Author: Bessel van der Kolk
This most enlightening book is a comprehensive assessment of the devastating impact of trauma on individuals, their families, and society as a whole. It depicts post-traumatic stress disorder as ‘much more than a story about something that happened long ago‘, but as a phenomenon with ‘disruptive physical reactions in the present’, its victims ‘hopelessly stuck in the past’, their minds ‘frozen, trapped in a place they desperately want to escape’ (pages 10 and 204). The book’s key message, as aptly expressed in it’s title, is that the health consequences of trauma affect the whole body, and therefore its successful management must ‘engage the entire organism, body, mind, and brain‘ (pages 46 and 53). The author, a psychiatrist who has dedicated his professional life to ‘trying to unravel the mysteries of trauma’, draws partly from his own personal experience of witnessing the ‘outbursts of explosive rage‘ his father manifested following internment in a Nazi concentration camp (pages 9-10).
The cornerstone of the book is undoubtedly its vivid portrayal of the impact of trauma on the mind. The author describes how, by altering the perceptions and thought processes of its victims, trauma leads to a failure of imagination, a loss of mental flexibility, and a pervading sense of emotional numbness which makes its victims unable to absorb and integrate new experiences ‘into the ongoing stream of their life’; the consequence of this is that they struggle to be ‘fully alive in the present‘ (pages 17-21, 47 and 84). Knowing that their traumatic experiences can be ‘reactivated at the slightest hint of danger‘, victims of trauma also often become hyper-vigilant and consequently incapable of enjoying ‘the ordinary pleasures that life has to offer’ (pages 84 and 54). Even more disruptive is when they manifest dissociation, the psychological phenomenon whereby their traumatic emotions, sounds, images, thoughts, and physical sensations become ‘split off and fragmented‘ and ‘take on a life of their own‘ (page 66). Depersonalisation is a related ‘biological freeze reaction’ which manifests as ‘blank stares and absent minds‘, and which may make the traumatised ‘chronically out of sync with the people around them’ (pages 72 and 79). In their desperate efforts to ‘shut off terrifying sensations‘, trauma victims may eventually loose their sense of self-awareness, and this may be so profound as to make them incapable of recognising their own image in a mirror (page 92).
The repercussions of trauma are as detrimental to the body as they are to the mind, and these often develop because trauma victims tend to convert their emotions into somatic symptoms. The traumatised may therefore present with disorders such as chronic pain, fibromyalgia, irritable bowel syndrome, and chronic fatigue (pages 97-99). They may also perceive sensations ‘that have no obvious physical cause’, or they may be unable to feel any sensation from large areas of their bodies (pages 25 and 89-91). Victims of trauma also become addicted to food, drugs and alcohol‘, and they may engage in dangerous, repellent, and self-harming activities; these are the avenues, the author explained, that victims of trauma adopt to relieve their ‘vague sense of emptiness and boredom‘, and to make them feel better about themselves (pages 88 and 31-34). Emotionally, victims of trauma are frequently overwhelmed by sensory overload, and they may alternate between ’bouts of explosive rage‘ and periods of emotional shut down. They may also easily ‘startle in response to any loud sound, become enraged by small frustrations, or freeze when somebody touches them’. The author demonstrated that these symptoms have correlates in dysfunction of specific brain areas; for example the amygdala which normally acts as a threat smoke detector, the medial prefrontal cortex which usually functions as an impulse control watchtower, and the thalamus whose normal function is as a sensory filter (pages 20, 42-46, 62-63, and 70).
