In an Unspoken Voice

by Peter A Levine

  They confided to me that six months earlier, Sammy fell off his high chair and split his chin open. Bleeding heavily, he was taken to the local emergency room. When the nurse came to take his temperature and blood pressure, he was so frightened that she was unable to record his vital signs. This vulnerable little boy was then strapped down in a “pediatric papoose” (a board with flaps and Velcro straps). With his torso and legs immobilized, the only parts of his body he could move were his head and neck—which, naturally, he did, as energetically as he could. The doctors responded by tightening the restraint and immobilizing his head with their hands in order to suture his chin.

  After this upsetting experience, mom and dad took Sammy out for a hamburger and then to the playground. His mother was very attentive and carefully validated his experience of being scared and hurt. Soon, all seemed forgotten. However, the boy’s overbearing attitude began shortly after this event. Could Sammy’s tantrums and controlling behavior be related to his perceived helplessness from this trauma?

  When his parents returned, we agreed to explore whether there might be a traumatic charge still associated with this recent experience. We all gathered in the cabin where I was staying. With parents, grandparents and Sammy watching, I placed his stuffed Pooh Bear on the edge of a chair in such a way that it fell to the floor. Sammy shrieked, bolted for the door and ran across a footbridge and down a narrow path to the creek. Our suspicions were confirmed. His most recent visit to the hospital was neither harmless nor forgotten. Sammy’s behavior told us that this game was potentially overwhelming for him.

  Sammy’s parents brought him back from the creek. He clung dearly to his mother as we prepared for another game. We reassured him that we would all be there to help protect Pooh Bear. Again he ran—but this time only into the next room. We followed him in there and waited to see what would happen next. Sammy ran to the bed and hit it with both arms while looking at me expectantly.

  “Mad, huh?” I said. He gave me a look that confirmed my question. Interpreting his expression as a go-ahead sign, I put Pooh Bear under a blanket and placed Sammy on the bed next to him.

  “Sammy, let’s all help Pooh Bear.”

  I held Pooh Bear under the blanket and asked everyone to help. Sammy watched with interest but soon got up and ran to his mother. With his arms held tightly around her legs, he said, “Mommy, I’m scared.”q Without pressuring him, we waited until Sammy was ready and willing to play the game again. The next time, grandma and Pooh Bear were held down together, and Sammy actively participated in their rescue. When Pooh Bear was freed, Sammy ran to his mother, clinging even more tightly than before. He began to tremble and shake in fear, and then, dramatically, his chest expanded in a growing sense of excitement and pride.

  Here we see the transition between traumatic reenactment and healing play. The next time he held on to his mommy, there was less clinging and more excited jumping. We waited until Sammy was ready to play again. Everyone except Sammy took a turn being rescued with Pooh Bear. Each time, Sammy became more vigorous as he pulled off the blanket and escaped into the safety of his mother’s arms.

  When it was Sammy’s turn to be held under the blanket with Pooh Bear, he became quite agitated and fearful. He ran back to his mother’s arms several times before he was able to accept the ultimate challenge. Bravely, he climbed under the blankets with Pooh Bear while I held the blanket gently down. I watched his eyes grow wide with fear, but only for a moment. Then he grabbed Pooh Bear, shoved the blanket away, and flung himself into his mother’s arms. Sobbing and trembling, he screamed, “Mommy, get me out of here! Mommy, get this off of me!” His startled father told me that these were the same words Sammy screamed while imprisoned in the papoose at the hospital. He remembered this clearly because he had been quite surprised by his son’s ability to make such a direct, well-spoken demand at just over two and a half years of age.

  We went through the escape several more times. Each time, Sammy exhibited more power and more triumph. Instead of running fearfully to his mother, he jumped excitedly up and down. With every successful escape, we all clapped and danced together, cheering, “Yeah for Sammy, yeah! Yeah, Sammy saved Pooh Bear!” Two-and-a-half-year-old Sammy had achieved mastery over the experience that had shattered him a few months earlier. The trauma-driven aggressive, foul-tempered behavior used in an attempt to control his environment disappeared, while his “hyperactivity” and avoidance (which occurred during the reworking of his medical trauma) was transformed into triumphant play.

  Five Principles to Guide Children’s Play toward Resolution

  The following analysis of Sammy’s experience will help clarify and apply the following principles for working using pediatric therapeutic play.

  1. Let the child control the pace of the game.

  Healing takes place in a moment-by-moment slowing down of time. In order to help the child you are working with feel safe, follow her pace and rhythm. If you put yourself in the child’s shoes (through careful observation of her behavior), you will learn quickly how to resonate with her. Let’s return to the story to see exactly how we did that with Sammy:

  By running out of the room when Pooh Bear fell off the chair, Sammy indicated loud and clear that he was not ready to engage in this new activating game. Sammy had to be rescued by his parents, comforted, and brought back to the scene before continuing. In order to make him feel safe, we all assured him that we would be there to protect Pooh Bear. By offering this support and reassurance, we help Sammy move closer to playing the game—in his own time at his own pace.

