Advances in the Treatment of Trauma

Transcription

1 Advances in the Treatment of Trauma Bessel van der Kolk, MD - Transcript - pg. 1 Advances in the Treatment of Trauma What Neuroscience Teaches Us about the Treatment of Trauma with Ruth Buczynski, PhD and Bessel van der Kolk, MD National Institute for the Clinical Application of Behavioral Medicine

2 Advances in the Treatment of Trauma Bessel van der Kolk, MD - Transcript - pg. 2 Advances in the Treatment of Trauma: Bessel van der Kolk, MD What Neuroscience Teaches Us about the Treatment of Trauma Table of Contents How Trauma Affects the Brain pg. 3 Remembering Past Trauma pg. 4 How the Entire Being Becomes Disorganized pg. 5 The Difference between Traumatic and Everyday Memory pg. 5 How the Lack of Context Impacts Treatment pg. 6 The Four Components of Trauma and Effective Treatment pg. 9 Trauma through the Lens of Politics and Economics pg. 12 The Effect of Neglect and Abuse on Brain Development pg. 13 Dissociation and Trauma pg. 15 The Inclusion of Yoga in the Treatment of Trauma pg. 16 Treatments and Mistakes in the Pursuit of Self-Regulation pg. 17

3 Advances in the Treatment of Trauma Bessel van der Kolk, MD - Transcript - pg. 3 Advances in the Treatment of Trauma: Bessel van der Kolk, MD What Neuroscience Teaches Us about the Treatment of Trauma Dr. Buczynski: Welcome everyone. I m Dr. Ruth Buczynski a licensed psychologist and President of the National Institute for the Clinical Application of Behavioral Medicine. Tonight we have the rare privilege and opportunity to speak with Dr. Bessel van der Kolk. I m sure most of you know him and don t need an introduction, so I won t take up a lot of time - we ve a lot to talk about and I want to jump right in, but he s a professor of psychiatry at Boston University Medical School and the Director of the Trauma Center at Justice Resource Institute in Brookline, Massachusetts. He s a very active clinician, researcher, teacher, and probably the world s leading expert on post traumatic stress disorder. Bessel, welcome and thanks for being part of this series. How Trauma Affects the Brain Dr. Buczynski: Jumping right in, how is the brain affected when someone is suffering from trauma? Dr. van der Kolk: That is quite a question. When somebody is exposed to extreme stress, many systems of the brain are activated to deal with that. Sometimes people get stuck, and the system doesn t come back to normal, so the brain s threat detection system is hyperactive. People have a hard time focusing on things and still continue to be hyper-aroused very much getting stuck in trauma. It interferes with people s capacity to pay attention to the present to have pleasure in the present, to focus in the present - to pay attention to what s going on right now and to pay attention to their physical body. Their body keeps racing, the stress hormones keep getting secreted, and they often become ill. When exposed to extreme stress, many systems of the brain are activated.

4 Advances in the Treatment of Trauma Bessel van der Kolk, MD - Transcript - pg. 4 Remembering Past Trauma Dr. Buczynski: When people are remembering, not necessarily currently and during trauma, but just remembering past trauma, are the same kinds of things happening or would you describe that differently? Dr. van der Kolk: Trauma sort of stays there. That s the issue with post-traumatic stress. It s not just remembering something that happened a long time ago, but the fact that your organism, your being, The body keeps remembering what has happened to it and it has changed in order to cope with the ongoing trauma. continues to live in the world as if you re in the trauma. The body keeps remembering what has happened to it and it has changed in order to cope with the ongoing trauma. I think there s a misconception, to which I contributed to myself, that there s a specific trigger zone, which turns out not to be the case unless people stay in a chronic pattern of hyper-arousal or numbing of normal information processing changes. Dr. Buczynski: So you re saying that it s not necessarily specific triggers, like I see someone and that reminds me... Dr. van der Kolk: Right, and that s the easier thing. The more easily visible part is that you get a trigger, or you are reminded of something, but that s only part of the picture. The rest of the picture is that your being, your organism, as I d like to call it, stays in a chronic state of hyper-arousal, fight and flight, and then explodes in these incidences. Your being stays in a chronic state of hyperarousal, fight and flight, and then explodes. Dr. Buczynski: Now, the central nervous system is that in an activated or a deactivated state? Dr. van der Kolk: It can go either way. In people with childhood trauma, oftentimes it s in a deactivated way or a shoved-down way, but then it s really about being caught between freezing and fighting and freezing and fighting. During regular times, people often go through life not really alive. They re not fully aware and then People with childhood trauma are caught between freezing and fighting. something triggers them. They become hyper-aroused, and it s embarrassing, it s destructive, and they start shutting down again. Also, it is both of these aspects of fight or flight that occur.

