The Body Keeps the Score: Brain, Mind, and Body in the Healing of Trauma by Bessel van der Kolk

(This review touches on PTSD and sexual assault)

Van der Kolk (van der Kolk) is an experienced researcher: his h-index is 106 and he was in residence at Harvard. His book sold 2 million copies and spent six months as Number One on the NYT bestseller list. Roughly once an hour, someone tweets about it.

TBKtS is rich in anecdotes about traumatised people. Its narrative covers the effects of PTSD, especially in veterans. It provides many case studies to make the case that childhood sexual abuse
1. affected millions of Americans,
2. can cause trauma,
3. leads to a lot of unpleasant effects.

The interesting and novel part is his central thesis:

Intense emotions activate the limbic area, especially the amygdala
The memories they induce are stored differently from your main memories.
They are different from normal memories: they are stored in an accurate way, and they surface unexpectedly.
The amygdala (which he calls the body’s ‘smoke detector’) functions incredibly quickly.
It warns us of impending danger, so if anything happens to remind you of your trauma, you may react in ways you don’t consciously control
Traditional ways of curing trauma are going to do badly, because they target the brain
To cure trauma, we need to work with your body.
Ways to do this include trauma-sensitive yoga, or Eye Movement Desensitisation and Reprocessing (EMDR)

This is super interesting! Some people reported finding the book useful despite having failed with, uh, ‘traditional’ techniques, so I got curious about it. A key part is that traumatic memories are qualitatively different from non-traumatic memories.

When he discusses memories, he asserts you remember events well if you were emotional:

Whether we remember a particular event at all, and how accurate our memories of it are, largely depends on how personally meaningful it was and how emotional we felt about it at the time. The key factor is our level of arousal…Most of us still have precise memories of where we were and what we saw on Tuesday, September 11, 2001, but only a fraction of us recall anything in particular about September 10.

Most humans do have more memories of September 11 than September 10.

But those memories are not necessarily accurate! An actual September 11 study says: “even traumatic memories…may be inconsistent over time and these inconsistencies can persist without the corrective force of external influences.”

van der Kolk admits memories are unreliable, but claimsPTSD and trauma memories will be intact.

We all know how fickle memory is; our stories change and are constantly revised and updated. When my brothers, sisters, and I talk about events in our childhood, we always end up feeling that we grew up in different families—so many of our memories simply do not match…

The extraordinary capacity of the human mind to rewrite memory is illustrated in the Grant Study of Adult Development, which has systematically followed the psychological and physical health of more than two hundred Harvard men from their sophomore years of 1939–44 to the present.2 Of course, the designers of the study could not have anticipated that most of the participants would go off to fight in World War II, but we can now track the evolution of their wartime memories. The men were interviewed in detail about their war experiences in 1945/1946 and again in 1989/1990. Four and a half decades later, the majority gave very different accounts from the narratives recorded in their immediate postwar interviews: With the passage of time, events had been bleached of their intense horror. In contrast, those who had been traumatized and subsequently developed PTSD did not modify their accounts; their memories were preserved essentially intact forty-five years after the war ended.

The first reason I dislike the emboldened part is that "people's memories stay consistent over decades" is a different claim from "people's memories are accurate".
But the main reason I dislike it is that the citation is to "A 50-Year Prospective Study of the Psychological Sequelae of World War II Combat", K.A.Lee et al.

That study is freely available online, and it says no such thing.

Here is what it actually says:

The 1988 questionnaire asked the men (age 64-70) questions about the presence of specific symptoms of PTSD "today". The symptoms were: (1) recurrent and intrusive recollections of combat.

In other words, the study needs a way to measure PTSD. They have a checklist to measure your PTSD score. If you keep remembering combat against your will, you get a higher PTSD score. If your score exceeds a threshold, you get assessed as having PTSD. Below the threshold, you don’t.
van der Kolk misrepresented this study (which interviewed only eight veterans with PTSD) and cited it in support of his thesis on memories.

His book misstates a lot of facts; I detail some of these below. Some of these issues could be blamed on poor scholarship. But I have a different explanation for why he misrepresents research on memory in particular.

I think he hates the idea that traumatic memories can be inaccurate.

He talks a lot about the victims of child abuser (and former priest) Paul Shanley.

by the early 1990s articles had started to appear in many leading newspapers and magazines in United States and in Europe about a so-called False Memory Syndrome in which psychiatric patients supposedly manufactured elaborate false memories of sexual abuse...

At least two dozen men had claimed they were molested by Paul Shanley…In February 2005 the former priest was found guilty on two counts of raping a child and two counts of assault and battery on a child. He was sentenced to twelve to fifteen years in prison.

