Category: Bessel van der Kolk

Treating the Somatic Sequelae of Moral Injury

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Moral Injury

I recently read a terrific Psychotherapy.net article about moral injury entitled “Beyond Resilience: Addressing Moral Distress During the COVID-19 Pandemic,” and it resonated with me in a way few articles have lately. It was an interoceptive resonance that was simultaneously cognitive, emotional, visceral, kinesthetic and proprioceptive. Some of these words are quite new to my vocabulary, as I am a clinical psychologist trained in the depth psychology traditions of classic and modern psychoanalytic thought — Gestalt therapy and Jungian analysis. But more recently, I was trained in a 3-year program of trauma resolution developed by Peter Levine called Somatic Experiencing, and I began to develop some powerful new perspectives on the human condition that, in this piece, I would like to apply to the understanding of moral injury.

Moral injury is a term coined by Jonathan Shay¹ that describes a traumatic act of omission or commission that crosses a personal boundary of conscience. Shay, a psychiatrist, developed the concept of moral injury through his long and meaningful work with Vietnam veterans and other combat veterans at the Department of Veteran Affairs. The primary feelings of moral injury are shame, dishonor and ignominy. Frequently cited examples of how moral injury can occur include military personnel electing to follow an illegal or immoral order, law enforcement officers engaging in the use of deadly force, people participating in state-ordered executions, doctors and nurses involved in end-of-life decisions or with a decision to save one?s own life while another?s is lost.

Shay?s writings and perspectives are compelling and contribute immensely to broadening our understanding of trauma. His conceptions have developed almost exclusively from his work with adults, but the psychological literature on child development is replete with evidence that conscience and the “moral self” develop at a very early age, primarily from the internalization of parental values and the quality of the parent-child relationship. Studies have shown that infants as young as 3 months can show a preference for shapes that behave “prosocially” to ones that behave “antisocially.”

Two distinct dimensions of conscience have been identified: a) one relating to the emotional capacity to experience guilt and to be empathic to others and b) one relating to rule-oriented compliance to authority and authority figures. The child?s sense of themself as a moral being — with feelings of pride, guilt, shame, and embarrassment — is believed to be clearly developing by the age of 5. Findings like these from developmental psychology become especially important when considering the impact that incidents of childhood trauma can have on the delicately budding moral self. For example, research has shown that Adverse Childhood Experiences (ACEs) are predictive of moral injury in adulthood. Furthermore, survivors of childhood abuse may seek out positions in the military, law enforcement and other danger-filled professions in order to escape the perpetrators of their abuse, making them more likely to expose themselves to life-threatening situations and consequentially to exacerbation of their original trauma.

“The spiritual, emotional, or physical scarring of a child wounds their conscience as well and is deeply damaging”. Endemic to these woundings are important somatic sequelae that bind the guilt- and shame-filled experiences, making them long-lasting and difficult to undo later in life. It is my proposition that a somatic examination of these sequelae can enhance our understanding of moral injury, how to ameliorate it and how to help resolve it. After providing a brief overview of a somatic approach to healing trauma, I would like to discuss a case that I hope will bring to life the application of somatic psychotherapy in resolving the wounds of shame and injury to the moral self.

A Somatic Approach

For years, somatic practitioners like Peter Levine², Pat Ogden and Bessel van der Kolk³ have appreciated that the wounds of trauma do not linger simply in the form of cognition or within the limbic system, but are also stored in the body in muscular, skeletal and visceral forms and structures — stored in what is commonly known as “muscle-memories.” And while there has been a great deal of research supporting the perspective that trauma takes a cognitive-emotional form and can be resolved through a process of exposure and catharsis, the conceptualization of how human beings retain and reenact past trauma took an evolutionary leap forward with the development from neuroscience of Stephen Porges? polyvagal theory?.

