Bessel van der Kolk Quotes
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Because drugs have become so profitable, major medical journals rarely publish studies on nondrug treatments of mental health problems.31 Practitioners who explore treatments are typically marginalized as “alternative.” Studies of nondrug treatments are rarely funded unless they involve so-called manualized protocols, where patients and therapists go through narrowly prescribed sequences that allow little fine-tuning to individual patients’ needs. Mainstream medicine is firmly committed to a better life through chemistry, and the fact that we can actually change our own physiology and inner equilibrium by means other than drugs is rarely considered.
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Deactivation of the left hemisphere has a direct impact on the capacity to organize experience into logical sequences and to translate our shifting feelings and perceptions into words. (Broca’s area, which blacks out during flashbacks, is on the left side.)
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Brain-imaging tools have started to show us what actually happens inside the brains of traumatized people. This has proven essential to understanding the damage inflicted by trauma and has guided us to formulate entirely new avenues of repair.
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Our study clearly showed that when traumatized people are presented with images, sounds, or thoughts related to their particular experience, the amygdala reacts with alarm—even, as in Marsha’s case, thirteen years after the event. Activation of this fear center triggers the cascade of stress hormones and nerve impulses that drive up blood pressure, heart rate, and oxygen intake—preparing the body for fight or flight. The monitors attached to Marsha’s arms recorded this physiological state of frantic arousal, even though she never totally lost track of the fact that she was resting quietly in the scanner.
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My colleague Rachel Yehuda studied rates of PTSD in adult New Yorkers who had been assaulted or rapes. Those whose mothers were Holocaust survivors with PTSD had a significantly higher rate of developing serious psychological problems after these traumatic experiences. The most reasonable explanation is that their upbringing had left them with a vulnerable physiology, making it difficult for them to regain their equilibrium after being violated. Yehuda found a similar vulnerability in the children of pregnant women who were in the World Trade Center that fatal day in 2001. Similarly, the reactions of children to painful events are largely determined by how calm or stressed their parents are.
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Memories evolve and change. Immediately after a memory is laid down, it undergoes a lengthy process of integration and reinterpretation—a process that automatically happens in the mind/brain without any input from the conscious self. When the process is complete, the experience is integrated with other life events and stops having a life of its own. As we have seen, in PTSD this process fails and the memory remains stuck—undigested and raw.
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Damasio starts by pointing out the deep divide between our sense of self and the sensory life of our bodies. As he poetically explains, Sometimes we use our minds not to discover facts, but to hide them. . . . One of the things the screen hides most effectively is the body, our own body, by which I mean the ins of it, its interiors. Like a veil thrown over the skin to secure its modesty, the screen partially removes from the mind the inner states of the body, those that constitute the flow of life as it wanders in the journey of each day.
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Our relationship maps are implicit, etched into the emotional brain and not reversible simply by understanding how they were created. You may realize that your fear of intimacy has something to do with your mother’s postpartum depression or with the fact that she herself was molested as a child, but that alone is unlikely to open you to happy, trusting engagement with others.
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Semrad taught us 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—with all its pleasures and heartbreak. “The greatest sources of our suffering are the lies we tell ourselves,” he’d say, urging us to be honest with ourselves about every facet of our experience. He often said that people can never get better without knowing what they know and feeling what they feel.
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Psychiatry, as a subspecialty of medicine, aspires to define mental illness as precisely as, let’s say, cancer of the pancreas, or streptococcal infection of the lungs. However, given the complexity of mind, brain, and human attachment systems, we have not come even close to achieving that sort of precision. Understanding what is “wrong” with people currently is more a question of the mind-set of the practitioner (and of what insurance companies will pay for) than of verifiable, objective facts.
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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.
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Being traumatized is not just an issue of being stuck in the past; it is just as much a problem of not being fully alive in the present. One form of exposure treatment is virtual-reality therapy in which veterans wear high-tech goggles that make it possible to refight the battle of Fallujah in lifelike detail. As far as I know, the US Marines performed very well in combat. The problem is that they cannot tolerate being home. Recent studies of Australian combat veterans show that their brains are rewired to be alert for emergencies, at the expense of being focused on the small details of everyday life.43 (We’ll learn more about this in chapter 19, on neurofeedback.) More than virtual-reality therapy, traumatized patients need “real world” therapy, which helps them to feel as alive when walking through the local supermarket or playing with their kids as they did in the streets of Baghdad.
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Dissociation prevents the trauma from becoming integrated within the conglomerated, ever-shifting stores of autobiographical memory, in essence creating a dual memory system. Normal memory integrates the elements of each experience into the continuous flow of self-experience by a complex process of association; think of a dense but flexible network where each element exerts a subtle influence on many others. But in Julian’s case, the sensations, thoughts, and emotions of the trauma were stored separately as frozen, barely comprehensible fragments.
