Rethinking Trauma - Amazon S3...Dr. van der Kolk: Yes. It is an old study, many, many years ago, but...

How to Work with the Traumatized Brain Bessel van der Kolk, MD - Main Session - pg. 1

Rethinking Trauma

the Main Session with

Bessel van der Kolk, MD and Ruth Buczynski, PhD

National Institute for the Clinical Application of Behavioral Medicine

How to Work with the Traumatized Brain


Table of Contents

(click to go to a page)

How PTSD Creates Differences in Brain Function .................................................. 3

How Trauma Changes Perception .......................................................................... 5

How the Flashback of PTSD Affects the Brain ........................................................ 7

Three Brain Systems: Smoke Detector, Cook, and Watchtower ............................. 9

The Importance of the Vagus Nerve in Treating Trauma ........................................ 12

How a Predisposition to PTSD Is an Attachment Issue ........................................... 16

Limbic System Therapy .......................................................................................... 17

Neurofeedback as PTSD Therapy ........................................................................... 19

EMDR and PTSD .................................................................................................... 21

References . ............................................................................................................ 24

About the Speakers ............................................................................................... 25


Rethinking Trauma: Bessel van der Kolk, MD


Dr. Buczynski: Hello everyone and welcome. I am Dr. Ruth Buczynski, a licensed psychologist in the State of

Connecticut and the President of the National Institute for the Clinical Application of Behavioral Medicine.

Welcome back to this series on the treatment of trauma.

We have the world’s leading expert with us today on the treatment of trauma, especially when it comes to

how trauma and PTSD affect the brain – and that is Bessel van der Kolk.

He is a neuroscientist and a professor of psychiatry at Boston University’s medical school, and he is also the

medical director of the Trauma Center there.

He is the author of a book, The Body Keeps the Score: Brain, Mind and Body in the Healing of Trauma, so we

are going to explore some of the ideas that he wrote about in this book.

So, Bessel, welcome. It’s great to see you. Thanks for coming back again. I am going to jump right in because

we have so much that we want to talk about today.

How PTSD Creates Differences in Brain Function

Dr. Buczynski: I would like to start by talking about how traumatic experience changes the way people

perceive the world – you talk about this in your new book.

Actually, you focus on how the body, mind and brain come into play when treating PTSD.

Let’s start with the brain: how is the brain different in a person with PTSD as compared to a person who

doesn’t have PTSD.

Dr. van der Kolk: There are three big differences. One is that the threat

perception system is enhanced in those with PTSD. These people see

danger where other people see what is manageable.

This perception is not in the cognitive part of the brain – this is in the core perceptual part, a very primitive

Rethinking Trauma: Bessel van der Kolk, MD

“The threat perception

system is enhanced in

those with PTSD.”



part of the brain.

Basically, this primitive part of the brain is in charge of making sure that your body is okay – it is the fear-

driven part of the brain. So, threat perception is enhanced – that is number one.

Number two is that your filtering system, which is a little higher up in your brain that helps you to distinguish

between what is relevant right now and what you can dismiss gets messed up.

What other people sort of ignore or don’t pay attention to, the PTSD

brain starts to pay attention to, and this makes it very hard to focus

on what is going on right now. The filtering system does not function

efficiently, and it’s difficult to fully engage with ordinary situations.

The third difference is with the self-sensing system, which runs through the midline structures of the brain

and various people probably have talked about on your program already.

The self-sensing system that is devoted to your experience of yourself gets blunt. This is probably a defensive

response – when you are in a state of terror, you feel it in your body: you feel it in terms of heartache and gut

-wrenching feelings –your body feels bad, and as a way of coping with that,

people start taking drugs to dampen that system, and other people

naturally find a way of dampening that internal response.

But when you start dampening your response to yourself, you also dampen

the response to pleasure, sensuality, excitement, and connection – all the

deep feelings that are at our core as human beings.

Dr. Buczynski: That is very interesting, and you can see how that

would affect the feeling of “aliveness” in a person with PTSD, or

even their motivation to do anything.

Dr. van der Kolk: Right, and paradoxically, they may feel alive

when they are involved in dangerous situations.

Dr. Buczynski: Say more about that.

Dr. van der Kolk: The very first thing that struck me, working with traumatized patients many years ago is

that, while they hated what they had gone through, they felt a natural attraction to it at the same time.

“The filtering system does

not function efficiently, and

it’s difficult to fully engage

with ordinary situations.”

“The self-sensing

system that is devoted

to your experience of

yourself gets blunt.”

“When you start dampening

your response to yourself,

you also dampen the

response to pleasure,

sensuality, excitement, and

connection – all the deep

feelings at our core.”


They felt alive when they were in situations similar to being beaten up or being molested or being back at

war. The feelings of pleasure and pain got confused with each other – while they were horrified by what had

been traumatic they felt alive at the same time.

