The Body Keeps the Score: how a bestselling book helps us understand trauma – but inflates the definition of it

·11-min read
Artem Maltsev/unsplash
Artem Maltsev/unsplash

In a new series, we look at books that have become cultural touchstones.

If new books are lucky they enjoy a brief honeymoon of attention before ebbing away into oblivion. Not so The Body Keeps the Score, a publishing phenomenon that has kept selling long after it first hit the shelves in 2014. The book has spent more than 150 weeks on the New York Times best seller list for paperback nonfiction, including over half a year in the coveted #1 spot during 2021. It has reportedly sold almost 2 million copies.

Why a long, dense, and demanding book on the psychology and neurobiology of trauma should occupy so bright a spotlight for so long is not immediately obvious. Post-traumatic stress disorder is old news, a staple of psychological chatter for over four decades, and the book doesn’t offer any quick fix solutions for self-helpers.

Clues to what has driven The Body Keeps the Score’s success can be found in its sales trajectory. On bookriot.com, writer Gina Nicoll notes that sales began to liven up around 2018 and then grew in spurts, reaching a peak in 2021. The pandemic may have contributed to this surge by bringing collective trauma to our doorsteps, she speculates, but the pre-pandemic upswing suggests other factors are also at play.

Reckonings with sexual and racial trauma in the wake of #MeToo and Black Lives Matter have combined to raise the cultural profile of trauma, Nicoll suggests.

But alongside this increase in cultural attention, there has been a broadening of what we take trauma to be.

People are seeing trauma everywhere and re-conceptualising their own experiences of misery and misadventure in its terms. They are doing so, at least in part, because the concept’s meaning has been stretched. More on that later.

Read more: Six psychiatric concepts that have mutated: for better or worse

The book explained

So what is all the fuss about? Bessel van der Kolk, a Dutch-born psychiatrist who has been a successful researcher and clinician in the Boston area since the late 1970s, wrote The Body Keeps the Score as a guide to the understanding and treatment of trauma.

The book adopts several standard features of the popular psychology genre: case studies from the author’s clinical practice, autobiographical reflections, and sharp critiques of mainstream views to assure readers the author is not merely doing good but slaying dragons in the process.

However, its presentation of the science of trauma is unusually compelling, setting it above most works of popularisation. Van der Kolk has substantial legitimacy as a researcher, and his interleaving of the personal and the scientific makes for an engaging read.

Van der Kolk begins his blockbuster with a discussion of the neuroscience of trauma, complete with explorations of brain anatomy and function and how they underpin reactions to extreme threat.

He presents traumatic reactions not simply as disturbances of fear and anxiety – how the amygdala becomes an over-sensitive “smoke detector” that triggers traumatised people into fight or flight reactions – but also as disruptors of interpersonal relationships and a stable sense of self.

Trauma’s somatic signature extends beyond the brain. Van der Kolk explains at length how hormonal influences and the vagus nerve, which runs from brain to abdomen and regulates several internal organ functions, reverberate its effects throughout the body.

In trauma, he argues, people may lose a sense of body ownership to accompany their loss of self, felt connection to others, and even their sense of being fully alive. Recovering a sense of personal agency and of bodily ownership – what he refers to as befriending the body – is a key to recovery.

Childhood trauma

Trauma in childhood becomes the second major focus of the book. Whereas early investigations of post-traumatic reactions focused on adult combatants in war, van de Kolk directs much of his attention to impacts of trauma and hardship earlier in life. Once again, his focus is expansive, extending beyond traumatised individuals in isolation to the disruptions trauma creates in their intimate attachments.

Abusive family environments produce children who lack a secure sense of connection to others and suffer elevated risks of illness and re-traumatisation. They are more likely than their peers to experience and perpetrate violence as adults, to engage in self-damaging behaviour, and to experience cancer, heart disease, obesity and a range of psychiatric conditions.

