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Friday, 02 January 2009 09:43

Applying the Brakes - Page 2

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The hippocampus assists the transfer of the initial information--the image of stick or snake--to the cortex, where it's then possible to make sense of the situation. This is the normal way information is communicated, as long as the hippocampus is able to function.

The hippocampus, however, is highly vulnerable to stress hormones, particularly adrenaline and noradrenaline, released by the amygdala's alarm. When those hormones reach a high level, they suppress the activity of the hippocampus and it loses its ability to function. Information that could make it possible to determine the difference between a snake and a stick (or, as in Paula's case, past danger and current safety) never reaches the cortex, and a rational evaluation of the situation isn't possible.

The hippocampus is also a key structure in facilitating resolution and integration of traumatic incidents and traumatic memory. It inscribes time context on events, giving each of them a beginning, middle, and--most important with regard to traumatic memory--an end. A well-functioning hippocampus makes it possible for the cortex to recognize when a trauma is over, perhaps even long past. Then it instructs the amygdala to stop sounding an alarm.

This has critical implications for therapy. Safe, successful trauma therapy must maintain stress hormone levels low enough to keep the hippocampus functioning. That's why it's so crucial for both client and therapist to know how to "apply the brakes" in therapy--to keep the hippocampus in commission and return it to action as promptly as possible when the system goes on overload.

When and How to Apply the Brakes


Knowing when to apply the brakes is as important as knowing how . Therapists can know when by watching for physical signals of autonomic system arousal, transmitted by the client's body, tone of voice, and physical movements. When a client turns pale, breathes in fast, panting breaths, has dilated pupils, and shivers or feels cold, her sympathetic nervous system (activated in states of stress) is aroused. Stress hormones are pouring into her body, threatening the hippocampus with shut-down. These symptoms mean it's time to calm the client down.


When, on the other hand, a client sighs, breathes more slowly, sobs deeply, sweats, or flushes, her parasympathetic nervous system (activated in states of rest and relaxation) has been activated, and her stress hormone levels are reducing. Recognizing these bodily signals is invaluable to the therapist. Likewise, a client who learns to recognize them often gains a greater sense of body awareness and self-control.

Paula's Brakes


After identifying Paula's hyperaroused state, I asked her a few specific questions to narrow her focus. For some clients, paying attention to body sensations helps put on the brakes, but that wasn't the case with Paula, as I quickly found out. Her continued hyperarousal told me that her amygdala persisted in assessing danger. I needed to find another way to help her evaluate this situation, in this room with me.

I decided to see if I could directly engage her cortex using what I call dual awareness. If I could help her to accurately see where she was and whom she was with, she might be able to calm down. So I asked her, "Can you see me?" She replied with a nod of the head. "Clearly?" I could see her breathing slow a little and she managed to say, "Yes."

As Paula's arousal lessened, I asked for more information. "Tell me what you see. Describe me: What color are my eyes? What color is my hair? Am I having a good hair day or a bad hair day?"

Breathing slightly easier, Paula was now able to reply, "Your eyes and hair are brown. I think you're having a good hair day." We both laughed a little; laughter is great for calming the nervous system. I could see color returning to her face and she was shaking less.

To increase her body awareness and the connection between what we were doing and her emotional state, I asked, Paula to describe what happened to her shaking as she looked at and described me.

"It's less," she realized. But she was still shaking a bit, so we weren't through. On a hunch I asked if she felt threatened by me in any way.


"No," she said, "but don't come closer."

Her reply gave me a big clue. "Perhaps," I ventured, "I'm actually sitting too close to you. I'd like to try moving back a little. Would that be okay?"

She wanted me to move back a foot. When I complied, she exhaled sharply. I drew her attention to that response as well as another. "Something else changed. Do you know what?"

"I stopped shaking."

At this point Paula was much calmer, visibly to me and noticeably to her. Her cortex was beginning to discern that she was in a safe place, with a person who wouldn't harm her. It seemed that increasing the distance between us was useful for her, and I asked if she wanted to try increasing it more.

This time, she was more assertive, asking me to move back two feet. Then she was aware of physiological changes even before I asked. "I can breathe easier," she said. She also told me that her heart rate was much slower, nearly normal. But she complained that her legs felt rather weak, which is a common consequence of fear--that feeling of being "weak in the knees."

Increasing strength in her legs could help her feel more secure, so I instructed her to put weight on her feet and press them into the floor. "Do it as if you're going to tip your chair back, but don't actually do that. The point is to increase the tone in your thighs. When they begin to get tired, release the tension very, very slowly." That would insure that some of the tone remained.

As her thighs became stronger, Paula felt even calmer, and was able to think clearly. Her hippocampus was functioning now that stress hormones were no longer being released. To facilitate integration I asked, "What have you learned in the last few minutes since you arrived?" I wanted her to know what had helped, so she'd be able to use some of these same tools to combat hyperarousal and anxiety in her daily life.


Paula easily identified that she felt calmer when I sat farther away and that it was helpful when I asked her to describe me. "Looking at you, I stopped thinking about my mother. Just before I came, we had a big fight."

It became obvious to both of us that in her hyperaroused state, Paula had entered the session expecting me to act like her mother. "Actually, I expect everybody to act like her," she said.

That insight laid the groundwork for the rest of the session, in which we focused on helping Paula to differentiate who was a person to fear and who wasn't. That work wouldn't have been possible at the beginning of the session, when her hippocampus was overwhelmed.

Had I immediately begun questioning Paula on the causes of her distress instead of first attending to putting on the brakes, her overwhelmed hippocampus would have made it difficult for her to clearly separate me from her mother, and together we might have wandered into one of those anguished quagmires well known to trauma therapists. Putting on the brakes helped to avoid a potential transference disaster.

There's a common misconception among many trauma survivors and trauma therapists that working in states of high distress, including flashbacks, is the way to resolve traumatic memories. But being in the throes of hyperarousal and flashback indicates that the hippocampus isn't available to distinguish past from present, danger from safety. Under those conditions, working with traumatic images and the emotions they engender can risk a variety of negative experiences. Moreover, as Judith Herman has said, a trauma survivor's primary need is to feel safe, particularly in therapy. Applying the brakes to keep arousal low and the hippocampus functioning makes this goal much easier to achieve.

Babette Rothschild, M.S.W., L.C.S.W., is in private practice in Los Angeles. She's the author of The Body Remembers: The Psychophysiology of Trauma & Trauma Treatment , and the forthcoming The Body Remembers Casebook: Unifying Methods and Models in the Treatment of Trauma and PTSD . Address: P.O. Box 241783, Los Angeles, CA 90024. E-mails to the author can be sent to: babette@trauma.cc.

Resources

Damasio, Antonio R. Descartes' Error: Emotion, Reason, and the Human Brain New York: Putnam's Sons, 1994.

Herman, Judith L. Trauma and Recovery. New York: Basic Books, 1997.

Nadel, L., & Jacobs, W.J. "The Role of the Hippocampus in PTSD, Panic, and Phobia." In Nobumasa  Kato, ed. Hippocampus: Functions and Clinical Relevance. Amsterdam: Elsevier, 1996.

van der Kolk, Bessel A., Alexander C. McFarlane, and Lars Weisaeth, eds. Traumatic Stress. New York: Guilford, 1996.

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