Dr. Buczynski: Bessel, is that because the brain has to pay so much closer attention when a person is in a

dangerous situation?

Dr. van der Kolk: I think something happens to the traumatized brain

that makes it hard to just take pleasure in a raindrop falling on a leaf,

or light coming through a window, or seeing two kids play – just the

little things that give color and texture to our lives.

Traumatized people tend to feel numb and not alive, and they can

make themselves feel alive by exposing themselves to the same

situations that caused their terror.

Dr. Buczynski: It is almost as if they have an on/off switch and no rheostat.

Dr. van der Kolk: That’s right – they have no rheostat.

How Trauma Changes Perception

Dr. Buczynski: Now, you did a study in the VA which started out looking at nightmares but ended up

exploring how trauma changes perceptions, and in that study you were using the Rorschach test. You were

working with twenty-two veterans. Can you talk to us about that study?

Dr. van der Kolk: Yes. It is an old study, many, many years ago, but to my mind, the Rorschach and tests like

that are still the best tests – they show how we make sense out of

the world.

If you show a large ink blot to each of us, we might see people on

motorcycles, or people dancing or similar kinds of scenes.

If you show the same ink blot to traumatized people, they’ll see a

torn vagina or a kid being killed – their mind has been refocused to see trauma everywhere.

“The Rorschach and tests like

that are still the best tests –

they show how we make

sense out of the world.”

“Traumatized people tend

to feel numb and not

alive, and they can make

themselves feel alive by

exposing themselves to

the same situations that

caused their terror.”


With trauma, there’s a real loss of innocence, a loss of just enjoying

because there is always this perception of: Is this the trauma again?

That perception interferes with feeling fully alive.

In this study, I used the Rorschach, and what is particularly alarming

is that about one out of four people didn’t see anything. These people would say, “There’s nothing here. This

is just a bunch of ink” – which is true, but human beings live through imagination.

For example, as we prepared ourselves for this talk, I thought, “Oh, good, I’ll be talking to Ruth,” and I was

imagining how that would go – I was projecting myself into the future and anticipating the pleasure of our

talk.

We live through imagination – and when you are sitting and maybe feeling a little bored at a lecture, you can

just leave the room and think about the tennis game you are going to

play, or the party you are going to go to, or whatever is coming up.

In a way, your imagination frees you of the tyranny of the boring

presence.

In traumatized people, the imagination gets very perturbed, and many

who are traumatized lose that imagination, or their imagination tends to draw them into danger again.

Trauma makes it hard to safely imagine the sort of fun stuff that most people organize their lives around.

If you can not imagine, you can not change your life. You can only

change your life if you can imagine what your life would look like if

you were doing something different from what you are doing.

Dr. Buczynski: Are you saying that you don't have motivation to change your life? What makes imagination

so important?

Dr. van der Kolk: Let’s say I plan on doing a new piece of research.

In order to do that, I need to imagine what it will be like for people to lie in a scanner, and what it will be like

to have my research assistants administer certain tests; I need to imagine what it would be like for people to

come into the lab and how we will receive them – we’ll need to buy furniture – we’ll need to create this area.

“Many who are

traumatized lose that

imagination, or their

imagination tends to draw

them into danger again.”

“With trauma, there’s

always this perception of: Is

this the trauma again?”

“If you can not imagine, you

can not change your life.”


All of that is done in your imagination before you execute the plan. If you have no imagination, you cannot

arrange anything for yourself in the future.

I’ll give you another example.

You need to have the image of where you want to go in order to go there. If you want to go visit your mom,

you need to remember where your mom lives and what it will be like for you to see your mom.

You might buy a present for her because you know that, “Mom will smile if I buy her these flowers.” If you

cannot imagine that, you cannot buy the flowers.

How the Flashback of PTSD Affects the Brain

Dr. Buczynski: Let’s talk a little bit about how PTSD and traumatic experiences affect the brain, and in

particular, with regard to flashbacks – that is one of the common symptoms of PTSD.

What is happening in the brain when someone experiences a flashback, and what does it explain about the

traumatized brain?

Dr. van der Kolk: Flashbacks are important and when we created a PTSD diagnosis, we made flashbacks

central – but that is not because that is the most problematic issue in traumatic stress.

We have made flashbacks a primary issue because we had to convince the VA that the problems that soldiers

were having were due to the war. Flashbacks connect the symptoms to a

particular memory.

Flashbacks are important, but, again, the flashbacks as we originally

conceded them are of specific events that people are aware of reliving.

We are talking about adults who again see their child die in front of them – we are talking about experiences

that have happened to them as adults.

That is not how flashbacks go for traumatized kids or people who have been traumatized as children, who are

now adults – they start behaving as if they were back there.

