Brain, Mind, and Body in the Healing of Trauma

Trauma – Bessel van der Kolk – 

I don't go to therapy to see if I'm crazy

Every week, I come and I look for only one answer. And when I talk about psychotherapy, I know what people think That it just makes you selfish and crush the quack therapist

But actually, I love others so much when I can talk about myself so much.

Dar Williams, What Do You Hear in These Sounds

No one can "heal" war, abuse, rape, mistreatment or other horrific event. What happened is irredeemable. But we can cope with the imprints of trauma etched on body, mind, and soul. These are heavy feelings in your chest that you might call anxiety or depression, the fear of losing control, the constant vigilance of danger or rejection, the self-loathing, the nightmares and flashbacks that are the fog in your mind that keep you from concentrating on work, is impossible to open your heart to another person.

Trauma makes you unable to control yourself (in the next chapters, I'll call self-control self-leadership).. Post-trauma recovery is about regaining control of your body and mind so that you are free to know what you know, feel what you feel without being overwhelmed, angry, ashamed, or devastated. For most people, leaving to master themselves they need: (1) find ways to stay calm and focused, (2) learn to maintain that calm in response to images, thoughts, sounds, or physical sensations that remind you of the past, (3) find a way to live fully in the present and bond with those around you, (4) No more keeping secrets about yourself, including secrets about how to help you manage to survive.

These four steps often overlap, how difficult it is to perform depends on each person's circumstances. I have done scientific studies on many of the treatments described here and have published the findings in peer-reviewed scientific journals."


We often start talking about trauma by telling a story or asking a question to the patient, such as: "What happened during the war?", "Have you ever been abused?", "Let me tell you about the accident/rape" or "Was anyone in your family an alcoholic?" However, trauma is not just a story about something that happened long ago. The emotions and physical sensations that have been etched throughout the trauma are not memories but disruptive physical reactions occurring in the present.

To regain control of yourself, you need to revisit your trauma: Sooner or later you have to confront what happened to you, but only after you feel safe and won't be traumatized again. The first is to find ways to deal with emotions overwhelmed by the feelings and emotions associated with the past.

The engine of the post-traumatic response lies in the emotional brain part. In contrast to the rational brain, which manifests itself in thinking, the emotional brain manifests itself in physical responses: a feeling of intestinal cramps, a pounding heart, rapid and shallow breathing, feelings of chest pain, a high-pitched voice, difficulty hearing, and characteristic body gestures indicating collapse, spastic, angry, or defensive.

The rational brain helps us understand where emotions come from (e.g., "I'm scared to approach a man because I was abused by my father" or "It's hard for me to express my love for my son because I feel guilty for killing a child in Iraq"). However, the rational part of the brain cannot suppress emotions, feelings, or thoughts such as living with very little sense of threat or feeling that you, essentially, are a terrible person, even though you know that you are not at fault for being raped).

Understanding why you feel this way won't change how you feel, but it can prevent you from getting carried away with backlash (e.g. preventing you from attacking your boss who reminds you of the culprit who did something horrible to you, etc. prevent you from breaking up with your lover after the first disagreement, or preventing you from plunging into the arms of a stranger). However, the more we suffer, the more the rational brain becomes distorted from emotions.


The fundamental problem in dealing with post-traumatic stress is to restore the right balance between the rational brain and the emotional brain, so that you can feel in control of how you react and control your life. When we are in a state of high agitation, we are pushed out of the "tolerance threshold"4. We suffer from backlash and disorder, our filters stop working, sounds and lights bother us, unwanted images from the past enter our minds, and then we panic or throw tantrums. If we stop receiving sensations, we feel empty in our bodies and minds, our thoughts become sluggish, and we have trouble moving.

People cannot learn from experiences if they are overstimulated or stop receiving sensations. Even if they manage to control themselves, they are so stressed that they become rigid, stubborn and depressed. Recovering from trauma involves restoring executive function, confidence and the ability to play and create.

If we want to change our post-traumatic response, we must approach the emotional part of the brain and do "limbic system therapy": repair faulty alarm systems and restore the emotional brain to its normal job of serving as a quiet background for taking care of the body. Make sure you eat, sleep, connect with close people, protect your children, and defend yourself against dangers.

Neuroscientist Joseph LeDoux and colleagues have shown that the only way we can consciously access the emotional part of the brain is through self-awareness, that is, by activating the middle region of the prefrontal cortex, the part of the brain that announces what is going on inside us and thus allows us to feel what We're feeling. (The term for this is "interoception"—Latin for "looking within.") Most of our conscious brain is devoted to focusing on the outside world: getting along with others and planning for the future. However, that doesn't help us manage ourselves. Neuroscience research shows that the only way we can change the way we feel is to become aware of our inner experiences and learn to become familiar with what is going on inside ourselves.



Over the past few decades, mainstream psychiatry has taken notice of the use of drugs to change the way we feel, and this has become the accepted modality of dealing with hyperarousal.

I need to emphasize that people have a lot of skills available to keep their psyche stable, solid. In chapter 5, we saw how emotions are recorded in the body. About 80% of the fibers of the vagus nerve (which connects the brain to many internal organs) are involved; that is, they run from the body to the brainº. This means we can directly train our arousal system by breathing, singing, and moving.

