Slate Star Codex

[Related: CBT In The Water Supply, Scientific Freud, Book Review: Method Of Levels, Different Worlds]

I.

All therapy books start with a claim that their form of therapy will change everything. Previous forms of therapy have required years or even decades to produce ambiguous results. Our form of therapy can produce total transformation in five to ten sessions! Previous forms of therapy have only helped ameliorate the stress of symptoms. Our form of therapy destroys symptoms at the root!

All psychotherapy books bring up the Dodo Bird Verdict – the observation, confirmed in study after study, that all psychotherapies are about equally good, and the only things that matters are “nonspecific factors” like how much patients like their therapist. Some people might think this suggests our form of therapy will only be about as good as other forms. This, all therapy books agree, would be a foolish and perverse interpretation of these findings. The correct interpretation is that all previous forms of therapy must be equally wrong. The only reason they ever produce good results at all is because sometimes therapists accidentally stumble into using our form of therapy, without even knowing it. Since every form of therapy is about equally likely to stumble into using our form of therapy, every other form is equally good. But now that our form of therapy has been formalized and written up, there is no longer any need to stumble blindly! Everyone can just use our form of therapy all the time, for everything! Nobody has ever done a study of our form of therapy. But when they do, it’s going to be amazing! Nobody has even invented numbers high enough to express how big the effect size of our form of therapy is going to be!

Consider the case of Bob. Bob had some standard-issue psychological problem. He had been in and out of therapy for years, tried dozens of different medications, none of them had helped at all. Then he decided to try our form of therapy. In his first session, the therapist asked him “Have you ever considered that your problems might be because of [the kind of thing our form of therapy says all problems are because of]?” Bob started laughing and crying simultaneously, eventually breaking into a convulsive fit. After three minutes, he recovered and proceeded to tell a story of how [everything in his life was exactly in accordance with our form of therapy’s predictions] and he had always reacted by [doing exactly the kind of thing our form of therapy predicts that he would]. Now that all of this was out in consciousness, he no longer felt any desire to have psychological problems. In a followup session two weeks later, the therapist confirmed that he no longer had any psychological problems, and had become the CEO of a Fortune 500 company and a renowned pentathlete.

Not every case goes this smoothly. Consider the case of Sarah. Sarah also has some standard-issue psychological problem. She had also been in and out of therapy for years, tried dozens of different medications, none of them had helped at all. Then she decided to try our form of therapy. In her first session, the therapist asked her “Have you ever considered that your problems might be because of [the kind of thing our form of therapy says all problems are because of]?” Sarah said “No, I don’t think they are.” The therapist asked “Are you sure you’re not just repressing the fact that they totally definitely are, for sure?” As soon as Sarah heard this, she gasped, and her eyes seemed to light up with an inner fire. Then she proceeded to tell a story of how [everything in her life was exactly in accordance with our form of therapy’s predictions] and she had always reacted by [doing exactly the kind of thing our form of therapy predicts that she would], only she was repressing this because she was scared of how powerful she would be if she recovered. Now that all of this was out in consciousness, she no longer felt any desire to have psychological problems. In a followup session two weeks later, the therapist confirmed that she no longer had any psychological problems, and had become the hand-picked successor to the Dalai Lama and the mother of five healthy children.

Previous forms of therapy have failed because they were ungrounded. They were ridiculous mental castles built in the clouds by armchair speculators. But our form of therapy is based on hard science! For example, it probably acts on synapses or the hippocampus or something. Here are three neuroscience papers which vaguely remind us of our form of therapy. One day, neuroscience will catch up to us and realize that the principles of our form of therapy are the principles that govern the organization of the entire brain – if not all of multicellular life.

II.

Maybe I’m being unfair here. I’m basing this off a small sample of therapy books (five textbooks I can think of, plus scattered papers on psychodynamic and psychedelic therapies), and only a subset are quite this bad.

But my basic confusion is this: I work in a clinic with about ten therapists. Some are better than others, but all of them are competent. I send my patients to them. In a few hundred patients I’ve worked with, zero have had the sudden, extraordinary, long-lasting change that the therapy books promise. Many have benefited a little. A few would say that, over the course of years, their lives have been turned around. But sudden complete transformations? Not that much.

