TRAUMATIZED CLIENTS OFTEN PRESENT with symptoms rather than with coherent verbal stories placed in time. Because traumatic “memory” consists largely of reactivated, nonverbal memories, sometimes combined with incomplete narrative accounts, Janet (1919, 1925; Van der Kolk & Van der Hart, 1989) suggested long ago that these memories are split off from conscious awareness and stored as sensory perceptions, obsessive thoughts, and behavioral reenactments. The individual apparently “remembers” what happened through reliving these nonverbal iterations of the historical traumatic event or through mysterious physical symptoms that seem to have no organic basis. These nonverbal traumatic memories are “self-contained form[s] of memory that [do] not necessarily interact with general autobiographical knowledge” Brewin. Inaccessible to verbal recall, they typically remain unintegrated and unaltered by the course of time (Van der Kolk & Van der Hart, 1991).
The lack of integration allows reminders of the trauma to trigger somatosensory fragments, causing detrimental effects on the client’s ability to modulate arousal and function in daily life. Because the trauma is not fully recollected as a coherent, autobiographical narrative, clients are unable to deal with the effects and implications of their memories by reflecting upon, discussing, or thinking about them. The memories remain unintegrated, and clients often become phobic of their contents (Steele et al., 2005b). As a result, phase 2 work with traumatic memories is daunting for many clients and unnerving for their therapists, who fear that their clients will become overwhelmed and mired still further in their past.
Successful memory work results in recall of, and reflection on, the traumatic event(s) and their implications (Claridge, 1992; Courtois, 1999; Van der Hart et al., 1993). Clients generally come to therapy with the hope of resolving the past by using the more familiar avenues of cognitive and emotional processing. The assumption of therapists and clients alike is that if dissociated fragments of the trauma are integrated into flexible, linguistic autobiographical memory, reduction or cessation of symptoms will result. Yet their best efforts to resolve their memories through these avenues can fail. Clients frequently continue to feel out of control as everyday stimuli continue to ignite bottom-up hijacking. And even after clients have created a relatively coherent narrative of the trauma, physiological symptoms may remain and occasionally worsen. Moreover, because the memories that need to be associated are unavailable through language, a verbal account of past trauma is not always possible.
What is available, no matter how much or how little narrative memory is intact, are the visual images, olfactory and auditory intrusions, intense emotions, sensations, and maladaptive physical actions. It is not the events themselves but these nonverbal fragments from the past and their unresolved maladaptive action tendencies that wreak havoc on the client’s experience and ability to function in daily life. Accordingly, successful treatment of traumatic memory might be conceptualized as the resolution of the effects of the traumatic past on the client’s current organization of experience, rather than as the formulation of a narrative.
Sensorimotor processing of traumatic memory is organized to target these repetitious sensory and physical tendencies until they no longer disrupt self-regulation and cognitive–emotional processing of current as well as past experience. Clients are helped to “overcome the traumatic imprints that dominate their lives, which are the sensations, emotions, and actions that are not relevant to the demands of the present but are triggered by current events that keep reactivating old, trauma-based states of mind” (Van der Kolk). By identifying these imprints as they emerge in clients’ organization of experience and helping them study, rather than react with trauma-related tendencies (dissociation, dysregulated arousal, and maladaptive defensive responses), the nonverbal traumatic residue can be resolved.
TRAUMATIC MEMORY
Memory is not a unitary process but a network of interconnecting systems that contributes to the storage and retrieval of information (Cordon, Pipe, Mayfan, Melinder, & Goodman, 2004). A careful clinical recognition of, and ability to distinguish between and work with, memory that is declarative or explicitly held in a conscious, narrative verbal format and nonverbal, implicit memory that is evoked by traumatic reminders is vital to the work of sensorimotor psychotherapy.
Explicit memory is generally described as containing both episodic representation as well as semantic or factual memory (Siegel, 2003). When we recall a past experience with a subjective sense that we are remembering something, we are retrieving explicit memory. This type of memory is verbally accessible and “supports ordinary autobiographical memories that can be retrieved either automatically or using deliberate, strategic processes (Brewin). Explicit memory retrieval is often a kind of “memory modification” rather than an exact recall of events (Siegel, 2003). Thus recall is not necessarily “factually” accurate; rather, it is an “active and constructive” process, subject to distortions and revisions based on the emotional state of the person at the time of recall and associations with both previous and subsequent experiences (Van der Kolk, 1996b). Schachtel explained that explicit memory “can be understood as a capacity for the organization and reconstruction of past experiences and impressions in the service of present needs, fears, and interests”. Like all narratives, explicit memories become elaborated in the service of “telling the story”: Those details essential to the story’s main points are elaborated, whereas other details may be discarded or become part of the subtext (Janet, 1928; Van der Kolk & Van der Hart, 1989). The elements of traumatic memory that are verbally accessible can be revised, edited, and placed in relationship to the individual’s autobiographical knowledge so that the trauma is “represented within a complete personal context comprising past, present, and future” (Brewin).
In contrast, implicit memory is memory for the nonverbal aspects of experience: the smell of your grandmother’s attic, the tensing of your body at the sound of a siren, an opening in your chest when you remember seeing the dawn break over the ocean, and so on. Implicit memories are best thought of as somatic and affective memory states that are not accompanied by an internal sense that something from the past is being remembered (Siegel, 1999, 2001). The implicit memories are often “situationally accessible,” activated in the client’s present life by both internal and external stimuli reminiscent of the trauma: They “[contain] information that has been obtained from more extensive, lower level perceptual processing of the traumatic scene(e.g. visuospatial information that has received little conscious processing) and of the person’s bodily (e.g. autonomic, motor) response to it” (Brewin) This form of memory includes the reactivated sensorimotor components of memory that emerge in response to traumatic reminders and are not usually integrated with verbally accessible, explicit components.
A century ago Janet (1909; quoted in Van der Kolk & Van der Hart) wrote that the vehement emotions—the intense arousal evoked in trauma—prevent adaptive information processing and thus impair efforts to formulate the traumatic event into an explicit narrative. One hundred years later research corroborates Janet’s observations, identifying significant alterations of frontal lobe functioning and Broca’s area (the part of the brain responsible for language) as a result of high arousal states associated with remembering traumatic experience (Van der Kolk, 2002). When memories cannot be organized through language, they are organized on a more primitive level of information processing (Piaget, 1962) that comprise three forms of implicit memory: procedural, perceptual, and emotional (Siegel, 2003). The traumatized person “remembers” via all three avenues: through somatic action tendencies (procedural), sensory intrusions and sensations (perceptual), and emotional storms (emotional).
Of particular importance in a sensorimotor approach to traumatic memory is procedural memory, which is “expressed in behavioral acts independent of cognitive representational storage” (Sokolov et al.,). The unconscious nature of procedural memory is efficient. As noted in Chapter 1, it enables us to automatically perform many tasks, and accounts for many of the behavioral tendencies that help us cope with trauma as well as defensive tendencies that persevere long after the danger is past.
“Body” memory is another term that has been used clinically to identify implicit somatic memory (Siegel, 2003). Body memory refers to recollections of trauma that emerge through somatic experience: muscle tension, movements, sensations, autonomic arousal, and so on. In 1907 Janet described body memories and their contribution to trauma symptoms:
The different regions of our body participate in all the events of our life and in all our sentiments. Let us consider two individuals, both of them wounded in the shoulder, one by an elevator, the other by an omnibus. These wounds have long been cured, but you can easily understand that the remembrance of a sensation in the shoulder, that even the idea of the shoulder, is a part of the remembrance of the accident; it is enough that you touch one of these patients on the shoulder for this peculiar sensation to remind him of his accident and determine the crisis.
Thus tactile sensations, internal sensations (such as trembling), kinesthetic responses (such as muscular tension), vestibular responses (such as feelings of dizziness that occur in response to trauma stimuli), and the somatic components of a defensive subsystem (such as the constriction associated with freezing) are all examples of ways in which the trauma is remembered through implicit body memories.
These nonverbal memories are difficult for most traumatized individuals to understand, let alone revise or change. They manifest in somatosensory intrusions and confusing emotional outbursts, as Raine eloquently described: “I could not connect the intense feelings that overpowered me that day…with the rape. They did not ‘come with a story,’ a linear narrative, the way non-traumatic memories do. They had no verbal context, and seemed to occupy another dimension, parallel to, but never intersecting with, language”. Without verbal representation, these memories may remain dissociated, with detrimental consequences. The failure to integrate traumatic memories is described as “the pathogenic agent leading to the development of complex biobehavioral changes, of which PTSD is the clinical manifestation” (Van der Kolk).
