The Blog of Marek Cottingham
By Bessel van der Kolk
Score: 8/10
Recovering from trauma, particularly from childhood, is a difficult and confusing process. Bessel van der Kolk presents a different paradigm for thinking about trauma, discussing how unprocessed memories can lead to subconscious physical responses and how one can learn to become aware of and take control of this process. The book goes into significant depth, drawing on more recent research and on the author's clinical experience. While at times more detailed than is necessary for the non-clinician reader, it is well worth the read for those interested in the topic, whether for their own personal struggles or to gain perspective on this area of mental illness.
When we experience trauma, we don't process the memories. Instead, we seperate them from our psyche (disassociate) keeping them apart from us so that we can continue to live our lives. However, if we are exposed to a trigger, we flashback into that memory, adopting the emotional state of the time as if the memory is occuring in the present, as we have not processed the memory properly.
As is reflective of the importance we place on group social bonds, our first response to danger or hardship is to cry out to help from others. (Mediated by the ventral vagal complex - VVC)
In trauma survivors, the VCC is underengaged, while the DVC is over engaged. This may cause us to shut down and feel awkward in supposedly safe, normal situations, like a party. This response often cannot be overruled merely by a top down rational analysis approach, as the allocation of control to these circuits occurs at a lower level in the brain. Instead, we must be taught to engage more using our VCC, via physically interacting with others (eg. physical play).
Children can develop a disordered (anxious-avoidant) attachment style when their caregiver is grossly neglectful, but most often when they come to fear their caregiver. This can happen because their caregiver regularly fails to understand emotional cues from the child. This failure to understand often explains how parents become abusive to their children. As the child becomes increasingly distressed and resistant, the mother becomes frustrated or defeated, coming to see the child as someone they need to contend with.
Children with avoidant or anxious-avoidant attachment styles may consciously think that they are not emotionally impacted, but will exhibit physical signs of readiness, such as elevated heart rate. Dissociative symptoms are specifically associated with childhood neglect, not showing up in cases involving abuse only in later life.
Where language and talk therapies can be effective is in their ability to provide an outlet for expression of experience. An initial label for an experience can allow us to start conceptualising it, thus starting to remove it from the limbo traumatic memories are stored in.
Trauma can leave people with physical symptoms: eg. tightness in the chest or in the gut. By learning to recognise these and how the way we feel changes when performing actions like breathing deeply, we become aware of our bodies and how to release this tension. We become able to recognise when we feel safe or anxious physically, which is a prerequisite to feeling safe mentally.
Theater can have a transformative effect on people, as by learning to act in a role as a character, we learn to act out a different version of ourselves, which we can over time expand broadly into all areas of our life.
Theatre programs also often involve exercises in reciprocity, which teach us to interact with others while paying attention to the physical actions (body language) of the other person. They can eventually build this up to the level of getting people to engage in continued eye contact, which is important to allowing us to understand others to be able to come to trust them.
These subpersonalities dominate at different times. Since they are often responsible for guiding conflicting reactions: grandiosity vs. self-criticism, rage vs. withdrawal vs. openness, they can come into conflict with each other, leading to repetitive negative thoughts.
A therapist cannot 'fix' a patient, they can create a safe environment for a patient to work on themselves.
There are two modes of regulating danger (fight-flight-freeze) response: top down from the cortex (rational contextualising) and bottom up from the amygdala (movement, sensory changes). In people with trauma, the amygda has too much control in this system.
When we experience trauma, we don't process the memories. Instead, we seperate them from our psyche (disassociate) keeping them apart from us so that we can continue to live our lives. However, if we are exposed to a trigger, we flashback into that memory, adopting the emotional state of the time as if the memory is occuring in the present, as we have not processed the memory properly.
Some people will go to a greater extreme: depersonalisation, where they become completely cut off from memories of the traumatic event, blanking out when exposed to triggering stimuli. However, they still experience the emotional response to a degree, despite being unable to recall what is causing it.
As is reflective of the importance we place on group social bonds, our first response to danger or hardship is to cry out to help from others. (Mediated by the ventral vagal complex - VVC)
If no help arrives, we switch to the "sympathetic nervous system". This connects to our heart and lungs, accelerating our heart and breathing rate and preparing us for a flight or fight response. This is what cause people to rage or to panic in the face of perceived danger.
Finally, if unable to act to protect ourselves, a freeze response is induced. (eg. when trapped) This plummets metabolic activity and causes us to ultimately lose awareness. (Mediated by the dorsal vagal complex - DVC)
In regards to our highly social nature, we spend a large section of our effort empathising with other. When we see someone else perform an action or express an emotion on their face, our mirror neurons fire, causing us to experience the same emotion or to tense our muscles, ready to replicate the same movement.
