Bringing unconscious choices to awareness: 'default mode', body rhythms, and hypnosis.
Patients with depression exhibit decreased connections between areas of the default mode network and brain regions involved with emotion, motivation, and reward processing, (181) leading to the conclusion that "deficits in default mode network connectivity with the caudate may be an early manifestation of major depressive disorder." (182) The caudate is involved in the processing of rewarding stimuli in healthy controls and is therefore intricately involved in pleasure and motivation.
Major depressive disorder has been characterized by excessive default-network activation and connectivity. These hyperconnectivities are often interpreted as reflecting rumination, where individuals perseverate on negative, self-referential thoughts, i.e., repetitively and passively focus on symptoms of distress and on the possible causes and consequences of these symptoms. (183) The research shows that rumination and brooding occur during off-task periods when the default network is activated, e.g. idle moments at work or non-engaged and unguided time periods at home. Consistent with common experience, the relationship between ruminative psychological processes and connectivity is mitigated by engaging in a task, decreasing the time spent brooding. Decreased activation of the default-mode network in patients with major depressive disorder correlates with depression severity and feelings of hopelessness. (184)
There is considerable evidence that depressive mood is related to lower parasympathetic control of the heart, which of course decreases ability to relax and increases cardiovascular risk. When depressed individuals are alone they evidence lower heart rate variability and higher negative affect, but not when they are engaged in social interactions with a partner, family members, or friends. (185) The quality of the relationships is crucial to this outcome, however; social interactions with strangers or colleagues (potentially insecure interactions) are not accompanied by higher heart rate variability in these individuals. This affirms our commonsense expectation that social interaction in an intimate relationship improves the emotional state of someone afflicted with depressive mood. Furthermore, the frequency of spousal interaction has been related with less progression of heart disease among older men with elevated depression scores. However, this effect only operates for individuals with depression, not necessarily for non-depressed individuals. (186)
Hypnotherapy combined with cognitive behavior therapy has been shown to be effective in treating major depressive disorder, (187) including depression in children and adolescents. (188)
Research findings suggest that drug addicts (chronic heroin users) have an abnormal functional organization of the default mode network, including the hippocampus, resulting in abnormally increased memory processing but diminished cognitive control related to attention and self-monitoring. (189) These findings may underlie the addict's hypersensitivity toward drug-related cues, and weakened strength of cognitive control, i.e., compulsive patterns. (190)
The hippocampus is the main brain structure involved in learning and memory, and thought to primarily contribute to the acquisition, consolidation and expression of learning of the drug-related cues that drive relapse to drug-seeking behaviors. (191 192) The hippocampus is also, as has been clearly determined, a prominent node within the default mode network.
There is growing evidence that hypnotically enhanced treatment for addictions is effective, (193) particularly by using the addictive urge to locate and process underlying trauma. Addiction uses three basic neuropathways in the brain. The arousal neuropathway concerns arousal and intensity, the numbing neuropathway produces a calming, sedative process and the fantasy neuropathway provides escape through a trance state. (194)
Early-onset pregnancy-induced hypertension
Pregnancy-induced hypertension is contributed to by both sympathetic overactivity and vagal withdrawal, especially in early-onset type, SVI is mainly due to vagal inhibition. One recent study shows that hypnosis is effective in reducing blood pressure in the short term but also in the middle and long terms. (195)
Relapsing-remitting multiple sclerosis patients show a consistent dysfunction of default mode network. (196 197) The dysfunction is more evident in cognitively impaired patients than in those who are cognitively preserved. Cognitive impairment occurs in up to 70% of multiple sclerosis patients, sometimes starting early in the disease course. (198) The degree of dysfunction of default mode network appears to be a marker for severity of symptoms for multiple sclerosis patients. In one study, hypnotic imagery and posthypnotic suggestion were accompanied by significantly improved control of pain, sitting balance, and diplopia in a 30-year-old female with multiple sclerosis. (199)
Nicotine is known to improve cognitive performance, in part by improving attention. Nicotinic decreases activity in regions within the default mode network, which then allows for more mental processing resources to be available for being attentive to task-orientation. (200) Nicotine use that is so constant that it interferes with the brain's normal default mode processing may deprive the individual of aspects of that processing, such as self-referential introspection, organizing memory and imagination. Hypnosis has been used successfully to assist in overcoming addictive nicotine use. In a metaanalysis on 633 studies of smoking cessation, with 48 studies in the hypnosis category, encompassing a total sample of 6,020 participants, hypnosis fared better than virtually any other comparison treatment (e.g., nicotine chewing gum, smoke aversion), achieving a success rate of 36%. (201)
