Sunday, January 11, 2015

Psychiatry for the laity: "The Body Keeps The Score"

The following is a review I wrote of a highly successful book written by my dear Dutch American friend, Dr. Bessel van der Kolk . The book has been on the New York Times best seller list for over three consecutive months. It has received 105 five-star reviews (against one1-star review) on Amazon where it has outsold DMS-5, the psychiatrists’ professional bible. So far it has gained contracts for translation into several languages including Chinese and Japanese.

The Body Keeps the Score
By Dr. Bessel van der Kolk

Let me take a reality-based swipe at explaining Post Traumatic Stress Disorder (PTSD) whose nature and therapy constitute the core of Dr. Bessel van der Kolk’s new book, “The Body Keeps the Score.” Bessel has been to my village residence in Galilee. In the fruit-tree orchard around it we keep a small flock of chickens. One dawn a wild mongoose party snuck in the cage and massacred all the chickens in it except for two agile birds that flew out to safety. They were at the prime of their egg-laying careers. We acquired a new clutch of chicks and paid more attention to locking their cage at night. The two surviving chickens stopped laying eggs, slept in the trees and never associated with the younger brood even as it reached maturity. The moral of the story is that it may take a genius a lifetime to explore the mechanism of PTSD but it takes little brain to suffer from it. It impacts the most elemental structures of the brain. It is an issue of survival not intellect.

Dr. Bessel van der Kolk is a medical colleague and my personal friend since college days in Hawaii in the beautiful sixties. I divulge this information to alert readers to my likely partiality to his views. To forestall likely accusations of undue bias or allegations against me of succumbing to hyperbole, I shall start with expressing my discontent with the books range of coverage. But more on that point later.

In the prologue to the well-ordered book based on Dr. van der Kolk’s career in searching to understand trauma and assessing the usefulness of various modes of alleviating its lifelong damaging effects he asserts that:

“We can now develop methods and experiences that utilize the brain’s own natural neuroplasticity to help survivors feel fully alive in the present and move on with their lives. There are fundamentally three avenues: 1) top down, by 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; 2) by taking medicines that shut down inappropriate alarm reactions, or by utilizing other technologies that change the way the brain organizes information, and 3) bottom up: by allowing the body to have experiences that deeply and viscerally contradict the helplessness, rage, or collapse that result from trauma. Which one of these is best for any particular survivor is an empirical question. Most people I have worked with require a combination. This has been my life’s work.”

But this level of comprehension and enlightened outlook comes with the author’s retrospective accumulated wisdom. At the very start, as we are introduced to Tom, the disturbed Vietnam war veteran, we get the impression that Dr. van der Kolk happened to be at the right place at the right time. He happened to be at the Boston Veterans Administration Clinic after Vietnam. He made the most of the opportunity that presented itself. Or, perhaps, his presence of mind and intellectual curiosity made it the right time and the right place to question the accepted frame of reference regarding the time-honored talking therapy for trauma victims. This same combination of nosiness and daring to question accepted wisdom has kept the man at the cutting edge of research efforts in the field that he seemed to have accidentally walked into: from Rorschaching combat veterans to participating at a very basic level in the creation of the American Psychiatric Association’s Diagnostic and Statistical Manual of Mental Disorders  (DSM), the psychiatrists’ modern bible, and of PTSD as a new psychiatric diagnosis; from researching the brain wave patterns in sleep to the testing of such novel neuropharmacological wonder drugs as Prozac; from experimenting with such bodily modalities of therapy as kickboxing to yoga; and from attempting to mainstream massage therapy, eye movement desensitization and reprocessing (EMDR), neurofeedback, psychomotor therapy and theater to establishing the National Child Traumatic Stress Network.

Throughout all of these career development stages in the author’s account, his fairylike life story is related with a focus on his subjects, whether combat veterans or survivors of childhood domestic violence and violation. Reading through the intimate accounts of PTSD victims’ life stories and their reliving of their traumas, we witness the enlightening of caregivers and of us with the victims’ truth. All along we are exposed to the author’s efforts together with his research associates and fellow accomplices to widen the professional horizons of American psychiatry. Reading through, I had a constant and unaltered image of my friend: He always stood hugging a patient or strode alongside a colleague with his arm on her shoulder. I envied his patients for the level of empathy and understanding that they gained from my friend even if the initial contact was not always all that friendly.