5 Advances in the Treatment of Trauma Bessel van der Kolk, MD - Transcript - pg. 5 How the Entire Being Becomes Disorganized Dr. Buczynski: You talked before about how the exposure, the constant exposure to so much stress, leads to illness, chronic disease. Dr. van der Kolk: No, you see, it s not really the external thing. When your body gets stuck in perceiving constant danger it s all Our entire being becomes disorganized in trauma. of you. Sadly, psychology has come to believe that it s all in your mind, but we are a body, we are organs. Trauma is about our entire being; our entire being becomes disorganized in traumatized people. Your immune system keeps fighting, the perceptual system keeps fighting, releasing stress hormones in the direction of the trauma and there are neurological issues you get this sort of invasive impact on the survival system s entire order. The Difference between Traumatic and Everyday Memory Dr. Buczynski: Let s talk about how memory is stored - specifically the difference between how traumatic memories are stored vs. more everyday memories. Dr. van der Kolk: Basically, again, we re talking about levels. If you re talking about verbal memories, like what I can tell you, that is one thing. I can tell you about events that have happened somewhere, but our Our brains continually form maps of the world maps of what is safe and what is dangerous. brains continually form maps of the world maps of what is safe and what is dangerous. That is how we become wired. We carry an internal map of who we are in relationship to the world that s one s memory system, but that s not a known memory system, this is an implicit memory system. If you re abused as a child, your brain gets wired with, I m a person to whom terrible things happen, and I better be on the alert for who s going to hurt me now. Those are conscious issues stored in a very elementary part of the brain. What happens in terms of adults when something horrible happens and they get traumatized, which is not always the same thing, is that the brain becomes overwhelmed.

6 Advances in the Treatment of Trauma Bessel van der Kolk, MD - Transcript - pg. 6 The thalamus shuts down and the entire picture cannot be stored in the brain. People remember images, sites, sounds, physical sensations without much context there are certain sensations that just become triggers of the past. People remember images, sites, sounds, physical sensations without context. Dr. Buczynski: With the thalamus shutting down, what does that mean for us in terms of functioning? What do we not have resource-wise available to us because of the thalamus shutting down? Dr. van der Kolk: All that means is that the particular incident is not remembered as a story of something that s happened a long time ago, but it gets triggered by sensations that you currently get that activate your emotional states. Again, it has little to do with, Oh, let me tell you of the incident of my father hitting me. It s just on a much more elementary, organic level of one sensation triggering the state of fear. You keep thinking about it and say, Oh, this must be because it reminds me of the time that my father hit me. But that s not the connection that the mind makes at that particular time. How the Lack of Context Impacts Treatment Dr. Buczynski: Given this lack of context where we re just remembering things in terms of pictures and sounds, let s talk a little bit about what that means for clinical practice. A lot of people on this call are psychotherapists, certainly not everyone, and we ll try to talk a little bit later about what physicians and nurses and physical therapists might keep in mind. But starting with psychotherapists, the social workers, the mental health counselors and psychologists, what should we be thinking about, realizing that it was encoded without context? Dr. van der Kolk: The main thing I think for psychotherapists is that PTSD or being traumatized is not about the past - it s about a body that continues to behave and PTSD is not about the past it s about a body that continues to behave and organize itself as if the trauma is happening now. organize itself as if it s happening right now. To my mind, the work with traumatized people consists of helping them to field the present as it is and to tolerate whatever goes on. The past is only relevant in as far as it

