PDF Summary:The Body Keeps the Score, by Bessel van der Kolk
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1-Page PDF Summary of The Body Keeps the Score
Trauma can stem from abuse to a severe car accident to wartime combat—and cause a lifetime of flashbacks, nightmares, isolation, insomnia, hypervigilance, and rage. In The Body Keeps the Score, the author explores how diagnosing and treating trauma has evolved as new technologies, research, and fields of science emerged.
Trauma’s impact is not only mental, emotional, and neurological, but also physiological: Trauma rewires the brain to put people in a constant state of stress or numbness, leading to a host of physical problems.
In this summary, you’ll learn:
- Why trauma survivors feel like their trauma is never-ending
- How flashbacks make parts of the brain shut down and others to go into overdrive
- Why some trauma survivors can’t recognize themselves in the mirror
- How activities like choral singing, yoga, and theater can be therapeutic
(continued)...
- Insecure attachment is when caregivers don’t reliably meet a baby’s needs. This creates some psychological issues, but although caregivers aren’t attentive enough to meet all the baby’s needs, their behavior is consistent enough that the baby learns what to expect and adapts in one of two ways:
- Avoidantly attached babies appear calm and unbothered, but have a consistently high heart rate that reveals a constant state of hyperarousal. These babies become adults who are not in touch with their feelings or others’, and they can often be bullies.
- Anxiously or ambivalently attached babies cry and fuss constantly, apparently reasoning that this is the only way to get attention. Anxious babies become anxious children and adults, and tend to be the victims of bullying.
- Disorganized attachment is when a caregiver causes the baby fear or distress. This is the most psychologically harmful form of attachment because the baby is stuck between fearing the caregiver and needing her for survival. Children with disorganized attachment often become aggressive or disengaged and exhibit related physical symptoms, including increased heart rate, high stress hormone levels, and decreased immune system. As adults, they don’t know who to trust, so they may be overly affectionate with strangers or distrusting of everyone.
Attachment and childhood experiences shape your inner maps of the world. As an adult, your inner map determines what you consider normal and familiar, how you interpret situations, and how you engage with the people and world around you. Inner maps are generally consistent through life, but they can be changed—negatively by trauma or positively through profound experiences.
Treatment Approaches for the Mind, Brain, and Body
Effective treatment must help trauma sufferers regain control of themselves and their thoughts, feelings, and body. Generally, this involves four steps:
- Learn how to be calm and focused.
- Find a way to stay calm in the face of sensations (images, sounds, smells) associated with your trauma.
- Learn how to be present and engage with the people around you.
- Don’t hide things from yourself, such as the ways you adapted in order to survive during and after your trauma.
There are three general approaches to treatment: the top-down approach, medication, and the bottom-up approach.
Top-Down: Talk it Out
The top-down approach involves talking, connecting with other people, and opening up about your traumatic memories and their present-day effects.
Opening up about your trauma has several healing benefits.
- Talking about the trauma breaks the silence and isolation of keeping such a big, life-impacting secret.
- Acknowledging the trauma and the emotions it triggers relieves you from the immense energy required to suppress those emotions, and it allows you to manage the emotions more effectively.
- Opening up to other people creates an opportunity for you to feel heard and understood and to reconnect with your community.
Talk therapy is inadequate as a sole form of treatment for trauma sufferers because revisiting their trauma often brings up overwhelming emotions that can retraumatize them and increase their fixation; this is the reason that cognitive behavioral therapy, which aims to desensitize patients through repeatedly talking about the trauma, isn’t an effective treatment method.
Instead of becoming desensitized, trauma survivors need help integrating the traumatic memory into the timeline of their lives, placing it securely in the past, so they can fully accept that it’s over. This still involves revisiting the memory, but first the patient must learn to cope with the reactions that the trauma will inevitably bring up to avoid becoming overwhelmed and enable her to complete the integration.