In studies supported by the National Institutes of Health, my colleagues and I have shown that 10 weeks of yoga practice provides marked relief from PTSD symptoms in patients who do not respond to any medications or any other treatment. (I'll discuss yoga in chapter 16.) Neurofeedback, the subject of chapter 19, can also be particularly effective for children and adults who are overstimulated or stop receiving information about sensations, symptoms that make it difficult for them to concentrate."

Learning to breathe calmly and maintain a state of relative physical relaxation, even while recalling painful and terrible memories, is an essential tool for recovery. When you pay attention to slow, deep breathing, you will notice the effects of the parasympathetic nervous system on your irritability (as explained in chapter 5). Focusing as much on your breath will be the better for you, especially if you pay attention to the bottom of your exhalation and then wait a moment before you inhale again. As you continue to breathe and pay attention to the flow of air in and out of your lungs, you can think about the role oxygen plays in nourishing your body and bathing your body with the energy it needs to make you feel alive and energetic. Chapter 16 describes the systemic effects of this simple practice.

Emotional regulation is critical in managing the effects of trauma, so things would have been much different if teachers, military officers, foster parents, and mental health professionals had been thoroughly instructed in emotional regulation techniques. Currently, almost only kindergarten and kindergarten teachers are trained in this technique to control the impulsive behaviors of 10-year-olds.

In addition to yoga, other traditional disciplines are currently being studied for use in PTSD treatment such as tai chi, qigong, African drumming, Aikido, Judo, Tae Kwon do, Kendo, Jujitsu, Capoeira from Brazil,... These disciplines involve physical movement, breathing and meditation.


The focus of recovery is self-awareness. The most important phrases in trauma therapy are "Pay attention to" and "What happens next?". People with trauma live with seemingly unbearable sensations: They feel chest pain and suffer discomfort deep in their abdomen or chest. However, avoiding feeling these sensations in our bodies only makes us more likely to be overwhelmed by those feelings.

Being aware of our bodies means that we are connected to the world within us. Just by noticing our frustration, fear, and anxiety, we immediately change our perspective and make new reaction choices beyond the habitual automatic responses. Mindfulness helps us recognize the transient nature of our emotions and perceptions. When we focus our attention on how our bodies feel, we can recognize emotional flows, thereby increasing our control over them.

Traumatized people are often AFRAID to feel their physical sensations because they are now like enemies. And because of fear, their bodies froze, their minds closed. Although trauma is a thing of the past, the emotional part of the brain continues to create feelings that make them feel scared and helpless. It's no surprise that so many traumatized people have suffered from bulimia, alcoholism, fear of sex, and avoidance of many social activities.

To change, you need to be open to experiencing what's going on inside your body. The first step is to let your mind focus on how you are feeling and notice that the bodily sensations are brief and respond to a gentle shift in body position, a change in breathing, a change in thinking.

Once you've noticed your physical sensations, the next step is to describe them, for example, "When I'm anxious, I feel like my chest is bursting." Then I can tell the patient, "Focus on that feeling and see how it changes when you take a deep breath, or when you lightly touch your chest just below your collarbone, or when you allow yourself to cry." Practicing mindfulness will help calm the sympathetic nervous system, so you're less likely to feel like you have to fight or flee. Learning to observe and accept bodily reactions is a prerequisite for safe reconsideration of the past. If you can't accept what you're feeling right now, opening up to your past will only hurt you and hurt you further.

As long as we are aware that our bodies are constantly changing, we will be able to accept unpleasant sensations in our bodies. You feel tightness in your chest, but after taking a deep breath and exhaling, that feeling eases and you may feel another sensation, such as a tense shoulder. Now you can begin to explore what happens when you breathe more deeply and pay attention to how your ribs will dilate. Once you feel calmer and more curious, you can return to feeling in your shoulders. Don't be surprised to find your shoulders somehow attached to an ancient memory that suddenly arises.

The next step is to observe the interaction between your thoughts and bodily sensations. How are separate thoughts recorded in your body? (Do thoughts like "My dad loves me" or "My girlfriend abandoned me" make you feel different?) Being aware of how your body organizes specific emotions and memories opens up the possibility of releasing those unconscious feelings and urges that you once held back to survive. In chapter 20, which talks about the benefits of drama, I will describe it in more detail.

Jon Kabat-Zinn, one of the pioneers of mind-body medicine, founded the Mindfulness-Based Stress Reduction (MBSR) program at the University of Massachusetts Medical Center in 1979. His method has been thoroughly studied for more than three decades. He describes mindfulness as follows: "One way to think about this transformation is to view mindfulness as a lens, taking the scattered and reactive energies in your mind and focusing them on a seamless source of energy to live, to solve problems, and to heal"15.

Mindfulness has been shown to positively affect symptoms of mental illness, psychosomatic and stress-related illness including depression and chronic pain 16. It has broad effects on physical health, including improving immune response, blood pressure, and cortisolº levels. Mindfulness also activates brain regions involved in emotional regulation18 and leads to changes in areas associated with body awareness and Fear19.

Studies by Britta Holzel and Sara Lazar show that the practice of mindfulness even reduces the activity of the brain's alarm system, the amygdala, and thus reduces the response to potential factors.


