Summary
Chapter 7—Getting on the Same Wavelength: Attachment and Attunement
Van der Kolk recalls working with abused and traumatized children at the MMHC Children's Clinic. He and other doctors working at the clinic used the Thematic Apperception Test and others like it with their young patients. The test involves showing the children images and asking for their narrative interpretation. This would reveal what themes preoccupied them. British psychiatrist and psychoanalyst John Bowlby's attachment theory largely guided van der Kolk's understanding of how children bond with their primary caregiver. The different attachment styles are secure, anxious, avoidant, and disorganized. If early attachment is secure and competence is gradually cultivated in the child, then this builds an "internal locus of control." In contrast, abused children are conditioned to give up in the face of challenges later in life. Van der Kolk ends the chapter by emphasizing the importance of helping parents learn how to be in synch with others and with their children.
Chapter 8—Trapped in Relationships: The Cost of Abuse and Neglect
Van der Kolk once had a patient named Marilyn who found herself unable to tolerate physical intimacy. Since any childhood memory of abuse or neglect seemed to have been repressed, van der Kolk chose to take a different approach with Marilyn rather than addressing the issue head-on. She developed an autoimmune disease that was eroding her vision, and van der Kolk suspected it had partly to do with trauma in her upbringing. According to van der Kolk, change can begin when we "start to befriend, rather than obliterate, the emotions" that guide our maps of behavior and relation. After hearing another woman share about her traumatic experiences in a group therapy session, Marilyn realized that she, too, had been molested as a child. At the end of the chapter, van der Kolk expresses awe at his patients' desire to live and own their lives.
Chapter 9—What's Love Got To Do With It?
At the beginning of Chapter 9, van der Kolk questions how mental health professionals can organize their thinking and learn to define their patients' problems, diagnoses, and care plans. Van der Kolk is skeptical that the Diagnostic and Statistical Manual of Mental Disorders is sufficient for guiding mental health professionals. Van der Kolk desires to close the gap between official diagnoses and what patients actually experience and suffer from. In collaboration with the psychiatrist Judith Herman, van der Kolk financed a study to investigate the relationship between childhood trauma and bipolar disorder. They designed an interview instrument called the Traumatic Antecedents Questionnaire. Though van der Kolk and his colleagues attempted to add a diagnosis in the DSM for victims of interpersonal trauma, it ended up being excluded in the revised manual.
Chapter 10
Van der Kolk enumerates the national resources that attempt to "deal with" children who were abused, but that often have a high cost without any real benefit. These include the financial costs of jails, welfare programs, and medical clinics, as well as the personal tolls these take on children. Taxpayers often foot the bills. As technological research expanded, the field of psychiatry sought to pinpoint genetic causes of mental illness. But it has failed to do so, even after millions of dollars in research funds have been spent. Various animal studies have shown that the social environment can significantly contribute to behavior and biology.
In 1998, van der Kolk partnered with a multidisciplinary group to create a national organization to promote the study of childhood trauma and the education of teachers, judges, ministers, foster parents, physicians, probation officers, nurses, mental health professionals, and anyone who works with abused and traumatized children. As a result, lawmakers crafted a bill that established the National Child Traumatic Stress Network in 2000. Over the course of four years, van der Kolk met twice annually with a core work group of twelve clinician-researchers specializing in childhood trauma to draft a proposal for an appropriate diagnosis for abused children. They called it Developmental Trauma Disorder (DTD). However, the executive director of the National Center for PTSD and chair of the relevant DSM subcommittee informed van der Kolk and his colleagues that DTD would not be included in the new DSM. Various studies refute the director's comment that there was no need to fill a "missing diagnostic niche." In contrast to the United States, many European countries have committed to universal health care, ensured a guaranteed minimum wage, paid parental leave for both parents following childbirth, and high-quality childcare for working mothers. These public health approaches have direct impacts on factors such as crime rates and incarceration.
Analysis
While The Body Keeps the Score is often lauded by both mental health professionals and laypeople interested in learning about trauma, many readers are struck by the brutal realities depicted in the book. As stated previously, van der Kolk candidly addresses the grim circumstances that surround traumatized individuals. Chapter 7 is particularly stark in that van der Kolk shares explicit details about the traumatized children he worked with at the Massachusetts Mental Health Center. For this reason, some mental health professionals do not recommend The Body Keeps the Score to patients still in the throes of intense trauma. However, van der Kolk's lack of sugarcoating also highlights the severity of the issues he confronts in the book. Throughout the book, he expresses shock at the detached clinical view that certain doctors and medical records reflected regarding traumatized patients.
Van der Kolk also expresses shock at the brutality with which many of his patients have been subjected to, particularly as children. Van der Kolk shares that despite his decades-long career, he regularly utters the words "that's unbelievable" in response to how parents could inflict such torture and terror on their own children (Chapter 8). Part of what sustained van der Kolk's career is his awe at the life force he witnessed in his patients; their will to live and have agency over their own lives energetically countered their trauma. Though the majority of the book focuses on the impacts and implications of trauma and how to address it, this brief personal interjection matters because it shows that mental health professionals can potentially experience bias, burnout, and even vicarious trauma.
Van der Kolk's approach seems to combine empathy and professional objectivity. These guidelines are subject to rigorous interrogation as researchers and clinicians push at the boundaries of what we know about trauma. In Chapter 9, van der Kolk underscores the lack of a blanket solution for patients being treated for trauma when he outlines the different courses that psychiatric treatment could take. The human mind, brain, and innate need for attachment can be considered a complex system in which the whole is greater than the sum of its parts. In addition, other factors like the practitioner's mindset and what insurance companies will pay for can influence the treatment approach.
One finding from the ACE study was that maladaptive behaviors in adulthood, such as smoking, drinking, taking drugs, and being obese, are in fact coping strategies to ameliorate the stress of trauma. The ACE study group concluded that the presenting problem is often only "the marker for the real problem, which lies buried in time, concealed by patient shame, secrecy and sometimes amnesia—and frequently clinician discomfort" (Chapter 9). This last point reveals the potential for human bias and error in mental health care.
The importance of getting at root causes can be seen on both individual and national levels. Most of this book focuses on the scale of the individual, but Chapter 9 divulges the national implications of early childhood trauma. The ACE study researchers calculated that ending child abuse in America would reduce the overall rate of depression by more than half, alcoholism by two-thirds, and suicide, IV drug use, and domestic violence by three-quarters. Other areas of impact include workplace performance and the need for incarceration.