Of course, this fits with the therapy books’ perspective. My colleagues practice normal therapy. Sometimes it’s from a boring old school like CBT; other times it’s “eclectic” or “supportive” or any of the other words we use to describe what we’re doing when we don’t know what we’re doing. So maybe there are two sets of therapies: boring old therapies that ordinary people practice, and exciting new therapies that people write glowing books about. And maybe the first set really don’t work (or work only a little), and the second set really is that good.

The problem is, the boring old therapies that everybody uses nowadays inspired equal excitement when they first arose. This is the point that I make in CBT In The Water Supply, and that Oliver Burkeman makes more cogently in Why CBT Is Falling Out Of Favor. Look at therapy books from the 1990s, and they were all about how CBT was a new miracle therapy that would cure your anxiety forever in a few sessions. From a cognitive therapy book:

[When I first learned about cognitive-behavioral therapy, I thought] depression and anxiety seemed far too serious and severe for such a simplistic approach. But when I tried these methods with some of my more difficult patients, my perceptions changed. Patients who’d felt hopeless, worthless, and desperate began to recover. At first, it was hard to believe that the techniques were working, but I could not deny the fact that when my patients learned to put the lie to their negative thoughts, they began to improve. Sometimes they recovered right before my eyes during sessions. Patients who’d felt demoralized and hopeless for years suddenly turned the corner on their problems. I can still recall an elderly French woman who’d been bitterly depressed for more than fifty years, with three nearly-successful suicide attempts, who started shouting “Joie de vivre! Joie de vivre!” (“joy of living”) one day in my office. These experiences made such a strong impact on me that I decided my calling was in clinical work rather than brain research. After considerable soul-searching, I decided to give up my research career and become a full-time clinician. Over the years, I’ve had more than 35,000 psychotherapy sessions with depressed and anxious patients, and I’m every bit as enthusiastic about CBT as when I first began learning about it.

But look at therapy books now, and they’re all people saying “Sure, CBT barely outperforms placebo…but what about this exciting new therapy which blows CBT out of the water?”

Studies reflect this decline:

…with the average studied effect size of CBT shrinking from 2.5 to 1.0 over the course of a generation. People have come up with various explanations for this. Maybe therapist quality is falling – when CBT was the hot new thing, you had to be a really plugged-in up-to-date therapist to have heard about it and to make the effort to retrain in it, so only the best therapists would practice it, but now it’s the default therapy used by everyone who’s just clocking it in. Maybe placebo effect is falling – when people viewed it as an astounding miracle therapy, it got astounding miracle results, but now that it’s lost its luster nobody takes it seriously anymore. Maybe its ideas are spreading, so that patients come into their first session already aware of CBT insights and inoculated against them. Or maybe it’s like all science, where the first studies are done quickly by true believers, and the later studies are done carefully by the Cochrane Collaboration, and so the level of hype naturally goes down.

These explanations have different practical implications. If it’s all about therapist quality and placebo expectations, then you should go get the exciting new therapies described in therapy books, since their unusually-qualified therapists and unusually-high expectations will deliver you the miracle cure you’re looking for.

If it’s just that study quality gets better and better until we realize how crappy the exciting new therapies really are, you might as well get the boring old therapies. At least insurance probably covers them.

And they also have different philosophical implications. If it’s all about therapist quality and placebo expectations, then even if it’s hard to deliver high-quality therapy consistently at scale, it means high-quality therapy is a thing. It means that if enough factors go right at once, therapy can be the kind of powerful tool that cures someone’s life-long psychiatric issues in a few sessions with a high success rate. If this is true it would be fascinating. It would be like saying that bananas cure cancer, but only if they’re really fresh bananas. Even if there are practical issues in getting every cancer patient a banana that’s fresh enough, you still want to take a step back and think “Whoa, what’s up with this?”

I can only say that I’ve had a few patients try the exciting new therapies, and none of them have reported miracle cures. They’ve all maybe gotten a little better over long periods, same as the boring old therapies. This makes me think it’s more likely that early results from the exciting new therapies get oversold, not that some combination of therapist skill and excitement makes them go shockingly well. And the Efficient Market agrees with my low estimation, given that therapists aren’t rushing to learn these new strategies and patients aren’t rushing to use them.

But the therapy books still confuse me. They’re full of stories of incredible instant cures, with the authors assuring us that these are all real and typical of their experience. How can you get this from merely “stretching the truth”, as opposed to outright data falsification? Are therapy book authors blatantly lying? I try to have a really low prior on this sort of thing, but I’m not sure.

