Wednesday, September 10, 2014

The Limits of Talk - An Interview with Bessel van der Kolk

Bessel van der Kolk has been a central figure in the study and treatment of traumatic stress for more than two decades. Among the books he has (co)written or (co)edited are Psychological Trauma (1987) Traumatic Stress: The Effects of Overwhelming Experience on Mind, Body, and Society (2006), Treating Complex Traumatic Stress Disorders (Adults): Scientific Foundations and Therapeutic Models (2013, reprint edition), and his newest book is The Body Keeps the Score: Brain, Mind, and Body in the Healing of Trauma (September 25 release date).

Posted below are the first few pages of an interview he did with Psychotherapy Networker magazine. The title link will take you to the full PDF of the interview.

The Limits of Talk

Bessel van der Kolk wants to transform the treatment of trauma
by Mary Sykes Wylie

Psychotherapy Networker:
The Limits of Talk
For more than 20 years, Bessel van der Kolk has been in the forefront of research in the psychobiology of trauma and in the quest for more effective treatments. Now he’s touched off an intense debate about the role of scientific evidence in finding ways to alleviate suffering and the future of the traditional talking cure itself.......

Bessel van der Kolk likes to introduce his workshops on Post-Traumatic Stress Disorder (PTSD) with medical film clips from World War I showing veterans diagnosed with what was then called “shell shock.” In these dramatic and riveting clips, one soldier sits hunched over on his hospital cot, staring blankly ahead, responding to nothing and nobody until the single word “bomb” is said, whereupon he dives for cover underneath the small bed. Another man lies almost naked on the bare floor, his back rigidly arched, his arms and hands clawing the air as he tries, spasmodically and without success, to clamber onto his side and stand up. Yet another, who once bayoneted an enemy in the face, now opens his mouth wide into a gaping yaw and then closes it, and opens it and closes it, over and over and over again.

The images are disturbing, heartbreaking, and all the stranger because these particular men, technically speaking, are physically unharmed. Their physical symptoms-paralysis, violent trembling, spasmodic movements, repetitive facial grimaces, zombie-like demeanor-look exotic to our eyes because PTSD generally doesn’t show up like this anymore in most clinicians’ offices. Time and Western cultural evolution have changed the way traumatized people express their distress in a therapist’s office. Now, trauma patients may look fine on the surface, but complain of nightmares, flashbacks, feelings of numbness, generalized fearfulness, dissociative symptoms, and other problems that aren’t as visible to the world at large. But to van der Kolk, these old images still represent what he calls the “pure form” of PTSD. The appearance in these World War I film clips that the veterans are possessed, mind and body, by invisible demons still captures the fundamental truth about PTSD-that it can reduce its victims to mute, almost animal-like, creatures, utterly isolated in their fear and horror from the human community.

Van der Kolk first became aware of the world of trauma in 1978, when he decided to go work for the Veterans Administration (VA), not to study PTSD (it hadn’t been recognized yet as a formal diagnosis), but to get the government benefits to pay for his own psychoanalysis. While there, he discovered the reality of PTSD - and the beginnings of a stunning, nationwide phenomenon. “At that time, tens of thousands of men who’d served in Vietnam suddenly seemed to come out of the woodwork, suffering from flashbacks, beating their wives, drinking and drugging to suppress their feelings, closing down emotionally,” recalls van der Kolk. “It was a phenomenon that spawned a whole generation of researchers and clinicians fascinated by what had happened to these guys.”

Van der Kolk himself soon became intrigued by the mysterious mental and emotional paralysis that seemed to afflict these traumatized veterans. Why, he wondered, did many of his patients seem so stuck emotionally in their horror that they relived it over and over in flashbacks and nightmares? What kept these men circling round and round on an endless treadmill of memory, unable to step off and resume life? In spite of their obvious suffering, why did they seem so obsessively attached to their traumatic experiences?

In the 25 years since then, the trauma field has gone from obscurity, if not disreputability, to become one of the most clinically innovative and scientifically supported specialties in mental health. Trauma researchers have led the pack in setting off an explosion of knowledge about psychobiology and the interaction of body and mind. And van der Kolk, as much as anyone else in the field, has defined the current framework for understanding trauma.