7 Advances in the Treatment of Trauma Bessel van der Kolk, MD - Transcript - pg. 7 stirs up current sensations, feelings, emotions and thoughts. The story about the past is just a story that we tell to explain how bad (the trauma) was or why we have the behavior that we do, but the real issue is that we get changed by the trauma we feel ourselves different and we experience certain sensations differently. The main focus of therapy is to shift people s internal experience how the trauma is lodged inside them. The main focus of therapy is to shift people s internal experience. Dr. Buczynski: Would that be having the person just stay with the sensation, maybe talk about it if they can - what they re aware of? Dr. van der Kolk: There may be an over-evaluation of talking. Talking also can convey a defense against feeling. Dr. Buczynski: Can you tell us more about that? I think that s an interesting point. Dr. van der Kolk: There are various images of people feeling something very deeply, and one part of the brain lights up. There are other images where people are beginning to talk about (their trauma) and another part of the brain lights up. So talking can be a distraction from yourself and noticing yourself. I think some of the best therapy one can do is therapy that is very largely non-verbal where the main task of Some of the best therapy is largely non-verbal. the therapist is to help people to feel what they feel to notice what they notice, to see how things flow within themselves, and to reestablish their sense of time inside. Dr. Buczynski: Tell me more about that, reestablishing the sense of time inside? Dr. van der Kolk: When people feel traumatized, right now, on a beautiful day like today, their bodies feel like they re under threat. I think the task is to help people to feel those feelings of threat, and to just notice how these feelings will go away as time goes on. The body never stays the same because the body is always in a state of flux. So it s important to learn that when a sensation comes up, it s okay to have it because something else will come next. We can When people feel traumatized, their bodies feel like they re under threat. re-establish this sense of time, which gets destroyed by the trauma the sense of time when you re being traumatized.

8 Advances in the Treatment of Trauma Bessel van der Kolk, MD - Transcript - pg. 8 You feel like this will last forever. Sensations and emotions become intolerable because you think, This will never come to an end. But once you know that something will come to an end, your whole attitude changes. Once you know that something will come to an end, your whole attitude changes. Dr. Buczynski: That sounds like an important piece, maybe for the folks in the medical side, the physical therapists and nurses and physicians, because they re often trying to administer procedures that are sometimes scary and painful. Is there a way they can use this idea? Dr. van der Kolk: I don t live in that environment, but my patients tell me about their various senses of nurses and physicians. They tell me that what is helpful to them is for (practitioners) to keep patients more or less in charge of the procedure and to ask them, Does this feel okay? Can I continue now? Would you like me to hold your hand? You can tell me not to touch you, and we can actually take some deep breaths and see what happens when you take a breath. We can do some acupuncture pressure points and see if that can calm you down. It s important to explore with people what helps them to stay calm and to keep the observational part of the mind alive. The biggest challenge in therapy and medical procedures is that people tend to sort of blow-out their observing ego. They re observing that, I m a person going under this medical procedure it s Thursday it hurts and right now somebody is putting something into me... The observing part may easily be blown away and you become this frightened organism who is being assaulted. It s important to explore with people what helps them to stay calm and to keep the observational part of the mind alive. The trick is to keep the observing part alive - to notice and to see what happens - what s happening now. I m here I m lying in the bed. Somebody s touching my shoulder You notice what s going on seeing and really observing the present moment and then, as I say, keeping the observing self in mind. This is the core issue of all traumatic therapy and all traumatic interventions. Dr. Buczynski: I m just taking a note here because I think that s really important. Would it be helpful for the physician or the nurse to even just say that the procedure s going to take about 15 minutes or something like that? Dr. van der Kolk: Absolutely. What that brings to mind is something we love to do we have a big yoga program. One of the things I love about yoga is that you go to your yoga coach - it s very challenging and you