Therapy books are often written by the researcher who invented the therapy. I imagine if you invent a therapy yourself, then it perfectly fits your personality and communication style, you believe in it wholeheartedly, and you understand every piece of it from the ground up. You’re also probably a really exceptional and talented person who’s obsessed with psychotherapy and how to make it better. So maybe they get results nobody else can replicate?

But that still raises the philosophical implication of it being possible, for somebody, to consistently produce dramatic change through therapy. This still bothers me a lot.

III.

Most therapy books share some assumptions, so deep as to be unspoken: current problems serve some purpose related to past traumas.

Different therapies take this in different directions. Some view problems as a passive residue of past traumas: for example you were abused as a child, that filled you with stress and rage, and now you take that out on other people and yourself. Others view them as maladaptive learning from past trauma: for example, you were abused as a child, that taught you that other people would hurt you if you opened up to them, so you never open up to anybody. I don’t know the official name for this, but let’s call it historicism: symptoms are the result of something that happened in a patient’s life history.

Some weak forms of historicism are obviously true. Many (though not all) phobias began with a clear incident where the patient was endangered by the phobic object; someone mauled by a dog as a child who then has cynophobia as an adult is hardly a medical mystery. Many (though not all) depressions are precipitated by some depressing event. And post-traumatic stress disorder has the historical perspective right there in the name; at the very least, going through trauma dysregulates something inside you. But it’s a long way from there to saying that a patient’s psychosomatic blindness is caused by persistent shame at having seen their parents having sex thirty years earlier, or something like that.

And some therapy books go beyond historicism into purposefulism: symptoms serve some quasi-logical purpose relating to the life history. I recently read a therapy book that included a case like this. Bob had a history of failing at work. He would go from job to job, making various mistakes and doing crappy work until he got fired. He went to a therapist for help. During the therapy, it came out that Bob’s abusive father had always pushed him really hard to succeed. The therapist suggested that maybe Bob failed at work to send a message to his father; ie to prove that his father’s abusive parenting had been a bad idea and would not make Bob successful. The therapist asked Bob to imagine confronting his father about this. After he worked through his anger at his father, Bob was able to succeed at work. In this story, the apparently dysfunctional symptom (failing at work) ended up having a legible purpose within Bob’s life history (it helped him send a message to his father). Only by teasing out the purpose and finding some other way to achieve it could the dysfunctional behavior be prevented.

A non-historical, non-purposeful account might argue that Bob failed at work because he was bad at work. Maybe he was bad at the specific jobs he was holding (in which case he should get more training). Maybe he was bad at social skills (in which case he should learn to communicate better). Maybe he had ADHD and kept getting distracted (in which he should get treatment for ADHD). In any case, him being bad at work isn’t related to any past traumas or serving any hidden purposes. It’s just an unfortunate fact.

I am constantly worried by the history of how many things we historically applied historical-purposeful reasoning to, totally confident at the time that our explanations made sense – which we now know are not historical-purposeful at all. Psychologists “knew” that autism was caused by distant mothers, and schizophrenia by overbearing mothers, right up until we discovered both conditions are about 80% genetic. And when they “knew” these things, they were able to come up with long lists of how exactly each individual patient fit the mold, and reported great progress by helping patients overcome their maternal attachment issues. Back when homosexuality was considered a disorder, historical-purposeful therapists would tell gay people patients they must be so angry at their mother that they had sworn off all female companionship and switched to men instead as a way of sending her a giant “F–K YOU” message; while homosexuality is mostly not genetic, few people today think this is a plausible explanation.

I sometimes see if I can come up with these kinds of historical-purposeful accounts of my patients’ symptoms. These always fit into place freakishly well – so well that either the historical-purposeful perspective is completely true, or there is some very strong bias that makes it extra-convincing despite its falsehood. But we already know there’s some very strong bias that makes it extra-convincing despite its falsehood! That bias must have been at work in all the therapists who applied historical-purposeful narratives to autistics, schizophrenics, and gays! At some point I notice the road I’m on is littered with skulls and start wondering if I should reconsider.

All therapy books propose an answer: the proof is that the patients get better. But my patients do not get better. When I tell them the historical-purposeful accounts I have devised for their symptoms, they usually shrug and say it sounds plausible and they’ve thought along those lines before, but what are they going to do? When I try all the exciting new therapies on them, they just sort of nod, say that this sounds like an interesting perspective, and then go off and keep having symptoms. It’s very rude!

