The Body Keeps the Score

by Bessel van der Kolk MD

  The first two years of my therapy with Annie focused on helping her learn to tolerate her physical sensations for what they were—just sensations in the present, with a beginning, a middle, and an end. We worked on helping her stay calm enough to notice what she felt without judgment, so she could observe these unbidden images and feelings as residues of a terrible past and not as unending threats to her life today.

  Patients like Annie continuously challenge us to find new ways of helping people regulate their arousal and control their own physiology. That is how my Trauma Center colleagues and I stumbled upon yoga.

  FINDING OUR WAY TO YOGA: BOTTOM-UP REGULATION

  Our involvement with yoga started in 1998 when Jim Hopper and I first heard about a new biological marker, heart rate variability (HRV), that had recently been discovered to be a good measure of how well the autonomic nervous system is working. As you’ll recall from chapter 5, the autonomic nervous system is our brain’s most elementary survival system, its two branches regulating arousal throughout the body. Roughly speaking, the sympathetic nervous system (SNS) uses chemicals like adrenaline to fuel the body and brain to take action, while the parasympathetic nervous system (PNS) uses acetylcholine to help regulate basic body functions like digestion, wound healing, and sleep and dream cycles. When we’re at our best, these two systems work closely together to keep us in an optimal state of engagement with our environment and with ourselves.

  Heart rate variability measures the relative balance between the sympathetic and the parasympathetic systems. When we inhale, we stimulate the SNS, which results in an increase in heart rate. Exhalations stimulate the PNS, which decreases how fast the heart beats. In healthy individuals inhalations and exhalations produce steady, rhythmical fluctuations in heart rate: Good heart rate variability is a measure of basic well-being.

  Why is HRV important? When our autonomic nervous system is well balanced, we have a reasonable degree of control over our response to minor frustrations and disappointments, enabling us to calmly assess what is going on when we feel insulted or left out. Effective arousal modulation gives us control over our impulses and emotions: As long as we manage to stay calm, we can choose how we want to respond. Individuals with poorly modulated autonomic nervous systems are easily thrown off balance, both mentally and physically. Since the autonomic nervous system organizes arousal in both body and brain, poor HRV—that is, a lack of fluctuation in heart rate in response to breathing—not only has negative effects on thinking and feeling but also on how the body responds to stress. Lack of coherence between breathing and heart rate makes people vulnerable to a variety of physical illnesses, such as heart disease and cancer, in addition to mental problems such as depression and PTSD.2

  In order to study this issue further, we acquired a machine to measure HRV and started to put bands around the chests of research subjects with and without PTSD to record the depth and rhythm of their breathing while little monitors attached to their earlobes picked up their pulse. After we’d tested about sixty subjects, it became clear that people with PTSD have unusually low HRV. In other words, in PTSD the sympathetic and parasympathetic nervous systems are out of sync.3 This added a new twist to the complicated trauma story: We confirmed that yet another brain regulatory system was not functioning as it should.4 Failure to keep this system in balance is one explanation why traumatized people like Annie are so vulnerable to overrespond to relatively minor stresses: The biological systems that are meant to help us cope with the vagaries of life fail to meet the challenge.

  Our next scientific question was: Is there a way for people to improve their HRV? I had a personal incentive to explore this question, as I had discovered that my own HRV was not nearly robust enough to guarantee long-term physical health. An Internet search turned up studies showing that marathon running markedly increased HRV. Sadly, that was of little use, since neither I nor our patients were good candidates for the Boston Marathon. Google also listed seventeen thousand yoga sites claiming that that yoga improved HRV, but we were unable to find any supporting studies. Yogis may have developed a wonderful method to help people find internal balance and health, but back in 1998 not much work had been done on evaluating their claims with the tools of the Western medical tradition.

  Heart rate variability (HRV) in a well-regulated person. The rising and falling black lines represent breathing, in this case slow and regular inhalations and exhalations. The gray area shows fluctuations in heart rate. Whenever this individual inhales, his heart rate goes up; during exhalations the heart slows down. This pattern of heart rate variability reflects excellent physiological health.