Usually, they don't have a mental connection of, “Oh, when my boyfriend says a particular thing, I start

“Flashbacks connect the

symptoms to a

particular memory.”


feeling like I’m getting molested again by my uncle.” That mental connection is not being made. They could

start to behave like a very frightened and enraged person, but they might not make a connection between

that and what happened thirty years ago.

Dr. Buczynski: You did a study after a patient you had named Marsha had a car accident and I believe her

daughter was killed.

You had the researchers reading a script that described what happened during the trauma – what Marsha

went through – to people who were in a scanner.

Can you tell us a little bit about that and what you learned from it?

Dr. van der Kolk: That was the first, one of the earliest studies ever, on

PTSD, and we lucked out because what we learned was very interesting.

We found that when people start reliving their trauma, much of their

brain goes offline.

They immediately get pulled back into the past. Their emotional brain on the right goes back there, sees the

images of what happened back then, and experiences physical sensations. Stress hormones get released and

the body starts behaving again as if the trauma is happening right now.

The timekeeping part of the brain that tells you, that was then and this is now, tends to go offline.

You experience the trauma as if it is happening right now, and the part of your brain that says, “Oh, but that

was forty years ago or that was last year,” cannot reassure you that this is an issue belonging to the past.

Dr. Buczynski: Again, it comes down to relevance: you have no way of knowing –you can’t determine if it is

in the present or even how relevant it’s going to be.

Dr. van der Kolk: Yes, and that’s what the dorsolateral prefrontal cortex (of the frontal lobe) says, “Oh, yes –

that happened to me but that’s a year ago – it’s not happening right now.”

With trauma, the brain cannot do that, so it is happening right now.

Dr. Buczynski: I think you also mentioned Broca’s area – they didn’t show any activation in Broca’s area. Why

is Broca’s area important?

“When people start

reliving their trauma, the

timekeeping part of the

brain that tells you, that

was then and this is now,

tends to go offline.”


Dr. van der Kolk: That, of course was the huge finding, to my mind.

People become dumbfounded when they go into their trauma. Clinicians see that, but we are such “talking”

type people that we tend to ignore the fact that when you really go into the most elementary, fear-driven

situation, you cannot talk – your body is just making you feel terrible.

Your speech center goes offline, and at that point, the speech center that can generate four-letter words

works very well. It is a different area, but the speech center that I am using right now to try to explain

something to you goes offline.

For me, that study – it is a long time ago now – about twenty years

ago was the opening salvo to help me realize that words are

important, but they are limited in their capacity to access the

trauma.

When you really go into to your trauma, you become a speechless person.

Dr. Buczynski: Yes. Enough about studies for a moment, but I just wanted to get that foundation for us as we

go on.

Three Brain Systems: Smoke Detector, Cook, and Watchtower

Dr. Buczynski: One of the things you talked about in your book and I thought it was a really good

characterization, was your description of the three brain systems: the smoke detector, the cook, and the

watchtower.

I think that analogy could be useful to practitioners when explaining to their patients what might be going on

in their brain. Could you tell us about that?

Dr. van der Kolk: Yes. What I call the smoke detector is that

primitive brain area that makes you be afraid – the amygdala.

Certainly, in almost every study of trauma, that smoke detector –

the amygdala –becomes hyperactive when people are exposed

to images/memories of what happened before.

“When you really go into to

your trauma, you become a

speechless person.”

“The smoke detector is that

primitive brain area that makes

you be afraid – the amygdala.”


When you show pictures of faces that look slightly angry to traumatized kids, the kids become afraid. That

sense of danger causes the smoke detector to become hyperactive.

One of the big questions in trauma treatment is how do you rewire

that amygdala? How do you rewire that smoke-detector system?

Nobody has nailed that yet. I am doing a study that might finally

prove that we are able to do it, but nobody has been able to prove that their particular method can rewire

the amygdala – that is very important to look at.

What we do know is that there is a part of consciousness that allows you to monitor and guide yourself in

some way.

That area of debate is called the medial prefrontal cortex, and

that is the area of your brain involved in interoception – looking

inward and noticing yourself – more or less noticing the ins and

outs of the landscape of your body.

One of the great advances in trauma treatment that was absent twenty years ago is this whole advance in

the practice of mindfulness, yoga, body work, and self-perception.

Twenty years ago, people were just talking and explaining what was happening by using their rational brains

to say, “Look how screwed up you are.”

To my mind, the real advance in trauma treatment is that we know

that you cannot change irrational, organic responses from your

body, except by becoming deeply involved in your self – noticing

your internal world.

That means you probably have to spend a lot of time being very

silent: to listen to messages from your body and to notice how your

body is living – and that is not part of our Western psychological tradition.

It is, of course, a very strong part of the Asian traditions of yoga, qi gong, t’ai chi, and kendo.

