The Body Keeps the Score is divided into two parts.
The first part of the book examines the brain's and body's physical response to trauma. There are essentially two kinds of trauma: the sustained, multiple traumas of childhood abuse and neglect, and adult trauma from a specific event. Many people, of course, survive multiple traumas, as both children and adults.
For me, this part of the book was absolutely revelatory. Bessel van der Kolk explains the neuroscience of trauma -- and the many scientific studies and clinical observations that have led to this understanding -- in clear, plain language, using lots of analogies and examples. I am not a fast reader, and I struggle with poor concentration from fibromyalgia, but I tore through the first part of this book.
I already knew that trauma changes the brain, but my knowledge was general and a bit vague. For example, I knew that people a traumatic event can produce permanent changes in the body's so-called fight-or-flight response. With PTSD, our bodies can be in a state of permanent emergency. The Body Keeps the Score expanded and refined my knowledge of this tremendously, especially the connection between that perceived state of emergency and physical issues -- gastrointenstinal issues, fibromyalgia, chronic fatigue, chronic pain, and other issues.
The second part of the book introduces readers to "paths to recovery" -- various types of therapies and therapeutic activities that have proven to be effective with trauma survivors, some remarkably so. For each modality, van der Kolk gives you real-life examples, the results of studies, and the neuroscience behind the results -- why the activity helps, how it works on the brain. Many of the therapies are unconventional and surprising but the documented results are unmistakable.
These paths to recovery include EMDR (which I've written about a bit on my fibromyalgia blog), psychomotor therapy, neuro-feedback, yoga-based therapy, and trauma-informed theatre workshops, and group singing, among others.
This is not advice that, for example, exercise or yoga makes you feel better. That may or may not be true, but van der Kolk writes about therapeutic yoga taught by instructors with a deep understanding of trauma and PTSD.
There is a lot of science in this book, but if you're not generally a science reader, don't let that stop you. The author is amazingly skilled at weaving together his own clinical observations and case histories with the neuroscience. His voice is warm and friendly, and his writing is highly readable.
The profound disappointment: the rejection of the Developmental Trauma diagnosis
The Body Keeps the Score is also a bitter, severe, profoundly discouraging -- and, it seems, entirely justified -- critique of the psychiatric establishment. Van der Kolk is a medical doctor, a psychiatrist, and he's not opposed to the use of medication to treat mental illness. But he demonstrates the tendency of his profession to over-prescribe medications as an expedient and profitable approach, with results generally no better than a short-term band-aid.
I was especially struck by a laundry-list of diagnoses that are doled out to children, while the root cause -- abuse -- is overlooked. Hyperactivity/Attention Deficit Disorder, Oppositional Defiant Disorder, Conduct Disorder, Obsessive-Compulsive Disorder, and several others are treated as causes rather than effects -- secondary conditions stemming from trauma.
One of van der Kolk's greatest disappointments has been the psychiatric establishment's refusal to include a diagnosis of Development Trauma Disorder in the hallowed DSM. (I assume readers know what the DSM is, and something about its troubling history.) Because children's brains are still developing, trauma has an extreme and long-term influence on their ability to cope with the world around them. Developmental trauma, as van der Kolk convincingly demonstrates, occurs when a child's brain does not develop properly, as a result of sustained childhood trauma.
[There is something about van der Kolk's quest for this official diagnosis here, here, and here. One of van der Kolk's proposals can be seen here.)
The absence of this diagnosis is catastrophic, as funding, research, treatment, and insurance coverage largely depends on DSM definitions. Van der Kolk and his more enlightened colleagues have continued their work despite the DSM exclusion, training other colleagues and opening trauma centres (mental health facilities with programs informed by the understanding of Development Trauma) wherever possible.
But in The Body Keeps the Score, van der Kolk makes clear that without the DSM diagnosis, this work -- always an uphill battle -- will be severely restricted.
The social determinants of trauma, and mental health
The book ends with an impassioned plea about the social determinants of trauma.
Poverty breeds trauma and trauma breeds poverty. People who were abused and neglected during childhood grow up with little or no emotional resiliency. They can't finish school, can't get and keep decent employment. They are in unstable and violent relationships, they drink and drug heavily, they are compulsively drawn to dangerous situations, they are incarcerated. If they have children they are likely to continue the cycle of neglect and/or abuse. (I have read only one other book that draws a link between child sexual abuse and poverty, David K Shipler's The Working Poor.)
From the epilogue [all emphasis mine].
...We know not only how to treat trauma but also, increasingly, how to prevent it.In the "paths to recovery" section, van der Kolk writes about a successful therapeutic theatre program with high school students in Boston. It reminded me of how much I used to love working with teens in a nontraditional learning environment. And when his team tried to introduce this to the public schools they were met with a "wall of bureaucratic resistance" -- and that is familiar to me, too.
