Severe trauma patients “typically receive five or six unrelated diagnoses in the course of their psychiatric treatment.” Bipolar, depression, adhd, ptsd, etc. None of these diagnoses will “meaningfully describe who these patients are and what they suffer from.”
Psychiatry “aspires to define mental illness as precisely as, let’s say, cancer of the pancreas.” But “we have not even come close to achieving that sort of precision.” It’s more a matter of “the mindset of the practioner (and of what insurance comapnies will pay for)”
Van der Kolk gets real about the DSM (an attempt at a systematic manual of mental illness). Now a requirement for insurance, research funding, and academic structure, it is “a virtual industry that has earned the ASA well over $100 million.” But has it benefited patients?
“Diagnosis informs treatment, and getting the wrong treatment can have disastrous effects. Also, a diagnostic label is likely to attach to people for the rest of their lives and have a profound influence on how they define themselves.”
“I have met countless patients who have told me that they ‘are’ bipolar or borderline or that they ‘have’ptsd, as if they had been sentenced to remain in an underground dungeon for the rest of their lives, like the Count of Monte Cristo”
“None of these diagnoses take into account the unusual talents that many of our patients develop, or the creative energies they have mustered to survive.” Diagnoses are “tallies of symptoms” that make it easy to view folks as “out-of-control women who need to be straighted out.”
Van der Kolk talks about a study he did, against institutional skepticism, that demonstrated a clear link between childhood trauma and Borderline Personal Disorder. Frequently BPD patients can’t even remember their trauma, excluding them from a PTSD disgnosis.
Van der Kolk tried to introduce a new DSM diagnoses for victims of personal trauma, and despite full support of the PTSD work group it was silently excluded from the next manual.
The ACE study, conducted by Robert Anda, concluded that “eradicating child abuse in America would reduce the overall rate of depression by more than half, alcoholism by two-thirds, and suicide, IV drug use, and domestic violence by three-quarters.”
Van der Kolk takes a moment to make clear that ample research demonstrates that there is no real conclusive evidence of genetic inheritance for most mental illnesses, and that the conditions of early childhood are going to be the cause in most cases. No eugenics here pls.
Many severely traumatized kids don’t meet the diagnosis criteria for PTSD. Instead, “they receive unscientific diagnoses such as ‘oppositional defiant disorder’, meaning ‘This kid hates my guts and won’t do anything I tell him to.”
The NCTSN wrote a letter asking to add “Developmental Trauma Disorder” to the DSM. The response? “The notion that early childhood adverse experiences lead to substantial disruptions is more clinical intuition than a research-based fact.” The research was in the letter!
Van der Kolk walks thru several studies that show the way early childhood trauma can alter our biology. Hormone levels shift to numb the body to distress. This is what “The Body Keeps the Score” means.
This book makes me never want to raise a kid lol. Such an immeasurable amount of power over someone’s entire life.
More stuff about how the DSM rakes in a profit despite being self-admittedly unreliable and entirely based on symptoms over causes. At this point I am concluding that this is intentional and that systematic change is not in their best interest.
“Social support is a biological necessity, not an option, and this reality should be the backbone of all prevention and treatment.” But we don’t need to blame parents: “We can assume that parents do the best they can, but all parents need help to nurture their kids.”
This section on childhood trauma closes with a call for real social services: “Economists have calculated that every dollar invested in high-quality home visitation, day care, and preschool programs results in seven dollars of savings on welfare, healthcare, and incarceration”
Finally to the last section of the book, on recovery. “The challenge of recovery is to reestablish ownership of your body and mind—of your self. This means feeling free to know what you know and to feel what you feel without becoming overwhelmed, enraged, ashamed, or collapsed.”
Recovery from trauma involves:
1) “finding a way to become calm and focused”
2) learning to “maintain that calm” in response to reminders of trauma
3) finding a way to be “fully alive in the present” and engaged with other people
4) “not having to keep secrets from yourself”
The above goals aren’t steps to achieve in order but rather a blurry collection of things that everyone will struggle with in different manners.
