Praise for The Body Keeps the Score “This book is a tour de force. Its deeply empathic, insightful, and compassionate perspective promises to further humanize the treatment of trauma victims, dramatically expand their repertoire of self-regulatory healing practices and therapeutic options, and also stimulate greater creative thinking and research on trauma and its effective treatment. The body does keep the score, and Van der Kolk’s ability to demonstrate this through compelling descriptions of the work of others, his own pioneering trajectory and experience as the field evolved and him along with it, and above all, his discovery of ways to work skillfully with people by bringing mindfulness to the body (as well as to their thoughts and emotions) through yoga, movement, and theater are a wonderful and welcome breath of fresh air and possibility in the therapy world.” —Jon Kabat-Zinn, professor of medicine emeritus, UMass Medical School; author of Full Catastrophe Living “This exceptional book will be a classic of modern psychiatric thought. The impact of overwhelming experience can only be truly understood when many disparate domains of knowledge, such as neuroscience, developmental psychopathology, and interpersonal neurobiology are integrated, as this work uniquely does. There is no other volume in the field of traumatic stress that has distilled these domains of science with such rich historical and clinical perspectives, and arrived at such innovative treatment approaches. The clarity of vision and breadth of wisdom of this unique but highly accessible work is remarkable. This book is essential reading for anyone interested in understanding and treating traumatic stress and the scope of its impact on society.” —Alexander McFarlane AO, MB BS (Hons) MD FRANZCP, director of the Centre for Traumatic Stress Studies, The University of Adelaide, South Australia. “This is an amazing accomplishment from the neuroscientist most responsible for the contemporary revolution in mental health toward the recognition that so many mental problems are the product of trauma. With the compelling writing of a good novelist, van der Kolk revisits his fascinating journey of discovery that has challenged established wisdom in psychiatry. Interspersed with that narrative are clear and understandable descriptions of the neurobiology of trauma; explanations of the ineffectiveness of traditional approaches to treating trauma; and introductions to the approaches that take patients beneath their cognitive minds to heal the parts of them that remained frozen in the past. All this is illustrated vividly with dramatic case histories and substantiated with convincing research. This is a watershed book that will be remembered as tipping the scales within psychiatry and the culture at large toward the recognition of the toll traumatic events and our attempts to deny their impact take on us all.” —Richard Schwartz, originator, Internal Family Systems Therapy “The Body Keeps the Score is clear, fascinating, hard to put down, and filled with powerful case histories. Van der Kolk, the eminent impresario of trauma treatment, who has spent a career bringing together diverse trauma scientists and clinicians and their ideas, while making his own pivotal contributions, describes what is arguably the most important series of breakthroughs in mental health in the last thirty years. We’ve known that psychological trauma fragments the mind. Here we see not only how psychological trauma also breaks connections within the brain, but also between mind and body, and learn about the exciting new approaches that allow people with the severest forms of trauma to put all the parts back together again.” —Norman Doidge, author of The Brain That Changes Itself “In The Body Keeps the Score we share the author’s courageous journey into the parallel dissociative worlds of trauma victims and the medical and psychological disciplines that are meant to provide relief. In this compelling book we learn that as our minds desperately try to leave trauma behind, our bodies keep us trapped in the past with wordless emotions and feelings. These inner disconnections cascade into ruptures in social relationships with disastrous effects on marriages, families, and friendships. Van der Kolk offers hope by describing treatments and strategies that have successfully helped his patients reconnect their thoughts with their bodies. We leave this shared journey understanding that only through fostering self-awareness and gaining an inner sense of safety will we, as a species, fully experience the richness of life. —Stephen W. Porges, PhD, professor of psychiatry, University of North Carolina at Chapel Hill; author of The Polyvagal Theory: Neurophysiological Foundations of Emotions, Attachment, Communication, and Self-Regulation “Bessel van der Kolk is unequaled in his ability to synthesize the stunning developments in the field of psychological trauma over the past few decades. Thanks in part to his work, psychological trauma—ranging from chronic child abuse and neglect, to war trauma and natural disasters—is now generally recognized as a major cause of individual, social, and cultural breakdown. In