In phase 2 work with the traumatic memory, the primary goal is the integration of all dissociated components of the memory. Achieving this goal reduces symptoms, as Janet explained: “The memory was morbific because it was dissociated. It existed in isolation, apart from the totality of the sensations and the ideas which comprised the subject’s personality; it developed in isolation, without control and without counterpoise; the morbid symptoms disappeared when the memory again became part of the synthesis that makes up individuality”. The unassimilated fragments that have remained separate or incoherent must be explored, metabolized, completed, and integrated in phase 2 treatment. Successful integration enables clients to think about the past when they want or need to, and although doing so may cause them to feel sad or troubled, it no longer hijacks their thoughts, emotions, and body to cause involuntary reexperiencing. Reminders of the trauma are manageable and do not disrupt daily functioning. The memory of the trauma has become one of many memories—some good, some bad, and some neutral—that constitute any individual’s life.
Disrupting Procedural Memory
Grigsby and Stevens suggested that disrupting what has been implicitly, procedurally learned is more effective in changing dysfunctional patterns than talking about what initially happened to cause them: “Talking about old events (i.e., episodic memories), or discussing ideas and information with a patient (the semantic memory system), may at best be indirect means of perturbing those behaviors in which people routinely engage”. For change to occur, the procedural learning—especially the body’s tendencies—must be “disrupted.” It may not be enough to gain insight: the tendency to enact the old pattern somatically must be changed. New actions must replace the old. (Here, cognitions are useful in motivating engagement in new actions.) Grigsby and Stevens described two ways that procedural learning can be addressed in therapy: “The first is…to observe, rather than interpret, what takes place, and repeatedly call attention to it. This in itself tends to disrupt the automaticity with which procedural learning ordinarily is expressed. The second therapeutic tactic is to engage in activities that directly disrupt what has been procedurally learned”.
Rather than focusing primarily on the development of a narrative, sensorimotor psychotherapy facilitates a gradual exposure to the situationally accessible, implicit components of the memory, with a primary focus on sensorimotor processing. Where appropriate, the memory narrative is utilized to stimulate implicitly held recollection, as when clients are asked what happens in their internal experience and body movement when they talk about the trauma. As the thoughts, emotions, sensations, perceptions, and actions associated with the memory are brought to consciousness and studied both separately and together, what has been procedurally learned is disrupted.
Speculation on Memory and the Brain
The intention of memory work is not just to disrupt procedural learning or to effect a verbal account of previously nonverbal memory, but also to bring nonverbal memory into a domain that is regulated by a different part of the brain (Siegel, 1999, 1995). Brewin (2001) proposed that the elements of the trauma that are encoded in amygdala-dominated situationally accessible memory need to be exposed gradually to the hippocampally mediated verbally accessible memory system. In this way the memory fragments acquire a verbally accessible component that gives them a particular context:
This in turn will assist the process whereby reminders of the trauma are inhibited by cortical influences from activating the person’s panoply of fear responses. Instead of reminders being processed by a memory system that does not discriminate between present and past time, the more sophisticated processing afforded by the hippocampus, with its access to the whole of autobiographical memory, will enable the event to be located in its appropriate context. (Brewin)
In this process the situationally accessible memory system, with its procedural, sensory, and autonomic components, “gradually acquires” verbal representation, and the client’s experience of the memory changes. At an explicit memory level, the client may have long known that the traumatic events are over. The work of phase 2 facilitates the felt experience that the danger is past by helping clients engage in new, empowering actions and experience sensorimotor remembering without dysregulation. The verbal representation then emerges out of this new, empowering experience, not the other way around.
FUNDAMENTAL CONCEPTS FOR MEMORY WORK
Memory work is inherently destabilizing and often terrifying to the client. As Remarque wrote, “It’s too dangerous for me to put these things [combat trauma] into words. I am afraid they might become gigantic and I will be no longer able to master them”. Working with traumatic memory necessitates careful planning, psychoeducation, and good collaboration between therapist and client. As with any exposure intervention, caution and pacing are imperative in order to assure the client’s continuing stability and to maximize therapeutic success.
At the beginning of work with traumatic memory, arousal often escalates. However, through emphasis on the resolution and prevention of bottom-up hijacking by attending to somatic sensations and movements rather than to the emotional and cognitive dimensions, arousal is brought back into a window of tolerance. Frequently, this restabilization process necessitates a temporary return to phase 1 resources. If phase 1 work has been carefully and thoughtfully accomplished, the client will be familiar with the importance of maintaining arousal within a window of tolerance and will have access to both top-down and bottom-up strategies as well as increased integrative capacity to accomplish this goal.
A major therapeutic error is to prioritize memory retrieval at the expense of the “less glamorous” aspects of good therapy. Some clients may strongly believe that the only way to effect real therapeutic change is to “get to the memories” and to get there quickly—which can lead to rapid destabilization if clients lack the capacity to integrate the material. Instead, clients are encouraged to commit to the “slower we go, the faster we get there” approach (Kluft, 1996), which minimizes the tendency to abreact and helps ensure that arousal remains manageable.
Therapist and client often need to negotiate the purpose of memory work. Some clients come to therapy with the hope that it will help them to learn “what really happened.” The therapist emphasizes that sensorimotor psychotherapy is not a memory retrieval technique; rather, it is intended for resolution, not recollection of the traumatic event. Therapy is not about judging the accuracy of the past in a fact-finding endeavor, although once recalled, the memories may provide insight, relevance, and meaning to the client. The therapist must refrain from verifying the memory as fact and, at the same time, avoid “[questioning] the credibility of a story, or [implying] that a memory is imagination, fantasy, or magical thinking [which] may make clients feel as misunderstood and discounted as they have in other relationships” (Sable). Therapists should follow good judgment in working with memories: Avoid leading questions, refrain from making recollection a goal of therapy, and decline to confirm or disconfirm memories that might emerge from somatic interventions, while providing appropriate empathic validation of the client’s experience.
The overarching intention in working with traumatic memory is integration. Abreaction and regression are not encouraged because both involve a loss of mindfulness that impedes integration. Further, “abreaction or uncontrolled catharsis of overwhelming traumatic affects leads to states of hyperarousal and, at times, to complete psychological decompensation” (Van der Hart et al., 1993, p 165). Abreactive reexperiencing is not only potentially retraumatizing but also unlikely to resolve the trauma unless accompanied by integrative techniques, cognitive awareness, and nonchaotic emotional expression (Braun, 1986; Brown & Fromm, 1986; Horowitz, 1986; Maldonado & Butler, 2002; Maldonado & Spiegel, 2002; Spiegel, 1981, 2003; Van der Hart & Brown, 1992; Van der Hart, Nijenhuis, & Steele, 2006b). Because sensorimotor psychotherapy works at a slow pace to study the organization of present experience in response to memory, prioritizes keeping the client within the window of tolerance, and facilitates a return to the window when it is breached, abreaction is almost impossible.
The risks of addressing traumatic memory are many: further dissociation, retraumatization, reliving of traumatic tendencies, intensification of triggers, and loss of ability to function well in normal life. To minimize these risks, phase 2 treatment is embarked upon only after an adequate therapeutic alliance has formed, phase 1 goals are completed, and the client is able to self-regulate sufficiently to return arousal to within the window of tolerance when necessary. In preparation for memory work, the therapist and client consciously review and practice resourcing skills by working with the activation that is stimulated by “thinking about thinking about” working with memory. The client’s capacity for mindfulness, utilization of resources, staying in the here-and-now, and ability to self-reflect with the therapist are all considered in determining readiness to move into phase 2.
Maintaining Social Engagement and Optimal Arousal
The client’s ability to rely on the therapeutic relationship as a “safe base” reflects his or her utilization of the social engagement system for interactive regulation. However, as clients begin to recount the trauma, they tend to lose contact with their social engagement system. For example, as Mary, a middle-aged, successful businesswoman who was raped repeatedly by her uncle from age 4–10, began to talk about her history, she spoke rapidly with few pauses that would provide opportunity for verbal interaction with the therapist. Her social engagement system was markedly diminished; it was almost as though she were talking to herself. As she spoke, Mary appeared increasingly isolated and alone. At times she experienced panic and hyperarousal, and she repeatedly spoke in judgment of herself for having “allowed” the abuse: “Why did I ever change clothes in front of him? Why didn’t I tell my mother what was happening?” She also condemned herself for her inability to defend herself against the abuse, interpreting her dissociation and freezing as a personal weakness—a common response among trauma survivors (Steele et al., 2005b).
When social engagement between client and therapist is diminished or lost, reestablishment through interactive regulation by the therapist and use of the somatic resources learned in phase 1 is essential. In Mary’s case, the therapist facilitated interactive regulation by tracking changes and movements in her body, making contact statements, demonstrating an ability to understand Mary’s distress and tolerating the description of her traumatic experience without withdrawing or becoming hyperaroused himself. He also encouraged Mary to look around the therapy room and name objects and colors of objects, thus reestablishing her orientation to the here-and-now, asked her to press her feet into the floor to facilitate grounding, and also experimented with her making eye contact with him as she spoke. Gradually, Mary began to soften slightly in her body, slow her speech, and engage in reciprocal interaction with the therapist.
