Bessel van der Kolk sat cross-legged on an oversize pillow in the center of a smallish room overlooking the Pacific Ocean in Big Sur. He wore khaki pants, a blue fleece zip-up and square wire-rimmed glasses. His feet were bare. It was the third day of his workshop, “Trauma Memory and Recovery of the Self,” and 30 or so workshop participants — all of them trauma victims or trauma therapists — lined the room’s perimeter. They, too, sat barefoot on cushy pillows, eyeing van der Kolk, notebooks in hand. For two days, they had listened to his lectures on the social history, neurobiology and clinical realities of post-traumatic stress disorder and its lesser-known sibling, complex trauma. Now, finally, he was about to demonstrate an actual therapeutic technique, and his gaze was fixed on the subject of his experiment: a 36-year-old Iraq war veteran named Eugene, who sat directly across from van der Kolk, looking mournful and expectant.
从不大的房间望出去，大瑟尔地区太平洋的风光尽收眼底。贝塞尔·范德科尔克(Bessel van der Kolk)盘腿坐在房间中央的超大号靠枕上。他戴着方形金丝眼镜，身穿蓝色拉链式绒头织物衫和卡其布裤子，赤着脚。这天是他主办的“创伤记忆与自我恢复”(Trauma Memory and Recovery of the Self)研讨会的第三天，约30名研讨会参与者（均为创伤受害者或创伤治疗师）沿着房间的四壁围成一圈。他们也都赤脚坐在舒适的靠枕上，手里拿着笔记本，眼睛盯着范德科尔克。两天来，他们聆听他讲解了创伤后应激障碍(post-traumatic stress disorder, PTSD)及其鲜为人知的同类——复杂创伤(complex trauma)的社会历史、神经生物学和临床现状。现在，他终于将向他们演示实际的治疗技术。范德科尔克将目光落在自己的实验对象尤金(Eugene)的身上。这是一名36岁的伊拉克战争退伍军人，此刻他正坐在范德科尔克的对面，面带悲伤，又充满期待。
Van der Kolk began as he often does, with a personal anecdote. “My mother was very unnurturing and unloving,” he said. “But I have a full memory and a complete sense of what it is like to be loved and nurtured by her.” That’s because, he explained, he had done the very exercise that we were about to try on Eugene. Here’s how it would work: Eugene would recreate the trauma that haunted him most by calling on people in the room to play certain roles. He would confront those people — with his anger, sorrow, remorse and confusion — and they would respond in character, apologizing, forgiving or validating his feelings as needed. By projecting his “inner world” into three-dimensional space, Eugene would be able to rewrite his troubled history more thoroughly than other forms of role-play therapy might allow. If the experiment succeeded, the bad memories would be supplemented with an alternative narrative — one that provided feelings of acceptance or forgiveness or love.
The exercise, which van der Kolk calls a “structure” but which is also known as psychomotor therapy, was developed by Albert Pesso, a dancer who studied with Martha Graham. He taught it to van der Kolk about two decades ago. Though it has never been tested in a controlled study, van der Kolk says he has had some success with it in workshops like this one. He likes to try it whenever he has a small group and a willing volunteer.
这种做法被范德科尔克称为“构造”(structure)，它还有个名字叫做精神运动疗法(psychomotor therapy)。舞蹈演员艾伯特·佩索(Albert Pesso)创立了该疗法，并在大约20年前教给了范德科尔克。尽管这种疗法未在对照研究中接受过检验，但范德科尔克称，在几次类似的研讨会中，他们已经有过若干成功的先例。无论何时何地，只要他身边聚集了一小群人，而且有人愿意站出来，他都喜欢尝试一下这种疗法。
With some gentle prodding from van der Kolk, Eugene told us how he came to be a specialist in the United States Army, how he spent a full year stationed in Mosul, the largest city in northern Iraq, and how his job involved disposing of exploded bombs. It was a year of dead bodies, he said. He saw, touched, smelled and stepped in more bodies than he could possibly count. Some of them were children. He was only 26.
People turn to grease when they explode, he told us, because their fat cells burst open. He witnessed multiple suicide bombings. Once, he accidentally stepped in an exploded corpse; only the legs were still recognizable as human. Another time, he saw a kitchen full of women sliced to bits. They’d been making couscous when a bomb went off and the windows shattered. He was shot in the back of the head once. He was also injured by an improvised explosive device.
But none of those experiences haunted him quite as much as this one: Several months into his tour, while on a security detail, Eugene killed an innocent man and then watched as the man’s mother discovered the body a short while later.
“Tell us more about that,” van der Kolk said. “What happened?” Eugene’s fragile composure broke at the question. He closed his eyes, covered his face and sobbed.
“The witness can see how distressed you are and how badly you feel,” van der Kolk said. Acknowledging and reflecting the protagonist’s emotions like this — what van der Kolk calls “witnessing” them — is a central part of the exercise, meant to instill a sense of validation and security in the patient.
Eugene had already called on some group members to play certain roles in his story. Kresta, a yoga instructor based in San Francisco, was serving as his “contact person,” a guide who helps the protagonist bear the pain the trauma evokes, usually by sitting nearby and offering a hand to hold or a shoulder to lean on. Dave, a child-abuse survivor and small-business owner in Southern California, was playing Eugene’s “ideal father,” a character whose role is to say all the things that Eugene wished his real father had said but never did. They sat on either side of Eugene, touching his shoulders. Next, van der Kolk asked who should play the man he killed. Eugene picked Sagar, a stand-up comedian and part-time financial consultant from Brooklyn. Finally, van der Kolk asked, Who should play the man’s mother?
Eugene pointed to me. “Can you do it?” he asked.
I swore myself in as the others had, by saying, “I enroll as the mother of the man you killed.” Then I moved my pillow to the center of the room, across from Eugene, next to van der Kolk.
“O.K.,” van der Kolk said. “Tell us more about that day. Tell us what happened.”