Van der Kolk presents childhood trauma as a “hidden epidemic”, swept under the carpet by society at large and by psychiatry in particular. He advocates for policy responses that combat the economic and societal drivers of childhood adversity, and for better recognition by organised psychiatry of the mental health impacts of trauma.

In this second quest he has had limited success. His proposal of new diagnoses that recognise the outcomes of repeated childhood trauma – “complex PTSD” and “developmental trauma disorder” – were rebuffed by the developers of American psychiatry’s classification of mental disorders, the DSM.

The DSM’s third edition, published in 1980, recognised PTSD for the first time. But the fourth and fifth editions, DSM-IV (1994) and DSM-5 (2013), would have none of these new proposals.

Van der Kolk’s outrage at this rejection, and his jaundiced, if sometimes straw-mannish view of the psychiatry profession, seasons his book with anti-establishment saltiness. The alternative view – that the DSM’s guardians were wary of adding new disorders that overlapped substantially with existing conditions, privileging trauma as the single, dominant cause of a diffuse and multi-determined set of symptoms – does not get a hearing.

The Body Keeps the Score closes with an extended exploration of alternative forms of treatment. Despite his neuro-biological leanings, van der Kolk does not see medication as the best line of intervention. He contends that effective therapies must target meaning rather than chemistry and allow traumatic memories to be processed rather than blunted.

Among his diverse collection of preferred treatments are neurofeedback, in which people learn to alter brain waves via real-time encephalographic feedback, somatic psychotherapies, yoga, theatre, and eye movement desensitisation and reprocessing (EMDR, in which people recall traumatic experiences while performing rhythmic, therapist-guided eye movements).

His enthusiasm for these interventions, some of which veer towards the fringe and the faddish, sometimes outstrips the evidence for their efficacy, but has contributed to their growing popularity.

Understanding the book’s appeal

The Body Keeps the Score has been remarkably popular for reasons beyond its alignment with our current cultural preoccupations. For one, it is a hopeful book. Although it underscores the sweeping extent of traumatic experiences and the severity and range of their impacts, it also argues that therapy works and post-traumatic distress need not be a life sentence.

The same optimism shines through in the book’s dialectical account of the history of the mental health disciplines. A period of “brain-less” psychoanalytic interest in the meaning of psychological distress – carried out with no eye for biological processes – gave way to an era of “mind-less” psychopharmacology. We have now arrived at a stage in which neurobiology and a deep appreciation of human psychology can go hand in hand.

The book also contributes to an ongoing de-masculinising of trauma studies. Psychiatric thinking about trauma was long dominated by investigations of combat reactions in soldiers, described variously as shell shock or battle fatigue. The flood of psychological casualties among Vietnam veterans spurred the official recognition of PTSD in 1980.

Van der Kolk pays much more attention to sexual abuse and violence as sources of trauma. These disproportionately affect women and girls and account at least partially for women’s higher rates of PTSD diagnoses.

Read more: What is complex PTSD and how does it relate to past abuse and trauma?

The same feminising of trauma can be seen more symbolically in van der Kolk’s emphasis on the bodily and relational dimensions of trauma. Historically, the gender binary has been overlaid on the mind/body distinction, and on the distinction between stereotypically masculine independence and stereotypically feminine relatedness.

By paying heed to somatic impacts and treatments of trauma, and the ways in which it disrupts attachments and relationships, van der Kolk is making the psychology of trauma more inclusive of the experiences of female trauma survivors.

Inflating trauma

The Body Keeps the Score offers a vision of trauma that is inclusive in some respects. But is it over-inclusive in others? Van der Kolk’s understanding of trauma is expansionary, offering a broad view of its impacts and implications.

He recognises a wide range of manifestations of trauma, promotes new trauma-related diagnoses, affirms a broad definition of what counts as a traumatic event, and recommends diverse modes of treatment.

