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What The Body Keeps the Score Talks About
The Body Keeps the Score is a book written by the psychiatrist and trauma specialist Dr. Bessel van der Kolk. It explains the effects of trauma on the body and discusses several methods (EMDR, yoga, IFS, PBSB, neurofeedback, theater) for their resolution.
The book is among one of the highest rated on Amazon with 4.8.
Is it that good? Well, it’s not bad. But it’s in no way revolutionary. One thing I learned was that CBT doesn’t work as well as often claimed as traumas must be solved by taking the body into account along with the mind.
So, how do you know which method is good for you?
You try. EMDR, IFS, and neurofeedback will be quick to show results. PBSB will take a bit more time. Yoga and theater are long-term methods, but they can’t do you any wrong.
Should you read the book?
Unless you really want to know what happens inside a traumatized brain, no.
Just read this summary.
9/10.
Summary of The Body Keeps the Score Written by Bessel van der Kolk
Prologue: Facing Trauma
Traumatized people struggle to regulate their emotions or/and fail to bond emotionally with others. Trauma affects everyone, both the victim and their entourage.
Long after the trauma, any minor cues can reactivate it, inflicting a great deal of suffering onto the survivors who feel like they’re damaged to the core.
While we all want to move beyond trauma, the part of our brain that is devoted to ensuring our survival is not very good at denial.
Trauma isn’t purely “psychological”; it produces physiological changes, including a recalibration of the brain’s alarm system, an increase in stress hormone activity, and the alterations in the system that filter relevant from irrelevant information.
Trauma compromises the brain area that communicates the physical, embodied feeling of being alive. These changes explain why traumatized individuals become hypervigilant to threat at the expense of spontaneously engaging in their day-to-day lives.
Thankfully, we have developed methods enabling individuals to fully come back to the present moment. There are three different kinds:
- Top-down: talking and reconnecting with others.
- Taking medicines.
- Bottom-up: by allowing the body to have experiences that deeply and viscerally contradict the helplessness, rage, or collapse that result from trauma.
These methods can be combined.
Part One: The Rediscovery of Trauma
Chapter 1: Lessons From Vietnam Veterans
Many Vietnam veterans came back traumatized from the war, drowning their feelings into addictions or going on violent tantrums at the slightest cue reminding them of their experiences.
At the time, there was little literature about the topic.
Trauma, whether it is the result of something done to you or something you yourself have done, almost always makes it difficult to engage in intimate relationships.
The worst symptom for soldiers was that they felt emotionally numb.
He desperately wanted to love his family, but he just couldn’t evoke any deep feelings for them. (…) He could not really feel anything except for his momentary rages and his shame.
Traumatized people superimpose their trauma on everything around them and struggle to understand what’s going on around them.
They can’t bridge the gap between their traumatized experiences and their current lives. The very event that caused them so much pain becomes their sole source of meaning. They only feel fully alive when they’re revisiting their traumatic past.
Traumas manifest themselves as memories that the victim cannot leave in the past.
While talking about it provides relief, it’s not enough. The bodies remain hypervigilant, prepared for defense.
For real change to take place, the body needs to learn that the danger has passed and to live in the reality of the present.
Chapter 2: Revolutions in Understanding Mind and Brain
Traumatized patients in the ward where the author worked had no coordination and often could not cooperate with others – at all.
Most human suffering is related to love and loss; the job of therapists is to help people “acknowledge, experience, and bear” the reality of life.
The greatest sources of our suffering are the lies we tell ourselves.
Healing depends on experiential knowledge: You can be fully in charge of your life only if you can acknowledge the reality of your body.
Many traumatized people get into a state of learned helplessness, described as the inability to escape abuse even when you have the chance to -> traumatized people give up.
Rather than risk experimenting with new options they stay stuck in the fear they know.
The fight/flight response is thwarted. The stress hormone remains at high levels even after the danger has passed.
Experiments have shown that scared animals return home in case of more fear, even if the home was scary and painful.
Addicted to Trauma: The Pain of Pleasure and the Pleasure of Pain
Many traumatized people feel bored when not in an extreme mood (anger, fear, etc). Many others get addicted to being in a situation that gave them their initial trauma -> they often have to enroll in a rehab program to get better.
Freud named this “the compulsion to repeat”. He believed that reenactments were an unconscious attempt to get control over a painful situation and that it could lead to mastery and resolution. There is no proof of this theory.
In fact, reliving a trauma many times in therapy can reinforce it.
New emotions create new chemical balances in the body. People can even get addicted to the pleasure they feel after pain (eg: running) which compels them to keep going.
This may be why traumatized people reenact their trauma.
In the brain, the amygdala is tasked to judge whether a sound, image, or sensation is perceived as a threat or not. The sensitivity of the amygdala depends partly on how much serotonin is present in that part of the brain.
High-status monkeys had high levels of serotonin; low-status monkeys did not. Low-status monkeys given high levels of serotonin became high-status monkeys.
That’s what Prozac does, but it doesn’t work for everyone and we don’t know why.
While drugs helped many, they also caused harm by propagating the idea that trauma was a consequence of a chemical imbalance in the brain. This has led doctors and insurance companies to take over people’s fate based on the brain-disease model.
Furthermore, despite abundant antidepressant prescriptions, depression has not decreased.
The brain-disease model overlooks four fundamental truths:
- We can destroy one another as much as we can heal one another. Restoring relationships and community is central to restoring well-being.
- Language gives us the power to change ourselves and others by communicating our experiences, helping us to define what we know, and finding a common sense of meaning.
- We have the ability to regulate our own physiology, including some of the so-called involuntary functions of the body and brain, through such basic activities as breathing, moving, and touching.
- We can change social conditions to create environments in which children and adults can feel safe and where they can thrive.
When we ignore these principles, we deprive people of the way of healing from trauma.
Being a patient rather than a participant alienates people from an inner sense of self (control).
Chapter 3: Looking Into the Brain: The Neuroscience Revolution
When the scanning technology was invented (PET and fMRI), doctors observed that when traumatized patients thought about trauma, the amygdala was bright (it’s the center of emotions, among other things) while the Broca’s area underwent a decrease in activity preventing the person from expressing their feelings.