Psychomotor therapy is neither widely practiced nor supported by clinical studies. In fact, most licensed psychiatrists probably wouldn’t give it a second glance. It’s hokey-sounding. It was developed by a dancer. But van der Kolk believes strongly that dancers — and musicians and actors — may have something to teach psychiatrists about healing from trauma and that even the hokey-sounding is worthy of our attention. He has spent four decades studying and trying to treat the effects of the worst atrocities we inflict on one another: war, rape, incest, torture and physical and mental abuse. He has written more than 100 peer-reviewed papers on psychological trauma. Trained as a psychiatrist, he treats more than a dozen patients a week in private practice — some have been going to him for many years now — and he oversees a nonprofit clinic in Boston, the Trauma Center, that treats hundreds more. If there’s one thing he’s certain about, it’s that standard treatments are not working. Patients are still suffering, and so are their families. We need to do better.
Van der Kolk takes particular issue with two of the most widely employed techniques in treating trauma: cognitive behavioral therapy and exposure therapy. Exposure therapy involves confronting patients over and over with what most haunts them, until they become desensitized to it. Van der Kolk places the technique “among the worst possible treatments” for trauma. It works less than half the time, he says, and even then does not provide true relief; desensitization is not the same as healing. He holds a similar view of cognitive behavioral therapy, or C.B.T., which seeks to alter behavior through a kind of Socratic dialogue that helps patients recognize the maladaptive connections between their thoughts and their emotions. “Trauma has nothing whatsoever to do with cognition,” he says. “It has to do with your body being reset to interpret the world as a dangerous place.” That reset begins in the deep recesses of the brain with its most primitive structures, regions that, he says, no cognitive therapy can access. “It’s not something you can talk yourself out of.” That view places him on the fringes of the psychiatric mainstream.
范德科尔克尤其对创伤治疗中最常用的两种方法持有异议：认知行为疗法（cognitive behavioral therapy，简称CBT）和暴露疗法(exposure therapy)。暴露疗法是让患者一遍又一遍地面对最困扰他们的问题，直到他们对此变得麻木。范德科尔克把它贬斥为“最不可能治疗”创伤的方法。它的成功率还不到一半，他说，就算“成功”了也无法提供真正的解脱：脱敏与痊愈是两个不同的概念。他对认知行为疗法，也有类似的看法。认知行为疗法试图通过一种苏格拉底式的对话，帮助患者认识到自己的思想与情绪之间的联系调试不良，从而改变患者的行为。“但创伤与认知可没有一丁点儿关系，”范德科尔克说。“真正的问题在于，创伤改造了你的身体，让你觉得这世界很危险。”这种改造源于我们大脑中最原始结构的深处，认知疗法所无法触及的地带。“这不是你劝解自己说几句就可以解决的。”这些观点令他游离出了精神学主流。
It’s not the first time van der Kolk has been there. In the early 1990s, he was a lead defender of repressed-memory therapy, which the Harvard psychologist Richard McNally later called “the worst catastrophe to befall the mental-health field since the lobotomy era.” Van der Kolk served as an expert witness in a string of high-profile sexual-abuse cases that centered on the recovery of repressed memories, testifying that it was possible — common, even — for victims of extreme or repeated sexual trauma to suppress all memory of that trauma and then recall it years later in therapy. He’d seen plenty of such examples in his own patients, he said, and could cite additional cases from the medical literature going back at least 100 years.
范德科尔克并不是第一次陷入这种境地。20世纪90年代初，他是记忆抑制治疗(repressed-memory therapy)的一名主要的拥护者。该疗法后来被哈佛大学的心理学家理查德·麦克纳利(Richard McNally)称为“自脑叶切除术时代以来降临到心理健康领域的最大灾难。”在当时的一系列引人注目的性虐待案件中（均与恢复受抑制的记忆密切相关），范德科尔克担任了专家证人，作证称遭受极端或反复性创伤的受害者有可能——甚至普遍——会压抑自己关于那些创伤的所有记忆，直至多年后在治疗中才回想起来。他表示，在自己的患者中见过很多这样的例子，此外，他还能从医学文献中找出此类案例，至少可以回溯100年。
In the 1980s and ‘90s, people from all over the country filed scores of legal cases accusing parents, priests and day care workers of horrific sex crimes, which they claimed to have only just remembered with the help of a therapist. For a time, judges and juries were persuaded by the testimony of van der Kolk and others. It made intuitive sense to them that the mind would find a way to shield itself from such deeply traumatic experiences. But as the claims grew more outlandish — alien abductions and secret satanic cults — support for the concept waned. Most research psychologists argued that it was much more likely for so-called repressed memories to have been implanted by suggestive questioning from overzealous doctors and therapists than to have been spontaneously recalled. In time, it became clear that innocent people had been wrongfully persecuted. Families, careers and, in some cases, entire lives were destroyed.
After the dust settled in what was dubbed “the memory wars,” van der Kolk found himself among the casualties. By the end of the decade, his lab at Massachusetts General Hospital was shuttered, and he lost his affiliation with Harvard Medical School. The official reason was a lack of funding, but van der Kolk and his allies believed that the true motives were political.
待这场日后被称为“记忆之战”的争论尘埃落定之后，范德科尔克自己也付出了代价。90年代末，他在马萨诸塞州总医院(Massachusetts General Hospital)的实验室被关停，还失去了在哈佛医学院(Harvard Medical School)的职位。官方给出的理由是资金不足，但范德科尔克及其支持者认为，真正的动机是政治因素。
Van der Kolk folded his clinic into a larger nonprofit organization. He began soliciting philanthropic donations and honed his views on traumatic memory and trauma therapy. He still believed that repressed memories were a common feature of traumatic stress. Traumatic experiences were not being processed into memories, he reasoned, but were somehow getting “stuck in the machine” and then expressed through the body. Many of his colleagues in the psychiatric mainstream spurned these ideas, but he found another, more receptive audience: body-oriented therapists who not only embraced his message but also introduced him to an array of alternative practices. He began using some of those practices with his own patients and then testing them in small-scale studies. Before long, he had built a new network of like-minded researchers, body therapists and loyal friends from his Harvard days.
