A NORTON PROFESSIONAL BOOK

The Body
Remembers

The Psychophysiology
of Trauma and
Trauma Treatmen

BABETTE ROTHSCHILD
For Margie
 Contents

ACKNOWLEDGMENTS
INTRODUCTION
On Building Bridges
Working with the Body Does Not Require Touch
The False Memory Controversy
Organization of This Book
A Disclaimer
PART I: THEORY
1. Overview of Posttraumatic Stress Disorder (PTSD): The Impact of
Trauma on Body and Mind
Charlie and the Dog, Part I
The Symptomatology of PTSD
Distinguishing Stress, Traumatic Stress, PTS, and PTSD
Survival and the Nervous System
Defensive Response to Remembered Threat
Dissociation, Freezing, and PTSD
Consequences of Trauma and PTSD

2. Development, Memory, and the Brain

The Developing Brain
 What is Memory?
3. The Body Remembers: Understanding Somatic Memory
The Sensory Roots of Memory
Charlie and the Dog, Part II
The Autonomic Nervous System: Hyperarousal and the Reflexes of
Fight, Flight, and Freeze
The Somatic Nervous System: Muscles, Movement, and Kinesthetic
Memory
Emotions and the Body

4. Expressions of Trauma Not Yet Remembered: Dissociation and

Flashbacks
Dissociation and the Body
Flashbacks

PART II: PRACTICE

5. First, Do No Harm
On Braking and Accelerating
Evaluation and Assessment
The Role of the Therapeutic Relationship in Trauma Therapy
Safety
Developing and Reacquainting Resources
Oases, Anchors, and the Safe Place
The Importance of Theory
Respecting Individual Differences
Ten Foundations for Safe Trauma Therapy

6. The Body as Resource

Body Awareness
Making Friends with Sensations
The Body as Anchor
The Body as Gauge
 The Body as Brake
The Body as Diary: Making Sense of Sensations
Somatic Memory as Resource
Facilitating Trauma Therapy Using the Body as Resource

7. Additional Somatic Techniques for Safer Trauma Therapy

Dual Awareness
Muscle Toning: Tension vs. Relaxation
Physical Boundaries
The Question of Client-Therapist Touch
Mitigating Session Closure

8. Somatic Memory Becomes Personal History

Beware the Wrong Road
Separating Past from Present
Working with the Aftermath of the Trauma First
Bridging the Implicit and the Explicit
Charlie and the Dog, the Final Episode

REFERENCES
INDEX
 Acknowledgments

It is not possible to tackle the arduous project of writing a professional

book without being taught, helped, influenced, inspired, and advised by
others. Those who have crossed my path in the 28 years since my entry into
the psychotherapy field are too numerous to mention individually, though
all have contributed in some way. Collectively, I would like to thank each of
the teachers, therapists, supervisors, and researchers who have helped me to
shape my opinions into a serviceable form. Those who have most
influenced my thinking with regard to trauma theory and treatment are
acknowledged by reference within the pages of this text. Nonetheless, I
would like to particularly recognize Lisbeth Marcher and her colleagues at
Denmark’s Bodynamic Institute, Peter Levine, and Bessel van der Kolk.
They have had a profound influence on the evolution of the ideas expressed
in these pages. I would also like to express my grateful thanks to the many
trainees, supervisees, students and clients who have all, in ways both small
and large, contributed to the content of this book. Like many, I have learned
—and continue to learn—the most from those I have had the privilege to
teach and treat.
I would like to express gratitude specifically to Karen Berman, Danny
Brom, Alison Freeman, Michael Gavin, David Grill, John May, Yvonne
Parkins, Gina Ross, and Sima Juliar Stanley for their brutally critical
comments on this manuscript. In addition, I want to thank life sciences
writer, Karin Rhines, for being such a great “coach” throughout this project.
Her knowledge of the business of writing, as well as her uncanny ability to
know just when to cheer and when to chide, has been invaluable.
I consider myself to be a very fortunate author to have Norton
Professional Books as my publisher. Having previously read many grateful
acknowledgments to my editor, Susan Munro, I now know what everybody
was talking about. In addition to being a skilled, patient, and good-humored
editor, her knowledge of my subject matter as well as her command of the
professional literature has been an invaluable bonus. In fact, I have been
heartened by my contacts with all of the staff I have encountered at W.W.
Norton—on both sides of the Atlantic. They have each and all contributed
to making the writing of this book a pleasure.
 Introduction

The Body Remembers is intended as a complement to existing books on

the theory and treatment of trauma and posttraumatic stress disorder and to
the existing methods of trauma therapy. It is hoped that it will add the
dimension of understanding and treating the traumatized body to the already
well-established knowledge of and interventions for treating the
traumatized mind. Psychotherapists working with traumatized clients will in
all likelihood find that the theory, principles, and techniques presented
within these pages are consistent with and applicable to the therapy
model(s) in which they are already trained. In addition, they should find
that the information presented here can be used and adapted without
conflict with, or abandonment of, their preferred principles or techniques.

ON BUILDING BRIDGES

The Body Remembers is meant to be a bridge-building book. It is my hope

to traverse at least two of the deep chasms within the field of traumatology.
The first bridge spans the gap between the theory developed by scientists,
particularly in the area of neurobiology, and the clinical practice of
therapists working directly with traumatized individuals and groups. The
second bridge aims to connect the traditional verbal psychotherapies and
those of body-oriented psychotherapy (body-psychotherapy).
 The gaps between mind and body, traditional psychotherapy and body-
psychotherapy, and between theory and practice have long been of concern
to me. Increasingly I have found that posttraumatic stress disorder (PTSD)
is forcing a bridging of these gaps. Even the most conservative of therapists
and researchers acknowledges that PTSD is not just a psychological
condition, but also a disorder with important somatic components.
Moreover, all professionals who deal with PTSD find that they must stretch
their theories and practice. Both psychotherapists and body-
psychotherapists are pressed to pay greater attention to neurobiologic theory
and to account for and treat somatic symptoms, the body-psychotherapist
must also find ways to work without touch and to increase verbal
integration, and the researcher is being challenged to make more pertinent
connections between theory and practice. It is my hope that The Body
Remembers will facilitate meaningful links in bridging these gaps.

Science vs. Practice

“A Widening Gulf Splits Lab and Couch” read the headline of the New York
Times’ Women’s Health section on June 21, 1998 (Tavris, 1998). Most
psychotherapists knew it, but many of my colleagues were surprised to see
such criticism in print. Not a few were offended. The author of that article,
Carol Tavris, claimed that “‘psychological science’ is an oxymoron.” She
criticized practitioners for paying too little attention to science, often being
more focused on technique than theory. Most of the professionals I have
spoken with agree with Carol Tavris that scientific theory and practice are
usually too divergent to be relevant when they are sitting with a client. I,
however, believe that this gap between scientist and practitioner is one of
semantics rather than principles. The language of the scientific literature is
often difficult to read and comprehend, though much that is being offered is
extremely relevant, if difficult to translate into the language of practice.
I have endeavored in The Body Remembers to present theory in an easily
accessible form that is relevant to direct practice. By so doing, I hope to
narrow the chasm between the neuroscientist and behavioral researcher
studying the phenomenon of trauma and the psychotherapist working
directly with the traumatized client.
 Theory is the most valuable tool of the trauma therapist, because
understanding the mechanisms of trauma as proposed by psychological,
neurobiological, and psychobiological theory greatly aids treatment. The
greater a therapist’s theory base, the less dependence there will be on
techniques learned by rote. Thorough understanding of the neurological and
physiological underpinnings of the trauma response and the development of
PTSD will enable on-the-spot creation and/or adaptation of interventions
that are appropriate and helpful to a particular client, with his* particular
trauma. A theoretical foundation also aids therapists in applying techniques
learned from various disciplines, choosing and enhancing those that have
the best chance of success in each unique situation. The therapist well
versed in theory is able to adapt the therapy to the client, rather than
assuming the client will fit into the therapy.

Psychotherapy vs. Body-psychotherapy

It is my additional hope that this book will build a bridge between the
practitioners of traditional verbal psychotherapies and the practitioners of
body-oriented psychotherapies. I believe that these two professional groups
have much to offer each other in the treatment of trauma and PTSD.
The first encouragement I came upon for traversing this chasm was
Bessel van der Kolk’s seminal article, “The Body Keeps the Score,” in the
Harvard Review of Psychiatry (van der Kolk, 1994). It was in this article
that I first found the body-mind connection legitimized in mainstream
psychiatry. In addition, Antonio Damasio’s Descartes’ Error (1994) has
been a great inspiration. This groundbreaking book presents a neurological,
theoretical basis for the mind-body connection. Both of these works have
laid the foundation for my understanding of the psychophysical,
neurobiological relationship between the mind and the body. Further, the
recent work of Perry, Pollard, Blakley, Baker, and Vigilante (1995), Schore
(1994, 1996), Siegel (1996, 1999), van der Kolk (1998), and others on
infant attachment, brain development, and memory systems has tremendous
implications for our understanding of how trauma could so adversely
disrupt the nervous system that an individual would develop PTSD.
 Bridging the gap between the verbal psychotherapies and the body-
psychotherapies means taking the best resources from both, rather than
choosing one over the other. Integrated trauma therapy must consider,
consist of, and utilize tools for identifying, understanding, and treating
traumas effects on both mind and body. Language is necessary for both. The
somatic disturbances of trauma require language to make sense of them,
comprehend their meaning, extract their message, and resolve their impact.
When healing trauma, it is crucial to give attention to both body and mind;
you can’t have one without the other.

* I have attempted to alternate the use of the pronouns he, she, him, her, his, and hers throughout the
text. I hope I have been equitable.

WORKING WITH THE BODY DOES NOT REQUIRE

TOUCH

Touching the body and working with the body are not, and need not be,
synonymous when it comes to psychotherapy or, for that matter, body-
psychotherapy. There are many ways to work with the body, integrating
important aspects of muscular, behavioral, and sensory input, without
intruding on bodily integrity.
There are many reasons not to use touch as a part of psychotherapeutic or
body-psychotherapeutic treatment. Aside from the obvious concerns about
the possible effect on the transference, there is the question of respect for
client boundaries, particularly with clients who have been physically or
sexually abused. Equally worthy of consideration is the personal preference
of the client and the personal preference of the therapist. In addition, many
malpractice insurance policies will not cover treatment methods that use
touch and the licensing boards of most U.S. states forbid it. Do not get me
wrong. I am not an extremist. In some cases I think judicious touch can be
useful when client and therapist agree, but in this book I focus on body
techniques that do not involve touch, since those are, in my opinion, the
most appropriate for use with traumatized clients.
 THE FALSE MEMORY CONTROVERSY

This is not a book about false memories, and I make no claims about, nor
have any ambition to resolve, the current controversy. However, as this
book involves the subjects of memory and trauma, I cannot avoid giving
voice to my opinion on this explosive and difficult issue.
My opinion is inclusive: I believe early memories of trauma can
sometimes be recovered with relative accuracy, and I am also equally
convinced that sometimes false memories can be inadvertently created or
encouraged—by the therapist as well as the client. I have been witness to
examples of both with clients and trainees, friends and family, and even
myself.
Somatic memory, a primary concern of this book, is, in my opinion,
neither more nor less reliable than any other form of memory—as will be
discussed later in this book. Somatic memory can be continuous, and it can
also be “forgotten,” just like cognitive memory. It can also be distorted, as it
is the mind that interprets and misinterprets the body’s message. The mind,
of course, is subject to a wealth of influences that can alter the accuracy of a
memory over time.
Though I offer no solutions to the controversy, I hope that The Body
Remembers will provide assistance in two areas: helping the therapist to be
more alert to and cautious of the risk of false memories, and offering tools
for identifying, understanding, and integrating what the body actually does
remember.
The International Society for Traumatic Stress Studies has struggled with
this controversy for several years. In 1998 it published a monograph on the
issue, Childhood Trauma Remembered (ISTSS, 1998). That concise
publication gives a balanced view of this controversy, and I highly
recommend it.

ORGANIZATION OF THIS BOOK

This book is organized into two major sections. Part I, Theory, presents and
discusses a theory for understanding how the human mind and body
process, record, and remember traumatic events and what can impede as
well as facilitate these faculties. The current and most convincing evidence
from neuroscience and psychobiology is included, as well as theories that
have survived the test of time. In Part II, Practice, strategies for helping the
traumatized body, as well as the traumatized mind, are presented. Non-
touch tools for helping survivors of trauma to make sense of, as well as
ease, their somatic symptoms are offered. The proffered tools are consistent
with and applicable to any model of therapy geared to working with
traumatized individuals.

A DISCLAIMER

The scientific study of the mechanisms of trauma, PTSD, and memory is

accelerating at such a fast pace that it is impossible to keep up. There are
sometimes strong disagreements between scientific groups. What causes
and what heals PTSD and how memory systems function are subject to
broad debate. The research-supported theories of one group are disputed by
another and vice versa. For better or worse, at least on the topics of trauma
and memory, science seems to be a matter of opinion.
Therefore, what you have here are my considered opinions based on
sometimes divergent theories. No clear-cut truths are to be found among
these pages because they do not, yet, exist. I hope, however, there will be a
great deal that is thought-provoking and useful. I trust each reader will
formulate his or her own considered opinions.
Neurologist Antonio Damasio eloquently states similar sentiments in his
introduction to Descartes’ Error. I believe his words are worthy of
repetition: “I am skeptical of sciences presumption of objectivity and
definitiveness. I have a difficult time seeing scientific results, especially in
neurobiology, as anything but provisional approximations, to be enjoyed for
a while and discarded as soon as better accounts become available” (1994,
p. xviii).
This is a minimalist book—short-winded—as I want anyone who is
interested to have the time to tackle it. Among these pages you will find
comprehensible theories and applicable techniques that will be useful with
many, though not all, of your clients—all told, what I believe to be the best
of the (as Damasio would say) current approximations.
PART ONE

Theory
CHAPTER ONE
 Overview of Posttraumatic Stress
Disorder (PTSD)
The Impact of Trauma on Body and Mind

If it is true that at the core of our traumatized and neglected

patients’ disorganization is the problem that they cannot analyze
what is going on when they re-experience the physical sensations
of past trauma, but that these sensations just produce intense
emotions without being able to modulate them, then our therapy
needs to consist of helping people to stay in their bodies and to
understand these bodily sensations. And that is certainly not
something that any of the traditional psychotherapies, which we
have all been taught, help people to do very well.
—Bessel van der Kolk (1998)

That the body remembers traumatic experiences is aptly illustrated by the

following case of “Charlie and the Dog.”* This case is presented in several
parts, beginning with this first part that introduces Charlie’s traumatic event
and his resulting somatic and psychological symptoms. In subsequent
chapters, the interventions that helped Charlie to resolve the impact of the
traumatic incident will be detailed. In addition, illustrative references to
Charlie will be woven throughout the text, providing a common thread
connecting the theory and practice elements of this book.
* For the sake of protecting privacy and confidentiality all identifying information has been altered in
every case example and session vignette throughout this book. For the same reason, many of the
cases presented are actually composites of several cases. In each instance the basic principles and
thrust of the therapy being presented have been maintained.

CHARLIE AND THE DOG, PART I

A few years ago, out for a leisurely Sunday afternoon bicycle ride on a
country lane, Charlie’s pedaling reverie was suddenly broken as a large dog
began to chase him, barking furiously. Charlie’s heart rate soared, his
mouth went dry, and his legs suddenly had more power and strength than he
had ever known. He pedaled faster and faster, but the dog matched and then
exceeded his pace. Eventually the dog caught up and bit Charlie on his
right thigh. As Charlie and his bike tumbled, the dog continued his barking
attack. Charlie lost consciousness. Luckily, he had landed in a public area
where several people rushed to his aid, chasing off the dog and calling an
ambulance. Charlie’s leg healed quickly, unlike his mind and nervous
system. He continued to be plagued each time he saw a dog. Just the sight
of one, even when locked in a house, behind a door, a window, and a fence,
would cause Charlie to break into a cold sweat, go dry in his mouth, and
feel faint. Since that incident he had kept his distance from all dogs, even
pets of friends, avoiding contact whenever possible. He would habitually
cross the street to evade a dog on his side of the street, whether on the
sidewalk or behind a fence. He would never encourage contact, never talk
to or stroke a dog. As time passed, Charlie’s life became more and more
restricted as he attempted to avoid any and all contact with dogs.
Then, once, during a training session at a retreat center, Charlie was
unexpectedly confronted with his worst fear. He sat comfortably on a
cushion listening to a lecture, focused on the lecturer (who stood to his left)
and not on his surroundings. Unbeknownst to Charlie, the center’s canine
mascot, Ruff, had joined the group. Ruff quietly approached uninvited from
Charlie’s right (outside of his field of vision) laid down, and gently placed
her head on Charlie’s right leg, hoping for a pat. Charlie, feeling the weight
on his right leg, looked down and caught a glimpse of Ruff out of the corner
of his right eye. He then immediately, and literally, froze in panic. Charlie’s
mouth went dry, his heart rate soared, and his limbs stiffened to the extent
that he was totally unable to move. He was barely able to speak.

Charlie’s reaction to Ruff was not just in his mind. Rationally, Charlie
remembered the dog attack and knew that he was scared of dogs. He also
knew that Ruff was not attacking him. But all of his rational thoughts
appeared to have no effect on his nervous system. Charlie’s body reacted as
if he was being, or about to be, attacked again. He became paralyzed. What
is it that occurred in Charlie’s brain and body that caused such an extreme
reaction in the absence of an actual threat? Why was Charlie unable to
move or push the dog away? Why did he continue to go dry in the mouth
and break into a cold sweat at the mere sight of a dog at a protected
distance? What could be done to help Charlie cease these extreme reactions
in the presence of dogs? Answering these questions provides the
underpinning of The Body Remembers.

A Basic Premise

Trauma is a psychophysical experience, even when the traumatic event

causes no direct bodily harm. That traumatic events exact a toll on the body
as well as the mind is a well-documented and agreed-upon conclusion of
the psychiatric community, as attested in the Diagnostic and Statistical
Manual of Mental Disorders, 4th Edition, of the American Psychiatric
Association (DSM-IV). A major category in the symptom list of
posttraumatic stress disorder (PTSD) is “persistent symptoms of increased
arousal” in the autonomic nervous system (ANS) (APA, 1994). Yet, despite
a plethora of study and writing on the neurobiology and psychobiology of
stress, trauma, and PTSD, the psychotherapist has until now had few tools
for healing the traumatized body as well as the traumatized mind. Attention
directed at the body has tended to focus on the distressing symptoms of
PTSD, the resulting problems of adaptation, and possible pharmacological
intervention. Using the body itself as a possible resource in the treatment of
trauma has rarely been explored. Somatic memory has been named as a
phenomenon (van der Kolk, 1994), but few scientifically supported theories
and strategies for identifying it, containing it, and making use of it in the
therapeutic process have emerged.
Understanding how the brain and body process, remember, and
perpetuate traumatic events holds many keys to the treatment of the
traumatized body and mind. In some instances, direct somatic interventions,
when used as adjuncts to existing trauma therapies, can be powerful in
combating the effects of trauma. In addition, various somatic techniques can
be used to make any therapy process easier to pace and less volatile.
Attention to the somatic side of trauma need not require the practitioner to
change his direction or focus. The tools offered here can be used or adapted
within existing models of trauma therapy, expanding and enhancing what is
already being done.

THE SYMPTOMATOLOGY OF PTSD

PTSD disrupts the functioning of those afflicted by it, interfering with their
abilities to meet daily needs and perform the most basic tasks. In PTSD a
traumatic event is not remembered and relegated to one’s past in the same
way as other life events. Trauma continues to intrude with visual, auditory,
and/or other somatic reality on the lives of its victims. Again and again they
relive the life-threatening experiences they have suffered, reacting in mind
and body as though such events were still occurring. PTSD is a complex
psychobiological condition. It can emerge in the wake of life-threatening
experiences when psychological and somatic stress responses persist long
after the traumatic event has passed.
There is a mistaken assumption that anyone experiencing a traumatic
event will develop PTSD. This is far from true. Results of studies vary but
in general confirm that only a fraction of those facing such incidents—
around 20%—will develop PTSD (Breslau, Davis, Andreski, & Peterson,
1991; Elliott, 1997; Kulka et al., 1990). What distinguishes those who do
not is still a controversial topic, but there are many clues. Nonclinical
factors that mediate traumatic stress appear to include: preparation for
expected stress (when possible), successful fight or flight responses,
developmental history, belief system, prior experience, internal resources,
and support (from family, community, and social networks).
In the history of psychology, PTSD is a relatively new diagnostic
category. It first appeared in 1980 in the internationally accepted authority
on psychology and psychodiagnosis, Diagnostic and Statistical Manual of
Mental Disorders, 3rd Edition (DSM-III; APA, 1980). DSM-III’s definition
of what could cause PTSD was limited. It was seen as developing from an
experience that anyone would find traumatic. There were at least two
problems with this definition: It left no room for individual perception or
experience of an event, and it mistakenly assumed that everyone would
develop PTSD from such an event. The currently accepted definition, as
revised in DSM-IV (APA, 1994), is much broader. This definition takes into
account that PTSD can develop in an individual in response to three types
of events: (1) incidents that are, or are perceived as, threatening to one’s
own life or bodily integrity; (2) being a witness to acts of violence to others;
or (3) hearing of violence to or the unexpected or violent death of close
associates. Events that could qualify as traumatic for both adults and
children, according to DSM-IV, include combat, sexual and physical assault,
being held hostage or imprisoned, terrorism, torture, natural and man-made
disasters, accidents, and receiving a diagnosis of a life-threatening illness.
In addition, DSM-IV notes that PTSD can develop in children who have
experienced sexual molestation, even if this is not life-threatening. It adds,
“The disorder may be especially severe or long lasting when the stressor is
of human design (e.g., torture, rape)” (APA, 1994, p. 424).
Symptoms associated with PTSD include (1) reexperiencing the event in
varying sensory forms (flashbacks), (2) avoiding reminders of the trauma,
and (3) chronic hyperarousal in the autonomic nervous system (ANS).
DSM-IV recognizes that such symptoms are normal in the immediate
aftermath of a traumatic event. PTSD is first diagnosed when these
symptoms last more than one month and are combined with loss of function
in areas such as one’s job or social relationships.
Somatic disturbance is at the core of PTSD. People who suffer from it
are plagued with many of the same frightening body symptoms that are
characteristic of ANS hyperarousal experienced during a traumatic incident
(as was Charlie): accelerated heart rate, cold sweating, rapid breathing,
heart palpitations, hypervigilance, and hyperstartle response (jumpiness).
When chronic, these symptoms can lead to sleep disturbances, loss of
appetite, sexual dysfunction, and difficulties in concentrating, which are
further hallmarks of PTSD. DSM-IV acknowledges that symptoms of PTSD
can be incited by external as well as internal reminders of a traumatic event,
cautioning us that somatic symptoms, alone, can trigger a PTSD reaction.
PTSD can be a very vicious circle.

DISTINGUISHING STRESS, TRAUMATIC STRESS, PTS,

AND PTSD

Hans Selye defined stress as, “the nonspecific response of the body to any
demand” (1984, p. 74). Generally regarded as a response to negative
experiences, stress can also result from desired, positive experiences, such
as marriage, moving, a job change, and leaving home for college.
The most extreme form of stress is, of course, stress that results from a
traumatic incident—traumatic stress. Posttraumatic stress (PTS) is
traumatic stress that persists following (post) a traumatic incident
(Rothschild, 1995a). It is only when posttraumatic stress accumulates to the
degree that it produces the symptoms outlined in DSM-IV that the term
posttraumatic stress disorder (PTSD) can be applied. PTSD implies a high
level of daily dysfunction. Though there are no statistics, one can guess that
there are a significant number of trauma survivors with PTS, those who fall
between the cracks—not recovered from their traumas, but without the
debilitation of PTSD. These individuals can also benefit from trauma
therapy. (Charlie’s level of disturbance is typical of PTS. It caused him
restriction in one area of his life—avoidance of dogs—but he functioned
normally in the rest of his life.)

SURVIVAL AND THE NERVOUS SYSTEM

Arousal, and therefore traumatic hyperarousal, is mediated by the limbic

system, which is located in the center of the brain between the brain stem
and the cerebral cortex. This part of the brain regulates survival behaviors
and emotional expression. It is primarily concerned with tasks of survival,
such as eating, sexual reproduction, and the instinctive defenses of fight and
flight. It also influences memory processing.
The limbic system has an intimate relationship with the autonomic
nervous system (ANS). It evaluates a situation, signaling the ANS either to
have the body rest or to prepare it for effort. The ANS plays a role in
regulating smooth muscles and other viscera: heart and circulatory system,
kidneys, lungs, intestines, bladder, bowel, pupils. Its two branches, the
sympathetic branch (SNS) and the parasympathetic branch (PNS), usually
function in balance with each other: When one is activated, the other is
suppressed. The SNS is primarily aroused in states of effort and stress, both
positive and negative. The PNS is primarily aroused in states of rest and
relaxation.
The limbic system responds to the extreme of traumatic threat, by
releasing hormones that tell the body to prepare for defensive action (see
Figure 1.1, p. 10). Following the perception of threat, the amygdala signals
an alarm to the hypothalamus (both structures in the limbic system) that
turns on two systems: (1) activation of the SNS, and (2) the release of
corticotropin-releasing hormone (CRH). Those actions continue, each with
a separate, but related, task. First, the activation of the SNS will, in turn,
activate the adrenal glands to release epinephrine and norepinephrine to
mobilize the body for fight or flight. This is accomplished by increasing
respiration and heart rate to provide more oxygen, sending blood away from
the skin and into the muscles for quick movement. (In Charlie’s case, the
increased respiration and blood flow to his legs made it possible for him to
pedal faster and farther than usual.) At the same time, in the other system,
the CRH is activating the pituitary gland to release adrenocortio-tropic
hormone (ACTH), which will also activate the adrenal glands, this time to
release a hydrocortizone, cortisol. Once the traumatic incident is over
and/or the fight or flight has been successful, the cortisol will halt the alarm
reaction and the production of epinephrine/norepinephrine, helping to
restore the body to homeostasis.
This system is called the HPA axis. The reason it is important to trauma
work is that in PTSD something goes wrong with it. Rachel Yehuda
(Yehuda et al., 1990) pioneered the discovery that in those with PTSD the
adrenal glands do not release enough cortisol to halt the alarm reaction (see
Figure 1.2). Several studies have shown that individuals with PTSD have
lower cortisol levels than controls, even those with other psychological
problems like depression (Bauer, Priebe, & Graf, 1994; Yehuda et al., 1990,
1995; Yehuda, Teicher, Levengood, Trestman, & Siever, 1996). One
conclusion that can be drawn from this evidence is that on a chemical level
the continued alarm reaction typical of PTSD is due to a deficiency of
cortisol production. However, whether it is a purely biological process or is
influenced by perception in the limbic system is not known. While the low
cortisol levels are documented in PTSD, their cause is still a question.
One area of interest with regard to the HPA axis and cortisol is the
freezing response to traumatic threat. When death may be imminent, escape
is impossible, or the traumatic threat is prolonged, the limbic system can
simultaneously activate the PNS, causing a state of freezing called tonic
immobility—like a mouse going dead when caught by a cat, or stiff, like a
deer caught in headlights (Gallup & Maser, 1977). The chemical picture
that causes the freeze must be linked to the HPA axis, but this has not been
studied as yet.
These nervous system responses—fight, flight, and freeze (or tonic
immobility)—are automatic survival actions. They are similar to reflexes in
that they are instantaneous, but the mechanisms underlying these responses
are much more complex than simple reflexes. If the perception in the limbic
system is that there is adequate strength, time, and space for flight, then the
body breaks into a run. If the limbic perception is that there is not time to
flee but there is adequate strength to defend, then the body will fight. If the
limbic system perceives that there is neither time nor strength for fight or
flight and death could be imminent, then the body will freeze. In this state
the victim of trauma enters an altered reality. Time slows down and there is
no fear or pain. In this state, if harm or death do occur, the pain is not felt as
intensely. People who have fallen from great heights, or been mauled by
animals and survived, report just such a reaction. The freeze response might
also increase chances of survival. If the cause is an attack by man or beast,
the attacker may lose interest once the prey has gone dead, as a cat will lose
interest in a lifeless mouse. (Charlie lost consciousness during the dog
attack, and when later confronted by contact with a dog he became
paralyzed. Both are forms of freezing responses.)
Figure 1.1. Hypothalamic-pituitary-adrenal (HPA) axis.

Figure 1.2. Hypothalamic-pituitary-adrenal (HPA) axis, others by fighting back or running away. In
those instances, understanding that freezing is automatic often facilitates the difficult process of self-
forgiveness.
 It is important to understand that these limbic system/ANS responses are
instantaneous, instinctive responses to perceived threat. They are not chosen
by thoughtful consideration. Many who have suffered trauma feel much
guilt and shame for freezing or “going dead” and not doing more to protect
themselves or

DEFENSIVE RESPONSE TO REMEMBERED THREAT

When the limbic system activates the ANS to meet the threat of a traumatic
event, it is a normal, healthy, adaptive survival response. When the ANS
continues to be chronically aroused even though the threat has passed and
has been survived, that is PTSD. The traumatic event seems to continue to
float free in time, rather than occupying its locus in one’s past, often coming
unbidden into the present perception as if it were, indeed, occurring now.
(Charlie was never again attacked by a dog. However, each time he
encountered one he continued to respond in his mind and body as if he were
being, or about to be, attacked again.)
Within the limbic system are two related areas that are central to memory
storage: the hippocampus and the amygdala. The last few years have
produced a growing body of research that indicates these two parts of the
brain are centrally involved in recording, filing, and remembering traumatic
events (Nadel & Jacobs, 1996; van der Kolk, 1994, among others). The
amygdala is known to aid in the processing of highly charged emotional
memories, such as terror and horror, becoming highly active both during
and while remembering a traumatic incident. The hippocampus, on the
other hand, gives time and space context to an event, putting our memories
into their proper perspective and place in our life’s time line. Hippocampal
processing gives events a beginning, a middle, and an end. This is very
important with regard to PTSD, as one of its features is a sense that the
trauma has not yet ended. It has been shown that the activity of the
hippocampus often becomes suppressed during traumatic threat; its usual
assistance in processing and storing an event is not available (Nadel &
Jacobs, 1996; van der Kolk, 1994, among others). When this occurs, the
traumatic event is prevented from occupying its proper position in the
individual’s history and continues to invade the present. The perception of
the event as being over and the victim as having survived is missing. This is
the likely mechanism at the core of the quintessential PTSD symptom of
“flashback”—episodes of reliving the trauma in mind and or body.

DISSOCIATION, FREEZING, AND PTSD

Surprisingly, dissociation, a splitting in awareness, is not mentioned by
either the DSM-III or DSM-IV as a symptom of PTSD, though it is
acknowledged as a symptom of acute stress disorder (APA, 1994). There is
a growing debate as to whether PTSD is actually a dissociative disorder,
rather than an anxiety disorder as it is currently classified (Brett, 1996). At
the International Society for Traumatic Stress Studies a panel debated this
issue (Wahlberg, van der Kolk, Brett, & Marmar, 1996). No one really
knows what dissociation is or how it occurs, though there is much
speculation. It appears to be a set of related forms of split awareness. The
wide range of splitting covers events as simple as forgetting why you were
going into the kitchen and as extreme as dissociative identity disorder
(previously called multiple personality disorder). The kind of dissociation
described by those with PTSD during their traumatic event(s)—altered
sense of time, reduced sensations of pain, absence of terror or horror—
resembles the characteristics of those who report having responded by
freezing to a traumatic threat. There will need to be more research before it
can be known if the freezing response is a form of dissociation.
Understanding this mechanism is important because it appears that the
most severe consequences of PTSD result from dissociation. While
dissociation appears to be an instinctive response to save the self from
suffering—and it does this very well—it exacts a high price in return. There
are several areas of research into the phenomenon of dissociation. Many
indicate the likelihood that dissociation during a traumatic event
(peritraumatic dissociation) predicts the eventual development of PTSD
(Bremner et al., 1992; Classen, Koopman, & Spiegel, 1993; Marmar et al.,
1996).

CONSEQUENCES OF TRAUMA AND PTSD

The consequences of trauma and PTSD vary greatly depending on the age
of the victim, the nature of the trauma, the response to the trauma, and the
support to the victim in the aftermath. In general, those afflicted with PTSD
suffer reduced quality of life due to intrusive symptoms, which restrict their
ability to function. They may alternate periods of overactivity with periods
of exhaustion as their bodies suffer the effects of traumatic hyperarousal of
the ANS. Reminders of the trauma they suffered may appear suddenly,
causing instant panic. They become fearful, not only of the trauma itself,
but also of their own reactions to the trauma. Body signals that once
provided essential information become dangerous. For example, heart rate
acceleration that might indicate overexertion or excitement can become a
danger signal in itself because it is a reminder of the accelerated heart rate
of the trauma response, and is therefore associated with trauma. The ability
to orient to safety and danger becomes decreased when many things, or
sometimes everything, in the environment are perceived as dangerous.
When daily reminders of trauma become extreme, freezing or dissociation
can be activated as if the trauma were occurring in the present. It can
become a vicious cycle. Eventually, a victim of PTSD can become
extremely restricted, fearing to be with others or to go out of her home. (As
mentioned before, Charlie had PTS not PTSD; the degree of his restriction
never reached this extreme. However, he was becoming increasingly
restricted with each fearful canine encounter, and the potential for
developing PTSD lingered.)
How is it possible for the mind to become so overwhelmed that it is no
longer able to process a traumatic event to completion and file it away in
the past? The next chapters move toward possible answers to that question.
CHAPTER TWO
Development, Memory, and the Brain

In many instances, people who experience traumatic events are able to

process and resolve those episodes free of long-term effects. They are able
to recall and narrate the events that befell them, make sense of what
happened, have emotions appropriate to their memories, and feel confident
that the incident lies in their past.
In people still plagued by their traumas, those with PTS and PTSD,
memory of traumatic events is different. It usually falls into one of two
divergent categories. Some traumatized people will remember the
traumatizing events in precise detail, able to describe what happened as if
they were watching a video replay. In these cases PTS or PTSD persists
because these individuals are not able to make sense of the events, or some
aspect of them. They may still be disturbed by intense emotions and/or
bodily sensations seemingly unconnected to the traumas they suffered.
(Charlie’s memory of the dog attack is an example. He remembered the
details up to the point where he lost consciousness, but continued to feel in
danger each time he was in the vicinity of a dog, no matter how benign that
dog was.) Or they might feel numb in body and/or emotions and complain
of a sense of deadness in their lives. Others remember little if any of the
actual traumatic events but are plagued by physical sensations and
emotional reactions that make no sense in the current context. Whether the
trauma is remembered or not, for those with PTS and PTSD the realization
that it lies in the past and that the danger is over is attained only with
difficulty.
 A look into how the brain develops may reveal clues to help us
understand these types of memory distortion.

THE DEVELOPING BRAIN

The newborn’s brain is by no means a fait accompli, not even close. At birth
the brain is among the most immature of the body’s organs. In fact it is
much like a new computer, equipped with a basic operating system that
incorporates all that will be needed for future development and programing,
memory file storage and expansion, but as yet unable to do much beyond
the basic system requirements.
The human brain is, for the most part, malleable—programmable and
reprogrammable—in its organization. It is highly responsive to external
influences. In fact, the higher and more complex the brain structure, the
greater its malleability (Perry, Pollard, Blakley, Baker, & Vigilante, 1995).
The cerebral cortex is the most complex, as well as the most flexible and
easily influenced, structure. The brain stem is the least complex and least
malleable structure in the brain. The brains susceptibility to influence and
change is necessary to growth and development. Without the ability of our
brains to adapt and change, it would be impossible to learn anything.
Growth, development, and change are necessary to health and to survival.
Though it remains flexible throughout the lifespan, the brains capacity for
alteration does decrease with age. And, of course, the first days, months,
and years of life are crucial for establishing the foundations of later
capacities and talents, as well as deficits.
How a brain first organizes is dependent on the infant’s interactions with
its environment. How a brain continues to grow, develop, and reorganize is
dependent on the subsequent experiences encountered throughout a child’s
life. As no two life experiences are the same, even for identical twins, it is
the brain’s malleability that makes each of us unique. Recognizing that the
brains organization is flexible and subject to influence is crucial to
understanding both how dysfunctional emotional patterns, such as PTSD,
can develop and how they can be changed.
 From the Beginning

The infant brain has the instincts and reflexes that are needed for existence
(heartbeat, respiration reflex), the ability to take in and make use of
nourishment (search, suck, and swallow reflexes; digestion and elimination)
and to benefit from contact (sensory pathways, grasp reflexes), etc. This
basic brain system, though, is not enough to ensure the infant’s survival.
The baby needs a more mature human (the primary caretaker—usually, but
not always, its mother) to care for and protect it. Moreover, many believe it
is the interaction between baby and caretaker that determines normal brain
and nervous system development.
None of this is new. Babies depend on their caregivers for every aspect
of their survival. Caregivers who are able to provide for infants’ emotional
as well as physical needs nurture them into toddlers, children, teens, and
adults with a wide scope of resources. Increasingly they are able to take
over caring for their own needs in adaptive and beneficial ways. Well-
cared-for babies become adults with resilience who are able to swing with
the punches dished out by life. Their brains are able to process and integrate
both positive and negative experiences, adding adaptive learning to their
repertoire of behaviors and attitudes.
On the other hand, babies raised by caregivers unable to meet significant
portions of their needs are at risk of growing into adults who lack resilience
and have trouble adapting to life’s ebbs and flows. Their brains may be less
able to process life’s experiences. They appear to have more difficulty
making sense of life’s events, particularly those that are stressful, and to be
more vulnerable to psychological disturbances and disorders, including
drug addiction, depression, and PTSD (Schore, 1994).
There is a growing body of research that describes how healthy bonding
and attachment are crucial to healthy development from the first days of life
(Schore, 1994; Siegel, 1999; van der Kolk, 1998). The attachment
relationship stimulates brain development which, in turn, expands and
enables an individual’s ability to cope emotionally throughout life. Science
is finally catching up with parents and psychotherapists, who have always
known that this was true but didn’t know why or how. It is now believed
that the nurturing interaction between caregiver and infant goes a long way
in promoting healthy emotional development, because that relationship, in
itself, stimulates normal maturation of the brain and nervous system.

A Few Basics

What follows is a very brief overview of how the brain develops. Later
chapters will expand on these basics. The material included here will be
limited to what is necessary for the purpose of understanding how brain
development eventually affects the processing of traumatic incidents.
The brain is the control center of the nervous system. It regulates body
temperature, tells us when to seek nourishment, and directs all the functions
involved in eating, digestion, and elimination. It tells our heart to beat and
causes us to inhale and exhale. Without the brain, procreation would be
impossible and the human species would die out. In addition, the brain, like
a computer, processes information. It receives information through all of the
body’s sensory pathways: sight (which includes written words), hearing
(which includes spoken words), taste, touch, smell, proprioception (which
informs on the body’s spatial and internal states), and the vestibular sense
(which indicates which way is up).

Nervous System Communication

The term synapse (see Figure 2.1) refers to a junction of two nerve cells
(neurons). It is at this site that the signal or information from one nerve
transfers to the next, as if a spark jumps the gap. The communication from
the one cell to the next can be accomplished with either an electrical
impulse or via a chemical neurotransmitter that passes from one cell to the
other. Epinephrine and norepinephrine are examples of neurotransmitters.
These hormones are secreted in response to traumatic stress (see “Survival
and the Nervous System” in Chapter 1), epinephrine by the sympathetic
nerves in the adrenal glands, norepinephrine by the sympathetic nerves in
the rest of the body (Sapolsky, 1994). When enough norepinephrine secretes
from the sympathetic nerve endings along the path from synapse to
synapse, the body is readied to fight or flee.
 Strings of synapses link neurons in configurations that produce the
complex activities that are carried out by the brain and the body. Each string
of synapses produces a single result: the contraction of a muscle, the recall
of an image, the blink of an eye, the stomach sensation of butterflies, one
heartbeat, the gasp of surprise. Combinations of synapse strings produce
more complicated results: walking, talking, solving a math problem,
understanding a written paragraph, remembering the details of a movie,
realizing one is cold and turning up the heat. All of the information coming
into the body and brain through the senses is realized and registered through
discrete sets of synapses, and each reflex, behavior, emotion, or thought is
produced through discrete sets of synapses. All experiences are encoded,
recorded, and recalled through synapses. The brain regulates all body
processes and behaviors through synapses that connect efferent nerves
(brain → body). Likewise, the body reports back to the brain on its internal
state and position in space through synapses connecting afferent nerves
(body → brain). It is also through sets of synapses that individual thoughts
become linked as concepts or tied to specific events. Cognitive memory
involves the linking of the nerves via synapses within the brain. Somatic
memory requires that sensory nerves be linked via synapses to the brain and
then recorded within the brain.

Figure 2.1. Synapse.

Reprinted with permission from the Press Office of the Charles A. Dana Foundation.

There is nothing fixed about the sequence of synapses, however. They

are subject to influence and can be changed. New learning is achieved
through the creation of new synapse strings, or adaptation of existing ones.
Forgetting (e.g., how to do something) is the result of disuse of synapse
strings—as the saying goes, “use it or lose it.” It is also, for better or worse,
through the alteration of synapses that memory can become distorted.

