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

“Five years after the last American soldier left Vietnam, the issue of wartime trauma was still not on anybody’s agenda.” 

Van der Kolk has been involved with psychiatry since before PTSD was a diagnosis, and, early in his career, he worked with Vietnam veterans. He struggled to treat a particular combat veteran because he was unable to find any literature on the man’s problem. This exemplifies van der Kolk’s larger theme that the psychiatric field largely fails traumatized individuals, uninterested in really helping them and believing that trauma isn’t as “worthy” of study as other diseases.

“Somehow the very event that caused them so much pain had also become their sole source of meaning. They felt fully alive only when they were revisiting their traumatic past.” 

Being unable to live in the present is one of the hallmarks of PTSD. People with PTSD often feel numb and seek out adrenaline-boosting activities as a way of feeling anything. Before he fully understands the biological underpinnings of this symptom, van der Kolk observes the behavior in veterans at a support therapy group that he conducts. 

“If you do something to a patient that you would not do to your friends or children, consider whether you are unwittingly replicating a trauma from the patient’s past.” 

Van der Kolk’s early experiences in psychiatric wards involve seeing and participating in aggressive control of patients, including in once instance, multiple doctors restraining a patient and force-feeding her. Van der Kolk’s sensitivity to patients as people, not disorders, makes him question this practice. He suggests that such “treatment” may do significantly more harm than good by retraumatizing patients. 

“The brain-disease model takes control over people’s fate out of their own hands and puts doctors and insurance companies in charge of fixing their problems.” 

Van der Kolk objects to modern psychiatry’s reliance on drugs to medicate symptoms of trauma rather than less “concrete” therapies to treat the trauma itself. He expresses particular disgust with the idea that mental and emotional trauma can diagnosed exactly like physical diseases—an idea promoted by people interested primarily in profiting from medication sales. 

“When the alarm bell of the emotional brain keeps signaling that you are in danger, no amount of insight will silence it.” 

“Talk therapy” has long been a recommended treatment for patients with trauma. Van der Kolk points out that appealing to someone’s rational mind when the rational mind isn’t really in control cannot help someone recover. A patient understanding intellectually that they have trauma to work through cannot “fix” their trauma—they need to address it on a more fundamental emotional and physical level.  

“But for people with PTSD a flashback can occur at any time, whether they are awake or asleep. There is no way of knowing when it’s going to occur again or how long it will last. […] Not being fully alive in the present keeps them more firmly imprisoned in the past.” 

Trauma is often devastating, and one of its most devastating aspects is unpredictability. The possibility of a PTSD flashback at any time, without warning, keeps those with PTSD constantly on edge, hyperaroused, and anticipating threat. Being unable to interface with their environment in a meaningful way perpetuates the trauma PTSD sufferers endure, making recovery more difficult. 

“We must most of all help our patients to live fully and securely in the present.” 

Van der Kolk firmly believes that treating patients with trauma means more than simply throwing medications at their surface symptoms. He understands that treatment must address the root issue, looking at patients as people rather than “disorders,” and helping them learn to take their lives back.  

“[A]lmost all mental suffering involves either trouble in creating workable and satisfying relationships or difficulties in regulating arousal (as in the case of habitually becoming enraged, shut down, overexcited, or disorganized).” 

As he builds his case for approaching trauma, van der Kolk explains that most mental illnesses are more than just "disorders" stemming from chemical imbalances. Rather, an inability to manage oneself and/or one's relationships with others can have serious repercussions on overall mental health. Ignoring that means treating symptoms, not the underlying cause, which does traumatized patients a disservice.

“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 […] panic symptoms are maintained largely because the individual develops a fear of the bodily sensations associated with panic attacks.” 

While trauma causes a shift in the mind of the person affected, it also has a profound effect on the body. Traumatized people frequently lose the ability to interpret the sensations in their bodies. This lack of self-knowledge causes panic, which can perpetuate trauma or even make it worse. 

“Kids will go to almost any length to feel seen and connected.” 

Van der Kolk places particular emphasis on abused and neglected children, noting that their need for connection is especially important. Many childhood behaviors characterized as “acting out” are just manifestations of a desire to connect—the child simply doesn’t know a better way. 

“If you have no internal sense of security, it is difficult to distinguish between safety and danger. If you feel chronically numbed out, potentially dangerous situations may make you feel alive. If you conclude that you must be a terrible person […] you start expecting other people to treat you horribly.” 

Traumatized people tend to be retraumatized or repeat patterns of trauma. These patterns are particularly likely (and dangerous) for traumatized children, who have no reference point for a time before their trauma when they felt safe. Van der Kolk lays out how a person repeats patterns based on how they were treated growing up. 

“Her immune system, her muscles, and her fear system all had kept the score, but her conscious mind lacked a story that could communicate the experience.” 