9 Advances in the Treatment of Trauma Bessel van der Kolk, MD - Transcript - pg. 9 The issue of timing is very important in medical procedures. say to yourself, Oh, this is too hard; I can t do it. And your yoga teacher says, We ll do this for three deep breaths or we ll do it for five breaths. You count your breaths - four, three, two... and you say to yourself, Oh, I can t do this anymore, but it s only one more breath and then it s over. I think the issue of timing is very important in medical procedures where people are awake, and to say, This is going to take 15 minutes - we re down to four minutes, two minutes... To count, to hear a person s voice will compose your sense of time and presence, and that s very helpful. The Four Components of Trauma and Effective Treatment Dr. Buczynski: Let s talk a little bit about what components are involved in an effective trauma treatment. What does this effective treatment need to involve? Dr. van der Kolk: I would say the foundation of all effective treatments involves some way for people to learn that they can change their arousal system and that s very elementary. Before any talking, it s important to notice that if you get upset, taking 60 breaths, focusing on the out breaths, can calm your brain right down. Attempting some acupressure points or going for a walk can be very calming. The core idea here is that I am not a victim of what happens. I can do things to change my own thoughts, which is very I am not a victim of what happens... I am in charge of my own physiological system. contrary to the medical system where, if you can t stand something, you can take a pill and make it go away. The core of trauma treatment is something is happening to you that you interpret as being frightening, and you can change the sensation by moving, breathing, tapping, and touching (or not touching). You can use any of these processes. Dr. Buczynski: So you re talking about learning to tolerate feelings and sensations. Dr. van der Kolk: It s more than tolerating. Actually, it is more about knowing that you, to some degree, are in charge of your own physiological system. There needs to be a considerable emphasis on cultivating in myself, not only as a therapist, but also as a

10 Advances in the Treatment of Trauma Bessel van der Kolk, MD - Transcript - pg. 10 patient this knowing that you can actually calm yourself down by talking or through one of these other processes. Dr. Buczynski: So this is learning to modulate arousal? Dr. van der Kolk: Yes, and there s alarmingly little in our mainstream culture to teach that. For example, this was something that kindergarten teachers used to teach, but once you enter the first grade, this whole notion that you can actually make yourself feel calm seems to disappear. Now, there s this of post-alcoholic culture where if you feel bad, you pop something into your mouth to make the feeling go away. Dr. Buczynski: You take a pill, have a beer, or whatever. Dr. van der Kolk: Exactly, there s always something bubbling. It s interesting that right now there are about six to ten million people in America who practice yoga, which is sort of a bizarre thing to do - to stand on one foot and bend yourself up into a pretzel. Why do people do that? They ve discovered that there s something they can do to regulate their internal systems. The issue of self-regulation needs to become front and center in the treatment of trauma. So the issue of self-regulation needs to become front and center in the treatment of traumatized people. That s step number one. Step number two is, I would say, the cultivation of being able to take effective action. Many traumatized people have been very helpless; they ve been unable to move. They feel paralyzed, sit in front of the television, and they don t do anything. Programs with physical impact, like model mugging (a form of self-defense training), martial arts or kickboxing or an activity that requires a range of physical effort where you actually learn to defend yourself, stand up for yourself, and feel power in your body, would be very, very effective treatments. Basically, they reinstate a sense that your organism is not a helpless (tool) of fate. That s the second piece. The third thing I would talk about is learning to know what you know and feel what you feel and that s where psychotherapy comes in: finding the language for internal experience. Programs with a range of physical impact are very effective treatments.

