“We think that by protecting ourselves from suffering we are being kind to ourselves. The truth is, we only become more fearful, more hardened, and more alienated. We experience ourselves as being separate from the whole. This separateness becomes like a prison for us, a prison that restricts us to our personal hopes and fears and to caring only for the people nearest to us. Curiously enough, if we primarily try to shield ourselves from discomfort, we suffer. Yet when we don’t close off and we let our hearts break, we discover our kinship with all beings.”
(Pema Chodren, 2008, p. xxxx)
In the aftermath of trauma, individuals’ symptoms and difficulties reflect how their minds and bodies once tried to adapt to circumstances beyond their control. “Not feeling alive in the present” might have once served as an antidote to the threat of annihilation: if we don’t feel alive, the threat loses its power to terrify us. Depression might once have provided a cushion against disappointment and being overwhelmed. Hypervigilance enables even children to stand guard over themselves. Numbing and loss of interest allow the individual protection against grief and disappointment: if you don’t care, it doesn’t matter anymore. Anger pushes others away before they cause harm or, worse yet, before the survivor develops an attachment to them. It would be rare in the mental health treatment world to think of these symptoms as adaptive strategies made possible by the body’s instinctive survival defenses. But from a neurobiologically informed perspective, they are “survival resources” (Ogden et al., 2006), ways that the body and mind adapted for optimal survival in a dangerous world. In the worst of circumstances, our survival resources save us—at a cost. By disowning the trauma, or the anger, or the need for contact with others, we lose or deny important aspects of ourselves. By over-identifying with the trauma-related shame, hopelessness, and fear of being seen, we constrict our lives and make ourselves smaller than we need to be. Both strategies, adaptive in a time of danger, become liabilities when the individual is ready to live a “life after trauma,” free of the constrictions and restrictions needed for living in a traumatogenic environment.
In the absence of a context of meaning (i.e., a narrative) to explain their bewildering reactions, afraid to be curious or even more afraid to face the events that created a need for these responses, clients assume the worst: they are crazy or damaged or inadequate. Without specialized training in trauma, most therapists would not know to be curious about differentiating normal emotional responses from traumatic reactions, desperate communications from parts, ingenious survival strategies, or implicit memories. Because the client presents in crisis or chaos with emotional pain or signs of a “mental disorder,” we feel a responsibility to diminish or alleviate the symptoms—curious about their origin in the childhood past perhaps but not necessarily curious about their role or their original purpose.
When the therapist subsequently encounters “resistance” or trauma treatments become “stuck,” our theoretical models make meaning of it, but rarely do these theories assume a creative, adaptive explanation. When clients continue to live from crisis to crisis or complain that they are not improving in therapy nor have energy for change, one hypothesis might be that they are “help-rejecting complainers” or “passive-aggressive.” Or the therapist might theorize that these clients are “borderline,” “attention-seeking,” or manipulative, “acting out” for some secondary gain. The ashamed, chronically depressed client might be described as having “low self-esteem.” Whether objectively accurate or not, these types of interpretations have gained clinicians little in terms of practical or successful client interventions for trauma.
In a neurobiologically informed treatment, a different set of theoretical principles guides our thinking. The root causes of the client’s difficulty, we now know, is not just the original event but the reactivation of implicit memories by trauma-related stimuli that mobilize the emergency stress response as if the individual were in danger again (Van der Kolk, 2014). A trauma-informed treatment therefore focuses on recognizing and working in present time with the spontaneous evoking of implicit memory and animal defense survival responses rather than on creating a verbal narrative of past experiences. But since implicit memories encoded in nonverbal areas of the brain are subjectively experienced as emotional and physical reactions not distinguishable as “memory,” the first task of therapy is often to help clients recognize and “befriend” their triggered reactions, rather than react to them with alarm, avoidance, or negative interpretations.
Many traumatized clients come to therapy with unusually difficult, painful histories: severe childhood physical, emotional and/or sexual abuse, neglect, abandonment at an early age, abuse/neglect coupled with other types of trauma, multiple perpetrators, or sadistic and malevolent abuse accompanied by mind control practices, child pornography, or forced witnessing of violence. These complex histories often are accompanied by “borderline” presentations, more severe compartmentalization, and dissociative disorders or by more severe self-destructive, suicidal, and addictive behavior—or both. For over twenty years, the “gold standard” of trauma therapy has been the Phase-Oriented Treatment Model (Ogden & Fisher, 2015; Van der Hart, Nijenhuis, & Steele, 2006; Herman, 1992), a sequential approach in which the consequences of autonomic dysregulation are treated first and then, only after a period of symptom stabilization, the traumatic memories and their implicit components are addressed. Only when the past is no longer “alive” in the client’s body can integration of past and present, child and adult, part and whole be completed. But for clients with chronic, multi-layered trauma histories and severe dissociative symptoms, dysregulated unsafe behavior, or chronic stuckness, the goal of stabilization can be elusive. Years of treatment focused on self-regulation and avoidance of traumatic content sometimes leads only to small steps forward—or bigger steps forward followed by setback after setback. For fear of exacerbating the dysregulation, the therapist might inadvertently collude with the client’s tendencies to ignore the trauma; or fearing empathic failure, the therapist might make the opposite mistake: allowing clients to say too much and, then having triggered themselves, become overwhelmed or unsafe. Often, the therapist comes to feel equally overwhelmed by the conflicting challenges of helping the client stabilize while also feeling heard and validated and to resolve the past.
A parts approach offers some new possibilities for addressing these challenges. First and foremost, working with symptoms as manifestations of parts allows the therapist to incorporate mindfulness-based practices: helping clients “notice” their experience rather than “get in touch with it.” In traumatized clients, the heightened intensity (or numbing) caused by autonomic dysregulation makes “getting in touch with feelings” either overwhelming or deadening, either of which can evoke anxiety, depression, or impulsive behavior. “Noticing” as in mindful awareness allows the client to achieve “dual awareness,” the ability to stay connected to the emotional or somatic experience while also observing it from a very slight mindful distance. Secondly, a parts approach allows us to titrate emotions or memories: if one part is overwhelmed by emotional pain, other parts of the mind and body can be calm, curious, or even empathic. If one part is remembering something alarming or devastating, other parts can offer support, validation, or comfort. As meditation practices, clinical hypnosis, and other uses of mindfulness attest, the human brain is capable of holding multiple states of consciousness “in mind” simultaneously, and this ability has important therapeutic uses. The left hemisphere is associated with more positive moods and the right hemisphere with more negative states (Hanson, 2014); the medial prefrontal cortex supports an observing consciousness that enables us to “hover above” whatever we are feeling so it can be experienced as a feeling in the body rather than lead to retraumatization (Van der Kolk, 2014). Using “dual awareness,” we have the capacity to fully inhabit the present moment: to feel our feet on the ground through awareness of body sensation while our visual perception takes in details of the room in which we are sitting—while, in the same moment, we can evoke an image from an earlier time in our lives that takes us “back there” to a state-specific memory.
