The Body Keeps the Score

by Bessel van der Kolk MD

  Defects in any of these areas are likely to manifest themselves later in life. A child who has been ignored or chronically humiliated is likely to lack self-respect. Children who have not been allowed to assert themselves will probably have difficulty standing up for themselves as adults, and most grown-ups who were brutalized as children carry a smoldering rage that will take a great deal of energy to contain.

  Our relationships will suffer as well. The more early pain and deprivation we have experienced, the more likely we are to interpret other people’s actions as being directed against us and the less understanding we will be of their struggles, insecurities, and concerns. If we cannot appreciate the complexity of their lives, we may see anything they do as a confirmation that we are going to get hurt and disappointed.

  In the chapters on the biology of trauma we saw how trauma and abandonment disconnect people from their body as a source of pleasure and comfort, or even as a part of themselves that needs care and nurturance. When we cannot rely on our body to signal safety or warning and instead feel chronically overwhelmed by physical stirrings, we lose the capacity to feel at home in our own skin and, by extension, in the world. As long as their map of the world is based on trauma, abuse, and neglect, people are likely to seek shortcuts to oblivion. Anticipating rejection, ridicule, and deprivation, they are reluctant to try out new options, certain that these will lead to failure. This lack of experimentation traps people in a matrix of fear, isolation, and scarcity where it is impossible to welcome the very experiences that might change their basic worldview.

  This is one reason the highly structured experiences of psychomotor therapy are so valuable. Participants can safely project their inner reality into a space filled with real people, where they can explore the cacophony and confusion of the past. This leads to concrete aha moments: “Yes, that is what it was like. That is what I had to deal with. And that is what it would have felt like back then if I had been cherished and cradled.” Acquiring a sensory experience of feeling treasured and protected as a three-year-old in the trancelike container of a structure allows people to rescript their inner experience, as in “I can spontaneously interact with other people without having to be afraid of being rejected or getting hurt.”

  Structures harness the extraordinary power of the imagination to transform the inner narratives that drive and confine our functioning in the world. With the proper support the secrets that once were too dangerous to be revealed can be disclosed not just to a therapist, a latter-day father confessor, but, in our imagination, to the people who actually hurt and betrayed us.

  The three-dimensional nature of the structure transforms the hidden, the forbidden, and the feared into visible, concrete reality. In this it is somewhat similar to IFS, which we explored in the previous chapter. IFS calls forth the split-off parts that you created in order to survive and enables you to identify and talk with them, so that your undamaged Self can emerge. In contrast, a structure creates a three-dimensional image of whom and what you had to deal with and gives you a chance to create a different outcome.

  Most people are hesitant to go into past pain and disappointment—it only promises to bring back the intolerable. But as they are mirrored and witnessed, a new reality begins to take shape. Accurate mirroring feels completely different from being ignored, criticized, and put down. It gives you permission to feel what you feel and know what you know—one of the essential foundations of recovery.

  Trauma causes people to remain stuck in interpreting the present in light of an unchanging past. The scene you re-create in a structure may or may not be precisely what happened, but it represents the structure of your inner world: your internal map and the hidden rules that you have been living by.

  DARING TO TELL THE TRUTH

  I recently led another group structure with a twenty-six-year-old man named Mark, who at age thirteen had accidentally overheard his father having phone sex with his aunt, his mother’s sister. Mark felt confused, embarrassed, hurt, betrayed, and paralyzed by this knowledge, but when he tried to talk with his father about it, he was met with rage and denial: he was told that he had a filthy imagination and accused of trying to break up the family. Mark never dared to tell his mom, but henceforth the family secrets and hypocrisy contaminated every aspect of his home life and gave him a pervasive sense that nobody could be trusted. After school, he spent his isolated adolescence hanging around neighborhood basketball courts or in his room watching TV. When he was twenty-one his mother died—of a broken heart, Mark says—and his father married the aunt. Mark was not invited to either the funeral or the wedding.

  Secrets like these become inner toxins—realities that you are not allowed to acknowledge to yourself or to others but that nevertheless become the template of your life. I knew none of this history when Mark joined the group, but he stood out by his emotional distance, and during check-ins he acknowledged that he felt separated from everyone by a dense fog. I was quite worried about what would be revealed once we started to look behind his frozen, expressionless exterior.

  When I invited Mark to talk about his family, he said a few words and then seemed to shut down even more. So I encouraged him to ask for a “contact figure” to support him. He chose a white-haired group member, Richard, and placed Richard on a pillow next to him, touching his shoulder. Then, as he began to tell his story, Mark placed Joe, as his real father, ten feet in front of him, and directed Carolyn, representing his mother, to crouch in a corner with her face hidden. Mark next asked Amanda to play his aunt, telling her to stand defiantly to one side, arms crossed over her chest—representing all the calculating, ruthless, and devious women who are after men.