In 2007 Shanley’s attorney, Robert F. Shaw Jr…tried to make the case that “repressed memories” were not generally accepted in the scientific community, that the convictions were based on “junk science,” and that there had been insufficient testimony about the scientific status of repressed memories before the trial.

To me, both of these things are true:

People can misremember or invent details of traumatic experiences.
Bad actors will cite that fact to defend themselves.

van der Kolk seems to assume that if the second statement is true, the first must not be.

A charitable reason is that he wants more people accused of sexual assault to be found guilty, some accused rapists use False Memory Syndrome as a defence, and so he pushes the case against it very hard.

I have a darker hypothesis.

In the 70s, awareness of child abuse was rising. Van der Kolk (then in his thirties) fought to get PTSD recognised in the DSM.
In the 80s, people remembered memories of being abused as children, in many cases decades ago. This kicked off the memory wars: some accusers (e.g. Paul Shanley’s victims) remembered their abuse accurately. Some did not. In 1989 George Franklin was convicted of murder based almost entirely on a recovered memory from 20 years previously. He was sentenced to life in jail. In 1995, his conviction was overturned: the memory had been produced by unreliable hypnosis methods. DNA showed two other murders he was accused of had a male profile that wasn’t his. In 2018, DNA evidence found the actual murderer was Rodney Lynn Halbower.
This was the time of the Satanic Panic. The basic theory was that a well-organised satanic cult was routinely sexually molesting, and in some cases torturing and murdering, children. That’s been debunked now - the National Center on Child Abuse and Neglect investigated 12,264 accounts of ritual abuse and couldn’t corroborate a single one - but at the time it was taken incredibly seriously.

Van der Kolk was often testifying in child abuse trials as an expert witness for the prosecution. (He mentions this proudly in TBKtS.)
To testify that recovered memories were reliable, in the 1990s, as an academic researcher, he was paid $350/hr.
What sorts of things was he saying?
In 1996 he testified that False Memory Syndrome is “not something that has any scientific validity, not scientifically recognized phenomenon”. He testified that adults can reliably remember details as trivial as a white shirt from when they were three (“These traumatic memories are like these pictures engraved in people’s minds”)

(This, to me, is key to the debunking of TBKtS. Under oath, he claimed 33 year olds can reliably remember shirt colour from 30 years ago, because traumatic memories are so well stored by your bodies. Pages 219-220 of this court transcript, but I recommend reading through to page 233.)

In February 1997 things went south for van der Kolk after he was cross-examined by Dr R Chris Barden, an astute scientist-trial-lawyer-psychologist. The final trial transcript is genuinely shocking; it’s hard to read it and remember van der Kolk was able to bounce back.

Under oath, van der Kolk admitted that his chief lab assistant, Danya Vardi had falsified data on memory research. He admitted that after Ms Vardi left his office in disgrace, without receiving her PhD, he testified for the prosecution in a criminal case in March 1995 using her falsified research.

He admitted that he chaired a symposium with Danya Vardi in which she presented her faked data, and at the trial date in February 1997, audiotapes of that symposium were still being sold with no mention of her disgrace and scientific fraud conviction following a federal investigation banning her from certain government transactions. He hadn’t cared to stop selling the audiotapes.

Most damningly, he was forced to admit that he deleted findings on a fragmentary memory study that didn’t suit his narrative.
He claimed to not remember why he had done this.
(Presumably, that memory wasn’t traumatic for him)

Dr Barden had, earlier in the proceedings, asked him if he had data for this study and van der Kolk had said that he did. After van der Kolk admitted deleting findings, Dr Barden asked him to provide his data so that they could figure out why he deleted the findings.
van der Kolk refused.
He was served a subpoena.
He refused to comply.
The court banned him from giving testimony as an expert witness unless he handed over his data, and that seems to have been his last court appearance: Dr Barden wrote later that “Van der Kolk fled from the process server and dropped out of multiple cases rather than turn over his claimed data”.He had been scheduled to act as an expert witness for a victim of sexual assault. She said van der Kolk tried to cancel, but then reassured her he was going to act as a witness for her. Then he left her a voicemail.
His book repeatedly implies that he was warm and caring to rape survivors.
This is what his voicemail actually said:“Mrs Shahzade this is Dr. Van der Kolk. I am actually out of town right now, but Mr. Mitchell asked me to give you a call. As I talked to you before, you must realize that if your case comes to trial I will not testify for you. That is not something you can bargain about and I think without my testimony you will probably not win, but as it stands now with my testimony you would not win either, because of certain legal maneuvers that are too complicated to tell you about. So, I urge you very strongly to take the advice of your attorney. This is not the time to be stubborn or to think that you know better than anybody else. Do take the advice of your attorney about how to proceed with this matter. I am no longer on your case. I cannot explain this to you. Don’t call me back. Pay your bill. You don’t do anybody a favor by being headstrong about it. So, good luck to you. Take care of yourself.”(reminder: the absolute best case for him is that he thought this was a real, traumatized victim of childhood sexual assault who he had agreed to support: “Don’t call me back. Pay your bill”.)