He’s the author of more than a hundred peer-reviewed scientific papers on subjects such as self-mutilation, dissociation, the therapeutic efficacy of Eye Movement Desensitization and Reprocessing (EMDR), the developmental impact of trauma, and the nature of traumatic memories. He’s also been a featured contributor in most of the standard textbooks in the trauma field. In addition to teaching at Boston University, Tufts, and Harvard, he directs the Trauma Center in Boston, possibly the largest trauma specialty center in the country, with 40 clinicians working with clients who range from infants to geriatrics, from incest survivors to international torture victims. Inhabiting both the world of the clinician and the researcher, he also runs a major research laboratory at the Trauma Center, staffed by 15 researchers who investigate everything from neuroimaging of treatment effects on the brain to the effects of theater groups on violent, traumatized teenagers.

Glowing testimonials about his contributions aren’t hard to come by from the field’s leading lights. “Very early on, more than anybody else, he introduced neurobiology to the trauma field, and helped us see the interaction between mind and body in trauma,” says Charles Figley, professor at the School of Social Work at Florida State University and Vietnam vet, whose early work on war trauma is often credited with prompting the inclusion of PTSD as a diagnosis in the DSM. “He’s one of the most generative and creative minds in the trauma field, and his influence has been pervasive,” says psychiatrist Judith Herman, renowned trauma expert at Harvard Medical School.

At the same time, van der Kolk is also one of the trauma field’s most controversial figures. Often prickly, rarely shy about offering his own opinions, and unafraid of a good fight, he’s scandalized a number of cognitive-behavioral therapists and academic researchers by openly embracing EMDR, demonstrating an interest in such truly outrĂ© techniques as Thought Field Therapy, enthusiastically taking up nonstandard somatic therapies, and even sending his patients off to participate in theater groups and martial arts training.

Van der Kolk’s bold criticism of the orthodoxies of psychotherapy and public advocacy of somatic approaches have, in particular, outraged many. “Advocating unproven body psychotherapies is professionally irresponsible,” says Edna Foa, professor of psychology in the psychiatry department at the University of Pennsylvania. “He’s marginalized himself as a scientific thinker-he’s no longer in the mainstream,” adds Richard Bryant, noted trauma researcher and psychology professor at the University of New South Wales in Australia. “Until he provides data in support of his new [somatic] approach, the field isn’t obligated to pay any attention to what he’s doing,” sniffs psychologist Richard McNally, author of the widely cited Remembering Trauma, a critique of recovered-memory theory.

The intensity of response van der Kolk kicks up is an indication of the crusader’s fervor underlying his work and his determination to make the field viscerally understand that trauma isn’t simply a neutral mental health issue, but a profoundly moral concern. Spicing his talks with earthy, Dutch-accented American slang, van der Kolk regularly reminds his audience in a tone of subdued indignation that trauma forces the reality of human evil into our consciousness, often the evil of presumably good and upright people-our neighbors, our leaders, our families, and ourselves. It’s not a perspective people always welcome because, as he writes in his book Traumatic Stress, most of us like to believe “that the world is essentially just, that ‘good’ people are in charge of their lives, and that bad things only happen to ‘bad’ people. . . . Victims are the members of society whose problems represent the memory of suffering, rage and pain in a world that longs to forget.”

A Diagnosis Non Grata

While trauma is always clinically described as a horrifically abnormal event, for any casual student of the human condition, it’s actually a perfectly normal feature of history, one that has emotionally scarred billions of men, women, and children since before the beginning of recorded time. And yet, while philosophers, writers, and ordinary people have always known that terrible events can cause a lifetime of psychological pain, until the latter part of the 20th century, mental health professionals were oddly blind to this fact of life. “Psychiatry itself has periodically suffered from marked amnesias in which well-established knowledge has been abruptly forgotten,” writes van der Kolk in Traumatic Stress, “and the psychological impact of overwhelming experiences has been ascribed to constitutional or intrapsychic factors alone.” In other words, a failure to “get over” a trauma was often ascribed to personal weakness or an unconscious desire not to recover.

