Great Throughts Treasury

This site is dedicated to the memory of Dr. Alan William Smolowe who gave birth to the creation of this database.

Bessel van der Kolk

Dutch Psychiatrist and Pioneering Post-Traumatic Stress Disorder (PTSD) Researcher

"Psychiatry, as a subspecialty of medicine, aspires to define mental illness as precisely as, let?s say, cancer of the pancreas, or streptococcal infection of the lungs. However, given the complexity of mind, brain, and human attachment systems, we have not come even close to achieving that sort of precision. Understanding what is wrong with people currently is more a question of the mind-set of the practitioner (and of what insurance companies will pay for) than of verifiable, objective facts."

"A further step is to observe the interplay between your thoughts and your physical sensations. How are particular thoughts registered in your body? (Do thoughts like ?My father loves me? or ?my girlfriend dumped me? produce different sensations?) Becoming aware of how your body organizes particular emotions or memories opens up the possibility of releasing sensations and impulses that you may have learned gto block in order to survive."

"After an acute trauma, like an assault, accident, or natural disaster, survivors require the presence of familiar people, faces, and voices; physical contact; food; shelter and a safe place; and time to sleep. It is critical to communicate with loved ones close and far and to reunite as soon as possible with family and friends in a place that feels safe. Our attachment bonds are our greatest protection against threat. For example, children who are separated from their parents after a traumatic event are likely to suffer serious negative long- term effects. Studies conducted during World War II in England showed that children who lived in London during the Blitz and were sent away to the countryside for protection against German bombing raids fared much worse than children who remained with their parents and endured nights in bomb shelters and frightening images of destroyed buildings and dead people."

"A secure attachment combined with the cultivation of competency builds an internal locus of control, the key factor in healthy coping throughout life. Securely attached children learn what makes them feel good; they discover what makes them (and others) feel bad, and they acquire a sense of agency: that their actions can change how they feel and how others respond. Securely attached kids learn the difference between situations they can control and situations where they need help. They learn that they can play an active role when faced with difficult situations. In contrast, children with histories of abuse and neglect learn that their terror, pleading, and crying do not register with their caregiver. Nothing they can do or say stops the beating or brings attention and help. In effect they?re being conditioned to give up when they face challenges later in life."

"As long as you keep secrets and suppress information, you are fundamentally at war with yourself?The critical issue is allowing yourself to know what you know. That takes an enormous amount of courage."

"After conducting numerous studies of medications for PTSD, I have come to realize that psychiatric medications have a serious downside, as they may deflect attention from dealing with the underlying issues. 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. Over the past three decades, psychiatric medications have become a mainstay in our culture, with dubious consequences. Consider the case of antidepressants. If they were indeed as effective as we have been led to believe, depression should by now have become a minor issue in our society. Instead, even as antidepressant use continues to increase, it has not made a dent in hospital admissions for depression. The number of people treated for depression has tripled over the past two decades, and one in ten Americans now take antidepressants."

"Agency starts with what scientists call interoception, our awareness of our subtle sensory, body-based feelings: the greater that awareness, the greater our potential to control our lives. Knowing what we feel is the first step to knowing why we feel that way. If we are aware of the constant changes in our inner and outer environment, we can mobilize to manage them."

"After trauma the world is experienced with a different nervous system. The survivor?s energy now becomes focused on suppressing inner chaos, at the expense of spontaneous involvement in their lives. These attempts to maintain control over unbearable physiological reactions can result in a whole range of physical symptoms, including fibromyalgia, chronic fatigue, and other autoimmune diseases. This explains why it is critical for trauma treatment to engage the entire organism, body, mind, and brain."

"All too often, however, drugs such as Abilify, Zyprexa, and Seroquel, are prescribed instead of teaching people the skills to deal with such distressing physical reactions. Of course, medications only blunt sensations and do nothing to resolve them or transform them from toxic agents into allies."

"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."