Limiting the Amount of Information
Stabilization needs to be reinstated after any challenging therapeutic task or personal crisis experienced by the client. The therapist must track the client’s capacity to regulate him-or herself psychologically, somatically, and socially in every session. Clients are helped to understand that stabilization always takes precedence over memory work, and that as exposure to the memory takes place, stabilization achieved by deliberately limiting the amount of information available to the client facilitates integration. For example, when Martin began speaking about his Viet Nam experience, his hyperarousal, shaking, panic, and terror began to escalate. Martin was instructed to “drop the content” of the memory, focus exclusively on his body, and concentrate on the sensations in the soles of his feet until he felt his arousal coming back into the window of tolerance. Only then did he resume talking about the memory, which was now accompanied by a level of activation that he could tolerate.
Limiting the amount of information the client must process and integrate at any given moment entails focusing selectively on the body and excluding awareness of emotions, cognitions, and the “story.” This focus makes the process more manageable and enables arousal to return to the window of tolerance. Directing the client to attend exclusively to sensorimotor experience usually entails a fair amount of therapeutic direction. The therapist must ask specific mindfulness questions that bring the client’s attention to precise details of sensorimotor experience in the body. For example:
“Let’s put the content and the emotions aside for now. Focus on your feet touching the floor—what do you notice? Do you experience tension? Shaking? Numbness? What impulses do you notice? Maybe there is a movement your body wants to make. Let’s just stay with your body and observe any movements that want to happen, until your arousal settles down.”
The client is taught to direct mindful, focused attention on body sensation and movement until the arousal settles. As therapy progresses and the client’s window of tolerance expands, cognitive and emotional elements of the memory can be carefully reintroduced, one at a time, into the therapy process.
Working at the Edge of the Window of Tolerance
To integrate traumatic memory, a piece or sliver of the memory itself must be reactivated. This reactivation may send arousal to the limits of the window of tolerance or over it, into the hyper-or hypoaroused zones. If this arousal dramatically exceeds the client’s window of tolerance, then the traumatic material cannot be integrated. Instead, “arousal levels must be carefully managed during [work with traumatic memory]. If arousal becomes too high, frontal and hippocampal activity will again become impaired and the person will reexperience the trauma without transferring information from the [situationally accessible memory system] to the [verbally accessible memory] system” (Brewin). On the other hand, if arousal does not approach the limits but remains within the middle of the window of tolerance (e.g., levels of arousal typical of low fear and anxiety states), integration can be hindered because the nonverbal traumatic memory fragments have not been adequately evoked. The therapist needs to elicit, carefully and slowly, fragments of the memory at a pace that enables the client to approach the edges of the window of tolerance but not remain in a hyper-or hypoaroused zone. The challenge is to process the past without retraumatizing the client, to facilitate a steady integration of fragments and increase in the “transfer” of memory from situationally accessible memory to verbally accessible memory. The work must take place at the upper and lower edges of the window of tolerance, accessing enough of the traumatic material to work with, but not so much that the client becomes dysregulated, dissociated, and retraumatized.
To accomplish this task, it is necessary, first and foremost, to induce mindfulness to help the client describe his or her experience without “going back there.” In phase 1 treatment, clients become capable of “dual processing” by learning to use mindful observation to stay in the here-and-now. They have learned to sense when arousal is reaching the limits of their window of tolerance. Therapist and client agree to track arousal and signal when it is beginning to exceed the window on either end, and then to turn the focus exclusively to body sensation and movement until the arousal settles. Accessing more traumatic material or content at such moments is discouraged. As a result of their phase 1 work on developing integrative capacity to achieve mastery over the dysregulation, clients understand that, at these times, they must cease talking about the trauma, inhibit any thoughts about it, put the emotions aside, and instead focus solely on the somatic sensations and movements—or, if that is not possible, on utilizing stabilizing resources to reregulate their physiology.
WORKING WITH RESOURCES
Memory work in phase 2 occurs in the context of resources: to reiterate, those skills, competencies, mental and physical actions, images, things, relationships, and memories that give people a sense of mastery and internal cohesion. When people feel “resourced,” they feel safer and more competent and subsequently tend to experience positive affect and pleasurable physical sensations—which, in turn, lead to other memories and experiences in which they felt similar pleasurable sensations. Identifying, acknowledging, and developing resources increase the availability of feelings of well-being and the corresponding pleasurable body sensations.
Identifying Peritraumatic Resources
Working with memory and working with resources thus go hand in hand. As the memories are addressed, new resources are cultivated and the resources used long ago to cope with the traumatic event are discovered and strengthened. The pleasurable body elements or those that heighten feelings of mastery are emphasized. Although it may seem counterintuitive, no matter how sudden or unexpected the traumatic event was, peritraumatic resources were utilized by the client and subsequently can be brought to awareness in therapy.
For example, as Joyce began to work with a memory of a home invasion and sexual assault, she recalled an image of allowing the assailant to force her to dance with him, which first evoked a sense of helplessness and shame. As she discussed this incident with her therapist, tracking her body sensation and movement, Joyce noted that she began to breathe more deeply and felt less terrified. She then remembered that his body relaxed as they danced and she sensed that he became less angry. Immediately, she felt a bodily shift from powerlessness to mastery: “I didn’t do it just because he forced me: I did it to save my life!” The client’s discovery of the resources that were present before, during, and after the event thus challenged her feelings of powerlessness.
Associating the past trauma with other nontraumatic elements might prove to be integrative and healing for the client (Breuer & Freud, 1895/ 1955; Janet, 1889, 1925). By identifying and experiencing existing peritraumatic resources, clients learn to associate trauma with nontraumatic, even positive, experiences. Acknowledging and “reliving” the memory of the resource and experiencing it somatically often help clients feel more competent, capable, and even proud of the resources they used, despite being “unsuccessful” in preventing the traumatic experience.
As a child Adanich had accidentally fallen through a glass door and nearly died from the injuries. She suffered from intrusive images of blood and hospital equipment for years following the event. Her therapist discussed with her doing a slow-paced recall of the events before, during, and after the accident, with the purpose of searching for, and remembering, the resources that were available and utilized during the time of her accident. The therapist asked Adanich to remember the “good things” that were occurring prior to the trauma. She reported that she had been roughhousing playfully with her brother in the living room and that it was “a wonderful feeling.” The therapist guided her to simply remember the play, to “hang out” in this moment in the memory and experience the pleasurable physical sensations as she remembered this resource of roughhousing with her brother. By making that moment the whole focus of her attention, Adanich started to find the building blocks of that “resourced” experience: the sounds of their childish laughter, the image of herself playing, the joyful and alive feeling in her body.
After this resource was identified and experienced, Adanich was encouraged to remember the accident itself—not to relive it but to discover what had supported her and how she coped during the event. She remembered that immediately her father rushed to pick her up in his arms with a tender, worried expression on his face. This was a particularly important recollection to Adanich because, prior to this therapy session, she could not recall even one time when her father had held her. The therapist, noting a change in Anadich as she mentioned her father’s expression, asked her to “pause right there: See his face in your mind’s eye…what happens when you remember the way he looked at you?” Anadich replied, “I take a breath…and my heart gets warm.” The therapist said, “There is something very important about this moment for you—just see his face…maybe the way he is looking at you communicates something…what might this special look tell you?” Anadich continued to focus on the image of her father’s face, enjoying the memory of his concern and tenderness. Finally, she realized, “His eyes tell me that he loves me,” and she began to softly cry. The somatic component of “warmth in my heart” and the meaning of “I am loved” were a revelation to her—the only time when she could remember this feeling with her father. It is important to emphasize that neither of these resourced experiences was recalled until the therapist guided Adanich to remember what had supported her and to feel the effects of that support on her body sensation.
Through “resourcing,” the nontraumatic elements of a traumatic experience are remembered, and clients learn to orient toward, and maintain attention to, these positive experiences—which in turn helps them learn that they can make more conscious choices about what they orient toward. Allocating attention to resources, rather than exclusively to traumatic elements of the memory, mitigates both the phobic avoidance of the memory and the continual replaying of it in a fixed form. As Adanich said after that session, “The memory will never be the same—now I will also remember how much I loved playing with my brother and my father’s love and the warmth in my heart.”
Helping the client uncover peritraumatic resources requires a particular kind of therapeutic artistry. The felt sense of having had any access to resources at that time of trauma may be overshadowed by strong negative feelings of fear and helplessness. For instance, as Bob recalled a difficult moment of a motor vehicle accident in which he suffered extensive injuries, he reported feeling that he had no resources. Without intruding too much on this vulnerable moment, the therapist said gently, “Somehow you came out alive; you could so easily have died.” Bob nodded in agreement, and the therapist softly asked, “What did you do that helped you at that terrible time?” After a pause, Bob replied, “I stayed very still.” In the midst of experiencing his utter helplessness, he had found the resource. The therapist responded by trying to help him deepen the experience, saying, “Somehow you knew that would help you—someone else might not have had the intuition to do that.” As Bob explored this spontaneously remembered capacity to remain physically still, he could experience in his body how the stillness helped him feel less helpless. As he and his therapist continued to experience the memory of his staying so still, he reported feelings of greater confidence in himself and his body. What allowed him to come to an appreciation of the resource on his own terms was his therapist’s slow pace and careful attunement, trying to find just the right words to bring his appreciation to that moment so that he could make the discovery himself. Prematurely positive or flattering comments would have taken him out of the resourced experience rather than deepening it.