The group converged around an idea that was powerful in its simplicity. The way to treat psychological trauma was not through the mind but through the body. In so many cases, it was patients’ bodies that had been grossly violated, and it was their bodies that had failed them — legs had not run quickly enough, arms had not pushed powerfully enough, voices had not screamed loudly enough to evade disaster. And it was their bodies that now crumpled under the slightest of stresses — that dove for cover with every car alarm or saw every stranger as an assailant in waiting. How could their minds possibly be healed if they found the bodies that encased those minds so intolerable? “The single most important issue for traumatized people is to find a sense of safety in their own bodies,” van der Kolk says. “Unfortunately, most psychiatrists pay no attention whatsoever to sensate experiences. They simply do not agree that it matters.”
That van der Kolk does think it matters has won him an impressive and diverse fan base. “He’s really a hero,” says Stephen Porges, a professor of psychiatry at the University of North Carolina, Chapel Hill. “He’s been extraordinarily courageous in confronting his own profession and in insisting that we not discount the bodily symptoms of traumatized people as something that’s ‘just in their heads.’ ”
范德科尔克对身体感受的重视为他赢得了背景各异的众多粉丝。“他是一个真正的英雄，”北卡罗来纳大学教堂山分校(University of North Carolina, Chapel Hill)的精神病学教授史蒂芬·波格斯(Stephen Porges)表示。“他一直表现出大无畏的态度，挑战自己的学术圈子，并始终坚持不应简单地认定创伤受害者存在身体症状‘仅仅是脑筋出了问题’。”
These days, van der Kolk’s calendar is filled with speaking engagements, from Boston to Amsterdam to Abu Dhabi. This spring, I trailed him down the East Coast and across the country. At each stop, his audience comprised the full spectrum of the therapeutic community: psychiatrists, psychologists, social workers, art therapists, yoga therapists, even life coaches. They formed long lines up to the podium to introduce themselves during coffee breaks and hovered around his table at lunchtime, hoping to speak with him. Some pulled out their cellphones and asked to take selfies with him. Most expressed similar sentiments:
Thank you so much for what you said about this treatment, that therapy, those studies.
Your research on cutting, child sexual abuse, family violence confirms what I have seen in my own patients, or experienced myself, for decades now.
Can you help me?
Van der Kolk’s entire life has been a study in human trauma. He was born in The Hague in the summer of 1943, three years into the German occupation of the Netherlands and one year before the great Dutch famine, when a military blockade cut off food and fuel shipments to the country’s western provinces and more than 20,000 people starved to death. His father was imprisoned in a Nazi work camp. According to van der Kolk family lore, his mother had to ride her bike to the hospital when she went into labor with him, and his first birthday cake was made of tulip bulbs because there was hardly any flour.
He was a weak and scrawny boy, but daring nonetheless. Ask him about his childhood, and he will tell you about playing amid the bombed-out ruins of his native city. Nearly everyone around him was deeply traumatized. His neighbors on either side were Holocaust survivors. His mother did not enjoy motherhood; she was pulled out of school at 14 to care for her father and then pulled away from a satisfying career to assume her wifely duties. By the time Bessel, her middle child, was old enough to know her, she had grown bitter and cold. His father was an executive at Royal Dutch Shell, and despite being a devout Protestant and dedicated pacifist, he suffered violent rages and inflicted them on his children. In his new book, “The Body Keeps the Score,” which comes out this fall, van der Kolk mentions being locked in the basement as a little boy for what he describes as “normal 3-year-old offenses” and hating himself for being too puny to fight back.
范德科尔克是一个骨瘦如柴的孱弱男孩，但这丝毫没有减损他的勇敢。如果问起他的童年往事，他会告诉你在故乡城市遭受轰炸后的废墟上玩耍的故事。他周围几乎每个人都遭受了深深的创伤。左右的邻居都是犹太人大屠杀的幸存者。他的母亲一点也不乐意当妈妈；14岁的时候她就辍学照顾自己的父亲，之后又被迫离开了自己喜爱的职业以承担身为人妻的责任。在家里的第二个孩子贝塞尔懂事之前，她的性格已经变得刻薄而冷漠。范德科尔克的父亲是荷兰皇家壳牌集团(Royal Dutch Shell)的高管。尽管他是一名虔诚的新教徒，也是忠实的和平主义者，但盛怒之下他也会在孩子们身上泄愤。在秋天将要面世的新书《身体记得》(The Body Keeps the Score)中，范德科尔克提到，当他还是个小男孩时，曾经因为“正常的3岁孩子都会惹的祸”而被关在地下室里，只能怨恨自己太弱小，无力反抗。
As a teenager, he began traveling on his own. He liked to hitchhike into France. On one such trip, as he passed a monastery, he heard the chanting of monks and was so taken with the sound that he asked the driver to let him off there. He spent the rest of that summer, and the following Easter break, and the summer after that, at the monastery contemplating monkhood. The abbot took a liking to him and promised that if he joined the order, they would send him to Geneva for medical school. “I seriously considered it,” he told me. But in the end, a youthful thirst for adventure beat out any yearning he might have felt for quiet meditation, and he chose the University of Hawaii instead. “I still have some spiritual feelings,” he says. “I believe that all things are connected. But organized religion gives me the creeps.”
十几岁的时候，他开始独自旅行。他喜欢搭便车到法国去。在一次这样的旅行中，他在途经一所修道院时听到修道士们诵经的声音，并为之深深打动，于是请求司机让他在那里下车。他在那所修道院度过了当年夏天剩下的所有时间，然后是次年的复活节假期，以及之后的又一个夏天，甚至考虑要不要成为一名修道士。修道院院长对他很有好感，并承诺如果他加入修会，他们就送他到日内瓦读医学院。“我认真考虑过这个提议，”他告诉我。但最终，年轻的心对冒险的渴望战胜了他对安静冥想的向往，于是他选择了夏威夷大学(University of Hawaii)。“我仍然有一些精神感应，”他说。“我相信万事万物都彼此关联。但组织有序的宗教让我浑身发毛。”
And so in 1962, he came to the United States and made his way from the University of Hawaii to the University of Chicago to Harvard Medical School, where he posed to science and medicine all of his many questions about the horrors of human nature and the miracles of human resilience. “The human species is messed up,” he says. “We make the same mistakes over and over, and I’m deeply curious about why that is. Why do we keep doing things that we know are horrible and will have terrible consequences?”