People with OCD have a distinctive brain pattern: excessive activity in the orbitofrontal cortex and the right caudate nucleus, areas of the brain that, when activated, signal that something is wrong. This overstimulation interferes with the ability to accurately assess a situation and plan appropriately. Both psychotherapy and medication can reduce activation in this area of the brain, relieving the symptoms of perseverating thoughts which lead to obsessive attempts to control anticipated outcomes. (202) Interestingly, positive emotionality has been shown to be experienced when the orbitofrontal cortex is active during resting conditions (introspection, mind wandering). (203)
In one recent study, (204) OCD symptoms, depression, anxiety and overall functioning improved robustly with brief intensive cognitive-behavioral therapy (CBT) treatment. In as little as four weeks, there was significant activation of the dorsal anterior cingulate cortex, a region involved in reappraisal and suppression of negative emotions. Studies of cognitive behavioral therapy effects in obsessive-compulsive disorder (OCD) are consistent in showing decreased metabolism in the right caudate nucleus as symptoms decrease. (205)
There is increasing evidence of default mode network dysfunction in schizophrenia, as well as brain structural changes in schizophrenia in the territory of the default mode network. On a task requiring identification or labeling of facial emotions, schizophrenic patients show failure to deactivate the default mode network in order to attend to the task. This failure is more extensive than that seen during performance of working memory tasks. Schizophrenics also show reductions of grey matter volume in cortical regions that overlap with the same parts of the default mode network. (206)
The default mode network has been shown to be selectively impaired during epileptic seizures associated with loss of consciousness; decreased activity has been confirmed during these three seizure types: complex partial, generalized tonicclonic, and absence seizures. (207)
It is well known that one night of sleep deprivation significantly disrupts cognitive task performance; it is now clear that it also disrupts task-related deactivation of the default mode network. (208) Interestingly, perturbations in default mode activity during wakefulness are observed in a number of disorders that display co-occurring abnormalities of sleep, including schizophrenia, autism spectrum disorders, anxiety disorders, attention deficit disorder and Alzheilner's disease. A characteristic signature of the sleep-deprived brain may be the dysregulation not only of on-task brain activity but also of off-task resting-state modes of brain activity, and may prevent the ability to sustain attention and to maintain stable task engagement, resulting in concentration lapses and slowed response times. Such an outcome has obvious implications for the disorders mentioned above, not to mention such conditions as drowsy driving. (209) It is safe to say that at least some aspects of the default mode network are dependent on prior sleep for their stability.
Perhaps this provides new evidence for the advice to "sleep on it" in making an important decision. One prominent hypothesis suggests that (210)
resting-state activity supports off-line processing of recently acquired information within the context of preexisting knowledge. (211) Such processing may allow for the testing of unique memory associations, and by doing so importantly make flexible predictions about the future. (211) In this regard, the role of sleep, and a lack thereof, becomes particularly relevant. For example, a recent report has demonstrated that sleep not only strengthens individual item memories but can actually facilitate the off-line building of distant relational associations between them. (213) Moreover, following initial practice on a problem-solving task, a night of sleep significantly increases the ability to gain insight of a hidden rule the following day. (214) However, this next-day insight was not evident immediately upon awaking. Instead, it emerged only following substantial additional waking (re)engagement on the task. Furthermore, participants who were sleep deprived and retested in the deprivation state failed to gain such creative insight.
During sleep, the default mode network connectivity and arousal level is at its lowest during deep non- rapid eye movement (NREM), while during rapid eye movement (REM) sleep it is as high as during wakefulness. This difference is true for subsystems of the default network, but connectivity among the core regions--the posterior cingulate cortex, rostral anterior cingulate cortex, and inferior parietal lobule--remain consistent across sleep states. The core network may serve to integrate brain regions throughout the sleep cycle, while certain subsystems perform functions specific to the level of arousal. (215)
Default mode network connectivity is a marker for social phobia. (216) Default mode activation increases the ability to predict another person's behavior, taking his or her perspective. Impairment in the default mode network in social phobia patients may be relevant in the development of the feeling of wariness of others' judgment and may be related to the so-called self-focused attention. Self-focused attention may prevent individuals from observing external information that could disconfirm their fears of being judged. Moreover, the abnormal modulation of activity in the default mode network may reflect persistent rumination or anxiety-related thoughts that are not modulated by the switch from rest to task.
