The Three Routes To Reversing Trauma
Top-down talk, medication, or bottom-up body work — and van der Kolk stakes almost everything on the third.
- Difficulty
- Moderate
- Time to result
- ~months to results
- Steps
- 5
- Confidence
- 93%
Van der Kolk organises every available intervention into three routes. Top-down is talk therapy: understanding, insight, explanation. He is openly suspicious of it, on the grounds that he is such a cerebral person that explaining things is not his handicap, so he deliberately downplays its importance. Route two is medication, which shuts down the body's alarm signals; he did the first-ever studies of Prozac and Zoloft for PTSD and says they are not bad and can be helpful, but they are not where his weight sits. Route three is bottom-up: allowing the body to have experiences that directly contradict the helplessness, rage or immobilisation of the trauma. These are the somatic therapies that target the body rather than the mind, and he calls this the big missing piece in mental health and medicine generally. Since writing the book he has added a fourth dimension he did not originally have — experiences that blow your mind open and give you an alternate reality, meaning psychedelic-assisted therapy. His sequencing principle is that the routes are not interchangeable and that a person who is chronically agitated and unable to focus is not ready for the mind-opening route at all.
Origin
The three-way division is the organising spine of The Body Keeps The Score. Van der Kolk built it from a career that spans all three: he began as a psychopharmacologist running the first PTSD trials of SSRIs, played a minor role in creating the DSM, and then spent decades demonstrating that yoga, neurofeedback, EMDR, bodywork and psychodrama produced results his academic colleagues initially dismissed as going off the deep end.
Core principles
- 01Top-down insight is real but insufficient and over-weighted.
- 02Medication shuts down alarms; it can help but does not resolve.
- 03Bottom-up work gives the body experiences that contradict helplessness.
- 04Sequence matters: calm the body before opening the mind.
- 05The profit motive is what keeps the field on routes one and two.
How to run it
- 1
Start with a map, not a diagnosis
Van der Kolk's step one is to ask who are you, what do you value, what is working, what is not working, what has helped, what has not, and what gets in the way. He explicitly refuses to open by listing how screwed up you are.
Pro tip He says the DSM — which he helped create in a minor role — is not a good way to start off.
Watch out He checks continually whether the work is helping, and gives very little advice by design.
- 2
Assess capacity to stay present
He watches how agitated you get and how much you can stay in focus. If a specific subject reliably produces agitation or shutdown, he works on that. If you are chronically agitated and unable to focus at all, the plan changes entirely.
Pro tip He is candid that matching treatment to person is the tricky thing — he tried to solve it in the book and says he failed.
Watch out Choosing a modality before this assessment risks giving someone an experience they cannot tolerate.
- 3
Calm the system first
For the chronically overwhelmed, start with things that calm body and brain — yoga, qigong, whatever movement makes sense to the person — and probably neurofeedback alongside.
Pro tip His phrasing is that this comes before we start blowing your mind open.
Watch out He explicitly tells some patients they are not ready for psychedelics yet.
- 4
Add the bottom-up contradiction
Introduce practices that give the body direct evidence against helplessness: martial arts for agency, bodywork and touch for connection, group movement for synchrony.
Pro tip He calls the missing piece giving people experiences of connection and pleasure.
Watch out Some poses and forms of touch are themselves triggering and must be introduced carefully.
- 5
Only then consider mind-opening work
The fourth dimension he added post-book: experiences that allow an alternate reality. He is emphatic that set and setting are not optional and that support must be present throughout.
Pro tip The majority of participants in his study told him afterwards they could not have done it without the team present.
Watch out The profit-driven version — one pill, go off by yourself, deal with it — is the failure mode he fears most.
In the wild
Van der Kolk was the first person to run yoga as a PTSD treatment. His academic colleagues' reaction was that he had gone off the deep end — putting your butt in the air and twisting your spine, Bessel, for trauma.
→ The study showed yoga was very effective, brain areas dampened by trauma came back to life, and yoga is now fairly well accepted. He is precise that you do not treat trauma with yoga — you treat your relationship to your body.
Van der Kolk was sickly until around 13. He describes rolfing — a very intense form of massage that tears muscle from fascia — as possibly the most helpful thing he ever did.
→ He says he came to live in a new body and no longer lived frozen in the body of the little child who almost died. He rates it as profound as anything he has done.
Common mistakes
Assuming one route fits everyone
Van der Kolk admits he tried to solve treatment matching in the book and failed, and is not doing much better in the new one. The honest position is assessment-led sequencing, not a protocol.
Letting cost and speed pick the route
He says the methods that work are unconventional and not practised in mainstream psychiatry because treatments need to be productive and cheap, and whether you get better does not matter. He calls the profit motive killing of good practice.
Opening the mind before calming the body
For chronically agitated patients he actively refuses the psychedelic route until neurofeedback and body practices have made living in the body tolerable.
Is it for you?
Best for
Anyone choosing between therapy modalities, and clinicians who want a sequencing logic rather than a single method.
Not ideal for
People wanting a specific protocol to follow — van der Kolk deliberately refuses to give one.
From the transcript
“the bottom-up approach is allowing the body to have experiences that contradict the helplessness or rage of trauma”
“I first want to know who you are what is working what isn't working what has helped you what hasn't helped you”
“I think the profit motive is killing good practice”
From the episode
The Body Trauma Expert: Medicating Kids Can Harm Brain Development! Eye Movement Trick That Fixes Trauma! The Secret To EMDR Therapy! - Bessel van Der Kolk
Bessel van der Kolk