Somatic Experiencing[R]: a neuroscientific approach to attachment trauma.
Psychic trauma (Diagnosis)
Psychic trauma (Care and treatment)
Medicine, Psychosomatic (Methods)
Carleton, Jacqueline A.
Gabay, Jaqlyn L.
|Publication:||Name: Annals of the American Psychotherapy Association Publisher: American Psychotherapy Association Audience: Academic; Professional Format: Magazine/Journal Subject: Psychology and mental health Copyright: COPYRIGHT 2012 American Psychotherapy Association ISSN: 1535-4075|
|Issue:||Date: Spring, 2012 Source Volume: 15 Source Issue: 1|
|Geographic:||Geographic Scope: United States Geographic Code: 1USA United States|
After a brief description of the causes and effects of trauma due to disruption in the autonomic nervous system's balanced functioning, the article will outline some aspects of Somatic Experiencing[R] that are especially relevant to attachment trauma, along with some basic principles of its utilization. Following these basic principles will be a short explanation of the neuroscientific and psychosocial research on attachment. There will then be a review of the four main attachment styles with examples of specific ways of working within the Somatic Fxperiencing[R] model with each of three attachment disruptions: ambivalent, avoidant (fearful and dismissive), and disorganized. This article will highlight mainly those aspects for which we have worked out treatment techniques and will end with a brief case example.
Current neuroscientific research underlines that the body and the mind are not separate entities but in fact are deeply interconnected and interdependent. The human brain is not only master of mind, but it also holds a physical connection to the muscles. Hence, it is vital to take both the mind and the body into consideration when working with patients, as what affects the mind can also affect the physical body, and vise versa. Somatic Experiencing[R] takes into account both the physical body and mind, working through the nervous system, in order to restabilize both the physical and mental well-being of an individual. We will explain why humans become traumatized and how they respond to overwhelming events in contrast to other mammals. We will employ the Polyvagal Theory to explain how trauma can have long-lasting and debilitating effects for the entirety of a person's life. Focus will be on attachment trauma and how attachment issues in early life result in the styles of attachment that affect one's thoughts and behaviors throughout adulthood. We will begin by introducing the principles of Somatic Experiencing[R] before going into how and why it is important and effective for healing trauma within the body and the nervous system, specifically attachment trauma, from a neurobiological perspective. The following are definitions of terms that will be used throughout the discussion of Somatic Experiencing[R]: (www.traumahealing.com)
An Experience of Somatic Experiencing[R]
Take a moment to check in with your body: heart rate, tension anywhere, breath? Then shake your hands and feet, as much of your body as possible (standing up) for 30 seconds. Then check in with heart rate, breathing, blood pressure, spots of tension.
You have just experienced your autonomic nervous system self-regulating. The nervous system is a self-regulating, self-organizing system. The body-mind is designed to heal intense, extreme experiences by utilizing the brain's unlimited neural plasticity. Interactive regulation and self-regulation, evident in the mother-infant relationship, are a part of any intimate relationship and are called upon constantly in psychotherapy. Before embarking upon Somatic Experiencing[R]with clients, it is strongly recommended to engage in psychoeducation with them to explain how the autonomic nervous system functions, how mirror neurons register imaginary experiences, etc. It is important and helpful for them to have some kind of general understanding of how and why this treatment is effective.
Somatic Experiencing Explained Neurobiologically With Special Reference to Attachment
The techniques of Somatic Experiencing[R] can be classified as naturalistic, as they have emerged as a reflection of those patterns that exist in nature. By observing methods of safety, protection, and preservation used by animals and even plants as innate mechanisms for survival, Peter Levine started to gain an understanding of the human patterns, behaviors, thoughts, emotions, and experiences that occur within the body, the nervous system, and the mind. This reflection of nature holds true in the many ancient practices of various cultures that have based their own methods of healing and treatments on the activities of nature for thousands of years. This reflection of nature is also now recognized within the realm of science, specifically the latest neuroscience research, and its empirical and anecdotal theories, intermingling all of instinct, intuition, and reason (Schore, 2003).
Humans respond to threats in a manner similar to other mammals. When one's nervous system becomes overwhelmed and threatened by an unexpected, unwanted stimulus, the body will innately and automatically take certain sequential biological steps, as the organism goes into survival mode, to regulate the nervous system and rebalance the body. It is ANS that is responsible for this self-regulation, acting as a control system and prompting the body to return to normalcy. The difference in the way that humans experience threats in relation to the way that animals do, lies in a person's utilization of the many assets of the left brain, which, although vital to our existence, can heighten trauma. This inability to let go is not a cognitive decision, as many trauma victims do not even remember their traumatic experience. Yet, whether or not the consciousness chooses to remember and acknowledge the trauma, the body remembers (Rothschild, 2000). For one reason or another, the effects of the experience can remain trapped in the body, embedded in the nervous system as pent-up survival energy, which causes the blockages responsible for the resulting mental, emotional, and physical distresses. As long as the memory of the event is still trapped in the body, it will continue to wreak havoc on the person's physical, mental, and spiritual health.
It is evident that trauma has a significant impact on a person's mental and emotional well-being, but it is less known that traumatic events are actually physically stored in the human body. Hence, psychotherapy is not always successful at treating trauma, and when it is successful, the recovery is often temporary and not sustainable if it does not include the physical body. Addressing trauma by focusing on its embodiment is what Daniel Siegel and Pat Ogden refer to as "bottom up" intervention, dealing with the problem at its root so that a deeper level of transformation may take place (Ogden et. al., 2006).
Some patients can, and often do, become retraumatized when they verbally and cognitively relate their past traumatic experiences. Somatic Experiencing[R] helps the person to consciously and carefully track the sensations within the body in a slow, mindful manner as the person relates or re-experiences a trauma, so as not to reactivate the defense system, which could cause retraumatization. Through tracking by both therapist and client, signs of distress can be seen in the body by observing posture, skin coloring, tensions, involuntary movements, heart rate and breathing patterns. Carefully observing the changes, however slight they may be, allows the therapist to bring insight, evidence, and preciously agreed-upon resources to what exactly is going on in the body so that the energies may be discharged and the nervous system reregulated.