Trauma survivors often struggle to articulate what happened to them and how it makes them feel because their brains didn’t process the event as a coherent narrative but rather as a collection of fragmented sensations. To bridge this gap, there are several other ways for trauma sufferers to express themselves, including
- Noticing physical sensations. Being aware of how your voice changes or where you feel tension in your body can lead you to notice the emotions behind those sensations.
- Engaging in art, music, and dance. These can be outlets for expressing your innermost feelings when you can’t put them into words. These outlets can also help you connect with your feelings so that you can then write about them.
- Free writing. This exercise encourages stream-of-consciousness writing without stopping, re-reading, or self-editing. Reading back through later often reveals surprising inner truths.
The top-down approach includes:
- Talk therapy
- Mindful breathing
- Mindful self-awareness
- Trusting relationships
- Group activities (e.g. kickboxing, choral singing, dancing)
- Bodywork (e.g. massage and Feldenkrais)
Medication: Alter Your Brain Chemistry
The medication approach involves using prescription drugs that inhibit trauma survivors’ overactive internal alarm systems or affect the brain’s chemistry in some other way to alleviate the symptoms of trauma. This approach goes hand-in-hand with the brain-disease model, which views mental problems as “disorders” that could be treated with drugs to adjust brain chemistry.
Although drugs can assist treatment by taming overwhelming emotions, there are several drawbacks to the rise of medications:
- Medications often become a substitution for therapy and allow patients to treat their symptoms without addressing the root problems.
- Reliance on medication also prevents patients from feeling empowered in their own healing, and instead places the power in the hands of the prescribing doctors and insurance companies.
- The profitability of medications deters studies of non-drug treatments from being carried out and/or published; as a result, many patients never consider or get the chance to explore other means of healing.
Bottom-Up: Engage Your Body
The bottom-up approach involves seeking physical experiences that connect the body and mind to counteract feelings of helplessness, rage, and emotional collapse that plague trauma survivors. Since trauma makes sufferers feel out of control of their bodies (e.g. hyperarousal, disconnection from physical sensations, and psychosomatic issues), helping them regain that control is vital to healing.
There are several treatments that help patients engage their bodies in healing.
Eye movement desensitization and reprocessing (EMDR) is a treatment in which patients focus on a therapist’s finger moving side-to-side while recalling their trauma and then processing whatever train of thought organically follows. While researchers don’t know exactly how EMDR works, the treatment helps people get in touch with loosely connected memories and images and then integrate their traumatic experience into a broader context.
Heart rate variability (HRV) is the balance between how your heart rate rises and falls, indicating how well you can stay calm and in control in the face of minor challenges. Trauma survivors have low HRV, creating negative effects on how they think, feel, and respond to stress, and making them vulnerable to physical issues such as heart disease and cancer, and depression. You can train yourself to change your breathing (and thus improve your HRV) through yoga as well as certain devices and smart phone apps.
Yoga teaches you to focus on your breath, listen and respond to your body, and notice how emotions can be connected to certain physical sensations. This helps trauma survivors to reconnect with their physical sensations so they can feel safe and in control of their own bodies. Additionally, yoga encourages you to be present by focusing on your breath and body sensations, and reinforces the fact that experiences are transitory (e.g. as hard as this pose may be, you only need to endure it for ten breaths).
Psychomotor therapy uses body awareness and physical expressions as a key aspect of therapy, activating the right hemisphere of the brain -- the same hemisphere where trauma is also largely imprinted. One form, called Pesso Boyden System Psychomotor (PBSP) therapy instructs a patient to physically recreate scenes of her childhood and trauma, and then essentially rewrite the story. This form of therapy doesn’t eliminate or neutralize traumatic memories, but it does create a new experience (e.g. of being loved or protected) that helps to rewrite your inner maps.
Neurofeedback aims to fix the circuitry in patients’ brains by mirror back patients’ brain waves in order to encourage certain frequencies and brain patterns while discouraging others. Different frequencies are associated with different mental and emotional states (e.g. foggy, creative, calm, relaxed, alert). Viewing brain activity as the source of their problematic behavior frees patients from self-blame, and instead puts their focus on learning new ways to process information, which is at the root of their behavior.