Divisions of the Brain

It is easy to conceptualize what the brain looks like (see Figure 2.2). Make
your right hand into a fist, holding it upright. Your right wrist represents the
brain stem, your fist the midbrain and limbic system. Now take your left
hand and cover your right fist. That is the cerebral cortex, the outer layer of
the brain.
The brain stem, sometimes referred to as the reptilian brain, regulates
basic bodily functions such as heart rate and respiration. This region of the
brain must be mature at birth for an infant to survive.
The limbic system is the seat of survival instincts and reflexes. It includes
the hypothalamus, which is responsible for maintaining body temperature,
essential nutrition and hydration, rest and balance. The limbic system also
regulates the autonomic nervous system, mediating smooth muscle and
visceral responses to stress and relaxation, including sexual arousal and
orgasm, and the traumatic stress reactions of fight, flight, and freeze. Two
other limbic system regions, the hippocampus and the amygdala, are
especially pertinent to understanding traumatic memory. Both the
hippocampus and the amygdala consist of two lobes, one on each side of
the brain. Both structures are integral to processing information transmitted
from the body on the way to the cerebral cortex.
The amygdala processes and then facilitates the storage of emotions and
reactions to emotionally charged events. The hippocampus processes the
data necessary to make sense of those experiences within the time line of
personal history (i.e., “When during my life did this happen?”) and the
sequence of the experience itself (i.e., “What happened first? What
happened next?” etc.). Nadel and Zola-Morgan (1984) have found that the
amygdala is mature at birth, and that the hippocampus matures later,
between the second and third year of life. Understanding the difference in
the maturational schedules, as well as the functions of these two structures,
provides one explanation for the phenomenon of infantile amnesia—the
fact that we usually don’t consciously remember our infancy. Infantile
experiences are processed through the amygdala on the way to storage in
the cortex. The amygdala facilitates storage of the emotional and sensory
content of these experiences. Hippocampal function is not yet available, so
the resulting memory of an infantile experience includes emotion and
physical sensations without context or sequence. This is the probable
explanation for why, in later life, infantile experiences cannot be accessed
as what we usually call “memories” (Nadel & Zola-Morgan, 1984).

Figure 2.2. Divisions of the brain.

Reprinted with permission from the Press Office of the Charles A. Dana Foundation.

Mature and adequate function of both amygdala and hippocampus is

necessary for sufficient processing of life’s events, especially the stressful
ones, though during a traumatic event this may not always be possible. As
the stress level increases, hormones may be released that suppress
hippocampal activity, while the amygdala remains unaffected. It is possible
that prolonged cortisol secretion, as may be found with trauma, affects the
hippocampus in this way (Gunnar & Barr, 1998). This might account for
some of the memory distortion associated with PTSD. Some individuals
with PTSD recall their traumatic experiences as highly disturbing emotional
and sensory states, lacking the time and space context that is facilitated by
hippocampal function. Hippocampal size has been the subject of recent
PTSD research. Several studies conclude that survivors of PTSD have
smaller hippocampi than the general population (among others: Bremner et
al., 1997; Rauch, Shin, Wahlen, & Pitman, 1998; Schuff et al., 1997). These
fascinating findings have not determined, however, whether the hippocampi
of those with PTSD have shrunk due to suppression of hippocampal activity
by stress hormones or whether these individuals had smaller hippocampi to
begin with. At any rate, it appears that smaller hippocampus size might
interfere with the brains processing of stressful life events.
The thalamus is also part of the midbrain; its two parts flank the limbic
system. It is the relay center for sensory information coming from all points
in the body on the way to the cortex.
Overlaying the more primitive structures of the brain is the cerebral
cortex, which is responsible for all higher mental functions, including
speech, thought, and semantic and procedural memory. Currently there is
great interest in the various information-processing functions of the right
and left cortices and their relationship to the limbic system. The right cortex
appears to play a greater role in the storage of sensory input. It appears that
the amygdala is the limbic structure through which sensory information
travels on its way to the right cortex. The left cortex, on the other hand,
seems to have a more intimate relationship with the hippocampus.
Moreover, it appears to depend on language for processing information.
Bessel van der Kolk (van der Kolk, McFarlane, & Weisaeth, 1996) has
found that activity in Broca’s area, which is a left cortical structure
responsible for speech production, is also suppressed (as is the
hippocampus) during a traumatic incident. He describes what he calls the
“speechless terror” of trauma. We have all experienced being at a loss for
words or forgetting what we were about to say. Under stress this difficulty
increases, sometimes to extreme degrees. (In Charlie’s case, he could still
speak in his panicked state, but the speech apparatus was so constricted
that he could barely squeak his words out.)

Mutual Connection and the Developing Brain

Allan Schore (1994) and Bruce Perry (Perry et al., 1995) have both
proposed neurological models for understanding the importance of infant
attachment in the mediation of stressful experiences throughout life.
According to both models, the primary caretaker, in addition to providing
for an infant’s basic needs, plays a crucial role in helping the infant to
regulate sometimes very high levels of stimulation. A healthy attachment
between infant and caretaker enables the infant to eventually develop the
capacity to self-regulate both positive and negative stimuli. Perry and his
colleagues (1995) further propose that positive early experiences are crucial
to optimal organization and development of specific brain regions.
The newborn infant is a bundle of raw sensory receptors. For nine
months the fetus is swathed and insulated in its mother’s amniotic fluid.
Though there are sensory stimuli in utero, they are dampened. The newborn
is ill-prepared for the sudden inundation of stimuli at birth. Suddenly it is
literally propelled into an environment full of new and intense sensations of
touch, sound, taste, sight, smell, cold, heat, and pain. The infant screams in
response to this first flood of stimuli. But when placed on its mother’s belly,
hearing her familiar (if previously muffled) voice, and feeling her loving
touch, perhaps even smelling her familiar scent, the newborn is quickly
soothed. This is the infant’s first experience of stimulus regulation mediated
by its primary caretaker. The baby’s mother has (usually), in an instant,
been able to intercede and quell the overwhelming inundation of multiple
new stimuli, calming the child. And so it goes, ideally, throughout infancy.
The baby is upset, and the caretaker’s presence soothes.
At first the caretaker helps the child regulate its responses to stimuli,
including being uncomfortable from hunger, thirst, wetness, cold, pain, etc.
Gradually, the caretaker also assists the child in regulating her emotional
responses: frustration, anger, loneliness, fear, and excitement. In the
beginning, much of the regulation process takes place through touch and
sound. However, as Schore (1996) describes, quite soon after birth the
caretaker and infant develop an interactional pattern that is central to the
process of affect regulation. They learn to stimulate each other through
face-to-face contact, which enables the infant gradually to acclimate to
greater and greater degrees of stimulation and arousal.
These interactions between the caretaker and infant—bonding and
attachment, upset and regulation, stimulus and attunement—are, Schore
believes, all right-brain mediated. During infancy the right cortex is
developing more quickly than the left—and, as previously stated, the left-
brain associated hippocampus is still immature (Schore, 1996).
 Toward the end of the first year, the relationship between primary
caretaker and baby changes drastically The baby makes its first movements
into toddlerhood—creeping, crawling, and eventually standing and walking
—and develops greater independence and possibilities for interaction with
the environment. Simultaneously, the caretakers role changes from being
nearly 100% nurturing, approving, and soothing into a regulator of
socialization who sets limits, says “no,” and sometimes disapproves and/or
causes pain. How caretaker and child resolve this change in roles depends
on at least three factors: the solidity of the attachment bond, the capacity of
the caretaker for continued love despite becoming angry at the child’s
misbehaviors, and the ability of the caretaker to set and maintain balanced
and consistent limits. It is also around this time that the left cortex begins an
accelerated growth period that continues as language, a left cortical
function, develops. Meanwhile, in the limbic system, the hippocampus
matures, enhancing the child’s capacity to make sense of his environment.
With a sound beginning, founded in a secure attachment, and later rational,
consistent limit-setting, the child will begin to use his growing language to
describe events and make sense of his emotional and sensory experiences.

The Developing Brain and Trauma

Why are some individuals more easily disturbed by traumatic events than
others? Schore (1996), van der Kolk (1987, 1998), Siegel (1999), De Bellis
and colleagues (1999), Perry and colleagues (1995), and others assert that
predisposition to psychological disturbance, including PTSD, can be found
in stressful events during early development: neglect, physical and sexual
abuse, failure of the attachment bond, and individual traumatic incidents
(hospitalization, death of a parent, car accident, etc.). There is speculation
that individuals who suffered early trauma and/or did not have the benefit of
a healthy attachment may have limited capacity for regulating stress and
making sense of traumatic experiences later in their lives. In some, it is
possible that reduced hippocampal activity, either because it was never fully
developed (attachment deficit) or because it became suppressed (traumatic
events), limits their ability to mediate stress (Gunnar & Barr, 1998). Under
those circumstances, later traumatic experiences might be remembered by
some only as highly charged emotions and body sensations. In others, it
may be that survival mechanisms such as dissociation or freezing have
become so habituated that more adaptive strategies either never develop or
are eliminated from the survival repertoire.

The Mature Brain and Trauma

Even when infancy and childhood have gone well, even ideally, an
adolescent or adult may confront a traumatic event so overwhelming that
PTS or PTSD results. Some of the most convincing evidence for this comes
from studies of Holocaust survivors who were settled in post World War II
Norway. Like the other Scandinavian countries, Norway played an
important role in the recovery and resettlement of thousands of survivors of
the German concentration camps. In addition to meeting their basic needs
for medical attention, nutrition, and clean and safe living quarters, the
Norwegians provided psychiatric support. Until WWII, Norwegian
psychiatry, similar to its European and American counterparts, regarded
mental illness as developing from childhood deficits. As symptoms of
mental illness were prevalent among the concentration camp survivors, the
Norwegian psychiatrists expected to hear childhood histories riddled with
dysfunction. They were astonished to find that most of the survivors
reported happy childhoods in cohesive, supportive families. What could
account for such a disparity? The psychiatrists were eventually compelled
to conclude that the evidence “convincingly demonstrated that chronic
mental illnesses could develop in persons who had a harmonious childhood
but who had been subjected to extreme physical and psychological stress”
(Malt & Weisaeth, 1989, p. 7). Thus, the aftermath of the Holocaust marked
a drastic change in how psychiatry viewed the effects of extreme stress on
adults. (Charlie also illustrates this theory, as his trauma occurred when he
was an adult. He developed PTS following the dog attack—and was well on
his way to PTSD as his life became more restricted. Charlie’s reaction was
not due to earlier trauma or to developmental deficits.)

Hopeful Implications for Psychotherapy

Infancy is not the only chance an individual has for a healthy attachment. A
traumatized infant is not necessarily condemned to dysfunction. For
example, many children who were deprived of a good infantile relationship
do, to a large extent, make up for that lack later in life—with a best friend,
special teacher, or comforting neighbor. And many adolescents and adults
find a healing bond within a mature love relationship. For many, such
relationships go a long way to compensate for what they missed or suffered
as infants. Still others find the needed bond in the psychotherapeutic
relationship. (The role of dynamic psychotherapy and body-psychotherapy
in the compensation of early deficits and healing of early and massive
trauma will be addressed in Chapter 5.)
Brain maturation provides the foundation for acquiring necessary skills
and resources, including recognizing and applying the lessons of life’s
events. How the brain processes and remembers traumatic incidents will
determine who does and who does not develop PTSD. The quality of the
infant-caregiver attachment is an important, though not the only, variable
involved in predicting healthy brain maturation. In the following section,
categories of memory and their relationship to the brain and to the
development of PTSD will be discussed.

WHAT IS MEMORY?

We met at nine. We met at eight.

I was on time. No, you were
late.
… Ah, yes, I remember it well…
—GIGI

Research into memory—the function of memory and memory systems—is

a rapidly expanding field of study. It has been accelerating since the 1960s
and reached a furious, sustained pace in the early 1990s. Among the reasons
for this increased interest is the controversy over traumatic memory recall.
 The Basics of Memory

In general, memory has to do with the recording, storage, and recall of

information perceived from the internal and external environments. All of
the senses are integral to how the world is perceived. The brain processes
perceptions and stores them as thoughts, emotions, images, sensations, and
behavioral impulses. When these stored items are recalled, that is memory.
For a piece of information to become a memory it must traverse at least
three major steps: encoding is the process of recording or etching
information onto the brain; memory storage is how and for how long that
information is kept; and memory retrieval accesses the stored information,
bringing it back into conscious awareness. Actually, the process of brain
memory is quite similar to computer memory. Writing words on a screen
encodes information onto the computer. But that is only a temporary
measure unless it is saved in a file, which is akin to memory storage. Once
saved in a file, that information lies dormant until retrieved by reopening
the file (recall). As with brain memory, a saved computer file can
sometimes be difficult to relocate.
Some types of information are more likely to be stored than others. The
greater the significance, and the higher the emotional charge—both positive
and negative—the more likely a piece of information (or an event made up
of multiple pieces of information) will be stored (Schacter, 1996).

The Long and the Short of It

As recently as 40 years ago, memory was thought to be only one thing:

either we remembered or we didn’t. What we now call long-term memory
was the only category recognized. When memory failed it was called
forgetting or, in the extreme, amnesia. It was thought that our experiences
were etched on the brain’s cortex as on a videotape. Memory was the video
playback. This theory was supported by the brain-stimulation studies
conducted by Wilder Penfield. These well-known experiments are
fascinating, but possibly misleading. While operating on epileptic patients,
Penfield randomly stimulated areas of the brain’s temporal lobe and
recorded the “memories” reported by his patients (Penfield & Perot, 1963).
Some reported astoundingly detailed sensory-laden images. Penfield has,
however, been criticized for exaggerating his discovery. It appears that
fewer than 10% of his patients actually reported “memories” during direct
brain stimulation and none of those were validated: There was no way to
distinguish genuine memory from induced hallucination (Squire, 1987).
Around 1960, scientists began to speculate about two different systems
of memory: long-term memory and a new category called short-term
memory. At that time there was no theory for where in the brain those types
of memory resided or what brain systems were responsible for them.
However, it was clear that short-term memory depended on a different brain
system than long-term memory. This was the birth of the idea of multiple
memory systems in the brain, which is now the norm (Nadel, 1994,
Schacter, 1996).
It is short-term memory that is used to remember a phone number from
the time it is seen or heard until it is dialed, test answers after “cramming”
the night before an exam, and a waiter’s face. Such items usually slip
quickly from one’s grasp, just as words written onto the computer screen
are quickly lost if they are not saved in a file. And that appears to be a good
thing, preventing the brain from becoming cluttered with an abundance of
unnecessary information—10 years of nightly dinners, every advertising
jingle, etc. It is short-term memory that often frustratingly begins to weaken
with age, “What was that I was just about to do?” “It was on the tip of my
tongue …”
Long-term memory is just what the name implies. It involves items of
information that are permanently stored—whether or not they are ever
recalled into consciousness.
However, there is much more to memory than the length of time an item
of information is stored. Understanding which items are stored, where they
are stored, and how the brain accomplishes storage are all necessary to
further comprehend memory.

The Implicit and the Explicit

In the late 1980s and early 1990s the idea of multiple memory systems
became widely accepted. An important discovery during this time was two
new types of memory: explicit and implicit. These two disparate memory
systems distinguish what types of information are stored and how they are
retrieved. Table 2.1 contrasts the explicit and implicit memory systems.

Explicit Memory

Explicit memory is what we usually mean when we use the term “memory.”
Sometimes called declarative memory, it is comprised of facts, concepts,
and ideas. When a person thinks consciously about something and describes
it with words—either aloud or in her head—she is using explicit memory.
Explicit memory depends on oral or written language, that is, words;
language is necessary to both the storage and the retrieval of explicit
memories. An opinion, an idea, a story, facts of a case, narration of Sunday
dinner at Grandma’s—all are examples of items of information that would
be stored in explicit memory. Explicit memory is not just facts, however; it
also involves remembering operations that require thought and step-by-step
narration, as in solving a mathematical equation or baking a cake. It is
explicit memory that enables the telling of the story of one’s life, narrating
events, putting experiences into words, constructing a chronology,
extracting a meaning.

Table 2.1. Categories of memory.

EXPLICIT =
DECLARATIVE
IMPLICIT =
NONDECLARATIVE
Process
conscious
unconscious

Information types

cognitive
 emotional

facts
conditioning

mind
body

verbal/semantic
sensory

description of operations
automatic skills

description of procedures
automatic procedures

Mediating limbic structure

hippocampus

amygdala

Maturity

around 3 years

from birth

Activity during traumatic event and/or flashback

suppressed
 activated

Language

constructs narrative

speechless

This table is similar to one in Hovdestad and Kristiansen, 1996, p. 133.

Explicit memory of a traumatic event (or any event, for that matter)
involves being able to recall and recount the event in a cohesive narrative.
Another aspect of explicit storage involves historical placement of an event
in the proper slot of one’s lifetime. Currently, there is speculation that some
incidences of PTSD may be caused, in part, when memory of a traumatic
event is somehow excluded from explicit storage.

Implicit Memory

Where explicit memory depends on language, implicit memory bypasses it.

Explicit memory involves facts, descriptions, and operations that are based
on thought; implicit memory involves procedures and internal states that are
automatic. It operates unconsciously, unless made conscious though a
bridging to explicit memory that narrates or makes sense of the remembered
operation, emotion, sensation, etc.
Implicit memory, first called procedural or nondeclarative memory, has
to do with the storage and recall of learned procedures and behaviors.
Without implicit procedural memory, accomplishing some tasks would be at
best laborious, at worst impossible. Bicycle riding provides a good
example. Implicit memory makes it possible to ride a bike without thinking
about it. While there may be an explicit memory of the time when riding a
bike was learned—often with Mom or Dad holding the back of the seat and
running alongside—one does not usually utilize explicit narrative memory
while riding a bicycle. Relying only on explicit memory to ride a bike, it
would be necessary to construct a narrative, following each step as you
might a recipe:

I stand to the right of the bike, facing it. I take hold of the handlebars with
my hands. Then, keeping my right foot on the ground, I lift my left leg over
the top, landing awkwardly with my left buttocks on the seat; the bike tipped
to the right. I keep holding onto the handlebars with both hands, bend my
right knee and push off the ground with my right foot. Simultaneously, I
shift the weight on my buttocks to the left so it becomes centered on the seat.
Quickly, I apply pressure to the left pedal, pushing it forward and then
down. As I do that, the right pedal, with my right foot on it, moves
backwards and up. When it reaches the top, I tilt the right pedal with my
right foot, toes pointed upward, and push it forward and down. I continue
the forward and down pressure on one pedal at a time. The bike moves
forward. I keep straight on the seat, controlling my balance by keeping my
head upright and letting my hips move from side to side …

No one approaches riding a bicycle with such explicit narration. They

would never get anywhere. Clearly, explicitly remembering such a
procedure is a laborious process. Implicit memory certainly has many
advantages.
However, when it comes to memory of traumatic events, implicit
memories not linked to explicit memories can be troublesome. It appears
that traumatic events are more easily recorded in implicit memory because
the amygdala does not succumb to the stress hormones that suppress the
activity of the hippocampus. No matter how high the arousal, it appears that
the amygdala continues to function. In some cases, upsetting emotions,
disturbing body sensations, and confusing behavioral impulses can all exist
in implicit memory without access to information about the context in
which they arose or what they are about.
 Conditioned Memory

A class of implicit memory includes behavior learned through classical

conditioning (CC) or operant conditioning (OC). These theories may be
familiar, as they are usually taught in basic psychology courses. Either or
both of them can be involved in the learned trauma responses of those with
PTS and PTSD.

Classical Conditioning
Classical conditioning, discovered by Ivan Pavlov, involves pairing a
known stimulus with a new, conditioned stimulus (CS) to elicit a new
behavior called a conditioned response (CR). In Pavlov’s famous
experiment, he taught a hungry dog to respond physiologically to a bell as
though it were food. He repeatedly rang a bell (CS) just before presenting
food (S) to the dog. Of course, it salivated—a normal response (R)—at the
sight and smell of the food. That sequence was repeated many times.
Eventually the bell became associated with the food. Pavlov then removed
the stimulus of the food and only rang the bell. Again the dog would
salivate (CR). It was no longer necessary to present the dog with food to
elicit the now conditioned response (Pavlov, 1927/1960). What had once
been a normal response to the stimulus of food became a conditioned
response to a bell:

bell → association to food → salivation, becomes bell → salivation

Classical conditioning is especially germane to the discussion of PTSD.

It is likely that this process is the mechanism underlying the phenomenon of
traumatic triggers. To put it simply, during a traumatic event, many cues
can become associated with the trauma. Those same cues can later elicit a
similar response (CR). For example, if a woman is raped (S) by a man in a
red (CS) shirt and is very afraid (R), she may later become fearful (CR)
when she sees the color red (CS). If enough information about the rape was
recorded explicitly in her brain, she may be able to make the connection
and reduce her reaction, “Oh yes, the color red frightens me because it
reminds me of the time I was raped.” However, even if she doesn’t
remember one or more items of information, she could still have a reaction.
That is one consequence of classically conditioned implicit memory:
automatic reactions in the absence of cognitive, factual thought. In the case
of trauma, the reaction is very distressing. Triggers (in this case, the color
red) often cause intense reaction. A person is unaware of the cause unless
the association is made, either spontaneously or with the help of
psychotherapy.
An additional problem with the phenomenon of triggers is that they can
be very difficult to track down. Classical conditioning can create chains of
conditioned stimuli such that an individual trigger (CS) may be several
generations away from the original stimulus-response scenario. The dog
who learned to salivate at the sound of the bell could be taught to salivate to
a flashing light just by pairing the bell to the light (second CS). The same
could happen following the above example of rape. At a later time, the same
woman walks down a street past a fabric store. In the window is an array of
red (first CS) material. A few steps past the store her heart starts beating
rapidly (CR) and she feels dizzy. She doesn’t know what is happening to
her and her anxiety escalates into a panic attack. If she has no conscious
clue to what caused the panic, she might reach for an explanation that
makes sense and conclude (consciously or unconsciously) that something
on that street must be dangerous or unsafe. She may later avoid walking on
that street (second CS). If this pattern continues without intervention, she
might eventually have a panic attack just from going out on any street (third
CS) and become agoraphobic, unable to go out at all without knowing why.
Now this, of course, is not the only explanation for agoraphobia, but it is a
very plausible scenario of how it could develop. Classically conditioned
associated generations of traumatic triggers can cause increasingly greater
degrees of restriction, avoidance, and, eventually, debilitation. (Charlie
generalized his fear of the type of dog that attacked him [CS] to all dogs
[second CS]—no matter what they looked like [large/small] or how they
acted [aggressive/docile]. His life became restricted as the sight of any dog,
even at a distance or on its owner’s leash, caused his heart to race and his
skin to break out in a cold sweat.)
Memory in the Absence of Memory. Classical conditioning helps to clarify
how it is possible to react to a reminder of a traumatic event without
recalling that event. An interesting case from the early days of psychology
provides a simple, yet fascinating illustration.
A female patient of the early 20th century French physician Edouard
Claparede was unable to create new memories due to brain damage. Each
time the doctor met this patient, it was as if it was for the first time. She
never remembered him, even if the last time she had seen him was just a
few minutes before. Curious, Dr. Claparede devised an experiment. One
time he entered the examining room holding out his hand in customary
greeting; however, that time, he hid a tack in his palm. As usual, she took
his hand, but she withdrew it immediately in response to the surprise of
pain. When the doctor subsequently visited the patient, she refused to shake
hands with him, but could not say why (Claparede, 1911/1951).
Familiarity with the theory of memory systems makes understanding this
seemingly phenomenal occurrence quite simple. Claparede’s patient was,
indeed, able to create new memories, just not explicit ones. Through
classical conditioning a previously neutral behavior (hand shaking) had
become paired with a conditioned stimulus (pain), causing a conditioned
response (recoiling in pain and fear). It only took one time to condition the
response. The very next time the doctor appeared, the patient refused to take
his hand (conditioned response). Her implicit memory system was fully
intact (no pun intended). Her hand remembered being the painful prick and
her arm remembered recoiling. She did not want to do that again. She did
recognize and remember the doctor, though not in the normal way that we
conceptualize recognition and memory.

Operant Conditioning
Operant conditioning, first known from the work of B. F. Skinner, involves
shaping behavior through a cause and effect system of positive and/or
negative reinforcement. Behavior modification is based on operant
conditioning. In a typical Skinner-type experiment a bird is taught to
depress a pedal with its beak to receive food. It is rewarded with a few
grains each time it performs the desired behavior, in this case pedal
pecking. Eventually the behavior becomes automatic. What starts out as a
random occurrence—the first time the bird accidentally depressing the
pedal—quickly becomes associated and learned through rewards of food.
The bird is then able to deliberately depress the pedal when it wants more.

random behavior → reward → conditioned behavior → reward

It is by this same method that animal actors are trained to perform

seemingly impossible tasks. A desired behavior, such as turning clockwise,
is broken down into small steps, each step being rewarded as it appears:
first a turn of a foot, then a turn of the head, then a half-turn of the whole
body, etc. (Skinner, 1961).
Operant conditioning is used to shape behaviors of all kinds, consciously
and unconsciously, in all walks of life. Behaviors that are preferable and
therefore rewarded (positive response) are increased in frequency.
Behaviors that are not desired, and therefore punished (negative response)
reduce in frequency or disappear altogether. With humans, operant
conditioning is a common mechanism for shaping the behavior of children,
friends, colleagues, spouses—everyone. Once a behavior is shaped, the
process that facilitated the shaped behavior falls from awareness (if it ever
was in awareness), and the resulting shaped behavior remains as an implicit
memory. Many behaviors and habits were first shaped by operant
conditioning—learning to say “please” and “thank you,” for example.
Praise, pleasure, and contact will increase a behavior; disapproval, pain, and
withdrawal will decrease it.
Traumatic incidents can shape behavior through operant conditioning.
When this happens adapted responses to stress can develop. For example, a
person’s difficulty speaking in public may be traceable to a childhood
where assertive speech elicited violent reprisal. When natural impulses for
assertive speech become associated with punishment they are extinguished.
If faced with a situation where public speaking is required—even at a
business meeting—that individual might suffer an anxiety or panic attack
with symptoms including racing heart, cold sweat, difficulty breathing, etc.
When a traumatic incident is repeated, as with physical abuse, domestic
violence, incest, or torture, mental, emotional, and behavioral strategies for
coping can become habituated, closing off the possibility of exercising
other options, even in less stressful circumstances. Those who were
molested or beaten as children or teenagers might later be vulnerable to
sexual abuse or violence, because their natural impulses to protect
themselves and protest (physical and verbal) were extinguished.
Expectation of hurtful treatment by others or one’s own failed capabilities
can stubbornly persist despite overwhelming evidence that such is no longer
the case. Behaviors and beliefs conditioned during traumatic events seem to
have a greater enduring power than those conditioned under lesser degrees
of stress. Even one instance of a failed or punished survival strategy during
traumatic circumstances can be enough to extinguish that behavior from
one’s repertoire.
On a hopeful note, operant conditioning can also work in reverse. When
strategies used to meet a traumatic threat are successful, they become more
available and more likely to be used again. Sometimes this is called stress
inoculation.

State-dependent Recall

State-dependent recall is another important phenomenon related to

traumatic memory. When a current internal state replicates the internal state
produced during a previous event, details, moods, information, and other
states associated to that event may be spontaneously recalled or set in
motion. This theory has often been applied to learning, predicting that
information learned during specific states induced by various drugs or
alcohol are better recalled under the same conditions, that is, under the
influence of the same substance (Eich, 1980; Reus, Weingartner, & Post,
1979). A tasty example is provided by college students who have tried to
use this phenomenon to advantage in the hopes of increasing their chances
of passing exams. The strategy is to increase recall of the difficult material
by eating chocolate while studying and then eating chocolate while taking
the exams. It is not known, however, whether the success of this strategy (as
reported by the students) is determined by the internal state elicited by the
increased blood sugar, the stimulant in the cocoa, or the psychological
associations of the chocolate. And, of course, it could just be a trumped-up
excuse for indulgence by collegiate chocoholics.
 State-dependent recall can also occur unbidden. It is not uncommon for a
trauma to be recalled into awareness by an internal condition (increased
heart rate or respiration, a particular emotional mood, etc.) that is
reminiscent of the original response to the trauma. This process can be set
in motion by a multitude of classically conditioned external triggers: a
color, sight, taste, touch, smell, etc. It can also be incited by exercise,
excitement, or sexual arousal. Anything that is a reminder of the trauma
response is a possible catalyst.
It is also possible that state-dependent recall could be elicited under
conditions that replicate body posture. This has not been discussed in the
literature, but it is a logical extension of this theory and a ripe area for
research. Feedback from postural proprioceptive nerves could have the
same memory power as the proprioceptive nerves of internal sensations that
must be involved in state-dependent recall under the influence of drugs or
alcohol (see the next chapter for a discussion of proprioception). Asking a
client to reconstruct his posture before and during a trauma will often bring
details to awareness. However, such a technique must be used with caution,
as it can easily stimulate more recall than the client is prepared to handle
(see Chapter 5). Postural state-dependent recall can also be caused
unwittingly, as, for example, when a physically abused child either freezes
or screams when casually or inadvertently tossed over another’s knee in
play. (Charlie’s traumatic recall was triggered by the sensation of pressure
on his right leg and his view of Ruff out of his right eye—replication of two
conditions from the dog attack. State-dependent reminders of touch and
sight set his reaction in motion.)

Memory and PTSD

PTSD appears to be a disorder of memory gone awry. Individuals with

PTSD cannot make sense of their symptoms in the context of the events
they have endured. They are further plagued by state-dependent triggers
and/or other classically conditioned associations to their traumas. Their
traumatic experiences freefloat in time without an end or place in history.
An understanding of the somatic side of memory may provide clues to
understanding the special memory features of PTS and PTSD. That is the
topic of the next chapter.
CHAPTER THREE
 The Body Remembers
Understanding Somatic Memory

Rhyme and Reason

There was an old woman who lived in a shoe,
She had so many children, she didn’t know what to do.
But try as she would she could never detect
which was the cause and which the effect.
—Piet Hein

This chapter addresses two questions: What is meant by somatic memory?

How can understanding this phenomenon be useful in the treatment of
posttraumatic stress disorder and other trauma-related conditions? The
implicit memory system is at the core of somatic memory. Individuals with
PTSD suffer inundation of images, sensations, and behavioral impulses
(implicit memory) disconnected from context, concepts, and understanding
(explicit memory). Hopefully, greater understanding of somatic memory
and implicit processes will help link implicit and the explicit memory
systems (which will be further discussed in Chapter 8).
Somatic memory relies on the communication network of the body’s
nervous system. It is through the nervous system, via synapses, that
information is transmitted between the brain and all points in the body. A
basic understanding of its organization will help in understanding the
phenomenon of somatic memory.
 Three nervous system divisions are the most relevant with regard to
trauma: the sensory, autonomic, and somatic. Each will be addressed
separately, and then consolidated in the section on “Emotions and the
Body.” Figure 3.1 illustrates the organization of the body’s central nervous
system.

Figure 3.1. Organization of the central nervous system.

This diagram is adapted from numerous similar ones.

THE SENSORY ROOTS OF MEMORY

The sensory system has everything to do with memory. The nervous system
transmits sensory information gathered from both the periphery and the
interior of the body via synapses, through the brains thalamus, on the way
to the somatosensory area of the cerebral cortex of the brain. This is the first
step of memory, the processing and encoding of information. Some of it
will be stored for future reference and retrieved when pertinent. Much of it
will never be stored and is quickly forgotten.
The sum total of experience, and therefore all memory, begins with
sensory input. It is through the senses that one perceives the world. They
provide continual feedback to the brain on the status of both internal and
external environments. It is through the senses that reality takes form.

Take a minute to become aware of the mass of sensory information coming

to and from your body right now. First notice your external environment.
You are standing, sitting, or lying on some kind of surface. Without looking
at it, can you can identify if that surface is soft or hard, cold or warm?
What sounds are your ears hearing? Is there enough light to easily see the
words on this page? Can you feel your hands holding this book? Notice
how the cover and pages feel to your hands. Is the cover smooth or
textured? Your external environment also includes how your clothes feel to
your skin. Is your shirt smooth or scratchy? Slacks comfortable or too
tight? Is the air temperature comfortable for the amount of clothing you
have on?
What about your internal environment? Without looking in a mirror, can
you estimate the position of your shoulders, back, neck, and head? Where,
and in which direction, are you tilted or twisted? Are you sitting up
straight? Are you relaxed or tense? And notice that you shift position from
time to time, even if only slightly. What are the sensations that cause you to
change your posture to maintain comfort? Is your foot going to sleep or
your neck beginning to ache? You might also notice if there is a taste in
your mouth—sweet, sour, salt, smoke, bitter? Are there any smells that you
are aware op Soon you will probably become gradually preoccupied with
additional internal bodily sensations that will tell you that you are hungry,
thirsty, tired, restless, stiff, have a full bladder, etc.

All of this input and more is constantly being transmitted to the brain all the
time—whether consciously or not. Each of these cues, whether coming
from the body’s periphery or from inside the body, is a sensation.
 Sensory Organization

There are two main sensory systems: exteroceptive and interoceptive.

Exteroceptors are nerves that receive and transmit information from the
environment outside of the body by way of the eyes, ears, tongue, nose, and
skin. Interoceptors are nerves that receive and transmit information from the
inside of the body, from the viscera, muscles, and connective tissue.

The Exteroceptive System

The exteroceptive system is the one with which you are likely to be the
most familiar. It includes the sensory nerves that respond to stimuli
emanating from outside of the body, that is, the external environment, via
the basic five senses: sight, hearing, taste, smell, and touch. All
exteroceptors are responsive to large and small changes in the external
environment. An individual will usually have greater facility in one or
another sense or heightened sensitivity to some kinds of stimuli. Individuals
with damage to one of these senses (for example, the visually or hearing
impaired) will often compensate for their deficit by developing greater
acuity in one or more of the others. The visually impaired, for example,
often have acutely sensitive hearing.

Which of the five senses are you most receptive to? What gets your
attention? Do you become particularly alert when you hear a strange
sound, smell a particular odor, or when something moves suddenly across
your field of vision? Do you easily feel nuances of contact to the surface of
your skin? Perhaps there is more than one, but you probably favor one over
the others. Which of these senses is most active in your memories? Are you
more likely to remember the taste of a meal, its smell, or how it looked? Are
you more visual, auditory, or tactile? When you are alone, remembering
your lover, do you have stronger images of his or her face, voice, or touch?

The Interoceptive System

The interoceptive system is comprised of sensory nerves that respond to
stimuli emanating from inside the body. There are two major types of
interoception: proprioception and the vestibular sense. Proprioception is
further comprised of the kinesthetic sense, which enables one to locate all
the parts of his body in space, and the internal sense, which gives feedback
on body states such as heart rate, respiration, internal temperature, muscular
tension, and visceral discomfort. The vestibular sense helps the body sustain
a balanced posture and maintain a comfortable relationship with gravity.

The Kinesthetic Sense

It is the kinesthetic sense that enables you to bring the tip of your finger to
touch the tip of your own nose when your eyes are closed. This small task,
familiar as a sobriety test, is an amazing feat. Those who doubt it should sit
beside a friend, and try to touch the friend’s nose while his own eyes are
closed. Successful nose targeting relies on input from muscles and skeletal
connective tissue that indicate the height and angle of one’s arm, hand, and
finger. It also requires an internal sensory schema for where all parts of
one’s body are located, to register just where the nose is. When aiming to
touch another’s nose there is access to the former, but not the latter. The
kinesthetic sense also makes walking possible by indicating where legs and
feet are located at any given point in time. It is the kinesthetic sense that
makes it possible to learn and execute all sorts of motor tasks and
behaviors.
The importance of the kinesthetic sense can best be illustrated by an
example of its loss. The APA Monitor (Azar, 1998) reported the fascinating
case of a man who, as the result of a viral infection, had lost the kinesthetic
part of his proprioceptive sense, as well as his sense of touch. Though all of
his motor functions were intact, without looking the man had not the least
notion of the position of his body; he could not even stand. Eventually he
was able to compensate to some degree for his loss. Through years of trial
and error, he learned to move and walk relatively normally, bring a glass to
mouth, etc., relying on his sense of sight to provide the cues that used to
come from his kinesthetic nerves. However, if when he was standing the
lights went out and he was deprived of visual cues, he would crumple to the
floor and be unable to rise until someone turned on the lights. Without
vision to help him, he had no idea how to place a hand palm down on the
floor, raise his elbow over his hand at the angle necessary to get enough
leverage to push himself up, etc. In addition, without vision he could not
tell where or how to place his feet under him or shift his weight properly for
support and to get his balance. Access to implicit memory of simple,
usually automatic movements and procedures was lost to him. Such cases
are exceedingly rare, but their study is useful in helping us understand how
necessary the senses are to everyday living.
The kinesthetic sense is central to implicit, procedural memory. It helps
one learn and then to remember how to do something. It keeps track of
where to put and how to move hands, fingers, feet, and trunk to replicate,
for example, walking, bike riding, skiing, typing, handwriting, or dancing.
Active in our waking hours, the kinesthetic sense functions automatically.
Though it is usually unconscious, you can increase your awareness of the
kinesthetic sense.

Close your eyes and see how accurately you can describe your current body
position. Notice, for example, the angle of your right arm. Is the palm of
your hand facing up or down? Is your left foot turned out or in? In which
direction is your head tilted? You can also try having a friend “sculpt” your
body into a different position and see if you can tell exactly where and how
each limb has been placed. Next time you sit down to write or eat—
something which is normally an automatic procedure for you, stored in
implicit memory—try doing it differently. Hold the pen or fork in a different
way or in the opposite hand. Can you now just write or eat without thinking
about what you are doing? Most likely you will not be able to. If such a
behavior is not stored in implicit memory, success will depend upon
conscious effort.

The Internal Sense

It is the internal sense that registers the state of the body’s internal
environment: heart rate, respiration, pain, internal temperature, visceral
sensations, and muscle tension. “Butterflies” or an ache in the stomach is a
familiar internal sensation. A “gut feeling” is a summation of the internal
sense. It is the internal sense that helps to identify and name our emotions.
Each basic emotion—fear, anger, shame, sadness, interest, frustration, or
happiness—has an accompanying set of discrete body sensations,
stimulated by patterned activity in the brain. This biology of emotion in the
body and brain is called affect.

Can you feel how fast your heart is beating without taking your pulse? Can
you feel your breathing—where and how deep? Where in your body are you
feeling tense or relaxed right now? Try again to eat or write with the
opposite hand. Notice your visceral reactions and any changes in muscular
tension. Do you feel discomfort anywhere? Is there a change in the tension
of your arm or shoulders? That is your internal sense alerting you to a
change in normal procedure. Then change back to write or eat in the way
that is normal for you and notice if there is a corresponding relaxation of
the internal alert. Remember the last time you were embarrassed. Did your
face get hot? How about when you are angry; do your shoulders get tense?

The internal sense is the foundation for neurologist Antonio Damasio’s

theory of somatic markers. He proposes that the experience of emotions is
comprised of body sensations that are elicited in response to various
stimuli. Those sensations, and their related emotions, become encoded and
then stored as implicit memories associated with the stimuli that originally
evoked them (classical conditioning). Memory of the emotions and
sensations can later be triggered into recall when similar stimuli are present,
though their origin will not always be remembered (Damasio, 1994). For
example, if someone eats something and becomes ill, the next time she sees,
smells, or is offered that same food she may feel some degree of nausea.
After a time the strong reaction will likely fade, but she may continue to
have an automatic aversion to that food, perhaps even forgetting the origin
of her dislike, “Oh, no thank you. I never eat that. I just don’t like it!”
Damasio’s somatic marker theory will be further discussed in the last
section of this chapter.
The Vestibular Sense
The vestibular sense indicates when one is in an upright position in
relationship to the earth’s gravity. Centered in the inner ear it may, when
disturbed, cause bouts of dizziness or vertigo, motion sickness, or loss of
balance. People particularly attuned to this sense may feel all the nuances of
motion. For example, during an airplane flight such a person will notice
each slight turn and tip of the plane that others register only when looking
out of the window.
Many amusement parks have an attraction that tricks the usually
cooperative relationship between sight and the vestibular sense. The
Haunted Shack at Knotts Berry Farm in Southern California is one
example. When one walks through this stationary building it is impossible
to keep one’s balance. It is necessary to hold onto railings to avoid falling.
The guides say it is because the house is built over a site where the earth’s
gravity is different, though they have no trouble negotiating the place
themselves—standing at an angle. The secret of such attractions is that a
seemingly normal structure is actually built at an angle. The floor, roof, and
walls slant 20 or 30 degrees. The tables, chairs, pictures, etc, are also placed
at the same slant and nailed in place. With eyes open, the normal person
will rely on visual cues to determine the direction of gravity. In this
instance, that causes a bit of chaos. One tries to get straight with what one
sees. However, with closed eyes the vestibular sense will kick in, telling
which way is up. The guides follow the vestibular information, which is
why they stand on a slant—but, of course it is never suggested that the
guests try that, as it would spoil the secret.