  Responding to upset. When someone remembers an upsetting experience, breathing speeds up and becomes irregular, as does heart rate. Heart and breath no longer stay perfectly in sync. This is a normal response.

  HRV in PTSD. Breathing is rapid and shallow. Heart rate is slow and out of synch with the breath. This is a typical pattern of a shut-down person with chronic PTSD.

  A person with chronic PTSD reliving a trauma memory. Breathing initially is labored and deep, typical of a panic reaction. The heart races out of synch with the breath. This is followed by rapid, shallow breathing and slow heart rate, signs that the person is shutting down.

  Since then, however, scientific methods have confirmed that changing the way one breathes can improve problems with anger, depression, and anxiety5 and that yoga can positively affect such wide-ranging medical problems as high blood pressure, elevated stress hormone secretion,6 asthma, and low-back pain.7 However, no psychiatric journal had published a scientific study of yoga for PTSD until our own work appeared in 2014.8

  As it happened, a few days after our Internet search a lanky yoga teacher named David Emerson walked through the front door of the Trauma Center. He told us that he’d developed a modified form of hatha yoga to deal with PTSD and that he’d been holding classes for veterans at a local vet center and for women in the Boston Area Rape Crisis Center. Would we be interested in working with him? Dave’s visit eventually grew into a very active yoga program, and in due course we received the first grant from the National Institutes of Health to study the effects of yoga on PTSD. Dave’s work also contributed to my developing my own regular yoga practice and becoming a frequent teacher at Kripalu, a yoga center in the Berkshire Mountains in western Massachusetts. (Along the way, my own HRV pattern improved as well.)

  In choosing to explore yoga to improve HRV we were taking an expansive approach to the problem. We could simply have used any of a number of reasonably priced handheld devices that train people to slow their breathing and synchronize it with their heart rate, resulting in a state of “cardiac coherence” like the pattern shown in the first illustration above.9 Today there are a variety of apps that can help improve HRV with the aid of a smartphone.10 In our clinic we have workstations where patients can train their HRV, and I urge all my patients who, for one reason or another, cannot practice yoga, martial arts, or qigong to train themselves at home. (See Resources for more information.)

  EXPLORING YOGA

  Our decision to study yoga led us deeper into trauma’s impact on the body. Our first experimental yoga classes met in a room generously donated by a nearby studio. David Emerson and his colleagues Dana Moore and Jodi Carey volunteered as instructors, and my research team figured out how we could best measure yoga’s effects on psychological functioning. We put flyers in neighborhood supermarkets and laundromats to advertise our classes and interviewed dozens of people who called in response. Ultimately we selected thirty-seven women who had severe trauma histories and who had already received many years of therapy without much benefit. Half the volunteers were selected at random for the yoga group, while the others would receive a well-established mental health treatment, dialectical behavior therapy (DBT), which teaches people how to apply mindfulness to stay calm and in control. Finally, we commissioned an engineer at MIT
to build us a complicated computer that could measure HRV simultaneously in eight different people. (In each study group there were multiple classes, each with no more than eight participants.) While yoga significantly improved arousal problems in PTSD and dramatically improved our subjects’ relationships to their bodies (“I now take care of my body”; “I listen to what my body needs”), eight weeks of DBT did not affect their arousal levels or PTSD symptoms. Thus, our interest in yoga gradually evolved from a focus on learning whether yoga can change HRV (which it can)11 to helping traumatized people learn to comfortably inhabit their tortured bodies.

  Over time we also started a yoga program for marines at Camp Lejeune and have worked successfully with various other programs to implement yoga programs for veterans with PTSD. Even though we have no formal research data on the veterans, it looks as if yoga is at least as effective for them as it has been for the women in our studies.