Even years later traumatized people often have enormous difficulty telling other people what has happened to them. Their bodies reexperience terror, rage, and helplessness, as well as the impulse to fight or flee, but these feelings are almost impossible to articulate.
Brodmann’s area 19 also lit up. This is a region that registers images when they’re seen for the first time.
When something reminds traumatized people of the past, the right part of the brain reacts as if the traumatic event was happening in the present.
But because their left brain is not working very well, they may not be aware that they are reexperiencing and reenacting the past—they become just furious, terrified, enraged, ashamed, or frozen.
Traumatized people relive the memory of the trauma as if it was happening to them for the first time, so the stress level goes disproportionally high and slows to come back down.
In some other people, the mind denies what happened but the body still shows the signs.
This is why sometimes, talking about the event is not enough as the trauma gets in the way of its own resolution.
No matter how much insight and understanding we develop, the rational brain is basically impotent to talk the emotional brain out of its own reality.
They continued to be “there” and did not know how to be “here”—fully alive in the present.
Part Two: This Is Your Brain on Trauma
Chapter 4: Running for Your Life: The Anatomy of Survival
During disasters young children usually take their cues from their parents. As long as their caregivers remain calm and responsive to their needs, they often survive terrible incidents without serious psychological scars.
Traumatized people become stuck. They stop growing because they can’t integrate new experiences into their lives.
Being traumatized means continuing your life as if the trauma was still going on. Every new encounter or event is contaminated by the past as the world is experienced with a different nervous system.
The victim focuses their energy on suppressing inner chaos at the expense of spontaneity.
Attempting to maintain control over these physiological reactions can lead to lots of different physical symptoms including fibromyalgia, chronic fatigue, and other autoimmune diseases.
This is why you need to engage your body and mind when treating traumas.
When we flee, the old brain takes over and shuts down the higher brain which contains our conscious mind, etc.
When the fight/flight option isn’t available, the brain keeps on secreting stress hormones long after the actual events have passed.
This intervenes and changes the parts of the brain that deal with survival.
The most important job of the brain is to ensure our survival, even under the most miserable conditions. Everything else is secondary.
To do that, the brain:
- Generate signals about needs that our body acts on (food, rest, protection, sex, and shelter)
- Create a map of the world to point us to where to go to satisfy those needs.
- Generate the necessary energy and actions to get us there.
- Warn us of dangers and opportunities along the way.
- Adjust our actions based on the requirements of the moment.
Psychological problems occur when our internal signals don’t work (we can’t get where we need to go, our actions don’t correspond to our needs, and our relationships break down).
Let’s look at the structure of the brain. The brain is built from the bottom up.
- Our rational brain is the youngest part and makes up only 30% of the brain. It’s primarily concerned with understanding the world outside us. The top layer of the brain is the neocortex, containing the frontal lobes which allow us to plan and reflect, to imagine and play out future scenarios. It’s also where mirror neurons “copy” the state of mind of other people. Well-functioning frontal lobes are crucial for good relationships. Without flexible and active frontal lobes, people get stuck in routines and superficial relationships. Beneath the rational brain lie two older brains:
- The reptilian brain is the most primitive part. It’s responsible for basic life-sustaining activities.
- The limbic system is tasked with the identification and expression of emotions. Its development starts after birth.
The brain develops according to how it is used: neurons that fire together, wire together. After a while, a specific circuit becomes default.
If you feel safe and loved, your brain becomes specialized in exploration, play, and cooperation; if you are frightened and unwanted, it specializes in managing feelings of fear and abandonment.
Taken together the reptilian brain and limbic system make up the “emotional brain”.
The emotional brain is at the heart of the nervous system; its key task is to look out for your welfare. When it sees an opportunity (for food, mating, etc), it tells you to move to get it.
The emotional brain’s organization is simpler than the one of the rational brain. As a result, it jumps to conclusions faster than the rational brain.
The emotional brain initiates preprogrammed escape plans, like the fight-or-flight responses.
Threats are processed in two ways.
The fast one: the thalamus sends a message to the amygdala (some sort of smoke detector). If it estimates the threat is worth fleeing, it sends a message to the hypothalamus which secretes stress hormones.
If not, it sends a message to the prefrontal cortex, which takes longer to decide. People with PTSD tend to use their amygdala even in situations that don’t warrant it.
Once the danger has passed, the body recovers to its normal state. But when recovery is blocked, the body remains agitated.
Trauma leads to misinterpreting whether a situation is dangerous or safe. One can get along with others only if they can accurately decide if they’re “safe” or not.
If the amygdala is a smoke detector, the medial prefrontal cortex (MPFC) is a watchtower. When it breaks down like under PTSD, we constantly remain in a fight or flight mode.
Effectively dealing with stress depends upon achieving a balance between the amygdala and the MPFC.
You can learn to do that top-down, or bottom-up.
- Top-down: strengthen the capacity of the watchtower to monitor your body’s sensations. Mindfulness meditation and yoga can help with this.
- Bottom-up: recalibrate the autonomic nervous system through breath, movement, or touch.
Emotion is not opposed to reason; our emotions assign value to experiences and thus are the foundation of reason. Our self-experience is the product of the balance between our rational and our emotional brains.
When the rational and the emotional are in balance, we feel like being ourselves. But when survival is at stake, they can work independently.
Whenever the limbic system decides that something is a question of life or death, the pathways between the frontal lobes and the limbic system become extremely tenuous.
Dissociation is the essence of trauma. The overwhelming experience is split off and fragmented, so that the emotions, sounds, images, thoughts, and physical sensations related to the trauma take on a life of their own.
As long as the trauma is not resolved, the stress hormones remain in the body as the emotional response from the defensive movement keeps getting replayed. The more the trauma is replayed, the more engrained into the mind it becomes.
The flashbacks can be even worse than the trauma itself; people suffering from flashbacks often organize their lives to protect themselves against them which is exhausting. Being stuck in the past prevents them from being in the present and feeling fully alive.
This is where therapy comes in: it helps sense, name, and identify what is going on inside.
It’s important to have an efficient smoke detector (…) you need to detect whether somebody is getting upset with you, but if your amygdala goes into overdrive, you may become chronically scared that people hate you, or you may feel like they are out to get you.
Two brain systems are relevant for the mental processing of trauma:
- Amygdala and medial prefrontal cortex: deal with emotional intensity.
