“The brain is first and foremost an organ of action”
For those of us who work with the traumatized, which like it or not is probably most of us to some extent, it is well known that trauma’s gravest and most painful sequelae are in the area of relationship. Even when the actual trauma is not interpersonal in nature, trust and safety in the world and in relation to others, tends to be shattered. The loneliness and anguish of this is what drives many of the traumatized into our offices, even if they themselves do not associate their isolation or relationship difficulty with their traumatic histories. Of course sexuality, already a delicate area for many people in the modern world, is hard hit. Couples where one or both partners have histories of trauma, often struggle and suffer with sex. Standard couple’s work or sex therapy may fall short in easing their distress and difficulties in functioning. Integrating concepts from relationship therapy, sex therapy and trauma theory is essential for helping them.
– Roger Sperry, Nobel Prize winner, 1981
Healthy sexuality is very much about balance and flow. It is free blood flow that facilitates engorgement, erection, and erotic sensation. (Vasoconstriction or constricted blood flow is what the erection enhancing drugs are designed to alleviate.) Anxiety is vaso-constricting. In an anxious body blood vessels and muscles tense and tighten, blood does not flow freely.
Both the sympathetic and parasympathetic branches of the autonomic nervous system are essential in sexuality. The sympathetic branch is responsible for arousal and activation; the parasympathetic branch is responsible for calming. Sex requires a balance or flow between relaxation and excitement. Without arousal, there will be no sexual activity, and a certain amount of calm is required for arousal to occur.
Satisfying sexuality involves a flow of energy between partners, an expression or communication passing back and forth between them that ideally would be physical, emotional and even spiritual. And finally, in good sex both individuals’ attention and awareness flow back and forth between themselves respectively, their own sensation; and the sensation or experience of the other. It is a quality of conscious presence that moves back and forth between the two.
What is the impact of trauma on all of this balance and flow?
Trauma’s Impact on Brain and Body
In the last 20 years, our field has advanced dramatically in understanding how trauma affects the body, brain and psyche. Since the advent of neuroimaging technology, researchers have become able to observe in vivo what happens in the traumatically activated nervous system. This parallels the surge of information and understanding that occurred when Masters and Johnson began to study live sexual functioning thirty years prior. We have learned, that the traumatized nervous system, floods with stress hormones and goes into a state of acute anxiety or hyper-arousal. This, in autonomic nervous system terms, is a sympathetic state, where the body now in high alert prepares to fight or flee. Blood flows into the limbs, and constricts in all other directions. Functions non-essential to survival (like sexual functioning,) recede into inactivity. The cognitive part of the brain shuts down, and the more primitive limbic or emotional brain holds sway. The organism directs all of its intention toward staying alive.
Most often in trauma, fight or flight fails. The child cannot escape or fight off the blows of the larger, more powerful adult; the driver cannot avert or overtake the oncoming car; the soldier cannot outrun or destroy the bomb. When fight or flight fails, the body resorts to a freeze response. This is a hypo-aroused or parasympathetic shutdown state. This is the analgesic state that an animal goes into to numb the pain of being eaten, or to “play possum” so that the predator will leave it for dead rather than eating it. Hypo-arousal can look like a deathly dullness, depression, or some of the range of dissociative states we are familiar with in our traumatized clients.
What this means is that trauma may involve wild extremes of sympathetic and parasympathetic arousal. By definition, trauma is overwhelming experience. It is more intense stress than the organism is designed to bear; and the traumatic stress response is an effort to adapt to circumstances that are not tenable. The residual post traumatic symptoms are evidence that although the attempt to survive succeeded, the attempt to adapt failed, and the body continues to struggle to find emotional and physical equilibrium.
We have also learned that once the nervous system has been shaken by a particular experience, the limbic brain is adamant that it will not happen again. It becomes highly sensitized to stimuli even slightly reminiscent of the original event, and responds to them as if the cataclysm is about to happen again. So even vague cues, often well outside of awareness, can activate the full blown trauma response. It is the limbic brain that prevails in trauma and the limbic brain has no sense of time. A traumatized veteran hearing a helicopter will not know the difference between 2006 in Berkeley and 1968 in Vietnam. The organism responds as if it is happening again now. And as the analytical prefrontal cortex shuts down in trauma activation, the pre-recovery veteran cannot readily be talked out of these feelings.