就这样，1962年，范德科尔克来到了美国，并先后就读于夏威夷大学、芝加哥大学(University of Chicago)和哈佛医学院。在这里，他将自己关于人性中恐怖的一面，以及人类神奇的适应和恢复能力的许多问题，摆在了科学和医学面前。“人类这个物种可真是一团糟，”他说。“我们总是一遍又一遍地犯同样的错误。我真好奇这究竟是为什么。为什么我们明知道会酿成大祸，惹来不可收拾的后果，却还是会一意孤行？”
One of van der Kolk’s first jobs out of school was as a staff psychiatrist at the Veterans Affairs clinic in Boston; he arrived there in 1978, in time for the influx of Vietnam veterans. “The waiting list to see a doctor was a mile long,” he says. “And the clinic’s walls were pocked full of fist imprints.”
The first thing van der Kolk noticed about his new patients was how utterly stuck in the past they were. Even the older veterans from World War II seemed to vacillate between one of two states: immersion in their wartime experiences or lifeless disengagement. In Rorschach tests, every inkblot was a dead baby, a fallen comrade or nothing at all. It was as if war had broken the projector of their imaginations, he says, and their only options were to play one reel over and over or turn the machine off altogether.
The second thing that struck van der Kolk was how the men managed their own conditions. Almost all of them claimed that highly risky behaviors were capable of yanking them into the present in a way that no form of therapy could (one patient, for example, rode his Harley at breakneck speeds whenever he felt himself swirling into a rage or disconnecting from his surroundings). Van der Kolk’s treatment — the only thing he had been taught in medical school — involved getting the men to talk. In both group and one-on-one sessions, he would ask them about their horrible memories, nightmares and troubles at home. But talking didn’t seem to help; in some cases, he thought, it made things worse.
Van der Kolk scoured the clinic’s medical library for books on shell shock and combat fatigue — anything that might help him better understand what he was seeing or give him some clue about how to treat it. Post-traumatic stress disorder was not yet a recognized condition. Then he came across a book at Harvard’s Francis A. Countway medical library, “The Traumatic Neurosis of War.” It was published in 1941, just before shellshocked American veterans would return from World War II. In its pages, van der Kolk found the first seeds of an idea that would ultimately shape his career: The nucleus of neurosis is physioneurosis. In other words, he thought, the root of what would eventually be called PTSD lay in our bodies.
范德科尔克翻遍了诊所的医学图书馆中关于炮弹休克症(shell shock)和战斗疲劳症(combat fatigue)的书籍，寻找可能帮助他更好地了解患者症状的任何信息，或者有助于他进行治疗的任何提示。在那个时代，创伤后应激障碍还未被公认为一种疾病。后来，他在哈佛的弗朗西斯·A·康特韦医学图书馆(Francis A. Countway Library of Medicine)里发现了一本书：《战争的创伤性神经官能症》(The Traumatic Neurosis of War)。该书出版于1941年，正好是在饱受炮弹休克症困扰的美国老兵从第二次世界大战中归来之前。在这本书中，范德科尔克找到了一些最初的灵感。这些灵感最终指明了他职业生涯的方向：神经官能症的核心在于躯体性神经官能症。换句话说，他认为，日后所称的PTSD的根源深埋在人类的身体之中。
This meshed perfectly with what van der Kolk was seeing in his patients. In addition to their nightmares and hallucinations, many of them had a host of physical ailments, including headaches, fatigue, digestive troubles and insomnia. When he tried accessing their traumas in therapy, they often became jittery, broke into cold sweats or shut down. The book, van der Kolk said, did not offer any suggestions for treatment, but it did give him a starting point. In the two decades that followed, he made a careful study of all his patients’ physiological symptoms. And in 1994, not long before his Harvard lab was shuttered, he wrote a paper in The Harvard Review of Psychiatry summarizing all he had learned. Traumatic stress, it seemed, triggered a cascade of physiological catastrophes that affected almost every major system in the body.
这与范德科尔克在患者身上的所见所闻完全吻合。除了噩梦和幻觉，许多患者还遭受着众多生理症状的折磨，包括头痛、疲劳、消化系统疾患和失眠等。当他在治疗中试图触及他们的创伤时，他们往往一下子就变得如同惊弓之鸟一般，浑身冷汗涔涔或者将自己完全封闭起来。范德科尔克表示，虽然这本书并没有提供任何治疗建议，但给了他一个起点。在接下来的20年里，他仔细研究了他所有患者的生理症状。1994年，就在他在哈佛的实验室被关闭前不久，他撰写了一篇论文总结了自己的所有发现，并发表在《哈佛精神病学评论》(The Harvard Review of Psychiatry)上。创伤应激似乎可以触发一连串的生理性灾难，几乎影响到身体的所有主要系统。
Eugene was on military leave in San Francisco, about halfway through his tour of duty, when he first realized something was wrong. The bay was cool and breezy; people were walking around in parkas and hoodies. But he was sweating profusely. He thought his months in the desert had maybe activated some weird sweat gene that needed time to turn itself off. He figured it would pass eventually. It didn’t. By the time he came home for good, sweat was the least of his problems. He was seeing dead bodies on the side of the road. And he could not stop going to the bathroom. At his first post-military job in the corporate offices of a large bank, he went to the bathroom so often that he was sure his co-workers wondered what was wrong with him.
The military had little to offer. “They are not even trying to help,” he would tell friends and relatives. “You say, ‘I have horrible diarrhea, and I can’t stop going to the bathroom.’ And they say, ‘Stop going to the bathroom.’ Or you say, ‘I have a horrible time with the subway; the noise just terrifies me.’ And they say, ‘Well, New York is pretty noisy.’ ” One doctor prescribed an anti-anxiety medication, but it was so strong that Eugene started walking into walls. He tried talk therapy and group therapy. Neither did anything to relieve the uncomfortable tingling up his spine or the constant feeling that he was about to be attacked from behind.
He was nearly a full decade into this private war by the time he came to sit across from van der Kolk in the room overlooking the Pacific and to tell a group of strangers how he killed an innocent man.
