Words&Dirt

Bessel van der Kolk’s The Body Keeps the Score was pitched to me by several people as the best book for a crash course in trauma research and modern treatments. It did not disappoint. This impressive summary of discoveries and lessons from van der Kolk’s long career is an essential text for anyone looking to enter the mental health profession, and will capture the interest of many nonprofessional readers as well.

The central message of van der Kolk’s work is that America is experiencing an ongoing and pervasive “hidden epidemic” of trauma and trauma-related problems. This sweeping claim seemed overblown to me at first glance, but van der Kolk’s evidence-based and compassion-driven approach quickly convinced me that his position is worth taking seriously. Its point of origin in modern research is the original study on Adverse Childhood Experiences (ACEs), which was conducted by Kaiser Permanente and the CDC in the 1990s. They administered questionnaires to more than 17,000 participants, searching for links between ACEs and subsequent health problems in Kaiser patients. Their findings were stunning:

They had stumbled upon the greatest and most costly public health issue in the United States: child abuse. He [[Robert Anda of the CDC]] had calculated that its overall costs exceeded those of cancer or heart disease and that eradicating child abuse in America would reduce the overall rate of depression by more than half, alcoholism by two-thirds, and suicide, IV drug use, and domestic violence by three-quarters. It would also have a dramatic effect on workplace performance and vastly decrease the need for incarceration. (150)

The general rule of thumb is that scoring four or more ACEs greatly increases a person’s risk for a wide range of mental and physical health problems. The CDC estimates that nearly one in six Americans (roughly 16%) fit into this category. These findings have since been supported by subsequent research. Assuming childhood trauma is as widespread and consequential as the evidence suggests, how can we better understand the nature of this tragic crisis? And how can our time and public resources be best spent trying to prevent childhood trauma and curb its worst effects?

These questions and their various answers comprise the heart of The Body Keeps the Score. The first four parts explain the history of trauma’s rediscovery by modern psychologists, the neuroscience of trauma, the dynamics and damage done when trauma is experienced during childhood, and the controversial topic of traumatic memory. As a layperson, I found these sections informative and empirically-sound, comporting nicely with my general knowledge from studying similar topics.

One of the most important subjects that van der Kolk returns to repeatedly is the distinction between normal and traumatic memory. Unlike normal memories, traumatic memories become “frozen” in a fashion that is not well-integrated with an individual’s autobiographical self––the story we tell ourselves about who we are. When such memories are activated by triggering stimuli (which can be very unpredictable), they essentially hijack a person’s body-mind, shutting off their awareness of time, stifling critical thinking, and pulling them back into a frightening and overwhelming simulation of trauma they experienced in the past. Here are a few of the ways van der Kolk describes this:

Being traumatized means continuing to organize your life as if the trauma were still going on––unchanged and immutable––as every new encounter or event is contaminated by the past. (53)

Trauma is the ultimate experience of “this will last forever.” (70)

If an organism is stuck in survival mode, its energies are focused on fighting off unseen enemies, which leaves no room for nurture, care, and love. For us humans, it means that as long as the mind is defending itself against invisible assaults, our closest bonds are threatened, along with our ability to imagine, plan, play, learn, and pay attention to other people’s needs. (76)

The essence of trauma is that it is overwhelming, unbelievable, and unbearable. Each patient demands that we suspend our sense of what is normal and accept that we are dealing with a dual reality: the reality of a relatively secure and predictable present that lives side by side with a ruinous, ever-present past. (197)

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 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. (307)

Given such incredibly difficult and debilitating circumstances, people trying to overcome traumatic histories must seek out the best possible therapeutic care. The last part of The Body Keeps the Score is devoted to describing cutting-edge modalities that are transforming the way practitioners approach and treat trauma in modern medicine and psychotherapy. Dr. van der Kolk surveys a variety of such therapies, but gives the most focus to Eye Movement Desensitization Reprocessing (EMDR), yoga and other forms of bodywork, Internal Family Systems, Pesso Boyden System Psychomotor (PBSP), Neurofeedback, and theater-based approaches. Although these practices differ dramatically in their theories and methods, they all attempt to defuse the power of traumatic memories by creating a novel pathway for healthy reintegration with a client’s normal memories and autobiographical self.

