Self and Society, May 1999

Traumatic events exact a toll on the body as well as the mind. This is a well documented and agreed upon conclusion of the psychiatric community as attested in the Diagnostic and Statistical Manual of the American Psychiatric Association. A major category in their symptom list of Post-traumatic Stress Disorder (PTSD) is "persistent symptoms of increased arousal" in the Autonomic Nervous System (ANS) (APA 1994). Yet, despite a plethora of study and writing since PTSD first appeared as a diagnostic category 17 years ago (APA 1980), there has been little attention given to this, the somatic side of trauma. The attention that has been given to the body tends to focus on the distressing symptoms of PTSD and the resulting problems. Consideration of using the body, itself, as a possible resource in the treatment of trauma has rarely been explored. The consequences of such an exclusion are multifold as comprehending traumatic impact on the body may be a vital key to understanding and treating the traumatized body as well as the traumatized mind. Moreover, somatic interventions may be useful as an adjunct to existing trauma therapies, making the therapy easier to pace, and less volatile. This article will review the phenomenon of "increased arousal" in the ANS and present several somatic techniques that are useful in stopping or reducing ANS hyperarousal.

INTRODUCTION
Most of my psychotherapy colleagues and professional workshop participants tell me that they know all too well just how tricky psychotherapy with trauma can be - regardless of the theory or techniques that are being applied. The risk of client overwhelm, anxiety and panic attacks, flashbacks, or worse re-traumatization, always lingers. I have heard reports of clients getting such overwhelming flashbacks during therapy sessions, that the treatment room became misinterpreted as the site of the trauma and the therapist the perpetrator of the trauma. Reports of clients becoming unable to function normally in their daily lives during a course of trauma therapy - some even requiring hospitalization - are not uncommon. Working with trauma seems, universally, to be rather more precarious than other realms of psychotherapy.

I have found it safest to approach trauma therapy in a similar way that I approach driving an automobile. My logic stems from the observation that both driving and trauma therapy involve controlling something that can easily go out of control.

I've taught several friends to drive. I always begin the same way. First, before my driving student is allowed to cause the car to move forward, I teach him how to stop, how to brake. It is only once my student (and I) are secure in his ability to find the brake pedal and stop the car reflexively, that I deem it safe for him to meet the accelerator and learn to (slowly) advance the car, while periodically returning to the brake pedal - stop and go. Safe driving involves timely and careful braking combined with acceleration at the rate that the traffic, driver and vehicle can bear. So does safe trauma therapy.

It is not a good idea to proceed with directly addressing a traumatic incident - accelerating trauma processes in the mind and body - unless both you and your client know how to apply the brakes: stop that process if it becomes too uncomfortable or destabilizing. Safe trauma therapy includes: 1) understanding the phenomenon of hyperarousal, 2) the ability to observe and gauge the state of the ANS, and 3) body oriented tools for stopping, containing and reducing hyperarousal - applying the brakes.

ANS AND THE PHYSIOLOGY OF HYPERAROUSAL
Notice what you feel in your body, particularly your heart rate and breathing as you read the following:

The limbic system of the brain responds to extreme stress/trauma/threat by releasing hormones that tell the body to prepare for defensive action, activating the sympathetic branch (SNS) of the autonomic nervous system (ANS), preparing the body for fight or flight: increasing respiration and heart rate, sending blood away from the skin and into the muscles, etc. When threat is imminent or prolonged (as with torture, rape, etc.), the brain can also release hormones to heighten the parasympathetic branch (PNS) of the ANS, and tonic immobility - like a mouse going dead (slack) or a frog or bird becoming paralyzed (stiff) - can result (Gallup 1977, Levine 1997).

With PTSD the brain continues to respond as if under stress/trauma/threat, continuing to prepare the body for fight/flight, or going dead (sometimes called "freezing") even though the actual traumatic event has ended. People with PTSD live with a chronic state of ANS activation - hyperarousal - in their bodies leading to physical symptoms that include: anxiety, panic, muscle stiffness, weakness, exhaustion, concentration problems, sleep disturbance, etc.

Diagram 1. illustrates the organization of the body's Nervous System:

During a traumatic event the brain tells the body there is threat. In PTSD, the body persists in telling the brain there is continued threat; the brain continues to stimulate the ANS for defense. It is a vicious circle. Objects, sounds, colors, movements, etc., that might otherwise be insignificant, become associated to the trauma and become external triggers that are experienced internally as danger (van der Kolk 1996). Confusion can result when recognition of external safety does not coincide with the inner experience of threat. Hyperarousal can become chronic, or can be triggered acutely. Breaking this cycle is an important step in the treatment of PTSD.

