A Community of Heart: Bessel van der Kolk

How does one choose one’s way in life? Bessel van der Kolk believes that “Lives are accidental and unexplainable. Stuff happens and then life is never the same, and you can’t explain why. We are subject to the whims of the universe.” Even though he grew up in the aftermath of war torn Europe, the fact that he would later devote himself to understanding, researching, and treating trauma was by no means inevitable. None of his brothers or sisters followed in the same path.

What has defined Bessel van der Kolk’s life has been his quest to understand how people deal with and survive the horrifying actions that people perpetrate on each other and the amnesia of both victims and perpetrators. Bessel was born during World War II and grew up in its aftermath in the coastal town of Scheveningen, Netherlands. Among his earliest memories, Bessel recalls the holocaust survivors who were his neighbors, the returning family members who had been in German and Japanese concentration camps, the legacy of Nazi brutality all around, bombed out cities and the reality of poverty and deprivation after the war. Yet, he also lived in a community of people who spoke about what was happening to them, in contrast to other communities who silenced their experiences of ruthlessness and terror.

As Bessel entered middle childhood, he had a close friend who was the son of a Schutzstaffel (SS) General. Through this connection, he was privy to the loving aspects of this German family that was in direct contrast to how Germans treated his relatives and neighbors during the war. At this early age, Bessel was exposed to how complex human behavior can be: loving kindness living side by side with cruelty. He thought, “How does this happen?”

He attended the Gymnasium in The Hague where he had a rigorous education, including instruction in Latin, Greek, four other foreign languages, and a deep immersion in science. This education in both the glories of the humanities and the rigors of science was a prelude to his later career. By the late 1950’s, Bessel was travelling through Europe. He hitchhiked through France and was drawn to music of the monastic Taizé Community and their life dedicated to kindness and simplicity. Here, he found a group life style that emphasized dedication, immersion, meditation, and chanting, and he seriously considered their offer to join them.

However, in 1962, when his uncle who had survived WWII as a slave laborer on the famous River Kwai, invited him to join him in Hawaii, Bessel eagerly accepted. He studied at the East West Center of the University of Hawaii, where he was awarded his B.A., and in 1970, he received his M.D. from the University of Chicago Pritzker School of Medicine. He decided on psychiatry and did his residency and early faculty years at Harvard.

He feels like his “real career” began in 1978 when he joined the Veterans Administration Outpatient Clinic in Boston, four years after the end of the Vietnam War. Working with combat soldiers, Bessel began working with his first patient, Jack. He was sure he could provide him with a quick solution to his nightmares, upon completion of his work with Ernest Hartmann on rapid-eye-movement (REM) sleep and pharmacology. Jack proved a much bigger challenge especially when he told him, “I need to have my nightmares, lest the death of my friends would have been in vain.” Bessel realized the complexity of this man’s trauma as it related to his need to be worthy of his father’s affection and follow in his footsteps. This was true especially after he was exposed to events as a soldier so close to his father’s that “it altered his view of his world, his biology, his conceptions of himself, and his capacity to engage with the next generation.” Bessel was riveted by what he was learning, and it was then he thought he would devote his professional life to understanding and treating trauma.

Eager to help his combat veteran patients, he was surprised that there were no books on war trauma in the hospital library. Eventually, he found Abram Kardiner’s, “The Traumatic Neuroses of War” (1941) and a series of articles by Henry Krystal, “Trauma and Affects,” that talked about how traumatization is often followed by loss of language and the somatization of experience.

He started to study the nightmares of Vietnam Vets and found that when they went into REM sleep, they woke themselves up. Bessel’s colleagues Ramon Greenberg and Chester Pearlman labeled this REM-interruption insomnia. Was this responsible for the vets’ inability to consolidate the remainders of the trauma memories into episodic memory? Using the Rorschach test to understand the perceptual processing that can occur in traumatic stress, fellow researcher, Charles Ducey and he found that the traumatized vets either overlaid their trauma onto the cards or saw nothing at all. In fact, the only time that they seemed to come alive was when talking about them Vietnam experiences. Later, on reflection and continuing to amass knowledge on trauma through observation, clinical work, research and interactions with other colleagues, he realized how stuck in the past these vets were, and that they used very risky behavior to pull themselves into the present, such as riding their motorcycles at high speeds. When he used the “talk therapy” he had learned during his residency, it made for a good therapeutic relationship, but it did not seem to resolve the traumatic stress.

In 1984, Bessel organized the American Psychiatric Association’s first symposium on PTSD, in which he was joined by Lawrence Kolb and Henry Krystal.

