In an Unspoken Voice

by Peter A Levine

  Trauma and Immobility: A Way Out

  In review: Trauma arises when one’s human immobility responses do not resolve; that is, when one cannot make the transition back to normal life, and the immobility reaction becomes chronically coupled with fear and other intense negative emotions such as dread, revulsion and helplessness. After this coupling has been established, the physical sensations of immobility by themselves evoke fear. A traumatized individual has become conditioned to be fearful of his or her internal (physical) sensations that now generate the fear that extends and deepens (potentiates) the paralysis. Fear begets paralysis, and fear of the sensations of paralysis begets more fear, promoting yet a deeper paralysis. In this way, a normally time-limited adaptive reaction becomes chronic and maladaptive. The feedback loop closes in on itself. In this downward spiral, the vortex of trauma is born.

  Successful trauma therapy helps people resolve trauma symptoms. The feedback loop is broken by uncoupling fear from immobility (see Figures 4.1a and 4.1b). Effective therapy breaks, or depotentiates, this trauma-fear feedback loop by helping a person safely learn to “contain” his or her powerful sensations, emotions and impulses without becoming overwhelmed. Thus, the immobility response is enabled to resolve as it is evolved to do.

  Uncoupling fear and allowing the normally time-limited immobility reaction to complete is, in principle, a straightforward matter. The therapist helps reduce the duration of immobility by gently diminishing the level of fear. In other words, the therapist’s job is to aid a client to gradually uncouple the fear from the paralysis, so as to gradually restore self-paced termination. In this way the (fear-immobility) feedback loop is broken; colloquially, it runs out of gas. As a client learns to experience the physical sensations of the immobility in the absence of fear, trauma’s grip is loosened, and equilibrium is restored. In the next four chapters, I discuss how therapists can help clients learn how to uncouple the fear from the immobility and restore active defensive responses. When clients achieve this, they often describe the physical sensation of immobility (in the absence of fear) with a mixture of curiosity and profound relief or, often, “as though waking from a nightmare.”

  There is an important caveat to this simple “prescription.” Where trauma has been lengthy and deeply entrenched, other factors come into play: primarily, one’s very faculty for change and reengagement in life becomes impaired. This aspect has been poignantly portrayed in Louise Erdrich’s compelling novel The Master Butchers Singing Club. In the first chapter, the male protagonist, Fidelis, leaves the trenches

  Charting Duration of Immobility Amongst Different Scenarios

  Figure 4.1a This figure illustrates the duration and severity of “freezing” in three situations. The first scenario is similar to an opossum being attacked and playing dead. The opossum freezes, and the predator, losing interest in this inert carrion, walks off in search of livelier prey. Left alone, the opossum “shakes off” this encounter and goes on its way, none the worse. This is called self-paced termination. The second scenario illustrates what happens when an animal emerging from immobility is restrained and frightened. It is thrust back into terror, and the immobility is far deeper, lasting for a much longer time. This paralyzing terror is the effect of fear-potentiated immobility and leads to PTSD. This is why the phrase “time heals all wounds” simply does not apply to trauma. The third scenario shows what happens in a successful therapy session. The therapist gradually guides the client to briefly touch into the immobility sensations, and then guides her to uncouple the immobility from the fear. In this way she can discharge the underlying hyperarousal and return to equilibrium. of World War I and returns to his mother’s cooking and kindness. He sleeps for the first time in his own familiar, comfortable bed, an experience that he has not known for years.

  Fear/Immobility Cycle

  Figure 4.1b This is how we become trapped in the fear/immobility cycle.

  Now that he was home, he understood, he must still be vigilant. Memories would creep up on him, emotions sabotaging his thinking brain. To come alive after dying to himself was dangerous. There was far too much to feel, so he must seek, he thought, only shallow sensations.

  We also learn that, “as a child, Fidelis had breathed lightly and gone motionless … whenever as a child sorrow had come down upon him.” As a young soldier, “he’d known from the first that in his talent for stillness lay the key to his survival.” The human need to gradually return from the land of the walking dead to the land of the living needs to be understood, respected and honored. Too much, too soon, threatens to overwhelm the fragile ego structure and adaptive personality. This is why the rate at which people resolve trauma must be gradual and “titrated.”

  Instinct and Reason

  In the final analysis, I believe that it is the dynamic balance between the most primitive and the most evolved/refined parts of the brain that allows trauma to be resolved and difficult emotions to be integrated and transformed. Effective treatment is a matter of helping individuals keep the “observing” prefrontal cortex online as it simultaneously experiences the raw primitive sensations generated in the archaic portions of the brain (the limbic system, hypothalamus and brain stem; see Figure 4.2). The key to this delicate undertaking is being able to safely sense both intense and subtle body sensations and feelings. It turns out that there is a paired brain structure that appears to do exactly that: wedged in between the limbic system and the prefrontal cortex are the insula (nearer to the limbic system) and cingulate (nearer to the cortex). Briefly, the insula receives input from the internal structures of the body, including muscles, joints and viscera. Together, insula and cingulate help us make sense of these primitive sensations by weaving them into nuanced feelings, perceptions and cognitions.52 Accessing that function is a key to the approach of transforming trauma and difficult emotions described in the following chapters.