Validating and experiencing resources help to bring balance to the traumatic memory, so that strength and competence are remembered along with the helplessness and overwhelming feelings (Levine, 1997). Assisting clients to oscillate between the two conditions of competence and traumatic reactions appears to help integrate trauma responses, prevent the reactions from escalating, and deepen feelings of confidence and mastery.
Installing New Resources While Working with a Memory
Sometimes the client cannot spontaneously locate peritraumatic or survival resources in the context of working through a memory. In this instance, it is the therapist’s job to help the client install new resources, which then become part of the transformation of the memory. For instance, while working with a memory of her childhood sexual abuse, Sally began to “fog out,” feeling hypoaroused and depersonalized and losing contact with current reality. The therapist asked Sally to drop the content of the memory and work with grounding, centering, and pushing to help regulate her arousal and stimulate a mobilizing defense. Sally felt powerful and forceful as her muscles engaged in pushing against the pillow held up by her therapist. After the session, she reported feeling fully present in her body and finally having a way to come out of the “fog” and be in the here-and-now.
Uncovering, strengthening, or installing resources, particularly their somatic components, in the context of the traumatic memory may change the way that memory is encoded by making the newly encoded memory “highly distinctive.” Clients tend to remember their feelings of mastery, competence, or pleasure. Taking the time in a therapeutic context to expand upon the resourced memories by facilitating the client’s awareness of the building blocks of present experience that correspond with this recollection—the somatic components, images, smells, sounds, thoughts, and emotions—strongly encodes these “unusual, distinctive attributes” of the memory, rendering them more available to recall (Brewin). These distinctive memories—such as remembering the compassion on a father’s face or experiencing the capacity to move during recall of a traumatic event that previously evoked immobility—“compete” with nondistinctive, non-verbal, situationally accessible memories. These recollections of competence become more available to clients as they continue to access associations connected with a specific event.
ACTS OF TRIUMPH: MOBILIZING DEFENSES
Janet eloquently wrote: “The patients who are affected by traumatic memories have not been able to perform any of the actions characteristic of the stage of triumph…. They are continually seeking this joy in action…which flees before them as they follow”. More recently, Van der Kolk suggested that “performing the actions that would have overcome one’s sense of helplessness at the time of the experience that became traumatic and expressing the sensations associated with the memory of trauma effectively helps people overcome their traumas”.
Failed mobilizing defensive responses can perpetuate action tendencies, delay resolution of the trauma, and fuel distressing trauma-related symptoms (Ogden & Minton, 2000). It is as if time stopped at the moment of threat, and the body is continuing to reenact the sequence of events: The threat is perceived, mobilizing defenses are stimulated, then suddenly halted, followed by persistent dysregulated arousal and immobilizing defenses of freezing, collapse, and numbing. Each time the traumatic memory is activated, the client may experience somatic initiation of a mobilizing defensive response followed by its truncation.
Janet (1919, 1925) referred to a variety of mental and physical actions that remain incomplete for people with trauma-related disorders. A sensorimotor approach to traumatic memory addresses the incomplete defensive responses, which, when completed, foster a sense of mastery and “triumph” that then facilitates the execution of more adaptive mental actions and the formation of autobiographical memory. As Levine wrote, “When the implicit (procedural) memory is activated and completed somatically, an explicit narrative can be constructed; not the other way around” (2005).
The therapist helps the client to “complete” failed defensive actions—to execute “acts of triumph”—through reactivating a “sliver” of memory, just enough to evoke the mental and sensorimotor tendencies. Then the physical actions that “wanted to happen” are discovered through awareness of the body. These actions, when executed, mitigate feelings of helplessness and shame and give rise to moments of joy, confidence, and satisfaction. A helpless response is exchanged for an active, empowering response (Levine, 1997). Through state-specific processing, the traumatic responses are activated but then processed in such a way that new reactions are evoked, and the traumatic memory becomes associated with empowering actions and their corresponding emotions and cognitions. These actions are usually dramatically different from those evoked by the original event.
Sexually assaulted during a home invasion when she was in her early 20s, Jenny had not been able to sleep through the night on the anniversary of the trauma in the ensuing 25 years. She and her therapist carefully scheduled an appointment on that date to work with the action tendencies evoked by the anniversary. As Jenny observed her internal experience in reaction to the decision to work on this memory, she noticed that trembling and shaking had already begun, along with a retraction of her field of consciousness to images of the assault. She felt a clenching in her jaw and “electricity” in her legs and arms. Her shoulders and head bent inward and she felt a pull to curl up into a ball. Instead, she and her therapist concentrated on the “electrical surges” she experienced in her limbs, and Jenny was invited to notice any action her body wanted to make. She reported that she could feel how she had wanted to push away her assailant, and she wanted to stand and push against the wall during the session. It is important to note that the impulse to push emerged from Jenny’s awareness of her body as she remembered the assault, and not as an idea or concept. As she mobilized not only her arms but her whole body in pushing, she began to feel a new sense of her own strength and power. Her anger, usually experienced with a sense of impotence, felt pleasurable and exciting. Jenny left the office with the words, “It’s over—I am done being scared.” And that night, she slept peacefully through the hours when the assault had occurred years ago.
Executing Voluntary Acts of Triumph
To uncover latent acts of triumph, it is necessary to reevoke a sliver of the nonverbal memory, slowly and mindfully in a step-by-step manner, with meticulous attention to the body’s responses. Often the somatic components of implicit memory emerge even when talking about working with the memory, as in the case of Jenny. They also can be stimulated by deliberately thinking about the memory or discussing reminders of the trauma. It is worth emphasizing again that the sensorimotor psychotherapist is not primarily interested in the client’s trauma narrative. The narrative in sensorimotor psychotherapy is a means to an end; its importance lies in its ability to bring the unassimilated nonverbal components of traumatic memory into present-moment conscious experience.
As the nonverbal components of the memory are activated, clients are helped to observe, rather than relive, the “state-specific” processing—that is, what happens inside. The therapist must cultivate the client’s acute awareness of body sensations and movement, first via tracking and making contact statements about the client’s sensorimotor experience, and second, as the client begins to become mindful, by encouraging the client to notice sensations and movement without prompting by the therapist. The evoked physical reenactments of orienting, defense, and arousal are slowly and consciously observed. Mindfulness questions are asked, such as: “What sensation do you feel in your body as you remember this incident? What happens inside as your hand makes a fist?” Because these questions compel the client to observe and report internal organization of experience, they maintain dual awareness and prevent reliving.
When clients remember the trauma, immobilizing defenses of freeze or submission/collapse are usually aroused. The somatic indicators of these defenses are noted by the therapist, who is also looking for indicators of orienting and mobilizing defensive responses that were not fully executed or were unsuccessful during the original trauma. These are often first seen in a barely perceptible movement, such as the client’s hand just starting to make a fist, or the client’s report of a precursor to movement, such as tightening in the jaw or arms. These are the involuntary and anticipatory movement adjustments that occur before a voluntary movement, such as hitting, and they are dependent upon the planned or voluntary movement for the form they take (Bouisset, 1991).
The therapist carefully tracks, and teaches the client to track, the body, looking for these small preparatory movements that might indicate that a more overt motor action is available. Once the therapist catches a glimpse of such a movement, or the client reports feeling a defensive impulse, the therapist helps the client drop the narrative and voluntarily execute the action “that wants to happen” slowly and mindfully.
In phase 1 treatment, a client might work with executing voluntary defensive movements such as pushing in order to experience the felt sense of having the capacity to resist or push away thus regulating arousal. In phase 2 treatment, the mobilizing defense that was originally truncated is elicited via state-specific processing, so that the client executes the active movement as it emerges spontaneously from the somatic experience of the memory that previously evoked only immobilizing defenses.
For example, as Martin began to talk about his war experience, his hands were resting quietly on his knees. Then the therapist noticed his fingers moving slightly upward, suggesting a larger movement of protection. This movement had occurred just as Martin recalled having had the sense that someone was aiming at him, although he could not see the enemy. The therapist requested that Martin cease his narration—momentarily “drop” the content—in order to focus his attention exclusively on his hands to look for what “wants to happen” somatically. Martin described feeling that his arms wanted to lift upward. As the therapist encouraged him to allow the movement, Martin reported that his arms wanted to move upward in a protective gesture. In staying with this movement, Martin started to notice a slight change. Instead of covering his head with his arms and freezing in a habitual immobilizing defense, he said that he had a feeling in his arms of wanting to push away. The therapist encouraged the slow enactment of this mobilizing defense, which had not been possible at the time of the trauma, holding a pillow for Martin to push against. The therapist asked Martin to temporarily disregard all memory and simply focus on his body in order to find a way to push that felt comfortable and “right.” Martin’s internal locus of control was increased as he was encouraged to guide this physical exploration by telling the therapist how much pressure to use in resisting his pushing with the pillow, what position to be in, and so on.