Somatic Memory and the Senses

Each of the senses discussed above is germane to the discussion of the

somatic basis of memory in general and traumatic memory in particular.
Our first impressions of an experience usually come from our senses—both
interoceptive and exteroceptive. These impressions are not encoded as
words, but as the somatic sensations they are: smells, sights, sounds,
touches, tastes, movement, position, behavioral sequences, visceral
reactions.
Memory of an event stored in implicit memory as sensations can
sometimes be elicited if similar sensory input is replicated (state-dependent
recall). There are many examples of this from normal daily life. Just about
everyone has at one time or another experienced state-dependent sensory-
based memory recall triggered by a song, taste, or smell: “Oh my gosh, I
hadn’t thought about that in years!” Sometimes it is something positive,
sometimes negative, but it happens all the time.

Sensory Memory and Trauma

Sensory memory is central to understanding how the memory of traumatic

events is laid down—how, as Bessel van der Kolk (1994) would put it, “The
Body Keeps the Score.” Memories of traumatic events can be encoded just
like other memories, both explicitly and implicitly. Typically, however,
individuals with PTS and PTSD are missing the explicit information
necessary to make sense of their distressing somatic symptoms—body
sensations—many of which are implicit memories of trauma. Which
information is missing varies: for some it will be a specific fact or facts that
have been forgotten; for others it may be a key, the “aha!” that puts the facts
at hand together into something meaningful. One of the goals of trauma
therapy is to help those individuals to understand their bodily sensations.
They must first feel and identify them on the body level. Then they must
use language to name and describe them, narrating what meaning the
sensations have for them in their current life. At times, though not always, it
then becomes possible to clarify the relationship of the sensations to past
trauma.
One of the difficulties of PTSD is the phenomenon of flashbacks, which
involve highly disturbing replays of implicit sensory memories of traumatic
events sometimes with explicit recall, sometimes without. The sensations
that accompany them are so intense that the suffering individual is unable to
distinguish the current reality from the past. It feels like it is happening now.
(Chapter 6 includes tools to help clients use sensory awareness to
distinguish the reality of the moment from memories of a past reality.
Chapter 8 includes a protocol for stopping a flashback.)
A flashback can be triggered through either or both exteroceptive and
interoceptive systems. It might be something seen, heard, tasted, or smelled
that serves as the reminder and sets the flashback in motion. It can just as
easily be a sensation arising from inside the body. Sensory messages from
muscles and connective tissue that remember a particular position, action,
or intention can be the source of a trigger. It is not uncommon, for example,
for a woman who has been raped to be just fine making love with her
husband except in the position that is reminiscent of the rape. Even an
internal state aroused during a traumatic event, for example, accelerated
heart rate, can be a trigger. For that reason, some individuals with PTSD do
not do well with aerobic exercise. The accelerated heart rate and increased
respiration can be implicit reminders of the accelerated heart rate and
increased respiration that accompanied the terror of their trauma.
Accelerated heart rate caused by stimulants in coffee, tea, cola, or dark
chocolate can also be problematic for some. These are all examples of
triggers elicited through state-dependent recall. The following case excerpt
(continued from p. 4) will illustrate.

CHARLIE AND THE DOG, PART II

Charlie summoned my attention in the most restricted of voices. I turned to

see him sitting on a cushion on the floor at my right, stricken. His body was
totally rigid—arms pinned to his sides, legs stretched out in front—and he
could barely speak. Ruff was calmly lying beside him with her head on
Charlie’s knee. He managed to squeak out, “I am very distressed right now.
I am terribly afraid of dogs.” I asked if he could move Ruff away, or move
away himself but I could see that was not possible. Charlie was literally,
and visibly, frozen stiff (tonic immobility). With the help of a group member,
I managed to get Ruff to move away from Charlie. But he remained frozen
in place. Later, following therapeutic intervention (which will be described
in Chapter 8), as we talked about what had just occurred, Charlie was
convinced that Ruff had had her mouth on his thigh where he had
previously been bitten, not on his knee. In fact, he was astounded to learn
that Ruff had just laid her head on his knee. Charlie’s reaction was set in
motion by exteroceptive stimuli of touch and sight. Ruff’s contact with
Charlie’s right leg, combined with a glimpse from his right peripheral
visual field, had been reminiscent enough of his previous traumatic
encounter to trigger Charlie’s traumatized condition. His body instantly
remembered the attack.

This example illustrates state-dependent recall brought about by specific,

state-related conditions. Amazingly, Charlie was a regular at this retreat
center and had encountered Ruff many times previously without incident,
though he avoided her. He had never been triggered on previous occasions
because the right combination of stimuli had never before occurred.

THE AUTONOMIC NERVOUS SYSTEM:

HYPERAROUSAL AND THE REFLEXES OF FIGHT,
FLIGHT, AND FREEZE

The limbic system of the brain could be called “survival central.” It

responds to extreme stress/trauma/threat by setting the HPA axis in motion,
releasing hormones that tell the body to prepare for defensive action. The
hypothalamus activates the sympathetic branch (SNS) of the autonomic
nervous system (ANS), provoking it into a state of heightened arousal that
readies the body for fight or flight. As epinephrine and norepinephrine are
released, respiration and heart rate quicken, the skin pales as the blood
flows away from its surface to the muscles, and the body prepares for quick
movement. When neither fight nor flight is perceived as possible, the limbic
system commands the simultaneous heightened arousal of the
parasympathetic branch (PNS) of the ANS, and tonic immobility
(sometimes called “freezing”)—like a mouse going dead (slack) or a frog or
bird becoming paralyzed (stiff)—will result (Gallup & Maser 1977). As
mentioned previously, it is not yet known what is happening in the HPA
axis that causes the body to freeze instead of fight or flee.
 In the case of PTSD, cortisol secretion is not adequate to halt the alarm
response. The brain persists in responding as if under stress/trauma/threat.
At this time it is not known which is the first driving factor: a continued
perception of threat in the mind or insufficient cortisol. The result, however,
is the same: The limbic system continues to command the hypothalmus to
activate the ANS, persisting in preparing the body for fight/flight or going
dead, even though the actual traumatic event has ended—perhaps years ago.
People with PTSD live with a chronic state of ANS activation—
hyperarousal—in their bodies, leading to physical symptoms that are the
basis of anxiety, panic, weakness, exhaustion, muscle stiffness,
concentration problems, and sleep disturbance.
It is a vicious cycle, first set in motion in the service of survival, but
enduring as impairment. During a traumatic event the brain alerts the body
to a threat. In PTSD, the brain persists in calling and recalling the same
alert, stimulating the ANS for defensive reactions of fight, flight, or freeze.
The once protective reactions of heightened pulse, paled skin, cold sweat,
etc., so necessary for defense, evolve into the distressing symptoms of
disability. With Pavlov’s dog, an originally neutral stimulus (the bell)
became associated with and capable of eliciting a normal physiological
response to food (salivation). With PTSD the same thing happens. Objects,
sounds, colors, movements, etc., that might otherwise be insignificant
neutral stimuli become associated through classical conditioning to the
traumatic incident, causing traumatic hyperarousal. These stimuli then
become external triggers that are experienced internally as danger.
Confusion can result when recognition of external safety doesn’t coincide
with the inner experience of threat. Symptoms can become chronic or can
be triggered acutely. Breaking this cycle is an important step in the
treatment of PTSD.
Under normal circumstances, the PNS and SNS branches of the ANS
function in balance with each other (see Table 3.1). The SNS is primarily
aroused in states of stress, both positive and negative. The PNS is primarily
aroused in states of rest and relaxation, pleasure, sexual arousal, and others.
Both branches are always engaged; however, one is usually more activated,
the other suppressed—like the dipping and rising arms of a scale. When one
side is up, the other is down. In other words, under normal circumstances
they constantly swing in complementary balance to each other (Bloch,
1985). The following scenario illustrates the interactive balance of the SNS
and PNS:

Table 3.1. Autonomic nervous system (smooth muscles, involuntary).

SYMPATHETIC BRANCH
PARASYMPATHETIC BRANCH

Activates during positive and negative stress states, including: sexual climax, rage, desperation,
terror, anxiety/panic, trauma

States of activation include: rest and relaxation, sexual arousal, happiness, anger, grief, sadness

Noticeable signs

Noticeable signs
Faster respiration
Slower, deeper respiration
Quicker heart rate (pulse)
Slower heart rate (pulse)
Increased blood pressure
Decreased blood pressure
Pupils dilate
Pupils constrict
Pale skin color
Flushed skin color
Increased sweating
Skin dry (usually warm) to touch
Skin cold (possibly clammy)
Digestion (and peristalsis) increases
Digestion (and peristalsis) decreases

During actual traumatic event OR with flashback (visual, auditory and/or sensory)

During actual traumatic event OR with flashback (visual, auditory and/or sensory)
Preparation for quick movement, leading to possible fight reflex or flight reflex
Can also activate concurrently with, while masking, sympathetic activation leading to tonic
immobility: freezing reflex (like a mouse, caught by a cat, going dead). Marked by simultaneous
signs of high sympathetic and parasympathetic activation.
You are sleeping peacefully; the PNS is active and the SNS suppressed.
Then you awaken and find you set the clock wrong and are already one
hour late for work. The SNS shoots up; your heart rate accelerates, you are
instantly awake. You move quickly—showering, dressing, then leaping into
your car and gunning it to get you down the road. When you get to the first
corner you notice the clock on the church tower and realize this was the
weekend that winter time started and the clocks have turned back one hour;
actually, you are not late after all. The SNS decreases and the PNS rises.
Your heart rate slows; you breathe more easily and continue your journey
more relaxed. However, when you get to work, you find you double
scheduled your first appointment time and have two irate clients to deal
with. The SNS again accelerates, suppressing the PNS.…

So it goes throughout the average day, with the SNS and PNS swaying in
balance with each other to meet the variety of stresses and demands typical
of daily life. However, something very different happens under the most
extreme form of stress, traumatic stress. First the limbic system commands
the SNS to prepare the body to fight or flee. But if that is not possible—
there is not time, strength, and/or stamina to succeed—the limbic system
commands the body to freeze.
The most commonly observed instance of freezing is the mouse that
“goes dead” when caught by a cat. That image is useful to many with PTSD
who have frozen in the face of mortal threat, as they can relate to the
mouse’s dilemma as well as its physiological response. Instinctively, a
mouse will flee if its limbic system estimates it can get away. As with all
animals facing threat, the SNS activates drastically in order to meet the
demand for fight or (in this case) flight. If, however, the mouse becomes
trapped, or if during its attempt to flee, the cat nabs it, the mouse will “go
dead.” It will lose muscle tone, like a rag doll. According to Gordon Gallup
(1977) and Peter Levine (1992, 1997), the likely mechanism underlying this
hypotonic response, tonic immobility, is an unusual imbalance in the ANS.
In this extreme circumstance the SNS will remain activated, while the PNS
simultaneously becomes highly activated, masking the SNS activity,
causing the mouse to “go dead.” This has several evolutionary purposes,
including relying on the likelihood that the cat will lose interest (felines will
not eat dead meat unless they are starving), affording the possibility of
escape. Analgesia is also an important function of tonic immobility,
numbing the body and the mind. If the cat does eat the mouse, in its
deadened state the pain and horror of death will be greatly diminished
(Gallup & Maser, 1977; Levine, 1992, 1997).
Something similar appears to happen with humans when mortally
threatened. Interviews with people who have fallen from great heights, or
been mauled by animals and survived, reveal that they tend to go into a kind
of altered state where they feel no fear or pain. Rape is another prime
example. It is typical for the victim of rape, at some point, to become
literally unable to resist. The body goes limp, and many report being in an
altered state during that time. Many victims of rape suffer from dreadful
shame and guilt because of it. It is infuriating to continue to hear of rape
cases being thrown out of court because the victim had not fought back.
“Going dead” and being unable to fight back are frequent reactions to
physical violence such as rape and torture (Suarez & Gallup, 1979). How
one reflexively/instinctively responds to a life-threatening situation depends
on many factors, including one’s own instincts and one’s physical and
psychological resources. Bruce Perry and colleagues (1995) have theorized
that men respond more often to threat with fight and flight, and women and
children more often with going dead or freezing. Their theory makes sense,
as men often have more physical resources—constitutionally greater
strength, speed, and agility—than women and children. Additionally, this
could be due to learned behavior, as men and women are conditioned to
respond differently to threat. This is another area ripe for research. (Charlie
fainted when he was attacked. Whether fainting is a form of tonic
immobility is not known at this time, but it is a likely consequence of an
overwhelmed ANS.)
Understanding the funtioning of the ANS helps in explaining the
vulnerability to stress of those with PTSD. PTSD is characterized, in part,
by chronic ANS hyperarousal. The system is always stressed. A person with
a normal balance in the ANS will be able to swing with rises and falls of
arousal. When a new stress comes along the arousal in the SNS moves from
little or no arousal to higher arousal and then back again when the stress is
dealt with. For those with PTSD the picture is different: When SNS arousal
is constantly high, adding a new stress shoots it up even higher; it is easy to
go over the top, causing them to feel overwhelmed. This difficulty is
familiar to many with PTSD who wonder why they cannot handle daily
stress like everyone else or like they used to be able to.

THE SOMATIC NERVOUS SYSTEM: MUSCLES,

MOVEMENT, AND KINESTHETIC MEMORY

The somatic nervous system (SomNS) is responsible for voluntary

movement executed through the contraction of skeletal muscles.
Understanding the function of the SomNS is pertinent to grasping the
mechanism by which traumatic events can be remembered implicitly
through the encoding of posture and movement.
Basically, the only thing a muscle can do actively is contract. That is it. A
muscle contracts when it receives an impulse through the nerve that serves
it. Impulses for contraction of visceral muscles are primarily transmitted
through nerves of the autonomic nervous system (ANS); impulses for
contraction of skeletal muscles are carried through nerves of the SomNS.
As long as a muscle continues to receive neural impulses, it continues to be
contracted. When lifting a heavy object, for example, several muscles are
stimulated to contract, remaining contracted until the object is released.
Muscle tension is an active process comprised of chronic muscle
contraction. Relaxation, usually thought of as an active process, “Hey, just
relax,” is actually a passive state. It is the absence of neural impulses,
noncontraction.
To move any part of the body in any way, in any direction, it is necessary
to contract at least one skeletal muscle.

Look at the palm of your left hand. Try to separate your left little finger
from the other fingers of that hand without moving the rest of your hand or
other fingers.
That little movement is accomplished by a neural impulse, sparked by the
words in the previous sentence. The impulse is transmitted from the brain
along the ulnar nerve and causes contraction of the muscle abductor digiti
minimi of the left hand, causing the little finger to move away from the
other fingers. When the finger is not purposefully moving to the side, it will
come back toward the other fingers. That lesser movement is actually
caused by the noncontraction (relaxation) of the abductor digiti minimi.
Most physical movement is much more complex, accomplished through
multiple, simultaneous, and/or consecutive muscle contractions and non-
contractions.

Next try to move your right index finger to touch your nose in slow motion.

That simple movement is actually made up of several muscle contractions

—some consecutive, some simultaneous—and noncontractions. Specific
muscles are being stimulated to contract in order to point the finger, close
the hand, turn the hand, bend the elbow, and raise the arm. At the same
time, there are other muscles that must remain noncontracted (relaxed) in
order for the arm to bend and permit the movement of the elbow away from
the body. All of these elements are necessary to accomplish what appears to
be the single, simple movement of touching index finger to nose. It is the
SomNS that commands the movement and the kinesthetic sense that assures
its accuracy.
It is through the SomNS that behaviors, movements, and physical
procedures are performed. It is via interoceptive, proprioceptive nerves that
they are perceived. For a movement to be encoded and recorded as implicit
memory, both nerve sets are necessary. The somatic nerves cause a
movement, the interoceptive nerves give you the feeling of it. It is the
interoceptive system that helps you know that you are making the correct
movement, especially when you are not observing what you are doing.
For a new procedure, movement, or behavior to be maintained in
memory, proprioceptive nerves from muscles, tendons, and skeletal
connective tissue—ligaments and fascia—relay information on position,
posture, and action via afferent nerves to the brain. For an old procedure,
movement, or behavior to be recalled into use, those same schemata need to
be activated and then relayed via efferent nerves, through the SomNS and
proprioceptive system, out to the appropriate muscles and connective
tissues. The SomNS will cause the contraction of the muscles necessary to
accomplish the movement. The proprioceptive nerves will give feedback on
the correctness of the movement.
When a new behavioral sequence is learned, images associated with that
learning experience (positive or negative) may be stored simultaneously.
When that same behavioral sequence is repeated, those images are
sometimes also recalled.

Have you ever taught a child to tie a shoe? I did last year and I remember it
as being a bit exasperating. As I’d been tying my own shoes for many, many
years, it was totally automatic. It took me several minutes to think of just
how I do it, and a while longer to be able to communicate the maneuver to
my young friend. I endeavored to simply describe what for my fingers
became automatic long ago. Once I had a feel for the procedure, I had to
further slow it down and break it up into microsteps that the child could
follow. For years, without thinking about it, each hand “knew” which lace
to take, which way to turn one over the other, etc. It was a great challenge
to resolutely think about what I was doing and, furthermore, explain it. I
sometimes became confused and, while in the midst of it all, I had flashes of
remembering my father teaching me to tie my shoes in this same way. Were
those images triggered by the situation, the theme, the replicated
movements, or a combination of all of these elements? Eventually, I was
able to competently explain and demonstrate the procedure in slow motion.
My young friend watched with great interest and attempted to duplicate my
every move. But for her, of course, it was something new and she tried many
times before getting it right once, several more to get it right consistently.
She had to concentrate intensely on what her fingers were doing each step
of the way. By the next week she had it down pat. That experience gave me
pause: I wonder if she will recall some of these images of me teaching her
when as an adult she engages in the behavior of teaching a child to tie his
laces in the same way? Will replicating these same movements bring me to
mind?
 Trauma, Defense, and the Somatic Nervous System

The autonomic nervous system, among other things, directs blood flow
away from viscera and skin to the muscles for the duration of fight, flight,
and freezing responses. The somatic nervous system directs the musculature
to carry out that response. Without quick and powerful movements of
muscles controlled by it, there would be no fight and there would be no
flight. The freezing—tonic immobility—state would also be impossible
without its action.
Defensive behavior can be instinctual or learned through instruction or
conditioning. Even usually instinctual defensive reflexes must sometimes
be taught. Some infants born prematurely will lack, for example, the falling
reflex. Many can then be taught to reach out hands and arms to catch their
falls. In such a circumstance the specific neural impulses must be trained to
respond automatically to the cue of falling.
Other types of training can go a long way to prepare individuals to meet
certain kinds of stressful or traumatic incidents, raising self-confidence. For
example, many women and men who have been assaulted or raped have
benefited from self-defense training, which reawakens normal fight
responses and teaches additional protective strategies. Self-defense training
is accomplished through repeatedly practicing defensive movements,
building synaptic patterns that will repeat spontaneously under threat.
Safety in schools and on the job also depends on the creation of
automatic reactions and behaviors. Fire, earthquake, and other types of
drills prevent panic through rehearsal of precise behaviors (where to go and
what to do) and sometimes of specific movements (dive under the desk).
Operant conditioning plays a role here, too. Fight, flight, and freeze
responses are not just instinctual behaviors; they are subject to influence—
positive and negative—according to how successful or unsuccessful they
have been in actual use. When a defensive behavior is successful, it
becomes recorded as effective; the chance of the same behavior being used
in a future threatening situation increases. Likewise, when a defensive
behavior fails, the chance of repeating it decreases. For example, if a boy is
harassed by a group of bullies and is successful in defending himself, later
as an adult, he will be more likely to strike a defensive posture when
threatened. If, however, he is overpowered by the bullies and, furthermore,
goes into tonic immobility, when threatened as an adult he will be more
likely to freeze. A behavior does not always require repetition to be encoded
and stored. Behaviors associated with traumatic incidents can be instantly
stored via the SomNS. In some cases it takes only one traumatic incident
where defensive behavior was either impossible or unsuccessful for it to be
wiped from an individual’s protective repertoire. (See Daniel’s case on p. 89
for an example of applying behavioral repetition as a resource in the
therapy session. The conclusion of Charlie’s therapy on p. 171 also
illustrates this principle.)

Traumatic Memory Recall and the Somatic Nervous System

You were just in your living room and wanted something. You come into the
kitchen and … “What was it I came in here for?” You scratch your head.
You swear. You can’t remember. You wrack your brain. You go back to the
spot where the intention originated, assuming the same sitting posture you
were in at that moment—BINGO! “Now I remember!”

That recall strategy doesn’t always work, but it does often enough that
many use it. What is it about resuming a particular body posture, one held at
the time an idea is germinated, that aids in memory recall? The above
example is a useful application of the concept of state-dependent recall. As
previously mentioned, the theory of state-dependent recall holds that if you
return to the state you were in at the time a piece of information was
encoded, you can retrieve that same piece of information. Though usually
discussed in reference to internal states, state-dependent recall is
exceedingly relevant to postural states.
State-dependent recall can sometimes be triggered through the SomNS
by inadvertently (or purposely) assuming a posture inherent in a traumatic
situation. When used purposefully, it can aid the possibility of memory
recall and/or reestablishment of behavioral resources. Reconstructing the
movements involved in a fall or a car accident can often accomplish this.
However, when state-dependent recall hits unexpectedly, it can cause chaos:
A mid-thirties woman sought therapy for panic that developed while making
love with her husband. Her arm had accidentally gotten caught under her
in an awkward position, firing off memories of a rape she thought she had
long put behind her. The rapist had pinned the same arm under her in the
same position.

Often, the movements caused by the SomNS can be used to intentionally

facilitate state-dependent recall. Following nuances of movement can also
be useful. The following case illustrates how focusing on a seemingly trival
movement has the potential to catalyze a trauma therapy.

Carla’s 3-year-old daughter had died four years ago. Carla had become
fixated on the horror of the illness and was unable to speak of her child’s
death and process the meaning of her loss. During one therapy session,
Carla mentioned one of the medical consultations; she remembered it as
being particularly difficult, but couldn’t recall why. As she spoke, I saw that
Carla’s head was making slight jerking movements to her right. I brought
this to her attention. She had not been aware of it, but noticed it now that I
mentioned it. I encouraged her to let the movement develop if she could.
Slowly the movement became bigger, becoming an obvious turn of the head
to the right. When her head made its full turn, Carla began to cry. Now
Carla remembered. At that consultation, she sat facing the doctor, but to her
right was the illuminated x-ray that told the tale of her daughter’s fate; she
had not been able to look at it. It was at that consultation that Carla first
knew her daughter would not be able to survive. Making this connection
was an important step in helping Carla to move past the horror of the
diagnosis to the grief of her loss.

The SomNS has many roles in the experience of trauma. It carries out the
trauma defensive responses of fight, flight, and freeze through simple and
complex combinations of muscular contractions that result in specific
positions, movements, and behaviors. In cooperation with proprioception,
the SomNS is also party to encoding traumatic experiences in the brain.
Somatic memory recall can occur when those same positions, movements,
and behaviors are replicated either purposefully or inadvertently.

EMOTIONS AND THE BODY

Emotions, though interpreted and named by the mind, are integrally an

experience of the body. Each emotion looks different to the observer and
has a different bodily expression. Every emotion is characterized by a
discrete pattern of skeletal muscle contraction visible on the face and in
body posture (somatic nervous system). Each emotion also feels different
on the inside of the body. Different patterns of visceral muscle contractions
are discernible as body sensations (the internal sense). Those sensations are
then transmitted to the brain through the proprioceptive nerves. How an
emotion looks on the outside of the body, in facial expression and posture,
communicates it to others in our environment. How an emotion feels on the
inside of the body communicates it to the self. To a large extent, each
emotion is the result of interplay between the sensory, autonomic, and
somatic nervous systems interpreted within the brains cortex.
The English language is a bit awkward when it comes to differentiating
the conscious experience of emotions from body sensations. The word
“feeling” usually stands for both: I feel sad and I feel a lump in my throat.
Perhaps it is no accident that “feel” stands for both experiences, a semantic
recognition that emotions are comprised of body sensations. A possible way
out of the confusion, though, might be to distinguish between feelings,
emotions, and affects. Donald Nathanson (1992) addresses this dilemma.
He distinguishes affect as the biological aspect of emotion, and feeling as
the conscious experience. Memory, he suggests, is necessary to create an
emotion, while affects and feelings can exist without memory of a prior
experience.
That emotions are connected in some way to the body should come as no
surprise. Everyday speech is full of phrases—in many languages—that
reflect the link of emotion and body, psyche and soma. Here are a few
examples from American English:
Anger—He’s a pain in the neck.
Sadness—I’m all choked up.
Disgust—She makes me sick.
Happiness—I could burst!
Fear—I have butterflies in my stomach.
Shame—I can’t look you in the eye.

There is also commonality in physical sensation of emotion—how an

emotion feels in the body:

Anger—muscular tension, particularly in jaw and shoulders

Sadness—wet eyes, “lump” in the throat
Disgust—nausea
Happiness—deep breathing, sighing
Fear—racing heart, trembling
Shame—rising heat, particularly in the face

And typical physical behaviors that go with each emotion:

Anger—yelling, fighting
Sadness—crying
Disgust—turning away
Happiness—laughing
Fear—flight, shaking
Shame—hiding
And, of course, many facial and postural expressions of emotion are easily
recognized (though some are much more subtle) by the observer:

Anger—clamped jaw, reddened neck

Sadness—flowing tears, reddened eyes
Disgust—wrinkled nose with raised upper lip
Happiness—(some kinds of) smile, bright eyes
Fear—wide eyes with lifted brows, trembling, blanching
Shame—blushing, averted gaze

Emotions are expressed from the first moments of life outside of the womb.
The typical wail of the newborn as it exhales its first breath could be
interpreted as a first expression of emotion. The newborn is limited in its
emotional repertoire. At first it is only able to distinguish between
discomfort and comfort, wailing in response to the former, calm in response
to the latter. During the first weeks of life, distinct emotions are of limited
range. Quickly, though, the baby’s collection increases, differentiating
nuances within the ranges of discomfort and comfort.
There are several theoretical models of emotion. What to call individual
affects is subject to debate, though most models include some form of
“anger,” sadness, rear, disgust, happiness, and shame among their lists.
Certainly how an individual names his own emotions is subject to variation,
depending on how emotions were labeled by her family and culture. In this
chapter, though, our concern is not with what an emotion is called. What is
pertinent to this part of the discussion of trauma and the body is how an
emotion is sensed and expressed.

A Select History of the Emotion-Body Connection

Charles Darwin’s Cross-cultural Survey

Charles Darwin was the first scientist to systematically investigate the
universality of emotion and the somatic features of emotional expression in
man. In 1867 he surveyed an international group of missionaries and others
who were living around the world in different cultures: Aboriginal, Indian,
African, Native American, Chinese, Malayan, and Ceylonese. He asked
specific questions in order to find out if types of emotions, as well as their
observable expressions, were consistent throughout different cultures. He
discovered that not only was there great commonality to all ranges of
emotion across unrelated and often isolated cultures, but there was also
commonality to the somatic expression of those emotions (Darwin,
1872/1965). When reviewing Darwin’s work, one can have little doubt that
emotions and the body go hand in hand the world over.

Tomkins’s Affect Theory

Silvan Tomkins’s affect theory was born simultaneously with his first child.
As he witnessed this momentous event he was drawn to the infant’s
emotional outburst, amazed at the similarity of expression between the
infant’s cry and an adults. From this impetus his study broadened to
encompass identifying the similarity of emotional expression across
generations. He was most interested in categorizing each identified affect
by physical expression, noting not just the facial characteristics of each, but
also changes in body posture. Donald Nathanson (1992) has taken
Tomkins’s theories several steps further.

Joseph LeDoux’s Emotional Brain

Joseph LeDoux’s theories on the relationship of the body and emotions are
well known and highly respected. He recognizes the interdependence of
brain and body, as well as the bodily expressions of emotion. The
evolutionary function of emotions, he believes, are associated with survival
—both with regard to dealing with hostile environments, and in furthering
the species through procreation (LeDoux, 1996).
 Antonio Damasio’s Somatic Marker Theory

Neurologist Antonio Damasio has worked with and studied individuals with
damage to regions of the brain having to do with emotion. He has
discovered that emotion is necessary to rational thought. Further, he found
that body sensations cue awareness of the emotions. Damasio (1994)
concludes that to be able to make a rational decision, one has to be able to
feel the consequences of that decision. Just projecting a cognitive judgment
is not enough; it is the feel of it that counts.
According to Damasio, an emotion is a conglomerate of sensations that
are experienced in differing degrees, positive and negative. They make up
what he calls somatic markers, which are used to help guide decision-
making. That is, body sensations underlie emotions and are the basis for
weighing consequences, deciding direction, and identifying preferences.
The most recognizable example of the function of somatic markers are
the kinds of choices people make everyday based on “gut feelings.”

The Somatic Basis of Emotion

The following four-part exercise is intended to offer a firsthand experience

of what is meant by the somatic basis of emotion.

First, take a minute to survey the sensations of your body right now. Notice
your breathing—where and how deep. What is your skin temperature—is it
consistent all over? Check your heart rate—either subjectively or by taking
your pulse. Check out the position of your shoulders—are they raised,
fallen, hunched? Are they tense or relaxed? Notice the sensations in your
gut—relaxed, tense, butterflies, hungry, etc. Lastly, notice if you are moving
or twisting or tilting your body or any body part in a particular way.
Second, think about the emotion of anger. Remember, the last time you
were angry. Can you bring forth any of that feeling? What were you angry
about and who were you angry with? What did you say and/or think? Are
there any remnants of that emotion? Again survey your breathing, skin
temperature, heart rate, shoulder position and tension, stomach sensations.
Also notice your position, posture, or behavior. Has anything changed from
your first survey: autonomic signs, muscle tension, movement?
Third, remember a time you felt happy and safe. Where were you? What
were you wearing? Who were you with? Bring up the scene with as much
visual, auditory, and sensory imagery as you can muster. What do you feel
in your body? Has it changed from when you were feeling angry? Is your
muscle tension the same? How about your heart rate? Are you smiling?
Fourth, remember a time you felt afraid. Do not pick your worst
traumatic event, but something with a small amount of fear. What was it
that scared you? When you remember it now, what happens in your body?
Are you breathing differently? Has your heart rate changed? Have muscles
become tense or flaccid? What is the temperature of your hands and feet?
Before ending the experiment, return to the memory of when you felt
happy and safe. Bring back the imagery of the place, activity, and others
who were present. Now what do you sense in your body?

Emotions and Trauma

Anger/Rage

Anger is an emotion of self-protection. It may involve an effort to prevent

injury or specify a boundary. It is also a common response to having been
threatened, hurt, or scared, or to the person who caused it. Anger can
escalate to rage when the threat is extreme or when assertions of “Don’t!”
or “Stop!” are not respected. When anger or rage become chronic in the
wake of trauma, difficulties can emerge in an individual’s daily life.
Inappropriate or misdirected anger can interfere with interpersonal
relationships and job stability; provoking others to anger can become a
danger in itself. How many instances of “road rage,” for example, are
incited by a short temper that has its roots in unresolved trauma?

Anxiety/Fear/Terror
Fear alerts one to danger or potential harm. Both fear and anxiety are
common emotions for those with PTS and PTSD. LeDoux (1996)
distinguishes between the two: Fear, he believes, is stimulated by something
in the environment; anxiety is stimulated within the self. LeDoux also sees
fear as the driving force in several psychological disorders: phobias, anxiety
and panic disorders, and obsessive-compulsive disorders.
Terror is the most extreme form of fear. It is central to the experience of
trauma, the result of the (perception of) threat to life. The biology of terror
involves the HPA axis and sympathetic nervous system arousal discussed
previously in this chapter. Once the trauma is over, terror usually reduces to
fear, even for those suffering its aftermath. However, during a flashback,
terror can return in all of its original intensity.
One of the problems for individuals with PTS and PTSD is that fear
persists long after the threat abates, frequently associating to more and more
aspects of their environment. The fear they once felt to an external threat
becomes anxiety generated from within. As discussed earlier, this might be
caused by insufficient cortisol production, or it could be caused by a
continued perception of threat. Whatever the cause, the result is debilitating.
When fear is so broadly generalized, its protective function becomes
handicapped. When everything is perceived as dangerous, there is no
discrimination of what truly is dangerous. It is like a burglar alarm that’s
ringing all the time. You never know when it is ringing for real. It is typical
for those with PTSD to repeatedly fall prey to dangerous situations. Their
internal alarm systems are so overloaded that they have become disabled.
One result of trauma therapy is the reestablishment of the protective
function of fear.

Shame—Disappointment in the Self

Shame is a difficult emotion to deal with in any context. This is no less true
for shame that arises as the result of trauma. Individuals with PTSD often
have a large component of shame involved in the disorder. Shame is
expected to be a component of PTSD when the trauma is the result of
sexual abuse or rape. It is less expected under other circumstances. Why,
then, is shame such a common feature of other trauma constellations? In
almost any unresolved trauma there will be the question of “Why couldn’t I
stop that (do more, fight back, run away, etc.)?” It is possible that
individuals with PTSD believe on some deep level that they have let
themselves (and perhaps others) down and/or that something integral is
wrong with them that they fell victim to the trauma. Of course, shame is not
the only driving force in PTSD, but it may be an important one.
One of the difficulties with shame is that it does not seem to be expressed
and released in the same way as other feelings: Sadness and grief are
released through crying, anger through yelling and stomping about, fear
through screaming and shaking. What, then, can be done to alleviate shame
when it does not discharge, abreact, or cathart? Acceptance and contact
appear to be keys to relieving shame. Though it appears not to discharge, it
does seem to dissipate under very special circumstances—the
nonjudgmental, accepting contact of another human being.
When considering shame, it can be important to look at both of its sides.
Usually shame is perceived as a terrible emotion, because it is so awful to
feel. Who wants to feel shame? However, shame, like every other affect has
a survival value. Fear, for example, warns of danger, while anger tells the
other not to take one step (literally or figuratively) closer. What, then, is the
survival value of shame? It appears that shame, at least through evolution,
has served to keep an individual’s behavior in line with cultural norms that
further “survival of the tribe.” It socializes. Shame is an accepted
component of socialization in many cultures. It is an emotion that has been
elicited for thousands of years when a person’s behavior has threatened not
only himself, but also his whole group. Shame is one element that stops us
from behaving in ways that might hurt us, our families, and our
communities. It may, in fact, be the emotion that underlies the formation of
a conscience. As an affect, shame is not all bad. It is common knowledge
that acceptance is the first step in resolving any unwanted emotional state,
and seeing shame as having a positive function might assist in achieving
that step.

Grief
Grief is a response to loss or change. It is a great resource in the treatment
of trauma and PTSD. By its nature, grief is a sign that an experience has
been relegated to the past. It is usually a positive sign when a trauma client
reaches the stage where grief arises. Sometimes a client will fear that his
grief is a regression into trauma, but it is usually just the opposite, a healing
progression. When working with body awareness, most clients will notice
that their grief helps them to feel more solid, less fearful, if more sad. Grief
usually emerges at various steps along the way in trauma therapy when an
aspect of the trauma is resolved and the internal experience changes from
present to past: “I was really scared,” “That was really bad,” etc. In this
context grief is a sign that healing is taking place.

Integrating vs. Disintegrating Emotional Expression—A Proposal

Catharsis and abreaction are often used interchangeably to describe

expression of emotions in the therapeutic setting. Catharsis actually refers
to the cleansing power of emotions when disturbing memories are brought
forth into consciousness. Abreaction is the emotional discharge that often
accompanies catharsis. Regardless of what one calls these emotional
eruptions, care must be taken, especially with trauma clients.
There is an ongoing professional debate as to the usefulness of
abreaction in the treatment of PTSD. When a client is crying or expressing
anger, it is not always easy to tell if such emoting is helping or making
matters worse. The question usually debated is whether or not abreaction
should be allowed or encouraged at all. However, the relevant question is:
When does abreaction help and when does it not?
This debate points the way to an important area for research: how to
distinguish integrating from disintegrating abreaction. Is it possible that
observation of autonomic nervous system (ANS) arousal could hold a key
to distinguishing these two ranges of emotional expression during trauma
therapy—the one that appears to be therapeutic and integrating and the
other that might be disintegrating and possibly retraumatizing?
It is possible that therapeutic abreaction can be recognized by hallmarks
of primarily parasympathetic arousal: The skin has color, respiration is deep
with emotional sounds coming on the exhale. Disintegrating abreaction, on
the other hand, might be revealed to have hallmarks of primarily
sympathetic arousal: The skin is pale, sometimes clammy, respiration is
rapid, sometimes jerky, emotional sounds come mostly on the inhale.
Observing the ANS to differentiate types of abreaction could greatly
facilitate and simplify the therapeutic process.
CHAPTER FOUR
 Expressions of Trauma Not Yet
Remembered
Dissociation and Flashbacks

Traumatic dissociation and traumatic flashbacks are the two most salient
features of PTSD. Both are at the root of its most distressing psychological
and somatic symptoms. As mentioned before, dissociation might be a
constant factor in every case of PTSD. Some form of flashback might also
be a constant. These two aspects of PTSD often occur in tandem; it is not
possible to have traumatic flashbacks without some form of traumatic
dissociation also being operable, though dissociation can occur without
flashbacks.
As mentioned before, dissociation implies a splitting of awareness.
During a traumatic incident, the victim may separate elements of the
experience, effectively reducing the impact of the incident. The process of
dissociation involves a partial or total separation of aspects of the traumatic
experience—both narrative components of facts and sequence and also
physiological and psychological reactions. Amnesia of varying degrees is
the most familiar kind of dissociation, but there are others. One person
might become anesthetized and feel no pain. Another might cut off feeling
emotions. Someone else might lose consciousness or feel as if he had
become disembodied. The most extreme form of dissociation happens when
whole personalities become separated from consciousness (dissociative
identity disorder). Later those same reactions and/or others may still be
operational. One might continue to become anesthesized when under stress,
be unable to access emotions, or feel disembodied when anxious.
A flashback is a reexperiencing of the traumatic event in part or in its
entirety. Most familiar are visual and auditory flashbacks, but the term
flashback might also apply to somatic symptoms that replicate the traumatic
event in some way. Whatever the sensory system involved, a flashback is
highly distressing, because it feels as though the trauma is continuing or
happening all over again.
In people with PTS and PTSD, traumatic event(s) are remembered
differently than nontraumatic events. They are not yet actually
“remembered” in the normal sense. Usually, “memory” implies the
relegation of an event into one’s history—a position on one’s lifeline.
Memory puts an experience into the past, “I remember when …” With PTS
and PTSD traumatic memories become dissociated, freefloating in time.
They pounce into the present unbidden in the form of flashbacks.

DISSOCIATION AND THE BODY

The term dissociation has been within the psychological lexicon for over
one hundred and fifty years. It was first coined by Moreau de Tours in 1845
(van der Hart & Friedman, 1989) as an attempt to understand hysteria. The
concept was further developed by Pierre Janet beginning in 1887 with his
article, “Systematized Anesthesia and the Psychological Phenomenon of
Dissociation.” Janet could be called the “father of dissociation,” as it is his
work in this area that laid the foundation for current theories. He
hypothesized that consciousness was comprised of varying levels, some of
which could be held outside of awareness. In the latter part of the twentieth
century, Janet’s work was rediscovered and applied to modern theories of
dissociation and PTSD (van der Hart & Friedman, 1989; van der Kolk,
Brown, & van der Hart, 1989).
Even though the concept has been in use for a long time, how
dissociation occurs is not yet known, though there is plenty of speculation.
It appears to be a neurobiological phenomenon that occurs under extreme
stress. Whether it is an attempt by body and mind to dampen traumas
impact or a secondary result of trauma is unknown. It is possible that
dissociation is the minds attempt to flee when flight is not possible
(Loewenstein, 1993).
Individuals who report dissociative phenomena during traumatic
incidents express it as: “It was like I left my body.” “Time slowed down.” “I
went dead and could not feel any pain.” “All I could see was the gun,
nothing else mattered.” After an event the victim can still feel dissociated,
continuing to feel “beside oneself” long after the event is over. In Sue
Grafton’s (1990), “G” is for Gumshoe, protagonist Kinsey Millhone
describes dissociation a few hours after she was nearly shot as, “My souls
not back in my body yet.”

Calvin and Hobbes ©1992 Watterson. Reprinted with permission of Universal Press Syndicate. All
rights reserved.

Following a traumatic event, dissociative phenomena can continue for

years or even arise for the first time years later. They may be identified by
numbing, flashbacks, depersonalization, partial or complete amnesia, out-
of-body experiences, inability to feel emotion, unexplained “irrational”
behaviors, and emotional reactions that seemingly have no basis in reality.
It is likely that some form of dissociation is fueling every case of PTS and
PTSD.

The SIBAM Model of Dissociation

Peter Levine’s SIBAM dissociation model is most useful for

conceptualizing dissociation. It is based upon the supposition that any
experience is comprised of several elements. Complete memory of an
experience involves integrated recall of all of the elements. SIBAM is the
acronym for: Sensation, Image, Behavior, Affect, and Meaning (Levine,
1992). These are the elements of experience identified by Levine. He
postulates that elements of highly distressing/traumatic experiences can be
dissociated from one another. This postulation is based on the premise that
less distressing experiences remain intact in memory. A simple example of a
complete experience can be found in the memory of last night’s dinner:

I had a Mexican meal. Right now I can still feel the bite of the chilis in my
mouth (sensation). I can visualize my plate with the variety of colors
(image). There is more saliva in my mouth and a urge to swallow
(behavior). I feel content and peaceful as I remember the pleasant meal
(affect). And it was a relaxing break from my work (meaning).