In trauma survivors, the VCC is underengaged, while the DVC is over engaged. This may cause us to shut down and feel awkward in supposedly safe, normal situations, like a party. This response often cannot be overruled merely by a top down rational analysis approach, as the allocation of control to these circuits occurs at a lower level in the brain. Instead, we must be taught to engage more using our VCC, via physically interacting with others (eg. physical play).
Often times, some people might struggle at first to engage with other people. However, our VCC is also triggered upon interaction with other animals. Because of this, working with dogs and horses has become an established form of therapy for trauma survivors.
Psychological trauma is physically learned when we experience a flight or fight response, but are unable to act it out, leaving us helpless to protect ourselves from danger. Our body becomes stuck in the trauma, elevating stress hormones and preventing us from recovering.
Flashbacks, such as in PTSD, are also characterised by a suppression of certain language processing regions of the brain, indicating that people struggle to articulate the feelings that occur during a flashback.
The formation of healthy parental attachment in early childhood is critical for healthy psychological development. It is also a significant predictor of how children will respond to a traumatic event later in life. Most children form their primary attachment bond with their mother.
If care from their mother is inconsistent, children may develop an anxious or avoidant attachment style. This allows them to adapted to their caregiver's inconsistencies, either by becoming resilient to them or by forcing attention.
Children can develop a disordered (anxious-avoidant) attachment style when their caregiver is grossly neglectful, but most often when they come to fear their caregiver. This can happen because their caregiver regularly fails to understand emotional cues from the child. This failure to understand often explains how parents become abusive to their children. As the child becomes increasingly distressed and resistant, the mother becomes frustrated or defeated, coming to see the child as someone they need to contend with.
Children with avoidant or anxious-avoidant attachment styles may consciously think that they are not emotionally impacted, but will exhibit physical signs of readiness, such as elevated heart rate. Dissociative symptoms are specifically associated with childhood neglect, not showing up in cases involving abuse only in later life.
Generally, in order to modify their attachment style, it helps patients to engage in activities involving synchronicity with others in regards to sensory and physical feedback. This can include playing team sports, singing or dancing.
Following trauma we become less aware of physical sensations within our own body. We can fail to recognise both sensations caused by external stimuli such as touch and sensations caused by our own emotional systems triggering.
Following severe trauma, we may fail to recognise our emotional state or the physical sensations such as discomfort in the gut. This is because trauma victims desensitise themselves to sensations from their trauma, to protect themselves from further harm.
Exposing people to physical touch on various part of their body can help them overcome this, by allowing them to once again be aware of detailed physical sensations. Additionally, it is helpful for us to become consciously aware of physical sensations which may relate to negative or positive emotions, in order to regain a better ability to quickly determine how we are feeling.
Trauma can make it difficult to connect with new people through two mechanisms. First we find it difficult to approach others. When we meet a stranger's gaze, instead of engaging in prefrontal activation in order to evaluate them, we experience a subconscious triggering of the fear circuit. Similarly, trauma victims suffer from a situation where they both have a strong craving for physical contact and a great fear of it.
The physical links to trauma can be very powerful. eg. Survivors of childhood trauma are 50 times more likely to have asthma than usual.
Recovering from trauma requires that the person is able to re-integrate the traumatic memory into their conception of themselves. Here, talk therapies can be of some help; however, often parts of consciousness which help process the trauma aren't activated during a flashback, blocking integration.
In these cases, patients can benefit from focusing on being able to observe their own feelings without becoming too drawn in (mindfulness), which can allow them to slowly move towards more and more traumatic memories.
In this regard, activities which aid awareness of the body such as yoga, massages or acupuncture can be beneficial.
CBT has limited efficacy with individuals with PTSD. Exposure to triggers risks complete re-traumatisation, which is generally counter productive. Additionally, being able to be exposed to and recall events, while useful to deal with anxiety and fear, cannot address guilt and shame which is often present.
Prolonged re-exposure is also not a truly effective treatment. While patients may appear to by less traumatised because they are less reactive, they have actually simply become further desensitised to the trauma and oftentimes, the rest of their life too.
Where language and talk therapies can be effective is in their ability to provide an outlet for expression of experience. An initial label for an experience can allow us to start conceptualising it, thus starting to remove it from the limbo traumatic memories are stored in.
Touch helps people become comfortable with the boundaries of their bodies and sensitive to feeling again.
Trauma can leave people with physical symptoms: eg. tightness in the chest or in the gut. By learning to recognise these and how the way we feel changes when performing actions like breathing deeply, we become aware of our bodies and how to release this tension. We become able to recognise when we feel safe or anxious physically, which is a prerequisite to feeling safe mentally.
Entering into rhythm with others: through song or through movement, can help us feel comfortable once again in their presence.