Theater targets many of the things trauma survivors struggle most with, providing healing experiences as well as challenges that push them to work through trauma-created mental and emotional barriers. Acting gives them a chance to embody a character that may be strong, resilient, and confident, and it makes valuable, contributing members of a community, which helps them regain a sense of worth and competence. Theater also pushes trauma sufferers to get in touch with their emotions, take full control of their bodies, and trust the other members of the theater community.
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PDF Summary Prologue: Trauma Haunts Many People for Life
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There are no clear-cut answers about trauma or the best ways to treat it. Different schools of thought in the psychiatric field have different approaches to treating trauma; some doctors rely heavily on medications, while others endorse various forms of talk therapy, including cognitive behavioral therapy and exposure therapy. Naturally, this book includes the author’s views about effective approaches and treatments, which will conflict with some practitioners’ opinions.
PDF Summary Chapter 1: Developing a Definition of Trauma and PTSD
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Tom constantly had nightmares of the ambush he experienced in Vietnam, during which everyone in his platoon was killed or wounded. Afraid of the nightmares, Tom would stay up most of the night drinking to dull his pain and memories. He was easily upset and worried about getting angry around his family because he had trouble controlling his actions when he was upset. The only things that seemed to bring Tom some sense of calm were speeding dangerously on his motorcycle and drinking heavily.
Tom’s story made the author wonder how and why people who experienced trauma remain seemingly trapped in the past, constantly reliving the traumatic event.
The Traumatic Neuroses of War, which psychiatrist Abram Kardiner published in 1941, offered some insight on Tom in its description of “traumatic neuroses” that cause a chronic hypervigilance to threat. The book explained that traumatic neuroses—which today we’d call PTSD—have a physiological basis, meaning that the symptoms of trauma come from the body’s response to the original trauma. In other words, trauma isn’t just in sufferers’ heads—it also leaves its mark on their bodies. We’ll explore this more in later sections....
PDF Summary Chapter 2: The Mental and Emotional Scars of Trauma
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Traumatic experiences are so overwhelming that the mind breaks them up into fragments of sights, sounds, sensations, emotions, and thoughts (we’ll discuss this more in a later section). Consequently, long after the trauma is over, seemingly ordinary things can trigger flashbacks—a particular smell, a word or phrase, a physical position, or an image that is somehow associated with the traumatic event.
Ordinary stimuli suddenly take on a new meaning because they’re associated with the trauma, and are thus perceived as a threat. You may look at a man walking down the street as simply that, but a rape survivor can see the same man and perceive him as a would-be attacker.
Trauma Inhibits Imagination
Trauma inhibits the imagination in one of two ways: First, trauma can cause victims to superimpose images of their trauma on neutral stimuli.
For example, in a study of trauma survivors, 21 veterans took a Rorschach test. Also known as the ink blot test, subjects look at a nondescript ink blot and describe what they see in it, as if they’re finding animals and other images in the shapes of clouds. Rorschach tests indicate how you create a mental image and association from...
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Learn more about our summaries →PDF Summary Chapter 3: Your Brain on Trauma: Flashbacks and Memories
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Flashbacks Inhibit Speech
During the brain scan experiment, the researchers also found that flashbacks cause the brain’s speech control center to go offline. The brain’s response to flashbacks is similar to its response to a traumatic event, and as we’ll learn later, parts of the brain that coordinate speech and other social functions freeze during trauma in order to put more energy toward functions necessary for survival (e.g. fight or flight).
This part of the brain is called Broca’s area, and it’s key to articulating thoughts and feelings (Broca’s area is often affected in stroke victims). Additionally, trauma survivors’ difficulty with speech lasts beyond the confines of a flashback: Years after a traumatic event, survivors struggle to express what happened.