And yet, after attending another wake for a teenager who was killed in a drive-by shooting in the Blue Hill Avenue section of Boston or after reading about the latest school budget cuts in impoverished cities and towns, I find myself close to despair. In many ways we seem to be regressing, with measures like the callous congressional elimination of food stamps for kids whose parents are unemployed or in jail; with the stubborn opposition to universal health care in some quarters; with psychiatry's obtuse refusal to make connection between psychic suffering and social conditions; with the refusal to prohibit the sale or possession of weapons whose only purpose is to kill larger numbers of human beings; and with our tolerance for incarcerating a huge segment of our population, wasting their lives as well as our resources.
Discussions of PTSD still tend to focus on recently returned soldiers, victims of terrorist bombings, or survivors of terrible accidents. But trauma remains a much larger public health issue, arguably the greatest threat to our national well-being. Since 2001 far more Americans have died at the hands of their partners or other family members than in the wars in Iraq and Afghanistan. American women are twice as likely to suffer domestic violence as breast cancer. . . .
When I give presentations on trauma and trauma treatment, participants sometimes ask me to leave out the politics and confine myself to talking about neuroscience and therapy. I wish I could separate trauma from politics, but as long as we continue to live in denial and treat only trauma while ignoring its origins, we are bound to fail. In today's world your zip code, even more than your genetic code, determines whether you will lead a safe and healthy life. People's income, family structure, housing , employment, and educational opportunities affect not only their risk of developing traumatic stress abut also their access to effective help to address it. . . .
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. However, if nothing they do seems to make a difference, they feel trapped and become susceptible to the lure of pills, gang leaders, extremist religions, or violent political movements -- anybody and anything that promises relief. As the ACE study has shown, child abuse and neglect is the single most preventable cause of mental illness, the single most common cause of drug and alcohol abuse, and a significant contributor to leading causes of death such as diabetes, heart disease, cancer, stroke, and suicide.
Van der Kolk's voice is warm, compassionate, and engaging. I love how he sees his patients as his greatest teachers. Although he has multiple degrees and designations, and his work is grounded in hard science, he believes he has learned the most through clinical observation.
Although the stories of child abuse and neglect are horrifying, a shining thread of optimism runs through the book. Using many of the creative therapies that van der Kolk writes about, people who have endured the most extreme childhoods have found peace, and learned how to live their lives with love and joy.
Read an excerpt here.
I've never included blurbs in a book review before, but some of the dozens of raves about this book help explain it better than I can.
In this inspirational work which seamlessly weaves keen clinical observation, neuroscience, historical analysis, the arts, and personal narrative, Dr. van der Kolk has created an authoritative guide to the effects of trauma and pathways to recovery. The book is full of wisdom, humanity, compassion, and scientific insight, gleaned from a lifetime of clinical service, research, and scholarship in the field of traumatic stress. A must-read for mental health and other health care professionals, trauma survivors, their loved ones, and those who seek clinical, social or political solutions to the cycle of trauma and violence in our society.
-- Rachel Yehuda, Ph.D., professor of psychiatry and neuroscience; director of the traumatic stress studies division at the Mount Sinai School of Medicine, New York
Every once in a while, a book comes along that fundamentally changes the way we look at the world. Bessel van der Kolk has written such a book. The arc of van der Kolk's sory is vast and comprehensive, but he is such a skillful storyteller that he keeps us riveted to the page. I could not put this book down. It is, simply put, a great work.
-- Stephen Cope, founder and director, Kripalu Institute for Extraordinary Living, author of Yoga and the Quest for the True Self
Dr. van der Kolk's masterpiece combines the boundless curiosity of the scientist, the erudition of the scholar, and the passion of the truth teller.
-- Judith Herman, MD, clinical professor of psychiatry, Harvard Medical School, author of Trauma and Recovery
This is a masterpiece of powerful understanding and brave heartedness, one of the most intelligent and helpful works on trauma I have ever read. Dr. van der Kolk offers a brilliant synthesis of clinical case, neuroscience, powerful tools, and caring humanity, offering a whole new level of healing for the traumas carried by so many.
-- Jack Kornfield, author of A Path with Heart
The Body Keeps the Score is masterful in bringing together science and humanism to clearly explain how trauma affects the whole person. Bessel van der Kolk brings deep understanding to the pain and chaos of the trauma experience. The treatment approaches he recommends heal the body and the mind, restoring hope, and the possibility of joy. One reads this book with profound gratitude for its wisdom.
-- Alicia Lieberman, Ph.D. professor of medical psychology UCSF, director of the Child Trauma Research Project, San Francisco General Hospital; author of the The Emotional Life of the Toddler
I was going to include a section in this post with some personal insights and connections that this book raised for me, but I've decided to write those in a separate post.