Describing these phenomena using the language of the brain, however, would not have the same result as does using the language of parts. To say, “I can sense my medial prefrontal cortex is curious about the negative mood state connected to the right subcortical areas of my brain” does not evoke interest, emotional connection, or self-compassion. When the therapist teaches clients to observe, “I can sense in myself some curiosity about the depressed part’s sadness,” they are more connected and attuned to their emotions and sensations—the first step toward achieving the ability to have compassion for themselves. Research shows that when the medial prefrontal cortex is activated, there is a decrease in activity in the right hemisphere amygdala (Van der Kolk, 2014). It is most likely activation of the amygdala by trauma-related triggers that results in flashbacks, intrusive implicit memories, automatic animal defense responses, or parasympathetic responses of disconnection, numbing, or spacing out.
If the purpose of modern trauma therapy is no longer to treat traumatic events, what should be the focus?
Van der Hart, Nijenhuis, and Steele (2006) have suggested that trauma treatment prioritize the effects or “pathogenic kernels” of the trauma, that is, those aspects of the post-traumatic legacy that still exert a traumatic effect on the client or constrict full participation in normal life even to this day. For example,
Even after years of therapy, Annie was still afraid to leave the house, resulting in a pattern of isolation—even though she hated feeling alone and lonely and stuck in the house. Although Annie was aware that it was safe in her small rural town, the shaking and trembling she experienced each time she tried to go out seemed more “real” than her factually based appraisal of her environment.
When I asked her, “What would have happened if you walked out the door in the home you grew up in?” she replied, “Anyone could get me—anyone.” There was a long pause. “No wonder I can’t even open the front door now—it wasn’t safe even to peek out my mother’s door back then!”
Though differentiating the implicit memory from factual reality gave her insight, it did not change her ability to leave the house—because the implicit memory was held not by Annie but by a structurally dissociated young part of her. Once we identified the part “who is afraid to leave the house,” I asked Annie to inquire of the part, “Ask her if she’d be willing to show you a picture that would help you understand what she’s afraid will happen if you walk out this door …” An image immediately came up connected to the experience of having been kidnapped at the age of seven. “Is that what you’re afraid of?” she asked the child part. She could feel her head wanting to nod. “Did you think it could happen again?” Another nod. Spontaneously, Annie said to the part, “Did you know that can’t happen at my house?” She felt her head nodding again. “Do you know why? Because I’m too big now, and no one can see you because you’re inside me.” She could feel a sense of relief and tension relaxing in her body each time she said again, “No one can see you—they only see me because you’re safe inside.”
Although there were many different traumatic events connected to the kidnapping, the “pathogenic kernel” that continued to affect her life and distort her reality was the experience of being away from home and alone—that is, what led up to the kidnapping. As we worked on ways of demonstrating to the part that Annie was too big to be kidnapped, such as measuring Annie’s height on the door jam and asking the little girl to show us how tall she was, the words that consistently regulated the little part were the words, “They can’t see you because you’re inside me! All they can see is my big, tall body.”
Another pathogenic kernel was the absence of a protective adult who would have supervised a seven-year-old that night and made sure no one would take her. That also needed to be addressed.
Unless her parts felt that someone cared about her/them, Annie disclosed, she had trouble feeling any safety even in her home—or in her body—because their fears were so intense. As the parts explained to her, “If someone cares about you, they watch over you to make sure nothing happens.” In her previous therapy, Annie had complied with the therapist’s insistence that she repeatedly recall and re-experience the traumatic events, stimulating recurrent flashbacks in and out of therapy. She remembered wanting to tell the therapist that the excavation of memory was making her worse. But, under the influence of young “attach for survival” parts wanting the therapist to care about them, she just did as the therapist said.
Influenced by widespread belief in the “talking cure,” the pioneers in the trauma field initially assumed that creation of a narrative and being able to “tell the story” to a witness were sufficient to process “what happened” and resolve the symptoms (Rothschild, in press). A corollary assumption was that the worst effects on the individual would be dictated by the worst aspects or details of the trauma. Therefore, one might think it important to process those “worst” memories.
These assumptions leave therapists trained to use the phase-oriented treatment model in a quandary: while it does not feel empathically attuned to ask clients to avoid telling their stories, the prioritizing of stabilization requires focusing away from traumatic events. On the other hand, meeting the client’s “need to ‘get it out’” is also risky. The former risks empathic failure; the latter risks destabilization. What does the therapist do when caught between “a rock and a hard place?”
When we start to understand traumatic memory from a neurobiological perspective, client memories do not have to be avoided or discharged. We simply have to help clients develop a different relationship to both their explicit and implicit memories. It is the details of memory and chronological scene-by-scene retelling that activates associated implicit memories, dysregulates the nervous system, and can have a retraumatizing effect on the client. Acknowledging the trauma or implicit triggered memories is never unsafe, especially when we allude to the “bad things that happened” in a more general way without vivifying the details of them or using triggering language, such as “rape,” “incest,” or “penetration.” When the therapist alludes to the “unsafe world you grew up in,” or “the years when nowhere was safe,” most clients feel validated and supported. This kind of matter-of-fact acknowledgment of the past often calms the traumatized nervous system rather than activating it: it conveys, “Someone knows how it was.”
In addition, when they talk about a traumatic event, therapist and client have a choice of focus: they can concentrate on the experience of horror (most likely to trigger implicit memories), or on the victimization and objectification (most likely to trigger shame), or they can bring attention to how the individual survived. How did he adapt to a traumatogenic environment? How did she “fight” or “flee” without incurring more punishment? How did he get up and go to school the next morning?