All over Asia, people have always done interoceptive techniques to deal with trauma – people there have

experienced just as much war and terror as we have.

“One of the big questions in

trauma treatment is how do

you rewire that amygdala?”

“We do know that there is a

part of consciousness called

the medial prefrontal cortex

that is involved in looking

inward and noticing yourself.”

“The real advance in trauma

treatment is that we know

that you cannot change

irrational, organic responses

from your body, except by

becoming deeply involved in

noticing your internal


Our solution has always been to take a swig of alcohol and make it go

away, or take a drug or pop a pill to change your brain.

But now there is this other tradition slowly coming into our world and this

is the tradition of meditation, mindfulness, and yoga through which we

can learn to activate the watchtower, which is the only part of your conscious brain to control the primitive

organism.

Dr. Buczynski: Yes, and let’s talk about the cook.

Dr. van der Kolk: Oh yes, the cook.

Dr. Buczynski: You’ve talked about the smoke detector and then we’ll talk more about the watchtower.

Dr. van der Kolk: The cook in your brain is the thalamus. At any particular moment, your brain gets input

through your ears, eyes, nose, skin and body, and it converges on the thalamus.

The thalamus cooks and stirs – the cook is the brain’s conductor that stirs and puts all these sensations

together. It says to me, for example, “Right now I’m talking to Ruth.” The thalamus puts all these sensations

together.

When you get in a very high state of arousal, your thalamus breaks down, and what is left are the

unintegrated images, sensations, thoughts, smells, and sounds of the

trauma that live a separate existence.

Trauma is really about sounds and images that make you flash back –

your body makes you flash back, and that is very much because the

thalamus is not able to do its job of putting all this together into a piece

of autobiography that says, “This – or that – is what happened to me.”

The unintegrated fragments, the “ingredients of the soup” continue to

live a separate existence.

In order to overcome your traumatic memories – the flashbacks –

you need to calm down the thalamus.

How we do that? We do that through neurofeedback. I think that

“The tradition of

meditation can activate

the watchtower.”

“The cook in your

brain is the thalamus.”

“When you get in a very

high state of arousal,

your thalamus breaks

down, and what is left

are the unintegrated

images, sensations,

thoughts, smells, and

sounds of the trauma.”

“In order to overcome your

traumatic memories – the

flashbacks – you need to

calm down the thalamus.”


EMDR can probably do that; we are studying that – how to get control over that out of control piece if the

brain and how to calm down the thalamus.

Dr. Buczynski: That’s exciting and we are going to be spending some time talking about neurofeedback and

also EMDR a little bit later, but let’s talk about the watchtower again.

Dr. van der Kolk: The watchtower is that medial prefrontal self-experience part of the brain.

There is very nice research by Gregory Quirk, PhD and Mohammed Milad that shows that the larger that

watchtower is, the more able you are to not respond to whatever happens to you.

How reactive you are to your environment to a large degree is

determined by the size, the activation, and the neural

connections of this part of your brain.

The bad news is that the more trauma you have, the worse that part of your brain functions, so that the

more trauma you have, the more reactive you become.

The good news is that the laws of neuroplasticity apply to that part of the brain, and the law of

neuroplasticity is that the more you use something, the more you build up that part of the brain.

As a traumatized person, you don’t want to experience your internal world – it feels so frightening.

But if you are helped to experience your internal world and you learn to meditate or do yoga, or you learn to

activate that part of your brain safely, then you experience less reactivity.

You become more mindful – you can see things happen and not

automatically react to them.

That is a very important part of what we now know about treatment – you

have to learn to be still, to notice your self, and to tolerate your sensations.

The Importance of the Vagus Nerve in Treating Trauma

Dr. Buczynski: Before we move on, let’s talk a little bit about the vagus nerve: why it is important in

understanding how people deal with trauma.

“The more trauma you have,

the more reactive you become.”

“You have to learn to

be still, to notice your

self, and to tolerate

your sensations.”


Dr. van der Kolk: The vagus nerve – and on a historical note here, Charles Darwin lived a long time ago, but

he wrote something very important, back in 1872, before anybody knew anything about the brain.

He said that there is a nerve – what today we call the vagus

nerve – that connects the brain with the body, and

whenever people have a strong emotion, they experience it

in the core of the vagus nerve, which means at the midline

structures of the throat, larynx, heart, lungs and gut.

Emotions are experienced in the core of the vagus nerve, and that means you get heart-wrenching, gut-

wrenching sensations as part of trauma – that is what Darwin points out.

He also pointed out that there are reciprocal relationships: the vagus nerve is a bidirectional nerve, so signals

go from the brain into the body and from the body into the brain.

If you can calm down your body, you send signals up into your

brain to calm your brain.

