The Body Keeps the Score

by Bessel van der Kolk MD

  This can be a life-changing process, as I witnessed in a workshop run by actors trained by Shakespeare & Company at the VA Medical Center in Bath, New York. Larry, a fifty-nine-year-old Vietnam veteran with twenty-seven detox hospitalizations during the previous year, had volunteered to play the role of Brutus in a scene from Julius Caesar. As the rehearsal began, he mumbled and hurried through his lines; he seemed to be terrified of what people were thinking of him.

  Remember March, the ides of March remember:

  Did not great Julius bleed for justice’ sake?

  What villain touch’d his body, that did stab,

  And not for justice?

  It seemed to take hours to rehearse the speech that begins with these lines. At first he was just standing there, shoulders slumped, repeating the words that the director whispered in his ear: “Remember—what do you remember? Do you remember too much? Or not enough? Remember. What don’t you want to remember? What is it like to remember?” Larry’s voice cracked, eyes to the floor, sweat beading on his forehead.

  After a short break and a sip of water, back to work. “Justice—did you receive justice? Did you ever bleed for justice’s sake? What does justice mean to you? Struck. Have you ever struck someone? Have you ever been struck? What was it like? What do you wish you had done? Stab. Have you ever stabbed someone? Have you ever felt stabbed in the back? Have you stabbed someone in the back?” At this point Larry bolted from the room.

  The next day he returned and we began again—Larry standing there, perspiring, heart racing, having a million associations going through his mind, gradually allowing himself to feel every word and learning to own the lines that he uttered.

  At the end of the program Larry started his first job in seven years, and he was still working the last I heard, six months later. Learning to experience and tolerate deep emotions is essential for recovery from trauma.

  • • •

  In Shakespeare in the Courts, the specificity of the language that is used in rehearsal extends to the students’ offstage speech. Kevin Coleman notes that their talk is riddled with the expression “I feel like . . .” He goes on: “If you are confusing your emotional experiences with your judgments, your work becomes vague. If you ask them, ‘How did that feel?’ they’ll immediately say: ‘It felt good’ or ‘That felt bad.’ Both of those are judgments. So we never say, ‘How did that feel?’ at the end of a scene, because it invites them to go to the judgment part of their brain.”

  Instead Coleman asks, “Did you notice any specific feelings that came up for you doing that scene?” That way they learn to name emotional experiences: “I felt angry when he said that.” “I felt scared when he looked at me.” Becoming embodied and, for lack of a better word, “en-languaged,” helps the actors realize that they have many different emotions. The more they notice, the more curious they get.

  When rehearsals begin, the kids have to learn to stand up straight and walk across a stage unselfconsciously. They have to learn to speak so that they can be heard in all parts of the theater, which in itself presents a huge challenge. The final performance means facing the community. The kids step out onto the stage, experiencing another level of vulnerability, danger, or safety, and they find out how much they can trust themselves. Gradually the eagerness to succeed, to show that they can do it, takes over. Kevin told me the story of a girl who played Ophelia in Hamlet. On the day of the performance he saw her waiting backstage, ready to go on, with a wastebasket clutched to her belly. (She explained that she was so nervous she was scared she’d throw up). She had been a chronic runaway from her foster homes and also from Shakespeare in the Courts. Because the program is committed to not throwing kids out if at all possible, the police and truant officers had repeatedly brought her back. There must have come a point when she began to realize that her role was essential to the group, or perhaps she sensed the intrinsic value of the experience for herself. At least for that day, she was choosing not to run.

  THERAPY AND THEATER

  I once heard Tina Packer declare to a roomful of trauma specialists: “Therapy and theater are intuition at work. They are the opposite of research, where one strives to step outside of one’s own personal experience, even outside your patients’ experience, to test the objective validity of assumptions. What makes therapy effective is deep, subjective resonance and that deep sense of truth and veracity that lives in the body.” I am still hoping that someday we will prove Tina wrong and combine the rigor of scientific methods with the power of embodied intuition.

  Edward, one of the Shakespeare & Company teachers, told me about an experience he’d had as a young actor in Packer’s advanced training workshop. The group had spent the morning doing exercises aimed at getting the muscles of the torso to release, so that the breath could drop in naturally and fully. Edward noticed that every time he rolled through one section of his ribs, he’d feel a wave of sadness. The coach asked if he’d ever been injured there, and he said no.

  For Packer’s afternoon class he’d prepared a speech from Richard II where the king is summoned to give up his crown to the lord who has usurped him. During the discussion afterward, he recalled that his mother had broken her ribs when she was pregnant with him and that he’d always associated this with his premature birth.

