In an Unspoken Voice

by Peter A Levine

  When their loneliness becomes too stark, traumatically disconnected individuals may seek increasingly more unrealistic (and sometimes dangerous) “hook-ups.” They see each new relationship possibility (or impossibility) as providing the caring protection that will calm their inner anxieties and buoy up their fragile sense of self. Having had a neglectful or abusive childhood predisposes them to chaotic relationships. These individuals continue to look for love “in all the wrong places”—a folly the song reminds us of. Even when one’s idealized (fantasy) rescuers become abusive, one seems oblivious to the early signs of that abuse and becomes increasingly ensnared in a damaging liaison precisely because it is so familiar or “like family.”

  Correcting such maladaptive patterns is the bane of many trauma therapists, who look on helplessly as their clients are repeatedly triggered and seduced into self-destructive affairs, reenacting their original trauma. Many therapists hold to the hope that they can somehow provide their clients with the positive, affirmative (I-thou) relationship that will assuage a client’s fractured psyche and restore his or her wounded soul to wholeness. However, what often happens is that a client’s dependency upon the therapist escalates and gets entirely out of hand–as shown so conspicuously in the gem of a film What About Bob? (1991). In it, Bob, the “abandoned” client, is so dependent, and his feelings about being left alone are so intolerable, that he tracks down his psychiatrist like a sleuth and follows him on a family vacation on Cape Cod.

  On the other hand, if a client experiences the therapist, who is supposed to be a healer, as a “proxy” abuser, the therapy often culminates in the client’s profound disappointment and/or seething rage. Traumatized individuals are not made whole through the therapeutic relationship alone. Even with the best of intentions, and highly developed empathic skills, a therapist often misses the mark here. The polyvagal theory and the Jacksonian principle of dissolution help us to understand why and how this happens.70 When the traumatized person is locked in either the immobilization response or the sympathetic arousal system, the social engagement function is physiologically compromised; the former, in particular, both inhibits sympathetic arousal and can almost completely suppress the social engagement system.

  A person whose social engagement system is suppressed has trouble reading positive emotions from other people’s faces and postures and also has little capacity to feel his or her own nuanced positive affects. Thus, one finds it difficult to know if that other person can be trusted (whether he or she is threatening or safe, friend or foe). According to the polyvagal theory, being in shutdown (immobility/freezing/or collapse) or in sympathetic/hyperactivation (fight or flight) greatly diminishes a person’s capacity to receive and incorporate empathy and support. The facility for safety and goodness is nowhere to be found. To the degree that traumatized people are dominated by shutdown (the immobility system), they are physiologically unavailable for face-to-face contact and the calming sharing of feelings and attachment. And while immobilization is rarely complete (as it is, for example, in catatonic schizophrenia), its ability to suppress life and one’s capacity for social engagement is extreme. A young man describes his dark plight as follows: “I feel all alone in the universe, dissociated from the human race … I am not sure that I even exist … Everyone is part of the flower; I am still part of the root.”i It is not surprising that, try as they may, many traumatized clients are little able to receive support and caring from their well-intentioned therapists—not because they don’t want to, but because they are stuck in the primitive root of immobility with its greatly reduced capability for reading faces, bodies and emotions; they become cut off from the human race.

  For this reason such a client may not be readily calmed by the positive feelings and attitude of empathy the therapist provides, and may even perceive the therapist as a potential threat. Unable to recognize caring feelings in the face and posture of others, such a client finds it extremely difficult to feel that anyone is safe or can really be trusted. And when high hopes are placed on the therapist, one small misstep or inadvertent fumble on the latter’s part can bring the entire relationship crashing down.

  As highly dissociated and shut-down clients involuntarily retreat, they experience additional self-recrimination and shame. Tormented by this loss of control, they are unable to accept and respond to the warmth and security offered by their therapist and may engage in unproductive transference and “acting out.” The inherent disconnect that then occurs often leaves both client and therapist bewildered and frustrated, feeling that they are failing in their respective roles. The client may perceive this breakdown as a devastating confirmation of his or her inadequacy, adding to a lifetime of (many perceived) failures. Therapists may also feel confused, helpless, inadequate and self-reproaching. Such situations, where the two partners are locked against one another, can readily become intractable Gordian knots. These therapeutic cul-de-sacs may eventually result in termination of treatment.

  A Way Out

  Shut-down and dissociated people are not “in their bodies,” being, as we have seen, nearly unable to make real here-and-now contact no matter how hard they try. It is only when they can first engage their arousal systems (enough to begin to pull them up, out of immobility and dissociation), and then discharge that activation, that it becomes physiologically possible to make contact and receive support. Fortunately, there is a way to escape the immobilization system’s domination of the two less primitive systems—a way that healing practitioners must learn to exercise.