Annie’s fear of leaving the house and the need to have proximity to a protective figure were reflections of how she survived: via hypervigilant anticipation of danger, constriction of her activities to what was safe, and a focus on pleasing people and gaining their loyalty. Though other parts longed to be a part of “normal life” and yearned for closer connections to others, the fearful agoraphobic 7-year-old had been dictating defensive avoidance for many years. As Annie learned to correctly interpret “her” fear of leaving the house as a communication from a frightened little girl, she could more easily work with her “agoraphobia.” She began by bringing up images of the door the little part was afraid to open (i.e., the door of her childhood home) and praising the seven-year-old for figuring out that she should never, ever, ever open that door. Then Annie would call up images of the door in her own home that she wanted to open to a safe neighborhood and community. She visualized taking hold of the seven-year-old’s hand, somatically communicating that she was there and would not let anyone harm her. Over many weeks of Annie’s patient reassurance and help in orienting her to the present by focusing on the images, this young child part was increasingly able to trust that the door she and Annie opened was not the same door that had once led to a dangerous world.
In today’s trauma treatment world, therapist and client have many more choices when it comes to treating traumatic memory. We can choose what kind of memory to treat: implicit or explicit memory? Memories of dehumanizing events or memories of ingenious survival? Memories as held by parts? Cognitive schemas? Incomplete actions? Or procedural memories of habitual actions and reactions? We can touch on memory by acknowledging it, naming it as a part’s memory or as an implicit feeling or body memory. The therapist can help the client observe how it continues to exert its effects through pathogenic kernels that may or may not have any obvious connection to narrative. What is different is that the therapist no longer has to be focused preferentially on becoming a witness to the client’s narrative regardless of its effects on his or her symptoms and stability. Instead, the trauma therapist’s job is to create in the therapy hour a neurobiologically regulating environment that enables the client’s nervous system to experience greater safety and therefore an expanded capacity for tolerating both past and present experience (Ogden et al., 2006).
Although many clients are relieved to know that “telling the story” is a choice but not a requirement of the therapy, some profess a longing or intense feeling of need to tell someone “what happened.” A neurobiologically informed therapist can also bear witness to the individual’s story but in a different way than in traditional models. As witness in a psychodynamic approach, the therapist is a receptive listener who can tolerate hearing the story, even its horrifying details, and still “be there” for the storyteller. A good witness in this approach never interrupts even when the client becomes autonomically activated or makes meaning of the events by constructing a “self-defeating narrative” (Meichenbaum, 2012), such as “it was my fault.” In a neurobiologically oriented world, this approach raises concerns: a story told chronologically and in detail to a silent witness is more likely to trigger trauma-related autonomic responses and implicit memories, reactivating the neural networks as if the client were again in danger. As a silent listener without a way to keep track of the client’s autonomic dysregulation or cortical activity, we have no way to know: is the client overwhelmed? Is the client able to mentalize and thereby witness being witnessed? Or is the prefrontal cortex shut down? If clients are dysregulated and cortically inhibited, they cannot take away a corrective memory or coherent narrative of having been heard.
The ability to differentiate being triggered and being threatened is key to trauma treatment. We have to know we are safe now in order to effectively process how unsafe it was then. The therapist has to be curious: can this client differentiate objectively between a trauma and a trigger? Or does he interpret the triggering as “danger now”? Without education about the phenomenon of implicit memory and a prefrontal cortex capable of taking in this new information, post-traumatic dysregulation, hypervigilance, impulsivity, and/or shutdown will be repeatedly reinforced by the simple phenomenon of triggering. In the example below, Sheila insisted that telling her story was the only way she could resolve the intense pressure she felt inside that kept communicating to her: “I have to tell someone.”
After setting a particular appointment time for this important moment of “telling,” Sheila arrived a few minutes late, a little breathless. First, I invited her to take a moment to let her breath settle: “We have all the time we need—all the time in the world,” I said slowly and gently (a technique drawn from Sensorimotor Psychotherapy [Ogden & Fisher, 2015]). “Take your time … and while you’re getting your breath back, let’s talk for a few minutes about this important process you want to have today. I know it’s something you’ve felt an intense need for … to be heard and believed. But it is also going to bring up a lot. I just want to be sure that it’s OK if I interrupt you from time to time—to ask how you’re doing, check on how your nervous system is coping, or slow things down so you can settle. It’s my philosophy: on my watch, I don’t want the telling of your story to be retraumatizing, so I might be annoying from time to time because I am going to interrupt to make sure that doesn’t happen. Is that OK?” (Getting the client’s explicit permission for an intervention is another important principle of treatment in Sensorimotor Psychotherapy.)
Sheila begins to describe the environment in which the abuse took place: “My mother was not the right match for my super-intellectual father—she wanted nice clothes and pretty things—he was frugal and worried about money. He didn’t like conflict or emotionality; she was always highly emotional. It was hard to be around her because she’d suddenly go into a rage.” Seeing her activation rising as she recalled her mother’s rages, and noticing how little she was breathing, I interrupted.
ME: “How are you doing right now, Sheila? That’s a lot to remember.”
SHEILA: “I’m a little overwhelmed but managing OK—when I was talking about my mother and her anger, I suddenly remembered something: she used to beat me when I was ‘too emotional,’ especially if I cried or I got angry … She could cry and scream at me, but I couldn’t scream back.”
ME: “She could yell, but you couldn’t … [I mirrored her words so she could hear them and take them in.] And you were just a little girl …”
SHEILA: [begins to cry]
ME: [speaking as she is crying]: “Yes, lots of feelings coming up—painful feelings?” [She nods] “Of course … You were just a little girl, and you couldn’t get mad and you couldn’t cry … lots of feelings there. … Just notice, though: right here, right now, that little girl inside is crying, and no one is getting mad at her … You and I are hearing her cry and hearing her feelings, and we’re not mad … we feel for her … Ask her to notice that it’s different here—it’s different with you and me. Right this minute, she’s being heard and we are feeling for her.”
In a more traditional psychodynamic approach, the therapist would most likely have spoken less and certainly interrupted less. But all of the “interruptions” had a purpose: to help Sheila stay “here” instead of going “there,” to help her slow down and pay attention to her breathing and activation, to keep her prefrontal cortex online to make sure she could witness being witnessed, and to provide a different experience, an antidote, for her young child self.
