The Evolution of Trauma Treatment

Bessel van der Kolk Shares His Hope for the Future of the Field

Bessel van der Kolk • 2/13/2017 • 10 Comments

Editor's Note: In the January 2017 issue, a group of innovators and leaders look back over different realms of therapeutic practice and offer their view of the eureka moments, the mistakes and misdirections, and the inevitable trial-and-error processes that have shaped the evolution of different specialty areas within the field. Here's one reflection.

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Most people think the field of trauma treatment began around 1980, when the diagnosis of post-traumatic stress disorder (PTSD) was first included in the DSM as a result of a movement among Vietnam veterans. But one could actually go back well over a hundred years, to the work of Charcot and Pierre Janet at Salpêtrière in Paris. In fact, Janet in particular articulated most of the relevant issues about trauma that are being rediscovered today, such as getting stuck in reliving trauma, dissociating, and having trouble integrating new experiences and going on with one’s life. Janet primarily used hypnosis with hospitalized trauma patients to help them put the experience to rest, but his work was largely eclipsed by that of Sigmund Freud, in part because fully recognizing the devastating impact of trauma tends to be too overwhelming for mental health professionals and politicians alike. For example, Freud and his mentor, Joseph Breuer, wrote some outstanding papers on the nature of trauma in the 1890s, but they later repudiated them because suggesting the occurrence of incest in upstanding middle-class families in Vienna was so disturbing to their colleagues.

Ever since, trauma has had a history of cycling between being recognized for the devastating, long-term role it can play in people’s lives and then going underground in the face of resistance to that idea. The horror of trench warfare led to wide recognition of the symptoms of shellshock during World War I, but in 1917 the British general staff put out an edict forbidding the military to use the word shellshock to describe the condition, because they assumed it would undermine the troops’ morale. The same thing happened after World War II, when the world quickly forgot the price that we pay for sending young men (and now women) into combat. Yet all the symptoms that we read about in the newspaper—suicides, drug addictions, family violence, homelessness, and chronic unemployment—have been well documented after every war within modern memory, starting with the American Civil War.

Nevertheless, in the 1980s, as a result of the work of many people like Charles Figley—a Marine vet from Vietnam, who wrote a book called Trauma and Its Wake and started the International Society of Traumatic Stress Studies—trauma began to attract more and more attention in mainstream psychiatry and psychology. Around that time, Judith Herman and I began to study the relationship between borderline personality disorder and self-injurious behavior and early years of trauma and neglect at the hands of caregivers. However, in the early 1990s, just as had happened in 1902, 1917, and 1947, as the study of the trauma movement began to gather steam, there came a backlash.

In this case, it came in the form of the false memory movement, which tried to discredit the stories of abuse that our clients told us by calling them the result of therapists’ systematically implanting false memories in their minds. Much of this movement was fueled by the Roman Catholic Church as it was facing innumerable charges of priests’ sexual abuse of children, and by psychologists who could make a good living in forensic settings disputing the allegations by victims of sexual abuse. After the suits against the church were settled, the false memory industry disappeared with it.

One of the results of the controversy surrounding the false memory backlash was that the trauma field got bifurcated into two parallel areas of development, with basically all the research funding being directed to the military and veterans. The other area of research—child abuse and neglect and women’s studies—was underfunded and therefore unable to garner enough high-quality studies to determine scientifically how best to treat this population. As a result, our field became one of passionate claims, but little solid scientific evidence.

Nonetheless, some key developments (or, more precisely, in most cases, rediscoveries) have advanced trauma treatment. One has been the recognition of the role that dissociation plays in the aftermath of trauma and how, in various ways, treatment must address the personality structures that can compete or alternate with each other when someone is traumatized. Another major advance was the emergence of EMDR in the 1990s as the first approach that showed that we didn’t need to rely on drugs or the traditional talking cure to get traumatized people to leave their traumatic memories behind. Similarly, body psychotherapists have recognized that “the body keeps the score” when it comes to trauma and have revitalized bottom-up approaches like Somatic Experiencing, Hakomi, and sensorimotor psychotherapy to help shut-down people get unstuck from the fight/flight/freeze response.

Through neurofeedback, we’re exploring the capacity to rewire brains that are stuck in freeze and terror, and our first published studies of this process show how traumatized children and adults can learn to change how their brains regulate themselves. We’ve rediscovered that true change is best made when the mind is open. Mindfulness enables people to become attentive to their body and can enable them to feel safe. In fact, our NIMH-funded research shows that it looks as if yoga is more effective than any medication for treating PTSD.

Being able to be mindful is a necessary precondition for change. Hypnotherapists have long known that getting people into a trance state can facilitate the integration of trauma into their overall consciousness. More recently, Internal Family Systems and approaches that use mind-altering drugs like MDMA have demonstrated how to get people into altered states of consciousness where they can actually observe themselves and develop a sense of self-compassion that enables them to integrate their dissociated self from the past into in a calm state of mind in the present.