DISTINGUISHING TRAUMA-BASED EMOTIONS FROM SENSATION
At one point when Martin was pushing, he described feeling panicky. The therapist asked him to focus on only the physical elements of the panic, which Martin reported as increased heart rate and tingling, rather than the emotion. This was an important directive whose intention was to separate trauma-based emotions from sensation so that sensorimotor processing could occur without interference from emotional processes—and without overloading Martin with more information than he could integrate effectively. As Martin focused only on his body sensation, and continued to experience the pushing along with the increased his heart rate and tingling, the therapist tracked his body responses and made contact statements about the somatic experience, such as, “The strength of the pushing is increasing,” and “You seem to be settling down now.” Martin’s panic, experienced not as emotion but as rapid heart rate, began to quiet, and he was again instructed to be mindful of the details of his sensations: “What happens as your heart quiets and you continue to push? What do you feel in your back and spine?” Slowly and mindfully, Martin was able to experience a full sequence of active defensive responses: lifting the arms, pushing tentatively at first, then increasing the pressure and engaging the muscles of his back, pelvis, and legs. As the therapist continued to use contact statements and mindfulness questions to ensure Martin’s mindful focus on the sensation, he began to experience the physical pleasure of pushing, reporting, “This feels great!” He was encouraged to push as long as he liked, until the exercise felt complete to him. When the defensive sequence had been thoroughly explored and completed, Martin was calmer, his arousal had returned to the window of tolerance, and he resumed the telling of the story—until somatic components were again stimulated, and sensorimotor processing began anew.
FINDING OTHER INCOMPLETE ACTIONS
This defensive pushing movement is one among many common “incomplete actions.” The therapist helps clients discover the action that is naturally emerging from their awareness of body sensation and impulses. One client experienced the urge to kick as she remembered sexual abuse; the therapist held a large therapy ball so that she could mindfully explore the motions of kicking with her legs and feet. Another client, who had suffered a terrible fall, experienced a twisting impulse in her body just before she struck the ground. Gently executing that impulse slowly and mindfully led to the awareness of how her body had tried to protect her by twisting away from the danger. Still another, who had suffered a motor vehicle accident, was able to reexperience and complete the impulse to push with his legs.
Rather than inadvertently facilitating the reenactment of immobilizing defenses, therapists must be diligent in their search for mobilizing, empowering defensive actions so that mobilizing (active) and immobilizing (passive) defensive subsystems can be integrated, rather than remain dissociated. The therapist’s meticulous search for empowering action is illustrated in Ashley’s therapy. Ashley was working on the memories of a date rape. Her therapist had expected that the hand movements elicited by her trauma story were precursors to a mobilizing defense of pushing, as in Martin’s case. However, as the therapist and Ashley focused on her arms moving very slowly up and over her head, Ashley suddenly said that she was so ashamed that her whole body wanted to curl up into a fetal position and hide. In allowing this movement of curling up, Ashley expressed sadness and shame, thus executing a “mental” action of expressing her emotion in the context of a supportive therapeutic relationship. However, in doing so, Ashley was moving away from mobilizing defenses into immobilizing defenses and their concomitant emotions of shame and sadness. Continuing to explore this posture after the emotions were expressed, even in the context of a supportive therapeutic relationship, would reenact the currently maladaptive fixed action tendency and most likely augment her feelings of helplessness and failure.
Therefore, after Ashley’s emotional arousal settled, the therapist asked her to go back to the moment in her memory when her date was beginning to make sexual advances and explore her somatic experience right then, as if she could extend the moment, making it last several minutes without moving forward in the memory. As Ashley came out of her curled up position, sat up slowly and explored that moment just before the rape occurred, she reported slight tension in her hand, which proved to be the nascent mobilizing defense that she had not been able to execute. What helped it emerge was taking one moment in Ashley’s memory where it was likely that mobilizing defenses were experienced but not executed, and drawing out that one moment so that she might notice all the subtle body sensations and impulses inherent in that one “sliver” of memory. As this moment was experienced, Ashley reported the tension in her hand, and said she wanted to make a fist. Following that tension and allowing it to develop into a movement, that is, of becoming a fist and pushing hard against a pillow, provided her, finally, with the possibility of a new action. In that moment she recognized that she was no longer doomed to the repetition of that disempowering, immobilizing response.
THE STORY AS A MEANS TO AN END
Although the narrative of the date rape was the starting point for the work with Ashley, the story is only the means to an end. It is a way to activate the nonverbal implicitly held memories and action tendencies, and with them, the mobilizing defensive movements that were truncated or interrupted so that they can be completed in current time. Executing these actions after so many years of reenacted failures to take action promotes a sense of mastery, giving rise to moments of joy, confidence, and satisfaction. Martin noted that after executing these mobilizing defensive reactions in therapy, a habitual cringing response was absent in his day-to-day life. He had progressed in his therapy from awareness of his implicit memories in the form of immobilizing tendencies, to the verbally encoded recognition of his past fear and helplessness, to the execution of a mobilizing defensive action, and finally to the verbal expression of power and mastery. Subsequently, Martin became more comfortable with asserting himself appropriately in his daily life. The years of therapeutic work he had previously spent retelling the events of his war experience had not succeeded in providing the bodily experience that action and self-assertion were now safe and empowering options. It was his in vivo somatic experience of being able to access his mobilizing defenses in their entirety that allowed this powerful transformation to take place.
Executing “Involuntary” Acts of Triumph: Sensorimotor Sequencing
Trauma-related involuntary movements and sensations tend to persist long after the danger has passed. Sensorimotor sequencing is a therapeutic technique that facilitates the completion of these involuntary bodily actions that are associated with traumatic memory. Instead of executing actions wilfully and voluntarily, sensorimotor sequencing entails slowly and mindfully tracking, detail by detail, the involuntary physical movements and sensations that pertain primarily to unresolved autonomic arousal, orienting, and defensive reactions. Clients are initially taught to cultivate awareness of sensations (e.g., tingling, buzzing, heaviness, temperature changes) and micromovements (e.g., trembling and miniscule changes in muscular tension) as they fluctuate in texture, quality, and intensity. Next, they are asked to mindfully track (a top-down cognitive process) the sequence of physical sensations and small movements (a sensorimotor process) as they progress through the body. These sensations and movements are experienced by clients as at least partially involuntary—that is, out of conscious control—and are typically perceived as threatening when they occur unbidden. To prevent dysregulation, it is essential to teach clients how to “uncouple” trauma-related emotions and traumatic content from these sensations and impulses in order to limit the amount of information to a manageable amount. Clients are directed to temporarily disregard the emotions and thoughts that arise, until the bodily sensations and movements resolve to a point of rest and stabilization. While the sequencing is unfolding, the therapist encourages the client to allow these involuntary impulses to happen and to “follow them.” This unique orientation emphasizes allowing the movements and refraining from voluntarily directing them through conscious control.
Using mindfulness, the client is able to witness and support the progression of sensations and impulses in the body, but not to control it. In the original trauma, the person’s awareness was embedded in the experience, and information-processing mechanisms were overwhelmed and out of conscious control. In sensorimotor sequencing, the client’s attention hovers over the experience, observing it, parsing it, and reporting it to the therapist. The slowness of this microprocessing and the maintenance of social engagement with the therapist keep the experience safe and manageable, thereby challenging the habitual reexperiencing. Clients often state that these movements seem to “happen by themselves,” without conscious intention or control, and generate feelings of well-being when they come to completion.
When working with traumatic memory, clients frequently experience involuntary trembling and shaking, which may be considered to be a discharge of “the tremendous energy generated by our survival preparations” (Levine, 2005). The immense arousal mediated by the sympathetic nervous system that is stimulated under threat serves to mobilize vigorous defensive actions. When those actions do not take place, as is so often the case in trauma, a similar heightened energy may emerge in therapy. “What is significant in the resolution of trauma is the completion of incomplete responses to threat and the ensuing discharge of the energy that was mobilized for survival” (Levine, 2005). Through sensorimotor sequencing, clients learn to stay with these involuntary sensations and movements until they are “discharged” and settle by themselves.
The therapist tracks closely for incipient signs that offer the possibility of sensorimotor sequencing: slight trembling or vibrating, or a movement that “wants to happen,” or the client’s report of sensations such as tingling or buzzing. At these moments, the client may be encouraged to track these sensations and involuntary movements until they resolve and the body is calm.