"As I discussed in the previous chapter, attachment researchers have shown that our earliest caregivers don't only feed us, dress us, and comfort us when we are upset; they shape the way our rapidly growing brain perceives reality. Our interactions with our caregivers convey what is safe and what is dangerous: whom we can count on and who will let us down; what we need to do to get our needs met. This information is embodied in the warp and woof of our brain circuitry and forms the template of how we think of ourselves and the world around us. These inner maps are remarkably stable across time. This doesn?t mean, however, that our maps can?t be modified by experience. A deep love relationship, particularly during adolescence, when the brain once again goes through a period of exponential change, truly can transform us. So can the birth of a child, as our babies often teach us how to love. Adults who were abused or neglected as children can still learn the beauty of intimacy and mutual trust or have a deep spiritual experience that opens them to a larger universe. In contrast, previously uncontaminated childhood maps can become so distorted by an adult rape or assault that all roads are rerouted into terror or despair. These responses are not reasonable and therefore cannot be changed simply by reframing irrational beliefs."

"As I often tell my students, the two most important phrases in therapy, as in yoga, are Notice that and What happens next? Once you start approaching your body with curiosity rather than with fear, everything shifts."

"As we have seen, much the wiring of our brain circuits is devoted to being in tune with others. Recovery from trauma involves (re)connecting with our fellow human beings. This is why trauma that has occurred within relationships is generally more difficult to treat than trauma resulting from traffic accidents or natural disasters. In our society the most common traumas in women and children occur at the hands of their parents or intimate partners. Child abuse, molestation, and domestic violence all are inflicted by people who are supposed to love you. That knocks out the most important protection against being traumatized: being sheltered by the people you love."

"Because drugs have become so profitable, major medical journals rarely publish studies on nondrug treatments of mental health problems.31 Practitioners who explore treatments are typically marginalized as alternative. Studies of nondrug treatments are rarely funded unless they involve so-called manualized protocols, where patients and therapists go through narrowly prescribed sequences that allow little fine-tuning to individual patients? needs. Mainstream medicine is firmly committed to a better life through chemistry, and the fact that we can actually change our own physiology and inner equilibrium by means other than drugs is rarely considered."

"Because humans are meaning-making creatures, we have a tendency to create some sort of image or story."

"Because most of these patients suffered from alexithymia, it was not easy for them to report their response to the treatments. But their actions spoke for them: They consistently showed up on time for their appointments, even if they had to drive through snowstorms. None of them dropped out, and at the end of the full twenty sessions, we could document significant improvements not only in their PTSD scores,10 but also in their interpersonal comfort, emotional balance, and self-awareness.11 They were less frantic, they slept better, and they felt calmer and more focused. In any case, self-reports can be unreliable; objective changes in behavior are much better indicators of how well treatment works."

"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 seemingly unbearable sensations: They feel heartbroken and suffer from intolerable sensations in the pit of their stomach or tightness in their chest. Yet avoiding feeling these sensations in our bodies 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. Mindfulness puts us in touch with the transitory nature of our feelings and perceptions. When we pay focused attention to our bodily sensations, we can recognize the ebb and flow of our emotions and, with that, increase our control over them."

"Being traumatized means continuing to organize your life as if the trauma were still going on?unchanged and immutable?as every new encounter or event is contaminated by the past."

"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."

"But the nature of our trauma is that you actually have no recollection for it as a story in a way. Many victims over time get to tell a story to explain why they are so messed up. But the nature of a traumatic experience is that the brain doesn't allow a story to be created and here you have an interesting paradox that it's normal to distort your memories. Like, you know, I'm one out of five kids, when we have a family reunion, we all tell stories about our own childhood and everybody always listens to everybody else's stories. Did he grow up in the same family as I did?"

"Because traumatized people often have trouble sensing what is going on in their bodies, they lack a nuanced response to frustration. They either react to stress by becoming spaced out or with excessive anger. Whatever their response, they often can?t tell what is upsetting them. This failure to be in touch with their bodies contributes to their well-documented lack of self-protection and high rates of revictimization23 and also to their remarkable difficulties feeling pleasure, sensuality, and having a sense of meaning. People with alexithymia can get better only by learning to recognize the relationship between their physical sensations and their emotions, much as colorblind people can only enter the world of color by learning to distinguish and appreciate shades of gray."

