f To the nervous system, being overwhelmed by an event is really little different than being overwhelmed by similar sensations and emotions that are internally generated.
g Until this was done, Sharon still experienced herself as being stuck in the stairwell. All of her thoughts had revolved around this deeply imprinted belief. By having the (new) physical sensation of running at a heightened level of arousal, Sharon contradicts her previous, bodily, experience of helpless freezing.
h The exuberance of ghetto kids joyfully flying such improvised kites is portrayed in the classic film Black Orpheus (Orfeu Negro), a reworking of the Greek myth set in Rio de Janeiro.
i At this point I did not want to ask Adam to try to feel something (this would only lead to frustration and failure), but rather to interest him in initiating exploration (in “finding the picture inside”).
j This is done to amplify figure ground perception and presence.
k It is important to take a little piece of new internal experience like this and connect it to external perceiving. This is the “figure ground” that gives rise to the “experience of now.”
l Figure-ground shifting is often a general movement to fluidity and flow.
m I believe that slow, mindful movements evoke the involuntary functions of the nervous system, particularly the extrapyramidal/gamma-efferent system.
n I am interrupting the urge to seek temporary relief by finding an explanation for a sensation, rather than completing the frozen action and welcoming the formation of new meanings.
o Often there is a significant delay between a traumatizing event and when the symptoms present.
p In a different situation the urge might be to save one’s own life, or to stay pinned down in a foxhole, as in the “fog of war.”
q This trust of safety would not happen without a solid attachment. Where healthy bonding is not the case, or where there is abuse, therapy is, of course much more complex and also generally involves therapy for the parents or caregivers.
CHAPTER 9
Annotation of Peter’s Accident
For my final case example, I come full circle from where we began this undertaking, my experience on that sunny, beautiful day. I have chosen to recount my horrific accident detailed in Chapter 1, with a brief imbedded analysis (in bold). This annotation serves not only as a review but also as a way to scrutinize the factors that prevented me from ending up with posttraumatic stress disorder (PTSD). The event itself—namely being struck by a car, smashed against a windshield, catapulted through the air and physically injured—certainly counts as a traumatic event. But why wasn’t I traumatized?
As I walked along that fateful February day, absorbed in happy anticipation of seeing my dear friend Butch to celebrate his sixtieth birthday, I stepped out into a crosswalk … The next moment, paralyzed and numb, I’m lying on the road, unable to move or breathe. I can’t figure out what has just happened. How did I get here? Out of a swirling fog of confusion and disbelief, a crowd of people rushes toward me. (1. Shock in my case was literally about having the wind knocked out of me. All traumas leave us breathless in some way. In the moment of shock people don’t really know what happened to them; they are breathless with a loss of inner and outer orientation.) They stop, aghast. Abruptly, they hover over me in a tightening circle, their staring eyes fixed on my limp and twisted body. From my helpless perspective they appear like a flock of carnivorous ravens, swooping down on an injured prey—me. Slowly I orient myself and identify the real attacker. As in an old-fashioned flashbulb photo, I see a beige car looming over me with its teeth-like grill and shattered windshield. (2. In the shock state images become disparate and fragmentary, and are focused exclusively on the most salient threat features.) The door suddenly jerks open. A wide-eyed teenager bursts out. She stares at me in dazed horror. In a strange way, I both know and don’t know what has just happened. (3. In one of the paradoxes of trauma, traumatized people have a split perception/reception. They are on autopilot, where they act calmly. They also enter into a dream/nightmare from which they cannot wake.) As the various fragments begin to converge, they convey a horrible reality: I must have been hit by this car as I entered the crosswalk. In confused disbelief, I sink back into a hazy twilight. I find that I am unable to think clearly or to will myself awake from this nightmare.