Memories associated with a greater degree of stress can also be

remembered fully.

When Karen was about 6 she fell from a tree swing. When as an adult she
described the incident during a therapy session, she remembered she was
pushed from behind: “I can feel the hands on my back side and the drop
feeling in my stomach from the swish of the swing (sensation). I can see the
ground below as I swing, and then the sky above after I fell (image). I feel a
little anxious, and then angry as I remember (affect) and I stop breathing so
deeply (behavior). I remember feeling I was out of control because the girl
pushing me wouldn’t stop (meaning).”

Levine proposes that during some episodes of traumatic stress elements of

the experience become disconnected. An individual with PTS or PTSD
might later report a disturbing visual memory (image) and a strong emotion
connected to it (affect), but cannot make any sense of it (dissociated
meaning); a child might exhibit repetitive play after a disturbing event
(behavior), but doesn’t display any emotion (dissociated affect) or appear to
remember it at all (image).
One shortcoming of the SIBAM model is that there is no mechanism for
distinguishing traumatic dissociation from simple forgetting. Of course,
forgetting might be just the result of an experience not being significant
enough to encode fully or at all into long-term memory.
Returning to the concept of memory systems, understanding dissociation
in the context of the SIBAM model becomes easier. Implicit memory
involves sensory images, body sensations, emotions, and automatic
behaviors. Explicit memory involves the facts, sequence, and resolution
(meaning). Dissociation can appear in many forms, as varying combinations
of elements are dissociated. And of course, unless there is complete
amnesia, when some elements are dissociated others are associated. In
Figure 4.1, possible pairings are proposed for understanding three
symptoms of PTSD.

Figure 4.1. A sampling of relationships of dissociated SIBAM elements with specific trauma
reactions. The dark lines indicate which elements are associated; the lighter lines, which elements are
dissociated.
 Clients with anxiety and panic attacks may talk persistently about
disturbing physical sensations and resulting fear (affect). It may be difficult
or impossible for them to identify what they heard or saw that triggered the
anxiety (image), what they need to do to reduce the anxiety (behavior), or
what the fear actually stems from (meaning). Clients trapped in visual
flashbacks will shuttle between the images and terror, blocked in their
ability to feel their body in the present (sensation), move in a way that
would break the spell (behavior), or put the memory into context (meaning).
The SIBAM model can be an effective tool for helping to identify which
elements of an experience are associated and which are dissociated. Once
identified, missing elements can be carefully assisted back into
consciousness when the client is ready. (Charlie remembered most of the
attack; he had visual images of it. He was very aware of his body sensations
and emotions, and he knew what it meant to him. However, he was missing
at least two salient pieces. One was an additional aspect of meaning: being
able to discriminate the dog who attacked him from other dogs. The other
was a protective behavioral strategy that he could engage to protect himself
See Chapter 8 for a description of how those elements were finally
integrated.)

FLASHBACKS

The term flashback was popularized in the 1960s to describe disturbing

sensory experiences reported by individuals who had used the drug LSD.
Following use of the drug—days, weeks, even years later—some of them
reexperienced aspects of their most frightening hallucinogenic “trips.”
Traumatic flashbacks are quite similar. They can occur while awake or in
the form of nightmares that disrupt sleep. One client called them “having
nightmares while I am awake.” Traumatic flashbacks are comprised of
sensory experiences of terrible events replayed with such realism and
intensity that they are difficult to distinguish from in-the-moment reality.
Flashbacks that are primarily visual and/or auditory are the type most
commonly identified. They are easily recognized, as the individual can
usually describe what he is seeing or hearing. Less familiar are flashbacks
that are primarily emotional, behavioral, and/or somatic. Instances of
hyperarousal, hyper-startle reflex, otherwise unexplainable emotional upset,
physical pain, or intense irritation may all be easily explained by the
phenomenon of flashback. Lindy, Green, and Grace (1992) reported on
sensory and behavioral flashbacks, describing what they termed “somatic
reenactment” of traumatic events. One woman’s recurring somatic and
behavioral flashback involved a persistent, debilitating symptom of urinary
urgency that caused her repeated, unnecessary trips to the restroom. Both
symptom and behavior developed following a restaurant fire where her life
was literally spared by an empty bladder; her friends had died, trapped in
the restroom. She had not needed to join them and escaped with her life.
“Mrs. F’s symptom repetitively captured the moment when she, sensing no
pressure on her bladder, chose not to join her friends while they, sensing full
bladders, went to their deaths” (Lindy et al., 1992, p. 182). This example
poignantly illustrates how someone can act in ways that seem to make no
sense unless you know the trauma history. However, the nature of somatic
reenactment becomes clear when the missing pieces of information are
supplied. It is possible that certain unexplainable physical symptoms that
puzzle doctors and plague patients may be incidents of somatic
reenactment.
Behavioral flashbacks are quite common, though not often recognized as
such. Young children, for example, are apt to act out their traumatic
experiences rather than verbalizing them. Which types of behavior are
flashbacks is sometimes not clear. For example, is the child who molests or
physically harms another youngster being aggressive, or is he reenacting
what was done to him? This is another area worthy of scientific research.

Flashbacks and the Brain

Flashbacks can be varied. They can involve the recall of implicit memory of
a traumatic event in the absence of explicit memory, so that the references
necessary to make sense of the memory or to put it in perspective are
lacking. They can also involve explicit memory of the sequence (including
scenes) of the whole or parts of the event. Flashbacks almost always include
the emotional and sensory aspects of the traumatic experience; that is why
they are so disturbing. This implies that the amygdala is part and parcel of
the flashback process. At the same time, it appears that the contextual
features typical of hippocampal processing are absent, which would be
consistent with theories indicating hippocampal suppression during trauma
and trauma recall (Nadel & Jacobs, 1996; van der Kolk, 1994, among
others). In addition, flashbacks are usually set in motion through either
classically conditioned or state-dependent triggers. That would imply that
the whole nervous system is involved in the phenomenon. Three examples:

Roger was in his early twenties when as a rookie policeman he shot and
killed a suspect for the first time. He froze as he watched blood flow from
the man’s chest. He kept yelling, “I’m sorry. Why’d you make me do that?”
He seemed to recover and handle the situation well until two years later
when he was the first officer on the scene where a man had been shot
during a brawl. The next officer to arrive found Roger yelling those same
words, apparently confusing the two situations.

With Roger it is clear that a visual cue, blood flowing from a dead man’s
chest, triggered his flashback. He was horrified to have killed someone.
When at first he could not reconcile what had happened, he just forgot
about it and it seemed not to bother him anymore. Obviously that was not
the case.

Marie was 29 when her daughter, Tanya, turned 5. On the first day of
kindergarten, Marie went into a panic and would not let Tanya go to school.
Marie kept Tanya home for several weeks, panicking each morning when
she should have dropped her off at school. The rest of the day, Maria was
fine. Finally her husband convinced her to seek treatment. Maria had
reacted without knowing why. It was only during psychotherapy that she
recalled being molested at the same age in her kindergarten. Newspaper
archives confirmed that a teacher’s aide had been convicted of molesting
several of the children.
Marcy suffered chronic bladder infections as a child. She was subject to
many forms of invasive treatments in an effort to cure her condition. As she
grew up, though she always remembered having the infections, she had no
memory of the doctor visits. Shortly after she was married she suffered a
bout of cystitis—not uncommon for a new bride. During the doctor’s
examination, she became so hyperaroused that she broke into a cold sweat
and became panicked. She was unable to tell the doctor what she was
feeling and she proceeded to faint.

Marcy’s sensory flashback was triggered by sensation and posture. It was

only later that she was able to connect her reaction to her earlier treatments.
They had clearly been more distressing than she had remembered.

Summary
Understanding the phenomenon of flashbacks is one of the best ways to
consolidate the theory that has been presented in Part I. Flashbacks are
comprised of dissociated, implicitly stored information that becomes
elicited under state-dependent conditions. They can be triggered by
interoceptive or exteroceptive sensory cues, and are expressed through
hyperarousal of the autonomic nervous system as well as behaviors directed
by the somatic nervous system.
In Part II, principles and techniques for stopping and preventing
flashbacks, as well as other trauma-related symptoms, will be presented.
 PART TWO

Practice
CHAPTER FIVE
 First, Do No Harm

Timing Toast
There’s an art of knowing when.
Never try to guess.
Toast until it smokes and then
twenty seconds less.
—Piet Hein

Most psychotherapists know all too well just how tricky trauma therapy
can be—regardless of the theory or techniques that are being applied. The
risk of a client’s becoming overwhelmed, decompensating, having anxiety
and panic attacks, flashbacks, or worse, retraumatization, always lingers.
Reports of clients’ getting such overwhelming flashbacks during therapy
sessions that the treatment room is misinterpreted as the site of the trauma
and the therapist perceived as the perpetrator of the trauma are common. It
is also not unusual for clients to become unable to function normally in
their daily lives during a course of trauma therapy—some even requiring
hospitalization. Working with trauma seems, universally, to be rather more
precarious than other areas of psychotherapy. We talk about the dangers, but
we do not usually write about them.
The dangers inherent in the therapeutic treatment of trauma are not news
even though posttraumatic stress disorder (PTSD) did not appear as an
official diagnosis until the publication of DSM-III in 1980. In 1932,
psychoanalyst Sándor Ferenczi presented a courageous paper before the
12th International Psychoanalytical Congress in Wiesbaden. In it he
admitted to his colleagues that psychoanalysis could be retraumatizing:
“some of my patients caused me a great deal of worry and
embarrassment… [they] began to suffer from nocturnal attacks of anxiety
even from severe nightmares, and the analytic session degenerated time and
again into an attack of anxiety hysteria” (Ferenczi, 1949, p. 225). He
acknowledged that the usual way to explain such phenomena among his
colleagues had been to blame the patient for having “too forceful resistance
or that he suffered from such severe repressions that abreaction and
emergence into consciousness could only occur piecemeal.” But he dug
deeper, “I had to give free rein to self-criticism. I started to listen to my
patients. …” He went on to speculate that both premature interpretations,
and unspoken countertransference feelings could lead to an undermining of
the therapeutic process, including patient decompensation to the point of
“hallucinatory repetitions of traumatic experiences” (Ferenczi, 1949).
In a more recent but equally courageous paper, “Relieving or Reliving
Childhood Trauma?” Onno van der Hart and Kathy Steele (1997) remind us
that directly addressing traumatic memories is not always helpful and can
sometimes be damaging to our clients. They propose that those clients who
are not able to tolerate memory-oriented trauma treatment may still benefit
from therapy geared to relieve symptoms, increase coping skills, and
improve daily functioning.
Just what is going wrong when trauma therapy becomes traumatizing? A
client is most at risk for becoming overwhelmed, possibly retraumatized, as
a result of treatment when the therapy process accelerates faster than he can
contain. This often happens when more memories are pressed or elicited
into consciousness—images, facts, and/or body sensations—than can be
integrated at one time. The major indicator of overly accelerated therapy is
that it produces more arousal in the client’s autonomic nervous system
(ANS) than he has the physical and psychological resources to handle. It is
like an automobile speeding out of control, the driver unable to find and/or
apply the brakes.
 ON BRAKING AND ACCELERATING

I’ve taught several friends to drive. The lessons always took place in my
car. I sat in the passenger seat with no dual controls. Being a bit worried
about my own safety as well as that of my student and my car, I always
began the same way. First, before my driving student was allowed to cause
the car to move forward, I taught her how to stop, how to brake.
My driving student was drilled in shifting her foot to the brake pedal
repeatedly until the movement was automatic, accurate, and performed
confidently without looking. Only when my student (and I) were secure in
her ability to find the brake pedal and stop the car reflexively did I deem it
safe for her to use the gas pedal and learn to (slowly) accelerate, while
periodically returning to the brake pedal—stop and go. The more confident
my student became in handling the car and braking appropriately, the more
acceleration (within the bounds of the speed limit) she could dare.

Safe driving involves timely and careful braking combined with

acceleration at the rate that the traffic, driver, and vehicle can bear. So does
safe trauma therapy. It is inadvisable for a therapist to accelerate trauma
processes in clients or for a client to accelerate toward his own trauma, until
each first knows how to hit the brakes—that is, to slow down and/or stop
the trauma process—and can do so reliably, thoroughly, and confidently
(Rothschild, 1999).

Why Brake, Slow Down, or Stop the Therapy Process?

The symptoms of PTSD are depleting. Typically, the client with PTSD
alternates periods of frenetic energy and periods of exhaustion. Sometimes
the therapy process is difficult because the client just doesn’t have the
reserves necessary to focus, confront, and resolve the issues at hand.
Reducing hyperarousal both in the therapy session and in the client’s daily
life will not only give the client much needed relief but also enable him to
rest more effectively. This, in turn, will give him a greater capacity and
resources to face his traumatic past.
A useful analogy is to liken the person with PTSD to a pressure cooker.
The unresolved trauma creates a tremendous amount of pressure both in the
body and in the mind in the form of ANS hyperarousal. With a modern
pressure cooker, once the pressure is built up, it becomes impossible to
open it, but if you could it would explode. You must first slowly relieve the
pressure, a little “pft” at a time. Then, and only then, can you open any
pressure cooker safely.
The same applies to PTS and PTSD. If you try to open the client up to
trauma while the pressure is extreme, you risk explosion—which in a
client’s case can mean decompensation, breakdown, serious illness, or
suicide. However, with judicious application of the brakes to gradually
relieve the pressure, the whole process of trauma therapy becomes less
risky. Each client should be evaluated on an individual basis. Some require
more liberal braking than others. Optimally, the pace of the therapy should
be no slower than necessary, but no quicker than the client can tolerate
while maintaining daily functioning.

EVALUATION AND ASSESSMENT

Determining which type of trauma and which type of trauma client you are
dealing with will go a long way in helping to determine the treatment plan.
Lenore Terr (1994) has distinguished two types of trauma victims, Type I
and Type II. She originally made this distinction with regard to children.
Type I refers to those who have experienced a single traumatic event. Type
II refers to those who have been repeatedly traumatized.
Terr’s typing system is quite applicable to adults, though further
designation is useful. Two subtypes of Terr’s Type II traumatized
individuals should be distinguished: Type IIA are individuals with multiple
traumas who have stable backgrounds that have imbued them with
sufficient resources to be able to separate the individual traumatic events
one from the other. This type of client can speak about a single trauma at a
time and can, therefore, address one at a time. Type IIB individuals are so
overwhelmed with multiple traumas that they are unable to separate one
traumatic event from the other. The Type IIB client begins talking about one
trauma but quickly finds links to others—often the list goes on and on.
Type IIB clients can also be divided into two categories. The Type IIB(R)
is someone with a stable background, but with a complexity of traumatic
experiences so overwhelming that she could no longer maintain her
resilience. Typical of this type of client are the Holocaust survivors
described in the aforementioned Norwegian study by Malt and Weisaeth
(1989). Type IIB(nR) is someone who never developed resources for
resilience, as described by Schore (1996).
One of the reasons for evaluating the client’s trauma type is that each has
different therapeutic needs, especially with regard to the therapeutic
relationship and transference. Usually, Type I and Type IIA individuals
require less attention to the therapeutic relationship and develop a less
intense transference to the therapist. Many have already internalized the
resources that might be offered within the framework of a long-term,
transference-focused relationship. This is not to say that transference issues
will not arise; however, with this kind of individual, the therapeutic
relationship is in the background and their need to work on specific
traumatic memories is the foreground. After the initial interview and
assessment, Type I and Type IIA clients can usually move quickly to
working directly with the traumatic incident(s) that brought them to therapy.
For Type IIB clients, on the other hand, resource (re)building through the
therapeutic relationship will be a prerequisite to directly addressing
traumatic memories. With the Type IIB(R), the therapeutic relationship will
help reacquaint the client with resources she knew but has lost touch with
due to the complex and overwhelming nature of the traumas she has
endured. With the Type IIB(nR) client, the therapeutic relationship may be
the whole of the therapy, building resources and resilience that were never
developed. The special needs of both categories of Type IIB clients will be
further discussed in the following section on the therapeutic relationship.
There is an additional type of client that is worthy of mention when
discussing trauma clients. This is the client who has many symptoms of
PTSD but reports no identifying event(s) that qualify him for that diagnosis.
Scott and Stradling (1994) proposed an additional diagnostic category they
call prolonged duress stress disorder (PDSD). Chronic, prolonged stress
during the developmental years (from neglect, chronic illness, a
dysfunctional family system, etc.) can take its toll on the autonomic nervous
system, just short of pushing it to the point of fight, flight, or freeze. The
needs of this type of client often resemble those of the Type IIB(nR) client.
When they do, the most helpful treatment method may also be the same. In
both instances, the therapeutic relationship has the potential to infuse many
of the coping skills and resilience that may have been missed during
development.

THE ROLE OF THE THERAPEUTIC RELATIONSHIP IN

TRAUMA THERAPY

There can be a tendency for a trauma therapy to be focused more on

individual traumatic incidents than on the overall impact a trauma has on
the client’s interpersonal relationships, including the therapy relationship.
For some clients that bias is beneficial; for others it can be detrimental. It is
important to address, at least briefly, the role of the therapeutic relationship
in trauma therapy in order to stress the individual needs of trauma clients.
In addition, the body does figure significantly in work with the
therapeutic relationship, as attention to it while focusing on the therapist-
client interaction can be very informative. Observing signs of autonomic
nervous system arousal, patterns of tension, and intentional movements
(Levine’s [1992] name for slight muscle contractions that may indicate a
behavioral intention that has not been fulfilled) may provide insight into the
impact of the relationship between therapist and client. With some trauma
clients, the trauma is reenacted in the transference—sometimes as
psychological symptoms (i.e., mistrust), sometimes as somatic symptoms
(as with the case example on p. 141).
Schore (1996) suggests that experiences in the therapeutic relationship
are encoded primarily as implicit memory, often effecting change within the
synaptic connections of that memory system with regard to bonding and
attachment. Attention to the therapeutic relationship will, with some clients,
help to transform negative implicit memories of relationships by creating a
new encoding of a positive experience of attachment. When this is
successful, the client internalizes a new representation of a caring
relationship in both mind and body. This does not change the clients past,
but will give him a new somatic marker (Damasio, 1994) when he thinks of
relationships or anticipates entering into one(s) in the future. When
successful, the positive attachment to the therapist can change habituated
avoidance or fear of interpersonal relationships into desire for healthy
contacts.

The Therapeutic Relationship: Foreground or Background?

It is generally accepted that the therapeutic relationship is critical to the

outcome of any psychotherapy. This is no less so in trauma therapy;
however, it will be of varying importance. Direct work with traumatic
memories should not begin until the therapeutic relationship is secure for
the client and the client feels safe with the therapist. Many clients will move
through this stage fairly quickly, sometimes even by the second or third
session. Others will require several sessions before they feel safe with the
therapist and the therapy process. For those clients the principles and tools
outlined in future chapters will aid in preparing them for the difficulties of
delving into their traumatic memories with the models of trauma therapy
favored by their therapists.
There are also a good number of trauma clients for whom developing
safety within the therapeutic relationship will take a very long time. In some
cases, working on feeling secure in that relationship may in fact be a large
portion of the therapy, pushing direct work with trauma to the sidelines. The
building of resources outlined in the next two chapters will be important for
such clients: body awareness, braking, muscle toning, resource building,
boundaries, dual awareness, etc. Trauma issues will not be avoided, though
they cannot be addressed directly. Instead, much of the traumatic material
will arise within the interaction between the therapist and the client. When
that happens, trauma is addressed through the transference the client
develops to the therapist as well as the therapist’s own countertransference
reactions. This type of trauma therapy is often arduous. However, it can be
very rewarding when both therapist and client are willing and able to see it
to completion.
 What distinguishes these types of trauma clients? Why is the therapeutic
relationship a more critical aspect of their therapy? What happens if the
therapist misjudges and directly addresses trauma prematurely with this
kind of client?
It is the Type IIB trauma client for whom the therapeutic relationship will
be most urgent. Included in this category is what Judith Herman (1992)
calls complex PTSD. As discussed above, these clients have suffered such
massive and/or multiple trauma that they lack the resources and resilience
necessary for any direct confrontation of traumatic memories to be
constructive. A betrayal of trust appears to figure in the overall picture of
these clients. Many clients in this group have suffered at the hands of others
in some way, either through neglect in their developing years or human-
caused victimization at any age (abuse, assault, rape, incest, war, torture,
domestic violence, etc.). The earlier this has occurred in life, the greater the
damage to the ability to trust other humans. When victimization occurs later
in life, betrayal of previously developed trust is the larger issue. In some
cases developmental deficits (neglect or other bonding failures) may also be
a factor. As discussed in Chapter 2, failures of attachment can contribute to
an individual’s vulnerability to developing PTSD or other disorders
(Schore, 1996).
With clients who have suffered interpersonal trauma, addressing trust
issues in the therapeutic relationship increases in importance. The client
who has never been able to trust another will need a chance to build it. The
individual whose trust has been betrayed will need the chance to reestablish
it. Both processes take time. Without trust, traumatic memories cannot be
constructively confronted.
Not until trust in the therapist is established does the client have an ally
with whom to confront his traumas. If traumatic memories are addressed
directly before this trust has been developed, the client will be in the
unfortunate situation of confronting his traumas (often again) in isolation.
Under that condition, not only is the trauma not resolved, but it also can be
made considerably worse.

Affect and Pain Regulation

While Allan Schore (1994) does not ponder the issue of trust directly, his
massive work in the area of early bonding and attachment holds many clues
to building trust with the Type IIB trauma client. Schore asserts that
bonding between caretaker and infant is necessary for the child to develop
the capacity to regulate its own emotions. He suggests that this capacity
grows through the interaction of the child and the caretaker over time and
has three critical phases: attunement, misattunement, and reattunement
(Schore, 1994). Basically, the child and caretaker interact in face-to-face
contact. As this proceeds at tolerable levels for the infant, it remains in
contact (attunement). When the arousal level goes too high—either because
of excitement or because of anger or disapproval on the part of the caretaker
—the infant breaks contact (misattunement). When the infant’s level of
arousal reduces again to a tolerable range, it reestablishes contact with the
caretaker—usually at a higher level of arousal than was previously tolerated
before (reattunement) (Schore, 1994). This type of interaction forms the
basis of attachment and may be critical to increasing the child’s (and later
the adult’s) capacity to regulate stress, emotion, and pain.

When 6-year-old Tony fell and gashed her leg it hurt very much. In
addition, she was very frightened as she was wheeled into the emergency
room to be stitched up and her mother was told to stay outside. Tony
became hysterical. Finally, the doctor allowed her mother to stand in the
doorway of the emergency room, where Tony could see her. Tony vividly
recalls how both her terror and her pain reduced dramatically at the sight
of her mother. As the doctor worked on her leg, Tony kept her eyes riveted
on her mother’s.

Implications for the therapeutic relationship are many. Most therapists are
familiar with its affect-regulating function. Unstable clients will often, for
periods of time, seek out the therapist when upset, calming or crying with
relief as they first catch sight of the therapist in the waiting room or at the
sound of the therapist’s voice on the telephone. There are a number of
clients who are soothed between sessions just by hearing the therapist’s
outgoing voicemail message.
 Attunement, Misattunement, and Reattunement

There is a conundrum with some Type IIB trauma clients. Trust in the
therapist may grow following a conflict (a perception or suspicion of
betrayal or other type of disruption), provided it is followed by repair of the
relationship—misattunement and reattunement. When conflict risk is high,
it can be a good idea to prepare the client for periods of perceived injury or
betrayal by the therapist. Actual planning for such occurrences can go a
long way toward turning them into constructive events.

Frank had never in his life had someone to depend on but himself Both of
his parents had been alcoholics, his father violent. Frank was fiercely
independent and feared intimacy. He was also unstable emotionally. He had
trouble keeping a job, as he was prone to emotional outbursts.
The first stage of therapy was aimed at increasing his stability. Resource
building (see the next chapter), both physical and psychological, figured
strongly in our early work together. Locating interpersonal resources,
however was difficult. Frank’s level of trust in anyone was very low. From
the start I believed Frank to be a good candidate for premature therapy
termination due to a conflict (misattunement). I waited, however, to broach
the subject until we had developed a bit of a relationship. During an early
therapy session I discussed with Frank the likelihood that later in the
therapy he might become so angry with me that he would want to quit. He
agreed that was possible; it had, in fact, been a problem with three previous
therapists. I discussed Schore’s concepts of attunement, misattunement, and
reattunement with Frank, explaining that misattunement was not only
predictable but desirable. Without it there was no opportunity for
reattunement, which was necessary to strengthen the relationship. What, I
asked, had he needed at those times when he could not resolve his anger
with the earlier therapists? He claimed that his previous therapists had
abdicated any responsibility for his feelings, that they had been unwilling to
see what they had actually done and, most importantly, apologize.
Discussing this with Frank before the fact gave me many insights into his
personality, as well as the psychological injuries he had suffered. He was
able to further reveal that the pain of his father’s violence had paled when
compared to his lack of remorse. Frank had never received an apology for
his father’s violent behavior.
A few weeks later, when I had to reschedule an appointment due to
illness, Frank became furious and felt abandoned. He canceled his next
appointment, leaving a message on my voicemail that he would call me if
and when he wanted another. Because we had previously set the stage, I
was in a good position to make contact with him and remind him of the
earlier prediction. I suggested that he come in at least once for us to discuss
what had happened. He agreed, but he was still very angry. In the session
he ranted for a long time. When he seemed well vented, I ventured an
apology for not being available when he needed me. He was skeptical and
required reassurance that I really meant what I said and wasn’t just
apologizing because of what he had told me earlier. When I explained that I
could see and hear the pain underneath his anger and felt genuinely sorry
to not have been there for him, he began to cry. When he recovered he was
able to accept my apology and our work together continued. That was our
first, but far from our last, experience with misattunement and
reattunement.

Another type of misattunement can occur when the client transfers the
memory of a perpetrator onto the therapist and becomes afraid in her
presence. When this occurs, the therapist must help the client to reality test
and separate the two. This type of transference is not conducive to trauma
therapy, as the client needs the therapist as an ally. Leaving a client to stew
in this type of transferential misattunement can be very detrimental to the
therapy process and can reinforce in the client a fear that nobody is safe.
As one can see, there are many routes to trauma treatment. The
therapeutic relationship is of more and less importance to trauma therapy
depending on the individual needs of the client. Evaluating the client’s type
as well as current level of functioning will help determine how much
emphasis to give to the relationship.

SAFETY
 In the Client’s Life

The first rule of any trauma therapy is safety (Herman, 1992). That applies
not only within the therapy setting, but also in the clients life. It is not
possible to resolve trauma when a client lives in an unsafe and/or
traumatizing environment. Resolving trauma implies releasing the defenses
that have helped to contain it. If one is still living in an unsafe or traumatic
situation, this will not be possible or advisable. When that is the case,
helping the client to be and/or feel safe must be the first step. Much of this
is common sense. For example: a battered wife must be safely separated
from the violent husband; a client who was assaulted in his home might
need to install extra door and window locks; a rape victim may need to
await dealing with the memory of the rape until the rapist is adjudicated and
imprisoned, etc.
Another strategy for increasing safety in the client’s life is to identify and
(temporarily) remove as many triggers as reasonably possible. Sometimes
clients will protest removing triggers. They usually insist that they need to
learn to live with their fears. However, sometimes they need the relief that
comes with removal of a trigger to be able to later tolerate living with it.
Temporarily removing a trigger will sometimes reduce or eliminate its
effect and it can be returned to the client’s life with little or no consequence.

Rodney frequently suffered episodes of depersonalization He literally lost

the sense of his own skin, a very frightening experience. I suggested that he
might regain it with the aid of a cool shower (the temperature differential
might bring back the sensation of the periphery of his body, his skin—see a
discussion of skin boundaries in Chapter 7). Though he agreed with this
idea in principle, he was reluctant to try it, he told me, because he was
terrified to take a shower. “Oh!” I responded, “What do you do instead?”
“I just hold my breath and take one anyway, as fast as I can,” he replied.
He was submitting himself to this torture daily. At that point in time I was
less interested in why he was scared of the shower than I was in removing
this daily terror from his life—giving him some relief Inquiring further I
discovered that he was not afraid of water or washing himself just the
shower. I asked him if he could wash his hair in the kitchen sink and take a
sponge bath. Yes, both those would be fine. (Had bathing itself been the
issue, a bit more ingenuity would have been required to provide some relief
for him within the bounds of good hygiene.) We negotiated that he would
cease showering for at least three weeks. After four weeks he reported to me
that he had resumed daily showering. He still didn’t like it very much, but
no longer suffered terror of it. Removing that trigger for a brief period of
time was enough to loosen its hold on him.

In the Therapeutic Setting

No trauma therapy can or should take place in the absence of a developed,

secure relationship between client and therapist. Of course, it is not possible
for a client to fully trust a new therapist; nor is it advisable. But there must
be enough basis for trust and some time for each to get used to the other.
Some instances of therapeutic failure can be traced to premature
introduction of techniques—sometimes during the first meeting. There
should be at least one session, preferably a minimum of two or three, before
trauma therapy techniques are applied, to allow the client time to get to
know and build trust in the therapist. But there is no rule of thumb. Some
clients may need years before they are ready to move beyond relationship
building to directly addressing traumatic memories.

DEVELOPING AND REACQUAINTING RESOURCES

The more resources the client has, the easier the therapy and the more
hopeful the prognosis. When taking a case history it is a good idea to be
equally on the lookout for resources as for traumas. It is advisable to
evaluate resources and build those that are lacking before embarking on a
difficult course of trauma therapy, though, of course, some must be
developed along the way. There are five major classes of resources:
functional, physical, psychological, interpersonal, and spiritual.
Functional resources include the practical, like a safe place to live, a
reliable car, extra locks, etc. In addition, it may be necessary to provide
resources in the form of protective contracts with clients during trauma
therapy. This idea stems from Transactional Analysis (Goulding &
Goulding, 1997). A trauma client is often confronted with situations that
mirror the issues being explored in therapy. It is a mystical, if common,
occurrence. The client working on trauma from a car accident has a near
miss; the one working on the aftermath of a rape is followed at night, etc.
The popular term for this phenomenon is “synchronicity.” Safety contracts
can be helpful in those circumstances. It may be useful, for example, to
make a contract to pay extra attention to safe driving with a client working
on PTSD following a car accident, or a contract for extra caution at night
with a client who has been assaulted.
Physical strength and agility are examples of physical resources. For
some clients, weight training that increases muscle tone will be beneficial.
For others, techniques that drill the body in protective movements, such as
self-defense training, will be useful adjuncts to trauma therapy. In general,
building physical resources will give many clients a greater feeling of
confidence.

Daniel had suffered anxiety since surviving a big earthquake. He was

hypervigilant, sleeping poorly and even having trouble bathing. He felt he
must be always at the ready for the next quake. As he talked I noticed a
dissonance in his posture. He appeared to be leaning back comfortably in
his chair, but his feet were placed on the floor in a manner suggestive of
preparation to bolt. When I pointed this out to him he agreed that he was
not able to relax at any time; he was always preparing to dive under the
nearest table or run to the nearest doorway for protection. In addition, right
at that moment, his heart rate was elevated and his hands were sweaty. I
asked him if he had practiced any of these defensive maneuvers. He had
not. I suggested that he do so now, following the impulse in his already
defensively positioned feet. He did, bolting toward my office door. He
opened it and crouched in the doorway. I encouraged him to repeat that
movement several times—chair to doorway to crouch. After three practices
I inquired as to his heart rate and hand moisture. Both were normalized. I
encouraged Daniel to continue practicing at home and at work, finding the
best routes to safety. By the next week his constant vigilance had eased
considerably, as he had by then anchored in his body the defensive moves
necessary to reach protection during an earthquake.

Psychological resources include (but are not limited to) intelligence, sense
of humor, curiosity, creativity (including artistic and musical talents), and
almost all defense mechanisms. It is empowering to regard defense
mechanisms as the positive coping strategies they once were. Each is a
positive resource. The only exceptions are defenses that harm other people.
Every defense was, at one time, an (usually successful) attempt to protect
the self. The problem with a defense mechanism is not in the mechanism
itself, but that it is one-sided, therefore limiting. What is missing with each
defense mechanism is the choice of its opposite (Rothschild, 1995b). Three
examples:

1. The defense of withdrawal is not a problem in itself—who of us

doesn’t need to withdraw at times? However, one is at a disadvantage
when only able to withdraw and never able to engage with others. On
the other hand, the person who is afraid to be alone and must always
be in the company of others—who has no capacity to enjoy solitude—
is equally handicapped.

2. The person who always expresses anger when stressed is able to

defend herself, but sometimes at a cost of alienating others. Though
the person who is unable to express anger may avoid alienation, he
may be unable to defend himself when necessary. Both strategies are
resources.
3. Many would envy an individual who can so dissociate at the dentist
that painful work can be done without anesthesia. But, of course,
unchecked dissociation of that caliber can cause problems in other
areas of daily functioning. What is needed in such an instance is to
help the client learn to control his dissociation, maintaining the ability
to do it when it is useful (like at the dentist) and being able to stay
present when that is safer or more useful (for example, when driving).
The solution to a limiting defense mechanism is not in removing it, but in
developing its opposite for both balance and choice. Such a positive view
can also help the client who feels ashamed of his defenses.
A client’s current social network, including spouse or partner, other
family members, and friends, is the core of interpersonal resources. In
addition, remembering significant people from the client’s past can bring
about positive feelings and sensations. Remembered friends, parents,
grandparents, teachers, and neighbors can all be powerful resources used to
facilitate the therapy. Animals also belong in this category. Pets are often
potent sources of resource—especially current pets, but often past pets as
well.

Alex’s love of rock climbing was cut short when she had a serious fall. She
suffered a concussion and broken arm. Four years later she was still
plagued by images of her fall, sometimes waking in a cold sweat in the
middle of the night. As she told me about it she paled and her breathing
quickened. Her husband was not sympathetic. He had never approved of
her choice of sport and had been angry when she was injured. That the
accident still haunted her was, for him, assurance that she would not go
climbing again. As we explored the aftermath of the accident (see Chapter 8
for the rationale behind working with the aftermath of the trauma first),
Alex remembered feeling totally abandoned by her husband. His reaction
was worse for Alex than her physical injuries. She came home from the
hospital in need of care and nurturing, and he was too angry to provide it.
He provided for her basic needs but was unable to give her the nurturing
support she needed. “How did you survive that?” I asked. “You know,”
Alex said, “I don’t think I would have if it weren’t for my Golden Retriever.
Solo stayed with me day and night, only leaving my side for short periods of
time.” I encouraged her to remember Solo’s attention now. Where did he
lie? How did his fur feel in her hand? Could she remember his warmth? As
she remembered her contact with Solo, Alex calmed and cried softly. She
felt touched to remember the dog’s love for her. Her breathing normalized
and color returned to her face.
Spiritual resources include belief in a higher power, following a religious
figure, adherence to religious practice, and communing with nature.
Sometimes utilizing a client’s spiritual resources is difficult for the therapist
whose belief system differs. One must come to terms with this
countertransferential response, since spiritual resources can be very
powerful aids to the healing of traumatic conditions. In addition, some
victims of trauma feel betrayed by their beliefs. For those individuals,
reclaiming the lost relationship to the spiritual will be a crucial step toward
healing.
Sometimes, helping clients with PTSD look at how they have survived
their lives and their traumas is a useful adjunct to treatment. Every survivor
of trauma has had some role in his or her survival, even if it is by freezing
or dissociating. Through such an exercise, many discover how many
resources they actually have. The result can be very hopeful. At the least,
reminding clients of their resources can prevent despair.

Fifty-year-old Arnold was at the threshold of hospitalization. His downward

spiral following a work-related traumatic incident had resulted in a belief
that he was totally hopeless and helpless. He feared his ability to cope was
so lost that the hospital was his only option. His wife forced him to call me
for an appointment, and she had to drive him as his anxiety was too high to
come alone. During the intake interview Arnold could only complain about
all of the faculties he had lost: He could no longer work, he had lost
friends, everyone was giving up on him, he was anxious all the time, he
could do nothing for himself. I picked up on that last comment and
observed, “I see you are clean shaven. Who shaved you today?” “Why, I
did,” he replied. “Who dressed you, then?” I asked further. “I dressed
myself,” he answered a bit suspiciously. I pressed on, “Who fed you your
breakfast?” “I didn’t eat much,” he asserted. “That’s okay,” I answered,
“but what you did eat, who fed you?” “Well I did, of course!” he answered,
beginning to get a little irritated with me. By the end of that session Arnold
was slightly encouraged. He had so convinced himself of total helplessness,
he had forgotten that he was still quite capable of taking care of his own
basic needs. Of course this one intervention was no cure, but it was a
microstep that enabled Arnold to remain at home.
 OASES, ANCHORS, AND THE SAFE PLACE

Oases

Many trauma clients benefit from engaging in activities that give them a
break from their trauma. What works will be different for each, but
diverting activities have common features. An oasis must be an activity that
demands concentration and attention. Watching TV and reading do not
usually work well, as it is easy to wander into one’s own thoughts.
Procedures that have not yet become automatic often do the trick. For
example, knitting will work for some, but not for those who have been
doing it all their lives—unless, of course, an exceedingly difficult pattern is
chosen. For some it will be car repair, for others gardening; many find
computer games or solitaire work well. Whatever is chosen, its value as an
oasis will be recognized through body awareness (see the next chapter), by
the reduction in hyperarousal as well as quieting of internal dialogue.

Anchors

The concept of anchors sprang from neuro-linguistic programming (NLP)

(Bandler & Grinder, 1979), but has been adapted for use in several trauma
therapies. Basically, an anchor is a concrete, observable resource (as
opposed to an internalized resource like self-confidence). It is preferable
that an anchor be chosen from the client’s life, so that the positive memories
in both body and mind can be utilized. Examples include a person
(grandmother, a special teacher, a spouse), an animal (favorite pet), a place
(home, a site in nature), an object (a tree, a boat, a stone), an activity
(swimming, hiking, gardening). A suitable anchor is one that gives the
client a feeling (in body and emotion) of relief and well-being.
When working with trauma, it is useful for each client to establish at
least one anchor to use as a braking tool anytime the therapy gets rough.
Anchors can also be improvised by introducing a previously noted resource.
I noticed that when Cynthia told me about her best friend during the
assessment interview her demeanor changed. She had entered the office
almost apologetically, fearful and suspicious. She sat hunched, anxious, and
pale. When speaking of her friend, though, Cynthia literally expanded; her
head straightened and her chest broadened. Color rose to her cheeks and
her breathing eased. I drew a star beside my notes about her friend. Later
during the interview, Cynthia became quite pale while telling me about the
many traumas she had experienced. She reported that her heart was racing.
At that point I interrupted and suggested we go back to some of the things
she had mentioned previously, “What was your friend’s name? I forgot to
write it down. Tell me a little more about her.” Just naming her friend
reduced Cynthia’s hyperarousal. While talking about the friend, color
returned to Cynthia’s face, and she told me her heart rate had decreased.
When she was more relaxed, she was better able to resume naming the
traumatic incidents she thought I should know about.

Anchors can also be used to insert a different spin on a traumatic event—

not changing the fact of it, but the internal impression.

In a subsequent session further on in Cynthia’s therapy, I was again able to

make use of her best friend. Cynthia trembled as she related an incident of
abuse at the hands of her mother. She had been terrified and too little to
defend herself I asked her, “How would that incident have been different if
your best friend had been there?” “Well, that’s not possible,” Cynthia
replied, “I didn’t know her then!” I persevered, “Of course, but if you had,
and she had been there at the time, how would it have been different?”
“Well, she would have stopped my mother completely. My friend is bigger
than my mother was, she could have overpowered her!” “If you remember
that incident now,” I suggested, “and imagine your friend there, how do
you feel in your body?” “I feel calmer. (She begins to cry.) I wish she had
been there, it was so awful!” The tears were calm and healing. Cynthia was
beginning, for the first time, to grieve just how bad it had been.
Inserting an anchor, especially one from the client’s current life, cannot—in
any way—change reality, but it might give a new impression and help to
separate the past trauma from current life.
Applying the anchor is easy. When the hyperarousal gets too high, the
therapist just changes the subject. “Let’s just stop this for a moment. Tell
me about [insert anchor].” The connection can be deepened by giving
sensory cues that are associated to the anchor. One of the biggest difficulties
of applying anchors is getting used to interrupting the client’s “flow.” When
it is clear how much inserting anchors helps the process, both therapist and
client gain greater tolerance for such interruptions. Anchors make it
possible to continue addressing difficult memories while periodically
lowering the base level of hyperarousal rather than allowing it to build and
build. Each time the anchor is used, the hyperarousal lowers. When the
client resumes addressing her trauma, it is from a lower level than before
the break. In this way, a traumatic memory can be fully addressed without
the hyperarousal going out of control.

addressing trauma → hyperarousal → anchor → lowered arousal

Use of the anchor figures prominently in the detailed therapy session at

the end of Chapter 6.

