The Body Keeps the Score

by Bessel van der Kolk MD

  THE FUTURE OF NEUROFEEDBACK

  In my practice I use neurofeedback primarily to help with the hyperarousal, confusion, and concentration problems of people who suffer from developmental trauma. However, it has also shown good results for numerous issues and conditions that go beyond the scope of this book, including relieving tension headaches, improving cognitive functioning following a traumatic brain injury, reducing anxiety and panic attacks, learning to deepen meditation states, treating autism, improving seizure control, self-regulation in mood disorders, and more. As of 2013 neurofeedback is being used in seventeen military and VA facilities to treat PTSD,32 and scientific documentation of its efficacy in recent combat vets is just beginning to be assessed. Frank Duffy, the director of the clinical neurophysiology and developmental neurophysiology laboratories of Boston Children’s Hospital, has commented: “The literature, which lacks any negative study, suggests that neurofeedback plays a major therapeutic role in many different areas. In my opinion, if any medication had demonstrated such a wide spectrum of efficacy it would be universally accepted and widely used.”33

  Many questions remain to be answered about treatment protocols for neurofeedback, but the scientific paradigm is gradually shifting in a direction that invites a deeper exploration of these questions. In 2010 Thomas Insel, director of the National Institute of Mental Health, published an article in Scientific American entitled “Faulty Circuits,” in which he called for a return to understanding mind and brain in terms of the rhythms and patterns of electrical communication: “Brain regions that function together to carry out normal (and abnormal) mental operations can be thought of as analogous to electrical circuits—the latest research shows that the malfunctioning of entire circuits may underlie many mental disorders.”34 Three years later Insel announced that NIMH was “re-orienting its research away from DSM categories”35 and focusing instead on “disorders of the human connectome.”36

  As explained by Francis Collins, director of the National Institutes of Health (of which NIMH is a part), “The connectome refers to the exquisitely interconnected network of neurons (nerve cells) in your brain. Like the genome, the microbiome, and other exciting ‘ome’ fields, the effort to map the connectome and decipher the electrical signals that zap through it to generate your thoughts, feelings, and behaviors has become possible through development of powerful new tools and technologies.”37 The connectome is now being mapped in detail under the auspices of NIMH.

  As we await the results of this research, I’d like to give the last word to Lisa, the survivor who introduced me to the enormous potential of neurofeedback. When I asked her to summarize what the treatment had done for her, she said: “It calmed me down. It stopped the dissociation. I can use my feelings; I’m not running away from them. I’m not held hostage by them. I can’t turn them off and on, but I can put them away. I may be sad about the abuse I went through, but I can put it away. I can call a friend and not talk about it if I don’t want to talk about it, or I can do homework or clean my apartment. Emotions mean something now. I’m not anxious all the time, and when I am anxious, I can reflect on it. If the anxiety’s coming from the past, I can find it there, or I can look at how it relates to my life now. And it’s not just negative emotions, like anger and anxiety—I can reflect on love and intimacy or sexual attraction. I’m not in fight-or-flight all the time. My blood pressure is down. I’m not physically prepared to take off at any moment or defend myself against an attack. Neurofeedback made it possible for me to have a relationship. Neurofeedback freed me up to live my life the way I want to, because I’m not always in the thrall of how I was hurt and what it did to me.”

  Four years after I met her and recorded our conversations, Lisa graduated near the top of her nursing school class, and she now works full time as a nurse at a local hospital.

  CHAPTER 20

  FINDING YOUR VOICE: COMMUNAL RHYTHMS AND THEATER

  Acting is not about putting on a character but discovering the character within you: you are the character, you just have to find it within yourself—albeit a very expanded version of yourself.

  —Tina Packer

  Many scientists I know were inspired by their children’s health problems to find new ways of understanding mind, brain, and therapy. My own son’s recovery from a mysterious illness that, for lack of a better name, we call chronic fatigue syndrome, convinced me of the therapeutic possibilities of theater.

