The body keeps score

How bodywork helps process life experiences

I have been reading the fascinating book “The body keeps score”  by psychiatrist Bessel van der Kolk whose work has led him to validate the importance of bodywork.  Although a lot of his work has been with clients suffering with extreme trauma, his understandings offer useful ideas for all our clients and indeed for us personally.  Stress and trauma affect us all in some way. Large numbers of the population have experienced traumatic events and most people have experienced periods of stress in their lives.  Each of us has probably had some contact with someone who has experienced extreme stress, and this will have a more profound impact on us if they are our parents, or close relatives.  War is particularly stressful and all of us have been touched by the First and Second world wars: my father was 17 when war broke out and, as well as affecting his future career choices, he witnessed some horrifying events. My mother’s father was missing presumed dead, for many months. Later, in the 50’s my mother, like many of her generation, was in a psychiatric hospital for some months having ECT (electroconvulsive therapy) and deep insulin shock therapy: treatments which left her body in trauma from which she never really recovered.

If we see ourselves as interconnected, then we all carry within us some degree of trauma, whether more or less extreme or obvious.  It is vital to understand what trauma does to the body and particularly why some people are more able to process trauma and stress, while others remain locked in their stress response, sometimes in extreme ways.

This blog covers some of the main themes that particularly interest me, but I would urge you to read the whole book. It is a real treasure trove of research, information and case studies as well as a detailed exploration of many different treatment modalities, including bodywork.  Trauma brings into our awareness more vividly how we process the many varied emotions and experiences of life.  Bessel states that the aim of any treatment for trauma is to enable us to become more fully present with life. All of us can struggle at times with being fully present, especially with more painful emotions, so understanding how to be more present, is helpful for us all.  Rumi, as quoted in Bessel’s book, expresses it particularly eloquently:

This being human is a guest house
Every morning a new arrival.
A joy, a depression, a meanness,
some momentary awareness comes
as an unexpected visitor.
Welcome and entertain them all!
Even if they are a crowd of sorrows,
who violently sweep your house
empty of its furniture,
still treat each guest honourably.
He may be clearing you out for some new delight.
The dark thought, the shame, the malice,
meet them at the door laughing,
and invite them in.
Be grateful for whoever comes,
because each has been sent
as a guide from beyond.

Rumi

Bessel van der Kolk

Bessel van der Kolk, is a Dutch psychiatrist who trained and works in the US. He has developed his understanding of how we process experiences, especially traumatic events, largely through his work with Vietnam war veterans, people with severe mental health issues, and those who have experienced sexual abuse. His conclusions resonate with me and give me more understanding of why I have been working in the way I have and why I have been drawn to body work, like massage, shiatsu, yoga and meditation in my personal as well as my professional life.

Van der Kolk grew up in post war Holland and his father had been sent to an internment camp because of his protests the Nazis. His father was a gentle man but had occasional fits of extreme anger. Only later in his career did Bessel understand more about his father’s behaviour.

During the 70’s, early in his career, he was working with Vietnam war veterans. He felt that the labels of bi polar, schizophrenia etc were only describing the symptoms and he wanted to understand why they were responding in this way, so he could work out the best way to support them. He also wanted to understand why some veterans expressed extreme symptoms and others were much less affected. At the time there was little knowledge of PTSD (post traumatic stress disorder) and so he began researching.

He rediscovered the suppressed knowledge developed through psychiatrists working with returning soldiers during and after the First World War. Their knowledge had been suppressed as it didn’t serve the Army/Government to acknowledge that it was the war that had caused the symptoms. They wanted to blame individual soldier’s inherent weakness. Further studies of Second World war and Vietnam veterans have helped us understand much more about the impact of traumatic events and develop the term PTSD: but still even today, people don’t necessarily get the most effective support.

Bessel writes that after 9/11 he proposed a study to evaluate all the different kinds of trauma therapies, but this was dismissed and only CBT (Cognitive Behavioural Therapy) and psychoanalysis were proposed. In fact, many of the people affected, both those in the towers and the rescuers, sought out bodywork therapies. My shiatsu colleague Diego Sanchez was one of those on the ground offering shiatsu.

