    
APPLYING THE BRAKES
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Jan/Feb
2004
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By Babette
Rothschild
Much as we don’t like to admit it publicly, it’s an
open secret among therapists that the road to
recovery from trauma can be fraught with clinical
missteps. In the past few years, I’ve frequently
been consulted by highly competent colleagues who
were dumbfounded by the speedy decline of clients
contending with traumatic memories.
Eight of these clients included a nurse, a
businesswoman, a salesman, a therapist and other men
and women who’d functioned relatively well prior to
therapy. Yet after attempts to address their
traumatic pasts (including rape, mugging, childhood
abuse, and household fire), three were hospitalized,
two went on disability, and the rest endured
debilitating flashbacks, panic attacks, or other
symptoms of dysfunction.
All the therapists involved were experienced and
well trained. Each one favored a different,
theoretically sound, therapeutic modality
(psychodynamic psychotherapy, EMDR, body
psychotherapy, and cognitive-behavioral). None was
irresponsible. So what exactly went wrong?
In each instance, I eventually discovered, traumatic
material was addressed before the client was
equipped to manage it. These therapists were
proceeding in a manner consistent with the usual aim
of psychotherapy: helping a client open up. They
knew very well how to call the genie of traumatic
experience out of the bottle, but as is all too
common, they didn’t know how to get the genie back
in.
My approach to trauma work, which is more cautious,
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.
My client Paula, for instance, first came to see me
for problems in her marriage. She was in her
mid-thirties and had three children under the age of
10. When she was a child, her mother had sometimes
harshly beaten her. Paula still lived in fear of her
mother’s aggression, although now it took the form
of yelling and criticism, rather than physical
violence.
One morning, 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.
Asking Paula about the source of her distress first
thing would have 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. "Y-y-ye-s," she
replied with difficulty. "I s-sometimes s-shake a
lot." A few seconds later, she was no longer able to
speak and could only show me how fast her heart was
beating by a rapid movement of her hand.
Paula 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. In
neurophysiological terms, her sympathetic nervous
system (which responds to situations of danger,
threat, and stress) was in overdrive, giving her a
pounding heart, a dry mouth, and muscle tremors.
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.
The
Early-Warning System
The amygdala is our early-warning system. It
processes emotion before the cortex even gets the
message that something has happened. When you smile
at the sight or sound of someone you love even
before you consciously recognize her, for instance,
the amygdala is at work. Here’s what happens: the
sound of the loved one’s voice is communicated to
the amygdala via exteroceptive auditory nerves in
the sensory nervous system. The amygdala then
generates an emotional response to that information
(pleasure or happiness, in this example) by
releasing hormones that stimulate the visceral
muscles of the autonomic nervous system and can be
felt as pleasant sensations in the stomach and
elsewhere. Lastly, the amygdala sets in motion an
accompanying somatic nervous system
(skeletal-muscle) response, in this case, tensing
muscles at the sides of the mouth into a smile.
A similar process occurs with other types of
stimuli, including trauma. When someone is
threatened, the amygdala perceives danger through
the exteroceptive senses (sight, hearing, touch,
taste and/or smell) and sets in motion the series of
hormone releases and other somatic reactions that
quickly lead to the defensive responses of fight,
flight, and freeze. Adrenaline stops digestive
processes (hence the dry mouth) and increases heart
rate and respiration to quickly increase oxygenation
of the muscles necessary to meet the demands of
self-defense.
The amygdala is immune to the effect of stress
hormones and may even continue to sound an alarm
inappropriately. In fact, that could be said to be
the core of post-traumatic stress disorder (PTSD) -
the amygdala’s perpetuating alarms even after the
actual danger has ceased. Unimpeded, the amygdala
stimulates the same hormonal release as during
actual threat, which leads to the same responses:
preparation for fight, flight, or - as with Paula -
freeze. In PTSD, this happens regularly, despite
outward evidence that these responses are no longer
needed. In sum, PTSD could be said to be a healthy
survival response gone amok.
Why does the amygdala continue to perceive danger?
What makes it possible for the whole body to
repeatedly respond as if there is danger, when in
fact the danger is past?
The
Rational System
The hippocampus helps to process information and
lends time and spatial context to memories of
events. How well it functions determines the
difference between normal and dysfunctional
responses to trauma and normal versus traumatic
memory. An example will help to explain.
In his book The Emotional Brain, Joseph
LeDoux explains the survival response involved when
encountering an object that looks like a snake.
Naturally, the amygdala signals an alarm message,
which sets in motion a series of reactions that
culminate in the footstep halting in mid-air. The
amygdala’s communication travels at lightening
speed. There’s a second communication pathway that
takes longer, eventually getting the message around
to the cortex, where rational thought takes place.
When the information "It’s a snake!" reaches the
cortex, it’s then possible to evaluate the accuracy
of the amygdala’s perception. If the message was
accurate and it is a snake, the halted step will
freeze until the danger is passed, i.e., the snake
slithers away. If, however, there’s a discrepancy
and what was thought to be a snake is discerned by
the cortex to be a bent piece of wood, the cortex
sends a new message to the amygdala, "Hey, it’s only
a stick," to stop the alarm immediately.
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.
Trauma Trumps Rational Thought
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, 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 further 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.
Further reading:
Damasio, A. R. (1994). Descartes¹ error. New
York: Putnam¹s Sons.
Herman, J. L. (1992). Trauma and recovery.
New York: Basic Books.
Nadel, L., & Jacobs, W.J. (1996). The role of the
hippocampus in PTSD, panic, and phobia. In N.
Kato (Ed.), Hippocampus: Functions and clinical
relevance. Amsterdam: Elsevier.
Rothschild, B. (2000). The body remembers: The
psychophysiology of trauma and trauma treatment.
New York:WW Norton.
Rothschild, B. (2003). The body remembers
casebook: Unifying methods and models in the
treatment of trauma and ptsd. New York: WW
Norton.
van der Kolk, B.A., McFarlane, A.C., & Weisaeth, L.
(1996). (Eds.). Traumatic stress. New York:
Guilford.
Babette
Rothschild, M.S.W., L.C.S.W.,
is in private practice in Los Angeles and gives
professional trainings worldwide. She’s the author
of:
-
The Body Remembers: The
Psychophysiology of Trauma & Trauma
Treatment, (WW
Norton, 2000)
-
The Body Remembers Casebook:
Unifying Methods and Models in the Treatment
of Trauma and PTSD,
(WW Norton, March 2003)
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