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Ruth Cohn
   
Body Oriented Psychotherapy in the Treatment of Trauma

In the past ten or so years of burgeoning progress, the growing subfield of traumatology has come to identify and elucidate much about the physiology of trauma. From the start it was undeniably obvious that trauma was a “physioneurosis,” (van der Kolk, McFarlane and Weisaeth, 1996) directly afflicting the body even if there was no direct bodily injury or even bodily threat. We slowly began to comprehend the impact on brain and nervous system, and subsequently, endocrine, motor and muscular function in addition to the most evident psychological and emotional suffering. The increase in information is good news, not only in terms of compassion for sufferers long told their problems were “all in their heads,” or a weakness of character, but also because increased information has extended the range of treatments.

One mechanism that is much better understood is the natural course of the fear response, and the aberration or overwhelming correlate to that, which is the natural course of the trauma response. Ordinary fear follows a typical bell shaped curve (LeDoux 1996, LeDoux 2002). It begins when, from a baseline state of relative bodily calm, a threatening stimulus is perceived via one or more of the five senses, by the thalamus. This initial stimulus activates an orienting response whereby attention becomes more focused in the direction of the stimulus and more information is gathered. The information is all sent to the amygdala for screening.

The amygdala is the little structure of the brain’s limbic system that evaluates the survival or danger significance of stimuli. It works like a smoke detector sniffing out danger cues. If danger is assessed, the amygdala activates the endocrine system to secrete stress hormones, non-survival activities like digestion or ovulation are suspended for the moment, and the body mobilizes for fight or flight. Attention narrows, becomes sharper and more focused. Mobilized by stress hormones, the heart and respiration quicken, muscles fill with blood and tense, ready for action.

Once action has been taken and the threat is either past, or turns out not in fact to have been a threat after all, (that is if the snake turns out to have been a stick,) the body calms down and the arousal resolves. The body is back to its initial baseline.

Meanwhile, the information about the threat is sent along its way to the hippocampus. The hippocampus is the brain’s filing system, a storage place for categories or files of information, that await being woven into the ongoing story of life. Information waiting in the hippocampus is not yet fully processed. Its complete processing takes place in the prefrontal cortex, or the part of the brain where “meaning is made.” The cortex knows what year it is, it knows location, and it has language for all of this. The cortex houses the locus of autobiography, and the cortex makes sense out of experience.

So if the stimulus is, for example, the sudden awareness that my wallet is not in its usual spot, I might momentarily have a rush of fear, especially if I am far from home. I forget everything else for the moment, and with heart racing and breath short, quickly search all other places where it might be. When I subsequently locate it in a different pocket than I usually keep it in, perhaps slowly remember why I put it there, my body readily settles back down and I continue on my way. When I arrive at my friend’s house I have a story to tell. The curve then is a heightening of arousal, a peaking out and a resolution. All of this takes place in what we know as the autonomic nervous system, the arousal being its sympathetic or energizing branch, and the parasympathetic being its calming down branch. This arousal curve is a natural progression. We share it with all mammals, and depending on their place in the food chain, they go through these ups and down continuously in the wild, throughout their stressful days (LeDoux, 1996).

With trauma, however, something different happens (van der Kolk et al, 1996). The stimulus is overwhelming and the natural fear response sequence is thus overwhelmed. The initial warning system is activated, stress hormones begin pumping away through the body, and the information makes it as far as the hippocampus, but the action of fight or flight is thwarted. The nature of trauma is that the threat is too great, the force of the danger cannot be fought or fled. A child cannot overpower an adult abuser, a driver cannot hold off an oncoming car, a gunshot victim cannot escape the bullet, a village cannot evade the bomb. The energy mobilized for fight or flight is frozen in a bath of stress hormones in the terrified person’s body. And the information gets stuck at the level of file storage, and not yet at the processing point where it can be verbalized, understood and integrated into autobiography. This is trauma.

Sensorimotor Psychotherapy has given us the “Modulation Model” as a map that illustrates in graphic form, the pathway arousal takes in trauma. (Ogden, Minton, 2000). Where the natural fear response curve takes place within a “window of tolerance,” the window within which our bodies are designed to respond effectively, the sympathetic arousal in trauma shoots well above the line, outside that window. In this state, traumatized people are scared “out of their minds,” unable to think or perhaps even know where they are in time or space. Or they might similarly dip beneath the window’s lower limit, into hypoarousal states, of frozen or numb blankness and paralysis. States on either the sympathetic and parasympathetic high end or low end may be “speechless” and “senseless.” And the worst of it is that, because the response is thwarted, it does not complete, it does not resolve and return to baseline. As a result, the experience does not end in either mind or body.