Van der Kolk makes clear that repressed memories are real and have scientific basis, even if some deny their existence. He illustrates this through the story of Marilyn, who, despite claiming she had a happy childhood, unconsciously draws a horrifying family portrait that suggests significant sexual abuse and terror as a child. Though she could not consciously acknowledge what had happened, her body had held onto the experience well into adulthood. 

“Children are programmed to be fundamentally loyal to their caretakers, even if they are abused by them. Terror increases the need for attachment, even if the source of comfort is also the source of terror.” 

Van der Kolk stresses repeatedly how terrible and lasting childhood trauma is. One of the mechanisms that makes child abuse so awful is that children are unable to distance themselves from the people who take care of them. This often prevents children from telling anyone about the abuse they are suffering, which prevents them from receiving much-needed help. 

“I concluded that, if you carry a memory of having felt safe with somebody long ago, the traces of that earlier affection can be reactivated in attuned relationships when you are an adult […] However, if you lack a deep memory of feeling loved and safe, the receptors in the brain that respond to human kindness may simply fail to develop.” 

Those who experience trauma in early childhood arguably suffer more than many of those who suffer trauma as adults, because one of the key factors in whether someone can overcome trauma is having a memory, however remote, of having once been safe. For children who have never felt safe, overcoming trauma means having to learn how to feel safe first after years of development without that feeling. 

“To this day, after twenty years and four subsequent revisions, the DSM and the entire system based on it fail victims of child abuse and neglect—just as they ignored the plight of veterans before PTSD was introduced back in 1980.” 

On multiple occasions, those in charge of the DSM rejected new diagnosis categories that van der Kolk and his colleagues developed to create classifications for those with non-PTSD type trauma and specifically childhood traumas. Without a DSM diagnosis code, therapists cannot properly classify victims of child abuse and help them—all they can do is misclassify and medicate them. 

“Oddly, the lack of reliability and validity did not keep the DSM-V from meeting its deadline for publication, despite the near-universal consensus that it represented no improvement over the previous diagnostic system. Could the fact that the APA had earned $100 million (because all mental health practitioners, many lawyers, and other professionals will be obliged to purchase the latest edition) be the reason we have this new diagnostic system?” 

Van der Kolk’s criticisms of the DSM go beyond its refusal to acknowledge much-needed new diagnosis categories. He points out that the new revisions do not add anything of value to the field, but do generate considerable income for the APA. In van der Kolk’s view, those who publish the DSM are motivated by money, not by an interest in helping people who need help. 

“Economists have calculated that every dollar invested in high-quality home visitation, day care, and preschool programs results in seven dollars of savings on welfare payments, health-care costs, substance-abuse treatment, and incarceration, plus higher tax revenues due to better-paying jobs.” 

Childhood trauma is not only a terrible reality; it is a threat to the economy. If society spent more money on preventing trauma in children, there would be significantly less money spent on treatments for the traumatized. 

“Dissociation prevents the trauma from becoming integrated within the conglomerated, ever-shifting stories of autobiographical memory, in essence creating a dual-memory system.” 

Dissociation is a key component of trauma, which fractures the brain into pieces rather than a coherent whole. Unlike in normal memory, where every experience is integrated into a whole, traumatic memory stays locked, making someone feel as if their trauma is perpetually happening in the present, alongside their actual present. 

“How can doctors, police officers, or social workers recognize that someone is suffering from traumatic stress as long as he reenacts rather than remembers?” 

Van der Kolk describes traumatic memory as reenacting because for a traumatized person, their trauma perpetually feels as though it’s happening, which leads people to exhibit odd or inappropriate behaviors because they are unaware of where, or when, they are. Only by learning about people who might commit crimes or engage in odd behavior can we understand what they might be experiencing to make them behave the way they do. 

“The fundamental problem is this: Events that take place is the laboratory cannot be considered equivalent to the conditions under which traumatic memories are created.” 

Van der Kolk has spent much of his career fighting for appropriate diagnosis categories and treatment methods for traumatized individuals. Here he explains part of his frustration with the psychiatric field’s insistence on “verifiable” testing methods—there is simply no way to reproduce trauma in a laboratory for study. 

“We all want to live in a world that is safe, manageable, and predictable, and victims remind us that this is not always the case.” 

Van der Kolk explains why so many people seem to resist changing their attitudes about trauma or even deny that it really exists—it makes them uncomfortable. 

“Like a splinter that causes an infection, it is the body’s response to the foreign object that becomes the problem more than the object itself.” 

Throughout the text, van der Kolk describes trauma in many different ways. This quote offers an especially succinct and easy to understand definition of how trauma works. The traumatic event is the “splinter” and the subsequent change in the brain and body are the response. 

“People who feel safe and meaningfully connected with others have little reason to squander their lives doing drugs or staring numbly at television; they don’t feel compelled to stuff themselves with carbohydrates or assault their fellow human beings.” 

Many addictions and destructive habits start as ways of escaping situations and feelings that feel inescapable. Preventative measures that help people connect with themselves and others—and therefore feel less trapped—could reduce the number of people who engage in unsafe or unhealthy practices. Society would be better off for it.