Post traumatic stress as we have all doubtless seen involves the swings between hyper and hypo arousal, or “intrusion and numbing.” Survivors may swing between being bombarded by traumatic memory and stimulation; and an even amnesic dullness or numbness. The inability to self regulate is the bane of the trauma survivors existence. They are as if batted around by their overly sensitized nervous systems and often cope by utilizing any imaginable means of avoidance and escape. The world is a jungle of unpredictable stimuli and traumatic cues. Safety and trust are elusive, the body and emotions may become a kind of minefield.
Obviously the delicate balances required by sexuality may be dysregulated at best. Or individuals seek adaptations to the dysregulation in one way or another: sexual avoidance, substance abuse, sexual compulsivity to name a few. In one couple I worked with for quite a while, one partner when she became erotically aroused would go into a full blown panic attack. The experience of sexual excitement was a trauma cue that activated her whole system. Her partner, also a trauma survivor, generally defended himself with a hypo-aroused, numb state and consequently had little or no sexual sensation or functioning when with her, although he functioned just fine when alone. Their intimate life had been an agony. And although the emotional relationship was not easy, they loved each other deeply and wanted to get married and have a family some day. They were wracked with distress about their sexual dynamic. So how do we help?
Effective relationship work is obviously essential. The dynamics of extremes of hyper and hypo arousal make for difficult enough emotional and interpersonal dynamics as do the vicissitudes of “triggering” of spontaneous trauma activation. As stated, relationship is difficult! And the emotions and emotional patterns that develop around the challenging sexual relationship may begin to take on a life of their own too. Given that trauma overpowers and has no regard for a person’s feelings or wishes, traumatized individuals may be highly sensitized to issues of control, or feeling unconsidered. Cycles of fear and rejection are a common theme in these couples. John Gottman the relationship researcher found that on the average, couples wait six years before showing up at our doors. By the time they get to therapy the patterns of pain and anger, fear and hurt may have substantially coagulated and hardened. So careful couple’s work that teaches both about empathy and trauma, is the necessary first phase. The couple described above, worked hard to create understanding and emotional safety before we even broached the sexual interaction.
1. “World Without End”
Again, the limbic brain has no time sense. Part of the terror of the trauma state is the feeling or the fear that it will never end. There may be either a sense that this torture is infinite and endless, or that the end is near, ie “I am going to die.” Both produce a terrible anxiety. The understanding that time passes, events resolve and life goes on, are advanced functions of the cognitive prefrontal cortex, which is inoperable during trauma. One of our tasks with the traumatized is to introduce the notion that time does pass. Given that the reasoning function may not be available to work with at all, a powerful way to begin this process is with awareness of the moment to moment changes in body sensations.
When a person in a trauma state shifts the focus of attention to the body and simply tracks the movement of sensation, it becomes possible to notice moment to moment sensation changes. By asking the client to pay attention to what happens next and what happens next, we introduce the concept of time. Time passes, things change, things pass: flow. With the focus on sensation, ultimately the body settles. The individual then becomes more available verbally and cognitively; and the sensory experience can be cognitively grounded and re-enforced by talking about it. Slowly through experience, the individual begins to learn both limbicly and cortically, about time. We are helping to get the various parts of the brain working together again, and also to make sensation and experience less threatening.
2. “Being Here and Not There”
Post traumatic stress is dominated by the loss of capacity to pay attention to current experience. One is catapulted willy-nilly into the past, or into a zone of hypo aroused unconsciousness. Part of what we need to help the traumatized to do is to be fully here. One brain area most activated during traumatic flashback is the thalamus, or sensory relay station. Its function is to integrate fragments of sensory input from any given experience. In trauma, where recall is predominantly sensory, these inputs may be scrambled and disorganized. An important goal in trauma recovery is integration: integrating the sensory fragments into a coherent narrative, and integrating dissociated brain functions.