A self-regulating nervous system automatically discharges periodic arousal. It facilitates resilience almost regardless of the chaotic outside environment. If a person did not have a loving, nurturing caregiver and did not learn to self-soothe as a part of early attachment, it would be difficult to have a steadily regulated nervous system. Unresolved trauma makes it difficult to stay in contact with even highly charged positive states. The ability to experience joy, bliss, expansion, compassion, gratitude, sexuality, etc., can be as difficult to tolerate as the more familiar negative states.
Attachment trauma survivors often have hyper-aroused bodies. The nervous system hasn't been able to discharge it, so the sympathetic nervous system remains activated. After prolonged periods of time, the body/ mind interprets the hyperaroused nervous system as normal. The threat response becomes internalized so that the person does not need a tiger, or an oncoming car, or a fire breaking out to trigger it: the bottled-up arousal within the nervous system itself triggers the threat response. To bring the arousal level down, the body needs to complete incomplete physiological sequences related to threat (Levine, 2010). It is subsequently much easier for the person to maintain contact with resources, relaxation, and expansion.
The therapist needs to carefully gauge the level of arousal of the patient. If resources, such as safe people or places, have been encoded physiologically at the beginning of therapy, utilizing the felt sense and in their own body, patients can revert to those resources when they start to feel hyperaroused. Trauma energy is often unintegrated, fragmented, and very highly charged: the person's life is a bit like walking through a minefield. When someone's nervous system becomes highly activated, the person can be swept away. The energy has a magnetic pull--hence, the term vortex--and it takes the client out of an integrated sense of self. In states of high arousal, focusing on the lower parts of the body facilitates the discharge of energy down the legs. To feel, for example, even five molecules moving down the legs helps neural pathways come back online and available for discharge of highly activated states.
Neuroscience and Attachment
Since a large proportion of attachment disruptions happen early and are preverbal, Somatic Experiencing[R] provides a way to work with them in an embodied way. What was originally conceived as treatment for traumas that patients could describe verbally, Diane Poole Heller, PhD, is now extrapolating to earlier experience and trying to work there by engaging body-based techniques, implicit movement, etc. Because attachment trauma is above all things relational, of course the therapeutic relationship is also paramount in its treatment.
A large body of neuroscience and attachment research supports the importance of the early attachment relationship to brain development and the subsequent ability to form close relationships throughout the life span (Schore, 2003). Summarized in many books and articles by Allan Schore (2001), we can see the outlines of how the infant brain develops in relationship to its caregivers. The normal/healthy caregiver is phylogenetically primed to nurture. When presented with infant stimuli such as audio-recorded infant cries, parents' basal forebrain regions are activated. Significant for its nurturing functions, the basal forebrain region activates the areas in the brain responsible for qualities of effective parenting, including empathy and emotion, in addition to regulating nurturing responses (Swain, Lorberbaum, Kose, and Strathern, 2007). This design is pivotal to the development of the infant's emotional foundation. Similarly, infants are innately designed to receive these caregiving responses. When a child is born, the nervous system has not yet been fully developed. Schore insists that from birth to 18 months, the child's nervous system is essentially sculpted by the interactions with the mother (Schore, 2002). The structures of the right brain, which are responsible for autonomic, involuntary stress regulation and emotional regulation, are designed to mature within the first two years, so the child-parent relationship is crucial. After birth, the baby naturally exhibits what Bowlby refers to as "proximity seeking behavior," by which the baby relies on the mother for emotional regulation (Bretherton, 2004). Because the parent is primed to respond positively to infant stimuli, in the ideal secure attachment situation, there is positive synchrony between the mother and the child. Thus, the child's nervous system is able to develop optimally.
However, in less than ideal situations, the infant endures undue stress. The neurological impacts of an insensitive parent-infant caregiving relationship are summed up by Schore (2002): Trauma causes biochemical alterations within the developing brain (15). The infant's limbic system still matures according to the same schedule as that of a securely attached child, but because the emotions of the infant are not regulated to promote optimal organization, the right connections are not formed among limbic system structures. This results in a suboptimally functioning limbic system, and the infant; therefore, is not as capable of regulating emotions in times of stress.
Stressful episodes result in large fluctuations in parasympathetic and sympathetic activity (Schore 2001b). An infant will react to the trauma of abuse in two stages: a hyperarousal stage mediated by an overactive sympathetic system, and a dissociative stage mediated by an overactive parasympathetic system. In the hyperaroused stage, the amygdala will initiate the stress response by signaling to the hypothalamus to increase the release of stress hormones, resulting in elevated blood pressure and an increase in heart rate and respiratory rate. During this state, the infant's mind will attempt to repair the damage of trauma by releasing endogenous opiates, which act to decrease the sensation of physical pain. The infant will be in a state of withdrawal (Tronick, 2007).
If stress is encountered frequently, the body may adapt by selecting connections that initiate the stress response at a lower threshold and prolong the response. A hyperactive, sympathetic nervous system will cause the stress response to be initiated when the infant encounters any type of stress. For example, the mere sight of the mother's face will cause the stress response to be enacted in an abused infant, even before she actually induces trauma in the infant. A hyperactive parasympathetic system will eventually cause the infant to dissociate and freeze. Infants who are exposed to extreme levels of stress lose their ability to regulate their shifts in state, leading to irregularities in development. MRI's provide evidence of the crucial interrelationship between infant and caregiver (Swain et. al., 2007).
