Up front, Van Der Kolk let us know that there are considered to three ways to treat someone with trauma:
...or some combination of all three. This book concerns his exploration and discovery of the value of treatment with the third way.
Trauma has serious effects on our lives:
PTSD was only recognised as a diagnosis in 1980, the combination of a number of symptoms that would present at the same time. This led, for the first time, a concerted effort to research it and attempts at treatment.
'I now saw that flashbacks could be even worse. You never know when you will be assaulted by them again and you have no way of telling when they will stop.' (Page 18)
It's not enough to just talk through a traumatic event—the 'talking therapy' that had been so popular when Van Der Kolk was training—relearning needs to happen.
'Rather than risk experimenting with new options they stay stuck in the fear they know.' (Page 34)
Inescapable shock: just having the ability to escape from a situation doesn't mean that you'll exercise your ability to do so.
'For real change to take place, the body needs to learn that the danger has passed and to live in the reality of the present.' (Page 24)
Cortisol continues coursing through after that event, causing a continuous barrage of fight/flight/freeze signals. Over time, this wreaks havoc on our health.
The introduction of drugs had huge benefits at first... and then drawbacks just as large. Many issues were swept under the rug of 'chemical imbalances', with prescriptions papering over cracks that should have been treated in a range of ways.
From early brain scans made while 'trauma scripts' were read to patients, Kolk made three interesting discoveries about what happens during a flashback:
The patients were left speechless as they relived their experiences as if they were happening there and then.
'Some people simply go into denial: Their bodies register the threat, but their conscious minds go on as if nothing has happened. However, even though the mind may learn to ignore the messages from the emotional brain, the alarm signals don't stop. The emotional brain keeps working, and stress hormones keep sending signals to the muscles to tense for action or immobilize in collapse. The physical effects on the organs go on unabated until they demand notice when they are expressed as illness. Medications, drugs, and alcohol can also temporarily dull or obliterate unbearable sensations and feelings. But the body continues to keep the score.' (Page 54)
'Being traumatized means continuing to organize your life as if the trauma were still going on - unchanged and immutable - as every new encounter or event is contaminated by the past.' (Page 62)
Brains are concerned with survival. They:
The brain exists in three distinct parts, the "Triune Brain":
The limbic brain is shaped in response to our experiences. Considered together the repitle and limbic brain can be together considered as the 'emotional brain'.
The emotional brain gets all its sensory input first. This comes via the thalamus, then to the amygdala next—the part of our brain that determines if something is a threat. It is the amygdala that can trigger cortisol and adrenaline.
'These early explorations shape the limbic structures devoted to emotions and memory, but these structures can also be significantly modified by later experiences: for the better by a close friendship or a beautiful first love, for example, or for the worse by a violent assault, relentless bullying, or neglect.' (Page 66)
Messages about our surroundings make it to the rational brain/prefrontal cortex last. Therefore it's hard to filter for things that aren't really a threat to us; our emotional brain has already reacted.
PTSD leads to a breakdown of the power balance between the medial prefrontal cortex (MPFC) and the amygdala. It creates a hair trigger that sends you into a tailspin.
'When our emotional and rational brains are in conflict (as when we're enraged with someone we love, frightened by someone we depend on, or lust after someone who is off limits), a tug-of-war ensues. This war is largely played out in the theater of visceral experience - your gut, your heart, your lungs- and will lead to both physical discomfort and psychological misery.' (Page 75)
There are a variety of physical responses to reliving trauma. Because they are irrational or feel like they are outside of our control, they lead to feelings of shame which becomes a dominant emotion.
'Being anchored in the present while revisiting the trauma opens the possibility of deeply knowing that the terrible events belong to the past.' (Page 81)
Therapy won't work in the present if you're stuck in the past. People with PTSD, though, will often avoid the past by closing down their field of vision, looking through life down a narrow tunnel. They are able to focus on what they need to, but at the cost of shutting everything else out: the joy and pleasure in life.
While one possible response to trauma is to repeatedly relive it, the other is to depersonalise. This is where we cannot handle what is happening to us and shut down completely. This can interfere with our lives in a multitude of ways.
'Our culture teaches us to focus on personal uniqueness, but at a deeper level we barely exist as individual organisms. Our brains are built to help us function as members of a tribe. We are part of that tribe even when we are by ourselves, whether listening to music (that other people created), watching a basketball game on television (our own muscles tensing as the players run and jump), or preparing a spreadsheet for a sales meeting (anticipating the boss's reactions). Most of our energy is devoted to connecting with others.' (Page 91)
Three levels of response to threat:
Emotional abuse can be just as damaging as physical abuse and sexual molestation.