  As he recalled:

  When I told Tina this, she started asking me questions about my first few months. I said I didn’t remember being in an incubator but that I remembered times later when I stopped breathing, and being in the hospital in an oxygen tent. I remembered being in my uncle’s car and him driving through red lights to get me to the emergency room. It was like having sudden infant death syndrome at the age of three.

  Tina kept asking me questions, and I started to get really frustrated and angry at her poking away at whatever shield I had around that pain. Then she said, “Was it painful when the doctors stuck all those needles in you?”

  At that moment, I just started screaming. I tried to leave the room, but two of the other actors—really big guys—held me down. They finally got me to sit in a chair, and I was trembling and shaking. Then Tina said, “You’re your mother and you’re going to do this speech. You’re your mother and you’re giving birth to yourself. And you’re telling yourself that you’re going to make it. You’re not going to die. You must convince yourself. You must convince that little newborn that you’re not going to die.”

  This became my intention with Richard’s speech. When I first brought the speech to class, I told myself that I wanted to get the role right, not that something welling deep inside me needed to say these words. When finally it did, it became so clear that my baby was like Richard; I was not ready to give up my throne. It was like megatons of energy and tension just left my body. Pathways opened up for expression that had been blocked by this baby holding his breath and being so afraid that it was going to die.

  The genius of Tina was in having me become my mother telling me I’d be okay. It was almost like going back and changing the story. Being reassured that someday I would feel safe enough to express my pain made it a precious part of my life.

  That night I had the first orgasm I’d ever had in the presence of another person. And I know it’s because I released something—some tension in my body—that allowed me to be more in the world.

  EPILOGUE

  CHOICES TO BE MADE

  We are on the verge of becoming a trauma-conscious society. Almost every day one of my colleagues publishes another report on how trauma disrupts the workings of mind, brain, and body. The ACE study showed how early abuse devastates health and social functioning, while James Heckman won a Nobel Prize for demonstrating the vast savings produced by early intervention in the lives of children from poor and troubled families: more high school graduations, less criminality, increased employment, and decreased family and community violence. All over the world I meet people who take these data seriously and who work tir
elessly to develop and apply more effective interventions, whether devoted teachers, social workers, doctors, therapists, nurses, philanthropists, theater directors, prison guards, police officers, or meditation coaches. If you have come this far with me in The Body Keeps the Score, you have also become part of this community.

  Advances in neuroscience have given us a better understanding of how trauma changes brain development, self-regulation, and the capacity to stay focused and in tune with others. Sophisticated imaging techniques have identified the origins of PTSD in the brain, so that we now understand why traumatized people become disengaged, why they are bothered by sounds and lights, and why they may blow up or withdraw in response to the slightest provocation. We have learned how, throughout life, experiences change the structure and function of the brain—and even affect the genes we pass on to our children. Understanding many of the fundamental processes that underlie traumatic stress opens the door to an array of interventions that can bring the brain areas related to self-regulation, self-perception, and attention back online. We know not only how to treat trauma but also, increasingly, how to prevent it.

  And yet, after attending another wake for a teenager who was killed in a drive-by shooting in the Blue Hill Avenue section of Boston or after reading about the latest school budget cuts in impoverished cities and towns, I find myself close to despair. In many ways we seem to be regressing, with measures like the callous congressional elimination of food stamps for kids whose parents are unemployed or in jail; with the stubborn opposition to universal health care in some quarters; with psychiatry’s obtuse refusal to make connection between psychic suffering and social conditions; with the refusal to prohibit the sale or possession of weapons whose only purpose is to kill large numbers of human beings; and with our tolerance for incarcerating a huge segment of our population, wasting their lives as well as our resources.

  Discussions of PTSD still tend to focus on recently returned soldiers, victims of terrorist bombings, or survivors of terrible accidents. But trauma remains a much larger public health issue, arguably the greatest threat to our national well-being. Since 2001 far more Americans have died at the hands of their partners or other family members than in the wars in Iraq and Afghanistan. American women are twice as likely to suffer domestic violence as breast cancer. The American Academy of Pediatrics estimates that firearms kill twice as many children as cancer does. All around Boston I see signs advertising the Jimmy Fund, which fights children’s cancer, and for marches to fund research on breast cancer and leukemia, but we seem too embarrassed or discouraged to mount a massive effort to help children and adults learn to deal with the fear, rage, and collapse, the predictable consequences of having been traumatized.