Up to this point, we had believed that the autonomic nervous system had two functions operating in two branches: the sympathetic (energizing) branch and the parasympathetic (calming) branch. Polyvagal theory states that there are actually two branches to the parasympathetic nervous system that are activated during the threat response that developed in evolutionary sequence. The most primitively formed of these parasympathetic branches defends the organism by simply shutting down, immobilizing and conserving its energy to survive — death feigning, “playing possum,” thanatosis, or “freezing.” Co-developing in early vertebrates and reptiles was the capacity for the fight/flight response — defensive responses activated by the sympathetic nervous system. Finally, the “social engagement system” developed, through which mammals became capable of identifying areas of danger and safety and communicating this information about what was safe and what was unsafe to others. This second branch of the parasympathetic system gave mammals an additional way of managing their threat response. What was revolutionary about Porges?s work was that it identified two distinct anatomical structures of the vagus nerve corresponding to each of these parasympathetic functions. What was previously thought of as a single parasympathetic system was actually two separate structures and functions — each of which plays their own essential role in the management of threat.

“Whenever we are threatened in any way, our body goes through a rapid sequence of automatic responses that are hard-wired into our nervous system”: a) movement stops, b) we orient ourselves to the environment and begin scanning it, c) we evaluate whether it?s safe or dangerous, d) we begin to initiate protective responses, if needed, like flight, fight, freeze, or reaching out to others for help, and e) when the danger has passed, the arousal dissipates and we naturally discharge our excessive energy and begin to settle. Based on millions of years of evolution, the human body knows how to do this automatically. This defense cascade — arousal, intentional motionlessness, flight, fight, tonic or collapsed immobility (freeze), and then rest — corresponds to unique neural patterns in the amygdala, hypothalamus, periaqueductal gray, ventral and dorsal medulla, and spinal cord.

When it comes to everyday experiences, we have long known that they are stored in two ways: in explicit memory and in implicit memory. Explicit memory stores the general knowledge of facts, ideas, and concepts (semantic memories), and it stores the memories of event locations, times, and sensory images that can be explicitly stated (episodic memories). Implicit memory stores things like how to ride a bike, use a hammer, walk, or button our shirt — what are called procedural memories. Explicit memories are available for conscious recollection; implicit memories are not, and it is in these implicit procedural memories where trauma is stored. With experiences that feel life threatening, we can become stuck somewhere in the defense cascade and procedurally fail to complete it. Implicit memory is where the memories associated with these incompletions are stored, and they are out of our conscious awareness. By attending to the somatic sequelae of a traumatic event, a client is able to gently release the somatic constriction and associated emotion-laden reminders of the experience by completing uncompleted defensive action sequences.

“While somatic trauma practitioners may vary in the particular categories, they all typically encourage their clients to notice their own bodily experience” — what?s called interoceptive awareness — they all try to attend to a derivative of the following somatic aspects of humanness:

a) sensations coming from inside the body (kinesthetic awareness of muscle tension, movement impulses, bracing, involuntary sensations like heart rate and respiration, and awareness of posture, balance and other proprioceptive processes)

b) inner images (memories, dreams, symbols, and input from the five primary senses)

c) behavioral movements (facial gestures, rocking, emotional expressions, postural shifts, yawning, tearing, swallowing, trembling, shifts in breathing pattern and stillness)

d) emotions (including those expressed and unexpressed by the client and those sensed by the therapist)

e) meaning-making (beliefs, judgments, thoughts, analyses, and interpretations)

To illustrate some examples of the interoceptive awareness integral to somatic trauma therapy, I would like to describe some of my somatic reactions while reading the essay “Beyond Resilience” mentioned at the outset of this essay. As I began reading, I quickly noticed a heaviness developing in my chest and a feeling that my face and shoulders were opening. An image of a butte or plateau came to mind, where I was imagining a new level of understanding, and the thought came to me, "What a fascinating line of thinking about something I have been familiar with for years but never really thought about in this very succinct way." I found myself leaning into the computer screen, my back arching backwards, and I noticed feelings of excitement emerging from within me, especially in my cheeks and jaw, where I felt a subtle tingling sensation. I began to feel grateful to the authors and to Psychotherapy.net for publishing their piece. I could also feel little micro-movements, movement impulses really, in my arms and hands, which were anticipatory responses later manifesting when I wrote Victor Yalom to tell him how much the article deepened my understanding of this very important aspect of trauma. As I noticed the richness of my own internal life, a memory came to mind. It was of Jessie.