Bessel began to realise how our early attachments, particularly parental support, are what can give us a basis for being able to more easily process later traumatic events. He developed the term “developmental trauma disorder”.

What is trauma and why are some people more affected?

We would all identify big events, like war, the Twin Towers, and, more recently in the UK, the Grenfell Tower fire, as traumatic. But why is it that some people are more affected than others?

As Bessel studied the backgrounds of his clients more, he gradually began to realise that those who were worst affected, and who took longer, if they were able, to “recover” were those who had been abused as a child, especially if the abuser was a parent or someone close to them.  He writes extensively about the importance of early attachment and bonding: highlighting the work of Winnicott: and “good enough” parenting and Bowlby’s attachment parenting.

Most children can form secure early attachments (good enough). Abuse or neglect affect this process. Even anxious or avoidant parenting is not so destructive for a child if their care is consistent because they can learn to adapt, essentially by assuming the mother role and adjusting their behaviour. However, if the care is disorganised and unpredictable, then the child becomes confused and this is the most difficult for the child. They have no secure base from which to move into the world, to adapt to their environment and to develop self-awareness.

More recent studies by Suomi on monkeys highlight the positive effects of parenting and how it can modify genes which predispose monkeys to schizophrenia.  The evidence is clear: safe and protective early relationships protect children from long term problems.

Traumatic memories are usually deeply buried as that is the only way that the child can bear their situation and the younger the child is, the more pre-verbal these memories are. When they are triggered as an adult, the memories can come flooding back in fragmentary ways. This means that people don’t necessarily know what has happened, but their bodies act as though they are in danger: the bodies keep score.

Bessel and his colleagues wanted the official diagnostic manual in the US to include what he calls “developmental trauma disorder” (Feb 2009) as what these children and adults are experiencing does not really fit the descriptions of PTSD. Still to this day it is not recognised and many children, especially from low income families, are treated by medications, rather than having the underlying issue of abuse addressed.  As a society we have a responsibility to create safe environments for everyone, but especially our children.

This is the part of the picture that can be harder for us to acknowledge. The figures Bessel quotes in his book about the US population make stark reading

1 in 5 have been sexually molested as child

1 in 4 have been beaten by a parent to point of having a physical mark

1 in 3 couples have experienced some form of physical violence

1 in 4 have an alcoholic relative

1 in 8 have witnessed their mother being hit

Bessel doesn’t talk about traumatic or stressful events in the womb, but based on my own experience, I would say that it follows that our time in the womb, and our birth experiences, when we form our very first attachments is a fundamental time to strengthen our resilience. It is also a time when stress can have a profound impact on the rest of our life. There is increasing evidence, coming from the relatively new field of epigenetics to support this. One of my favourite authors on this topic is Nessa Carey. Her book “The Epigenetics revolution.”  Is fairly accessible.

I have also mentioned in previous blogs William Emmerson, Bonnie Bainbridge Cohen and Cherionna Menzam Sills whose work is about understanding life in the womb and how this can relate to our work with the energies of Chinese medicine. The way I support the body to have the opportunity to connect with this pre-verbal level of being is primarily through working with the Extraordinary Vessels. These are deep channels which are said to contain our ancestral memory. They are how we transmit our energy to our children when we are pregnant: and they offer gentle and effective ways to support our body to integrate past events and become more fully present. Babies in the womb experience their mother’s moods: if she is depressed, if she is in a violent relationship or feeling happy and supported. However, babies are extremely resilient and, with appropriate support, can change their states very quickly. If we work with pregnant women we are supporting their babies to integrate changing emotional states.

What happens to the body in trauma?

This understanding of this has changed radically over the past few years especially with the development of neuroscience.  Bessel gives detailed explanations, but here I will simply present some of his key findings.

Trauma recalibrates the brain’s alarm system and compromises our feelings of being alive, making it hard for us to be present in the moment.