“I was surprised and alarmed by the satisfaction I sometimes felt after I’d wrestled a patient to the floor so a nurse could give an injection, and I gradually realized how much of our professional training was geared to helping us stay in control in the face of terrifying and confusing realities.”

“… because in my experience patients get better only if they develop deep positive feelings for their therapists. … Therapy is a collaborative process— a mutual exploration of your self.”

 At least that is how empathetic Dr. van der Kolk comes across in his case reports, so artfully and smoothly woven into the telling of the story of his “life’s work.” And no wonder; Bessel weaves in intimate accounts of traumatic experiences from his own childhood and from that of his son, for example, to exemplify and buttress his understanding of trauma and its modes of therapy.

“If you’ve been hurt, you need to acknowledge and name what happened to you. I know that from personal experience: As long as I had no place where I could let myself know what it was like when my father locked me in the cellar of our house for various three-year-old offenses, I was chronically preoccupied with being exiled and abandoned. Only when I could talk about how that little boy felt, only when I could forgive him for having been as scared and submissive as he was, did I start to enjoy the pleasure of my own company.”

This type of sincerity and personal involvement with his subject matter makes the author so much more readable. And he has “a lot to say about how trauma is held in people’s bodies,” knowledge that implies and inspires intimacy. The direct real-life accounts of his many encounters with children and adult patients make this personalized memoir-like book so fascinating. Bessel excels in making his point in this manner. He drags the reader through the muck of a psychiatrist’s daily drudgery to where the conclusion becomes self-evident. Then he shines a redundant light on the inevitable conclusion.

Early on in his career this healer observed that

“Mainstream medicine [including psychiatry] is firmly committed to a better life through chemistry, and the fact that we can actually change our own physiology and inner equilibrium by means other than drugs is rarely considered.”

And again,

“… my professional training, with its focus on understanding and insight, had largely ignored the relevance of the living, breathing body, the foundation of our selves.”
Here he pauses the question to himself “if we could find more natural ways to help people deal with their post-traumatic responses?“ He seems to have spent the rest of his professional life trying to answer his own question to the consternation and opposition of many colleagues and most of the established professional power centers. Repeatedly he gets refused and lectured about his unorthodox views. But he persists and, against all odds, establishes his own trauma center. Gradually he attains credit and prominence to where he is sought out by like-minded colleagues not to mention impressed patients and established care and research institutions.

Masterfully, my colleague slips in several purely didactic but very succinct segments in his skilled discourse. Thus he dwells at length on the anatomy of the brain and the newly visualized connections between its various functional centers, and on issues of neuropharmacology and of physiology. I found much of this of little interest to me, perhaps because of my familiarity, even if limited, with its content. Yet, even such less dramatic and less engagingly autobiographical segments have enough charm and poetry to be quite readable. Their simplified explanations must be very instructive and helpful to the lay reader:

“However, our scans clearly showed that images of past trauma  activate the right hemisphere of the brain and deactivate the left. We now know that the two halves of the brain do speak different languages. The right is intuitive, emotional, visual, spatial, and tactual, and the left is linguistic, sequential, and analytical. While the left half of the brain does all the talking, the right half of the brain carries the music of experience. It communicates through facial expressions and body language and by making the sounds of love and sorrow: by singing, swearing, crying, dancing, or mimicking. The right brain is the first to develop in the womb, and it carries the nonverbal communication between mothers and infants. We know the left hemisphere has come online when children start to understand language and learn how to speak. This enables them to name things, compare them, understand their interrelations, and begin to communicate their own unique, subjective experiences to others.”
Or take for example:
… the brain is formed in a “use-dependent manner.” This is another way of describing neuroplasticity, the relatively recent discovery that neurons that “fire together, wire together.”

