneliness, despair, and the inevitable rage of helplessness. Rage that has nowhere to go is redirected against the self, in the form of depression, self-hatred, and self-destructive actions. One of my patients told me, “It is like hating your home, your kitchen and pots and pans, your bed, your chairs, your table, your rugs.” Nothing feels safe—least of all your own body.

  Learning to trust is a major challenge. One of my other patients, a schoolteacher whose grandfather raped her repeatedly before she was six, sent me the following e-mail: “I started mulling the danger of opening up with you in traffic on the way home after our therapy appointment, and then, as I merged into Route 124, I realized that I had broken the rule of not getting attached, to you and to my students.”

  During our next meeting she told me she had also been raped by her lab instructor in college. I asked her whether she had sought help and made a complaint against him. “I couldn’t make myself cross the road to the clinic,” she replied. “I was desperate for help, but as I stood there, I felt very deeply that I would only be hurt even more. And that might well have been true. Of course, I had to hide what had happened from my parents—and from everyone else.”

  After I told her that I was concerned about what was going on with her, she wrote me another e-mail: “I’m trying to remind myself that I didn’t do anything to deserve such treatment. I don’t think I have ever had anyone look at me like that and say they were worried about me, and I am holding on to it like a treasure: the idea that I am worth being worried about by someone I respect and who does understand how deeply I am struggling now.”

  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 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.5

  REPLAYING THE TRAUMA

  One memory of Marilyn’s childhood trauma came to her in a dream in which she felt as if she were being choked and was unable to breathe. A white tea towel was wrapped around her hands, and then she was lifted up with the towel around her neck, so that she could not touch the ground with her feet. She woke in a panic, thinking that she was surely going to die. Her dream reminded me of the nightmares war veterans had reported to me: seeing the precise, unadulterated images of faces and body parts they had encountered in battle. These dreams were so terrifying that they tried to not fall asleep at night; only daytime napping, which was not associated with nocturnal ambushes, felt halfway safe.

  During this stage of therapy Marilyn was repeatedly flooded with images and sensations related to the choking dream. She remembered sitting in the kitchen as a four-year-old with swollen eyes, a sore neck, and a bloody nose, while her father and brother laughed at her and called her a stupid, stupid girl. One day Marilyn reported, “As I was brushing my teeth last evening, I was overcome with feelings of thrashing around. I was like a fish out of water, violently turning my body as I fought against the lack of air. I sobbed and choked as I brushed my teeth. Panic was rising up out of my chest with the feeling of thrashing. I had to use every bit of strength I had not to scream, ‘NONONONONONO,’ as I stood over the sink.” She went to bed and fell asleep but woke up like clockwork every two hours during the rest of the night.

  Trauma is not stored as a narrative with an orderly beginning, middle, and end. As I’ll discuss in detail in chapters 11 and 12, memories initially return as they did for Marilyn: as flashbacks that contain fragments of the experience, isolated images, sounds, and body sensations that initially have no context other than fear and panic. When Marilyn was a child, she had no way of giving voice to the unspeakable, and it would have made no difference anyway—nobody was listening.

  Like so many survivors of childhood abuse, Marilyn exemplified the power of the life force, the will to live and to own one’s life, the energy that counteracts the annihilation of trauma. I gradually came to realize that the only thing that makes it possible to do the work of healing trauma is awe at the dedication to survival that enabled my patients to endure their abuse and then to endure the dark nights of the soul that inevitably occur on the road to recovery.

  CHAPTER 9

  WHAT’S LOVE GOT TO DO WITH IT?

  Initiation, intimidation, stigmatization, isolation, helplessness and self-blame depend on a terrifying reality of child sexual abuse. . . . “Don’t worry about things like that; that could never happen in our family.” “How could you ever think of such a terrible thing?” “Don’t let me ever hear you say anything like that again!” The average child never asks and never tells.

  —Roland Summit The Child Sexual Abuse Accommodation Syndrome

  How do we organize our thinking with regard to individuals like Marilyn, Mary, and Kathy, and what can we do to help them? The way we define their problems, our diagnosis, will determine how we approach their care. Such patients typically receive five or six different unrelated diagnoses in the course of their psychiatric treatment. If their doctors focus on their mood swings, they will be identified as bipolar and prescribed lithium or valproate. If the professionals are most impressed with their despair, they will be told they are suffering from major depression and given antidepressants. If the doctors focus on their restlessness and lack of attention, they may be categorized as ADHD and treated with Ritalin or other stimulants. And if the clinic staff happens to take a trauma history, and the patient actually volunteers the relevant information, he or she might receive the diagnosis of PTSD. None of these diagnoses will be completely off the mark, and none of them will begin to meaningfully describe who these patients are and what they suffer from.

  Psychiatry, as a subspecialty of medicine, aspires to define mental illness as precisely as, let’s say, cancer of the pancreas, or streptococcal infection of the lungs. However, given the complexity of mind, brain, and human attachment systems, we have not come even close to achieving that sort of precision. Understanding what is “wrong” with people currently is more a question of the mind-set of the practitioner (and of what insurance companies will pay for) than of verifiable, objective facts.

  The first serious attempt to create a systematic manual of psychiatric diagnoses occurred in 1980, with the release of the thi
rd edition of the Diagnostic and Statistical Manual of Mental Disorders, the official list of all mental diseases recognized by the American Psychiatric Association (APA). The preamble to the DSM-III warned explicitly that its categories were insufficiently precise to be used in forensic settings or for insurance purposes. Nonetheless it gradually became an instrument of enormous power: Insurance companies require a DSM diagnosis for reimbursement, until recently all research funding was based on DSM diagnoses, and academic programs are organized around DSM categories. DSM labels quickly found their way into the larger culture as well. Millions of people know that Tony Soprano suffered from panic attacks and depression and that Carrie Mathison of Homeland struggles with bipolar disorder. The manual has become a virtual industry that has earned the American Psychiatric Association well over $100 million.1 The question is: Has it provided comparable benefits for the patients it is meant to serve?

  A psychiatric diagnosis has serious consequences: Diagnosis informs treatment, and getting the wrong treatment can have disastrous effects. Also, a diagnostic label is likely to attach to people for the rest of their lives and have a profound influence on how they define themselves. I have met countless patients who told me that they “are” bipolar or borderline or that they “have” PTSD, as if they had been sentenced to remain in an underground dungeon for the rest of their lives, like the Count of Monte Cristo.