Imagine cruising down a highway at 65 mph some dark and rainy night until a pothole thumps your right tire, explodes it, whips you off the road, flips you—now you’re upside down skidding on the hood of your car, the squeal of metal on concrete or maybe on your skull piercing the night and your mind, for an eternity, until you smash into silence. Later you wake in an ambulance, but no siren. Nice people in jumpsuits tell you about your “minor laceration where your forehead knocked your steering wheel.” Hours later the emergency room doc deems your survival a “seat-belt miracle,” and you take a cab home with just a band-aid above your eyebrow to show for your near-death experience with a pothole in the rain. Will this experience mark the end of your life as a driver or just another bump in the road?
I’ve spent this past month reading and rereading and relishing Bessel van der Kolk’s book (2014) The Body Keeps the Score: Brain, Mind, and Body in the Healing of Trauma. This book fascinates me in ways that will fascinate anyone who has ever marveled at the power of traumatic memories to tyrannize an otherwise promising life. How does trauma get such a grip on us and work its curse in such tormenting ways over so many years? The surprising lesson here is embedded in his title: pay attention to the body.
Van der Kolk, a psychiatrist now in his early seventies, has given us the essence of his career devoted to plumbing the mysteries of psychological trauma, given it to us in a friendly voice that weaves clinical anecdotes and research pearls into a somewhat autobiographical narrative. His book serves also as a history of the recent emergence of trauma psychology into popular culture and our diagnostic nomenclature. I hear his voice more vividly for having worked with him for several years starting in 1982 at the Massachusetts Mental Health Center, where I was a resident and Bessel, about six years my senior, was starting his academic career as one of our psychopharmacology teachers. Back then it was clear he was more passionate about the mysteries of trauma than the promises of pharmacology.
His title The Body Keeps the Score hints at the peculiar way we process traumatic memories when an event overwhelms us. Instead of storing the memory along with the rest of our related events and associations that give it meaning and context, instead of reworking those memories over and over in the remembering and telling and retelling until we achieve a coherent narrative that helps us cope, other less adaptive memory processes can take over in the heat of the crisis. During an adrenaline surge our frontal lobes can shut down temporarily, robbing us of judgment and the capacity to make complex decisions. We shift into automatic mode and operate on reflex. We flee or we brace for a fight. Or we freeze when we’re helpless. Some sensory processes operate on high alert while others shut down, so we end up with intense but fragmented memories.
After the experience we may be left with just a few pieces that make no coherent story. Sequences are confused. Sensations are recalled out of proportion to their meaning. The intensity of the memories defies words, so it’s easy to avoid talking about it. Without intending to, we may repress or “forget” large parts of the event. The next time you watch Good Will Hunting or read Toni Morrison’s Beloved, notice how the fragmentation and repression of traumatic memories drive the patchwork telling of the story.
Instead of being “metabolized” and stored as part of some coherent narrative like most memories, the traumatic memory is stored like a foreign body that forms an abscess around it. The traumatic flashback fragment remains hot, retains the original intensity of feeling and content, lacks context. Flashbacks repeat the threat and do not contribute to distancing or reworking the experience toward a sense of safety.
What toll does traumatic memory take on the body? The toll varies with the trauma, the frequency of re-experiencing the trauma through flashbacks and nightmares, the duration of the re-experiencing, and the person’s innate vulnerability to stress. Van der Kolk’s point is that no matter how much our conscious mind spares us awareness of the trauma through denial and repression and forgetting, the body and the unconscious mind keep the score.
Imagine the toll on a twelve-year old girl who has grown up with the threat of being raped by her stepfather for four years. How fast does her heart beat when he walks in the door each evening? How deep does she sleep each night? What food or drink or drug or mental gymnastic can buffer her from her fear, her rage? Long after the stepfather is removed, long after she has blanked out from memory large periods of her childhood, she may struggle to read her own alarm signals, to figure out whom she can trust. The enemy is now within. “After trauma the world is experienced with a different nervous system,” writes van der Kolk. When you can’t tell whether you’re in a safe zone or a danger zone, you live on high alert, day and night. Or you learn to discount all alarms.
People with post-traumatic stress disorder (PTSD) often live at the extremes of hyperarousal or numbness. They feel either overcharged or emotionally dead, without much experience in the middle of the emotional spectrum where the rest of us live. For them regulating affect often requires deliberate effort, much effort, sometimes seems impossible when the next highway pothole comes along. That means they’re more likely to lose control of their behavior in costly ways, such as fighting, weeping, bingeing, drinking, racing, spending, road raging. They’re more likely to develop chronic physical pain in concert with their anguish. They’re more likely to develop heart disease at a young age, diabetes from overeating, and irritable bowel syndrome from a chronically inflamed gut. Their capacity to dissociate as a way of coping with the helpless position of the victim makes them adept at ignoring internal signals of distress or dysregulation, such as denying chest pain or a lump in the breast. Is it any wonder that several studies have found that PTSD predicts early death.
Eight of the 20 chapters in The Body Keeps the Score detail the “paths to recovery.” The list of effective and promising new treatments for trauma is long and not what you would expect from a psychiatrist. Van der Kolk is not impressed with psychiatry’s standard approaches to therapy and medications. He writes, “Physical awareness is the first step in releasing the tyranny of the past.” (p. 101) This means comprehensive treatment should begin with yoga or neurofeedback or massage therapy or body work or meditation or dance—some practice that helps the person tune in to internal signals about body states.
When your own physical sensations become the enemy, you have to learn to “befriend your body,” as van der Kolk calls it. This process of relearning can be painful and slow, like learning to walk or talk again after a stroke, but trusting yourself is the first step toward trusting others. The goal is the capacity to achieve a visceral sense of safety, which requires learning to control intense affects and endure exposure to triggers without hyperarousal. This means retraining your body as you retrain your mind and brain. Medications can pave the way at times, but the foundations of recovery from trauma are laid through therapy that fosters the reintegration of the mind, brain, and body at the deepest levels. For many of us, that’s what it takes to prevent a near-death experience from tyrannizing the rest of our lives.