this masterfully lucid and engaging tour de force, Van der Kolk takes us—both specialists and the general public— on his personal journey and shows what he has learned from his research, from his colleagues and students, and, most important, from his patients. The Body Keeps the Score is, simply put, brilliant.” —Onno van der Hart, PhD, Utrecht University, The Netherlands; senior author, The Haunted Self: Structural Dissociation and the Treatment of Chronic Traumatization “The Body Keeps the Score articulates new and better therapies for toxic stress based on a deep understanding of the effects of trauma on brain development and attachment systems. This volume provides a moving summary of what is currently known about the effects of trauma on individuals and societies, and introduces the healing potential of both age-old and novel approaches to help traumatized children and adults fully engage in the present.” —Jessica Stern, policy consultant on terrorism; author of Denial: A Memoir of Terror “A book about understanding the impact of trauma by one of the true pioneers in the field. It is a rare book that integrates cutting edge neuroscience with wisdom and understanding about the experience and meaning of trauma, for people who have suffered from it. Like its author, this book is wise and compassionate, occasionally quite provocative, and always interesting.” —Glenn N. Saxe, MD, Arnold Simon Professor and chairman, Department of Child and Adolescent Psychiatry; director, NYU Child Study Center, New York University School of Medicine. “A fascinating exploration of a wide range of therapeutic treatments shows readers how to take charge of the healing process, gain a sense of safety, and find their way out of the morass of suffering.” —Francine Shapiro, PhD, originator of EMDR therapy; senior research fellow, Emeritus Mental Research Institute; author of Getting Past Your Past “As an attachment researcher I know that infants are psychobiological beings. They are as much of the body as they are of the brain. Without language or symbols infants use every one of their biological systems to make meaning of their self in relation to the world of things and people. Van der Kolk shows that those very same systems continue to operate at every age, and that traumatic experiences, especially chronic toxic experience during early development, produce psychic devastation. With this understanding he provides insight and guidance for survivors, researchers, and clinicians alike. Bessel van der Kolk may focus on the body and trauma, but what a mind he must have to have written this book.” —Ed Tronick, distinguished professor, University of Massachusetts, Boston; author of Neurobehavior and Social Emotional Development of Infants and Young Children “The Body Keeps the Score eloquently articulates how overwhelming experiences affect the development of brain, mind, and body awareness, all of which are closely intertwined. The resulting derailments have a profound impact on the capacity for love and work. This rich integration of clinical case examples with ground breaking scientific studies provides us with a new understanding of trauma, which inevitably leads to the exploration of novel therapeutic approaches that ‘rewire’ the brain, and help traumatized people to reengage in the present. This book will provide traumatized individuals with a guide to healing and permanently change how psychologists and psychiatrists think about trauma and recovery.” —Ruth A. Lanius, MD, PhD, Harris-Woodman chair in Psyche and Soma, professor of psychiatry, and director PTSD research at the University of Western Ontario; author of The Impact of Early Life Trauma on Health and Disease “When it comes to understanding the impact of trauma and being able to continue to grow despite overwhelming life experiences, Bessel van der Kolk leads the way in his comprehensive knowledge, clinical courage, and creative strategies to help us heal. The Body Keeps the Score is a cutting-edge offering for the general reader to comprehend the complex effects of trauma, and a guide to a wide array of scientifically informed approaches to not only reduce suffering, but to move beyond mere survival— and to thrive.” —Daniel J. Siegel, MD, clinical professor, UCLA School of Medicine, author of Brainstorm: The Power and Purpose of the Teenage Brain; Mindsight: The New Science of Personal Transformation; and The Developing Mind: How Relationships and the Brain Interact to Shape Who We Are “In this magnificent book, Bessel van der Kolk takes the reader on a captivating journey that is chock-full of riveting stories of patients and their struggles interpreted through history, research, and neuroscience made accessible in the words of a gifted storyteller. We are privy to the author’s own courageous efforts to understand and treat trauma over the past forty years, the results of which have broken new ground and challenged the status quo of psychiatry and psychotherapy. The Body Keeps the Score leaves us with both a profound appreciation for and a felt sense of the debilitating effects of trauma, along with hope for the future through fascinating descriptions of novel approaches to