SENSORIMOTOR SEQUENCING OF MOBILIZING DEFENSES
To illustrate involuntary sensorimotor sequencing of defenses, we will use the example of Mary, the client who was repeatedly raped by her uncle throughout her childhood. As Mary talked about this long-lasting trauma, her jaw began to tighten, her right shoulder and arm began to constrict, and her breath became labored—all possible signs of defensive responses emerging spontaneously. After bringing her attention to these physical observations, saying, “Your jaw and arm seem to be tightening up and your breathing is changing,” the therapist directed Mary to be mindful of her bodily sensations, suggesting that Mary drop the content of the memory (“Let’s take a few moments to sense what’s happening in your body before we go on with the content”). Mary was aware of physical impulses that seemed involuntary, as if they were happening “by themselves.” At this point, Mary was no longer describing the past but was attentive only to present bodily experience. Her body seemed to take on a life of its own as she was encouraged to be mindful of her sensations and movements. Mary reported that “my hand wants to become a fist,” and the therapist encouraged her to “feel the impulse and allow that to happen” but without doing it voluntarily. Very slowly, as client and therapist tracked her micromovements, Mary’s hand now began to curl into a fist.
Next, Mary reported that her arm wanted to “hit out.” The mobilizing defensive movement sequence was now emerging without conscious top-down direction from either the client or the therapist. The therapist said, “Feel that impulse to hit out and just notice what happens next in your body.” Mary was encouraged to simply track and allow the involuntary micromovements and gestures, rather than “do” them voluntarily. Sensorimotor sequencing was occurring spontaneously in response to the mindful attention given to body sensation and impulses, and through a harnessing of cognitive direction by suspending content and emotion.
As the therapist directed Mary to track her sensations and involuntary movements, her right hand formed a fist, her forearm also tightened, and her arm slowly rose off her lap apparently without conscious intention on her part. Gradually, Mary’s right arm progressed through an extremely slow rising and hitting motion accompanied by shaking, quite possibly the “discharge” described above. This experience of shaking is similar to that of shudders passing through the body when one is cold. After several minutes of sensorimotor sequencing, during which both Mary and the therapist followed the slow and unintended progression of movements, accompanied by shaking and trembling, Mary’s arm finally came to rest in her lap. She continued to shudder for a bit longer and was instructed to stay with the shudders and sensations as long as she was comfortable doing so, until they stopped spontaneously.
All the while, Mary was encouraged to trust her body by allowing the movements and the shudders to occur without trying to direct them or change them in any way. She was also encouraged to self-regulate—to stop if the feelings became too intense or if she felt too much discomfort to go on. Because physical sensations from the gradual “exposure” to the traumatic memory can be extremely intense before they begin to unwind and soften, clients need the therapist’s help in following the sensorimotor process. Eventually the shudders ceased, and Mary said she felt relief and a sensation of tingling throughout her body. The therapist instructed her to savor her bodily feeling and sense of relief and to describe these new sensations in detail. Reporting a softening in her musculature, a slowed heart rate, and a good feeling of heaviness throughout her body, Mary stated that she felt peaceful for the first time in weeks.
Involuntary movement indicative of mobilizing defensive responses can often be experienced in the legs as well. During the step-by-step exposure of Martin to his Viet Nam experience, he reported being in the jungle and having the thought “This is the wrong place to be.” Realizing that the moment of threat recognition is a potential indicator of a mobilizing flight response, the therapist encouraged Martin to focus on what happened in his body when he said those words, “This is the wrong place to be.” Martin reported a tension in his thighs and some small restless leg movements and then realized that he “wanted to flee.” Note that Martin’s verbalization of a flight response emerged from his awareness of his body as he remembered the trauma. Encouraged to track these movements, Martin’s legs began to vibrate; he remained aware of these micromovements until they discharged and settled on their own, at which point he reported feeling calmer. It must be noted that the therapist has no specific agenda for how the sequencing occurs: In Mary’s case, it led spontaneously to the execution of a mobilizing defense; in Martin’s case, the same approach led to a resolution of the autonomic dysregulation and vibratory energy in his legs.
SENSORIMOTOR SEQUENCING OF ORIENTING RESPONSES
A traumatic memory can also be explored for incomplete acts of orienting, so that orienting actions can be reestablished and executed during state-specific processing of the memory. Incipient orienting actions are often evident in slight movements of the neck indicative of the “scanning” stage of the orienting response. Truncated orienting responses sometimes manifest as neck tension. For example, Amelie came to therapy complaining of nightmares and chronic neck tension and pain following a skiing accident. As she began to describe the accident, she and the therapist noticed that her neck was becoming tenser and stiffer. As she became aware of the stiffness, Amelie spontaneously remembered being at the top of a very steep mountain with her father, who was encouraging her to ski down a slope that she felt was beyond her capabilities. She reported wanting to please her father and being pulled internally to acquiesce to his wishes. When the therapist asked Amelie what happened in her body as she remembered this moment, Amelie described an increase in neck tension on the left side. The therapist and Amelie took their time to explore the sensations and tension in her neck, and Amelie slowly felt her head turning, following the pull of the tension. Amelie’s experience of her neck turning had a strangely nonvolitional aspect to it. She found her neck moving to the left, as if “by itself,” saying, “I’m not trying to move it; I’m just following it.” As she did so, Amelie realized that the slope she had wanted to ski down—a much more gradual and safer route—was to the left of the mountain where she had stood with her father. Instead of orienting forward and following her own desire to ski down the gentle slope, she had complied with her father’s request, resulting in the accident. In the treatment session, Amelie took several minutes to follow the turn of her head and experienced a relaxation of the tension in her neck as this orienting action, truncated during the actual event, was executed. By following the movement of turning to the left, she realized that she had wanted to ski down the easier slope; this realization created a new verbal representation of the accident that challenged her previously held self-blame. The completion of the orienting movement left her feeling a somatic, emotional, and cognitive sense of resolution.
INDICATORS OF AROUSAL, ORIENTING, AND DEFENSIVE RESPONSES
Orienting, arousal, and defensive responses manifest themselves in any of the building blocks of present experience: thoughts, emotions, sensations, sensory perceptions, or movement. As noted in the above examples, tracking the client’s body reveals moments when preparatory or intentional movements herald the beginning of an orienting or defensive response. The thoughts, emotions, and perceptual experiences that accompany memory recall also indicate the availability of mobilizing defenses. For example, the statements “I feel like running away” or “I wish I could have hit him back” suggest that fight and/or flight responses may be activated. If the client reports a feeling that “Something’s not right,” an orienting response may be evoked. When the verbal indicators of an orienting or defensive action are expressed, the therapist may call attention to them by asking the client to repeat those words and notice what happens in the body. Almost always, the client will sense an impulse that accompanies the words and seems to fit with them. Other examples of thoughts that signal the presence of defensive impulses include:
“My jaw is getting tight.”
“My neck wants to turn.”
“My hands are clenched.”
“I can feel my heels pushing into the floor.”
“My eyes get narrow when I hear that sound.”
Similarly, clients’ expressions of feeling scared, nervous, angry, or guarded often indicate incipient mobilizing defenses or arousal. The therapist may again ask the client to focus on those emotions and notice what the body is doing—“what wants to happen in the body”—or what sensations the client notices when these feelings emerge.
THE SPONTANEOUS EMERGENCE OF RESPONSES
An important element of sequencing involuntary defensive impulses is to let them emerge involuntarily and refrain from making them bigger, smaller, or faster than they already are. Characteristically, involuntary defensive and orienting movements emerge in a slow pattern of unfolding. As they manifest, the client is directed to “just stay with” the sensation of the micromovements that prepare for the defensive response. This movement often reflects what didn’t get to happen at the time of the traumatic event, but what wanted to happen in the body—the action potential. It may have been cut off due to fear of being physically overpowered, or because of lack of time (e.g., in a high-speed car accident). If the memory of the traumatic event is being used to access the defensive and orienting responses, the client is instructed to remember the events to evoke body movement, but then follow the movement impulses in the body that want to happen now. The movements that happen in the body now may be precisely what did not happen at the time of the trauma.
This is not a somatic rewriting of history: It is a completion as the body is allowed to execute, and thereby restore, the defensive responses that were disabled. Sequencing involuntary movement may permit the body to unwind or unpack the stifled impulse that still “wants” to happen as the memory is recalled—allowing the long-delayed moment of triumph to occur spontaneously. These involuntary responses appear not only to provide a powerful sense of relief and mastery, but also seem to bring calmness and peace in place of depletion and exhaustion.
Working with Hyper-and Hypoarousal
Clients often report being intimidated by the prospect of reexperiencing traumatic hyperarousal and, as a result, feel revictimized by exposure to their own memories. As noted, voluntary resources can be utilized to regulate arousal. In addition, sensorimotor sequencing of these hyperaroused states can restore a sense of distance and control over the excessive activation and possibly discharge, and consequently lower, the arousal by allowing the accompanying involuntary trembling. When hyperarousal is noted, the client learns to orient away from the narrative and become mindful of body sensations and movement. These sensations may vary from tingling to the micromovement of a slight tremble or even to strong tremors, if unchecked. At these moments clients are encouraged to follow the progression of the spontaneous sensations, movements, and impulses through the body until the arousal has subsided. To press for additional traumatic material when clients are already activated can promote an escalation of arousal and dissociation. Because clients are being asked to attend solely to body sensation and movement, excluding emotions, cognitions, and content, the amount and intensity of information available to be processed in the moment become tolerable.