To achieve the purpose of witnessing, it is of crucial importance to remember that the longing to be heard may be a natural human response to having to keep terrible secrets, but it is also an implicit memory. Few children “tell their stories” to someone at the time of the abuse, leaving a feeling memory of the longing or impulse to tell that was never satisfied. Often, the clients who are desperate “to tell” are being driven by that implicit memory. In addition, the wish to tell or be heard does not guarantee that client can remain fully present in the moment when activated by the details of the narrative. The syndrome of “post-traumatic stress disorder” reflects the degree to which traumatic reactions can intrude upon and “upstage” the experience of “being here now.” The research (Van der Kolk, 2014) is clear that trauma-related stimuli, including one’s own narrative, stimulates the body to alarm responses, animal defense reactions, and inhibition of prefrontal activity—all of which prevent witnessing the therapist’s attentive presence. In Sensorimotor Psychotherapy (Ogden & Fisher, 2015), the therapist periodically directs the client’s attention back to the present moment by asking clients to: “Pause for a moment and just notice what’s happening right now: you are telling your story … and I’m hearing you … I’m hearing you and I believe you … Notice what that’s like to feel me here with you, listening to you … and believing you.” In a parts approach, I might ask: “What’s it like for the parts to hear those words, ‘I believe you’?” In Sensorimotor Psychotherapy, the therapist would next ask, “What happens in your body when you notice that?” Or “What happens inside when I say the words, ‘I hear you, and I believe you’?”
I can also bring the client’s attention to the difference between now and then: “I am hearing you, and … I believe you,” “I’m hearing you, and I’m not angry,” “I’m hearing you and I’m not going away,” “I hear you, and I am not shocked, not horrified … Just notice that. What’s it like to have someone hear you without shock or horror?” At these moments of recognition (when the client can experience how different “now” is, how attentively someone listens now, how it feels to be believed), the old experience is changed: there is a different ending to the story now—and that changes the feelings inside.
In a neurobiologically informed treatment approach, the issues presented by traumatized clients are seen as stemming from dysregulated autonomic arousal, implicit memories, disorganized attachment, and structural dissociation, requiring that the therapist play a somewhat different role in the treatment. In traditional models, it has always been assumed that individuals had access to words that could describe the traumatic experiences but without the opportunity to express them.
In the light of the neuroscience research, however, that assumption has to be re-examined. Brain scan evidence on traumatic recall of events is clear that traumatic memory evokes “speechless terror” and experiences “beyond words” (Ogden & Fisher, 2015; Van der Kolk, 2014), not a clear-cut narrative that can be verbalized. In brain scan studies, narrative recall resulted in inhibited cortical activity, including inhibition of expressive language centers in the left brain, leaving the subjects “speechless,” while the limbic system, especially the right hemisphere amygdala, became highly active (Van der Kolk & Fisler, 1995). These findings describe what therapists often observe in traumatized clients: when the prefrontal cortex, inhibited by autonomic responses to traumatic memory, cuts them off from language areas of the brain, their ability to observe even their own experience verbally and sequentially is lost. The overwhelming emotions and physical impact are too big to be captured by language. After the events are over, many victims attempt to put words to what has happened but can only approximate a “feeling of what happened” biased by whatever meaning-making they have attached to the event (Damasio, 1999). Often these stories are distorted by the experience of degradation, humiliation, terror, and abandonment: they do not capture the event itself but rather how the victims experienced themselves as a result of it. Shame, feeling dirty or disgusting, or painfully exposed is not a description of an event. They are the implicit memories of the effects of that event on them.
A neurobiologically informed therapist is aware that clients do not know these facts about traumatic remembering. They have not read the brain scan research, and do not know why they can’t remember at all or why they remember only in fragments that feel “unreal,” or why they feel so much shame or are afraid of remembering at all. They experience themselves as crazy or inadequate or damaged without understanding the role of the trauma in biasing their interpretations. Without the words and without a template to make meaning of what has happened, let alone understand the resulting symptoms, our clients will not be able to make headway in therapy or in their normal lives. It therefore becomes imperative for the therapist to act as an educator and temporary “auxiliary cortex” (Diamond, Balvin, & Diamond, 1963, p. 46). When the therapist is willing to reinterpret the client’s “self-defeating story” and give it psychoeducationally informed meaning, it has a different effect than providing empathy or challenging distorted cognitions. When the therapist provides a template for understanding the trauma-related symptoms or the phenomenon of triggering, and makes sense of their prefrontal shutdown and animal defenses, clients are reassured that there is logic to their actions and reactions: what I call “trauma logic.” Lillian provides us with an illustration of these issues and how I dealt with them on the occasion of our first meeting.
Seventy years old and a recently retired pediatrician, Lillian appeared barely able to walk, even with the help of her son who had set up a consultation to “find out what’s wrong with my mother.” Shaking, trembling, her head hanging, she made her way into the office and sat on the couch, rocking back and forth like a small child. “All I can say is I feel like a frightened child, and I don’t know why,” she said. “I’m afraid of my own shadow—I can’t look at you—I can’t go out of the house by myself.”
I asked, “When did this frightened child appear? When did the fear begin?”
After a terrifying childhood, Lillian described herself as having become a headstrong, independent young adult, determined to become a doctor and help children around the world. That fearlessness persisted for many decades: in her pediatric career, raising her children as a single mother, and then volunteering for Doctors Without Borders after retirement. Then she came home from Africa at the age of 70 without a job, structure, or a cause. “I was just alone in the house all day—I felt lonely and useless and of no value—and then the fear started.”
I said excitedly, “I just realized what must have happened, Lillian—can I tell you the story about what is going on right now?”
She nodded.
“A very brave young woman left home fifty years ago, walked away from the trauma and the intimidation, and she never looked back. There was a lot of trauma in her body—a lot of traumatized young parts—but she had a strong drive to build a normal life, and she did! With that strong, determined normal life self, she created a family, chose a career, and even fulfilled her goal of helping children just as afraid as she was once. She never looked back—even once. But after the return from Africa, there were no more goals for the normal life part to pursue, no more people to help or kids to raise—nothing to keep her going. The empty house and the loneliness triggered the young traumatized parts she’d been able to ignore for so many years. Triggered by being alone in the house, they began to have intense feeling and body memories of feeling hopeless, unlovable, alone, and, most of all, scared out of their minds. This fear you are having is a memory, their feeling memory of what it was like to be in their home—in your family’s home.”
