The Body Keeps the Score
“He heals the brokenhearted and binds up their wounds” (Psalm 147:3). Some wounds are invisible. Every coach will meet clients carrying them, whether or not they say so.
Dr. Bessel van der Kolk is a Dutch-born psychiatrist who has spent more than forty years studying and treating trauma in Boston. He founded the Trauma Center there, taught at Boston University School of Medicine, and helped lead the research that brought post-traumatic stress into modern medicine. His book The Body Keeps the Score: Brain, Mind, and Body in the Healing of Trauma (2014) has sold millions of copies and has been on the bestseller lists for years.
His central teaching is in the title. Trauma is not only a painful memory of something that happened in the past. It is an imprint left on the mind, the brain and the body, which keeps the person reacting in the present as if the danger were still happening.
What Trauma Is
A trauma is an experience that overwhelms a person’s ability to cope: violence, abuse, neglect, war, a terrible accident, a sudden loss, a frightening medical event. What makes an event traumatic is not only how bad it was, but whether the person felt helpless and alone in it. Two people can live through the same storm; one recovers in weeks, the other is still shaking years later.
Dr. van der Kolk describes what happens in the brain:
- The amygdala, deep in the brain, is the smoke detector. It scans for danger and sets off the alarm (racing heart, stress hormones, fight or flight) before the thinking brain knows what is happening.
- The medial prefrontal cortex, just behind the forehead, is the watchtower. It looks at the bigger picture and can tell the alarm, “It’s only toast burning, not a fire.”
- In trauma, the smoke detector becomes oversensitive and the watchtower goes quiet. A sound, a smell or a tone of voice that resembles the old danger sets off the full alarm.
- During flashbacks, brain scans show that Broca’s area, a speech center, can shut down. People are left in speechless terror, unable to put the experience into words. This is one reason talking alone is often not enough.
- When fight or flight is impossible, the body freezes or collapses. Many survivors live with a numbness or disconnection (dissociation) that once protected them.
Many survivors lose touch with the inner sensations of their bodies, which Dr. van der Kolk calls a loss of interoception. They don’t notice hunger, fatigue, tension or calm until it is extreme. Healing, in his view, means coming back to feel safe in one’s own body.
The ACE Study
The largest study of childhood trauma and adult health was the Adverse Childhood Experiences (ACE) Study, run in the 1990s by Dr. Vincent Felitti of Kaiser Permanente and Dr. Robert Anda of the CDC with more than 17,000 adults. It asked about ten kinds of childhood adversity: physical, emotional and sexual abuse; physical and emotional neglect; and growing up with domestic violence, a parent with addiction or mental illness, a parent in prison, or divorce or separation.
The findings changed medicine:
- ACEs were common: about two-thirds of these mostly middle-class, insured adults had at least one, and about one in eight had four or more.
- The more ACEs a person had, the higher their risk, decades later, of heart disease, lung disease, liver disease, diabetes, obesity, depression, addiction and suicide attempts. People with four or more ACEs were many times more likely to have attempted suicide or to struggle with alcoholism or drug use.
This is ruach and nefesh joined: the stress of a child’s home becomes the disease of the adult’s body, as Dr. Maté also teaches (Chapter 5).
What Heals
Dr. van der Kolk describes three ways into healing:
- From the top down: talking, connecting with others, understanding what happened.
- Medications that dampen the alarm.
- From the bottom up: letting the body have experiences that contradict the helplessness and fear of the trauma.
He emphasizes the bottom-up paths most of all, and he has studied several:
- Safe relationships. Being seen, heard and accompanied by people who are trustworthy is the foundation of all healing. Isolation deepens trauma; connection heals it.
- Yoga. In his research with women who had long-standing post-traumatic stress, a ten-week trauma-sensitive yoga program reduced symptoms more than a comparison group did. Breathing, gentle movement and noticing sensations rebuild the connection to the body.
- EMDR (Eye Movement Desensitization and Reprocessing), a therapy in which the client recalls the trauma briefly while following side-to-side movements or taps, helps traumatic memories become ordinary memories.
- Neurofeedback, which trains brain-wave patterns.
