In an Unspoken Voice

by Peter A Levine

  Even adults who meditate often struggle with sitting still. Those few fortunate ones who can crawl into a warm bed, lie absolutely still, and drift quickly off into a restorative sleep are bestowed a most precious blessing. However, for many (perhaps even a majority), bedtime is often fraught with anxiety. It can become a nightmare in itself. In frustration, you may try to lie still while “counting sheep.” Mind spinning, you are unable to let go and surrender into Morpheus’s waiting arms. And then when some people awaken during (or shortly after) REM sleep, their bodies are still literally paralyzed by the neurological mechanisms designed to inhibit running or fighting (or even actively moving) in a dream for self-protection and prevention against hurting someone else. Waking up from this normal “sleep paralysis” can be terrifying, particularly when people experience themselves detaching from their bodies, a frequent component of immobility. For others, the sleep-induced REM paralysis is a curious, enjoyable, even “mystical,” out-of-body experience. For those who perceive this detaching from their bodies as terrifying, panic reactions are typical. In traumatized people, fear-potentiated immobility is their wrenching companion, day and night.

  Although avoidance of immobility is understandable, it has a price. Whatever experiences you turn away from, your brain-body registers as dangerous; or colloquially, “that which we resist persists.” Thus, the time-honored expression, “time heals all wounds,” simply does not apply to trauma. In the short run, the suppression of immobility sensations appears (to our denial-biased mind) to keep the paralysis and helplessness at bay. However, in time, it becomes apparent that evasive maneuvers are an abject failure. This “sweeping under the rug” not only prolongs the inevitable, it often makes the eventual encounter with immobility even more frightening. It is as if the mind recognizes the extent of our resistance and in response interprets it as further evidence of peril. If, on the other hand, one is able to utilize the vital assistance of titration and pendulation, one can touch gently and briefly into that deathlike void without coming undone. Hence, the immobility response can move ahead in time toward its natural conclusion, self-paced termination.

  The fear of exiting immobility: In the wild, when a prey animal has succumbed to the immobility response, it remains motionless for a time. Then, just as easily as it stopped moving, it twitches, reorients and scampers off. But if the predator has remained and sees its prey returning to life, the story has a very different ending. As the prey comes back to life and sees the predator standing ready for a second (and this time lethal) attack, it either defaults to all-out rage and counterattacks, or it attempts to run away in frantic non-directed flight. Thus reaction is wild and “mindless.” As I mentioned in Chapter 4, I once saw a mouse counterattack a cat that had been batting it about with its paws (bringing the mouse out of its stupor), and then scurry away, leaving the cat dazed, like Tom-cat in a Tom and Jerry cartoon. Just as the immobilized animal (in the presence of the predator) comes out ready for violent counterattack, so too does a traumatized person abruptly swing from paralysis and shutdown to hyper-agitation and rage. Fear of this rage and the associated hyper-intense sensations prevents a tolerable exit from immobility unless there is education, preparation, titration and guidance.

  The fear of rage is also the fear of violence—both toward others and against oneself. The exiting of immobility is inhibited by the following double bind: to come back to life, one must feel the sensations of rage and intense energy. However, at the same time, these sensations evoke the possibility of mortal harm. This possibility inhibits sustained contact with the very sensations that bring relief from the experience of immobility, thereby leading to resolution. Recall the prescience of Kahlbaum (in Chapter 4) when he wrote in 1874: “In most cases catatonia is preceded by grief and anxiety and in general by depressive moods and affects aimed against the patient by himself.”56 Because the rage associated with the termination of immobility is both intense and potentially violent, frequently traumatized people inadvertently turn this rage against themselves in the form of depression, self-hatred and self-harm.

  The inability to exit from the immobility response generates unbearable frustration, shame and corrosive self-hatred. The therapist must approach this Gordian knot carefully and untangle it through deliberate and careful titration, along with reliance on the experience of pendulation and a resolve to befriend intense aggressive sensations. In this way, the individual is able to move out of this “kill or be killed” counterattack bind. As one begins to open gradually to accepting one’s intense sensations, one enhances the capacity for healthy aggression, pleasure and goodness.

