Dr Bessel van der Kolk, a leading expert in the study of trauma, suggests that post-traumatic stress is a widespread problem in our society and that the solution to this problem may lie in going beyond traditional treatment. The symptoms of PTSD (post-traumatic stress disorder) are well known to most. People with PTSD suffer from flashbacks and nightmares of the traumatic experience and as a result, have difficulty in forming relationships and navigating through life. Similarly, many people also have an idea of who suffers from PTSD. We know that veterans are especially likely to have PTSD with a quarter of soldiers who serve in war zones expected to develop the condition.
However, Dr Van der Kolk argues that there is much more about trauma to be understood. He suggests that while we may know the symptoms of post-traumatic stress, we need to understand what causes it to develop effective treatments. And while we acknowledge the unfortunate fate of many soldiers, we must also recognise that for many people, “the war begins at home”. Each year about three million children in the United States are reported as victims of child abuse and neglect. For every soldier who serves in a war zone abroad, ten children are endangered in their own homes. These children suffer traumatic terror and pain at the hand of their caretakers and indeed, more than half of people who seek psychiatric care in adulthood experienced trauma as a child. Trauma is widespread and needs to be understood.
Hijacked by memories
When someone experiences flashbacks and nightmares that are the result of trauma, they are essentially suffering from their memories. At the moment when a survivor is remembering the trauma, they are smelling the same smells and feeling the same physical sensations they felt during the original event. This means that the memories of the original event are so overwhelming that it renders their mind in a state of horror and their body in a state of helplessness. Thus, trauma is not just an unpleasant event that happened in the past; it is a destructive imprint left by that experience on the mind and body. The consequences of being hijacked by memories are detrimental to the trauma survivor. The imprint of the experience alters the mind in such a way that survivors think differently to those around them and have trouble integrating with everyone else. Indeed, early psychologists had a name for traumatic memories – they called them “mental parasites”.
The unbearable heaviness of such memories may be because traumatic memory differs from other types of memory. For most people, the memory of an unpleasant event either fades away over time or morphs into something more benign. The French psychologist Pierre Janet was first to point out that these memories are the stories we tell ourselves. He called this type of harmless memory “narrative memory” and stated that it is quite different from harmful “traumatic memory”.
Janet noted significant differences between the two types of memory. First, traumatic memories are different from ordinary narrative memory because they are precipitated by specific triggers. For trauma survivors, anything from a familiar-looking object to certain words can trigger flashbacks of the original event. Furthermore, traumatic memories serve no function. Ordinary narrative memory is especially useful for us because it allows us to take part socially in the world. We form stories in our minds about ourselves and the things that have happened to us so that we can tell them to others for a purpose. Traumatic memories, on the other hand, have no social utility but instead cause problems with social interaction.
“The essence of trauma is that is is overwhelming, unbelievable, and unbearable. Each patient demands that we suspend our sense of what is normal and accept that we are dealing with a dual reality: the reality of a relatively secure and predictable present that lives side by side with a ruinous, ever-present past.”Bessel van der Kolk, from The Body Keeps the Score
Traumatic memories also have the unfortunate characteristic of being personally meaningful to the trauma survivor. Because the memory of the event is meaningful to the survivor, they are likely to remember the memory very accurately. This is because whether we remember a particular event at all is largely due to whether the event made an impact on us. If an event or a particular song or smell was emotionally arousing at the time we first experienced it, we are likely to remember it. For example, most of us have precise memories about where we were on September 11, 2001, but not many of us can say where we were on September 10th. This is because most memories are not particularly arousing and fall into oblivion. For trauma survivors, the traumatic event falls out of the established pattern of normal events and unfortunately, is much easier to retain.
This distinction between ordinary and traumatic memory was illustrated in a study conducted in 1945/1946 and later again in 1989/1990. The Grant Study of Adult Development aimed to track the physical and psychological health of more than 200 students. The designers of the study could not anticipate that the students would soon be draft to fight in World War II, but they were now in the position to study their memories of the events of the war. After conducting interviews four decades after the war, they found that those who suffered from PTSD remembered the war much different from those who developed no psychological condition. While for those who developed no condition, memories were bleached of their intense horror; those who had been traumatised had memories that were preserved intact.
Possibly the most destructive feature of traumatic memory is that the mind splits the memory of the original event away from the memory of other events. This is known as dissociation and it means that because the mind has made the memory distinctive, the emotions, sounds, images and thoughts that the survivor experienced during the original event in the past have a life of their own in the present. This is what causes survivors to suffer from memories and in some ways, their flashbacks and nightmares are worse than original event because while the original event had a beginning and an end, the now fragmented memory can cause flashbacks at any time. Dissociation is an especially problematic part of traumatic memory because it makes treatment difficult. When the traumatic memory is split off from other memories, it is prevented from being integrated into the ordinary narrative memory. As a result, those who suffer from PTSD are unable to put the traumatic event behind them.