There are a number of reasons why the trauma lives on and on as it does. First of all, wired for survival, the amygdala is adamant about learning from experience and protecting the organism from another such traumatic episode. So it becomes hypersensitive to any stimulus that might even vaguely resemble the original one. For example if a child was beaten by an adult with an angry face, angry faces may become a “trigger.” If the smell of alcohol was part of a rape, the smell of alcohol might become a trigger, etc. The trauma response is readily re-activated by these triggers, and the body mobilizes into emotions and physical patterns that prepare it to fight, flee or perhaps freeze just like the first time around. The hyper alert nervous system behaves as if the danger is in fact happening again.

Because ordinary life may be filled with angry faces and alcohol smells and whatever else might be consciously or unconsciously associated with the trauma by the overly sensitized amygdala, the traumatized person’s body may be in and out of trauma states continuously, and the person bounced around between what may in fact be “real” dangers, and simply the over-reactions of the trauma-sensitive system. Needless to say this wreaks havoc in relationships and in life in general, where an innocent, passing angry face may bring on a cascade of seemingly irrelevant emotions and behavior.

Due to what we have also come to discover as a “kindling effect” (van der Kolk et al, 1996), the more often the brain is activated in these ways, the more easily it becomes activated. The circuitry of traumatic fear becomes more easily turned on. So being triggered, beyond its unpleasantness, chaos, conflict and confusion, is in effect deleterious. It strengthens its own circuitry and people get worse. We also know that the continuing flood of stress hormones that are part of the trauma activation have many other health eroding effects on the body. Some correlation has been discovered between trauma and hippocampal size and function (which are associated with memory processing;) autoimmune function, and depression to name a few of the potential health costs of trauma. It is not good to stay triggered or to stay in cycles of triggering!

Intuitively we know this and the body knows this. So another characteristic of trauma is the compulsion to avoid it. Survivors avoid reminders and avoid sensations, emotions: really anything reminiscent of the trauma. Depending on their level of sensitivity and the nature of their trauma, the list of what survivors avoid may be quite long. This is why many survivors never talk about what happened to them and simply “don’t want to go there” or even don’t want to do much. This is why many sexual trauma survivors do not want to have sex or truly believe they are unable. And it makes sense. To re-experience unbearable terror and helplessness, or to enter situations where one might be surprised by it, and to invite experiences that are known to have a long, unpleasant half life (i.e., it can take a long time to calm down after a triggering episode,) are things to avoid whenever possible. And in life, avoidance is not even possible that much of the time.

One final point about triggering and the body: research has shown us that very often at least some of the trauma information does not arrive at the prefrontal cortex of the brain (van der Kolk, Burbridge and Suzuki, 1997). This part of the brain is in charge of much of what we call “cognitive” processing. Cognition is knowing, so this is the thinking part of the brain, least developed when we are born, that develops slowly as we progress through childhood. Not only is it responsible for time and place location, logic and reasoning and speech, but it completes the task of processing experience into coherent memory. Information that is not processed in this part of the brain, therefore may not be cognitively “known” or remembered. This is why there is so much confusion about traumatic memory. Some survivors do not remember things cognitively, with clear picture and story-like sequences of what happened to them. They might have body reactions, behaviors and emotions that point to an event of which they have no clear recollection. This is also very confusing! Having intense emotions, sensations, strong reactions or extreme behaviors and not being able to link them to clearly remembered experience can make them uncertain about what is true or real; or make them feel as if they are crazy. Where in the past therapists emphasized the significance of traumatic memories, we now understand memory of trauma differently. For many, remembering and speaking of what caused all the havoc they are experiencing is not possible. We must explain this to them.

Peter Levine in his audio series “Sexual Healing” talks about “re-membering.” (Levine, 2003.) Where trauma brutally fragments or “dismembers” the body, soul and psyche; healing is the process of collecting the pieces, organizing and putting them back together again. It is a making whole of the person after having been blown apart by the overwhelming experience. This is how re-membering has been recast as the goal of healing.