Shortly after he refused to comply with the subpoena, Harvard ended its affiliation with van der Kolk. “The official reason was a lack of funding, but van der Kolk and his allies believed that the true motives were political.”
To sum up:

In the 70s Van der Kolk worked on trauma. He won several prestigious prizes, and was affiliated with Harvard.
In the 80s and 90s there was tension over whether traumatic recovered childhood memories could be wrong.
He was paid handsomely to testify that resurfaced memories are accurate.
More and more evidence came in supporting False Memory Syndrome, suggesting he was wrong.
He doubled down, citing data he knew his research assistant had falsified, and deleting data that didn’t support his narrative.
He was caught.
He had the option to turn over his data to find a reason why he might have deleted data.
Rather than do this, he ended his career as an expert witness and was fired from Harvard.
He never backed down; he shifted his grift slightly over the decades but kept his basic claim about traumatic memories. (his book shifts the claim to one that can’t be easily disproved, “The fundamental problem is this: Events that take place in the laboratory cannot be considered equivalent to the conditions under which traumatic memories are created”)
The result is this 2014 work claiming that traumatic memories are stored specially. It’s sold two million copies, so has made him maybe five million dollars in royalties, plus speaking fees, etc.

If I were to fight van der Kolk on his own terms - appeal to emotion - I would talk about Leonard Mack, who was wrongfully convicted of rape after being falsely identified by a traumatised victim. Mack’s alibi was overruled because the victim believed he was her rapist. He spent nearly ten years in prison. In 2023 DNA proved Mack was innocent. I don’t think the victim was lying (I think her memory was mistaken). van der Kolk, however, charged $350/hr in 1996 ($5600 a day in 2024 dollars) to cite falsified research to put people like Leonard Mack in prison. His financial incentives were clear.

But I don't want to fight van der Kolk on his terms; I want to fight him on the playing field of truth.

And it isn't true that people, traumatised or otherwise, have perfect memory. Humans misremember things.

How did I find this? Because I kept seeing more and more problems. There was a running theme through TBKtS:

van der Kolk would present an interesting claim
I would be surprised
I would check the citation
It did not say anything like his claim

Here's an example: "Traumatized children have fifty times the rate of asthma as their nontraumatized peers''.

That’s a bold claim, Cotton. Let’s see how the citation pays off for him.I found the study he cites.

It does not once mention the word 'asthma'.

A quick web search suggests traumatized children have a 42% higher rate of asthma.
Van der Kolk may have rounded 42% up to 50%, confused a 50% increase for a 50x increase (5000%), and cited a random study about sexually abused women. This is itself not damning. But that kind of mistake kept happening:

Another surprising claim was that “twelve million women in the United States have been victims of rape. More than half of all rapes occur in girls below age fifteen.”The citation is to "Prevalence and Consequences of Child Victimization", whose methodology is clear: Eligible for selection were all adolescents between the ages of 12 and 17…
The study asked 12-17 year olds if they’d been raped, and if so how old they were at the time. Van der Kolk takes this to be representative of women.
You could use this methodology to show that more than half of all women in the USA are under 15. (It's hard to get reliable rape data, but it looks to me like the median age of rape victims is early twenties.)

I don't want to minimise childhood sexual assault. I do want to convey that Van Der Kolk uses numbers the way Humpty Dumpty uses words: they mean what he wants them to mean. The most charitable case I can make is that some of his errors are directionally right: a depressingly large number of children under 15 are sexually abused. This has lasting effects and increases their risk of asthma.

But I find it hard to take his claims seriously, independent of the central thesis.

I was amazed to discover how many of my patients told me they could not feel whole areas of their bodies. Sometimes I’d ask them to close their eyes and tell me what I had put into their outstretched hands. Whether it was a car key, a quarter, or a can opener, they often could not even guess what they were holding—their sensory perceptions simply weren’t working. I talked this over with my friend Alexander McFarlane in Australia, who had observed the same phenomenon. In his laboratory in Adelaide he had studied the question: How do we know without looking at it that we’re holding a car key? Recognizing an object in the palm of your hand requires sensing its shape, weight, temperature, texture, and position. Each of those distinct sensory experiences is transmitted to a different part of the brain, which then needs to integrate them into a single perception. McFarlane found that people with PTSD often have trouble putting the picture together.

