Bessel van der Kolk - The Body Keeps the Score (Part Two)

The title of this talk is the nearly identical to that of a new book from Bessel van der Kolk due out in June, 2014 The Body Keeps the Score: Brain, Mind, and Body in the Healing of Trauma (pre-order at Amazon). I will be excited to see this new work - his research in the recent years has focused on yoga, tapping (Emotional Freedom Technique), chi gong, and neurofeedback, among other body-centered modalities for healing trauma.

What follows are my notes, as best as I can make them sensible from yesterday's 3 hour talk. This is part two - part one is here. This second installment is more than half of the talk and it gets into the neuroscience a lot more.


The Body Keeps the Score, Part II

Mental illness is now conceived of as a dysfunction in brain wiring or function. However, 80-90% of our brain function is outside of our conscious control (fast thinking, or Type I), and only 10-20% of our brain function is consciously controlled (slow thinking, or Type II). [I am including the references to Daniel Kahneman's work, BvdK didn' t make these references].

Our brain stem does the basic housekeeping in the brain - controlling arousal, sleep, breathing, food/elimination, and chemical balance, among other things. In working with trauma, these core regulation functions must be stabilized BEFORE we can do any kind of deeper work. All of these functions, however, are outside of our verbal influence - we cannot talk our way to better sleep or out of hyper-arousal. Traditional talk therapy is helpless to reset these physiological regulatory functions.

Development

The limbic system comes online at birth and develops extensively through about age six, after which the primate brain is more the developmental focus. The limbic system controls right brain function (see Allen Schore), including affect regulation, interpersonal skills, and the core map of our self in relation to the world. [When Schore writes about affect dys/regulation and the development of the self, he is basically outlining the ways trauma impacts this core self map.]

Survivors of incest or molestation, and/or extreme neglect often talk about how they are evil or damaged or worthless. When we tell them that is not true, it can make them feel even worse, more alone and misunderstood - despite our good intentions, we have just told them again how wrong they are, even about their own reality. They need for us, as their therapists, to get how ugly they feel about themselves, how ugly their core self map really is.

We need to help them go inside themselves with an adult ego and notice what happened to them without dissociating or avoiding. There is no need to relive the memories, only to witness them as an observer (the reliving of a memory is known entering the memory field). If they bring adult awareness to wounded child-part of themselves, it becomes easier to regulate the core brain stem functions. [This is the foundation of self compassion training.]

Brain Anatomy

According to Antonio Damasio, fear is held in the cerebellum and brain stem (including the amygdala), but these systems are not accessible by the cerebral cortex or the prefrontal cortex. In addition, the insula (which plays a major role in sense of self, acting as an integration point between body systems and higher order functions), is nearly always damaged in trauma survivors.

Because of this, the core experiential self (Damasio's proto-self) gets hijacked by the trauma - yet this experiential self is essential in healing the trauma. The only way to heal this self through verbal approaches is to describe it in very precise sensory detail (smells, sounds, tastes, pressure on the skin, and so on). Again, this is a challenge because the left anterior prefrontal cortex (including Broca's Area) goes offline when the trauma system is activated, which limits the ability to talk about it.

When the trauma system is activated there is a shift to right brain function, including the amygdala, the insula, and the anterior temporal lobe. As this occurs, the dorsal lateral prefrontal cortex (site of working memory, integrating past, present, and future) goes offline, which is why we get stuck in the trauma as if we are always in that horrific moment/experience. Negative cognition's are often a form of verbal flashback to thoughts we had while in the neurochemical soup of the trauma experience.

The thalamus integrates sensory and temporal data into a story explaining who we are, where we are, and what we are doing. This process is seriously compromised in trauma so any sense data similar to the original sensory data triggers a flashback experience.

People who shut down or dissociate during the trauma experience can often remain in that state even while retelling their story - unless we can get them to focus on their interiority (interception) as experienced in sensory data during the traumatic event. In these survivors, brain activity throughout the whole brain is two standard deviations lower than the norm.