We now think that about eigh80% of the fibers of that nerve are

afferent fibers that run from the body into the brain, and that

means that we can do things with our bodies to calm our brain down.

The Same Experience with Two Different Responses

Dr. Buczynski: Let’s look at connecting – actually I think I would like to talk about Stan and Ute. You shared

that case study in your book, and they were patients of Dr. Ruth Lanius.

She has been in our series many times and is in this series as well. That was fascinating, how they had the

same experience but showed two different responses to it.

Would you first share with us what happened with Stan and Ute and then the two different ways that they

responded?

Dr. van der Kolk: Yes, and this was for us an amazing stroke of luck. For them, it was not a stroke of luck

because they got into this terrible car accident – the worst car accident in Canadian history – lots of cars piled

“Emotions are experienced in the

core of the vagus nerve, so you get

heart-wrenching, gut-wrenching

sensations as part of trauma.”

“If you can calm down your

body, you send signals up into

your brain to calm your brain.”


on top of each other.

Stan was the driver, which is important, because he tried to take some action: he was trapped, and he tried

to get out of the car and he couldn’t – he was trapped.

The issue of mobilization as a precursor to PTSD is terribly important – and he is a good example of that. He

was trapped and he thought, Oh, my God, I’m going to die. Then somebody came by, smashed his windshield

and he was able to get out.

His wife was frozen in her seat – hers was a freeze response, which is the other branch of the vagus nerve.

You get fight/flight – which was Stan – or you get freeze, which happened to be Ute. She was immobile and

they had to drag her out of the car. The ambulance came, and they were both taken to the hospital, and

supposedly, they were fine.

They both have PTSD and their PTSD looks pretty similar, but their brains look very different.

In the brain of the husband, Stan, what you see as you activate the memory of the trauma is the absence of

the dorsolateral prefrontal cortex, which is the timekeeper of your brain – the part of your frontal lobe that

tells you, “This is now and that was then.”

When that part of your brain disappears, and you start thinking about your trauma, it is happening to you as

opposed to remembering it.

Dr. Buczynski: The trauma is in the now.

Dr. van der Kolk: Right – it’s happening right now. This is a beautiful illustration of why traumatized people

have flashbacks and not memories: it is because that certain part of their brain is missing.

For a therapist, it is very useful to know that – and part of our job is to keep that part of the brain active.

That means when you work with patients (I call them patients because I’m a doctor, but many therapists call

them clients), it’s important to remember that in order for them to overcome their trauma, the therapist

needs to bring the dorsolateral prefrontal cortex back online – at the time of the trauma it was knocked out.

As a matter of fact, this area keeps getting knocked out over and over again when people are reliving their

trauma.


The observing part of the brain is critical. It’s the part that knows where you are; it feels your body sitting

here and says, “Even though I’m thinking about that little boy who I once was who was being molested/hurt,

I am still sitting here and I know it was a long time ago.”

The important part for therapists is not to find solutions for their

patients – our brains have everything built in already.

But our job as therapists is to keep people quiet and still enough so

they can observe what happened without a total reliving, flashback

experience.

Therapists need to help clients keep the parts of their brain aligned – that’s what made the experience

traumatic in the first place – being overwhelmed and not aligned.

The trauma creates fireworks in the brain, and those fireworks knock out

one area after another and that interferes with the integration.

In our therapy with clients, we help them to integrate the story and it becomes a memory of the past.

Dr. Buczynski: How do you keep that part online?

Dr. van der Kolk: By focusing on being very present in the here and now at any moment.

You do that with breathing, tapping, eye contact, feeling your

body – keeping your interoception aligned.

A big job of being a therapist for traumatized people is to be an

affect regulator who keeps their body safe and makes it safe for

the mind to visit the past without getting hijacked by it – and

Stan showed that beautifully.

His wife, Ute, who was totally spaced out at the time of the accident, went into the scanner, and in the

scanner her brain was blank – almost every part of her brain disappeared. She came out and said, “I felt

nothing. I felt just like I felt at the time of the trauma” – her brain was basically shut off.

We see this in our offices all the time: we see people who tell these terrible stories in a very flat tone of voice

– they seem to be somewhere else.

“Our job as therapists is to

keep people quiet and still

enough so they can

observe what happened

without a total reliving,

flashback experience.”

“The trauma creates

fireworks in the brain.”

“A big job of being a therapist

for traumatized people is to be

an affect regulator who keeps

their body safe and makes it safe

for the mind to visit the past

without getting hijacked by it.”


We feel either terribly upset by the stories they tell, and we become more upset than they are, or we join

them in spacing out and everybody becomes dissociated.

But what is very useful to realize, at this point, is that the brain of someone seeking help is shut down in

response to remembering the trauma, and that means the job of

the therapist is to help their brain to become activated.