  It is no surprise, then, that traumatized individuals constrict and brace against their rage as socialized animals. But let us look at the cumulative consequence of suppressing rage. Tremendous amounts of energy need to be exerted (on an already strained system) to keep rage and other primitive emotions at bay. This “turning in” of anger against the self, and the need to defend against its eruption, leads to debilitating shame, as well as to eventual exhaustion. This involution adds another layer to the complexity and seeming intransigence of the festering traumatic state. For these reasons, titration becomes even more crucial as a measure to interrupt this self-perpetuating “shame cycle.”

  In the case of molestation and other forms of previous abuse, a substratum of self-reproach has already been laid beneath a later trauma during adulthood. Indeed, because immobility is experienced as a passive response, many molestation and rape victims feel tremendous shame for not having successfully fought their attackers. This perception and the overwhelming sense of defeat can occur regardless of the reality of the situation: the relative size of the attacker doesn’t matter; nor does the fact that the immobility might have even protected the victim from further harm or possibly death.† And I haven’t even included here the additional blanket of confusion and shame that occurs within the complex dynamics of secrecy and betrayal in the incestuous family.

  As traumatized individuals begin to reown their sense of agency and power, they gradually come to a place of self-forgiveness and self-acceptance. They achieve the compassionate realization that both their immobility and their rage are a biologically driven, instinctual imperative and not something to be ashamed of as if it were a character defect. They own their rage as undifferentiated power and agency, a vital life-preserving force to be harnessed and used to benefit oneself. Because of its profound importance in the resolution of trauma, I’ll repeat myself: the fear that fuels immobility can be categorized, broadly, as two separate fears: the fear of entering immobility, which is the fear of paralysis, entrapment, helplessness and death; and the fear of exiting immobility, of the intense energy of the “rage-based” sensations of counterattack. Caught in this two-sided clamp (of entering and exiting), immobility repels its antidote implacably so that it seems impossible to break through it. However, when the skillful therapist assists clients in uncoupling the fear from the immobility by restoring “self-paced termination of immobility,” the rich reward is the client’s capability to move forward in time. This “forward experiencing” dispels fear, entrapment and helplessness by breaking this endless feedback loop of terror and paralysis.

  As fear uncouples from the immobilization sensations, you may scratch your head and ask, where does the fear go? The short and confounding answer is that when titrated, “fear” simply does not really exist as an independent entity. The actual acute fear that occurred at the time of the traumatic event, of course, no longer exists. What happens, however, is that one provokes and perpetuates a new fear state (one literally frightens oneself) and becomes one’s own self-imposed predator by bracing against the residual sensations of immobility and rage. While paralysis itself need not actually be terrifying, what is frightening is our resistance to feeling paralyzed or enraged. Because we don’t know it is a temporary state, and because our bodies do not register that we are now safe, we remain stuck in the past, rather than being in present time. Pendulation helps t
o dissolve this resistance. We might best heed the words of the 1960s jug band Dan Hicks and his Hot Licks: “It’s me I’m afraid of … I won’t scare myself.”

  During therapy, a graduated (titrated) progression or “forward moving of experiencing” keeps building on itself until the fear (now receding into the background) is eclipsed by a fully experienced immobility response. Frequently, one notices this physical sensation and acknowledges it with simple comments such as “I feel paralyzed, like I can’t move,” or “it feels like I am dead,” or even “it’s funny—I am dead and it doesn’t frighten me.” In addition, individuals may even experience blissful states similar to those reported in studies about near-death experiences. In exiting immobility, people may report that they feel “tingling vibrations all over my body” or “I feel deeply alive and real.” As the innate response of paralysis naturally resolves, sensations of “pure energy” are accepted; the individual opens into a mother lode of existential relief, transformative gratitude and vital aliveness. The mystic poet William Blake celebrated the intrinsic relationship between energy and the body: “The Body is a portion of the Soul discerned by the Senses, the chief inlet of the Soul in this age. Energy is the only life and is from the Body … and energy is pure delight.”

