The Body Keeps the Score

by Bessel van der Kolk MD

  However, we still do not know whether this conclusion—that language is essential to healing—is, in fact, always true. Writing studies that have focused on PTSD symptoms (as opposed to general health) have been disappointing. When I discussed this with Pennebaker, he cautioned me that most writing studies of PTSD patients have been done in group settings where participants were expected to share their stories. He reiterated the point I’ve made above—that the object of writing is to write to yourself, to let your self know what you have been trying to avoid.

  THE LIMITS OF LANGUAGE

  Trauma overwhelms listeners as well as speakers. In The Great War in Modern Memory, his masterful study of World War I, Paul Fussell comments brilliantly on the zone of silence that trauma creates:

  One of the cruxes of war . . . is the collision between events and the language available—or thought appropriate—to describe them. . . . Logically there is no reason why the English language could not perfectly well render the actuality of . . . warfare: it is rich in terms like blood, terror, agony, madness, shit, cruelty, murder, sell-out, pain and hoax, as well as phrases like legs blown off, intestines gushing out over his hands, screaming all night, bleeding to death from the rectum, and the like. . . . The problem was less one of “language” than of gentility and optimism. . . . The real reason [that soldiers fall silent] is that soldiers have discovered that no one is very interested in the bad news they have to report. What listener wants to be torn and shaken when he doesn’t have to be? We have made unspeakable mean indescribable: it really means nasty.20

  Talking about painful events doesn’t necessarily establish community—often quite the contrary. Families and organizations may reject members who air the dirty laundry; friends and family can lose patience with people who get stuck in their grief or hurt. This is one reason why trauma victims often withdraw and why their stories become rote narratives, edited into a form least likely to provoke rejection.

  It is an enormous challenge to find safe places to express the pain of trauma, which is why survivor groups like Alcoholics Anonymous, Adult Children of Alcoholics, Narcotics Anonymous, and other support groups can be so critical. Finding a responsive community in which to tell your truth makes recovery possible. That is also why survivors need professional therapists who are trained to listen to the agonizing details of their lives. I recall the first time a veteran told me about killing a child in Vietnam. I had a vivid flashback to when I was about seven years old and my father told me that a child next door had been beaten to death by Nazi soldiers in front of our house for showing a lack of respect. My reaction to the veteran’s confession was too much to bear, and I had to end the session. That is why therapists need to have done their own intensive therapy, so they can take care of themselves and remain emotionally available to their patients, even when their patients’ stories arouse feelings of rage or revulsion.

  A different problem arises when trauma victims themselves become literally speechless—when the language area of the brain shuts down.21 I have seen this shutdown in the courtroom in many immigration cases and also in a case brought against a perpetrator of mass slaughter in Rwanda. When asked to testify about their experiences, victims often become so overwhelmed that they are barely able to speak or are hijacked into such panic that they can’t clearly articulate what happened to them. Their testimony is often dismissed as being too chaotic, confused, and fragmented to be credible.

  Others try to recount their history in a way that keeps them from being triggered. This can make them come across as evasive and unreliable witnesses. I have seen dozens of legal cases dismissed because asylum seekers were unable to give coherent accounts of their reasons for fleeing. I’ve also known numerous veterans whose claims were denied by the Veterans Administration because they could not tell precisely what had happened to them.

  Confusion and mutism are routine in therapy offices: We fully expect that our patients will become overwhelmed if we keep pressing them for the details of their story. For that reason we’ve learned to “pendulate” our approach to trauma, to use a term coined by my friend Peter Levine. We don’t avoid confronting the details, but we teach our patients how to safely dip one toe in the water and then take it out again, thus approaching the truth gradually.

  We start by establishing inner “islands of safety” within the body.22 This means helping patients identify parts of the body, postures, or movements where they can ground themselves whenever they feel stuck, terrified, or enraged. These parts usually lie outside the reach of the vagus nerve, which carries the messages of panic to the chest, abdomen, and throat, and they can serve as allies in integrating the trauma. I might ask a patient if her hands feel okay, and if she says yes, I’ll ask her to move them, exploring their lightness and warmth and flexibility. Later, if I see her chest tighten and her breath almost disappear, I can stop her and ask her to focus on her hands and move them, so that she can feel herself as separate from the trauma. Or I might ask her to focus on her out breath and notice how she can change it, or ask her to lift her arms up and down with each breath—a qigong movement.

  For some patients tapping acupressure points is a good anchor.23 I ask others to feel the weight of their body in the chair or to plant their feet on the floor. I might ask a patient who is collapsing into silence to see what happens when he sits up straight. Some patients discover their own islands of safety—they begin to “get” that they can create body sensations to counterbalance feeling out of control. This sets the stage for trauma resolution: pendulating between states of exploration and safety, between language and body, between remembering the past and feeling alive in the present.

