Talking About it Doesn’t Put it Behind You
David Bullard: Bessel, you are the medical director and founder of the Trauma Center at Justice Resource Institute and professor of psychiatry at the Boston University School of Medicine. You have been one of the most influential and outspoken clinicians, educators and researchers contributing to our understanding of trauma and its treatment.
I don’t remember reading a professional book in several intense sittings like I just did with your new book, The Body Keeps The Score: Brain, Mind, and Body in the Healing of Trauma. It’s been praised by everyone from Jon Kabat-Zinn and Francine Shapiro to Jack Kornfield, Peter Levine and Judith Herman, who called it a “masterpiece that combines the boundless curiosity of the scientist, the erudition of the scholar, and the passion of the truth teller.” (Read an excerpt from the book accompanying this interview.)
Let me start with some basics: Could you say something about why talk therapy alone doesn’t work when treating trauma?
Bessel van der Kolk: From my vantage point as a researcher we know that the impact of trauma is upon the survival or animal part of the brain. That means that our automatic danger signals are disturbed, and we become hyper- or hypo-active: aroused or numbed out. We become like frightened animals. We cannot reason ourselves out of being frightened or upset.
Of course, talking can be very helpful in acknowledging the reality about what’s happened and how it’s affected you, but talking about it doesn’t put it behind you because it doesn’t go deep enough into the survival brain.
DB: Would you say that is one of the distinctions between your work and Edna Foa’s “prolonged exposure therapy”? In a New Yorker article on trauma, Foa talked about rewriting memories, rather than destroying them, and describes her work with a patient with PTSD who had been raped years before: “We asked her to tell the story of that New Year’s Eve (when the rape occurred) and repeat it many times….to distinguish between remembering what happened in the past and actually being back there…and when, finally, the woman did that she realized that the terror and her rape were not her fault.”That sounds like cognitive learning.
Bv: That’s a lovely example of the ability of talk to get a better perspective. But there is a mistaken notion that trauma is primarily about memory—the story of what has happened; and that is probably often true for the first few days after the traumatic event, but then a cascade of defenses precipitate a variety of reactions in mind and brain that are attempts to blunt the impact of the ongoing sense of threat, but which tend to set up their own plethora of problems. So, trying to find a chemical to abolish bad memories is an interesting academic enterprise, but it’s unlikely to help many patients. It’s a too-simplistic view in my opinion. Your whole mind, brain and sense of self is changed in response to trauma.
In the long term the largest problem of being traumatized is that it’s hard to feel that anything that’s going on around you really matters. It is difficult to love and take care of people and get involved in pleasure and engagements because your brain has been re-organized to deal with danger.
It is only partly an issue of consciousness. Much has to do with unconscious parts of the brain that keep interpreting the world as being dangerous and frightening and feeling helpless. You know you shouldn’t feel that way, but you do, and that makes you feel defective and ashamed.
EMDR and Body Awareness Approaches to Trauma Treatment
DB: You are a big proponent of body awareness approaches to trauma treatment—and for a fully lived life. For example, you’ve done research on yoga for trauma survivors and recommend yoga for patients. I saw recently that your Trauma Center offers trainings to yoga teachers in working with the trauma of their students. You also speak very highly of the body-oriented therapies of Peter Levine and Pat Ogden, and especially of EMDR. You devote a whole chapter to your learning EMDR and examples of your use of it.
Bv: We have done the only NIMH-funded study on EMDR. As of 2014, the results of that study were more positive than any published study of those who developed their PTSD in reaction to a traumatic event as an adult.
There are opinions and there are facts.
Traumatized people often become insensible to themselves. They find it difficult to sense pleasure and to feel engaged. These understandings force us to use methods to awaken the sensory modalities in the person.
The facts are that the EMDR study was spectacularly successful in adults, a bit less with childhood trauma–at least not in the short period of time (eight 90-minute sessions) in the research protocol. But our research found that the impact of trauma is in the somatosensory self, trauma changes the insula, the self-awareness systems. Traumatized people often become insensible to themselves. They find it difficult to sense pleasure and to feel engaged. These understandings force us to use methods to awaken the sensory modalities in the person.
