EP. 68: HEALING FROM TRAUMA

Jun 27

WITH BESSEL VAN DER KOLK, MD

A psychiatrist, bestselling author, and leading expert on post-traumatic stress discusses what happens to the brain during trauma, the nature of human resilience, and healing through self-expression, creativity, and imagination.

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Episode Summary

Though often invisible in our society, studies have shown that more than seven out of ten people experience trauma at some point in their lives, whether it's physical, sexual, or emotional abuse or a life-threatening accident or illness. In this episode, we speak with Bessel van der Kolk, MD, a psychiatrist and pioneering researcher on post-traumatic stress. His 2014 book, The Body Keeps the Score: Brain, Mind, and Body in the Healing of Trauma, spent 27 weeks at the top of the New York Times bestseller list. He's the past president of the International Society for Traumatic Stress Studies. Over the course of our conversation, we discuss why Dr. van der Kolk began studying trauma, the role of non-pharmaceutical methods in treating post-traumatic stress, how health care providers can overcome the psychological and emotional burden of encountering stressful situations in their practice, and how we can get back in touch with the irreducible human dimensions of love, belonging, and meaning through creativity, fellowship, self-expression, and imagination.

Bessel van der Kolk, MD is a psychiatrist, author, researcher, and educator based in Boston, United States. Since the 1970s his research has been in the area of post-traumatic stress. He is the author of the New York Times bestseller, The Body Keeps the Score. Van der Kolk formerly served as president of the International Society for Traumatic Stress Studies, and is a former co-director of the National Child Traumatic Stress Network. He is a professor of psychiatry at Boston University School of Medicine and president of the Trauma Research Foundation in Brookline, Massachusetts.
In this episode, you will hear about:
• Why Dr. van der Kolk finds trauma a fascinating area of study - 2:16
• How Dr. van der Kolk views the emotional burden he carries from helping patients - 3:4
• A discussion of empathy and sympathy, and how they impact physicians dealing with patient suffering on a daily basis - 7:5
• Self-compassion: what does it look like and how do you cultivate it? - 14:1
• A discussion of trauma how it manifests physically and mentally - 19:2
• The difference between the “top-down” and “bottom-up” paradigms of coping with trauma and stress - 29:3
• How the complexities of trauma have been oversimplified repeatedly throughout history - 32:06
• Advice on cultivating a compassionate and sympathetic mindset for new physicians - 41:36
• How medical practitioners can safely process the trauma of medical training - 47:38
Henry Bair: [00:00:01] Hi, I'm Henry Bair.
Tyler Johnson: [00:00:02] And I'm Tyler Johnson.
Henry Bair: [00:00:04] And you're listening to the Doctor's Art, a podcast that explores meaning in medicine. Throughout our medical training and career, we have pondered what makes medicine meaningful. Can a stronger understanding of this meaning create better doctors? How can we build healthcare institutions that nurture the doctor patient connection? What can we learn about the human condition from accompanying our patients in times of suffering?
Tyler Johnson: [00:00:27] In seeking answers to these questions, we meet with deep thinkers working across healthcare, from doctors and nurses to patients and health care executives, those who have collected a career's worth of hard earned wisdom probing the moral heart that beats at the core of medicine. We will hear stories that are by turns heartbreaking, amusing, inspiring, challenging and enlightening. We welcome anyone curious about why doctors do what they do. Join us as we think out loud about what illness and healing can teach us about some of life's biggest questions.
Henry Bair: [00:00:59] Though often invisible or suppressed in our society, studies have shown that more than seven out of ten people experienced trauma at some point in their lives, whether it's physical, sexual, emotional abuse or a life threatening accident, illness or injury. In this episode, we speak with Doctor Bessel van der Kolk, a psychiatrist and pioneering researcher on post-traumatic stress. His 2014 book, The Body Keeps the Score: Brain, Mind, and Body in the Healing of Trauma, spent 27 weeks at the top of the New York Times bestseller list. He's the past president of the International Society for Traumatic Stress Studies. Over the course of our conversation, we discuss why Dr. Van der Kolk began studying trauma, the role of non-pharmaceutical methods in treating post-traumatic stress, how health care providers themselves can overcome the psychological and emotional burden of encountering stressful situations in their practice, and how we can get back in touch with the irreducible human dimensions of love, belonging, and meaning through creativity, fellowship, self-expression, and imagination. Dr. Van der Kolk, thank you for joining us and welcome to the show.
Bessel van der Kolk: [00:02:14] Thank you for having me.
Henry Bair: [00:02:16] To start us off and you start your book this way, too. Can you tell us what compelled you to a career in medicine and studying trauma?
Bessel van der Kolk: [00:02:25] My book was very much about learning medicine. And I said, I'm on the residency admissions committees at various Harvard hospitals and Boston University. And I always asked the applicants, What books have you read that makes you want to become a psychiatrist? And for the last ten years, nobody came up with a book that they had read that had inspired them. I was very inspired as an undergraduate by many books, and I thought, I'll write this book about how everything we learned about neuroscience is relevant. Everything we learned about political science is important. Sociology is important, human development is important, culture is important. If you really want to do something that engages all of your faculties, the work had to- trauma is the place to work. It's the human condition happens everywhere all the time. So I've had a great chance to travel a great deal, work quite a bit in South Africa, Egypt, many, many other parts of the world. And so you get to see how people in different cultures have different solutions, different models of medicine, different models of pathology, different models of the community. And so this just happens to be the most interesting topic in the world.