I’ve told this story before: when I was a teenager, I got really into pseudohistory for a while. What snapped me out of it wasn’t the sober historians, who totally went AWOL on their job of explaining why they were right and the whackos were wrong. It was that a bunch of mutually exclusive pseudohistories all sounded equally plausible: the Pyramids couldn’t have been built by Atlanteans and Lemurians and mole-people! At that point I was able to halt, melt, catch fire, and realize there was something really wrong with my reasoning processes, which I continue to worry about and work on twenty years later.

I bring this up because I’m going to be reviewing some specific psychotherapy books. Each of them on their own can be convincing. But they should be taken in the context of All Therapy Books, which as a category are pretty worrying.

I.

The Body Keeps The Score is a book about post-traumatic stress disorder.

The author, Bessel van der Kolk, helped discover the condition and lobby for its inclusion in the DSM, and the brief forays into that history are the best part of the book. Like so many things, PTSD feels self-evident once you know about it. But this took decades of conceptual work by people like van der Kolk, crystallizing some ideas and hacking away at others until they ended up with something legible to the Establishment. Before that there was nothing. It was absolutely shocking how much nothing there was. As soon as the APA officialy recognized PTSD as a diagnosis in 1980, Bessel and his friends applied for a grant from the VA to study it. The grant was rejected on the grounds that (actual quote from the rejection letter) “it has never been shown that PTSD is relevant to the mission of the Veterans Administration”. So the first step in raising awareness of PTSD was – amazingly – convincing the US military that some people might get PTSD from combat.

After the military relented, the next step was convincing everyone else. PTSD was temporarily pigeonholed as “the thing veterans get when they come back from a war”. The next push was convincing people that civilian trauma could have similar effects. It was simple to extend the theory to sudden disasters like fires or violent crimes. But van der Kolk and his colleagues started noticing that a history of child abuse, and especially childhood sexual abuse, correlated with a lot of psychiatric problems later on.

Again, “child abuse is bad” sounds self-evident once you know it. But van der Kolk insists this is the result of hard work by a coalition of psychiatrists, psychologists, activists, and victims. When he first started raising awareness of the problem, nobody believed him. His grant proposal to study whether childhood trauma was associated with personality disorders got rejected too. He recalls that:

I was particularly struck by how many female patients spoke of being sexually abused as children. The standard textbook of psychiatry at the time stated that incest was extremely rare in the United States, cocurring about once in every million women. Given that there were then only about one hundred million women in the United States, I wondered how forty-seven, almost half of them, had found their way to my office in the basement of the hospital.

Furthermore, the textbook said, “There is little agreement about the role of father-daughter incest as a source of serious subsequent psychopathology”…the textbook went on to practically endorse incest, explaining that “such incestuous activity diminishes the subject’s chance of psychosis, and allows for a better adjustment to the external world.”

Van der Kolk found that child abuse (sexual and otherwise) was both far more common and far more destructive than anybody else thought. He also found that it worked differently than regular PTSD. A soldier traumatized during war has already developed a sense of self, and has a concept of a safe homeland to return to if he makes it out alive; a child has neither, and has to deal with trauma again and again absent any trustworthy external support system. This is the same insight some researchers call “complex PTSD”; van der Kolk uses the terms “developmental trauma disorder” and argues it is the real culprit behind many people currently diagnosed with ADHD, bipolar, intermittent explosive disorder, oppositional defiant disorder, etc. He rejects at least some of these diagnoses as “pseudoscience…impressive but meaningless labels”.

A group including Van der Kolk tried to get developmental trauma disorder added to the DSM; the APA decided against it. He denounces this decision, which he thinks ignored several great studies that prove developmental trauma (ie child abuse) is much more important than anyone else thinks. I have a lot of opinions about this section.

First, I think van der Kolk downplays the importance of the APA’s philosophical commitment to categorizing by symptoms rather than cause. Consider four patients, Alice, Bob, Carol, and Dan. Alice has poor concentration caused by child abuse. Bob has poor concentration caused by bad genes. Carol throws tantrums because child abuse. Dan throws tantrums because bad genes. The current DSM would categorize Alice and Bob as ADHD, and Carol and Dan as intermittent explosive disorder. Van der Kolk would like to classify Alice and Carol as having Developmental Trauma Disorder, and Bob and Dan as…I don’t know. Bad Gene Disorder? Seems sketchy. When the APA decides not to do that, they’re not necessarily rejecting the seriousness of child abuse, only saying it’s not the kind of thing they build their categories around.