DB: The following quote from your book beautifully addresses some of this:
“The neuroscience of selfhood and agency validates the kinds of somatic therapies that my friends Peter Levine and Pat Ogden have developed…. [In] essence their aim is threefold:
- to draw out the sensory information that is blocked and frozen by trauma;
- to help patients befriend (rather than suppress) the energies released by that inner experience;
- to complete the self-preserving physical actions that were thwarted when they were trapped, restrained, or immobilized by terror.
Our gut feelings signal what is safe, life sustaining, or threatening, even if we cannot quite explain why we feel a particular way. Our sensory interiority continuously sends us subtle messages about the needs of our organism. Gut feelings also help us to evaluate what is going on around us. They warn us that the guy who is approaching feels creepy, but they also convey that a room with western exposure surrounded by daylilies makes us feel serene. If you have a comfortable connection with your inner sensations—if you can trust them to give you accurate information—you will feel in charge of your body, your feelings, and your self” (p.96).
EMDR trainers now seem to be focusing more on sensory modalities than when I first was taught about EMDR, and they also use “resource installation” (Leeds) and more recently “dyadic resourcing” (Manfield). But if there has been an identified single trauma that doesn’t resolve after several sessions, they look for an older “feeder memory,” and get there by asking the patient to focus on body sensations to see if he or she has ever felt those sensations before. It often is a gateway to an earlier trauma.
Bv: A lot of different schools do that, where the body is a pronounced part of therapy. My own teacher, Elvin Semrad, in the early 1970s in Boston, was very somatically oriented; same thing for Milton Erikson and many schools of hypnotherapy. Most people I hang out with who work with traumatic stress are somatically oriented.
The Limits of CBT
DB: The popular media are often puzzlingly ignorant about the nature of trauma and its treatment. You are very well aware of this, but an otherwise interesting article in the May, 2014 issue of The New Yorker magazine stated that a study “published in Nature in 2010, offered the first clear suggestion that it might be possible to provide long-term treatment for people who suffer from PTSD and other anxiety disorders without drugs.” That article never even mentioned EMDR, which was listed in a 1998 task force report of the Clinical Division of the American Psychological Association as being one of three psychological therapies (together with exposure and stress inoculation therapy) empirically supported for the treatment of PTSD. How could they miss that?
Bv: Well, they often get things not quite right! It intrigues me how the public is much more fascinated with the potential of false memories in patients than in the gross distortions of our society’s memory of trauma.
Articles like the one you cited often relate to the study of memories in mice. It is a huge leap, of course, from rodents to human beings, which not only leads to misinformation about the nature of traumatic stress and its treatments, but also about the rather trenchant differences between humans and mice. Humans are profoundly social animals—everything we do and think is in relation to a larger tribe. Our brains are cultural organs. It probably has something to do with people’s temperaments; people who do rodent research are drawn to the simplicity of rodent brains. In order to work with humans you need to have a taste for culture, complexity and uncertainty. People would be astonished if a psychotherapist gave advice to rodent researchers on how to run their labs! But the popular press takes the liberty of making these misinformed leaps with the general public all the time.
DB: How best to treat trauma is a crucial question, of course. You saw CBS’ 60 Minutes television show that first aired in November, 2013, describing a Veterans Administration program treating war veterans using “cognitive processing therapy” and prolonged exposure treatment methods. Your understanding of and approach to treating trauma is very different. Can you address a couple of points that distinguish your views from those presented by that VA treatment program?
Bv: Cognitive Behavioral Therapy (and “Trauma Focused CBT”), talk therapies, and prolonged exposure therapies can make some changes in people’s distress, but traumatic stress has little to do with cognition—it emanates from the emotional part of the brain that is rewired to constantly send out messages of dangers and distress, with the result that it becomes difficult to feel fully alive in the present. Blasting people with the memories of the trauma may lead to desensitization and numbing, but it does not lead to integration: an organic awareness that the event is over, and that you are fully alive in the present. The VA seems to be surprised by how many veterans drop out of prolonged exposure therapy. It would be helpful for them to find out why, but the likely answer is that it is re-traumatizing them.
