A "we" author
It is likely, to one degree or another, that in our lifetimes we will all suffer an experience of severe stress - a traumatic experience which leaves a lifelong trace. Whether as a soldier who has been to war, a child who has been abused, or some other, less harrowing event, which nevertheless leaves a permanent mark upon us.
Extreme cases of trauma bequeath the legacy of what the psychologists call Post Traumatic Stresss Disorder (PTSD) where the body is locked in a reactionary cycle to future threats, real, or more often, imaginary. The slightest and most innocent event can set off a train of irrational fears and responses that were never experienced before the traumatic event.
Van Der Kolk, speaking in the American setting sees trauma as the most urgent "threat to our national well-being" (p.418)
Although the author is a practicing psychiatrist who sees patients / clients, he freely admits that experiences he and family members have passed through have shaped his approach.
There's a warm human being behind this book - a "we're in this together" rather than the more common distant "I'm the expert here to help you my patient" approach.
His own father locked him in the cellar of the family house for petty three-year old offences and as a result he felt "chronically preocupied with being exiled and abandoned." (page 278). The author's son suffered a mysterious illness given the name, for want of another, chronic fatigue syndrome (page 397).
Bessel has learnt to listen patiently to the tragic stories he hears "without trying to jump in immediately to fix the problem" (p. 148) because he himself has suffered.
Why I read this book
Earlier this year, my wife and I attended a very helpful Bible and Mental Health Conference, run by the excellent Biblical Counselling UK. The pandemic had spawned a noticable increase in pastoral problems around mental illness and this conference - one of the best I have attended - proved invaluable.
This book was mentioned. Experts in the field, we were informed, are becoming more and more critical of the "give 'em a pill" approach and moving more towards an understanding that people need Place (a safe place to call home), Purpose (a reason to get up in the morning) and People (that's it, just people) around them. The author Bessel Van Der Kolk (whom I shall just call Bessel) is one of the psychiatrists moving away from chemicals and moving towards humanity. So I bought the book and read every one of the 431 pages.
And certainly the book displays that move in psychiatry. And of course, any pioneer that questions the paradigms of a movement will get into trouble, so we are in no way surprised that Bessel has attracted criticism as well as praise:
"My own profession often compounds, rather than alleviates, the problem. Many psychiatrists today work in assembly-line offices where they see patients they hardly know for fifteen minutes and then dole out pills to relieve pain, anxiety, or depression. Their message seems to be 'Leave it to us to fix you; just be compliant and take these drugs and come back in three months...'" (420)
Ouch!
The purpose of this review is to ask what the world is saying about trauma and then try to put the conversation into a Christain perspective, especially a church pastor's perspective: how do we help people who have passed through stressful events in their lives, which continue to haunt and/or immobilise them?
A Review
Part A - the Problem
This is a long review, but if it spares someone the many hours I have spent pouring over 400+ pages, I will consider it worthwhile!
Perhaps the most alarming facts around trauma is just how many people in the USA - a deeply troubled nation - have suffered them. Family strife: since 2001 more Americans have died at the hands of their partners or family members than in the wars of Iraq and Afganistan. Women are twice as likely to suffer domestic violence than breast cancer. Firearms kill twice as many children as cancer does (page 418). Approximately one in four children experience child abuse or neglect in their lifetime.
No wonder the US is filled with traumatised people.
Bessel begins with Vitenam war veterans, folk who have experienced violent trauma in their lives. They discover that the least noise or unwitting comment can send them into mysterious anger or fear or retreat. They easily became hopelesly stuck in the past. Their world becomes divided into those people who have been through their experience and those who frankly don't have a clue, further increasing the alienation between them and family and friends.
But, as Bessel points out, for every soldier who serves in a war zone abroad there are ten children endangered in their own "safe" homes (p.22). More than half of the people who seek psychiatric care have been assaulted, abandoned, neglected, or even raped as children, or have witnessed violence in their familes (p.27).
So what is "the gravest and mosty costly health issue in the United States?" "Child abuse." (178)
The vast majority of traumatised kids come "from extremely dysfunctional families" (187).
Trauma, all too often, it seems, starts in the home.
Whatever the source of trauma it results in a change in the way the mind and brain manage perceptions. Traumatised people keep secreting large amounts of stress hormones long after the actual fight-or-flight danger has disappeared. In normal people these hormones decrease after the threat has passed, in PTSD folks, they don't return to baseline levels.
