The Body Keeps The Score, by Bessel van der Kolk

Last updated on 

Trauma is "the biggest public health problem in America", way more common than people realise, and often long-lasting. Trauma lives in the body.

The title of this book has become a catchphrase, and I agree with it and believe in it -- I think one of the great mistakes of the first 25 years of my life was to think I could exist entirely in the mind, and to misunderstand how interrelated the body and the mind are. I also agree with the core premise that trauma is a massively important and still-underrated way to understand a lot of our lives and therefore a lot of what happens in society. Many of my friends have also read the book, and it has created a really helpful conceptual touchstone that we reference to each other -- it functions both as a kind of secret password to the treehouse, a way of identifying other people who also want to talk about trauma, but also just as a really quick check-in about whether some experience someone is having might also be a trauma response.

However... actually reading this book, for me, was like pulling teeth. It took me more than a year to finish it, I found it incredibly slow going and don't honestly remember most of van der Kolk's points, even though some were very good. I want to say a much shorter, better-edited version of this book would do well... but maybe that's not true, maybe this book is successful in part because it's so long and slow. (Also, caveat: maybe this book was more revolutionary when it came out, maybe we've just internalised its ideas, though I was then surprised to realise it came out in 2014).

notes I took from the book:

  • trauma is largely remembered not as a story but as isolated sensory imprints [this seems important, central somehow]
  • trauma is also a kind of sensory overload -- try to shut down by developing tunnel vision and hyperfocus, either internally or through drugs and alcohol. But this comes at the cost of shutting out joy and pleasure too
  • sex (and physical intimacy) requires the ability to allow onself to experience immobilisation without fear -- that is, to correctly identify when you are physically safe. Which for the traumatised requires having experiences that restore the sense of physical safety.
  • Auden: "Truth, like love and sleep, resents approaches that are too intense." [vdK often recommends "pendulumising", that is, moving in and out of talking about someone's trauma, letting them approach and back away again, not trying to do the whole thing immediately]
  • vdK talks to one of his patients and tells her she "shouldn't" feel the way she does.... and then she calls him out for this, says he can't tell her how she should feel, but that for most of her life she would have just accepted it from him, because she was used to submitting to authoritative men! And this seems like a big issue for therapy more generally, and one of those issues that people can claim to acknowledge more easily than they can really do something about.
  • the authors of the DSM refuse to include "childhood interpersonal trauma" (child abuse and neglect) in thier manual, which makes it hard to get funding for research or to develop treatments because "you cannot develop a treatment for a condition that doesn't exist." Therapists are therefore "forced" to diagnose abuse survivors with "depression, panic disorder, bipolar or borderline", which don't address the actual issue. [vdK only talks about this one example, but... surely this speaks to a MUCH bigger problem with the DSM and the psychiatric establishment and maybe all of medicine?]

    [Actually, a doctor-friend once told me that laypeople misunderstand what it means for a condition to be "real": a lot of the time there's a cluster of symptoms, and we know that certain treatments sometimes help those symptoms, and we call that cluster of symptoms "Condition X", but only in the sense of "exhibiting the cluster of symptoms that often responds to this treatment", rather than any etiological knowledge. But it sounds like in this case, per vdK at least, it's the medical establishment that is forcing people into boxes that don't make sense for them?]
  • The American Psychiatric Association pushed through DSM-5, even though the American Journal of Psychiatry itself found that many of the DSM diagnoses lack "reliability" (in the statistical sense) -- "the ability to produce consistent, replicable results"  -- and consensus among psychiatrists was that the DSM-5 was not actually an improvement. Why? Because the APA earned $100m on the DSM-4, and expected the same from DSM-5, because every mental health practitioner and various lawyers etc are obliged to buy it. [I just looked it up and it's priced at $150]. This... shouldn't be legal, right? If there's a book that any set of people are legally required to own, the text should also legally be open-sourced or cost-priced or available for free online or something. Right? Right?
  • "overweight is overlooked, and that's the way I need to be" -- women become overweight in order to protect from abuse and sex. [vdK's broader point: if you mistake someone's solution, e.g. becoming overweight, for a problem that needs to be solved, you're going to have a hard time treating them.]
  • child abuse is "the gravest and most costly public health issue", and eradicating child abuse would reduce the overall rate of depression by half, alcoholism by 2/3rds, and suicide and domestic violence by 3/4. [These are v strong claims, and I don't think they're actually backed up in the text at least]
  • after 9/11, there was an opportunity to try out different approaches of treatment on a "random" set of people. But vdK was on a post 9-11 committee that recommended only two types of therapy: psychoanalysis and CBT. Why these two? Because "Manhattan is one of the last bastions of Freudian psychoanalysis, it would have been bad politics to exclude a substantial proportion of local health practitioners. Why CBT? Because [it] can be broken down into concrete steps and manualised into uniform protocols, it is the favourite treatment of academic researchers, another group who couldn't be ignored." Whatttt is this world we live in? [Almost-nobody used these officially-sanctioned therapies; rescue workers credited massage, as well as acupuncture and yoga etc. Relieving the physical symptoms turns out to be v important. But vdK supposes that it might not actually be that helpful to talk about your trauma, in and of itself.]
  • vdK admits he got into therapy in order to solve some of his own personal issues, and got meaning from hearing people's trauma stories. (He learns this when a colleague accuses him of it during a training session where they'd been practicing on each other. His trainer agrees, and says that vdK should "put his voyeuristic tendency on hold," learn the difference between "your desire to hear stories and your patients' internal process of healing." If he wants to hear trauma stories, vdK should go to a bar and buy people drinks in exchange for their stories).

    So.... it's all very admirable that vdK realises this now, and that he's changed his ways, and teaches this new understanding to his students. But it's BATS that he could get so far into being a therapist without realising this previously, this is so deeply obviously true about so many mental health practitioners, and the idea it hadn't crossed his mind (I think) says bad things about the collective self-awareness of the mental health world.