He cited a study that did not say anything like this. I don’t even know which bit he was talking about; the study doesn’t include the word ‘object’, ‘hand’, or ‘palm’.
And ok, van der Kolk is clear that this is partly from an in-person conversation (I read through a lot of McFarlane’s research and didn’t find anything supporting van der Kolk’s claim). But I don’t know why he cited a random study.

I got to the point where I didn’t trust anything he’s written. I went back to the beginning to see his Rorschach test description:On seeing the second card of the Rorschach test, Bill exclaimed in horror, “This is that child that I saw being blown up in Vietnam. In the middle, you see the charred flesh, the wounds, and the blood is spurting out all over.” Panting and with sweat beading on his forehead, he was in a panic similar to the one that had initially brought him to the VA clinic…When we gave the Rorschach test to twenty-one additional veterans, the response was consistent: Sixteen of them, on seeing the second card, reacted as if they were experiencing a wartime trauma…While the majority of the veterans were greatly upset by what they saw, the reactions of the remaining five were even more alarming: They simply went blank.

What are the odds that every war veteran with PTSD reacted to van der Kolk’s Rorschach test abnormally? I looked up another study at random and veterans with PTSD did react differently to Rorschach cards. For example, while looking at cards, their average heart rate rose to 81 bpm rather than 75 bpm or 77 bpm, i.e. about third of a standard deviation faster.
Van der Kolk claimed three quarters of veterans with PTSD reacted to Rorschach cards “as if they were experiencing a wartime drama”.
If he was just exaggerating for effect, then okay. But he put this in a study. I don’t want to accuse him of fraudulently misrepresenting his results, because it is theoretically possible his veterans reacted the way he claimed. I will say that his results are not the results found by other researchers.

Am I dismissing a lot of his claims? Yes. But after a good-faith attempt to find the truth. van der Kolk dismisses ideas he dislikes out of hand. For example, he raved for five pages about Prozac as a cure for trauma caused by sexual assault, but says "Surprisingly, however, the Prozac had no effect at all on the combat veterans at the VA—their PTSD symptoms were unchanged. These results have held true for most subsequent pharmacological studies on veterans: While a few have shown modest improvements, most have not benefited at all. I have never been able to explain this, and I cannot accept the most common explanation: that receiving a pension or disability benefits prevents people from getting better. After all, the amygdala knows nothing of pensions—it just detects threats."

PTSD is not fake, people are suffering, and I agree the amygdala does not understand pensions. But:

PTSD symptoms are largely self-reported.
Veterans, and only veterans, get regular checks if their PTSD symptoms remain
If a form asks things like "do you still have unpleasant memories of war", I can imagine people say “yes” more often if their checks depend on it.

I’m not saying I’m sure this is right. I’m saying this (the most common explanation, apparently) seems totally plausible to me, while van der Kolk rejects it with no evidence.

I don’t have the space to debunk all of his claims, but I was particularly unimpressed with his genetics comments. It’s an obvious confounder for the correlation between child abuse and later bad outcomes. He not only totally ignores it, but outright claims that “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 other psychiatric illness, for that matter”.My gut says that if someone claims we don’t know any genetic patterns for schizophrenia, it’s probably a good idea to disregard his views on psychiatry. But there’s no reason to trust my gut when we can check the citation for his choice of study:
“While little is known about specific disease mechanisms, family and twin studies show that genes contribute substantially to risk of the disorder at a population level. Thus, the risk to the siblings of an affected individual is about 10-fold greater than in the general population, and heritability (the contribution genes make to the population variance in risk) is 80% or more. While we have known for a long time that genes are involved in schizophrenia, the expected mode of inheritance has been less clear.”I’m not asking you to trust me. I’m asking you not to trust van der Kolk: he’s a psychiatrist who claims no genetic patterns have been found for psychiatric illnesses!

Finding false claim after false claim isn’t itself a debunking, but the book seems to be built on a house of cards. The central thesis, that trauma is stored in the body, looks to have originated in van der Kolk’s belief on false memories, back when he was highly paid to cite falsified research to jail people. Today we consider most of that debunked. I would like The Body Keeps the Score to be treated with strong scepticism.

My only concern before writing this book off entirely is that some people found it useful. I don’t want to get in the way of that. I liken it to the way faith healing or homeopathy works: some people report lower pain, but this doesn’t imply the homeopath is accurately describing the world, or the faith healer isn’t a charlatan.
Faith healing and homeopathy can deter people from seeking treatment that works. I think that’s a real concern with The Body Keeps the Score.