Summary
Prologue
In the prologue, van der Kolk highlights the ubiquity of trauma by providing various statistics. Despite the human capacity for resilience, trauma leaves its traces on lives, histories, and cultures. According to the author, denial is not a sustainable response to trauma because of physical processes that take place in the body. Posttraumatic reactions can trigger the release of stress hormones and overwhelm a person in the present day, long after the trauma has occurred. Overall, understanding how trauma physically alters the brain and body should change the way it is treated. Van der Kolk characterizes this as his life's work.
Chapter 1—Lessons From Vietnam Veterans
Van der Kolk recalls his first day working as a staff psychiatrist at the Boston Veterans Administration Clinic in 1978. One patient, a Vietnam veteran prone to alcoholism and explosive rage, reminded van der Kolk of his own father and uncle. Two weeks after van der Kolk prescribed a drug to reduce the man's nightmares, the new doctor was surprised to find that his patient had refused to take the pills. The patient's reason was that the nightmares allowed him to be a living memorial to his friends who died in the war. From there, van der Kolk immersed himself in the early (and scant) medical literature on what would become known as posttraumatic stress disorder (PTSD). However, van der Kolk also took care not to over-rely on textbooks at the expense of learning from real patients.
One of the studies that van der Kolk conducted at the VA initially concerned nightmares but eventually expanded into an exploration of how trauma changes people's perceptions and imagination. Using Rorschach ink blot tests, van der Kolk and his colleagues concluded that traumatized people "superimpose" their trauma on everything and also have altered capacities for imagination. Facilitating group therapy sessions for veterans also showed van der Kolk how trauma can mire people in the past. A turning point for treatment arrived in 1980 when the American Psychiatric Association accepted a new name for a particular diagnosis: posttraumatic stress disorder. In the rest of Chapter 1, van der Kolk analyzes how PTSD afflicts not just veterans, but people who survive crimes such as child molestation and rape.
Chapter 2—Revolutions in Understanding Mind and Brain
In the late 1960s, van der Kolk worked as an attendant on a research ward at the Massachusetts Mental Health Center. The researchers sought to determine the best approach to treating young people who had suffered a first mental breakdown diagnosed as schizophrenia. While there, van der Kolk heard stories that patients shared about early abuse, but he never heard doctors discuss these stories during care meetings. The professional training he received consisted of attempting to control terrifying and turbulent situations.
Van der Kolk goes on to describe the evolution of medicinal approaches to human suffering. It wasn't until the 19th century that psychiatry became a valid paradigm, one in which disorders could be treated by administering chemicals. Early in his career, van der Kolk eagerly embraced psychopharmacology as the surefire way to "conquer human misery." However, his mind opened to the possibility of pairing drug treatments with somatic therapy after hearing about learned helplessness. Groundbreaking research had found that repeated exposure to uncontrollable and negative circumstances contributed to passivity, decreased motivation, and hopelessness. In addition to this, traumatized individuals might experience the compulsion to repeat dangerous and painful situations as a result of their brain chemistry responding to environmental stimuli. Despite the benefits of medications, van der Kolk argues that we should not consider them to be the best course of treatment in every circumstance.
Chapter 3—Looking Into the Brain: The Neuroscience Revolution
Van der Kolk describes the innovative technologies that revolutionized our understanding of cognitive processing. PET and fMRI scanning allowed scientists to observe how different activities and recollections engaged different parts of the brain. In one study that van der Kolk and his research assistant, Rita Fisler, conducted, they consensually recreated the traumatic experiences of eight patients and scanned their brains during flashbacks. One part that showed heightened activation was the amygdala, a small structure in the limbic system that contributes to the fight, flight, or freeze response. Another was the visual cortex. On the other hand, Broca's area (one of the brain's speech centers) showed markedly decreased activation.
Analysis
From the very beginning of the book, van der Kolk argues that human beings are by nature a remarkably resilient species, but that traumatic experiences can alter people's minds, emotions, relationships, and health. Van der Kolk acknowledges that the research in his field is still ongoing, but that cutting-edge studies in neuroscience, developmental psychopathology, and interpersonal neurobiology greatly inform his understanding of trauma. Rhetorically, admitting that humans are years away from attaining a "detailed understanding" of "brains, minds, and love" suggests the author's intellectual humility and openness (Prologue). This ethos is further cultivated when van der Kolk states that he has "no preferred treatment modality, as no single approach fits everybody." Despite the criticisms van der Kolk and his ideas have faced, he has certainly paved the way for wider conversations about trauma to take place.
Van der Kolk does not shy away from examining the dark contours of trauma and how it can impact and destroy many lives as a result. For instance, one of van der Kolk's first patients at the Boston Veterans Administration Clinic was a Vietnam veteran who killed and raped innocent people after witnessing the death of his friend and fellow soldier. Some readers take issue with van der Kolk's frank description of these horrendous acts, saying that the author does not do justice to the victims. The tone of the book is both personal and clinical, and van der Kolk does not endlessly widen the scope. Instead, he shares outcomes from studies and trial-and-error results from his practice as a psychiatrist. This leaves readers (both mental health professionals and laypeople) the space to glean what may be of use and apply the knowledge as they see fit.
As a mental health professional, van der Kolk witnessed significant advancements in research and treatment protocols. Whereas the sole focus used to be on managing symptoms such as suicidal ideation and self-harm, van der Kolk advocates for care practices based on what he calls "the ecology" of patients' lives: possible root causes for despair, early formative experiences, accomplishments, aspirations, relationships, motivations, etc. He teaches empathy as a rule of thumb, advising his students to consider whether they would use a particular treatment on their own friends or children. If not, then this opens the question of when care crosses the line into harm. Additionally, van der Kolk criticizes the use of psychiatric medications as the primary solution to human suffering. Instead, he favors a more holistic approach that equips individuals with the ability to participate in their own healing. By outlining a brief history of psychopharmacology and criticizing the use of drugs as the primary method of treatment, van der Kolk implicitly shows that mental health care is still an evolving field.
The fact that Broca's area (a region of the brain concerned with the production of speech) is deactivated during post-traumatic flashbacks indicates why verbalizing or narrating traumatic experiences can be so challenging. Broca's area is conventionally located in the left hemisphere, which van der Kolk characterizes as "linguistic, sequential, and analytical" in comparison to the "intuitive, emotional, visual, spatial, and tactual" right side (Chapter 3). Brain imaging technology equips scientists with the means to push the boundaries of what we know about the brain. The brain's ability to understand itself exemplifies a recursive process because it is both the subject and object of the study. Metacognition holds possibilities for those impacted by trauma, which is why all eight of the patients that van der Kolk asked to participate in the brain imaging study consented to reliving their traumatic experiences via guided flashbacks. They hoped to contribute to the research and help ease the suffering of others, and themselves, as a result.
At various points in Part 1 of the book, van der Kolk maintains that as a doctor, he does not stand on higher ground than his patients. He dedicates the book to his patients, whom he refers to as his true teachers and textbooks in Chapter 1. His teacher and mentor, the psychiatrist and psychotherapy supervisor Dr. Elvin Semrad, taught him to trust what he could learn from patients themselves. Van der Kolk credits Tom (his first patient) and the other veterans as his teachers in seeking to understand trauma.