- Dorsolateral prefrontal cortex (DLPFC) and the hippocampus: context and meaning of an experience.
The DLPFC tells us how our present experience relates to the past and how it may affect the future. It signals that whatever begins will eventually end. This is why people should feel calm and secure when talking about traumas in therapy – so that they can activate these parts of the brain that shut down when the trauma happened.
Trauma is the ultimate experience of “this will last forever.”
Being anchored in the present while revisiting the trauma opens the possibility of deeply knowing that the terrible events belong to the past. For that to happen, the brain’s watchtower, cook, and timekeeper need to be online. Therapy won’t work as long as people keep being pulled back into the past.
People with PTSD have their floodgates wide open. Lacking a filter, they are on constant sensory overload. In order to cope, they try to shut themselves down and develop tunnel vision and hyperfocus. The tragedy is that the price of closing down includes filtering out sources of pleasure and joy, as well.
The other way to deal with trauma is going blank, also called “depersonalization”.
Anyone who deals with traumatized men, women, or children is sooner or later confronted with blank stares and absent minds, the outward manifestation of the biological freeze reaction.
People who experiment with depersonalization become lifeless which makes it hard for the therapist to focus. This is where a bottom-up approach is necessary.
Many people start out with flashbacks, then move on to numbing.
The challenge of trauma treatment is not only dealing with the past but, even more, enhancing the quality of day-to-day experience.
One reason why traumatic memories become dominant in PTSD is that it’s so difficult to feel truly alive right now, so you go back to a moment when you felt truly alive – during the trauma.
Many treatments focus on desensitizing patients to their past, but the real purpose should be to help them live in the present.
To do that, we need to bring back the areas of the brain that went numb during the trauma.
If you cannot feel satisfaction in ordinary everyday things like taking a walk, cooking a meal, or playing with your kids, life will pass you by.
Chapter 5: Body-Brain Connections
In The Expression of the Emotions in Man and Animals, Charles Darwin noticed that humans shared their emotions with animals which led him to deduce that they likely had a biological basis and origin.
Emotions are conveyed by the muscles of the body and face and are instinctively read by other people. For Darwin, emotions are the indispensable source of motivation to initiate action, but serve also to restore the organism to safety and physical equilibrium.
He also wrote that being in a constant fight or flight mode was detrimental since the animal could not ensure its own survival by reproducing, sheltering, or feeding (activities that demand one to be relaxed).
If an organism is stuck in survival mode, its energies are focused on fighting off unseen enemies, which leaves no room for nurture, care, and love.
Emotions are also felt in the gut and heart (chest).
The signs about our and others’ bodies are linked by the two branches of the autonomic nervous system:
- The sympathetic nervous system acts as the body’s accelerator (responsible for arousal, including the fight-or-flight response). Activates with deep breaths.
- The parasympathetic serves as its brake (promotes self-preservative functions like digestion and wound healing). Activates with deep exhalations.
Human beings are sensitive to subtle emotional shifts in people. Slight changes (tension of the brow, wrinkles around the eyes, curvature of the lips) inform about how comfortable, suspicious, relaxed, or frightened someone is.
Our mirror neurons register other people’s inner experiences and our own bodies make internal adjustments to whatever we notice. When the message we receive from others is that they’re safe to be with, we relax.
If we’re lucky in our relationships, we also feel nourished, supported, and restored as we look into the face and eyes of the other.
Our culture teaches us to focus on personal uniqueness, but at a deeper level we barely exist as individual organisms. Our brains are built to help us function as members of a tribe. Most of our energy is devoted to connecting with others.
Almost all mental suffering involves either trouble in creating workable and satisfying relationships or difficulties in regulating arousal (becoming enraged, shut down, overexcited, or disorganized).
Being able to feel safe with other people is probably the single most important aspect of mental health; safe connections are fundamental to meaningful and satisfying lives.
Social support is the most powerful protection against being overwhelmed by stress and trauma.
Social support ≠ being with other people. Social support means having a relationship (being heard and validated.)
Many traumatized people find themselves chronically out of sync with the people around them.
They find friends in other traumatized people. They can hardly bond with those who haven’t been traumatized.
Isolating oneself into a narrowly defined victim group promotes a view of others as irrelevant at best and dangerous at worst, which eventually only leads to further alienation.
Traumatized people experience the world differently after the trauma, usually in three different ways:
- Focused
- Collapsed
- Frantic
There are three physiological states we get in, regulated by the nervous system and based on how safe we feel.
Being social depends on nerves located in the vagus, linking to nerves that activate the muscles of the face, throat, middle ear, and voice box or larynx.
When the “ventral vagal complex” (VVC) runs the show, we have calm and normal social reactions (smile when others smile at us, etc).
Any threat to our safety or social connections triggers changes in the areas innervated by the VVC.
When a traumatic event happens, we signal our distress through the facial muscles (calling on someone); if it doesn’t work, we move on to the limbic brain (fight or flight); if this fails, we activate the dorsal vagal complex (DVC) which slows down the metabolism (disengage, collapse, freeze).
For many people, panic and rage are better than shutting down.
That is why many traumatized people feel fully alive in the face of actual danger, while they go numb in situations that are more complex but objectively safe, like birthday parties or family dinners.
The more efficiently the VVC synchronizes the activity of the sympathetic and parasympathetic nervous systems, the better the physiology of each individual will be attuned to that of other members of the tribe.
Being in tune with other members of our species via the VVC is enormously rewarding (dancing, playing sports, music).
Trauma happens when that synchronicity fails. Eg: you beg for your life but the person ignores your plea.
Immobilization is at the root of most traumas. When that occurs the DVC is likely to take over: Your heart slows down, your breathing becomes shallow, and, zombielike, you lose touch with yourself and your surroundings. You dissociate, faint and collapse.
The natural state of mammals is to be on guard; but to feel close to someone, you have to put your guard down.
Many traumatized individuals are too hypervigilant to enjoy the ordinary pleasures that life has to offer, while others are too numb to absorb new experiences or recognize signs of danger.
Consequence: women who had an early history of abuse and neglect were seven times more likely to be raped in adulthood.
The only way to get traumatized people out of these modes is through cooperation.