What I use for activation at this point is tapping/acupressure

points, which I am very happy with. Other people do other kinds

of activation, such as touch, but we need to do something to keep

that body in the present.

Dr. Buczynski: Thanks – and we will get a little bit more into that in a moment.

How a Predisposition to PTSD Is an Attachment Issue

Dr. Buczynski: I’d like to talk about the concept of people being predisposed to having PTSD.

Rachel Yehuda did some work with people who had been raped, and found that many of the ones who had

been raped and still had PTSD were children of holocaust survivors – she was looking at a population in New

York, and it wouldn’t necessarily have to be that particular issue, but let’s talk about that idea of

predisposition to PTSD.

Dr. van der Kolk: Basically, that idea gets you to the whole issue of affect regulation and attachment and the

intergenerational predisposition to trauma which I think I spoke about before.

Parents are our first affect regulators. They, for example, get you hyperaroused when they wake you up from

sleep to get you to school – and as affect regulators, your parents more or

less help you to train your central nervous system.

There is now very robust literature from the attachment world which shows

that if you have disorganized attachment – your parents are not a source of physiological safety and you are

left to your own devices to cope with the vagaries of the world – then it is the disorganized attachment that

causes dissociation.

“Parents are our first

affect regulators.”

“The brain of someone seeking

help is shut down in response

to remembering the trauma,

and that means the job of the

therapist is to help their brain

to become activated.”


We thought, when we started in this field thirty years ago,

that dissociation is caused by trauma, but there is more and

more evidence that dissociation is caused by dysfunctional

attachment – you don't have somebody who looks at you

and picks you up and responds to you when you are in distress and you learn to deal with your misery by

shutting yourself down.

In that way, trauma becomes an interpersonal issue.

What you find is that if you have a parent who is traumatized and your

parent either spaces out when you become upset, or becomes more upset than you are – there are quite a

few people with parents like that – a child gets hurt and the mother freaks out, and then, the child feels,

What do I do with my getting hurt?

You never learn to regulate yourself. You don't have the experience in your mind and your brain and your

body that says, Bad things have happened to me, but I will be okay.

You don't have this conditioned response of bad things happening to

you, so if they do, you can get yourself back on track again.

If you have disorganized attachment as a child, you become much

more vulnerable to developing PTSD as an adult.

Limbic System Therapy

Dr. Buczynski: Bessel, you talked about limbic-system therapy in your book. It is an interesting way to

characterize therapy. Would you tell us what you mean by limbic-system therapy?

Dr. van der Kolk: The impact of trauma is in your animal brain – in your survival brain – and your survival

brain doesn’t have words or concepts or ideas.

Your limbic system is like a little animal that responds to thunder by

blowing up or biting.

Actually, you can be highly traumatized, and be very smart, extremely

“There is more and more evidence

that dissociation is caused by

dysfunctional attachment.”

“Trauma becomes an

interpersonal issue.”

“If you have disorganized

attachment as a child, you

become much more

vulnerable to developing

PTSD as an adult.”

“Your limbic system is

like a little animal that

responds to thunder by

blowing up or biting.”


insightful, and have it all down.

You might have had ten years of psychoanalysis and cognitive behavioral treatment, but when your animal

brain gets triggered by a particular sound, smell, or visualization, that animal part of your brain takes over.

Your frontal lobes will be running like crazy to keep it under control –

you’ll be trying to manage that “raging dog” inside of you.

But in order to really overcome trauma, you need to take care of that

“frightened dog” inside – and that is really the challenge.

Our knowledge about all of this is relatively young. It started off with people like Pat Ogden, Peter Levine,

Moshe Feldenkrais, and Ronald Alexander – body people who were able to help people to be still and quiet in

their bodies.

They really were the first people who helped us to think about limbic-system therapy – of quieting down this

frightened animal inside, and it wasn’t by saying, “You shouldn’t be scared,” or “You’re scared because your

father messed with you” – understanding with words like that doesn’t make the fright go away.

Insight does not quiet down the limbic system.

So, the big question is this: How do you quiet down the frightened animal inside of you?

The answer to that is probably in the same way that you quiet down babies. You quiet them by holding and

touching them, by being very much in tune with them, by feeding and rocking them, and by very gradual

exposure to trying new things.

Little kids do a lot of exploring – they can fail or succeed – but they can only do all the exploring because

there is somebody who picks them up when they get hurt.

The way human beings learn is by doing, and this includes learning

that there are certain things you can do to make yourself feel better.

A very important part of trauma therapy is to help people to once

again engage in activities that make them feel safe.

I think our Chinese and Japanese colleagues, since time immemorial, were very good at that: Taiko

drumming, kendo (the art of sword fighting) zen, and qi gong are ways in which you reset your body to once

“In order to really

overcome trauma, you

need to take care of that

“frightened dog” inside.”