Theater can have a transformative effect on people, as by learning to act in a role as a character, we learn to act out a different version of ourselves, which we can over time expand broadly into all areas of our life.
Song, dance and theatre also build shared community identities, providing support to the people in them and thus making them more able to act. They also act as a way to diffuse anger, sadness and fear without turning to aggression, either directed outwards or inwards (violence or depression / suicidality).
Through acting and theater, we learn to recognise our own emotions and feelings, express them visibly on our exterior, and that if we do this that others will in turn recognise our emotions.
Theatre programs also often involve exercises in reciprocity, which teach us to interact with others while paying attention to the physical actions (body language) of the other person. They can eventually build this up to the level of getting people to engage in continued eye contact, which is important to allowing us to understand others to be able to come to trust them.
Patient focuses on emotionally distressing memories while also focusing on an external stimuli (general indications for lateral eye movement). Aids memory reprocessing.
Can lead to effective recovery in patients with adult trauma PTSD and quite rapidly too. However, is far less effective in tackling childhood traumatic memories because it can't address the loss of ability to trust resulting from the early betrayal.
Doesn't require patient to tell the clinician about their trauma, allowing them to address things they are uncomfortable talking about.
Can even work in situations where there is poor trust in the patient clinician relationship.
EMDR brain activity shows associations with the memory processing which may occur during REM sleep.
We do not operate as a single 'self' which is always in control
Rather, the mind appears to be divided into a series of sub-personalities
These subpersonalities dominate at different times. Since they are often responsible for guiding conflicting reactions: grandiosity vs. self-criticism, rage vs. withdrawal vs. openness, they can come into conflict with each other, leading to repetitive negative thoughts.
We can identify 3 different types parts of the traumatised mind:
Often times a large part of the work is learning about what each of the parts thinks about the other parts, before asking them to step back to allow the 'self' to consider what it thinks about each part
Each part holds a role in maintaining the person's function, parts shouldn't be criticised or seen as sources of guilt, although this requires time and practise.
By using electrodes affixed to the head, electrical activity in different areas of the brain can be detected based upon when the electrodes are affixed.
These signals can be presented a patient as a game on a screen, where they receive real time feedback about their brain activity. Through attempting to play the game, they can learn to consciously modify their brain activity.
Targeting different regions of the brain to generate various frequencies of 'brain waves' allows selection between a wide variety of effects.
| Position on head | Brain region | Frequency | Effect |
| Temples | - | - | Calm and focused |
| Left brow | Frontal Cortex | Beta waves | Alert focus |
| - | - | Alpha waves | Relaxation |
| Right side | Sensori-motor strip | 11-14 Alpha/SMR | Anxiety relief |
Neurofeedback has been shown to effective to treat epilepsy, PTSD, ADHD, alcohol addiction and even to improve the mental performance of musicians and athletes.
Oftentimes, showing people real time brain imaging results can help them to recognise that their problems are deeply embedded in their neurology and thus to allow them to let go of self blaming thoughts.
Research in the discipline is often underfunded due to limited commercial interest.
By replicating the structure inside our minds in the world outside it, we become more aware of the way we perceive the world in our memories. Furthermore, we are able to restructure the projection onto the physical world in order to restructure the memories we hold.
In the exercise described, a primary participant, the 'protagonist', instructs others to play the roles of various figures in their childhood. These actors act as the characters within the person's internal structure of the world. People are often very specifically aware of how these actors should be positioned. Through the exercise, they can gain access to the feelings that are suppressed regarding their trauma. They can also experience the modification of the scenario, by instructing others to act out their ideal of what 'should' have happened.
The mediator running the exercise makes sure to recognise the feelings and body language of the 'protagonist', allowing them to be recognised.
A therapist cannot 'fix' a patient, they can create a safe environment for a patient to work on themselves.
There is a tendency when treating patients for many clinicians to seek to get the patient to tell them about their trauma, gaining validation from this as a step forward. However, this is not at all the same thing as treating the patient. Often times, in order to help someone deal with an emotional problem, it is not necessary to find out all the details about it, but rather focus should be put on the wellbeing of the person who is supposedly being helped.
Choosing a good therapist:
About 50% of rapes of females occurred when they were less than 15 years old.
10% of the US population now uses at least one psychiatric medication. Prescriptions for these are often very expensive, generating large profits for the responsible companies, despite limited efficacy.
I found it interesting how attachment theory casts doubt on the assertion that poor later life outcomes in fatherless families is due directly to the absence of the father. Rather, this seems to be caused by a lack of attention and care, generally by a mother who is emotionally overloaded, due to a high-stress environment along with potential further psychological problems that would make it hard for her to find a supportive partner. Of course, the father contributes indirectly, through stressing or abusing the mother as well as through their failure to support their partner and reduce the stress they face. (This doesn't account for cases of physical or sexual abuse by a father).