  All yoga programs consist of a combination of breath practices (pranayama), stretches or postures (asanas), and meditation. Different schools of yoga emphasize variations in intensity and focus within these core components. For example, variations in the speed and depth of breathing and use of the mouth, nostrils, and throat all produce different results, and some techniques have powerful effects on energy.12 In our classes we keep the approach simple. Many of our patients are barely aware of their breath, so learning to focus on the in and out breath, to notice whether the breath was fast or slow, and to count breaths in some poses can be a significant accomplishment.13

  We gradually introduce a limited number of classic postures. The emphasis is not on getting the poses “right” but on helping the participants notice which muscles are active at different times. The sequences are designed to create a rhythm between tension and relaxation—something we hope they will begin to perceive in their day-to-day lives.

  We do not teach meditation as such, but we do foster mindfulness by encouraging students to observe what is happening in different parts of the body from pose to pose. In our studies we keep seeing how difficult it is for traumatized people to feel completely relaxed and physically safe in their bodies. We measure our subjects’ HRV by placing tiny monitors on their arms during shavasana, the pose at the end of most classes during which practitioners lie face up, palms up, arms and legs relaxed. Instead of relaxation we picked up too much muscle activity to get a clear signal. Rather than going into a state of quiet repose, our students’ muscles often continue to prepare them to fight unseen enemies. A major challenge in recovering from trauma remains being able to achieve a state of total relaxation and safe surrender.

  LEARNING SELF-REGULATION

  After seeing the success of our pilot studies, we established a therapeutic yoga program at the Trauma Center. I thought that this might be an opportunity for Annie to develop a more caring relationship with her body, and I urged her to try it. The first class was difficult. Merely being given an adjustment by the instructor was so terrifying that she went home and slashed herself—her malfunctioning alarm system interpreted even a gentle touch on her back as an assault. At the same time Annie realized that yoga might offer her a way to liberate herself from the constant sense of danger that she felt in her body. With my encouragement she returned the following week.

  Annie had always found it easier to write about her experiences than to talk about them. After her second yoga class she wrote to me: “I don’t know all of the reasons that yoga terrifies me so much, but I do know that it will be an incredible source of healing for me and that is why I am working on myself to try it. Yoga is about looking inward instead of outward and listening to my body, and a lot of my survival has been geared around never doing those things. Going to the class today my heart was racing and part of me really wanted to turn around, but then I just kept putting one foot in front of the other until I got to the door and went in. After the class I came home and slept for four hours. This week I tried doing yoga at home and the words came to me ‘Your body has things to say.’ I said back to myself, ‘I will try and listen.’”

  A few days later Annie wrote: “Some thoughts during and after yoga today. It occurred to me how disconnected I must be from my body when I cut it. When I was doing the poses I noticed that my jaw and the whole area from where my legs end to my bellybutton is where I am tight, tense and holding the pain and memories. Sometimes you have asked me where I feel things and I can’t even begin to locate them, but today I felt those places very clearly and it made me want to cry in a gentle kind of way.”

  The following month both of us went on vacation and, invited to stay in touch, Annie wrote to me again: “I’ve been doing yoga on my own in a room that overlooks the lake. I’m continuing to read the book you lent me [Stephen Cope’s wonderful Yoga and the Quest for the True Self]. It’s really interesting to think about how much I have been refusing to listen to my body, which is such an important part of who I am. Yesterday when I did yoga I thought about letting my body tell me the story it wants to tell and in the hip opening poses there was a lot of pain and sadness. I don’t think my mind is going to let really vivid images come up as long as I am away from home, which is good. I think now about how unbalanced I have been and about how hard I have tried to deny the past, which is a part of my true self. There is so much I can learn if I am open to it and then I won’t have to fight myself every minute of every day.”

  One of the hardest yoga positions for Annie to tolerate was one that’s often called Happy Baby, in which you lie on your back with your knees deeply bent and the soles of your feet pointing to the ceiling, while holding your toes with your hands. This rotates the pelvis into a wide-open position. It’s easy to understand why this would make a rape victim feel extremely vulnerable. Yet, as long as Happy Baby (or any posture that resembles it) precipitates intense panic, it is difficult to be intimate. Learning how to comfortably assume Happy Baby is a challenge for many patients in our yoga classes.