“Human beings learn by

doing, and this includes

learning that there are

certain things you can do to

make yourself feel better.”


again be in charge of yourself.

That, to my mind, is limbic-system therapy.

Neurofeedback as PTSD Therapy

Dr. Buczynski: While we’re on therapies, let’s talk about neurofeedback, which is something that hasn’t

been written about very much. You shared a lot in your book about what you have discovered – it was really

pretty exciting, so let’s jump into that.

Dr. van der Kolk: Let’s talk first about what neurofeedback is.

I meet people all the time who tell me about their methods of neurofeedback and they say, “You can put

electrodes on somebody’s skull and harvest their brainwaves, feed it back to a computer and teach patients

how to play computer games with their own brainwaves so they can change their brainwaves.”

When I hear that, it sounds reasonable, and I’m sure you can do that.

Then, as I talk about in the book, for a variety of reasons, we got into ourselves – training ourselves and

training our staff.

Neurofeedback is not a new therapy, but it has been overwhelmed by the pharmacological revolution – there

is so much more money in “them pharmacological hills than there is those neurofeedback hills.”

You can’t make a lot of money with neurofeedback, and so it never really became a big deal, even though it

has been around for about thirty years.

Some very good studies were done in the late eighties/early nineties, and as I read these studies, they looked

about as good as any of the studies I had ever seen of PTSD – and very good studies of addiction, actually –

very strikingly good results in addiction that other methods haven’t uncovered.

We have been doing some neurofeedback research – not much because the funding is so very hard to come

by – but we just finished our second study of PTSD, and we got a very robust drop in arousal/confusion

scores and an increase in executive functioning scores in a group of about twenty-five people and a control

group study who had had multiple/different forms of treatment and who had been resistant to anything else.


Let me talk about this in terms of the watchtower: you can only work

with yourself if you can observe yourself and if you can notice what

you are doing and be curious about it.

If your frontal lobes are just frantic all the time, you are going to be

very involved in what you are doing to me, and the terrible person you

are.

You are not going to be spending a lot of time with, “Hey, what is it about me that gets so upset all the

time?”

The self-reflective part of your brain is not working. Instead, you’re always working with the signals that

come from the back of your brain, “You’re in danger. You’re in danger,” and so you’re focused on the dangers

outside.

Neurofeedback can quiet down the back of the brain so that you don't feel

that danger all the time.

You can actually rewire these brainwaves and you can change the frontal

lobes so you can observe yourself and notice what is going on inside.

Such a critical part of overcoming trauma is to be curious about yourself. Actually, being curious about

yourself is an important part of being alive!

But if you cannot be curious because you are scared to death or you

are enraged, you cannot really change.

Once you can help people change these internal brain states, you can

increase people’s curiosity and then they become ready to do psychotherapy.

Dr. Buczynski: Let’s talk a little bit more about neurofeedback with addiction –that really was pretty

interesting – actually, some studies had profound results.

Dr. van der Kolk: Addiction is not my thing; I’m a trauma person, and I’m always surprised at how a few

people with addictions make it over the threshold of my office – I have no idea why that is.

I hear about addictions from my colleagues and other people, so I don't really have firsthand experience with

“You can only work with

yourself if you can observe

yourself and if you can

notice what you are doing

and be curious about it.”

“Neurofeedback can

quiet down the back

of the brain so that

you don't feel that

danger all the time.”

“Such a critical part of

overcoming trauma is to

be curious about yourself.”


addictions. Occasionally, I have had some good results with a few people with sexual addictions who have

come to see me – working to rewire their brain to change the impulse.

If I were the head of one of the federal funding agencies, I would put a lot of money into that – to study that

further.

EMDR and PTSD

Dr. Buczynski: We don't have a lot of time left, but let’s talk a little bit about EMDR. You have done some

studies recently that showed very strong effects for EMDR, and I want to make sure that people understand

this and how you have come to see it.

Dr. van der Kolk: People like me, who try to be respectable in the academic world, would be skeptical about

wriggling their fingers in front of people’s eyes –so like all my colleagues, I was very skeptical about EMDR.

Then some of my smartest staff members started to do EMDR over my objections – and they got fantastic

results. Some of my patients have been treated by others with good results.

We went to the NIMH and we did a big EMDR study, and that is still the study with the best treatment

outcome of any study done on PTSD.

I would never say that EMDR is the treatment of choice because we haven't studied every possibility, but

EMDR is a very good treatment for one-time trauma, and also a very

useful adjunct for more chronic trauma.

The research shows that EMDR is able to neutralize traumatic memories,

and when we have finished with our EMDR protocols and it is over,

people say, “Yes, this happened to me, but this happened to me a long

time ago.”