A biological system that keeps pumping out stress hormones leads to physical problems: "sleep disturbances, headaches, unexplained pain, oversensitivity to touch or sound." (p.190) "When people remember an ordinary event they do not also relive the physical sensations, emotions, images, smells, or sounds associated with that event. In contrast, when people fully recall their traumas they 'have' the experience: they are engulfed by the sensory or emotional elements of the past." (p.263)
Early psychiatry, diagnosed mental illness as a chemical imbalance - and therefore, QED, embraced chemicals as the solution; the pharmacological revolution was in full swing. And the initial "success" seemed to warrant the approach - the number of people living in mental hospitals went down dramatically. Pharmacology revolutionised psychiatry.
But there are big problems with the brain-disease model, and the drug revolution that promised so much may have done "as much harm as good." (p.42). For one it removes control from the patient's own hands and puts it into the hands of doctors and insurance companies.
Taking just the example of antidepressants, Bessel points out that if they were as effective as the hype suggests depression should be a minor issue in society today. The truth is that antidepressants have "not made a dent in hospital ommissions". (p.43) The number of people teated for depression has tripled in 20 years to the point where 1 in 10 Americans now take them.
The basic contention of Bessel is that we need to move away from chemicals to human friendship and normal human activity for the recovery of traumatised people. PPP (Place, People and Purpose).
A traumatised person's brain reveals the distress, says Bessel. The left-hand part of their brains (logic, reasoning) does not work very well, while the right-hand part (emotion, visual) brings back the taumatic event. So the age-old cure for traumatised people - that they need to talk their way through the trauma - can sometimes meet a barrier because the speaking part shuts down and is unable to talk the emotional side out of trauma.
Indeed the whole person, body, mind and brain is affected and therefore all must come into the treatment equation. Bessel goes into complex discussion here; in brief the experience of trauma splits emotions, sounds, images, thoughts and physical sensations into their own dissasociated worlds.
The brains threat perception system has now changed and physical reactions in the now are dictated by that past event. The smoke detector goes off at the tiniest whiff of smoke, real or imagined. The opposite may also happen, the explosive flashbacks may numb out in later life and this sense of "not bothered / not feeling/ not alive in the present" can be just as destructive.
The brain affects the body, yes, but the body also affects the brain. This latter notion - that the body feeds back to the brain where our minds are housed - once disregarded in the West is now having a come back.
We can't disregard the body "The body keeps the score: If the memory of trauma is encoded in the viscera, in heartbreaking and gut-wrendhcing emotions, in auto-immune disorders and skeletal/muscular problems, and if mind/brain/visceral communication is the royal road to emotion regulation, this demands a radical shift in therapeutic assumptions." (p.101) Of war victims, "their bodies keep the score: Their stomachs are upset, their hearts race, and they are overwhelmed by panic." (p. 225)
Psychiatry has neglected the body, "the foundation of our selves." (104) Three of Bessel's patients who had a history of incest - three in one year - were diagnosed with an auto-immune disease, in which the body starts to attack itself. The connections are impossible to deny.
The need for attachment, the bond created between baby and mother, never leaves us. Our sense of security is very much connected to those around us and to our wellbeing. If we are not secure it's hard to distinguish between safety and danger. Incest victims who have endured profound insecurity find it hard to distinguish between danger and safety. Children, who have no authority except their families, have to organise themselves to survive in that environment. The greatest predictor of how people will cope with life's disappointments is "the level of security established with their primary caregiver during the first two years of life." (p.194)
So given the magnitude and complexity of the problem, what can be done?
A typical patient may receive 5 or 6 different related diagnoses, because psychiatry, a branch of medicine aspires to define mental illness as precisely as it does physical diseases. The handbook DSM (The Diagnostic and Statistical Manual of Mental Disorders) earning the American Psychiatric Association (APA) $100 million dollars, lists all of these "conditions", now numbering above 300 spread over 945 pages. If the label is wrong, a faulty cure is prescribed, and besides, the poor patient is forced to carry a lifelong sentence created by these labels.
And besides, none of these diagnoses get to the real person who lies behind the label. "Before they reach their twenties, many patients have been given four, five, six, or more of these impressive but meaningless labels." (189)
Bessel argues that there is a "chasm between official diagnoses and what our patients actually suffer from" (p.165) It's clear that this pioneer has locked horns with The APA - and for good reason, it seems to me, for all human institutions are subject to corruption.
The diagnoses of the DSM "describe surface phenomena that completely ignore the underlying causes." (p. 198) Relationships and social conditions are completely left out - that is the problem with psychiatry - it treats mental illness as if they were like cancer, ignoring the fact that humans are social creatures. "Everything about us - our brains, our minds, and our bodies - is geared towards collaboration in social systems." (p.199)
People need people.
In summary then, Bessel points reveals a traumatised United States, with a lot of that trauma originating in dysfunctional familes during childhood. He severely criticises the "give 'em a pill" solutions pointing out that people need more than pills.