Jessie

Jessie was 38 and had been raised by a family in the Ku Klux Klan. He was the oldest of three children and had been conscripted to parent his younger siblings in his parents? frequent absence. He also was a survivor of severe childhood physical abuse, which he had been indoctrinated to believe was his fault. Somehow he survived and, in his teens, managed to escape the family clutches, learning a specialized trade in healthcare and, remarkably, developing and maintaining, by the time he came to me, a healthy marital relationship of some 18 years.

When Jessie first came to my office, you could feel the frozenness in his gait. As he told his story, there was a stiffness in his posture and there were very few facial movements, but I could see, almost imperceptibly, the muscles in his lower legs flexing and tightening with a kind of rhythmic regularity. His authenticity about the life he had lived was both touching and tragic. As I took comfort in developing my bond with this man, I could feel my own visceral reaction to his story, which elicited my empathic responses while simultaneously interfering with my ability to do so. My own humanness was on full display.

Despite all that he had been through, Jessie was remarkably adept at learning how to reflect on his own somatic experience. While a client?s narrative themes are essential to track, a greater emphasis in somatic trauma work is placed on the story that the body tells. Two fundamental principles guided my somatic work with him: a) to focus first on what traumatic material was most available and accessible and b) to titrate and process only small changes in arousal level before proceeding to deeper levels of emotion. This is one of the biggest distinctions between somatic approaches to trauma work and exposure therapy. Somatic psychotherapy pays meticulous attention to taking small but manageable steps in order to avoid excessive cathartic releases that, while seemingly helpful, can themselves be retraumatizing. The goal of somatic trauma work is to assist the client in learning how to reregulate their own nervous system in the context of their traumatic memories.

Like all other psychotherapeutic approaches, somatic psychotherapy does not progress linearly, and there were ups and downs in my work with Jessie. At one point, though, we began to deal directly with more of the core of his moral injury, which for Jessie was two-layered: a) the stubborn belief that because he did not fight back against his father?s physical abuse, he was a living betrayal of what it meant to be a man and b) his belief that he had betrayed his younger siblings by failing to protect them from their abusers. As a society, as a culture, and even cross-culturally, we tend to shame others who don?t fight back, who cry for help, or who run away. We are expected to fight our perpetrators (or at least flee from them) but never cower, collapse, or freeze. This is consistent with Porges? notion that survivors are shamed and blamed because they didn?t mobilize, when in actuality, their bodies were involuntarily incapable of movement.

When we have transgressed, episodic shame is a healthy response. Awareness of our shame motivates us to apologize, to acknowledge our wrongdoing and to repair the injury we may have inflicted on another. Likewise, when we witness someone doing something harmful to another, we call it out. We inform them of their wrongdoing. Their momentary shame is healthy because it encourages peaceful cooperation and fosters a sense of social fairness. But when we call out someone?s wrongdoing, it is imperative that we also exercise our responsibility to repair their momentary shame by honoring and reinforcing their human dignity—to communicate to them that they are much more than the identified transgression. For example, when we interrupt a child from intentionally hurting their sibling, we are guiding them about what is acceptable in a family and in a society. But we must also commit ourselves to repair their shame by letting them know we continue to love and respect them. It?s chronic shame — the kind of shame we stay stuck in and can?t shake — that?s not healthy. Chronic shame demeans, degrades and obliterates human dignity — it kills the spirit. “Many clients who have been chronically shamed carry these wounds with them…and this was true for Jessie”.

My therapy with Jessie progressed, and in a particularly important session I noticed he began it with his eyes looking downward, his head lowered, his back curved forward and his breathing shallow. This kind of kinesthetic and postural presentation is typical of the shame-based, collapsed immobility (freeze) characteristic of moral injury. I asked Jessie if he noticed that his gaze was averted, which he acknowledged, so I asked him if he could become curious about it and see what might happen next. At first, he was out of touch with what he was introceptively trying to observe, until he said, “It?s kinda comfortable to look down … and not be judged for it.”

