Bessel van der Kolk Quotes
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Porges’s theory provides an explanation: The autonomic nervous system regulates three fundamental physiological states. The level of safety determines which one of these is activated at any particular time. Whenever we feel threatened, we instinctively turn to the first level, social engagement. We call out for help, support, and comfort from the people around us. But if no one comes to our aid, or we’re in immediate danger, the organism reverts to a more primitive way to survive: fight or flight. We fight off our attacker, or we run to a safe place. However, if this fails—we can’t get away, we’re held down or trapped—the organism tries to preserve itself by shutting down and expending as little energy as possible. We are then in a state of freeze or collapse.
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Research has shown that depressed patients without prior histories of abuse or neglect tend to respond much better to antidepressants than patients with those backgrounds.
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As the previous parts of this book have shown, the engines of posttraumatic reactions are located in the emotional brain. In contrast with the rational brain, which expresses itself in thoughts, the emotional brain manifests itself in physical reactions: gut-wrenching sensations, heart pounding, breathing becoming fast and shallow, feelings of heartbreak, speaking with an uptight and reedy voice, and the characteristic body movements that signify collapse, rigidity, rage, or defensiveness.
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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.
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There was no activation of any part of the brain involved in social engagement. In response to being looked at they simply went into survival mode. What does this mean for their ability to make friends and get along with others?
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The more you stay focused on your breathing, the more you will benefit, particularly if you pay attention until the very end of the out breath and then wait a moment before you inhale again. As you continue to breathe and notice the air moving in and out of your lungs you may think about the role that oxygen plays in nourishing your body and bathing your tissues with the energy you need to feel alive and engaged.
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We don’t really want to know what soldiers go through in combat. We do not really want to know how many children are being molested and abused in our own society or how many couples—almost a third, as it turns out—engage in violence at some point during their relationship. We want to think of families as safe havens in a heartless world and of our own country as populated by enlightened, civilized people. We prefer to believe that cruelty occurs only in faraway places like Darfur or the Congo. It is hard enough for observers to bear witness to pain. Is it any wonder, then, that the traumatized individuals themselves cannot tolerate remembering it and that they often resort to using drugs, alcohol, or self-mutilation to block out their unbearable knowledge?
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For many people the war begins at home: Each year about three million children in the United States are reported as victims of child abuse and neglect. One million of these cases are serious and credible enough to force local child protective services or the courts to take action.12 In other words, for every soldier who serves in a war zone abroad, there are ten children who are endangered in their own homes. This is particularly tragic, since it is very difficult for growing children to recover when the source of terror and pain is not enemy combatants but their own caretakers.
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Spend an afternoon with them sharing the latest research on the treatment of traumatized children, adolescents, and their families. The same is true for many of my colleagues. These countries have already made a commitment to universal health care, ensuring a guaranteed minimum wage, paid parental leave for both parents after a child is born, and high-quality childcare for all working mothers.
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The scientific study of suffering inevitably raises questions of causation, and with these, issues of blame and responsibility. Historically, doctors have highlighted predisposing vulnerability factors for developing PTSD, at the expense of recognizing the reality of their patients' experiences… This search for predisposing factors probably had its origins in the need to deny that all people can be stressed beyond endurance, rather than in solid scientific data; until recently such data were simply not available… When the issue of causation becomes a legitimate area of investigation, one is inevitably confronted with issues of man's inhumanity to man, with carelessness and callousness, with abrogation of responsibility, with manipulation and with failures to protect.
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Many of my patients respond to stress not by noticing and naming it but by developing migraine headaches or asthma attacks.15 Sandy, a middle-aged visiting nurse, told me she’d felt terrified and lonely as a child, unseen by her alcoholic parents. She dealt with this by becoming deferential to everybody she depended on (including me, her therapist). Whenever her husband made an insensitive remark, she would come down with an asthma attack.