Sensorimotor Sequencing

Sensorimotor Psychotherapy, gave us a system for processing trauma called “sensorimotor sequencing” (Ogden, Minton, 2000). It is an exquisitely simple and brilliant method for healing the unprocessed trauma that continues to rumble in the body. Although Sensorimotor Psychotherapy is certainly not the only trauma therapy, it is a good one and a therapy that I like very much. In this approach, the story is not necessary or useful. As stated above, much as they try to avoid them, survivors are readily pitched into states of traumatic activation. I see it happen often when I work with couples, who are singularly skilled at triggering one another like almost no one else can. Even little stimuli can bring on the big reaction. What sensorimotor sequencing attempts to do, is make traumatic activation or re-experiencing bearable, in tiny bite sized increments, to help patients stay aware of sensation and allow the trauma response cycle to complete. In the moment of trauma and in the usual course of triggered activation, the natural reaction to overwhelming sensation is to “jump out of the body.” In lesser or greater degrees, survivors describe numbness and alienation from sensation, especially when triggered. They just do not feel, and are rather phobic of feeling, at least when trauma activation has produced the sensation. So staying present to the huge and frightening sensations and emotions must be a conscious, calculated therapeutic intention. In sensorimotor sequencing, with the gentle support of an attentive therapist, carefully paced and in small doses, the survivor is encouraged to drop the story or cognitions, and even set aside the emotions, and just track the physical sensations as they move through the body. In effect, the frozen unexecuted movement patterns of fight or flight, not allowed to manifest at the time of the actual trauma, are able to unfold and be expressed. But slowly! (Scaer, 2001).

In the late 1960’s and early 70’s there was a mushrooming of alternative therapy techniques that involved pounding pillows, yelling, using foam battacas to expressed unexpressed rage, and primal screams. We thought then that noisy, windy catharsis was good: a way to get feelings “out.” Although some people may have initially felt relieved or energized from the discharge of tension in the moment, we have since learned that these methods are not helpful and in many cases they were retraumatizing and harmful. And in general, in exercising cathartic methods survivors were no more present to their body experience than they had originally been. Sensorimotor sequencing and any safe somatic method of trauma healing is above all else slow and mindful. Slow in that it is carefully regulated to keep survivors in the window of tolerance as they move along; mindful in that the healing is in being able to feel the sensations and discover that they are not lethal, as they complete their interrupted course.

So what does Sensorimotor sequencing look like? In a recent session, Molly arrived pale and shaken. On her way to my office she had been involved in a minor rear end car accident. It was a tiny bump and there was no damage to her car and no bodily injury, but she was massively triggered. Molly has an extensive trauma history, which does not include car accident trauma. But being hit and helpless had her whole system in upheaval. After Molly only briefly recounted the story of the mini-accident and was clear that there was no real harm at all, I had her just drop all thoughts and focus on her body. We even gently postponed the emotions: the tears and fear until a later time. I reflected to her what I saw: her shoulders pulled back, tension in her neck, and she told me what she physically felt. Her breath was short and her heart was pounding, her stomach was in a knot. And I then asked her “and what happens next, what wants to happen next in your body?” And she kept following the movement of her sensations as they slowly progressed, lessened, changed and ultimately passed. The session lasted one hour and by the end of it she was completely calm and free of any tension or activation at all. We then talked about the accident and the emotions; how the emotions related to emotions from past events; and how she might take the feeling of calm she now had along with her into her life. We were not only resolving this upset, we were reworking a piece of the trauma that had been activated by it. When Molly came back the next week, she was amazed. It was her first experience of sensorimotor sequencing. The calm was a deeper calm than she remembered ever having experienced, and it seemed to last. She said, “Something is definitely different,” and she beamed.

Sensorimotor sequencing is not the whole story in trauma healing but it is a powerful tool. Careful attentive pacing, mindfulness to the body and its subtle changes moment to moment, getting acquainted with sensation and finding that it is in fact bearable, are powerful experiences that begin to alter the nervous system and reverse the kindling tendency (Ogden, Minton, 2000).


References

LeDoux, Joseph (1996) The Emotional Brain, New York: Simon & Schuster.

LeDoux, Joseph. (2002) The Synaptic Self: How Our Brains Become Who We Are,New York: Penguin Books.

Levine, P. (2003) Sexual Healing: Transforming The Sacred Wound, Sounds True Recordings.

Levine, P. (1997) Waking The Tiger, Berkeley: North Atlantic books.

Ogden, P., Minton, K. (2000) Sensorimotor psychotherapy: one method for processing traumatic memory, Traumatology,
6 (3) article 3.

Scaer, R. (2001) The Body Bears The Burden: Trauma, Dissociation And Disease, New York: The Haworth Medical Press.

Van der Kolk, B., McFarlane, A.C. & Weiseth, L. (eds.). (1996) Traumatic Stress: The Effects Of Overwhelming Experience On Mind, Body And Society, New York: The Guildford Press.

Van der Kolk, B., Burbridge, J. A., & Suzuki, J. (1997). The psychobiology of traumatic memory: clinical implications of neuroimaging studies, In R. Yehuda and A.C. McFarlane (Eds.) Annals of the New York Academy of Sciences, 821 (pp.99-113).

Ruth Cohn, MFT is in private practice in Oakland. She specializes in individual and couple’s therapy with survivors of childhood trauma or neglect and their intimate partners and families. She is an AASECT Certified Sex Therapist, also certified in EMDR and
Sensorimotor Psychotherapy.

© 2004