Bessel A. van der Kolk

As long as you keep secrets and suppress information, you are fundamentally at war with yourself.

While trauma keeps us dumbfounded, the path out of it is paved with words, carefully assembled, piece by piece, until the whole story can be revealed.

The scientific study of suffering inevitably raises questions of causation, and with these, issues of blame and responsibility. Historically, doctors have highlighted predisposing vulnerability factors for developing PTSD, at the expense of recognizing the reality of their patients' experiences_ This search for predisposing factors probably had its origins in the need to deny that all people can be stressed beyond endurance, rather than in solid scientific data; until recently such data were simply not available_ When the issue of causation becomes a legitimate area of investigation, one is inevitably confronted with issues of man's inhumanity to man, with carelessness and callousness, with abrogation of responsibility, with manipulation and with failures to protect.

The traumatic stress field has adopted the term __omplex Trauma_ to describe the experience of multiple and/or chronic and prolonged, developmentally adverse traumatic events, most often of an interpersonal nature (e.g., sexual or physical abuse, war, community violence) and early-life onset. These exposures often occur within the child__ caregiving system and include physical, emotional, and educational neglect and child maltreatment beginning in early childhood- Developmental Trauma Disorder

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

Unlike other forms of psychological disorders, the core issue in trauma is reality.

Imagination is absolutely critical to the quality of our lives. Our imagination enables us to leave our routine everyday existence by fantasizing about travel, food, sex, falling in love, or having the last word__ll the things that make life interesting. Imagination gives us the opportunity to envision new possibilities__t is an essential launchpad for making our hopes come true. It fires our creativity, relieves our boredom, alleviates our pain, enhances our pleasure, and enriches our most intimate relationships.

Victims are members of society whose problems represent the memory of suffering, rage, and pain in a world that longs to forget.

BEFRIENDING THE BODY Trauma victims cannot recover until they become familiar with and befriend the sensations in their bodies. Being frightened means that you live in a body that is always on guard. Angry people live in angry bodies. The bodies of child-abuse victims are tense and defensive until they find a way to relax and feel safe. In order to change, people need to become aware of their sensations and the way that their bodies interact with the world around them. Physical self-awareness is the first step in releasing the tyranny of the past.In my practice I begin the process by helping my patients to first notice and then describe the feelings in their bodies__ot emotions such as anger or anxiety or fear but the physical sensations beneath the emotions: pressure, heat, muscular tension, tingling, caving in, feeling hollow, and so on. I also work on identifying the sensations associated with relaxation or pleasure. I help them become aware of their breath, their gestures and movements.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. The mind needs to be reeducated to feel physical sensations, and the body needs to be helped to tolerate and enjoy the comforts of touch. Individuals who lack emotional awareness are able, with practice, to connect their physical sensations to psychological events. Then they can slowly reconnect with themselves.

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 __ppositional defiant disorder,_ meaning __his kid hates my guts and won__ do anything I tell him to do,_ or __isruptive 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.

It was_early_in my career, and I had been seeing Mary, a shy, lonely, and physically collapsed young woman, for about three months in weekly psychotherapy, dealing with the_ravages of her terrible history of early abuse._One day I opened the door_to my waiting room and saw_her_standing there provocatively, dressed in a miniskirt,_her hair dyed flaming red,_with a cup of coffee in one hand and a snarl on her face. __ou must be Dr. van der Kolk,_ she said. __y name is Jane, and I came to warn you not to believe any the lies that Mary has been telling you. Can I come in and tell you about her?_ I was stunned but fortunately kept myself from confronting __ane_ and instead heard her out. Over the course of our session I met not only Jane but also a hurt little girl and an angry male adolescent. That was the beginning of a long and productive treatment.

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.

We don__ really want to know what soldiers go through in combat. We do not really want to know how many children are being molested and abused in our own society or how many couples__lmost a third, as it turns out__ngage in violence at some point during their relationship. We want to think of families as safe havens in a heartless world and of our own country as populated by enlightened, civilized people. We prefer to believe that cruelty occurs only in faraway places like Darfur or the Congo. It is hard enough for observers to bear witness to pain. Is it any wonder, then, that the traumatized individuals themselves cannot tolerate remembering it and that they often resort to using drugs, alcohol, or self-mutilation to block out their unbearable knowledge?

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.

Mary was my first encounter with dissociative identity disorder (DID), which at that time was called multiple personality disorder. As dramatic as its symptoms are, the internal splitting and emergence of distinct identities experienced in DID represent only the extreme end of the spectrum of mental life.

I cut myself up really badly with the lid of a tin can. They took me to the emergency room, but I couldn__ tell the doctor what I had done to cut myself__ didn__ have any memory of it. The ER doctor was convinced that dissociative identity disorder didn__ exist._._._. A lot of people involved in mental health tell you it doesn__ exist. Not that you don__ have it, but that it doesn__ exist.

In the culture people talk about trauma as an event that happened a long time ago. But what trauma is, is the imprints that event has left on your mind and in your sensations... the discomfort you feel and the agitation you feel and the rage and the helplessness you feel right now.

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__ mean, however, that our maps can__ 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.