A Psychological Approach to wellness: SUMMARy I
Photo by isco
By Sterling M. Hawkins, MSW, LCSW-C, LICSW
The Body Keeps the Score: Brain, Mind, and Body in the Healing of Trauma, by Dr. Bessel van der Kolk, is the culmination of the author’s forty years of research, along with that of others. Van der Kolk presents traumatic reactions not simply as disturbances of fear and anxiety but also as the provocateur of interpersonal relationships that create trauma, which is stored in the body. Understanding the neurobiological connection is key to addressing psychic gridlock and past experiences that prevent positive behavioral change. The book is well vetted by internationally known researchers in the field and praised as an authoritative guide that outlines the scientific advances in understanding the effects of trauma on the brain and body.
The text is accessible to both academics and the general public, offering innovative tools for working with those affected by trauma. The book contains five sections and has 445 pages, including the index. Due to its length, I have divided this book review into three summaries, each of which can be read independently. The titles in the summaries match those in the book and are numbered chronologically.
The first summary will focus on:
PART ONE The Rediscovery of Trauma, and
PART TWO This is your Brain on Trauma
The second summary will focus on:
PART THREE The Minds of Children
The third and final summary will focus on:
PART FOUR The Imprint of Trauma, and
PART FIVE Paths to Recovery
I will pull key points and quotations from each of the five sections of the text and share my personal insights and opinions when applicable.
Summary I, PART ONE: The Rediscovery of Trauma
We don’t find trauma; it finds us. For Dr. van der Kolk, it was at the Boston Veterans Administration Clinic, where he first observed the effects of war in many of the patients he treated. He acknowledged that nothing in his psychiatric training had prepared him to deal with the symptoms some patients presented. He began his research with a simple premise: to trust only what he could learn from his patients and his own experience. He recalled the words spoken by one of his faculty advisors: “The greatest sources of suffering are the lies we tell ourselves.” (van der Kolk, 2014, p.11) Most avoid experiences associated with trauma. He writes, We don’t really want to know what soldiers go through in combat, or how many children are being molested and abused, or how many couples engage in violence at some point during their relationship. We prefer instead to think of our country as populated by enlightened and civilized people. And that cruelty occurs only in faraway places. (van der Kolk, 2014, p.11-12) One of the salient features of trauma is the inability to engage in intimate relationships. This is true regardless of whether trauma is the result of something done to you or something you yourself have done.
Seeing patients in the clinic and running therapeutic groups taught him that those who have experienced trauma sharply divide the world between those who know and those who don’t. And that people who have not shared that particular traumatic experience cannot be trusted, because they can’t understand it. (van der Kolk, 2014, p.18)
Between his first and second year of medical school in the late 1960s, van der Kolk took a year off and worked as a research attendant at a leading psychiatric hospital in Boston. It was there that he spent long hours on the ward getting to know patients after many of the day staff had gone home. Since he was not directly involved in the research itself, he had time to listen to the stories of traumatized patients who were close in age to him. His primary role during this time was to keep them involved in regular daily recreational activities, both in-house and out in the local community. It was there that he learned to deal with irrational outbursts and terrified withdrawal. He also learned that “most human suffering is related to love and loss, and that the job of therapists is to help people’ acknowledge, experience, and bear’ the reality of life.” (van der Kolk, 2014, p.26-27). Moreover, according to a favorite professor, healing depends on experiential knowledge, and you can be fully in charge of your life only if you acknowledge the reality of your body in all its visceral dimensions.
He concludes this first section by framing the question of how we should respond to trauma. And how our response is often tailored to whether we see trauma as something that requires adaptation, or is it purely a disease that can be chemically treated. Suppose practitioners see trauma and its effects only as chemical imbalances in the brain that can be corrected with specific drugs. In that case, they will deflect attention from dealing with the underlying issues. (van der Kolk, 2014, p.36-37) Van der Kolk provides us with four fundamental truths to help practitioners avoid this one-sided thinking. I have summarized these truths in the list below:
[1] Restoring relationships and community is central to restoring well-being.
[2] Language gives us the power to change ourselves and others by communicating our experiences.