11 Advances in the Treatment of Trauma Bessel van der Kolk, MD - Transcript - pg. 11 Without being able to communicate, you re locked up inside of yourself. The function of language is to tie us together; the function of language is communication. Without being able to communicate, you re locked up inside of yourself. So, learning to communicate and finding words for your internal states would be very helpful in terms of normalizing ourselves accepting and making (the communication of internal states) a part of ourselves and part of the community. That s the third part. In my mind, there are two other, sort of cutting-edge, types of trauma that we are pretty much exploring. One of them is that the way that you come into the world and move through the world just as you and I are talking to each other on these video streams - I say something and you move your hand a little bit maybe smile or move your head a little bit. We re physical animals, and to some level, we re always dancing with each other. Our communication is as much through head nodding and smiles and frowns and moving as anything else. Kids, in particular, and adults, who as kids were victims of physical abuse and neglect, lose those interpersonal rhythms. So, some sort of rhythmical interaction to establish internal sensory integration is an important piece that we are working on in our lab. With kids, we work with sensory integration techniques like having them jump on trampolines Rhythmical interaction to establish internal sensory integration is an important piece. and covering them with heavy blankets to have them feel how their bodies relate to the environment because that s an area that gets very disturbed by trauma, neglect, and abuse, especially in kids. For adults, I think we ve resolved rhythmical issues with experiences like tango dancing, Qi Gong, drumming any of these put one organism in rhythm with other organisms and is a way of overcoming this frozen sense of separation that traumatized people have with others. Then lastly, what for me is really becoming a very current issue, is that the brain changes because of trauma. I just had the chance to look at the quantitative EEG s on 13,000 Australian soldiers who went to Iraq and Afghanistan. They were tested after every call to duty and what you really see is a steady disorganization of the brain with every new involvement, every new exposure. What you see is that the brain becomes more and more hyper, less and less able to be quiet, and less and less able to see, or even feel, the larger picture.

12 Advances in the Treatment of Trauma Bessel van der Kolk, MD - Transcript - pg. 12 As long as your brain is very much disorganized, you cannot think clearly and you cannot relate to other people. If that s true for very healthy soldiers that can certainly be true even more for kids who are chronically exposed to abuse and neglect. What you see is that their brains are very much disorganized. As long as your brain is very much disorganized, you cannot think clearly and you cannot relate very clearly to other people. All you can experience is fear and shame, and you can barely make use of human relationships. So our main focus in treatment right now is something called neuro-feedback where we help people we make assessments of a person s brain and we have people play computer games with their own brain waves. Then, we alter brain connections after which people are calmer, more engaged, more mindful, more present, etc. So, those are the four main components of trauma. Dr. Buczynski: How long does the neuro-feedback take? Dr. van der Kolk: We don t know. Some people get better in ten sessions; some people get better in 20 sessions. It s like saying, how long does psychopharmacology work? Or, how long does psychotherapy work? Dr. Buczynski: Sure. Thank you, that was very helpful. Trauma through the Lens of Politics and Economics I m glad you brought up the soldiers because the next thing I wanted to ask you is in a New York Times op-ed piece, you said that for every soldier returning from Iraq and Afghanistan with symptoms of depression or PTSD, there are about ten children in the US who are... Dr. van der Kolk: Thirty... Actually, I said a hundred, but the New York Times forced me to put it down to make sure that we weren t exaggerating, so we cut it down to thirty (children). Dr. Buczynski: These are children who are traumatized by exposure to family violence and sexual abuse. Dr. van der Kolk: That s right.

13 Advances in the Treatment of Trauma Bessel van der Kolk, MD - Transcript - pg. 13 Dr. Buczynski: Tell us more about that? There are hundreds of thousands of children who are being maltreated, abused, and neglected. Dr. van der Kolk: Well, it s a fact. There s an enormous level of child maltreatment going on throughout the US. Every department, every state, is working with the Departments of Social Services (that are doing terribly) because there are hundreds of thousands of children who are being maltreated, abused, and neglected. These are not only poor kids who come to the attention of authorities, but also those in well-off families who can be abused and neglected. What is interesting to me is that when there s a war, young guys and young women go out and come back broken. Society pays attention to that particular segment of society, as they should and wish they had thought about these issues before they sent them off to war, but they didn t. So, people, once again, are aware of it, but if you have an economic situation like ours right now, the money for the treatment has to come from somewhere, and it usually comes from (resources targeted for the treatment of kids as well as areas for research) The social services are being depleted in order to keep the war machine going. We re depriving our society of the chance to help the children who are currently abused and neglected to become productive members of our society. There s a stunning lack of attention to the fact that about 10% of our 10% of our population will never become productive members of our society unless we put some serious research into treatment. population will never become productive members of our society unless we put some serious research into treatment. The Effect of Neglect and Abuse on Brain Development Dr. Buczynski: What do we know about the effect of neglect and abuse on the development of the brain? Dr. van der Kolk: An enormous amount. We know that it changes the functions of the frontal cortex which helps you to contain yourself and to focus. It changes your capacity to notice yourself - to feel yourself (in context). It drops people s IQ by about 30% on the average, and it interferes with people s capacity to pay