Getting people to play, sing, build, etc together helps them relax, deactivate the fight/flight mode so they are open to new information.
When children are oppositional, defensive, numbed out, or enraged, it’s also important to recognize that such “bad behavior” may repeat action patterns that were established to survive serious threats, even if they are intensely upsetting or off-putting.
Dancing, playing, singing, and cooperating help shift people out of fight/flight states, reorganize their perception of danger, and increase their capacity to manage relationships.
Chapter 6: Losing Your Body, Losing Your Self
If no one has ever looked at you with loving eyes or broken out in a smile when she sees you; if no one has rushed to help you, but instead said, “Stop crying, or I’ll give you something to cry about”, then you need to discover other ways of taking care of yourself.
These ways are drugs, alcohol, cutting yourself…anything that can make you feel something.
Many people with trauma get completely disconnected from their bodies. Some of them cannot even feel whole parts of it.
While trauma-free people think about themselves when not doing anything in particular, traumatized people cannot because they shut down their relationship with themselves due to the terror.
In an effort to shut off terrifying sensations, they also deadened their capacity to feel fully alive.
The disappearance of medial prefrontal activation could explain why so many traumatized people lose their sense of purpose and direction.
The lack of self-awareness in victims of chronic childhood trauma is sometimes so profound that they cannot recognize themselves in a mirror.
To feel present, you need to know what is going on with you. You can’t do that if the self-sensing system breaks down.
Massage is a good way to learn to reconnect to one’s body.
When we remember an emotion from the past, we reexperience what we experienced then. Traumatized people remain stuck in their life-or-death situation.
Agency, the feeling of being in charge of your life, helps you regain control and unstuck your brain from this state of constant arousal.
Agency means that you know:
- Where you stand.
- That you have a say in what happens to you.
- That you have some ability to shape your circumstances.
Agency begins with self-awareness. The bigger the awareness of your self, the greater the potential to control your life. Mindfulness is a great tool to strengthen the MPFC and increase awareness of your gut feeling. Once you trust it, you feel in charge of your body.
Traumatized people feel unsafe inside their bodies as the past is constantly replaying in their brains, bombarding them with warning signs. In an attempt to control these, they split and numb themselves by hiding their selves.
People who cannot comfortably notice what is going on inside become vulnerable to respond to any sensory shift either by shutting down or by going into a panic—they develop a fear of fear itself.
Panic symptoms are maintained largely because the individual develops a fear of panic attacks.
On the flip side, people become unable to detect real dangers when they numb themselves.
Suppressing our inner cries for help does not stop our stress hormones from mobilizing the body.
Furthermore, numbing doesn’t mean that the consequences of a feeling disappear. Rather, they manifest as chronic back and neck pain, fibromyalgia, migraines, digestive problems, spastic colon/irritable bowel syndrome, chronic fatigue, and some forms of asthma.
Many people will feel emotions but won’t be able to name them. This is called alexithymic.
They substitute feelings for actions. If you ask them how they’d feel if a crazy truck ran toward them, they’d say “I would move” instead of saying “I’d be terrified”.
Instead of feeling angry or sad, they experience muscle pain, bowel irregularities, or other symptoms for which no cause can be found.
One step further is depersonalization— losing your sense of yourself.
Trauma victims cannot recover until they become familiar with and befriend the sensations in their bodies.
Being frightened means that you live in a body that is always on guard. Angry people live in angry bodies.
Physical self-awareness is the first step in releasing the tyranny of the past.
Traumatized people often cannot look at others because they feel disgusting and shameful.
Part Three: The Minds of Children
Chapter 7: Getting on the Same Wavelength: Attachment and Attunement
Most research is me-search.
Beatrice Beebe
We are profoundly social creatures; our lives consist of finding our place within the community of human beings.
At the beginning of our lives, we are incapable of taking care of ourselves and remain at the mercy of our parents and family. As a result, we get our first lesson in self-care from the way our parents cared for us.
Mastering the skill of self-regulation depends to a large degree on how harmonious our early interactions with our caregivers are. Children whose parents are reliable sources of comfort and strength have a lifetime advantage—a kind of buffer against the worst that fate can hand them.
Children choose one adult (whoever takes care of them the most) with whom they develop an attachment bond. The attachment should be secure and to do so, must include emotional attunement (sync). When the child is in sync with his caretaker, he’s happy.
The more responsive the adult is with the child -> the deeper the attachment -> the better the child can respond to people around him.
When infants and young children notice that their mothers are not fully engaged with them, they become nervous. When their mothers disappear from sight, they may cry and become inconsolable, but as soon as their mothers return, they quiet down and resume their play.
Attachment is a secure base from which the child explores the world.
Growing up in a safe environment helps the child develop self-reliance and feel sympathetic and helpful to people in distress. They learn how to become social and the difference between situations they can control, and those they cannot.
But children who didn’t grow up in a safe environment learned that no amount of crying registered with their caregivers.
This is the case of babies whose needs aren’t met by the mother. Since the mother does not adapt to the baby, the baby adapts to the mother.
Abused kids tend to be very focused on angry faces or voices, but they interpret them as threats rather than cues.
The need for attachment never lessens. Most human beings simply cannot tolerate being disengaged from others for any length of time.
People who cannot connect through work, friendships, or family usually find other ways of bonding, as through illnesses, lawsuits, or family feuds. Anything is preferable to that godforsaken sense of irrelevance and alienation.
Children whose main caregiver is unresponsive deal with anxiety in two ways:
- Being upset (anxious).
- Being passive and withdrawn (avoidant).
These children don’t become happy again when the mother comes back.
Attachment researchers think that there are three “organized” attachment strategies:
- Secure
- Avoidant
- Anxious
Avoidant/anxious kids tend to become avoidant/anxious adults. As long as the attachment style remains constant, the child can cope even though it is not ideal.
Then there is another category of children whose caregivers are a source of terror and distress (called disorganized attachment, solely caused by parental abuse). Eg: parents (source of joy) who molest their children (source of distress).
Children in this situation have no one to turn to, and they are faced with an unsolvable dilemma; their mothers are simultaneously necessary for survival and a source of fear.
Children who don’t feel safe in infancy have trouble regulating their moods and emotional responses as they grow older.