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Could this approach to public health have something to do with the fact that the incarceration rate in Norway is 71/ 100,000, in the Netherlands 81/ 100,000, and the US 781/ 100,000, while the crime rate in those countries is much lower than in ours, and the cost of medical care about half? Seventy percent of prisoners in California spent time in foster care while growing up. The United States spends $ 84 billion per year to incarcerate people at approximately $ 44,000 per prisoner; the northern European countries a fraction of that amount. Instead, they invest in helping parents to raise their children in safe and predictable surroundings. Their academic test scores and crime rates seem to reflect the success of those investments.
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She was convinced that men didn’t give a damn about other people’s feelings and that they got away with whatever they wanted. Women couldn’t be trusted either. They were too weak to stand up for themselves, and they’d sell their bodies to get men to take care of them. If you were in trouble, they wouldn’t lift a finger to help you. This worldview manifested itself in the way Marilyn approached her colleagues at work: She was suspicious of the motives of anyone who was kind to her and called them on the slightest deviation from the nursing regulations. As for herself: She was a bad seed, a fundamentally toxic person who made bad things happen to those around her.
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If you do something to a patient that you would not do to your friends or children, consider whether you are unwittingly replicating a trauma from the patient’s past.
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As Schwartz states: “If one accepts the basic idea that people have an innate drive toward nurturing their own health, this implies that, when people have chronic problems, something gets in the way of accessing inner resources. Recognizing this, the role of therapists is to collaborate rather than to teach, confront, or fill holes in your psyche.”14 The first step in this collaboration is to assure the internal system that all parts are welcome and that all of them—even those that are suicidal or destructive—were formed in an attempt to protect the self-system, no matter how much they now seem to threaten it.
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Trauma causes people to remain stuck in interpreting the present in light of an unchanging past. The scene you re-create in a structure may or may not be precisely what happened, but it represents the structure of your inner world: your internal map and the hidden rules that you have been living by.
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The first time I heard Robert Anda present the results of the ACE study, he could not hold back his tears. In his career at the CDC he had previously worked in several major risk areas, including tobacco research and cardiovascular health. But when the ACE study data started to appear on his computer screen, he realized that they had stumbled upon the gravest and most costly public health issue in the United States: child abuse. He 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. 20 It would also have a dramatic effect on workplace performance and vastly decrease the need for incarceration.
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How can people open up to and explore their internal world of sensations and emotions? In my practice I begin the process by helping my patients to first notice and then describe the feelings in their bodies—not emotions such as anger or anxiety or fear but the physical sensations beneath the emotions: pressure, heat, muscular tension, tingling, caving in, feeling hollow, and so on. I also work on identifying the sensations associated with.
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Body awareness puts us in touch with our inner world.
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Dave’s visit eventually grew into a very active yoga program, and in due course we received the first grant from the National Institutes of Health to study the effects of yoga on PTSD. Dave’s work also contributed to my developing my own regular yoga practice and becoming a frequent teacher at Kripalu, a yoga center in the Berkshire Mountains in western Massachusetts. (Along the way, my own HRV pattern improved as well.)
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Many traumatized people seem to seek out experiences that would repel most of us,14 and patients often complain about a vague sense of emptiness and boredom when they are not angry, under duress, or involved in some dangerous activity.
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Research from these new disciplines has revealed that trauma produces actual physiological changes, including a recalibration of the brain’s alarm system, an increase in stress hormone activity, and alterations in the system that filters relevant information from irrelevant. We now know that trauma compromises the brain area that communicates the physical, embodied feeling of being alive. These changes explain why traumatized individuals become hypervigilant to threat at the expense of spontaneously engaging in their day-to-day lives. They also help us understand why traumatized people so often keep repeating the same problems and have such trouble learning from experience. We now know that their behaviors are not the result of moral failings or signs of lack of willpower or bad character—they are caused by actual changes in the brain.
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Desensitization: helping patients become less reactive to certain emotions and sensations. But is this the correct goal? Maybe the issue is not desensitization but integration: putting the traumatic event into its proper place in the overall arc of one’s life.
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Study after study shows that having a good support network constitutes the single most powerful protection against becoming traumatized.