The Safe Place

The safe place is a specialized anchor. It was first used in hypnosis for
reducing the stress of working with traumatic memories (see, e.g., Napier,
1996). A safe place is a current or remembered site of protection (Jørgensen,
1992). It is preferable for the safe place to be an actual, earthly location that
the client has known in life. As such, there will be somatic resonance in the
memory of it—sights, smells, sounds, etc., connected to that site will all be
recorded as sensory memory traces—which will make it highly accessible
and useful to the client. The client can imagine his safe place during times
of stress and anxiety, or it can be used as any anchor is used, to reduce
hyperarousal during a therapy session.
 And When Nothing Works?

A few clients will appear unable to imagine and/or use calming images of
anchors and safe places. What may happen with such individuals is that
each time they begin to imagine one, it becomes contaminated in some way
and feels unsafe. This pitfall can occur when the client believes that the
fantasy controls him, rather than that he controls the fantasy. For example, a
client with a nurturing grandparent as anchor will suddenly remember a
disappointment, or the client will become afraid a safe place in the woods
could be invaded. When this happens, the therapist needs to have a frank
discussion with the client, first reminding the client that it is his fantasy and
he can make it anything he wants, and then explaining that what is required
is not the perfect anchor or safe place but one that is “good enough.” The
fantasy safe place and safe person can be controlled in ways that real life
places and people cannot. For example, limit the anchor to the best or ideal
memories of the grandparent. Another strategy might be to imagine a
barrier (visible or invisible) around the safe place in the woods and/or
sentries posted for protection (Bodynamic, 1988–1992). Imagined
embellishments that serve to strengthen the calming effect of the anchor or
safe place are often useful in these circumstances.
Problems with positive affect tolerance can also limit the usefulness of
an anchor or safe place. A small percentage of clients will become anxious
when imagining or actually being in positive situations or feeling states. For
some PTSD clients it is difficult to differentiate the nervous system
responses of positive emotions (happiness, excitement, etc.) from those of
anxiety; increased heart rate and respiration can accompany both. Body
awareness training (see the next chapter) will help this discrimination, as
anxiety is usually accompanied by pallor and decreased temperature in the
face and extremities, whereas excitement and happiness are usually
accompanied by increased color and temperature.
Another problem with positive affect tolerance occurs when the client
fears the good feeling because he anticipates it will not last. Again, body
awareness can be useful in helping to recognize that no emotional or
somatic state lasts forever. Learning to follow the ebb and flow of somatic
sensations may reinforce the idea that emotional states also ebb and flow.
 THE IMPORTANCE OF THEORY

One of the ways the therapist can increase the safety of trauma therapy is to
be familiar with trauma theory. When the therapist knows what she is doing
and why, she is less apt to make mistakes. Theory is more useful than
technique, as techniques can fail, but theory rarely lets you down. When
one is well versed in the theory of trauma, it is not even necessary to know
a lot of techniques, as ideas for interventions will arise from understanding
and applying theory to a particular client, at a particular moment, with a
particular trauma. Moreover, when a therapist is well versed in theory, it
becomes possible to adapt the therapy to the needs of the client rather than
requiring the client to adapt to the demands of a particular technique.
Sometimes teaching theory itself to the client will be just what is needed.
Teaching theory is especially useful when the client has multiple traumas
and is not ready for the use of techniques. Two examples:

Fred had struggled for a while to connect his debilitating physiological

reactions to beatings he received as a child. Intellectually he knew that
there must be a connection, but he couldn’t relate to it. One day he came to
therapy very depressed. He was worried because he had become
“suicidal”—unusual for him. As we explored his feelings and his body
awareness he began to cry, “It’s not that I want to die, it’s just that I feel so
dead inside.” A picture formed in my mind. I asked him if he had ever seen
a mouse caught by a cat. Having grown up in a rural area, he had seen this
many times; he remembered the mouse “playing dead.” I asked him to
consider the mouse’s behavior, which led to a discussion about the
autonomic nervous system and the theory of freeze reactions. He was very
touched, quickly able to relate to the mouse’s talent for surviving by going
dead. He remembered doing the same numerous times in response to the
beatings. After a few minutes of letting this information sink in, it clicked.
Fred realized that he was not suicidal after all, but connecting to his own
“mouse.” His relief was palpable. That session was a catalyst to his
subsequent therapy. Having found a positive explanation for his deadness,
he became less afraid to identify other body sensations and their connection
to his traumatized past. Previously frightening sensations became friends
(like the mouse going dead for survival) rather than enemies.

Scott came to therapy in his early twenties because he lacked self-

confidence. A major problem was his inability to pass a driving test; he had
failed numerous times. He felt like a failure—all of his friends had passed
their tests and begun to drive. His parents were frustrated and could not
understand what his problem was. His driving teacher noticed that Scott
could drive quite competently at times, but at other times Scott would not
even notice a truck right next to him. The teacher was at her wit’s end.
On closer probing during our first meeting, Scott described his difficulty
as something that sounded akin to a kind of dissociation. He would “space
out” and lose track of what he was doing and where he was going. As Scott
described this phenomenon to me, he began to dissociate in a similar
manner right in the therapy session. He lost track of what he was going to
say, became rather pale, and heard my voice from a great distance. I
changed the subject, pulling up something positive he had mentioned
previously, and he stabilized. He was then able to take up the thread of what
he had intended to say.
After taking a case history, which included several incidents of earlier
trauma, I proceeded to explain the function of the ANS and the phenomenon
of dissociation. Scott was easily able to see his dissociative reaction and
speculate its cause. The impact was dramatic. By the next session he had
stopped thinking of himself as a bungling and incompetent driver. He
realized he had a driving difficulty, not because something was inherently
wrong with him, but because he had some past experiences that were still
affecting him adversely. He was able to explain this to his parents and
friends, who mostly became more sympathetic. Amazingly, he was able to
use the information and the experience of controlling the dissociation
during the session to decrease his dissociation while driving. He would
distract his thoughts to something positive and then was able to keep his
focus on the road. Scott was so successful that soon after he was able to
pass his test. Scott, his instructor, parents, and friends were all amazed.
Moreover, as Scott’s perception of his problem changed to one of past
traumatic incidents rather than innate ineptitude, his self-perception also
changed. He began to see himself as someone having past experiences to
deal with rather than being a “bungling fool.” That shift gave Scott the
courage to take on other tasks, both physical and interpersonal, that he had
previously felt were beyond him.

Of course, such dramatic changes are not the norm. But for many, theory is
a key that unlocks a wealth of resources.

RESPECTING INDIVIDUAL DIFFERENCES

Therapeutic error can be reduced by never expecting one intervention to

work the same for two clients. When a technique does not work, it is
advisable for the therapist to look for the failure in the timing, or in the
choice of or application of the technique, not in the client. Consider that
what this client needs may not yet have been discovered. This perspective
will keep the therapist from blaming a client for “resistance.” Further, it is a
good idea for any therapist working with PTSD to be trained in more than
one modality. This will go a long way in assuring that the therapy is tailored
to the needs of the client, not vice versa. And, of course, the therapist must
be prepared for those times when the best technique is no technique.
Sometimes the most effective intervention is just to be with the client
talking about mundane things.

TEN FOUNDATIONS FOR SAFE TRAUMA THERAPY

The following list distills the most salient points of safe trauma therapy and
serves as a review of this chapter.

1. First and foremost: Establish safety for the client within and outside
the therapy
 2. Develop good contact between therapist and client as a prerequisite to
addressing traumatic memories or applying any techniques—even if
that takes months or years.
3. Client and therapist must be confident in applying the “brake” before
they use the “accelerator.”

4. Identify and build on the client’s internal and external resources.

5. Regard defenses as resources. Never “get rid of” coping
strategies/defenses; instead, create more choices.
6. View the trauma system as a “pressure cooker.” Always work to
reduce—never to increase—the pressure.
7. Adapt the therapy to the client, rather than expecting the client to adapt
to the therapy. This requires that the therapist be familiar with several
theory and treatment models.
8. Have a broad knowledge of theory—both psychology and physiology
of trauma and PTSD. This reduces errors and allows the therapist to
create techniques tailored to a particular client’s needs.
9. Regard the client with his/her individual differences, and do not judge
her for noncompliance or for the failure of an intervention. Never
expect one intervention to have the same result with two clients.
10. The therapist must be prepared, at times—or even for a whole course
of therapy—to put aside any and all techniques and just talk with the
client.

Principles and techniques for increasing client resources, slowing down

processes, and applying the brakes follow in the next chapters.
CHAPTER SIX
 The Body as Resource

A Toast
The soul may be a mere
pretense,
the mind makes very little sense.
So let us value the appeal
of that which we can taste and
feel.
—Piet Hein

The potential benefits of being able to use the body as a resource in the
treatment of trauma and PTSD, regardless of the treatment model, cannot be
overemphasized. In this chapter, non-touch strategies and interventions for
increasing somatic resources—making the body an ally—will be presented.
Most should find the ideas outlined here to be easily adapted to their own
way of working.

BODY AWARENESS

Employing the client’s own awareness of the state of his body—his

perception of the precise, coexisting sensations that arise from external and
internal stimuli—is a most practical tool in the treatment of trauma and
PTSD. Consciousness of current sensory stimuli is our primary link to the
here and now; it is also a direct link to our emotions. As a therapeutic tool,
simple body awareness makes it possible to gauge, slow down, and halt
traumatic hyperarousal, and to separate past from present. Moreover, body
awareness is a first step toward interpreting somatic memory.
The practice of concentrating on body sensations and body processes is
not new. There are many body-oriented therapies that, more and less, use
body awareness as the foundation of or adjunct to their methods. The
usefulness of cultivating awareness of the state of the body has ancient
roots in the Eastern practices of meditation and yoga. The idea of utilizing
body awareness as a tool of Western psychotherapy was first introduced by
Gestalt therapist Fritz Perls in Ego, Hunger and Aggression in 1942. It was
then popularized in his 1969 book, In and Out of the Garbage Pail.
Personal growth exercises based on Perls’s awareness principle—following
shifts in precise sensory awareness of the internal and external
environments—were published two years later in Awareness: Exploring,
Experimenting, Experiencing by John O. Stevens.
Attention to the body has not commonly been central to the
psychotherapeutic treatment of trauma and PTSD. While it is well
documented that PTSD goes hand in hand with disturbing bodily sensations
and avoidance behaviors (APA, 1994), attention to sensation and movement
as a part of the trauma treatment strategy in psychotherapy has not often
been proposed.

What Is Body Awareness?

It is difficult to define something as subjective as body awareness. The

following is a definition that will have to suffice for the purposes of this
discussion and future reference in this book:

Body awareness implies the precise, subjective consciousness of body

sensations arising from stimuli that originate both outside of and inside the
body.
Body awareness has everything to do with the awareness of cues from the
sensory nervous system discussed earlier. Just to refresh your memory,
body awareness from exteroceptors originates from stimuli that have their
origin outside of the body (touch, taste, smell, sound, sights). Body
awareness from interoceptors consists of sensations that originate on the
inside of the body (connective tissue, muscles, and viscera). Body
awareness is not an emotion, such as “afraid.” Emotions are identified by a
combination of distinct body sensations:

shallow breathing + elevated heart rate + cold sweat = afraid

Terms that help to identify the various bodily sensations include (but are
not limited to):

breathing: location, speed, and depth; position of a body part in space; skin
humidity (dry or moist); hot, cold; tense, relaxed; big, small; restless, calm;
movement, still; dizzy; shivers, prickles; pressure, pulling; rotation, twist;
contraction, expansion; pulse rate, heartbeat; pain, burning; vibration,
shaking; weak, strong; sleepy, awake; yawning; tears, crying; light, heavy;
soft, hard; tight, loose; crooked, straight; balanced, unsteady; upright, tilted;
butterflies; shaky; empty, full

Developing Body Awareness

Many clients already have a good idea of what they sense in their bodies
and will be able to communicate this to you. With them, you can go straight
to utilizing their body awareness as a resource (see the next section).
However, some clients, when asked, “What are you aware of (or sense) in
your body right now?” will not know. They may be unable to feel their
body sensations at all, or they may feel something but not have the
vocabulary to describe the sensations. Others will have so little contact with
their bodies that when they are asked that same question, they respond on a
totally different topic, “It feels like what I was telling you about my boss
last week.…”
 But do not despair. Most clients can learn to identify and pay greater
attention to their sensations. Many will even find the experience quite
rewarding. The following exercise illustrates basic body awareness:

• First, do not move. Notice the position you are sitting in right now
• What sensations do you become aware of? Scan your whole body:
notice your head, neck, chest, back, stomach, buttocks, legs, feet,
arms, hands.
• Are you comfortable?—Do not move, yet.
• How do you know if you are comfortable or not? Which sensations
indicate comfort/discomfort?
• Do you have an impulse to change your position?—Do not do it
yet, just notice the impulse.
• Where does that impulse come from? If you were to change your
position, what part of your body would you move first?—Do not
do it yet. First follow that impulse back to the discomfort that is
driving it: Is your neck tense? Is there somewhere that is
beginning to become numb? Are your toes cold?
• Now follow the impulse and change position. What changes have
occurred in your body? Do you breathe easier? Is a pain or area
of tension relieved? Are you more alert?
• If you have no impulse to change your position you might just be
comfortable. See which bodily cues you get that signal that you
are comfortable: Are your shoulders relaxed? Is your breathing
deep? Is your body generally warm?
• Next, change your position whether or not you are comfortable
(again, if you already did it above). Change where or how you are
sitting. Move somewhere else: Try a new chair, stand up, or sit on
the floor. Take a new position and hold it. Then evaluate again:
Are you comfortable or not? Which bodily sensations tell you:
tension, relaxation; warmth, cold; ache; numbness; breathing
 depth and location, etc. This time also notice if you are more alert
or awake in this position or in the last one.
• Try a third position. Evaluate as above.
• Jot a few notes about your experience, keeping in the language of
body sensation: tension, temperature, breathing, etc. “When I was
sitting in my chair I felt tense in my shoulders and my feet were
warm. When I moved to stand on the floor, my feet became cold
and my shoulders relaxed.…”

The above exercise can be adapted for clients. It will help many to get the
idea of identifying body sensations, though some it will not. Following up
the exercise with inquiries about body awareness in subsequent therapy
sessions will reinforce and further develop this resource.
For clients who cannot distinguish sensations as they scan their body,
specific questions will help: “What is the sensation in your stomach right
now?” “What is the temperature of your hands?” “Do you notice where
your breath goes?” etc.
With those for whom the whole area of body awareness is just too
foreign, frightening, untimely, and/or frustrating, it is often possible to first
approach it indirectly. One way to encourage body awareness in such
clients is by asking their opinion on room temperature, if the chair cushion
is soft or hard, or if they are thirsty and want something to drink. Another
strategy for increasing body awareness would be to explore the kinesthetic
sense: “Without looking, can you tell how your legs (or hands) are
positioned right now?”

Angie was trying to stay away from her abusive husband. Sometimes he
would show up where she was staying and she would go with him. It wasn’t
until later that she realized she had made a mistake. For her it was like she
entered an altered state. The fact that she couldn’t control her behavior, let
alone describe what that state felt like, disturbed her immensely; she felt
stupid and ashamed. Body awareness was difficult, generally, for Angie, but
despite some anxiety, she was willing to try. I decided not to ask her about
her body specifically, as she could quickly become frustrated when she did
not produce the “right” answer. Instead I asked, “Can you feel the chair
under your buttocks?” That she could feel. I ventured, “What does it feel
like?” She was able to describe how the consistency of the cushion felt, as
well as that the chair was unsteady since one leg was slightly shorter than
the others. “Do you feel more anxious, less anxious, or the same as when
you arrived?” She felt slightly less anxious. So far, so good; I could dare a
bit more. “You can feel the chair under you now. Do you think that when
your husband is around, you would be able to feel the chair?” Her interest
increased as she answered the question, “No, I don’t think I could. Actually,
I don’t think I can feel anything when I get around him.” For the first time
she could describe an aspect of her altered state: the absence of sensation.
Already, via this short introduction to her body, it began to make sense to
Angie that if she couldn’t feel anything in the presence of her husband she
would easily acquiesce. This was a microstep on the road to helping her
gain control over her life.

In a few instances it will be possible to eliminate some trauma symptoms

just by using body awareness. Such an intervention will not necessarily
resolve the trauma, but it could go a long way to restoring normal
functioning. At that point the client will be in a much more powerful
position to decide the direction of his therapy.

Carl began having periodic flashbacks and frequent panic attacks as an

adolescent following two bad LSD trips. He had tried medical help to no
avail. At 25 he decided to try psychotherapy. After a few sessions Carl
became able to identify and describe what it was that initiated the current
panic attacks. It was a particular sensation in his gut that he recognized as
preceding the onset of a flashback. When he felt that sensation, he feared he
was about to have another one and broke into panic. The fact that the
actual flashbacks were decreasing in frequency didn’t help. That gut
sensation scared him and set the panic attacks in motion.
We discussed the alternatives. There were two possible directions the
therapy could take: (1) focusing on the here-and-now situation (gut
sensation and panic attacks), or (2) delving into the past (the bad LSD
trips). Carl did not want to go near memories of those LSD trips, but he was
willing to work on his current situation. We further developed his body
awareness and explored what the gut sensation felt like, specifically, when it
occurred. I asked Carl to become a detective, carefully noting when he got
the sensation, what time, under which circumstances, of how long duration,
etc. Over the next few weeks he found out that he usually had that sensation
around mid-morning on days that he was constipated. On days that he had
a morning bowel movement, there was no sensation to contend with, and he
would be free of panic. Then the way became clear. The next assignment
was for Carl to observe his morning routine and breakfast menu to find out
what was different on the non-panic days. This was easy. On mornings that
he woke up with at least one and a half hours before he had to leave for
work and ate breakfast, he would be fine. On panic mornings he bolted
awake with only a half-hour before running out the door, gulping a cup of
coffee and skipping breakfast altogether. I proposed that the caffeine kick
unmediated by any protein or carbohydrates, plus the drop in blood sugar
from skipping breakfast probably added to his vulnerability to panic on
those days. Voluntarily, Carl began a strict schedule of early rising and
daily breakfast. Within a very short time the panic attacks had disappeared
entirely. At that point he decided to take a break from therapy, as his goal
had been met. However, his therapy experience was so successful that he
was determined to return within the year to address his fears of the
flashbacks and the impact of the bad LSD trips themselves.

A caution: There are several situations where teaching body awareness

would be contraindicated. Here are two examples (there are certainly
others): (1) Some traumas are so damaging to the bodily integrity that any
attempt at sensing the body will overly accelerate contact to the trauma(s),
causing overwhelming feelings and risking decompensation; (2) there are
clients who will feel pressured to sense their body “correctly” and so
develop a kind of performance anxiety. With such clients, the task of
developing body awareness must be laid aside in favor of work with the
basics outlined in the previous chapter—developing safety, establishing the
therapeutic relationship, building internal and external resources, finding
oases. Later, when such clients are feeling calmer, delving into the daunting
territory of body sensation usually becomes more manageable.
 MAKING FRIENDS WITH SENSATIONS

As can be seen from the above case example, clients with PTSD,
particularly those with anxiety and panic attacks, often come to identify
their current body sensations as dangerous when they remind them of
previous trauma. When it is not possible to distinguish safe sensations from
dangerous ones, all sensations may become perceived as dangerous.
Through well-timed and paced body awareness training, a client can be
reintroduced to the friendly function of sensations.
Sensations are a gauge. They tell us when we are tired, alert, hungry, full,
thirsty, sated, cold, warm, comfortable, uncomfortable, happy, sad, etc. With
clients who are scared to feel their sensations, or those who wish they had
none, imagining the consequences of being unable to feel pain or the
sensations that indicate fear can be illuminating. How would you know the
pot was too hot to touch? You could get burned and not know it. How would
you know where the limits of exercise were? Injuries would be common.
How would you know not to walk on a deserted street alone or not to
approach a dog on the street if you could not feel fear? It does not take long
to realize that life would be very dangerous if these sensations and emotions
could not be perceived.
With graduated body awareness training clients become familiar with
their body sensations. Usually they discover that the better acquainted they
are with them, the less scary they become.

Body Awareness as the Basis of Identifying Emotions

You may remember from the discussion in Chapter 3 of Damasio’s theory

of somatic markers that each emotion has a discrete set of body sensations
associated with it, though individual body sensations may be shared by
several emotions. With clients who are unable to identify and name their
emotions (the clinical term is alexithymic), establishing body awareness is
invaluable.
One strategy for helping clients to identify emotions involves taking
advantage of situations in which the therapist observes an expression of
emotion in the client: facial expression, posture, tone of voice. This is a
good time to interrupt the current discussion or procedure and ask the client,
“What are you aware of in your body right now?” or, more specifically,
“Did you notice your breathing just change (or heat rise in your face, or
how hard it was to swallow just then)?” Gradual association of body states
may accumulate until the client experiences several at one time. At that
point the client can be asked if he has experienced those sensations together
earlier in his life, and if so, what emotion he was feeling then. Another
possibility is to externalize the experience by asking the client what
someone else would be feeling if that person had those same body
sensations.

THE BODY AS ANCHOR

Awareness of current body sensations can anchor one in the present, here
and now, facilitating separation of past from present. One is less likely to
stay lost or stuck in the past while aware of body sensations. This is very
important when working with trauma and PTSD, since the pull into the
memories of the past can be great and decompensation severe. Sensing the
body is a current-time activity. One can remember a sensation, but one feels
the remembered sensation now. Of course, some clients will require an
added reminder of that when the sensations trigger a flashback.

Body Awareness as Anchor vs. Accelerator

This next brief installment, Charlie and the Dog, Part III (continued from
pp. 45–46), illustrates the use of body awareness as an anchor.

Helping Charlie to focus on his body awareness was critical to calming and
thawing his frozen state. I repeatedly directed his attention to his body,
“What is happening in your body right now? And what else are you aware
of?” His legs were stiff, his breathing restricted, his mouth was dry, and his
heart was racing. Luckily, Charlie had a well-developed sense of his body
and we used it to great advantage. I kept leading him back to the same
areas to evaluate nuances of change in legs, breath, heart, and mouth. The
more he scanned his body, the calmer he felt. Round after round, his legs
loosened, his breathing and heart rate relaxed; only the dryness in his
mouth persisted without relief.

When anchoring is the goal, body awareness inquiry must be fairly quick
paced—not speeding, but not allowing the client to focus on any one
sensation for very long. The question must also be phrased in the present
tense. The aim is to keep the client in the here and now. This type of quick
body awareness query is used to “pft” or reduce some of the pressure. The
opposite, going slowly, staying with one sensation a long time, risks stirring
up more memories. (That would have been contraindicated for Charlie, as
he was not ready to handle more at that time—the pressure cooker was
already at maximum pressure.)
Contrary to expectation, clients usually become less, rather than more,
anxious when encouraged to notice and describe their body sensations
under this quick scan method. Once they become adept at it, many clients
report that during trauma therapy it is a relief for them to shift focus to
current sensations. Body awareness can become a secure link to the present.
Body awareness can also be used to reinforce the anchors and safe places
as discussed above. The greater the degree of positive body sensations
associated to them, the greater calming effect they will have.

THE BODY AS GAUGE

Monitoring the client’s body sensations, particularly those that identify the
state of the autonomic nervous system (ANS) (see Figure 3.1, p. 38),
provides a dependable guide to the pacing of the therapy.
The ability to recognize indications of hyperarousal, ANS overactivation,
is an easily acquired skill. But like any skill it takes practice. By noticing
what is happening in the client, the therapist secures a valuable, objective
gauge for reading the client’s arousal state. It can also be useful to teach the
client to recognize signs of ANS activation in himself—to gain a greater
sense of body awareness and of self-knowledge and control.
 The ANS is not the only usable gauge in trauma therapy. It can be useful
to note other types of body awareness: tightness, stomach upset, changes in
vision or hearing, etc. Sometimes sticking with one sensation, tracking
changes in it as the therapy progresses, will be useful (see the detailed
session at the end of this chapter).

Limitations

Therapist observation combined with client sensory feedback on the state of

the ANS is one of the most powerful tools available to the trauma therapist
for pacing the therapy. But there are certain limitations to those
observations.
Observing skin tone is a major tool for evaluating the state of the ANS,
as the skin—particularly of the face—is usually quite available to the eye of
the therapist. Of course, this is easier with light-toned skin; however, dark
skin also flushes and pales. It is just a matter of attuning the eye to
recognize it. A dark skin doesn’t blush in the same way a light skin does.
With the increase of blood flow to the skin, it darkens. Likewise, it doesn’t
blanch white, but when it loses the red pigment caused by blood flow, it
becomes more gray than brown.
The visually handicapped therapist is, of course, limited in the task of
observing ANS arousal. However, some of those limitations can be
converted into advantages. The client must supply the information that the
therapist cannot observe firsthand, giving him practice in noticing and
reporting sensations. A similar problem arises with clients whose
hyperarousal is clearly worsened by eye contact. With these clients, turning
about or changing the direction of the therapists gaze for a time can be very
helpful. When that happens, take advantage of the situation: “It is just fine
for me not to look at you. However, since I can’t see you, I’ll need a little
help. Tell me, what is the temperature in your face right now?” (Elevated
temperature goes hand-in-hand with more flush; cold skin with pale.)
“Where is your breath going mostly—is your chest moving up and down or
your stomach moving out and back?” etc. Clients in that situation are
usually happy to help—even when their body awareness skills appear to be
minimal under other circumstances.
 Gauging and Pacing Hyperarousal

Gauging the ANS through observation and the client’s body awareness can
increase reliability of the popular SUDS scale (Subjective Units of
Disturbance Scale) (Wolpe, 1969). As its title indicates, this is a subjective
measure. The client gives his opinion of his emotional state on a 1–10 scale,
1 = totally calm, 10 = the most disturbed possible. By observing the ANS,
both visually and with client feedback on sensory awareness, the therapist
secures an additional measure. It is not uncommon, for example, for clients
to give a low SUDS rating while hearts race or hands are clammy (signs of
high ANS arousal), which might indicate underlying anxiety that is being
dissociated in some way. Using both SUDS and ANS observation gives the
therapist important information when there is agreement and when there is
disagreement.
Once you learn the indicators, good pacing of the therapy is possible
only when those tools are applied. The following is an example of what can
go wrong.

Grette was assaulted as a small child. A mass of emotional problems ensued

as she grew up. She came to therapy in her early thirties quite
decompensated and terrified to confront memories of the assault. After
many, many sessions of helping her to stabilize, develop a therapeutic
relationship, etc., she came to therapy one day with newfound courage to
tell me about the incident. I listened to her, both moved and transfixed. I
was pleased that she felt ready to delve into her trauma and I was curious
about what she would reveal. In my interest, I forgot one of my own rules of
thumb: Sometimes it is better to contain my curiosity. I also neglected to
monitor her ANS reactions and to periodically help her to apply the brakes.
Despite my peripheral awareness of her gradually paling and increasingly
immobile face, I let her talk on. By the end of the session, her once
animated features were frozen into a mask. She said that she was okay, if
feeling a little “weird.” After she left the session, it didn’t take long for the
anxiety to hit. The rest of the week was filled with panicked phone calls.
All that was needed to make Grette’s discourse containable was monitoring
of her growing hyperarousal and increasing facial tension. Periodic pauses,
diverting to an anchor, safe place, or other resource, before hyperarousal got
too high would have changed the therapeutic result completely. It would
have been easy to take breaks—and put on the brakes. And even if she had
not been able to finish her whole story, she would have had a much easier
week.
Interrupting a client in such a fashion prevents the level of arousal from
climbing to the point of dissociation or freezing or becoming
overwhelming. Periodic breaks, braking, and resource building lowers the
arousal level. Continued intervention of this type throughout a therapy
session makes it possible for the client to work with terrifying memories at
a greater level of comfort.
When observing the client and asking about body awareness, it is fairly
simple to evaluate the state of the ANS. The following outlines a scale of
arousal to hyperarousal:

• Relaxed system—primarily moderate activation of

parasympathetic nervous system (PNS). Breathing is easy and
deep, heart rate is slow, skin tone is normal.
• Slight arousal—signs of low to moderate PNS activation
combined with low-level sympathetic nervous system (SNS)
activation. Breathing or heart rate may quicken while skin color
remains normal; skin may pale and moisten slightly without
increases in respiration and pulse, etc.
• Moderate hyperarousal—primarily signs of increased SNS
arousal: rapid heart beat, rapid respiration, becoming pale, etc.
• Severe hyperarousal—primarily signs of very high SNS arousal:
accelerated heart beat, accelerated respiration, pale skin tone, cold
sweating, etc.
• Endangering hyperarousal—signs of very high activation of both
SNS and PNS, for example: pale (or reduced color) skin (SNS) with slow
heart rate (PNS); widely dilated pupils (SNS) with flushed color (PNS);
slow heart rate (PNS) with rapid breathing (SNS); very slow respiration
(PNS) with fast heart rate (SNS), etc.

A relaxed system indicates the client is calm and that the therapy is
progressing at a comfortable rate. Slight arousal indicates excitement and/or
containable discomfort. A primarily relaxed or slightly aroused PNS system
might include emotions of sadness, anger, or grief. Most clients are stable
enough to tolerate slight arousal. Moderate arousal may mean the client is
having trouble dealing with what is going on and may be quite anxious; it
may be time to apply the brakes. Severe arousal is a sign that it is time to hit
the brakes with any client.
Endangering arousal is a sign that the client is in a highly traumatized
state; the process is speeding out of control. He is likely experiencing some
type of flashback (in images, body sensations, emotions, or a combination),
which could lead to panic, breakdown, or tonic immobility. High states of
arousal might also include emotions of rage, terror, or desperation. At this
point one must apply the brakes, either through body awareness and/or
strategies that are addressed in the next chapter. Before sending the client
home or continuing with the exploration or working through of trauma
memories, the therapist must help him stabilize. Stabilization is indicated
by either low sympathetic activation or primarily parasympathetic
activation. One purpose of learning to observe the bodily signs of ANS
arousal is to become competent in avoiding this highly traumatized (and
possibly retraumatizing) state, slowing down the therapy before that state is
reached.

During a therapy session, while working with a trauma, Bob became

noticeably flushed in his face and upper chest (he was wearing a v-neck
shift). He reported feeling heat in the front of his face and trunk, and an
elevated heart rate. I could also see that his breathing was very quick and
shallow—signs of high activation in both SNS and PNS. The client was
experiencing a high degree of discomfort, and I could see it. We hit the
brakes by changing the topic to one that reminded him of his strengths and
resources. Once he was calmer (his color, breathing, and heart rate mostly
normalized), he returned to the difficult topic. It took a few sessions,
shuttling back and forth between the traumatic material and the brakes, but
eventually both Bob and I knew we had reached a resolution. Finally, while
again addressing the traumatic material, his heart rate, color, and
temperature remained in PNS ranges, and his breathing deepened and
slowed—all signs of normal PNS activation. He could feel and I could see
that his SUDS had dropped to 0.

The purpose of hitting the brakes and dropping the level of arousal is not
just to give a pause and a sense of safety. It also, as with the above example,
enables the therapy to proceed at a reduced level of arousal. Without hitting
the brakes, arousal will just build and build (see Figure 6.1).

Figure 6.1. Addressing the trauma in therapy

 Pacing the Trauma Narrative

In retelling the circumstances of a traumatic event, the greater the amount

of detail the client uses, the greater the risk of hyperarousal. ANS
monitoring with the option of braking will go a long way toward making
this process tolerable and digestible for the client. Dividing a narrative into
three stages will also help control the process: (1) name the trauma, (2)
outline the trauma by designating titles to the main incidents, (3) fill in the
details of each incident, one at a time.
First have the client just name the trauma (e.g., “I was injured during a
terrorist bombing”). Observe and ask for feedback on the client’s body
state. If there is hyperarousal already, the client is not in a psychophysical
condition to narrate any more of the story. Stabilization, muscle toning,
building trust and safety should be the priority.
If, however, the client can name the incident without significant arousal
or dissociation, or if emotion discharges in a managable catharsis and the
arousal drops, the next step is to outline the main topics of the trauma—
again, without details:

“There was an explosion.”

“I was hit by shrapnel and thrown against the ground.”
“Paramedics thought I was dead and passed me by.”
“I was able to call for help and was then attended to.”
“At the hospital my mother got hysterical and called me stupid for being in
that area of town.”

Sometimes it will be difficult for a client to keep to the titles; instead she
will digress into details. It may be necessary for the therapist to interrupt,
holding the client within the parameters of the task and containing potential
hyperarousal. Even when the client wants to tell the whole story in detail at
once, it may not be a good idea. If a client insists, sometimes it will be best
to let her go ahead, sometimes not. A better idea may be to explain the
rationale of pacing to the client and encourage her to monitor her own
responses. Monitoring the ANS and other somatic signs will be a good
gauge. It is best to not go any faster than the client’s ANS can handle. It is
also preferable to set a pace that facilitates the client’s ability to make sense
out of her responses and the events that caused them.
Finally, when the client is ready—which could be immediately or only
after many years—the client narrates each incident in detail while both she
and the therapist monitor her level of hyperarousal:

“There was an explosion. It was deafening. I felt it before I heard it. I didn’t
have time to be scared because everything happened so fast. Everyone was
screaming—I couldn’t hear them because of the blast, but I could see
mouths opened in anguish. I tried to move, but I couldn’t. I nearly fainted
…”

During this step, it will be important for the therapist to periodically

interrupt the client and check the level of ANS arousal. If an anchor has
been established, it can be used during breaks to calm any hyperarousal,
which makes continuing with the narrative easier for the client. Clients
usually report that this strategy gives them a sense of control over their
memories that was not possible before.

THE BODY AS BRAKE

The following case, reprinted from an earlier article (Rothschild, 1993),

illustrates how simple body awareness can be used to reduce hyperarousal
and halt persistent panic attacks.

A young woman was referred to me for therapy because of panic attacks

and agoraphobia. Initially our work involved focusing on building her body
awareness, increasing her boundaries, and establishing a network of
friends. The body awareness work involved structured increase of tolerance
for her body sensations, which she was quite frightened of. We would
discuss an issue and keep returning to her sensations to notice how they
changed from topic to topic. If she became anxious, we would stay with the
sensations until they subsided. After a short time she was able to move into
her own apartment and begin a job that was close to her home.
After five months she came to therapy and announced that the previous
week at work she had the worst panic attack of her life. She proceeded to
describe in precise bodily detail the course of the attack: where the anxiety
began, what happened in her breathing, heart rate, muscles, temperature.
She ended the report, “I became very warm all over, and then it ended”—it
had lasted only one or two minutes. She was tremendously proud of herself.
It was the first time in her long history of such attacks that she was able to
follow a course of panic to its conclusion. She never knew that it was
possible or that a panic attack was actually so short. To my knowledge,
although she experienced occasional anxiety, she never had a panic attack
again.

THE BODY AS DIARY: MAKING SENSE OF SENSATIONS

Through its sensory storage and messaging system, the body holds many
keys to a wealth of resources for identifying, accessing, and resolving
traumatic experiences.
Identifying traumatic triggers is one of the great challenges of trauma
therapy Stimuli from the environment can inadvertently set off a traumatic
reaction in a client. Often the client is left with the reaction but has no idea
what caused it. Tracing the reaction back to the source, the trigger, can be
an important task. To that end, body awareness can be a useful assistant.
The following protocol is useful for identifying triggers:

• Notice what you feel in your body right now. Be as precise as

possible, particularly with regard to disturbances in breathing,
heart rate, and temperature.
• Think back and identify when you were last feeling calm—that is
point A.
• Identify, approximately, when you began to feel disturbed—that is
point B.
• Shuttle back and forth between points A and B, taking note of all
aspects of your environment: people, conversation, objects,
behaviors. Recall, also, what you were thinking about each step of
the way. Notice your body awareness as you focus on each aspect.
• For each element, ask yourself, “Is this what
upset/scared/disturbed me?” and notice your bodily and emotional
response.
• You will likely identify the triggering element by an increase now
in disturbing body sensations and/or an increase in emotion.
This protocol doesn’t work for everyone, but it is very useful for many of
my clients, particularly those with panic and anxiety attacks.

Sarah used this procedure after she saw a film that left her in a highly
distressed state. Her heart raced for the duration of the evening after seeing
the film, much to her confusion. It was no mystery that the disturbance
arose in the course of the movie (she had been quite calm beforehand), but
she couldn’t grasp just what it was that had upset her, or why. As she had
learned in therapy, before going to bed (sleep would have been difficult in
her hyperaroused state anyway), she sat alone and retold herself, aloud, the
story of the film. It was toward the end of the retelling that her tears gushed
forth and she began to tremble. The source of her upset was a bit of a
surprise, but made sense—a neglected corner of her history that had been
illuminated by the light of the film. She suspected she had hit the right spot,
for when she stopped crying her pulse had again returned to normal and
remained so. She made a note of the incident to take up in therapy later that
week. After a nurturing cup of chamomile tea, she had a good night’s sleep.

Through simple body awareness and shuttling between point A (before the
film) and point B (after the film), Sarah identified the source of her upset. It
was the reminder of an unresolved issue from earlier in her life.
Identification of the trigger halted the anxiety, and she was able to contain
the issue until her therapy session later that week.
Sensations can also be used to make sense of somatic memory. This is
often facilitated by slow body awareness inquiry. The client stays with any
one sensation a minute or more to see what emerges. An example:

Sixty-year-old Donna was still mourning the death, five years earlier, of her
husband of 35 years. It had been a shocking blow. He had a heart attack
while a passenger in the car she was driving. She had driven like a maniac
in an attempt to get him to an emergency room before he died. Of course we
spent a lot of time processing the incident and her grief. She also suffered a
persistent right hip problem, which caused chronic pain. The condition had
emerged about one year after her husband’s death. Each in a series of
orthopedists, chiropractors, and acupuncturists had helped a little, but the
pain persisted. She decided she wanted to see if I could help with that, too. I
had her focus on the hip, describing the sensations and being as specific as
she could about the pain—its type, location, if it was steady or throbbing,
etc. Inspired by Levine’s SIBAM model (discussed in Chapter 4), I
investigated other aspects of her consciousness. While she stayed focused
on the hip pain, I asked about other sensations in her body. It seemed that
the more she focused on the pain, the faster her heart beat. I also asked her
to notice what emotions she was feeling. She was scared. I had her just stay
with those sensations a few minutes: pain, heart rate, fear. As she persisted
her right foot dug deeper and deeper into my carpet. It wasn’t long before
she took a huge breath and began to sob, “I drove as fast as I could. I
floored the accelerator. It was an old car and I just couldn’t get it to go
faster!” It became very clear that a significant part of her hip problem was
this memory of bearing down on the gas pedal. This work didn’t cure her
physical problem completely, as she had been holding that leg tension for
four years. But the pain eased and medical treatment became more
effective. The session also facilitated her mourning process. She was able to
release some of the guilt she had harbored for not making it to the hospital
soon enough.

SOMATIC MEMORY AS RESOURCE

The term somatic memory is usually associated with the memory of

frightening traumatic events. But the body also remembers positive
feelings. Awareness of body sensations can be a superhighway to the past, a
tool for helping the client connect not only with forgotten traumatic
memories but also with forgotten resources.
Remembering how safe and secure it felt to sit in grandma’s kitchen—
with an emphasis on the comfortable body sensations—may be even more
important to current functioning than remembering a frightening incident.
Sometimes a positive somatic memory can help an individual resolve a
current difficulty without having to confront the terrifying traumatic
memory that is triggering it. Then, eventually, if the client decides to work
with the traumatic incident, the successful use of the positive memory can
be used to help ease the terror.

Tom had to ask his boss for a raise. He couldn’t afford to continue his job at
the same rate of pay. And he had put off the confrontation too long as it
was. Tom’s father had been rather tyrannical and had beaten Tom severely
when he had shown any signs of aggression. The idea of having to assert
himself at work left Tom weak with fear. We decided, at this particular
juncture in his therapy, that it would be more useful to build up his
resources than to work on his father issues.
I asked Tom to remember if there was any time when he had been able to
safely and successfully assert himself His biggest triumph in this arena had
been five years earlier, when, gathering his courage, he had asked a woman
he was attracted to out on a first date. She later became his wife, and he
was still very much in love with her. I helped him recall, in both body and
mind, how afraid he had been before he asked her out, and how victorious
and proud he felt afterward. He made some slight movements with his feet
as he recalled leaving her door after their first date. I drew his attention to
the movement. Was he aware of it? No, he had not been, but when I
mentioned it he was. I encouraged him to repeat the movement and then to
slightly exaggerate it. He recognized it immediately. He had virtually
danced down the stairs of her apartment building after their first date, and
his feet were, subtly, remembering their celebration. How did he feel as his
feet danced? Great! Excited, confident, relaxed.
Next came the challenge. I suggested he imagine approaching his boss
for the raise while dancing with his feet. He still felt anxious but less so,
and he was able to feel a little excited at the idea of a challenge. Now, of
course, it would not be prudent for Tom to “dance his way” into his boss’s
office. So we worked on refining the dance movement down into very subtle
small turns of toe and heel that he could, without drawing attention, make
while he was talking with his boss, whether sitting or standing.
When he eventually approached his boss the next week, he did get his
raise—not as much as he asked for, but acceptable. He was also very proud
of himself He had been scared, but making the subtle dance movements with
his feet had reinforced his memory of successful assertion as well as the
love and support of his wife, and that had helped him persevere.