The ability to recognize indications of hyperarousal, that is, ANS over-activation can help in breaking that cycle. It is easy to learn, but as with any skill it takes a degree of practice. I suggest that all professionals (psychotherapists, and body workers alike) working with traumatized clients - no matter what theory base or techniques are being used -, memorize the signs for both SNS, PNS and combined activation and practice observing them in others. It is also very useful to ask your client periodically what he is aware of in his heart rate, breathing, etc. - particularly those ANS signs that are more difficult to observe. By noticing what is happening in the client, the psychotherapist secures a valuable, objective gauge for reading the arousal state of the client. It can also be useful to teach the client to recognize signs of ANS activation in himself - he will gain a greater sense of body awareness and a greater sense of self-knowledge and self-control.

Diagram 2. illustrates the organization of the Autonomic Nervous System:

The PNS and SNS branches of the ANS function in balance with each other. The SNS is primarily aroused in states of stress, both positive and negative. Examples of positive experiences that create stress in the body include: orgasm, getting married, a challenging sport. Stress can also be the result of pressured expectations at work or school, financial problems, family conflicts, etc. The most extreme stress is traumatic stress as the result of threat to life. The PNS is primarily aroused in states of rest and relaxation, pleasure, sexual arousal, etc. Both branches are always engaged, but one is usually more active, the other suppressed - like a scale: when one side is up, the other is down. They constantly swing in complementary balance to each other (Bloch 1985). The following will illustrate the interactive balance of the SNS and PNS:

So it goes throughout the average day with the SNS and PNS swaying in balance with each other.

APPLYING ANS KNOWLEDGE IN THE THERAPY SETTING
A major advantage of learning to observe the bodily signs of ANS activation is having additional tools to help clients contain and reduce hyperarousal in their daily lives, as well as avoiding this highly traumatized (and possibly re-traumatizing) state during therapy sessions.

PNS activation (slow respiration, slow heart rate, contracted pupils, etc.) indicates the client is relaxed, and the therapy is progressing at a comfortable rate. Low SNS activation (increased respiration, increased heart rate, dilated pupils, etc.) indicates excitement and/or containable discomfort. High SNS activation (rapid heart rate, hyperventilation, etc.) may mean the client is having trouble dealing with what is going on and may be quite anxious. And when high sympathetic activation becomes masked by high parasympathetic activation (and there are indications that both are aroused simultaneously - i.e., pale skin with slow breathing, dilated eyes with flushed skin, slow heart rate and rapid breathing, etc.), the client is in a highly traumatized state and it is time to hit the brakes. He is likely experiencing some type of flashback (in images, body sensations, emotions, or a combination). In such an instance, the therapist must help stabilize the client - as indicated by either lowered sympathetic activation or primarily parasympathetic activation - before proceeding further with the therapeutic work or sending him home. Not to do so could risk panic, re-traumatization, breakdown, or worse. Several strategies useful for accomplishing such stabilization are addressed in the next section of this article.

CAUTION: Not all of the following techniques will work for all clients. Some clients may find one or more of them provoking rather than containing. Experiment slowly using bodyawareness and drop any technique that increases anxiety or symptoms.

SOMATIC RESOURCES FOR BRAKING: SLOWING DOWN AND CONTAINING HYPERAROUSAL

Bodyawareness
Bodyawareness - being able to accurately sense what is happening in one's body - appears to be a powerful tool in trauma therapy for braking though it can also be accessed to enable acceleration of the therapy process (when the client is ready) as a catalyst to somatic memory (van der Kolk 1994). Client skill in bodyawareness will make the other techniques described below more effective. "Bodyawareness" in this usage - as taught in the BODYnamic training programs (BODYnamic Institute 1988-1992) - refers to the precise awareness of the physical body: skin, muscles, bones, organs, breathing, movement, position in space, etc. It further implies how the body is actually being experienced/sensed in the here-and-now: temperature, tension/relaxation, pain, prickles, pressure, size, humidity (i.e., sweating hands), heart rate, "growling stomach", vibration, etc. Contrary to what you might think, clients usually become less, rather than more anxious when encouraged to notice and describe their bodily sensations. (But there are exceptions to this rule - bodyawareness is not for everybody.) Once they get the hang of it, many clients report that during trauma therapy, it is a relief for them to be periodically asked about their bodyawareness - the bodyawareness can become a secure resource in itself.