  Surveying the tableau he had created, Mark sat up straight, eyes wide open; clearly the fog had lifted. I said: “A witness can see how startled you are seeing what you had to deal with.” Mark nodded appreciatively and remained silent and somber for some time. Then, looking at his “father,” he burst out: “You asshole, you hypocrite, you ruined my life.” I invited Mark to tell his “father” all the things that he had wanted to tell him but never could. A long list of accusations followed. I directed the “father” to respond physically as if he had been punched, so that Mark could see that that his blows had landed. It did not surprise me when Mark spontaneously said that he’d always worried that his rage would get out of control and that this fear had kept him from standing up for himself in school, at work, and in other relationships.

  After Mark had confronted his “father,” I asked if he would like Richard to assume a new role: that of his ideal father. I instructed Richard to look Mark directly in the eye and to say: “If I had been your ideal father back then, I would have listened to you and not accused you of having a filthy imagination.” When Richard repeated this, Mark started to tremble. “Oh my God, life would have been so different if I could have trusted my father and talked about what was going on. I could have had a father.” I then told Richard to say: “If I had been your ideal father back then, I would have welcomed your anger and you would have had a father you could have trusted.” Mark visibly relaxed and said that would have made all the difference in the world.

  Then Mark addressed the stand-in for his aunt. The group was visibly stunned as he unleashed a torrent of abuse on her: “You conniving whore, you backstabber. You betrayed your sister and ruined her life. You ruined our family.” After he was done, Mark started to sob. He then said he’d always been deeply suspicious of any woman who showed an interest in him. The remainder of the structure took another half hour, in which we slowly set up conditions for him to create two new women: the ideal aunt, who did not betray her sister but who helped support their isolated immigrant family, and the ideal mother, who kept her husband’s interest and devotion and so did not die of heartbreak. Mark ended the structure quietly surveying the scene he had created with a contented smile on his face.

  For the remainder of the workshop Mark was an open and valuable
member of the group, and three months later he sent me an e-mail saying that this experience had changed his life. He had recently moved in with his first girlfriend, and although they’d had some heated discussions about their new arrangement, he’d been able to take in her point of view without clamming up defensively, going back to his fear or rage, or feeling that she was trying to pull a fast one. He was amazed that he felt okay disagreeing with her and that he was able to stand up for himself. He then asked for the name of a therapist in his community to help with the huge changes he was making in his life, and I fortunately had a colleague I could refer him to.

  ANTIDOTES TO PAINFUL MEMORIES

  Like the model mugging classes that I discussed in chapter 13, the structures in psychomotor therapy hold out the possibility of forming virtual memories that live side by side with the painful realities of the past and provide sensory experiences of feeling seen, cradled, and supported that can serve as antidotes to memories of hurt and betrayal. In order to change, people need to become viscerally familiar with realities that directly contradict the static feelings of the frozen or panicked self of trauma, replacing them with sensations rooted in safety, mastery, delight, and connection. As we saw in the chapter on EMDR, one of the functions of dreaming is to create associations in which the frustrating events of the day are interwoven with the rest of one’s life. Unlike our dreams, psychomotor structures are still subject to the laws of physics, but they too can reweave the past.

  Of course we can never undo what happened, but we can create new emotional scenarios intense and real enough to defuse and counter some of those old ones. The healing tableaus of structures offer an experience that many participants have never believed was possible for them: to be welcomed into a world where people delight in them, protect them, meet their needs, and make you feel at home.

  CHAPTER 19

  REWIRING THE BRAIN: NEUROFEEDBACK

  Is it a fact—or have I dreamt it—that by means of electricity, the world of matter has become a great nerve, vibrating thousands of miles in a breathless point of time?

  —Nathaniel Hawthorne

  The faculty of voluntarily bringing back a wandering attention, over and over again, is the very root of the judgment, character, and will.

  —William James

  The summer after my first year of medical school, I worked as a part-time research assistant in Ernest Hartmann’s sleep laboratory at Boston State Hospital. My job was to prepare and monitor the study participants and to analyze their EEG—electroencephalogram, or brain wave—tracings. Subjects would show up in the evening; I would paste an array of wires onto their scalps and another set of electrodes around their eyes to register the rapid eye movements that occur during dreaming. Then I would walk them to their bedrooms, bid them good night, and start the polygraph, a bulky machine with thirty-two pens that transmitted their brain activity onto a continuous spool of paper.

  Even though our subjects were fast asleep, the neurons in their brains kept up their frenzied internal communication, which was transmitted to the polygraph throughout the night. I’d settle down to pore over the previous night’s EEGs, stopping from time to time to pick up baseball scores on my radio, and use the intercom to wake subjects whenever the polygraph showed a REM sleep cycle. I would ask what they had dreamed about and write down what they reported and then in the morning help them fill out a questionnaire about sleep quality and send them on their way.

  Those quiet nights at Hartmann’s lab documented a great deal about REM sleep and contributed to building the basic understanding of sleep processes, which paved the way for the crucial discoveries that I discussed in chapter 15. However, until recently, the long-standing hope that the EEG would help us better understand how electrical brain activity contributes to psychiatric problems remained largely unrealized.

