the future of trauma work

For Bessel van der Kolk, Professor of Psychiatry and Director of the Trauma Centre in Boston, it is our bodies more than our minds that control how we respond to trauma. Clare Pointon talks to him about how he sees trauma work developing in the future

WHY did so many people living in and around New York go for massage treatments - rather than psychotherapy - in the aftermath of September 11? According to Bessel van der Kolk, they were seeking something that lies at the heart of his theories about trauma - a way of 'resetting the body'. Since the publication of his major textbook Traumatic Stress: The Effects of Overwhelming Experience on Mind, Body and Society,² van der Kolk's theories have become increasingly focused on the somatic aspects of trauma and how to work with them. I met him during a brief trip to London in February to present at a conference on trauma at the Institute for Child Mental Health in Islington.

'The imprint of trauma is the imprint on people's senses, on people's sensory systems,' he says. 'That becomes particularly important because these sensations stay in people's memory banks and stay unprocessed. If you do effective trauma processing, the individual smells, sounds, images and physical impressions of the trauma slowly disappear over time and that is something that doesn't happen with talking. It happens by working with people's bodily states.'

A controversial message
This is a hard subject to address- particularly, one might imagine, when delivered to an audience of counsellors and psychotherapists. And it's one that has already drawn fire from a number of psychologists within the trauma field. However, for Bessel van der Kolk, Professor of Psychiatry, Director of the Trauma Centre in Boston in the United States and author of more than 100 peer-reviewed scientific papers on subjects including self-mutilation, dissociation and the therapeutic efficacy of Eye Movement Desensitisation Reprocessing (EMDR), it is a passionately held belief about how to help traumatised people.

At its core is the issue of how human beings calm themselves down. This, he points out, is the developmental task of every child. It begins in infancy in a relationship with a primary caregiver who, in Stern's terms, provides 'affect regulation' - the sounds, facial expressions, touch, holding and/or rocking which help a baby modulate its physiological arousal (Stern, 1985).² Later on the growing child is able to draw on these experiences to find its own way of coping with external stresses in the environment surrounding it.

When a person experiences trauma, says van der Kolk, they become highly aroused and, for a period of time, lose this capacity for self-regulation. However, if in these moments, they are able to respond to the physical presence of those around them, they will be able to think clearly and are likely to cope relatively well. It is those who cannot do this, who remain in a state of high physiological arousal, unable either to calm themselves or to use their environment to do so, who, he argues, end up 'taking leave of their senses', organising their internal world around the trauma and often going on to develop Post-Traumatic Stress Disorder (PTSD).

Use of brain scans
Van der Kolk uses brain scans of trauma patient volunteers to highlight the biology behind his theories. The images, taken while patients remember a traumatic event, show how areas of the right hemisphere of the brain - those associated with emotional states and autonomic arousal - are lit up. The 'imprint of trauma' he says, 'is located mainly in the limbic system, the part that interprets what is safe or dangerous in the world and in the brain stem that modulates arousal levels - sleeping, breathing, urinating and chemical balances. At the same time, parts of the frontal lobe that deal with the capacity to plan, to rationalise, to inhibit inappropriate behaviour - and specifically one area associated with speech - are shown to be shut down.'

What this suggests, says van der Kolk, is that 'when people relive their traumatic experiences, the frontal lobes become impaired and as a result they have trouble thinking and speaking. They are no longer capable of communicating to others precisely what's going on.' Nor, he argues, are they capable of imagining how things could change. This ability is located in the prefrontal cortex of the brain, an area that needs to be engaged if someone is to have the possibility of transforming their experience and moving on.

Meanwhile, he says, research also shows the way in which the possibility to physically move at the time of the trauma is a key factor in a person's experience. Movement, he points out, is organised in the limbic system where a part of the brain known as the amygdala acts as a 'smoke detector', sending out alarm signals when a person is in a sensory situation similar to the trauma. The more immobile a person felt at the time of the experience when the original alarm was going off, the more sensitive this detector is likely to be in the future - and the more they are at risk of trauma.

The nature of this person's 'fight or flight' response is also affected. For example, children - often less likely to be in a position to physically flee a traumatic environment - may well resort to freezing, numbing or dissociating as their only options for 'leaving'.

