The Body Keeps the Score - critical summary review

People react to traumatic experiences differently. Nevertheless, as a species, we are exceptionally fragile beings, and all of us are susceptible to developing post-traumatic stress disorder (PTSD, for short). In “The Body Keeps the Score,” Boston-based Dutch psychiatrist and PTSD researcher Bessel van der Kolk explains why and what to do once the trauma is engraved in a person’s mind and body.

So, get ready to learn how traumas develop into disorders and why Prozac might help – but will never be enough.

Your brain is primarily a survival tool

Even though you might think that the most important job of your brain is to think and solve complex problems, it is to ensure your survival – even under the most miserable conditions. Everything else is secondary. According to the author, to do this, brains need to: 

1. Generate internal signals that register what our bodies need, such as food, rest, protection, sex, and shelter.
2. Create a map of the world to point us where to go to satisfy those needs.
3. Generate the necessary energy and actions to get us there.
4. Warn us of dangers and opportunities along the way.
5. Adjust our actions based on the requirements of the moment.

Now, the brain is built from the bottom up and develops, within every child in the womb, level by level – just as it did in the course of evolution. The process can be arbitrarily divided into three phases. The so-called reptilian brain is “already online when we are born.” It is the most primitive part of the brain, and it is responsible for all the things that newborn babies can do – from eating, breathing and sleeping to getting rid of the toxins of the body. 

Soon after birth, the development of the second part of the brain sets off. This second part is the limbic system – colloquially called “the mammalian brain” because we share it with all animals that live in groups and nurture their young ones.

The limbic system is “the seat of the emotions, the monitor of danger, the judge of what is pleasurable or scary, the arbiter of what is or is not important for survival purposes.” More importantly, the limbic system develops in a “use-dependent manner”: it is shaped in response to experiences. In other words, a large part of your emotional map of the world depends on the way your parents treated you when you were a baby – and all the things that might have happened to you during this time.

Finally, the neocortex – our rational, cognitive brain – starts developing in the second year of life. The youngest part of the brain, it occupies only about 30% of the area inside your skull. It is responsible for the qualities that make us unique within the animal kingdom, most relevantly in our case – empathy, our ability to feel into someone else.

The anatomy of trauma: defending against a past threat

Most mammals have similar brains to humans. However, because our neocortex is much thicker and much more developed than even that of primates, the way we deal with external threats, in the long run, differs significantly from the way animals sort them out. In a way, our neocortex is the primary reason why humans are much more liable to being devastated by a traumatic experience than animals. And here’s why.

Since the alarm system of our brain is embedded within its oldest parts, animals and humans react quite similarly in the presence of danger: either face it, run away from it, or stop dead. This is the so-called fight/flight/freeze reflex. Preprogrammed in our “emotional brain” – how Van der Kolk refers to our reptilian and mammalian brains together – the fight/flight/freeze reflex employs the body-brain connections, so often disregarded even in serious science.

After first shutting down the neocortex, the emotional brain orders the body – through stress hormones – to either attack or escape. Either action should end the threat 9 out of 10 times: as soon as safety is restored reaching a new place, the stress hormones come to rest, the high brain is back online, and we recover our internal equilibrium, by gradually regaining our senses.

However, that tenth time, something problematic happens: the normal physical response to the brain’s suggestions – fight or flight – is, for some reason, blocked. This can happen due to external factors (one can be trapped or held down, for example) or because of some internal inhibitions (you neither want to hurt nor run away from the offender, who is someone close). As a result, the body freezes.

However, since the brain is still in pursuit of effective action, the stress chemicals are secreted nevertheless. Thus, the freeze effect is twofold: not only are sufferers incapable of doing something, but their bodies also become immune to the orders of their brains that tell them the opposite. “Immobilization keeps the body in a state of inescapable shock and learned helplessness” – writes Van der Kolk.

In essence, this is how PTSD emerges: it is basically the product of a miscommunication between the brain and the body. In animals, this happens only on the rarest of occasions: man-made threats, after all, are neither as short-lived nor as obvious as a predator attack, so we can’t really get rid of them by immediately taking effective action. We can be shaken to our very core by anything from deadlines to severe pain, and – because of our ability to empathize – by someone else’s agony as well.

Trauma affects the entire human organism – body, mind, and brain – and leaves sufferers stuck in time: the brain is waiting for the effective action that the body is unable to take. Van  der Kolk affirms that, in PTSD, “the body continues to defend against a threat that belongs to the past. Healing from PTSD means being able to terminate this continued stress mobilization and restoring the entire organism to safety.”

The prevalence of PTSD

Now, most people think that PTSD is something only soldiers have to deal with. However, you don’t need to have fought in Vietnam or Iraq – or visited a refugee camp in Syria or the Congo – to experience trauma. “Trauma happens to us, our friends, our families, and our neighbors,” writes soberingly Van der Kolk.

And, indeed, if you live in the U.S., there’s a big chance that you already know at least a few people who have gone through a traumatic experience. The numbers don’t lie: according to a research by the Centers for Disease Control and Prevention, 1 in 8 Americans witnessed their mother being beaten and half of them have been beaten themselves by a parent to the point of a mark being left on their body; a quarter of Americans have a relative with problems with alcoholism; at least a fifth were sexually molested as children. 