  Nick spent most of seventh and eighth grade in bed, bloated by allergies and medications that left him too exhausted to go to school. His mother and I saw him becoming entrenched in his identity as a self-hating and isolated kid, and we were desperate to help him. When his mother realized that he picked up a little energy round 5:00 p.m., we signed him up for an evening class in improvisational theater where he would at least have a chance to interact with other boys and girls his age. He took to the group and to the acting exercises and soon landed his first role, as Action in West Side Story, a tough kid who’s always ready to fight and has the lead in singing “Gee, Officer Krupke.” One day at home I caught him walking with a swagger, practicing what it was like to be somebody with clout. Was he developing a physical sense of pleasure, imagining himself as a strong guy who commands respect?

  Then he was cast as the Fonz in Happy Days. Being adored by girls and keeping an audience spellbound became the real tipping point in his recovery. Unlike his experience with the numerous therapists who had talked with him about how bad he felt, theater gave him a chance to deeply and physically experience what it was like to be someone other than the learning-disabled, oversensitive boy that he had gradually become. Being a valued contributor to a group gave him a visceral experience of power and competence. I believe that this new embodied version of himself set him on the road to becoming the creative, loving adult he is today.

  Our sense of agency, how much we feel in control, is defined by our relationship with our bodies and its rhythms: Our waking and sleeping and how we eat, sit, and walk define the contours of our days. In order to find our voice, we have to be in our bodies—able to breathe fully and able to access our inner sensations. This is the opposite of dissociation, of being “out of body” and making yourself disappear. It’s also the opposite of depression, lying slumped in front of a screen that provides passive entertainment. Acting is an experience of using your body to take your place in life.

  THE THEATER OF WAR

  Nick’s transformation was not the first time I’d witnessed the benefits of theater. In 1988 I was still treating three veterans with PTSD whom I’d met at the VA, and when they showed a sudden improvement in their vitality, optimism, and family relationships, I attributed it to my growing therapeutic skills. Then I discovered that all three were involved in a theatrical production.

  Wanting to dramatize the plight of homeless veterans, they had persuaded playwright David Mamet, who was living nearby, to meet weekly with their group to develop a script around their experiences. Mamet then recruited Al Pacino, Donald Sutherland, and Michael J. Fox to come to Boston for an evening called Sketches of War, which raised money to convert the VA clinic where I’d met my patients into a shelter for homeless veterans.1 Standing on a stage with professional actors, speaking about their memories of the war, and reading their poetry was clearly a more transformative experience than any therapy could have offered them.

  Since time immemorial human beings have used communal rituals to cope with their most powerful and terrifying feelings. Ancient Greek theater, the oldest of which we have written records, seems to have grown out of religious rites that involved dancing, singing, and reenacting mythical stories. By the fifth century BCE, theater played a central role in civic life, with the audience seated in a horseshoe around the stage, which enabled them to see one another’s emotions and reactions.

  Greek drama may have served as a ritual reintegration for combat veterans. At the time Aeschylus wrote the Oresteia trilogy, Athens w
as at war on six fronts; the cycle of tragedy is set in motion when the returning warrior king Agamemnon is murdered by his wife, Clytemnestra, for having sacrificed their daughter before sailing to the Trojan War. Military service was required of every adult citizen of Athens, so audiences were undoubtedly composed of combat veterans and active-duty soldiers on leave. The performers themselves must have been citizen-soldiers.