DB: More recently, there was the profile of your work with trauma in the Sunday Magazine of the New York Times (May 22, 2014). The author shadowed you for a month, and it seemed to me that the article minimized the outcome of the clinical demonstration you did with an Iraqi war veteran at an Esalen Institute workshop.
Bv: The current Family Therapy Networker magazine just ran a piece about all the inaccuracies in that article, and the difficulties journalists have in getting the story straight. “Eugene” was the participant in the workshop, and he said “The takeaway when I read [the New York Times article] was that I was confused by the experience and that it didn’t help, which just isn’t true…When I spoke with the reporter, I said very positive things about the concrete ways that it helped me in terms of physical symptoms that disappeared, and also the fact that Dr. van der Kolk recommended people for me to work with afterward. He really spent some time finding a good recommendation for EMDR, and it really helps.” He wrote a letter to that effect and they wouldn’t publish it. I just got an email from him with a picture of my new book saying, “Thank you for helping me to regain the capacity for calmness and focus to be able to engage, and read books again.”
DB: The New York Times article also quoted sound bites from some other researchers, seemingly questioning your work, but later corrected some misinformation.
Bv: That’s another intriguing issue. There seems to be a tendency among therapists to become very religious about their own particular method—some seem to be more committed to their method than to the welfare of their patients. When patients don’t improve, they blame their resistance, and slam the people who point out that one size never fits all. The New York Times article also alluded to the Roman Catholic Church’s problems with clergy abuse and trying to defend itself by claiming that these plaintiffs suffered from “false memories,” and were the victims of “repressed memory therapy.” Testifying on behalf of pedophiles became a whole industry that seems to have entirely disappeared now that these trials are over.
DB: The newspaper did publish your brief (and, I thought, restrained!) rejoinder clarifying the issues presented, and you received an overwhelmingly supportive response in other letters to the editor and online comments. Here’s an excerpt from your letter to the New York Times:
“Trauma is much more than a story about the past that explains why people are frightened, angry or out of control. Trauma is re-experienced in the present, not as a story, but as profoundly disturbing physical sensations and emotions that may not be consciously associated with memories of past trauma. Terror, rage and helplessness are manifested as bodily reactions, like a pounding heart, nausea, gut-wrenching sensations and characteristic body movements that signify collapse, rigidity or rage…. The challenge in recovering from trauma is to learn to tolerate feeling what you feel and knowing what you know without becoming overwhelmed. There are many ways to achieve this, but all involve establishing a sense of safety and the regulation of physiological arousal.“
Bv: I also mentioned in the Networker article, “What happened …is a reflection of the incredible difficulties society has with staring trauma in the face and providing people with the facts of what happens, how bad it is, and how well treatments work.”
Talent and Compassion Aren’t Enough
DB: I appreciate your emphasis on research and fact-based discussions versus theoretical ones. Along those lines,
George Silberschatz, a past-president of the international Society for Psychotherapy Research, said in a recent interview that the between-therapist effects were as large if not larger than the between-treatment effects in current psychotherapy research, and this is perhaps from non-specific treatment effects.
Bv: Well, talent and compassion are central elements of being an effective therapist, but learning to feel your feelings and be in charge of your self, and working with someone who knows how to deal with bodily sensations and impulses can make all the difference between visiting an understanding friend once a week, and actually healing your trauma.
DB: Could it relate to Stephen Porges’ description of the Polyvagal Theory and the social engagement system? The nonspecific treatment effects from psychotherapy research seem to be powerful about the therapist helping to create a safe environment.
Bv: I have been very much inspired by Porges’ work. The reason that Porges has become an important part of our world is his finding that trauma interferes with face-to-face communication. It is very important how you get regulated in the presence of other people.
We need to learn very specific ways to activate the social engagement system. Sitting in your chair and chatting might not always be the most effective way of doing that.
Porges’ work was very helpful and clarifying about where in the brain trauma makes it difficult to feel comfort, to feel intimate and connected with other people. Knowing those things can help therapists to become more conscious about the specifics of their interactions, and should become part of the training of therapists. For example, I recently took a month-long intensive training course for Shakespearean actors to learn how the modulations of my voice, the configurations of my facial muscles, and the attitudes of my body affect my self-experience, and that of the people around me.