Tyler Johnson: [00:03:47] You know, one of the things, though, that I have to say that really strikes me, you know, so I'm a medical oncologist, right? And I will often have people who come to me and they say, oh, my gosh, how can you possibly do that? Right? How can you work with cancer patients every day and chemotherapy? And they have all these terrible symptoms and many of them end up dying of their disease. And, you know, and I have my own personal set of answers to those questions. But I have to say that when I speak to people who are in psychiatry, let alone somebody who is a psychiatrist, who has spent his life basically thinking about how people process trauma and working with people as they attempt to process their trauma. I have to admit that my reaction to what you do is similar to a lot of laypeople's reactions to what I do. Right. I mean, I like it just it feels like such a and this comes out in many parts of your book, too, right? That when I read some of the parts of your book, I have to put the book down and go over and do something else for a while because it's so heavy. So how I mean, I guess as you were thinking about going into psychiatry, how did you think about the burden that would come with sharing the burdens, such heavy burdens from so many patients?
Bessel van der Kolk: [00:05:05] Well, you know. To some degree, this work is always the same whether you are an intern, an internist, an ob gyn person or oncologist. Facing death is very much part of what we do as physicians. So to some degree we are trained for that. It's interesting that my field is largely run by psychologists and social workers, and they don't really have that that life cycle idea that you so very much get with the medical training that, you know, that life begin, they get fought and they come to an end. And that's what medicine is all about. And to some degree, what I do with trauma fits in there in that you see people struggle with horrendously difficult issues, but it also puts you in touch with human resiliency and with the life force. I'm sure you see this as an oncologist that it is incredible drive that we have to make things happen, like oncology patients being traumatized. You carry all this pain and this hurt. And I think to some degree, our professions are professions of hope. And that despite enormous suffering, sometimes it can bring relief. So that's really a very important part of it. On the other hand, to sort an interesting take on this also, because people had asked me this question many times and I tend to underestimate it.
Bessel van der Kolk: [00:06:39] And then we started to do psychedelic therapies. And as part of my psychedelic therapies as the PI, I had to have a psychedelic experience also. And so I went through our MDMA protocol. And as I was lying there in that altered state of consciousness, all of the patients that I had treated came to visit me and I lied there for eight hours going, Oh shit, oh shit. Are you sure this is a party drug? Do people take this for fun? Because I was confronted with all the horror that I had carried and I had become much more vulnerable since that time and much more protective because I feel more open. So part of medicine, of course, medical training is very much about helping you to face horrendous stuff and walling off your emotions to some degree. And I think we get pretty good at that. But in the last few years, I can't wall off my emotions very well anymore. And I feel I feel what people go through. Much more deeply, I have.
Tyler Johnson: [00:07:53] So I attend on one of the inpatient oncology services at Stanford. And, you know, on a normal internal medicine service, it is usually the exception if you have a patient who actually dies in the hospital. But on the inpatient oncology service, where almost everybody on the service has metastatic cancer, it's the exception. If you do not have a patient die on service when you're on even for a week or two. But of course, the the interns and residents that I am training while I'm attending, for most of them, when a patient dies, it may be their first time that they've ever seen this. Right? So often when I am there as the teacher, of course, we do everything we can to stave off death as long as possible. But in spite of our best efforts, it often comes for many sick cancer patients. And one of the things that I have really grappled with is how to best...How to best engage with the person who is confronting death for the first time as a person who has seen it many times. Right. And that balance between vulnerability and a sort of a learned callousness is I don't want to call it callousness, but but you have to develop something of, as you put it, a wall or a shield, because if you take every patient's death as if it is a personal loss, it just becomes such a heavy burden that it's at some point it becomes difficult to carry it. But at the same time, you don't want to become so, as you put it, walled off from it that you become insensitive or that you lose the humanity that brought you to medicine in the first place.
Bessel van der Kolk: [00:09:29] You know, I think it's a real issue here of a difference between empathy and sympathy. And so when you're a second year medical student, you get sophomores, disease, and you sympathize with every disease. You're reading your textbooks. And then at some point, you really you really cultivate a capacity to feel for people, but to also be very aware this is your suffering. And I feel really bad for your suffering. And I'll do whatever I can to help you with your suffering. But this is not my suffering and and to really know the difference. So it's not to cut off your mirror neuron system and not register almost on a sensory level, but the pain is the people you go through. I'm sure our fields aren't all that different in that regard. So you feel it on a sensory level of, Oh God, this is terrible. But you also cultivate a capacity to say this is their life and not my life. And then you develop that capacity which, you know, Buddhist meditators actually developed it very well. It's part of the mindfulness tradition that you learn to feel your feelings very deeply, but also to know that other people feelings are their feelings, and that can reach out to them. But I don't have to carry them inside. And I think we all learn that in the course of our of our experiences here.
