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心理疾患的身体疗法 把旧日伤痛"演"出来
“你真心的悔恨和难过，见证人都看到了，”范德科尔克说。我一直凝视着尤金，所以我看不到范德科尔克的表情。但后来克雷斯塔告诉我，看着他，就好像是看着一个巫师或魔法师，又或者像一台超高速电脑。她留意到，他一直密切关注着尤金的面部表情、语调和姿势中的变化，并在几微秒内就对它们作出相应的反应，时而提出问题，时而旁白“见证人看到了”。
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.
范德科尔克以低沉平稳的声音指示我。“告诉他，你原谅他，”他说。“告诉他你明白那时候是非常时刻，你知道他不是故意的。他还很年轻，你们都同样被困在地狱中饱受折磨。告诉他你原谅他，你现在已经没事了。”我重复着这些话，尽力让它们听起来发自肺腑。我发现自己热切地盼望尤金能够把我的话听进心里。
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.
说起来令人难以置信，作为一个每年听众总数可达1.5万以上的人，范德科尔克并不擅长演讲。他带着厚重的荷兰口音，如果你就坐在他旁边的话倒是也不难听懂，但哪怕只隔开几英尺远，你就会觉得不知所云了。所以情况经常会像他在费城的最近一次讲座这样，听众们对他的第一条评论是：“我们听不清！”范德科尔克请求音效师帮他调高音量，并向与会的200来人承诺，他会尽可能地大声。但还是有听众们听不到他在说什么，即使有些人已经是在前排，于是颇有些抱怨的声音。但范德科尔克总是那么热情洋溢，令人倾倒。与往常一样，他很快就征服了听众。
“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.
“请大家弓起后背并低头，就像这样，”他一边说一边亲身示范。“现在请试着说：‘哦，我感觉好极了！我今天非常开心！’ ”场下出现了笑声。“你看，在这种姿势下，你是不可能感到幸福的。”为了彻底表明自己的观点，他让我们摆出相反的姿势：坐直身子，展现欢快的表情，然后试着去感觉难过。
The mind follows the body, he said.
心随体转，他说。
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.
范德科尔克总喜欢说，创伤受害者的精神与身体脱节了，而这是由大脑深处被称为杏仁核的结构开始的级联反应造成的。在遇到威胁时，杏仁核会激发出“战或逃”反应，其中涉及大量激素的释放。这种反应通常会持续到威胁消除为止。但如果威胁一直没有消失——如果我们不能反抗也不能逃跑——那么杏仁核这个“人体的烟雾探测器”就会不停地拉响警报。于是我们就不断地制造应激激素，进而大肆破坏我们身体的其余部分。这与慢性应激的过程非常相似，区别只在于在创伤应激中，关于创伤事件的记忆侵入了患者的潜意识中，哪怕是最轻微的刺激都会令他们回到“战或逃”模式。治疗师和患者将其称为被“激发”。短期内，患者会通过“游离于世外”的方式来回避它所引发的痛苦。也就是说，他们会将自己的精神从躯体上抽离开，以至于无法准确地描述自己的身体感觉。这在治疗中屡见不鲜，范德科尔克说。
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.
范德科尔克的一些最亲密的同事指出，他的夸张其实是刻意为之。他并没有那么厌弃传统疗法，也并不认为自己的方法无懈可击。他只是试图说服人们保持一种更加开通的态度。事实上，当我就认知行为疗法追问他时，他承认这种疗法在焦虑症或强迫症的治疗中大概还是可以派上用场的。而且，虽然他认为百忧解(Prozac)治疗PTSD的效果不如EMDR，但他并不是绝对地反对用药。
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.”
一直以来，范德科尔克都在借助评估自己的临床经验来寻找最佳疗法的蛛丝马迹。“或许我该对尤金用EMDR，而不是构造练习，”在加州的研讨会后不久，他对我说。“我不太确定它会有多大效果。”
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。
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