The Body Keeps the Score

by Bessel van der Kolk MD

  Helen’s story reminds me of the abused, recalcitrant, uncommunicative kids we see in our residential treatment programs. Before she acquired language, she was bewildered and self-centered—looking back, she called that creature “Phantom.” And indeed, our kids come across as phantoms until they can discover who they are and feel safe enough to communicate what is going on with them.

  In a later book, The World I Live In, Keller again described her birth into selfhood: “Before my teacher came to me, I did not know that I am. I lived in a world that was a no-world. . . . I had neither will nor intellect. . . . I can remember all this, not because I knew that it was so, but because I have tactual memory. It enables me to remember that I never contracted my forehead in the act of thinking.”9

  Helen’s “tactual” memories—memories based only on touch—could not be shared. But language opened up the possibility of joining a community. At age eight, when Helen went with Anne to the Perkins Institution for the Blind in Boston (where Sullivan herself had trained), she became able to communicate with other children for the first time: “Oh, what happiness!” she wrote. “To talk freely with other children! To feel at home in the great world!”

  Helen’s discovery of language with the help of Anne Sullivan captures the essence of a therapeutic relationship: finding words where words were absent before and, as a result, being able to share your deepest pain and deepest feelings with another human being. This is one of most profound experiences we can have, and such resonance, in which hitherto unspoken words can be discovered, uttered, and received, is fundamental to healing the isolation of trauma—especially if other people in our lives have ignored or silenced us. Communicating fully is the opposite of being traumatized.

  KNOWING YOURSELF OR TELLING YOUR STORY? OUR DUAL AWARENESS SYSTEM

  Anyone who enters talk therapy, however, almost immediately confronts the limitations of language. This was true of my own psychoanalysis. While I talk easily and can tell interesting tales, I quickly realized how difficult it was to feel my feelings deeply and simultaneously report them to someone else. When I got in touch with the most intimate, painful, or confusing moments of my life, I often found myself faced with a choice: I could either focus on reliving old scenes in my mind’s eye and let myself feel what I had felt back then, or I could tell my analyst logically and coherently what had transpired. When I chose the latter, I would quickly lose touch with myself and start to focus on his opinion of what I was telling him. The slightest hint of doubt or judgment would shut me down, and I would shift my attention to regaining his approval.

  Since then neuroscience research has shown that we possess two distinct forms of self-awareness: one that keeps track of the self across time and one that registers the self in the present moment. The first, our autobiographical self, creates connections among experiences and assembles them into a coherent story. This system is rooted in language. Our narratives change with the telling, as our perspective changes and as we incorporate new input.

  The other system, moment-to-moment self-awareness, is based primarily in physical sensations, but if we feel safe are not rushed, we can find words to communicate that experience as well. These two ways of knowing are localized in different parts of the brain that are largely disconnected from each other.10 Only the system devoted to self-awareness, which is based in the medial prefrontal cortex, can change the emotional brain.

  In the groups I used to lead for veterans, I could sometimes see these two systems working side by side. The soldiers told horrible tales of death and destruction, but I noticed that their bodies often simultaneously radiated a sense of pride and belonging. Similarly, many patients tell me about the happy families they grew up in while their bodies are slumped over and their voices sound anxious and uptight. One system creates a story for public consumption, and if we tell that story often enough, we are likely to start believing that it contains the whole truth. But the other system registers a different truth: how we experience the situation deep inside. It is this second system that needs to be accessed, befriended, and reconciled.

  Just recently at my teaching hospital, a group of psychiatric residents and I interviewed a young woman with temporal lobe epilepsy who was being evaluated following a suicide attempt. The residents asked her standard questions about her symptoms, the medications she was taking, how old she was when the diagnosis was made, what had made her try to kill herself. She responded in a flat, matter-of-fact voice: She’d been five when she was diagnosed. She’d lost her job; she knew she’d been faking it; she felt worthless. For some reason one of the residents asked whether she had been sexually abused. That question surprised me: She had given us no indication that she had had problems with intimacy or sexuality, and I wondered if the doctor was pursuing a private agenda.

  Yet the story our patient told did not explain why she had fallen apart after losing her job. So I asked her what it had been like for that five-year-old girl to be told that something was wrong with her brain. That forced her to check in with herself, as she had no ready-made script for that question. In a subdued tone of voice she told us that the worst part of her diagnosis was that afterward her father wanted nothing more to do with her: “He just saw me as a defective child.” Nobody had supported her, she said, so she basically had to manage by herself.

  I then asked her how she felt now about that little girl with newly diagnosed epilepsy who was left on her own. Instead of crying for her loneliness or being angry about the lack of support, she said fiercely: “She was stupid, whiny, and dependent. She should have stepped up to the plate and sucked it up.” That passion obviously came from the part of her that had valiantly tried to cope with her distress, and I acknowledged that it probably had helped her survive back then. I asked her to allow that frightened, abandoned girl to tell her what it had been like to be all alone, her illness compounded by family rejection. She started to sob and kept quiet for a long time until finally she said: “No, she did not deserve that. She should have been supported; somebody should have looked after her.” Then she shifted again and proudly told me about her accomplishments—how much she’d achieved despite that lack of support. Public story and inner experience finally met.