Mosul reminded Eugene of a movie, he said: an old western in which the bad guys take over some small town, and all the townsfolk hide indoors and tumbleweed blows across the screen. In this movie, though, the bad guys were crazy terrorists who not only fired on Eugene and his team constantly but also strapped explosives to themselves, wandered into residential areas and detonated.
Eugene was on the security detail for a bomb patrol when a man drove up without yielding for inspection. Eugene signaled to him to stop, but the man kept his foot on the gas. Eugene signaled a second time, and a third.
Stop. Stop. Stop.
The man kept driving. So Eugene opened fire. His team searched the car afterward but found no bombs. As Eugene left the scene, he saw the man’s mother. She ran over to the car, distraught.
As he told us this, Eugene stared into the empty space between him and van der Kolk. His face was red and contorted, and it was easy to imagine that he was not so much remembering what happened as reliving it. I wondered what torments had led him to submit to such an experiment. I wondered how it could possibly work.
“What do you want the mother to know?” van der Kolk asked. Again, Eugene covered his face and broke into loud sobs.
“I’m sorry,” he said. “I’m so, so sorry. There are not words for how sorry. . . .” He buried his face in his hands again. “Do you want to look at her?” van der Kolk asked. Eugene couldn’t seem to speak, but he lifted his head and squinted at me with one eye. It was too much. He tucked his chin into his chest, wracked by sobs.
“The witness sees how truly sorry and how upset you are,” van der Kolk said. I kept my eyes focused on Eugene, so I didn’t see van der Kolk’s face. But Kresta would later tell me that watching him was like watching a wizard or a magician or a superfast computer. She could see him tracking Eugene’s facial expressions, tone of voice and changes in posture and responding to each in microseconds, posing a question or remarking “the witness sees.”
Van der Kolk instructed me in a low, steady voice. “Tell him that you forgive him,” he said. “Tell him you understand that it was a crazy time, and you know that he didn’t mean to do what he did. He was very young, and both of you were trapped in the same hell. Tell him you forgive him. And that you are O.K. now.” I repeated the words. I tried to make them sound genuine. I found myself hoping, fervently, that Eugene could hear me.
For a man who speaks to more than 15,000 people a year, van der Kolk has a surprisingly hard time projecting his voice. His thick Dutch accent is easy enough to decipher if you’re sitting right next to him, but it is difficult to penetrate from even a few feet away. As is often the case, the first audience comment at a recent lecture he gave in Philadelphia was “We can’t hear you!” Van der Kolk asked a sound technician to turn up the volume and promised the 200 or so attendees that he would speak as loudly as he could. There were some grumbles, even from people in the front row, who still couldn’t hear him. But van der Kolk is effusively charming and, as usual, managed to win the group over quickly.
“Everybody hunch their backs forward and droop their heads, like this,” he said, demonstrating. “Now try saying: ‘Oh, I’m feeling great! I’m very happy today!’ ” The audience laughed. “See, it’s impossible to feel happy in that position.” To drive the point home, he asked us to do the opposite: sit upright, assume cheerful expressions and then try to feel bad.
The mind follows the body, he said.
Trauma victims, van der Kolk likes to say, are alienated from their bodies by a cascade of events that begins deep in the brain with an almond-shaped structure known as the amygdala. When faced with a threat, the amygdala triggers a fight-or-flight response, which includes the release of a flood of hormones. This response usually persists until the threat is vanquished. But if the threat isn’t vanquished — if we can’t fight or flee — the amygdala, which can be thought of as the body’s smoke detector, keeps sounding the alarm. We keep producing stress hormones, which in turn wreak havoc on the rest of our bodies. It’s similar to what happens in chronic stress, except that in traumatic stress, the memories of the traumatic event invade patients’ subconscious thoughts, sending them back into fight-or-flight mode at the slightest provocation. Therapists and patients refer to this as being “reactivated.” In the short term, patients avoid the pain it causes by “dissociating.” That is, they take leave of their bodies, so much so that they often cannot describe their own physical sensations. This happens a lot in therapy, van der Kolk says.
In the long term, they become experts in self-numbing. They use food, exercise, work — or worse, drugs and alcohol — to stifle physical discomfort. The longer they do this, the more difficult it becomes to remain present in any given moment. “That’s why the guy at the end of ‘The Hurt Locker’ is so utterly incapable of playing with his kid,” van der Kolk says.
长此以往，他们往往会成为自我麻木的高手，用食物、运动、工作——或者是更糟糕的毒品和酒精——来遏杀身体上的不适。这样做的时间越长，他们就越难以在哪个时刻不游离。“这就是电影《拆弹部队》(The Hurt Locker)结尾时那人根本无法与自己的孩子一起玩耍的原因，”范德科尔克说。
The goal of treatment should be to resolve this disconnect. “If we can help our patients tolerate their own bodily sensations, they’ll be able to process the trauma themselves,” he says. In his own patients, particularly those suffering from treatment-resistant PTSD, yoga has proved an especially good way to do this. So has emotional freedom technique, or tapping. With a therapist’s guidance, the patient taps various acupressure points with his or her own fingertips. If done correctly, it can calm the sympathetic nervous system and prevent the patient from being thrown into fight-or-flight mode. Ultimately, van der Kolk supports almost any therapy that involves paying careful attention to patients’ physiological states, like psychomotor therapy, or getting up and moving around through theater, dance and even karate. For patients with acute PTSD from isolated traumatic memories (think car accidents or single-episode assaults), van der Kolk is a fan of eye movement desensitization and reprocessing, or E.M.D.R., in which a therapist wiggles fingers back and forth across the patient’s field of vision and the patient tracks the fingers while “holding in mind” the traumatic memory. Proponents say the technique enables patients to process their traumas so that they pass into memories and stop invading the present. Van der Kolk likes to point out that he came to the technique as a skeptic. “It’s this weird treatment,” he said. “You ask people to remember what happened to them, and you wiggle your finger in front of their eyes and have them follow it. Crazy.” More than 60,000 therapists around the world have now been certified in E.M.D.R., though the practice remains controversial, with critics and supporters debating the validity of each new study. Van der Kolk places his faith in what he sees in his own patients, he says. For them, E.M.D.R. has been a godsend.