  After this reassurance, Sammy ran into the bedroom instead of out the door. This was a clear signal that he felt less threatened and more confident of our support. Children may not state verbally whether they want to continue, so take cues from their behavior and responses. Respect their wishes in whatever way they choose to communicate them. Children should never be rushed to move through an episode too fast or forced to do more than they are willing and able to do. Just like with Sammy, it is important to slow down the process if you notice signs of fear, constricted breathing, stiffening or a dazed (dissociated) demeanor. These reactions will dissipate if you simply wait, quietly and patiently, while reassuring the child that you are still by his side and on his side. Usually, the youngster’s eyes and breathing pattern will indicate when it’s time to continue.

  2. Distinguish between fear, terror and excitement.

  Experiencing fear or terror for more than a brief moment during traumatic play will not help the child move through the trauma. Most children will take action to avoid it. Let them! At the same time, try and discern whether it is avoidance or escape. The following is a clear-cut example to help in developing the skill of “reading” when a break is needed and when it’s time to guide the momentum forward.

  When Sammy ran down to the creek, he was demonstrating avoidance behavior. In order to resolve his traumatic reaction, Sammy had to feel that he was in control of his actions rather than driven to act by his emotions. Avoidance behavior occurs when fear and terror threaten to overwhelm both children and adults. With kids this behavior is usually accompanied by some sign of emotional distress (crying, frightened eyes, screaming). Active escape, on the other hand, is exhilarating. Children become excited by their small triumphs and often show pleasure by glowing with smiles, clapping their hands or laughing heartily. Overall, the response is much different from avoidance behavior. Excitement is evidence of the child’s successful discharge of emotions that accompanied the original experience. This is positive, desirable and necessary.

  Trauma is transformed by changing intolerable feelings and sensations into desirable ones. This can only happen at a level of activation that is similar to the activation that led to the traumatic reaction in the first place.

  If the child appears excited, it is OK to offer encouragement and continue as we did when we clapped and danced with Sammy.

  However, if the child appears frightened or cowed, give rea
ssurance, but don’t encourage any further movement. Instead, be present with your full attention and support, waiting patiently until a substantial amount of the fear subsides. If the child shows signs of fatigue, take a rest break.

  3. Take one small step at a time.

  You can never move too slowly in renegotiating a traumatic event with anyone; this is especially true with a young child. Traumatic play is repetitious almost by definition. Make use of this cyclical characteristic. The key difference between renegotiation and traumatic play (reenactment) is that in renegotiation there are incremental differences in the child’s responses and behaviors in moving toward mastery and resolution. The following illustrates how I noticed these small changes with Sammy.

  When Sammy ran into the bedroom instead of out the door, he was responding with a different behavior, indicative that progress had been made. No matter how many repetitions it takes, if the child you are helping is responding differently—such as with a slight increase in excitement, with more speech or with more spontaneous movements—he is moving through the trauma. If the child’s responses appear to be moving in the direction of constriction or compulsive repetition instead of expansion and variety, you may be attempting to renegotiate the event with scenarios that involve too much arousal for the child to make progress. If you notice that your attempts at playful renegotiation are backfiring, ground yourself and pay attention to your sensations until your breathing brings a sense of calm, confidence and spontaneity. Then, slow down the rate of change by breaking the play into smaller increments. This may seem contradictory to what was stated earlier about following the child’s pace. However, attuning to children’s needs sometimes means setting limits to prevent them from getting wound up and collapsing in overwhelm. If the child appears tense or frightened, it’s OK to invite some healing steps. For example, when renegotiating a medical trauma, you might say, “Let’s see, I wonder what we can do so that Pooh Bear (Dolly, GI Joe, etc.) doesn’t get so scared before you [the pretend doctor/nurse] give him the shot?” Often children will come up with creative solutions showing you exactly what they needed—the missing ingredient that would have helped them settle more during their experience.

  Don’t be concerned about how many times you have to go through what seems to be the “same old thing.” (We engaged Sammy in playing the game with Pooh Bear at least ten times.) Sammy was able to renegotiate his traumatic responses fairly quickly. Another child in your care might require more time. You don’t need to do it all in one day! Resting and time are needed to help internally reorganize the child’s experience at subtle levels. Be assured that if the resolution is not complete, the child will return to a similar phase when given the opportunity to play during the next session.

  4. Become a safe container.

  Remember that biology is on your side. Perhaps the most difficult and important aspect of renegotiating a traumatic event with a child is maintaining your own belief that things will turn out OK. This feeling comes from inside you and is projected out to the child. It becomes a container that surrounds the child with a feeling of confidence. This may be particularly difficult if the child resists your attempts to renegotiate the trauma.

  If the child resists, be patient and reassuring. The instinctive part of your child wants to rework this experience. All you have to do is wait for that part to feel confident and safe enough to assert itself. If you are excessively worried about whether the child’s traumatic reaction can be transformed, you may inadvertently send a conflicting message. Adults with their own unresolved childhood trauma may be particularly susceptible to falling into this trap.