  THE BODY IS THE BRIDGE

  Trauma stories lessen the isolation of trauma, and they provide an explanation for why people suffer the way they do. They allow doctors to make diagnoses, so that they can address problems like insomnia, rage, nightmares, or numbing. Stories can also provide people with a target to blame. Blaming is a universal human trait that helps people feel good while feeling bad, or, as my old teacher Elvin Semrad used to say: “Hate makes the world go round.” But stories also obscure a more important issue, namely, that trauma radically changes people: that in fact they no longer are “themselves.”

  It is excruciatingly difficult to put that feeling of no longer being yourself into words. Language evolved primarily to share “things out there,” not to communicate our inner feelings, our interiority. (Again, the language center of the brain is about as far removed from the center for experiencing one’s self as is geographically possible.) Most of us are better at describing someone else than we are at describing ourselves. As I once heard Harvard psychologist Jerome Kagan say: “The task of describing most private experiences can be likened to reaching down to a deep well to pick up small fragile crystal figures while you are wearing thick leather mittens.”11

  We can get past the slipperiness of words by engaging the self-observing, body-based self system, which speaks through sensations, tone of voice, and body tensions. Being able to perceive visceral sensations is the very foundation of emotional awareness.12 If a patient tells me that he was eight when his father deserted the family, I am likely to stop and ask him to check in with himself: What happens inside when he tells me about that boy who never saw his father again? Where is it registered in his body? When you activate your gut feelings and listen to your heartbreak—when you follo
w the interoceptive pathways to your innermost recesses—things begin to change.

  WRITING TO YOURSELF

  There are other ways to access your inner world of feelings. One of the most effective is through writing. Most of us have poured out our hearts in angry, accusatory, plaintive, or sad letters after people have betrayed or abandoned us. Doing so almost always makes us feel better, even if we never send them. When you write to yourself, you don’t have to worry about other people’s judgment—you just listen to your own thoughts and let their flow take over. Later, when you reread what you wrote, you often discover surprising truths.

  As functioning members of society, we’re supposed to be “cool” in our day-to-day interactions and subordinate our feelings to the task at hand. When we talk with someone with whom we don’t feel completely safe, our social editor jumps in on full alert and our guard is up. Writing is different. If you ask your editor to leave you alone for a while, things will come out that you had no idea were there. You are free to go into a sort of a trance state in which your pen (or keyboard) seems to channel whatever bubbles up from inside. You can connect those self-observing and narrative parts of your brain without worrying about the reception you’ll get.

  In the practice called free writing, you can use any object as your own personal Rorschach test for entering a stream of associations. Simply write the first thing that comes to your mind as you look at the object in front of you and then keep going without stopping, rereading, or crossing out. A wooden spoon on the counter may trigger memories of making tomato sauce with your grandmother—or of being beaten as a child. The teapot that’s been passed down for generations may take you meandering to the furthest reaches of your mind to the loved ones you’ve lost or family holidays that were a mix of love and conflict. Soon an image will emerge, then a memory, and then a paragraph to record it. Whatever shows up on the paper will be a manifestation of associations that are uniquely yours.

  My patients often bring in fragments of writing and drawings about memories that they may not yet be ready to discuss. Reading the content out loud would probably overwhelm them, but they want me to be aware of what they are wrestling with. I tell them how much I appreciate their courage in allowing themselves to explore hitherto hidden parts of themselves and in entrusting me with them. These tentative communications guide my treatment plan—for example, by helping me to decide whether to add somatic processing, neurofeedback, or EMDR to our current work.

  As far as I’m aware, the first systematic test of the power of language to relieve trauma was done in 1986, when James Pennebaker at the University of Texas in Austin turned his introductory psychology class into an experimental laboratory. Pennebaker started off with a healthy respect for the importance of inhibition, of keeping things to yourself, which he viewed as the glue of civilization.13 But he also assumed that people pay a price for trying to suppress being aware of the elephant in the room.

  He began by asking each student to identify a deeply personal experience that they’d found very stressful or traumatic. He then divided the class into three groups: One would write about what was currently going on in their lives; the second would write about the details of the traumatic or stressful event; and the third would recount the facts of the experience, their feelings and emotions about it, and what impact they thought this event had had on their lives. All of the students wrote continuously for fifteen minutes on four consecutive days while sitting alone in a small cubicle in the psychology building.

  The students took the study very seriously; many revealed secrets that they had never told anyone. They often cried as they wrote, and many confided in the course assistants that they’d become preoccupied with these experiences. Of the two hundred participants, sixty-five wrote about a childhood trauma. Although the death of a family member was the most frequent topic, 22 percent of the women and 10 percent of the men reported sexual trauma prior to the age of seventeen.