The good news is that, as human beings, we belong to an extremely resilient species. We have found ways to rebound from countless disasters and numerous wars, not to mention the incessant betrayals and violence in our own lives. “But traumatic experiences,” writes Van der Kolk, “do leave traces, whether on a large scale (on our histories and cultures) or close to home, on our families, with dark secrets being imperceptibly passed down through generations. They also leave traces on our minds and emotions, on our capacity for joy and intimacy, and even on our biology and immune systems.”

The brain-disease model of trauma

About half a century ago, psychologists and psychiatrists realized that the difference between resilient people and people unable to cope with trauma might be physiological. For example, Kings College professor Jeffrey Gray demonstrated that, in animals, the sensitivity of the amygdala – the almond-shaped part of the brain responsible for our emotional responses – depended, at least in part, on the amount of the neurotransmitter serotonin in that part of the brain. The lower the serotonin levels, the more reactive the animals were to stressful external stimuli; conversely, animals with high serotonin levels were less likely to be frozen or aggressive in response to potential threats.

This revolutionized psychiatry. On February 8th, 1988, the drug company Eli Lilly released Prozac, one of the first drugs of the selective serotonin reuptake inhibitor class. And because Prozac worked by increasing the level of usable serotonin in the brain – just like Gray hypothesized – it immediately made sufferers of traumatic experience much less reactive and, thus, much more serene.

Soon enough, the media and the public accepted the theory “that mental illness is caused primarily by chemical imbalances in the brain that can be corrected by specific drugs,” and there was no turning back from there. The problem is that this was never the full story: human suffering is just as much about love and loss as it is about hormonal imbalance. As a result, writes Van der Kolk, “the drug revolution that started out with so much promise may, in the end, have done as much harm as good.”

If we want to address trauma adequately, we must turn away from this brain-disease model and treat trauma as an adaptation and not as a mental ailment. The latter overlooks four fundamental truths about the human condition:

1. We can heal each other just as much as we can destroy each other. One of the best antidotes to trauma might be connection. 
2. Language is an immensely powerful tool. By communicating our experiences and defining our knowledge, we can – solely through the power of language – find meaning and profoundly change ourselves and those around us. 
3. We can regulate our own physiology. Even some of the so-called involuntary functions of the body and brain can be regulated through such basic activities as “breathing, moving, and touching.”
4. We can change society and social conditions. We know enough about the causes of diseases to be able to create “environments in which children and adults can feel safe and where they can thrive.”

“When we ignore these quintessential dimensions of humanity, we deprive people of ways to heal from trauma and restore their autonomy. Being a patient, rather than a participant in one’s healing process, separates suffering people from their community and alienates them from an inner sense of self,” concludes Van der Kolk.

Trauma is much more than a story: paths to recovery

Nothing is more important for the mental health of a human being than the feeling of being safe with other people: no meaningful or satisfying life is possible without it. However, it is important to note that merely being in the presence of others means little. “The critical issue is reciprocity: being truly heard and seen by the people around us, feeling that we are held in someone else’s mind and heart,” notes Van der Kolk.

He continues – “For our physiology to calm down, heal, and grow we need a visceral feeling of safety. No doctor can write a prescription for friendship and love: These are complex and hard-earned capacities. You don’t need a history of trauma to feel self-conscious and even panicked at a party with strangers – but trauma can turn the whole world into a gathering of aliens.”

The treatment of PTSD cannot – and should not – be a treatment of past experiences, but present symptoms. What has happened cannot be undone, but the imprints left by a certain trauma on the body, mind, and soul of a human being can be mollified and even wiped out, irrespective of whether they are anxiety, depression, self-loathing, incessant nightmares, fears of rejection, or the inability to fully open your heart to another person.

Essentially caused by the absence of effective physical action, PTSD means losing control of your body as much as it means losing control of your mind. Consequently, reestablishing ownership of the body is the first step toward bringing your mind under control as well. 

If it is the body that keeps the score – i.e., the memory of trauma is encoded in the viscera – we must radically shift the way we treat PTSD and deal with it in a bottom-to-top manner rather than vice versa. It has been demonstrated numerous times that yoga, theater, dance, ball games, and psychomotor therapy immensely help victims of PTSD.

However, that’s merely the beginning: transcending the traumatic experience is also about being able to let go of the past while not forgetting it completely, about “feeling free to know what you know and to feel what you feel without becoming overwhelmed, enraged, ashamed, or collapsed.” Mindfulness, hypnosis, language, and some specialized treatments such as EMDR (eye movement desensitization and reprocessing) and neurofeedback can help: most of them are capable of resetting the brain to calmness.

Final Notes

If you want to understand the nature of traumas and the different ways to treat them, this is an essential read.

Comprehensive and insightful, empathic, and immensely helpful, “The Body Keeps the Score” is a masterpiece in every sense of the word.

Highly recommended.

12min Tip

Move and play more – and ask this from your children as well. Even though the brain and the body are connected, most school programs ignore the need for physical education. According to Van der Kolk, this – in addition to “anything else involving movement, play, and joyful engagement” – is the last thing that should get cut from school schedules.