I asked Jessie how it might be for him if we were to just sit with and notice the comfort together. As we did, his breathing became fuller, which we both acknowledged. When addressing such potentially powerful traumatic states — which are being expressed somatically and almost certainly out of the awareness of the client — it?s so important to help them first establish a strong-enough connection with their own inner resources — what one of my Somatic Experiencing teachers described as “islands of safety.” Pausing on these soft places to rest and to moderate and titrate traumatic pain is essential to anchor and center a client and to stay off, for the moment, the rush of feeling overwhelmed that is almost certainly waiting in the wings.

I then asked Jessie if he noticed his downturned posture and invited him to take his mind?s eye and go into his curved back and see what he noticed. After a time, he said, “It feels dark … I know this feeling, but I can?t name it … I don?t like it.” Because traumatic emotions are stored in implicit memory and not readily accessible to awareness, they often cannot be identified with semantic labels like anger, sadness or shame. As I mentioned earlier, emotions are only one of the critical memory elements of trauma. Equally important to somatic trauma work is accessing the procedural memories themselves — those kinesthetic, proprioceptive and neuroceptive containers of trauma. I sensed Jessie was adequately tolerating his discomfort, but I asked him anyway to be sure, which he confirmed. I then suggested a little experiment to see what might happen if he were to curve his back downward a little further, but only just a very small amount. As he did so, a memory emerged of himself kneeling, pleading with his father not to beat him as his father yelled, “You?re a pussy! Quit your cowering! Take it like a man!”

As he recalled his humiliation, Jessie became aware of greater tension in his back. I asked him, “If your back could move in any way it wanted, what might it want to do right now?” When he said he didn?t know, I invited him to become curious about what it might be like if he were to very slightly lower his head even further. As he did so, his hand became tremulous as he said, “He hurt me so badly!” I wondered if I might have been pushing him past his window of tolerance, so in order to lower his activation level, I then empathized with his pain. This is a good example of an important choice-point in psychotherapy, and in somatic work in particular — that is, I made the decision to go a little deeper into what Peter Levine calls the “trauma vortex.” This is reliably going to raise the client?s level of arousal and can be quite helpful, but a) only when it?s done slowly and in small steps and b) only when the client is ready and able to contain the added arousal. To gauge the appropriateness of this kind of intervention, the clinician must rely on their observations of their client?s somatic markers and the clinician?s own felt sense.

I asked Jessie to consider what it might be like to raise up his head and back a bit. Doing this calmed his tremble, more color returned to his face, and his breath became more regular as he stated clearly and with some conviction, “I wish I would have stood up to him.” “I asked him what it felt like to raise his head and back, and he said that it felt “freeing” and that he “felt taller.”” We took the time for his nervous system to reregulate to what he had just experienced, and we just sat with his calm sense of freedom and taller-ness for the rest of the session. This was a big part of Jessie?s moral injury — the notion that he had abandoned being true to himself by not confronting his father and not fighting the abuse he was forced to endure. For years, he had worn his valueless humiliation as a scarlet letter of his own worthlessness, until he returned to an essential element of his trauma that was yet to be completed — physically embodying the posture of standing up for himself.

As my sessions with Jessie proceeded, he became better able to honor and stand up for his own moral beliefs of fairness and respect. He also became more comfortable with articulating his belief that what his father had perpetrated against him and his siblings was wrong, while moderating his nervous system activation and later feeling the calm and peaceful presence of embodying his budding moral convictions.

* * *

Everything in the universe oscillates — the tides come in and they go out, day turns into night and into day again, the seasons change, the breath goes in and the breath goes out. This is the natural way of things. With trauma though, that pendulation — the natural flow between physiological polarities — gets shunted and needs to be repaired. With Jessie, there was much work that followed, but a key to his recovery was embedded in his newly acquired ability to regulate his arousal and return to a safe-enough place so he could repair and repair again what he had been forced to internalize.

References

Shay, J. (2011). Casualties. Daedalus, 140, 179-188.

Shay, J. (2014). Moral responsibility. Psychoanalytic Psychology, 31, 182–191.