With time, most develop what the author calls a “cover story,” an outline of the basic events, but these cover stories fail to capture the depth of the experience.
Flashbacks Trigger Intense Emotions While Debilitating Logic
While speech is inhibited during flashbacks, another part of the brain called Brodmann’s area 19 was activated in participants’ brains during the flashbacks.
Under normal...
PDF Summary Chapter 4: Understanding Trauma Through Brain Anatomy
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This area of the brain is largely shaped by your experiences. For example, if most of your childhood experiences make you feel safe and loved, your brain will be conditioned to feel safe to play, explore, and cooperate. However, if you’re constantly scared and feel unwanted, your brain will operate in fear and feelings of abandonment, and continue to operate this way into adulthood.
The Emotional Brain
The reptilian brain and the limbic system together comprise the emotional brain, which is responsible for your well-being. Your emotional brain looks out for danger and opportunity, alerting you with hormones that fire off physical sensations (e.g. when you feel your chest tighten in response to panic) to get you to react immediately.
The emotional brain works quickly and fairly simply so that you can react as soon as possible in case of immediate threats; it interprets information in a general way, and may jump to conclusions based on the rough perception of threat. For instance, your emotional brain makes you jump back at the sight of a snake … before your rational brain realizes that it’s actually just a rope.
The emotional brain jump-starts your...
PDF Summary Chapter 5: Your Mind Impacts Your Body and Vice Versa
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Many trauma survivors struggle to feel truly understood, seen, and heard by those around them, and thus seldom feel safe and comfortable in social settings. Some trauma sufferers find a community in fellow trauma survivors, but confining yourself to a community of fellow victims, while comforting, ultimately leads to further isolation from the rest of society.
Healing from trauma means restoring the ability to feel safe and experience reciprocity. For trauma survivors who especially struggle to feel safe with people, animals—particularly dogs and horses—are used in treatment because they offer companionship and safety without the complexities of human relationships.
Even Eye Contact Is Threatening
Trauma sufferers’ hypervigilance to threats makes direct eye contact with other people intimidating, rather than intimate. People with PTSD were put through a brain scanner and shown images of a cartoon figure making direct eye contact, and the part of their emotional brains that lit up (called the Periaqueductal Gray) is responsible for startling, cowering, hypervigilance, and other protective behaviors.
Non-trauma sufferers, by contrast, had a more socially oriented...
PDF Summary Chapter 6: Traumatized People Disconnect From Their Physical Sensations
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During a traumatic event, victims learn to cut off the connection between physical sensations, such as abuse, and emotional reactions, such as fear. The trouble is that this response continues long after the event is over, and inhibits survivors from experiencing physical sensations and their accompanying emotions—both positive and negative—in everyday life. Unable to register warmth, arousal, hunger, or pain, trauma survivors end up feeling numb.
Not Understanding Physical Sensations Makes Trauma Survivors Feel Out of Control
Agency is the feeling of being in control of your life—knowing where you are (literally and figuratively), that you’re in control of your actions, and that you can affect your circumstances.
Trauma sufferers tend to lose their sense of agency when they’re disconnected from their physical sensations: If they can’t register what they’re feeling, then they can’t figure out why they’re feeling that way, and they can’t do anything about it. For example, if you can’t recognize that your body is tense, then you can’t use that clue to intuit that you’re feeling stressed, and you can’t do anything to manage that stress. By the same token, you can’t...
PDF Summary Chapter 7: Resilience Builds From Birth
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Insecure Attachment
When caregivers don’t reliably meet a baby’s needs, it creates an insecure attachment. Insecure attachments create psychological issues, as we’ll see, but insecure attachments are still considered organized attachments (as are secure attachments, as opposed to disorganized attachments, which we’ll discuss next) because the caregiver’s behavior is consistent and the baby can learn what to expect and how to cope.