Tyler Johnson: [00:10:58] You know, I had this sort of myth in my brain and my heart when I finally finished my medical training, when I, you know, was 36 or 37 or something, that, okay, now I'm done with my fellowship. Now I've learned most of the stuff and now I can go be an attending and just practice the stuff that I learned. What I didn't realize that was that much of the most important and most visceral learning actually came for me as an attending. And one of the things that was the hardest for me to learn is exactly what you're talking about. Because at first, you know, now I'm the attending, I'm the person where the buck stops. I'm the person who's signing the notes and feels like I'm, quote unquote, in charge of the team. And there was a part of me that therefore felt deeply responsible for everything that happened on my team in the hospital under my watch, so that if a patient died at first, I often processed that as being, in effect, my fault, even though that really made no sense because usually the people were very sick with metastatic cancer and whatever, but that was just how it felt. Right? And that that ability to say this is a thing that has happened, but it's not my thing that has happened, I think was actually one of the most difficult things for me to learn. And I have to imagine that as a psychiatrist, and also as a psychiatrist who is helping to teach other psychiatrists, that that has to be one of the most important learned and taught skills with which you engage is that figuring out how to be able to do that as a doctor. Does that does that feel about right?
Bessel van der Kolk: [00:12:31] In that regard. Being a psychiatrist, you're lucky in that as a surgeon, as an oncologist, there probably is not a lot of room for you to talk about your reactions. And a tool in psychiatry is very much that we are an agent. Our presence, the way we talk, what we say - is basically our tools. We don't have tools like you have have we don't have heavy stuff to put into people. And so it's awkward. So you so very much part of the psychiatry training, hopefully, although all of that is becoming more mechanized, is to really get to know yourself, talk about your own reactions, get psychotherapy yourself. How can you help other people with their stuff if you don't know how to help yourself with your stuff? And I think you really can learn very gradually this issue of self compassion also that need to take care of myself and I need to break and I need to and talking to each other. And another thing, of course, that we do in medicine is we love to tell medical student jokes to each other, which should never be published because they're terrible things that you say about people to each other. And we got to do it. Sometimes you just need to just have the irreverence and say things that you hope nobody ever gets to hear to just get it, get that weight off your shoulders.
Tyler Johnson: [00:14:02] Now you're letting out our medical secrets on a public podcast. Dr. Van der Kolk You have to be careful. All right?
Henry Bair: [00:14:10] So Dr. Van Der Kolk, you just mentioned the word self-compassion, which is something that has actually come up quite a few times in our recent conversations. Can you tell us exactly what that looks like and how we can cultivate it? I'm asking this from the perspective of a newly minted resident physician. I've actually just finished my first ten days as an intern and they started me off in the ICU. So for the first time, I am taking real responsibility for people who are gravely ill and acutely dying and seeing a lot of trauma for patients and their families.
Bessel van der Kolk: [00:14:50] Well, one role is our role as physicians, and that is to bring compassion to our patients. And self compassion can be very different. Certainly my medical training I went to University of Chicago was that medical students have no feelings. They have no needs. They can work with very little sleep. There never was much attention to our well-being. And now in my medical school, people teaching the healers art and they talk about our feelings and they talk about what it's like to see horribly deformed third degree burns. And I think the processing that's come into the medical school in the past few years is very much a step in the right direction. And when I see the medical students are treated with more of a compassionate attitude by the faculty, I think then they can also have a more compassionate attitude to themselves. My medical training very much was like a marine boot camp. You just worked and worked and worked and worked. That's it. Do you think, is this changing? Are medical schools becoming more thoughtful about the needs of their of the residents in some ways?
Henry Bair: [00:16:13] Well, it's a little tricky for me to talk about this because I, of course, only ever went to one medical school and my institution in particular, Stanford University, has a reputation for giving students a lot of latitude to explore and express whatever interests them, whether it's in or out of medicine. So it's not uncommon to see students perform music, make movies, write books, create nonprofits, or even compete in professional sports while still in school. I've certainly benefited from this open environment. I also recognize that this is just not the case at most schools. And certainly at the residency level, there's still a pervasive mentality where you just keep working and working. And I think a lot of it is the what we would call the unwritten curriculum, right? Like no one's telling you necessarily. No one's saying you have to work 30 hours. It's just everybody else is and it's just a self-perpetuating system.
Tyler Johnson: [00:17:14] Yeah. I mean, I will say that for my part. So I was in medical school from 2005 to 2009, and it was much more of the old school approach that you were saying, right? I mean, there was I mean, not to say that they didn't care about us, but it was much more of a sort of push you into the deep end of the pool and say, you better learn how to swim and we'll see you on the other end. And even at Stanford, which I totally agree with Henry, I mean, by and large, my experience I've been at Stanford from my internship on so internship, residency, Chief residency, Fellowship, and now as faculty. And by and large, my experience there has been wonderful. But even so, I was telling a class that Henry and I teach that I had a time in the ICU when I was post-call on like my 26th hour of working and was presenting to an attending and was visibly tired. And the attending sort of, you know, at one point interrupted my presentation, slammed his fist on the, you know, computer terminal that we were using and said, "Back in my day, we used to work 36 hour shifts and 100 hours a week and you guys are all wimps and don't know what you're doing being tired on my service!" Right. But it was still this sort of so there is still even at a place like Stanford, which I think on the spectrum, you know, does really well. But even there, there is still certainly some of that sort of old school mentality.
Bessel van der Kolk: [00:18:35] And that, of course, would carry on if you're being treated as a way to cut off your feelings, you have the same attitude to your patients. And so in retrospect, I think about my medical school years and how we didn't connect with our patients and we didn't take their social situation into account, and we didn't try to understand people who came from different cultures. And it's in retrospect, really back then it was quite a heartless enterprise. And I think if we get trained that way, we will also treat the people who we treat in a similar way. So I think it's a very, very dangerous culture to to embrace, actually.