Second, van der Kolk really does not come across as a great source about the effects of development. He does not mention the possibility that links between parent behavior and child pathology might be genetic (ie a disordered parent is more likely to abuse their child, and to pass on genes for disordered behavior). In fact, he is weirdly and vocally ignorant about genetics in general, dismissing the entire field because “after thirty years and millions upon millions of dollars worth of research, we have failed to find consistent genetic patterns for schizophrenia – or for any psychiatric illness, for that matter”. When TBKtS was published in 2014, we already know with certainty that schizophrenia was about 80% genetic, and at least 15 genes had been identified as especially likely to be involved; today we know hundreds and can even make primitive polygenic predictors. The only gene he considers sympathetically is good old 5-HTTLPR, which he says proves that genes have different effects in children with vs. without abuse histories (like everything else about 5-HTTLPR, this has since been proven false). He shows total lack of interest in behavioral genetics and the challenge it raises to his hypothesis.

This is a very pre-replication crisis book. I don’t hold this against the author, I don’t think anyone’s really proud of what they believed pre-replication crisis, but it’s undoubtedly a product of its time. Mirror neurons, candidate genes, left- vs right-brained people, etc all make dramatic appearances. Nothing (except the genetics parts) are inexcusable or even certainly wrong, but all of them together concern me. And several of the book’s key studies are contradicted by later, larger studies. Van der Kolk talks about how childhood trauma decreases IQ, but some pretty good studies say it doesn’t. Even the studies that have passed the test of time look a little weird. The Adverse Childhood Experiences study found that obesity and other seemingly nonpsychiatric diseases were linked to child abuse, and recent studies confirm this – but the controls for socioeconomic status are always insufficient, and there’s surprisingly little shared environmental component. I’m biased about this, everyone’s biased, but part of the book was meant to prove that child abuse mattered shockingly more than you thought it possibly could, and that part was wasted on me.

II.

Fine, okay, drop that hobby horse, what does this book have to say about PTSD?

The book stressed the variety of responses to PTSD. Some people get anxious. Some people get angry. But a lot of people, whatever their other symptoms, also go completely numb. They are probably still “having” “emotions” “under” “the” “surface”, but they have no perception of them. Sometimes this mental deficit is accompanied by equally surprising bodily deficits. Van der Kolk describes a study on stereoagnosia in PTSD patients: if blindfolded and given a small object (like a key), they are unable to recognize it by feel, even though this task is easy for healthy people. Sometimes this gets even more extreme, like the case of a massage therapy patient who did not realize they were being massaged until the therapist verbally acknowledged she had started.

The book is called The Body Keeps The Score, and it returns again and again to the idea of PTSD patients as disconnected from their bodies. The body sends a rich flow of information to the brain, which is part of what we mean when we say we “feel alive” or “feel like I’m in my body”. In PTSD, this flow gets interrupted. People feel “like nothing”. For example:

I don’t know what I feel, it’s like my head and body aren’t connected. I’m living in a tunnel, a fog, no matter what happens it’s the same reaction – numbness, nothing. Having a bubble bath and being burned or raped is the same feeling.

Or, borrowed from one of William James’ patients:

I have no human sensations. I am surrounded by all that can render life happy and agreeable, still to me the faculty of enjoyment and of feeling is wanting. Each of my senses, each part of my proper self, is as it were separated from me and can no longer afford me any feeling; this impossibility seems to depend upon a void which I feel in the front of my head, and to be due to the diminuition of the sensibility over the whole surface of my body, for it seems to me that I never actually reach the objects that I touch. All this would be a small matter enough, but for its frightful result, which is that of the impossibility of any other kind of feeling and of any sort of enjoyment, although I experience a need and desire of them that render my life an incomprehensible torture.

One other new thing I learned about PTSD is the importance of immobilization. Van der Kolk thinks that traumas are much more likely to cause PTSD when the victim is somehow unable to respond to them. Enemy soldiers shooting at you and you are running away = less likelihood of trauma. Enemy soldiers shooting at you and you are hiding motionless behind a tree = more likelihood of trauma. Speculatively, your body feels like its going into trauma mode hasn’t gotten you to take the right actions, and so the trauma mode cannot end.

