Q: I know that the study of neuroscience is intellectually fascinating, but how can it offer practical guidance when I’m working with a client with a trauma history?
A: As both a psychiatrist and a therapist some of the most challenging moments in my career have been with clients who suffer from complex trauma, disorganized attachment, and dissociative identity disorder. The extreme reactions associated with these diagnoses—including rage, cutting, suicidal ideation, panic, numbing, dissociation, and severe shame—have often left me frustrated, helpless, confused, and at times totally overwhelmed. But over the years, my knowledge of neuroscience has increased my ability to understand these reactions and how exactly to work with them while closely monitoring my own reactions. So while neuroscience isn’t a therapeutic approach in itself, it does help us understand why different interventions are required to address reactions that originate from different pathways in the brain.
To start, most extreme reactions resulting from trauma fall under one of two categories: sympathetic hyperarousal and parasympathetic blunting. Understanding what happens in the nervous system when clients experience sympathetic activation (a state of high physical energy, high emotion, and low ability to regulate and calm things) and parasympathetic blunting, or hypoarousal (characterized by low physical energy, low emotion, and low access to cognitive functioning), orient me on how to go beyond my immediate reactions when confronted with trauma symptoms in the therapy room.
Know Your Triggers
While being guided by an understanding of the neurobiology of trauma, therapists must never overlook the importance of what the client’s hyperarousal or hypoarousal triggers in them. For example, I might be sitting across from someone I’ve inadvertently triggered when they suddenly blurt out, “You really don’t get it, do you? I don’t know why I waste my time and money coming in week after week to see you!” In this case, I might struggle with whether to sit patiently and tolerate the intensity or let the person know directly that I don’t appreciate being talked to that way. Compare this with the experience of sitting with someone who’s looking down at the floor for most of the session and barely speaking. Should I just sit with them and share the silence, or try to come up with just the right thing to say that will pull them out of their current state?
Since I’m very relational and outgoing, I know that sitting with disconnection is much harder for me. I can become a clock-watcher and often work much too hard to try to bring someone out of that state than may be helpful. I have to tell myself, Slow it down, Frank. Just try to trust that there’s a really good reason that Jane is needing to be here right now. In contrast, when someone’s angry or totally overwhelmed, I have to calm down the controlling parts of me that want to shut down the intensity. My fighter often gets going, wanting to regain control of the situation. It’s completely normal for all of us to have these immediate internal responses, and sometimes they’re as intense as our clients’ responses. But learning how to recognize and relax our physiology in the moment is key in helping our clients.
Helping Clients Shift States
Whether your clients are acutely suicidal and highly agitated or numbed out and dissociated or rapidly switching from one extreme state to another, to move therapy forward, we need to help them separate or get out of the extreme response. The goal is to help them shift states and be mindfully present, feel safe enough, and observe what’s going on for them internally. In other words, we need to help clients be with, not in, their trauma. After all, nothing therapeutic can happen when clients are just reexperiencing or reenacting their trauma.
When clients experience sympathetic hyperarousal, the parts of their brain that can calm things down are shut down, or offline. This is where therapists need to help them bring those parts of their brain back online. Monitoring your reactions while staying present and nonreactive allows you to be the “rational brain” in the room and helps your client shift out of danger into mindful curiosity. To do this, we need to tolerate and meet the intensity of their reaction with confidence and clarity, and not allow ourselves to get overwhelmed or reactive. This can be a real challenge for those of us who get scared or frightened by extreme emotion.
For example, John comes into a session and begins to talk about an argument he had with his wife the previous night. “I’m so pissed at her,” he tells me. “She constantly puts our son in the middle of everything, forcing him to choose between us. Doesn’t she get how destructive that is?”
“That sounds really complicated, John, and I can see how difficult that would be for you based on your history,” I respond, trying to validate his feelings in hopes that it would calm him down.
“It makes me want to kill her, or myself!”
“I totally hear how angry you are, but see if you can separate from that anger just a little bit,” I suggest, on the lookout to see if enough of his rational brain is onboard to be able to gain some distance and perspective.