Numerous studies show that having a good support network constitutes the strongest defense against trauma. A sense of security can overcome feelings of fear. When we are afraid, only the reassurance or tight hug of someone we trust can calm us down. When we are scared, adults like to be comforted just like children, which means that we like to have someone to cuddle us, to comfort us, to be assured that someone older than us, stronger than us, will take care of everything, so that we can go to bed peacefully. In order to recover from trauma, the mind, body, and brain need to be convinced that it will be perfectly safe for them to let go of traumatic memories. That only happens when you feel safe from inside your body and allow you to connect your sense of security with memories of your helpless past.

After an acute trauma, such as an attack, accident, or natural disaster, survivors expect to see their loved ones' faces and voices, be touched, have physical contact with their loved ones, eat, be in a safe shelter, and have time to sleep. Traumatized people desperately need early contact with loved ones near and far, and early reunion with family and friends in a place where they feel safe. Close relationships are our strongest line of defense against threats. For example, children who are separated from their parents after they experience a traumatic event may experience severe long-term negative effects.

Studies conducted during World War II in Britain showed that children living in London who were evacuated to the countryside to escape German bombing performed worse than those who stayed with their parents, although staying meant spending nights in bomb shelters and witnessing the Terrifying images of destroyed buildings and dead 21.

Traumatized people recover when they have relationships such as family, relatives, veterans organizations, religious organizations, professional therapists. The role of such relationships is to help the traumatized person feel safe physically and emotionally, to help them to be resilient to feelings of shame, rants or comments, and to give them the courage to endure, face and process what is happening.

Most of our neural connections are devoted to being in tune with others. Recovery from trauma involves (re)connecting with others. This is why trauma that occurs in relationships is often more difficult to treat than trauma caused by a traffic accident or natural disaster.

In our society, the most common traumas in women and children are usually caused by their parents or close partners. Those who abuse children, sexually abuse children, perpetrate domestic violence are all people who are supposed to love children. This causes children to lose their most important barrier of defense against trauma.

If the people who are supposed to care for and protect you are the ones who reject you, or frighten you, then you will learn to stop receiving sensory information and ignore what you are feeling. You struggle to find ways to deal with your feelings of fear, anger, frustration. Self-management of fear gives rise to a number of problems such as dissociation, despair, addictions, prolonged feelings of panic, discordant, disjointed relationships, and outbursts. Patients with these histories rarely connect what happened to them long ago with their feelings and behaviors in the present. Things seem to be out of control.

They won't be able to go through trauma without acknowledging what happened and recognizing the invisible demons they're grappling with. Many people feel very ashamed: "When you understand me, you will see how corrupt and disgusting I am." Unresolved trauma can adversely impact relationships. For example, if you are abused by your partner, you will be afraid to love a new person because you are afraid of hurting again. And it's more likely that you'll accidentally hurt the newcomer before they have a chance to hurt you.

When you can muster up the courage to face and listen to the sounds of your inner world, you need to find a reliable helper. The person who can sustain your emotions and help you listen to painful messages from your emotional brain. He or she is not afraid of your terrors, can endure your Rage, can protect you while you explore fragmented experiences that you had to keep a secret from yourself for a long time. Most traumatized people need a reliable fulcrum and need a lot of training to do this.

Choice of therapist

Trained trauma therapists can do three things: (1) stabilize and calm patients, (2) put haunting memories to rest forever, and (3) reconnect patients with their men and women. Ideally, the therapist himself will also benefit from carrying out therapy for the patient.

It makes perfect sense for patients to ask the trauma therapist about where the therapist studied, about the treatments they were trained in, about whether they would benefit from the very therapy they offered to treat the patient.

There are many therapies for trauma therapy, so beware of trauma therapists who insist that their particular approach is the only solution. The therapist needs to have an open mind, needs to be willing to learn from the patient.

You need to ask yourself if you are comfortable with this therapist? Does the therapist feel comfortable expressing himself or herself to you as a friend? Feeling safe with your therapist is essential for you to face your fears and anxieties. A therapist who is harsh, critical, emotional, or harsh can make you feel scared, abandoned, and offended, and certainly won't help you deal with traumatic stress. When old feelings from the past are stirring, you may suspect that this therapist is like someone who once hurt or abused you.

I hope you can cooperate with your therapist because in my experience, patients will improve their situation as they gradually develop deep feelings in a positive way towards their therapist. I also don't think you can grow and change unless you feel that the therapist has some impact on you.

The important question is: Do you feel that your therapist is curious to get to know you, wants to know who you are, and what you need? Does your therapist take the time to find out why you do what you do and think what you think? Therapy is a collaborative process, a mutual discovery of yourself.

People who have been mistreated by caregivers as children often don't feel safe with anyone. I often ask my patients if they can think of any person they felt safe with growing up. Many people remember very well the teacher, the neighbor, the shopkeeper, the coach, that is, the people who showed interest in them. Memories are often the seeds of reengagement. People are full of hope. Coping with inter-fracture trauma. It's about remembering how we survived as well as what we did

I also ask my patients to imagine how they are like babies, whether they will feel adorable or still feel humiliated. They all believe that they have envisioned themselves before they were hurt.

