A Psychological Approach to wellness: SUMMARy III
Photo by Alex Green
By Sterling M. Hawkins, MSW, LCSW-C, LICSW
Summary III PART FOUR: The Imprint of Trauma
In this section, chapter eleven, Van der Kolk addresses the problem of recurrence. He writes: “Whether we remember a particular event at all, and how accurate our memories of it are, largely depends on how personally meaningful it was and how we felt about it at the time.” (van der Kolk, 2014, p. 177) He briefly takes us back to Section II, Chapter Four, where he first gave us the physical structure of the brain (the limbic system and brain stem) and how memories are transmitted and stored. When examining the literature, he learned that it was in the late nineteenth century that medicine first began the systematic study of mental problems, and that the physiological and neurological effects of what was labeled as hysteria(a mental disorder characterized by emotional outbursts, susceptibility to suggestion, and contractions and paralysis) drew intense study. Jean-Martin Charcot, Sigmund Freud, and Pierre Janet were pioneers in the field. They helped to develop treatment approaches that enabled traumatized patients to reproduce repressed and fragmented memories through acting them out as a way of creating a narrative from which they could begin putting into words what they had experienced. According to Freud and his Viennese mentor, Josef Breuer, “Recollection without affect almost invariably produces no result.” This discovery became the origins of the “Talking Cure” or modern-day psychoanalysis, and psychotherapeutic (CBT) approaches. (van der Kolk, 2014, pp. 183-184)
One of the things that has helped to garner international attention to trauma is the aftermath of war. In chapter 12, van der Kolk describes how, in both Europe and America, the military and their respective governments were forced to examine trauma’s impact on the soldiers who fought in them. The recognition was slow. He writes: “Denial of the consequences of trauma can wreak havoc with the social fabric of society.” (van der Kolk, 2014, p. 188)
Van der Kolk recalled an experience that I identified with during my years at the VA. He writes: “I was puzzled by that the vast majority of the patients we saw on the psychiatry service were young, recently discharged Vietnam veterans, while the corridors and elevators that led to the medical departments were filled by old men. Curious about this disparity, I conducted a survey of World War II veterans at medical clinics in 1983. The vast majority of them scored positive for PTSD on the rating scales that I administered, but their treatment focused on medical rather than psychiatric complaints. These vets communicated their distress via stomach cramps and chest pains rather than with nightmares and rage, from which my research showed they also suffered. Doctors shape how their patients communicate their distress: When a patient complains of terrifying nightmares and his doctor orders a chest X-ray, the patient realizes that he’ll get better care if he focuses on his physical problems. Most of these men were extremely reluctant to share their experiences. My sense was that neither the doctors nor their patients wanted to revisit the war.” (van der Kolk, 2014, pp. 189-190)
My own experience was similar to van der Kolk’s. I witnessed this same phenomenon during my time at the VA. It made perfect sense. As noted by van der Kolk, this disparity would play out over the years until research in the mid-1990s confirmed the seriousness of mental illness among the veteran population and the public’s acknowledgment that both men and women who returned home post-deployment were not the same. I know in retrospect that the stigma of a psychiatric diagnosis was a massive threat to the future of these young (WWII and Korean War) veterans who still had much of their lives ahead of them. Prior to the 1990s, average Americans had limited experiences with post-traumatic stress, and often didn’t know how to respond to friends and family members who had suffered from combat trauma. This experience often led veterans to disassociate and deny their symptoms in order to avoid becoming stigmatized and estranged from the important people in their lives. Many who returned home brought the war home with them.
It wasn’t until I became an adult that I understood how my own father, who fought in World War II and was also a Prisoner of War, was impacted by trauma. He was never diagnosed with PTSD. However, he had the classic symptoms: nightmares, depression, irritability, detachment, and estrangement from others. He also had physical wounds and chronic medical diagnoses resulting from being severely wounded and cold injury exposure. I remember a couple of times, as a young boy, asking my father about his military experiences. He talked only about those experiences that he felt good about. He never talked about his nightmares, his imprisonment, his treatment, or his fears. I quickly learned that these subjects were not open for discussion. And much later, I realized that many of these memories were repressed, buried, and forbidden topics, without a narrative to explain them.