治疗的目标应该是解决这种脱节问题。“如果我们能够帮助患者耐受自己的身体感觉，他们就可以自己处理所受到的创伤，”范德科尔克解释道。在他自己的患者，尤其是那些难治性PTSD患者中，瑜伽在这方面的效果被证明尤其值得称道。情绪释放术(emotional freedom technique)又被称为穴位按摩，效果也不错。在治疗师的指导下，患者们使用自己的指尖点按不同的穴位。如果方法正确，它可以平复交感神经系统，防止患者陷入“战或逃”模式。归根结底，范德科尔克对所有密切关注患者生理状态的疗法几乎都抱着支持的态度，如精神运动疗法、起立并在剧场中漫步、舞蹈，乃至空手道。对于从孤立的创伤记忆（如车祸或一次性的袭击）中罹患急性PTSD的病人，范德科尔克也很赞成采用眼动脱敏与再加工疗法（eye movement desensitization and reprocessing，简称EMDR)。在这种疗法中，治疗师在患者的视野前来回晃动手指，并要求患者一面将“思绪停留”在创伤记忆上，一面用目光追随着治疗师的手指。支持者称，这项技术可促使患者加工创伤事件，并将其转化为过去的记忆，从而使它们不再侵犯当前的日常生活。范德科尔克很喜欢指明的一点是，最初接触这项技术时，他也是满腹狐疑。“这真是种古怪的治疗，”他说。“你教人们记起自己的遭遇，还在他们的眼前晃动手指，让他们的眼睛跟着转。这太疯狂了。”目前，世界各地已经有超过6万名治疗师获得了EMDR治疗认证，但人们对这种疗法一直存在争议，批评者和支持者对每一项新研究正确与否都争论不休。范德科尔克说，他更相信从自己患者身上观察到的结果。对于他们而言，EMDR简直是天赐的福音。
Van der Kolk’s most vocal critics tend to have the same complaint: He overstates his case. There is far less evidence for therapeutic tapping or theater or massage therapy than for cognitive behavioral therapy or even exposure therapy. And while the National Institutes of Health and the Department of Defense have begun studying the benefits of yoga and E.M.D.R., van der Kolk’s own studies have been criticized for a lack of rigor and small sample sizes; there were just 88 people in his 2007 study of E.M.D.R. and 64 people in his 2014 study of yoga. “Anyone is going to tell their therapist that they’re doing better if they like their therapist,” says Patricia Resick, a clinical psychologist and researcher in the use of C.B.T. for post-traumatic stress at Duke University. “You need an independent assessor.” There is a standard in the field, Resick says, speaking broadly of his methodology. “If he wants to be taken seriously, he has to do studies that live up to that standard.” (Van der Kolk points out that his E.M.D.R. and yoga studies both had blind raters.)
范德科尔克最为人诟病的地方似乎集中于一点：他过分夸大了自己病例的代表性。有关治疗性穴位点按、剧院疗法以及按摩疗法的证据都远远少于认知行为疗法，甚至还比不上暴露疗法。虽然美国国立卫生研究院(National Institutes of Health)和国防部都已经开始研究瑜伽和EMDR的效益，但批评者指出，范德科尔克自己的研究缺乏严谨性，样本也过小；他2007年的EMDR研究只涉及了88人，2014年的瑜伽研究也只入组了64人。“只要喜欢自己的治疗师，任何人都乐意告诉他们自己的感觉越来越好，”杜克大学(Duke University)的临床心理学家、研究使用认知行为疗法治疗创伤应激的帕特里夏·雷斯尼克(Patricia Resick)说。“你需要独立的评估。”在谈到范德科尔克的大致研究方法时，雷斯尼克表示，该研究领域自有其标准。“如果他希望人们把他当回事儿，他就需要完成符合这一标准的研究。”（对此，范德科尔克指出，他的EMDR和瑜伽研究均设有不知情的评价者。）
Van der Kolk has also been charged with oversimplifying neuroscience to support his clinical work. He likes to divide the brain into distinct regions — rational and emotional — that he says are “not all that connected to one another.” He says the techniques he favors are capable of accessing the emotional brain, where the amygdala resides, whereas C.B.T., exposure therapy and talk therapy aren’t necessarily capable of doing so. Van der Kolk has scores of fMRI scans showing that when faced with a trauma — or in the case of PTSD, with a traumatic memory — the prefrontal cortex becomes muted, the speech center becomes muted and the amygdala becomes hyperactive. But a vast majority of neurobiologists say the so-called rational and emotional brains are much more integrated than his model suggests. In fact, the two communicate regularly through a multitude of circuitous loops that researchers have only just begun to map. And the scans that van der Kolk uses offer a bird’s-eye view of the brain — too sweeping to justify such detailed inferences. “He has a lot of interesting and important ideas, but the relatively weak connection to the brain detracts from his message,” says Joseph LeDoux, a neuroscientist at New York University. “This happens in a lot of fields now. Everybody wants to use the brain to justify certain things. But sometimes what the brain does is more important than how it does it.”
此外，也有人指责范德科尔克将神经科学过度简单化，以支持自己的临床工作。他喜欢将大脑划分为理性与感性两个截然不同的区域，用他的原话说是：“它们的相互联系并非那么紧密。”他声称自己所热衷的技术可以作用于杏仁核所在的“情绪脑”，而认知行为疗法、暴露疗法和谈话治疗却未必有这神通。范德科尔克手中有大量的功能性磁共振成像扫描资料显示，在面对创伤时（对于PTSD患者则是面对创伤记忆时），前额叶皮层、语言中枢都沉寂下来，而杏仁核却变得异常活跃。但绝大多数的神经生物学家都认为，所谓的理性脑和情绪脑并非如他的模型显示的那样彼此孤立，而是一个更为融合的有机体。实际上，它们经常通过众多迂回曲折的神经回路彼此通讯，而科研人员在这方面的研究才刚刚起步。范德科尔克所使用的扫描图提供的是大脑活动的概况，要是想解释如此细节的问题，它们未免太过笼统。“他提出了很多十分有趣也非常重要的想法，但与脑部的关联并不紧密这一点是一大败笔，”纽约大学(New York University)的神经科学家约瑟夫·勒杜(Joseph LeDoux)说。“这种现象在当今的很多领域都层出不穷。每个人都希望扯上大脑来证明些什么。然而有时候，大脑能做什么比它是怎么做的更加重要。”
Some of van der Kolk’s closest colleagues have suggested that his exaggerations are by design. It’s not so much that he abhors conventional therapies or thinks his own methods are ironclad. It’s that he is trying to persuade people to be more open-minded. Indeed, when I pressed him on C.B.T., he acknowledged that it might have some uses, perhaps for anxiety or obsessive-compulsive disorder. And despite his contention that Prozac is less effective than E.M.D.R. at treating PTSD, he is not antimedication.