A man rushes to my side and drops to his knees. He announces himself as an off-duty paramedic. When I try to see where the voice is coming from, (4. This is an automatic, initial biological orienting response.) he sternly orders, “Don’t move your head.” (5. Now I am put in a double bind with two contradictory commands: one is the innate effort to orient; the other is a demand not to execute this compelling instinct. The result is a collision of opposing impulses. This results in a thwarting of the biological orienting impulse. This was also the case with Vince, the fireman with the frozen shoulder in Chapter 8.) The contradiction between his sharp command and what my body naturally wants—to turn toward his voice—frightens and stuns me into a sort of paralysis. My awareness strangely splits, and I experience an uncanny “dislocation.” It’s as if I’m floating above my body, looking down on the unfolding scene. (6. This description is a classic presentation of dissociation. However, dissociation takes many forms, including the panoply of psychological fragmentation and physical symptoms that can occur in the wake of trauma.)
I am snapped back when he roughly grabs my wrist and takes my pulse. He then shifts his position, directly above me. Awkwardly, he grasps my head with both of his hands, trapping it and keeping it from moving. His abrupt actions and the stinging ring of his command panic me; they immobilize me further. (7. This conflict deepens the thwarting and intensifies the immobility response by introducing more fear. This results in fear-potentiated immobility.) Dread seeps into my dazed, foggy consciousness: Maybe I have a broken neck, I think. (8. Dread and helplessness increase the depth and duration of immobility.) I have a compelling impulse to find someone else to focus on. (9. The need for human contact, when threatened, is a mammalian survival instinct—see Chapter 6.) Simply, I need to have someone’s comforting gaze, a lifeline to hold onto. But I’m too terrified to move and feel helplessly frozen. (10. Due to the power of the shock and the immobilization response, there is a reduced ability to ask for help—that is, to engage that more recently developed mammalian social survival instinct.)
The Good Samaritan fires off questions in rapid succession: “What is your name? Where are you? Where were you going? What is today’s date?” But I can’t connect with my mouth and make words. I don’t have the energy to answer his questions. His manner of asking them makes me feel more disoriented and utterly confused. Finally, I manage to shape my words and speak. My voice is strained and tight. (11. Voiceless terror is part of the immobility response and is seen in all species that normally vocalize.) I ask him, both with my hands and words, “Please back off.” (12. This is the first time I am able to mobilize an effective defense against intrusion by beginning to establish a protective boundary.) He complies. As though a neutral observer, speaking about the person sprawled out on the blacktop, I assure him that I understand I am not to move my head, and that I will answer his questions later. (13. As the shock is reduced by making an effective boundary, the communication centers in my brain—Broca’s area—are coming online to further delineate and articulate my boundary.)
The Power of Kindness
After a few minutes, a woman unobtrusively inserts herself and quietly sits by my side. “I’m a doctor, a pediatrician,” she says. “Can I be of help?”
“Please just stay with me,” I reply. Her simple, kind face seems supportive and calmly concerned. She takes my hand in hers, and I squeeze it. (14. Her outreach and physical touch provide a source of orientation and help to enlist my diminished capacity for social engagement. The activation of the ventral vagal system—see Chapter 6—is helping to buffer me against being sucked down into the black hole of trauma.) She gently returns the gesture. As my
eyes reach for hers, I feel a tear form. (15. The eye-to-eye contact is integral to the social engagement system, as is touch. This physiological exchange, in which we are participating in each other’s nervous systems, leads to stabilization and relief.) The delicate and strangely familiar scent of her perfume tells me that I am not alone. I feel emotionally held by her encouraging presence. (16. Through smell we have direct access to the limbic system—formerly called the olfactory-smell-brain—for this very reason.) A trembling wave of release moves through me, and I take my first deep breath. (17. This powerful moment is the first instance of physiological discharge and self-regulation.) Then a jagged shudder of terror passes though my body. Tears are now streaming from my eyes. In my mind, I hear the words, I can’t believe this has happened to me; it’s not possible; this is not what I planned for Butch’s birthday tonight. (18. This is recognition of my own denial.) I am sucked down by a deep undertow of unfathomable regret. (19. In this moment I am contacting the deep emotional truth by acknowledging the loss. In therapy this frequently happens, gradually, over time.) My body continues to shudder. Reality sets in.