When speaking about an independent study van der Kolk conducted with several colleagues in 1994, he describes normal (positive) versus traumatic memory by noting the following distinctions: “There were two major differences between how people talked about memories of positive versus traumatic experiences: (1) how the memories were organized, and (2) their physical reactions to them. . . Remembering the trauma with all its associated effects does not. . . resolve it. . . finding words to describe what has happened to you can be transformative, but it does not always abolish flashbacks or improve concentration, stimulate vital involvement in your life, or reduce hypersensitivity to disappointments and perceived injuries. (van der Kolk, 2014, pp. 195-196)
Van der Kolk concludes this section by stating the following: “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.” (van der Kolk, 2014, p. 197)
Summary III PART FIVE: Paths to Recovery
In this final section, van der Kolk focuses on the process of healing from trauma. He opens with a sobering statement: “Nobody can treat a war, or abuse, rape, molestation, or any other horrendous event, for that matter; what has happened cannot be undone. But what can be dealt with are the imprints of the trauma on body, mind, and soul.” (van der Kolk, 2014, p. 205)
He first outlines what that means in summary form, then in greater detail. He says that trauma robs us of what he refers to as self-leadership, and the challenges to self-leadership: “feeling free to know what you know and to feel what you feel without becoming overwhelmed, enraged, ashamed, or collapsed.” (van der Kolk, 2014, p. 205)
Recovery is measured differently for each person. However, in general, it embodies the following four characteristics:
(1) Finding a way to become calm and focused.
(2) Learning to maintain that calm in response to images, thoughts, sounds, or physical sensations that remind you of the past.
(3) Finding a way to be fully alive in the present and engaged with the people around you.
(4) Not having to keep secrets from yourself, including secrets about the ways that you have managed to survive.
This four-step process is not linear but rather holistic and creative, incorporating these approaches in a multifactorial manner with overlap and repetition. (van der Kolk, 2014, p. 205-206)
The true extreme states that prevent recovery are (1) hyper-arousal or (2) shutdown. Learning to avoid extremes involves restoring executive function, self-confidence, and the capacity for playfulness and creativity. (van der Kolk, 2014, p. 207)
Van der Kolk identifies somatic and non-somatic therapies and processes that lead to calm and becoming fully present. Among the several therapies cited, he begins with breath work. Breathing calmly and remaining in a state of relative relaxation, even while accessing painful and horrifying memories, is an essential tool for recovery. (van der Kolk, 2014, p. 209) In chapters thirteen through seventeen, he also discusses cognitive-behavioral therapy (CBT), Internal Family Systems Therapy (IFS), Eye Movement Desensitization and Reprocessing (EMDR), and the role of medications.
Similarly reported are studies by the National Institutes of Health that affirm yoga practice has shown to markedly reduce PTSD symptoms of patients who failed medication trials or other forms of treatment. van der Kolk writes: Mainstream Western psychiatric and psychological healing traditions have paid scant attention to self-management. In contrast to the Western reliance on drugs and verbal therapies, other traditions from around the world rely on mindfulness, movement, rhythms, and action. (van der Kolk, 2014, p. 209)
Among the somatic therapies that van der Kolk has utilized, either independently or in collaboration with others, he emphasizes that their effectiveness lies in the context of relationships. He defines this as “physical and emotional safety, including safety from feeling shamed, admonished or judged, and to bolster the courage to tolerate, face and process the reality of what has happened.” (van der Kolk, 2014, p. 212) The problem is that many who experience trauma attempt to manage their anxiety, anger, and frustration by themself because the promise of closeness often evokes fear of getting hurt, betrayed, and abandoned, which poses a real challenge to recovery. (van der Kolk, 2014, p. 213)
In addition to Breathwork, Yoga, Art, Music, and Dance as add-ons to traditional Talk-therapy, the author explores other modes of accessing and expressing inner feelings as a treatment modality with certain clients. Often referred to as Narrative Therapy, a process in which individuals learn to separate themselves from their problems and ultimately reauthor their life stories, turning negative experiences into empowering outcomes. Van der Kolk cites the work of James Pennebaker, PhD, a social psychologist and researcher who concluded that analyzing the words that people use in their daily lives can offer insights into their emotions, motivations, and personality. He proposed that expressive writing can serve as a tool or an antibiotic for the negative experiences of trauma, whenever there is a need for grounding and emotional healing.
I enjoy utilizing this modality, primarily in the form of journaling, and have done so for most of my adult life. It serves as a catharsis and allows for the release of strong emotions that otherwise would be repressed and potentially forgotten, while leaving behind the invisible effects of the initial trauma.
Van der Kolk comments that writing about trauma can prove to be a safer alternative than talking about it for some. “Families and organizations may reject members who air the dirty laundry; friends and family can lose patience with people who get stuck in their grief or hurt” (van der Kolk, 2014, p. 246) This is why groups like Alcoholics Anonymous, Adult Children of Alcoholics, Narcotics Anonymous, and other support groups can be so critical.