There are two forms of insecure attachments, depending upon how the baby adapts to her caregiver’s shortcomings:
1. Avoidant attachment is typically a reaction to mothers who don’t enjoy touching, cuddling, or holding their babies, and who fail to use their voices and facial expressions to communicate with their babies. These babies are quiet and withdrawn, and never seem to get upset.
In the study, avoidantly attached babies didn’t cry when their mothers left and didn’t react when they returned. However, despite their calm exterior, avoidantly attached infants’ heart rates remained high, revealing that they’re constantly in a state of hyperarousal.
Avoidantly attached babies become adults who are not in touch with their...
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PDF Summary Chapter 8: Treatments to Heal the Mind, Brain, and Body
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Second, talking about your experience and emotions relieves the incredible amount of energy and attention required to suppress them and allows you to work through your psychological wounds. Bottling up such overwhelming feelings doesn’t make them go away, and in the meantime it saps your energy from engaging in the present and pursuing goals; as a result, you’re likely to feel bored and disengaged from life. Despite your efforts to suppress the trauma, your chronic hypervigilance is continuing to trigger stress hormones—causing physical ailments such as headaches, muscle pain, and digestive issues, as well as irrational emotions and behavior. You can’t deal with these symptoms until you’ve identified what’s causing them.
Third, when you open up to other people, you create the opportunity to feel heard and understood, which activates your limbic brain and helps in the physiological healing process. Sharing your experience with others can help break down the isolation of trauma and reconnect you with your community.
On the other hand, if someone fails to respond or understand, it can be further damaging. Non-trauma survivors often can’t handle or don’t want to hear the...
PDF Summary Chapter 9: Medication Revolutionized Mental Disorders
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Shortcomings of the Brain-Disease Model
The brain-disease model behind pharmacology ignores four fundamental truths.
- Reconnecting with people and communities is vital to healing.
- Communication gives patients the power to change themselves by talking about their experiences and finding common meaning with others.
- People have power over their physiology through activities such as breathing and moving.
- People can change their social conditions to create safe spaces where they can thrive.
Ignoring these truths means depriving people of the power to heal themselves and regain control over their minds, bodies, and experiences. Reliance on pharmacology makes people patients, at the hands of someone else’s power to heal them, instead of participants in their own healing process, which connects them with their sense of self.
Medications Used to Treat Trauma Survivors
Medications are widely used to treat symptoms of trauma, which can make it easier to control your emotions and behavior. However, **drugs are most effective when incorporated with other forms of treatment because they can also dampen positive feelings and they don’t help you learn how to...
PDF Summary Chapter 10: Bottom-Up: Engaging the Body in Healing
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EMDR has been shown to be less effective for people who were traumatized as children. As we discussed earlier, childhood trauma creates unique mental and physiological problems, and EMDR can’t necessarily resolve deep-seated betrayal and abandonment issues.
Heart Rate Variability (HRV)
Heart rate variability (HRV) is the balance between how your heart rate rises and falls. As a reminder, inhaling activates the sympathetic nervous system (SNS), which increases heart rate and fuels arousal, while exhaling stimulates the parasympathetic nervous system (PNS), which slows your heart rate and aids body functions like digestion and healing of wounds. A healthy balance between your arousal and relaxation—your HRV—indicates that your autonomic nervous system (ANS) is in good working order, and that helps you stay calm and in control in the face of minor challenges.
Poor HRV means your breathing and heart rate are out of sync, which has negative effects on how you think, feel, and respond to stress; it can make you vulnerable to physical issues such as heart disease and cancer, as well as depression and PTSD. Trauma survivors have low HRV, which helps explain why they are...
PDF Summary Epilogue: Invest in Prevention
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- Give teachers and school employees training on how to recognize and work with traumatized students.
- Instead of reprimanding or punishing students for outbursts, create a safe environment where they can calm down, explain what upset them, and explore possible solutions.
- Make emotional intelligence part of the curriculum: Teach students how to be self-aware, recognize and identify their emotions, communicate their thoughts and feelings to others, and read others’ emotions through body language.