14 Advances in the Treatment of Trauma Bessel van der Kolk, MD - Transcript - pg. 14 attention, fit in, and notice other people s need. Basically, abuse and neglect cause problems in people, and it makes it very hard for them, when they grow up, to become productive members of society, relatively focused and attentive, in steady relationships, able to work, take care of their kids, contain their aggression, and feel Abuse and neglect make it very hard to be focused, attentive, and engaged. engaged. All of these attributes are very much affected by abuse and neglect. Dr. Buczynski: If you re talking about a kid that gets a lot of harsh words and put downs, but not necessarily beaten or sexually abused, are they still vulnerable? Dr. van der Kolk: I can t answer that question. You don t measure in numbers of beatings, at least I don t. It s interesting that some people can introduce engineering questions, but at the end this isn t an engineering question, it s a question of growing up knowing that somebody may hurt you at any particular time or knowing that nobody sees you or sees your needs and you cannot turn to anybody when you re upset. Maybe you can quantify it somehow, but these are internal experiences of, I m not being seen; I m not seen because I m probably a bad person; life is an emergency - everything becomes an emergency; I need to be on constant guard; I cannot pay attention to my schoolwork because I m afraid I m going to get beaten... Dr. Buczynski: In thinking about the effect on the brain, you see it in terms of a variety of symptoms, depression... Dr. van der Kolk: You see it in certain areas of the brain. The self-reflection, self-understanding, and self-care are not developed very well. Basically, areas of the brain having to do with alertness, danger, and fear are over-developed, and the result of all of these things, logically, is what you see in a therapist s office or in schools or wherever you go. Dr. Buczynski: That might account for the increase in ADHD and other oppositional disorders and anxiety disorders, even eating disorders that we see in kids. The brain areas having to do with alertness, danger, and fear are over-developed. Dr. van der Kolk: I can t comment on that. I don t know if there s an increase and nobody has really done the studies to document all of these relationships actually, so I wouldn t want to jump to that.

15 Advances in the Treatment of Trauma Bessel van der Kolk, MD - Transcript - pg. 15 There are a lot, and are they all due to abuse and neglect? I don t know. There are certainly other ways of getting there. You don t need to have been abused to develop ADHD, and you don t need to be abused to become an angry kid, but abuse might contribute. Dissociation and Trauma Dr. Buczynski: Let s talk a little bit about dissociation. We haven t really brought that up yet. Do you see that a lot in people that are traumatized? Dr. van der Kolk: I see it everywhere. We see it in our society. We learned a lot from Korea and the Vietnam War - about what war does to people. So, before the invasion of Iraq, there should have been a discussion about effects: for every soldier who will die in the battlefield, there will be 30 suicides, as that is happening right now. In the Times, I read that they say, Yes, same figures as Korea, same figures as Vietnam. So society dissociates from the realty of and then they rediscover it and say, Oh, my God, isn t it amazing! Well, no, it s not amazing because that s just what happens in war. People dissociate for the same reason that societies dissociate mainly because they like to believe that life is okay. People dissociate for the same reason that societies dissociate mainly because they like to believe that life is okay - my parents are safe or my neighbor is safe and so we have these dissociative defenses in society and among traumatized people. Certainly for traumatized people, dissociation can be a wonderful defense. Kids who don t dissociate are constantly living in fear and terror and have no life at all. Kids who dissociate can have one identity that is able to learn, able to have friends, and able to become a sex slave to whomever is molesting them. It s a very nice split, which allows a person to have some semblance of a life, to go forward, and at least support oneself to some degree. Dissociation is a good thing because it very much functions in the service of survival. Dissociation in society is equally good. Based on dissociation findings of the American Psychiatric Association... when they take family histories or past histories on patients... they ask two questions Dissociation is a good thing because it very much functions in the service of survival.