Hypnosis is an effective and powerful intervention for most types of stress and anxiety because hypnosis exploits the intimate connection between mind and body, provides relief through improved self-regulation, and also beneficially affects cognition and the experience of self-mastery. (217)
Traumatic brain injury (TBI)
Sustained attention impairments in patients with traumatic brain injury (TBI) are associated with an increase in default mode network activation, and the degree of structural disconnection within the default mode network correlates with the level of sustained inability to attend. Abnormalities in default mode network function are a sensitive marker of impairments of attention and suggest that changes in connectivity within the default mode network are central to the development of attentional impairment after TBI. (218)
Trauma and PTSD
The integrity of the default mode network is compromised in posttraumatie stress disorder (PTSD). (219) And the alteration of brain function is not restricted to a years- or decades-long process of deterioration. Physically healthy survivors of the magnitude 8.0 earthquake in Wenchuan, China who experienced severe emotional trauma, were assessed within 25 days after the disaster. These trauma victims had a reduced temporal synchronization within the default mode network of resting state brain function. (220) The increased regional activity and reduced functional connectivity occurred in areas known to be important for emotion processing. (221) Atypical function in these areas has been implicated in previous studies of patients with chronic stress-related disorders. (222)
One recent study investigated relationships between default mode network connectivity and the severity of PTSD symptoms in a sample of subjects recently exposed to a traumatic event. (223) Individuals with the most impaired connectivity developed the most severe and most persistent PTSD symptoms, even controlling for comorbid major depressive disorder. "The present study certainly suggests that examination of connectivity patterns of brain networks predict persistence of PTSD symptoms or related post-traumatic symptomatology." (224)
Altered default mode network connectivity in individuals with PTSD has now been related to prolonged childhood maltreatment, suggesting that early-life trauma may interfere with the developmental trajectory of the default mode network and its associated functions. (225) Moreover, deficient default mode network connectivity in adults with childhood maltreatmentrelated PTSD appears similar to patterns of default mode network connectivity observed in healthy children aged 7 to 9 years. (226) For example, default mode network connectivity observed in women with severe chronic PTSD due to prolonged maltreatment during childhood closely paralleled that observed in children age 7 to 9 years. (227)
Healthy, normal default mode network structures begin to develop by age 1, but integration and connectivity between the default mode network nodes remains immature until about age 9 years. Impairment of the normal development of default mode network in childhood has far-reaching consequences over the lifespan. Typically, adults with chronic PTSD due to early-life trauma exhibit remarkable deficiencies in functions reliant upon self-referential processing such as emotion recognition and emotional awareness. Alexithymia, the inability to appropriately recognize one's own emotions, is known to be widespread in early-traumatized PTSD populations. It is also widely acknowledged that repeated exposure to traumatic events can affect one's sense of an adaptive and agentive self. This is illustrated by altered posttraumatic cognitions and disrupted self-referential processing in patients with PTSD, arguably the most severe example being dissociative symptoms that may include depersonalization and identity disturbance. Neuroimaging studies suggest that dissociative experiences involve brain regions also implicated in the default mode network. Finally, although results are conflicting, a number of studies also point toward impoverished recollection of episodic events in survivors of early-life trauma, particularly among those in whom PTSD develops as a result of this exposure. (228)
PTSD patients who have suffered a trauma such as a serious car accident show lower activity in processing empathy in social situations. Following therapy, there is a greater activation in the left middle temporal gyrus, related to the experience of empathy, and increased posterior cingulated gyrus activation, related to the ability to forgive. (229)
The brain's theta rhythm circuitry is involved in memory retrieval, survival behavior, navigation including virtual reality tracking, wellbeing, and the integration of emotion and cognition. These processes are all implicated in the pathology and treatment of PTSD. Hypnosis, which elevates the brain's theta rhythm, has been found effective in contributing to the treatment of PTSD. (230) Hypnosis has obvious affinities with the symptoms of PTSD. In fact, trauma may be viewed as a hypnotizing agent; Spiegel (231) has articulated three clusters of symptoms of PTSD in parallel with hypnosis as follows: intrusive flashbacks and nightmares with hypnotic absorption; dissociation with hypnotic dissociation; exaggerated response to disturbing stimuli with hypnotic automaticity. Hypnosis can enable the access of these symptoms and facilitate their reprocessing. Hypnotherapy assists in memory revivification and the integration of fragmented episodic memories, against a background of anxiety reduction, empowerment and psychic integration. (232)
"People come to therapy with a strong set of beliefs, entrenched feelings, and redundant behavior patterns. One aspect of the therapeutic process involves sensitively attuning to this apparently filled mind and brain, and look for the spaces between. Here we find the opportunities for movement and change." (233)
The most effective psychotherapy promotes brain connectivity; in other words accessing different parts of the brain at the same time and activating them so that they engage each other in new and productive ways. We design our interventions to trigger different structures and sense modalities in the brain, whether visual or kinesthetic or verbal. We allow the client's unconscious to select what material to work on, and then allow her to approach that material as directly as she is capable of. Initially that may mean approaching it tangentially, talking about a traumatic event, narrating the experience removed from actually re-experiencing it. We know that eventually deep trauma healing will come with facing the original traumatic moment directly, experientially, and creating a corrective experience to replace the original defensive behavior pattern.