  Step 7. Resolve arousal states by promoting discharge of the vast survival energy mobilized for life-preserving action

  As one’s passive responses are replaced by active ones in the exit from immobility, a particular physiological process occurs: one experiences waves of involuntary shaking and trembling, followed by spontaneous changes in breathing—from tight and shallow to deep and relaxed. These involuntary reactions function, essentially, to discharge the vast energy that, though mobilized to prepare the organism to fight, flee or otherwise self-protect, was not fully executed. (See Chapter 1 for my own experience of such reactions after my accident, and Chapter 2 for Nancy’s as she discharged the arousal energy that had been bound up in ever-increasing symptoms since her early-childhood tonsillectomy.) Perhaps the easiest way to visualize the release of energy is through an analogy from physics. Imagine a spring fastened firmly to the ceiling above you. A weight is attached to the free end of the spring (see Figure 5.4). You reach up and pull the weight down toward you, stretching the spring and creating in it potential energy. Then as you release the spring, the weight oscillates up and down until all of the spring’s energy is discharged. In this way, the potential energy held in the spring is transformed into the kinetic energy of movement. The spring finally comes to rest when all the stored potential energy that has been converted to this kinetic energy is fully discharged.

  Discharge of Traumatic Activation and Restoration of Equilibrium

  Figure 5.4 Stretching the spring increases its potential energy. Releasing the spring transforms this potential into kinetic energy, where it is discharged and equilibrium restored.

  Similarly, your muscles are energized (“stretched”) in preparation for action. However, when such mobilization is not carried out (whether fight-or-flight or some other protective response such as stiffening, twisting, retracting or ducking), then that potential energy becomes “stored” or “filed” as an unfinished procedure within the implicit memory of the sensorimotor system. When a conscious or unconscious association is activated through a general or specific stimulus, all of the original hormonal and chemical warriors reenergize the muscles as if the original threat were still operating. Later this energy can be released as trembling and vibration. Risking oversimplification, I can say that an amount of energy (arousal) similar to what was mobilized for fight-or-flight must be discharged, through effective action and/or through shaking and trembling. These can be dramatic as with Nancy (Chapter 2), while others are subtle. They may be expressed as gentle fasciculations and/or changes in skin temperature. Along with these autonomic nervous system releases, the self-protective and defensive responses that were incomplete at the time of the incident (and lie dormant as potential energy) are frequently liberated through micro-movements. These are almost imperceptible and are sometimes referred to as “premovements”). In this way, Steps 4 through 7 link together.

  Step 8. Restore self-regulation and dynamic equilibrium

  A direct consequence of discharge of the survival energy mobilized for fight-or-flight is the restoration of equilibrium and balance (as in the previous example of the spring). The nineteenth-century French physiologist Claude Bernard, considered the father of experimental physiology, coined the term homeostasis to describe “the constancy of the internal environment [milieu intérieur] as the condition for a free and independent life.”57 More than a hundred and fifty years later, this remains the underlying and defining principle for the sustenance of life. However, since equilibrium is not a static process, I will use the term dynamic equilibrium instead of homeostasis to describe what happens when the nervous system becomes hyperaroused in response to threat and is then “reset,” only to be aroused and reset once again. This continual resetting both restores the prethreat level of arousal and promotes the shifting state (process) of relaxed alertness. Over time this contributes to the building of a robust resilience. Finally, the interoceptive experience of equilibrium, felt in viscera and in your internal milieu, is the salubrious one of goodness: that is, the background sense that—whatever you are feeling at a given moment, however dreadful the upset or unpleasant the arousal—you have a secure home base within your organism.

  Step 9. Reorient to the environment in the here and now

  Trauma could appropriately be called a disorder in one’s capacity to be grounded in present time and to engage, appropriately, with other human beings. Along with the restoration of dynamic equilibrium, the capacity for presence, for being in “the here and now,” becomes a reality. This occurs along with the desire and capacity for embodied social engagement.