“What do I do?” she asked.
ME: “Think as a mother and a pediatrician for a moment: what do we do when a child is feeling scared and doesn’t know she’s safe? When the scary feeling is a memory?”
LILLIAN: “We’d reassure her that she’s safe …”
ME: “OK, and what would you do if she didn’t believe you right away?”
LILLIAN: “We’d have to tell her over and over again—tell her that we’re there, that nothing can hurt her now.”
ME: “You know children well, don’t you? Yes, you’d have to tell her over and over, wouldn’t you? Can you start now? Just tell her with your feelings and your body that you’re here.”
Lillian was quiet for a moment, then she chuckled: “Smart kid—she says if there’s nothing scary happening, why am I so scared?”
ME: “Explain to her that you did get scared—you got frightened when she got scared—always tell the truth to her because no one ever did that before.”
Lillian was quiet again, her attention inside: “She likes me admitting that I got scared, too, but then I told her that I looked around, and nothing bad was happening. And that is why I came here today even though I was scared.”
ME: “Right—it isn’t that grownups never get scared, but they do something different with their fear than kids do.”
LILLIAN: “Yeah, and now I have to remember not to get scared when she gets scared.”
ME: “That’s right—you don’t want to blend with her fear—because then she has no one. You want her to have access to your confidence and courage so it will be there for her, too.”
In this single session, it was immediately clear to me that Lillian’s return from Africa had stimulated a flooding of implicit memories of terror, loneliness, shame, and fears of abandonment. She had neither the knowledge base nor the words to explain her sudden transformation from confident globe-trotter to quivering child other than “I feel like a frightened child.” Notice that the therapist/educator does not hesitate to make psychoeducational meaning of the client’s symptoms and story, to introduce words like “trigger,” “part,” “feeling memory,” “dysregulation.” A therapist/educator does not deflect or interpret a question such as, “What do I do?” Knowing that the question is a request from the normal life self for a roadmap, the therapist provides both concrete information and the opportunity to experiment with using it.
Clearly, Lillian’s frightened part had “hijacked the body” (Ogden & Fisher, 2015), inhibiting her prefrontal cortex from being able to conceptualize an answer to the question, “What is wrong with me?” If the therapist’s role is to educate, rather than elicit the client’s interpretation of what is wrong, then this question provides an opportunity to teach the client about autonomic dysregulation, implicit memory, and structural dissociation. Lillian’s description, “I’ve turned into a frightened child,” immediately opened the door to the discussion of child parts, and although it was only the second or third sentence she uttered, I did not hesitate to say, “Yes, you have. You’ve been hijacked by a very young, very scared little girl.” Another client might have described it as, “My body is running amuck—I can’t sleep, I can’t stop shaking, I am paralyzed,” calling for psychoeducation about the body’s participation in trauma-related symptoms. Some narratives might have emphasized deficiencies: “I’ve fallen apart—I’m so ashamed—I don’t want anyone to see me like this—I’ll never be the person I used to be.” For clients with shame-related cognitive schemas, psychoeducation becomes imperative to help them disidentify from the self-defeating story of failure and inadequacy. They will need education about their symptoms: “Yes, it feels as if you’ve fallen apart, and you don’t want anyone to see you. The good news is that you haven’t fallen apart—your body is just remembering feeling broken, shattered. The shame is a feeling memory, too, that often helps keep children safer.” When clients lament that they’ll never “be the person I used to be,” they can often be reassured that the “person I used to be” is alive and well in their left hemispheres. They are experiencing “limbic hijacking,” which inhibits cortical functioning and thereby disconnects them from the “person I used to be.”
As illustrated in the session with Lillian, another important part of the therapist/educator’s role is to help clients connect not only to their vulnerability but also to their strengths. Historically, trauma treatment has emphasized helping clients get in touch with vulnerable emotions of fear, grief, and shame and with their rage—with the expectation that grief and anger will empower, dissipate shame, and free them to let go of the past. However, clients often get stymied when the anger and grief are overwhelming rather than empowering or when shame is exacerbated rather than relieved by access to grief. In addition, focus primarily on trauma-related emotions creates a bias in the treatment by leaving out a very important aspect of any traumatic experience: how the child’s survival resources and animal defenses enabled him or her to remain intact, to “keep on keeping on.”
Even when the only option is to “feign death” (go numb, pretend to be asleep, float up to the ceiling, or go unconscious), the body instinctively chooses the defensive response most likely to succeed in limiting the injury, shock, or pain. When we freeze, inhibit active defenses, and can’t speak, it is also adaptive: what could we say that wouldn’t provoke the aggressor? When children fight back, even if it’s a losing battle, their animal defense systems may instinctively assess that, in this situation, it is safer to fight than to submit—even though it might result in punishment. It seemed important to emphasize the strengths connected to Lillian’s going on with her normal life self, to reassure her that we can temporarily lose access to a part of the brain, but, unless we sustain a brain injury, those strengths are still encoded and potentially accessible. The intrepid, determined woman she had been most of her adult life was still intact and available for reconnection.
At the moment a trigger precipitates flooding of implicit memories held by structurally dissociated parts, the client frequently loses access to verbal information or conceptual thinking. For the time being, Lillian was going to need her therapist to be an auxiliary cortex, providing psychoeducation about trauma and parts, helping her “test-drive” different interventions and practice those that worked, and mapping out step by step how to stop the flooding and access her normal life self once again. Her biggest risks were going to be regression and avoidance. Without a therapy that emphasized the importance of using mindful observation, curiosity, and psychoeducation to gain access to her normal life self, Lillian would be at risk to “blend” with the parts (Schwartz, 2001) and become a frightened child rather than building relationships with them. Or, having reconnected to her going on with her normal life self, she might feel so much relief that it might be tempting to ignore and suppress the trauma-related parts again. In the initial consultation session, it was important to establish a way of working that emphasized that she could heal and go on with her life—if she were willing to build a protective, caring relationship with her young parts by calling upon the same determination to help suffering children that had been her strength and motivation since her twenties.