According to Stephen Porges's polyvagal theory, there are three systems of defense strategies the body may utilize when experiencing a threat: immobility, fight-or-flight, or social engagement. Immobility is actually a form of paralysis in which the muscles go limp and the person collapses, frozen in an altered state of consciousness and left without any energy. In other words, the body is essentially playing dead in order to avoid attack by its perceived predator. In nature we witness this commonly in animals like possums, beetles, and snakes.
Most of us are more familiar with what occurs during the fight-or-flight stage. It is inherent within a human to seek what is pleasurable and to avoid what is perceived to be painful. When a threat is upon us, we feel compelled to get away from it, thus the body reacts in a way that will prepare one to either flee or to attack the threat. A release of adrenaline will lead to increased heart rate, blood flow, and tension level, urging the person to take some sort of action. This neural energy subsystem evolved from the reptilian period nearly 300 million years ago (Levine and Frederick, 1997).
The third and most recently acquired form of defense is called the social engagement system. As humans are social beings, they rely upon, and exist interdependently in, the relationships built with others. Thus, it is expected that they will try to protect those relationships and thus protect themselves. Therefore, when someone is angry with us, we try to verbally defend or explain ourselves in the situation so that the person will not lash out at us. If we, like animals, do not immediately fight or flee, the energy becomes stuck in the nervous system, requiring later release in some form. We are intellectual beings and that intellect and intelligence has developed in accordance with the functions of our physical bodies. Therefore, when we are feeling stressed or threatened by a person or a relationship, we usually do not want to physically attack that person or run away, but we may want to protect ourselves by protecting the relationship itself, or by releasing the pent-up survival energy in a verbal manner, which would require us to talk out such things with family, friends, or ones close to HS.
One way or another, the system will inevitably become activated during a time of threat. When circumstances or the body fail to protect the person by engaging in the proper biological protection protocol during an overwhelming threat, the energy that has been activated cannot be properly released. It becomes blocked and stuck in the body, deeply embedded within the muscles and the nervous system. A malfunction in this third defense system, the social engagement system, is often closely related to a person's attachment issues, which will be discussed after the principles of Somatic Experiencing[R] are understood.
Resources are identified, and alluded to, throughout the treatment. They are reparative and they aid titration. Before beginning to process a trauma in psychotherapy, it is vital that a resource is established by the trauma survivor as an antidote to those painful experiences. A resource can be an internal or external focal point to which the person working on the trauma issues can safely return. It can range from a soothing, calming image, feeling, or sensation, to an actual person who evokes the same feelings of safety and security, as long as it is something positive in the person's life. This is a necessary support stratagem for when too much activation begins to emanate within the nervous system, risking retraumatization. This resource will help with grounding by reestablishing feelings of safety, security and confidence. When people are able to locate and utilize a resource, they will be able to calm themselves and to reconnect with themselves on a deeper level. When they feel a secure sense of attachment to the therapist, they will also gain strength to be able to move forward in coping with past traumas. After a resource is established, the therapist and client can then begin the process.
Some people have never experienced the feeling of being safe or secure, which makes it much more difficult to activate a resource, if it has never consciously been physically felt or experienced. If it is not within their physiology, then it does not exist within their frame of reference. This is especially common in those who have had severe attachment trauma. For them, resources may have to be imaginary; however, it is possible to reestablish a secure felt sense, as we all inherently have a sense of intactness at our very core. It will just require more work to find and instill it within the nervous system so that it can be truly felt and experienced in the present, in the body. At this point alternative strategies must be employed to ensure that these people know this kind of secure attachment in fact does exist, whether or not they have experienced it in the past, and to repair their trust in society and in the world. Perhaps they can imagine what an ideal experience may have been for them or what they wish would have happened. Or maybe there is a movie that they can relate to, and the movie's heroic character can be used as their secure base resource.
Most of us have been trained to allow the patient to complete a horrific narrative in the hopes that the neocortex will make sense of it and thereby lessen its ramifications in the person's present life; however, this strategy frequently leaves the patient highly activated in one branch or the other, but pausing in the account to allow the nervous system to "recycle" avoids iatrogenic retraumatization of the nervous system. This can be done in a number of ways: by asking the patient to focus on a resource, by asking the patient to focus in the present, and by any one of a number of grounding and stabilizing exercises. It is necessary to activate the body very slowly and carefully through the process of titration so that the nervous system can regulate and reintegrate at each step. This involves introducing traumatic material in small amounts. It keeps the nervous-system activation within the window of tolerance. The energy locked into the system by trauma is most effectively released in small increments. Trauma can be represented as a vortex. We are working with a polarity so sometimes the counter vortex, the healing vortex, is small. We try to strengthen the ability to stabilize. Titration weakens the pull of the trauma vortex. [Edited from Transcript p.7 DPH]
From chaos theory, we learn that in nonlinear, self-organizing systems (Bloom, 2000), the right amount of perturbation (disturbance) allows a system to reorganize to a higher level. Excess perturbation results in retraumatized clients at a lower level of functioning. If you introduce just the right amount of perturbation, it leads to a tolerable activation of the nervous system, which can then proceed to a higher level of organization. Subsequently, the person can tolerate more expansion, more flexibility, and more activation in the nervous system.
After a small amount of expansion, the next step is stabilization which allows the person to accommodate to increased energy in their system. If they don't, they may revert to old patterns of disregulation. It is very important to give people time to stabilize changes in and out of the session, to really develop the container to hold all that aliveness and energy that's been trapped in the trauma.
Multiple Elements of Experiencing: SIBAM
We want to bring awareness to as many elements of experience as possible for the most discharge to take place to allow the body's maximum release. It is necessary to work in as many channels as possible to enlarge the experience, making it wider and deeper. Discharge can occur through awareness of any element of the acronym SIBAM. Be sure to allow lots of time for the nervous system to reorganize itself. We don't want to rush the session.
a. Sensation involves any of the five senses.
b. Image can be internal or external (red ball in chest vs. sunset).
c. Behavior can be verbal or nonverbal, voluntary or involuntary, conscious or unconscious.
d. Affects are emotions, actually patterns of sensations.
e. Meaning is explicit linguistic concept or statement.