In chapter eighteen, van der Kolk introduces a concept I was not familiar with —Pesso-Boyden System (PBSP) Psychomotor therapy. Developed in 1961 by Albert Pesso and Diane Boyden-Pesso. It is a body-based, experiential psychotherapy designed to heal emotional deficits and trauma by creating new, symbolic, and positive memories through movement and interaction. Van der Kolk refers to the technique used by Pesso as “Restructuring Inner Maps,” in which the therapist guides the client by creating a metaphorical chessboard as placeholders for important people in their life. These placeholders can then be moved closer or further away from the client to mirror the proximity and type of relationships similar to those in the client’s early childhood or young adult history. (van der Kolk, 2014, p.301).
The goal of the therapy is to enable the client to rescript their life as an imaginary ideal. The interventions in this type of therapy fascinate me. The approach appears similar to Gestalt therapy developed by Fritz and Laura Perls during the 1950s, which focuses on increasing self-awareness, personal responsibility, and present-moment experience. However, unlike Gestalt therapy, PBSP requires clients to revisit their past and to request stand-in protagonists and antagonists to serve as parents, guardians, and authority figures in place of the client’s real parents or guardians from the client's childhood. The therapist serves as a witness to the emotional state of the client and provides cues to what they (the witness) observe in the client. The therapist may also direct the protagonists to help create a supportive, positive experience for the client. Van der Kolk writes that “Structures” promote one of the essential conditions for big therapeutic change in which multiple realities, past and present can live side by side, past and present. (van der Kolk, 2014, p.301).
In the final chapters, van der Kolk returns to the subject of Applied Neuroscience in chapter nineteen, which he first introduced in chapter five on the Body-Brain Connection. Here, he outlines the history of mapping the brain's electrical circuits and the birth of Neurofeedback. In chapter twenty, the author outlines his experiences treating trauma through theater, collaborating with gifted artists who worked individually with clients with unresolved trauma histories. He writes, “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 to tell the truth and convey deep truths to your audience. (van der Kolk, 2014, p.337).
In the Epilogue, van der Kolk summarizes this voluminous work by saying that feeling safe with other people defines mental health more than anything else. Safe connections are meaningful and result in satisfying lives. Trauma reveals our fragility in its attempts to destroy our humanity. Despite this reality, trauma also supplies us with extraordinary resilience. As a practitioner, he has learned to view trauma symptoms as a part of sufferers’ strength. Many of those who have suffered from trauma go on be great instigators of social change. (van der Kolk, 2014, p.354).
“Trauma is now our most urgent public health issue; we have the knowledge necessary to respond effectively. The choice is ours to act on what we know.” (van der Kolk, 2014, p.301).
Conclusion:
Where to begin. I wish I had read this text when it was first released. Having done so would have provided me with greater depth and the ability to apply neuropsychology to my work as a therapist. Dr. van der Kolk keeps the focus on what his own research, combined with that of his predecessors, has revealed.
The Body Keeps the Score is a timeless work. It has remained on The New York Times Best Sellers list since its publication in 2014. An extraordinarily long run that demonstrates its value to both the academic community and the public at large. The Appendix and additional references add value for students and practitioners alike.
What I like specifically is that he uses empirical data to substantiate his conclusions. While reminding readers that he is an MD and that the research is his own, the result of hours of independent and collaborative study at some of the world's most elite academic institutions. He demonstrates a broad understanding of the literature.
Another positive is his compassion, which the reader feels from the very first chapter. He has taken a special interest in highlighting the experiences of traumatized persons and their desire to be freed from traumatic memories and their negative impact. This is where van der Kolk shines. Many of the patients he has researched have been ignored by mainstream psychiatry.
Concerning the negative, I have nothing. I think van der Kolk accomplished his goal: to shed light on the unexamined trauma experiences that remain trapped within the mind, that are often expressed negatively, without a clear path for release or remedy. This is no small feat. Some who have reviewed the book criticize the author for his overemphasis on the individual and their neurological responses and not enough on the social, political, and historical contexts (like racism or systemic oppression) that create trauma. I disagree with this criticism. To do this, van der Kolk would need to address trauma in each of those contexts. He, however, leaves that to the sociologists and historians to sort through. The author, as a medical doctor, confines his research to his known area of expertise: the human body and the way trauma is experienced by those he has observed and treated clinically.
I recommend this book without reservation as an enlightening and transformative work, and a great read that offers hope for de-stigmatizing PTSD and mental illness.
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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