  Balancing Instinct and Reason

  Figure 4.2 This illustrates the importance of keeping the prefrontal cortex online during activation of survival-based arousal in the brain stem and limbic system. Note how nerve impulses flow between the instinctual brain structures of the thalamus and hypothalamus (which controls the secretion of the pituitary gland that is vital for maintaining organ and cellular homeostasis) and the frontal lobe (or rational brain).

  Restoring the balance and rhythm between instinct and reason also plays a central part in healing the mind/body split. Integration of brain and body, of right and left cerebral hemispheres, and of primitive and evolved brain regions promotes wholeness and makes us fully human. Until then, we are, as Margaret Mead noted, “the missing link between apes and humans.”

  * Bonobos are a notable exception to cohort attacks, largely through the strategy of free sex for all, as well as their matriarchal organization.

  † These experiments were carried out with still photos taken from video clips of actors imagining opening a door and seeing a mugger. Doubtless these effects would be of a much greater magnitude with a real threat or even just acting but showing subjects moving pictures.

  ‡ When neutral postures are shown (such as pouring a glass of water), only the parts of the brain associated with vision (area 17 in the neocortex) are activated. So far as I know, the researchers have not enlisted extraordinarily peaceful beings, such as the Dalai Lama, for the positive postures.

  § This transition is orchestrated by the autonomic nervous system between states of sympathetic arousal and parasympathetic rebound and relaxation. This fluid shifting maintains an overall quality of “relaxed alertness.”

  ‖ This earlier usage is, for example, consistent with that of such ethologists as A. Eric Salzen and Desmond Morris. See Desmond Morris, Primate Ethology, (London: Weidenfield and Nicholson, 1969); A. Eric Salzen (1991), “On the Nature of Emotion,” Journal of Comparative Psychology, 5, 47–110; and Salzen (1967), “Social Attachment and a Sense of Security,” Social Sciences Information 12, 555–627.

  a Abandoning the prey may
serve to protect the predator from being poisoned by eating infected carrion.

  b The same is clearly not true of animals placed in laboratory conditions. As Pavlov first observed, stressed experimental animals are readily traumatized.

  c Embellished from Steve Martin’s play Picasso at the Lapin Agile (New Village Arts Theater, Carlsbad, California, January 2010).

  d Although domestic animals appear to not reliably enter TI, indicating that at least some degree of fear—or at least unfamiliarity—may be necessary to induce TI. However, if traumatized or highly anxious subjects are induced into hypnotic catalepsy (to the dismay of the unsuspecting clinician), they may have abrupt panic attacks or even prolonged catatonia-like states.

  e Although, in threatening situations, special-service warriors experience about the same rush of the stress hormone cortisol as any other soldier does, the formers’ levels typically drop off much faster than do those of less well-trained troops.

  f This is a central dilemma in working with so-called Borderline Personality Disorder.

  CHAPTER 5

  From Paralysis to Transformation

  Basic Building Blocks

  Fear is the mind killer. Fear is the little death that brings total obliteration.

  I will face my fear. I will permit it to pass over me and through me.

  And when it has gone past me, I will turn to see fear’s path.

  Where the fear has gone there will be nothing. Only I will remain.

  —Dune by Frank Herbert

  If you do not understand the nature of fear, you will never find fearlessness.

  —Shambhala Buddhism

  In the previous chapter we explored just how experimental animals and humans become trapped in fear-dominated paralysis; and, thus, how they become traumatized. In this chapter, I introduce the “antidote” for trauma: the core biological mechanisms that therapists must be aware of and able to elicit in their clients in order to assist in resolving their traumatic reactions. The engaging of these biological processes is equally essential whether treating the acute phase immediately following threatening and overwhelming incidents, such as rape, accidents and disasters, or in transforming chronic PTSD.

  Until the core physical experience of trauma—feeling scared stiff, frozen in fear or collapsing and going numb—unwinds and transforms, one remains stuck, a captive of one’s own entwined fear and helplessness. The sensations of paralysis or collapse seem intolerable, utterly unacceptable; they terrify and threaten to entrap and defeat us. This perception of seemingly unbearable experiences leads us to avoid and deny them, to tighten up against them and then split off from them. Resorting to these “defenses” is, however, like drinking salt water to quench extreme thirst: while they may give temporary relief, they only make the problem drastically worse and are, over the long haul, counterproductive. In order to unravel this tangle of fear and paralysis, we must be able to voluntarily contact and experience those frightening physical sensations; we must be able to confront them long enough for them to shift and change. To resist the immediate defensive ploy of avoidance, the most potent strategy is to move toward the fear, to contact the immobility itself and to consciously explore the various sensations, textures, images and thoughts associated with any discomfort that may arise.

