The Body Keeps the Score

by Bessel van der Kolk MD

  Until it lost its patent, the pharmaceutical company Johnson & Johnson doled out LEGO blocks stamped with the word “Risperdal” for the waiting rooms of child psychiatrists. Children from low-income families are four times as likely as the privately insured to receive antipsychotic medicines. In one year alone Texas Medicaid spent $96 million on antipsychotic drugs for teenagers and children—including three unidentified infants who were given the drugs before their first birthdays.62 There have been no studies on the effects of psychotropic medications on the developing brain. Dissociation, self-mutilation, fragmented memories, and amnesia generally do not respond to any of these medications.

  The Prozac study that I discussed in chapter 2 was the first to discover that traumatized civilians tend to respond much better to medications than do combat veterans.63 Since then other studies have found similar discrepancies. In this light it is worrisome that the Department of Defense and the VA prescribe enormous quantities of medications to combat soldiers and returning veterans, often without providing other forms of therapy. Between 2001 and 2011 the VA spent about $1.5 billion on Seroquel and Risperdal, while Defense spent about $90 million during the same period, even though a research paper published in 2001 showed that Risperdal was no more effective than a placebo in treating PTSD.64 Similarly, between 2001 and 2012 the VA spent $72.1 million and Defense spent $44.1 million on benzodiazepines65—medications that clinicians generally avoid prescribing to civilians with PTSD because of their addiction potential and lack of significant effectiveness for PTSD symptoms.

  THE ROAD OF RECOVERY IS THE ROAD OF LIFE

  In the first chapter of this book I introduced you to a patient named Bill whom I met over thirty years ago at the VA. Bill became one of my longtime patient-teachers, and our relationship is also the story of my evolution of trauma treatment.

  Bill had served as a medic in Vietnam in 1967–71, and after he returned, he tried to use the skills he had learned in the army by working on a burn unit in a local hospital. Nursing kept him frazzled, explosive, and on edge, but he had no idea that these problems had anything to do with what he had experienced in Vietnam. After all, the PTSD diagnosis did not yet exist, and Irish working-class guys in Boston didn’t consult shrinks. His nightmares and insomnia subsided a bit after he left nursing and enrolled in a seminary to become a minister. He did not seek help until after his first son was born in 1978.

  The baby’s crying triggered unrelenting flashbacks, in which he saw, heard, and smelled burned and mutilated children in Vietnam. He was so out of control that some of my colleagues at the VA wanted to put him in the hospital to treat what they thought was a psychosis. However, as he and I started to work together and he began to feel safe with me, he gradually opened up about what he had witnessed in Vietnam, and he slowly started to tolerate his feelings without becoming overwhelmed. This helped him to refocus on taking care of his family and on finishing his training as a minister. After two years he was a pastor with his own parish, and we felt that our work was done.

  I had no further contact with Bill until he called me up eighteen years to the day after I first met him. He was experiencing exactly the same symptoms—flashbacks, terrible nightmares, feelings that he was going crazy—that he’d had right after his baby was born. That son had just turned eighteen, and Bill had accompanied him to register for the draft—at the same armory from which Bill himself had been shipped off to Vietnam. By then I knew much more about treating traumatic stress, and Bill and I dealt with the specific memories of what he had seen, heard, and smelled back in Vietnam, details that he had been too scared to recall when we first met. We could now integrate these memories with EMDR, so that they became stories of what happened long ago instead of instant transports into the hell of Vietnam. Once he felt more settled, he wanted to deal with his childhood: his brutal upbringing and his guilt about having left behind his younger schizophrenic brother when he enlisted for Vietnam, unprotected against their father’s violent outbursts.

  Another important theme of our time together was the day-to-day pain Bill confronted as a minister—having to bury adolescents killed in car crashes only a few years after he’d baptized them or having couples he’d married come back in crisis over domestic violence. Bill went on to organize a support group for fellow clergy faced with similar traumas, and he became an important force in his community.

  Bill’s third treatment started five years later, when he developed a serious neurological illness at age fifty-three. He had suddenly started to experience episodic paralysis in several parts of his body, and he was beginning to accept that he would probably spend the rest of his life in a wheelchair. I thought his problems might be due to multiple sclerosis, but his neurologists could not find specific lesions, and they said there was no cure for his condition. He told me how grateful he was for his wife’s support. She already had arranged to have a wheelchair ramp built to the kitchen entrance to their house.

  Given his grim prognosis, I urged Bill to find a way to fully feel and befriend the distressing feelings in his body, just as he had learned to tolerate and live with his most painful memories of the war. I suggested that he consult a body worker who had introduced me to Feldenkrais, a gentle, hands-on approach to rearranging physical sensations and muscle movements. When Bill came back to report on how he was doing, he expressed delight with his increased sense of control. I mentioned that I’d recently started to do yoga myself and that we had just opened up a yoga program at the Trauma Center. I invited him to explore that as his next step.

  Bill found a local Bikram yoga class, a hot and intense practice usually reserved for young and energetic people. Bill loved it, even though parts of his body occasionally gave way in class. Despite his physical disability, he gained a sense of bodily pleasure and mastery that he had never felt before.