In early attachment relationships, parent figures provide not only an auxiliary cortex for their infants but also externally mediated neurobiological regulation or soothing. Successfully regulating a child’s immature nervous system is necessary not only for his or her sense of attunement and well-being but also critical for growing affect tolerance via an expanding “window of tolerance” (Ogden et al., 2006; Siegel, 1999) that allows children to increasingly regulate and tolerate a range of emotions. Childhood neglect, trauma, early loss, witnessing of violence, or “frightened and frightening” caregiving (Liotti, 2004; Lyons-Ruth, 2006) all interfere with attachment formation and therefore with developing a spacious and flexible window of tolerance that fosters resilience. With or without childhood trauma, adult traumatic experiences, such as combat, assaults, rape, and domestic violence, disrupt previously established autonomic patterns and prime the nervous system to respond to environmental stressors with over- or under-activity.
The result is a client who enters therapy with a dysregulated nervous system and a truncated window of tolerance, with a brain conditioned to activate the emergency stress response in the presence of trauma-related stimuli. Unless the therapist is prepared to offer interactive neurobiological regulation, a dysregulated client will encounter difficulty with some of the basic aspects of traditional psychotherapy: the request to “free-associate” or say what comes to mind, the ability to connect to affect, to trust the therapist’s good intentions, to focus, conceptualize (why he or she is there, what hopes or goals bring the client to therapy), connect past/present, and “sit with” whatever emotions and physical reactions are activated in the course of the therapeutic hour without hyper- or hypoarousal, dissociation, or impulsive responses. This is a challenging expectation, one for which a window of tolerance and a prefrontal cortex are necessary prerequisites.
At her first visit, Carla, a 45-year-old attorney, was visibly shaking as she described why she was there. Her speech pressured, she leaned forward as if ready to leap out of her chair at a moment’s notice. “I haven’t been able to eat or sleep in months. My last therapist said she couldn’t help me, and this new one lets me out early each week because I get too overwhelmed to do ‘the work,’ as she calls it.” Holding out her shaking hands for me to see, she asked, “Why isn’t ‘the work’ helping me with all this? Why does the work have to be about the abuse? I don’t know how I’m managing at my job, but it’s the only place I almost feel like my old self.”
Talking very slowly and calmly to slow the pace of conversation, but with a smile to signal that things were not so bad as she felt, I said, “I have good news and bad news for you—which do you want first?” [More smiling.]
“The bad news,” Carla said, “Better to get it over with.”
“The bad news is you are flooded with trauma-related feelings and body memories, and your nervous system has gone through the roof into extreme hyperarousal. Want to hear the good news? The good news is that you are not going crazy! [The therapist laughs and smiles, and Carla does, too.] In fact, there is a very simple remedy for this! Would you like to hear it?
“Yes!”
“To help your nervous system and stop the flooding of feeling memories, we need to get your frontal lobes back online. That’s why you feel better at work: your job requires you to think—it ‘pulls’ your prefrontal cortex to do what it does so well.”
In this vignette, I use a number of “tools” available to all therapists: my tone of voice, pacing of speech, smiling and laughing versus a serious facial expression, choice of focus (beliefs, affect, body, vulnerability, strength, parts), projecting a confident energy versus a questioning, more tentative energy. Focusing attention on the client’s strengths often elicits a moment of recognition and reconnection to resources long forgotten; reframing negative interpretations or providing corrective information helps to change the story, elicit curiosity, and even regulate the nervous system.
To help facilitate getting her prefrontal cortex back online, I next provide some psychoeducation by reinterpreting Carla’s difficulties as dysregulation: “No one can think clearly or manage intense feelings when the nervous system is in a state of traumatic activation—it’s too overwhelming. So, let’s go very slowly and stay curious. I’m going to ask you to pause and just notice what your body is doing right now.”
“The shaking has gone down,” she observed in a less pressured tone. “I feel less speedy and on edge—actually, as soon as you said, ‘we just need to get your frontal lobes back online,’ I felt better.”
“Great! Your body really responds to those words: ‘all we have to do is get your frontal lobes back online.’ Now, let’s be curious about what else gets your frontal lobes back online other than going to work. Over the years, has your prefrontal cortex been a resource for you?”
“Oh yes! I’m a civil rights attorney. I have to inspire people, challenge them, out-argue them, make them see what needs to be done.”
“Wonderful—your prefrontal cortex is a resource, and so is your sense of purpose, being more determined than the other side. Now we need to focus your determination on getting your frontal lobes back online. Here’s what I want you to do: I want you to notice when you’re speeding up and starting to feel more shaky and overwhelmed, then pause and just keep saying to yourself, ‘I’m just triggered—these are feeling memories’—or body memories—which do you prefer? Feeling memory? Or body memory?”
“Body memory—it feels like my whole body, not just my feelings.”
“Wonderful—then remind yourself that it’s just your body being triggered, just body memory, and then become interested and curious in what’s happening rather than panicking.” As the session continued, the therapist kept watching for the signs that Carla was getting hyperaroused again, asked her to pause periodically and then use her frontal lobes to be curious and interested in these body memories without trying to figure out to what event they were best matched. Each time, the observing and curiosity slowed her down, increased activity in the prefrontal cortex, settled her nervous system a bit, and allowed her to think more clearly.
The neurobiologically astute therapist has one primary goal: to ensure that each intervention, including even the physical presence of the therapist, has a regulating effect on the client’s nervous system. We can be confident that trauma-related material will be dysregulating and that trusting the therapist, being the center of attention, revealing avoided emotions or secrets, feeling too close or not close enough will all be triggering. Even the proximity to another human being in a small, enclosed space may be activating for some clients. Once committed to therapy, the potential triggers keep multiplying: changes in schedule, not feeling “gotten,” inadequate time or words to express all one wants to say, disappointed hopes for some particular response, separation between sessions, distorted beliefs, and projections.
Unlike traditional models of treatment, the assumption in neurobiologically informed trauma treatment is that clients are just as likely to be dysregulated by therapy than to feel “safe,” more likely to come to therapy with limitations imposed by trauma-related hypo- or hyperarousal, sensitivity to triggering, and some degree of structural dissociation. The most complex regulating challenges are posed by clients with dissociative disorders and more severe structural dissociation (see Chapter 8 on Treatment Challenges: Dissociative Systems and Disorders).