FACILITATING TRAUMA THERAPY USING THE BODY

AS RESOURCE

The following case illustrates the application of body awareness, braking,

and an anchor to reduce the distress of addressing a traumatic memory.
Therapists will be able to recognize where their own disciplines would fit
well: extending exposure, using bilateral stimulation, suggesting viewing
the memory from a distance, etc. Explanatory comments regarding the
therapist’s intention and/or theory are identified by italic print in
parentheses.

(Gail is a forty-something mother of two. She had been wanting for some
time to face dealing with a car accident that happened when she was 18.
She is just now feeling prepared to confront it. G = Gail, T = Therapist.)
T: Are you okay with how we are sitting? (I am sitting in a chair, while G
had chosen a spot on the floor.)
(Establishing safety by attending to boundaries, position, and distance.)
G: No. You’re too far away and we’re uneven in height.
T: How do you want to change that? (G comes closer and moves from the
floor to a chair.) (Giving the client control where possible.)
G: This distance feels good.
T: How do you know it feels good? (Connecting body awareness to
cognitive evaluation.)
G: Because I don’t feel myself leaning forward or leaning back.
T: Okay. What do you want from this session? (Client control: working
on what G wants to work on.)
G: To work with that car accident that happened when I was a teenager.
It’s still really affecting me.
T: How does that feel in your body when you say that? Sounds like
you’re making a commitment.
G: Scary.
T: What do you feel in your body that tells you you’re scared?
(Connecting body awareness to emotions.)
G: My hands feel clammy and sweaty, and I just feel jittery in here
(points to chest). I think, “do I really want to do this?” And I also feel jittery
across my shoulders.
T: Do you really want to do this?
G: YEAH!! (Smiles)
T: How do you feel the part that does? That comes across differently
when you smile and say, “YEAH!”
(Reinforcing the part that is up to the challenge of facing the trauma.)
G: That accident affected me in lots of ways and I don’t want that effect
in my life.
T: How does that feel in your body when you say that? Does the
jitteriness feel the same?
G: No, it’s less.
T: So you can be in touch with the part of you that does want to go ahead
and work through this?
G: Yes.
T: Can you also feel the part that doesn’t?
(Acknowledging and containing both realities for G: Part of her wants to
face and work through the trauma; part of her doesn’t. That’s true for
almost everyone with almost any trauma. Trauma work is rewarding, but
not particularly fun.)
G: I can feel my heart beat faster. I feel scared. I’m thinking, I don’t
know what this means. I don’t know what this means.
T: Okay. And do you know why you want to work with this now? Why
you think it’s important to address it?
(Engaging the part of G that wants to confront the accident. That part will
be a resourceful ally when the process gets more difficult.)
G: I keep getting scared people will hurt themselves. I know I do that
when my kids are being adventurous. I get afraid they won’t know
their limits and will get hurt. That’s exactly what happened in the car
accident. I didn’t respect a limit. I now know it’s connected with that. I
can do something about that! I realize that accident has had a lot of
power in my life, and now I feel I can deal with it.
T: What you said a minute ago was, “I can do something about that!”
G: That’s what it feels like, I can do something about this. It feels within
my power to do something about it.
T: Say that sentence, “I can do something about that!” and see what it
feels like in your body (Supporting G’s confidence that she is ready to
deal with this now by connecting to her body sense.)
G: It feels like I have the power to do something about it.
T: How do you sense that power in your body?
G: I feel it in here (points to chest).
T: The same spot as the jitteriness?
G: Yes.
T: How does that feel there?
G: It feels good; it really feels really good that I have the power to do
something.
T: And you feel that power here (I point to my chest), just to the left?
G: Yes.
T: Okay. Let’s go on then. If we get into a place in working with this that
you feel pretty uncomfortable: anxious, stiff (possible freezing), or
whatever, how could we take a vacation, a break, from that? Is there
any topic I could bring you into that is a source of strength or good
feelings for you?
(Establishing an anchor for when the trauma work becomes too
distressing.)
G: Nature, trees, a walk in the woods.
T: Is there a particular path you like to walk on?
G: With a clear stream and lots of rocks, trees …
T: Are you remembering a particular place?
G: Yes. There is one place that’s my favorite.
T: How do you feel in your body when you speak about it?
(Bringing in as many body senses as possible when connecting and
reconnecting with an anchor: sight, hearing, touch, smell, taste, movement,
posture.)
G: I feel very nice (laughs). I feel myself smiling.
T: I think we can go forward a little now. Do you think so too?
(Again, giving G the control, even while I am steering.)
G: Yes.
T: Okay. First, I would like to hear a very brief outline of the accident—
not the details.
(Holding her to the edge of connection with the trauma at this point, not
allowing G to fall too deeply into the memory. Not going deeper than G has
resources—cognitive, physical, and emotional—to handle.)
G: I was in my late teens. I was driving. The car hit a soft shoulder. I lost
control and it flipped about three times. I was stuck in the car until
somebody got me out.
T: What happens in your body when you tell me the outline?
G: My heart is beating a lot faster. My palms are sweaty again. I feel
something here (points to head).
(Even when keeping to an outline she experiences a lot of arousal in the
ANS.)
T: Can you still see me?
G: Yes … but you’re not as clear as you were.
T: Something happened with your eyes, I can see it.
(I saw G’s eyes lose their focus.)
G: I feel like I’m further away from you.
T: Is there any physical sensation with feeling further away?
G: No. If anything it’s more like a sense of tunnel-y-ness.
T: With your eyes? Like retreating in a tunnel?
G: Yes.
(G may he at the edge of dissociating and/or freezing. Time to divert to the
anchor.)
T: Where was that place you like to walk?
G: (Names and describes the location of a river.)
T: Are there particular kinds of rocks or trees there that you like?
G: The rocks are granite, and they are really big. I like to step across the
rocks and sit on the ones in the middle of the river; the water moves all
around me.
T: How are you feeling in your body right now?
G: Really different. I’ve got sort of tingly feelings in my arms.
T: A positive kind of tingly?
G: Yes. And a lot cooler.
T: How’s our distance right now?
(Checking to see if G has associated again.)
G: I’m closer again, and you’re clearer. And I can feel the smile on my
face.
T: Okay Good. So, it works?
(Reassuring both G and myself that the anchor technique is effective.)
G: Yeah. (laughs)
T: Is it okay we go back a little bit to the accident?
(Steering the process, I take G back to the trauma after the break.)
G: Yes.
T: What happened after the accident? You said you were stuck. You got
out sometime, you know that?
(It is my preference to explore the events after a traumatic event first. Often
the events after are as or more traumatizing than the traumatic event itself.
And it is in the wake of the traumatic event that decisions and changes in
the belief system are often made. See Chapter 8 for a more detailed
discussion of this strategy.)
G: Yes, I was conscious the whole time, but I can’t remember who got
me out. Then we rode in an ambulance or a police car. My friend kept
asking the same 4 questions, over and over again. I could tell that was
really driving the policeman crazy (laughs). I sort of went into shock
at that time. I started to feel nauseous and all that. The policeman was
worried I had internal injuries, but he kept being distracted by my
friend.
T: Was your friend in the car? (A new piece of information emerges.)
G: Yeah, but I was driving. I was officially a learner, I was just about to
take my test.
T: I stick on your saying, “but I was driving.” Did you stick on that too?
(A suspicion worth checking out. There are often decisions, judgments, or
beliefs connected to feelings of responsibility.)
G: Yes. It’s really relevant because we’d made a contract to switch at
(names a junction before the accident). But I had been doing so well
and was enjoying it so much that we decided I’d drive further. It was
after that we had the accident.
T: How are you feeling in your body right now?
G: Weird in my stomach, something about making that decision for me to
drive on, if we hadn’t …
T: What does that mean to you, that you two had an agreement and then
decided to go beyond the agreement, and that it was in the part where
…
G: … beyond the limit we’d set …
T: … “beyond the limit” you’d set that you had the accident?
(Understanding the meaning of a traumatic event is often crucial to
integrating that event into the continuum of one’s life.)
G: When I say that I can feel anger at myself for not sticking to a limit I
set.
T: What do you sense in your body?
G: Not much. It’s not a body anger. More like a criticism, “Why do I do
that?”
T: I want to do a little reality check with you: Do you think that had
anything to do with the accident?
(Reality testing can be very useful, challenging a client’s view, conclusion,
judgment.)
G: Totally!
T: Why?
G: Because just going onto the shoulder shouldn’t have made us flip. I
didn’t know how to control a car in a skid. But my friend had done a
lot of driving and could have controlled a skid. I don’t believe my
friend would have driven off the edge in the first place—there was no
reason to. I’d been distracted and lost my concentration.
T: How are you feeling in your body right now?
G: Okay.
T: How’s our distance?
G: Our distance is fine. And you’re clear. I think this is interesting.
T: It sounds like you think that you were distracted, but that you went
over the shoulder and into a skid because you’d gone over your limit.
Is it possible that could have happened also in the stretch before you’d
come to the agreed limit?
G: Oh. It could have happened then, too. But the area where the accident
happened was much less safe. I hadn’t said that. On the other side of
the road where we flipped over there was a long drop down to a raging
river. In the stretch I’d agreed to drive, there were no drop-offs.
T: And how are you feeling in your body right now?
G: A bit more nauseous. It turned out okay, but what might have
happened!?
(This is something to come back to. Some of G’s trauma response might
come from imagining contingencies. But first, I’m concerned about the
nausea.)
T: And our distance?
G: I’m a bit further back, but not as far as I was. You kind of go dark.
Your face stays white, but the rest of you goes dark. (Possible edge of
dissociating, again. Time to go back to the anchor.)
T: Let’s talk about a different river.
G: (Laughs)
T: What was the name of that one you like?
G: (Names it again and we discuss its difficult pronunciation).
T: What color are the rocks?
G: White with speckles of gray and lots of moss on them.
T: Are there also trees?
G: Yes. Oak. Oak forest. I’ve probably spent more time there with the
leaves off the trees than on. A lot of winter walks.
T: What time of day do you like to walk?
G: Anytime I can.
T: In light? In dark?
G: Only in light.
T: Are there any smells?
G: I find it really hard to imagine smells.
T: How do you feel right now?
G: More here, but still a little distant. I want to tell you what I can do. I
can’t do smells, but I can tell you what I feel. I can feel the moistness,
the humidity.
T: Where do you feel that humidity?
G: On the skin of my arms and face, in my hands.
T: How’s our distance?
G: Much better.
(G told me at a later date just how significant it had been to be able to
connect with the senses that were available, not focus on the ones that
weren’t. Everyone varies in which senses are more prominent—some more
visual, some more tactile, some more auditory, etc.)
T: Are you ready to go back a little bit?
G: Yes.
T: I wanted to ask you, you said this stretch you were driving on was
much more dangerous than the stretch you had been driving on before.
Did you and your friend know that when you two made the decision
that you would continue to drive?
G: Yes.
T: Who’s responsible for the decision?
(Assigning sensible responsibility is often crucial to working through a
trauma.)
G: I guess it was pretty mutual. We discussed it.
T: How do you feel in your body right now?
G: Fine.
T: Does that mean anything to you, that the decision was mutual?
(I wanted G to connect her new statement with her previous judgment.)
G: Not really. I’m thinking maybe it should after what I said earlier, but
it…
T: About what that you said earlier?
G: About that I can be angry with myself for going over my limits.
T: I was thinking the same thing. Do you know why I would ask you
about that?
(I will often ask a client if he knows why I asked a question. I’m not wanting
to start a guessing game, and will answer my question if the client is not
able to. However, the question is often useful in helping the client’s
cognitive process.)
G: Because it wasn’t only my responsibility It was our responsibility. It
seemed a reasonable decision. And, in fact, I don’t know if that stretch
actually was more dangerous than the other stretch I drove. They’re
dangerous in different ways. There’s a lot less traffic on that stretch of
road. There was a lot of traffic on the road before the junction.
Differently dangerous. Oh! That feels nice.
(A dramatic change in G’s making sense of the accident)
T: How does that “nice” feel, in your body?
G: More relaxed. It was an understandable decision.
(The change in judgment seems congruent, as G’s body sense has also
changed.)
T: It wasn’t far-out?
G: It wasn’t far-out.
T: How are you feeling about what we’ve done so far?
G: It’s really interesting. It’s less of a big deal. I realize I’ve been
blaming myself that if I hadn’t been driving it wouldn’t have
happened. That’s why I haven’t been trusting my driving now. That’s
important.
T: I think, this is a good stopping point.
G: Yes, that feels right for me as well.
T: How’s our distance?
G: We’re both here.
T: How’s your heart rate?
G: It’s normal.
T: The nervousness?
G: It’s gone.
T: Okay, then let’s stop here.

With a useful insight and the ANS back to primarily PNS activation, it is
safe to end the session. Of course, this trauma is not fully resolved, but
resources are in place to further that process. In addition, now that the issue
of responsibility has been clarified, the rest of the work should go more
easily. A subsequent session with Gail follows in Chapter 8.
CHAPTER SEVEN
 Additional Somatic Techniques for
Safer Trauma Therapy

DUAL AWARENESS

A normal process among the nontraumatized, dual awareness simply

involves being able to maintain awareness of one or more areas of
experience simultaneously. As with body awareness, the concept of holding
simultaneous awareness of multiple stimuli has its roots in meditation and
in gestalt therapy. Here we focus on dual awareness as a prerequisite for
safe trauma therapy and as a tool for braking and containment.

PTSD Splits Perception

Most of us are able to strike a balance between the many internal and
external sensory stimuli that occupy our awareness at any one time. We are
able to notice more than one aspect of our current experience as our focus
shifts from one sensation, movement, or activity to another, reconciling
physical sensations with respect to our current environment and activity. We
are able to shuttle our perceptions from one point of reference to the other,
negotiating, compromising, and reconciling the various inputs into a
cohesive whole that we term our current “reality.” You get a pain in your
gut and are able to process that sensation with other information and
perceptions you have at hand and remember that you ate too much lunch. In
another situation, a similar pain might lead you to the conclusion that you
don’t like the direction of the current conversation or the tone of someone’s
voice. A third possibility is that someone just mentioned going to the dentist
and you are reminded that it will be your turn tomorrow.
One of the problems that develops in individuals with PTSD is that they
become habituated to paying an inordinate amount of attention to internal
stimuli and interpreting the world from that point of view. They lose
discrimination. Internal sensations become associated with past events, and
current reality is evaluated on that restricted information. External
perception pales in significance compared to the internal stimuli. The
customary reconciliation between what we experience in the body and what
we perceive outside of the body is lost. The ability to process multiple
stimuli simultaneously becomes diminished. Perception narrows.
This can lead to severe distortions in perceptions of reality and provoke
further distress. For example, when a sensation has been associated with the
experience of danger (as is the norm with PTSD), perception of any kind of
similar sensation may cause one to leap to the conclusion that something
dangerous is going on in the environment. There is no regard for other
stimuli or information. Anxiety or panic may ensue. As the traumatized
individual becomes more and more hypervigilant in an effort to foresee
danger, she actually becomes less and less able to identify it. When danger
cannot be adequately identified, recognition of safety also becomes
impossible. Danger is everywhere, and fear is constant.
I have heard several terms to describe this perceptual split between
internal and external sensory stimuli: self and observing ego, core self and
witness, child and adult, internal and external reality, etc. However, I prefer
the terms coined by van der Kolk, McFarlane, and Weisaeth (1996): the
experiencing self and the observing self.

Developing Dual Awareness

Reconciling this perceptual split is not only necessary to healing trauma but
also mandatory for conducting safe trauma therapy. It is not possible for
clients to safely address traumatic memories until and unless they are able
to maintain a simultaneous awareness and discrimination of past and
present. They must be able to know, at least intellectually, that the trauma
being addressed is in the past, even though it may feel as though it is
happening now. Delving into traumatic memory with a client who is unable
to maintain this dual awareness risks uncontainable hyperarousal and a
possible dive into flashback. This is fertile ground for retraumatization:
reexperiencing trauma with all the terror, hopelessness, and desperation first
tied to it.
Developing or reconnecting with the facility for dual awareness enables
the client to address a trauma while secure in the knowledge that the actual,
present environment is trauma-free. It is an extremely useful tool for
healing discrepancies between the experiencing and observing selves.
The following client exercise illustrates the difference between the
experiencing and the observing selves and demonstrates how to move
between the two. This type of exercise can be used with a client before
delving into trauma memories. Not only does it give him a chance to
practice this new skill, but it is also an indicator of the client’s capacity for
dual awareness and thereby his readiness to address more difficult material.
The instructions are directed to the client.

• Remember a recent mildly distressing event—something where

you were slightly anxious or embarrassed. What do you notice in
your body? What happens in your muscles? What happens in your
gut? How does your breathing change? Does your heart rate
increase or decrease? Do you become warmer or colder? If there
is any change in temperature, is it uniform or variable in sectors
of your body?
• Then bring your awareness back into this room you are in now.
Notice the color of the walls, the texture of the rug. What is the
temperature of this room? What do you smell here? Does your
breathing change as your focus of awareness changes?
• Now try to keep awareness of your present surroundings while you
remember that slightly distressing event. Is it possible for you to
 maintain awareness of where you are physically as you remember
that event?
• End this exercise with your awareness focused on your current
surroundings.

Applying Dual Awareness to Panic and Anxiety Attacks

Acknowledging the split between the experiencing self and the observing
self has helped many clients to tolerate being in situations where they are
prone to anxiety attacks. A simple technique involves accepting and stating
(aloud or in one’s thoughts) the reality of both the selves simultaneously:
“I’m feeling very scared here” (experiencing self’s reality), while at the
same time actually looking around, evaluating the situation, and saying (if it
is true), “and I’m not in any actual danger right now” (observing self’s
reality). It is very important that the conjunction is “and,” as that implies a
connection between the two phrases; “but” would imply negation of the
first phrase. The message is, “Both realities count,” not, “There is nothing
to be afraid of.” Accepting the two perspectives (that of the experiencing
self and that of the observing self) simultaneously will often reduce anxiety
quickly. It is not clear why this works so well. Perhaps anxiety escalates
with nonacceptance of the experiencing self’s reality, and when that
changes, the whole system relaxes.

Applying Dual Awareness to Flashbacks

It is not advisable to try to resolve PTSD through flashbacks as the

experience of a flashback reinforces terror and feelings of helplessness.
Psychological tools that were missing to meet the overwhelming trauma are
also usually missing to meet the overwhelming flashback; otherwise it
would not be a flashback. Integration under those circumstances was and is
not possible. Reexperiencing a trauma with the same feelings of
helplessness and terror only serves to reinforce its impact. A first step in
helping many individuals with PTSD is to teach them to stop and prevent
their flashbacks. When flashbacks are under control, it will be possible to
equip clients with the resources necessary to meet their traumatic memories
on more stable ground. Controlling flashbacks makes it feasible to approach
digestible portions of traumatic memories, one at a time.
One problem with flashbacks is that they cannot be predicted. They are
difficult to prepare for. They can be triggered anywhere, anytime, even by
the therapy setting.
A common therapeutic dilemma occurs when a client goes into flashback
during the session, believing the therapy room to be the scene of the trauma
and the therapist to be the perpetrator. When this is a regular occurrence, the
therapy can be compromised. It is a sign that the client’s experiencing self
is having free rein, perceiving danger in the place where he is seeking help.
The therapist who is perceived as dangerous is not in a position to be
helpful.
Under these circumstances, the client’s observing self must be awakened
and called back into the therapy room, usually with a measure of authority
(firm, but not angry) from the therapist: “Look where you are now. What
color is the wall here? What color is the rug? What kind of shoes do you
have on right now? What is today’s date? etc.”
When the client’s observing self is (again) operational, the following
flashback halting protocol can be taught. It is based on the principles of
dual awareness, reconciling the experiencing self with the observing self. It
usually will stop a traumatic flashback quite quickly.
The client says, preferably aloud, the following sentences filling in the
blanks and following the instructions:

• Right now I am feeling ______,

(insert name of the current emotion, usually fear)
• and I am sensing in my body ______,
(describe your current bodily sensations—name at least three),
• because I am remembering ______.
(name the trauma by title, only—no details).
• At the same time, I am looking around where I am now in______
(the actual current year),
 • here ______,
(name the place where you are)
• and I can see ______,
(describe some of the things that you see right now, in this place),
• and so I know ______,
(name the trauma, by title only, again)
• is not happening now/anymore.

An example:

I was consulted by a therapist whose client had been held hostage in a

cellar. Recently she had arrived at her therapist’s new office to find it
slightly below street level. The superficial similarity of the placement and
approach to the new office to the site of the captivity triggered a flashback
in the client. It was so strong that she became terrified of her (otherwise
trusted) therapist of two years and considered termination of treatment—he
became associated with her captor. I suggested that her dual awareness
needed to be reestablished—separating the therapist’s new office from the
site of the captivity and the therapist from the captor. The therapist brought
this distinction into awareness at the next session, helping the client to
acknowledge the realities of both her experiencing and observing selves.
Using the flashback halting protocol, the client said, “I am feeling very
scared of you because the placement of your new office reminds me of
when I was a hostage, and I got afraid you were my captor. And I can see
you right now and I know you are my therapist. I can also see right now that
you are not, nor are you about to, hurt me. And I know I can leave here any
time I want.” The client was able to regain her separation of past from
present and they were able to continue the therapeutic relationship and
therapy.

The flashback halting protocol can also be effectively adapted for use with
nightmares that may be traumatic flashbacks. This has been used as a ritual
before sleep, to prepare for the expected nightmare:
 • I am going to awaken in the night feeling ______,
(insert name of the anticipated emotion, usually fear)
• and will be sensing in my body______,
(describe your anticipated bodily sensations—name at least three),
• because I will be remembering ______.
(name the trauma by title, only—no details).
• At the same time, I will look around where I am now in______
(the actual current year),
• here______,
(name the place where you will be)
• and I will see______,
(describe some of the things that you see right now, in this place),
• and so I will know______,
(name the trauma, by title only, again)
• is not happening now/anymore.

If the client awakens with a flashback or nightmare, the regular protocol can
be used. The client might teach her partner or parent (who ever she is living
with) to prompt the protocol, or even state it herself until the client’s
observing self wakes up.

MUSCLE TONING: TENSION VS. RELAXATION

Chronic muscle contraction underlies what is commonly called “tension.”

Muscle contraction is not a bad thing; it is necessary to be able to hold
ourselves up and for all the movements we make throughout our day. It is
also necessary for the development of muscle tone. As previously
mentioned, a muscle can only do one thing: contract. When a muscle is not
contracting, it is doing what is usually called relaxation. Actually, though, a
relaxed muscle is not doing anything.
 Muscle tension has come to be regarded as a foe. It seems no one wants
to be “tense.” People spend a fortune for massages, spas, potions to relax,
relax, relax. The positive function of muscle tension is rarely discussed.
Muscle tension is taken for granted; it is often regarded with scorn. It is
uncomfortable, so how can it possibly be something good? That muscle
tension is a friend is rarely considered. But what would life be like without
it? First of all, our bodies would collapse to the ground in a blob of bone
and flesh. It is the tension in our muscles that makes it possible for us to
stand and sit straight. Muscle tension gives our bodies form, grace, posture,
and locomotion. Without muscle tension it would not be possible to perform
even the simplest of tasks. Dressing or feeding oneself, holding a pen,
playing a sport would not be possible. It is muscle tension that makes
possible a baby’s first step and the socialization of toilet training. If you are
still in doubt, consider muscle-wasting diseases like muscular dystrophy
and amyotrophic lateral sclerosis (ALS). They may serve as reminders of
just how important muscle tension is. Muscle tension is necessary for daily
living.
Certainly there are times when the degree of chronic muscle tension
becomes discomforting. And for some, induced relaxation through massage,
hot baths, muscle stretching, progressive muscle relaxation, etc. may be
very beneficial. However, there are many with PTSD for whom induced
relaxation will precipitate a trauma reaction, increasing hyperarousal and
anxiety, risking flashbacks. There are no studies that discuss this
phenomenon; it is an area yet to be researched. However, there are a few
articles that mention increases in anxiety in some people due to relaxation-
type trainings (Heide & Borkovec, 1983, 1984; Jacobsen & Edinger, 1982;
Lehrer & Woolfolk, 1993).
© The New Yorker Collection 1987 Arnie Levin from cartoonbank.com. All rights reserved.

Informal discussion among colleagues suggests that a significant

percentage of PTSD clients may become more anxious from relaxation
training. In such cases, building or maintaining muscle tension is preferable
to relaxation. Simple body awareness is a reliable measure of which is best
for a particular client. Clients who become calmer with relaxation can
benefit from it. Those who become more anxious when relaxing may be
better off tensing instead. There may be a generalized positive or negative
response to tensing or relaxation throughout the body. But it is also possible
to have a positive experience tensing a particular muscle and a negative
experience tensing another (even the same muscle on different sides). Every
body is built with different distributions of muscle tone (Bodynamic, 1988–
1992). Body awareness is the key to determining when tensing or relaxing a
particular muscle benefits or impedes.
It is confusing to think that someone could actually be more relaxed
when more tense, an oxymoron. However, it may be that individuals with
greater muscle tone are better able to tolerate hyperarousal than those with
lesser tone. For instance, a greater degree of muscle tone increases self-
confidence and reduces feelings of vulnerability and helplessness.
 One consequence of PTSD is body sensations that are very unpleasant.
Those that exacerbate feelings of anxiety and panic abound. They usually
coincide with autonomic nervous system (ANS) hyperarousal. Some clients
describe a peripheral “buzz” just under the skin, as if they had their finger
in an electric socket. These unpleasant sensations go hand in hand with the
sleep disturbance that so many with PTSD suffer. A common nighttime
experience is to feel tired, even sleepy, go to bed and start to relax only to
jolt awake with a racing heart and buzzing sensations in the limbs. At that
point sleep becomes hopeless for many hours.
Muscle tensing has helped many reduce these unpleasant sensations—
even to the point of enabling sleep. The kind of tensing being discussed
here does not include aerobic exercise. That is contraindicated for some
individuals with PTSD and panic attacks, as the elevated heart and
respiration rates can be trauma triggers in themselves. Rather, it is slow,
focused, muscle-building exercise that is beneficial in these circumstances.
For this kind of muscle building to be effective, it must be done with body
awareness—with attention to body sensations generally and to the muscles
being exercised specifically (Bodynamic, 1988–1992). Also, the exercise
must stop at the point of mild tiredness in the muscle, while it is still a
pleasant experience. Doing repetitions “till you feel the burn” is not helpful
for building muscle tone that aids emotional containment. Exercises that
enhance sensations of calm, solidity, and increased presence are beneficial.
Any that bring anxiety, nausea, disorientation, etc., are not. The idea is to
build a positive experience of being in the body by developing musculature
that can better contain hyperarousal and the full range of the emotions. A
further goal is to build a positive experience of being in the body so that the
desire to reside in the body and continue the exercise develops. In that way
it becomes self-rewarding.

Joanie was intimately aware of her need for muscle tension. She had been
vulnerable and impulsive as a young adult, prone to drifting from project to
project. She had trouble keeping a job and was subject to periodic bursts of
anger as well as a general level of anxiety. Moving to a country where
bicycle riding was a major form of transportation turned out to be a
blessing for her. As she got used to riding great distances, her legs became
stronger and stronger, and, amazingly, she grew more and more stable—all
this before she ever considered psychotherapy. She was very aware of the
role increased muscle tone in her thighs had in her newfound ability to
maintain her focus and contain her emotions. However, when she was ill or
visiting family in another country and unable to ride for a while, her
previous instability would creep back.

A simple toning exercise to begin with is push-ups. They build tone in the
backs of the arms (triceps), the chest (pectorals), and the back (trapezius
and rhomboids). They can also be done at home with no special equipment.
It is easiest to begin standing a few feet from a wall, leaning into it and
pushing away. Gradually one can move lower on the wall until there is
enough strength to push off from stairs or the floor. Leg lifts in many
directions (quadriceps, tensor fascia lata, hamstrings, and gluteals) also
need no special equipment. Cheap free weights, milk cartons, or books can
be used for strengthening the front of the upper arms (biceps).
In addition to increasing general emotional stability, muscle tensing is
used by some as an emergency measure when anxiety threatens to escalate
into overwhelming anxiety or panic. Below are a few postures that can be
used to tense specific muscles. Most people will find at least one of them an
aid to on-the-spot containment. Of course, any postures that increase
anxiety should not be used.

Tensing Peripheral Muscles—Holding Together

Important: Any tensing should be done only until the muscle feels slightly
tired. Release of the tensing must be done slowly. This is not progressive
muscle relaxation. The idea here is to try to maintain a little of the
contraction/tension. Try one exercise and evaluate with body awareness
before going on to the next. If tensing causes any adverse reaction (nausea,
spacyness, anxiety, etc.), you can usually neutralize that reaction by gently
stretching the same muscle—making an opposite movement (Bodynamic,
1988–1992).
 • Side of Legs: Stand with feet a little less than shoulder-width
apart, knees relaxed (neither locked, nor bent). Press knees out
directly to the side so that you can feel tension along the sides of
the legs from knee to hip (Bodynamic, 1988–1992).
• Left arm: Sit or stand with arms crossed right over left. The right
hand should be covering the left elbow. First, the right hand
provides resistance as the left arm lifts directly away from the
body. You should feel tension in the forward-directed part of the
upper arm from shoulder to elbow. Next, the right hand provides
resistance to the back of the elbow as the left arm pushes directly
left. You should feel tension in the left-directed part of the upper
arm from shoulder to elbow (Robyn Bohen, personal
communication, 1991).
• Right arm: Sit or stand with arms crossed left over right. The left
hand should be covering the right elbow. First, the left hand
provides resistance as the right arm lifts directly away from the
body. You should feel tension in the forward-directed part of the
upper arm from shoulder to elbow. Next, the left hand provides
resistance to the back of the elbow as the right arm pushes directly
right. You should feel tension in the right-directed part of the
upper arm from shoulder to elbow (Robyn Bohen, personal
communication, 1991).
• Thighs: Sitting in a chair, place both feet flat on the floor. Press
weight onto your feet just until you feel tension build in your
thighs.

Muscle tensing became the foundation of therapy with one client:

Theresa was in her mid thirties when she began seeing me. She suffered
from PTSD and borderline personality disorder. She was not very functional
and was unable to work. She had difficulty setting goals—she was either
empty of ideas or full of pipe dreams. Early in my work with Theresa she
expressed the desire to someday be able to hold a steady job, get married,
and raise a family. I affirmed her desire but commented that we couldn’t
achieve it that day. “What,” I asked, “is one thing you can do today that is
a small step toward those goals?” After considering this she surprised me
by saying, “I need backbone” She meant it both figuratively and literally.
Upon closer inquiry, I found out that she felt very weak in her back and
could not, in fact, feel the support of her spine. That day we began
strengthening Theresa’s spinal muscles through slow exercise, using body
awareness. I would have her slump in her usual posture, then slowly
straighten up, becoming taller. We kept the pace slow, so that she could
keep up with the change in muscle tension and monitor other body
sensations. I was particularly interested in her noticing where she was
having to tense up to sit up. It was hard work. She repeated the movement
several times—slump, straighten, slump, straighten. The exercise became
homework. In subsequent sessions we regularly referred to her newly
developed spinal tension—her “backbone.” Gradually, it became a
dependable support and resource for her—both literally and figuratively—
as she traversed some of the difficult themes in her life.

PHYSICAL BOUNDARIES

Boundaries are of many kinds. This section will focus on discussion of

interpersonal and concrete boundaries that are associated with the body.

Interpersonal Boundaries

If you have ever “known” someone was standing behind you before you
turned to look, or felt the person you were talking to was standing too close,
you have perceived an interpersonal boundary. It is not a mysterious or
mystical line, but something quite palpable that is often experienced at
various distances. Your interpersonal boundary circumscribes what you feel
to be your personal space. One interpersonal boundary is that point at which
the distance between you and another turns from comfortable to
uncomfortable. Another kind is what animal behaviorists call critical
distance, the point at which a wild animal turns from cautious alert to
attack. Determining a boundary’s distance is not only very individual but
also dependent on the situation. What might be an uncomfortable distance
at a particular time or with a particular person might well be quite
comfortable at another time or with someone else, and vice versa.

Therapeutic Distance

Sometimes a problem develops during therapy that seems to have no origin

and no solution. The following consultation illustrates a problem that has
occurred both with seasoned therapists and with therapists in training.
Although a bit extreme, the situation described here is not unusual. In this
instance, the client was becoming ill—headaches and vomiting—within a
few hours after each therapy session. The therapist and client could not
identify a cause, and both were concerned.

I met with therapist and client together. First I was briefed on the client’s
personal history and the history of the therapy. As the therapist worked a lot
with the body, I ventured that perhaps the body work was too provoking and
rigorous for the client. No, they did no body work at all; they just talked.
Okay. Well then, might the material being discussed be too traumatic, too
much for the client, too provocative? No, they were only discussing issues
from the client’s daily life. Since the problem was not in the content or
method, I became curious about the physical arrangements. How did they
usually sit together? They showed me by placing themselves facing each
other in chairs approximately one meter apart.
I asked the client to scan for body awareness and report any sensations.
The client felt a rapid heart rate, cold sweaty hands, and slight nausea. I
suggested that the client move back and see what happened. He felt a slight
relief. I encouraged him to find a distance and a placement that further
reduced the discomforting symptoms. He moved back further and to the
side. There was more relief, but the client was still a bit uncomfortable. The
client continued to experiment in this way. Finally, a placement of chairs
about three meters apart, turned diagonally so they were no longer facing
each other, gave a lot of relief—all signs of sympathetic arousal, were
replaced by signs of parasympathetic arousal.

The client did not become ill after that consultation. Both client and
therapist continued to pay close attention to their sitting position in
subsequent sessions, and the client had no further problem with illness
following therapy sessions.

Two Exercises to Explore Boundaries*

While the following exercises will be familiar to many, they are worth
including for those who have not encountered them before.

The first interpersonal boundary exercise is done in pairs. One partner

slowly walks toward the other. The stationary partner keeps track of her
own body sensations and says “stop” when she begins to feel
uncomfortable. It is a good idea to repeat the exercise several times with the
stationary partner standing at different angles to the moving partner—face,
right and left shoulder, back toward the walking partner. It is important that
the stationary partner talks about what she senses in her body and feelings.

This exercise illustrates the difficulty many have feeling their boundary and
being able to say “no” or “stop.” Sometimes the stationary partners body
and emotional state never change, so she never says “stop” and the moving
partner ends up walking into her. When this happens it is usually because
the starting distance was already inside of the stationary partner’s
interpersonal boundary. It is not possible for the stationary partner to feel
her boundary when the moving partner is already past it at the start point.
If this happens, try repeating the exercise from a greater start distance. This
is also true for people in their daily lives. It is not possible to feel where
your “stop” or “no” point is if you have already crossed it. So if a client
reports that the distance between the two of you is okay, consider if the
client is actually comfortable or if she can’t feel her boundary because you
are already too close. When in doubt, have either of you move a little and
see what happens. You can always move back to where you started. An
example:

As we began our second session, Thomas looked like he was holding his
breath. I inquired about our placement. He said it was fine, but still did not
breathe. I suggested I move back a little just to see what happened and he
agreed. When I did he immediately exhaled and breathed easier. He also
noticed the change. We proceeded with the session from that distance.

The second interpersonal boundary exercise involves the use of yarn (or
string or rope) to help visualize one’s boundary. The client in individual
therapy or in a group therapy takes a length of yarn and uses it to draw a
circle around himself at the radius he perceives his comfort distance to be.
It is good to have the client talk about the experience while he is doing it,
including how it feels in his body to make his boundary concrete. Then, with
the client’s permission, the therapist can roam about the room moving in
and out of the client’s boundary (as we actually do with others all the time).
The client is asked to track his somatic and emotional responses, expressing
what is happening while the therapist walks. He should notice when he feels
an unmolested space, and when he feels intruded on. He should also feel
free to adjust his boundary at any time. A point worthy of note: The wider
the radius of the boundary, the more easily it is invaded and the more
frequent and intense the client’s feelings of intrusion. Eventually, the client
can be taught to redraw his boundary (actually with the yarn, as well as
figuratively).
When the client is ready, an additional intervention can be useful: With
the client’s permission the therapist comes to a pause just inside the client’s
yarn and does not move. The client will usually feel uncomfortable,
sometimes angry. The therapist then helps the client to figure out that if he
draws his boundary in a tighter circle around him, the therapist will no
longer be intruding inside of his boundary. Often this gives a client a
feeling of mastery over his personal space that he can take out into his daily
life in business, social, and personal contacts, on public transportation, in
restaurants, etc.

Concrete Boundary at the Skin Level

The expression “thin skinned” is apt in describing many with PTSD.

Traumatic events often intrude past the skin, either physically or
psychologically.

A 3-year-old friend of mine, Lane, had suffered plenty of medical trauma.

She greatly enjoyed the company of one child at a time, but was unable to
tolerate the stimulation of multiple children. At an annual family gathering
she clung desperately to one or the other of her parents. Though she was
usually secure with their comfort, this time it was not enough for her as the
excitement generated by several children increased.
I was touched by her plight and carefully approached her as she held fast
to her mother, visibly shaken. I took my hand and began to gently, but
firmly, rub the surface of her back. As I did this I said, “Here’s Lane. Can
you feel Lane here?” She began to calm and relax. Her whimpering ceased.
As long as I kept my hand at her back, reminding her of where her physical
body was, and where it stopped, she could maintain her composure.
Whenever I withdrew my hand, her upset would again increase, even if I
continued the verbal reminders. Her mother and I were both fascinated at
the dramatic change when I marked her boundary, and disturbed that she
couldn’t maintain it in the absence of my hand. Later that week Lane’s
mother and I discussed strategies for increasing her sense of physical
boundary. We invented games they could play together. One involved their
placing hands, arms, legs, or feet together and mom instructing Lane to
shift the focus of the sensations at the surface of her skin: “Feel Mommy,
now feel Lane.” As such exercises helped Lane to have a more secure sense
of the edges of her body, her tolerance of child uproar improved.

Thickening Helen’s Skin

Helen was in her mid-twenties when she sought therapy following a
childhood marred by sexual and physical abuse. Needless to say, she had
many problems and was very “thin skinned.” A city dweller without a car,
she was often plagued with anxiety when confronted with public
transportation. It wasn’t the travel itself that was intimidating, but the risk
of inadvertent physical contact. Her fear of casual touch was evident even
in the therapy situation. She needed to be very careful as she entered and
left my room lest we accidentally brushed shoulders. She made me promise
I would never give her an affectionate pat on the shoulder on her way out
the door. I’d never had a client so fearful of even bumping shoulders with
someone.
As my first principle is attending to the safety of the client both in and
outside of the session, I proposed that we figure out a way to help her feel in
control of casual touch—to give her some tools to avoid it, stop it, and keep
it from feeling like it invaded beneath her skin. We both knew that bumping
into people was sometimes inevitable on buses, trains, and subways.
First Helen worked on building muscle tone to thicken and toughen the
cushioning under her skin. Highly motivated, she lifted weights, did push-
ups and sit-ups and walked daily for several months. Next we constructed a
program whereby she could learn to move away from an unwanted touch or
move the hand or shoulder of another away from her. She was convinced
she needed to become proficient at this and was willing to brave some
discomfort to achieve it. In this instance I made an exception to my rule of
not touching trauma clients, as the program we created necessitated brief
touch. Helen insisted that the potential gains outweighed the risks. (An
option would have been to encourage her to try the same exercises with a
trusted friend, or have her bring a friend to the therapy. That would bypass
the therapist-client touch issue. However, Helen had no friends at the time
we embarked on this task—she was too afraid of being touched to have any)
Helen chose the initial task I would demonstrate first; then she would try
herself We stood, facing each other at arm’s length, and when she was
ready, she would place her hand on my shoulder. Then I would twist my
trunk away from her hand and step back out of reach, causing her hand to
fall to her side. When it was Helen’s turn, she would tell me when she was
ready for me to place my hand on her shoulder. She would then try a similar
twist with a back step until my arm fell at my side.
 Next we tried standing shoulder to shoulder. I instructed her first to just
try stepping to the side away from my shoulder. Once she had that down I
suggested she stay where she was and just pull her shoulders in toward the
center of her body, narrowing her shoulder width, so that the distance
between our shoulders increased.
This may seem very simplistic, but for Helen it was very hard work. She
had a lot of anxiety at first, but as her facility grew she became calmer and
more confident.
Our third exercise involved standing facing at arm’s length again. Helen
would ask me to place my hand on her shoulder; then she would remove it
more directly. One way was to just push it with the opposite hand; another
was to rotate the arm on the same side in a circle, gently batting my arm
away. We discussed the importance of doing this calmly, even if she were
angry. The idea was to stop someone from touching her, not to provoke a
conflict.
We drilled these exercises again and again over many weeks. As Helen’s
facility grew, her “skin” seemed to toughen and thicken and with that her
confidence to venture out in the world increased. She also became more
trusting of me, as she felt more capable of stopping me from doing
something she didn’t want. Eventually she eased her vigilance. One day she
surprised me by asking me to change my promise. Now she wanted me to
casually touch her as she entered and left my room—a pat on the shoulder
or the like. She wanted to see how it felt and decide herself if she would
accept the touch or move away from it.