  Bill’s psychological treatment had helped him put the horrendous experience of Vietnam in the past. Now befriending his body was keeping him from organizing his life around the loss of physical control. He decided to become certified as a yoga instructor, and he began teaching yoga at his local armory to the veterans who were returning from Iraq and Afghanistan.

  Today, ten years later, Bill continues to be fully engaged in life—with his children and grandchildren, through his work with veterans, and in his church. He copes with his physical limitations as an inconvenience. To date he has taught yoga classes to more than 1,300 returning combat veterans. He still regularly suffers from the sudden weakness in his limbs that requires him to sit or lie down. But, like his memories of childhood and Vietnam, these episodes do not dominate his existence. They are simply part of the ongoing, evolving story of his life.

  CHAPTER 14

  LANGUAGE: MIRACLE AND TYRANNY

  Give sorrow words; the grief that does not speak knits up the o’er wrought heart and bids it break.

  —William Shakespeare, Macbeth

  We can hardly bear to look. The shadow may carry the best of the life we have not lived. Go into the basement, the attic, the refuse bin. Find gold there. Find an animal who has not been fed or watered. It is you!! This neglected, exiled animal, hungry for attention, is a part of your self.

  —Marion Woodman (as quoted by Stephen Cope in The Great Work of Your Life)

  In September 2001 several organizations, including the National Institutes of Health, Pfizer pharmaceuticals, and the New York Times Company Foundation, organized expert panels to recommend the best treatments for people traumatized by the attacks on the World Trade Center. Because many widely used trauma interventions had never been carefully evaluated in random communities (as opposed to patients who seek psychiatric help), I thought that this presented an extraordinary opportunity to compare how well a variety of different approaches would work. My colleagues were more conservative, and after lengthy deliberations the committees recommended only two forms of treatment: psychoanalytically oriented therapy and cognitive behavioral therapy. Why
analytic talk therapy? Since Manhattan is one of the last bastions of Freudian psychoanalysis, it would have been bad politics to exclude a substantial proportion of local mental health practitioners. Why CBT? Because behavioral treatment can be broken down into concrete steps and “manualized” into uniform protocols, it is the favorite treatment of academic researchers, another group that could not be ignored. After the recommendations were approved, we sat back and waited for New Yorkers to find their way to therapists’ offices. Almost nobody showed up.

  Dr. Spencer Eth, who ran the psychiatry department at the now-defunct St. Vincent’s Hospital in Greenwich Village, was curious where survivors had turned for help, and early in 2002, together with some medical students, he conducted a survey of 225 people who had escaped from the Twin Towers. Asked what had been most helpful in overcoming the effects of their experience, the survivors credited acupuncture, massage, yoga, and EMDR, in that order.1 Among rescue workers, massages were particularly popular. Eth’s survey suggests that the most helpful interventions focused on relieving the physical burdens generated by trauma. The disparity between the survivors’ experience and the experts’ recommendations is intriguing. Of course, we don’t know how many survivors eventually did seek out more traditional therapies. But the apparent lack of interest in talk therapy raises a basic question: What good is it to talk about your trauma?

  THE UNSPEAKABLE TRUTH

  Therapists have an undying faith in the capacity of talk to resolve trauma. That confidence dates back to 1893, when Freud (and his mentor, Breuer) wrote that trauma “immediately and permanently disappeared when we had succeeded in bringing clearly to light the memory of the event by which it was provoked and in arousing its accompanying affect, and when the patient had described that event in the greatest possible detail and had put the affect into words.”2

  Unfortunately, it’s not so simple: Traumatic events are almost impossible to put into words. This is true for all of us, not just for people who suffer from PTSD. The initial imprints of the events of September 11 were not stories but images: frantic people running down the street, their faces covered with ash; an airplane smashing into Tower One of the World Trade Center; the distant specks that were people jumping hand in hand. Those images were replayed over and over, in our minds and on the TV screen, until Mayor Giuliani and the media helped us create a narrative we could share with one another.

  In Seven Pillars of Wisdom T. E. Lawrence wrote of his war experiences: “We learned that there were pangs too sharp, griefs too deep, ecstasies too high for our finite selves to register. When emotion reached this pitch the mind choked; and memory went white till the circumstances were humdrum once more.”3 While trauma keeps us dumbfounded, the path out of it is paved with words, carefully assembled, piece by piece, until the whole story can be revealed.

  BREAKING THE SILENCE

  Activists in the early campaign for AIDS awareness created a powerful slogan: “Silence = Death.” Silence about trauma also leads to death—the death of the soul. Silence reinforces the godforsaken isolation of trauma. Being able to say aloud to another human being, “I was raped” or “I was battered by my husband” or “My parents called it discipline, but it was abuse” or “I’m not making it since I got back from Iraq,” is a sign that healing can begin.

  We may think we can control our grief, our terror, or our shame by remaining silent, but naming offers the possibility of a different kind of control. When Adam was put in charge of the animal kingdom in the Book of Genesis, his first act was to give a name to every living creature.

