The Body Keeps the Score
Bessel van der Kolk's book changed the way I understand trauma and public health
The book in three sentences
Trauma rewires our brains such that it becomes difficult for our bodies to distinguish threats to our well-being (which cause our fight/flight/freeze reaction) from normal stimuli. The effects of this trauma manifest mentally and physically (e.g., through the chronic release of stress hormones). The earlier trauma takes place in our lives, the more difficult it is to overcome; the Adverse Childhood Experiences (ACE) Study revealed that childhood trauma the United States’ most expensive public health crisis.
How the book changed me
This book taught me that childhood trauma is the costliest public health issue in the United States, reaffirmed my belief in the importance of strong and supportive relationships, and made me reflect on adverse experiences people go through and the resulting effects on their perceptions of the world and their behavior.
This book also taught me how important it is to nurture a safe environment for our young. I learned that our brain is most open to influence when we are youngest (i.e., in our first two years), and that the imprints on our brain that occur at this time are most difficult to change.
Top three quotes
1. Trauma results in a fundamental reorganization of the way mind and brain manage perceptions. It changes not only how we think and what we think about, but also our very capacity to think.
2. 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.
3. “The greatest discovery of my generation is that human beings can alter their lives by altering their attitudes of mind.” —William James
Key takeaways
On relationships and social support
Feeling cared for is crucial to our well-being. Patients assigned to placebo of trials evaluating the efficacy of a drug on mental health often improve. This may occur because these patients feel important: they receive attention and are asked detailed questions about how they feel and think. “But maybe the mother’s kisses that soothe her child’s scrapes are “just” a placebo as well.”
Terrified adults “respond to the same comforts as terrified children.” “When we are terrified, nothing calms us down like the reassuring voice or the firm embrace of someone we trust… gentle holding and rocking and the assurance that somebody bigger and stronger is taking care of things, so you can safely go to sleep.” Safe places to touch are those where they can touch you back, such as their hand or forearm.
Feeling that we can overcoming or escape adverse experiences is essential to preventing trauma. “People who feel safe and meaningfully connected with others have little reason to squander their lives doing drugs or staring numbly at television; they don’t feel compelled to stuff themselves with carbohydrates or assault their fellow human beings. However, if nothing they do seems to make a difference, they feel trapped and become susceptible to the lure of pills, gang leaders, extremist religions, or violent political movements—anybody and anything that promises relief.”
Contemporary trauma management
The treatment of distress solely with psychiatric medications “deflects attention from dealing with the underlying issues.” “The brain-disease model takes control over people’s fate out of their own hands and puts doctors and insurance companies in charge of fixing their problems.”
Our response to stress and its effects on brain function
Our emotional and rational brains engage in a tug-of-war. When one is strongly activated (e.g., the emotional brain in response to a distressing stimulus), it becomes much more difficult to engage the other (the rational brain).
When we feel threatened, we first turn to people; if no one helps us, we fight or flight; if that fails, we freeze.
Turning to people: “[calling] out for help, support, and comfort from the people around us”
Fight or flight: “We fight off our attacker, or we run to a safe place.”
Freeze or collapse: “the organism tries to preserve itself by shutting down and expending as little energy as possible.”
Many traumatized people feel more alive in the face of real danger because “panic and rage are preferable shutting down and becoming dead to the world… activating fight/flight at least makes them feel energized. That is why so many abused and traumatized people feel fully alive in the face of actual danger, while they go numb in situations that are more complex but objectively safe, like birthday parties or family dinners.”
Attachment styles and parenting
The way our parents/guardians treat us as children determines our attachment style and consequently has great influence over the future relationships we seek. “If our parents or grandparents keep telling us we’re the cutest, most delicious thing in the world, we don’t question their judgment—we must be exactly that. And deep down, no matter what else we learn about ourselves, we will carry that sense with us: that we are basically adorable. As a result, if we later hook up with somebody who treats us badly, we will be outraged. It won’t feel right: It’s not familiar; it’s not like home. But if we are abused or ignored in childhood, or grow up in a family where sexuality is treated with disgust, our inner map contains a different message. Our sense of our self is marked by contempt and humiliation, and we are more likely to think “he (or she) has my number” and fail to protest if we are mistreated.”
Children “have a biological instinct to attach”, and attachment styles work because “they elicit the best care a particular caregiver is capable of providing.” Children have no choice but to attach, no matter how their parents treat them. If a child’s parents treat them poorly, the child may adjust their behavior to have their needs met, leading to attachment styles (secure, avoidant, or anxious). “Infants who encounter a consistent pattern of care—even if it’s marked by emotional distance or insensitivity—can adapt to maintain the relationship.”
Clinically relevant insights:
Long-term health risks (e.g., smoking, drugs, obesity) are often short-term solutions to other problems, which clinicians often feel uncomfortable discussing. ‘The ACE study group concluded: “Although widely understood to be harmful to health, each adaptation [such as smoking, drinking, drugs, obesity] is notably difficult to give up. Little consideration is given to the possibility that many long-term health risks might also be personally beneficial in the short term. We repeatedly hear from patients of the benefits of these ‘health risks.’ The idea of the problem being a solution, while understandably disturbing to many, is certainly in keeping with the fact that opposing forces routinely coexist in biological systems. . . . What one sees, the presenting problem, is often only the marker for the real problem, which lies buried in time, concealed by patient shame, secrecy and sometimes amnesia—and frequently clinician discomfort.”’