"Beneath the surface of the protective parts of trauma survivors there exists an undamaged essence, a Self that is confident, curious, and calm, a Self that has been sheltered from destruction by the various protectors that have emerged in their efforts to ensure survival. Once those protectors trust that it is safe to separate, the Self will spontaneously emerge, and the parts can be enlisted in the healing process"

"Children who don?t feel safe in infancy have trouble regulating their moods and emotional responses as they grow older. By kindergarten, many disorganized infants are either aggressive or spaced out and disengaged, and they go on to develop a range of psychiatric problems.23 They also show more physiological stress, as expressed in heart rate, heart rate variability,24 stress hormone responses, and lowered immune factors.25 Does this kind of biological dysregulation automatically reset to normal as a child matures or is moved to a safe environment? So far as we know, it does not."

"Consensus Proposed Criteria For Developmental Trauma Disorder A. Exposure. The child or adolescent has experienced or witnessed multiple or prolonged adverse events over a period of at least one year beginning in childhood or early adolescence, including: A. 1. Direct experience or witnessing of repeated and severe episodes of interpersonal violence; and A. 2. Significant disruptions of protective caregiving as the result of repeated changes in primary caregiver; repeated separation from the primary caregiver; or exposure to severe and persistent emotional abuse B. Affective and Physiological Dysregulation. The child exhibits impaired normative developmental competencies related to arousal regulation, including at least two of the following: B. 1. Inability to modulate, tolerate, or recover from extreme affect states (e.g., fear, anger, shame), including prolonged and extreme tantrums, or immobilization B. 2. Disturbances in regulation in bodily functions (e.g. persistent disturbances in sleeping, eating, and elimination; over-reactivity or under-reactivity to touch and sounds; disorganization during routine transitions) B. 3. Diminished awareness/dissociation of sensations, emotions and bodily states B. 4. Impaired capacity to describe emotions or bodily states C. Attentional and Behavioral Dysregulation: The child exhibits impaired normative developmental competencies related to sustained attention, learning, or coping with stress, including at least three of the following: C. 1. Preoccupation with threat, or impaired capacity to perceive threat, including misreading of safety and danger cues C. 2. Impaired capacity for self-protection, including extreme risk-taking or thrill-seeking C. 3. Maladaptive attempts at self-soothing (e.g., rocking and other rhythmical movements, compulsive masturbation) C. 4. Habitual (intentional or automatic) or reactive self-harm C. 5. Inability to initiate or sustain goal-directed behavior D. Self and Relational Dysregulation. The child exhibits impaired normative developmental competencies in their sense of personal identity and involvement in relationships, including at least three of the following: D. 1. Intense preoccupation with safety of the caregiver or other loved ones (including precocious caregiving) or difficulty tolerating reunion with them after separation D. 2. Persistent negative sense of self, including self-loathing, helplessness, worthlessness, ineffectiveness, or defectiveness D. 3. Extreme and persistent distrust, defiance or lack of reciprocal behavior in close relationships with adults or peers D. 4. Reactive physical or verbal aggression toward peers, caregivers, or other adults D. 5. Inappropriate (excessive or promiscuous) attempts to get intimate contact (including but not limited to sexual or physical intimacy) or excessive reliance on peers or adults for safety and reassurance D. 6. Impaired capacity to regulate empathic arousal as evidenced by lack of empathy for, or intolerance of, expressions of distress of others, or excessive responsiveness to the distress of others E. Posttraumatic Spectrum Symptoms. The child exhibits at least one symptom in at least two of the three PTSD symptom clusters B, C, & D. F. Duration of disturbance (symptoms in DTD Criteria B, C, D, and E) at least 6 months. G. Functional Impairment. The disturbance causes clinically significant distress or impairment in at least two of the following areas of functioning: Scholastic Familial Peer Group Legal Health Vocational (for youth involved in, seeking or referred for employment, volunteer work or job training)"

"Dave?s visit eventually grew into a very active yoga program, and in due course we received the first grant from the National Institutes of Health to study the effects of yoga on PTSD. Dave?s work also contributed to my developing my own regular yoga practice and becoming a frequent teacher at Kripalu, a yoga center in the Berkshire Mountains in western Massachusetts. (Along the way, my own HRV pattern improved as well.)"

"Damasio starts by pointing out the deep divide between our sense of self and the sensory life of our bodies. As he poetically explains, ?Sometimes we use our minds not to discover facts, but to hide them. . . . One of the things the screen hides most effectively is the body, our own body, by which I mean the ins of it, its interiors. Like a veil thrown over the skin to secure its modesty, the screen partially removes from the mind the inner states of the body, those that constitute the flow of life as it wanders in the journey of each day.?"