Bessel uses the model of the brain as being in three parts: the reptilian, mammalian and rational. He focuses more on its development after we are born, but I would say that we are increasingly becoming aware of how the mammalian part of the brain is already enabling babies in the womb to be aware of the feelings of their mothers and those around them. Babies in the womb already demonstrate some awareness of the outer environment and its safety or otherwise.

The rational part of our brain is the youngest part and occupies only about 30% of our skull: it is concerned primarily with the world outside and develops more once we are born.

Beneath it live our older brains which oversee everything else: i.e.” moment by moment registration and management of our body’s physiology and the identification of comfort, safety, threat, hunger, fatigue, desire, pain” and so on.

The brain is built from the bottom up: the lowest part, the reptilian brain, in the brain stem is responsible for the things new-born babies do: eat sleep, cry, eliminate, coordinating their heart, lungs, endocrine and immune systems.

Above it is the mammalian brain which takes off after a baby is born. This is more about our emotions “central command post for coping with the challenges of living within our complex social networks”. This is the limbic system which is shaped in response to experience. If one is safe and loved, the brain becomes specialised in exploration, play and cooperation. If one is frightened and unwanted it specialises in managing feelings of fear and abandonment. These feelings can be significantly modified by later experiences either through being exposed to pleasurable events and feeling safe or by violent assaults or traumatic events.

Bessel describes the reptilian brain and the mammalian brain (especially the limbic system) as being the emotional brain by releasing hormones which have visceral effects in our body. They have a huge influence on how we feel day to day and the choices we make. They sense information in a global way, creating automatic reactions which our conscious/rational brain must catch up with later.

The amygdala, part of the mammalian brain and the limbic system, he calls the “smoke alarm”. It warns of impending danger and activates the body’s stress response. If this has been over triggered through extreme traumatic events which the body has not processed, then the stress hormones take longer to return to the base line and are more quickly stimulated by mildly stressful stimuli. This overstimulation contributes to long term health issues, including many auto immune diseases. This is an interesting link for me with the Kidneys in Chinese medicine, which include the adrenals and are part of the Extraordinary Vessel circuit which links the Brain with the Heart and the Reproductive Organs. I have found in my work that the Extraordinary Vessels can be very supportive in helping people access and process trauma when they are ready to.

Even people who go into denial mentally about their trauma will still be experiencing the stress in their body.  This is why so many people turn to medication, drugs, alcohol and dangerous sports to temporarily dull their stressful physical feelings.

All trauma is pre-verbal: even years later it is very difficult for people to explain what has happened to them: as they are cut off from language. They develop cover stories: which give some explanation for their behaviour but doesn’t usually help them process the changes.

It is the top part of the brain, the neocortex, the rational part of the brain, which enables us to use language and abstract thought, plan and reflect, make choices and express empathy. Bessel calls this the “watch tower”. It (specifically the medial prefrontal cortex MPFC) gets the messages of danger slightly after the limbic brain. This means that often we are reacting before we have realised what we are reacting to. If we are not too upset, balance can be restored if there is a false alarm.

However, in PTSD the balance between the amygdala and MPFC shifts radically and makes it hard to control emotions and impulses. People have an altered perception of risk and safety. They might “take leave of their senses” and startle in response to loud sound, freeze if someone touches them i.e. overreact. These “overreactions” explain why they are often labelled with psychiatric disorders. Furthermore, If the prefrontal cortex is not functioning then our relationship to time is altered and it feels as though the traumatic event is happening now. This is why it is crucial that if people are encouraged to re visit their trauma, they need to be able to access how to feel calm, safe and grounded in the present in their body to keep the prefrontal cortex operational. If it is not, then re-experiencing the traumatic event will become overwhelming because they will simply be pulled back into the past.  This is where bodywork, and breathing, can be helpful, but again we need to be careful of how and where we touch, as touch may re trigger memories.