There are parts of the brain, and therefore mental processing, that you can't reach with language. These areas of the brain, too, must be accessed in order to simultaneously activate dissociated networks in the brain--fear circuits, language circuits, reward circuits, default mode--in ways that enable clients to reorganize their neural connections.
The hypnotic trance provides fertile interconnection between the cortex and the midbrain which is the requirement for repair of the damage done to the brain's hippocampus in childhood abuse. Trauma resolution focuses on time-stamping experiences to a discreet circumstance rather than a globally generalized reexperience of the original trauma. One of the core aspects of treating PTSD is to route the original traumatic memory through the brain's hippocampus region to time-stamp it, which did not occur during the original trauma.
Early trauma through abuse or neglect results in a significant decrease in the volume of the hippocampus structure in the midbrain. "The integrative failure that is characteristic of traumatized individuals may also relate to structural brain changes, notably in the hippocampus." (234) The hippocampus is a brain structure instrumental in the synthesis of experiences, providing a conscious structure, context and a time stamp to the experience in the process of memory encoding, storage and retrieval. Smaller hippocampal volumes have been reported in female adult survivors of childhood sexual abuse. (235 236) That damage consists of a loss of neurons and synapses (a loss of up t018%), and results in corruption of thought process and learning, particularly deficits of encoding short-term into long-term memory. (237)
fMRI images reveal that when people are emotionally distressed (anxious, angry, depressed), the most active sites in the brain are circuitry converging on the amygdala, part of the brain's emotional center, and the right prefrontal cortex, a brain region important for the hypervigilance typical of people under stress. (238) By contrast, when people are in positive moods (upbeat, enthusiastic and energized) those sites are quiet, with the heightened activity in the left prefrontal cortex.
Activation of the amygdala is a manifestation of a neurobiological fear reaction, and enhanced amygdala activation is found in individuals with Borderline Personality Disorder (239), posttraumatic stress disorder (240), and obsessive-compulsive disorder (241 242) during fMRI scanning of their provoked symptoms. Further, the amygdala is activated by perseverative thoughts and memories. (243)
These two systems (amygdala and hippocampus) represent separable memory systems as well as separable processing systems: the amygdala as a "hot" memory system, and the hippocampus as a "cool" memory system. Psychopathology develops when there are dissociations between these two memory systems. Elevated cortisol levels--produced by fear, anxiety and stress--for chronic periods are associated with increased activity in anxiety-related brain regions, especially the amygdala. (244) Chronically elevated cortisol levels are also damaging to hippocampal neurons. (245)
Under traumatic stress, emotional memories are encoded without a significant contribution of context from the hippocampal system. "This produces a pool of stimulus-bound emotional memories that have been encoded without a coherent event-specific spatiotemporal frame to organize them. This pool is, essentially, a population of traumatic memory fragments. Upon retrieval, traumatic memories cannot be experienced as a memorial event with a beginning, end, and internal spatiotemporal structure. Instead, each emotional memory is experienced as fragmented, disorganized, and intrusive". (246 247)
The traumatic experiences, etched in procedural memory but not converted into long-term memory, interfere with current working memory. Past threats are perceived to be present threats, suggested by intrusive thoughts, flashbacks, and hypervigilance. Not only does PTSD obscure the ability to distinguish between past and present, but the "repertoire of survival skills remains confined to those skills that were acquired up to the time of the trauma, and they lack the resilience to learn new strategies." (248) An aspect of this individual is frozen in the past, or perhaps more accurately that frozen dissociated part of the person is carried like deadweight in the ever-present--a "primitively organized alternative self."