Because of the dysregulating nature of hyperarousal, the therapist endeavors to work slowly through one arousal cycle at a time. When arousal is noted, the client is instructed to become mindful of that sensation until the nervous system begins to settle down. That is one cycle of arousal, starting with a sensation or micromovement, processing through discharge or involuntary movement, and then the autonomic settling and resolution that brings arousal back into the window of tolerance. The arousal is metabolized, either through bodily discharge (e.g., tingling, trembling, shaking) or mobilization and demobilization of defensive responses. As the cycle comes to completion, another sliver of traumatic material is accessed if time allows in the therapy session, and the cycle is repeated.
By processing one arousal cycle at a time, clients begin to trust that working with arousal is manageable. They learn that even if the arousal becomes quite high, it will not escalate beyond control if they attend exclusively to the body. By uncoupling the arousal from trauma-related emotions, images, and repetitive thoughts, sensorimotor sequencing minimizes the risk of the escalation that occurs when emotions, meaning making, and interpretations drive arousal out of control. As clients learn to track the sequence of the sensation of arousal, they often experience a new freedom and a sense of mastery. As one client said, “Following the sensation lowers the fear.” No longer is the sensation of arousal experienced as trauma; now it is just sensation.
During many years of therapy, Cate worked with her teenage experience of identifying her sister’s murdered body, reexperiencing the terror and grief. Her symptoms of panic and hyperarousal, which alternated with depression, did not abate. With the help of a new therapist who practiced sensorimotor psychotherapy, Cate was asked to refrain from orienting to the emotions as she described the memory and to orient exclusively toward her body sensation. Rather than cathartically discharging the energy associated with the traumatic memory in sobs and continued recollection, or suppressing it by contraction of the body or “spacing out,” she was encouraged to stay mindful of her inner somatic experience without interpreting or interfering with it. Her body began to tremble slightly, but the emotions did not escalate. Cate focused all her attention on body sensation and the trembling, describing to her therapist how the sensation changed and moved through her body. After several minutes, the sensation settled, the trembling stopped, and Cate’s arousal was once again within the window of tolerance. Gradually, Cate learned to inhibit her internal orienting tendencies toward the emotions and memories and instead orient toward body sensations and movements, without wilfully interfering with her internal somatic process. Only when her sensations had settled was additional content described and emotional and cognitive processing included. Eventually, through this fractionated, mindful reexperiencing, the arousal was discharged, her emotions and memories were integrated, and her symptoms abated. Cate reported that up to now, she had not been able to talk with her adult daughter about her sister because she became too dysregulated. After the session she was able, for the first time, to tell her daughter the full story of what had happened.
Clients frequently become hypoaroused during phase 2 treatment, which often indicates the emergence of a submissive defensive response, an increase in dorsal vagal tone, and a decrease in sympathetic tone. At this point, clients’ social engagement and ability to feel their bodies and maintain awareness of present reality can be lost quickly. They are “there” instead of “here,” re-experiencing the helplessness and numbing responses that accompanied the original event. At such times the focus of the work becomes finding some type of active defensive response—an action “that wanted to happen”—within the memory recall. Often clients discover these actions by exploring a point in the memory when mobilizing defenses were available as preparatory movements. If that fails, the therapist might propose experimenting to find a somatic resource in the session, such as standing and moving the legs. Often after helping the client become somatically resourced, a mobilizing defense emerges spontaneously.
As Victoria began to talk about her early sexual abuse, she stopped being aware of her therapist’s face and voice, and her social engagement system became disabled. Orientation to present reality was lost. The therapist tried to help her resource herself while she was still sitting down by having her look around the therapy office, but that experiment was unsuccessful: She still felt numb and in a “fog.” Eventually, Victoria was asked to notice what happened if she stood up. Immediately, she felt more resourced because this movement enabled her to sense her legs firmly on the ground. She then spontaneously experienced the urge to push out with her arms, an impulse that the therapist encouraged in order to capitalize on the emerging mobilizing defense. As she and the therapist allowed the active movement to unfold, the fog lifted; Victoria’s vision cleared, and her contact with the therapist was reestablished.
COGNITIVE AND EMOTIONAL PROCESSING
Breuer and Freud wrote, “Recollection without affect almost invariably produces no results”. Just as sensorimotor reactions need to be expressed to a point of resolution, so do emotions. However, the therapist must be careful to assess whether the focus on emotional responses will prove useful, deciding when to put affect aside and focus on sensorimotor processing and when to focus on emotional processing. Brewin(2001) cautioned that if the client is overly activated, the situationally accessible memory system will be sparked off and instead of reorganizing the memory through the hippocampally mediated and verbally accessible memory system, these fragments will simply be retriggered. Therefore, the non-verbal memory fragments must be evoked with caution, preventing abreaction to keep the verbal memory system and its attendant hippocampal machinery online.
When adequate sensorimotor processing has occurred so that arousal can remain within a window of tolerance, emotional and cognitive work with traumatic experiences can resume. Dysregulated sensorimotor tendencies no longer usurp these upper levels of information processing. For example, after Martin’s work with truncated mobilizing defenses and hyperarousal, he reported, “I feel really easy in my body—more connected there, an easier overall feeling. I’m able to go back and think about that event and not really get activated. I’ve done a lot of emotional work around it [in previous therapy] but there was still that inner body stuff going on when I would think about it.” At this point in his therapy, he was able to work with the profound despair and suicidal tendencies while remaining anchored in the body. During work with emotions, his processing occurred at the upper limits of the window of tolerance, not far out of the optimal arousal zone. Afterward he reported, “There were no negative repercussions from this work, not like the last time” (when he did emotional processing in his previous therapy).
The therapist and client must assess whether the client can remain within or at the edge of the window of tolerance during work with trauma-related emotions. Cate had completed years of therapy in which she expressed her panic, anger, and grief at her sister’s murder, but her therapy had not been completely successful because the work took place as Cate was hyperaroused, outside of her window of tolerance: She would talk about her sister’s murder while she was highly anxious and emotional. In hyper-and hypoaroused zones, clients are dissociated and cannot integrate the emotions or other fragments of the traumatic memory. When Cate came to a sensorimotor psychotherapist and spoke of the memory, it was clear that sensorimotor processing was needed: Her arousal escalated immediately, her body began to tremble, and her automatic emotional tendency was to cry profusely. Such emotional catharsis was incapable of changing her tendency, because the root of the hyperarousal was physiological activation—that is, her sensorimotor, rather than emotional, experience of the trauma. Whereas “talk” therapies often return to stabilization at this point in order to regulate the arousal, sensorimotor psychotherapy offers an alternative: to focus on sensorimotor processing of the arousal. Cate’s therapist did just that by asking her to put her emotion aside and just sense, describe, and track what was going on in her body.
When emotion emerges, the therapist and client can assess together what is contributing to the emotional arousal: physiological activation; a lack of mobilizing defenses; a trauma-based, habitual emotional response; or an emotional response that reflects the true weight of emotional meaning for the client. In the latter case, the emotion has a genuine, fresh quality, rather than a habitual, repetitive quality, and although arousal will likely be at the edge of the window of tolerance, it usually does not escalate to hyperarousal. For example, after several rounds of sensorimotor processing, Cate expressed a deep grief at her “loss of innocence.” Because her arousal was right at the edge of the window of tolerance, but not far over, her therapist encouraged Cate to mindfully experience this deep emotion. However, if the emotion is accompanied by strong physiological responses, such as shaking, or if the emotion brings arousal excessively over the window of tolerance, it may be associated primarily with physiological arousal, a lack of mobilizing defenses, or trauma-based emotions. In these cases, the sensorimotor processing techniques described above can be used.
Trauma-based emotions—what Janet called “vehement emotions”—involve powerful feelings of fear, terror, anger, shame, horror, and helplessness that emerge when an individual cannot respond adaptively to an inescapable threatening situation (Van der Hart et al., 2006). These traumatically driven emotions manifest as repetitive and reactive: Neither their intensity nor their expression changes over time, nor do they change when they are vented. This emotional tendency is evident in clients who habitually interpret the experience of arousal as anger. Even when the authentic feeling might be more accurately recognized as fear or sadness, the client feels and expresses it as anger. This was the case with Martin, who reported that “I get angry at the drop of a hat—it feels like that’s the only emotion I ever feel!” The expression or discharge of these repetitive emotions often reinforces maladaptive tendencies that do not resolve, despite best efforts of client and therapist, as was the case for Cate in the years of cathartic therapy. As Janet wrote: “The subjects, who seem so emotional…are indifferent to all new feelings and confine themselves to reproducing with an automatic exaggeration a few old feelings, always the same. Their emotions, which seem so violent, are not just; that is to say, they are not en rapport with the event that seems to call them up”. Trauma-based emotions feel familiar, circular, endless, and without resolution. They may appear dramatic, but they do not have the quality of emerging from an authentic contact with oneself. The therapist often finds it difficult to resonate with them. These trauma-based emotions are usually best addressed on the sensorimotor, rather than emotional, level of information processing.