“Recovery from trauma involves the restoration of executive functioning and, with it, self-confidence and the capacity for playfulness and creativity.”
“Neuroscience research shows that the only way we can change the way we feel is by becoming aware of inner experience and learning to befriend what is going on inside ourselves.”
“We can train our arousal system by the way we breathe, chant, and move, a principle that has been utilized since time immemorial in places like India and China, and in every religious practice that I know of, but that is suspiciously eyed as ‘alternative’ in mainstream culture.”
“At the core of recovery is self-awareness. The most important phrases in trauma therapy are ‘Notice that’ and ‘What happens next?’”
When you focus on your physical sensations, you can learn that they are transient, unlike the fixed temporal reality of trauma. Then, you can label these sensations, and identify how changes to your behavior and mood transform them.
“Study after study shows that having a good support network constitutes the single most powerful protection against becoming traumatized.” Show up for your friends and accept them for who they are without judgement or shame, y’all. It’s life-changing.
In order to recover from interpersonal trauma and be able to rebuild your capacity for relationships, you have to find someone you can trust. “You need a guide who is not afraid of your terror and who can contain your darkest.” Typically, this is a therapist.
Finding therapy advice:
1) ask what forms they‘ve been trained in, if it was effective for them
2) if they insist on their fav solution only, they’re prob an ideologue
3) Do you feel comfortable with them? Are they comfortable with themselves and you? Are they curious abt you?
“We are a hopeful species. Working with trauma is as much remembering how we survived as it is about what is broken.”
“Some people don’t remember anyone they felt safe with. For them, engaging with horses or dogs may be much safer than dealing with human beings.”
To heal from trauma, we need to be attuned to our bodies and "experience a sense of connection and joy". Yoga, theater, choral singing, improv, aikido, tango dancing, kickboxing: all ways to become familiar with your body, to feel it as your own and to be curious thru it.
Human touch & intimacy is "the most elementary tool that we have to calm down," but "you can't full recover if you don't feel safe in your skin." Dr. Van der Kolk suggests bodywork to most patients: massage, Feldenkrais, craniosacral therapy, etc.
I'd of course add that you can't feel safe in your skin if you're overwhelmed by dysphoria, so HRT and clothes and support for trans folks is critical. For me personally it was like a door opened that I never even knew was there. Not a cure but the possibility to move forward.
Upon learning to tolerate an awareness of their body & memories, a traumatized person can discover physical impulses (hitting, running, etc) that arose during trauma but were surpressed to survive. Safely exploring these and taking pleasure in them can restore a sense of agency.
Van der Kolk discusses studies showing that Cognitive Behavioral Therapy (CBT), effective for treating irrational anxieties, doesn't heal trauma for most. Healing doesn't just mean recontextualizing the past, but also requires connecting to the present & everyday.
"Over the past two decades the prevailing treatment taught to pyschology students has been some form of systematic desensitization: helping patients become less reactive to certain emotions and sensations." Desensitization blunts our emotional sensitivity: the opposite of healing
Studies showed promising results for using Ecstacy to treat ptsd! It "increases people's awareness of themselves". People report "a heightened sense of compassionate energy, accompanied by curiosity, clarity, confidence, creativity, and connectedness." Things that help healing!
Balancing this optomism: "Pyschedelic substances are powerful agents with a troubled history. They can easily be misued through careless administration and poor maintenance of therapeutic boundaries." No drug will be a miracle cure, just another tool in the box.
The final chapters of the Body Keeps the Score are deep dives into 6 different cutting-edge (or long-known-but-rarely-acknowledged) approaches to trauma treatment, several of which I had never heard of: EMDR, yoga, IFS, psychomotor therapy, neurofeedback, and communal theater
EMDR is a practice that allows patients to re-integrate trauamatic memories, putting them into the context of their larger life narrative. It takes advantage of the interesting properties of eye motion, which may be related to how REM sleep allows us to draw unlikely connections.
"EMDR doesn't require the patient to speak about the intolerable or explain to a therapist why they feel so upset" and as such "it allows them to stay fully focused on their internal experience, with sometimes extraordinary results." It can be given even over a language barrier!
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