There are several such priceless summary explanations throughout the text. I know my friend is grounded in the classic school of European education with Latin and Greek as foundational blocks. He fancies poetics and mysticism and prefers a turn of phrase that leaves much to fancy and to experiential interpretation. I must acknowledge finding many of my friend’s pithy nuggets quite enlightening. Yet, on occasion he seems to oversimplify things.  Or perhaps we, the laity, have grown to feel that neuropsychology is complex and not understandable, so that when someone like him explains it he/she sounds overly mundane. Several times I found myself adding my own interpretations to his statements. On one occasion, for example, as I read his assertion that “most of our energy is devoted to connecting with others” I made a mental note to the effect that this is the rock base of tribalism. Then I thought about it and reached the exact opposite conclusion. Why can’t you make up your mind, Bessel?

Speed-reading through the early chapters of “The Body Keeps the Score” I felt a level of reluctance to accept some of the author’s conclusions. They seemed to be based more on the author’s particular understanding of his field of study and sound to the non-specialist more like oversimplifications and jumping to conclusions. Yet, these conclusions are so much common sense that they sound downright self-evident and need no proving.  What is remarkable is the man’s daring to act on such seemingly circuitous logic. What is even more striking is his successful interventions based on those ‘hunches.’ But then, to the outsider, the entire discipline of psychiatry is fraught with massive, even if inspirational, jumping to conclusions:

“Suppressing our inner cries for help does not stop our stress hormones from mobilizing the body. Even though Sandy had learned to ignore her relationship problems and block out her physical distress signals, they showed up in symptoms that demanded her attention. Her therapy focused on identifying the link between her physical sensations and her emotions, and I also encouraged her to enroll in a kickboxing program. She had no emergency room visits during the three years she was my patient.”

Yet, there was always an alternative image to that of the attuned healer and teacher lurking in the background behind the pages, that of the rebel standing his ground against all odds and managing to stare down such powerful adversaries as the NIH bureaucracy, the American Psychiatric Association and their DSM advisory committees, before his hunches were proven right again and again. In reporting on his rebellious tendencies, Bessel coopts the non-specialist reader and wins him/her over with the deception that he, Bessel, is on their side. In doing this he risks alienating many colleagues with his damning statement against the profession:

“Psychiatry, as a subspecialty of medicine, aspires to define mental illness as precisely as, let’s say, cancer of the pancreas, or streptococcal infection of the lungs. However, given the complexity of mind, brain, and human attachment systems, we have not come even close to achieving that sort of precision. Understanding what is “wrong” with people currently is more a question of the mind-set of the practitioner (and of what insurance companies will pay for) than of verifiable, objective facts.”
And again:
“In this chapter, and the next, I will discuss the chasm between official diagnoses and what our patients actually suffer from and discuss how my colleagues and I have tried to change the way patients with chronic trauma histories are diagnosed.”

The man has the courage and strength of his convictions to go out on a limb and to gamble on his unconventional understanding of his friends, the patients with whom he seems to sympathize so much. He conducts research denied funding by the NIH and convinces funded colleagues of his point of view. “When does a hypothesis become a scientifically established fact?” he repeatedly and justifiably asks. He opens his account with a bang about veterans of the Vietnam War and his push for the acceptance of the PTSD diagnosis. After four decades he is on the professional warpath on another front, domestic abuse of children. Here he is at odds again with the traditional gurus of his profession and the purse string holders, the Developmental Trauma Disorder deniers at whom he leashes out with his considerable outrage. With one case report after the other, he leads the readers in conceptually formulating the diagnosis and sways them to join him in castigating developmental trauma deniers. But then we get the authorities’ response of “There is no known evidence of developmental disruptions that were preceded in time in a causal fashion by any type of trauma syndrome.”  That sounds to me like the same impossible argument that invested energy companies offer to counter global warming believers: prove it to us in a direct observable causal fashion.

Dr. van der Kolk repeatedly declares that he utilizes all three psycho-therapeutic approaches, talking therapy, psychoactive drugs and psychomotor therapy in varying combinations adjusted to the needs of the individual patient. Yet, quite early-on we get an inkling of his general bias when we are warned that

“The last things that should be cut from school schedules are chorus, physical education, recess, and anything else involving movement, play, and joyful engagement.”