Perhaps the most disheartening revelation of the book is the unimaginable scale of the problem of trauma, and the significant threat it poses to society. In this regard the book specifically highlighted the case of child abuse, what the author depicted as a ‘hidden pandemic‘ and ‘arguably the greatest threat to our national well-being’ (pages 148-149 and 348). To illustrate the enormity of this challenging problem, the author cited harrowing statistics of the extent of child abandonment, neglect, assault, molestation, rape, incest, and witnessing family violence (pages 1 and 24). Using mind-numbing data to dispel the misperception that all families are ‘safe havens in a heartless world‘, the author wondered how any parent could inflict such torture and terror on their own child’; at the same time he warned society to acknowledge that these are trauma’s true origins (pages 11, 125-132, and 348). Further demonstrating the long-lasting impact of child abuse on personal wellbeing and public health, the author described it as ‘the single most preventable cause of mental illness, and a significant contributor to psychiatric and physical disorders such as bipolar disorder, morbid obesity, alcoholism, sexually transmitted diseases, chronic lung and heart diseases, diabetes, stroke, and cancer (pages 144-147 and 351).
Nothing illustrated the ravaging aftermath of trauma as the heartrending stories the author narrated throughout the book. One such case is of Martina; abandoned by her parents, she was ‘raised by a series of relatives’ who abused and sexually assaulted her. She got pregnant by ‘a drunken boyfriend who left her’; the child she delivered went on to manifest many signs of trauma such as ‘intractable crying, head banging, and rocking‘. The author said the child was ‘scared to death and fighting for his life’, but ‘he did not trust that his mother could help him’ (page 150). Another striking story was of Tom, a Vietnam War veteran who had ‘watched in horror as all the members of his platoon were killed or wounded in a matter of seconds’. He ‘went into a frenzy to a neighbouring village’ the next day, killing and raping the inhabitants, but the consequence was that he developed recurring nightmares and flashbacks of ‘dead Vietnamese children’. Furthermore, he became emotionally numb, behaving ‘like a monster‘ towards his whole family, and incapable of feeling ‘any real affection for his wife’ (pages 8-13). Another agonising story was of Stan and Ute Lawrence, a couple who, whilst trapped in their car in an eighty-seven car pile up, were forced to witness as a girl burned in flames as she screamed for help (page 65).
Drawing from his extensive clinical and research experience, the author made many practical and helpful recommendations on how people can ‘gain control over the residues of past trauma and return to being masters of their own ship’ (page 4). He fashioned his management approach on the premise that ‘for real change to take place, the body needs to learn that the danger has passed and to live in the reality of the present’ (page 21). Strongly de-emphasising the role of drug treatments which he said ‘may deflect attention from dealing with the underlying issues‘, he argued for better understanding of the causes and impact of trauma, and for the natural management strategies which empower victims of post traumatic stress to ‘gain mastery’ over their ‘internal sensations and emotions‘ (pages 24, 36-38 and 68). For this reason, he endoresed emotion-regulation techniques such as yoga, neurofeedback, sensory integration, and eye movement desensitisation and reprocessing (EMDR). He also recommended mindfulness, ‘a cornerstone of recovery from trauma’, psychomotor, equine, and theatre therapies (pages 204-227, 96, 296-300, 150-151, and 330-346).
This book expertly portrays the horrendous burden that trauma imposes on its victims, and on everyone associated with them. It demonstrates the life-long medical and emotional consequences of trauma, highlighting the diverse experiences that lie in its historical roots. The book strongly advocates for a better understanding of post traumatic stress, and it outlines a management strategy that requires health care and society as a whole to acknowledge the horrific experiences that trigger it. The stories the book relates are very graphic and distressing, but this is perhaps inevitable if the full impact of trauma is to be appreciated. The author’s passion for the subject, and empathy for his patients, shone through in every page, and should serve as an example for all those who engage with trauma victims.
Trauma has a long reach in health care, and this book reveals the causes, manifestations, and best management approaches to mitigate its impact. The author has laid bare what trauma victims have gone through, and continue to bear. It is to his credit that he discusses this distressing subject dispassionately, a necessary approach to understanding and teaching the key lessons of trauma. The book is a powerful lesson for healthcare to treat their traumatised patients with compassion and not, as is often the case, with disdain. It emphasises the fundamental importance of this subject to medicine and I recommend it to all doctors.
Publisher, Place, Year: Penguin Books, London, 2014
Number of chapters: 20
Number of pages: 443
Star rating: 5