  GETTING TO KNOW ME: CULTIVATING INTEROCEPTION

  One of the clearest lessons from contemporary neuroscience is that our sense of ourselves is anchored in a vital connection with our bodies.14 We do not truly know ourselves unless we can feel and interpret our physical sensations; we need to register and act on these sensations to navigate safely through life.15 While numbing (or compensatory sensation seeking) may make life tolerable, the price you pay is that you lose awareness of what is going on inside your body and, with that, the sense of being fully, sensually alive.

  In chapter 6 I discussed alexithymia, the technical term for not being able to identify what is going on inside oneself.16 People who suffer from alexithymia tend to feel physically uncomfortable but cannot describe exactly what the problem is. As a result they often have multiple vague and distressing physical complaints that doctors can’t diagnose. In addition, they can’t figure out for themselves what they’re really feeling about any given situation or what makes them feel better or worse. This is the result of numbing, which keeps them from anticipating and responding to the ordinary demands of their bodies in quiet, mindful ways. At the same time, it muffles the everyday sensory delights of experiences like music, touch, and light, which imbue life with value. Yoga turned out to be a terrific way to (re)gain a relationship with the interior world and with it a caring, loving, sensual relationship to the self.

  If you are not aware of what your body needs, you can’t take care of it. If you don’t feel hunger, you can’t nourish yourself. If you mistake anxiety for hunger, you may eat too much. And if you can’t feel when you’re satiated, you’ll keep eating. This is why cultivating sensory awareness is such a critical aspect of trauma recovery. Most traditional therapies downplay or ignore the moment-to-moment shifts in our inner sensory world. But these shifts carry the essence of the organism’s responses: the emotional states that are imprinted in the body’s chemical profile, in the viscera, in the contraction of the striated muscles of the face, throat, trunk, and limbs.1
7 Traumatized people need to learn that they can tolerate their sensations, befriend their inner experiences, and cultivate new action patterns.

  In yoga you focus your attention on your breathing and on your sensations moment to moment. You begin to notice the connection between your emotions and your body—perhaps how anxiety about doing a pose actually throws you off balance. You begin to experiment with changing the way you feel. Will taking a deep breath relieve that tension in your shoulder? Will focusing on your exhalations produce a sense of calm?18

  Simply noticing what you feel fosters emotional regulation, and it helps you to stop trying to ignore what is going on inside you. As I often tell my students, the two most important phrases in therapy, as in yoga, are “Notice that” and “What happens next?” Once you start approaching your body with curiosity rather than with fear, everything shifts.

  Body awareness also changes your sense of time. Trauma makes you feel as if you are stuck forever in a helpless state of horror. In yoga you learn that sensations rise to a peak and then fall. For example, if an instructor invites you to enter a particularly challenging position, you may at first feel a sense of defeat or resistance, anticipating that you won’t be able to tolerate the feelings brought up by this particular position. A good yoga teacher will encourage you to just notice any tension while timing what you feel with the flow of your breath: “We’ll be holding this position for ten breaths.” This helps you anticipate the end of discomfort and strengthens your capacity to deal with physical and emotional distress. Awareness that all experience is transitory changes your perspective on yourself.

  This is not to say that regaining interoception isn’t potentially upsetting. What happens when a newly accessed feeling in your chest is experienced as rage, or fear, or anxiety? In our first yoga study we had a 50 percent dropout rate, the highest of any study we’d ever done. When we interviewed the patients who’d left, we learned that they had found the program too intense: Any posture that involved the pelvis could precipitate intense panic or even flashbacks to sexual assaults. Intense physical sensations unleashed the demons from the past that had been so carefully kept in check by numbing and inattention. This taught us to go slow, often at a snail’s pace. That approach paid off: In our most recent study only one out of thirty-four participants did not finish.