It is important to be able to recognize signs of discharge without inhibiting them in both self and patient. Traumatized people who have undergone harrowing experiences have a lot of energy built up within their systems, adding extra weight onto their emotional and physical frame. If the body has been in a state of hyperarousal for an extended period of time, it most likely will have forgotten how to discharge excess arousal. A few examples are exhaling, yawning (a parasympathetic response), burping, tingling or numbing depending on the context, a sense of flow, warmth/heat (or mobilization), sweating, crying or tears, shaking and trembling (which may have fear mixed in it), and coughing.
Creating Continuity and Time (ANS Regulation) through Language (DPH Transcript)
A sense of awareness is crucial for Somatic Experiencing[R] to take place most effectively, so the therapist conducting the session must continuously facilitate this awareness. One of the best ways to do this is through the use of language, specifically invitational language spoken in a well-regulated tone.
Connecting words and phrases often provide a sense of continuity within patients, allowing them to fill in the blanks of their trauma. We start with connecting phrases such as, "And as you feel that resource in your legs, what do you notice in your upper body?" We keep things moving. We often start sentences with "And ..." and "As you ..." to obtain that sense of continuity. The prompt, "What happens next?" is useful for helping someone keep moving through time. You may say, "So you're noticing some emotion coming up, and it's related to this particular event. This person did something that was upsetting. Just let yourself stay with that, let that have some space. What do you notice happening next?" The prompt may serve to move the experience along, or to move along a story that actually was interrupted in the past, a story we want to continue and eventually finish to help release the trauma.
Signs of discharge are positive indications the session is moving in the right direction. The individual might rapidly go to a next thought, or another memory, but we need to help the person move through his or her physiology in tandem with what's being experienced emotionally. An example: "After discharge, what do you notice next? After that strong movement, what do you notice next in your legs?" (When someone experiences too much arousal, language needs to become much more directive. You may have to say firmly: "Open your eyes, look at the carpet, look at the colors," etc.)
Language, in short, is used to support the unfolding of the process. One of the hallmarks of trauma is that it stops the experience, and the person spins in the arousal. We want to tap into that resource enough so that the individual feels safe enough to move forward. The experience could be a sensation, an image, a picture, a sound, a smell--trying to bring elements of the experience back in a soft enough way. The goal is to always help move towards integration instead of disintegration.
Humans, like other mammals, are hardwired from birth to seek attachment to a caregiver, both for protection and nurture and as a secure base from which to explore the world. Since Bowlby first proposed its main features, attachment theory and research has grown exponentially in many areas of psychology. If an infant is unable to form this primary attachment relationship with a caregiver, the infant adapts to the deficient caregiver by creating secondary attachment strategies, or a secondary attachment system. These systems have been variously categorized as ambivalent/anxious, avoidant (dismissive and fearful), and disorganized. Diane Poole Heller, PhD, a collaborative colleague of Peter Levine, PhD, founder of Somatic Experiencing[R], has conducted a number of intensive workshops in which she demonstrates how to apply Somatic Experiencing[R] to attachment. She believes that the key to restoring our intrinsic core intactness, as well as building and maintaining healthy, fulfilling adult relationships, is to work through childhood traumas and heal our early attachment styles through an integration of the mind and body. (http://www.drdianepooleheller.com).
Attachment Styles Adapted from Diane Poole Heller, PhD)
Secure attachment thrives when the holding environment is safe and engenders basic trust. Parents are present, consistent, and show interest in and align with the state of mind of the child. Communication is predictable, sensitive, and attuned. Securely attached adults show realistic optimism in their worldview, have a capacity for attunement and clear communications, and have resiliency in recovering from stress, especially in relationships. These people tend to be unflappable and level-headed and give others the benefit of the doubt when appropriate. They also demonstrate the capacity to initiate and receive repair attempts.
Avoidant people tend to be relatively disconnected from their physiology and/or their emotions. Avoidant attachment is usually the result of parents who were emotionally distant, rejecting, and aversive to the child's signals of distress and bids for proximity. The child did not receive the mirroring or the exchange optimal for the development of the prefrontal cortex around emotional connectedness. In therapy, we have to set up conditions to allow those impulses to resurface. The therapist can embody the correction in the relational field and can highlight a particular aspect of presence, quality of being, or attunement.
Even memories and perceptions of the past are biologically detached in avoidant people. Felt sense depends on limbic exchange. Hence, there needs to be an emotional connection for our brains to configure a personal memory and a limbic connection for a "feeling" memory to imprint. Avoidant people may recall their childhood: "Yes, I went to that red brick school, and my teacher's name was Mrs. Harris, and there was a playground, and I played ball." They can describe the fact of it, but there is not a felt sense memory of the experience, only an "I was there." Avoidantly attached people describe their history the same way they approach relationships, which is that the narrative is detached and impersonal. They may have large gaps in their memory, as their memory was not consolidated due to a lack of emotional connectedness.
As adults, one of the primary characteristics of such a person is to be solely self-reliant, but unfortunately it is a self-reliance based on deficiency. It is an autonomy that is driven by fear and self-deprivation. It is an unhealthy, fear-driven autonomy. The criticized child grows up to be the critical adult, and the roles are flipped. The person acts out both sides, in line with the projection experienced, which was criticism, excess pessimism, and a cold, distant demeanor. The avoidant person is either the rejected or the rejecting one. But either one of those is an ultimately uncomfortable place to be.
Avoidantly attached people view connection as something dark and dangerous, to be deeply feared. So it's very important that you understand and can say to the person, "I know that what I'm suggesting to you feels like a huge risk." You must validate that because it is true. [transcript 11-13 all avoidant]. These people tend to be somewhat dissociated and not fully present in their bodies. The optimal condition for attachment to thrive is a connection in which communication is predictable, sensitive, and attuned. The therapist must try to embody and enact those qualities. Avoidant people will be particularly sensitive to eye contact.