Establishing a Sense of Boundary at the Skin Level

Trauma and PTSD are often the result of events that were in one way or
another physically invasive: assault, rape, car accidents, surgery, torture,
beatings, etc. Often it is loss of the sense of bodily integrity that accelerates
a trauma process out of control. Reestablishing the sense of boundary at the
skin level will often reduce hyperarousal and increase the feeling of control
over one’s own body. To increase the sense of bodily integrity, I often
suggest that a client physically feel his/her periphery/boundary—the skin.
This can be done in several ways:
 1. Have your client use his own hands to rub firmly (not too light, not too
hard) over his entire surface. Make sure the rubbing stays on the
surface—skin (clothes over skin)—and does not become a gripping or
massaging of muscles. If your client doesn’t like touching himself, he
can use a wall or door (often a cold wall is great) to rub against a
pillow or towel to make the contact. Remember, especially, the back
and the sides of the arms and legs.
2. Some clients will feel too provoked even touching their own skin or
being observed doing it. In that case it might work to have them sense
their skin through sensing the objects they are in contact with. Have
the person feel where his buttocks meet the chair, his feet meet the
inside of his shoes, the palms of his hands rest on his thighs, etc.
3. As the client does one of these, it is sometimes also useful to have him
saying to himself, “This is me,” “This is where I stop,” etc.

Visual Boundaries

For some clients, just having the therapist look at them is an intrusion.
Reactions can be strong. Often intense feelings of shame or embarrassment
underlie this difficulty. In such cases it can be a fairly simple matter for the
therapist to turn her gaze away Clients with this difficulty will be greatly
relieved when the therapist looks away. It takes some getting used to for the
therapist who is accustomed to relying on visual cues, but the potential
benefit to the client should help the therapist to tolerate her discomfort.

THE QUESTION OF CLIENT-THERAPIST TOUCH

There is no denying the universal need for touch and human contact. This is
no less true for the traumatized—perhaps more so. However, there can be
complications when the need for touch is met in the therapeutic situation.
Both transference and countertransference can be provoked to an
uncontainable degree. For more stable clients (Type I and Type IIA), the
hazards may be minimized, but with Type IIB clients therapist touch is too
risky to be advisable. For example, it is not unusual for the touching
therapist to become perceived as a perpetrator to the physically or sexually
abused client. Needless to say, this is not helpful to the therapeutic process.
Here is an example of learning the hard way:

Kurt had been both abused and neglected in his developmental years. He
demanded a lot of my time and attention. I encouraged Kurt to increase his
body awareness and learn his interpersonal boundaries, but he was
skeptical. During several sessions he complained of needing to be held. He
was sure that was what he needed from me. He became angry when I
hesitated. He finally insisted that we just try it and see how it went. Going
against my better judgment, I relented. He wanted me to put my arms
around him as we sat side by side on the couch. Instead of experiencing the
relieving contact he envisioned, his anxiety climbed. He couldn’t relax and
became frustrated with himself, and then with me. He felt that I must have
been doing something wrong because he was feeling so scared. Kurt was
not able to connect his rising fear at being held now with his earlier history
of abuse; I became perceived as the perpetrator. It was not possible to
resolve the conflict during subsequent sessions and he eventually left
therapy with me.

A better strategy for helping the traumatized client to get her needs for
touch met is to teach her how to meet those needs among her closest family
and friends or in a group therapy situation. For a client to be able to ask for,
receive, and utilize touch among her network, she must have developed the
ability to perceive and respect her own boundaries.

As a consequence of years of incest, Blair was confused about her

boundaries. She knew she needed contact and often went beyond what was
comfortable for her to get it. She was often promiscuous in an effort to get
physical contact. In the past she had suffered several bouts of sexually
transmitted diseases. It was a confusing dilemma for her: If she respected
her interpersonal boundary she was afraid she would never again be
touched. She knew no compromise. After helping her to increase her body
awareness, I suggested that she run an experiment at home. She agreed. I
advised that she choose a friend, male or female, with whom she could
experiment with her touch boundaries. We discussed the pros and cons of
several choices; Blair settled on two people she would ask. When one friend
agreed, I coached Blair in the experiment. Blair would monitor her body
awareness throughout and record the changes for us to discuss at the next
session.
The experiment involved Blair’s finding out what kind of touch her friend
could give while Blair maintained a normal heart rate and breathing—that
is, did not become anxious. At first Blair thought the experiment was a bit
ludicrous. She was so used to being touched that she was skeptical that she
needed such caution. But she found out differently. When she focused on her
sensations, she discovered that she did indeed become anxious when she
was held around her whole body. It was the first time she realized that her
promiscuous behavior necessitated cutting off from her body sensations.
Through pursuing the experiment, she further discovered that hand holding
was completely comfortable. In the ensuing weeks, Blair paid more
attention to her body awareness when she was being touched. In the
therapy sessions, we looked at her discoveries and she received further
coaching on how to ask for the kind of touch she wanted and how to say no
to touch she didn’t want.

MITIGATING SESSION CLOSURE

Every trauma therapist knows that ending a single trauma therapy session
can sometimes be difficult; as discussed previously, trauma processes can
easily accelerate. When timing of a session does not fit within the usual
therapeutic time frame, it can be difficult for both therapist and client. Most
of the principles and techniques discussed in this and the preceding two
chapters can be used as aids to easing the problem of session closure. They
can be applied both to pace the session and to end it.
Equipping the client to apply the brakes gives an advantage to both client
and therapist. For the client, the safety of the therapeutic process is
increased as he gains confidence in his ability to control—turn on and turn
off—his traumatic memories. Courage to confront difficult issues usually
increases when the client knows he can come out of it any time. When
client and therapist are well practiced in braking before traumatic material
is addressed, acceleration can be stopped at any time. Further, keeping the
client’s arousal at a low level throughout the therapy session assures that the
process will not get out of control in the first place. Familiarity with the
client’s resources will help the therapist keep the client from processes
where he does not have the tools to stop. Of course, there will be times
when judgment slips and the session will need to be extended a few minutes
for the purpose of putting on the brakes, but this will not occur often if the
preparation is adequate.
Sometimes the best strategy to timing session closure is to end early. It
can be useful to be on the look-out for “stopping places” (as with Gail’s
session at the end of the previous chapter)—an integration, an “aha!,” a
spontaneous reduction in arousal. There are often several within a single
session. It is usually better to send the client home after a briefer session
where he reached a significant integration or relief than to continue the
session to the end of the allotted time when he may be uncomfortable or in
a muddle. The time left after stopping specific trauma work can also be well
used to address integration of trauma therapy into the client’s daily life.

In the next chapter, application of body awareness and other somatic tools
will be discussed in relationship to facilitating the addressing of traumatic
memories.

* The history of these exercises is curious as there are several organizations that claim to have
originated each. Either the original inspiration for them has been long forgotten, or those groups have
coincidentally developed similar exercises at around the same time.
CHAPTER EIGHT
 Somatic Memory Becomes Personal
History

Regardless of the techniques or modalities employed, the goals of trauma

therapy should be:

1. To unite implicit and explicit memories into a comprehensive narrative

of the events and aftermath of the traumatic incident. This includes
making sense of body sensations and behaviors within that context.
2. To eliminate symptoms of ANS hyperarousal in connection with those
memories.
3. To relegate the traumatic event to the past: “It is over. That was a long
time ago. I survived.”

Since the mid-1980s several treatment models for working with trauma
have emerged. In fact, within the field a feeling of competition has arisen.
The prevailing expectation is for one therapy model to emerge as the
therapy for trauma. This attitude is cause for concern, because it does a
disservice to our clients. Each available therapy helps some clients, and
each of them also fails at times. Every modality has strengths as well as
weaknesses. Just as there is no one medication to treat anxiety or
depression, there is no one-size-fits-all trauma therapy. In fact, sometimes it
is the therapeutic relationship, not any technique or model, that is the
primary force for healing trauma. All of the trauma treatment modalities,
though, have two things in common: They are all highly structured, and
they are all highly directive. Each method involves a precise protocol that
must be followed to reach resolution of traumatic memories. This requires
that the therapist be directive, steering the protocol rather than following the
client’s process. It appears that this commonality is no accident. Those
working with trauma—from divergent disciplines—demonstrate agreement
that working with trauma requires structure and direction. This makes sense
as following the client’s process without intervention usually results in
either avoidance of traumatic memories or becoming overwhelmed by
them.
Though efficacy studies can help point the way to suitable models, they
can also be misleading. First of all, most such studies are based on Type I
trauma clients. In addition, studies conducted by the proponents of one
method primarily report positive results, whereas those conducted by
opponents report negative results. Perhaps a better basis for judging the
success or failure of a method might be to trust the client’s body awareness
and symptom profile: “Has this helped you? Are you calmer, more
contained, better functioning? Okay, let’s continue.” “This isn’t helping?
You feel worse, more unstable, less able to handle your daily life? Okay,
let’s try something else.” As previously stated, the safest trauma therapy
comprises several models, so the therapy can be adapted to the specific
needs of the client.
Regardless of the therapy methods that are being employed, the topics
presented in this chapter will be fundamental to improving the quality and
outcome of trauma therapy.

BEWARE THE WRONG ROAD

Memory is malleable and subject to influence. Continuous as well as

recovered memories can be highly accurate, and they can also have
inaccuracies. A good illustration of the vulnerability of memory is provided
by a friend’s son who broke his arm at the age of 8. The boy, now 12,
remembers most of the incident accurately: falling from the tree, breaking
the arm, the trip to the hospital, having the arm set by a doctor. However,
there is one integral detail that he misremembers. In the boy’s memory it is
his mother who held him as the broken bone was set. Actually, it was his
father. The implications of this kind of memory distortion are profound. A
continuous or recovered memory of an incidence of abuse could, for
example, be generally true, while the perpetrator, or age, or place, etc.,
could be remembered inaccurately. This is not to say that all recovered
memories should be suspect; it is also possible for them to be highly
accurate, as has been shown in studies and reports by Andrews (1997),
Duggal and Sroufe (1998), and Williams (1995).
The uncertain nature of memory forces the trauma therapist into a
difficult position. Clients present memories of trauma that have been
continuous; they also present memories that have been recalled as a part of
therapy, outside of therapy, and even prior to therapy Memories can also be
recalled whether or not you or the client are attempting to recover them. No
matter how the memories occur, the problem remains. How does one
evaluate the accuracy of a memory? When there are corroborative records,
witnesses, or evidence, the veracity of memory can be determined. When
there is no corroboration, accuracy may be suspect. It may not be possible
to determine the correctness of a “memory.”
A therapeutic dilemma occurs when either the therapist and/or the client
feels a need to credit an unsubstantiated memory as “true” or “false.” Onno
Van der Hart and Ellert Nijenhuis (1999) call this “reflexive belief” and
caution against its practice as the risk of false negatives or false positives is
high. Whichever attribution, true or false, is applied, it will greatly
influence the direction of the therapy and the client’s life. The only route
under such circumstances is to continue the work but restrain the judgment.
That can be difficult to bear for both client and therapist. But not to do so
risks making a mistake with dire consequences.

Risks Along the Wrong Road

It is easy to get led down the wrong road. When that happens, the client can
suffer greatly. Decompensation can even occur. Of course, it is not always
possible to tell if decompensation is the result of the impact of a recovered
traumatic memory or destabilization from seeking the memory of a trauma
that is not there. When in doubt, signs of hyperarousal in the autonomic
nervous system as well as other symptoms, are good indicators. An
example:

Brad came to therapy depressed, anxious, and suicidal. He was pale, his
breathing quick and shallow. This, he reported, was not his normal mode.
He became increasingly decompensated while seeing another
psychotherapist whom he had engaged after developing feelings of having
been raped as a child. The therapist had been working with him to recover
memories of a possible childhood rape. When Brad became seriously
suicidal, he realized something was wrong and went looking for another
therapist.
Brad’s childhood had been troubled. He was arrested a couple of times
as a juvenile and had spent several months in detention. This background
became pertinent in accessing Brad’s current state. Approximately nine
months prior to his engaging the other psychotherapist, Brad’s house had
been burglarized and ransacked while he was out one evening with his
family; the burglar had set off a silent alarm. Brad arrived home to find his
house crawling with police. The previous therapist had not paid attention to
that disturbing, recent incident at all, but had headed straight for the felt,
but unknown rape. Brad proceeded to decompensate more and more as they
looked further for childhood memories to explain the feeling of rape.
After I took Brad’s history I said to him, “You may or may not have been
raped as a child. There is no way to know as you do not remember and
there are no records. However, the fact of the recent burglary and
subsequent police intrusion is enough to account for your symptoms, your
feelings of having been raped. Many people would describe their reaction
to such an intrusion as feeling as if I have been raped.’ If you factor in your
juvenile arrest record, I can imagine that both the burglary and the police
intrusion were very shocking for you.”
Upon hearing my evaluation, Brad visibly calmed. Healthy color crept
into his cheeks. His respiration deepened and slowed. The decrease in
arousal was palpable in the room; Brad could feel it distinctly in his body.
His suicidal ideation disappeared. Within the week he was emotionally
contained and back to a normal level of functioning. In subsequent sessions,
we addressed those more recent events.

Unfortunately, this is not an isolated example. One way to avoid this kind of
therapeutic error is to take a careful history and always ask, “What brings
you into therapy now?” If the answer is something like “a suspicion” of
early abuse or other forms of trauma, always ask further, “What brought
that up now?” or “What triggered that now?” If the client isn’t sure, careful
questioning about stressful events within the last few months to a year may
lead to a triggering incident that needs to be addressed first. Focusing on the
current event that brought a client to therapy in the first place is one way to
avoid going down the wrong road.

Getting All the Information

An excellent example of avoiding a wrong road by getting all the pertinent

information is provided by Donald Nathanson in the first chapter of Shame
and Pride (1992). Nathanson used common sense that saved his client a lot
of money and a lot of anguish. He describes a former patient who returned
for therapy confounded that he had lost his capacity for dealing with his
anxiety something his previous therapy had emphasized. His current high
level of anxiety was impervious to all of the tools he had gained. He was
“afraid of everything.” At the first interview, among other information-
gathering, Nathanson wisely questioned the patients “nasal speech” and
found out he had been suffering a cold. It turned out that the client was
taking medication that contained pseudoephedrine, a kind of synthetic
adrenaline. Such medications mimic the body’s reaction to stress—
heightened sympathetic arousal. It quickly became clear to Nathanson that
this patients symptoms were caused by the medication, not by anxiety
Relieving the anxiety symptoms then became easy—just change the
medication.
Imagine what would have happened to Nathanson’s patient if this doctor
had not been so wise. They would have begun to look for a psychological
cause for his anxiety, digging and digging. The results could have been
disastrous as well as costly. Such mistakes are easily made when either a
therapist or client acts on preconceived predictions and leaps to
psychological causes for somatic symptoms. Severe problems can occur
when the preconceived leap is to trauma.
Other physical conditions can mimic psychological problems. For
example, consider the hormonal changes due to aging. Perimenopause is
the term now being applied to the extended period of hormonal and
menstrual changes that lead up to the menopause, the complete cessation of
menstruation. Perimenopause can begin as many as ten years before actual
menopause. During that time hormones may fluctuate erratically and create
numerous physical and psychological symptoms (Begley 1999), including
ones that mimic anxiety.

Dorothy, 48, would awaken suddenly in the night feeling very warm, her
heart racing. Influenced by a friend who was in therapy and a self-help
book she had read, she began to wonder if she had been molested as a child
and was starting to have disturbing dreams. She was very upset. I suspected
her symptoms might be consistent with perimenopausal changes. She was
not waking with a sweaty hot flash, but something similar. Because she still
had regular periods, she had not considered that her symptoms could be
hormone related. I suggested that she keep a log of the pattern of the night-
time incidents and referred her to her gynecologist for hormone tests. Both
the tests and the log confirmed that these incidents occurred cyclically,
when estrogen levels were the lowest. Her anxiety over possible molestation
disappeared.

One further caution: The effects of early medical trauma can be mistaken
for effects of physical and sexual abuse. Medical intervention that involves
genital or anal areas—surgery, examinations, treatment of vaginal or
bladder infections, rectal thermometers, suppositories, and enemas—can be
traumatic for some children. As adults, the somatic symptoms can mimic
those of sexual abuse. It is important to consider possible medical trauma
when evaluating adults with unconfirmed suspicions of child physical or
sexual abuse.
 It is critical to consider more than the client’s belief or the therapists
intuition of the cause of symptoms. Careful and comprehensive history-
taking, as well as a generous dose of common sense, will go a long way to
prevent potentially damaging excursions down the wrong road.

SEPARATING PAST FROM PRESENT

Ultimately, the main goal of trauma therapy is to relegate the trauma to its
rightful place in the client’s past. For that, explicit memory processes must
be engaged to secure the context of the event in time and space. Usually
separation of past and present is an automatic result of any good trauma
therapy; it does not usually need to be addressed head-on. The following
example is an exception. It is included here to emphasize the importance of
recognizing a trauma is over, past, done, and survived. In this unusual
instance, that message sank in with only one intervention. It is not likely to
happen in the normal course of trauma therapy, though it is what we are
striving for.

Usually anxious in a group, Dorte became panicked during a workshop

exercise (racing heart, dry mouth, cold sweat). Through simple attention to
body awareness, a memory emerged. As a child Dorte had been trapped by
a group of other youngsters who taunted and restrained her. She had been
very frightened. She kept repeating to me, “I couldn’t get away, I couldn’t
get away.” Each time she repeated the phrase her hyperarousal increased
both to my observation and by Dorte’s report. In an attempt to circumvent
this rise, I commented, “But you did get away. I know you got away.” Her
symptoms continued and she became confused. I asked her if she would like
to know how I knew she got away. She nodded vigorously, yes, she did.
Pointing to the place where she was sitting I responded simply, “I know you
got away because you are here.” “Oh!” she replied—and I could almost see
the light bulb go on over her head. She comprehended immediately that she
could not be sitting in front of me if she had not, indeed, gotten away. Her
symptoms of panic disappeared simultaneously with that insight and did not
return. She was still not wild about being in groups, but her extreme anxiety
decreased considerably following that intervention.

Separating past from present can also be accomplished on a body level.

Sometimes an intervention as simple as encouraging a client to move a
finger or an arm or just get up and walk while working with a traumatic
memory will help to reinforce the here-and-now reality that the trauma is no
longer occurring: I could not move then, but I can move now.

WORKING WITH THE AFTERMATH OF THE TRAUMA

FIRST

It is a mistake to consider a single traumatic incident as a solitary event.

Every traumatic event is comprised of three distinct stages, any one of
which can increase or decrease the ultimate impact of trauma. The three
stages are: (1) circumstances leading up to the traumatic incident, (2) the
traumatic incident itself, and (3) the circumstances following the incident,
both short-term (minutes and hours) and long-term (days, weeks, months).

before the trauma → the actual traumatic event → after the

trauma

The time following a traumatic event is critical. The quality of contact

and help the victim receives can greatly influence the outcome. It is for this
reason that it is often advisable to resolve the issues following a traumatic
incident first, before attempting to address the incident itself. Sometimes
what occurs after the incident is more emotionally devastating than the
incident itself. Imagine, for example, the potential outcomes for the trauma
victims in the following scenarios:

1. Two women with corresponding backgrounds and personalities are

similarly injured in the same type of car accident.
 As husband arrives at the hospital visibly shaken, worried about his
wife’s condition. He greets her warmly and with obvious concern.
B’s husband arrives at the hospital angry. He is worried about the
condition of the new, expensive car. He greets his wife with accusation.

2. Two war veterans also with corresponding backgrounds and

personalities are from the same combat unit. They are both discharged
following injuries received during the same offensive.
In his community A is welcomed home as a hero. Everyone is concerned
about his injuries. He is given help to reestablish himself
B, on the other hand, is greeted by his friends with contempt for his
violent acts. His family is impatient that his recovery seems slow. He is not
given help to reestablish himself in his community

It does not take a research study to speculate that, all other variables
being equal, the As in the above scenarios are likely to fare better than the
Bs. Just as a tidal wave sometimes follows an earthquake, the aftermath of
trauma can wreak even greater damage.
Regardless of the treatment method, choosing which part of a traumatic
incident is to be addressed first can be critical to the course and outcome of
the therapy. Approaching direct work with traumatic memories is always
difficult. When started from the beginning of the event, the load can be
insurmountable:

before the trauma → the actual traumatic event + after the trauma
Start at the beginning, and there is all of it to face.
One of the wisdoms of addressing the circumstances that came after the
trauma first is that it reduces the load considerably when addressing the
actual incident. Afterward, when approaching the actual event, there is only
that to contend with:

before the trauma → the actual traumatic event → after the trauma
Moreover, when you start at the end, the client gets to face the worst of
the traumatic event secure in the knowledge that it did actually end, and she
has survived.
The following case, illustrates these points:

Ruth* is a Western European woman in her mid-thirties who at 19 was

raped during a student vacation in a Middle Eastern country. She works as
a social worker for immigrants and often comes in contact with refugees
from the Middle East. She sought therapy after noticing that over the
previous few months she had growing anxiety at work, which was beginning
to interfere with her ability to continue her job. She was experiencing
increasing flashbacks of the rape, difficulty concentrating, and periodic
nightmares.
The therapy began with my taking a careful case history. As we discussed
her past and current situation, it became clear that her current anxiety had
been set off after she had been threatened by one of her Middle Eastern
clients several months earlier. She hadn’t thought much about it at the time,
but could now see the connection. She was a Type I client with no other
incidence of sexual assault or other trauma in her history. We discussed
Ruth’s situation at work and she agreed that for the time being she would
not work with potentially violent clients—she was already receiving support
for this from her colleagues.
Early in therapy Ruth outlined the circumstances surrounding the rape.
She had been traveling with a group of friends, but had chosen to go off by
herself one day with a polite young Arab, Abdul, who offered to show her
the city. No one thought much about it. Abdul was very knowledgeable and
showed her many places she wouldn’t have otherwise seen. Toward the end
of the day they encountered one of Abdul’s friends and went back to Abdul’s
apartment. As night fell, she was told by Abdul that he would have sex with
her but would not allow his friend to because Abdul was “in love” with her.
She protested and asked to be taken back to her hotel. Abdul threatened that
if she didn’t allow him, both of them would have sex with her. Ruth then
went dead in her body. The next morning Abdul showed her back to her
hotel, stopping to buy her breakfast on the way. When they arrived, her
friends expressed concern about where she had been, but Ruth was so
embarrassed and ashamed about what had happened that she told them she
had spent the night dancing.
 Once home, a vaginal infection forced Ruth to seek medical treatment. A
gynecologist was the first person she told about the rape. His response was
cold and clinical, with an edge of sexual interest that increased her feeling
of shame. Eventually she told one of the friends she had traveled with. She
remembered feeling ashamed and fearing she would be judged. Her friend,
however, was very compassionate, terribly sorry for what had happened.
Ruth felt relieved to have finally told someone.
Over several sessions early in the therapy we decided to take a look at
the situation immediately following the actual rape. Here the connections to
her inability to act against the offender or seek help gradually became
clear.
When Ruth and Abdul left his apartment the next morning, Ruth felt she
had to be nice to him. She didn’t know where she was or how to get to her
hotel. She couldn’t speak the language. She felt dependent on Abdul to get
her back to safety—dependent for safety on the man who had raped her! So
she let him hold her right hand. As she remembered, she could feel the
tension in that hand and the impulse to draw it away.
As Ruth and Abdul approached her friends, she had an urge to scream
out, “Call the police! He raped me!” but stifled it by tensing in her throat;
she feared the reaction of the crowd.
As Ruth had a Middle Eastern girlfriend in her current life, I suggested
that she ask her about the cultural attitudes involved here. Ruth received a
lot of insight from her friend and realized that a Middle Eastern crowd
would have considered Ruth, a young European woman accusing a local
man of rape, to be a whore. At best they would have ignored her; at worst
they would have accused her or beat her. The police, the friend was sure,
would not have taken the situation seriously. They might even have arrested
Ruth, instead. This cultural insight was critical in alleviating Ruth’s guilt
for not having sought help or retribution.
Upon returning to her memories, I had Ruth sense what she had to do in
her body to make herself hold the rapist’s hand and not cry out: it was a
difficult feat. She had to tense her arm while relaxing her hand, tense her
throat, not run, etc. At the same time I encouraged her to consider how
smart she had been—how she had likely saved herself additional harm,
shame, and anguish by controlling herself in these ways.
 Now Ruth became angry at the rapist and how he had set her up.
Previously she had always been angry only at herself. She was ready to
separate her responsibility from his, realizing that it was he who was in the
wrong. (She knew—and we still needed to work on—that there was
something amiss in her judgment that she walked into the situation. But she
realized at this point that the responsibility for the rape itself clearly was
Abdul’s.) Ruth had clearly said “No!” to his sexual advances. Then, for the
first time since the incident, Ruth remembered that Abdul had attempted to
strangle her when she resisted.
This was an important step. It was crucial to assign guilt. Many trauma
survivors are all too ready to take all blame, and many therapists are too
quick to place all blame on the offender. For the client to reclaim his or her
power and sanity, the truth of guilt must be illuminated. A rapist is
responsible for a rape. Period. And the victim of rape must be willing to
look at how he or she came into the situation—not to feel guilty, but so that
he or she can prevent the same from happening in the future.
Ruth expressed her anger and cried that it was not fair that Abdul got off
free and she had suffered all these years. I suggested that she allow herself
a fantasy of what she would have liked to have happen. She was very quick
and clear: he should have been caught, tried, and castrated. “Men who
can’t contain their sexual hormones shouldn’t be allowed to have them.”
She was sure she didn’t want him killed and didn’t want him to suffer pain,
just be deprived of the hormones that she saw as the cause of what he did to
her.
Ruth now felt different. For the first time since the rape she didn’t feel
ashamed for having been raped. Instead she felt angry at the rapist.

This was the pivotal turn in Ruth’s therapy. The rest was much easier. When
she worked with the rape itself, Ruth was not plagued with shame and
doubts about who was in the wrong. And when she approached looking at
how she got herself into that situation, the shame of the rape itself was
separated from her guilt for not having been more cautious.

BRIDGING THE IMPLICIT AND THE EXPLICIT

When PTSD splits mind and body, implicitly remembered images,
emotions, somatic sensations, and behaviors become disengaged from
explicitly stored facts and meanings about the traumatic event(s)—whether
they are consciously remembered or not. Healing trauma requires a linking
of all aspects of a traumatic event. The implicit and the explicit must be
bridged in order to create a cohesive narration of those events, as well as to
place them in their proper slot in the client’s past. Making sense of
implicitly encoded sensations, emotions, and behaviors in the context of the
traumatic memory is a crucial part of this process. The tools for creating
this bridge are to be found in both psychotherapy and body-psychotherapy.
It is necessary to address what occurs in the body, and it is equally
necessary to use words to make sense of and describe the experience. The
bottom line is that clients need to be helped to think and feel concurrently—
that is, to be able to sense their sensations, emotions, and behaviors while
formulating coherent conclusions about the relationship between those and
the images and thoughts that accompany them. Finally, a cohesive narrative
of the traumatic incident will take form and the event will come to occupy
its proper place in the client’s past.
The two therapy sessions presented below illustrate the integration that is
possible with trauma therapy when both dimensions—mind and body—are
included. As before, therapists are encouraged to think about which
elements might enhance their own ways of working.

Gail, Part II

Gail’s first therapy session to resolve an earlier car accident was described
at the end of Chapter 6. What follows is the transcript of a subsequent
session.

T: What do you want to work on today?

G: Someone recently asked me how I got the scars on my arm and it
made me feel light headed and nauseous. I got a very clear image of
the end of the accident, when the car stopped rolling and I looked
down and saw that my left arm was broken.
T: What are you feeling in your body as you talk about that now?
G: Slightly anxious here (she points toward her belly) and a funny feeling
in my jaw, a slight shaking.
T: How’s our distance?
(I remembered her tendency to dissociate.)
G: (She smiles.) It’s fine.
T: Tell me what you remember about your anchor.
(It is important to recheck the anchor at each session. Sometimes it will
need to he changed or altered.)
G: It’s at a place near my friends house in a beautifully forested valley
with a crystal-clear shallow river; you can see the rocks in the bottom.
There’s a particular granite rock I like to sit on.
T: What are you feeling in your body right now?
G: My stomach is looser and my shoulders have dropped, my hands are
dry.
(Parasympathetic signs mean the nervous system is relaxed; it is safe to
proceed.)
T: Then let’s get to it. Okay?
G: Okay.
T: Where do you want to start? (Giving the client control.)
G: I want to tell you what happened when the car stopped moving. It was
then I first realized I was still here, still alive. I looked down and saw
that my forearm was bent [broken], and I straightened it. It was as if I
could not bear it being bent like that.
T: What are you feeling as you talk about this?
G: Nothing, no feeling, but somewhere in me I know it was really scary.
T: What is that like to know it was scary but not feel it?
(Gail has dissociated her fear. I want to know how she regards the
incongruence. A client should not he pushed to feel dissociated feelings.)
G: It’s weird. I don’t like it. I want to put those two things together.
T: Which two things?
G: Feeling scared about my arm.
T: Don’t assume that it needs to be BIG scary.
(Gail is afraid to feel her fear and I do not want her to imagine it any
bigger than it is. Sometimes emotions are dissociated because of the fear
they will be overwhelming. Trauma clients usually expect dramatic
expressions of emotion. The fact is that sometimes they are very subtle.)
T: What do you feel in your body right now?
G: I feel my shoulder more.
T: It looks like you are moving. Are you?
G: I’m twisting to the right.
T: Do you want to follow that? See if you can stay behind the impulse.
Just follow it. (She twists more to her right.) What happens when you
do that?
G: I remember wanting to throw my arms around my boyfriend and feel
him there, but he was unconscious. (She begins to speak faster, and her
voice tone rises.) Then this policeman came to my window and I
yelled, “Get me out of here!” I was afraid the car would explode. And
…
T: Wait. Slow down. Tell me what you are feeling right now.
(She’s starting to he swept away by her narrative. We have to apply the
brakes, to prevent overwhelm or retraumatization.)
G: I feel kind of shaky, teary.
T: Do you know what the emotion is?
(At this point I do not want her to sink into the emotion. She’s too dubious
for that. I want her to know what it is before she feels it strongly so it will be
more familiar, and hopefully more digestible.)
G: Frightened. And a bit like, I can’t think of the word, like something
has to be taken care of right now—urgent.
T: How does that feel in your body?
G: Shaky. And I have an impulse to get up, to move.
(Many feelings and sensations are being remembered at once.)
T: Follow the impulse.
G: I don’t feel like I can. What I want to do is tell you how the policeman
wouldn’t let me do that. He wasn’t letting me get up and out. He was
doing all the right things. He said, “Hang on. Can you feel your feet?
Can you feel your legs? Do you have any pain in your back?” But I
kept saying, “I just want to get out of here. I’m okay. Get me out of
here!” But he was making me go through all these things.
T: Do you know why he was doing that?
(Reality checking.)
G: He wanted to make sure I didn’t have a back injury. But I knew I
didn’t. I’d already checked that, myself. I’d done that bit!! I’d already
done that and I just wanted to get out of there.
T: What are you feeling now?
G: Angry. I want to say, “Shut up! I know it is safe to move me, get me
out of here.”
T: Do you remember and/or know how long it was from the time he got
to you till he helped you out of the car.
(Another reality check. At the time it probably felt like an eternity.)
G: I don’t think it was very long.
T: What are you feeling in your body now?
G: A bit calmer. I feel a slight trembling in my legs.
(Trembling often accompanies a release of fear, but it is not time to focus on
it yet as she is not very connected with it.)
T: What is happening with your hands and arms?
G: (She looks down.) My right hand is holding my left arm. That’s what I
did then: I braced my broken arm.
(Visual cues and kinesthetic nerves help the body to remember a posture
central to Gail’s memory of the trauma.)
T: How does that feel?
G: I can feel something in my throat, but I don’t know what it is.
T: How’s the distance between you and me?
G: It’s fine.
T: Does it feel okay to go on? I’m aware I’m not taking you to the
anchor, but it seems this level of arousal is tolerable for you.
(Checking to see if she is dissociating. A lot is going on and she does not
seem very hyperaroused. It is usually the case that when emotions are
integrated, hyperarousal is reduced, but it’s a good idea to check.)
G: Yes, that’s fine.
T: What are you aware of in your arms?
G: I don’t want to take my right arm away from my left [broken] arm.
T: You don’t seem to look at your left arm. Is that right?
G: Yes. I don’t want to, but there’s something there.
T: You don’t have to.
G: It’s okay, I will.
T: Don’t do it yet. When you do, I suggest you just take a little peek at a
time. Take just one peek and see what happens.
(Taking a small, controlled bite.)
G: (She glances quickly.)
T: What happened?
G: I felt a shiver go through my body.
T: All the way through?
G: Yeah. It feels like: oohhhh, it was horrible. (The shivering increases.)
T: Let that trembling happen.
(There is more connection to the fear now, and more chance for
integration.)
G: I feel kind of sick.
T: See if it’s okay to stay with the trembling and sick feeling a minute or
so. (She does and the trembling subsides.)
T: How are you feeling?
G: Calmer, but still a bit sick.
T: Don’t you think that’s a normal reaction? When someone sees a
broken limb in an unnatural position, you get a bit of a sick feeling.
G: Oh, yeah! It looked awful. Uuuh. (More shaking.)
T: How does the shaking feel?
G: It feels quite good actually.
(She is integrating this memory: images, sensations, and feelings.)
T: Don’t make it more or less, just let it do its thing. What happens to the
sick feeling when you shake like that? Does it get more or less?
G: It gets less.
T: How’s our distance?
G: Okay
T: The same?
G: Only a slight pulling back.
(Slight dissociation. Time to put on the brakes and use the anchor.)
T: Let’s take a little break.
G: (Laughs with relief.)
T: What kind of trees are in your place?
G: Oak.
T: Is oak the kind of tree that has those little helicopters that fall
spinning?
G: No, that’s maple. Oaks have acorns!
T: Oh, yeah, that’s right. (We both laugh.)
(Laughter is a great remedy for hyperaousal and dissociation.)
T: Are you usually there when leaves are on the trees, or not?
G: I’ve been there with both.
T: All seasons? Have you seen the leaves turn colors, too?
G: Yes.
T: What are you aware of in your body?
G: Relief. Less tension.
T: Do you ever go barefoot in the stream?
(Associating various sensations connected to the anchor.)
G: Oh, yeah! All the time. Well, not all the time. Even in the winter just
to get my toes wet.
T: How does that feel?
G: It’s incredibly cleansing. And very cold. But it really can clean
out anything. (She sighs deeply.)
T: Can you feel yourself breathing?
G: Yes.
T: Do you want to stay there for a while, or is it time to go back?
G: Stay a little while. I feel a rock under me. (The client takes control.)
T: What else?
G: I can hear the sound of the water running around me.
T: Have you ever shown your rock to a friend?
G: Not this one. Other ones, yes. But this one is too special to me. Now
I’m ready to go back.
(The more the client is in control, the more courage she gathers to face the
frightening past.)
T: When you think of your arm, what do you feel in your body?
G: I feel myself tilt to the right and pull back from seeing it.
T: Can you describe that further?
G: Yeah. It’s weird. It feels like if I leaned to the left, I’d get very
emotional.
T: And when you lean to the right?
G: There I feel nothing, like when I thought, “I’m not going to let anyone
see me like that,” and I straightened my arm. And I was “okay” from
then on.
T: And when you moved your arm in that state, what did it feel like?
G: Nothing. No pain. No feeling. Entirely numb.
T: So you partially dissociated to accomplish an important task.
(Recognizing the resource in the defense.)
G: Yes. I was afraid the bone would rip through my skin if it was left like
that when I was moved. But the doctors didn’t like that I had done it.
T: You were doing everything you could do to protect yourself. To
accomplish that you had to make some kind of internal split, which
looks to be off to your right.
G: Yes, and back. It’s definitely back.
T: To your right and back. Can you feel yourself in that place now?
G: Sort of, but I haven’t moved completely into it. I’m hovering in the
middle.
T: I’m quite aware of your hands. Are you aware of anything with your
hands?
G: They’re shaking.
T: They?
G: Well, actually my left one is shaking and my right one is not.
T: Exactly.
G: It’s like the left one is holding the fear.
T: And the right?
G: It’s like the right one is more steady, “I can handle this.” (The right
and left hands are representing the right and left split that is occurring
between feeling and numbing.)
T: I’m going to suggest that you put your awareness in both hands at the
same time. Can you do that?
G: Yes.
T: Good. Keep your awareness in both while moving them closer
together, very slowly
(The movement symbolizes integration of the feeling and the numb parts of
her.)
G: (Trembles as she does this.)
T: Do you feel your shaking?
G: Yes. (She slowly continues.)
T: What’s happening?
G: I feel angry. There’s something about me taking care of myself and
others not taking care of me. Like that I straightened my arm and made
myself okay.
T: What’s happening in your eyes?
G: I’m getting tearful, sad.
T: Do you know why?
(Can she make sense of her sensations and feelings—think while she is
feeling?)
G: It wasn’t that they didn’t take care of me. I wouldn’t let them take care
of me. I kept telling everybody I was okay.
T: What was the truth?
G: Of what I did or how I felt?
T: Of how you felt.
G: I felt really scared. (She starts to cry and her voice gets softer and
rises an octave.) The car went out of control and rolled over and over
…
(She’s integrating the image of the accident with the dissociated emotion.)
T: … and you were really scared …
G: … and I was really scared. It was like it turned over in slow motion so
it seemed like it took hours, and I didn’t know where it was going to
land.
T: … and you were really scared …
(Encouraging her to stay connected to the fear while she is remembering. A
big step in healing of trauma takes place when the client feels safe enough,
now, to feel the previously dissociated fear.)
G: … and I was really scared. I was really scared!
T: Do you feel that right now?
G: Yeah. (She trembles.)
T: I can see it. Just let the trembling happen.
(With more connection to the fear, the trembling will be more effective in
releasing it.)
G: And …
T: Slow down. See if it is okay to stay with the feeling in your body a bit
longer. (G trembles a bit more.)
G: I can feel I’m beginning to get angry now. I want to tell you about it.
What was most unhelpful is what the policeman said. He came over
 and the first thing out of his mouth was (G’s voice becomes stronger),
“Wow, when I arrived and saw this car, I thought I was just going to be
picking up pieces!” And (she gets even louder with tears in her voice)
I DIDN’T NEED TO HEAR THAT!
T: That scared you more.
G: Yes! I really, really didn’t need to hear that!
T: See if you can stay connected to the anger and at the same time feel
how much his words scared you.
G: No. I’m not going to feel how much that scared me.
T: Okay. What are you feeling in your body right now?
G: Solid on my seat. A little gone away though.
T: Do you know why?
G: I think because I don’t want to feel that fear.
T: Did you ever tell anyone how scared you were?
G: No, I was “okay.” I told everyone how lucky I was that I survived. I
never told anyone I was scared.
T: Could you tell anyone, now?
G: That might be hard. Maybe my best friend.
T: Can you imagine telling her?
G: I know I could tell her, but I don’t know if I could feel anything.
T: Would you like to try?
G: Yes.
T: Do you know why I am suggesting this?
(It is not a guessing game. I want to know if she is thinking and able to
follow my motivation. I will tell her if she does not know.)
G: Because I haven’t had any contact or support about it.
T: Exactly. It seems you’ve been much alone with that fear.
G: Yes, I have.
T: Okay, are you game?
G: Yes, I’d like to.
T: So, in your mind, imagine being together with your friend. Where
would you two be?
G: In my kitchen. Just imagining it, I can feel I’m shaking a little.
T: Just let that happen. (She does and also cries for a while. Then the
tears and shaking subside.) What do you want to tell your friend?
G: (With a lot of emotion) I was so scared. I thought I was going to die.
Then this stupid policeman comes and tells me he thought I was dead!
I got so angry. What a stupid thing to say!
T: You didn’t die, but you were very scared.
G: That seems like a good thing to mention! (Laughs) And I didn’t! I
didn’t die. I actually wasn’t even that hurt.
T: But, you were scared you were going to die.
G: Physically, I wasn’t very hurt. But, boy, I was scared I was going to
die!
T: What are you feeling in your body?
G: Really awake. More calm. And my heart’s stopped racing.
T: Do you think you could really tell your friend?
G: Yes. Actually, I want to. I think I’ll call her when I get home.
(Making a bridge between therapy and the client’s daily life is very
important. If the therapy is not relevant to current functioning then it is not
worth much.)
T: How are you feeling in your body now?
G: Quite calm, actually.
T: If it’s okay, I’d like you to try looking at your left arm again. (G looks
at her arm.) What happens? (Checking to see how much has been
integrated and relieved.)
G: I feel a bit sad seeing those scars, but I’m not feeling sick or scared.
T: Do you know what the sadness is about?
G: I’m just sorry my arm was hurt and I didn’t tell anyone I was scared.
T: I can well understand that. Does this feel like a good place to stop?
G: Yes it does.

Commencing with a traumatic trigger, the scars on her arm, Gail was able to
recognize and integrate the most frightening events of the car accident.
Gradually, she made sense of somatic sensations, emotions, and movements
in the context of the visual and auditory memory images that occurred. One
of the most important insights was the acknowledgment of how alone she
was and has been with the frightening memories of that accident. Talking
with her best friend about it will initiate a new behavior in Gail’s current
life. Hopefully, the next time she is scared she’ll be able to tell someone. By
the end of the session, Gail was able to return to the original stimulus—
looking at her arm—with absolutely no hyperarousal.