  Sophocles was a general officer in Athens’s wars against the Persians, and his play Ajax, which ends with the suicide of one of the Trojan War’s greatest heroes, reads like a textbook description of traumatic stress. In 2008 writer and director Bryan Doerries arranged a reading of Ajax for five hundred marines in San Diego and was stunned by the reception it received. (Like many of us who work with trauma, Doerries’s inspiration was personal; he had studied classics in college and turned to the Greek texts for comfort when he lost a girlfriend to cystic fibrosis.) His project “The Theater of War” evolved from that first event, and with funding from the U.S. Department of Defense, this 2,500-year-old play has since been performed more than two hundred times here and abroad to give voice to the plight of combat veterans and foster dialogue and understanding in their families and friends.2

  Theater of War performances are followed by a town hall–style discussion. I attended a reading of Ajax in Cambridge, Massachusetts, shortly after the news media had publicized a 27 percent increase in suicides among combat veterans over the previous three years. Some forty people—Vietnam veterans, military wives, recently discharged men and women who had served in Iraq and Afghanistan—lined up behind the microphone. Many of them quoted lines from the play as they spoke about their sleepless nights, drug addiction, and alienation from their families. The atmosphere was electric, and afterward the audience huddled in the foyer, some holding each other and crying, others in deep conversation.

  As Doerries later said: “Anyone who has come into contact with extreme pain, suffering or death has no trouble understanding Greek drama. It’s all about bearing witness to the stories of veterans.”3

  KEEPING TOGETHER IN TIME

  Collective movement and music create a larger context for our lives, a meaning beyond our individual fate. Religious rituals universally involve rhythmic movements, from davening at the Wailing Wall in Jerusalem to the sung liturgy and gestures of the Catholic Mass to moving meditation in Buddhist ceremonies and the rhythmic prayer rituals performed five times a day by devout Muslims.

  Music was a backbone of the civil rights movement in the United States. Anyone alive at that time will not forget the lines of marchers, arms linked, singing “We Shall Overcome” as they walked steadily toward the police who were massed to stop them. Music binds together people who might individually be terrified but who collectively become powerful advocates for themselves and others. Along with language, dancing, marching, and singing are uniquely human ways to install a sense of hope and courage.

  I observed the force of communal rhythms in action when I watched Archbishop Desmond Tutu conduct public hearings for the Truth and Reconciliation Commission in South Africa in 1996. These events were framed by collective singing and dancing. Witnesses recounted the unspeakable atrocities that had been inflicted on them and their families. When they became overwhelmed, Tutu would interrupt their testimony and lead the entire audience in prayer, song, and dance until the witnesses could contain their sobbing and halt their physical collapse. This enabled participants to pendulate in and out of reliving their horror and eventually to find words to describe what had happened to them. I fully credit Tutu and the other member of the commission with averting what might have been an orgy of revenge, as is so common when victims are finally set free.

  A few years ago I discovered Keeping Together in Time,4 written by the great historian William H. McNeill near the end of his career. This short book examines the historical role of dance and military drill in creating what McNeill calls “muscular bonding” and sheds a new light on the importance of theater, communal dance, and movement. It also solved a long-standing puzzle in my own mind. Having been raised in the Netherlands, I had always wondered how a group of simple Dutch peasants and fishermen had won their liberation from the mighty Spanish empire. The Eighty Years’ War, which lasted from the late sixteenth to the midseventeenth century, began as a series of guerrilla actions, and it seemed destined to remain that way, since the ill-disciplined, ill-paid soldiers regularly fled under volleys of musket fire.

  This changed when Prince Maurice of Orange became the leader of the Dutch rebels. Still in his early twenties, he had recently completed his schooling in Latin, which enabled him to read 1,500-year-old Roman manuals on military tactics. He learned that the Roman general Lycurgus had introduced marching in step to the Roman legions and that the historian Plutarch had attributed their invincibility to this practice: “It was at once a magnificent and terrible sight, to see them march on to the tune of their flutes, without any disorder in their ranks, any discomposure in their minds or change in their countenances, calmly and cheerfully moving with music to the deadly fight.”5

  Prince Maurice instituted close-order drill, accompanied by drums, flutes, and trumpets, in his ragtag army. This collective ritual not only provided his men with a sense of purpose and solidarity, but also made it possible for them to execute complicated maneuvers. Close-order drill subsequently spread across Europe, and to this day the major services of the U.S. military spend liberally on their marching bands, even though fifes and drums no longer accompany troops into battle.