Soon after, Bessel started to wonder if his patients with borderline personality disorders (BPD) became that way as a result of early childhood trauma. As Bessel said, “In their case, however, the battlefield had not been overseas but in their own homes.” Were they re-enacting their early childhood traumas in a similar way as the Vietnam Vets were re-enacting their trauma in their family lives? He started a study group on BPD that resulted in clinicians being fascinated with this new perspective on treating what had been considered one of the most difficult groups of patients to treat. By the late 1980s, Judy Herman, Chris Perry and Bessel had documented that a majority of patients with BPD had histories of severe childhood trauma and neglect, starting prior to age 7. Could neurobiological shifts in traumatized children have a major effect on their capacity for self-regulation?

As the result of this early research, Bessel was invited to the American College of Neuropsychopharmacology meeting in 1983 where Steve Meier introduced him to the animal model of inescapable shock. Bessel wondered if this was relevant to traumatized people as well and it resulted in his paper, “Inescapable Shock, Neurotransmitters, and Addiction to Trauma,” the first theoretical paper on the neurobiology of PTSD. In 1987, this work led to the first symposium on the biology of traumatic stress at the World Congress on Biological Psychiatry, in Jersusalem. With Roger Pitman, Ariel Shalev and Frank Putnam, they presented on the neurobiology of trauma. Later that evening, they were joined by Onno van der Hart at dinner, who introduced them to the work of Pierre Janet and his theory of the psychology of action that addressed dissociative phenomena in traumatized individuals. Through Janet’s contributions, one of the things Bessel learned was how trauma returns to patients’ minds through isolated images, smells, physical sensations and sounds and this later led to three studies on the nature of memory in traumatized people who had the experience of “awareness” during anesthesia.

Bessel co-directed the DSM IV PTSD field trial group with Dean Kilpatrick that put together a more complex adaptation to trauma that they called disorders of extreme stress not otherwise specified (DESNOS), or Complex PTSD. Their study found that people with early childhood interfamilial abuse and neglect, in addition to PTSD symptoms, had many problems in the areas of self-regulation, attention, self-esteem, intimacy and somatization. Even though his committee overwhelmingly voted for inclusion of this new diagnosis, the leadership of the DSM decided against inclusion. Tragically, an important opportunity to actually capture the effects of chronic abuse and trauma over children’s development and thereby make accurate diagnoses and develop effective treatments was lost.

By the early 1990s, the issue of trauma had entered the cultural arena. The False Memory Debate spurred a great deal of research in the nature of traumatic memory. Bessel was struck by how little attention was paid to the differences between the quality of memories of trauma vs. everyday life. His team conducted studies with people with childhood trauma and later with rape victims and victims of car accidents and patients who experienced “awareness” during surgical procedures. They found that memories of trauma mainly consist of “implicit” memories “in the form of physical sensations, images, physical hyperarousal, and physical reliving.” What caused these implicit memories to not be translated into narratives of past events and instead be split off? More importantly, how can you put them back together and help them become a narrative of a distant past?

Increasingly, Bessel and his colleagues were demonstrating what went wrong in trauma and the types of psychophysiological reactions and neuroendocrine responses that were occurring for people with PTSD. However, he had yet to find an effective treatment that would minimize the time spent reliving the past and experiencing its concomitant emotional devastation and help patients to live fully in the present, without the residual dissociation and hyperarousal, characteristic of PTSD (van der Kolk, 2002).

Around 1994, two clinicians in his Trauma Center in Boston, Patti Levin and Libby Call told Bessel about their experience with EMDR. His first response was to tell them, in no uncertain terms, “Stop doing that!” However, still being curious, he accepted the invitation of his friend and colleague, Steve Lazrove, to show him two videotapes of Steve using EMDR to treat patients with PTSD. After he witnessed the intense physiological reactions and psychological distress of the people talking about their trauma disappearing after several sessions of EMDR.

Bessel decided to take the EMDR training. The three subsequent impressions that he had about EMDR were the following:

• EMDR seems to loosen up free associative processes, giving people very rapid access to memories and images of their past and possibly allowing them to, in some way, associate current painful life experiences with previous life events that have been successfully mastered.
• EMDR seems to be able to accomplish its therapeutic action without forcing people to articulate in words the source of their distress.
• EMDR may be beneficial even in the absence of a trusting relationship between the patient and therapist (van der Kolk, 2002, p. 72).

Bessel later confirmed these three impressions through his personal experience. In addition, he found the following:

• EMDR is capable of softening the pain of past experiences while it can also enhance feelings of pleasure and serenity associated with others (van der Kolk, 2002, p.72).