I lack both the expertise and experience to comment on the scientific validity or efficacy of these treatments, but in general van der Kolk provides convincing evidence that they are worthy of serious consideration. It helps that he comes from a traditional psychiatry background and has a firm footing in the established science, as demonstrated earlier in the book. Several of the chapters begin with some version of “this seemed pretty wacky until I saw for myself how it works.” Also encouraging is van der Kolk’s refusal to present any single technique as a “silver bullet” that should be applied to everyone. I’d sum up his attitude this way: Let’s keep an open mind, experiment responsibly, and make use of whatever seems to help people even if we don’t understand the precise mechanisms that are producing the results we observe. 

Unsurprisingly, van der Kolk is not a big fan of the medical model of mental illness, tending to shy away from psychotropic medications as a primary form of treatment for traumatized clients. He admits that medications can have appropriate and helpful applications, but generally characterizes them as ways of numbing or suppressing symptoms rather than tools for fixing root causes. He also takes a balanced view when it comes to the limitations of talk therapy, which is useful in many circumstances but often proves ineffective for people in the early stages of recovery from serious trauma:

Even years later traumatized people often have enormous difficulty telling other people what has happened to them. Their bodies reexperience terror, rage, and helplessness, as well as the impulse to fight or flee, but these feelings are almost impossible to articulate. Trauma by nature drives us to the edge of comprehension, cutting us off from language based on common experience or an imaginable past. (43)

In such cases, therapies that involve little or no speaking can precipitate improvements in a client’s relationship with their own body-mind. Once clients learn to self-sooth and autonomously disengage from states of hyperarousal, talk therapy often becomes a viable route to healing:

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 the 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. (237)

Depending on one’s training and orientation (or lack thereof), readers may come away quite skeptical of van der Kolk’s perspective and recommendations. Others will enthusiastically see his work as ahead of the curve, boldly advancing the future of his field. For my part, I think this is a very valuable text that I’m glad to have encountered. That said, the book is quite dense, and overly-repetitive at times. It’s also challenging to read, both intellectually and emotionally. I worry that people who misinterpret van der Kolk’s work might use it to support a “culture of victimhood” in which traumatized people are depicted as severely and irreparably impaired by their challenging histories. Another potential problem is that the term “trauma” will undergo concept creep, with people beginning to use it to describe negative aspects of life that truly don’t rise to the level of what van der Kolk deals with. But to be clear: I can’t find anything in The Body Keeps the Score that directly leads to either of these pitfalls; van der Kolk’s stance is unambiguously that trauma, despite its impactful and long-lasting consequences, can and ought to be overcome.

I’ll end with a final word of appreciation, which is that van der Kolk understands and honors the structural and social nature of trauma in a way I haven’t yet encountered from other authors writing on this topic. In his own words:

Humans are social animals, and mental problems involve not being able to get along with other people, not fitting in, not belonging, and in general not being able to get on the same wavelength. Everything about us––our brains, our minds, and our bodies––is geared toward collaboration in social systems. This is our most powerful survival strategy, the key to our success as a species, and it is precisely this that breaks down in most forms of mental suffering…The neural connections in brain and body are vitally important for understanding human suffering, but it is important not to ignore the foundations of our humanity: relationships and interactions that shape our minds and brains when we are young and that give substance and meaning to our entire lives. (168)

Dealing with this issue will require so much more than inventing or applying the “correct” therapeutic treatment in any given case. It will require dedicated dismantling of the underlying causes of trauma: poverty, underfunded schools, racism, frivolous wars, and restricted access to healthcare, to name just a few. “Trauma is now our most urgent public health issue,” van der Kolk writes, “and we have the knowledge necessary to respond effectively. The choice is ours to act on what we know” (358).

Rating: 8/10