In this attachment style, children at 18 months return to parents on reunion but are not easily soothed and do not return to play quickly. They exhibit crying, then relief, and then cry again. They appear not to trust the consistent availability of the parent. They always remain overdependent, hypervigilant, and hyperactivated in expression of needs. The child simultaneously feels hunger for closeness and a debilitating fear of losing the closeness.
Anxious adults may experience chronic anxiety, frustration, and despair in relationships, always expecting the worst of their partners. They have difficulty trusting themselves, their partner, and the relationship. They will accept what they are given instead of asking clearly for what they want. They may "give in order to get" and wonder why their partners sometimes feel angry instead of appreciative. Anxiously attached people feel that they have to please their partners all the time in order to keep them. They say they want pleasure, but their life experience has taught them to be more comfortable with pain because it is familiar. In identifying with deprivation, ambivalently attached people reject love when it is truly offered because it feels unfamiliar and disorienting.
Fortunately, there are a number of ways to help ambivalent/anxious people repair anxious attachment. One is to help them somatically experience having something versus wanting and not having. Anxiously attached people can easily identify with wanting, and yet are almost dazed when they receive, and they don't know how to embody the experience. We need to help them have an embodied experience of receiving love and support. The following somatic exercise may be useful: First, what happens when you attempt to receive? Track in your body and your emotional self what your responses are when others are available and you have the opportunity to receive. What happens? Secondly, what is your experience when giving? Again, track the responses in your body.
The disorganized infant displays chaotic and disoriented behavior. At 18 months, the child may run toward and then abruptly away from the parent because the child simultaneously needs and is terrified of the parent, who is frightening and/or deeply frightened (Mikulincer & Shaver, 2007). Two major biological drives are in constant conflict: the innate drive to attach and the instinctual drive to survive. Both deactivating and hyperactivating strategies are used, often simultaneously. These people are equally terrified of both intimacy and abandonment. The avoidance is due to fear of attack coupled with a desperate need to turn to someone to not be alone, or to have a safe haven with an "other" in order to attach. The main problem here is that two very strong psycho-biological instinctive drives are in direct conflict with each other--the need to attach and the need to survive danger.
As their survival depends on entering an unsafe environment on a regular basis, these children learn to override their self protective instincts so that, ultimately, they cannot distinguish between safe and unsafe circumstances because their self-protective alarms no longer sound. As adults, they may frequently dissociate and be attracted to danger or be unaware they are walking straight into it. They may not find options that are available to increase their safety. For example, abuse survivors often ignore the early signals of inappropriate behavior from others, such as off-color jokes, invasive touch, and "bad vibes." As facilitators, we may need to help bring these original survival instincts back into awareness and "reactivate" this early radar system.
When repairing disorganized attachment, the therapist must play the role of good parenting by generating increasingly secure attachment experiences in sessions, as well as be willing to tolerate protest, set limits, and stay present in the struggle so the patient learns that he or she can stay connected even when feeling separate or angry. The therapist needs to contain this distress through responses that convey empathetic understanding, provide contingent, coherent affect-mirroring, and provide a secure base and safe haven. This is necessary in order for the client to be able to tolerate, modulate, and communicate emotions and experiences that were previously unbearable and possibly unconscious.
The goal is to bring the disorganizedly attached person out from dissociation and back into embodiment. There are often alternating patterns of flooding and dissociation that we want to lessen by helping them to reregulate the overarousal in the ANS. Because a common characteristic of these people includes splitting in the sense of self and their perception of others, we want to be able to integrate these splits so that the person can stand on a balanced middle ground. It will also help them to deal with their contradictory impulses for closeness and distance that bring about their chaotic, incoherent, confusing, and overwhelming feelings. We want to replace this confusion with clarity, build their capacity to problem solve, install a felt sense of protection, and untangle those wires that have been crossed. We can achieve these goals by repairing primary attachment, and the original radar for danger, with the ability to take action, rather than freezing and dissociating.
Vignette I--Avoidant Attachment in a Group Setting
The Avoidant Attachment style exhibits issues with contact with self and others to the point of feeling "alien" or alienated. It is as if they are not fully on the earth plane, and they have one foot on and one foot out in the cosmos. The therapeutic goals are to help them arrive more completely, to feel fully embodied, and to engage in the physical emotional realm--to have the sense that "I have arrived," in welcome.
Difficulty feeling that "I exist" in safety can be caused by the absence of another presence early in life to help the child to be present. Often children develop this when their caregiver is actively rejecting or hostile to the extent that the child reacts by disconnecting. The child decides implicitly that relationships in general do not work and are not satisfying. Having basically given up on others, one relies on oneself for nurturance or seeks fulfillment in work or other nonrelationship activities.
Nicole's concern is the lack of intimate relationships in her life. She feels alien and "walled off" from others when she has needs or requests. She explains that her parents had tried to have her aborted. It was a large family, her mother did not like children, and both parents were very busy and preoccupied. She describes an emotionally dead, vacant family life. The felt sense of the family deadness shocks her. We start with grounding to check ANS regulation.
As Nicole connects in imagination with a male friend who is grounded and present, she feels solid inside and safer. We emphasize how her body feels safe in the felt sense and she has the experience of "I arrive"; "I show up when in the presence of presence." Looking into the face of a secure attachment figure like her friend, Nicole feels solid, out of chaos, and grounded. When we alternate from the family deadness to the rightness of this man's presence, Nicole feels her "sparkle" come back amidst laughter and lightness. Humor is a ventral vagal capacity, and we see her socially engaged. Here is a fine example of how a healthy friendship can restore healthy secure attachment. She sees herself at age 10, when the family moved a lot, dealing with a hostile mother. We access friendly faces present in the group to enhance her sense of having allies imported to that time. She feels safer, stronger. The therapist has her imagine her 10-year-old self seeing her current adult self and experience the difference it makes to feel safer now. We have the adult Nicole give the 10-year-old a tour of her life now, which brings integration and relief.