  The researchers asked the students about their health and were surprised how often the students spontaneously reported histories of major and minor health problems: cancer, high blood pressure, ulcers, flu, headaches, and earaches.14 Those who reported a traumatic sexual experience in childhood had been hospitalized an average of 1.7 days in the previous year—almost twice the rate of the others.

  The team then compared the number of visits to the student health center participants had made during the month prior to the study to the number in the month following it. The group that had written about both the facts and the emotions related to their trauma clearly benefited the most: They had a 50 percent drop in doctor visits compared with the other two groups. Writing about their deepest thoughts and feelings about traumas had improved their mood and resulted in a more optimistic attitude and better physical health.

  When the students themselves were asked to assess the study, they focused on how it had increased their self-understanding: “It helped me think about what I felt during those times. I never realized how it affected me before.” “I had to think and resolve past experiences. One result of the experiment was peace of mind. To have to write about emotions and feelings helped me understand how I felt and why.”15

  In a subsequent study Pennebaker asked half of a group of seventy-two students to talk into a tape recorder about the most traumatic experience of their lives; the other half discussed their plans for the rest of the day. As they spoke, researchers monitored their physiological reactions: blood pleasure, heart rate, muscle tension, and hand temperature.16 This study had similar results: Those who allowed themselves to feel their emotions showed significant physiological changes, both immediate and long term. During their confessions blood pressure, heart rate, and other autonomic functions increased, but afterward their arousal fell to levels below where they had been at the start of the study. The drop in blood pressure could still be measured six weeks after the experiment ended.

  It is now widely accepted that stressful experiences—whether divorce or final exams or loneliness—have a negative effect on immune function, but this was a highly controversial notion at the time of Pennebaker’s study. Building on his protocols, a team of researchers at the Ohio State University College of Medicine compared two groups of students who wrote either about a personal trauma or about a superficial topic.17 Again, those who wrote about personal traumas had fewer visits to the student health center, and their improved health correlated with improved immune function, as measured by the action of T lymphocytes (natural killer cells) and other immune markers in the blood. This effect was most obvious directly after the experiment, but it could still be the detected six weeks later. Writing experiments from around the world, with grade school students, nursing home residents, medical students, maximum-security prisoners, arthritis sufferers, new mothers, and rape victims, consistently show that writing about upsetting events improves physical and mental health.

  Another aspect of Pennebaker’s studies caught my attention: When his subjects talked about intimate or difficult issues, they often changed their tone of voice and speaking style. The differences were so striking that Pennebaker wondered if he had mixed up his tapes. For example, one woman described her plans for the day in a childlike, high-pitched voice, but a few minutes later, when she described stealing one hundred dollars from an open cash register, both the volume and pitch of her voice became so much lower that she sounded like an entirely different person. Alterations in emotional states were also reflected in the subjects’ handwriting. As participants changed topics, they might move from cursive to block letters and back to cursive; there were also variations in the slant of the letters and in the pressure of their pens.

  Such changes are called “switching” in clinical practice, and we see them often in individuals with trauma histories. Patients activate distinctly different emotional and physiological states as they move from one topic to another. Switching manifests not only as remarkably different vocal patterns but al
so in different facial expressions and body movements. Some patients even appear to change their personal identity, from timid to forceful and aggressive or from anxiously compliant to starkly seductive. When they write about their deepest fears, their handwriting often becomes more childlike and primitive.

  If patients who present in such dramatically different states are treated as fakes, or if they are told to stop showing their unpredictably annoying parts, they are likely to become mute. They probably will continue to seek help, but after they have been silenced they will transmit their cries for help not by talking but by acting: with suicide attempts, depression, and rage attacks. As we will see in chapter 17, they will improve only if both patient and therapist appreciate the roles that these different states have played in their survival.

  ART, MUSIC, AND DANCE

  There are thousands of art, music, and dance therapists who do beautiful work with abused children, soldiers suffering from PTSD, incest victims, refugees, and torture survivors, and numerous accounts attest to the effectiveness of expressive therapies.18 However, at this point we know very little about how they work or about the specific aspects of traumatic stress they address, and it would present an enormous logistical and financial challenge to do the research necessary to establish their value scientifically.

  The capacity of art, music, and dance to circumvent the speechlessness that comes with terror may be one reason they are used as trauma treatments in cultures around the world. One of the few systematic studies to compare nonverbal artistic expression with writing was done by James Pennebaker and Anne Krantz, a San Francisco dance and movement therapist.19 One-third of a group of sixty-four students was asked to disclose a personal traumatic experience through expressive body movements for at least ten minutes a day for three consecutive days and then to write about it for another ten minutes. A second group danced but did not write about their trauma, and a third group engaged in a routine exercise program. Over the three following months members of all groups reported that they felt happier and healthier. However, only the expressive movement group that also wrote showed objective evidence: better physical health and an improved grade-point average. (The study did not evaluate specific PTSD symptoms.) Pennebaker and Krantz concluded: “The mere expression of the trauma is not sufficient. Health does appear to require translating experiences into language.”