Part B. The Secular Solutions
The last third of the book becomes a long list of different therapies all designed to relieve the symptoms of trauma.
"What has happened cannot be undone. But what can be dealt with are the imprints of trauma on body, mind and soul..." (p.243)
Traumatised people need to find ways to become calm and focused; learn to mainatain that calm in response to sensations that remind them of the past; find ways of being fully alove in the present engaged with the people around us and then avoiding secrets.
Trauma must be revisited he insists, but only when we are calm enough to do so; thus some of the techniques are designed to calm the person down.
Not being an expert, I can do little more than bullet-point the large raft of therapies Bessel desrcibes. What I think is significant is that most of them revolve around the components of an ordinary life. So when the therapy is professional I will place a "P" after it, and when it's something just done in Ordinary life, I will place an "O":
- Limbic System Therapy, to restore the balance between the rational and emotional brains, learning to breath calmly (P)
- having a good support network, "the single most powerful protection against becoming traumatised." (page 251), "Traumatised people recover in the context of relationships: with families , loved ones..." (p.252) (O)
- [Bessel encourages choosing therapists who actually listen (p.254)]
- Communities where there is music and rythm (O)
- Massage "the most natural way that we humans calm down our distress is by being touched, hugged and rocked." (257). Why employ a "bodywork practitioner" when we have brothers and sisters in Christ who can comfort us with a loving arm around our shoulders? (O)
- you must talk about what happened, "as long as you keep secrets and suppress information you are fundamentally at war with yourself." (page 278). Soldiers remained silent often because no-one wanted to hear their terrible stories (290) (O)
- write to yourself - the psalmist did it (O)
- art, music and dance has been found to be helpful (in other words, returning to the stuff of ordinary life?) (O)
- Some strange therapy called EMDR (Eye Movement Desensitization and Reprocessing) which seems to work - because we are so complex beings, we may stumble upon odd proceedures which just work! Follow the therapist's finger 12 inches from right eye while speaking what happened! (P)
- Yoga - listening to your body, getting your breathing and heartrate correct, synchronised (O)
- Internal family Systems Therapy (IFS) where each part of us is regarded separately and together as a family (P)
- representing people and events as physical objects! (p.358) Bessel's dad was a "gigantic black leather couch" because he was "stern Calvanistic." (O?P?)
- neurofeedback (P)
- his son was greatly helped by theatre. War veterans "speaking about their memories of the war and reading their poetry was clearly a more transformative experience than any therapy could have offered them." (page 399) (O)
Out of the 13 "therapies" listed above, 8 or 9 naturally occur as we live out a normal human life.
Bessel ends his book "close to despair" because, though people are now aware of trauma, and know how to treat it, treatment is just not happening in the USA. He says that society can make the choices that can make it happen.
Personal Reflections
There is so much in this book that is helpful and positive, and I wish I'd read the book - and about trauma - many years ago. I make the following reflections, not from a professional point of view but from that of a Christian pastor:
We must never be slaves to the fads of the day; in any field of human investigation. One moment Psychiatry is all drugs and pills, then there's a reaction to more human helps.
We are all fearfully and wonderfully made. For that reason, we should not be surprised that quite unusual treatments such as EMDR may have some effect. We should not ridicule the stranger treatments because they may tap into some facet of the way God made us.
The Psalmist confirms that writing our way out of trouble by writing out our troubles, is one of God's appointed healing balms.
There is no talk of sin or confession of sin, which is a central omission, because there is no God-centredness in the book. Acknowledging our wrongdoing and confessing it is a major route to healing, as Psalm 32 reveals.
Nowhere does Bessel discuss the fundamental problem in US society which is the break up of the family, leading to traumatised children in their millions. Psychiatry cannot deal with the power of sin, including lust and adultery.
Nowhere does Bessel talk about our relationship with God, the deepest source of all our problems, the alienation which immediately and directly leads to the breakdown of all other relationships too.
There were times when I wondered how concerned we should be about having perfect mental health in this life, when that will be our experience in the world to come. Christians have hope that allows us to put up with a measure of suffering in this world.
If you were to sum up Bessel's humanistic findings, they are that people need PPP, a secure Place, People around them and Purpose in life. All of these blessings - and far more - should come from the Gospel.
Time and again, I found myself saying "the Gospel is the answer here. It provides meaning to life, it provides a safe place, the community of God's people, and it provides a relationship with God, who by his Spirit comforts us in all our troubles."
People need family and friends around them - not professionals.
I kept thinking to myself that the Gospel, and the Gospel alone, has the answer to all the ills of the mind and soul. We should not discard psychiatry but our hope is not in men but in God.
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