  MAPPING THE ELECTRICAL CIRCUITS OF THE BRAIN

  Before the advent of the pharmacological revolution, it was widely understood that brain activity depends on both chemical and electrical signals. The subsequent dominance of pharmacology almost obliterated interest in the electrophysiology of the brain for several decades.

  The first recording of the brain’s electrical activity was made in 1924 by the German psychiatrist Hans Berger. This new technology was initially met with skepticism and ridicule by the medical establishment, but electroencephalography gradually became an indispensable tool for diagnosing seizure activity in patients with epilepsy. Berger discovered that different brain-wave patterns reflected different mental activities. (For example, trying to solve a math problem resulted in bursts at a moderately fast frequency band known as beta.) He hoped that eventually science would be able to correlate different psychiatric problems with specific EEG irregularities. This expectation was fueled by the first reports on EEG patterns in “behavior problem children” in 1938.1 Most of these hyperactive and impulsive children had slower-than-normal waves in their frontal lobes. This finding has been reproduced innumerable times since then, and in 2013 slow-wave prefrontal activity was certified by the Food and Drug Administration as a biomarker for ADHD. Slow frontal lobe electrical activity explains why these kids have poor executive functioning: Their rational brains lack proper control over their emotional brains, which also occurs when abuse and trauma have made the emotional centers hyperalert to danger and organized for fight or flight.

  Early in my career I also hoped that the EEG might help us to make better diagnoses, and between 1980 and 1990 I sent many of my patients to get EEGs to determine if their emotional instability was rooted in neurological abnormalities. The reports usually came back with the phrase: “nonspecific temporal lobe abnormalities.”2 This told me very little, and because at that time the only way we could change these ambiguous patterns was with drugs that had more side effects than benefits, I gave up doing routine EEGs on my patients.

  Then, in 2000, a study by my friend Alexander McFarlane and his associates (researchers in Adelaide, Australia) rekindled my interest, as it documented clear differences in information processing between traumatized subjects and a group of “normal” Australians. The researchers used a standardized test called “the oddball paradigm” in which subjects are asked to detect the item that doesn’t fit in a series of otherwise related images (like a trumpet in a group of tables and chairs). None of the images was related to trauma.

  Normal versus PTSD. Patterns of attention. Milliseconds after the brain is presented with input it starts organizing the meaning of the incoming information. Normally, all regions of the brain collaborate in a synchronized pattern (left), while the brainwaves in PTSD are less well coordinated; the brain has trouble filtering out irrelevant information, and has problems attending to the stimulus at hand.

  In the “normal” group key parts of the brain worked together to produce a coherent pattern of filtering, focus, and analysis. (See left image below.) In contrast, the brain waves of traumatized subjects were more loosely coordinated and failed to come together into a coherent pattern. Specifically, they did not generate the brain-wave pattern that helps people pay attention on the task at hand by filtering out irrelevant information (the upward curve, labeled N200). In addition, the core information-processing configuration of the brain (the downward peak, P300) was poorly defined; the depth of the wave determines how well we are able to take in and analyze new data. This was important new information about how traumatized people process nontraumatic information that has profound implications for understanding day-to-day information processing. These brain-wave patterns could explain why so many traumatized people have trouble learning from experience and fully engaging in their daily lives. Their brains are not organized to pay careful attention to what is going on in the present moment.

  Sandy McFarlane’s study reminded me of what Pierre Janet had said back in 1889: “Traumatic stress is an illness of not being able to be fully alive in the present.” Years later, when I saw the movie The Hurt Locker, wh
ich dealt with the experiences of soldiers in Iraq, I immediately recalled Sandy’s study: As long as they were coping with extreme stress, these men performed with pinpoint focus; but back in civilian life they were overwhelmed having to make simple choices in a supermarket. We are now seeing alarming statistics about the number of returning combat veterans who enroll in college on the GI Bill but do not complete their degrees. (Some estimates are over 80 percent.) Their well-documented problems with focusing and attention are surely contributing to these poor results.

  McFarlane’s study clarified a possible mechanism for the lack of focus and attention in PTSD, but it also presented a whole new challenge: Was there any way to change these dysfunctional brain-wave patterns? It was seven years before I learned that there might be ways to do that.

  In 2007 I met Sebern Fisher at a conference on attachment-disordered children. Sebern was the former clinical director of a residential treatment center for severely disturbed adolescents, and she told me that she’d been using neurofeedback in her private practice for about ten years. She showed me before-and-after drawings made by a ten-year-old. This boy had had such severe temper tantrums, learning disabilities, and overall difficulties with self-organization that he could not be handled in school.3

  His first family portrait (on the left opposite), drawn before treatment started, was at the developmental level of a three-year-old. Less than five weeks later, after twenty sessions of neurofeedback, his tantrums had decreased and his drawing showed a marked improvement in complexity. Ten weeks and another twenty sessions later, his drawing took another leap in complexity and his behavior normalized.