When a traumatic event happens in a family, the impact on children is largely determined by how calm or stressed their parents are -> mimesis at play.
When children were hospitalized for treatment of severe burns, the development of PTSD could be predicted by how safe they felt with their mothers.
When you have no sense of security, you can’t distinguish between safety and danger. If you feel numb, you may seek potentially dangerous experiences. When you think you are a terrible person, you expect others to treat you badly.
Among the different types of abuse, emotional distance and role reversal (kids look after their parents) are specifically linked to aggressive behavior against themselves and others in young adults.
Let’s talk about dissociation. Dissociation is feeling lost, overwhelmed, abandoned, and disconnected from the world. These people see themselves as unloved, empty, helpless, trapped, and weighed down.
There is a relationship between maternal disengagement and misattunement during the first two years of life and dissociative symptoms in early adulthood.
Infants who are not truly seen and known by their mothers are at high risk to grow into adolescents who are unable to know and to see.
If your parents ignore your needs, or resent your very existence, you learn to anticipate rejection and withdrawal. You may pretend it doesn’t matter, but your body feels otherwise.
When you don’t feel, nothing matters, so you can’t protect yourself well. Lack of safety leads to an impaired sense of inner reality, excessive clinging, and self-damaging behavior -> the quality of early caregiving is critically important in preventing mental health.
Chapter 8: Trapped in Relationships: The Cost of Abuse and Neglect
People who have been victims of incest are prone to auto-immune diseases because the body has used a considerable amount of RA cells, memory cells part of the immune system that helps it defend against known threats. The body becomes incapable of distinguishing between danger and safety.
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.
We become how we were treated. If we were well-treated, we like ourselves. If we weren’t, we don’t.
It’s important NOT to tell people they should not feel the way they feel when they blame everything on themselves or when they say they don’t like themselves. It makes them feel even lonelier and more frustrated.
To change the map of our world, we need to reorganize our nervous system where it’s located.
The first thing to do is to observe and tolerate the bad feelings (mindfulness). Once we do, we can befriend them instead of trying to numb and suppress them.
Trauma is not stored as a narrative. It can be expressed as flashbacks that contain fragments of the experience, isolated images, sounds, and body sensations that initially have no context other than fear and panic.
Lots of people don’t even remember their trauma.
Chapter 9: What’s Love Got to Do With It?
The diagnosis of a traumatized patient will depend on what the healthcare provider focuses on. Traumatized people can be described as having ADHD, PSTD, depression, or bipolar disorder.
It’s never entirely wrong, but it’s never entirely right either.
The vast majority of patients with psychiatric problems were traumatized as kids.
When children feel pervasively angry or guilty or are chronically frightened about being abandoned, they have come by such feelings honestly; that is because of experience.
People typically don’t grow up in a household where one brother is in prison but everything else is fine.
The impact of trauma doesn’t vanish in time but remains.
Many of the patients’ treatments today are for problems from many years ago.
The more isolated and unprotected a person feels, the more death will feel like the only escape.
How traumatized someone was can be measured by the ACE, a test of ten questions.
In the case of obesity, it may as well be the solution for many people (prison guards want to be big to feel safe and women who have been raped don’t want to be looked at).
Other kids ate because as they got fat, they didn’t get beaten.
When these people lose weight, many struggle with depression, suicidal thoughts, or even panic.
What one sees, the presenting problem, is often only the marker for the real problem, which lies buried in time, concealed by patient shame, secrecy and sometimes amnesia—and frequently clinician discomfort.
Obesity isn’t the worst problem; child abuse is.
Chapter 10: Developmental Trauma: The Hidden Epidemic
Many are tempted to describe the problems of difficult children with genetic determinism. After millions of dollars and years of research, no one found the “gene” responsible for misbehavior.
It turns out that many genes work together to influence a single outcome. Even more important, genes are not fixed; life events can trigger biochemical messages that turn them on or off.
One of the most widely cited studies in epigenetics showed that rats whose mother licked them and took care of them 12 hours after birth permanently affected the brain chemicals that respond to stress—and modified the configuration of over a thousand genes.
They recovered better when hurt, too.
Of course, stressful experiences affect gene expression in humans, as well.
In rhesus monkeys, two personalities run often into social problems:
- Uptight, anxious monkeys, who become fearful, withdrawn, and depressed.
- Highly aggressive monkeys, who end up beaten up, or killed.
It’s been observed that early experiences of young monkeys had as much impact on their biology as heredity does through the level of cortisol that they have.
In 1975, a study tracked 180 children for 30 years to find out what best predicted their outcome in life.
Neither the mother’s personality, nor the infant’s neurological anomalies at birth, nor its IQ, nor its temperament predicted whether a child would develop serious behavioral problems in adolescence. The key issue, rather, was (…) how parents felt about and interacted with their kids.
As with Suomi’s monkeys, the combination of vulnerable infants and inflexible caregivers made for clingy, uptight kids. Insensitive, pushy, and intrusive behavior on the part of the parents at six months predicted hyperactivity and attention problems in kindergarten and beyond.
The children who received consistent caregiving became well-regulated kids, while erratic caregiving produced kids who were chronically physiologically aroused.
They were also much more resilient.
In 1986, Putnam and Trickett ran the first study on the impact of sexual abuse on female development.
They found out that sexually abused girls suffer from a large range of profoundly negative effects, including cognitive deficits, depression, dissociative symptoms, troubled sexual development, high rates of obesity, and self-mutilation.
Despite that, the APA still does not recognize traumatic relationships as a cause for traumas.
Part Four: The Imprint of Trauma
Chapter 11: Uncovering Secrets: The Problem of Traumatic Memory
We don’t remember things exactly as they happened, and we don’t remember everything either.
Pierre Janet was the find out about the difference between “narrative memory”—the stories people tell about trauma—and traumatic memory itself.
Traumatized people remember both too little because they can’t have a defined memory of the experience, and too much because their body remembers. But they never remember the trauma as a story.
Traumatic memories are precipitated by specific triggers. In contrast, ordinary memory is adaptive; our stories are flexible and can be modified to fit the circumstances.
Ordinary memory is social; it’s a story that we tell for a purpose. But there is nothing social about traumatic memory.