  This therapeutic solution is supported by Lanius and Hopper’s fMRI work mentioned earlier.71 This compelling research, recording activity in the part of the brain associated with the awareness of bodily states and emotions, makes a clear differentiation between sympathetic arousal and dissociation in traumatized subjects. The brain area associated with awareness of bodily states and emotions is called the right anterior insula and is located in the frontal part of the limbic (emotional) brain, squeezed in directly under the prefrontal cortex—the locus of our most refined consciousness. The research showed that the insulaj is strongly inhibited during shutdown and dissociation, and it confirmed that these traumatized individuals are unable to feel their bodies, to differentiate their emotions, or even to know who they (or another person) really are.72 On the other hand, when subjects are in a state of sympathetic hyperarousal, this same area is highly activated. This dramatic increase in the activity of the right anterior insula strongly suggests a clear differentiation of little or no body awareness (in immobility/shutdown and dissociation) to a kind of “hyper-sensation” in sympathetic arousal. In addition, the sympathetic state, at least, provides the possibility of coherent awareness, processing and resolution. These data support the crucial steps to trauma resolution outlined in Chapter 5 (Step 5) and further clarify the strategy of helping clients move from shutdown to mobilization while learning to manage their physical (bodily) sensations as they shift into sympathetic arousal.

  A related, and seminal, research study was carried out by Bessel van der Kolk.73 He and his colleagues read a traumatic story to a group of clients and compared two brain regions in each (measured with fMRI). The researchers found that the amygdala, the so-called fear or “smoke detector,” lit up with electrical activity; at the same time, a region in the left cerebral cortex, called Broca’s area, went dim. The latter is the primary language center—the part of the brain that takes what we are feeling and expresses it with words. That trauma is about wordless terror is also demonstrated in these brain scans. Frequently when traumatized people try to put their feelings into words—as when, for example, one is asked by the therapist to tell about his or her rape—they speak about it as though it had happened to someone else (see the story of Sharon in Chapter 8). Or clients try to speak of their horror, then become frustrated and flooded, incurring more shutdown in Broca’s area, and thus enter into a retraumatizing feedback loop of frustration, shutdown and dissociation.

  This languag
e barrier in traumatized individuals makes it especially important to work with sensations—the only language that the reptilian brain speaks. Doing so both helps people to move out of shutdown and dissociation and diminishes a client’s frustration and flooding when working with traumatic material.

  The body must be doing something to keep the insula, the cingulate cortex, and Broca’s area online. Even though the capacity for engagement is inhibited by the sympathetic nervous system, it is not thoroughly squelched in the debilitating way it was by the more primitive immobility system. In sympathetic arousal, clients are better able to respond to their therapist’s promptings and suggestions, as well as to be more receptive to his or her calming presence. In turn, it is this very receptivity that helps to attenuate the sympathetic arousal. When a client begins to make the breakthrough out of immobility and into sympathetic arousal, the astute therapist seizes this momentary opportunity, first by detecting the client’s shift and then by facilitating the awareness of his or her transition. The therapist endeavors to enlarge the client’s awareness of what is going on in him- or herself while simultaneously helping the client avoid being overwhelmed by the intense sympathetic arousal. Such guidance helps clients move out of immobility and through complete cycles of activation, discharge/deactivation and equilibrium (steps 7 and 8 in Chapter 5). In this way, the individual learns that what goes up (gets activated) can, and will, come down. Clients learn to trust that moderate activation unwinds on its own when one doesn’t avoid and recoil from it: that is, when one doesn’t interfere with the natural course of one’s sensations of arousal. Thus a therapist can seize the day—by giving clients the gift of this bodily experience.

  The Brain/Body Connection

  Whatever increases, decreases, limits or extends the body’s power of action, increases, decreases, limits or extends the mind’s power of action. And whatever increases, decreases, limits or extends the mind’s power of action, also increases, decreases, limits or extends the body’s power of action.

  —Spinoza (1632–1677), Ethics

  Many therapists, realizing how difficult it is to reach highly dissociated and shut-down clients, have developed valuable cognitive and emotional methods to help connect with them.74 Somatic approaches can also be enormously useful, or even critical, in this healing effort. They help clients move out of immobility, into sympathetic arousal, through mobilization, into discharge of activation and then finally onward to equilibrium, embodiment and social engagement. The following somatically based awareness exercises begin this process by helping individuals move out of shutdown and dissociation.

  The first is a simple exercise that clients can do by themselves to help enliven their body-sense and minimize shutdown, dissociation and collapse. By being able to practice in the privacy of their own homes, clients can spare themselves potential embarrassment or shame in their awakening process. This exercise, and those that follow, are meant to be done regularly, over time, for maximum benefit—and therapists should practice the exercises themselves.

  For ten minutes or so (a few times a week), take a gentle, pulsating shower in the following way: at a comfortable temperature, expose your body to the pulsing water. Direct your awareness into the region of your body where the rhythmical stimulation is focused. Let your consciousness move to each part of your body. For example, hold the backs of your hands to the shower head, then the palms and wrists, then your head, shoulders, underarms, both sides of your neck, etc. Try to include each part of your body, and pay attention to the sensation in each area, even if it feels blank, numb, or uncomfortable. While you are doing this, say, “This is my arm, head, neck,” etc. “I welcome you back.” You can also do this exercise by gently tapping those same parts of your body with your fingertips. When done regularly over time, this and the following exercises will help reestablish awareness of your body boundary through awakening skin sensations.