Nicole can feel connected to members of the group and regain her emotional self with the support of others who are connected and compassionate. She sees that she is no longer limited to her difficult family. We explore contact issues and the walls that come up when she attempts sustained contact with others. She can feel herself conditioned from her history within her body. It feels great for her to articulate, "I'm alienated."
She sees the projection of the past onto the group and how real it feels to not belong. Nicole worries about the group's reactions to her. She decides she can survive on her own, a reiteration of avoidant attachment style that is not really a "decision." We honor the fact that isolation from a difficult family worked in the past and allowed her to survive. This time, when she lets her allies in, she can breathe and regulate herself again. She feels her real self and feels lighthearted and playful. She risks looking at the group and feels, "I want to connect with them, but will they want connect with me?" Nicole stays with the impulse for contact and feels a new sense of connection in her body, which was not a mom-and-dad experience for her. She can tell she is not projecting her history now. Weight drops off her shoulders and she takes time to integrate. The sparkle is back!
Vignette II--Ambivalent/ Anxious
Linda was struggling with her partner; she was frustrated because she felt that he was always leaving her. The therapist asked her if this was a frustration she had experienced in past relationships, and she confirmed saying, "Yes, they always leave!" After the therapist explained the ambivalent attachment style to her, they then discussed her childhood and identified an on-again, off-again relationship with her parents. The therapist told Linda to look at her partner now as objectively as she could, and tell everything that he is doing to try to communicate that he loves her. She was able to list dozens of little actions he had made in attempts to communicate his love and care for her: taking her out to dinner, buying her flowers, calling her from the road, and again when he got to his destination. She identified all the things he did around the house and the fact that he told her he loved her all the time. She wasn't able to recognize any of that until they started to do an inquiry on it. Originally, her description of him was unflattering in terms of availability. They were able to work through the insecurities that she had, once Linda could see that this was an internal dynamic that she was projecting. For ambivalently attached people, there is a tendency to be chronically dissatisfied. This is because they are projecting their history on the other so that they are only really seeing their parents. Because ambivalently attached people have a hard time receiving availability, they will become unavailable if their partner is available. Availability does not fit their history. It does not fit the object relation of "I can want, but I cannot have." Therefore if somebody shows up where they can actually have something, then they will move into "I don't want to be there."
Vignette III--Disorganized Attachment
Johanna grew up in a chaotic household with a father who was violent and a mother who was suicidal. Her stepfather was also emotionally abusive. She is asked to think of a person in her past who was a more stable presence in her life, and she chose a teacher named Joan. "When she thinks of Joan, her face becomes alive. She reports that she feels lighter and warmer. Working through the trauma, she begins to be aware of energy moving down and out through her arms. She becomes a bit afraid of the energy releasing, and the therapist brings her attention back to the resource of her teacher Joan. More sensations of discharge are aroused. The therapist comments on how this is a good thing. She feels such relief in the resource that she wants to cry. She feels her teacher understood her and accepted her sensitivity. As she accesses the relationship with the teacher, her back starts to relax, her breathing deepens, and she is able to orient. She feels she would have wanted to leave her family and go with the teacher. She would like the teacher to come speak to her family about their behavior and tell them how they should treat her. She wants the truth seen and heard. Helping Coral find her voice, "This needs to stop!" "This is not good enough," and "You need to recognize the children's needs." As her arousal around her family begins to rise, we shift focus back to her "protector" teacher. She feels the final phases of the discharge in her hands. She finds herself feeling safe and secure in the relational field of the treatment space. Colors are brighter.
Through these examples, we can see how the therapist was able to use corrective experience and antidote resources to recall the core intactness of the client's original attachment system. By resorting to the resources, which were about safety and a friend's relational continuity, the therapist assisted in integrating ego state. Through the ego state work and integration, she was able to access the activation related to the frightened 10-year-old Nicole and bring her into the present. She helped break Nicole's isolation and projection of the past by accessing and stabilizing the group relational field as a safe resource. The therapist also helped to get the impulse for contact with one's self and others to emerge and broaden to allow fuller social engagement and connection, which allowed Nicole to finally be able to reclaim her authentic self.
The effective principles in the Somatic Experiencing[R] modality have great potential as a cross-modality approach to the treatment of attachment trauma, which occurs when the precarious mother-infant relationship is disrupted and the child grows up with attachment wounds. When left untreated, attachment wounds worsen, drastically diminishing and reducing quality of subsequent relationships. Somatic Experiencing[R] allows an individual to pendulate effectively between states of resource and states of highly charged traumatic energy. This allows for the blocked energy of feelings and impulses locked in the nervous system to be safely released, while giving the individual space to utilize resourced states of safety. As the therapy operates under an assumption that within all of us is an innate secure attachment, it simply works to bring out our secure attachment, freeing us from the emotionally heavy obstructions within our nervous system that hinder our potential for a healthy, thriving, and generative development.
A) RESOURCES: Discovering what's right with the client and using that information to develop an inventory of resources to help the client access a sense of safety or support that can help neutralize overarousal, etc.
B) FELT SENSE/SENSATE FOCUS: Helping clients develop a sensate focus and ability to track their experiences in the body.
C) PENDULATION AND MODULATION: Pendulation is defined as the body's natural rhythm supporting the basic process of contraction and expansion, i.e., the movement between tension and relaxation or inhalation and exhalation. Modulation is guiding clients to shift their attention back and forth between the calming effect of resources and the high activation of traumatic material in a manageable, balanced way to help them digest overwhelming material without becoming overwhelmed in the process helps to facilitate the pendulation.
D) PACING: Learning the slower rate and rhythm needed to integrate traumatic material when including the physiological reorganization. "Slow is fast and less is more" in the service of effective integration. Note: It has been suggested that the reptilian brain processes much more slowly than the neocortex.