[3] We can regulate our own physiology: (breathing, moving, touching).
[4] Changing social conditions to create safe environments will allow children and adults to feel safe and thrive.
Summary I, PART TWO: This is your Brain on Trauma
Trauma affects the entire human organism- body, mind, and brain. The brain’s job is to ensure our survival. Our brains generate internal signals that register what our bodies need physically and then create a map of the world to direct us to where to go to satisfy those needs while generating the necessary energy and actions to get us there, warn us of danger and opportunity along the way, and adjust our actions to the requirements of the moment (van der Kolk, 2014, pp. 53, 55)
Van der Kolk then goes into extensive detail, describing the Triune brain for the reader, composed of three parts: the Prefrontal Cortex, the Limbic brain, and the Brain Stem. Each of these develops separately, with specific yet interconnected roles that organize basic life-sustaining functions throughout our lives. He states that the amygdala (part of the prefrontal cortex or the temporal lobe) is like a smoke detector. The amygdala is good at detecting danger cues, but trauma increases the risk of misinterpreting whether a particular situation is dangerous or safe. We are in a state of constant adjustment, continually adjusting our behavior. Faulty alarm systems lead to blow-ups or shutdowns in response to innocuous comments or facial expressions. (van der Kolk, 2014, p. 62)
Significant attention is given to the triune brain and the communication and information processing it receives. Unlike the amygdala, which is designed to detect potential threats, the Medial Prefrontal Cortex (MPFC) functions as a watchtower, serving as a hub for interpreting, decision-making, and social and emotional regulation. Any impairment in communication between the smoke-detector and watchtower results in highly intense emotional states. He says that achieving a balance between these two parts of the brain requires a dual approach.
First, a bottom-up approach requires individuals who have experienced trauma to change their physiology in response to their bodily sensations. For example, tossing a ball back and forth, drawing a picture, or dancing to music. Body-based therapies (Breathwork, Dance/Yoga, Body Scan, Pendulation) help individuals identify and/or connect specific emotions with their body's reactions to those emotions. Whereas a top-down approach may focus on breathing patterns, listening to music, and other mindful approaches. (van der Kolk, 2014, pp. 63-64, 72)
Mind-based therapies (Meditation, CBT, Guided Imagery, Biofeedback ) begin with your thinking brain and allow you to process your experiences through thoughts and words, making meaning through the narrative you create. It allows you to discern your thought patterns and find ways to shift your experiences and/or change what emotions you associate with specific situations or how you react to them.
The challenge within trauma treatment is teaching victims of trauma to live in the present. Desensitization to traumatic experiences may lower your reactivity to them. Still, if you cannot feel satisfaction in ordinary, everyday, non-threatening, and/or pleasurable activities, life will pass you by. (van der Kolk, 2014, p. 73)
Van der Kolk turned to the works of Charles Darwin to deepen his understanding of the foundations of our emotional life, as cited in Darwin's lesser-known work titled The Expression of Emotions in Man and Animals (1872). In it, Darwin asserted that mammalian emotions are fundamentally rooted in biology and an indispensable source of motivation for initiating action. “Movement that will restore the organism to safety and physical equilibrium." (van der Kolk, 2014, p. 75)
Intrigued by Darwin, van der Kolk also studied the works of Russian scientist Ivan Pavlov (1849 - 1936) on what he termed “Reflex of Purpose,” which helps answer the question: How do people regain the energy to engage with life and develop themselves to the fullest? Pavlov's question is the same question that Maslow attempted to answer with his hierarchy of needs pyramid, which I cited in my essay titled "A Psychological Approach to Wellness: An Introduction."