Tyler Johnson: [00:19:22] Um, I wanted to change tacks for just a minute. You know, we we do want to come back to talking specifically about how some of these ideas apply both to the patients that we care for as medical practitioners and also to ourselves as medical practitioners. But before we get to that, I wanted to cover a couple of the topics that you cover in your book that I think are important to lay sort of a conceptual framework for how we're going to have the later discussion. So I wanted to start I'm going to read a paragraph from I think this might be the second chapter or something of the book, but I wanted to read this to you and then ask you a follow up question. So this has trauma results in a fundamental reorganization of the way mind and brain manage perceptions. It changes not only how we think and what we think about, but our very capacity to think. We have discovered that helping victims of trauma find the words to describe what has happened to them is profoundly meaningful. But usually it is not enough. The act of telling the story doesn't necessarily alter the automatic, physical and hormonal responses of bodies that remain hypervigilant, prepared to be assaulted or violated at any time. For real change to take place, the body needs to learn that the danger has passed and to live in the reality of present.
Tyler Johnson: [00:20:40] Our search to understand trauma has led us to think differently, not only about the structure of the mind, but also about the processes by which it heals. So, you know, I think that this is this is emblematic of a striking idea from the book, which I'm going to sort of comment briefly and then ask you to expound, which is that, you know, I think that many of us, if you say, oh, I went through a traumatic thing, you think, okay, well, that's, you know, a thing that happened however many years ago. And it's kind of, you know, somewhere back in the far reaches of your memory. And if you wanted to go back and sort of pull it out, sort of like you would pull a dusty book off a shelf, you could pull it out and look at it and read about it, and then you just put it back and then it just stays on the shelf like a book, right? But what you're suggesting here is that it is actually nothing like that. So can you talk to us as a psychiatrist instead? What is the experience of trauma like and how does it actually alter us?
Bessel van der Kolk: [00:21:37] The experience of trauma in and of itself is an experience, but as you sort of mentioned, for most people, it's multiple experiences. It's not like the way we first defined it is there's an event outside of the ordinary human experience and it turned out was not at all extraordinary. It's very common and that people have an experience of complete helplessness. There's nothing I can do. Your whole sense of meaning get destroyed. Your sense of self and self-respect get destroyed because you cannot rise to the occasion. And so after it's over, the nature of trauma is that you get stuck. The nature of the surgery rotation in medical school is a stressful as hell, but when the rotation is over, you go like, Wow, I survived. Now trauma is the opposite. You hold on for dear life and you fail at the end. Your whole concept of yourself and the world has changed. The world is no longer a benign place. People cannot be trusted. I need to be on alert because otherwise people are going to hurt me. I'm getting need, fight, fight back to people. So you tend to be in fight and flight mode.
Bessel van der Kolk: [00:22:59] Very useful thing for medical students to learn that people who get really nasty and upset as medical students are very frightened people usually and how you need to calm them down and not meet their anger with anger, but to meet their anger with. Tell me more about that. Like for you, let's see what we can do and to really calm that body down out of that fight. Flight reaction or but you also see in medicine a lot is how when you have been helpless long enough, you basically give up on yourself, you shut down and you become like a zombie like person. And it's very hard for us physicians to deal with people who take no responsibility for themselves and are passive and who basically have given up on self care. And so but you cannot reinstate some of these capacities until the body feels calm. Until you're you're on a visceral level. You don't feel like you're on the threat anymore. And that's a different part of your brain than your reasonable brain. You're thinking brain. Yeah.
Tyler Johnson: [00:24:12] Can I ask one question that I was really struck I don't mean to get too philosophical because I know that I'm certainly incapable of answering this question for as much as I've thought about it. But it really comes up a lot in your book. One of the things that you talk about is that there's this sort of divide with how the mind deals with trauma and how the body deals with trauma, right? So that even if the mind has wanted to move on from trauma, the body is still mired there. Right. And it's still you're still having these sort of autonomic responses and whatever. And yet, at the same time, one of the paradoxes of medicine is that at least the physical. Thing of the brain is a part of the body. So how do you, as a psychiatrist think about the brain and the body? Do you think of them as two separate things? Do you think of them as sort of differently functioning parts of the same thing? And how do you think about the relationship between the two?
Bessel van der Kolk: [00:25:12] Well, I wouldn't. I wouldn't put such a sharp divide between the two of them. But basically, you know, Roger Sperry in his Nobel Prize speech in 1953, says the brain is the organ that makes the muscles move. There's a few other secondary functions.
Bessel van der Kolk: [00:25:34] The Function of the brain is to keep this organism that's us alive. So it gets us to breathe and to sleep and to go to the bathroom and all these basic things that we have to do that we actually have no control over. We cannot make ourselves go to sleep unless you're some extraordinary person or you cannot make yourself lose your appetite. You cannot make yourself not tired. You cannot make yourself not upset when there's a threat. And all these things come from our primitive mammalian brain that we have in common with all other animals. And just go spend some time in the Serengeti recently. And I was again just stunned how similar all mammals are. You know, this nurturing and territoriality and fighting with each other. And so, so, so but then happened to human beings. Is that on top of that brain that takes care of your body and gets you to move in rhythm with other people? And we develop this frontal cortex where we can understand and figure things out and communicate things and, and find words for things. So the last accomplishment and that we as human beings think that that is us, what we think and what we talk about. But in fact, we completely ignore the organization of the body and that this podcast is over. We probably have to run to the bathroom. So. So that continues demands from our body and what we learn as human beings. And that's why we get all civilized, is that at some point you put yourself and your own needs on the diet and you start organizing it.
