Return to Base: The Unspeakable PTSD of Veterans with Dr. Bessel van der Kolk

Victor Lima, we are RTB. This is Return to Base, a Veteran Life podcast. Hello, we're with Dr. Bessel van der Kolk, MD. He spent his career studying how children and adults adapt to traumatic experiences. He has translated his findings from neuroscience and attachment research to develop and study a range of treatments for traumatic stress in children and adults. He's the author of bestselling The Body Keeps the Score, which is helping transform our understanding of trauma and explores innovative ways to confront trauma. Dr. van der Kolk's patients come from all walks of life and experiences, but for the purpose of this conversation, we're going to focus on veterans and issues involving post-traumatic stress disorder. Dr. van der Kolk, welcome to the program. Thank you. Good to be here. Great. Well, for those listeners who haven't read your book or aren't familiar with your I hope I get this right. The Body Keeps the Score explains that the brain as a self-defense mechanism tries to hide our traumatic experiences from us and our bodies, yet our bodies don't forget. And this battle between our mind and the body can have grave consequences to our health. Would you mind elaborating on that? And I hope I got that right. That's not quite how I would have said it. We are complex creatures, all of us human beings. And so it's really good to hang out with little babies. And little babies cannot talk yet. They don't understand anything about the world, but they do all kinds of things. They eat and they sleep and they fart and they suck and breathe. So little babies already do a lot of things and they get scared and they get angry and they have a lot of emotions. And that's because they have a small part of their brain that's involved in self-preservation is already in line. That's also the part of the brain where trauma hits. So trauma hits in what in neuroscience we call the housekeeping of the body. When you get traumatized, your body doesn't work for you anymore. You have feelings, emotions, sensations that are disturbing and your mind is trying to, just like you see little kids when they start talking and start going to school, they create a new reality that is sort of a social reality. So we live in ideologies and systems and concepts of the world that very much depends on where we live and who we hang out with. But the core part that takes care of ourselves and our bodies is sort of almost like a separate part. So something terrible happens to you and you get raped or you see your best friend get killed and you are heartbroken and you feel terrible and then you say to yourself, okay, man up, let's be strong, let's not do it. Everybody says, okay, it's over. And you say, okay, it's over. And then you start behaving as if you're over it and you keep sort of pretending like it didn't matter. And before too long, you're able to talk yourself into that it didn't matter. But the primitive part of your brain doesn't have the capacity to rationalize it and continues to experience all kinds of stuff as if your life is a danger, as if people try to hurt you. And you get this internal war to your rational brain and your emotional brain. And the result of that war is that you feel out of touch with yourself and out of tune with yourself. Things keep happening to you. You keep doing things that other people are, makes other people angry or makes other people scared of you. And then when you end up, you see you become deeply ashamed about who you are. Deep feeling of shame of there's something wrong with me. And I need to be careful that nobody finds out there's something wrong with me. And so you start arranging your life around trying to pretend like everything is just fine, but it isn't. And then oftentimes, very many people at that point start drinking in order to sort of tranquilize themselves against these sensations, or they start taking drugs. What's astounding to me, for example, is the whole opioid epidemic. Everybody says it's about opioids. No, it's about people who take opioids. Most people I know, if I say, hey, have a little heroin, would say, like, hell, I'm not going to take heroin. But if you feel terrible, and you feel like the world is out to get you, heroin may give you a nice little piece of relief. So you start taking heroin. So it is people start doing these drugs in order to deal with feelings and sensations that they can't stand. Interesting. Interesting. So with all that understood, should we suspect that the goal of treatment in the end should be to forget the trauma, to remember it, to remember in a different way? To know that it happens, and to know what happens, but to know when it happens. So the goal of treatment is to go, yes, when I was 18 years old, I was in that war zone. And I saw my best friend blow up. And then I became so angry that I mowed some kids down. Okay, it was terrible, terrible thing, both your friend getting killed, and what you may have done in response to it was horrendous. You don't want to remember that. You don't want to remember how heartbroken you were, how enraged you are. And so you go to push it away. And in fact, you need to go back and say, yes, this is what happened. It happened to me when I was a stupid 18-year-old kid who didn't have the resources to deal with it any other way. So it's really feeling what you as a creature have gone through and say, yeah, this is what I went through, but it happened back then. You really know the difference between what you're feeling today and what you're feeling back then. Interesting. You know, a lot of times I think to myself, when we discuss the past and how people dwell on it, I remind them, and I'm not a super religious person, but I remind them of the serenity prayer, which says, you know, we must accept the things we