But there is a larger issue, too. “Testing a therapeutic technique is not like conducting a drug trial,” says Frank Ochberg, a professor at Michigan State University and clinical psychiatrist who specializes in PTSD. “With a drug trial, everyone gets the exact same pill or the exact same placebo. With therapy, you can’t separate the tools from the person using the tools. There’s no good experimental technique for measuring a therapist’s kindness, wisdom or judgment.”
不过，还有一个更大的问题。“测试治疗技术与进行药物试验不同，”密歇根州立大学(Michigan State University)的教授、专门从事PTSD研究的临床精神病学家弗兰克·欧什博格(Frank Ochberg)说。“在药物试验中，所有受试者得到的是完全相同的药丸或完全一样的安慰剂。而对于治疗技术而言，就无法将工具与使用工具的人割裂开来。目前还没有足够成熟的实验技术来衡量治疗师的友善程度、智慧或判断力。”
For his part, van der Kolk says he would love to do large-scale studies comparing some of his preferred methods of treatment with some of the more commonly accepted approaches. But funding is nearly impossible to come by for anything outside the mainstream. In the wake of the Sept. 11 terrorist attacks, he says, he was invited to sit on a handful of expert panels. Money had been designated for therapeutic interventions, and the people in charge of parceling it out wanted to know which treatments to back. To van der Kolk, it was a golden opportunity. We really don’t know what would help people most, he told the panel members. Why not open it up and fund everything, and not be prejudiced about it? Then we could study the results and really learn something. Instead, the panels recommended two forms of treatment: psychoanalysis and cognitive behavioral therapy. “So then we sat back and waited for all the patients to show up for analysis and C.B.T. And almost nobody did.” Spencer Eth, who was then the medical director of behavioral health services at St. Vincent’s Hospital in Manhattan, gathered data on the mental-health care provided to more than 10,000 Sept. 11 survivors. The most popular service by far was acupuncture. Yoga and massage were also in high demand. “Nobody looks at acupuncture academically,” van der Kolk says. “But here are all these people saying that it’s helped them.”
至于范德科尔克，他表示自己很希望能进行一些大规模的研究，将他比较偏爱的治疗方法与已经获得普遍接受的其他一些方法进行比较。只是，想要做些主流之外的事情，几乎是不可能弄到资助的。他回忆道，在9·11恐怖袭击之后，他曾应邀参与四五个专家小组。他们已经拿到了一笔指定用于治疗干预的经费，于是负责人征求他们的意见，问他们应该拿这些钱来支持哪些治疗。对范德科尔克来说，这是一个千载难逢的好机会。我们确实不知道什么方法可以最大限度地为人们提供帮助，他对小组成员这样说道。那我们为什么不彻底放开成见，资助所有的疗法呢？这样我们就可以研究所得的结果，从中真正获得一些知识。可惜事与愿违，专家小组推荐了两种形式的治疗：精神分析和认知行为疗法。“于是我们坐等患者来接受分析和认知行为治疗。结果几乎是无人问津。”斯潘塞·艾斯(Spencer Eth)当时在曼哈顿的圣文森特医院(St. Vincent’s Hospital)行为健康服务部门担任医疗主任，他搜集了关于1万多名9·11幸存者接受心理健康医疗服务的资料。截至目前，最受欢迎的服务是针灸，瑜伽和按摩的呼声也甚高。“没人把针灸抬入学术的大雅之堂，”范德科尔克说。“但所有这些人都说它很有用。”
Van der Kolk is always evaluating his own clinical experiences for clues to what works best. “Maybe I should have done E.M.D.R. with Eugene instead of that structure,” he said not long after the California workshop. “I’m not sure how much good it will do.”
Back at the Trauma Center in Boston, van der Kolk and his colleagues are working on what he sees as the next step: redefining trauma itself. “We have a tendency now to label everything as PTSD,” he says. “But so much of what we see is the result of long-term, chronic abuse and neglect. And that produces a different condition than one-off, acute traumatic incidents.” Van der Kolk and his colleagues call this chronic form of traumatic stress “developmental trauma disorder”; in 2010, they lobbied unsuccessfully to have it listed in the Diagnostic and Statistical Manual of Mental Disorders as a condition separate from PTSD. They’re hoping that with more data, they might finally prevail. Formal acceptance, van der Kolk says, is the key to getting support.
回到波士顿的创伤中心，范德科尔克及其同事们正投身于他信奉的下一步研究：重新定义创伤本身。“如今我们总是倾向于把什么都贴上PTSD的标签，”他说。“但是，我们今天所见的很多症状都是长期、慢性的虐待和忽视的结果。由此产生的疾病与一次性的急性创伤事件有所不同。”范德科尔克及其同事们将这种创伤应激的慢性形式称为“进行性创伤障碍(developmental trauma disorder)”。2010年，他们曾经试图游说 《精神疾病诊断与统计手册》(Diagnostic and Statistical Manual of Mental Disorders)的编制机构将其从PTSD中分离出来，作为一种单独的疾病列入，但未能成功。他们希望在更多数据的支持下，最终将得偿所愿。来自官方的正式接受是争取支持的关键，范德科尔克说。
“There’s a grant to give more than $8 million to help survivors of the marathon bombing,” van der Kolk mentioned one afternoon. “That’s psychotic. Yes, it was horrible, and yes, those people are suffering and deserve help. But we have tens of thousands of children being traumatized every day, right in the same city — a couple million across the country — and no one is offering to help them.” I asked why he thought that was. He told me about Pierre Janet, a psychiatrist at the Salpêtrière Hospital in 19th-century Paris. Janet published the first book on what was then called hysteria but which we now refer to as PTSD. He, too, became enmeshed in a dispute with his peers. He, too, was forced out of his laboratory.