Fortunately, however, the hippocampus is a unique region of the human brain in that it can replicate new neurons as well as new synapses. Treatment of PTSD and resolution of early childhood trauma can reverse the damage to the hippocampus, and there is evidence that the hippocampal volume actually increases along with a decrease of PTSD symptoms and significant improvements in verbal declarative memory. (249 250)
The age regression capability within hypnotherapy is an ideal means of access to mend the damage to the hippocampus, allowing the brain to return to the origins of the traumatic loss of neurons and synapses, and "rewire" the processing of experience and laying down of memory. Some of the relevant factors that apply to the state of hypnosis (as well as meditative states) are a proclivity to dissociation, tolerance of ambiguity, experiencing states of nonordinary reality, boundarylessness, merging, and fluid ego boundaries. (251) Further, the state of hypnosis is known to promote a state of being deeply engrossed in imaginative activities, to produce vivid imagery, and to engage in "holistic information-processing styles." (252) The panoramic bird's-eye view common in the state of hypnosis, or meditation, activates the brain's lateral network circuits, associated with mindful, open, spacious awareness. Activating these lateral networks contributes to steadiness of mind, the capacity for deep concentration, and resilience. (253)
Theta frequency brain waves are dominant with unconscious mental processing, and the source of these theta rhythms is the hippocampus. (254) The theta is especially pronounced during rapid eye movement (REM), such as during dreaming or hypnosis. A person can emerge into conscious thinking (beta brain waves) from unconsciousness (theta) either rapidly or more gradually. When the transition occurs abruptly, little of the experience can be brought back to be accessible to the conscious mind. However, when that same transition occurs more gradually, more of the theta-level experience can be accessed consciously. And the difference within the brain is that gradual transition allows alpha brain wave patterns to participate in the crossover. Alpha waves are associated with right brain processing, aesthetics, intuition, sensuality. So the hypnotic trance state allows us to experience with a theta rhythm, and yet access the material with an alpha rhythm. Theta rhythms originate in the hippocampus, important for "time-stamping" memories, which must then be forwarded to the prefrontal cortex to be processed in conscious awareness utilizing alpha and beta waves.
Cozolino (255) has a number of suggestions for how to facilitate neural integration in psychotherapy that are solidly grounded in neurobiology. He proposes that neural growth and integration in psychotherapy may be enhanced by:
1. The establishment of a safe and trusting relationship.
2. Gaining new information and experiences across the domains of cognition, emotion, sensation, and behavior.
3. The simultaneous or alternating activation of neural networks that are inadequately integrated or dissociated.
4. Moderate levels of stress or emotional arousal alternating with periods of calm and safety.
5. The integration of conceptual knowledge with emotional and bodily experience through narratives that are coconstructed with the therapist.
Following is a brief summary of the guidelines outlined in a 2006 article (256) by the current authors for differential approaches to treatment of sympathetic and parasympathetic nervous system dysfunction. While accessing the hyperarousal or hypoarousal response, we must facilitate the person to stay present, feel safe, communicate their experience, and feel empowered. Following are some suggested guidelines for treatment of trauma, complex trauma, DESNOS, and shock.
1. Approach trauma-related material gradually to avoid intensification of the affects and physiologic states related to the trauma. With the advent of distinguishing between trauma and complex trauma, or PTSD and complex PTSD, we now know that certain prerequisites must be in place for the client before proceeding to confront the trauma directly, namely
the capacity of our patients to modulate their affective arousal: whether they are able to be emotionally upset without hurting themselves, becoming aggressive, or dissociating. As long as they cannot do this, addressing the trauma is likely to lead to negative therapeutic outcomes. Similarly, as long as they dissociate when they feel upset they will be unable to take charge of their lives and will be unable to 'process' traumatic experiences. (257)
2. Cultivate an acute awareness of inner body sensations (bodily feelings of a distinctly physical character, such as trembling lips, heaviness in the chest, twitching in the hands, clamminess in the feet, tightness in the throat, tension in the buttocks, pounding heart, numbness in the extremities, tingling in the right arm, shallow breathing, or vibrating sensations in the solar plexus area, etc.).