cannot change. And that kind of reminds me of something like that, where it's important to acknowledge that these things did happen, rather than pretending that they didn't. And knowing that we can't change the past. See, and there's another complex story here, and that's the trauma changed your brain. Let me give you an example. I've seen, I know quite a number of people, one of whom is actually a good friend of mine, who are foreign correspondents. And they go to Afghanistan and Eritrea and the Congo and Libya and Syria, and you see all these horrendous things. And they're tense and they're uptight, but when they come to Cambridge, Massachusetts, they go into a panic reaction, because their brain has changed to be alive under extreme danger, but they feel terrified when they feel safe. And so I think a lot of people who have been exposed to a lot of trauma, feel better when there is a high level of anxiety, high level of danger around them. And oftentimes they create this feeling of danger, because their brain is good in dealing with danger. Their brain is terrible in dealing with putting diapers on a one-year-old. Right, yeah, well that can be frightening for anybody. I don't know, you know, I've had two boys, so it's kind of like a war zone anyways. And when you're a combat vet, you may see it as a war zone. In fact, they're just little babies who need to have their diapers changed, but it may evoke all these feelings like, oh my god, this kid's not listening to me. These intense reactions to minor issues. Interesting, yeah. So sir, one of your first jobs out of school was as a staff psychiatrist at the BA clinic in Boston, correct? After I finished the 29th grade, yeah. Well, you know, I saw that you had started your learning there, really, on how veterans reacted. My first job was to run a state mental hospital, the last state mental hospital, before we sent the patients home. And that was also very interesting. But my next job was at the VA, yeah. Okay, yeah, so your experience with the Vietnam War and the veterans who came back from Vietnam, to help get the audience oriented, can you tell us a little bit more about your time there and how it's affected your career since you left? Well, yeah, the veterans immediately just caught my attention and my interest and my fascination and my sympathy, in part, I think, because I was born at the very end of the Second World War, and as a small kid, relatives came back from concentration camps, and they came back from war zones. And so my early imprint was of seeing a lot of people come back from the war, and being intrigued with both their stories, but also how they would blow up from time to time or become very irascible or withdraw. And even as a kid, I was very fascinated by that. And then I started to work at VA, and here were these young guys still, powerful guys, smart people, and something has happened to them. They were frozen in their bodies, they kept exploding. The waiting room in the VA was filled with, the walls were filled with holes in the wall, that people had put their fists through the wall, and the minor things that would blow up and become very angry. And I thought, something happened to these guys. And these guys were able to fly a helicopter and rescue a platoon out of a war zone. You have to be very calm and very focused for that. And now when they sit in the waiting room at the VA, and somebody says you have to wait for five minutes, they get enraged. I go like, something happened. And so I got really intrigued with what might have happened to these guys that damaged them. And the next thing was that the VA was filled with people, and we put people on the waiting list. And I said to my boss, is it okay if in the waiting room, even before people become patients, I meet with people and they can meet with each other, because these guys are hurting, and they need to get some sort of support. And so we started these groups, sort of, not as part of the VA, but outside of it almost. And we started off and say, you can talk about anything. And so we say, I don't want to talk about a war. And I said, fine, you can talk about it. Other guy said, I want to talk about a war. And then nobody said anything for half an hour. And then he started to talk about a war. And when he talked about the war, they came to life. And it turned out that the war had for them, by and large, a very powerful experience. They had felt powerful, they had felt skilled, they had felt great about their comrades and their friends. And then something that happens, that sort of blew up, that feeling in their heads of, boy, I'm a much better person than I thought I was. I can fire a machine gun, I can fly a helicopter, I can repair complex engines. And so they got a very good feeling from being in the military. And then something happened that broke them. And they go like, oh my god. And then often that they had done things that they felt very bad about, which later on came to be called as moral injury. But the moral injury piece was a very important part for most people, that they had been involved in stuff that their conscience could not live with, actually. And once they started to talk about it, they opened up. And the next thing that happens, interesting to me also, is that they took me in, but they could not take me in as a guy who had not been in Vietnam. So they gave me a uniform, they made me an honorary Marine. And so they had this need that you belong to the in group, or you belong to the out group. And if you want us to trust you, you have to become a Marine in my mind also. And so what they saw is this very strong bond based on the common experience. People would induct me into it, you know, in order to become acceptable. And what struck me at the time also, is that these guys were extraordinarily loyal to people who had gone through similar