  A sequel to this shower exercise involves bringing boundary awareness into the muscles. You start by using a hand to grasp and gently squeeze the opposite forearm; then you squeeze the upper arm, the shoulders, neck, thighs, calves, feet, etc. The important element is to be mindful of how your muscles feel from the inside as they are being squeezed. You can begin to recognize the rigidity or flaccidity of the tissue as well as its general quality of aliveness. Generally, tight, constricted muscles are associated with the alarm and hypervigilence of the sympathetic arousal system. Flaccid muscles, on the other hand, belie how the body collapses when dominated by the immobilization system. In the case of flaccid muscles, you need to linger and gently hold them, almost as though you were holding a baby. With the practice of gentle, focused touch and resistance exercises, you can learn to bring life back into those muscles as the fragile fibers learn to fire coherently and thus vitalize the organism.

  These two exercises are best done regularly, several times per week. As body consciousness grows, so, too, will a more palpable sense of boundary awareness, as well as greater aliveness. For some clients, classes in gentle yoga or martial arts, such as tai chi, aikido or chi gong, can be beneficial in restoring connection to their bodies and defining body boundaries. For these classes to be helpful, it is important that the teacher have some experience in working with traumatized individuals.

  Changing the Paradigm

  Most psychotherapists work with clients when both are sitting in chairs. Since sitting requires little proprioceptive and kinesthetic information to maintain an erect posture, the body easily becomes absent, disappearing from its owner. Recall the fMRI study of Lanius and Hopper, where dissociated patients showed a great reduction of activity in the parts of the brain (insula and cingulate) that register body sensations. In contrast, a standing position requires one to engage in at least a modicum of interoceptive activity and awareness to maintain one’s balance via proprioceptive and kinesthetic integration. Often, this simple change in stance can make the difference between whether or not a client is able to stay present in the body while processing difficult sensations and feelings. Another supportive variant is to invite the client to sit on a suitable-sized gymnastic ball. Since balancing on a ball requires making multiple adjustments to maintain equilibrium, not only does it help one to be in touch with internal sensations due to the feedback from this pliable surface, but in addition, explorations in muscle awareness, grounding, centering, protective reflexes and core strength bring a whole new dimension to developing a body consciousness. Naturally, the therapist has to be sure that the client is present and integrated enough not to fall off the ball and possibly sustain an injury.

  The following is another technique to help clients remain conscious of their bodily sensations while at the same time learning how to manage assertion and aggression. First, have your client stand up and face you. It is important to check whether she is comfortable with the distance between the two of you. Next, ask the client to notice what she is aware of as her feet contact the ground. Then encourage her to broaden her perception, moving up through her ankles, calves and thighs. To encourage a sense of groundedness, continue this exercise by proposing a slow and gentle weight shift from one foot to the other. Also, you could suggest that your client think of her feet as suction cups (like the feet of a frog) flexibly rooted in the earth. Next, have the client bring her attention to her hips, spine, neck, and then head. Now have her notice how her shoulders hang from her neck like a tent. Awareness of breathing is evoked as the client is asked to sense her shoulders as they gently rise and fall with each breath. Now bring her attention to her chest and belly; and, using breath, help the client locate the center of gravity in her abdomen. Again have her slowly shift her weight from side to side between her two feet, and then have her add a slight sway from front to back. This type of movement requires a fairly sophisticated proprioceptive ability (joint position) and sense of muscle tension (kinesthesia).k As your client practices this, have her imagine a plumb line from her center down to the floor between her feet. Finally, have her notice ho
w this line moves with her gentle swaying. A client who has developed this centered awareness is ready to move to the position shown in Figure 6.3a.l

  Figure 6.3a Physical awareness exercise to cultivate the experience of healthy aggression. Hand positioning for evoking healthy aggression (in Figure 6.3a).

  Figure 6.3b

  The idea, now, is to have the client feel her feet on the ground, feel her center and then push firmly, but gently, into the therapist’s hand (see Figure 6.3b). As the therapist, you will offer just enough resistance to allow the client to sense herself pushing out from her center. You will be asking her to feel how the movement seems to originate from her belly and is expressed through her shoulders and into her arms and hands. Continue to check with the client to ascertain whether the resistance feels right—not too much or too little—and whether the distance feels safe enough. Should the client feel unsafe, first ask whether she can indicate where she would like you to stand. Now suggest that she try to notice where in her body it feels unsafe or unstable, and then to notice what happens if she brings her attention back to her feet and legs. Ask her to attempt to recapture a sense of the grounding established at the beginning of the exercise. When your client is able to feel a sense of safety, ask her to notice where in her body she feels safe now and to describe how she experiences her (often brand-new) sense of self. Repeat this resistance activity several times, having your client push with both hands, until there is a loosening up and developing sense of confidence. The next progression of this exercise involves more of a give and take between the therapist and the client, each of you alternately pushing and receiving the movement. When one’s body is able to experience a relaxed sense of strength, one’s mind is able to experience a relaxed sense of focused alertness.