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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 that we are held in someone else’s mind and heart. For our physiology to calm down, heal, and grow we need a visceral feeling of safety. No doctor can write a prescription for friendship and love: These are complex and hard-earned capacities. You don’t need a history of trauma to feel self-conscious and even panicked at a party with strangers—but trauma can turn the whole world into a gathering of aliens.
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Some 80 percent of the fibers of the vagus nerve (which connects the brain with many internal organs) are afferent; that is, they run from the body into the brain.6 This means that we can directly train our arousal system by the way we breathe, chant, and move, a principle that has been utilized since time immemorial in places like China and India, and in every religious practice that I know of, but that is suspiciously eyed as “alternative” in mainstream culture.
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The disappearance of medial prefrontal activation could explain why so many traumatized people lose their sense of purpose and direction. I used to be surprised by how often my patients asked me for advice about the most ordinary things, and then by how rarely they followed it. Now I understood that their relationship with their own inner reality was impaired. How could they make decisions, or put any plan into action, if they couldn't define what they wanted or, to be more precise, what the sensations in their bodies, the basis of all emotions, were trying to tell them?
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The lack of literature on the topic was a handicap, but my great teacher, Elvin Semrad, had taught us to be skeptical about textbooks. We had only one real textbook, he said: our patients. We should trust only what we could learn from them—and from our own experience.
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I decided to ask eight Vietnam combat veterans if they would be willing to take a standard pain test while they watched scenes from a number of movies. The first clip we showed was from Oliver Stone’s graphically violent Platoon (1986), and while it ran we measured how long the veterans could keep their right hands in a bucket of ice water. We then repeated this process with a peaceful (and long-forgotten) movie clip. Seven of the eight veterans kept their hands in the painfully cold water 30 percent longer during Platoon. We then calculated that the amount of analgesia produced by watching fifteen minutes of a combat movie was equivalent to that produced by being injected with eight milligrams of morphine, about the same dose a person would receive in an emergency room for crushing chest pain.
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There can be no growth without curiosity and no adaptability without being able to explore, through trial and error, who you are and what matters to you.
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Talking about painful events doesn’t necessarily establish community – often quite the contrary. Families and organizations may reject members who air the dirty laundry; friends and family can lost patience with people who get stuck in their grief or hurt. This is one reason why trauma victims often withdraw and why their stories become rote narratives, edited into a form least likely to provoke rejection.
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Were not only healthier but also less likely to report having been abused or neglected than a similar group whose mothers had not been visited. They also were more likely to have finished school, to have stayed out of jail, and to be working in well-paying jobs. Economists have calculated that every dollar invested in high-quality home visitation, day care, and preschool programs results in seven dollars of savings on welfare payments, health-care costs, substance-abuse treatment, and incarceration, plus higher tax revenues due to better-paying jobs.
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Nothing was written in stone. Neither the mother’s personality, nor the infant’s neurological anomalies at birth, nor its IQ, nor its temperament—including its activity level and reactivity to stress—predicted whether a child would develop serious behavioral problems in adolescence.20 The key issue, rather, was the nature of the parent-child relationship: how parents felt about and interacted with their kids. As with Suomi’s monkeys, the combination of vulnerable infants and inflexible caregivers made for clingy, uptight kids. Insensitive, pushy, and intrusive behavior on the part of the parents at six months predicted hyperactivity and attention problems in kindergarten and beyond.
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I have met countless patients who told me that they “are” bipolar or borderline or that they “have” PTSD, as if they had been sentenced to remain in an underground dungeon for the rest of their lives, like the Count of Monte Cristo. None of these diagnoses takes into account the unusual talents that many of our patients develop or the creative energies they have mustered to survive.
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I vividly remember a videotape Beatrice Beebe showed me.28 It featured a young mother playing with her three-month-old infant. Everything was going well until the baby pulled back and turned his head away, signaling that he needed a break. But the mother did not pick up on his cue, and she intensified her efforts to engage him by bringing her face closer to his and increasing the volume of her voice. When he recoiled even more, she kept bouncing and poking him. Finally he started to scream, at which point the mother put him down and walked away, looking crestfallen. She obviously felt terrible, but she had simply missed the relevant cues. It’s easy to imagine how this kind of misattunement, repeated over and over again, can gradually lead to a chronic disconnection. (Anyone who’s raised a colicky or hyperactive baby knows how quickly stress rises when nothing seems to make a difference.) Chronically failing to calm her baby down and establish an enjoyable face-to-face interaction, the mother is likely to come to perceive him as a difficult child who makes her feel like a failure, and give up on trying to comfort her child.