  DEALING WITH REALITY

  Dealing with traumatic memories is, however, just the beginning of treatment. Numerous studies have found that people with PTSD have more general problems with focused attention and with learning new information.24 Alexander McFarlane did a simple test: He asked a group of people to name as many words beginning with the letter B as they could in one minute. Normal subjects averaged fifteen words; those with PTSD averaged three or four. Normal subjects hesitated when they saw threatening words like “blood,” “wound,” or “rape”; McFarlane’s PTSD subjects reacted just as hesitantly to ordinary words like “wool,” “ice cream,” and “bicycle.”25

  After a while most people with PTSD don’t spend a great deal of time or effort on dealing with the past—their problem is simply making it through the day. Even traumatized patients who are making real contributions in teaching, business, medicine, or the arts and who are successfully raising their children expend a lot more energy on the everyday tasks of living than do ordinary mortals.

  Yet another pitfall of language is the illusion that our thinking can easily be corrected if it doesn’t “make sense.” The “cognitive” part of cognitive behavioral therapy focuses on changing such “dysfunctional thinking.” This is a top-down approach to change in which the therapist challenges or “reframes” negative cognitions, as in “Let’s compare your feelings that you are to blame for your rape with the actual facts of the matter” or “Let’s compare your terror of driving with the statistics about road safety today.”

  I’m reminded of the distraught woman who once came to our clinic asking for help with her two-month-old because the baby was “so selfish.” Would she have benefited from a fact sheet on child development or an explanation of the concept of altruism? Such information would be unlikely to help her until she gained access to the frightened, abandoned parts of herself—the parts expressed by her terror of dependence.

  There is no question traumatized people have irrational thoughts: “I was to blame for being so sexy.” “The other guys weren’t afraid—they’re real men.” “I should have known better than to walk down that street.” It’s best to treat those thoughts as cognitive flashbacks—you don’t argue with them any more than you would argue with someone who keeps having visual flashbacks of a terrible
accident. They are residues of traumatic incidents: thoughts they were thinking when, or shortly after, the traumas occurred that are reactivated under stressful conditions. A better way to treat them is with EMDR, the subject of the following chapter.

  BECOMING SOME BODY

  The reason people become overwhelmed by telling their stories, and the reason they have cognitive flashbacks, is that their brains have changed. As Freud and Breuer observed, trauma does not simply act as a releasing agent for symptoms. Rather, “the psychical trauma—or more precisely the memory of the trauma—acts like a foreign body which long after its entry must continue to be regarded as an agent that still is at work.”26 Like a splinter that causes an infection, it is the body’s response to the foreign object that becomes the problem more than the object itself.

  Modern neuroscience solidly supports Freud’s notion that many of our conscious thoughts are complex rationalizations for the flood of instincts, reflexes, motives, and deep-seated memories that emanate from the unconscious. As we have seen, trauma interferes with the proper functioning of brain areas that manage and interpret experience. A robust sense of self—one that allows a person to state confidently, “This is what I think and feel” and “This is what is going on with me”—depends on a healthy and dynamic interplay among these areas.

  Almost every brain-imaging study of trauma patients finds abnormal activation of the insula. This part of the brain integrates and interprets the input from the internal organs—including our muscles, joints, and balance (proprioceptive) system—to generate the sense of being embodied. The insula can transmit signals to the amygdala that trigger fight/fight responses. This does not require any cognitive input or any conscious recognition that something has gone awry—you just feel on edge and unable to focus or, at worst, have a sense of imminent doom. These powerful feelings are generated deep inside the brain and cannot be eliminated by reason or understanding.

  Being constantly assaulted by, but consciously cut off from, the origin of bodily sensations produces alexithymia: not being able to sense and communicate what is going on with you. Only by getting in touch with your body, by connecting viscerally with your self, can you regain a sense of who you are, your priorities and values. Alexithymia, dissociation, and shutdown all involve the brain structures that enable us to focus, know what we feel, and take action to protect ourselves. When these essential structures are subjected to inescapable shock, the result may be confusion and agitation, or it may be emotional detachment, often accompanied by out-of-body experiences—the feeling you’re watching yourself from far away. In other words trauma makes people feel like either some body else, or like no body. In order to overcome trauma, you need help to get back in touch with your body, with your Self.

  There is no question that language is essential: Our sense of Self depends on being able to organize our memories into a coherent whole.27 This requires well-functioning connections between the conscious brain and the self system of the body—connections that often are damaged by trauma. The full story can be told only after those structures are repaired and after the groundwork has been laid: after no body becomes some body.

  CHAPTER 15

  LETTING GO OF THE PAST: EMDR

  Was it a vision, or a waking dream?

  Fled is that music;—Do I wake or sleep?