Tessa came to her first therapy session with a very sophisticated question, “How does one deal with the effects of attachment trauma in personal relationships?” But as she talked about her new dating relationship, it became increasingly clear that she was describing structural dissociation: “I really like him, but when we’re together, I start feeling very ambivalent. I begin questioning: should I have come on this date? Should I let him hold my hand? What if he becomes sexual?” The picture she described suggested conflicts between several parts: a part that liked him and longed to be his girlfriend, a part that pulled away and began questioning as soon as things got closer, a part that wanted sex, and a part disgusted and frightened by the thought. “So I keep my distance when we’re out taking a walk, but then I get home to an empty apartment, and I feel a longing for him, and I wish I’d let him take my hand. I hate this—I can’t think about anything else at home, but then I get ambivalent in his presence.”
ME: “Of course it’s a battle …” I knew that validating the normality of her internal conflicts would help her feel understood. “How could it not be? This is what relational trauma leaves as a legacy: the terrible longing when you’re not together and a ‘yuck, don’t get too close’ feeling in his presence.”
The “of course” is said with conviction but also a softness and sadness. “How could it not be?” is said with a smile that normalizes and lightens it. “Terrible longing” conveys the yearning in its tone; “yuck” is equally spoken with conviction but also toughness. Both are expressed as if each is entirely normal and to be expected.
“What generally happens next?” I ask.
TESSA: “I don’t know … I try to be honest about my ambivalence but at the same time, he’s all I ever think about … Usually, these guys stop returning my texts and emails, and I don’t know why, so I get very upset and keep texting to explain myself. And then I get brushed off. He isn’t ready for commitment either, he’ll say. But what’s the ‘either’? What makes him think I’m not ready for commitment?” [Note that she is out of touch in this moment with the part of her that speaks openly to her dates about feeling ambivalent.]
ME: [Again, I mirror her words so she can hear herself better:] “So the ambivalent part discourages him, and then the part that yearns for connection encourages him—the guy must get very, very confused!” [Laughs softly.]
TESSA: “Why do you keep talking to me like I’m some multiple personality?” she suddenly says in a new gruff, irritated tone.
I use an authoritative but empathic tone: “Because I can hear both sides in your story, Tessa. Both sides of you are there. This is what happens when we have relational trauma when we’re young: a battle starts up inside whenever we might possibly, maybe get close to someone.” [The last few words are said with a tone of regret or sadness.]
If clients like Tessa are willing to embrace the structural dissociation model, learn to consciously and voluntarily “split off” the intense affects and assign them to younger, more vulnerable parts, they can achieve the necessary mindful distance to feel some relief without having to resort to denial or disconnection. Only when they are able to “see” the parts in these paradoxical responses will they be able to begin healing their wounds. But they cannot successfully learn the abilities needed without help and direction from the therapist.
Many therapists have been carefully trained to avoid directing the treatment for fear that clients will become automatically compliant and lose an opportunity to get “in touch” with an inner sense of direction. But because dissociative fragmentation results in multiple senses of direction and an inhibited prefrontal cortex, because of the risks of retraumatization or stuckness and avoidance, the therapist has to be unafraid to gently direct the focus and pacing of treatment.
One way of conceptualizing this aspect of the therapist’s role is to think of it as providing a roadmap for clients whose traumatic reactions inhibit consistent access to the prefrontal cortex, leaving them confused and overwhelmed with no sense of direction. Or, because we are working with fragmented systems of parts, the more active role of family therapist is also a good model for trauma therapists, especially in the face of the need to prevent chaos and crisis. As family members engage in old, unhealthy patterns of behavior in the session, the family therapist has no choice but to guide and direct the session to prevent increased conflict and help family members begin to develop increasing acceptance of and compassion for each other. The therapist working with a fragmented client is in the same role—made more challenging by the fact that he or she can’t actually see the other family members!
As clients are taught by the therapist to mindfully notice the child parts’ distress and understand it as “her” or “his” pain, they are next encouraged to empathize with “the child part’s feelings.” This is not always an easy step for clients whose way of distancing the “not me” parts has been to loathe and despise their feelings. But the therapist whose compassion for the parts is genuine and spontaneous can create a contagion effect, evoking compassion even in the client who resists. To evoke empathy for the child, the therapist has to ask the client to pause and be curious about this child part that is afraid, ashamed, or hurt and lonely. How old is he or she? Can the client see the part? What does he or she look like? What expression does the client see on that little face? Acknowledging the enormity of what this child part has experienced can also evoke compassion, as long as the therapist is clearly asking, “What kinds of things has this child experienced?” rather than “What happened to you at this age?” The latter is more likely to trigger implicit reliving, while the former helps the client “see” the child as a helpless, innocent victim. Lastly, the client is next taught to use the resources characteristic of the normal life self to “help” the child parts that are so frightened and in so much distress.
In session after session, as clients present the issues or feelings most troubling on that day, the therapist continues to ask them to notice “which part” is upset today and what has triggered that part. The assumption that upset is always a communication from a part is not a scientific fact, of course—it represents a way of relating to triggered states or implicit memories in a mindful, compassionate, non-pathologizing way.
Underlying this assumption is a mindfulness-related bias that noticing our thoughts, feelings, and body experience with interest, curiosity, and compassion is likely to lead to positive change (Davis & Hayes, 2011; Ogden & Fisher, 2015). If we as therapists consistently encourage the normal life self to take a mental step back, increase curiosity about the younger parts that are “having a hard time,” notice the bodily and emotional signs that communicate “their” feelings, and then experiment with what might help the parts feel safer, better protected, less ashamed, we will be “processing” post-traumatic memory. Simply by noticing spontaneously evoked implicit memories and assigning the feelings to younger selves, clients can learn to feel less afraid of their triggered responses and more connected to and protective of their parts, rather than ashamed and alienated.
When I help clients foster empathy for their vulnerable or protector parts, they cannot help but feel that empathy in their bodies. If I were to ask, “Do you feel compassion for yourself, too?” the answer would be “Absolutely not!” But when they say, “I feel badly for that little part—I feel sad for him [her],” I can observe their faces softening and their bodies relaxing a little bit. They can feel the empathy extended to a young child part or brave protective fight part, can feel the part responding positively, and it feels good inside the shared whole of the body. Although human beings tend to put words to experiences of empathy (“I feel understood—it feels like someone ‘gets it’—I feel like you believe me”), attunement and empathy are actually nonverbal somatic experiences of warmth, relaxation, being able to breathe more deeply, and feeling emotionally closer and more connected.