  The capacity for social engagement has powerful consequences for health and happiness. As young children we are wired to participate in the social nervous systems of our parents and to find excitement and joy in such engagement. In addition, fascination with the face of another person generalizes to the environment and to the wonder of “newness.” Colors become vibrant, while one perceives shapes and textures as though seeing them for the first time—the very miracle of life unfolding.

  In addition, the social engagement system is intrinsically self-calming and is, therefore, built-in protection against one’s organism being “hijacked” by the sympathetic arousal system and/or frozen into submission by the more primitive emergency shutdown system. The social engagement branch of the nervous system is probably both cardioprotective and immuno-protective. This may be why individuals with strong personal affiliations live longer, healthier lives. They also maintain sharper cognitive skills into old age. Indeed, one study examining the effects of playing bridge in reducing dementia symptoms concluded that the main independent variable was socialization (rather than computational skills per se).‡ And, finally, to be engaged in the social world is not only to be engaged in the here and now, but also to feel a sense of both belonging and safety. So, ultimately freeing clients from the repercussive isolation that fear and immobility create has the potential of bringing not only freedom from debilitating symptoms, but also the potential to generate energy into the establishment of satisfying connections and relationships.

  * This is a method I have developed over the past forty years.

  † It is not clear when fighting or succumbing is the best survival strategy for rape. A dependent child experiencing molestation, however, really has little choice but to succumb.

  ‡ The so-called 90+ study at the University of Southern California began in 1981. It has included more than 14,000 people aged 65 and older and more than 1,000 aged 90 or older. Dr. Kawas, a senior investigator, concluded, “Interacting with people regularly, even strangers, uses easily as much brain power as doing puzzles, and it wouldn’t surprise me if this is what it’s all about.”

  CHAPTER 6<
br />
  A Map for Therapy

  The map may not be the territory, but it sure helps you to get around.

  —Me (PAL)

  Ancient Unspoken Voices

  Just as maps are useful in finding a particular part of the city, maps of the human organism* are important in navigating the landscape of trauma and informing its healing. The groundbreaking work of Stephen Porges, director of the Brain Body Center at the University of Illinois, Department of Psychiatry, has provided an eloquent, well-reasoned and broadly supported “treasure map” of the psychophysiological systems that govern the traumatic state. These same systems also mediate core feelings of goodness and belonging. Porges’s polyvagal theory of emotion58 illuminates the pathways for recovery and integration described in Chapter 5. In addition, his model clarifies why certain common approaches to trauma psychotherapy frequently fail.

  Briefly, Porges’s theory states that, in humans, three basic neural energy subsystems underpin the overall state of the nervous system and correlative behaviors and emotions. The most primitive of these three (spanning about 500 million years) stems from its origin in early fish species.† The function of this primitive system is immobilization, metabolic conservation, and shutdown. Its target of action is the internal organs. Next in evolutionary development is the sympathetic nervous system. This global arousal system has evolved from the reptilian period about 300 million years ago. Its function is mobilization and enhanced action (as in fight or flight); its target in the body is the limbs. Finally, the third, and phylogenetically most recent, system (deriving from about 80 million years ago) exists only in mammals. This neural subsystem shows its greatest refinement in the primates, where it mediates complex social and attachment behaviors. It is the branch of the parasympathetic nervous system that regulates the so-called mammalian or “smart” vagus nerve, which is neuroanatomically linked to the cranial nerves that mediate facial expression and vocalization. This most recently acquired system animates the unconsciously mediated muscles in throat, face, middle ear, heart and lungs, which together communicate our emotions, both to others and to ourselves.59 This most refined system orchestrates relationship, attachment and bonding and also mediates emotional intelligence. Figure 6.1 summarizes the basic mammalian nervous subsystems. For more detail, see Diagram B after this page, which shows the complex wandering of the vagus nerve affecting and being affected by most of the internal organs. The basic functions of these phylogenetic systems are summarized in Figures 6.2a through 6.2d.