treatment. This outstanding volume is absolutely essential reading not only for therapists but for all who seek to understand, prevent, or treat the immense suffering caused by trauma.” —Pat Ogden PhD, founder/educational director of the Sensorimotor Psychotherapy Institute; author of Sensorimotor Psychotherapy: Interventions for Trauma and Attachment “This is masterpiece of powerful understanding and brave heartedness, one of the most intelligent and helpful works on trauma I have ever read. Dr. Van der Kolk offer a brilliant synthesis of clinical cases, neuroscience, powerful tools and caring humanity, offering a whole new level of healing for the traumas carried by so many.” —Jack Kornfield, author of A Path with Heart VIKING Published by the Penguin Group Penguin Group (USA) LLC 375 Hudson Street New York, New York 10014 USA | Canada | UK | Ireland | Australia | New Zealand | India | South Africa | China penguin.com A Penguin Random House Company First published by Viking Penguin, a member of Penguin Group (USA) LLC, 2014 Copyright © 2014 by Bessel van der Kolk Penguin supports copyright. Copyright fuels creativity, encourages diverse voices, promotes free speech, and creates a vibrant culture. Thank you for buying an authorized edition of this book and for complying with copyright laws by not reproducing, scanning, or distributing any part of it in any form without permission. You are supporting writers and allowing Penguin to continue to publish books for every reader. LIBRARY OF CONGRESS CATALOGING-IN-PUBLICATION DATA [Van der Kolk, Bessel A., 1943-author. The body keeps the score : brain, mind, and body in the healing of trauma / Bessel A. van der Kolk. p. ; cm. Includes bibliographical references and index. eBook ISBN 978-1-10160830-2 I. Title. [DNLM: 1. Stress Disorders, Post-Traumatic—physiopathology. 2. Stress Disorders, Post-Traumatic— therapy. WM 172.5] RC552.P67 616.85'21206—dc23 2014021365 Neither the publisher nor the author is engaged in rendering professional advice or services to the individual reader. The ideas, procedures, and suggestions contained in this book are not intended as a substitute for consulting with your physician. All matters regarding your health require medical supervision. Neither the author nor the publisher shall be liable or responsible for any loss or damage allegedly arising from any information or suggestion in this book. Version_1 To my patients, who kept the score and were the textbook. CONTENTS Praise for The Body Keeps the Score Title Page Copyright Dedication PROLOGUE: FACING TRAUMA PART ONE: THE REDISCOVERY OF TRAUMA 1. LESSONS FROM VIETNAM VETERANS 2. REVOLUTIONS IN UNDERSTANDING MIND AND BRAIN 3. LOOKING INTO THE BRAIN: THE NEUROSCIENCE REVOLUTION PART TWO: THIS IS YOUR BRAIN ON TRAUMA 4. RUNNING FOR YOUR LIFE: THE ANATOMY OF SURVIVAL 5. BODY-BRAIN CONNECTIONS 6. LOSING YOUR BODY, LOSING YOUR SELF PART THREE: THE MINDS OF CHILDREN 7. GETTING ON THE SAME WAVELENGTH: ATTACHMENT AND ATTUNEMENT 8. TRAPPED IN RELATIONSHIPS: THE COST OF ABUSE AND NEGLECT 9. WHAT’S LOVE GOT TO DO WITH IT? 10. DEVELOPMENTAL TRAUMA: THE HIDDEN EPIDEMIC PART FOUR: THE IMPRINT OF TRAUMA 11. UNCOVERING SECRETS: THE PROBLEM OF TRAUMATIC MEMORY 12. THE UNBEARABLE HEAVINESS OF REMEMBERING PART FIVE: PATHS TO RECOVERY 13. HEALING FROM TRAUMA: OWNING YOUR SELF 14. LANGUAGE: MIRACLE AND TYRANNY 15. LETTING GO OF THE PAST: EMDR 16. LEARNING TO INHABIT YOUR BODY: YOGA 17. PUTTING THE PIECES TOGETHER: SELF-LEADERSHIP 18. FILLING IN THE HOLES: CREATING STRUCTURES 19. REWIRING THE BRAIN: NEUROFEEDBACK 20. FINDING YOUR VOICE: COMMUNAL RHYTHMS AND THEATER EPILOGUE: CHOICES TO BE MADE ACKNOWLEDGMENTS APPENDIX: CONSENSUS PROPOSED CRITERIA FOR DEVELOPMENTAL TRAUMA DISORDER RESOURCES FURTHER READING NOTES INDEX O PROLOGUE FACING TRAUMA ne does not have be a combat soldier, or visit a refugee camp in Syria or the Congo to encounter trauma. Trauma happens to us, our friends, our families, and our neighbors. Research by the Centers for Disease Control and Prevention has shown that one in five Americans was sexually molested as a child; one in four was beaten by a parent to the point of a mark being left on their body; and one in three couples engages in physical violence. A quarter of us grew up with alcoholic relatives, and one out of eight witnessed their mother being beaten or hit.1 As human beings we belong to an extremely resilient species. Since time immemorial we have rebounded from our relentless wars, countless disasters (both natural and man-made), and the violence and betrayal in our own lives. But traumatic experiences 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. Trauma affects not only those who are directly exposed to it, but also those around them. Soldiers returning home from combat may frighten their families with their rages and emotional absence. The wives of men who suffer from PTSD tend to become depressed, and the children of depressed mothers are at risk of growing up insecure and anxious. Having been exposed to family violence as a child often makes it difficult to establish stable, trusting relationships as an adult. Trauma, by definition, is unbearable and intolerable. Most rape