Porges’ work points to the importance of working with the reptilian brain—the brain stem, as well as the limbic system. We need to teach breathing and movement and work with the parts of the brain that are most impacted by trauma—areas that the conscious brain has no access to.
So I am dubious about the nonspecific relational impact of treatment on benefiting traumatized individuals. Seeing someone nonspecifically does not help the fear circuits and that collapsed sense of self. We need to learn very specific ways to activate the social engagement system. Sitting in your chair and chatting might not always be the most effective way of doing that.
DB: A colleague of yours from your Harvard days, neuroscientist Catherine Kerr, recently writing about mindfulness research, said:
“The placebo effect is usually defined, somewhat tortuously, as the sum of the nonspecific effects that are not hypothesized to be the direct mechanism of treatment. For example, having a face-to-face conversation is not hypothesized as what makes psychotherapy work—you could have a face-to-face conversation with anybody. But for some reason, if you go every week to therapy, you are going to get better. But you could talk about the weather! When we perform these rituals with a desire to get better, we often do. We now know that a lot of the positive therapeutic benefit from psychotherapy and from various pain drugs may come from that initial context; it often has nothing to do with the specific treatment that is being offered. It is really just about the person approaching a situation with a sense of hope and being met by something that seems to hold out that hope” (October 01, 2014, Tricycle Magazine).
And I think Allan Schore at UCLA would say that there is “unconscious right brain to unconscious right brain communication” going on, between therapists and patients, or between any of us in close relationships that might be what is otherwise thought to be “nonspecific” in therapy research. A deep ability to be present and connect empathically with patients is easier for some individual therapists than for others. Perhaps we are discussing a situation in therapy of “necessary, but not sufficient!”
Bv: I can’t really comment on all that—you’ll have to ask Catherine Kerr and Allan Schore. I have always been a bit puzzled about that “right brain to right brain” stuff. The research shows that the part of the brain most impacted by trauma is the left hemisphere, and I would imagine that every single part of the brain is necessary for effective functioning and feeling fully alive in the present.
DB: Well, I will be interviewing Schore next month, so we now have some good material to discuss!
Bv: I’ll look forward to reading that.
Neurofeedback & Yoga
DB: Is there anything in your own thinking that you feel has significantly changed in the last couple of years due to your continuing growth in the work and in all you are exposed to?
Bv: The biggest has been my exposure to neurofeedback (a type of biofeedback that focuses on brain waves, instead of peripheral phenomena like heart rate and skin conductance). In neurofeedback you change your brain’s electrical activity by playing computer games with your own brain waves. Learning how to interpret quantitative EEG’s helped me to visualize better how the brain processes information, and how disorganized the brain becomes in response to trauma. What made it necessary to look for other, non-interpersonally-based therapies was the realization, followed by research that dramatically illustrated how being traumatized may interfere with the ability to engage with other human beings to feel curious, open and alive.
Learning how to interpret quantitative EEGs allowed me to actually visualize what parts of the brain are distorted by traumatic experiences, and this can help us target specific brain areas where there is abnormal activity and where the problem actually is.
The trauma is not the story of what happened long ago; the long-term trauma is that you are robbed of feeling fully alive and in charge of your self.
For example, for the part of the brain supposed to be in charge, after trauma it will have excessive activity, keeping people in a state of chronic arousal—making it difficult to sleep, hard to engage and to relax. We find neurofeedback can change the activity in parts of the brain to allow it to be more calm and self-observant.
In another example, the frontal lobes of traumatized people often have activity similar to that of kids with ADHD, which makes it difficult to attend with the subtlety that we need to lead nuanced lives.
DB: So would the neurofeedback be with or without exposure to a particular traumatic memory?
Bv: Again, traumatic stress results in not being able to fully engage in the present. The trauma is not the story of what happened long ago; the long-term trauma is that you are robbed of feeling fully alive and in charge of your self.
DB: You would say that also is a positive outcome from yoga and other body awareness exercises, activating and strengthening the parasympathetic nervous system?
Bv: In our NIH-funded yoga for PTSD study we saw people did considerably better after 8 weeks of yoga. It can make a contribution to help people be more present in the here and now. The whole brain gets reorganized. Some quotes from participants in that study included:
- “My emotions feel more powerful. Maybe it’s just that I can recognize them now.”