'What is your brain doing when you have nothing in particular your mind? It turns out that you pay attention to yourself: The default state activates the brain areas that work together to create your sense of 'self.'' (Page 106)
Default State Network: this is who we are. A shut down stops everything, including this, meaning we lose our sense of self after any trauma.
Agency is being in charge of your life:
Alexithymia is where you have no words for your feelings:
'After several days of exchanging pleasantries, conversation would come to a halt, and I'd have to work hard to fill the long silences. On the last day of her visits I'd drive her to the airport, where she'd give me a stiff goodbye hug while tears streamed down her face. Without a trace of irony she'd then complain that the cold wind at Logan International Airport made her eyes water. Her body felt the sadness that her mind couldn't register she was leaving our young family, her closest living relatives.' (Page 115)
This is a state in which you can't identify what physical feelings mean, so there are no words to go with them. These people tend to register emotions as physical feelings. It can lead to muscle pain, bowel problems, other apparently causeless symptoms.
'Most seem to have made an unconscious decision that it is better to keep visiting doctors and treating ailments that don't heal than to do the painful work of facing the demons of the past' (Page 117)
Depersonalisation is losing the sense of self completely, including the connection to the body. The solution is to reconnect people with their physical sensations, slowly, in therapy.
'I love the expression of the great French psychiatrist Pierre Janet: 'Every life is a piece of art, put together with all means available.'' (Page 131)
Attachment is the base from which we build out into the world. It begins with our parents, with us becoming attached to our primary caregiver first. For many of us, this means our mothers.
With our caregivers when we are infants, emotional synchronisation leads also to physical synchronisation. This gives us an 'internal locus of control', something that allows us to have healthy coping throughout our lives.
This locus of control is about knowing what makes you and others feel good & bad. With this knowledge, we are able to handle ourselves and what we do in relation to our peers. This helps us fit in and function socially. Children who cannot attune to others‚ whether through overreaction or poor ability to pick up on the needs of others, normally get shunned.
There are four types of attachment, all with their own distinct coping styles:
At this point, Van Der Kolk tells the story of an incest survivor who develops an auto-immune disease because of their trauma. This spurs him to research this, looking at the difference between incest survivors and a control group, specifically something called the CD45RA antibodies versus CD45RO antibodies.
These two sets of antibodies exist in the body in a certain ration. RA cells are the ones that have been activated before, have memory, and are able to act again should the original threat/pathogen reappear. RO cells wait in the wings, ready to adapt and pounce.
Van Der Kolk and his colleagues found that the incest survivor group had a far higher RA to RO ratio, indicating that their past experiences had activated far more antibodies. This left them with hyperactive immune systems that could potentially damage them.
'Kids from lower socioeconomic groups are more likely to be disorganized, with parents often severely stressed by economic and family instability.' (Page 140)
Van Der Kolk is also sceptical of the DSM (diagnostic and statistical manual of mental disorders) and how it is compiled. The conditions in there, once diagnosed in someone, can affect how people identify themselves: they often have a habit of attaching themselves to people throughout a lifetime—but it's hardly that cut and dry, and not that simple.
'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' (Page 164)
Traumatic experiences during childhood and adolescence are far more common than expected. Adverse experiences are interrelated, but often studied (and treated) separately. Adversity is often concealed over time by shame, secrecy, and social taboo.
ACE scores (adverse childhood experience) have a strong correlation to depression, suicide, and self-harm in adulthood.
'People typically don't grow up in a household where one brother is in prison but everything else is fine. They don't live in families where their mother is regularly beaten but life is otherwise hunkydory. Incidents of abuse are never stand-alone events. And for each additional adverse experience reported, the toll in later damage increases.' (Page 174)
Child abuse, Van Der Kolk states, is the single biggest public health risk in the USA. Recounting Robert Anda at the CDC:
'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. It would also have a dramatic effect on workplace performance and vastly decrease the need for incarceration' (Page 178)
Drugs, diagnoses and DNA are hardly the answer to this complex problem. We must find ways to help victims of trauma rebuild and lead productive lives. We would save enormous amounts of public money and, hopefully, stop the cycle of abuse and trauma afflicting millions.
Quality of child-parent relationships is far more important than most other factors (such as IQ, neural abnormalities, behaviours) in whether there will be developmental issues later down the line in adolescence.
Our ability to handle life's disappointments is determined by the level of security we experience during the first two years of life.
Van Der Kolk again identifies many problems with the way the DSM has been published and how they have ignored and not included the disorders has has been part of identifying, primarily DTD (developmental trauma disorder).
'In a statement released in June 2011, the British Psychological Society complained to the APA that the sources of psychological suffering in the DSM-5 were identified 'as located within individuals' and overlooked the 'undeniable social causation of many such problems.' (Page 198)
Trauma has a deep impact on what we are able to remember. It's quite common for people to forget everything, but to then regain access to things in fragments later on.