Not every client can use this braking tool, though. There are several situations where it would be contraindicated. Two examples: 1) Some traumas are so damaging to the bodily integrity that any sensing of the body over-accelerates contact to the trauma(s); 2) There are also clients who will feel pressured to sense their body "correctly" - a kind of performance anxiety can develop. In such cases it is better to bypass training in bodyawareness and use other braking techniques instead.

Tensing Peripheral Muscles - Holding Together
Tensing in peripheral muscles of arms and legs is often calming and containing. Tensing is a particularly useful braking technique and is usually very effective for reducing hyperarousal, or at least making it seem more containable. The principles for this were taught to me in the Bodynamic Training Program (1988-1992), as well as the leg exercises. The arm exercises were taught to me by my colleague, physical therapist and body-psychotherapist, Robyn Bohen (Bohen 1991). I

IMPORTANT: Any tensing should be done only until the muscle feels slightly tired. Release of the tensing must be done very, very slowly. Try one tensing and evaluate with bodyawareness before going on to the next. If tensing causes any adverse reaction (nausea, spaciness, anxiety, etc.), you can usually neutralize the reaction by gently stretching the same muscle - making an opposite movement.

Legs: Stand with feet a little less than shoulder-width apart, knees relaxed (neither locked, nor bent). Press knees out directly to the side so that you can feel tension along the sides of the legs from knee to hip.

Left arm: Sit or stand with arms crossed right over left. The right hand should be covering the left elbow.

• The right hand provides resistance as the left arm lifts directly away from the body. You should feel tension in the forward directed part of the upper arm from shoulder to elbow.
• The right hands provides resistance to the back of the elbow as the left arm pushes directly left. You should feel tension in the left-directed part of the upper arm from shoulder to elbow.

Right arm: Sit or stand with arms crossed left over right. The left hand should be covering the right elbow.

• The left hand provides resistance as the right arm lifts directly away from the body. You should feel tension in the forward directed part of the upper arm from shoulder to elbow.
• The left hands provides resistance to the back of the elbow as the right arm pushes directly right. You should feel tension in the right-directed part of the upper arm from shoulder to elbow.

Dual Awareness
A few years ago, in a professional workshop I was asked the following question by a psychotherapist participant: "What do I do about a client who, as soon as she enters the therapy room goes into flashback, believing the therapy room to be the scene of the trauma and me to be the perpetrator?" My answer was simple, "Stop her!" Of course, sometimes this is easier said then done.

In my experience it is not possible for a client to work through a trauma until and unless he can maintain a dual awareness of past and present. I have found that allowing a client to continue in flashback and hyperarousal, only adds to his experience of trauma and sense of hopelessness to overcome it.

Sometimes you have to work with a client for a period of time (weeks, months, years) before he has enough ego strength to be able to maintain this dual awareness while addressing the trauma. When this is the case, that must be the prerequisite focus of the therapy. Once the client has developed this capacity, the use of dual awareness, it can also be used as a braking tool. This is a great asset.

Bessel van der Kolk discusses the difference between the "experiencing self" and the "observing self" in the traumatized client (van der Kolk 1996b). In a traumatized person, there may be a marked split. Teaching the client to acknowledge both parts by stating the reality of both selves at the same time, is often a key to calm.

Acknowledging this split has helped several of my Danish clients to wait for the train in the one underground station in Copenhagen, Nørreport , where they otherwise were prone to anxiety attacks. This simple technique involves accepting and stating (aloud or in thought) the reality of both the experiencing self and the observing self at the same time: "I'm feeling very scared here (experiencing self)," while at the same time actually looking around, evaluating the situation, and if it is true, saying, "But I'm not in any danger (observing self)."

It's also an effective technique for stopping a flashback: "I am feeling very [insert emotion, usually scared] right now because I am remembering [insert traumatic event]..." "...And I am looking around and can see that [insert traumatic event] is not happening right now ."

Establishing a Sense of Boundary at the Skin Level
Much trauma is the result of events that were in one way or another physically invasive: assault, rape, car accidents, surgery, torture, beatings, etc. Often it is loss of the sense of bodily integrity that accelerates a trauma process out of control. Reestablishing the sense of boundary at the skin level will often reduce hyperarousal. To increase the sense of bodily integrity, I will often suggest that a client physically feel his/her periphery/boundary - the skin. This can be done in two ways:

1) Have your client use his own hand to rub firmly (not too light, not too hard) over his surface. Try one spot, e.g. an arm or leg, first. If it is containing and calming for the client, go on to another place, eventually covering the entire body. Make sure the rubbing stays on the surface - skin (clothes over skin), and does not become a gripping or massaging of muscles. If your client doesn't like touching himself, he can use a wall or door (often a cold wall is great) to rub against or have him use a pillow or towel to make the contact. Remember, especially, the back, and the sides of the arms and legs.