Chapter 12: The Unbearable Heaviness of Remembering
Memory loss is frequent in the case of trauma, but it took a long time before it was recognized by the medical community.
Normal memories are remembered as stories, with a beginning, middle, and end.
Traumatic memories are remembered in a disorganized way. Victims remember details but cannot explain how the events unfolded.
Traumatic memories are fundamentally different from the stories we tell about the past. They are dissociated: The different sensations that entered the brain at the time of the trauma are not properly assembled into a story, a piece of autobiography.
Furthermore, remembering the trauma does not necessarily resolve it.
Finding words to describe what has happened to you can be transformative, but it does not always abolish flashbacks or improve concentration, stimulate vital involvement in your life or reduce hypersensitivity to disappointments and perceived injuries.
The truth is that nobody wants to remember trauma.
The essence of trauma is that it is overwhelming, unbelievable, and unbearable. Each patient demands that we suspend our sense of what is normal and accept that we are dealing with a dual reality: the reality of a relatively secure and predictable present that lives side by side with a ruinous, ever-present past.
Part Five: Paths to Recovery
Chapter 13: Healing From Trauma: Owning Your Self
Whatever trauma happened to you cannot be undone. What you need to deal with isn’t the trauma, but its consequences.
- The crushing sensations in your chest that may look like anxiety or depression.
- The fear of losing control.
- Always being on alert for danger or rejection.
- The self-loathing; the nightmares and flashbacks.
- The fog that keeps you from staying on task and from engaging fully in what you are doing.
- Being unable to fully open your heart to another human being.
Trauma robs you of the feeling that you are in charge of yourself.
The challenge of recovery is to reestablish ownership of your body and your mind—of your self. This means feeling free to know what you know and to feel what you feel without becoming overwhelmed, enraged, ashamed, or collapsed.
This means:
- Finding a way to be calm and focused.
- Learning to maintain that calm in the face of images, thoughts, sounds, or physical sensations from the past (or that remind you of it)
- Finding a way to be alive and engaged in the present and with the people around you,
- Not having to keep secrets from yourself, including secrets about the ways that you have managed to survive.
These don’t necessarily have to be achieved in this order. They can also be achieved at the same time.
Posttraumatic reactions come from the emotional brain and manifest themselves in physical reactions: (heart pounding, fast breathing, speaking with an uptight and reedy voice).
Unfortunately, the rational brain cannot abolish those feelings.
Understanding why you feel a certain way does not change how you feel.
The fundamental issue in resolving traumatic stress is to restore the proper balance between the rational and emotional brains, so that you can feel in charge of how you respond and how you conduct your life.
When we are triggered into states of hyper- or hypoarousal, we get outside of our “window of tolerance”.
We become reactive and disorganized and we panic or fly into rages; or we shut down, feel numb, and have low energy.
Either way, we can’t learn from experience in these states.
Even if we keep control, we become so uptight that we are inflexible, stubborn, and depressed.
Recovery from trauma involves the restoration of executive functioning and, with it, self-confidence and the capacity for playfulness and creativity.
If we want to change posttraumatic reactions, we have to access the emotional brain and do “limbic system therapy”: repairing faulty alarm systems and restoring the emotional brain to its ordinary job of being a quiet background presence that takes care of the housekeeping of the body, ensuring that you eat, sleep, connect with intimate partners, protect your children, and defend against danger.
The rational (analyzing) brain does not have direct connections with the emotional brain, but the self-awareness brain does. It’s the only way to access the emotional brain.
Neuroscience research shows that the only way we can change the way we feel is by becoming aware of our inner experience and learning to befriend what is going inside ourselves.
Befriending the Emotional Brain
1. Dealing with Hyperarousal
80% of the fibers of the vagus nerve run from the body into the brain. This means we can retrain the brain from the body.
Eg: 10 weeks of yoga can reduce PTSD syndrome where everything else failed.
Learning how to breathe calmly and remaining in a state of relative physical relaxation, even while accessing painful and horrifying memories, is an essential tool for recovery.
Taking a few deep breaths will already make you more relaxed. The more you focus on the breathing, the better it is.
2. No Mind Without Mindfulness
At the core of recovery is self-awareness. The most important phrases in trauma therapy are “Notice that” and “What happens next?”
Traumatized people live with unbearable sensations (tightness in the chest, etc). Ignoring them increases our vulnerability to being overwhelmed by them.
Body awareness puts us in touch with our inner world, the landscape of our organism. Simply noticing our annoyance, nervousness, or anxiety immediately helps us shift our perspective and opens up new options other than our automatic, habitual reactions.
Traumatized people are often afraid of feelings because they felt some that were really painful.
It’s not surprising that so many trauma survivors are compulsive eaters and drinkers, fear making love, and avoid many social activities: Their sensory world is largely off limits.
If you want to change though, you have to open up to your inner experience.
Here’s how.
- Focus on your sensations and notice how they’re transient and respond to slight shifts in body position, changes in breathing, and shifts in thinking.
- Label them. Eg: “When I feel anxious, I feel X in my chest.”
Mindfulness calms down the sympathetic nervous system.
If you cannot tolerate what you are feeling right now, opening up the past will only compound the misery and retraumatize you further.
3. Relationships
A solid network of people constitutes the best way to avoid being traumatized.
The British children sent to the countryside during the war were more traumatized than the children who remained with their parents during the bombings.
Recovery from trauma involves (re)connecting with our fellow human beings.
This is why the traumas that happen within relationships are harder to solve. When the solution is the cause of the problem, people shut down,
If your heart is still broken because you were assaulted by someone you loved, you are likely to be preoccupied with not getting hurt again and fear opening up to someone new. In fact, you may unwittingly try to hurt them before they have a chance to hurt you.
4. Communal Rhythms and Synchrony
Trauma breaks synchronicity with other people. A community can fix that, particularly through music and rhythms, choral singing, aikido, tango dancing, improvisation, or kickboxing.
5. Getting in Touch
You can’t recover if you don’t feel safe in your skin.
People should engage in some sort of bodywork, be it therapeutic massage, Feldenkrais, or craniosacral therapy.
6. Taking Action
When the body secretes stress hormones, these help the person get moving. If you remain immobile, your body will work against you.
Sensorimotor psychotherapy and somatic experiencing were developed to deal with these issues where the purpose is to deal with the parts of the body where the trauma was imprinted rather than dealing with the story.