E) TITRATION: Breaking the activation down into small enough pieces to be integrated easily so that a client can process overwhelming material in a nonoverwhelming way. The process is analogous to adding drops of HCL into caustic soda until the liquid gradually transforms into water and salt, the building blocks of life.
F) BIOLOGICAL SEQUENCING: Learning to work with the biological sequences innate in the body in terms of how it deals with threat, i.e. the threat response sequence, the brace-collapse-rebound sequence, and the Dorsal Vagal (driving the PNS response), sympathetic, Ventral Vagal (driving the PNS) sequencing studied by Porges.
G) DISCHARGE: Supporting discharge of residual arousal in the autonomic nervous system (ANS) including completion of defensive orienting responses (DPH).
Not every overwhelming event results in traumatic stress. Many challenges will not disturb a person beyond a short time after the event if that person has an adequate support system, enough internal strengths to rely on, and/or if they were sufficiently able to discharge the survival energies generated by the threat.
SOMATIC EXPERIENCING[R] TECHNIQUES
RENEGOTIATE THE EXPERIENCE: USE OF NARRATIVE
LANGUAGING SPECIFIC TO THE BODY EXPERIENCE
RECOVERY / REBALANCE OF THE ANS: RANGE OF RESILIENCE
A mnemonic (memory) device for remembering the five elements to which you should attend while conducting a session.
SENSATION tingling, numbness, urge to move, nausea, dizziness, pressure, pain
IMAGE person, place, thing, color, metaphor
BEHAVIOR head movement, limb movement, eyelids blinking, shaking, trembling, yawns, tears
AFFECT client reports feelings, patterns of sensation, body looks collapsed, mouth is smiling
MEANING Client says: "I just had a thought that ..." Oh, I just realized that ... " "I know that this is"
SIGNS OF DISCHARGE
1 Exhale or yawn (yawning is a parasympathetic response)
3 Tingling / Numbing
4 Sense of flow
5 Warmth / heat, can also be mobilization
8 Shaking and trembling (trembling may have fear mixed in)
RESOURCING: ANYTHING THAT CALMS US DOWN
1. What works for you? What do you do when you need to calm down?
2. How can you tell? What changes in your body?
3. Put words on the sensations or the experience.
TIGHTNESS OF SKIN
This article is approved by the following for 2 continuing education credits:
The American College of Forensic Examiners International is an NBCC-Approved Continuing Education Provider (ACEP[TM]) and may offer NBCC-approved clock hours for events that meet NBCC requirements. The ACEP solely is responsible for all aspects of the program. The American College of Forensic Examiners International is an approved provider of the California Board of Behavioral Sciences, approval PCE 1896. Course meets the qualification for 2 hours of continuing education credits for MFTs and/or LCSWs as required by the California board of Behavioral Sciences.
The American Psychotherapy Association[R] provides this continuing education credit(s) for Diplomates and certified members, who we recommend obtain 15 credits per year to maintain their status.
1. Explain the physiological components of the effects of trauma as they relate to the neuroscience, the nervous system and the body as a whole.
2. List the different styles of attachment and how and why these attachment styles emerge and influence adult behavior.
3. Describe the basic principles of somatic experiencing[R] and why this is effective in treating and healing trauma.
KEYWORDS: trauma, attachment, neuroscience, somatic, mind-body
TARGET AUDIENCE: psychotherapists and other health care professionals
PROGRAM LEVEL: basic
DISCLOSURES: The authors would like to note that this paper draws heavily in the work of Diane Poole Heller, PhD and her series of DARe workshops.
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1. Read the continuing education article.
2. Complete the exam by circling the chosen answer the each question. Complete the evaluation form.
3. Mail or fax the completed form, along with the $15 payment for each CE exam taken to: American Psychotheraphy Association, 2750 East Sunshine, Springfield, MO 65804. Or Fax to: 417-823-9959. Or go online to www.americanpsychotherapy.com and take the test for FREE.
For each exam passed with a grade of 70% or above, a certificate of completion for 2.0 continuing education credits will he mailed. Please allow at least 2 weeks to receive your certificate. The participants who do not pass the exam are notified and will have a second opportunity to complete the exam. Any questions, grievances or comments can be directed to the Registrar at (800) 205-9165, fax (417) 823-9959, or email to firstname.lastname@example.org. Continuing education credits for participation in this activity may not apply toward license renewal in all states. It is the responsibility of each participant to verify the requirements of his/her state licensing board(s). Continuing education activities printed in the journals will not be issued any retired.
CE ACCREDITATIONS FOR THIS ARTICLE
This article is approved by the following for 2 continuing education credits:
The American College of Forensic Examiners International is an approved provider of the California Board of Behavioral Sciences, approval PCL 1896. Course meets the qualification for 2.0 hours of continuing education credit for MFI's and/or LCSWs as required by the California board of Behavioral Sciences.
The American College of Forensic Examiners International is an NBCC-Approved Continuing Education Provider (ACEP[TM]) and may offer NBCC-approved clock hours for events that meet NBCC requirements. The ACEP solely is responsible for all aspects of the program.
The American Psychotherapy Association' provides this continuing education credit(s) for Diplomates and certified members, who we recommend obtain 15 credits per year to maintain their status.
KEYWORDS: trauma, attachment, neuroscience, somatic, mind-body
TARGET AUDIENCE: psychotherapists and other health care professionals
PROGRAM LEVEL: Basic
DISCLOSURE: The authors have nothing to disclose.
After studying this article, participants should he better able to do the following:
1. Recognize the physiological components of the effects of trauma as they relate to the nenroscience, the nervous system and the body as a whole.
2. Describe the different styles of attachment, as well as how and why these attachment styles emerge and influence adult behavior.