Part of how we can work with this integration is with naming, putting words to the experience of both emotion and sensation. The prefrontal cortex, which is the part of the brain capable of self reflection also has the ability to inhibit the amygdala, (a key player in the limbic system,) and regulate emotion. Calling upon the individual to simultaneously experience and observe experience, to use one part of the brain to attend to another, is a way of enlisting the prefrontal region. Helping clients and couples begin to speak precisely about experience, to articulate aloud and to each other what is happening, facilitates a shift from sensory gales to narrative; and strengthens prefrontal function. It also enables the client eventually to experience and to feel more control.
3. “Mediating Visceral States”
The vagus nerve is a long and very important nerve extending from the brain stem to the far reaches of the body. It relays information back and forth from brain to body, the information whereby we “know” what we “feel.” Interestingly, 80% of the information carried by the vagus is “afferent” meaning that it carries the information from the body to the brain. Only 20% of the information runs in the other direction. Using this advantage, there is a potential for the body to effect changes in the brain. Method actors know this, as do the researchers who study facial expression. Method actors who configure their bodies in the positions associated with particular emotions begin to powerfully feel those emotions. Manipulating facial expression can have a similar effect.
In the trauma experience, natural physical defense functions and movements fail. The lasting visceral memory is of powerlessness and defenselessness. The feeling of potency and the capacity for self protection can be slowly re-introduced through movement. An individual who begins to experience the strength and ability to push against or push away, natural defensive functions, will come to feel safer and more confident in close proximity with another’s body. Coaching couples to experiment, for example, with pushing against one another in a structured and contained way, may begin such a process. Mediating or modulating visceral states we get a new outcome. Again working with the body is a path to self regulation as well as relationship safety.
Breath is a powerful vehicle of affect regulation. It is certainly evident in the sexual interaction. The inhale is activating or autonomically sympathetic. The exhale is parasympathetic or calming. Of course whenever we are addressing anxiety disorders of which post traumatic stress is one, utilization of the breath for calming is an important skill and habit to teach. And of course calming breath facilitates the blood flow requisite for sexual sexual activity.
Helping couples to make use of their breath in the service of their own respective body calm as well as getting in synch with each another, is important work. Synchronized breathing is one of many activities borrowed from tantric practice that helps couples begin to move between their own and their partner’s body rhythm and sensation, while also calming themselves. It also slows everything down, which facilitates a sense of control and safety. Awareness of breath is another element of the attention to sensation, all of which serves to bring clients into present time. I like to tell them “Right here, right now, everything is OK.” And they generally admit that that is so.
Sex therapy technique, such as adaptations of sensate focus, continue to be invaluable with these couples, as does much sex education about both healthy sexuality and “garden variety” (ie non-trauma–related) sexual difficulties. Many couples need a fair amount of in-the-office help with the relationship and the trauma activation patterns before they feel comfortable doing sensual or sexual homework. This needs to be normalized. Given that both hyper and hypo arousal takes individuals out of the moment and out of presence with one another, all of our practice at staying present, naming emotions, moving between contact with the other and contact with the self, are “money in the bank” for when the overtly sexual practice begins. Presence is perhaps the most crucial element in satisfying sex, and a challenge for these folks to achieve. All our work in that direction is essential.
The task at hand in working with traumatized sexuality is more than anything the work of integration: integration of dissociated brain functions; integration of fragmented experience; integration of body, emotion and brain. For the therapist it requires an integration of trauma theory and practice, sex therapy and sound relational work. It also requires a good deal of patience, probably time; and a hefty measure of love that keeps everyone hanging in there.
Ruth Cohn, MFT is in private practice in Rockridge. AASECT Certified Sex Therapist, also certified in EMDR and Sensorimotor Psychotherapy. She specializes in relationship work with adults overcoming histories of childhood trauma and neglect, their intimate partners and families. She can be reached at email@example.com or www.cominghometopassion.com.