For me, EMDR is a fascinating treatment, both from our point of view – because it is so effective for relatively

circumscribed trauma in particular – but also from a neuroscience point of view.

What is it about wriggling our fingers, or doing alternated movements, that can make the brain ready to

put something into the past?

“EMDR is a very good

treatment for one-time

trauma, and a very

useful adjunct for more

chronic trauma.”


Even though we’ve tried, I’m disappointed that we have been

unable to get more funding from that NIMH to really study that.

I have been accumulating little pockets of money here and there

for many years, and we are finally now doing another neural

imagery study on what EMDR does to some of these core brain

functions, and we are still in the middle of it.

EMDR is a fascinating, fascinating idea, from a neuroscience point of view. It is a great art!

Dr. Buczynski: In your book, you talked about Thomas Insel, the director of the National Institute of Mental

Health. He wrote a paper and said that they were reorienting research away from DSM categories and

focusing instead on disorders of the human connectome. What did you make of that?

Dr. van der Kolk: I make a lot of it. For one thing, I think the DSM is just an abomination.

Right now, we have about eight or nine different trauma-related disorders: intermittent explosive disorder,

intermittent self-mutilation disorder –all these disorders. They’re mostly due to childhood trauma, and

obviously, we know about them.

So that takes us back to nineteenth-century medicine, where you have a guide or you describe them, but you

don’t talk about the underlying issues.

Tom Insel was disgusted with that, as am I.

But Insel surprises me – he is a primate researcher, and what do you study as a primate researcher? You

study attachment. The hallmark of primates is that we are attached to each other.

Now, he is interested in the connectome inside of the brain, but what he doesn’t talk about is the

connectome between us – and that blows my mind because we are connected creatures.

Dr. Buczynski: You’re saying, then, that he’s talking about the interconnection of the brain – the synapses

between different parts of the brain – not so much the interpersonal neurobiology.

Dr. van der Kolk: Yes. I am astounded by it because everything about us is interconnected.

We don't exist as individuals. We are products of each other. If

I don't talk to anybody for many days, I cease to exist – as do

“What is it about doing

alternated movements that

can make the brain ready to

put something into the past?”

“We don't exist as individuals.

We are products of each other.”


you – because that is what our brain is for – our brain is to link

with each other.

Almost every form of mental illness, including PTSD, is an illness

that affects our relationships with each other – the aggression,

the evasion, and the shutting down, which is all about

defending ourselves against fellow human beings who have become the origin of danger.

Somehow, we have managed to just completely dissociate that issue from the discussion once again, and I

am baffled because mental illness and PTSD are all about broken

connections and treatment is all about healing connections.

Here is what also continues to disturb me. I’m a neuroscientist, and I get

grants occasionally from the National Institute of Health, but the clinical

world and the research world are still worlds apart.

The clinical world has a certain wisdom that is very hard to reconcile with

the wisdom that comes out of laboratories – we live in profoundly different realities, and actually, that’s a

very pathetic reality of our field.

Dr. Buczynski: Bessel, I want to say, first of all, thank you for all the work you have done. You have really

hung in there and pioneered, whether people were praising your work, as they do now for the most part, or

whether they were criticizing your work, you were a steady balance, continuing to do the research, put it out,

and teach us all about how the brain is affected by trauma.

You take good care, and we will talk again.

“Almost every form of mental

illness, including PTSD, is an

illness that affects our

relationships with each other.”

“Mental illness and

PTSD are all about

broken connections and

treatment is all about

healing connections.”


Quirk, G., & Milad, M. (2002). Neurons in medial prefrontal cortex signal memory for fear

extinction. Nature, 420, 70-74.

References


Bessel van der Kolk, MD is a neuroscientist and Professor of

Psychiatry and Boston University Medical School. He is also the

Medical Director of the Trauma Center, where he incorporates such

diverse resources a yoga studio, theater program, and neurofeedback

laboratory. His research has ranged from neuroimaging and

psychopharmacology to memory processes and EMDR.

He is past President of the International Society for Traumatic Stress

Studies and he has taught at universities and hospitals around the world. His current research involves the

effects of trauma on memory processes and brain imaging studies of PTSD.

He is author of well over a hundred scientific articles, author of Psychological Trauma, and co-editor of

Traumatic Stress.

Ruth Buczynski, PhD has been combining her commitment to mind/body medicine with a savvy

business model since 1989. As the founder and president of the National

Institute for the Clinical Application of Behavioral Medicine, she’s been a

leader in bringing innovative training and professional development programs

to thousands of health and mental health care practitioners throughout the

world.

Ruth has successfully sponsored distance-learning programs, teleseminars,

and annual conferences for over 20 years. Now she’s expanded into the

‘cloud,’ where she’s developed intelligent and thoughtfully researched

webinars that continue to grow exponentially.

About the Speakers . . .

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