Bessel van der Kolk: [00:27:13] So you go and you go to the bathroom after the end of class and you can only sleep at the end of the day. And so you learn to adapt at more elementary brain to some social demands, but you don't learn to control it. That part of the brain still has a life of its own, a very powerful life. And once you get traumatized that that elementary housekeeping part of your body is no longer working. So you may blow up at people or you may fall asleep as you present to your attendant. And people say you shouldn't fall asleep because I know. But you know, I haven't slept for 72 hours. I know I shouldn't be pissed off with you for being so insensitive, but I cannot help it because I feel very threatened by you, you know? And so once you get traumatized, you have all these reactions to things that other people may think that is sort of a stupid way of reacting. Somebody says something nasty to you and if you're a secure person, good boy, this guy has a bad day. So he always like this. If you're a traumatized person, you go, He hates me. He's a terrible person. He's going to kill me. And you go to a lawyer, you go to a hospital administration. But the terrible thing that people have done to you and so so when you're traumatized, all kinds of things that for other people, a minor inconvenience of insults for you become a life threatening situation.
Henry Bair: [00:28:40] Yeah, I think I think that really highlights the importance for us to be more open and more understanding to dealing with, you know, with our patients who are dealing with difficult experiences.
Bessel van der Kolk: [00:28:51] You know, about us because our natural reaction is if I become rude to you, for you to become rude back. And so that's why we can get these sometimes very difficult situations with our patients. But if we really feel like that's your problem or you look very angry, what's going on with you that you call me all kinds of names because I know I'm not misdirectors, but you must be very upset about something. How can I help to calm you down without saying How can I help you to calm yourself down? Because it will make you more upset.
Henry Bair: [00:29:31] One of the ideas we haven't quite addressed head on, but that comes up a lot in your book is the intricate connection between how the mind works and how the body functions. In the book, you discuss the two main paradigms of addressing stress top down and bottom up top down modalities begin from the mind, whereas bottom up approaches originate from the body. Can you tell us more about that distinction?
Bessel van der Kolk: [00:29:59] The top down is understanding things. Figuring things out. Being able to communicate what's going on and being able to tell somebody what is hurting and what's bothering you. Does have a major effect on calming the physiology down. So that's really what therapy is very good for, is that another person can really share your soul with you and your words with you. But most of the post-match reactions are not completely amenable to just talking and contact in that the body contains to feel to agitate it or to frozen. And so the issue of touch movements, synchronous rhythms, synchronous engagement, other human beings is very powerful and somewhat uniquely not practiced much in in North America. Uh, if you go to Asia, you go to Beijing and you see all these people in the parks doing qigong, and you go to the park and you practice qigong with you. You go like, Oh, these people are doing it because they need it, because it makes them feel so much better. And you go to Africa. I did some work with Bishop Tutu and he was always singing with people. Now, I don't see you guys at Stanford singing with your patients, but boy, is it a beautiful thing to be to harmonize with other human beings and produce beautiful sounds together. I say more and more insistently, We are so trapped by our culture and our Western culture is I call it a post alcoholic culture, meaning that if you feel bad, you take a swig. And so anything you put in your mouth, that's normal. And if you don't put something in your mouth, that's alternative medicine. In my mind, popping pills in your mouth should be called alternative therapy. The way you move, the way you're touched may be more effective, but we don't pay attention to that.
Tyler Johnson: [00:32:06] You know, one of the things, one of the paradoxes that is in your book is that on the one hand, you can sort of gather from some of the comments that specific patients make and also from just some of the anecdotes that you tell that one of the things that's so difficult about trauma is the way that it disrupts the connections that form community, right? Because people who go through trauma tend to think that they're the only one who's ever experienced something similar, which then brings on this sense of shame and all the rest of it. But the paradox is that you quote all these statistics that it's actually almost unimaginably common, right? And by the time you go through all of the different ways that a person might have experienced something traumatic, it's hard not to come to the conclusion that pretty much everybody has experienced probably some trauma in some regard at some point in their life, or at least, you know, a large majority of people. And so you have all these people feeling like they're the only one in the world where, in fact, they are part of at least the vast majority, if it's not just part of the human experience. Right. And so at some at some level, the question becomes, how do we help each other just as humans, but especially how do psychiatrists who train for this? How do how do you confront the suffering that is, for most people inherent in the human condition? And so in confronting that question, you write,
Tyler Johnson: [00:33:25] "The way medicine approaches human suffering has always been determined by the technology available at any given time. Before the Enlightenment, aberrations in behavior were ascribed to God, sin, magic, witches and evil spirits. It was only in the 19th century that scientists in France and Germany began to investigate behavior as an adaptation to the complexities of the world. Now a new paradigm was emerging anger, lust, pride, greed, avarice and sloth, as well as all the other problems we humans have always struggled to manage were recast as quote unquote disorders that could be fixed by the administration of appropriate chemicals. Many psychiatrists were relieved and delighted to become, quote, real scientists, unquote, just like their med school classmates who had laboratories, animal experiments, expensive equipment and complicated diagnostic tests, and set aside the wooly headed theories of philosophers like Freud and Jung. A major textbook of psychiatry went so far as to state, quote, The cause of mental illness is now considered an aberration of the brain, a chemical imbalance, unquote." Right. And then you go on in there and in other parts of the book to talk about how and I'll let you expand on this. But in effect, we've realized that, again, we're being too simplistic, just like we had put our faith in the idea of witches and, you know, whatever centuries ago, then we put our faith in the idea that it was all just neurochemistry. And now I think it's fair to say, but you can you can tell us sort of more holistically your thoughts that we know that it's a lot more complicated.