  If you’ve been hurt, you need to acknowledge and name what happened to you. I know that from personal experience: As long as I had no place where I could let myself know what it was like when my father locked me in the cellar of our house for various three-year-old offenses, I was chronically preoccupied with being exiled and abandoned. Only when I could talk about how that little boy felt, only when I could forgive him for having been as scared and submissive as he was, did I start to enjoy the pleasure of my own company. Feeling listened to and understood changes our physiology; being able to articulate a complex feeling, and having our feelings recognized, lights up our limbic brain and creates an “aha moment.” In contrast, being met by silence and incomprehension kills the spirit. Or, as John Bowlby so memorably put it: “What can not be spoken to the [m]other cannot be told to the self.”

  If you hide from yourself the fact that an uncle molested you when you were young, you are vulnerable to react to triggers like an animal in a thunderstorm: with a full-body response to the hormones that signal “danger.” Without language and context, your awareness may be limited to: “I’m scared.” Yet, determined to stay in control, you are likely to avoid anybody or anything that reminds you even vaguely of your trauma. You may also alternate between being inhibited and being uptight or reactive and explosive—all without knowing why.

  As long as you keep secrets and suppress information, you are fundamentally at war with yourself. Hiding your core feelings takes an enormous amount of energy, it saps your motivation to pursue worthwhile goals, and it leaves you feeling bored and shut down. Meanwhile, stress hormones keep flooding your body, leading to headaches, muscle aches, problems with your bowels or sexual functions—and irrational behaviors that may embarrass you and hurt the people around you. Only after you identify the source of these responses can you start using your feelings as signals of problems that require your urgent attention.

  Ignoring inner reality also eats away at your sense of self, identity, and purpose. Clinical psychologist Edna Foa and her colleagues developed the Posttraumatic Cognitions Inventory to assess how patients think about themselves.4 Symptoms of PTSD often include statements like “I feel dead inside,” “I will never be able to feel normal emotions again,” “I have permanently changed for the worse,” “I feel like an object, not like a person,” “I have no future,” and “I feel like I don’t know myself anymore.”

  The critical issue is allowing yourself to know what you know. That takes an enormous amount of courage. In What It Is Like to Go to War, Vietnam veteran Karl Marlantes grapples with his memories of belonging to a brilliantly effective Marine combat unit and confronts the terrible split he discovered inside himself:

  For years I was unaware of the need to heal that split, and there was no one, after I returned, to point this out to me. . . . Why did I assume there was only one person inside me? . . . There’s a part of me that just loves maiming, killing, and torturing. This part of me isn’t all of me. I have other elements that indeed are just the opposite, of which I am proud. So am I a killer? No, but part of me is. Am I a torturer? No, but part of me is. Do I feel horror and sadness when I read in the newspapers of an abused child? Yes. But am I fascinated?5

  Marlantes tells us that his road to recovery required learning to tell the truth, even if that truth was brutally painful.

  Death, destruction, and sorrow need to be constantly justified in the absence of some overarching meaning for the suffering. Lack of this overarching meaning encourages making things up, lying, to fill the gap in meaning.6

  I’d never been able to tell anyone what was going on inside. So I forced these images back, away, for years. I began to reintegrate that split-off part of my experience only after I actually began to imagine that kid as a kid, my kid perhaps. Then, out came this overwhelming sadness—and healing. Integrating the feelings of sadness, rage, or all of the above with the action should be standard operating procedure for all soldiers who have killed face-to-face. It requires no sophisticated psychological training. Just form groups under a fellow squad or platoon member who has had a few days of group leadership training and encourage people to talk.7

  Getting perspective on your terror and sharing it with others can reestablish the feeling that you are a member of the human race. After the Vietnam veterans I treated joined a therapy group where they could share the atrocities they had witne
ssed and committed, they reported beginning to open their hearts to their girlfriends.

  THE MIRACLE OF SELF-DISCOVERY

  Discovering your Self in language is always an epiphany, even if finding the words to describe your inner reality can be an agonizing process. That is why I find Helen Keller’s account of how she was “born into language”8 so inspiring.

  When Helen was nineteen months old and just starting to talk, a viral infection robbed her of her sight and hearing. Now deaf, blind, and mute, this lovely, lively child turned into an untamed, isolated creature. After five desperate years her family invited a partially blind teacher, Anne Sullivan, to come from Boston to their home in rural Alabama as Helen’s tutor. Anne began immediately to teach Helen the manual alphabet, spelling words into her hand letter by letter, but it took ten weeks of trying to connect with this wild child before the breakthrough occurred. It came as Anne spelled the word “water” into one of Helen’s hands while she held the other under the water pump.

  Helen later recalled that moment in The Story of My Life: “Water! That word startled my soul, and it awoke, full of the spirit of the morning. . . . Until that day my mind had been like a darkened chamber, waiting for words to enter and light the lamp, which is thought. I learned a great many words that day.”

  Learning the names of things enabled the child not only to create an inner representation of the invisible and inaudible physical reality around her but also to find herself: Six months later she started to use the first-person “I.”