“Separate from it? Are you serious? You’re no better than she is!” John shouts.
“I see that I’m talking to the part of you that’s really pissed off right now, and I sense it’s mad because it’s trying to prevent your son from being in the middle like you were with your own mom and dad,” I tell him. “If you and I can decrease the intensity a bit, I bet you’ll have a much better chance at coming up with a workable solution.” After a brief moment, John tilts his head and relaxes his shoulders. In this situation, I tolerate his rage, calmly take charge to become the rational brain in the room because he’s unable to do it himself in the moment, and offer a rational perspective.
Separating John from his anger is key here. If you focus on feelings and body sensations with someone who’s activated, you’re likely to increase the intensity of what they’re experiencing. So I often tell clients who get activated between sessions to take a time out, not to do anything or make any decisions in this state. Instead, I suggest they try to meditate, check email, or read something—anything that allows them to step outside of their emotional self and observe their reaction.
Working with Withdrawal
On the opposite end of the spectrum, hypoarousal, or the blunted response, activates the dorsal branch of the parasympathetic nervous system. This causes several structures in the brain to go offline, including the insula (body connection and awareness); the amygdala (emotion); and the hippocampus, anterior cingulate, and prefrontal cortex (processing information and having the appropriate response). The result is disconnection from the body, feelings, and the rational mind. Clearly, the blunted response is biologically different from the activated response, and therefore different therapeutic interventions are required.
Hypoarousal originates from lower, more primitive brain structures and works its way up to higher, more evolved structures, so bottom-up interventions make sense here, compared to top-down strategies with hyperarousal. In essence, start with the body and work your way up to emotions and then to thoughts. If the client appears totally shut down, it’s best for you again to become the auxiliary brain and use your thoughts, feelings, and body sense to help them shift out of the state of threat into a safer, more mindful place. It takes the blunting response much longer to recover than the aroused response, so it’s helpful to slow things down, giving clients as much time, space, and control as they need. Remember that blunting stems from an internal sense of danger and life threat.
In the middle of my session with Sue, for example, someone inadvertently opens the door of my office to loudly ask how to get to the office of another therapist in my suite. “This is my first time here and I’m lost,” the person announces. This unexpected intrusion immediately sends Sue into a state of paralysis.
“Sue, can you hear me? Can you look at me?” I ask. Getting no response tells me that she’s not in the safe zone (the ventral portion of the parasympathetic nervous system). “Can you let me know what you’re thinking or feeling right now? I can see you’re really struggling,” I try again. Still getting no response, I ask her if she can move her finger, and she does. “Great,” I say, knowing that she’s not totally shut down. “I want you to know that I’m here for you, and we’ll take as long as your system needs for you to feel safe again. I’m not going to push you in any way. You’re the boss here, I trust you.” I just sit with her in silence and after a few minutes, I see her take a breath and move her head slightly. I know she’s back, and we slowly proceed with my asking if she can share her experience with me—which she does.
Photo by meo/Pexels
Even for experienced therapists, it’s easy for trauma treatment to get derailed, especially when encountering the extreme reactions associated with it. Logic and instinct may tell us to be relational and empathic when clients are overwhelmed; however, not providing the tolerance and perspective they need but can’t provide for themselves will only increase the emotional intensity and make things worse. We may also have the urge to help clients understand the dissociative experience, but this can be quite unnerving for them. Usually, it just perpetuates the disconnection, instead of shifting their focus to help them sense, rather than intellectualize, what’s happening in their body and emotions, with the goal of bringing key parts of their brain back online.
Neuroscience helps us differentiate the origins of these reactions. It also gives us a clear direction about how to help clients move beyond the extremes to a place of safety, where vulnerability can be tolerated and the healing work of therapy can be most fully engaged in.
Frank Anderson, MD, a psychiatrist and psychotherapist in Concord, MA, specializes in the treatment of trauma and dissociation. A lead trainer at the IFS Institute, he’s affiliated with Bessel van der Kolk’s Trauma Center and advises the International Association of Trauma Professionals. His most recent book is Transcending Trauma: Healing Complex PTSD with Internal Family Systems.