Trauma robs you of the feeling that you are in charge of yourself, [or what is referred to as 'self-leadership'.] The challenge of recovery is to reestablish ownership of your body and your 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. - Bessel van der Kolk
Recently, I finished reading Bessel van der Kolk’s new book, The Body Keeps the Score: Brain, Mind, and Body in the Healing of Trauma. I can’t recommend it enough; the book is incredibly well-written and accessible, and an equally important read for clinicians, trauma survivors, and their loved ones. This post is not intended to be a comprehensive review of the book, but rather a few points that I wanted to pull out and highlight to convey some of the “big picture” ideas about traumatic stress and trauma resolution.
Why Diagnosing Trauma Matters
As a psychiatrist at the Veterans Administration (VA) in the late 1970’s, van der Kolk witnessed first-hand the impact of traumatic stress on vets returning from Vietnam. At that point, there was no diagnosis for traumatic stress, and very little research into the impacts of trauma on the functioning of mind and body, or how to successfully treat the symptoms these vets were struggling with. In 1980, a group of researchers and clinicians lobbied the American Psychological Association (APA) to include Post-Tramatic Stress Disorder (PTSD) in the DSM-III (third edition of the Diagnostic and Statistical Manual of Mental Disorders). (Gotta love the alphabet soup of healthcare, eh?) The creation of this new diagnosis resulted in a flurry of interest and funding for research and the development of effective interventions for treating post-traumatic stress.
Thirty-five years later, thanks to a wealth of research as well as major advancements in neuroscience, we know a lot about how trauma affects the mind and body and how to effectively treat it. But we’re far from done. Many studies have pointed to the need for additional trauma-based diagnoses, as traumatized individuals don’t all fall into one homogenous category. Different types of trauma impact the body and brain in different ways, and a one-size-fits all diagnostic and treatment approach is woefully insufficient. One study found that traumatized people fell into three basic groups: those with histories of childhood physical or sexual abuse by caregivers, recent victims of domestic violence, and people who had recently been through a natural disaster. The failure of the APA to acknowledge a need for additional diagnoses like Developmental Trauma Disorder (DTD) and Complex PTSD (also known as DESNOS, Disorders of Extreme Stress, Not Otherwise Specified for victims of interpersonal trauma) has a very real impact, as a lack of sufficient funding for research and treatment directly impacts individuals struggling with traumatic stress that do not fit in the “traditional PTSD” box. I will avoid going off on a tangent about just how broken the DSM is, but suffice to say that the American Journal of Psychiatry and the National Institute of Mental Health have both published strong criticisms of the DSM-V, with NIMH’s president stating that the agency could no longer support DSM’s “symptom-based diagnosis.”
One of the topics that fascinated me most in The Body Keeps the Score was the information van der Kolk presents about DTD. I could see so many of my clients in his case studies and descriptions of how traditional mental health treatment fall short for these individuals. He makes a compelling case for child abuse as our nation’s largest public health problem, and as a therapist working with traumatized clients, I couldn’t agree more. So, whether the DSM ever gets on board or not, clinicians need to acknowledge these distinctions and the unique needs of trauma survivors that may not look like the “typical” PTSD patients. Where do we start?
“Top-Down” and “Bottom-Up” Regulation
Van der Kolk asserts that, when your brain has been impacted by traumatic stress and the areas responsible for emotion regulation are out of whack, we essentially have three choices for how to help our brain regulate, utilizing its own natural neuroplasticity. Some of the examples of treatment modalities and interventions below actually combine two or all three of these, and trauma survivors almost always need a combination of these rather than just one in order to achieve regulation.
1) Top-down regulation (via modulating messages from the medial prefrontal cortex):This type of regulation involves “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.” It's also about strengthening your mind’s ability to monitor your body’s sensations, so mindfulness, meditation, and yoga can be helpful interventions. More traditional methods of psychotherapy such as Cognitive Behavioral Therapy (CBT), and coping skills training like Dialectical Behavior Therapy (DBT) can be valuable for this type of regulation as well, but it’s important to remember that talk therapy alone is not enough for trauma resolution.
2) Working directly with the brain: This can be achieved through taking psychiatric medications that “shut down inappropriate alarm reactions” or utilizing technologies such as neurofeedback and eye movement desensitization and reprocessing (EMDR) that fundamentally change the way the brain organizes information.
3) Bottom-up regulation (via the reptilian brain, specifically the amygdala): This type of regulation focuses on "allowing the body to have experiences that deeply and viscerally contradict the helplessness, rage, or collapse that result from trauma.” From a neuroscience perspective, it involves recalibrating the autonomic nervous system, which can be accessed through breath, movement, or touch. Thus, interventions such as breath work, dance, massage, somatic and experiential therapies, and utilizing biofeedback (for example, to improve heart rate variability) can be very effective. Yoga is also valuable for bottom-up regulation, as it is proven to significantly improve arousal problems in traumatized individuals, increase self-awareness and self-regulation, and cultivate interoception by "gaining a relationship with the interior world, and with it a caring, loving, sensual relationship to the self.”
What Does it All Boil Down To?
At the end of the day, trauma treatment is about helping people to:
- find a way to become calm and focused;
- learn to maintain that calm in response to images, thoughts, sounds, or physical sensations that remind them of the past;
- find a way to be fully alive in the present and engaged with the people around them; and
- not have to keep secrets from themselves, including secrets about the ways they have managed to survive (often self-destructive behavior patterns that originated as protective defenses.)
As van der Kolk reminds us, “these goals are not steps to be achieved, one by one, in some fixed sequence. They overlap, and some may be more difficult than others, depending on individual circumstances.”
I was tremendously inspired by this book, as it validated many of the trauma treatment methods we use with clients on a daily basis at The Ranch, and helped me understand more about the neuropsychological underpinnings of both trauma and trauma recovery. I’m also excited to get my EMDR certification later this year as well as start yoga teacher training in the fall. We need a lot more clinicians who understand the “big picture” of trauma treatment based on the most recent research, and are open to the wide range of holistic interventions to help people find health and healing in mind, body, and spirit.