  When working with traumatic reactions, such as states of intense fear, Somatic Experiencing®* provides therapists with nine building blocks. These basic tools for “renegotiating” and transforming trauma are not linear, rigid or unidirectional. Instead, in therapy sessions, these steps are intertwined and dependent upon one another and may be accessed repeatedly and in any order. However, if this psychobiological process is to be built on firm ground, Steps 1, 2 and 3 must occur first and must follow sequentially. Thus, the therapist needs to:

  1. Establish an environment of relative safety.

  2. Support initial exploration and acceptance of sensation.

  3. Establish “pendulation” and containment: the innate power of rhythm.

  4. Use titration to create increasing stability, resilience and organization. Titration is about carefully touching into the smallest “drop” of survival-based arousal, and other difficult sensations, to prevent retraumatization.

  5. Provide a corrective experience by supplanting the passive responses of collapse and helplessness with active, empowered, defensive responses.

  6. Separate or “uncouple” the conditioned association of fear and helplessness from the (normally time-limited but now maladaptive) biological immobility response.

  7. Resolve hyperarousal states by gently guiding the “discharge” and redistribution of the vast survival energy mobilized for life-preserving action while freeing that energy to support higher-level brain functioning.

  8. Engage self-regulation to restore “dynamic equilibrium” and relaxed alertness.

  9. Orient to the here and now, contact the environment and reestablish the capacity for social engagement.

  Step 1. Establish an environment of relative safety

  After my accident, the first inkling my body had of being other than profoundly helpless and disoriented was when the pediatrician came and sat by my side. As simple as this seems, her calm, centered presence gave me a slight glimmer of hope that things might turn out OK. Such soothing support in the midst of chaos is a critical element that trauma therapists must provide for their unsettled and troubled clients. This truly is the starting point for one’s return to equilibrium. The therapist must, in other words, help to create an environment of relative safety, an atmosphere that conveys refuge, hope and possibility. For traumatized individuals, this can be a very delicate task. Fortunately, given propitious conditions, the human nervous system is designed and attuned both to receive and to offer a regulating influence to another person.53 Thankfully, biology is on our side. This transference of succor, our mammalian birthright, is fostered by the therapeutic tone and working alliance you create by tuning in to your client’s sensibilities.

  With the therapist’s calm secure center, relaxed alertness, compassionate containment and evident patience, the client’s distress begins to lessen. However minimally, his or her willingness to explore is prompted, encouraged and owned. While resistance will inevitably appear, it will soften and recede with the holding environment created by the skilled therapist. One possible roadblock, however, happens between sessions; when they are without their therapist’s calm, regulating presence, clients may feel raw and thrown back into the lion’s den of chaotic sensations when exposed to the same triggers that overwhelmed them in the first place. The therapist who provides only a sense of safety (no matter how effectively) will only make the client increasingly dependent—and thus will increase the imbalance of power between therapist and client. To avoid such sabotage, the next steps are aimed at helping the client move toward establishing his or her own agency and capacity for mastering self-soothing and feelings of empowerment and self-regulation.

  Step 2. Support initial exploration and acceptance of sensation

  Traumatized individuals have lost both their way in the world and the vital guidance of their inner promptings. Cut off from the primal sensations, instincts and feelings arising from the interior of their bodies, they are unable to orient to the “here and now.” Therapists must be able to help clients navigate the labyrinth of trauma by helping them find their way home to their bodily sensations and capacity to self-soothe.

  To become self-regulating and authentically autonomous, traumatized individuals must ultimately learn to access, tolerate and utilize their inner sensations. It would, however, be unwise to have one attempt a sustained focus on one’s body without adequate preparation. Initially, in contacting inner sensations, one may feel the threat of a consuming fear of the unknown. Or, premature focus on the sensations can be overwhelming, potentially causing retraumatization. For many wounded individuals, their body has become the enemy: the experience of almost any sensation is interpreted as an unbidden harbinger of renewed t
error and helplessness.

  To solve this perplexing situation, a therapist who (while engaging in initial conversation) notices a momentary positive shift in a client’s affect—in facial expression, say, or a shift in posture—indicating relief and brightness, can seize the opportunity and try to direct the client toward attending to her sensations. “Touching in” to positive experiences gradually gives a client the confidence to explore her internal bodily landscape and develop a tolerance for all of her sensations, comfortable and uncomfortable, pleasant and unpleasant.

  The client can now begin to allow the underlying disowned sensations—especially those of paralysis, helplessness and rage—to emerge into consciousness. She develops her experience of agency by choosing between the two opposing states: resistance/fear and acceptance/exploration. With a gentle rocking back and forth, oscillating between resistance and acceptance, fear and exploration, the client gradually sheds some of her protective armoring. The therapist guides her into a comforting rhythm—a supported shifting between paralyzing fear and the pure sensations associated with the immobility. In Gestalt psychology, these back-and-forth movements between two different states are described as figure/ground alternations (see Figure 5.1). This shifting, in turn, reduces fear’s grip and allows more access to the quintessential and unencumbered (by emotion) immobility sensations. This back-and-forth switching of attention (between the fear/resistance and the unadulterated physical sensations of immobility) deepens relaxation and enhances aliveness. It is the beginning of hope and the acquiring of tools that will empower her as she begins to navigate the interoceptive (or the direct felt experiencing of viscera, joints and muscles) landscape of trauma and healing. These skills lead to a core innate transformative process: pendulation.