Bessel recounts that his introduction to EMDR was “the opening of my world,” marking the first time that he learned something that really could treat PTSD effectively, with a method that departed sharply from conventional therapeutic approaches.

In 1996, Bessel and Scott Rauch et al. conducted the first neuroimaging study of PTSD to visualize what happens in the brain when people have flashbacks. This showed that when people relive their trauma, Broca’s area (the speech center in the brain), shut down. They had managed to visualize what happens to people who are dumbfounded by speechless terror. Later, Bessel and his colleagues at the Trauma Center did a pilot study of treatment outcomes using EMDR and used changes in brain function as one of the outcome measures. Some findings of the pilot study of 12 subjects were the following: 8 participants had a 30% decrease in their Clinician Administered PTSD Scale scores after three sessions and a decrease in physiological reactivity to a personalized trauma script; several subjects had an increase in prefrontal lobe activation; and the narratives of the trauma had a more symbolic quality than before. These were encouraging findings. Shortly after, he was asked to present how we can visualize mental states in a brain scanner at the first US Body Psychotherapy Conference, where another world opened up. There he met three of the leaders in this field who offered to teach him about body states: Albert Pesso, Pat Ogden and Peter Levine.

In 1999, under the auspices of the Cummings Foundation, Bessel was responsible for convening leading child psychiatrists, psychologists, and policy makers from the Justice Department, the Department of Health and Human Services and congressional staffers to look at the state of trauma treatment for children. They came together at the Brain Center on Cape Cod and decided that there was a need to set up a national center for the study of childhood trauma. Six months later, Congress passed the bill that authorized the establishment of a National Center for Child Traumatic Stress. UCLA and Duke University became the lead agencies of this new network.

One of the most important experiences for Bessel was his involvement with the Truth and Reconciliation Commission in South Africa. This Commission was convened by Nelson Mandela to address Bessel’s fundamental question about the nature of man’s brutality to man. However, here was a new possibility, an answer to his question. As Bessel writes in the “Acknowledgments” section in, “Traumatic Stress: The effects of overwhelming experience on mind, body and society,” (van der Kolk, McFarlane & Weisaeth, 1996):

Mandela became president of his country knowing trauma and the havoc it wreaks in people’s souls. In articulating his vision of how his people should overcome their legacy of trauma. Mandela has put into action a program that is based on hope for understanding, instead of vengeance; for reparation, rather than retaliation; for Ubuntu, not victimization. Believing that only a True Memory Society can guarantee dignity, peace and stability, Mandela, after 27 years of being imprisoned for his beliefs, proposes that before perpetrators can be forgiven, there first needs to be an honest accounting and a restoration of honor and dignity to victims; the facts need to be fully acknowledged in order to heal the wounds of the past. Only then can there be genuine forgiveness. Despite all the contrary lessons from history, we fervently hope that Mandela’s dream will be fulfilled. We believe that the spirit of squarely facing the facts as a prelude to healing should guide both our clinical and research work with victims of trauma and violence. (p.xxi)

In 2006, Van der Kolk et al. did the first, and thus far only, National Institute of Mental Health funded EMDR study. “A Randomized Clinical Trial of EMDR, Fluoxetine, and Pill Placebo in the Treatment of Posttraumatic Stress Disorder: Treatment effects and long-term maintenance,” comparing the efficacy of EMDR and Prozac. This study was significant because it is the only National Institute of Mental Health study of EMDR and PTSD, and the first comparison of EMDR with Prozac. This study found that patients with adult-onset PTSD recover with a short period of intense, exposure-type treatment, with lasting positive results. Just paying attention to the patients’ symptoms in the placebo condition, as well as treating patients with SSRIs, was found to be helpful, especially when they were suffering from childhood-onset trauma. However, those treated with EMDR remained asymptomatic while the majority of those taking Prozac reverted back to most of their PTSD symptoms. The study showed that acute trauma can be treated with short periods of trauma processing, a trauma processing method that does not rely mainly on words and understanding and does much better than the pharmacology agent. After painstakingly trying to accumulate research funding over a ten-year period, Bessel and Ruth Lanius are currently studying what happens in the brains of traumatized individuals who process their trauma with EMDR in an fMRI scanner.

Bessel has never been interested in just studying one particular treatment method. As a true scientist, his understanding of the nature of traumatic stress has led him to explore a range of interventions. Currently, Bessel is studying theater and neurofeedback for treating PTSD, and this past June he published the first scientific study to show the effectiveness of Yoga in treating chronic PTSD in a major psychiatric journal.