- “I can express my feelings more because I can recognize them more. I feel them in my body, recognize them, and address them.”
This research needs much more work, but it opens up new perspectives on how actions that involve noticing and befriending the sensations in our bodies can produce profound changes in both mind and brain that can lead to healing from trauma. When we understand these things about the brain, how it works, we learn more about how to adjust our treatments.
DB: I’ve heard you say that you do not identify as belonging to any one particular school of therapy; that you do not even identify as an EMDR therapist even though you often utilize it.
Bv: Well, that would be like a carpenter saying he was a “hammer carpenter.” We need many different tools that will work for different patients and different problems.
Meaningless Pseudo-Diagnoses
DB: Can you talk a bit about your battles to get deeper and more sophisticated understandings of trauma treatment into the professional arena? Your book recounts the research you did that identified a traumatized population quite distinct from the combat soldiers and accident victims for whom the PTSD diagnosis had been created.
Bv: Yes, well, in the early 1990’s our PTSD work group for the Diagnostic and Statistical Manual of Mental Disorders voted nineteen to two to create a new diagnosis for victims of interpersonal trauma: “Disorders of Extreme Stress, Not Otherwise Specified” (DESNOS), or “Complex PTSD” for short. But when the DSM-IV was published in May 1994 the diagnosis did not appear in the final product.
Fifteen years later, in 2009, we lobbied to have “Developmental Trauma Disorder” listed in the DSM-5. We marshaled a lot of support, such as that from the National Association of State Mental Health Program Directors, who serve 6.1 million people annually, with a combined budget of $29.5 billion.
Everybody who holds forth should have a practice, otherwise you get seduced by your ideas and don’t get confronted with the limits of your ideas in clinical practice.
Their letter of support concluded: “We urge the American Psychiatric Association to add developmental trauma to its list of priority areas to clarify and better characterize its course and clinical sequelae and to emphasize the strong need to address developmental trauma in the assessment of patients.”
It was turned down also, and a lot of criticism of DSM-5’s approach has since been levied and they have lost credibility from a variety of professional sources.
DB: You recently published the results of an international survey of clinicians on the clinical significance of a Developmental Trauma Disorder diagnosis. Can you tell us why it might be so beneficial to have such a diagnosis?
Bv: Because it would help us to start focusing on helping kids feel safe and in control , rather than labeling them with meaningless pseudo-diagnoses like oppositional defiant disorder, impulse control disorder, self-injury disorder, etc.
DB: A significant part of your career at the Trauma Center has been working with traumatized children. There is a lot in your book relevant to work with children.
Bv: Yes, with Joseph Spinazzola and Julian Ford, we are involved in studies through the Complex Trauma Treatment Network of the National Child Traumatic Stress Network, which now is comprised of 164 institutions in almost all States.
DB: You are doing so much traveling with international teaching, you are involved in ongoing research, and you have quite a large staff at the Trauma Center in Boston to manage.
Bv: About 40 people are working at the trauma center now.
DB: Are you still personally able to do one-on-one clinical work or only have a supervisory role?
Bv: Everybody who holds forth should have a practice, otherwise you get seduced by your ideas and don’t get confronted with the limits of your ideas in clinical practice.
Posttraumatic Growth and Aliveness
DB: I’ve always liked the subtitle of Peter Levine’s book Waking the Tiger: Through Trauma Into Aliveness. Others are talking about “posttraumatic growth.”
Bv: That’s what the New York Times article should have been about. The guy they described so poorly actually recouped his life. People get better by befriending themselves. People can leave the trauma behind if they learn to feel safe in their bodies—they can feel the pleasure to know what they know and feel what they feel. The brain does change because of trauma and now we have tools to help people be quiet and present versus hijacked by the past. The question is: Will these tools become available to most people?
DB: You are certainly doing your part, Bessel, by being so very active and productive. I counted 35 workshops out-of-town on your calendar for 2014, in addition to your teaching at the various medical schools in Boston, at the Trauma Center and a new certification program. Right now you are about to embark on a 10-day bo