Some people don't remember ever feeling safe with anyone. For them, contact with horses and dogs is safer than communication with humans. The method of using animals to treat trauma is currently being applied in many treatment facilities and has great effect.

Jennifer is a graduate of the first class of the Van der Kolk Center^3 who participated in a trauma treatment program as a silent, out-of-control 14-year-old girl. Jennifer said at the graduation ceremony that being given the responsibility of caring for a horse was a very important first step for her. Her growing relationship with the horse helped her feel safe enough to start connecting with the center's staff and then focus on studying, taking the SAT and getting accepted to college.


In the process of treating trauma patients, I realized that music, dancing, drama, movement, martial arts have a great therapeutic effect, especially when these activities take place in groups.

Imagine the following scene, a group of women who have been raped sitting sullenly, silent. One of them started humming and swinging people back and forth. The other women began singing along in a low voice. Soon the group began to sing, move, stand up and dance. Their faces, their bodies became vigorous.

In chapter 20, I will talk about the effects of drama on youth criminals and children raised in less safe environments. They participated in Shakespeare plays.

Other patients said they felt better when they joined the choir, practiced Aikido, danced tango or played kickboxing.

I once examined a non-talking five-year-old girl named Ying me. She was adopted from an orphanage in China. My rhythm cohesion system doesn't work, meaning I can't resonate with the voices and faces of those around me. So we decided to treat him with sensorimotor therapy. We let Ying me lie in the plastic ball house to help her feel the sensations on her skin, let her sit on the swing, crawl under heavy blankets. After six weeks, something changed in him and he started talking to other people 26.

We also developed parent-child interaction therapy (PCIT). This therapy, like the Sensory motor arousal regulation treatment (SMART) developed by my colleagues at Trauma Treatment Center 27, helps parents and children feel physically and emotionally in harmony through playful activities, discover. Information is available at


Drugs such as Serotonin, Respiridol and Seroquel are increasingly being used to help people cope with their sensory world28. However, the most natural way to ease our pain is if someone touches us, cuddles us, and comforts us. These actions help us reduce over-excitement, making us feel intact, safe, protected, and in control.

You can't fully recover if you don't feel safe being touched by someone's flesh. Therefore, I encourage all my patients to participate in some body therapy, be it massage therapy, Feldenkrais or craniosacral therapy.

Body therapist Licia Sky describes how she treats traumatized people: "I never embark on a patient treatment without establishing a personal connection with the patient. I'm not trying to ask about their personal history, nor am I trying to understand how traumatized they were or what happened to them. I checked to see if they were really in their bodies right now. I asked them if there was anything they wanted me to pay attention to. During that time, I was assessing their posture, for example whether they looked me in the eye, how stressed they were, whether they connected with me.

The first thing I need to decide is whether they are comfortable lying on their back or stomach. If I didn't know anything about them, I used to lay them on their backs. I am very careful in choosing my outfits, so that they feel safe with whatever kind of clothes they want to wear. These are important boundaries that need to be set from the beginning.

Then, with the first touch, I established a strong, secure bond with them. Not strong, not suddenly, not too fast. My hands move very slowly so that it is easy for the patient to grasp, gently in tune. The force of touch is the same as when we shake hands. The first places I can touch are their hands and arms, as it's the safest place to touch anyone and also where patients can touch me again.

The therapist must meet the patient's point of resistance, where stress is most, and respond to it with an equal amount of energy. That releases tension. The therapist should not hesitate, because that means a lack of confidence in himself. The therapist slowly touches the patient, focusing attention on the patient does not mean that the therapist is hesitating. You have to touch the patient with great confidence and empathy, let the pressure of your hands meet the tension they are holding in their body.

What are the benefits of body therapy? Licia replied, "Patients can be as desperate to be touched by someone as thirsty as a thirsty person craves a glass of water. Confident, deep, sure, gentle, wholehearted touches will make patients feel comforted, helping them to explore stresses that they have held on for so long that they are no longer aware. When you touch a certain part of a patient's body, you are waking that part of the body.

The body can be "blocked" by its own internal emotions. For example, their shoulders contract, their facial muscles tense, they put their strength to hold back the tears that fall, stifle the sounds of sobs. When physical tension is released, emotions are released as well, breathing becomes deeper, and when the tension is gone, they can turn out expressive sounds. The body becomes freer, the patient will breathe freely, freely immerse himself in the flow of emotions. Physical contact helps the patient's body gradually react to touches and contacts.

People who are frightened need to get a sense of their body's place in space and within their boundaries. Firm, safe touches with others help them know where those worlds are, i.e. what's outside of them, where their bodies end. They discover that they don't often have to wonder who they are, where they are. They discover that their bodies are very solid and that they don't have to constantly defend. Collisions let them know that they are safe.


The body responds to extreme experiences by secreting stress hormones. People often blame stress hormones when they get sick. However, the hormones of stress give us the strength and endurance to meet unusual conditions. People who actively do something to deal with a disaster, such as saving a loved one, saving strangers, taking others to the hospital, participating in the medical team, setting up tents, cooking, mean they are leveraging stress hormones for the proper purpose, As a result, their risk of trauma is much lower (however, everyone has their own tolerance limits, and even the most psychologically prepared person can still be shocked by varying degrees of ordeal).