Bessel van der Kolk: [00:34:57] Yes. We we should know it's more complicated, but we don't really. For example, I'm doing psychedelic research. My colleagues, they say, oh, it changes certain serotonin receptors in the hippocampus. And now we understand how it works. And I say, but that's bio babble. You know, you throw in some chemicals and now I understand how the mind is transformed by by having mystical experiences, seeing God. No, it doesn't explain it, but it keeps seeing. I think that does not overlap with psychology, is that people come up with these simplistic answers and these so-called evidence based treatments. You have to practice cognitive behavioral treatment because that's the only thing that works, really. It's the only thing that people have been able to get money for, to study in a laboratory, possibly. But it doesn't mean it's the only thing that works. For example, I suspect that capoeira and. Martial arts might be a very good treatment for trauma. I couldn't imagine somebody getting funded by NIH to do capoeira for PTSD. So we keep getting into these very narrow possibilities. We we learn about epigenetics and we say, oh, now we know the epigenetics of trauma. No, we know that there's some slight alteration methylation on some molecules, but that doesn't explain how your mom yelling at you all the time and grounding you changed your identity. Like, you know, we are very complex and fascinating creatures.
Tyler Johnson: [00:36:36] Well, and I think that one way that does actually resonate with a theme that has come up in various guises, but that has come up again and again and again on the podcast. Is that part of what I hear you saying is that, you know, doctors have always been sort of amphibious, we've always been hybrid creatures because on the one hand, I totally understand what you're saying, that it's sort of funny, that part in the paragraph I read about psychiatrists wanting to be considered real scientists, right? There's something great about being able to put up kaplan-meier curves and diagrams of neurotransmitters and whatever that it's like, okay, now I get to be part of the Cool Kids club right now where the real scientists. But the other part of it is I think that if we lean too heavily into that, we forget that always at the center of medicine, there is going to be an element of irreducible mystery, which is what is it that makes life beautiful and that makes love worthy and that makes that makes existence magical and that makes suffering so terrible, right? Like there is always going to be some core at the center of those kinds of questions that is mysterious and cannot be captured by a kaplan-meier curve or or a diagram of a neurotransmitter. And what we have learned in talking from many doctors, you know, from medical oncologists to ICU physicians to pediatricians to psychiatrists, to everybody in between, is that when we when we try to reduce everything in medicine to a sort of biologically reductionistic schema, it loses something that it desperately needs and it becomes more like technical work or machine ism. Nothing against machinists, but it but it loses the mystery and magic that are what make it so meaningful in the first place.
Bessel van der Kolk: [00:38:38] So but but I think it's happened in psychiatry is that mental processes are very complex issues and have been at various points very well studied. And anybody who has young children or young grandchildren cannot be but astounded how this little mind develops and how one one moment a kid sees the world a particular way and something happens and a week later they see the world in a completely different way. Some new connection has been made in the brain. I think neuroscience is spectacularly important. It's a great technology that we can measure that. But but we don't measure is changing the mind. We can we can measure biology, but we could measure mental performances also. So there's the world of Jean Piaget, who showed how children go through different ages of mental development. It's very striking. When you get traumatized, you tend to relapse into much earlier ways of of information processing. But most psychiatrists don't learn about mental processes. The mind has disappeared from our field.
Tyler Johnson: [00:39:48] To be clear, you know nothing. I mean, look, I'm an oncologist, right? So I look at kaplan-meier curves all day, every day, and I cite them to my patients. And, you know, I'm not in any way undermining the importance of those or of understanding, you know, pharmacology or, you know, whatever the dynamics of chemotherapy or anything else. But it's just to say that when we run into trouble is if we try to have either without the other. Right. It's like trying to fly a plane with one wing, right? You just you have to have both wings or the plane just can't fly. And, you know, different people who are maybe oriented in different ways might might tend to go in one direction or the other. But we just have to make sure I think that both of them are there.
Bessel van der Kolk: [00:40:30] And it hasn't happened, huh? I think psychiatry, by and large, has lost its mind. And the earliest you talked about is this irreducible human issues of love and affiliation and belonging and meaning and sharing music and sounds and colors are very, very central human capacities that also develop over time and that can be measured if we bother to measure them. You know, in some ways you don't get into Stanford Medical School unless you have a proven track record of having pretty damn good executive functioning and being able to work on one subject for 16 hours a row. Otherwise you don't get through Stanford Medical School. But the underlying issue is that capacity to focus and to wrap your mind about very complex stuff and not get distracted by all kinds of other things. So these are measurable things, but. It's no longer the central part of science. It doesn't get measured.
Henry Bair: [00:41:36] So I guess my then my reaction is how do we cultivate that? Let's say you were you were teaching a group of residents or medical students. By and large, as you mentioned in medical school, we don't deal with these topics either because we don't think they belong in medicine or in the world of science, or maybe because we think they're distractions for whatever reason. But obviously it's very important for our patients who are humans dealing with human experiences. So how would you strive to bring back an understanding and awareness and expertise even in dealing with these kinds of ideas for for medical trainees?
