The Real Story about PTSD–Groundbreaking Information Part II

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.

12 Responses to The Real Story about PTSD–Groundbreaking Information Part II

  1. Wendy – have you tried EMDR? I did it for quite a while with a skilled therapist (who also did the talky kind as well) and found it helpful (I think) although maybe it was hard to tease that specific technique out of many others…

  2. No, I haven’t. What was helpful about it? I’d like to try it. Also, what do you mean “it was hard to tease that specific technique”? Do you mean that if a therapist knows how to use EMDR, it’s challenging to get him or her to actually use it? Thanks.

  3. Thank you, Wendy, for more about van der kolk’s perspective. What he describes parallels exactly my own long-term experience with psychotherapy.
    Beginning in my teens, as a result of intense social and sexual shyness, I saw a talk-therapy psychiatrist from 1963 to 1972. He was a kind person who seemed to enjoy reassuring me that I needn’t be so shy. He urged me to date and develop more self-confidence and also prescribed antidepressants. His expensive friendship (my parents were paying) helped me get through college and all the way through my first marriage, but from my current perspective, all the work I did with the psychiatrist was superficial.
    I feel that my first encounter with my real underlying problems began when a woman friend suggested I try a body-focused psychotherapy in 1974 in a place called The Community of the Whole Person in Washington, D.C. (It doesn’t exist anymore but other therapists can offer similar help if you search hard enough. EMDR fits into this realm but isn’t the only body-focused therapy.) My first evening at the Community I was shown how to lean back over a special stool in such a way that my solar plexus–a muscle band below our rib cage that helps repress strong emotions–was relaxed. I immediately began to sob. That was the beginning of a journey that has continued off and on until today. Over a stretch of many years I experienced a peeling away of layers of previously hidden emotional memories that in recent times transported me all the way back to infancy and the re-experiencing of my infant circumcision. Not an easy experience to integrate into a happy feeling of renewal, but an excellent development for a person like me who for so many decades had no clue as to why I was so shy about sex for much of my life.
    As you say, Wendy, this kind of therapy is conducive to discovering and re-experiencing in digestible doses the traumas that may have shaped us in our most vulnerable years. One can’t always expect even one’s therapist to be completely wise about what we experience in this kind of therapy because it is our experience, not theirs. We need lots of kindness and support, though, in venturing into this world of our repressed feelings and memories. In my opinion, it is the surest way to become a whole person, aware of how our emotional lives have been shaped. It requires courage, but in my opinion it rewards the brave more than any other kind of therapy.

    • Wow, what an astonishingly rich and meaningful response. Thank you! When I read what you wrote about your solar-plexus experience, I was reminded of my showing up at The Berkeley Women’s Center in 1977 and telling the counselor there that day that I needed to cry but was afraid my stitches would burst. I told her, “I know this sounds nuts, that the operation was 26 years ago, but….” She basically told me to cry, let it out, and that she would hold me. I literally sat on the floor between her legs, my back to her front and she wrapped her arms around me and I sobbed. For the next few years in my therapy with her, I cried and cried, mostly at home, for after crying with her and being reassured I would not die, I felt safe enough to feel strong emotions on my own. (I’ve written often about the words of my surgeon to my mother after my infant surgery: If she cries, she dies.) Thank you so much for sharing your journey with me and the readers of ReStory. You are such a brave person and your experience and courage strengthen me and cement my resolve to educate people about these issues. Maybe when folks read of your journey in this comment, they will feel supported to find out more about themselves–their relationship with their bodies and the places of tension, shame, and pain within in order to liberate themselves. Your ability to be vulnerable and to share in this way is your strength. I’m so glad that I know you.

  4. I am following with great interest your series on van der Kolk and therapies that focus on much more than talk. Thank you, Wendy, for digging into his work, of which I have also found some pieces on the web. Robert, your response to this post is so telling and helps ground what Wendy has given us of van der Kolk. This is an important area of healing to explore and bring to those of us so long and deeply affected by “procedures” during our infancy. I look forward to more!

    • Thank you for your interest, Fred. About the pieces you found on the web–if one is particularly powerful, I’d love it if you would share the link with us. Our bodies hold some of the answers for us if we dare to open these doors. Integrating information bit by bit over time seems key. Doesn’t Robert write beautifully about his experience with body-based therapy? His story really gives readers the inside view of the journey and the riches that can be reaped. I am grateful for you both.

  5. I have so much physical experience that’s not connected up with any mental knowing at all. When an incident occurs or I witness something or am part of a circumstance, I experience it in my body as sensation. Sometimes big sensation. The vast majority of the time I’m completely unaware of it. Only when someone else brings it up or it becomes so intense as to become a crisis can I become aware of what’s going on in my body. And when I get some understanding of it in my mind, my awareness, I can process it and have it dissipate from my body, at least partially. But masses of stresses are accumulated and stored.
    I’m not talking about emotion here. My emotions are quite intense and I’m much more aware of them. I’m talking about that my body has its own life — and I wish I were better at checking in on it frequently to ask how it’s doing.
    Reading the comments about EMDR and PTSD have prompted my writing this, although it may not be relevant to the discussion.

    • Thank you for your very relevant comment. Before I studied Middendorf Breathwork, I felt disconnected from my body. For me, I was into dominating my body and most often, did not really care or check in with what my body was telling me. I ran away from my body after my infant surgery; I was dissociated from it. I’m sure I was frozen, in a sense. I know this response has to do with how my nervous system processed the early trauma. While I can’t say that I completely understand the physiology of the trauma response, I do know that I’ve had to make a conscious attempt to reconnect with my body. I have to face the fears I have about my own body being dangerous. Breathwork helped me find my way back. Writing also helps. While I still cope with dissociation, I’m so much more grounded than I was. Oh to be at peace and feel comfortable in one’s own skin! Thanks again for sharing your experience.

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