Helplessness and immobility prevent people from using their stress hormones to defend themselves. When that happens, stress hormones that still secrete actions that this hormone intends to "energize" are hindered. Eventually, the trigger patterns used to promote coping are pushed back into the body and form an inappropriate paralysis response. To return to normal operations, this ongoing emergency response must end. The body needs to be restored to its original state of safety and relaxation, from which it can mobilize action in response to real danger.

Pat Ogden and Peter Levine have developed body-based therapies, sensorimotor psychotherapy and somatic experiencing to address this. In these therapeutic approaches, we focus on exploring bodily sensations and exploring the location and shape of past traumatic imprints on the Body.

Before exploring trauma, patients are helped to build internal resources to facilitate a safe approach to the feelings and emotions that overwhelmed them at the time of trauma. Peter Levine calls this the pendulum process, gently going in and out of the inner emotional world and traumatic memories. Gradually, the patient's tolerance will increase.

Once patients have been able to tolerate the perception of their trauma-based physical experiences, they will be able to explore strong physical contact such as hitting, shoving, or running. These may be the same actions they did when they were harmed in the past, but they have been pent up so that they can survive in the present. They can have subtle body movements such as twisting, turning, stepping back. When we help them reinforce these actions, trying different ways to modify these actions, we initiate a process of perfecting the defective "action tendencies" associated with trauma so that we can eventually address the trauma.

Experiential therapy can help patients position themselves in the present by experiencing safety when they are in motion. The joy of taking certain actions can help patients restore their sense of self-defense and proactive self-defense.

One of my favorite body-based therapies to effectively build a fight/flight response is the robbery simulator. Specifically, women (and also men) are taught how to actively resist an attacker in a simulated situation. The program began in Oakland, California, in 1971, after a woman with a black belt in Karate was raped. I wondered how this could happen to someone with high martial arts who could beat someone to death with their bare hands? Her friends concluded that her martial arts skills were overshadowed because she was too scared. According to the book, her executive functions, the frontal lobe, stopped working and she became paralyzed.

This robbery simulation program teaches women to restore their response to escape paralysis through repeated repetition of "zero hour" (action hour, this is a military term for the exact moment of an attack) and learn how to turn fear into positive combat energy.

One of my patients was a college student who had been sexually abused repeatedly as a child who took this course. When I first met her, she looked depressed, depressed and too submissive. Three months later, on the final graduation ceremony, she successfully knocked out a burly man who played the role of an attacker. She faces him vigorously, hands raised in a Karate pose, calmly shouting a clear "No!"

Not long after, late one night, she was walking home from the library when three people jumped out of the bushes, shouting, "Give me the money."

She stood in Karate, shouting, "Ok, I've been waiting for this moment for a long time! Who wants to go first?" The thugs ran away. In that situation, if you cringe and look around in fear, you'll easily fall prey to your abusers, but when you say, "Don't bother me!" there's a good chance they won't bother you.


We can only put traumatic events behind us when we can acknowledge what happened and begin to recognize the invisible demons we are battling. Traditional psychotherapy is primarily focused on constructing a narrative that explains why a person feels in such a particular way or as Sigmund Freud said in 1914 in his book Remembering, Repeating and Working Through: "Although patients survive trauma], we must complete their treatment, essentially helping them reinterpret it in language." Recounting the traumatic story we went through is a very important step because without telling it, the memory will freeze; And without memory, we can't imagine how things could be different.

But telling it doesn't guarantee that painful memories will forever be dormant. This is explained by the fact that when we remember an ordinary event, we don't recall the physical sensations, emotions, images, smells, or sounds associated with that event, but when we recall our traumatic situations, we "have" the type of experience that: We are engulfed by the sensory or emotional elements of the past.

The brain scans of Stan and Ute Lawrence, traffic accident victims in chapter 4, show how this happened. When Stan remembers the horrific accident, two main areas of his brain are empty: the area that creates a sense of time and space that helps to perceive "it was back then, and now I'm safe" and another area that integrates images, Sound and sense of trauma into a coherent story. When parts of the brain are brushed aside, you experience something that is not an event full of beginnings, happenings, endings but fragments of feeling, imagery, and emotion.

An injury can be successfully treated only if all brain structures are functioning. In Stan's case, eye movement desensitization and reprocessing (EMDR) allowed him to access memories of the accident without being overwhelmed by them. When areas of the brain, the areas whose inactivation causes flashbacks, can become active again while reliving what happened, people can integrate their traumatic memories into the past.

Ute's dissociation causes her to recover in a complex way in a different fashion. The brain structure needed to know that you are in the present is no longer functioning, so Ute cannot cope with trauma. She needed help to build up her stamina before she could cope with her PTSD symptoms.

Hypnosis was the most popular treatment of trauma from the late 1800s until after World War II. On YouTube, you can watch the documentary Let There Be Light directed by John Huston. In the film, there are scenes of men being hypnotized to treat "war-induced neurosis."

Since the early 1990s, hypnosis has fallen out of favor and there have been no recent studies on the effectiveness of hypnotherapy in treating PTSD. However, hypnosis can bring about a state of relative calm, from which patients can follow their traumatic experiences without being overwhelmed by them.