There’s some discussion of the neurobiology of all this, but it never really connects with the vividness of the anecdotes. A lot of stuff about how trauma causes the lizard brain to inappropriately activate in ways the rational brain can’t control, how your “smoke detector” can be set to overdrive, all backed up with the proper set of big words like “dorsolateral prefrontal cortex” – but none of it seemed to reach the point where I felt like I was making progress to a gears-level explanation. I felt like the level on which I wanted an explanation of PTSD, and the level at which van der Kolk was explaining PTSD, never really connected; I can’t put it any better than that.

Why does PTSD exist? “The brain isn’t prepared to feel emotions as intense as…” Yes it is! Trauma is as old as living creatures; war, disaster, bullying, and rape far predate homo sapiens. Even if child abuse is rare in hunter-gatherer tribes (as some optimistic anthropologists claim) killing all the adults in a tribe and enslaving their children is pretty common, which cashes out to kids getting abused. Our evolutionary history should have prepared us incredibly well for all of this; the brain “getting stuck” in fear mode after a particularly bad trauma should be no more likely than the legs “getting stuck” in running mode after a particularly long chase.

And why would the body be so confused by the right action being “hide” or “accept the pain and abuse” rather than “run” or “fight”? The safest action has been “hide” or “accept the pain and the abuse” in a pretty good fraction of traumatic events since humanity came down from the trees.

And why should the consequences of this be the body going numb? Why not other things that seem more like the consequences of garden-variety acute or chronic stress?

I missed any answers that TBKtS might have contained to questions like these, and so a lot of its neurobiology ended up feeling more like a random collection of simplified facts than like real enlightenment.

III.

But all of this would be excusable if TBKtS had answered the most important question: how do you treat PTSD? There are a wide variety of proposed methods, and I was looking forward to having an authority like van der Kolk sort through the evidence for and against each.

Instead, I felt like he rejected every conventional treatment on the grounds that they didn’t treat the root problem, then waxed rhapsodic about every single weird alternative treatment and how it was a perfect miracle cure that truly gave patients their lives back. I understand that he may just be presenting the alternative treatments that he found most effective, but something about the style here really turned me off.

There are a lot of alternative treatments for PTSD. Neurofeedback, where you attach yourself to a machine that reads your brain waves and try to explore the effect your thoughts have on brain wave production until you are consciously able to manipulate your neural states. Internal family systems, where a therapist guides you through discovering “parts” of yourself (think a weak version of multiple personalities), and you talk to them, and figure out what they want, and make bargains with them where they get what they want and so stop causing mental illness. Eye movement directed reprocessing (alternative when the book was written, now basically establishment) where you move your eyes back and forth while talking about your trauma, and this seems to somehow help you process it better. Acupuncture. Massage. Yoga.

There was a thing called “PBSP psychomotor therapy”, where the therapist would create “tableaus” representing people’s traumas. They would enlist an actor to play the victim’s abusive father, then another actor to play an idealized version of their father who didn’t abuse them and was always there when they needed them, then have them recite formulaic lines that “played their part” in the remembered (or alternative hypothetical) versions of the patient’s trauma. Gradually they would progress from the real trauma to a version where things had worked out better, with the therapist discussing the patient’s reaction the whole time.

There was a chapter on community theater, where troubled youth who would otherwise be sent to jail were instead asked to put on a Shakespeare production. This encountered some early hitches:

We were shocked to discover that, in scenes where someone was in physical danger, the students always sided with the aggressors. Because they could not tolerate any sign of weakness in themselves, they could not accept it in others. They showed nothing but contempt for potential victims, yelling things like “Kill the bitch, she deserves it,” during a skit about dating violence.

At first some of the actors wanted to give up – it was simply too painful to see how mean these kids were – but they stuck it out, and I was amazed to see how they gradually got the students to experiment, however reluctantly, with new roles. Toward the end of the program, a few students were even volunteering for parts that involved showing vulnerability or fear.

The traumatic incidents in Shakespeare’s work helped them come to terms with their own difficult history:

As we’ve seen, the essence of trauma is feeling godforsaken, cut off from the human race. Theater involves a collective confrontation with the realities of the human condition. As Paul Griffin, discussing his theater program for foster care children, told me: “The stuff of tragedy in theater revolves around coping with betrayal, assault, and destruction. These kids have no trouble understanding what Lear, Othello, Macbeth, or Hamlet is all about.” In Tina Packer’s words: “Everything is about using the whole body and having other bodies resonate with your feelings, emotions, and thoughts.” Theater gives trauma survivors a chance to connect with one another by deeply experiencing their common humanity.”

