The Body Keeps the Score is an absolutely magisterial examination of the role of trauma in mental health, and the necessity of healing both body and mind. Van der Kolk has had a fascinating career, getting started in psychiatry treating Vietnam veterans with PTSD in the late 1970s, and then moving through the great pharmacological and neuro-imaging transformations of the following decades into advocacy of unconventional treatments for complex PTSD.

In van der Kolk's theory, being faced with annihilation creates longstanding neurological changes that trap a person in the moment of trauma, a permanently elevated stress response that has innumerable health and social consequences. The signs of trauma are many, and range from patterns of fMRI that indicate issues with speech and memory, to signature low levels of heart rate variability, to sunken body language. 

There are many kinds of traumatic events: combat, violent accidents, but van der Kolk focuses mostly on domestic violence and sexual assault. Children are utterly dependent on their caregivers, and a shockingly high percentage, perhaps 10%-25%, are simply unfit for the role, disinterested to outright abusive. Without having a healthy relationship to pattern onto, childhood victims of trauma are set up for a life of bad consequences. Adverse childhood events are strongly associated with everything from addiction, to depression, to criminal activity as both victim and perpetrator. 

There are ways through trauma. While van der Kolk does not discount traditional talk therapy, including its more stressful exposure therapy variations, or psychotropic medication, he argues that trauma is basically a pattern of activity encoded in the body, and that the somatic signs of trauma have to be met head on. Victims of trauma have to be taught to breath and feel their own bodies before they can face their memories and rebuild trust. 

Reading some other reviews, I can see that van der Kolk has garnered a fair deal of criticism, especially for arguing in favor of repressed memories in court, and for pushing some treatments without a great deal of peer-reviewed evidence, including EMDR, emotional family systems, and theater-based therapies. Repressed memories are a complex subject. The converse, that victims of trauma accurately recall details of happened to them, is definitely not true. Emotional memories focus on some sensations, and leave context and sequence in disarray. Yet, how can we do justice when it is the word of a victim decades later against an alleged abuser? Even if van der Kolk has served as an expert witness, that judgement is outside of the scope of this book. 

But I am firmly in agreement, as someone with a PhD in the social aspects of mental health, that psychopharmacology and the DSM are simply not living up to the requirement of reducing suffering. I'm not sure trauma is the be all, but there are a lot of damaged people walking around.  And van der Kolk is persuasive in his argument, that historically from Freud forward, trauma-infused psychiatry was always slapped down when it asked the awkward question of "So who exactly is hurting these kids?"