Because, despite the presence of many parts, there is only one shared whole of a body, it also means that any intervention having a positive effect on body experience will have a positive effect in some way on each part. For example,
Ted had been “hijacked” or taken over by a depressed, ashamed submit part many years previously when early professional success unexpectedly triggered a flooding of post-traumatic implicit memory, sending him into a tailspin from which he had never recovered. Now, twenty years later, he was still depressed, still struggling to function, still ashamed of his “fall from grace” as he termed it. A tall, thin man, his shoulders and spine were collapsed; he walked with a duck-footed awkwardness; and he tended to look down at the floor rather than at me. His refrain was: “You don’t understand.” He was correct about that: it was hard for me to understand how this bright, talented man had just given up and given in to the depression—until one day, as I listened to his self-punitive confession of the week’s failures, I felt myself collapse. My spine and shoulders sunk; I began to feel energy-less and helpless; I found myself questioning my ability as a therapist.
Without consciously choosing to disclose, I heard myself saying, “You know, Ted, as you talk, I can feel myself collapsing in my chair, going numb, feeling absolutely helpless, questioning my adequacy … I may not be as good at this as I thought I was …”
Suddenly, he sat up: “That’s how I feel!” he said. “You finally got it! Now you know what I’m going through.”
ME: “I do.” [Still slumped in my chair with no energy to meet his energy.]
TED: “I feel so much better now that I know you ‘get’ it!” Now he was sitting up with his back straight and aliveness in his face and tone of voice.
ME: “It seems like you felt better as soon as you sat up, though. Is it OK if I do that, too?” [I imitate his posture of excitement and pleasure] “Oh, that is so much better—thank you.”
TED: [Sitting up even straighter with his shoulders back] “Yes, that does help, doesn’t it?”
ME: “Would it be OK if we stood rather than sit? Maybe that would help me with this hopeless feeling …” [We both stood up.]
TED: “This is much better!” [He suddenly looked like a new person: more assured, more masculine, more related to me instead of alone in his depressive world.]
ME: “It sure is—what a difference! In you, too—it’s like your grownup self is standing tall and sending a whole new message to the depressed part!”
TED: “I feel like a man,” he said. “It’s been a long time since I felt like a real man. If that makes the depressed part feel better, I’m glad.”
ME: “Maybe before, your physical collapse communicated to him that he was right—he should be depressed and hopeless and question himself. Now your body is sending him a really different message, isn’t it?”
Utilizing movement interventions drawn from Sensorimotor Psychotherapy (Ogden et al., 2006; Ogden & Fisher, 2015), Ted transformed his internal experience, especially that of the depressed submit part. His new body language communicated to the depressed part that he wasn’t a little boy alone in an intimidating world, that he wasn’t “less than,” and that the boy could hold his head high along with Ted. By combining a parts perspective with the somatic interventions of Sensorimotor Psychotherapy, Ted and I could work simultaneously with the parts and the whole, rather than feeling pressure to choose one approach or the other.
Not only does a parts approach require role changes for the therapist (from listener to educator, from individualistically oriented to systems-oriented, from facilitator to role model), but so do the demands of neurobiologically informed trauma treatment. The emphasis on greater differentiation between parts as a vehicle for mindful self-observation conflicts with the prevailing view in the field that the therapist must de-emphasize parts language and emphasize that the patient is one whole person in one body. However, when that one mind and body is in chaos or bent on self-destructive behavior or so fragmented that reality-testing is compromised, the goal of treatment must be to restore order and provide a period of stability during which clients can learn to identify the different perspectives inside them, develop more conscious and effective defenses, and differentiate their normal life selves from the impulsive, ashamed, or critical voices they hear inside. When the client reports many years of traditional talking therapy without the kind of progress in treatment one might expect, or describes having been stuck in an ongoing internal conflict over months or years without much success in resolving it, or describes the signs of structurally dissociated parts, it should be clear that treating the client as one person in one integrated body has not worked. Traditional talking therapy approaches might work well with individuals who are less fragmented or traumatized, but it does not work with clients whose habits of self-alienation and self-rejection recreate the rejections and humiliations of childhood.
Therapists often feel pressure to address traumatic memory as early in treatment as possible because they have been taught that “trauma processing” is the gold standard of trauma therapy. Often unaware of changes in the standard of care in the field or familiar with new mindfulness-based treatments, they assume the need to access event memories.
But in the model of treatment described here, the focus is not on traumatic events but on the “legacy of trauma” as it is carried by the parts and continues to intrude even decades later into the minds, bodies, and ongoing lives of survivors. “Processing the trauma” is equated in this model with “transforming” how the parts have encoded the effects of the traumatic events and transforming the client’s relationship to the parts from one of alienation to one of unconditional acceptance and “earned secure attachment.” For therapists with years of event-focused trauma treatment experience, it is often hard to shift from a narrative approach to a “repair” perspective. What they need to remember is that the event focus of the early trauma treatment field simply reflected an extension of the “talking cure” to trauma therapy (Rothschild, in press), not the creation of an approach specifically tailored to the in-depth understanding of traumatization available to therapists today (Van der Kolk, 2014).
Throughout treatment, the therapist will encounter event-related issues. There will inevitably be parts that want to “tell all” or parts that tell and retell stories of the same events over and over again. Equally likely are parts that resist the therapist and the therapy in order to keep the secrets of the past intact or avoid “going there.” Because therapists will encounter all these different points of view in their clients, it helps to keep in mind that the goal in trauma treatment is not remembering what happened but the ability to be “here” instead of “there” (Van der Kolk, 2014).
When individuals can be conscious and present in the here-and-now and tolerate the ups and downs and the highs and lows of normal life, they are ready to heal the injuries caused by the trauma—the injuries to innocence, to trust, to faith—the injuries to the body and the injuries to the heart and soul. Remembering the past is helpful only to the extent that it helps to heal rather than reopen the wounds. However much remembering plays a role in trauma treatment, it should never be used in the service of reliving the painful past or asking the parts to relive it.
Remembering in fact should serve a larger purpose: to help the client “be here now” by transforming the past and changing the ending to each part’s story. Remembrance should be used as a catalyst to evoke a deeper appreciation of how the client has survived “with heart and soul intact” and a gratitude for all the parts that helped the client survive and now deserve to be part of a safe and healthy present.
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