Bessel van der Kolk's book, The Body Keeps the Score, really shook up how we think about trauma. It's a powerful idea suggesting that trauma isn't just something we process in our thoughts; it gets physically stored in our bodies, affecting everything from our nervous system to our gut. For years, the conversation around trauma was very much housed in the area of talk therapy, focusing on narrative retelling. However, van der Kolk argued forcefully that when the threat is overwhelming, the brain's survival systems kick in, and the body remembers what the mind might try to forget.
How does trauma physically change the brain and body?
The core argument that van der Kolk presents is that trauma hijacks our basic biology. When we experience something terrifying, our fight-or-flight response kicks in. This isn't a conscious choice; it's a deep, ancient survival mechanism. The body floods with stress hormones, like adrenaline and cortisol. The problem, according to the research, is that if the trauma is prolonged or overwhelming, the brain doesn't get a chance to process it safely. Instead, these intense experiences get stored in ways that aren't purely narrative. This is where the body comes in. Van der Kolk (1994) wrote about how memory formation isn't always a neat, linear video recording. Sometimes, the memory is more like a feeling, a physical sensation, or a snapshot of pure alarm. This concept is crucial because it explains why someone who has experienced trauma might have vivid flashbacks - they aren't remembering an event; they are re-experiencing the physiological state of the event.
This understanding has pushed therapy beyond just "talking it out." If the body is holding the memory, then the healing has to involve the body. This is where approaches like somatic experiencing, yoga, and even rhythm and movement become relevant. The goal, in these models, isn't just to know that something was traumatic, but to feel that the body is safe now. The body needs to learn that the alarm system can turn off when the danger is gone. Macaskill-Webb (2020) touches on this by discussing the integration of the brain, mind, and body in healing. They highlight that effective treatment needs to address the whole person, not just the cognitive symptoms. The research suggests that simply talking about the event, while necessary, isn't enough if the nervous system remains stuck in a state of hyperarousal or hypoarousal (feeling numb or overly activated).
Furthermore, the concept of embodiment - the idea that we are inseparable from our physical selves - is central. Daly (2015) (preliminary) and others reviewing the work point out that the body becomes a repository for unexpressed emotion. If a child cannot process the terror of an event through language because they are too overwhelmed, that terror gets encoded into muscle tension, gut distress, or altered emotional responses. The research reviewed by Gill (2024) (review) reinforces this by looking at how these physical manifestations are understood in different contexts, suggesting that the physical symptoms are the evidence of the trauma that hasn't been fully integrated into the self-narrative. The implication for clinicians is huge: if the client presents with chronic stomach issues or persistent tension headaches, those aren't just unrelated physical ailments; they might be the body's way of keeping the score of past danger.
The literature reviewed suggests a shift from viewing trauma as purely a psychological narrative deficit to viewing it as a complex neurobiological and physiological survival pattern. The body, in its wisdom, keeps a record that our conscious mind sometimes cannot access or process. This is why interventions that engage the senses, the movement, and the physical regulation of the nervous system are gaining traction as evidence-based additions to traditional talk therapies.
What does the current research say about therapeutic approaches?
The body of literature surrounding this topic is rich, showing a clear evolution in best practices. The initial framework laid out by van der Kolk (1994) was groundbreaking because it forced psychiatry and psychology to acknowledge the profound impact of physical survival on mental health. Subsequent reviews have helped solidify which interventions are most supported. For instance, the emphasis on psychoeducation - teaching the patient how their nervous system works - is a recurring theme. Daly (2015) (preliminary) notes the importance of understanding the trauma response cycle so that patients aren't blaming themselves for their reactions. When a patient understands that their panic attack is a biological alarm system going off, rather than a sign of personal failure, the therapeutic relationship shifts from judgment to understanding.
The integration of different modalities is key. Macaskill-Webb (2020) points toward the necessity of multimodal care. This means that if a patient is resistant to talking about the event, forcing the narrative might be retraumatizing. Instead, working with art, movement, or even play (as suggested by the work cited in the Journal of Sandplay Therapy, 2015) allows the emotional material to move through the body and the hands before it is ready for words. The sandplay technique, for example, allows for symbolic externalization of internal chaos in a contained, safe environment. The patient can manipulate the sand to represent the threat, giving them a sense of mastery over the representation, which is a vital step toward reclaiming agency.
Another area of focus, highlighted by Gill (2024) (review), is the importance of the therapeutic relationship itself - the "holding environment." For trauma survivors, trust is not a given; it must be painstakingly rebuilt. The therapist must model safety. This means being attuned to subtle bodily cues - a sudden stiffening, a shallow breath - and responding to those cues with validation rather than intellectual correction. The evidence suggests that the quality of the relational experience, where the client feels seen in their physical discomfort as well as their emotional distress, is a powerful predictor of positive outcomes. The cumulative weight of these sources suggests that healing is not a single breakthrough moment, but a slow, embodied process of relearning safety in the body.