  5. Stop if you feel that the child is genuinely not benefiting from the play.

  In Too Scared to Cry, Lenore Terr,107 the brilliant and esteemed child psychologist, warns clinicians about allowing children to engage in traumatic play “therapy” that reenacts the original horror. She describes the responses of three-and-a-half-year-old Lauren as she plays with toy cars. “The cars are going on the people,” Lauren says as she zooms two racing cars toward some finger puppets. “They’re pointing their pointy parts into the people. The people are scared. A pointy part will come on their tummies, and in their mouths, and on their … [she points to her skirt]. My tummy hurts. I don’t want to play anymore.” Lauren stops herself as her bodily sensation of fear abruptly surfaces. This is a typical reaction. She may return over and over to the same play, each time stopping when the fearful sensations in her tummy become uncomfortable. Some therapists would say that Lauren is using her play as an attempt to gain some control over the situation that traumatized her. Her play does resemble “exposure” treatments used routinely to help adults overcome phobias. But Terr cautions that such play ordinarily doesn’t yield much success. Even if it does serve to reduce a child’s distress, this process is quite slow in producing results. Most often, the play is compulsively repeated without resolution. Unresolved, repetitious, traumatic play can reinforce the traumatic impact in the same way that reenactment and cathartic reliving of traumatic experiences can reinforce trauma in adults.

  The reworking or renegotiation of a traumatic experience, as we saw with Sammy, represents a process that is fundamentally different from traumatic play or reenactment. Left to their own devices, most children, not unlike Lauren in the above example, will attempt to avoid the traumatic feelings that their play evokes. But with guided play, Sammy was able to “live his feelings through” by gradually and sequentially mastering his fear. Using this stepwise renegotiation of the traumatic event and Pooh Bear’s companionship, Sammy was able to emerge as the victor and hero. A sense of triumph and heroism almost always signals the successful conclusion of a renegotiated traumatic event. By following Sammy’s lead after setting up a potentially activating scene, joining in his play and making the game up as we went along, Sammy got to let go of his fear. It took minimal direction (30–45 minutes) and support to achieve the unspoken goal of aiding him to experience a corrective outcome.

  * Recall the discussion in Chapter 4 of Beatrice Gelder’s work demonstrating how attuned we humans are to the survival-based postures of others. These findings also relate to research on mirror neurons. A mirror neuron is a neuron that fires both when an animal acts and when it observes the same action performed by another animal. Thus, the neuron mirrors the behavior of the other, as though the observer herself were performing the very same act. Such neurons have been directly observed in primates and are found in the premotor cortex and in the insula and cingulate, suggesting their importance in communicating internal bodily states and emotions. The neuroscientist Stephanie Preston, the Dutch primatologist Frans de Waal and other neuroscientists have independently posited that the mirror neuron system is centrally involved in empathy and that since it is the body that is being mirrored, intimate moments are nonverbal in nature. In humans, brain activity consistent with that of mirror neurons has been found in the premotor cortex and the inferior parietal cortex. See Chapter 4 for specific references to this research.

  † I do this to help her keep connected with me as she goes inside, as well as to feel more grounded.

  ‡ This is an important difference between “talk therapy” and body-oriented therapy. Rather than trying to help patients make new meanings or understand their problems, body therapy creates a space for the “body story” to unfold and complete. When this occurs, new meanings and insights emerge spontaneously, generated by the patients themselves, as an integral part of this process.

  § The sense of a foreshortened life, of wordless despair, is a central characteristic of severe trauma. The person is in a fundamental way stuck in the horrific imprint of the past and thus cannot imagine a future different from the past.

  ‖ This is an effect of dissociation. It is as though Sharon is describing what happened to another person; it is as though she is outside of her body, observing, but not really being present. She lives back at the moment of shock where dissociation is what allowed her to survive the
unimaginable horror and terror. In the Hollywood, Hitchcock version of trauma, the sufferer is barraged by flashbacks. In real life, though, the numbing or shutting-down phase is often more significant and is generally characteristic of severe and/or chronic trauma. These are the people who become the “walking dead.”

  a Frequently, people will make exaggerated gestures as a way of avoiding feeling the underlying sensations.

  b I believe that this is because these very slow (“intrinsic”) movements, when done mindfully, operate through the gamma efferent system. This system is intimately connected to the brain stem–autonomic nervous system and involves the extra pyramidal motor system. Voluntary movement, on the other hand, is controlled by the alpha motor system and is independent of the autonomic nervous system. Gamma-mediated movements tend to “re-set” the nervous system away from extremes of activation.

  c Returning to these positive, expansive sights is not an avoidance, but rather an integral part of trauma resolution.

  d This is similar to the widely accepted principle of reciprocal inhibition discovered by the Nobel Prize–winning physiologist Sir Charles Sherrington.

  e This is the inherent capacity to pendulate (to rhythmically shift between states of distress/contraction and pleasure/expansion; see Step 3 in Chapter 5). Pendulation is an essential ingredient in the alchemy of transformation—it is what brings people into present time.