Feeling safe again
So what does all this mean for treatment? Van der Kolk's starting point is that people who have experienced trauma need to feel safe in their bodies again: 'It's via the awareness of deep bodily experience that people can begin to move around the way that they feel - not by keeping it out there,' he says. 'The story of what happened is worth telling, but to change your reaction to it, you have to go via the deep internal felt sense.' He believes that this 'internal felt sense', dealt with by the medial prefrontal cortex of the brain, is accessed by being still and noticing what is going on internally.

In a psychotherapy session this may be facilitated by a practitioner who pays sensitive and moment-by-moment attention to a patient's somatic experience, alongside their emotional state. It's a practice he believes is crucial for patients before they can engage in the deeper work of processing the trauma itself.

At the Trauma Centre in Boston, van der Kolk says that all his workers engage in a 'self-regulatory' activity, such as yoga or T'ai chi to help them to stay in their bodies and be still, even when in distress. They use these practices to support themselves in their work and are also then able to model the experience with their patients. With children and young people, this work may take the form of dance, movement or martial arts training - all aimed at empowering, and helping them to remain grounded and embodied. Some of the projects are specifically designed to allow participants to replay their trauma, but to script in what van der Kolk calls 'a motorically different ending' - one that allows them to do things differently this time.

In 'model mugging', young people who have already undertaken a significant amount of therapy perform role-play attacks in which the group and facilitator support a 'victim' to triumph over a 'persecutor'. In theatre projects, groups write plays together, amalgamating their individual stories and creating new outcomes: 'Since our brain is an action organ, and since trauma destroys or adversely affects the capacity for organised focused thinking about the future - where to go, what to do - I think that exposing traumatised children to actions that are organised and focused can help them to feel competent and goal-directed, and that this is an essential part of the overall treatment,' he says. Van der Kolk's basic ideas of what goes wrong biologically in trauma are the same as they were in 1996 when he published Traumatic Stress. What has changed since then, he says, is his understanding of what it means for treatment when a traumatised person is so disorganised on a physiological level:

'We hadn't quite appreciated how hard a time traumatised people have to think clearly, and that you can't teach someone to do this just by telling them to. You have to really do something with people's bodily states. Until then, the only thing I and most other people knew was medication. What changed for me was a whole bunch of things, including my getting exposed to yoga and T'ai chi. I came to realise that, for thousands of years, people had worked on perfecting techniques that got them into their bodies, that allowed them to stay focused and centred in the face of very difficult situations.'

Major influences
He was also greatly influenced by the work of eminent body psychotherapists in the US, including Albert Pesso (see box opposite) who does somatic work in groups and Peter Levine who evolved the 'Somatic Experiencing' approach to trauma treatment and with whom van der Kolk then did his own personal work. Levine argues that trauma derives from a biological response to threat, which in human beings is often unable to be physically discharged and remains 'locked' in the body. His way of working is to access this energy somatically and help someone who has suffered trauma to regain the capacity to move again physically and live in their body again (see box opposite). 'I was blown away by their work,' says van der Kolk. 'I saw transformations occurring in people by getting a hold of their internal states, which was beyond anything I had seen in traditional psychotherapy.' His other major influence in this period was Eye Movement Desensitisation Reprocessing (EMDR), an approach of which he was sceptical until he saw the dramatic effects it had on some of his trauma patients. When he went to explore the work for himself, he wasn't impressed by the training approach used, but says he had a powerful personal experience of the technique and finding that he was able to facilitate another participant's change. Since then, he has used the method in his clinic - guiding patients through specific eye movements at key moments, while thinking about a traumatic experience - to great effect. He acknowledges that there is much to be explained about the science of this approach, but believes that it can be likened to the integrating impact that dreams have on our daytime experiences, one that allows the past to be the past: 'Eye movements seem to set up a state of psychophysiological de-arousal, which makes it possible for the mind brain to integrate the fragments of the traumatic memory that cannot be integrated when the organism is in a state of high arousal,' he says.

Where do talking therapies fit in?
So where does traditional insight-oriented talking therapy come in all this? Does it have an important place anywhere in his work? Van der Kolk is clear that his somatic work, including EMDR, has dramatically changed the way he thinks therapeutically. When using EMDR with a traumatised person, he doesn't believe that the therapeutic relationship will necessarily be an agent of change. Nor does he believe that talking will be useful with everyone. Much will depend on the context of the trauma and the developmental stage at which it occurred:

'Talking therapy is particularly important for people who have lived in situations where their realities were denied,' he says, 'where they had to pretend that what they saw and heard and felt wasn't happening or where they tried to hide it. To say that it happened, to use words and internally to know what that means gives you a sense of ownership and a capacity to start moving things around. Words give you a sense of direction. Once you have symbols, you can start moving again.'