- Internal Family Systems, a therapy that works with the different “parts” of a person.
- Theater, rhythm, music and movement, which let people experience power, play and connection in their bodies.
- Mindfulness: learning to notice sensations and feelings without being swept away.
EMDR, neurofeedback, Internal Family Systems and trauma therapy are clinical treatments. They are done by trained, licensed professionals, not by coaches. Breathing, movement, rest, time outdoors, music, community and prayer are everyday practices a coach can encourage.
The Other Side of the Debate
Dr. van der Kolk’s work is widely respected, and some of it is debated. Some neuroscientists say his descriptions of the brain are simplified, and that “the body keeps the score” is a powerful image rather than a literal fact: memories are stored in the brain, while the body carries the stress responses. Researchers also point out that most people who live through a trauma recover without lasting post-traumatic stress; resilience is the common outcome. The therapies with the strongest research for PTSD are trauma-focused talk therapies such as cognitive processing therapy and prolonged exposure, and EMDR. The evidence for yoga and neurofeedback is promising but smaller.
Trauma-Informed Coaching
A coach does not treat trauma. A trauma-informed coach knows that many clients carry trauma, recognizes its signs, avoids re-wounding, and knows when and how to refer. The U.S. Substance Abuse and Mental Health Services Administration (SAMHSA) lists six principles of a trauma-informed approach:
- Safety, physical and emotional.
- Trustworthiness and transparency: say what you will do, and do what you say.
- Peer support: connection with others who understand.
- Collaboration and mutuality: the client is a partner, not a case.
- Empowerment, voice and choice: the client chooses what to talk about and what to do.
- Respect for cultural, historical and gender issues.
In practice, a trauma-informed coach:
- lets the client lead. You never ask for the details of a traumatic experience. If a client begins to share one, you can say, “Thank you for trusting me with that. You don’t need to tell me more than you want to.”
- offers choice constantly: “Would you like to talk about that today, or set it aside?”
- stays in the present and future. Coaching asks, “How is this affecting you now, and what would you like going forward?”
- watches for overwhelm and slows down.
- knows the edge of their role and refers when the past needs healing.
The Window of Tolerance
The psychiatrist Dr. Dan Siegel described a window of tolerance: the zone in which a person can feel emotions and still think clearly. Above the window, a person is hyperaroused: panicky, flooded, shaking, speaking fast, angry. Below it, a person is hypoaroused: numb, flat, foggy, far away, staring. Coaching only works inside the window.
When a client leaves the window during a session:
- Slow down. Lower your voice and pace.
- Pause the topic. “Let’s take a breath together before we go on.”
- Ground in the present. Invite the client to feel their feet on the floor and their back against the chair, to look around and name five things they see, or to hold something with texture.
- Breathe with a long exhale. Breathing in for a count of four and out for a count of six or eight calms the alarm.
- Orient. “You’re here, in my office, it’s Tuesday afternoon, and you’re safe right now.”
- Offer choice. “Would you like to keep going, change the subject, or stop here for today?”
- Follow up. After the session, check in. If overwhelm happens often, it is a sign to refer.
When to Refer
Refer a client to a licensed mental health professional (a psychologist, licensed professional counselor, marriage and family therapist, clinical social worker or psychiatrist) when you see:
- thoughts of suicide or self-harm (see below);
- emotional distress that keeps them from functioning: they can’t work, care for themselves or their children, sleep or eat for weeks;
- symptoms of depression, anxiety or panic that last or worsen;
- flashbacks, nightmares, dissociation or overwhelm that keep coming back;
- a wish to work through past trauma or abuse;
- signs of severe mental illness: hearing or seeing things others don’t, beliefs far out of touch with reality, days without sleep with racing thoughts and grand plans;
- addiction to alcohol or drugs;
- an eating disorder;
- grief that isn’t easing after many months;
- abuse or violence happening now.
Refer to a medical doctor for physical red flags, and to a psychiatrist or the prescribing doctor for any question about psychiatric medication.
How to refer
- Name it kindly and plainly. “What you’re describing sounds really painful, and you deserve more support than coaching can give. I’d like to help you find someone who specializes in this.”