Even the official nosology of the psychiatric profession reflected this peculiar obtuseness. The 1952 edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-I) had included combat-related stress under the diagnosis of “gross stress reaction,” but this was dropped from the DSM-II in 1968-the same year that troop strength reached its peak in Vietnam. All that was left of trauma in DSM-II was the pallid diagnosis “adjustment reaction to adult life,” under the general heading of “transient situational disturbance.” Adjustment reaction was a grab-bag diagnosis, including “fear associated with military combat and manifested by trembling, running and hiding” and “unwanted pregnancy.” It wasn’t until 1980, after years of lobbying and wrangling, that PTSD was included in DSM-III.

So when van der Kolk first went to the VA in 1978, not only was there no official traumatic stress diagnosis, but the VA assumed that any psychiatric problems occurring more than one year after discharge couldn’t be related to military service. Besides denying veterans any compensation for delayed traumatic reactions probably the overriding consideration in the VA’s longstanding lack of interest in the enduring impact of “combat stress”-this rule effectively scotched any research or clinical treatment directly focused on trauma. “When I went to work for the Boston VA,” remembers van der Kolk, “there wasn’t a single book in the library on war neurosis.”

Unable to do research on war trauma because the VA wouldn’t fund studies on a diagnosis that didn’t exist, van der Kolk and his colleagues did the first study ever on the real nightmares the vets had and, in another first, used the Rorschach inkblot test to reveal the twin pattern of hyperarousal and dissociation that traumatized vets showed. For van der Kolk, this research pointed to the paradoxical conundrum at the heart of trauma. “This is still the issue with traumatized people-they see and feel only their trauma, or they see and feel nothing at all; they’re fixated on their traumas or they’re somehow psychically absent.” In either case, traumatic memories from the past have utterly usurped the present.

By the late-1980s, van der Kolk had had extensive experience working with vets and was becoming a well-known figure among PTSD researchers. He’d been responsible for several important studies, including, besides the Rorschach and nightmare papers, research into psychopharmacology and trauma, and had published the book Post-Traumatic Stress Disorder: Psychological and Biological Sequelae, the first book published specifically about PTSD. But in spite of his impressive re´sume´, he felt deeply discouraged. He’d learned a lot, but he didn’t think he was fundamentally helping his patients. Even after months or years of work, his patients still suffered from flashbacks, nightmares, depression, aggressive rage, anxiety. They still either couldn’t talk about their trauma at all or when he pushed them to talk about it - as he and many therapists often did, and still do - they began hyperventilating, shaking, yelling, crying, became physically agitated, or just collapsed in a state of helpless fear and dread. “I’d become a reputable PTSD researcher and clinician, but I felt I’d utterly failed my patients,” van der Kolk remembers. “I guess they thought I was a good guy, they felt understood by me, but that didn’t necessarily help them to get back into their lives.”

And what was the treatment that he felt was not really helping his patients to move on? It was standard talk therapy 101-helping them explore their thoughts and feelings-supplemented with group therapy and medications. During individual sessions with clients, he often focused intensely on patients’ past traumas, in the interest of getting them to process and integrate their memories. “I very quickly went to people’s trauma, and many of my patients actually got worse rather than better,” he says. “There was an increase in suicide attempts. Some of my colleagues even told me that they didn’t trust me as a therapist.”

The Neurobiology of Trauma

The fundamental conundrum of how trauma affects the mind and body that still plays out in treating trauma survivors was already crystallizing in van der Kolk’s mind 20 years ago. “When people get close to reexperiencing their trauma, they get so upset that they can no longer speak,” he says. “It seemed to me then that we needed to find some way to access their trauma, but help them stay physiologically quiet enough to tolerate it, so they didn’t freak out or shut down in treatment. It was pretty obvious that as long as people just sat and moved their tongues around, there wasn’t enough real change.”

Back in the early 1980s, believing that future progress lay in a better understanding of the biology particularly the neurobiology of trauma, van der Kolk had applied for a VA research grant on the subject. Even though PTSD was now “official,” his proposal was turned down flat. The opening sentence of the rejection letter still vividly resonates in his mind. “It’s never been shown that PTSD is relevant to the mission of the Veterans Administration.” Since then, the VA has grown up and become a leading supporter and funder of trauma research, but in the early ’80s, it was clearly a diagnosis non grata to the establishment. Both dumbfounded and enraged by the VA’s response, van der Kolk says he never read past that first sentence, and decided right then to seek greener pastures and put in his notice.