In a little while, a softer trembling begins to replace the abrupt shudders. I feel alternating waves of fear and sorrow. (20. This discharge in waves allows for the natural experience of pendulation—expansions/contraction as discussed in Step 3 in Chapter 5—and softens the feelings of sorrow and fear.) It comes to me as a stark possibility that I may be seriously injured. (21. It is part of a mammalian response to injury to scan the body and to assess the nature and level of the injury.) Perhaps I will end up in a wheelchair, crippled and dependent. Again, deep waves of sorrow flood me. I’m afraid of being swallowed up by the sorrow and hold onto the woman’s eyes. (22. I am now actively engaging the woman as a resource.) A slower breath brings me the scent of her perfume. Her continued presence sustains me. As I feel less overwhelmed, my fear softens and begins to subside. I feel a flicker of hope, then a rolling wave of rage. (23. Rage is a strong defensive response—it is about the impulse to kill! Hence people become terrified by this impulse and try to suppress it. The pediatrician is helping me to contain this rage and not be overwhelmed by it.) My body continues to shake and tremble. It is alternately icy cold and feverishly hot. (24. This is indicative of a continued strong discharge.) A burning red fury erupts from deep within my belly: How could that stupid kid hit me in a crosswalk? Wasn’t she paying attention? Damn her! (25. More rage—accompanied with the human neocortical tendency to blame.)
A blast of shrill sirens and flashing red lights block out everything. My belly tightens, and my eyes again reach to find the woman’s kind gaze. We squeeze hands, and the knot in my gut loosens.
I hear my shirt ripping. I am startled and again jump to the vantage of an observer hovering above my sprawling body. (26. The abruptness with which the shirt is removed restimulates the dissociation.) I watch uniformed strangers methodically attach electrodes to my chest. The Good Samaritan paramedic reports to someone that my pulse was 170. I hear my shirt ripping even more. (27. As I notice that I’m dissociating, I am able to bring myself back to my body.) I see the emergency team slip a collar onto my neck and then cautiously slide me onto a board. While they strap me down, I hear some garbled radio communication. The paramedics are requesting a full trauma team. Alarm jolts me. I ask to be taken to the nearest hospital only a mile away, but they tell me that my injuries may require the major trauma center in La Jolla, some thirty miles farther. My heart sinks. Surprisingly, though, the fear quickly subsides. (28. The surging and receding of the emotional arousal is evidence of deepening self-regulation.) As I am lifted into the ambulance, I close my eyes for the first time. A vague scent of the woman’s perfume and the look of her quiet, kind eyes linger. Again, I have that comforting feeling of being held by her presence.
Opening my eyes in the ambulance, I feel a heightened alertness, as though I’m supercharged with adrenaline. (29. I am adequately resourced now—enough to close my eyes and stay with the hyperarousal sensations in my body; the lingering scent of the woman’s perfume helps calm my limbic system and body, providing additional support for exploring what’s going inside of me.) Though intense, this feeling does not overwhelm me. Even though my eyes want to dart around, to survey the unfamiliar and foreboding environment, I consciously direct myself to go inward. I begin to take stock of my body sensations. (30. The perception of danger that my life is being threatened is receding, and the ability to access my body is increasing.) This active focusing draws my attention to an intense, and uncomfortable, buzzing throughout my body.