Emotional Freedom Technique

BvdK uses "tapping" to get dissociated people back into their bodies. EFT, which is based on pressure points, causes a decrease in limbic system activity, making it a solid grounding technology even where the verbal system fails. He is currently researching EFT, qi gong, chanting, and "om-ing," which seem to offer similar benefits.

Amygdala

The following information is based on a graph based on the work of Joseph LeDoux.

There are two pathways for threats to follow when they activate the limbic/amygdala (LA):

1. The threat can move from the LA to the basal ganglia, associated with movement, which leads to active coping (planning, action)

2. The threat can move from the LA to the central nucleus of the amygdala, which leads to passive coping (freeze, despondency). [BvdK did not mention this directly, but this what we often see in those with a number of adverse childhood experiences.]

Van den Kolk believes an amygdala stuck in these patterns can be rewired. Action resets the amygdala. Activities like boxing, tai chi, akido, and other martial arts are treatments, not simply physical activity. We need a visceral impact of something that felt bad (being connected to and in our bodies) now feeling good in order to rewire the amygdala. He is doing research on exactly this idea.

More information from Joseph LeDoux that supports BvdK's model:

As mentioned above, the dorsal lateral prefrontal cortex is where our working memory resides, as well as being the location of planning. It has no direct access to the amygdala and the limbic system, information out simply feeds back in.

However, the medial prefrontal cortex (and to a lesser extent, the posterior cingulate), which is where we process inner experience or interoception has a direct link to the amygdala and limbic system. This is the only system through which we can access and change our emotional self. This is the power of mindfulness practice, it's centered in the MPC. Dan Siegel is the current expert in this realm.

The moment of trauma often feels like forever because the dorsal lateral prefrontal cortex is offline during the initial trauma experience. The fact that Broca's Area also is offline during the experience means we have no words or language associated with the experience. We have images and other sense data, but not language.

The Body in Trauma

Trauma survivors often can't tell us where they feel things in their bodies. The body is too scary of a place to go into for them. We need to be persistent to get them to go inside, to activate the MPC. However, the earlier the trauma the harder it is to get them to go inside because they have no experience of interception that is not terrifying.

Part of the healing process involves helping them to feel safe in their own interior world, possibly for the first time. However, when clients go into the images, sounds, scents - into the wounding - the arousal system is activated, so we must monitor their reactions to keep them in the experience and not retreating into the story.

Trauma Repetition

BvdK has a theory that part of trauma repetition might be due to the release of endogenous opioid chemicals (about 8 mg worth) during the original trauma experience. Replaying the trauma activates all of them same brain chemicals as the original trauma, but in the absence of pain, the opioid drugs alter consciousness and can also generate nausea (many clients describe feeling sick after a replay of the original trauma.

Part of trauma repetition may be self-medicating with our own brain chemicals.

Internal Family Systems

BvdK has done considerable work with Richard Schwartz on his Internal Family Systems Therapy model, including appearances at the IFS conference. In this final piece of the talk, he brings in IFS as a way to work with emotions "exiled" in the body.

Allowing ourselves to feel the grief or fear or terror of the trauma and then use our adult self to comfort that wounded part of us brings the medial prefrontal cortex into connection with the trauma. It's somatic, experiential, and nonverbal.

Incest survivors almost universally hate and/despise the child part that was the victim of the molestation, which is likely true in survivors of repeated physical abuse or neglect.

These hated and despised parts of ourselves are known as exiles in the IFS model. It is the exile that holds the trauma memories and sensory data.

[ME: The psyche, through manager parts (pleaser, perfectionist, inner critic, for example) try to keep the exiled part locked a psychological closet, preferably forever. Should the managers fail, there are parts called firefighters whose job it is to jump into action and prevent those pesky exiles from breaking through into consciousness, usually through addictive behaviors (and even the addictive behaviors will one day fail.)