(2) Levine, P. (2015 June 10). Peter A Levine, PhD on Shame – Interview by Caryn Scotto D?Luzia [Video]. YouTube.

(3) Van der Kolk, B. A. (2014). The body keeps the score: Brain, mind, and body in the healing of trauma. New York: Viking.

(4) Porges, S. W. (2001). The polyvagal theory: phylogenetic substrates of a social nervous system. International Journal of Psychophysiology, 42, 123-146 

The Body Keeps the Score: Brain, Mind, and Body in the Healing of Trauma

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The following is an excerpt from The Body Keeps the Score: Brain, Mind, and Body in the Healing of Trauma by Bessel van der Kolk, MD. Reprinted by arrangement with Viking, a member of Penguin Group (USA) LLC, A Penguin Random House Company. Copyright © Bessel van der Kolk, MD, 2014.

****

Marilyn was a tall, athletic-looking woman in her mid-thirties who worked as an operating-room nurse in a nearby town. She told me that a few months earlier she’d started to play tennis at her sports club with a Boston fireman named Michael. She usually steered clear of men, she said, but she had gradually become comfortable enough with Michael to accept his invitations to go out for pizza after their matches. They’d talk about tennis, movies, their nephews and nieces—nothing too personal. Michael clearly enjoyed her company, but she told herself he didn’t really know her.

One Saturday evening in August, after tennis and pizza, she invited him to stay over at her apartment. She described feeling “uptight and unreal” as soon as they were alone together. She remembered asking him to go slow but had very little sense of what had happened after that. After a few glasses of wine and a rerun of “Law & Order,” they apparently fell asleep together on top of her bed. At around two in the morning, Michael turned over in his sleep. When Marilyn felt his body touch hers, she exploded—pounding him with her fists, scratching and biting, screaming, “You bastard, you bastard!” Michael, startled awake, grabbed his belongings and fled. After he left, Marilyn sat on her bed for hours, stunned by what had happened. She felt deeply humiliated and hated herself for what she had done, and now she’d come to me for help in dealing with her terror of men and her inexplicable rage attacks.

My work with veterans had prepared me to listen to painful stories like Marilyn’s without trying to jump in immediately to fix the problem. Therapy often starts with some inexplicable behavior: attacking a boyfriend in the middle of the night, feeling terrified when somebody looks you in the eye, finding yourself covered with blood after cutting yourself with a piece of glass, or deliberately vomiting up every meal. It takes time and patience to allow the reality behind such symptoms to reveal itself.

Terror and Numbness

As we talked, Marilyn told me that Michael was the first man she’d taken home in more than five years, but this was not the first time she’d lost control when a man spent the night with her. She repeated that she always felt uptight and spaced out when she was alone with a man, and there had been other times when she’d “come to” in her apartment, cowering in a corner, unable to remember clearly what had happened.

Marilyn also said she felt as if she was just “going through the motions” of having a life. Except for when she was at the club playing tennis or at work in the OR, she usually felt numb. A few years earlier she’d found that she could relieve her numbness by scratching herself with a razor blade, but she had become frightened when she found that she was cutting herself more and more deeply, and more and more often, to get relief. She had tried alcohol, too, but that reminded her of her dad and his out?of?control drinking, which made her feel disgusted with herself. So instead she played tennis fanatically, whenever she could. That gave her a feeling of being alive.

When I asked her about her past, Marilyn said she guessed that she “must have had” a happy childhood, but she could remember very little from before age twelve. She told me she’d been a timid adolescent, until she had a violent confrontation with her alcoholic father when she was sixteen and ran away from home. She worked her way through community college and went on to get a degree in nursing without any help from her parents. She felt ashamed that during this time she’d slept around, which she described as “looking for love in all the wrong places.”

As I often did with new patients, I asked her to draw a family portrait, and when I saw her drawing, I decided to go slowly. Clearly Marilyn was harboring some terrible memories, but she could not allow herself to recognize what her own picture revealed. She had drawn a wild and terrified child, trapped in some kind of cage and threatened not only by three nightmarish figures—one with no eyes—but also by a huge erect penis protruding into her space. And yet this woman said she “must have had” a happy childhood.