As Bessel opened to the possibility of EMDR, he remembered Kardiner’s caveat that “the nucleus of neurosis is physioneurosis,” and he began to ask new questions concerning how treatments for PTSD could help with the self-regulation of the body. His new book, “The Body Keeps the Score” (Viking, 2014) is testimony to his pursuit for a way to treat and understand how brain and body are transformed by trauma and how they can be restored to functioning with treatment modalities such as EMDR, Somatic Therapies (Sensory Integration and meditation/mindfulness), Internal Family Systems Therapy, Movement and action (yoga and martial arts), Neuro-feedback and Theater.

Perhaps, this new chapter of changing the effects of trauma through physical self-regulation and the nurturing of joy and delight is a new chapter in Bessel’s quest to find out why people do such horrible things to each other and how they can be restored to health and wellbeing. In 2012, during a meeting, Bessel asked the Dalai Lama the question that has been important to his understanding the nature of humanity, “How is it that the last three genocides have been in Buddhist countries?” The Dalai Lama had no easy answer and Bessel concluded that, “We still have not found a way to stop man’s inhumanity to man.”

For now, he is exploring the body-based therapies as a way of changing the body’s response to traumatic stimuli. As Bessel says, “Anything that makes the brain calm puts the mind in the opposite of what it does when it is hyper-aroused. Anything that enables the brain to calmly observe should be effective.” By working with the body, he has begun to change his own life, and the work that he is doing with his patients and what he is teaching us.

Through Bessel’s persistence, the world has come to better understand the nature of trauma. He has travelled and succeeded in teaching mental health practitioners the importance of this ubiquitous human experience. He and his colleagues have been shining the light on this problem for more than 40 years. It is time for us to take up the baton and to raise the funds to support the research of more randomized controlled studies of EMDR therapy in a variety of different populations, present our findings at meetings and conferences, and write the articles in peer-reviewed journals that are crucial for the forward movement of EMDR Therapy and its very existence. He implores EMDR therapists to donate 10% of their income to the research that will benefit the world, our community, and ourselves.

Let’s not let him down.

References

Figley, C.R. (2005). Mapping Trauma and Its Wake: Autobiographic essays by pioneer trauma scholars. New York: Routledge Psychosocial Stress Series.

Kardiner, A. (1941). The Traumatic Neuroses of War. New York: Hoeber.

Krystal, H. (1978). Trauma and Affects. Psychoanalytic Study of the Child, 33, 81-116.

Rauch S, van der Kolk BA, Fisler R, Alpert N, Orr S, Savage C, Jenike M, Pitman R. (1996). A symptom provocation study using Positron Emission Tomography and Script Driven Imagery. Arch Gen Psychiatry, 53, 380-387van der Kolk, B.A. (2014). The Body keeps the Score. Brain, mind and body in healing trauma. New York: Viking.

van der Kolk, B.A., Blitz R., Burr, W.A., Hartmann E. (1984). Nightmares and trauma: Life-long and traumatic nightmares in veterans. Am J Psychiatry 141:187-190.

van der Kolk, B.A., & Ducey C. (1984). Clinical Implications of the Rorschach in Post Traumatic Stress Disorder. In, B.A. van der Kolk, BA(Ed.), Post Traumatic Stress Disorder: Psychological and biological Sequelae. Washington D.C. American Psychiatric Press.

van der Kolk B.A., Greenberg M., Boyd H., Krystal J. (1985). Inescapable shock, neurotransmitters, and addiction to trauma: toward a psychobiology of post traumatic stress. Biol Psychiatry, 20:314-325.

van der Kolk, B.A., McFarlane, A.C., & Weisaeth, L. (1996). The Body Keeps the Score: Brain, mind, and body in the healing of trauma. New York: The Guilford Press.

van der Kolk, B. A., Spinazzola, J., Blaustein, M. E., Hopper, J. W., Hopper, E. K., Korn, D. L., & Simpson, W. B. (2007, January). A randomized clinical trial of eye movement desensitization and reprocessing (EMDR), fluoxetine, and pill placebo in the treatment of posttraumatic stress disorder: Treatment effects and long-term maintenance. Journal of Clinical Psychiatry, 68(1), 37-46. doi:10.4088/JCP.v68n0105.

van der Kolk, B.A., Stone, L., West, J., Rhodes, A., Emerson, D., Suvak, M. & Spinazzola, J. Yoga as an adjunctive treatment for PTSD. J Clinical Psychiatry, June 2014.