3. Discuss the basic principles of Somatic Experiencing[R] and why they are effective in treating and healing trauma.
POST CE TEST QUESTIONS
(Answer the following questions after reading the article)
1. According to the recent neuroscientific research
a. Psychotherapy is the only form of treatment successful in relieving trauma
b. Physical trauma does not have as great long term effects as psychological trauma
c. Once a person dissociates, there is a very great chance that they will continue to have episodes of dissociaiton throughout their life time
d. The mind and body are deeply interconnected
2. What is a resource?
a. An imaginary feeling resulting from a trauma
b. Something that causes a flashback
c. A defense mechanism resulting from a reaction to a stimulus
d. A focal point to which the person working trauma issues can safely return to
3. Why does discharge happen?
a. The person working through the trauma has accidentally become retraumatized through excess talk therapy.
b. The person working through the trauma is holding out from the therapist and the discharge is evidence of their omissions.
c. Traumatized people have a lot of energy built up within their systems. Being in a state of hyperarousal for an extended period of time, the body may have forgotten how to discharge this excess arousal.
d. The body is going back through one of its defense systems and the discharge is a form of fight-or-flight.
4. Disorganized attachment results from:
a. A child who grew up in a cluttered house and now has difficulty with his own organization of thoughts and things
b. A fearful parent causing two major biological-drives to be in constant conflict within the child: the innate drive to attach and the instinctual drive to survive.
c. An emotionally involved relationship with an unfaithful partner in which there was a lack of respect and trust for one another
d. Growing up with parents who were emotionally distant and rejecting of a child's signals of distress and bids for proximity.
5. An insensitive parent-infant caregiving relationship will most seriously cause:
a. Improper connections formed along the child's limbic system structures resulting in a suboptireally functioning limbic system lacking ability to regulate emotions during times of stress
b. A release of endogenous opiates in attempt to repair the trauma damage and decrease physical pain, altering the perception of pain and throwing infant into a state of withdrawal
c. Hyperactivity of the parasympathetic and sympathetic nervous systems
d. An increase in neuroplasticity
6. Who or what is responsible for self-regulation?
a. The parent whose duty it is to teach the child to self-regulate
b. The adult who was traumatized as a child and must now learn how to self-regulate by controlling their emotions
c. The autonomic nervous system
d. The therapist's treatment given to the traumatized individual
7. What does Somatic Experiencing[R] do that talk therapy does not?
a. Helps the person to consciously and carefully track sensations in the body so as not to reactivate the defense system
b. Can cause the patient to become retraumatized.
c. Causes temporary numbing of emotions so that the patient is able to speak more about their traumatic events
d. Blocks the consciousness front having to remember the experience so that the person is capable of experiencing healthy, fulfilling adult relationships
8. What is the difference between the way humans and animals experience and respond to a threat?
a. Animals will always instinctually either fight or flee while humans will always freeze and/or collapse.
b. When a human experiences a threat the energy from the threat may remain trapped in the body for years to come, wreaking havoc on all aspects of heir life, whereas animals promptly discharge it.
c. Animals have the ability to self-regulate through their autonomic nervous system
d. It is necessary for humans to recovery front threat by talking it out with someone close to them or with a therapist, or else their brain's biochemical structure may be permanently altered.
Circle one (1=Poor 2=Below Average 3=Average 4=Above Average 5=Excellent)
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Author unknown. What is Somatic Experiencing (SE)? n.d. Retrieved July 8th, 2009, from Foundation for Human Enrichment--Trauma Healing website:
By Jacqueline A. Carleton, PhD and Jaqlyn L. Gabay, HHC, LDC
JACQUELINE A. CARLETON, PhD, has been in private psychotherapy practice in Manhattan since the 1970s. She attended Smith College (AB with honors), MIT, and holds a PhD from Columbia University. Since the 1980s she has taught both body psychotherapy and principles of psychoanalytic psychotherapy internationally. For the past 10 years she has been involved with Somatic Experiencing[R] a neurologically based treatment for trauma. She practices and lectures on Somatic Experiencing[R] in the United States, Europe, and the Middle East. She is also on the Executive Committee of the Trauma Program of the National Institute for the Psychotherapies (NIP) in New York City, where she works on curriculum development. She is currently working on a book with Diane Poole Heller, PhD, applying Somatic Experiencing[R] techniques to early developmental (attachment) trauma, www. jacquelineacarletonphd.com
JAQLYN L. GABAY, HHC, LDC, graduated NYU with honors a year prior to expected graduation date with a BS in Media, Culture, and Communications. Upon her realization of the great impact food and nutrition have on well-being, she joined the Academy of Healing Nutrition in East Midtown Manhattan, from which she has emerged a certified Holistic Health Counselor and Longevity Diet Coach. In pursuing her desire to integrate all forms of healing, she intends to obtain her doctorate in psychology. She has been interning with Dr. Carleton since January 2010, which has stimulated her interest in body psychotherapy, trauma, and attachment. Jaqlyn has also done volunteer research work at the NYU Center for Research on Culture, Development, and Education, analyzing the effects of mother-child interaction and gender appearance on developmental processes. As a devoted practitioner of Bikram Yoga, she also plans to become a certified yoga instructor to complement her holistic healing approaches.
ATTACHMENT ACROSS THE LIFE SPAN childhood adulthood SECURE SECURE INSECURE/AMBIVALENT PREOCCUPIED INSECURE / AVOIDANT DISMISSIVE * DISORGANIZED DISORGANIZED (Ainsworth, 1978; (Main, 1995) * Main & Solomon, 1986)
PRIMITIVE SURVIVAL ISSUES PHYSICAL TRAUMA Loss of life or limb SEXUAL TRAUMA Instinctual patterns are wired for survival of the species BONDING TRAUMA Any threat to mother--infant bonding, pair bonding and membership in the tribe read as survival issues BIRTH TRAUMA Issues can be related to both bonding and sexuality, because sex and bonding hormones are active around birth. Birth and early trauma issues can play out over the life cycle.
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