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."
Their physical symptoms---paralysis, violent trembling, spasmodic movements, repetitive facial grimaces, zombielike 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.
Van der Kolk first became aware of the world of trauma in 1978, when he decided to go work for the Veterans Administration (VA). "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.
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. 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.
At the same time, van der Kolk is also one of the trauma field's most controversial figures. He's scandalized a number of cognitive-behavioral therapists and academic researchers by openly embracing EMDR, demonstrating an interest in 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.A Diagnosis Non Grata
By the late-1980s, van der Kolk had had extensive experience working with vets and was becoming a well-known figure among PTSD researchers. But in spite of his impressive resume, he felt deeply discouraged. Even after months or years of work, his patients still suffered from flashbacks, nightmares, depression, aggressive rage, anxiety.The Monopoly of Talk
Van der Kolk was now sure that, just as the experience of physical helplessness was at the core of trauma, there was something about frustrated action to repair the situation that played a role in developing long-term PTSD. And he began to wonder if helping traumatized people engage in meaningful, physical action would allow them to recover from PTSD.
His own therapy is still "very talky," he adds. But, van der Kolk continues, "fundamentally, words can't integrate the disorganized sensations and action patterns that form the core imprint of the trauma." Treatment needs to integrate the sensations and actions that have become stuck, so that people can regain a sense of familiarity and efficacy in their "organism."
To underscore the shocking possibility that neither talk nor relationship may be necessary in trauma treatment, van der Kolk likes to tell the story of his training in Eye Movement Desensitization and Reprocessing (EMDR).
He didn't like the training at all: "It felt too packaged, too much like a Billy Graham revival-type thing." He was, however, amazed at what happened to him when he subjected himself to EMDR as part of the training. "During the session, I was fascinated by all the different images from my early childhood that made their way very rapidly through my consciousness. Afterward, he felt as if "something had been processed and left behind.”
His own EMDR practice student during the training was another clinician, who refused to tell van der Kolk anything about what he wanted to work on, except that it was "some very tough stuff between me and my dad when I was little." Overtly hostile and uncommunicative throughout the session, the clinician kept saying that he didn't really want to share what he was upset about. As a result, van der Kolk was totally in the dark about what was going on inside the person he was trying to "help" with the EMDR.
At the end of the session, the man looked relieved of much of his distress.
"How was that?" van der Kolk asked.
"I'd never refer a patient to you," the man barked at him.
Van der Kolk replied, "Oh, why is that?"
The man replied, "I really hated the way you dropped your fingers at the end of each movement!"
"But what about your original problem?" van der Kolk asked.
"Oh, I feel I completely resolved the issue with my dad."
This episode engaged van der Kolk's curiosity about the role of the therapeutic relationship. "This guy didn't trust me. We didn't have a warm relationship. I never knew anything about what was bothering him. Yet he seemed to have processed whatever it was he needed to take care of. It drove home to me the possibility that maybe people can do excellent therapeutic work, even if they don't like and trust you, as long as the therapist knows how to help them "digest" the imprint of the trauma."This blog is excerpted from “The Limits of Talk."Read the full article here. >>Want to read more articles like this? Subscribe to Psychotherapy Networker Today!