Public health implications:
Child abuse is the “most costly public health issue in the United States,” according to the ACE study. “Its overall costs exceeded those of cancer or heart disease [and] 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… child abuse and neglect is the single most preventable cause of mental illness, the single most common cause of drug and alcohol abuse, and a significant contributor to leading causes of death such as diabetes, heart disease, cancer, stroke, and suicide.”
“Social support is a biological necessity, not an option, and this reality should be the backbone of all prevention and treatment. Recognizing the profound effects of trauma and deprivation on child development need not lead to blaming parents. We can assume that parents do the best they can, but all parents need help to nurture their kids. Nearly every industrialized nation, with the exception of the United States, recognizes this and provides some form of guaranteed support to families.”
Trauma and politics are directly linked. “In today’s world your ZIP code, even more than your genetic code, determines whether you will lead a safe and healthy life. People’s income, family structure, housing, employment, and educational opportunities affect not only their risk of developing traumatic stress but also their access to effective help to address it. Poverty, unemployment, inferior schools, social isolation, widespread availability of guns, and substandard housing all are breeding grounds for trauma. Trauma breeds further trauma; hurt people hurt other people.”
Healing from trauma
When the emotional brain has taken over (e.g., when recalling a traumatic experience), one cannot learn from their experience. To recover from trauma requires being able to remain calm when describing a traumatic event. This ability can be developed through meditation. “Learning how to breathe calmly and remaining in a state of relative physical relaxation, even while accessing painful and horrifying memories, is an essential tool for recovery.”
Hiding traumatic prior experiences is harmful. “As long as you keep secrets and suppress information, you are fundamentally at war with yourself. Hiding your core feelings takes an enormous amount of energy, it saps your motivation to pursue worthwhile goals, and it leaves you feeling bored and shut down. Meanwhile, stress hormones keep flooding your body, leading to headaches, muscle aches, problems with your bowels or sexual functions—and irrational behaviors that may embarrass you and hurt the people around you. Only after you identify the source of these responses can you start using your feelings as signals of problems that require your urgent attention.”
Writing to yourself is a highly effective method of accessing our inner world of feelings. When we write to ourselves, we don’t have to worry about other people’s judgements.
Traumatized people often avoid the sensations they feel when discussing their trauma; recovery requires “open[ing] ourselves to [our] inner experience.” “At the core of recovery is self-awareness. The most important phrases in trauma therapy are ‘Notice that’ and ‘What happens next?’ Traumatized people live with seemingly unbearable sensations: They feel heartbroken and suffer from intolerable sensations in the pit of their stomach or tightness in their chest. Yet avoiding feeling these sensations in our bodies increases our vulnerability to being overwhelmed by them… Simply noticing our annoyance, nervousness, or anxiety immediately helps us shift our perspective and opens up new options other than our automatic, habitual reactions.”
Noticing to our physical sensations helps us open ourselves to our feelings by allowing us to tolerate what we feel when we revisit the past. “The first step [to opening yourself to your inner experience] is to allow your mind to focus on your sensations and notice how, in contrast to the timeless, ever-present experience of trauma, physical sensations are transient and respond to slight shifts in body position, changes in breathing, and shifts in thinking. Once you pay attention to your physical sensations, the next step is to label them, as in ‘When I feel anxious, I feel a crushing sensation in my chest.’ I may then say to a patient: ‘Focus on that sensation and see how it changes when you take a deep breath out, or when you tap your chest just below your collarbone, or when you allow yourself to cry.’ Practicing mindfulness calms down the sympathetic nervous system, so that you are less likely to be thrown into fight-or-flight. Learning to observe and tolerate your physical reactions is a prerequisite for safely revisiting the past. If you cannot tolerate what you are feeling right now, opening up the past will only compound the misery and retraumatize you further.”
School
For children living in unsafe households, schools can be a safe haven. Unfortunately, we often respond to children who exhibit symptoms of traumatic stress (e.g., “tantrums, spacing out, or aggressive outbursts”) by punishing them, causing school to become “yet another traumatic trigger.” Instead of punishment (e.g., making a student sit alone in a corner) or yelling, Bessel encourages teachers acknowledge, notice, and name their students feelings, then calm the student, and finally “discuss possible solutions. For example, when a first-grader melts down, hitting his teacher and throwing objects around, we encourage his teacher to set clear limits while gently talking to him: ‘Would you like to wrap that blanket around you to help you calm down?’ (The kid is likely to scream, “No!” but then curl up under the blanket and settle down.)”
“Punishment can at best temporarily halt unacceptable behaviors, but since the underlying alarm system and stress hormones are not laid to rest, they [children] are certain to erupt again at the next provocation.”
“Predictability and clarity of expectations are critical; consistency is essential. Children from chaotic backgrounds often have no idea how people can effectively work together, and inconsistency only promotes further confusion. Trauma-sensitive teachers soon realize that calling a parent about an obstreperous kid is likely to result in a beating and further traumatization.”
Misc
“We remember insults and injuries best: The adrenaline that we secrete to defend against potential threats helps to engrave those incidents into our minds. Even if the content of the remark fades, our dislike for the person who made it usually persists.”
Our imagination is “critical to the quality of our lives. Our imagination enables us to leave our routine everyday existence by fantasizing about travel, food, sex, falling in love, or having the last word—all the things that make life interesting. Imagination gives us the opportunity to envision new possibilities—it is an essential launchpad for making our hopes come true.”