My approach to trauma therapy is rooted in an experience I had in college. A friend asked me to teach her to drive---in a new car my father had just given me. Sitting in the passenger seat next to her as she prepared to turn on the ignition, I suddenly panicked. I quickly realized that before I taught her how to make that powerful machine go, I had to make sure that she knew how to put on the brakes.
I apply the same principle to therapy, especially trauma therapy. I never help clients call forth traumatic memories unless I and my clients are confident that the flow of their anxiety, emotion, memories, and body sensations can be contained at will. I never teach a client to hit the accelerator, in other words, before I know that he can find the brake.
Following this principle not only makes trauma therapy safer and easier to control, it also gives clients more courage as they approach this daunting material. Once they know they're in the driver's seat and can stop the flow of distress at any time, they can dare to go deeper. Developing "trauma brakes" makes it possible for clients, often for the first time, to have control over their traumatic memories, rather than feeling controlled by them.
One morning, my client Paula came into her session pale, with her head bowed. Hardly looking up at me, she moved to her chair and crouched in it, shaking. I'd later learn that she'd just finished a searing telephone conversation with her mother, who'd abused her as a child.
Asking Paula about the source of her distress first would've let the genie of her traumatic past out of the bottle, increasing her distress. First I needed to help her calm down, to put her in charge of her somatic and emotional responses.
"You're really shaking, aren't you?" I said, drawing her attention to her body sensations. Sometimes this type of intervention is enough to help a client calm down, though for Paula it wasn't. She was exhibiting symptoms of what neuroscientists call hyperarousal---a flood of adrenaline and other stress hormones that made her feel threatened and confused. The brain structures most involved in rational thought and memory were, practically speaking, out of commission.
To help a client when she comes as unglued as Paula was that day, it's useful to understand what's currently known about how the brain handles danger and emotion, especially in the limbic system and two of its major structures: the hippocampus and the amygdala.
The limbic system is survival central, the area of the mid-brain that initiates fight, flight, or freeze responses in the face of threat. (Paula was on the verge of freezing.) The amygdala and the hippocampus, part of the limbic system, are also deeply involved in responding to traumatic events.
The cortex, the more rational, outermost layer of the brain, is the seat of our thinking capacity and our ability to judge, deliberate, contrast, and compare. It's where most memory--traumatic and otherwise--is stored. The cool, rational cortex is in constant communication with the amygdala and the hippocampus.
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.
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.This blog is excerpted from “Applying the Brakes.” Read the full article here. >>Want to read more articles like this? Subscribe to Psychotherapy Networker Today!