Now we also understand, because of the work of Steven Porges on the polyvagal nerve, how our response to stress is more than simply fight and flight. There is a more complex relationship between our sympathetic (arousal: fight and flight) and parasympathetic (calming, slowing breathing) nervous systems.

Porges discovered that when we experience a threat, we first engage our social engagement system by calling out for support. This explains why early attachment is so vital: parents help new-borns to regulate their responses. Social contact can slow down our heart rate and increase our breathing. It also helps explain why kind words and relationships with other people can help to create a visceral feeling of safety. In supporting people to process trauma, human contact is often helpful but, in some cases, it can be too triggering.  if it is, then often contact with animals can be a helpful first step in helping people feel safe with other beings.

However, if no one comes to our aid we go to the more primitive fight or flight (amygdala limbic mammalian). If we can’t fight or flee, then we go into freeze or collapse. (reptilian brain: shuts down).

Dissociation is the essence of trauma: the experience is split off and fragmented so that the emotions, sounds, image, thoughts take on a life of their own. Sensory fragments of memory intrude into the present where they are relived. The more they are replayed, the more the memories become engraved in the mind. It means it is harder to take in what is going on in the present: people become imprisoned in the past. This is why Bessel states that Cognitive Behavioural Therapy (CBT) is not so effective for working with traumatic experiences.

Ways to work with trauma

The aim of any work is to help the person become more fully alive in the present: the body needs to learn that the danger is past.

Bessel has discovered that traumatic stress can be treated by mindfulness mediation, yoga and bodywork, and indeed any modality which includes an awareness of breath as a fundamental part of the work. Breathing is one of the few body functions which is both under conscious and autonomic control.

Traumatic memories are by their nature disorganised. Normal memories have a beginning middle and end. Remembering the trauma does not necessarily resolve it. Telling the story does not make the images and physical sensations go away.

At some point people need to revisit their trauma but only after they feel safe and will not be re-traumatised. Since the memory of trauma is in the emotional brain, the rational brain cannot change the emotions.  A balance needs to be restored between the rational and emotional sides of our brains. The only way to do this is to be become aware of our inner experience and learn to befriend it.

Bessel explores a huge range of different modalities, varying from working with Inner Family Systems, drama, singing as well as drug-based treatments and neurofeedback therapy.  I will focus more on how we can work with bodywork. He identifies three main treatments but suggests that often a combination of the three is helpful.

1: Top down talk and reconnect with others: right brain

These include the more traditional psychiatry: talk therapies, activities which include social engagement: rhythmic activities such as singing, dancing, drama (Porges theory). Of course, singing and drama may also include aspects of bodywork. Talking is important, even when working with bodywork modalities. However, talking on its own is not enough as the trauma is stored in our body and so can not only be processed by the rational brain.

2: Drugs: brain disease model

Drugs are still a large part of dealing with the symptoms of trauma, even though it is known that they do not offer a cure.

In the US in 2012 $ 1,526,228,000 was spent on Abilify (one anti-psychotic drug) alone. Half a million children in the US are currently on antipsychotics.

This view is that mental illness is caused by a chemical imbalance in brain. While in extreme situations drugs can offer temporary relief, they are not helpful if they displace therapy.  Drugs can be an adjunct: but they can’t help us to process what has happened to us nor deal with the causes of underlying pain. They take the fate out of our hands and make us dependant on others/medicines.

3: Bottom up: bodywork: left brain

Body experiences which deeply and viscerally contradict the helplessness, rage or collapse which result from trauma can be a vital part of processing trauma. Our physical body and physical sensations convey the inner states of the body and our sensory world takes shape before we are born (Damasio). We need to befriend our body, so we are not on guard.

Neuroscience has shown us that our sense of self is anchored in our body. However, we must remember that touch is not always safe: especially for those who have experienced sexual abuse.  For some pregnant women, birth can trigger memories of abuse and this is why it can be such a difficult experience.