  —John Keats

  David, a middle-aged contractor, came to see me because his violent rage attacks were making his home a living hell. During our first session he told me a story about something that had happened to him the summer he was twenty-three. He was working as a lifeguard, and one afternoon a group of kids were roughhousing in the pool and drinking beer. David told them alcohol was not allowed. In response the boys attacked him, and one of them took out his left eye with a broken beer bottle. Thirty years later he still had nightmares and flashbacks about the stabbing.

  He was merciless in his criticisms of his own teenage son and often yelled at him for the slightest infraction, and he simply could not bring himself to show any affection toward his wife. On some level he felt that the tragic loss of his eye gave him permission to abuse other people, but he also hated the angry, vengeful person he had become. He had noticed that his efforts to manage his rage made him chronically tense, and he wondered if his fear of losing control had made love and friendship impossible.

  During his second visit I introduced a procedure called eye movement desensitization and reprocessing (EMDR). I asked David to go back to the details of his assault and bring to mind his images of the attack, the sounds he had heard, and the thoughts that had gone through his mind. “Just let those moments come back,” I told him.

  I then asked him to follow my index finger as I moved it slowly back and forth about twelve inches from his right eye. Within seconds a cascade of rage and terror came to the surface, accompanied by vivid sensations of pain, blood running down his cheek, and the realization that he couldn’t see. As he reported these sensations, I made an occasional encouraging sound and kept moving my finger back and forth. Every few minutes I stopped and asked him to take a deep breath. Then I asked him to pay attention to what was now on his mind, which was a fight he had had in school. I told him to notice that and to stay with that memory. Other memories emerged, seemingly at random: looking for his assailants everywhere, wanting to hurt them, getting into barroom brawls. Each time he reported a new memory or sensation, I urged him to notice what was coming to mind and resumed the finger movements.

  At the end of that visit he looked calmer and visibly relieved. He told me that the memory of the stabbing had lost its intensity—it was now something unpleasant that had happened a long time ago. “It really sucked,” he said thoughtfully, “and it kept me off-kilter for years, but I’m surprised what a good life I eventually was able to carve out for myself.”

  Our third session, the following week, dealt with the aftermath of the trauma: how he had used drugs and alcohol for years to cope with his rage. As we repeated the EMDR sequences, still more memories arose. David remembered talking with a prison guard he knew about having his incarcerated assailant killed and then changing his mind. Recalling this decision was profoundly liberating: He had come to see himself as a monster who was barely in control, but realizing that he’d turned away from revenge put him back in touch with a mindful, generous side of himself.

  Next he spontaneously realized he was treating his son the way he had felt toward his teenaged attackers. As our session ended, he asked if I could meet with him and his family so he could tell his son what had happened and ask for his forgiveness. At our fifth and final session he reported that he was sleeping better and said that for the first time in his life he felt a sense of inner peace. A year later he called to report not only that his he and wife had grown closer and had started to practice yoga together but also that he laughed more and took real pleasure in his gardening and woodworking.

  LEARNING ABOUT EMDR

  My experience with David is one of many I have had over the past two decades in which EMDR helped to make painful re-creations of the trauma a thing of the past. My introduction to this method came through Maggie, a spunky young psychologist who ran a halfway house for sexually abused girls. Maggie got into one confrontation after another, clashing with nearly everybody—except the thirteen- and fourteen-year-old girls she cared for. She did drugs, had dangerous and often violent boyfriends, had frequent altercations with her bosses, and moved from place to place because she could not tolerate her roommates (nor they her). I never understood how she had mobilized enough stability and concentration to earn a PhD in psychology from a reputable graduate school.

  Maggie had been referred to a therapy group I was running for women with similar problems. During her second meeting she told us that her father had raped her twice, once when she was five years old and once when she was seven. She was convinced it had been her fault. She loved her daddy, she explained, and she must have been so seductive
that he could not control himself. Listening to her I thought, “She might not blame her father, but she sure is blaming just about everybody else”—including her previous therapists for not helping her get better. Like many trauma survivors, she told one story with words and another in her actions, in which she kept replaying various aspects of her trauma.

  Then one day Maggie came to the group eager to discuss a remarkable experience she’d had the previous weekend at an EMDR training for professionals. At that time I’d heard only that EMDR was a new fad in which therapists wiggled their fingers in front of patients’ eyes. To me and my academic colleagues, it sounded like yet another of the crazes that have always plagued psychiatry, and I was convinced that this would turn out to be another of Maggie’s misadventures.

  Maggie told us that during her EMDR session she had vividly remembered her father’s rape when she was seven—remembered it from inside her child’s body. She could feel physically how small she was; she could feel her father’s huge body on top of her and could smell the alcohol on his breath. And yet, she told us, even as she relived the incident she was able to observe it from the point of view of her twenty-nine-year-old self. She burst into tears: “I was such a little girl. How could a huge man do this to a little girl?” She cried for a while and then said: “It’s over now. I now know what happened. It wasn’t my fault. I was a little girl and there was nothing I could do to keep him from molesting me.”