- Normalize it. Many strong people work with a therapist; it is a sign of wisdom, not weakness.
- Help them find someone. Keep a list of trusted local professionals. Online directories such as Psychology Today’s let clients search by location, specialty and insurance; EMDR-trained professionals can be found through EMDRIA; and a primary care doctor or insurance company can recommend names.
- Make it easy. Offer to sit with them while they call or book.
- Follow up. “Were you able to make that appointment?”
- Decide together about coaching. Coaching can often continue alongside therapy, focused on present goals, if the client and their clinician both want it.
Psychiatric Medications
Never tell a client to stop or reduce a psychiatric medication, and teach clients never to stop one on their own. Antidepressants, anti-anxiety drugs, mood stabilizers and antipsychotics must come down gradually with the prescriber. Stopping antidepressants suddenly can cause dizziness, “brain zaps,” nausea and a return of depression; stopping benzodiazepines (such as Xanax, Valium or Klonopin) suddenly can cause seizures; stopping lithium or antipsychotics suddenly can bring a rapid relapse. Antidepressants carry an FDA warning about increased suicidal thoughts in children and young adults under 25, especially when starting or changing a dose. A client who wants to come off a medication can plan it with their prescriber, and a coach can support their nutrition, sleep, stress and habits during the process.
Suicide: Asking and Responding
Nearly 50,000 people die by suicide in the United States each year. Many saw a doctor or spoke to someone in the weeks before. A coach may be that person.
Warning signs
- talking about wanting to die, being a burden, feeling trapped, or having no reason to live
- looking for a way to die, such as searching online or getting a gun or pills
- giving away belongings, saying goodbye, putting affairs in order
- withdrawing from people; more alcohol or drug use
- extreme mood swings, rage, or reckless behavior
- a sudden calm after a long depression, which can mean a decision has been made
Ask directly
Asking someone whether they are thinking about suicide does not put the idea in their head. Research shows it brings relief and lowers distress. Ask plainly:
“Sometimes when people feel the way you’re describing, they think about ending their life. Are you thinking about suicide?”
Respond
The national #BeThe1To campaign teaches five steps:
- Ask directly, as above.
- Be there. Listen without judging, arguing or lecturing. Thank them for telling you.
- Keep them safe. Ask whether they have a plan and the means. Help put distance between them and the means: guns locked away or held by someone else, extra medications removed.
- Help them connect. In the United States, call or text 988, the Suicide & Crisis Lifeline, or chat at 988lifeline.org, together if they’re willing. If someone is in immediate danger, call 911 and stay with them until help arrives. Connect them with their doctor, a therapist, and people who care about them.
- Follow up. Contact them in the next day or two. Follow-up contact saves lives.
Never promise to keep suicidal thoughts secret. If a client says, “Promise you won’t tell anyone,” answer honestly: “I care about you too much to make that promise. I’ll always tell you before I involve anyone else, and we’ll decide together how to get you support.”
Confidentiality and Its Limits
A coach keeps clients’ information private, and that privacy is part of what makes coaching safe. But a coach must never promise absolute confidentiality, because:
- Coaching is not privileged. Unlike a licensed therapist or a lawyer, a coach’s notes and testimony can be ordered by a court.
- Safety comes first. If a client is at serious risk of harming themselves or someone else, you act to protect life.
- The law may require a report. Every state requires certain people to report suspected child abuse or neglect, and some, including Texas, require every adult to report it. Texas also requires anyone who believes an elderly or disabled adult is being abused, neglected or exploited to report it. Learn the law in your own state.
Put these limits in your coaching agreement, explain them in the first session, and remind a client of them if a conversation is heading toward them. Keep brief, factual notes of any crisis: what was said, what you did and when.
Caring for the Coach
Listening to pain, session after session, affects the listener. Coaches can carry vicarious trauma: sleeplessness, irritability, numbness, or the client’s stories replaying in their minds. Protect your own five levels: rest, move, eat well, keep a Shabbat or a weekly day of rest, pray, and talk regularly with a mentor, a peer group or your own coach. A coach who is cared for can care for others.