Not only do traumatized individuals demonstrate emotional tendencies fueled by traumatic activation and immobilizing defensive tendencies, but also repetitive and habitual cognitive tendencies that do not resolve no matter how much they are confronted or interpreted. Janet (1945) used the term substitute beliefs to describe the habitual cognitions or mental actions that resulted from low integrative capacity, such as “It was all my own fault” or “I am bad and that is why these things happened to me.” Although these cognitive distortions may provide the client with a sense of internal locus of control and mitigate severe helplessness, they also prevent adaptive functioning in current life (Steele et al., 2005b). These beliefs, along with dysregulated arousal and immobilizing defenses, form the underpinning of trauma-based emotions.
Although direct work with cognitive distortions is primarily the purview of phase 3 treatment, often beliefs change on their own in phases 1 and 2 as the client’s body reorganizes and becomes more “resourced” for example, more aligned or grounded. These physical changes alone help to mitigate substitute beliefs and their emotional counterparts; the “meaning” and somatic sense of self is naturally different when the body is more resourced. After her sensorimotor psychotherapy sessions, Cate reported that, contrary to her previous belief of “It’s not okay to feel good,” it was possible for her to feel sensations in her body that were actually pleasurable. These sensations came about not as a result of cognitive work but in the aftermath of a shift in sensorimotor experience from hyperarousal and overwhelm to calmness, aliveness, and pleasure. After she experienced the power of previously lost mobilizing defenses, Victoria reported, “I can reach out; I can say no; I feel empowered in my body!”—statements that were in sharp contrast to her belief “It’s not safe to reach out to others or to set a boundary.” Martin, after years of feeling powerless in the face of debilitating, overwhelming experiences related to his Viet Nam memories, had come to believe that he would never be free from the energy-sapping and humiliating hold of these memories. After his sessions, he reported:
“Since [the sessions,] something’s really shifted. I’m so much more attentive to my body and aware of any reactions…. Sometimes I feel challenged, but it is so different for me…more comfortable, easy. I’m not as excitable. It’s much more manageable. I was just sharing some of my experience [in Viet Nam] and it was not charged at all. Before, there was always some charge. And with world events [specifically, the war in Iraq] I just take a breath and move on. It’s not as triggering. The despair is not so much present—I sense it a little bit, but I’m much more willing to be with it and let it move through, which it does. That’s different…. I feel good about myself. It brings tears [of relief]to my eyes…I’ve done such long and hard work.”
Somatic reorganization provides the resource to work on these “pathogenic kernels” and prevent the reexperiencing the trauma-based emotions (Van der Hart & Op den Velde). Many deep emotions were often denied in the past, especially when there was no support for them. Martin described how, in Viet Nam, the despair and grief were never addressed; Mary reported that she put aside her hurt and grief because no one believed her. Grief, especially, is an important emotional response to trauma that emerges, not only during the work of traumatic memory, but when the client completes actions and achieves a higher level of mastery. At these moments, the grief for what was lost and for “all the years spent so miserable” is especially salient. Van der Hart et al. wrote: “Grief is an important part of the emotional pain which must be worked through. With the passage of time, episodes of grief gradually increase in intensity and duration. Survivors come to understand and accept that loss is an inevitable part of trauma, and that it is ultimately a lifelong task to assimilate the ebb and flow of re-experienced grief with equanimity”.
This view is illustrated in Mary’s case, wherein the grief emerged with each therapeutic gain. As she developed the skill of tracking her body sensation and executing mobilizing defenses, she stated that she felt more “in” her body. She was able to feel her legs as more grounded, supporting her, and with this support she expressed grief for “all the years when I was out of my body.” Mary eventually confronted the memory of the moment she first watched from the ceiling and saw what “he [her uncle] was doing to another little girl,” while another part of her submitted to the abuse. She was again instructed to be mindful of her body, and as she remembered the trauma, she became aware of the physical reactions she had experienced as a child. She experienced the physical components of submitting and “leaving” her body (numbness, muscle flaccidity, the feeling of paralysis) along with the impulse to fight back (tension in her jaw and arms). Awareness of sensation became the unifying force in resolving this “dissociative split,” as Mary realized that “This disintegration is not real—I’m two bodies in the same body, doing two different things.” As Mary experienced this dissociative compartmentalization somatically and processed the physical components of it (such as the impulse to fight her uncle), she experienced a deeper sense of grief associated with the abuse while remaining within her window of tolerance.
After working with her somatic tendencies, and then her emotions, Mary was better able to process her cognitive distortions about herself and eventually replace them with a sense of accomplishment in the realization of how she had actually been able to defend herself through the trauma-induced dissociation that occurred because she was unable to defend herself physically. As a result, she experienced several compartmentalized parts of herself: parts that first fought, but then submitted and froze. Realizing the risk it would have been to continue to engage mobilizing defenses that would have angered her uncle and increased the abuse, she was able to acknowledge how effective her immobilizing defenses had been in that particular situation. At one point in the session, Mary proudly stated: “There is nothing wrong with me—look what I did!” Her cognitive distortion (“There’s something wrong with me”) had finally been replaced by a sense of confidence and mastery. Again, this realization was also accompanied by grief, as Mary said, “It only took me 50 years to find out there is nothing wrong with me.”
In speaking about the abuse, Mary became less judgmental toward herself and also able to express her anger that her mother had turned a blind eye to her uncle’s behavior, saying: “No 4-year-old girl should have to endure such abuse!” Although she had not worked directly with the self-judgments, beliefs, or emotions associated with the traumatic experience, sensorimotor processing had had a positive effect on both her emotional and thinking processes. Mary gave full expression to her sadness and grief and arrived at new meanings, all in the process of becoming fully conscious of her sensorimotor reactions. Ultimately, she experienced a new integration and reorganization of the physical, emotional, and cognitive levels of her experience as these levels were addressed simultaneously. Six months after Mary’s therapy was terminated, she wrote:
I am aware that there has been a lasting and profound change in both my body (the way I hold it) and my sense of integration and ability to stay present with fearful situations, memories and sensations that would previously have been so overwhelming that they would be suppressed…. I also feel emotionally integrated in a new way. It’s as though the part of me that had been the victim of…abuse is not alone any more but has other stronger, more whole and resistant parts mixed up with it. I no longer so desperately need the contact [with the therapist]. It’s as though I can be there for myself.
CONCLUSION
Because traumatic “memory” is composed largely of nonverbal, situationally accessible memories, techniques for resolving trauma must elicit, process, and aid in the digestion of all its components: procedural, perceptual, autonomic, motor, emotional, and cognitive. When the traumatic event remains a nonverbal situationally accessible memory, unavailable to verbal recall or processing, the client continues to reexperience its activation without resolution and often without even the conscious awareness that the sensations and emotions are traumatically driven.
In phase 2 work using sensorimotor psychotherapy, titrated amounts of the memory of the event are carefully evoked to activate its somatic and autonomic components at a pace that does not unduly dysregulate the client. By slowly and mindfully observing the bodily expression of the nonverbal memory, clients are helped to have a new experience in relationship to the trauma: Rather than becoming needlessly dysregulated, clients feel the mastery inherent in their ability to use somatic resources to maintain a window of tolerance. Instead of reliving habitual frozen or collapsed, submissive tendencies, clients experience the emergence and completion of actions “that wanted to happen” at the time of the trauma—which leaves them feeling alive and triumphant instead of numb and defeated.
Rather than becoming overwhelmed by the emotions or cognitive distortions connected to the trauma, clients discover that that these can be contained and reworked from the bottom-up, that it is possible to feel grief and stay present or to laugh with pleasure as new empowering actions are experienced, where before there were feelings of helplessness and worthlessness. As clients slowly integrate these new experiences of old events, they are able to formulate a narrative that makes sense of the past.
The final result of phase 2 work is what Janet called a process of “realization”: “the formulation of a belief about what happened (the trauma), when it happened (in the past), and to whom it happened (to self). The trauma becomes personalized, relegated to the past, and takes on symbolic, rather than sensorimotor properties” (as cited in Van der Hart et al.,). Janet (1919, 1925) emphasized that realization requires a change in both physical actions—movement, arousal, and sensation—and mental action—the way the person thinks and talks about the trauma. It is important to note that realization is a process, evolving over time as more information from the traumatic events is discovered, processed, and integrated (Van der Hart et al., 1993).
Clients often complain that their responses to the traumatic events “just don’t make sense. I know that I’m okay now, but I react in my body as if the trauma were still happening.” This description captures the experience of nonverbal memory fragments, retriggered by traumatic reminders, that have not been assimilated in the process of working with narrative memory, cognition, or emotion. Successful integration of these fragments is optimized when therapist and client work somatically with the nonverbal memory. A new realization emerges—a sense of “Yes, this did happen, and it greatly affected me for many years. But now I have experienced it in my body without being overwhelmed by it and, in fact, I feel empowered in relation to it. It is in the past now, and I can finally move on.”