The physiological basis of post-traumatic stress
Because of the nature of traumatic memory, trauma is much more than the recollection of a distressing event that happened a long time ago. Because of the emotional and physical sensations that were imprinted during the event, trauma is experienced as disruptive physical reactions rather than just a memory. The body of those who suffer from PTSD develop a constant sensitivity to threat. Unbearable physical sensations then take ahold of them such as feeling heartbroken, tightness in the chest and intolerable pain in the stomach. Thus, post-traumatic stress has a physiological basis.
The symptoms of post-traumatic stress have their origin in the body’s response to the original trauma. In particular, the body’s defence against the threat in the traumatic event. Under normal conditions, our bodies react to a threat in the environment with a temporary increase in stress hormones. Like other animals, our brains have evolved to develop an alarm system which, when confronted with a threat, prompts the body to either confront or escape it. This is known as the fight or flight response. Our bodies prepare for a fight or flight response by releasing a cascade of stress hormones that drive up blood pressure, oxygen intake and heart rate. Once the threat has gone, the body’s stress hormone system quickly returns to equilibrium.
“Trauma does not simply act as a releasing agent for symptoms. Rather, the psychical trauma- or more precisely the memory of the trauma- acts like a foreign body which long after its entry must continue to be regarded as an agent that still is at work. Like a splinter that causes an infection, it is the body’s response to the foreign object that becomes the problem more than the object itself.”Bessel van der Kolk, from The Body Keeps the Score
If for some reason, someone is not able to confront the threat or escape from it, the normal fight or flight response is blocked. This is what happens with people who suffer from post-traumatic stress as these people are often held down, trapped or stuck in inescapable situations like a warzone. Because they are prevented from taking effective action, their brains continue to secrete stress hormones long after the original event has passed. This means that the stress hormone system fails to come back to stability and because of this, they are constantly stuck in fight or flight mode. Thus, because of a fault in their survival traits, sufferers of post-traumatic stress become stuck. Stopped in their growth away from the traumatic experience, they are unable to move on. Unfortunately, the constant elevated stress hormone level has physiological effects, expressing itself in problems with attention, memory, sleep and long-term health.
Indeed, the inability to move on imposed by the fight or flight response being continually aroused means that traumatised people see the world in a very different way to the rest of us. Studies involving Rorschach tests, a psychological test in which a subject interpretations of abstract images are analysed, show that traumatised people reacted to the images as if they were seeing a traumatic experience. In another study, children who suffered from trauma reacted to meaningless photographs with intense feelings of aggression and terror. People who suffer from post-traumatic stress have adapted to see the world as full of triggers. Treatment must, therefore, reset their physiology so that their survival mechanisms are not working against them.
A new paradigm for treatment
For treatment to be effective, it must consider this. But Dr van der Kolk suggests that while the traditional modes of treatment have been somewhat successful for treating the symptoms of post-traumatic stress, they do not treat the root cause which lies in physiology. For example, for many years, psychologists and psychotherapists have found that some method of talking about distressing feelings is useful for the patient to resolve them. However, for the experience of trauma, this is not always the best thing for the patient. As mentioned, sufferers of post-traumatic stress experience memories as intense physical sensations and so traumatic memories are anything but laid to rest.
Some textbooks in psychiatry state that the cause of all mental illness is due to chemical imbalances in the brain. This theory, known as the brain-disease model, has become broadly accepted by some in the media, public and even medical profession. Because of this, drugs are seen as the perfect treatment to correct these imbalances. Indeed, in some places, drugs have replaced talking therapy. But the prescription of drugs to treat PTSD may be doing more harm than good. Medication only blunts sensations and does nothing to treat and transform them. Rather than treating faulty physiology, medication dampens it by blocking the chemical systems that regulate pain but also motivation, engagement and pleasure.
Dr van der Kolk suggests that there may be alternative treatments that regulate physiology instead of numbing it. Because those with PTSD suffer physically from the memories of their trauma, he proposes that one possible effective avenue of treatment involves calming physical tensions. These range from breathing exercises to body awareness exercises, and they rely on a person perceiving the inner rhythms of their mind and body and away from their perception of danger. Nobody can treat a war or molestation. But the imprints of these experiences on the mind and body cause a sense of losing control that can be treated. According to Dr van der Kolk, treatment must reestablish ownership of the mind and body.
Studies looking at the effect of breathing in emotional regulation have shown that the way one breathes can improve the way they deal with anger, depression and anxiety. Meditation and yoga, which Dr van der Kolk suggests are self-regulating treatment, have been shown to have a positive effect on physiological problems like high blood pressure and elevated stress hormone level. The way we breathe and move can directly train our arousal system. 80% of the fibres that connect the brain to internal organs run from the body into the brain. Exercises like meditation and yoga put the person in control of their body and, therefore, better able to control their hyperarousal to a memory, object or event. By experiencing the sensations of their breath and movements, for PTSD sufferers, these types of treatment restore the sense of ownership of their mind and body which they once lost.