While all this has been going on, cognitive behavioral therapy (CBT) has accumulated the most research support, even though we know that the whole cognitive part of the brain shuts down when people are traumatized, triggering the primitive survival part of the brain. So using CBT with trauma is like telling somebody with an amputated leg to take up running. It can certainly give people a sense of perspective on their coping options when they’re in the right frame of mind, but it has limited value with severe trauma.

The most commonly used CBT approach to trauma is exposure therapy, which assumes that desensitizing someone to something that used to trigger them is the best way to help them be less affected by their memories. The problem is that desensitization leads to a global lack of feelings and engagement, so when you get desensitized from your trauma, you also get desensitized to joy, pleasure, engagement, and everything else going on. Desensitizing people shouldn’t be the goal of treatment: rather, we should help traumatized clients realize that Yes, this happened to me years ago, but not today; today is a different day, and I’m no longer the person I was back then. That kind of integration involves a neural network different from the neural network of desensitization.

My hope for the field of trauma treatment is that we learn how to help people bring their imaginations more fully to bear on their possibilities. For example, I’m involved with several theater programs for highly at-risk kids so they get to experience what it feels like to be somebody other than the identity that they’ve assumed. They can get the chance to say, “Oh, this is what it feels like to be a powerful general,” rather than “Nobody likes me; everybody hates me; I’m going to get hurt.”

I think theater and new techniques, like neurofeedback, can play an important role in calming the brain down and helping it become organized and more in touch with the body. In our culture, we too often rely on swigging alcohol and taking drugs to make ourselves feel better. Perhaps the most important contribution the therapy world, including the field of trauma, can make to the wider culture is to give people greater access to their innate self-regulatory systems—the way that they move, breathe, sing, interact with each other—so they can discover their natural resources to regulate themselves in a different way, especially when life gets challenging.

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This blog appears in our January/February 2017 issue, The Connected Self: Therapy's Role in the Wider World.

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Topic: Trauma

Tags: Bessel van der Kolk | PTSD | ptsd and depression | PTSD diagnosis | ptsd symptoms | ptsd treatment | Trauma | treating ptsd

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10 Comments

Wednesday, February 15, 2017 9:19:49 AM | posted by Frank Zuñiga I.
Excelents articles!

Friday, February 17, 2017 5:36:51 PM | posted by Jerry Ciffone
Thank you Dr. van der Kolk for providing another extremely intelligent, thoughtful and helpful reflection about a very important, yet often misunderstood and mistreated human reaction!

Friday, February 17, 2017 6:47:27 PM | posted by wendy
My experience fits exactly with your research path, and I lacked benefit of it until finally arriving with competent women-oriented trauma therapists at the same time The Body Keeps The Score was published. From adverse childhood experiences, chronic failures, being blamed, requests for professional help dismissed, lifelong substance abuse, total family estrangement and finally misdiagnosed with BPD, trapped in abusive relationship ending up in criminal justice system in spite of managing to distinguish myself professionally and earn several degrees. BPD was a nightmare, DBT was a bad experience over and over. Rejecting DBT was best thing I ever did and I was thoroughly berated for it. In the meantime my immune system gave out and life taken over by severe allergies and other autoimmune problems. Finally on right path, established safety, navigated health care to get better doctors and medical attention, got an EMDR therapist, kicked substance abuse. Psychiatrists still insisting I have BPD which is completely ridiculous, but it is all over my permanent records and I am continually subjected to demeaning stigma because of it. Have learned to not pay attention and keep going. Finally, after kicking drug habit, I began meditation practice just one month ago. At 51, I have a new life, the one I was always meant to have. There is no turning back. Following your POV and TBKTS no small part. There is much yet to be done for traumatized people like me, but for those strong enough to persevere, there can be a happy ending. Thank you Dr Van Der Kolk.

Saturday, February 18, 2017 3:07:23 PM | posted by Thomas
Based on what I've seen treating flight phobia, when Reflective Function is not well-developed it can collapse easily under stress, leaving the person unable to distinguish memory and imagination from perception. Simply thinking of an upcoming flight - and the possibility of a crash or a panic attack - they can trigger enough stress to shut down Reflective Function. They (unknowingly) are no longer separating imagination from reality, and "just" know the awful thing they are imagining will happen. On the plane, imagination of the plane falling out of the sky is experienced as falling out of the sky. I propose that a PTSD flashback takes place when Reflective Function shuts down and a traumatic memory is no longer recognized as a memory but is indistinguishable from something happening in the present. Similarly, a person can not maintain "this happened to me years ago, but not today" unless Reflective Function is robust and able to withstand stress. Thus, Reflective Function must be strengthened (or stress on it must be lessened) to keep it from collapsing and throwing the person into this state. Peter Fonagy calls this state "psychic equivalence:" what is in the mind and reality and one and the same in the person's experience. The work of Stephen Porges needs to be understood. It is valuable to separate fight/flight/freeze. Many people are "Mobilization System Dependent:" they have very limited ability to self-regulate except through fight or flight. When fighting doesn't work and escape (one form of mobilization) is not immediately available (elevators, bridges, tunnels, being controlled or assaulted, etc.) the person may fall into "freeze," an even more primitive defensive system Porges calls the "Immobilization System." We know some animals "play dead." In humans, this is not play; it is not a decision; it is simply what may happen when mobilization fails to provide safety and emotional regulation. Porges points out that humans (and other mammals), when trapped, may slide into this state without any choice whatsoever. The Immobilization System, when active, does not supply enough blood to the brain. Insufficient blood flow may be what causes dissociation, and fragmented memory of a traumatic event. An unfragmented memory fades; a fragmented memory doesn't. Thus, if a fragment is elicited by some association, the fragment may replay in awareness, cause stress hormone release which in turn causes Reflective Function to collapse, which allows the memory fragment to be experienced as taking place in the present.