experiences as they had gone through, but had a very hard time connecting with people who had not had that experience. And so what struck me, for example, is that I met several of their wives who were very competent, smart people, but they had a hard time making connection with their wives, because their emotions were stuck in the war, and their wives were not part of the war experience. Wow. And that's something I've not heard people talk about after Iraq and Afghanistan, but I bet that's still happening today. Right. Interesting thing you said there is how you grew up in, you know, right at the end of World War II. For our listeners, can you tell us where you grew up? And I'd like to know if you recognize the signs of trauma, looking back when you were a kid, and if it was just on the soldiers, the people who fought in the war, or as you know, civilians are very much a part of combat in World War II. How did you see that they were reacting to this trauma as you were growing up? Well, you know, I was a kid, so you don't see the larger context. And basically, I grew up, you know, very much like, you know, basically, you know, I grew up in a place very similar to what Kabul is like today. You know, people getting killed, people getting carted off, people evacuating, like chaos. And I don't remember that, actually, I was too young to remember, but the imprints are there. And so what I saw after that is slowly a society that's started to get back together. But I saw people do these weird things from time to time. Both people had been affected by the war, but also people in civilian life, of course. So I never in my mind, to this day, had made a very clear distinction between civilian trauma and war trauma. In many ways, it's the same thing. A girl who gets gang raped in high school has a similar fundamental experience as a guy who goes off to war and sees atrocities. Interesting. The war experience is one of, oh my God, this is too much for anybody to bear. Yeah. Okay. So in your experience, you brought up Kabul, you brought up the war on terror veterans. Have you seen, are there similarities or differences that you've seen from the folks who came back from Vietnam to the people who served in the Gulf War, the first Gulf War to post 9-11 veterans and their trauma? I know it's different. I'd be very intrigued to that question. I don't know the answer to that because I've not seen enough people who were in Iraq and Afghanistan to be able to generalize from that. I saw a large number of people who came back from Vietnam who were my age at the time. And what struck me at that time is that I grew up, my parents were Second World War veteran people and the Second World War veterans were different from the Vietnam veterans. And they studied it scientifically and the Second World War veterans put things into their bodies and they by and large mainly became medically ill. They had heart problems, bowel problems, muscle problems, but they did not talk about their psychological problems. Then Vietnam comes along and things are mainly acted out in terms of people's relationship, their families and people, their work. Historically, the culture you live in determines to some degree how you deal with, how you organize your traumatic experiences. So my hunch is that today people will look somewhat differently than they did after Vietnam. But I've personally not had that capacity and not studied enough people to know that for sure. Maybe you have thoughts about that. I do have some thoughts, but obviously not as informed or educated as you. But you know a lot of people. Do you have any thoughts about it? Do you think there is a difference yourself? I think that there has to be something to the way Vietnam War veterans were received back home where they had to suffer in silence. A lot of times they weren't proud of their service. See, having lived through that, I don't completely buy that. There was a lot of, I don't know, common, what people commonly say is that Vietnam veterans were treated with contempt and badly. That was very much not my experience. And I lived in Cambridge, Massachusetts and in Chicago and Hawaii during those times. We were always very respectful to people who had gone to Vietnam. And I don't think that's universally true that people were received that badly. I think that's a sort of a myth that was created afterwards. It's a painting that we're viewing now from a different perspective. And you have all these mythologies that occur around this stuff. And everybody who's traumatized feels cut off from their environment. And so you come back from Vietnam, you may feel terrible about other people smoking dope and having a great time being home. And there may be a feeling of, oh, they despise us. But that was not my personal experience. That's refreshing. Honestly, growing up in the 80s and the 90s, the perception that I always understood was that there was a lot of contempt. Of course, that's just what you kind of see on TVs and movies. Yeah, that's what the story that people start reading about. Well, when you ask how do I feel the global war on terror veterans are coping? Obviously, we're not coping successfully in many ways. I think we have an enormous amount of service members who deployed to those regions. I myself am one of them. I have no personal trauma that I can recall. Certainly, I've been in places where other people would have been traumatized. For some reason, I haven't been. We'll kind of get to that a little bit later. You mentioned actually something that I also thought was interesting is that different cultures maybe deal with things in different ways. Do you think that your methods or your hypothesis for treatment and for diagnosis, does it work in the eastern part of the world, for instance? Does this work as a western model? Can it work for, let's say, our allies in