CBT was first developed to treat phobias such as fear of spiders, airplanes or heights, helping patients compare irrational fears with harmless realities. Patients gradually become less afraid of these absurdities by visualizing what they fear most with their own language and images ("imaginal exposure"), or they are placed in real (but actually safe) situations that make them anxious ("in vivo exposure") or give them virtual reality experiences.

The basic idea of CBT is to expose patients repeatedly to stimuli without actually happening badly, so that they become less afraid, less uncomfortable, they will know that their fear is irrational and that they are completely safe. CBT also tries to help patients address their tendency to avoid facing their fears, such as "I don't want to talk about that"34.

It sounds simple, but recalling a traumatic situation reactivates the brain's alarm system and disables key brain areas needed for past integration, making it possible for patients to relive rather than resolve the trauma.

Prolonged exposure has been studied more thoroughly than any other PTSD treatment. Patients are asked to "focus their attention on the situation that left them traumatized and not distracted with other thoughts and activities"35. Research shows that it takes exposure for up to nearly 100 minutes (during which they are stimulated to intensify and prolonged anxiety) before patients begin to reduce anxiety. Exposure sometimes helps resolve fear and anxiety, but has not been shown to be effective with guilt or other complex emotions*7.

Although CBT is effective in treating irrational fears such as fear of spiders, it is not effective for traumatized people, especially those with a history of abuse as children. Only about one-third of participants in a study treated for PTSD with CBT showed some improvement. People who complete treatment with CBT often experience relief from PTSD symptoms, but rarely do they fully recover: Most of them continue to have problems with their health, work, or mental well-being.

In the largest published study on the use of CBT to treat PTSD, more than one-third of patients gave up; The rest had some significant adverse reactions. Most women still had PTSD three months after participating in the study, and only 15 percent no longer had major symptoms of PTSD. A thorough analysis of all scientific studies of CBT shows that it is effective as an adjuvant therapy. The worst outcome in exposure therapy was when applied to patients with "mental failures" who gave up 42.

Trauma is not only a matter of the victim being trapped in the past, but also the victim's inability to fully live in the present. Recent studies on Australian veterans show that their brains are altered to be alert to emergency situations, at the cost of their inability to focus on the small details of everyday life. (We'll learn more about this in chapter 19, Neural Feedback.)

Patients can only benefit from reliving their traumatic situation only if they are not overwhelmed by the flashback process. A good example to illustrate this is the work of my colleague Roger Pitman, conducted in the early 1990s, on U.S. Vietnam veterans. He and his colleagues pushed veterans to leave over and over again every detail of their experiences in Vietnam. But the researchers had to stop the study because many patients became alarmed by their recollections and the terror often persisted until after the session. Some never return. Among those who continued to participate in the study, many became more depressed, more violent, and more fearful; Some will cope with these worsening symptoms by drinking, leading to violence and assault to the point where some have been taken to hospital by their families.


Systematic desensitization helps patients become less reactive to certain emotions and feelings. But is this the right goal? Perhaps the point is not desensitization but integration, that is, bringing the traumatic event into its proper place in the overall arc of one's life.

Desensitization reminded me of what I once witnessed about a boy about 5 years old and his father. The father screamed behind him as the boy plunged his tricycle into the road. My heart raced when I saw it, wanting to give the dad an owl, but the baby didn't flinch, kept driving away. I wonder how much brutality that child had to go through to become empty of his father's brutality. Her indifference to her father's screaming must have been the result of constant revination, but I wondered, what was the price here?

We can take drugs to dilute our emotions or we can learn to desensitize ourselves. However, University of Chicago neuroscientist Jean Decety suggests that losing sensitivity to our own pain or the pain of others can cause us to lose our total sensitivity to emotions45.

A 2010 report of 49,425 veterans from the Iraq and Afghanistan wars newly diagnosed with PTSD found that less than 10% of them actually completed the recommended treatment. This suggests that the treatment has little effect. We can only "process" terrible experiences if they don't overwhelm us. And that means more approaches are needed.


In 2000, Michael Mithoefer and colleagues in South Carolina obtained FDA permission to conduct experiments with MDMA (ecstasy drug). MDMA was classified as a controlled drug in 1985 after years of use as a recreational drug. As with Prozac and psychiatric drugs, we don't know exactly how MDMA works, but it is known to increase levels of several important hormones including oxytocin, vasopressin, cortisol and prolactin*7. The most relevant point for trauma treatment is that MDMA drugs increase people's awareness of themselves, helping them to be more empathetic, curious, clear, confident, creative, and connected to people. Mithoefer and his colleagues searched for a drug that could increase the effectiveness of psychotherapy. Then they became interested in MDMA because it reduces fear, defense, and emptiness as well as provides access to inner experiences18. They think MDMA could allow patients not to overstep their tolerance threshold so they can recall traumatic memories without being unduly affected by physical or emotional stimulation.

