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

 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 others by
fighting back or running away. In those instances, understanding
that freezing is automatic often facilitates the difficult process of self-
forgiveness.
 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 hypothalamus 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 functioning 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 trivial 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).
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 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

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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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