Things to be aware of in our work as bodywork therapists

Sensory awareness is an important part of processing our experience.   It is important however that by working with the body, we are not triggering memories too quickly. I find with shiatsu and massage if we really listen to the body, it will only open to the level it is ready, but it is extremely important to respect that. That is why it is helpful to enable clients, especially those we know who have experienced trauma, particularly sexual abuse as a young child, to express what is not ok for them.   They need to be able to experience that they can connect to their resources and be able to assert their own boundaries.  While we may sense when there is some resistance or memories arising, through observing changes in their breathing or physical posture, it is important to give them space to verbally express their limits, their safe zones, so that they can feel in control.

It is easier to work with those who expressing the fight or flight: over aroused state since their bodies will react more clearly.  We can notice the changes in the expressions of tension or their breathing patterns. They may often find it hard to switch off and relax and keep their eyes open. However, if people have gone into the freeze and collapse response (the reptilian brain) it can be harder to gauge their response: so, verbalising is even more important. They may not be aware of their body nor sense where we are touching them.

This is why it is important to work slowly and perhaps check in when we are going to change where we are working. Some areas of the body can be potentially triggering of memories. Naturally the pelvic area is often a place where sexual trauma is held:  this includes not just the abdomen but also the lower back and sacrum.  This is why in shiatsu and massage I don’t always work with the abdomen and hara assessment. However, remember anything could potentially be a trigger, a word, a gesture, a part of the body that we might not consider, like the feet.

The Extraordinary Vessels all pass through the pelvic area, connecting with our reproductive organs,  but they also all connect in with the feet and hands. This means we that we don’t have to directly touch the pelvis in order to access their support.  Sometimes working their points and connections in the feet can support a client’s connection to a safe quality of earth and anchoring. Sometimes working the points in the hands can support a connection to the heart and opening up into supporting relationships with others and themselves. The essence of the Extraordinary Vessels is a spacious slow connection back to our potential, indeed enabling us to access not only ancestral support but a more universal quality of support allowing deep energies to shift within the body. People often experience a deep sense of peace with what has happened in their life while experiencing this work and a sense of safety.

I like to show clients ways which they can access this support themselves, through touch, breathing and movement. For parents, touching their baby in the womb through caressing the abdomen or sacrum can offer a pre-verbal way of connecting with the baby and each other and support them in developing appropriate touch during and after birth through baby massage and shiatsu. Appropriate touch can help a young child know the difference when touch is not safe.

Two important questions to consider asking in any kind of therapy

Bessel says that in whatever modality we are working with, there are two important questions to ask of the client.

1: Notice that: this helps to keep people anchored in the current moment, the present

We can verbalise this as a question when we notice that people are drifting away from the present, or we want to check in with what is going on. It can be helpful for our clients to verbalise what is going on in their body as we work with them.

2: What happens next? This gives a possibility for new understanding and new choices.

This can be a question to ask if we notice people are getting stuck in a feeling or experiencing a difficult sensation.  It gives them a chance to ask us to do something else or to stop, and so experience something different which they have chosen.

Bessel says that it is important for the therapist to work with curiosity rather than fear. I agree: if we work with fear, the client will sense that and then they will not feel safe and able to be present.

Conclusions

These is so much more that I could write about, particularly regarding specific treatments, but I hope this has stimulated your interest in Bessel’s work, as well as in the power of touch and especially the Extraordinary Vessels.

What I have particularly appreciated about Bessel’s work is his sense of hope: that we can make a difference and change our experiences of life.  I am inspired by his observations that:

1: our capacity to destroy is matched by our capacity to heal

2: language is power

3: we can regulate our physiology: breath, movement, touch

4: we can change the social environment, so people can feel safe, by working to prevent war, abuse and so on.

I will end on a quote that can perhaps give some sense of hope for creating a new future. It is from the founder of the Internal Families System (IFS) Robert Schwartz, which is explored in the book

“Self does not need to be cultivated: under the protective parts is a confident, curious, self which can organise”

Within each of us, there is a self which can guide us to be fully present in each moment: there is nothing to heal, create or fix. We are already whole.