16 Advances in the Treatment of Trauma Bessel van der Kolk, MD - Transcript - pg. 16 about who was supportive while you were growing up and did anybody have alcohol or drug abuse in your family? There are no questions about family violence, physical abuse, sexual abuse, emotional neglect, and absence of caregivers... so any family history of trauma is totally ignored by the American Psychiatric Association. Is that good dissociation? No, I don t think so. I don t think that s serving people very well. The current dissociation of calling the majority of traumatized kids, who are referred to us, bipolar illness and medicating them with antidepressant agents, I think is often not useful dissociation. The fact that in the US, you spend $16.1 billion on giving drugs to kids, mainly abused kid s, is not a good dissociation. Does it help patient? Yes, it helps patients, but once again, they have a semblance of a life. The Inclusion of Yoga in the Treatment of Trauma Dr. Buczynski: Let s talk a little more about yoga. You re known for pioneering the work on the inclusion of yoga in the treatment of people with trauma. How did you get started doing that? Dr. van der Kolk: Well, you don t exaggerate! I think there are a lot of people doing yoga, but we put a research grant together. We were the first people who got research funding for it, but other people are doing it. We were interested in a phenomenon called heart rate variability, which is a self-regulation piece. We learned that there s a way in which you can regulate your brain stem, arousal system... actually that s heart rate variability. We learned that people can change their own heart rate variability and thereby change their own arousal systems. Then we learned that people can change their own heart rate variability and thereby change their own arousal systems. When I looked up what can do that, the first thing that showed up is marathon running, which I didn t see much future in as a therapeutic approach in the trauma center. The next thing I found was yoga, and what I ignored at that point, sadly, were also these very nice, little machines with computer games that can help you to regulate your heart rate variability. We did not do that and that s actually the piece of research that I feel we should have done, but instead we hooked up with

17 Advances in the Treatment of Trauma Bessel van der Kolk, MD - Transcript - pg. 17 some fantastic yoga teachers and we set up this yoga program. And indeed, we showed that yoga changed the heart rate variability and that people can become more focused and calm. So, this is the next thing I became curious about when I started to do yoga myself what is it about these yoga postures that changes people? That really pushed me into understanding the whole issue of mindfulness in relationship to one s body. What s very clear from many different angles is that some of these people have very attentive, very disturbed relationships to their bodies, but the part of the brain The insula, which is involved in taking care of the body, is often quite damaged in traumatized people. that s really involved in knowing what s going on in your body and taking care of it, the insula, is oftentimes quite damaged in traumatized people. Also, what you need to do in yoga is to really notice yourself and to feel yourself very deeply. It goes into the whole mindfulness area (of Jon Kabat-Zinn, Richard Davidson and all of these other people). It really got us into embracing the whole scientific enterprise of studying mindfulness, and in our case, how mindful attention to the body can change the brain. We just did a little mirror imaging study and what we found is, indeed, people exhibited change. In certain In certain areas of the brain that have to do with self-care, self-awareness, and arousal there were shifts after yoga. areas of the brain that have to do with self-care, selfawareness and arousal, there were shifts after yoga. So we have a first - scientific proof, though very small, that yoga can sort of reverse secondary brain damage in trauma. Treatments and Mistakes in the Pursuit of Self-Regulation Dr. Buczynski: So, throughout this call, I ve heard you say that yoga helps a person stay in the present; it helps them to learn to modulate arousal and to self-regulate; it helps them learn that things don t last forever because they re counting down the number of minutes in holding posture... Dr. van der Kolk: Most of all, and that s where you started, is that our culture or our psychological culture thinks about mental disorders and PTSD and depression as mental events that sort of happen up here in this