Afghanistan who are dealing with some of this? Our brains are basically the same from culture to culture, but our symbols are very different from culture to culture. I'd be very lucky that I've traveled a lot and with some depth. I had a good immersion in India. I was an advisor to the Truth Commission of South Africa, so I was very, very close to what happened back then in Africa, traveled to South America, China quite a lot, Japan. A lot of what I've learned, I've learned from other cultures. Western culture, as they're very much exemplified by the VA, is based on two things. I call western culture a post-alcoholic culture. It comes from Europe. In Europe, when you feel bad, you take a swig. In the army, if you feel bad, you go to the commissary, you take a swig. I don't know how it is today, but traditionally, the army is a very alcoholic culture. This is how you deal with your emotions, is by drinking. The other thing you do as western people, you talk a lot. You explain a lot. That's the two pillars of western approaches to suffering, very much exemplified by the VA. You get pills, pills that incidentally don't work. I did the studies on these pills. My name is on those papers. It didn't work. Yet, people keep getting pills at the VA to a huge amount of money. They don't work. That's part of how I got involved in this whole PTSD research, because pills didn't work. You talk. You reframe your cognitions. Then I go to Japan. I see people do kendo fighting. I see them do jiu-jitsu. I see them do taiko drumming. They do that to get their bodies back in shape and in tune. I go to Africa, and I follow Bishop Tutu, dealing with trauma. What does Tutu do? He sings with people. He dances with people. He moves with people. They write songs about their suffering. I go like, wow, we wouldn't do that in the Veterans Administration. Clearly, what he was doing in Africa was extremely powerful. You go to China. I went to China early on when China was really a very tough society, just after Mao died. Nobody talks about it. It happens. In every place in China, people are doing tai chi. I joined these tai chi people in China doing tai chi. I go like, wow, they don't do this because it's good for the tourists. They do this because their relatives all got killed by Mao. They make these movements in order to help their bodies to become calm. A lot of what I learned, I learned by stepping outside of the premises of Western culture of drugs and yakking. Of course, what I always love is that the military has always known that, was invented way back in Roman times, resurrected by some Dutch prince, is that basic training is not about talking, not about understanding. It's not about taking drugs. It's about moving, singing, working, having your body move. After 12 weeks of basic training, you are a different person, probably a different person. I think what's so intriguing to me is that the military knows extremely well how to change a pimply, horny, difficult to get along with adolescence into a very good working person. They're very good at this. It doesn't involve any of the methods that the VA uses to treat traumatized people. Thank you, Uncle Sam, for teaching me how to march and make me a man is what I say. All those things you mentioned in your book, you mentioned even yoga. All those things are practices that people generally do together. They have a sense of community. It's almost like they're moving in unison as if in one body. That's a huge issue. Synchrony is what makes the military possible. Feeling that you're in touch with people, in tune with people, that you're on the same wavelength makes for a powerful fighting force and a fighting unit. I bet the special operations guy, you know that very well about how the movement and the rhythms that you and your colleagues is critical for the success of operation. It's that synchronicity with other people that disappears after you leave the military and you feel out of sync with everybody else around you. That's an important question for all of us to ask is how we can help people whose body was helped to be in sync in a different situation to be in sync now that the war is over for you. Some of the best programs I know of for veterans, for example, is a program run by my friend Stefan Wolfert. It's deep fruit. They do Shakespearean acting with soldiers, with veterans, and they learn how to do a play together, in part written on their own life experiences. Another program I know is called songwriting with soldiers, where they sing together and they move together. These are some of the dimensions that are not mainstream, but that are very powerful ways of helping you to get back in sync with other human beings. That's a powerful statement though. At the end of your career, you do largely fall out of sync with others. You don't go to formations. You're going to your own appointments. A lot of people, that is when they slip into, as you alluded to, alcoholism and other self-destructive behaviors. You mentioned that our war is over. Pretty appropriate. 9-11, 20 years ago, I was in Germany. I was a young specialist at the time, but now we have the end of the war in Afghanistan. It's been reported that the suicide hotline for veterans has had a significant increase in calls since the fall of Kabul. Why do you think that is? Do you think it's about what's been happening in Afghanistan has triggered trauma that maybe some people haven't even recognized now? I venture to say that some of the trauma that people are experiencing right now has not manifested until now. Do you agree with that thought? It's a huge issue. We are meaning-making creatures. This happened at the end of the Second World War. The Second World War was a good war. We won the war. Actually, you won the war and liberated me as a little baby. There was no question who the victor of the war was.