“帮助波士顿马拉松爆炸案幸存者的专项拨款达800万美元以上，”范德科尔克在一天下午提到。“简直是精神错乱！没错，爆炸案非常可怕，而且，那些人也的确备受煎熬，值得救助。然而，就在这同一座城市里，每天都有数以万计的儿童遭受创伤，如果把统计范围扩展到全美，这个数字可达两百万，却没有人向他们伸出援手。”我问他认为其中的原因何在。他对我讲述了19世纪巴黎萨伯特慈善医院(Salpêtrière Hospital)的一名精神科医生皮埃尔·雅内(Pierre Janet)的故事。雅内出版了第一本关于当时被称为“歇斯底里”的PTSD的著作。他也陷入了与同行的争论之中，也被迫离开了自己的实验室。
“There’s this cycle of knowing and forgetting,” van der Kolk told me. “We discover trauma. And then when we see how horrifying and how inconvenient it is, we turn on the concept and peel off the messengers.” Without missing a beat, he segued from Janet to World War I and World War II, explaining how the military establishments in both Europe and the United States stigmatized shell shock and combat fatigue, for fear that they would undermine the war effort. It’s willful amnesia, he said, and he had plenty of more recent examples. Just a few years ago, he interviewed a group of foster children at a United States Senate hearing on the state of foster care. “Afterward, I’m sitting with the kids,” van der Kolk said. “And a judge walks past us on his way out, and he says to the kids: ‘You’re all doing so great! Look how terrific you all are!’ And I say, ‘Well, no, why don’t you ask them how they’re doing?’ These are kids that have suffered significant abuse and neglect. A couple of them are suicidal. They have substance-abuse problems. One of them cuts herself. But the judge didn’t want to hear about that any more than we want to hear about what really happens to soldiers when they’re off at war.”
Before enlisting in the Army, Eugene earned a bachelor’s degree in art history from the American University of Paris. Now he’s an antique art dealer. He lives in Queens with his wife and 3-year-old daughter but often goes into Manhattan to meet clients and visit galleries. I met him for coffee on the Upper East Side a couple of months after van der Kolk’s workshop. I wanted to know how he felt about the exercise now that some time had passed. Did he think it had any impact on his PTSD?
在从军之前，尤金在巴黎美国大学(American University of Paris)拿到了艺术史学士学位。现在，他是一名古董艺术品经销商。他与妻子和3岁的女儿住在皇后区，经常到曼哈顿去见客户或拜访画廊。在参加范德科尔克的研讨会几个月之后，我约他在上东区喝咖啡。我想知道，经过一段时间之后，他现在对“架构”练习的感觉如何。他觉得这对PTSD有效果么？
What intrigued him most, he said, is how well it worked in the moment. Whatever spell van der Kolk cast lingered into the next day, so that Eugene really saw me, a complete stranger, as the object of his guilt. “I was terrified of you,” he told me. It wasn’t until the following day, when van der Kolk had me forgive him a second time, that the spell finally broke and he was able to face me as just another workshop participant. “It reminded me of that movie ‘The Master,’ with Philip Seymour Hoffman,” he said. “When Amy Adams asks Joaquin Phoenix, ‘What color are my eyes?’ and he says, ‘Green,’ and she says, ‘Turn them blue,’ and you see them change color. It really reminded me of that.”
最令他着迷的，是这种练习的效果立竿见影，尤金说。范德科尔克的“咒语”的魔力直到第二天也没有消退，这让尤金真的将我，一个完全的陌生人，当成了他心怀愧疚的对象。“我很怕你，”他告诉我。然后又过了一天，范德科尔克让我第二次对他表示原谅，那咒语才最终被打破，他终于能够面对我，将我还原为研讨会的普通参与者而已。“这让我想起了菲利普·塞默·霍夫曼(Philip Seymour Hoffman)主演的电影《大师》(The Master)，”他说。“埃米·亚当斯(Amy Adams)问华金·菲尼克斯(Joaquin Phoenix)，‘我的眼睛是什么颜色？’他回答，‘绿色。’她又说，‘请把它们变成蓝色，’然后你就看到那眼睛真的变色了。真的，这确实让我想起了那一幕。”
For a while at least, he said, he felt better. He recalled driving down the Pacific coast with his wife the day the workshop ended and noticing how weird it was not to feel stressed out. For weeks he was able to drive and use the subway with no trouble. “It felt like it sort of repaired my perception somehow,” he said. “I used to always feel paranoid — like, I’d get freaked out going to my doctor because there were all these security guards in the waiting room — and for a while that was lifted.”
But some of those effects were starting to fade. He was having headaches and memory problems again, and he was trying to figure out what triggered the relapse. He thought it had something to do with a painting he saw. He attended an Asian art fair earlier in the week, and an Arab dealer was selling some contemporary paintings; most of them were of soldiers, but one was of a woman. She looked like me, he said. He remembered staring at it and freezing up. The next day at a client’s house, he misplaced his briefcase. “It was like I threw it out the window,” he said. He spent 20 frantic and embarrassing minutes searching the house in a sweaty panic before he finally found it, right where he’d left it, near a window by the door.
Still, he was feeling hopeful. Van der Kolk had suggested some other possible approaches at the end of the workshop. He was planning to try E.M.D.R. next.
I asked him how he felt sitting across from me now. He said that he had to go to the bathroom and that his face felt numb around one eye. Ever since the exercise, the area around his right eye — the one he’d squinted at me with — went numb whenever he got nervous. He said he didn’t know why exactly, but he was sure it had something to do with the exercise itself. “I’ve been reading everything I can get my hands on,” he said. “It definitely helped, more than anything else I’ve tried so far. But I still have no idea what he did to me.”