He moved back to the Massachusetts Mental Health Center, a state hospital and psychiatric teaching institution associated with Harvard Medical School, where he’d received his psychiatric training and, before that, had spent a year as a mental health worker on a research ward for unmedicated schizophrenic patients. Here he discovered how easy it is for the best-intentioned therapist to inadvertently make traumatized patients worse. He was struck how some female patients fell apart during personal contacts with him and other male staff, becoming agitated and assaultive. Why would they so suddenly switch from being pleasant and sensible, to losing their minds when a man would pay attention to them? he wondered. Looking into the histories of the women, most of whom had been diagnosed as borderlines or schizophrenics, he found that they’d all been severely and chronically sexually abused as children and adults.

Van der Kolk began to realize that, for these women, being in a room alone with a man who directed questions at them emotionally hurled them back into their traumas. He noted that their entire bodies responded as if they were being molested again-heart pounding, muscles tensing-they seemed, literally, to take leave of their senses-unable to distinguish now from then. “It seemed that their traumatic memories, like those of Vietnam veterans, prevented them from being able to modulate their autonomic arousal,” he observes. “Their physiological housekeeping systems had been messed up by trauma.”

It now seemed to him that chronic trauma explained a great deal about how borderline patients acquired their deep impairments, and why they were so hard for therapists to treat. “Borderlines have a terrible reputation because they often are simply impossible,” says van der Kolk. “They cling to you and then hate you, and, either way, they won’t leave you alone. But if you look at their behavior through their traumatic background, it makes perfect sense. If you’ve been raped and abused for years as a child and adult, your entire organism and personality has been organized around your trauma. If they have PTSD, the way they act is understandable-they’re not just people trying to make your life miserable, but people trying to survive.”

Van der Kolk’s experience with borderlines reinforced his belief that talk therapy by itself, even in the context of a warm, supportive therapeutic encounter, wasn’t enough to reverse the profound physical and emotional changes wrought in his patients by pervasive trauma. But he credits Hurricane Hugo with showing him see just how physical helplessness contributes to the development of serious post-traumatic symptoms, and making him wonder if physical movement might not contribute to healing.

In 1989, directly after Hurricane Hugo had ravaged Puerto Rico, van der Kolk accompanied FEMA officials to lend his expertise to dealing with the traumatic aftermath of the devastating storm. “I arrived in the middle of this devastation, and what I saw were lots and lots of people working with each other, actively putting their lives back together-carrying lumber, rebuilding houses and shops, cleaning up, repairing things.”

But the FEMA officials immediately told everybody to cease and desist until assorted bureaucracies could formally assess the damage, establish reimbursement formulas, and organize financial aid and loans. Everything came to a halt. “People were suddenly forced to sit still in the middle of their disaster and do nothing,” van der Kolk remembers. “Very quickly, an enormous amount of violence broke out-rioting, looting, assault. All this energy mobilized by the disaster, which had gone into a flurry of rebuilding and recovery activity, now was turned on everybody else. It was one of the first times I saw very vividly how important it is for people to overcome their sense of helplessness after a trauma by actively doing something. Preventing people from moving when something terrible happens, that’s one of the things that makes trauma a trauma.”

Pondering this striking lesson, van der Kolk wondered if perhaps the most damaging aspect of trauma wasn’t necessarily the awfulness of it, but the feeling of powerlessness in the face of it, the experience of being unable to escape or fight or have any impact on what was happening. “The brain is an action organ,” he says, “and as it matures, it’s increasingly characterized by the formation of patterns and schemas geared to promoting action. People are physically organized to respond to things that happen to them with actions that change the situation.” But when people are traumatized, and can’t do anything to stop it or reverse it or correct it, “they freeze, explode, or engage in irrelevant actions,” he adds. Then, to tame their disorganized, chaotic physiological systems, they start drinking, taking drugs, and engaging in violence-like the looting and assault that took place after Hurricane Hugo. If they can’t reestablish their physical efficacy as a biological organism and recreate a sense of safety, they often develop PTSD.
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