Early pilot studies supported this expectationº". The first study, involving veterans, firefighters and police officers with PTSD, yielded positive results. The study followed a group of 20 victims of abuse who did not respond to previous therapies. 12 patients received MDMA, 8 received placebo. They sat or lay down in a comfortable room, and all attended two psychotherapy sessions, each 8 hours long, mainly using internal family systems (IFS) therapy. Two months later, 83% of patients who received MDMA plus psychotherapy were considered completely cured, compared to 25% of the placebo group. None of the patients had unwanted side effects. Perhaps most interestingly, when interviewing participants more than a year after the study was completed, they maintained their status.

When we are able to observe trauma in a calm, mindful state (IFS calls this state the Ego), the mind and brain can integrate the trauma into the whole of life. This is very different from traditional desensitization techniques, which only reduce a person's response to past horrors. This is about coherence and integration — making a horrific past event that overwhelms you into a memory of something that happened a long time ago.

However, we need to be careful when using hallucinogens when treating trauma, which means we need to establish and maintain certain therapeutic boundaries.


When people feel hopeless, they often turn to stimulants, narcotics like alcohol, marijuana, painkillers, tranquilizers, anything to make them calmer or more self-controlled.

Psychiatry follows this tradition. Over the past decade, the Department of Defense and the U.S. Department of Veterans Affairs have spent more together

$4.5 billion for antidepressants, antipsychotics and anti-anxiety medications. A June 6 internal report by the U.S. Department of Defense's Center for Pharmacological Economics at Fort Sam Houston in San Antonio found that of the 2010.1 million active-duty soldiers surveyed, 1 percent were taking some form of psychotropic medication: antidepressants, antipsychotics, tranquilizers, or other controlled medications.

However, drugs cannot "cure" trauma, but can only relieve disturbed physiological symptoms. Drugs can't help us master ourselves in the long run. They can help control emotions and behavior by blocking the chemical systems that regulate commitment, motivation, pain, and pleasure and the drinker always pays a price.

Only a few classes of psychotropic drugs have been used to treat some aspects of PTSD. Serotonin reuptake inhibitors (SSRIs) such as Prozac, Zoloft, Effexor and Paxil have been studied most thoroughly, and they can reduce stress, making life more manageable. Patients taking SSRIs often feel calmer and more in control, feel less overwhelmed, and therefore more easily participate in therapy.

Other patients felt SSRIs were blinding them, as if they were "losing their acumen." I approach it as an empirical question: Let's see what works, and only the patient can judge that. On the other hand, if one type of SSRI doesn't work, you should try another, because each has quite different effects. Interestingly, SSRIs are widely used to treat depression, but in a study comparing Prozac to Eye Movement and Cognitive Load (EMDR) therapy for patients with PTSD, many of whom also suffer from depression, EMDR proved to be a more effective antidepressant than Prozacº. I'll return to that topic in chapter 155.

Drugs that target the autonomic nervous system such as propranolol or clonidine may help reduce oversensitivity and stress response55. This class of drugs works by blocking the effects of adrenaline on the body and thus reducing nightmares, insomnia, and response to traumatic stimuli. Suppressing adrenaline can help keep your rational brain active and making more viable choices: "Is this really what I want to do?" Since I started integrating mindfulness and yoga into my healing, I've also used these medications less often, unless, occasionally, I want to help patients sleep better.

Traumatized patients tend to prefer sedatives such as Klonopin, Valium, Xanax, and Ativan. Generally, they act like alcoholic beverages, making people feel calm and avoiding anxiety (casino owners prefer customers who take antipsychotics because these people usually don't feel sad about losing money, so keep gambling). But like alcohol, benzos weaken inhibitions against things that hurt those we love. Most civilian doctors are reluctant to prescribe these drugs because they have a high potential for addiction and can interfere with the handling of trauma. Patients who stop taking the drug after prolonged use often have withdrawal reactions that cause them to become agitated and increase post-traumatic symptoms.

Occasionally, I prescribe low-dose benzodiazepines to patients, just to take them when needed but not enough for them to take daily. They have to choose when to take that precious medicine and I ask them to take a note of what is happening when they decide to take it. This recording helps us to know which specific incidents provoked them.

"Some studies show that anticonvulsants and mood stabilizers, such as lithium or valproate, may have a soothing positive effect, reducing over-arousal and panic." The most controversial drugs are second-generation antipsychotics such as Risperdal and Seroquel, the best-selling psychotropic drugs in the United States ($14.6 billion in 2008). Using low doses of these drugs can help in calming veterans and women with PTSD related to being abused as 58-year-olds.

Sometimes it makes sense to take these medications, for example when patients feel completely out of control and can't sleep or other treatments fail." But it's important to note that these drugs work by suppressing the dopamine system, which produces pleasure and motivation.

Antipsychotic drugs such as Risperdal, Abilify or Seroquel can significantly reduce the activity of the emotional brain and thus make the patient less anxious or angry, but they can also interfere with the ability to evaluate subtle signals of pleasure, dangerous or satisfying. They also cause the drinker to gain weight, increase the risk of diabetes and make the patient's body sluggish and sluggish, which in turn makes them want to withdraw from others.

These drugs are widely used to treat abused children who have been diagnosed with mismatches such as bipolar disorder or mood adjustment disorder. More than half a million children and adolescents in the U.S. are currently taking antipsychotics, which can calm them down but also interfere with learning age-appropriate skills and developing friendships with other children. A recent Columbia University study found that the number of prescriptions for antipsychosis given to two- to five-year-olds doubled between 2000 and 2007°•. Only 40% of them were properly assessed for mental health.