The therapist asks questions that require awareness (mindfulness) to answer, such as, "What do you feel in your body? Where in your body do you experience that? What happens in the rest of your body when your hand makes a fist?" This focusing is especially important when the client is accessing traumatic memories so that he/she can experience the content of that moment consciously embodied. Questions such as these encourage the client to come out of a dissociated state, and future- or past-centered ideation, and be really present in the body, experienced from the perspective of an observing ego whose intention is simply observing rather than controlling or changing the experience, or reacting to it.
3. Access enough traumatic material to process but not so much as to dissociate. The therapist must "hold" the client's arousal within the optimal limits, while encouraging the accessing, exploring, and expressing of the trauma memory. When arousal reaches either the upper or lower limit, ask the client to temporarily suspend attending to her feelings and thoughts and instead focus on observing the physical sensations and movements in detail until these sensations settle and the movements complete themselves. Redirect the person's attention by asking him/her to refocus as well as in other ways. That may be with a touch or specific eye contact, a sip of water or inquiring about level of comfort. In addition to interrupting the dysfunctional sequence, such attending to the personal comfort and safety of the client is nurturing and elicits their own social engagement activation. This process is one of titrating the traumatic pattern, alternating between small pieces of the traumatic material and one of the client's resources, discharging the activation in the nervous system that emerges as the person slowly works through the traumatic event.
4. Interrupt a client's unconscious, autonomic patterns somatically. One of the most common patterns is some form of "bracing", a condition in which a person in stress resorts to a destructive habitual physiological response, such as muscle tension, vaso-constriction or dilation, or breath suppression. A timely reminder to breathe can be immensely empowering to the person's body. The vaso-constriction or dilation in the hands or feet, stomach, neck or forehead, or any particular body part, causes them to be too cold or too hot, respectively. Hence, the application of the reverse effect (heat or cold) brings the constriction to the body's attention (not to conscious awareness) and allows a relaxing of the hyperarousal. Encouragement to yell or scream when the individual is imploding with suppressed fear is permission and an instruction to the body to change a very old and deeply embedded habit. One of the most effective means of relaxing muscle tension is laughter. The therapist can insert humor to accomplish this, as long as it is properly timed and not used to dissipate emotion and thus avoid cathartic release.
5. Work toward cathartic release, or other physical forms of release such as "unwinding" the paralyzed energy in limbs or head. Levine discusses the concept of "exchanging ... an active response for one of helplessness". (258) Here we are coaxing the person to use will power, and the support of the therapist or group members, to initiate a sympathetic response (fight/flight) to replace the deeply embedded parasympathetic response (freeze). For the person to experience the active defense sequence (pushing with legs or arms, moving out of paralysis into proactive movement, yelling "No!") brings her out of dissociation, into her body, and begins a kinesthetic reframing process. The client may begin to experience the somatic pleasure of physical resistance and defense, and the emotional delight of a new experience of personal power. The sequence, produced through will power and trust, becomes a template for the same new response to occur spontaneously in the future.
6. Experience having personal needs acknowledged and responded to by a caring and safe support person. The therapist may offer a drink of water (which also flushes toxins from the system), offer heat or cold if it would be soothing, offer additional means of protection (such as something to cover the vulnerable umbilicus, the hand to hold of a supportive group member, or bringing into an age regressed scene a virtual resource person from the client's life at that time to ameliorate the terror), or establish direct contact nurturing (touch, open eye contact).
7. Discover and develop personal resources, real or imagined, that would be available so that the client is not facing the threat alone, isolated, in secret, or unsupported. The resources help to initiate a social engagement response and to discharge excess fight/flight or freeze messages. The resources should be experienced not just as an imagined creative visualization, but with awareness to the sensations experienced in their bodies.
8. Speak the experience of victimization in order to integrate the memory functions and lessen the immobilizing emotional/sensory reflex. The client is literally reconnecting the experience (implicit or body memory) with the cognitive context for it (explicit memory), and in the process is repairing the physical damage done to her hippocampus. Verbalizing reflectively in the age-regressed traumatized ego state, in the presence of the caring therapist, begins to repair the damage through regeneration within the hippocampus.