Against this unpleasant sensation, I notice a peculiar tension in my left arm. I let this sensation come into the foreground of my consciousness and track the arm’s tension as it builds and builds. Gradually, I recognize that the arm wants to flex and move up. (31. I am now able to track my physical sensations. I am able to distinguish within the “noise” and buzzing of arousal a purposeful tension. This curiosity helps to reestablish present time orientation; trauma and curiosity are reciprocal psychophysiological functions and cannot coexist.) As this inner impulse toward movement develops, the back of my hand also wants to rotate. Ever so slightly, I sense it moving toward the left side of my face—as though to protect it against a blow. (32. This is the reassertion of an involuntary defensive response, a strong and protective response that was either inadequate or incomplete—its execution was interrupted by the clobbering impact of the window and the road.) Suddenly, there passes before my eyes a fleeting image of the window of the beige car, and once again—as in a flashbulb snapshot—vacant eyes stare from behind the spiderweb of the shattered window. (33. This image, associated with the original threat, reappears.) I hear the momentary “chinging” thud of my left shoulder shattering the windshield. (34. The sense impressions or images referred to in the SIBAM model, discussed in Chapter 7, are now expanding to include the auditory component of the impact, rather than only the visual.) Then, unexpectedly, an enveloping sense of relief floods over me. I feel myself coming back into my body. The electric buzzing has retreated. The image of the blank eyes and shattered windshield recedes and seems to dissolve. In its place, I picture myself leaving my house, feeling the warm sun on my face, and being filled with gladness at the expectation of seeing Butch this evening. My eyes can relax as I focus outwardly. As I look around the ambulance, it somehow seems less alien and foreboding. I see more clearly and “softly.” I have the deeply reassuring sense that I am no longer frozen, that time has started to move forward, that I am awakening from the nightmare. (35. The image is continuing to expand, allowing a deeper level of completion with the detailed linking of the visual and auditory elements. I have now moved through the moment of impact, t = 0. I have gone from t – 1 (the moment before impact) to t = 0 (the moment of impact) to t + 1, the moment of time just after t = 0, exiting from the shock core—see Figure 9.1. I have emerged through the “eye of the needle,” returning and orienting to present time and to the remembrances of that perfect winter morning.) I gaze at the paramedic sitting by my side. Her calmness reassures me. (36. This reassurance reinforces my felt experience that I have woken up from this nightmare and that I can extend my sense of resource and support to include the woman in the ambulance.)
Reestablishing Continuity of Experience
Figure 9.1 This shows movement toward, and then through, the core moment of shock. This dissolves immobility.
After a few bumpy miles, I feel another strong tension pattern developing from the spine in my upper back. I sense my right arm wanting to extend outward—I see a momentary flash; the black asphalt road rushes toward me. I hear my hand slapping the pavement and feel a raw burning sensation on the palm of my right hand. I associate this with the perception of my hand extending to protect my head from smashing onto the road. I feel tremendous relief, along with a deep sense of gratitude that my body did not betray me, knowing exactly what to do to guard my fragile brain from a potentially mortal injury. (37. I am now
beginning to process the event in sequential time—from t – 1 to t + 1—and have a growing self-confidence in my body’s ability to protect me.) As I continue to gently tremble, I sense a warm tingling wave along with an inner strength building up from deep within my body.
As the shrill siren blasts away, the ambulance paramedic takes my blood pressure and records my EKG. When I ask her to tell me my vital signs, she informs me in a gentle professional manner that she cannot give me that information. I feel a subtle urge to extend our contact, to engage with her as a person. Calmly, I tell her that I’m a doctor (a half-truth). There is the light quality of a shared joke. (38. This kind of playful social engagement is possible only when the ventral vagal system, discussed in Chapter 6, is online.) She fiddles with the equipment and then indicates that it might be a false reading. A minute or two later she tells me that my heart rate is 74 and my blood pressure is 125/70.
“What were my readings when you first hooked me up?” I ask.
“Well, your heart rate was 150. The guy who took it before we came said it was about 170.”
I breathe a deep sigh of relief. “Thank you,” I say, then add: “Thank God, I won’t be getting PTSD.”
“What do you mean?” she asks with genuine curiosity.
“Well, I mean that I probably won’t be getting posttraumatic stress disorder.” When she still looks perplexed, I explain how my shaking and following my self-protective responses had helped me to “reset” my nervous system and brought me back into my body.
“This way,” I go on, “I am no longer in fight-or-flight mode.”
“Hmm,” she comments, “is that why accident victims sometimes struggle with us—are they still in fight-or-flight?”
In an Unspoken Voice Page 24