By the time we get to the epilogue, he is clearly siding with this last modality. In fact he waxes quite verbose and patronizing in preaching the preventive value of the practice of its various modalities through the public school system. Here my good friend seems to step down from his high pedestal as the grand master of the “Bessel van der Kolk Trauma Center” to mix with commoners and school teachers and preach to them again on the benefits of such commonsense measures as maintaining the school activities enumerated above.

I will end with reverting to my sense of disappointment in my friend’s huge achievement in this successful amalgam of textbook and memoir: The focus of Bessel’s concern and the subject matter of his discourse, whether we consider the topics of his many reported research achievements or the case reports he so excels in recounting for his readers, is limited mainly to two groups. These are the survivors of childhood domestic trauma and the veterans of war, both within the confines of the USA. The author, and in my estimation, with the publication of his The Body Keeps the Score, the greatest world authority on trauma therapy, seems to do himself and his subject matter a disservice by limiting his range of discourse geopolitically to America. There are other trauma sufferers in the world, not least survivors of natural disasters, of motor vehicle and industrial accidents and of household violence abroad, especially, from my perspective, the problem of ‘honor killing’ of women in the Middle East countries for example. Here and there, Dr. van der Kolk does touch on some of those other victims of trauma, including survivors of Nazi concentration camps, but very lightly and tangentially and with little reference to research done on them.

And now I will get personal: My colleague ends his book with an epilogue that opens a trifle triumphantly: “We are on the verge of becoming a trauma-conscious society.” Upon reading that I first hastened to add: “Thanks to Dr. van der Kolk’s lifelong dedication and tireless advocacy.” Then quickly I added: “But it is a self-contained and selfish consciousness that seems to begin and end with the USA public.” The author declares himself “close to despair” with, among other things, “psychiatry’s obtuse refusal to make connection between psychic suffering and social conditions.” I can hardly resist asserting my own despair at my colleague’s myopic focus on his privileged country’s trauma sufferers. I am at loss for words! From the focus on combat veterans, I am left with the impression that war is more traumatic to its perpetrators than to their victims. The most glaring defect I find in my friend’s scholarly discourse in this volume is the absence of relevant discussion of the trauma of war victims: How can we deal at length with the trauma of American Vietnam combat veterans without addressing the trauma of sufferers among the Vietnamese. And what about the Abu-Ghraib detainees and all of Iraq’s and Afghanistan’s orphans and bereaved families? What about the trauma of all the maimed survivors and witnesses of death and devastation on the other side? Had no one done any research on trauma and its therapy there? How can anyone write about any aspect of trauma in the year of our lord of 2014 without visiting Gaza? The AIDS awareness slogan, Silence=Death, is good for what happens there as well, Bessel! Except that it is the international community’s (and your) silence and the Palestinians’ death.

And yet, I can imagine myself defending my friend against others blaming him for such a blatant shortcoming: “Folks, let us keep clear of politics and partisan arguing, please! The target readership of this volume is the educated American public as a whole and not only its specialist psychiatrists.  Hence, the context of its discourse has to match the American public’s concerns and largely local horizons. And remember, my friend had always to adjust his research subject matter and parameters to what major American research funding sources were willing to fund. Besides, my friends conclusions regarding his American PTSD sufferers have universal applicability.”

Well, Bessel, my friend: Just between the two of us, now that we have made the world class rank of science writers, it is time to embark on writing the next volume, the one summing up all of the world’s scientific literature on trauma therapy. You need to rise to the next level and address yourself to the global trauma scene.
Also you took a lead part in establishing the National Child Traumatic Stress Network. Why not make it the International CTSN? It may well lead you to the same ‘commonsense’ conclusions. But at least I will sleep better and love you even more.


Micaella Lopez said...

`The Body Keeps the Score' provides reader with the strength and hope for those trauma affected either personally or professionally and therefore this educating and powerful Bessel van der Kolk work can be highly recommended.

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Marlene Detierro said...

I am very glad that this wonderful book is being so widely read (judging by the number of five-star reviews). May we take its recommendations seriously and use what we know about effective prevention and treatment of traumatic stress to create a healthy society where all children and adults can reach their full potential.

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