"Dissociation is adaptive: it allows relatively normal functioning for the duration of the traumatic event and then leaves a large part of the personality unaffected by the trauma."

"Dr. Spencer Eth, who ran the psychiatry department at the now-defunct St. Vincent?s Hospital in Greenwich Village, was curious where survivors had turned for help, and early in 2002, together with some medical students, he conducted a survey of 225 people who had escaped from the Twin Towers. Asked what had been most helpful in overcoming the effects of their experience, the survivors credited acupuncture, massage, yoga, and EMDR, in that order.1 Among rescue workers, massages were particularly popular."

"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."

"Despite the well-documented effects of anger, fear, and anxiety on the ability to reason, many programs continue to ignore the need to engage the safety system of the brain before trying to promote new ways of thinking. The last things that should be cut from school schedules are chorus, physical education, recess, and anything else involving movement, play, and joyful engagement. 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."

"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.37"

"Eighty two percent of the traumatized children seen in the National Child Traumatic Stress Network do not meet diagnostic criteria for PTSD.15 Because they often are shut down, suspicious, or aggressive they now receive pseudoscientific diagnoses such as oppositional defiant disorder, meaning This kid hates my guts and won?t do anything I tell him to do, or disruptive mood dysregulation disorder, meaning he has temper tantrums. Having as many problems as they do, these kids accumulate numerous diagnoses over time. Before they reach their twenties, many patients have been given four, five, six, or more of these impressive but meaningless labels. If they receive treatment at all, they get whatever is being promulgated as the method of management du jour: medications, behavioral modification, or exposure therapy. These rarely work and often cause more damage."

"Feeling out of control, survivors of trauma often begin to fear that they are damaged to the core and beyond redemption."

"EMDR is a bizarre and wondrous treatment and anybody who first hears about it, myself included, thinks this is pretty hokey and strange. It's something invented by Francine Shapiro who found that, if you move your eyes from side to side as you think about distressing memories, that the memories lose their power. And because of some experiences, both with myself, but even more with the patients of mine who told me about their experiences, I took a training in it. It turned out to be incredibly helpful. Then I did what's probably the largest NIH-funded study on EMDR. And we found that, of people with adult-onset traumas, a one-time trauma as an adult, that it had the best outcome of any treatment that has been published. What's intriguing about EMDR is both how well it works and the question is how it works and that got me into this dream stuff that I talked about earlier, and how it does not work through figuring things out and understanding things. But it activates some natural processes in the brain that's helped you to integrate these past memories."

"For many people the war begins at home: Each year about three million children in the United States are reported as victims of child abuse and neglect. One million of these cases are serious and credible enough to force local child protective services or the courts to take action.12 In other words, for every soldier who serves in a war zone abroad, there are ten children who are endangered in their own homes. This is particularly tragic, since it is very difficult for growing children to recover when the source of terror and pain is not enemy combatants but their own caretakers."

"Frewen and his colleague Ruth Lanius found that the more people were out of touch with their feelings, the less activity they had in the self-sensing areas of the brain.22 Because traumatized people often have trouble sensing what is going on in their bodies, they lack a nuanced response to frustration. They either react to stress by becoming spaced out or with excessive anger. Whatever their response, they often can?t tell what is upsetting them. This failure to be in touch with their bodies contributes to their well-documented lack of self-protection and high rates of revictimization23 and also to their remarkable difficulties feeling pleasure, sensuality, and having a sense of meaning."

"For a hundred years or more, every textbook of psychology and psychotherapy has advised that some method of talking about distressing feelings can resolve them. However, as we?ve seen, the experience of trauma itself gets in the way of being able to do that. 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. I am continually impressed by how difficult it is for people who have gone through the unspeakable to convey the essence of their experience. It is so much easier for them to talk about what has been done to them?to tell a story of victimization and revenge?than to notice, feel, and put into words the reality of their internal experience. Our scans had revealed how their dread persisted and could be triggered by multiple aspects of daily experience. They had not integrated their experience into the ongoing stream of their life. They continued to be there and did not know how to be here?fully alive in the present."