Saturday, February 18, 2017 6:48:56 PM | posted by Barbara Stern
Thank you for the historical summary. I can trace some of my family issues back to specific incidents during the Civil War. Are you aware of the concept of "toxic stress" that results from Adverse Childhood Experiences? Please see the TEDMED talk by Dr. Nadine Burke Harris and the websites www.ACESTOOHIGH.com and ACESCONNECTION.org. In Northern California, this knowledge is being integrated into the public health system because ACES affect our physical, emotional, cognitive, social and economic health. See also the work of Dr. Vincent Felitti. Perhaps you could hold another Psychotherapy Networker conference in San Francisco one day and focus on primary prevention of ACES. We are working on all our institutions becoming "trauma-informed and resilience building."

Saturday, February 18, 2017 11:12:12 PM | posted by Wanda Viola
I appreciate this excellent summary by Bessel van der Kolk of healing therapies and the responses of societies to various origins of adult problems. I've seen the movements progress through the years during my healing journey but didn't ever connect the False Memory Syndrome groups with the Catholic Church. Years ago in a used book store I found a book about Freud's first paper where he talked about incest and then went on to talk about how he changed his approach. As an incest survivor, I totally understood why his statements were rejected. Nobody in my family or people who knew my family believed me, either, when I first started telling them about my father and grandfather ("well-respected" men in their communities)! The only part of the healing history left out of this article are the discoveries and approaches made in the spiritual areas of healing prayer by such ministries founded by Dr. Ed Smith (Transformation Prayer Ministry), Dr. Karl Lehman (Immanuel), Dr. James Wilder and others (THRIVE), Father Andrew Miller (HeartSync), and Restoration in Christ Ministries (the late Dr. Tom R. Hawkins and now led by his wife, Diane Hawkins). I have found God's deep healing for severe traumatic memories through fine therapists and with these approaches through the power and grace of the Lord Jesus Christ and the Holy Spirit. In our secular society we often fail to consider that the God who made us loves us and understands us, for He has seen every trauma. He knows how to heal us if we will just ask Him and He gives us the power to forgive what often seems unforgivable.

Sunday, February 19, 2017 10:33:27 AM | posted by Maggie
Emotional Freedom Techniques (EFT) isn't mentioned here, but it's an excellent tool for working with trauma as it doesn't re-sensitize. It's very gentle.

Thursday, July 13, 2017 5:02:54 PM | posted by Mel
After years of EMDR, EFT, neurofeedback, TMS and trials of various medications, Ketamine infusions were my ticket to freedom from PTSD and depression. I just did 3 out of the recommended 6 infusions and have experienced long lasting relief. It was an immediate solution from the first infusion rather than having to suffer through months if not years of pain to find relief from any of the other methods I tried.

Thursday, July 13, 2017 5:30:46 PM | posted by Donna Bunce
As a 61 year old who has spent over 40 years healing and recovering from complex trauma. No one mentioned neuro-feedback. Please let me share, that I have done 3 types in the past 6 years including a home unit. I am currently doing "Brain Paint". OMG my memory is coming back and the insight to integrate the pieces!! I was stuck in EMDR. Don't ever give up on your clients!! I was lost and numbed into a hell for 16 years on psychiatric medications. Mindfulness skills and tools set me free! Insight meditation to know how to sit in meditation and become my own best friend! So much has helped me but I am betting on Brain Paint for anyone to open up the frozen brain of trauma. Find me on Trauma Flowers via facebook....anyone can heal the monster of trauma!!!

Thursday, July 13, 2017 11:49:44 PM | posted by Hatim Kanaaneh
Have you or other trauma experts dealt with the preventive side of the trauma when you have no means of stopping a current traumatic experience? What do I do when my trauma is ongoing, daily and collective? How does one face up to current, ongoing, repetitive, collective, psychological and physical daily trauma? When trauma is the norm not the exception? This is not a personal experience and I am not a trauma specialist. But I know that this is happening to 2 million Palestinians of all ages, but mostly children, in Gaza. They are denied freedom of movement, with drones buzzing overhead and with the the threat of bombs falling from the busy skies. And with the ambient temperatures of 40 degrees centigrade and access to erratic supply of electricity for as little as 2 hours a day and constantly told by the world that you are to blame. And it goes on year after year. Shouldn't we be considering some preventive strategy for individuals in this situation? You seem to fall retroactively on the power of the body to deal with the outcome of trauma, to heal. Shouldn't we consider devising a preventive strategy that relies on the body's own resources?