18 Advances in the Treatment of Trauma Bessel van der Kolk, MD - Transcript - pg. 18 little light bulb in the front of your brain, but we are bodies and the function of our minds is to take care of our bodies. The function of our minds is to take care of our bodies. If the body goes, we go and so what yoga has done for me is to really reinstate the core notion that we are a whole creature - we re not just disembodied people sitting in a chair yakking. We are people who move and do things with our lives, going from one place to another, which are all things that get messed up by trauma. Dr. Buczynski: If you were to think of just one or two things that you would want to tell people, maybe mistakes that practitioners can make? Dr. van der Kolk: Mistakes that I ve made - there are a lot! One mistake is storytelling - the idea that telling stories about your trauma is, at the end, going to make your organism feel safe and powerful. The pathway to re-owning yourself, re-empowering The pathway to re-owning and re-empowering yourself is through feeling, noticing, and coming to peace with yourself. yourself, is through feeling yourself, noticing yourself and coming to peace with yourself. That s what trauma is all about inside, and it took me a long time to learn that. I think the other thing is really one of the hard lessons that I had to learn, and it is this: our job is to keep people regulated and not to send people out of our office in a dissociative state or believing that you can make people alert and in charge of their lives by giving them a drug. I m in no way opposed to psychopharmacology; it can be a very helpful tool, but like everything else, it is one little tool in the overall therapeutic armamentarium. The most important goal for trauma treatment is to help people be truly alive in the present. Any therapeutic technique that can get people to feel good about being right here should be an effective technique. And that may involve strange things like pleasure and fun which are not in the indices of psychiatric textbooks. Our job is to keep people regulated and not to send people out of our office in a dissociative state. Dr. Buczynski: You ve talked about a role for treatments like EMDR. Do you feel the same way about some of the tapping treatments, such as EFT and others?

19 Advances in the Treatment of Trauma Bessel van der Kolk, MD - Transcript - pg. 19 Dr. van der Kolk: Yes... and there s some nice research now on tapping. I use tapping all the time. EMDR is an indispensable tool my hands I couldn t practice without having EMDR, but what tends to happen is that people tend to learn one particular technique and then believe that that s the be-all and end-all. It s really important to know that these are techniques these are tools. Every tool doesn t work for everybody, and every person needs to have a lot of tools in their toolbox. When people start making claims about one tool doing everything, you say: No, no, no! That s not how it is. It s a beautiful tool that has its limitations. Dr. Buczynski: How about hypnosis? Dr. van der Kolk: That s very hard as a therapist; you need to know a lot of different things. Every tool doesn t work for everybody, and every person needs to have a lot of tools in their toolbox. Dr. Buczynski: Thank you very much. I appreciate the time you ve given us, and all of the work that you ve done. Thank you so much! Dr. van der Kolk: It was fun. Thanks very much. Dr. Buczynski: Take care. Bye now.

20 Advances in the Treatment of Trauma Bessel van der Kolk, MD - Transcript - pg. 20 About the speakers... Bessel van der Kolk, MD is a neuroscientist and Professor of Psychiatry at Boston University Medical School. He is also the Medical Director of the Trauma Center, where he incorporates such diverse resources as a yoga studio, theater program, and neurofeedback laboratory. His research has ranged from neuroimaging and psychopharmacology to memory processes and EMDR. He is past President of the International Society for Traumatic Stress Studies and he has taught at universities and hospitals around the world. His current research involves the effects of trauma on memory processes and brain imaging studies of PTSD. He is author of well over a hundred scientific articles, author of Psychological Trauma, and co-editor of Traumatic Stress. Ruth Buczynski, PhD has been combining her commitment to mind/body medicine with a savvy business model since As the founder and president of the National Institute for the Clinical Application of Behavioral Medicine, she s been a leader in bringing innovative training and professional development programs to thousands of health and mental health care practitioners throughout the world. Ruth has successfully sponsored distance-learning programs, teleseminars, and annual conferences for over 20 years. Now she s expanded into the cloud, where she s developed intelligent and thoughtfully researched webinars that continue to grow exponentially.