Feeling the pleasure of taking effective action restores a sense of agency and a sense of being able to actively defend and protect themselves.
When people are forced to submit to a stronger power, they survive with “resigned compliance”.
The best way to overcome ingrained patterns of submission is to restore a physical capacity to engage and defend.
People cannot put traumatic events behind until they are able to acknowledge what has happened and start to recognize the invisible demons they’re struggling with.
CBT
The purpose of CBT is to desensitize patients to their irrational fears so they become less upset.
Exposure sometimes helps to deal with fear and anxiety, but it has not been proven to help with guilt or other complex emotions.
Furthermore, remembering traumas may reinforce them rather than solve them.
In contrast to its effectiveness for irrational fears such as spiders, CBT has not done so well for traumatized individuals, particularly those with histories of childhood abuse. Only about one in three participants with PTSD who finish research studies show some improvement.
Being traumatized is not just an issue of being stuck in the past; it is just as much a problem of not being fully alive in the present.
Veterans traumatized by war were given virtual-reality therapy where they relieved the battle. They performed well in the same environment but remained traumatized outside of it.
Desensitization
Most medical students learn that the purpose of therapy is to desensitize the patient to his trauma, but this is incorrect.
The real purpose is to help them integrate it.
Drugs to Safely Access Trauma?
MDMA + internal family system (IFS) therapy has given good results on veterans and firefighters with PTSD.
When it comes to medicines like Prozac, EMDR had better results. Some types of traumas respond better to drugs than others (combat veterans don’t respond well).
Chapter 14: Language: Miracle and Tyranny
After 9/11, the survivors were offered two methods to deal with their trauma: psychoanalysis, and CBT.
Nobody showed up to either of them. After a year, people were asked which method they had used to deal with the stress since they hadn’t gone to their CBT/psychoanalysis appointments.
The answer was: acupuncture, massage, yoga, and EMDR.
The lack of interest in talking therapies led specialists to wonder why anyone would talk about their traumas in the first place.
Therapists have had full faith in talking therapies since Freud and Breuer wrote that talking about them made them disappear instantly. As we said above, this isn’t true. On the other hand, being silent isn’t good either.
Recovery begins when one manages to say out loud: “I was beaten/r*ped/etc”.
You need to name and acknowledge what happened to you.
If you hide from yourself the fact that an uncle molested you when you were young, you are vulnerable to react to triggers like an animal in a thunderstorm.
As long as you keep secrets and suppress information, you are fundamentally at war with yourself.
Hiding your core feelings leaves you tired, decreases your motivation, and leaves you bored and shut down. It eats your identity, sense of self, and purpose.
The stress hormones keep flooding your body, leading to headaches, muscle aches, bowel and sexual problems, etc.
Naming what happened to you is crucial. It’s the first step of recovery.
Knowing Yourself or Telling Your Story? Our Dual Awareness System
We possess two distinct forms of self-awareness:
- The intellectual one: keeps track of the self across time, creating one coherent story.
- The “feeling-based” one: registers the self in the now (self-awareness), based primarily in physical sensations.
Only the second one can change the emotional brain.
It’s possible to observe these two systems working simultaneously, when people tell a “happy story” while being slumped, or a sad story while standing straight.
The Body Is the Bridge
Trauma stories lessen the isolation of trauma, and they provide an explanation for why people suffer the way they do.
But trauma also transforms people, and people can’t quite phrase how they were transformed by the trauma, which makes, in many cases, talking therapy useless.
Writing to Yourself
Writing about your traumas and what happened has been shown to help people move forward, but we don’t know if it’s due to the writing or to something else.
The purpose of writing is to talk to yourself – to tell yourself what you have been trying to avoid.
Art, Music, and Dance
A lot of therapists use these but we know little about how they work.
The Limits of Language
Talking about trauma is overwhelming for both listeners and speakers and doesn’t help people bond with one another.
People don’t want to hang out with those depressed by their traumas, which is why trauma victims withdrawn and ruminate over the same stories again and again.
That doesn’t mean you shouldn’t tell your story. Rather, you should tell it in an acceptable setting, like group therapies.
Other people are so overwhelmed by the emotion that they’re incapable of speaking.
Dealing With Reality
Dealing with traumatic memories, however, is only the beginning.
People with PTSD also struggle often with focused attention and learning new information.
A trauma is inside the brain what a splinter would be inside the hand. It constantly sends your body annoying sensations you have to deal with during the day.
Being constantly assaulted by, but consciously cut off from, the origin of bodily sensations produces alexithymia: not being able to sense and communicate what is going on with you.
To overcome trauma, you need to get back in touch with your body, that is, with your self.
Chapter 15: Letting Go of the Past: EMDR
EMDR means Eye Movement Desensitization and Reprocessing. The patient recalls a traumatic story then quickly follows with his eyes the finger of the therapist moving left and right. Another variant of it uses taps on the hands.
Doing so, the trauma is often released and the patient may even remember other traumatic incidents to talk about.
- EMDR seems to give people access to memories and images from their past which seems to contextualize the trauma differently.
- Talking isn’t needed for people to solve their trauma.
- EMDR can help even if the patient and the therapist do not have a trusting relationship.
Studying EMDR
After only three EMDR sessions, most patients had a different brain scan than they did prior (sharp increase in prefrontal lobe activation).
However, EMDR seems to work mostly on people traumatized as adults rather than those traumatized as children.
We’re not sure how EMDR works exactly, but it seems to help integrate a traumatic memory.
Chapter 16: Learning to Inhabit Your Body: Yoga
The memory of helplessness is stored as muscle tension or feelings of disintegration in the affected body parts: head, back, and limbs in accident victims, vagina, and rectum in victims of sexual abuse.
The lives of many trauma survivors revolve around fighting against unwanted sensory experiences which they do with self-numbing (with addictions, mostly).
The other side to self-numbing is sensation seeking (high-risk activities, prostitution, gambling, etc).
When people are chronically angry or scared, constant muscle tension ultimately leads to spasms, back pain, migraine headaches, fibromyalgia, and other forms of chronic pain.