Children from low-income families are 4 times more likely to receive antipsychotics. In one year alone, Texas Medicaid spent $96 million on antipsychotic drugs for adolescents and children — including three unidentified children who were given drugs before age 1. There have been no studies on the effect of psychotropic drugs on the developing brain. Dissociation, physical self-harm, fragmented memories, and dementia often don't respond to any medication.

The Prozac study I discussed in chapter 2 is the first to find that the average person with trauma tends to respond better to medication than veterans. Since then, many other studies have found similar differences. In this situation, it is worrying that the Ministry of Defense and the Ministry of Health have prescribed very large quantities of drugs for soldiers and veterans, and often without additional forms of therapy. Between 2001 and 2011, the Department of Veterans Affairs spent about $1.5 billion on Seroquel and Risperdal, while the Department of Defense spent about $90 million during the same period, although a study published in 2001 found that Risperdal was no more effective than placebo at treating PTSD°. Similarly, between 2001 and 2012, the Department of Veterans Affairs spent $72.1 million, and the Department of Defense spent $44.1 million on benzodiazepines 65 — drugs that clinicians generally avoid prescribing to normal patients with PTSD because the drugs can be addictive and significantly ineffective in treating PTSD symptoms.


In the first chapter of the book, I mention a veteran named Bill. Bill was a doctor in Vietnam during the period

1967-1971. After returning to the United States, he worked in a local hospital. Caring for the sick made him emotional, short-tempered and irritable, but he had no idea what these issues had to do with his experience in Vietnam. Anyway, a diagnosis of PTSD was not available at the time. After quitting his job at the hospital and taking training to become a pastor, he had less sleep and a little less nightmares. It wasn't until his first child was born in 1978 that he sought treatment from a doctor.

His children's cries reminded him endlessly of the traumatic scenes in Vietnam. He was so out of control that some of my colleagues at the Department of Veterans Affairs wanted to put him in the hospital for treatment because they thought he had a mental disorder. However, as he and I began to work together, as he began to feel safe with me, he gradually opened up to tell me about what he had witnessed in Vietnam. He slowly tolerated his emotions without being overwhelmed. This also helped him refocus on taking care of his family and finish his training as a pastor. After two years, he became a pastor and had his own parish and we felt our work was done.

It wasn't until 18 years later that Bill contacted me again and told me he was experiencing the same symptoms again: reminiscing about the past, having terrible nightmares, feeling crazy — just like when his first child was born. The day his son Bill went to enlist, Bill went with him. The registered place is the arsenal Bill worked for before being sent to fight in Vietnam.

By that time, I knew more about how to treat post-traumatic stress, so Bill and I addressed specific memories of what he saw, heard and smelled in Vietnam, details he was too scared to recall when he first encountered them. Now we can integrate these memories with EMDR therapy, so that they truly become stories of olden times.

Once he feels better, Bill wants to deal with the events of his childhood: his cruel upbringing, the guilt of leaving his mentally ill brother alone in his hometown to enlist in the military, the feeling of loneliness and lack of protection when his father throws a tantrum at him.

Another important theme of our time working together was the daily pain Bill faced as a pastor: having to bury teenagers who died in car accidents just a few years after he baptized them or the couples he had been married to return to see him in a crisis. domestic violence. Bill went on to organize a support group for clergy facing similar traumas, and he became an important source of strength in his community.

Bill's third treatment began 5 years later, when he developed a serious neurological condition at the age of 13. He suddenly became paralyzed in parts of his body and began to accept the fact that he would probably be confined to a wheelchair for the rest of his life.

I thought his problems might be due to multiple sclerosis, but neurologists couldn't find specific lesions, and they said there was no cure for his condition.

I urged Bill to find a way to feel and get used to the emotions of grief in his body, just as he had learned to endure and live with the most painful war memories. I suggested he contact a body therapist who introduced me to the Feldenkrais method, which uses hand contact to rearrange physical sensations and muscle movement.

When Bill came back and told me about his condition, he looked glad he was getting more and more self-reliant. I told him I had recently started practicing yoga on my own and we had just opened a yoga program at the Trauma Treatment Center. I invited Bill to learn about yoga as the second step in therapy.

Bill found a Bikram yoga class, a high-temperature and high-intensity yoga class that is usually reserved for young and energetic people. Bill loved this method even though some parts of his body often gave up in the middle of class. Despite his physical impairments, he still felt physical pleasure and spiritual care that he had never felt before.

Bill's psychological treatment helped him leave behind horrific war experiences. When he was friends with his body, he no longer had the headache of being paralyzed. He decided to become a yoga instructor, beginning teaching yoga at the local arsenal to veterans returning from Iraq and Afghanistan.

10 years later, Bill continues to be fully involved in life with his children and grandchildren. He accepted his physical limitations as an inconvenience. To date, he has taught yoga classes to more than 1,300 veterans returning from Vietnam. He often had to sit or lie down because his limbs suddenly weakened. But these health issues, as well as his memories of his childhood and of Vietnam, could no longer block his life. They were simply part of his ongoing life.


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