In my last post, I discussed the first part of the article “Beyond the Talking Cure” by Dr. Bessel van der Kolk and provided quotes that communicated some of his main ideas. The second part of the essay reveals the “clinical dilemmas facing the therapist of traumatized patients.” Van der Kolk basically concludes that talk therapy may not be best for people with PTSD.
The clinical dilemmas he discusses are as follows: the “speechlessness” of the client; possible “re-traumatization,” an unintended consequence; “the relationship” itself, lack of trust a main factor; “avoidance” by the client; and “physiological conditioning,” whereby a client reacts to a non-threatening situation in the present as a threat from the past (9-11). A few quotes stand out that may provide more clarity. With regard to speechlessness, van der Kolk remarks: “. . . people with PTSD simply have their feelings, maladaptive behaviors, and uncomfortable bodily sensations, without knowing where they come from. . . . they simply may not know what they feel” (10). So talking may not be the best therapy mode. With regard to the therapeutic relationship, ” he writes: “Many people with PTSD have seen their trust shattered and are reluctant to make themselves vulnerable to other human beings, particularly when it comes to issues that make them feel frightened and ashamed” (10), so relating with a therapist may be problematic in itself.
To help us understand further, Van der Kolk talks about “top-down versus bottom-up emotional processing” (11). He writes: “Emotional states are generated by the state of the body’s chemical profile, the state of one’s viscera, and the contraction of the striated muscles of the face, throat, trunk, and limbs (Damasio, 1999)” (11). In other words, emotions result from physiological processes. We experience a change in our bodies and then feel it as an emotion–bottom-up. Mothers, for example, shift how their babies feel by changing their physical experiences “by rocking, feeding, stroking, changing sources of physical discomfort, such as wet diapers,” etc. (11). Van der Kolk infers that the best way to help traumatized people, who may not know what they feel, is to work from the bottom up–to help them read their own bodies so that they can learn to know what they feel.
Van der Kolk goes on to discuss why the top-down therapies aren’t as effective, top-down in the sense that the client learns to suppress or ignore unwanted emotions by his or her will, activity derived from the neocortex (13). He writes, “Traditional psychotherapy relies on top-down techniques to manage disruptive emotions and sensations. These are approached as unwanted disruptions of ‘normal’ functioning that need to be harnessed by reason . . . “(14), instead of clues that can help clients learn to manage old triggers and then make better decisions about the action to be taken.
For those of us with post-traumatic stress, traditional talk therapy is not the way to go, according to van der Kolk. The body has information that our minds need to integrate. Van der Kolk believes that EMDR (Eye Movement Desensitization and Reprocessing) may offer a more effective approach to the challenge of transforming trauma. Next post, I’ll do my best to communicate what it is and why he believes it is effective. In the meantime, practice listening to what your body feels if you can.