2) Some clients will feel too provoked even touching their own skin. In that case it might work to have them sense their skin through sensing the objects they are in contact with. Have the person feel where his buttocks meets the chair, his feet meet the inside of his shoes, the palms of his/her hands rest on his thighs, etc. As the client tries either of these, it may be useful to have him thinking or saying to himself "this is me", "this is where I stop", etc.

Feeling the boundary of the skin can serve as a braking technique for many. But note, for some this technique will be more provoking than calming; use caution.

Feeling the Solidness of the Bones
Some people who become provoked when feeling their skin may respond well to feeling the solidness of their bones (caution, though, as a few could be frightened by this - bones remind some of skeletons and death).

Sensing the spine, in particular, can be a great aid to braking. This can be done sitting or standing, placing the spine against a wall or out-facing corner. It can also be done without outside contact by focusing on the internal support of the spine. Ask your client if he can feel his spine supporting his trunk to stay upright.

You can also offer your client a wooden spoon or pencil to tap gently on bone projections at elbow and wrist, or knee and ankle - it helps to know a little anatomy if you use this one so you can guide your client to tapping the proximal and distal ends of the same bone. When done correctly, the client will feel a vibration along the length of the bone. For many, this has a very solidifying - and braking - effect, reducing or stopping hyperarousal.

CONCLUSION

Observation of the ANS combined with simple somatic techniques can be an effective adjunct in the containment and reduction of traumatic symptoms, making trauma therapy safer and less traumatic.

REFERENCES

American Psychiatric Association (APA), DIAGNOSTIC AND STATISTICAL MANUAL OF MENTAL DISORDERS, Third Edition, 1980.

American Psychiatric Association (APA), DIAGNOSTIC AND STATISTICAL MANUAL OF MENTAL DISORDERS, Forth Edition, 1994.

Bloch, George, Ph.D., BODY AND SELF: Elements of Human Biology, Behavior and Health. William Kaufmann, Inc., 1985

Brett, EA, "The Classification of Posttraumatic Stress Disorder," in van der Kolk, BA, McFarlane, AC, & Weisaeth, L (Eds.) TRAUMATIC STRESS, Guilford Press 1996.

Diamond, MC, Scheibel, AB, & Elson, LM, THE HUMAN BRAIN COLORING BOOK, Harper Perennial 1985.

Gallup, Gordon G., Jr., and Maser, Jack D., "Tonic Immobility: Evolutionary Underpinnings of Human Catalepsy and Catatonia", in Seligman, Martin E. P., and Masser, Jack D., PSYCHOPATHOLOGY: EXPERIMENTAL MODELS, San Francisco: W.H. Freeman and Company, 1977.

Levine, Peter, Ph.D., WAKING THE TIGER, 1997

Ornstein, Robert & Thompson, Richard, THE AMAZING BRAIN, Houghton Mifflin, USA, 1986

Rothschild, Babette, M.S.W., "A Shock Primer for the Bodypsychotherapist", Energy and Character, Vol. 24, No. 1, April 1993.

Rothschild, Babette, M.S.W., "Defining Shock and Trauma in Bodypsychotherapy," Energy and Character, Vol. 26, No.2, September 1995.

Rothschild, Babette, M.S.W., "Applying the Brakes: Theory and tools for understanding, slowing down and reducing Autonomic Nervous System activation in Traumatized Clients," Paper presented at the Tenth Scandinavian Conference for Psychotherapists working with Traumatized Refugees, 24-26 May 1996, Åbo, Finland.

Rothschild, Babette, M.S.W., "A Trauma Case History," Somatics, Fall 1996/Spring 1997.

Rothschild, Babette, M.S.W., "Slowing Down and Controlling Traumatic Hyperarousal," in, Vanderberger, L (Ed.) THE MANY FACES OF TRAUMA, INTERNATIONAL PERSPECTIVES (in press). 1997

van der Kolk, Bessel, M.D. (1996a), "The Body Keeps the Score," Harvard Psychiatric Review, Vol., 1, 1994.

van der Kolk, BA, McFarlane, AC, & Weisaeth, L (Eds.) TRAUMATIC STRESS, Guilford Press 1996.