CHARLIE AND THE DOG, THE FINAL EPISODE

This case was introduced in Chapter 1 and was used to weave a thread
through the Theory section. In Chapter 6 it was used to illustrate how
simple body awareness could calm a seriously hyperaroused state. Charlie
and the Dog will now be concluded as an example of the importance of
linking the implicit to the explicit. Here both reality checking and attention
to somatic impulses assist in changing the reaction to a traumatic trigger.

When Charlie could sense his body (and this had helped him to calm
substantially—all signs of sympathetic activation were decreasing except
his dry mouth), he was ready to think. I asked him, “Is Ruff anything like
the dog that attacked you?” Startled, he answered, “I don’t know, I never
looked at Ruff.” This was amazing to everyone in the group, as Charlie had
been around Ruff several times over the preceding two years. However,
Charlie had managed to avoid Ruff completely He became quite anxious
just at the thought of looking at Ruff. I encouraged him by suggesting that
he take just a very quick peek through his fingers (as a shy child might do).
He did it very fast—with the speed of a camera shutter—just long enough to
snap a visual image of Ruff. At that point Charlie exclaimed with great
surprise, “My goodness! Ruff doesn’t look anything like that dog who
attacked me!” With that realization he calmed down considerably, the
stiffness melting from his body and sympathetic excitation further
decreased. It was a very dramatic response. Both he and I waited and
watched the melting happen, checking body awareness from time to time.
When the stiffness had fully melted, his legs gradually became restless—it
was easy to see the little tick-like movements that developed in his thighs
and shins. I brought his attention to the movements, what Levine (1992)
would call intentional movements (slight muscle contractions that may
indicate a behavioral intention that has not been fulfilled) and I encouraged
him to sense them from the inside (through the interoceptive, kinesthetic
nerves). I suspected the movements would develop further if we were
patient, and they did. After a couple more minutes Charlie felt the impulse
to curl his legs away from where Ruff had been sitting. He did that, and
remarked, rather pleased, “I can move like this if Ruff comes back. Then
she couldn’t put her head on my knee.” Charlie then found he had a further
impulse to get up and walk a couple of meters away, which he did saying, “I
could also walk away if Ruff comes back.” (As obvious as that might seem,
in Charlie’s hyperaroused state, there had been no such option.) At this
point I checked Charlie’s body awareness again; all signs of hyperarousal
were gone.
Later in the workshop Charlie had the opportunity to exercise his new
tools as Ruff did, indeed, come again to sit by him—twice. The first time
Charlie was able to turn away from Ruff without being triggered into
flashback, though he reported that he was a bit anxious. By the second time,
Charlie just curled his legs away from Ruff, who settled herself nearby. This
time Charlie felt no anxiety whatsoever. We never addressed the details of
Charlie’s trauma of being attacked by a dog. Instead we facilitated body
awareness, reality testing, and the development of new behavioral
resources. 1 met Charlie some time after that workshop and he reported to
me that he no longer froze or broke into a cold sweat when seeing dogs
behind windows or even meeting them on the street, though he maintained a
high level of caution with the type of dog that had attacked him. A few years
later I saw Charlie again and he proudly told me that he and his family had
adopted a dog and welcomed it into their home. It was the frosting on his
sweet victory.

The implicit memories represented by Charlie’s stiff tonic immobility, dry

mouth, accelerated heart rate, and the sensation of Ruff’s head on his thigh
were integrated with his factual, explicit memory (“I was attacked by a
dog”). Explicit processes were engaged to identify here-and-now reality as
separate from the past (“Ruff doesn’t look anything like the dog who
attacked me”). New behaviors (curling the legs to one side, getting up and
walking away) were also encoded in both implicit memory (through
practice) and explicit memory (through describing and making sense of
both old and new behaviors).
The body remembers traumatic events through the encoding in the brain of
sensations, movements, and emotions that are associated with trauma.
Healing PTS and PTSD necessitates attention to what is happening in the
body as well as the interpretations being made in the mind. Language
bridges the mind/body gap, linking explicit and implicit memories. Somatic
memory becomes personal history when the impact of traumatic events are
so weakened that the events can finally be placed in their proper point in the
client’s past.

THE FAR SIDE © 1990 FARWORKS, INC. Used by permission. All rights reserved.

* This case example is extracted and condensed from a previously published article (Rothschild,
1996/7, 1997).
 References

American Psychiatric Association. (1980). Diagnostic and statistical

manual of mental disorders (3rd ed.). Washington DC: Author.
American Psychiatric Association. (1994). Diagnostic and statistical
manual of mental disorders (4th ed.). Washington DC: Author.
Andrews, B. (1997). Forms of memory recovery among adults in
therapy: Preliminary results from an in-depth survey. In J. D. Read & D. S.
Lindsay (Eds.), Recollections of trauma: Scientific evidence and clinical
practice (pp. 455–460). New York: Plenum.
Azar, B. (1998). Why can’t this man feel whether or not he’s standing
up? APA Monitor, 29(6), 18–20.
Bandler, R., & Grinder, J. (1979). Frogs into princes. Moab, UT: Real
People.
Bauer, M., Priebe, S., & Graf, K. J. (1994). Psychological and endocrine
abnormalities in refugees from East Germany, part II: Serum levels of
Cortisol, prolactin, luteinizing hormone, follicle stimulating hormone and
testosterone. Psychiatry Research, 51, 75–85.
Begley, S. (1999, Spring/Summer). Understanding perimenopause.
Newsweek, Special Issue, 30–33.
Bloch, G. (1985). Body and self: Elements of human biology, behavior
and health. Los Altos: William Kaufmann.
 Bodynamic Institute Training Program, 1988–1992, Copenhagen,
Denmark: Author.
Bremner, J. D., Randall, P. K., Scott, T. M., Bronen, R. A., Seibyl, J. P.,
Southwick, S. M., Delaney, R. C, McCarthy, G., Charney, D. S., & Innis, R.
B. (1997). Magnetic resonance imaging-based measurement of
hippocampal volume in posttraumatic stress disorder related to childhood
physical and sexual abuse: a preliminary report. Biological Psychiatry,
41(1), 23–32.
Bremner, J. D., Southwick, S., Brett, E., Fontana, A., Rosenheck, R., &
Charney, D. S. (1992). Dissociation and posttraumatic stress disorder in
Vietnam combat veterans. American Journal of Psychiatry, 149, 328–332.
Breslau, N., Davis, G. C, Andreski, P., & Peterson, E. (1991). Traumatic
events and posttraumatic stress disorder in an urban population of young
adults. Archives of General Psychiatry, 48(3), 216–222.
Breslau, N., Davis, G. C, Andreski, P., & Peterson, E. (1991). Traumatic
events and posttraumatic stress disorder in an urban population of young
adults. Archives of General Psychiatry, 48(3), 216–222.
Brett, E. A. (1996). The classification of posttraumatic stress disorder. In
B. A. van der Kolk, A. C. McFarlane, & L. Weisaeth (Eds.), Traumatic
stress (pp. 117–128). New York: Guilford.
Claparede, E. (1951). Recognition and “me-ness.” In D. Rapaport (Ed.),
Organization and pathology of thought (pp. 58–75). New York: Columbia
University Press. (Original work published 1911)
Classen, C., Koopman, C, & Spiegel, D. (1993). Trauma and
dissociation. Bulletin of the Menninger Clinic, 57(2), 178–194.
Damasio, A. R. (1994). Descartes⑥ error. New York: Putnam.
Darwin, C. (1872/1965). The expression of the emotions in man and
animals. Chicago: University of Chicago Press. (Original work published
1872)
De Bellis, M. D., Keshavan, M. S., Clark, D. B., Casey, B. J., Giedd, J.
N., Boring, A. M., Frustaci, K., & Ryan, N. D. (1999). Developmental
traumatology, part II: Brain development. Biological Psychiatry, 45(10),
1271–1284.
 Duggal, S., & Sroufe, L. A. (1998). Recovered memory of childhood
sexual trauma: A documented case from a longitudinal study. Journal of
Traumatic Stress, 11(2), 301–321.
Eich, J. E. (1980). The cue-dependent nature of state-dependent retrieval.
Memory and Cognition, 8(2), 157–173.
Elliott, D. M. (1997). Traumatic events: Prevalence and delayed recall in
the general population. Journal of Consulting and Clinical Psychology,
65(8), 811–820.
Ferenczi, S. (1949). Confusion of tongues between the adult and the
child. International Journal of Psychoanalysis, 30, 225–230. (Paper
originally read at the 12th International Psychoanalytical Congress,
Wiesbaden, September 1932)
Gallup, G. G., & Maser, J. D. (1977). Tonic immobility: Evolutionary
underpinnings of human catalepsy and catatonia. In M. E. P. Seligman & J.
D. Maser (Eds.), Psychopathology: Experimental models (pp. 334–357).
San Francisco: W. H. Freeman.
Grafton, S. (1990). “G” is for gumshoe. New York: Ballantine.
Goulding, M. M., & Goulding, R. L. (1997). Changing lives through
redecision therapy (Rev. ed.). New York: Grove.
Gunnar, M. R., & Barr, Ronald G. (1998). Stress, early brain
development, and behavior. Infants and Young Children, 11(1), 1–14.
Heide, F. J., & Borkovec, T. D. (1984). Relaxation-induced anxiety:
Mechanisms and theoretical implications. Behavioral Research and
Therapy, 22(1), 1–12.
Heide, F. J., & Borkovec, T. D. (1983). Relaxation-induced anxiety:
Paradoxical anxiety enhancement due to relaxation training. Journal of
Consulting and Clinical Psychology, 51(2), 171–182.
Herman, J. L. (1992). Trauma and recovery. New York: Basic.
Hovdestad, W. E., & Kristiansen, C. M. (1996). Mind meets body: On
the nature of recovered memories of trauma. Women and Therapy, 19(1),
31–45.
International Society for Traumatic Stress Studies. (1998). Childhood
trauma remembered: A report on the current scientific knowledge base and
its applications. Northbrook, IL: Author.
Jacobsen, R., & Edinger, J. D. (1982). Side effects of relaxation
treatment. American Journal of Psychiatry, 13(7), 952–953.
 Janet, P. (1887). L’Anesthésie systematisée et la dissociation des
phénomemés psychologiques [Systematized anesthesia and the
psychological phenomenon of dissociation]. Revue Philosophique, 23(1),
449–472.
Jørgensen, S. (1992). Bodynamic analytic work with shock/post-
traumatic stress. Energy and Character, 23(2), 30–46.
Kulka, R. A., Schlenger, W. E., Fairbank, J. A., Hough, R. L., Jordan, B.
K., Marmar, C. R., & Weiss, D. S., (1990). Trauma and the Vietnam war
generation: Report of findings from the National Vietnam Veterans
Readjustment Study. New York: Brunner/Mazel.
LeDoux, J. E. (1996). The emotional brain. New York: Simon &
Schuster.
Lehrer, P. M., & Woolfolk, R. L. (1993). Specific effects of stress
management techniques. In P. M. Lehrer & R. L. Woolfolk (Eds.),
Principles and practice of stress management (pp. 481–520). New York:
Guilford.
Levine, P. (1992). The body as healer: Transforming trauma and anxiety.
Lyons, CO: Author.
Levine, P. (1997). Waking the tiger. Berkeley, CA: North Atlantic.
Lindy, J. D., Green, B. L., & Grace, M. (1992). Somatic reenactment in
the treatment of posttraumatic stress disorder. Psychotherapy and
Psychosomatics, 57, 180–186.
Loewenstein, R. J. (1993). Dissociation, development and the
psychobiology of trauma, Journal of the American Academy of
Psychoanalysis, 21(4), 581–603.
Malt, U. F., & Weisaeth, L. (1989). Disaster psychiatry and traumatic
stress studies in Norway. Acta Psychiatrica Scandinavia, 355(Suppl.), 7–12.
Marmar, C. R., Weiss, D. S., Metzler, T. J., & Delucchi, K. (1996).
Characteristics of emergency services personnel related to peritraumatic
dissociations during critical incident exposure. American Journal of
Psychiatry, I 53 (Festschrift suppl.), 94–102.
Nadel, L. (1994). Multiple memory systems: What and why, an update.
In D. L. Schacter & E. Tulving (Eds.), Memory systems (pp. 39–63).
Cambridge: MIT Press.
Nadel, L., & Jacobs, W. J. (1996). The role of the hippocampus in PTSD,
panic, and phobia. In N. Kato (Ed.), Hippocampus: Functions and clinical
relevance (pp. 455–463). Amsterdam: Elsevier.
Nadel, L., & Zola-Morgan, S. (1984). Infantile amnesia. In M.
Moscovitch (Ed.), Infantile memory (pp. 145–172). New York: Plenum.
Napier, N. (1996). Recreating your self: Increasing self-esteem through
imaging and self-hypnosis. New York: Norton.
Nathanson, D. L. (1992). Shame and pride: Affect, sex, and the birth of
the self. New York: Norton.
Pavlov, I. P. (1960). Conditioned reflexes. New York: Dover. (Original
work published 1927)
Penfield, W., & Perot, P. (1963). The brains record of auditory and visual
experience. Brain, 86, 595–696.
Perls, F. (1942). Ego, hunger and aggression. Durban, South Africa:
Knox.
Perls, F. (1969). In and out of the garbage pail. Moab, UT: Real People.
Perry, B. D., Pollard, R. A., Blakley, T. L., Baker, W. L., & Vigilante, D.
(1995). Childhood trauma, the neurobiology of adaptation, and “use-
dependent” development of the brain: How “states” become “traits.” Infant
Mental Health Journal, 16(4), 271–291.
Rauch, S. L., Shin, L. M, Wahlen, P. J. H., & Pitman, R. K. (1998).
Neuroimaging and the neuroanatomy of posttraumatic stress disorder. CNS
Spectrums, 3(7) (Supple. 2), 31–41.
Reus, V. I., Weingartner, H., & Post, R. M. (1979). Clinical implications
of state-dependent learning. American Journal of Psychiatry, 136(7), 927–
931.
Rothschild, B. (1993). A shock primer for the bodypsychotherapist.
Energy and Character, 24(1), 33–38.
Rothschild, B. (1995a). Defining shock and trauma in body-
psychotherapy. Energy and Character, 26(2), 61–65.
Rothschild, B. (1995b). Defense, resource and choice. Presentation at
The 5th European Congress of Body-Psychotherapy, Carry-Le Rouet,
France.
Rothschild, B. (1996/97). An annotated trauma case history: Somatic
trauma therapy, part I. Somatics, 11(1), 48–53.
Rothschild, B. (1997). An annotated trauma case history: Somatic trauma
therapy, part II. Somatics, 11(2), 44–49.
 Rothschild, B. (1999). Making trauma therapy safe. Self and Society,
27(2), 17–23.
Sapolsky, R. (1994). Why zebras don’t get ulcers. New York: W. H.
Freeman.
Schacter, D. (1996). Searching for memory. New York: Basic.
Schore, A. (1994). Affect regulation and the origin of the self. Hillsdale,
NJ: Lawrence Erlbaum.
Schore, A. (1996). The experience-dependent maturation of a regulatory
system in the orbital prefrontal cortex and the origin of developmental
psychopathology. Development and Psychopathology, 8, 59–87.
Schuff, N., Marmar, C. R., Weiss, D. S., Neylan, T., Schoenfeld, F. B.,
Fein, G., & Weiner, M. W. (1997). Reduced hippocampal volume and n-
acetyl aspartate in posttraumatic stress disorder. Annals of the New York
Academy of Sciences, 821, 516–520.
Scott, M. J., & Stradling, S. G. (1994). Post-traumatic stress disorder
without the trauma. British Journal of Clinical Psychology 33(1), 71–74.
Selye, H. (1984). The stress of life. New York: McGraw-Hill.
Siegel, D. J. (1996). Cognition, memory and dissociation. Child and
Adolescent Psychiatric Clinics of North America, 5(2), 509–536.
Siegel, D. J. (1999). The developing mind. New York: Guilford.
Skinner, B. F. (1961). Teaching machines. Scientific American, 205(5),
90–107.
Squire, L. R. (1987). Memory and brain, New York: Oxford University
Press.
Stevens, J. O. (1971). Awareness: Exploring, experimenting,
experiencing. Moab, UT: Real People.
Suarez, S. D., & Gallup, G. G. (1979). Tonic immobility as a response to
rape in humans: A theoretical note. Psychological Record, 29, 315–320.
Tavris, C. (1998, June 21). A widening gulf splits lab and couch. The
New York Times.
Terr, L. (1994). Unchained memories. New York: Basic. van der Hart,
O., & Friedman, B. (1989). A readers guide to Pierre Janet on dissociation:
A neglected intellectual heritage. Dissociation, 2(1), 3–16.
 van der Hart, O., & Nijenhuis, E. R. S. (1999). Bearing witness to
uncorroborated trauma: The clinician’s development of reflective belief.
Professional Psychology: Research and Practice, 30(1), 37–44.
van der Hart, O. & Steele, K. (1997). Relieving or reliving childhood
trauma? A commentary on Miltenburg and Singer. Theory and Psychology,
9(4), 533–540.
van der Kolk, B. A. (1987). Psychological trauma. Washington, DC:
American Psychiatric.
van der Kolk, B. A. (1994). The body keeps the score. Harvard Review
of Psychiatry, 1, 253–265.
van der Kolk, B. A. (1998, November). Neurobiology, attachment and
trauma. Presentation at the annual meeting of the International Society for
Traumatic Stress Studies, Washington, D.C.
van der Kolk, B. A., Brown, P., & van der Hart, O. (1989). Pierre Janet
on post-traumatic stress. Journal of Traumatic Stress, 2(4), 365–377.
van der Kolk, B. A., McFarlane, A. C., & Weisaeth, L. (1996). (Eds.).
Traumatic stress. New York: Guilford.
Wahlberg, L., van der Kolk, B. A., Brett, E., & Marmar, C. R. (1996,
November). PTSD: Anxiety disorder or dissociative disorder? Symposium
conducted at the annual meeting of the International Society for Traumatic
Stress Studies, San Francisco.
Williams, L. M. (1995). Recovered memories of abuse in women with
documented child sexual victimization histories. Journal of Traumatic
Stress, 8(4), 649–673.
Wolpe, J. (1969). The practice of behavior therapy. New York:
Pergamon.
Yehuda, R., Southwick, S. M., Nussbaum, G., Wahby, V, Giller, E. L. Jr.,
& Mason, J. W. (1990). Low urinary Cortisol excretion in patients with
posttraumatic stress disorder. Journal of Nervous and Mental Disease, 178,
366–369.
 Yehuda R., Kahana, B., Binder-Brynes, K., Southwick, S., Zemelman, S.,
Mason, J. W., & Giller, E. L., (1995). Low urinary Cortisol excretion in
Holocaust survivors with posttraumatic stress disorder. American Journal of
Psychiatry, 152, 982–986.
Yehuda, R., Teicher, M. H., Levengood, R., Trestman, R., & Siever, L. J.
(1996). Cortisol regulation in posttraumatic stress disorder and major
depression: A chronobiological analysis. Biological Psychiatry, 40, 79–88.
 Index

abreaction
defined
integrating versus disintegrating
acute stress disorder, dissociation as a symptom of
adrenal gland
activation in response to threat
adrenocorticotropic hormone (ACTH), release in response to stress
aerobic exercises
affect
and attachment, Tony (case)
as the biological aspect of emotion
and pain regulation
positive, problems with tolerance for
regulation of, learning in interaction between infant and caretaker
affect theory
aftermath of trauma, working with first
Ruth (case)
alcohol, influence on memory
alexithymic clients
altered state, in trauma, see also dissociation; split awareness
American Psychiatric Association
amnesia
infantile
amygdala
functioning in stress
involvement in memory storage
processing of emotionally charged events in
role in the flashback process
signaling of alarm by
anchor
the body as
establishing, Gail, Part I (case)
when nothing works
for pacing therapy
for reducing hyperarousal
safe place as
using
Gail, Part I (case)
Gail, Part II (case)
Andrews, B.
anger
positive side of, and disadvantages of
as self-protection
anxiety
applying dual awareness in attacks of
function of
applying the brakes, defined
arousal
mediation by the autonomic nervous system
of the parasympathetic nervous system
in therapy
in therapy, checking
see also autonomic nervous system; hyperarousal; parasympathetic
nervous system
attachment
and affect/pain regulation, Tony (case)
basis of, in interactions with caretakers
infant
effect on brain development
 and mediation of stress later in life
attunement, defined
autonomic nervous system (ANS)
arousal in therapy
as a danger
assessing
arousal mediated by
functions of, in trauma
gauging
hyperarousal of
reducing in therapy sessions
as a symptom of posttraumatic stress disorder
impulses for visceral muscle contraction in
monitoring, to pace therapy
posttraumatic stress disorder as persistent increased arousal of
relationship with the limbic system
and survival
awareness
of the body
consciousness outside of
split
dissociation as
forms of
see also body awareness; dual awareness
Awareness: Exploring, Experimenting, Experiencing (Stevens)
Azar, B.

Baker, W. L.
balance, between the parasympathetic and sympathetic nervous systems
Bandler, R.
Barr, Ronald G.
Bauer, M.
Begley, S.
behavioral flashbacks
Binder-Byrnes, K.
Blakley, T. L.
Bloch, G.
body
as an anchor
as brake, a young woman (case)
as a resource
body awareness
as a brake in therapy
defined
and flashbacks, Carl (case)
using, Angie (case)
Bodynamic Institute Training Program
body-psychotherapy
Bohen, R.
bonding
effect on brain development
right-brain mediation of
see also attachment
borderline personality disorder
Boring, A. M.
Borkovec, T. D.
boundaries
client, and touch in therapy
exercises to explore
interpersonal
Thomas (case)
skin
Helen (case)
Lane (case)
therapeutic distance
visual
brain
development of
factors affecting
and memory
mutual connection and
and trauma
 divisions of
flashback and
mature, and trauma
multiple systems of memory in
emotional, theory of
brain stem
braking and accelerating
braking tool
anchor as
body awareness as
in a therapy session, Gail, Part I (case)
Bremner, J. D.
Brett, E. A.
bridges
building
between daily life and therapy, Gail, Part II (case)
between explicit and implicit memory, Gail, Part II (case)
in language
Broca’s area
Brown, P.

caretaker, primary
aid in learning to regulate stimulation
critical phases for interaction with
case history, seeking resources in
case illustrations
Alex, using resources
Angie, using body awareness
Arnold, identifying resources
Blair, touch and the therapeutic relationship
Bob, gauging and pacing hyperarousal in therapy
Brad, dangers of the wrong road
Carla, kinesthetic memory
Carl, flashbacks and body awareness
client and therapist
consultation, flashback-halting protocol
 therapeutic distance
Cynthia, a friend as a resource
Daniel, behavioral resources
Donna, somatic memory
Dorothy, dangers of the wrong road
Dorte, separating past from present
Frank, therapeutic relationship
Fred, advantage of teaching theory to clients
Gail, Part I
using brakes in a therapy session
Gail, Part II, bridging explicit and implicit memory
Grette, pacing therapy
Helen, thickening the skin through exercises in therapy
hostage, flashback-halting protocol
Joanie, muscle tension as resource
Karen, memory recall
Kurt, danger of client-therapist touching
Lane, skin boundaries
Marcy, flashback
Marie, flashback
mid-thirties woman, state-dependent recall
Rodney, safety: removing triggers
Roger, flashback
Ruth, working with the aftermath of trauma first
Sarah, protocol for identifying triggers
Scott, advantage of teaching theory to clients
therapeutic distance
Theresa, muscle tensing as resource
Thomas, interpersonal boundaries
Tom, somatic memory as a resource
Tony, attachment and affect/pain regulation
a young woman, the body as brake
see also Charlie and the Dog
Casey, B. J.
catharsis, defined
central nervous system, organization of
cerebral cortex
flexibility of
as the locus of memory
somatosensory area of
Charlie and the Dog
bridging the explicit and implicit
the final episode
illustration of intentional movements
Part I
Part II, state-dependent recall
Part III, body awareness
reality checking and attention to somatic impulses
SIBAM description of
Charney, D. S.
Claparede, E.
Clark, D. B.
Classen, C.
classical conditioning, see conditioning
cognitive judgment, emotion and
cognitive memory
communication
through the nervous system
network of the nervous system
complex posttraumatic stress disorder
conditioned response (CR)
tonic immobility as
conditioned stimulus (CS)
conditioning
and agoraphobia
basis of triggers in
mechanisms underlying
source
classical
to a traumatic incident
memory in the absence of memory
operant
 and stress inoculation
consciousness, levels of
contraindications
to aerobic exercise, in posttraumatic stress disorder
to body awareness development
coping strategies
in repeated trauma
teaching in therapy
in trauma from chronic stress during development
corticotropin-releasing hormone (CRH), in the response to threat
cortisol
adrenal release of, in trauma
production of, and anxiety
secretion of
in posttraumatic stress disorder
in trauma, effect on memory
current event, focusing on, to avoid error

Damasio, A. R.
somatic marker theory
danger
constant sense of, in posttraumatic stress disorder
inherent in therapy for trauma
Darwin, C., cross-cultural survey of emotion
De Bellis, M. D.
declarative memory, see also explicit memory
decompensation
risk of
in therapy
defense mechanisms, positive aspects of
defensive behavior
learning
response to a remembered threat
Delaney, R. C.
Delucchi, K.
depersonalization
destabilization, from seeking memory of a trauma presumed to be there
de Tours, Moreau
Diagnostic and Statistical Manual of Mental Disorders
3rd Edition (DSM-III),
4th Edition (DSM-IV),
dissociation
avoiding in therapy
pacing for
and the body
from fear
peritraumatic, and development of posttraumatic stress disorder
positive side of, and disadvantages of
and posttraumatic stress disorder
as a survival mechanism
traumatic
dissociation model (Sensation, Image, Behavior, Affect, and Meaning
model)
dissociative identity disorder
distance, therapeutic
between client and therapist (case)
diverting activities, in therapy
drugs, influence on memory
dual awareness
applying to panic and anxiety attacks
basis of flashback-halting protocol
developing, in therapy
as a flashback-halting protocol
Duggal, S.

Edinger, J. D.
efficacy studies, for evaluating treatment models
Ego, Hunger and Aggression (Perls)
Eich, J. E.
emotion
and the body
body awareness as a basis for identifying
 and cognitive judgment
integrating vs. disintegrating expression of
somatic basis of
and trauma
encoding memory
of information
of interaction with the therapist
environment, unsafe and/or traumatizing
epinephrine
effects on the body
mobilization for fight or flight by
as a neurotransmitter
evaluation, for therapy, categorizing traumatized clients
experiencing self
acknowledging the split from the observing self, in
versus the observing self, in posttraumatic stress disorder
explicit memory
bridging to implicit memory
composition of
integration with implicit memory
linking with implicit memory
exteroceptive system
cues triggering flashbacks

false memory
fear
dissociation from
in posttraumatic stress disorder
protective function of
feeling, as the conscious experience of emotion
Fein, G.
Ferenczi, S.
fight, flight, and freeze responses
to hyperarousal
operant conditioning of successful choice among
somatic nervous system’s role in
 see also freezing response
flashback-halting protocol, client and therapist consultation (case)
flashbacks
applying dual awareness to
and body awareness, Carl (case)
hostage (case)
Marcy (case)
Marie (case)
mechanism of
protocol for halting
client and therapist (case)
teaching in therapy
Roger (case)
as a symptom of posttraumatic stress disorder
terror in
in therapy
traumatic
Fontana, A.
forgetting
versus traumatic dissociation
freezing response
and posttraumatic stress disorder
in response to traumatic threat
as a survival mechanism
see also dissociation; tonic immobility
Friedman, B.
Frustaci, K.
functional resources

Gallup, G. G.
gauge
the body as
sensation as
Giedd, J. N.
Giller, Jr., E. L.
goals, of trauma therapy
Goulding, M. M.
Goulding, R. L.
Grace, M.
Graf, K. J.
Grafton, S.
Green, B. L.
grief
and healing
release of
Grinder, J.
guilt
from freezing in response to trauma
in rape
and tonic immobility
Gunnar, M. R.

healing trauma
grief as a sign of
linking all aspects of a traumatic event for
spiritual resources for
Heide, F. J.
Herman, J. L.
hippocampus
function in processing the context of events
role in memory
suppressed activity during trauma
suppressed activity in response to stress
Holocaust survivors
differences among, in resources for resilience
evidence for posttraumatic stress disorder in
homeostasis, restoration of
horror, processing in the amygdala
Hovdestad, W. E.
hyperarousal
checking for, in therapy
due to flashbacks
 gauging
gauging and pacing in therapy, Bob (case)
in posttraumatic stress disorder
reducing with an anchor in therapy
and reflexes of fight, flight, and freeze
traumatic, of the autonomic nervous system
see also arousal; autonomic nervous system
hypothalamic-pituitary-adrenal (HPA) axis
role in the biology of terror
hypothalamus
activation of the sympathetic nervous system
role in arousal

identity disorder, see dissociative identity disorder

implicit memory
bridging to explicit memory
composition of
eliciting in flashbacks
integrating with explicit memory
interaction with the therapist encoded in
linking with explicit memory
recording of movement in
role of the senses in
kinesthetic
In and Out of the Garbage Pail (Perls)
individual differences
of needs in therapy for trauma
respecting in therapy
induced relaxation, trauma reaction precipitated by
infant, newborn, stimulus regulation by mother
information
encoding as memory
sensory, processing of
transmission from the brain to the body
Innis, R. B.
integration
 Charlie and the Dog, the final episode
of emotional expression
of explicit memory with implicit memory
Gail, Part II (case)
intentional movements
assessing in therapy
Charlie and the Dog, example of
internal sense
defined
internal stimuli, focus on, in posttraumatic stress disorder
International Society for Traumatic Stress Studies
interoceptive sensory system
cues triggering flashbacks
interpersonal boundaries
interpersonal relationships
client’s, impact of trauma on
social network as a resource
interpersonal resources

Jacobs, W. J.
Jacobsen, R.
Janet, P.
Jørgensen, S.

Kahana, B.
Keshavan, M. S.
kinesthetic memory
Carla (case)
kinesthetic nerves, interoceptive
kinesthetic sense
controlling the accuracy of movement
defined
interoceptive
memory of movement
Koopman, C.
Kristiansen, C. M.
language
meanings of “feel,”
necessary
for bridging the mind/body gap
to make sense of emotional and sensory experiences
in therapy, LeDoux, J. E.
Lehrer, P. M.
Levengood, R.
Levine, P.
limbic system
functions of
maturing of
relationship with the autonomic nervous system
role in posttraumatic stress disorder
“survival center,”
Lindy, J. D.
linking
of all aspects of a traumatic event, for healing
explicit memory with implicit memory
see also bridges; integration
Loewenstein, R. J.
love relationship, mature, as a healing bond
lysergic acid diethylamide (LSD), flashbacks after use of

McCarthy, G.
McFarlane, A. C.
Malt, U. F.
markers, see somatic markers
Marmar, C. R.
Maser, J. D.
Mason, J. W.
medical intervention, mistaking for physical and sexual abuse
memory
cognitive
development of, and the brain
function of
 kinesthetic
long-term
malleability of
recall, Karen (case)
reflexive belief in
retrieval of
roles of the hippocampus and amygdala in
short-term
storage of
see also encoding memory; explicit memory; implicit memory; somatic
memory; triggers
Metzler, T. J.
misattunement
in therapy
mitigating session closure
monitoring, of the autonomic nervous system
to pace therapy
in therapy
movement, perception of, in the proprioceptive system
muscle(s)
contraction versus non-contraction of
control of visceral and skeletal
positive function of tension in
tensing
peripheral muscles
as resource, Theresa (case)
tension versus relaxation
as resource, Joanie (case)
toning

Nadel, L.
Napier, N.
narrative, trauma, pacing of
Nathanson, D. L.
nerves, proprioceptive
nervous system
 communication through
effect of rational thoughts on, Charlie and the Dog
see also autonomic nervous system; parasympathetic nervous system;
sensory nervous system; somatic nervous system; sympathetic
nervous system
neuro-linguistic programming, concept of anchors
Neylan, T.
nightmares, flashback-halting protocol for
Nijenhuis, E. R. S.
nondeclarative memory
nontouch
norepinephrine
effects on the body
mobilization for fight or flight by
as a neurotransmitter
Nussbaum, G.

oasis, as a braking tool

observing self
split from the experiencing self
operant conditioning, effect on fight, flight, and freeze responses

pacing therapy
Grette (case)
see also braking and accelerating; safety
pain regulation, and attachment, Tony (case)
parasympathetic nervous system (PNS)
arousal of
Pavlov, I. P.
Penfield, W.
perception, splitting by posttraumatic stress disorder
performance anxiety, in developing body awareness
Perls, F.
Perot, P.
Perry, B. D.
personal history, somatic memory as
physical resources
Pitman, R. K.
pituitary gland, release of adrenocorticotropic hormone by
Pollard, R. A.
Post, R. M.
posttraumatic stress (PTS)
clients who fall between the cracks
defined
posttraumatic stress disorder (PTSD)
complex
as a condition of memory gone awry
defined
overview
symptomatology of
predictions, preconceived
present, separating from the past, Dorte (case)
Priebe, S.
prolonged duress stress disorder (PDSD), defined
proprioceptive nerves, postural, feedback from
proprioceptive system
interoceptive
perception of movement in
transmission of sensations accompanying emotion by
protective function, of fear, see also survival value
pseudoephedrine, reaction to, mimicking anxiety
psychological resources
psychological symptoms
attributed to stress in early development
psychotherapy
versus body-psychotherapy
implications for attachment relationships in maturity
and trauma

rape
Ruth (case)
shame in
 and traumatic triggers
Rauch, S. L.
reality testing
bridging and explicit memory (case)
Gail, Part I (case)
Gail, Part II (case)
of transferential misattunement
using brakes in a therapy session (case)
reattunement, defined
recall
state-dependent
see also forgetting; memory
recording of movement, in implicit memory
recovered memories
the wrong road
reflexive belief, in memories
regulation, of emotional responses, learning in infancy
relationship, therapeutic
trust as a requirement in
for Type IIB clients
remembered threat, defensive response to
resilience, developing in therapy for chronic stress during development
resource/resources
behavioral, Daniel (case)
the body as
classes of
friend as, Cynthia (case)
identifying, Arnold (case)
muscle tensing as, Theresa (case)
muscle tension as, Joanie (case)
somatic memory as, Tom (case)
using, Alex (case)
responsibility
clarifying in therapy, Gail, Part I (case)
in rape, assigning correctly
retraumatization
 avoiding by dual awareness
in therapy
avoiding
retrieval, memory
Reus, V. I.
Rosenbeck, R.
Rothschild, B.
Ryan, N. D.
safe place
as an anchor
reinforcing with body awareness
safety
foundations of, in trauma therapy
removing triggers, Rodney (case)
in the therapeutic relationship
in therapy
Sapolsky, R.
scale, of arousal to hyperarousal
Schacter, D.
Schoenfeld, F. B.
Schore, S.
Schuff, N.
Scott, M. J.
self-forgiveness
Selye, H.
sensations, safe, distinguishing
sensory nervous system
cues from, and body awareness
exteroceptive
sensory cues
interoceptive
kinesthetic sense
sensory cues
vestibular sense
see also proprioceptive system
sensory stimulus, in utero
session closure, mitigating
sexual dysfunction, in posttraumatic stress disorder
shame
as disappointment in the self
from freezing in response to threat
positive side of
in rape
in sexual abuse
from tonic immobility
and visual boundaries
Shame and Pride (Nathanson)
shaping behavior, with operant conditioning
Shin, L. M.
SIBAM dissociation model
Siegel, D. J.
Siever, L. J.
skin level boundaries
establishing
Skinner, B. F.
skin tone, observing in therapy
sleep disturbances, in posttraumatic stress disorder
socialization
in the relationship between caretaker and child
and the survival value of shame
somatic disturbance, in posttraumatic stress disorder
somatic interventions, for trauma therapy
somatic markers
new, in successful therapy
theory of
somatic memory
body awareness as a step toward interpreting
Donna (case)
as personal history
reliability of
as a resource
Tom (case)
 sensations for making sense of
and the senses
understanding
somatic nervous system (SomNS)
movements caused by, using to facilitate recall
somatic symptoms
Southwick, S. M.
Spiegel, D.
spiritual resources
split awareness, forms of, see also dissociation Squire, L. R.
Sroufe, L. A.
state-dependent recall
Steele, K.
Stevens, J. O.
stimulus, exteroceptive, example
storage, of memory
Stradling, S. G.
stress
defined
medications that mimic body response in
traumatic, defined
stress inoculation
Suarez, S. D.
Subjective Units of Disturbance Scale (SUDS)
survival/survival responses
of affects
automatic
and the nervous system
see also protective function of fear
sympathetic nervous system (SNS)
activation by the hypothalamus
arousal of
autonomic nervous system
symptomatology, of posttraumatic stress disorder (PTSD)
synapse
role in communication
synaptic patterns, building in self-defense training

Tavris, C
Teicher, M. H.
Terr, L.
terror
biology of
processing in the amygdala
from visual flashbacks
thalamus, information transmission through
theory
advantage of teaching to clients
Fred (case)
Scott (case)
of trauma
affect
therapeutic relationship
Frank (case)
touch and, Blair (case)
see relationship, therapeutic
therapist
directive, models requiring
fear of, during a flashback
interaction with, encoding in implicit memory
limitations of observations by
perception of, as a perpetrator of abuse
visually handicapped, asking for help from clients
therapy
decompensation in
ease of inserting anchors in
evaluation and assessment in
respecting individuality in
trust issues in
using traumatic triggers in,
time, separating past from present
Tomkins, S., affect theory
tonic immobility
Charlie and the Dog
conditioned
defined
response of the parasympathetic nervous system
see also freezing response
touch/touching
client-therapist interaction
danger of client-therapist, Kurt (case)
and not touching
and working with the body
Transactional Analysis (Goulding & Goulding)
transference, in building resources for coping with trauma
transferential misattunement, reality testing of
trauma
behavior shaped through
consequences of
and emotion
expression of unremembered
freeze response to the threat of
hallucinatory repetition of the experience of
physically invasive, reestablishing boundaries after
and psychotherapy
recall of
and sensory memory
theory of
triggers of memories of
trauma therapy
facilitating using the body as resource
safety in, foundations of
somatic techniques for
therapeutic relationship in
working with aftermath first
traumatic stress, defined
traumatic triggers
and classical conditioning
 identifying in therapy
using in therapy
see also triggers
trauma victims
categories of, using for assessment
Type IIB, conflict in therapy
treatment models, efficacy studies for evaluating
Trestman, R.
triggers
aerobic exercise
and classical conditioning
external, for hyperarousal
for flashbacks
protocol for identifying
Sarah (case)
removing, Rodney (case)
sensory cues
for state-dependent recall
trust
betrayal of, experience of Type IIB clients
issues in therapy
in a therapeutic relationship
Type I clients
Type II clients
Type IIB clients
building trust with
risk of conflict with

van der Hart, O.

van der Kolk, B. A.
vestibular sense
interoceptive
Vigilante, D.
visceral muscle contraction, impulses for, autonomic nervous system (ANS)
visual boundaries
voluntary movement, response to the somatic nervous system
Wahby, V.
Wahlberg, L.
Wahlen, R J.
Weiner, M. W.
Weingartner, H.
Weisaeth, L.
Weiss, D. S.
when nothing works, in therapy
Williams, L. M.
withdrawal, positive side of, and disadvantages of
Wolpe, J.
Woolfolk, R. L.
wrong road, dangers of in therapy
Brad (case)
Dorothy (case)

Yehuda, R.
yoga, roots of body awareness in

Zemelman, S.
Zola-Morgan, S.
page 26: I Remember It Well from GIGI. Words by Alan Jay Lerner. Music by Frederick Loewe.
Copyright © 1957, 1958 by Chappell & Co. Copyright Renewed. International Copyright Secured.
All Rights Reserved.

Piet Hein Grooks © Rhyme and Reason (p. 37), Timing Toast (p. 77), A Toast (p. 100) are
reproduced with kind permission from Piet Hein a/s, DK-5500 Middelfart, Denmark.

The author welcomes correspondence from readers. She may be reached at:
Babette Rothschild
P.O. Box 241778
Los Angeles, California 90024
Telephone: 310-281-9646
Fax: 310-281-9729
E-mail: [email protected]
Web site: www.trauma.cc

Copyright © 2000 by Babette Rothschild

All rights reserved
Printed in the United States of America
First Edition

For information about permission to reproduce selections from this book, write to Permissions, W. W.
Norton & Company, Inc., 500 Fifth Avenue, New York, NY 10110

Library of Congress Cataloging-in-Publication Data

Rothschild, Babette
The body remembers: the psychophysiology of trauma and trauma treatment / Babette Rothschild.
p. cm. — (Norton professional book)
Includes bibliographical references and index.
ISBN 978-0-393-06868-9 (e-book)
1. Post-traumatic stress disorder—Psychological aspects. 2. Mind and body therapies. 3. Post-
traumatic stress disorder—Physiological aspects. I. Title. II. Series.
RC489.M53 R68 2000
616.85'21—dc21
00-062520

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