  When I give presentations on trauma and trauma treatment, participants sometimes ask me to leave out the politics and confine myself to talking about neuroscience and therapy. I wish I could separate trauma from politics, but as long as we continue to live in denial and treat only trauma while ignoring its origins, we are bound to fail. 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.

  My most profound experience with healing from collective trauma was witnessing the work of the South African Truth and Reconciliation Commission, which was based on the central guiding principle of Ubuntu, a Xhosa word that denotes sharing what you have, as in “My humanity is inextricably bound up in yours.” Ubuntu recognizes that true healing is impossible without recognition of our common humanity and our common destiny.

  We are fundamentally social creatures—our brains are wired to foster working and playing together. Trauma devastates the social-engagement system and interferes with cooperation, nurturing, and the ability to function as a productive member of the clan. In this book we have seen how many mental health problems, from drug addiction to self-injurious behavior, start off as attempts to cope with emotions that became unbearable because of a lack of adequate human contact and support. Yet institutions that deal with traumatized children and adults all too often bypass the emotional-engagement system that is the foundation of who we are and instead focus narrowly on correcting “faulty thinking” and on suppressing unpleasant emotions and troublesome behaviors.

  People can learn to control and change their behavior, but only if they feel safe enough to experiment with new solutions. The body keeps the score: If trauma is encoded in heartbreaking and gut-wrenching sensations, then our first priority is to help people move out of fight-or-flight states, reorganize their perception of danger, and manage relationships. Where traumatized children are concerned, the last things we should be cutting from school schedules are the activities that can do precisely that: chorus, physical education, recess, and anything else that involves movement, play, and other forms of joyful engagement.

  As we’ve seen, my own profession often compounds, rather than alleviates, the problem. Many psychiatrists today work in assembly-line offices where they see patients they hardly know for fifteen minutes and then dole out pills to relieve pain, anxiety, or depression. Their message seems to be “Leave it to us to fix you; just be compliant and take these drugs and come back in three months—but be sure not to use alcohol or (illegal) drugs to relieve your problems.” Such shortcuts in treatment make it impossible to develop self-care and self-leadership. One tragic example of this orientation is the rampant prescription of painkillers, which now kill more people each year in the United States than guns or car accidents.

  Our increasing use of drugs to treat these conditions doesn’t address the real issues: What are these patients trying to cope with? What are their internal or external resources? How do they calm themselves down? Do they have caring relationships with their bodies, and what do they do to cultivate a physical sense of power, vitality, and relaxation? Do they have dynamic interactions with other people? Who really knows them, loves them, and cares about them? Whom can they count on when they’re scared, when their babies are ill, or when they are sick themselves? Are they members of a community, and do they play vital roles in the lives of the people around them? What specific skills do they need to focus, pay attention, and make choices? Do they have a sense of purpose? What are they good at? How can we help them feel in charge of their lives?

  I like to believe that once our society truly focuses on the needs of children, all forms of social support for families—a policy that remains so controversial in this country—will gradually come to seem not only desirable but also doable. What difference would it make if all American children had access to high-quality day care where parents could safely leave their children as they went off to work or school? What would our school systems look like if all children could attend well-staffed preschools that cultivated cooperation, self-regulation, perseverance, and concentration (as opposed to focusing on passing tests, which will likely happen once children are allowed to follow their natural curiosity and desire to excel, and are not shut down by hopelessness, fear, and hyperarousal)?

  I have a family photograph of myself as a five-year-old, perched between my older (obviously wiser) and younger (obviously more dependent) siblings. In the picture I proudly hold up a wooden toy boat, grinning from ear to ear: “See what a wonderful kid I am and see what an incredible boat I have! Wouldn’t you love to come and play with me?” All of us, but especially children, need such confidence—confidence that others will know, affirm, and cherish us. Without that we can’t develop a sense of agency that will enable us to assert: “This is what I believe in; this is what I stand for; this is what I will devote myself to.” As long
as we feel safely held in the hearts and minds of the people who love us, we will climb mountains and cross deserts and stay up all night to finish projects. Children and adults will do anything for people they trust and whose opinion they value.

  But if we feel abandoned, worthless, or invisible, nothing seems to matter. Fear destroys curiosity and playfulness. In order to have a healthy society we must raise children who can safely play and learn. 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. Currently more than 50 percent of the children served by Head Start have had three or more adverse childhood experiences like those included in the ACE study: incarcerated family members, depression, violence, abuse, or drug use in the home, or periods of homelessness.

  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. As the ACE study has shown, 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.