For example, conventional descriptions of PTSD point to a restricted set of symptoms, such as flashbacks, nightmares, and hyper-vigilance. Van der Kolk connects trauma to a much wider web of phenomena. It is examined as a primary source of relationship problems, emotional disturbances, and forms of acting out such as rebellious, defiant, impulsive, and inattentive behaviour.

Most significantly of all, Van der Kolk sees trauma lurking beneath an array of somatic complaints. Trauma is embodied and manifested in such concerns as irritable bowel, auto-immune conditions, fibromyalgia, headaches, and a range of diffuse physical symptoms.

Similarly, Van der Kolk’s work expands the range of events that are considered traumas. When PTSD was first defined in DSM-III, the condition could only be diagnosed if the event that precipitated it was life-threatening and outside the range of normal human experience.

Later editions of the diagnostic manual loosened the definition to include unpleasant events witnessed indirectly, which are not physically endangering.

Van der Kolk uses the term “trauma” more freely still, often employing it to refer to almost any form of life adversity, including enduring circumstances rather than only discrete incidents. Trauma can easily be stretched to encompass minor illnesses, normal romantic breakups and disappointing exam results.

On this broadened definition, all but the most cosseted among us have been traumatised and can view our struggles and sufferings through the potentially magnifying lens of trauma.

This expansion of the meaning of trauma has taken place in parallel with a steep rise in the cultural prominence of the concept. Research shows that the word “trauma” appears in everyday discourse much more frequently now than it did even two decades ago.

That rise has been even more dizzying within the mental health professions, a recent study finding that “trauma” appeared at an almost 20 times higher rate in psychology journal articles in the 2010s as it did in the 1970s.

Read more: More than half of Australians will experience trauma, most before they turn 17. We need to talk about it

Backlash

It should not be surprising to learn that this sharply spiking interest in trauma has generated some push-back. In 2021, Eleanor Cummins observed in The Atlantic that the concept of trauma has become “uselessly vague – a swirl of psychiatric diagnoses, folk wisdom, and popular misconceptions”. In the same year, writer Will Self criticised “how everything became trauma” and Parul Sehgal decried how trauma-driven plots flatten fictional narratives and hollow out characters in The New Yorker.

In 2022, in the New York Times, Jessica Bennett asked “if everything is trauma, is anything?” and denounced “post-traumatic hyperbole”. Lexi Pandell, writing for Vox, argued this “word of the decade” has become close to meaningless.

Like Bennett and Pandell, several writers have queried whether trauma is now being used too promiscuously. Some have distinguished big “T” trauma from less severe little “t” trauma to resist this concept creep.

Others worry that the growing popularity of trauma narratives represents an encroachment of medical language into the realm of ordinary adversity, reducing unjust social arrangements to individual pathologies, or promoting personal fragility. Still others have voiced concerns that the concept of trauma has become politicised.

The argument that broad concepts of trauma produce fragility rests on the belief that defining moderate life challenges as mind-shattering traumas might undermine our resilience.

Understanding an adversity as a trauma implies that it overwhelms our capacity to cope and is likely to have lasting effects. In the popular mind, trauma still carries a connotation of indelibility.

Of course, many adversities do take people beyond their breaking points and have enduring consequences. The question is whether perceiving less severe experiences as traumas makes them loom larger and longer than they need to. Emerging research evidence suggests that it might.

Van der Kolk can’t be held entirely responsible for the runaway success of his book or for the runaway semantic inflation and popularity of its central concept. The Body Keeps the Score has been successful because it resonates with its cultural moment, and it has helped to mould that moment for millions of readers.

The recent elevation of trauma attests to a time in which people are keenly attuned to their individual and collective suffering, increasingly attribute it to causes beyond their control, and look to a therapeutic mindset to resolve it. Van der Kolk’s book is a lucid guide to this new reality.

This article is republished from The Conversation is the world's leading publisher of research-based news and analysis. A unique collaboration between academics and journalists. It was written by: Nick Haslam, The University of Melbourne.

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Nick Haslam receives funding from the Australian Research Council.