Memories becomes more intense when we secrete adrenaline, but only up to a point. Faced with overwhelming horror, the brain shuts down.
Humans have a narrative memory. This is how we weave together the story of our lives by integrating our memories together into the bigger story we tell about ourselves. Traumatic memory, though, is disjointed and separate from our narrative memory.
'If the problem with PTSD is dissociation, the goal of treatment would be association: integrating the cut-off elements of the trauma into the ongoing narrative of life, so that the brain can recognize that 'that was then, and this is now.'' (Page 217)
Trauma is more than a story of something that happened long ago. It is something that has a real, physical effect on our bodies in the here and now. Overcoming that traumaisn't simply about re-telling the story (in talking therapy) or 'figuring things out'.
The rational brain cannot abolish emotions, or change how we feel.
There are exercises that can connect the introception/self-awareness with memory. The 'remembering brain' is not connected directly to the amygdala.
'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. Yoga in India, tai chi and qigong in China, and rhythmical drumming throughout Africa are just a few examples.' (Page 248)
The important first step is recognising what you are thinking and how it makes you feel.
Relationships, safety, trust, familiarity are all very important for trauma recovery. This is why trauma that involves relationships is so much harder to heal than other forms of trauma.
Stress hormones serve an important purpose, but even people using them for good (in overcoming a perhaps prolonged crisis) have a breaking point:
'The body responds to extreme experiences by secreting stress hormones. These are often blamed for subsequent illness and disease. However, stress hormones are meant to give us the strength and endurance to respond to extraordinary conditions. People who actively do something to deal with a disaster - rescuing loved ones or strangers, transporting people to a hospital, being part of a medical team, pitching tents or cooking meals - utilize their stress hormones for their proper purpose and therefore are at much lower risk of becoming traumatized. (Nonetheless, everyone has his or her breaking point, and even the bestprepared person may become overwhelmed by the magnitude of the challenge.' (Page 260)
'Somatic' therapy is movement/touch related and is all about helping to realise and release the actions that you suppressed long ago, such as hitting, running, pushing away.
CBT has not shown to be useful for trauma/PTSD patients. Many drop out and/or have adverse reactions because it resurfaces the trauma without dealing with the physical nature of it.
The same is true for desensitization: it only numbs and desensitizes, it does not heal. So while some symptoms may be controlled, it is at considerable cost.
'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' (Page 278)
On the other hand, one study showed MDMA therapy to be 83% effective for war PTSD trauma treatment.
After 9/11, a group of New York therapists recommended a mixutre of psychoanalysis and CBT to first responders and people affected by the attacks. Almost nobody showed for these sessions. Instead, the most popular forms of dealing with this trauma were acupuncture, massage, yoga, and EMDR.
'Getting perspective on your terror and sharing it with others can reestablish the feeling that you are a member of the human race.' (Page 279)
Writing has an enormous impact on stress levels and blood pressure.
'When you write to yourself you don't have to worry about other people's judgment - you just listen to your own thoughts and let their flow take over. Later, when you reread what you wrote, you often discover surprising truths.' (Page 284)
EMDR is Eye Movement Desensitization and Reprocessing. Roughly speaking, involves the therapist passing their finger back and forth in front of the patient's eye while giving them prompts to think on and recall different things while their eyes move left and right.
Healing trauma without talking about it loosens something in the brain. Far more effective than drugs for treating PTSD.
It's incredibly useful for integrating traumatic memories and material. Researchers aren't sure exactly how it works, but it does seem to work.
One hypothesis is a connection with REM (rapid eye movement) and how the brain processes things during sleep.
Heart-rate variability (HRV) is an important indicator of overall health. Traumatised people do not have very good variability.
'We do not truly know ourselves unless we can feel and interpret our physical sensations; we need to register and act on these sensations to navigate safely through life.¹5 While numbing (or compensatory sensation seeking) may make life tolerable, the price you pay is that you lose awareness of what is going on inside your body and, with that, the sense of being fully, sensually alive.' (Page 326)
Van Der Kolk researched impact of yoga on HRV vs talking therapies with positive results for yoga. Yoga allows us to inhabit our bodies, actively working with breathing and movement.
If you do not know your body and how it feels, you run into problems. If you don't feel hungry, you'll never eat. If you don't feel full, you'll never stop eating. We need to be able to hear what our body is telling us, but this is not always possible.
Better to think of the psyche as made up of many different parts. Our "personality" is not a monolith.
Internal family systems (IFS) therapy. Many different parts to a person: exiles, managers, firefighters. Managers are productive perfectionists who won't let us get close to anyone, for example.
'The Self is like an orchestra conductor who helps all the parts to function harmoniously as a symphony rather than a cacophony.' (Page 340)
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