victims, combat soldiers, and children who have been molested become so upset when they think about what they experienced that they try to push it out of their minds, trying to act as if nothing happened, and move on. It takes tremendous energy to keep functioning while carrying the memory of terror, and the shame of utter weakness and vulnerability. While we all want to move beyond trauma, the part of our brain that is devoted to ensuring our survival (deep below our rational brain) is not very good at denial. Long after a traumatic experience is over, it may be reactivated at the slightest hint of danger and mobilize disturbed brain circuits and secrete massive amounts of stress hormones. This precipitates unpleasant emotions intense physical sensations, and impulsive and aggressive actions. These posttraumatic reactions feel incomprehensible and overwhelming. Feeling out of control, survivors of trauma often begin to fear that they are damaged to the core and beyond redemption. • • • The first time I remember being drawn to study medicine was at a summer camp when I was about fourteen years old. My cousin Michael kept me up all night explaining the intricacies of how kidneys work, how they secrete the body’s waste materials and then reabsorb the chemicals that keep the system in balance. I was riveted by his account of the miraculous way the body functions. Later, during every stage of my medical training, whether I was studying surgery, cardiology, or pediatrics, it was obvious to me that the key to healing was understanding how the human organism works. When I began my psychiatry rotation, however, I was struck by the contrast between the incredible complexity of the mind and the ways that we human beings are connected and attached to one another, and how little psychiatrists knew about the origins of the problems they were treating. Would it be possible one day to know as much about brains, minds, and love as we do about the other systems that make up our organism? We are obviously still years from attaining that sort of detailed understanding, but the birth of three new branches of science has led to an explosion of knowledge about the effects of psychological trauma, abuse, and neglect. Those new disciplines are neuroscience, the study of how the brain supports mental processes; developmental psychopathology, the study of the impact of adverse experiences on the development of mind and brain; and interpersonal neurobiology, the study of how our behavior influences the emotions, biology, and mind-sets of those around us. Research from these new disciplines has revealed that trauma produces actual physiological changes, including a recalibration of the brain’s alarm system, an increase in stress hormone activity, and alterations in the system that filters relevant information from irrelevant. We now know that trauma compromises the brain area that communicates the physical, embodied feeling of being alive. These changes explain why traumatized individuals become hypervigilant to threat at the expense of spontaneously engaging in their day-to- day lives. They also help us understand why traumatized people so often keep repeating the same problems and have such trouble learning from experience. We now know that their behaviors are not the result of moral failings or signs of lack of willpower or bad character—they are caused by actual changes in the brain. This vast increase in our knowledge about the basic processes that underlie trauma has also opened up new possibilities to palliate or even reverse the damage. We can now develop methods and experiences that utilize the brain’s own natural neuroplasticity to help survivors feel fully alive in the present and move on with their lives. There are fundamentally three avenues: 1) top down, by talking, (re-) connecting with others, and allowing ourselves to know and understand what is going on with us, while processing the memories of the trauma; 2) by taking medicines that shut down inappropriate alarm reactions, or by utilizing other technologies that change the way the brain organizes information, and 3) bottom up: by allowing the body to have experiences that deeply and viscerally contradict the helplessness, rage, or collapse that result from trauma. Which one of these is best for any particular survivor is an empirical question. Most people I have worked with require a combination. This has been my life’s work. In this effort I have been supported by my colleagues and students at the Trauma Center, which I founded thirty years ago. Together we have treated thousands of traumatized children and adults: victims of child abuse, natural disasters, wars, accidents, and human trafficking; people who have suffered assaults by intimates and strangers. We have a long tradition of discussing all our patients in great depth at weekly treatment team meetings and carefully tracking how well different forms of treatment work for particular individuals. Our principal mission has always been to take care of the children and adults who have come to us for treatment, but from the very beginning we also have dedicated ourselves to conducting research to explore the effects of traumatic