Bessel van der Kolk: [00:42:21] You know, what comes to mind is that as a medical student, you have no idea how important you are and how this poor old lady with cancer on the ward looks at you as a. Look at my doctor. He's so young, but he takes good care of me. Isn't he amazing? You know, and most students don't have a sense of how their youth and their ignorance to some degree, can be an enormous comfort for the people you work with and that you can be a source of hope. That was also very much my experience as a medical student is that my attendance attendings were oftentimes too busy to communicate a lot to the patients, but I was the last guy out of the room and my patient would call me and say, Hey doc, tell me what's going on. And so as a medical student, you can really tune into people in a in a very powerful way. And while you're mainly interested in passing that course and getting approval by your teachers, but you shouldn't forget is that the people you work with look up to you and can derive an enormous amount of comfort from your presence and your attention, actually.
Tyler Johnson: [00:43:34] Yeah. So two quick anecdotes. One, just to that point, I remember one time when I was a trainee, I was working with a world famous oncologist and we went in to see a patient who had just received a new diagnosis of cancer. And as most oncologists do, this oncologist had a sort of a presentation style, right? We'd go in with a new patient and being a world expert, this attending would say, you know, all of the things about what the treatment was going to be and all these things in any case. So we we got done with this sort of monologue that was erudite and you know, better than almost anybody in the world could have given it. And then the entire entourage of the team walks out, except for me as the trainee and the person whose first language was not English. So all of this had been, you know, conveyed through an interpreter, looks at me with these big, clearly fear filled eyes and says, So. Dr.. Is cancer contagious? And it was just clear that there had been like, no, like nothing had landed. Nothing. Right. But the only person that she felt comfortable saying that to was someone who was not the erudite world expert, you know, giving the whole whatever.
Tyler Johnson: [00:44:48] The other thing that I just wanted to mention, this is back a few points ago, is that I was so interested to hear and read about this idea about sort of humans moving in synchrony. So way back when, before I started my medical training, I used to love to sing, but then I remember very distinctly there was a point in my undergraduate education where I was working quite a bit and then also doing all of my pre-med stuff, and I wanted to be in a choir, but it just there just weren't enough hours in the day. And I sort of took the singing part of myself and sort of laid it aside and said, I hope I'll pick this up at some point, you know, later down the road. And as things tend to happen in medical training, I literally did not sing again in any formal way for more than a decade. Right. It was the last part of undergrad and then medical school and residency and fellowship. So finally, a year or two after I finished my fellowship and was an attending, there was a semiprofessional choir that was started by my wife and some friends. And after I'd been going for a few years, I tried out and got in and I cannot tell you how beautiful and the best word that I can think of is healing.
Tyler Johnson: [00:46:04] It was to sing in this choir. I mean, it was just and and I remember I mean, it was such a striking it had such a striking impact on me that there were often times when I would look around when we were done, we would rehearse for two hours a week. I would I would look around when we were done rehearsing. And it was almost like, what happened? This felt like magic or something. Like what? And it was so interesting because we had people in the choir who were, you know, high powered Silicon Valley, you know, executives and and coming from all walks of life. But you could just tell that no matter where they were coming from or what else they were doing this and many people said so explicitly was like the most important thing in their week. And to your point about that, not everything is about, you know, needing an SSRI or MDMA or whatever, but that there is something about that sort of shared experience of human connection and human, you know, creating something beautiful. That that idea resonated with me deeply because of that experience.
Bessel van der Kolk: [00:47:09] Well, what you're telling, I hope that everybody takes your your words to heart. You know, making music together is one of the glorious experiences in life and such a comfort. Also, you know, in times of stress and family tragedies, if you have acquired the singing and you can just sing the Mozart's C minor mass or C major mass or something like you bring that comfort back into people's lives. Yeah, yeah, yeah.
Tyler Johnson: [00:47:38] Yeah. So, you know, we have about ten minutes left. I wanted to turn before we finish to one thing that I think is really important and that is that, I think that although we don't often maybe think about it this way or use this vocabulary to talk about it, I think there are also experiences in medical training that in their own way can be traumatic. And one of the ones that I'm thinking about specifically just to share an experience from my own training is that I remember there was a woman who had cystic fibrosis. I didn't know her. She was not my patient. I was literally walking down the hall one day and a code was called in her room. And so I rushed into the room. And as you do, if she had become pulseless, it wasn't immediately clear why. So we, you know, tore her shirt so that we could administer CPR correctly. And then two things well, three things happened simultaneously. One was that we took turns administering chest compressions while they mobilized the rest of the crash cart and whatever. Two was that I don't even know. I think she had an infection in her lungs secondary to the cystic fibrosis. But what I do know is that she developed massive hemoptysis. So in effect, she began exsanguinating through her mouth. So there's maroon colored blood sort of flying everywhere in the room. And then the third thing was that this happened, as best I could gather, not knowing her as a patient. But this happened as best I could gather, almost instantaneously. She was okay one moment and then began having massive hemoptysis the next moment.