Each of these stories about an alternative therapy was, on its own, inspiring. But after chapter after chapter on these, plus other even weirder things, you start to wish there was at least one alternative therapy that Bessel van der Kolk didn’t like, or one conventional therapy that he did.

This is a very pre-replication-crisis book. In these more cynical days, we know that the first few studies on any technique – usually done in an atmosphere of frothy excitement, by the technique’s most fervent early adapters – are always highly positive. And later studies – done in an atmosphere of boredom, by large multi-center consortia – are almost always disappointing. Half the time van der Kolk is so excited about the miraculous life-changing potential of the latest alternative therapy that he doesn’t list studies at all. The other half of the time, the studies are there to support his enthusiasm. But can they be trusted?

Overall, so many bizarre methods seemed to work so well (with no examples of anything that didn’t work) that it was hard for me to figure out how this book should affect my treatment decisions. Find the closest person in a robe and wizard hat and send all of my trauma patients to them, because every alternative therapy works equally well as long as it’s weird? This might actually be a good lesson, there are a lot of things in psychiatry where as long as people feel drawn in and “validated” the treatment works. But I’m annoyed I have to ponder this kind of thing on my own rather than have the book take a step back and wonder about these kinds of questions.

[Update, written a few weeks after the rest of this post: maybe it is all wizardry. I recommended this book to a severely traumatized patient of mine, who had not benefited from years of conventional treatment, and who wanted to know more about their condition. The next week the patient came in, claiming to be completely cured, and displaying behaviors consistent with this. They did not use any of the techniques in this book, but said that reading the book helped them figure out an indescribable mental motion they could take to resolve their trauma, and that after taking this mental motion their problems were gone. I’m not sure what to think of this or how much I should revise the negative opinion of this book which I formed before this event.]

Maybe the most consistent lesson from this book’s tour of successful alternative therapies – keeping with the theme of the title – is that it’s important for PTSD patients to get back in touch with their bodies. Massage therapy, yoga, and acupuncture addressed this directly, usually creating gentle, comfortable sensations that patients could take note of to gradually relax the absolute firewall between bodily sensation and conscious processing. Some of the other methods – the community theater, maybe even the internal family systems – seemed like tricks to get people afraid of emotions back in touch with their emotions anyway: “Oh, you’re not going to be feeling your emotions, just emotions from Macbeth or Hamlet or this other personality living in your mind”. I don’t know how plausible this interpretation is.

IV.

Overall, I was not too impressed with this book. The highlight was van der Kolk’s personal reminisces from the fight to get PTSD recognized as a real disease – but some of them were so over-the-top that I would have liked to triangulate them with a more objective history. The sections with the symptomatology and neurobiology of PTSD were helpful in exploring the boundaries of the syndrome, but didn’t make me feel like I really understood what was going on. The sections on the dangers of child abuse were a good knock-down of some hypothetical “child abuse isn’t really that bad” position, but I don’t know anyone who holds that position, and some of the research seemed questionable. And the section on treatment was so glowing about everything that it was hard to draw any specific conclusions.

Maybe a broader concern is that I seem to inhabit a different world than van der Kolk. All of his patients showed bizarre and florid sequelae from serious trauma. My patients seem to discuss their trauma with comparative equanimity, have only the usual psychiatric symptoms (depression, anxiety, etc) and not experience much benefit from the weirder alternative therapies they try. Some of this might be van der Kolk being a better doctor than I am, or having sicker patients. But I’m concerned about this because van der Kolk seems pretty good at doing what he does, and I would like to be able to inhabit his world insofar as he’s able to get good results in it. But insofar as my goal is to become more like Bessel van der Kolk, I was surprised how little this book helped guide me along that journey.

I think my actual takeaway is to screen for trauma more carefully, especially in patients who seem anhedonic or numb, and to recommend they go to a trauma clinic. There are a lot of places like this (I sometimes send patients to this one in Berkeley), and they practice a lot of the weirder alternative therapies that van der Kolk mentions (in fact, van der Kolk seems to work at/lead a very similar type of institution in Massachussetts). Whether or not these work for everybody, I think everybody deserves a chance at them, and I should take them more seriously at least until I get a better sense of the terrain here myself.