"Generally the rational brain can override the emotional brain, as long as our fears don?t hijack us. (For example, your fear at being flagged down by the police can turn instantly to gratitude when the cop warns you that there?s an accident ahead.) But the moment we feel trapped, enraged, or rejected, we are vulnerable to activating old maps and to follow their directions. Change begins when we learn to own our emotional brains. That means learning to observe and tolerate the heartbreaking and gut-wrenching sensations that register misery and humiliation. Only after learning to bear what is going on inside can we start to befriend, rather than obliterate, the emotions that keep our maps fixed and immutable."

"Games like Simon Says lead to lots of sniggering and giggling?signs of safety and relaxation. When teenagers balk at these stupid games, we nod understandingly and enlist their cooperation by asking them to demonstrate games to the little kids, who need their help."

"How did his brain come to derive comfort from fishing rather than from compulsive sexual behavior? At this point we simply don?t know. Neurofeedback changes brain connectivity patterns; the mind follows by creating new patterns of engagement."

"Healing, he told us, depends on experiential knowledge: You can be fully in charge of your life only if you can acknowledge the reality of your body, in all its visceral dimensions."

"However, traumatized people chronically feel unsafe inside their bodies: The past is alive in the form of gnawing interior discomfort. Their bodies are constantly bombarded by visceral warning signs, and, in an attempt to control these processes, they often become expert at ignoring their gut feelings and in numbing awareness of what is played out inside. They learn to hide from their selves. The more people try to push away and ignore internal warning signs, the more likely they are to take over and leave them bewildered, confused, and ashamed. 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."

"I discovered that my professional training, with its focus on understanding and insight, had largely ignored the relevance of the living, breathing body, the foundation of our selves."

"How many mental health problems, from drug addiction to self-injurious behavior, start as attempts to cope with the unbearable physical pain of our emotions? If Darwin was right, the solution requires finding ways to help people alter the inner sensory landscape of their bodies. Until recently, this bidirectional communication between body and mind was largely ignored by Western science, even as it had long been central to traditional healing practices in many other parts of the world, notably in India and China. Today it is transforming our understanding of trauma and recovery."

"I remember him saying: The greatest sources of our suffering are the lies we tell ourselves."

"I cut myself up really badly with the lid of a tin can. They took me to the emergency room, but I couldn?t tell the doctor what I had done to cut myself?I didn?t have any memory of it. The ER doctor was convinced that dissociative identity disorder didn?t exist. . . . A lot of people involved in mental health tell you it doesn?t exist. Not that you don?t have it, but that it doesn?t exist."

"I didn't practice yoga myself and then we saw all these abnormalities in people's heart rate, their breathing patterns, the way they relate to their bodies. It was very clear that their bodies were on fire, their bodies felt deeply unsafe, so the enemy that was once living outside was now living within. And you need to befriend your body, you need to calm your body down."

"I vividly remember a videotape Beatrice Beebe showed me.28 It featured a young mother playing with her three-month-old infant. Everything was going well until the baby pulled back and turned his head away, signaling that he needed a break. But the mother did not pick up on his cue, and she intensified her efforts to engage him by bringing her face closer to his and increasing the volume of her voice. When he recoiled even more, she kept bouncing and poking him. Finally he started to scream, at which point the mother put him down and walked away, looking crestfallen. She obviously felt terrible, but she had simply missed the relevant cues. It?s easy to imagine how this kind of misattunement, repeated over and over again, can gradually lead to a chronic disconnection. (Anyone who?s raised a colicky or hyperactive baby knows how quickly stress rises when nothing seems to make a difference.) Chronically failing to calm her baby down and establish an enjoyable face-to-face interaction, the mother is likely to come to perceive him as a difficult child who makes her feel like a failure, and give up on trying to comfort her child."

"I think trauma really does confront you with the best and the worst. You see the horrendous things that people do to each other, but you also see resiliency, the power of love, the power of caring, the power of commitment, the power of commitment to oneself, the knowledge that there are things that are larger than our individual survival. And in some ways, I don't think you can appreciate the glory of life unless you also know the dark side of life."

"I was fascinated to learn that a group of neuroscientists at the University of Geneva had induced similar out-of-body experiences by delivering mild electric current to a specific spot in the brain, the temporal parietal junction. In one patient this produced a sensation that she was hanging from the ceiling, looking down at her body; in another it induced an eerie feeling that someone was standing behind her. This research confirms what our patients tell us: that the self can be detached from the body and live a phantom existence on its own."