As the poet W. H. Auden wrote:
Truth, like love and sleep, resents
Approaches that are too intense.

I call this Auden’s rule, and in keeping with it I deliberately did not push Marilyn to tell me what she remembered. In fact, “I’ve learned that it’s not important for me to know every detail of a patient’s trauma. What is critical is that the patients themselves learn to tolerate feeling what they feel and knowing what they know.” This may take weeks or even years. I decided to start Marilyn’s treatment by inviting her to join an established therapy group where she could find support and acceptance before facing the engine of her distrust, shame, and rage.

As I expected, Marilyn arrived at the first group meeting looking terrified, much like the girl in her family portrait; she was withdrawn and did not reach out to anybody. I’d chosen this group for her because its members had always been helpful and accepting of new participants who were too scared to talk. They knew from their own experience that unlocking secrets is a gradual process. But this time they surprised me, asking so many intrusive questions about Marilyn’s love life that I recalled her drawing of the little girl under assault. It was almost as though Marilyn had unwittingly enlisted the group to repeat her traumatic past. I intervened to help her set some boundaries about what she’d talk about, and she began to settle in.

Three months later Marilyn told the group that she had stumbled and fallen a few times on the sidewalk between the subway and my office. She worried that her eyesight was beginning to fail: She’d also been missing a lot of tennis balls recently. I thought again about her drawing and the wild child with the huge, terrified eyes. Was this was some sort of “conversion reaction,” in which patients express their conflicts by losing function in some part of their body? Many soldiers in both world wars had suffered paralysis that couldn’t be traced to physical injuries, and I had seen cases of “hysterical blindness” in Mexico and India.

Still, as a physician, I wasn’t about to conclude without further assessment that this was “all in her head.” I referred her to colleagues at the Massachusetts Eye and Ear Infirmary and asked them to do a very thorough workup. Several weeks later the tests came back. Marilyn had lupus erythematosus of her retina, an autoimmune disease that was eroding her vision, and she would need immediate treatment. I was appalled: “Marilyn was the third person that year whom I’d suspected of having an incest history and who was then diagnosed with an autoimmune disease—a disease in which the body starts attacking itself.”

After making sure that Marilyn was getting the proper medical care, I consulted with two of my colleagues at Massachusetts General, psychiatrist Scott Wilson and Richard Kradin, who ran the immunology laboratory there. I told them Marilyn’s story, showed them the picture she’d drawn, and asked them to collaborate on a study. They generously volunteered their time and the considerable expense of a full immunology workup. We recruited twelve women with incest histories who were not taking any medications, plus twelve women who had never been traumatized and who also did not take meds—a surprisingly difficult control group to find. (Marilyn was not in the study; we generally do not ask our clinical patients to be part of our research efforts.)

When the study was completed and the data analyzed, Rich reported that the group of incest survivors had abnormalities in their CD45 RA?to?RO ratio, compared with their nontraumatized peers. CD45 cells are the “memory cells” of the immune system. Some of them, called RA cells, have been activated by past exposure to toxins; they quickly respond to environmental threats they have encountered before. The RO cells, in contrast, are kept in reserve for new challenges; they are turned on to deal with threats the body has not met previously. The RA?to?RO ratio is the balance between cells that recognize known toxins and cells that wait for new information to activate. In patients with histories of incest, the proportion of RA cells that are ready to pounce is larger than normal. This makes the immune system oversensitive to threat, so that it is prone to mount a defense when none is needed, even when this means attacking the body’s own cells.

Our study showed that, on a deep level, the bodies of incest victims have trouble distinguishing between danger and safety. This means that the imprint of past trauma does not consist only of distorted perceptions of information coming from the outside; the organism itself also has a problem knowing how to feel safe. The past is impressed not only on their minds, and in misinterpretations of innocuous events (as when Marilyn attacked Michael because he accidentally touched her in her sleep), but also on the very core of their beings: in the safety of their bodies.

Note: Find out about Bessel’s new in-depth, online Trauma Certificate Course. 

Bessel van der Kolk on Trauma, Development and Healing

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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