  Neuroscientist Jaak Panksepp, who was born in the tiny Baltic country of Estonia, told me the remarkable story of Estonia’s “Singing Revolution.” In June 1987, on one of those endless sub-Arctic summer evenings, more than ten thousand concertgoers at the Tallinn Song Festival Grounds linked hands and began to sing patriotic songs that had been forbidden during half a century of Soviet occupation. These songfests and protests continued, and on September 11, 1988, three hundred thousand people, about a quarter of the population of Estonia, gathered to sing and make a public demand for independence. By August 1991 the Congress of Estonia had proclaimed the restoration of the Estonian state, and when Soviet tanks attempted to intervene, people acted as human shields to protect Tallinn’s radio and TV stations. As a columnist noted in the New York Times: “Imagine the scene in Casablanca in which the French patrons sing “La Marseillaise” in defiance of the Germans, then multiply its power by a factor of thousands, and you’ve only begun to imagine the force of the Singing Revolution.”6

  TREATING TRAUMA THROUGH THEATER

  It is surprising how little research exists on how collective ceremonies affect the mind and brain and how they might prevent or alleviate trauma. Over the past decade, however, I have had a chance to observe and study three different programs for treating trauma through theater: Urban Improv in Boston7 and the Trauma Drama program it inspired in the Boston public schools and in our residential centers;8 the Possibility Project, directed by Paul Griffin in New York City;9 and Shakespeare & Company, in Lenox, Massachusetts, which runs a program for juvenile offenders called Shakespeare in the Courts.10 In this chapter, I’ll focus on these three groups, but there are many excellent therapeutic drama programs in the United States and abroad, making theater a widely available resource for recovery.

  Despite their differences, all of these programs share a common foundation: confrontation of the painful realities of life and symbolic transformation through communal action. Love and hate, aggression and surrender, loyalty and betrayal are the stuff of theater and the stuff of trauma. As a culture we are trained to cut ourselves off from the truth of what we’re feeling. In the words of Tina Packer, the charismatic founder of Shakespeare & Company: “Training actors involves training people to go against that tendency—not only to feel deeply, but to convey that feeling at every moment to the audience, so the audience will get it—and not close off against it.”

  Traumatized pe
ople are terrified to feel deeply. They are afraid to experience their emotions, because emotions lead to loss of control. In contrast, theater is about embodying emotions, giving voice to them, becoming rhythmically engaged, taking on and embodying different roles.

  As we’ve seen, the essence of trauma is feeling godforsaken, cut off from the human race. Theater involves a collective confrontation with the realities of the human condition. As Paul Griffin, discussing his theater program for foster-care children, told me: “The stuff of tragedy in theater revolves around coping with betrayal, assault, and destruction. These kids have no trouble understanding what Lear, Othello, Macbeth, or Hamlet are all about.” In Tina Packer’s words: “Everything is about using the whole body and having other bodies resonate with your feelings, emotions and thoughts.” Theater gives trauma survivors a chance to connect with one another by deeply experiencing their common humanity.

  Traumatized people are afraid of conflict. They fear losing control and ending up on the losing side once again. Conflict is central to theater—inner conflicts, interpersonal conflicts, family conflicts, social conflicts, and their consequences. Trauma is about trying to forget, hiding how scared, enraged, or helpless you are. Theater is about finding ways of telling the truth and conveying deep truths to your audience. This requires pushing through blockages to discover your own truth, exploring and examining your own internal experience so that it can emerge in your voice and body on stage.

  MAKING IT SAFE TO ENGAGE

  These theater programs are not for aspiring actors but for angry, frightened, and obstreperous teenagers or withdrawn, alcoholic, burned-out veterans. When they come to rehearsal, they slump into their chairs, fearful that others will immediately see what failures they are. Traumatized adolescents are a jumble: inhibited, out of tune, inarticulate, uncoordinated, and purposeless. They are too hyperaroused to notice what is going on around them. They are easily triggered and rely on action rather than words to discharge their feelings.