While many concepts seek to explain what helps to regain or sustain life energy, “Safety and Reciprocity” resonates deeply for me. Van der Kolk writes: “Being able to feel safe with other people is probably the single most important aspect of mental health; safe connections are fundamental to meaningful and satisfying lives. . . Social support is not the same as merely being in the presence of others. The critical issue is reciprocity: being truly heard and seen by the people around us, feeling we are held in someone else's mind and heart. (van der Kolk, 2014, p. 81)
Safety is identified at three distinct levels according to American psychologist Stephen Porges, who developed the Polyvagal Theory. This theory, cited by van der Kolk, emphasizes the role of the autonomic nervous system (ANS): (1) The Ventral Vagal State, (2) The Sympathetic State, and (3) The Dorsal Vagal State. Each level represents an evolutionary hierarchy that influences our ability to connect, cope, or dissociate. (van der Kolk, 2014, p. 82)
Regarding this theory, van der Kolk observes that many people feel safe as long as they can limit their social contact to superficial conversations, but actual physical contact can trigger intense reactions. However, any sort of deep intimacy— a close embrace, sleeping with a mate, and sex requires allowing oneself to experience immobilization without fear. It is especially challenging for traumatized people to discern when they are actually safe and to be able to activate their defenses when they are in danger. (van der Kolk, 2014, p. 87)
This is challenging because of the number of experiences required to restore one's equilibrium and a sense of feeling safe. As a therapist, I frequently see evidence of this. Safety is established, only to be threatened. Where there is no safety, there can be no trust. Years of progress toward reaching safety can evaporate in a matter of seconds. At the first hint of danger. Re-traumatization involves repeated encounters with a supposed lack of safety or becoming a victim. A cycle is then initiated, which repeats over time, fostering a sense of hopeless withdrawal and inability to engage. Even when there is no immediate threat.
Since trauma is encoded in the viscera of our bodies (i.e., the body's autoimmune system), the brain's safety system demands that we utilize treatment approaches that incorporate Mind-Body techniques.
Our sensory interior signals us to what is safe, life-sustaining, or threatening, even if we cannot name it. Van der Kolk refers to this as our "Gut" feelings, which help us evaluate what is going on around us. However, traumatized people chronically feel unsafe inside their bodies. These individuals often ignore internal warning signs, leaving them bewildered, confused, and ashamed. He concludes with— “The price for ignoring or distorting the body's messages is being unable to detect what is truly dangerous or harmful for you, and just as bad, what is safe or nourishing.” (van der Kolk, 2014, p. 99). Ignorance of this type is seen as an inability to self-regulate, or to “have a friendly relationship with your body.” Persons who do not have this awareness and ability to self-regulate rely on external regulation— medication, drugs like alcohol, constant reassurance, or compliance with the wishes of others. (van der Kolk, 2014, p. 99)
Of particular interest is the term “Alexithymia,” a Greek word for not having words for feelings. Van der Kolk says that people with alexithymia tend to register emotions as physical problems rather than as signals that something deserves their attention. “Instead of feeling angry or sad, they experience muscle pain, bowel irregularities, or other symptoms for which no cause can be found. “ (van der Kolk, 2014, p. 100)
People with this condition are said to improve only by learning to recognize the relationship between their physical sensations and their emotions.
Van der Kolk concludes this section with several questions and probable resolutions:
How can people open up to explore their internal world of sensations and emotions?
What happens in chronically traumatized people when they make face-to-face contact?
What does this (chronic traumatization) mean for their ability to make friends and get along with others, and benefit from therapy?
To answer these questions, the author describes his approach to working with people impacted by trauma and assisting patients by helping them to describe the feelings in their bodies and not their emotions. When patients become aware of their physical sensations, they can, with practice, connect these sensations to psychological events. When this happens for the first time, it can be distressing. However, with proper guidance, torrents of emotions can be stemmed. School teachers, nurses, and police officers are often very skilled at bringing calm to traumatized persons, because many of them are confronted almost daily with out-of-control or painfully disorganized people. (van der Kolk, 2014, p. 104)
To have genuine relationships, you have to be able to experience others, each with his or her particular motivations and intentions. While you need to be able to stand up for yourself, you also need to recognize that other people have their own agendas. Trauma can make all that hazy and gray. (van der Kolk, 2014, p. 104)
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References:
Kolk, V. D., & Bessel, A. (2014). The body keeps the score: brain, mind, and body in the healing of trauma. In Medical Entomology and Zoology. https://ci.nii.ac.jp/ncid/BB19708339