They also give someone who has been deeply alienated by their trauma a point of connection to others, which is obviously hugely important: 'To be able to describe to someone else what you see and know, so that you can put it into the social realm, means that you can conspire, collaborate, commiserate and reintegrate yourself with the human community by speaking,' he says.

However, when people really 'go into their trauma' and certain parts of the brain shut down, he argues that words become less useful. Even if they are able to speak about their experience, it can be extremely upsetting - and if they are not 'firmly anchored in the present' when they do so, he says, someone with PTSD can end up retraumatised. With this in mind, he cautions therapists working with trauma to 'go easy on the narrative' and not to nudge patients into it with 'tell me more'. Van der Kolk believes that insight-oriented psychotherapy might teach a person that their reactions belong to the past, but that, while this may help them override automatically their physiological responses to traumatic triggers, it won't get rid of them.

Working with children suffering from trauma
In his work with children, he testifies to the power of self-expression through drawing, an activity that re-engages the prefrontal cortex of the brain and provides an alternative way of symbolically representing the trauma. He argues that this helps to restore the lost capacity for imagination, allows for the possibility of transformation and gives someone a way out. He shows a picture drawn by a young American boy who on September 11 saw an aircraft hit one of the Twin Towers. There are bodies of people falling out of the windows, petrol fumes billowing in the air - and, down below, firefighters and a couple of 'trampolines', which the boy said he drew so that those who fell would be OK. It is the possibility to depict images like the trampolines that van der Kolk believes makes a person capable of moving on with their life and transforming the traumatic experience into something else.

For discrete incidents of trauma - a car crash, a fire, an experience of torture - his treatment of choice today is EMDR. In his view, it is quick, 'gets to the imprint' and effectively processes the fragmented pieces of the past. However, where a person has suffered severe developmental deficit - perhaps with no early experience at all of what it felt like to be safe with someone - he believes that the challenges of any therapy will be immense. In such cases, it will be hard for the patient to feel safe in the therapeutic relationship, and for him the answer lies in the kind of body work done by Albert Pesso in which a patient in a group context is able to orchestrate their own reparative somatic experience - perhaps being held or touched by another member:

'Someone like this needs a psychodramatic experience where they can physically feel what it's like to be little again, and be held and safe at the same time - but not by their therapist,' he says. 'They need to go into an altered state of consciousness where they can have that experience. And this kind of work should never be done on a one-to-one level.'

Looking to the future of trauma work
These are techniques that van der Kolk regards as very difficult to learn - and which he admits that he, himself, hasn't yet mastered. For him they are part of the future of trauma work - one to which he is powerfully committed and is not afraid, whatever the comeback, to champion. Above all else, he says, they are about the priority of working with a person's physical experience:

'I believe the most important thing that all mental health professionals need to know is not how to interpret complex behaviour, but how to help people to stay on an even keel,' he says. 'If someone is on an even keel, they are in a physiological condition where they can keep hold of their senses. This means that they can continue to be able to think and be quiet.'

References

1. Van der Kolk B.A., McFarlane A.C and Weisaeth L. Traumatic Stress: The Effects of Overwhelming Experience on Mind, Body and Society. New York: Guildford Publications; 1996
2. Stern D. Waking the Tiger, Healing Trauma. Berkeley: North Atlantic Books; 1997

People and websites

Bessel van der Kolk www.traumacenter.org has a biography of van der Kolk, articles by him and others, contents of and comments on the book Traumatic Stress, and details of how to order the Psychological Trauma Assessment Package (contains four tools).

Albert Pesso www.pbsp.com contains articles on the theories, techniques and procedures of the Pesso Boyden System Psychomotor theory (not to be confused with other psychomotor body therapies), and has an online video and other links.

Peter Levine www.traumahealing.com describes Somatic Experiencing, includes articles and offers tapes and videos to buy.

EMDR www.emdr.com has a description, theory, history, efficacy and research, and a comparison with CBT methods (desensitisation and flooding) among other extras. www.emdr-europe.org has an overview of EMDR and lists of European trainers, consultants and practitioners.