For a man who was a leading defender of repressed memory syndrome in the early 1990’s, providing expert testimony in a number of high profile cases, Bessel van der Kolk has done remarkably well for himself. No matter that he seems to have lost his lab and his Harvard medical school affiliation as a result (New York Times). Some of the qualities that led him off the deep end of the repressed memory bandwagon have led him to write what an important, but flawed, book on trauma, The Body Keeps the Score (2014).

Van der Kolk (vdK) holds that the real problem with trauma is not in the past. The problem is that trauma keeps the sufferer from feeling alive in the present, and so able to enjoy everyday life. All the desensitization in the world isn’t going to do any good if a person can’t enjoy the everyday pleasures of life. The way to approach trauma is to work from body to mind. If you are traumatized, and talking isn’t helping, and you are picking the scabs on your body as a means of self-stimulation and soothing, go see a massage therapist. And while you do that we will continue to talk (pp. 88-89). This isn’t all he has to say, but it is at the core.

There are problems with vdK’s approach. The reason people become overwhelmed when telling their story, the reason they have flashbacks, is because “their brains have changed.” (p. 246) Ordinarily this is the preface to an irrelevant statement. Of course it is true. Every time I look at something, feel something, or think something, my brain has changed. What vdK in effect ends up saying is that `the reason people become overwhelmed is because their bodies have changed.’ If we can help the body to change itself, the brain changes (of course), and with it one’s entire being. Vitality in everyday life is restored. That, not cognitive understanding, is the goal. Vitality is achieved primarily through the body, in conjunction with talking in a safe atmosphere.

Van der Kolk claims that “our goal in all these efforts is to translate brain science into everyday practice.” (p. 353) There are more than enough references to “brain science” in this longish book. And yet his neuroscience is already out of date. He still holds to the localization of function, and none of the images of the brain, which he loves, were produced with diffusion tensor imaging or diffusion functional MRI (DfMRI), a version of fMRI that allows one to see the active connections among areas of the brain. Instead, he continues to attribute much of the damage of trauma to the much maligned amygdala. “He has a lot of interesting and important ideas, but the relatively weak connection to the brain detracts from his message,” says Joseph LeDoux, a neuroscientist at New York University. “This happens in a lot of fields now. Everybody wants to use the brain to justify certain things. But sometimes what the brain does is more important than how it does it.” (New York Times)

In fact, vdK doesn’t rely on neuroscience as much as he uses it. Instead, he writes that the goal of therapy has nothing to do with accepting that something terrible happened. The goal is to learn how to gain mastery over one’s internal sensations and emotions. This takes body work. It also takes social work. Among his many references to the British Object Relations Theorists, he focuses on their understanding of trauma as a social problem, the failure of community. In doing so, vdK refers to the British Psychological Society’s objection to the DSM 5 for assuming that the sources of trauma are located within individuals, rather than recognizing the “undeniable social causation of many such problems.” (p. 165)

Brain science or relationship science?

By this point, vdK has become something of a wild man within the psychiatric community, suggesting that DSM 5 ignored his group’s suggestion that it include Developmental Trauma Disorder (trauma caused by child abuse and neglect) as an element of PTSD because it wanted to rush the edition into print in order to make a million dollars as quickly as possible (p. 165). But, being a wild man isn’t the same as being a wrong man.

His basic idea, that trauma is a disruption of attunement, adds to the account of trauma as a disruption of attachment to values, beliefs, and people. For in linking attachment with attunement, he includes attunement with the rhythms of one’s own body, such as digestion, heart rate, and blood pressure. And finally attunement with one’s own mind, by which he means the ability to know what one feels, not relying on numbing and dissociation. One cannot help but feel the presence of John Bowlby and D. W. Winnicott, to whom he often refers. This is not brain science. This is relationship science, including the relationship to one’s own body

Yet, there remains problems with vdK’s account. He opens his book with a story about a traumatized Vietnam Veteran who wouldn’t take his pills because his trauma served as a living memorial to his dead buddies. To let go of traumatic memory would be to lose his buddies forever (pp. 9-10). If this is serves as motto to the book, then it is the meaning of the trauma that keeps the score. The body is just the medium.

In this mélange of a book, vdK writes of how war veterans have “cover stories” that explain their symptoms and behavior for public consumption. However, these stories don’t grasp the inner truth of experience. “It is enormously difficult to put traumatic experiences into a coherent account,” one with a beginning, middle, and an end (p. 43). Conversely, the ability to do so is a measure of recovery from trauma.

Yet, if one takes the idea that the body keeps the score seriously, then one must at least consider that every narrative is a cover story, and that the ability to tell a coherent narrative is a misleading measure of recovery from trauma. This would help explain the suicide of such brilliant narrators of Holocaust trauma as Primo Levi and Jean Améry. To tell the story may become a way of not feeling it. Or as Maurice Blanchot put it, the danger is “that the disaster acquire meaning instead of body.” (p. 41) One would think vdK would be more aware of this contradiction. In fact, the book is filled with contradictions because vdK throws everything into the pot.

Mélange

One sees this particularly in the concluding section, where he recommends a variety of treatments, including EMDR (eye movement desensitization and reprocessing), yoga, internal family systems theory (the mind is the internal family), and body psychotherapy, or “trauma drama,” which sounds to me like a version of of Jacob Moreno’s psychodrama from the 1950’s.

The article in The New York Times which featured vdK, along with full color drawings of the distinguished man in relaxed poses, gives an elaborate account of vdK’s body psychotherapy, in which different group members play various roles in the sufferer’s internal life. Eugene had suffered from PTSD for over a decade when he came to vdK’s trauma drama. The member representing the mother of the innocent man he had killed in Iraq forgave him, and Eugene felt much relieved afterward. However, the diligent reporter took the trouble to track Eugene down a couple of months later, and the trauma seemed to have returned. Eugene was now feeling a weird numbness around his eye, and he once-again had to run to the bathroom.

At the time, vdK had wondered aloud if EMDR might have been a better approach with Eugene, unsure whether he had helped him or not. This tells you all you need to know about vdK’s strengths and weaknesses. That vdK could imagine that one session of trauma drama might have helped Eugene seems hopelessly naive. At the same time, vdK knows that nothing has proved terribly effective in treating PTSD, and is willing to try almost anything, but not everything. For example, he dismisses some approaches, such as exposure therapy (when the sufferer is exposed to the traumatic event again and again in order to desensitize him or her) as worse than nothing. About this he seems correct. Providing a safe environment in which to confront trauma is the single most important thing.

Politics of trauma

Van der Kolk is more than willing to take on American psychiatry. Psychiatrists, he says, work in assembly-line offices, dealing with patients they hardly know in fifteen minute segments, doling out pills to relieve pain, anxiety, or depression (p. 349). For vdK, PTSD, with its echoes of repressed memory, is a hidden epidemic. Or as vdK puts it, “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.” (p. 348)

True enough. Van der Kolk is a remarkably eclectic attachment theorist with affinities to British object relations masquerading as a neuroscientist. Not a bad disguise these days, though I doubt if he knows he is wearing one.

References

Maurice Blanchot, The Writing of the Disaster. Lincoln: University of Nebraska Press, 1995.

Interlandi, Janeen (May 22, 2014). “A Revolutionary Approach to Treating PTSD.” NY Times Magazine.