The biological marker “heart rate variability” (HRV, fluctuation in heart rate in response to breathing) is a reliable indicator of how well the autonomic nervous system is going (with its two branches, the sympathetic nervous system and the parasympathetic nervous system).
When these two systems work closely together (when the autonomic nervous system is modulated), we feel at our best and we have reasonable control over minor frustrations (feeling insulted or left out).
Individuals whose ANS isn’t well modulated are easily out of balance because there is no coherence between breathing and heart rate.
It makes people likelier to contract heart disease, cancer, depression and PTSD.
In people with PTSD, the two systems are out of sync.
Luckily, yoga can help recover a proper HRV and help people to “re-inhabit” and take care of their bodies; it puts people “back in touch” with their bodies.
Chapter 17: Putting the Pieces Together: Self-Leadership (IFS)
Every traumatized person copes in their own way. Traumatized children often choose to hate themselves rather than being angry at their caretakers, or running away.
As a result, abused children are likely to grow up believing that they are fundamentally unlovable.
It’s the only way they can explain why so much harm was done to them.
If you were abused as a child, you are likely to have a childlike part living inside you that is frozen in time, still holding fast to this kind of self-loathing and denial.
While resolving your trauma is important, you’ll also need to resolve the part of yourself you developed to cope with it.
IFS (internal family system) effectively deals with this problem.
IFS was built on the idea that the mind works like a family. Any change to one part will affect the other parts.
In trauma the self-system breaks down, and parts of the self become polarized and go to war with one another.
Self-loathing co-exists with grandiosity, loving care with hatred and numbing, and passivity with rage and aggression.
IFS considers each part as a distinct mental system. Trauma injects into these parts some beliefs and emotions that hijack them. They become toxic and must be denied; IFS calls these parts exile.
Then there is the part called manager whose task is to manage the individual’s life around the trauma so that they never get hurt again; then there’s the firefighter which awakens when the exile becomes conscious or attempts to come back. The firefighter often expresses itself through binge drinking, risky behavior, self-harm, etc. It’s an attempt at suppressing the emotion associated with the exile.
Each part holds a memory or an emotion. The purpose of IFS is to bring all of these parts together and get them to collaborate especially the exiles.
IFS recognizes that the cultivation of mindful self-leadership is the foundation for healing from trauma.
When the Self is no longer in charge, it identifies with one of its parts. It is further assumed that the Self remains untouched in the person, protected by the parts, and that once the parts trust they can separate, the Self emerges.
Furthermore, the mindful Self can help reorganize the inner system and communicate with the parts in ways that help those parts trust that there is someone inside who can handle things.
In fact, mindfulness increases activation of the medial prefrontal cortex and decreases activation of structures like the amygdala that trigger our emotional responses.
IFS builds a relationship between the Self and the various parts -> the Self has an active leadership role.
The role of the IFS therapist is to separate the parts so that the patient can objectively look at his parts rather than identify with them.
The patient must then ask his parts to “stand back”. After a while, the Self emerges.
After, the therapist asks the patient how they feel about a certain part. If the patient says “I hate it”, the therapist knows he stumbled onto another part and asks “can that part that hates it, step back?”
Once the Self begins to emerge, it spontaneously talks to the parts.
Internal managers who are obsessed with power are usually created as a bulwark against feeling helpless.
Chapter 18: Filling in the Holes: Creating Structures (PBSB)
People who felt unwanted as children, and those who did not remember feeling safe with anyone while growing up, did not fully benefit from conventional psychotherapy, presumably because they could not activate old traces of feeling cared for.
PBSB (Pesso Boyden System Psychomotor) is a form of therapy that asks the patient to represent in real life the most important people in their lives, either using real individuals, or symbols (furniture).
Projecting your inner world into the three-dimensional space of a structure enables you to see what’s happening in the theater of your mind and gives you a much clearer perspective on your reactions to people and events in the past.
It feels as if you were going back to the past and rewrote the scenes that stuck with you; it brings closure.
Chapter 19: Rewiring the Brain: Neurofeedback
In 2000, a study showed that key parts of the brain worked together in non-traumatized individuals, while the brain waves of traumatized subjects failed to come together.
Changing this pattern is made with neurofeedback.
Neurofeedback intervenes in the brain circuits that promote fearfulness, shame, and rage.
Electrodes are placed on the patient’s head.
They can observe their brain’s waves in real-time and are rewarded when they emit the “right” brain waves.
Neurofeedback has helped with ADHD, PTSD, and addictions.
Neurofeedback nudges the brain to make more of some frequencies and less of others, creating new patterns that enhance its natural complexity and its bias toward self-regulation.
Chapter 20 Finding Your Voice: Communal Rhythms and Theater
Our sense of agency, how much we feel in control, is defined by our relationship with our bodies and its rhythms.
To function properly, we have to be in our bodies. Depression, dissociation, etc is the opposite.
Acting helps you put yourself back in your body.
The fact that you do it with other people helps establish relationships and empathy. Furthermore, many plays portray what happens to traumatized people which has a healing effect.
…confrontation of the painful realities of life and symbolic transformation through communal action.
Traumatized people are terrified to feel deeply. They are afraid to experience their emotions, because emotions lead to loss of control. In contrast, theater is about embodying emotions, giving voice to them, becoming rhythmically engaged, taking on and embodying different roles.
Theater gives trauma survivors a chance to connect with one another by deeply experiencing their common humanity.
Epilogue: Choices to Be Made
As long as we feel safely held in the hearts and minds of the people who love us, we will climb mountains and cross deserts and stay up all night to finish projects. Children and adults will do anything for people they trust and whose opinion they value. But if we feel abandoned, worthless, or invisible, nothing seems to matter. Fear destroys curiosity and playfulness.
It is standard practice in many schools to punish children for tantrums, spacing out, or aggressive outbursts—all of which are often symptoms of traumatic stress. When that happens, the school, instead of offering a safe haven, becomes yet another traumatic trigger.
One of the prime reasons for habitual drug use in teens is that they cannot stand the physical sensations that signal fear, rage, and helplessness.
In addition to reading, writing, and arithmetic, all kids need to learn self-awareness, self-regulation, and communication as part of their core curriculum.
Children and adults alike need to experience how rewarding it is to work at the edge of their abilities. Resilience is the product of agency: knowing that what you do can make a difference.
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