Practical Application: Integrating Somatic Awareness
The core takeaway from understanding how trauma impacts the body is that talk therapy alone is often insufficient. The nervous system needs to be retrained through embodied experience. One highly recommended, evidence-informed protocol for beginning to process stored trauma is a modified Polyvagal Theory-informed Somatic Experiencing approach. This is not a replacement for professional therapy, but rather a set of tools to practice with a skilled practitioner.
The Grounding & Titration Protocol
The goal of this protocol is to gently guide the client into states of "felt safety" (ventral vagal activation) and then allow for small, manageable increases in arousal (titration) without overwhelming the system.
- Phase 1: Establishing Baseline Safety (Duration: 10-15 minutes). Begin by focusing on the most neutral, grounding sensory input available. This might involve noticing the weight of the body in the chair, the texture of the clothing, or the steady rhythm of the breath. The practitioner guides the client to identify three specific points of physical contact with the chair or floor (e.g., the sit bones, the heels, the back). The client is asked to mentally "name" the sensation at each point - is it pressure, warmth, coolness? This anchors the client in the present, non-threatening moment.
- Phase 2: Gentle Titration (Frequency: 2-3 times per session, Duration: 3-5 minutes per cycle). Once grounded, the practitioner gently invites the client to notice a subtle, manageable sensation related to the trauma memory, but only to the extent that it feels tolerable. For example, noticing a slight tightening in the chest, or a fleeting warmth in the throat. The instruction is always to notice it, without trying to fix it or analyze it. The client tracks the sensation - where does it start, how does it move, and what happens to it when they consciously shift their focus back to their feet? This is the "pendulation" process.
- Phase 3: Completion and Integration (Duration: 10 minutes). The session must conclude by deliberately down-regulating the system. This involves slow, deep diaphragmatic breathing, often paired with rhythmic movement (like gentle rocking or swaying, if comfortable). The practitioner guides the client through a "completion ritual," acknowledging the work done and reinforcing the body's inherent capacity to self-regulate.
Consistency is key. These protocols are best practiced weekly, allowing the nervous system time to integrate the small "discharge" of energy that occurs during titration, rather than being flooded by it.
What Remains Uncertain
While the model that the body keeps the score is profoundly useful for reframing symptoms, it is crucial to acknowledge what the current understanding does not fully account for. Firstly, the concept of "discharge" or "completion" remains highly theoretical in practice. While we can guide clients to notice sensations, the biological mechanism by which a traumatic energy pattern is fully discharged and metabolized by the body remains poorly understood at a clinical level. We are describing a process, but the precise neurochemical pathway for its resolution is still under intense investigation.
Secondly, the variability in trauma presentation is immense. What works for a client whose trauma manifests as hypervigilance (a sympathetic overdrive) may be entirely ineffective or even destabilizing for a client whose primary presentation is profound emotional numbing (a dorsal vagal shutdown). Current protocols often require significant customization based on the client's dominant state, necessitating a high degree of practitioner intuition built upon foundational knowledge. Furthermore, the role of genetics and epigenetic markers in determining vulnerability to trauma responses is an area where more integrated research is needed to move beyond purely behavioral or somatic interventions.
Finally, the integration of pharmacological interventions with somatic work is often left unaddressed in popular literature. How does the timing of medication - whether for anxiety, mood stabilization, or sleep - interact with the physical "re-experiencing" required in somatic therapy? These complex interactions require more standardized, longitudinal research to provide clear guidelines for multidisciplinary care teams.
Core claims are supported by peer-reviewed research. Some practical applications extend beyond direct findings.
References
- Gill S (2024). Book Review: A Review of: The Body Keeps the Score: Brain, Mind, and Body in the Healing of Trauma b. Journal of Human Lactation. DOI
- Daly S (2015). The Body Keeps the Score: Mind, Brain and Body in the Transformation of Trauma van der Kolk Bessel T. Emergency Nurse. DOI
- Daly S (2015). The Body Keeps the Score van der Kolk Bessel The Body Keeps the Score 443pp £25 Penguin 978024100398. Emergency Nurse. DOI
- Macaskill-Webb P (2020). The Body Keeps the Score: Brain, Mind, and Body in the Healing of Trauma by Bessel van der Kolk. New Zealand Medical Student Journal. DOI
- (2015). The Body Keeps the Score: Brain, Mind and Body in the Healing of Trauma, by Bessel A. van der. Journal of Sandplay Therapy. DOI
- van der Kolk B (1994). The Body Keeps the Score: Memory and the Evolving Psychobiology of Posttraumatic Stress. Harvard Review of Psychiatry. DOI