Tyler Johnson: [00:49:12] And so her family was still in the room. So as we're ripping off her shirt, starting to do CPR and blood is coming out of her mouth, they're still trying to maneuver her family members around, the doctors rushing into the room to get the family members out of the room so that they wouldn't see the horrible thing that was happening. And then we administered CPR for, I don't know, a half an hour or something, and then eventually, you know, concluded that it wasn't going to work and that she had died. And I just remember, to your point from earlier, this horrible sense of absolute helplessness. Right. Just this and and this. Deep, visceral sense that I had witnessed something that felt sort of grotesque and and so foreign to to anything that I had ever experienced. And I imagine that if you lined up a hundred doctors and said and they were all being totally transparent and you said, have you ever had an experience that is not exactly like that, but somewhere in that neighborhood that many or most of them would say yes. And so I wanted you to speak a little bit to for people who are listening to the podcast, who are health care workers or trainees or preparing to go into training. What recommendations can you give for how health care workers can grapple with those kinds of experiences that happen in their own life or their own training?
Bessel van der Kolk: [00:50:39] I almost feel like turning the question around and asking you what was helpful for you to deal with that experience? Because, you know, I can my senses pick up what your experience was and it sounds horrifying. And my association, too, is, is that in those environments, in hospitals, people tend to get very close to each other and very physical to each other. Actually, I remember working in the ICU as one of the most nurturing parts of my life because people were so supportive of each other because they have to be. And so if you're not. Too unpleasant a person that alienates people under the circumstance that people tend to put their arms around each other, go out for a beer afterwards, do some screaming, some storytelling, get inducted into the brotherhood of people who have seen horrible things and we share it with each other. But that that that group of of fellows that we are with in medicine is incredibly important. The support and also having an attendant who you feel is interested in your fate and who worries about you and who says from time to time, are you okay? I'm sorry you had to see that and looks at you benignly. I think what makes these experiences bad is if you get blamed, if you get called on the carpet or what happened during the pandemic when people would see scenes like you just talked to us about and they would not be able to talk to anybody because they were too isolated and the family wasn't there.
Bessel van der Kolk: [00:52:29] And so they were the only people responsible for for this horrendous thing. And they had nobody and they couldn't go home because if they would go home, they might infect their parents with Covid. When people talk about our collective trauma of Covid, you know, most of us did just fine. But the people who go through experiences like you describe here, for them, it was horrendous. And so I think medicine has a long tradition of really automatically forming brotherhoods and sisterhoods and and groups of people who can be quite honest with each other. And that's what we need. And of course, we all know there's a big crisis in medicine, in outpatient medicine, particularly because these connections are not as well preserved as they have been at some point in most places. And I think that's very worrisome. You see it in hospitals, you see it in school systems also of people not forming the peer support networks that we all need to do this very hard work.
Tyler Johnson: [00:53:34] Yeah, I mean, I completely agree that I think if there were if there I mean, there are many answers to those things. But the two that I think are the most important in my mind align exactly with what you were saying, which is that one, you need to have a community of peers and that requires some work, right? Community doesn't just happen spontaneously. You need to cultivate community and and it needs. And so on the one hand, you need community with people who are about at your training level because, you know, one thing that I have realized now as an attending is that it's more difficult for me. Even when I consciously cultivate it, it's more difficult for me than I would have imagined to remember what it was like to be an intern or to be a fellow or to be whatever. Right? And so you need people who are in sort of more or less the same boat as you who who understand that intuitively. That's part number one. And then part number two. And the particular reason that you need those people above you in that kind of circumstance is precisely so that you can have someone who knows what they're talking about and who you trust, who says this was not your fault, right? Like you need someone whose authority you intuitively accept and who has a broader range of experience and more knowledge than you to say, don't feel responsible for this. This was not your doing, because otherwise it can feel incredibly incriminating if you don't have someone in authority to tell you that.
Bessel van der Kolk: [00:55:05] Yeah, I would even put it a little bit further than that. Somebody who has seen what you have gone through and say, Boy, that was really tough, wasn't it? I think that statement would make all the difference in the world.
Tyler Johnson: [00:55:20] To your point about empathy and sympathy.
Bessel van der Kolk: [00:55:23] You always feel a little like it's my fault. You can almost not get away from that. I might have been able to do something better if I were just a little bit smarter, more alert. I could have done it. I said. The first response to a trauma type thing is to blame yourself, which is a good response in a way, because you start thinking about next time when this happens, can I do better than I did now? So that the self-blame isn't has some adaptive functioning. But you need somebody to also say that was as hard as it gets in a very warm, physical way. And that body like the other thing, of course, is how to deal with it. It's very nice that when you come home to have a warm body that holds your body when you go through extreme stresses of medical school training, the body holding is a very core issue of what we as human beings also need.
Henry Bair: [00:56:24] Well, Dr. van der Kolk, on that hopeful note, we thank you for sharing all of your stories and ideas. It's been wonderful speaking with you and I hope this will be tremendously valuable and insightful for our listeners.
Bessel van der Kolk: [00:56:38] Thank you. It's a pleasure. Good luck. It's very important work we all do.
Henry Bair: [00:56:46] Thank you for joining our conversation on this week's episode of The Doctor's Art. You can find program notes and transcripts of all episodes at www.thedoctorsart.com. If you enjoyed the episode, please subscribe rate and review our show available for free on Spotify, Apple Podcasts or wherever you get your podcasts.
Tyler Johnson: [00:57:04] We also encourage you to share the podcast with any friends or colleagues who you think might enjoy the program. And if you know of a doctor, patient or anyone working in health care who would love to explore meaning in medicine with us on the show, feel free to leave a suggestion in the comments.
Henry Bair: [00:57:19] I'm Henry Bair.
Tyler Johnson: [00:57:19] And I'm Tyler Johnson. We hope you can join us next time. Until then, be well.