When it was discovered that syphilis progressed to mental illness, psychiatry was grandfathered into medicine. Surgery and drugs became the preferred interventions. These were applied when the psychosis was fully evolved, as desperate measures for those that could no longer conform to social expectations, and thus endangered themselves and others.
Application of these measures is guided by the American Psychiatric Association’s Diagnostics and Statistical Manual (DSM), a compendium of assessment criteria for psychological disorders. Given the failure of the discipline to evolve reproducible treatments for the disorders, perhaps its greatest value was in building sophistication in the public about mental illness. People began to diagnose mood swings and behavior patterns and take action to prevent them from progressing to harm.
Bessel van de Kolk, author of “The Body Keeps the Score,” witnessed the folly of pharmacology first-hand. The ham-fisted therapeutics that woke the psychotics from their torpor have been applied broadly to control misbehavior and anxiety, neutering a whole generation of misunderstood children.
In part because his practice began before the widespread prescribing of psychoactive medication, van de Kolk was aware that alternatives were efficacious. His treatment of traumatized veterans and victims of sexual assault showed that in confrontation with their memories, sufferers could act out the responses that were suppressed by circumstance, and so finally escape from the trauma. Thus the title of the book: it is in the body that answers to trauma are found.
From this observation, van de Kolk turns to functional neurology. The abnormal behaviors of trauma victims are evidence that the brain has lost balance between the regions that manage emotion, self-awareness, situational awareness, and time. Specific patterns of repression are seen depending upon the degree of agency felt in the context of trauma. “Fight/flight” suppresses reason in favor of emotional reaction. “Freeze” suppresses almost all brain activity, disassociating the victim from experience until safety is restored.
In illustrating the responses of a couple trapped in a multi-vehicle pile-up, van de Kolk pulls on the thread of childhood conditioning. Two people, sitting side-by-side, can go down completely different paths of trauma response. In diagnosing those outcomes, van de Kolk discovered that childhood conditioning is the key. Children raised in traumatizing circumstances enter adulthood with a predisposition for their response to stress.
The assembled statistics support van de Kolk’s assertion that childhood trauma is the most serious public health problem in the world. Not only are children stunted emotionally and mentally, they lose touch with their physical being, and so are comfortable with choices that others would find painful. Substance abuse, obesity, anxiety and its associated physical infirmities, and abusive relationships are all traced to conditioning established in childhood. van de Kolk emphasizes that sufferers do not make bad choices based upon the logic of their upbringing. Their choices are a consequence of mental dis-integration that blocks their ability to assemble and prioritize possibilities evident to the well-balanced mind.
Here van de Kolk finds real hope. Brain wave recordings allow ready analysis of the operation of the mind. Restoring proper balance can be accomplished though confrontation with the past (van de Kolk highlights EMDR here) but does not require it. Much as we learn to draw lines and circles without thinking in detail about individual muscles, biofeedback games (such as a race between spaceships) allow the brain to reactivate underutilized regions. Shakespearean drama also allows children to confront powerful emotions and organize them to achieve a rewarding outcome – such as a reduced prison sentence.
In this van de Kolk responds meaningfully to the challenge posed by Anne Harrington in “The Mind Fixers.” Harrington skewered psychiatry, concluding that it must go back to basics or it will lose its credibility. Van de Kolk, in highlighting electrical activity as a credible and objective diagnostic and feedback (of various types) as therapeutic tool, demonstrates that an answer is at hand.
And the response of the psychiatric community? Resistance. First van de Kolk and his peers were stymied in trying to add a cross-cutting condition to the DSM that recognized the chameleon-like behaviors spawned from childhood trauma. Depending upon their circumstances and diagnostic process, adults seeking to avoid confrontation with authority will exhibit any number of conditions. But the diagnostic proposal was rejected without justification by the APA – perhaps because it undermined much of the premise of the DSM and thus pharmacology as the central pillar of care for the mentally ill.
And as for alternative treatments, the challenge is that the complex conditions do not fit into the neat boxes needed for academic pilot studies. Those that pursue them do so as a labor of love for children carrying the burden of abuse. Many of the therapies come from outside psychiatry, evolved by actors and recovered addicts through personal experience (if not desperation).
If there is any complaint to voice with this book, it is that van de Kolk’s fascination with brain regions and activation obscures larger principles. He still upholds the primacy of reason in behavior, when so many of his therapies prove that storytelling is central to healing. And his summary of an EMDR case history – with the voices of generations of mothers guiding the patient toward conciliation and forgiveness – begs for recognition of spiritual experience.
But as a hypnotherapist, I do take some heart in van de Kolk’s observation that hypnosis, which lost favor in the 90’s, deserves reconsideration. EMDR, as he describes it, is obviously a hypnotic modality, and acting demands trance to achieve a believable presentation of alternate identity. I do my best to summarize hypnotherapy’s benefits in a recent book.
To summarize: the career of Bessel van de Kolk began before the pharmacological insurrection in psychiatry, and his compassion drew him to engage complex cases that defy academic study. Through functional neurology, experience, and intuition, he has gained insights that have been integrating in a powerful and hopeful practice of mental healing. While I believe aspects of the story are still to be addressed, “The Body Keeps the Score” points toward a hopeful reconstitution of psychiatry. It must be read by professionals, academics, patients, and their advocates.