9. Reconnect memories and emotions to events. Bucci (259) states the case succinctly: "One may be aware of the physiological activation, the painful physical arousal, associated with the activated schema of anger or fear, and also aware of aspects of one's history, including the trauma and abuse, but without connecting the two. We see patients telling the stories of their history without emotion, feeling the physiological activation without recognizing its emotional connections." This is dissociation. The physiological or cognitive activation is not connected in memory to the source of the trauma because they were not connected at the highly stressful time of originally laying down the memory. (260)
10. Reframe basic assumptions about the self as secure and intrinsically worthy, and about the world as orderly and just. The person's most deeply embedded beliefs are accessible for review and reframing, because in the age regression process you have arrived at the very scene of their inception. These personal conclusions and beliefs about the self and the world are held by the immature, developmentally arrested inner child and carried by the physical body (Reich's character armor).
11. Release the anger and blame directed against the self for the inability to defend against the abuse. A common response among trauma survivors is to interpret her dissociation and freezing as a personal weakness. (261) This is a golden opportunity for re-establishing a loving, accepting relationship with the inner child, who until now the client has likely reviled and rejected. One of the most important truths that child ego state needs to hear and accept from the adult ego state is a reattribution of responsibility. (262-263) "It was not your fault. There was nothing you could do to stop it from happening. The responsibility and blame belong to the perpetrator."
12. Locate the traumatic experiences in time and place, to start making distinctions between current life stresses and past trauma. During traumatic threat, it has been shown, the hippocampus becomes suppressed. Its usual function of placing a memory into the past is not active. The traumatic event is prevented from becoming a memory in the past, causing it to seem to float in time, often invading the present. (264 265) We must recognize, too, that traumatic memories are stored as emotions and senses (implicit memory), and are therefore often hazy, impressionistic, or kinesthetic. Understandably, survivors become haunted by feelings and senses they suspect are related to the trauma, but cannot clearly identify as explicit memories.
Sometimes it takes a lot of patience to eventually get to clear memories of what happened at the time of the trauma. It is common in therapy with trauma victims to observe their healing process begin with awareness of "body memories" and other procedural-implicit memories, and then gradually expand to include specific episodic memories of where, when, and how the trauma occurred. (266)
13. Learn to trust and surrender to a healthy interpersonal relationship with the therapist, who demonstrates an ability to understand the client's distress and tolerates the description and re-experience of her traumatic experience without as therapist withdrawing or becoming hyperaroused or hypoaroused. The therapist must overcome the client's mistrust and suspicion the old fashioned way: he/she must earn it.
14. Recognize that current life stresses tend to be experienced as somatic states, and accept physical symptoms as ally rather than enemy. Physical symptoms are the body's way of communicating an unmet need to the person; they are not a statement of defiance, mutiny, hostility, or weakness. Developing an awareness of inner body sensations and a precise sensation vocabulary are helpful steps toward restoring a sense of the body and its sensations as friend, not foe.
15. Develop new outlets for discharging stress and for creating a sense of well-being. The individual may have relied on reenactment of stress and trauma, through endorphin release and dissociation, to achieve relief, numbing of the pain, and what has passed as a sense of well-being. In other words the pattern is to seek re-exposure to stress for the same effect as taking pain-killing opiates, providing a similar relief from stress. Expression rather than repression of feelings may be a new option for the person. It is important to engage in the process of learning to discharge excess stress response in a healthy way. And that requires a clear understanding of one's own response patterns.
An individual who is aware of a tendency toward hyperarousal (fight/flight) response will discover that it is, in fact, the body's attempt to discharge excess parasympathetic load. The quick temper or incessant talking (dissociated sympathetic response) is preceded by, if only momentarily, a fear of rejection or sense of shame (parasympathetic response). Likewise, if a person tends toward hypoarousal (freeze) stress response, he/she will discover that it may be, in fact, the body's attempt to discharge excess sympathetic load. The sense of exhaustion or constant snacking (dissociated parasympathetic response) is preceded by, if only momentarily, a flash of rage or frustrated need (sympathetic response). With this knowledge, the therapist can encourage the client to look directly at the momentary initial response that needs discharging rather than at the dissociated defensive response, and to develop new outlets to accomplish that discharge.
16. Increase self-regulation and thereby prevent the escalation of arousal to the point of discharge through aggression or other undesirable behavior. Hyperactive defenses can take the form of uncontrollable rage or frenzy (directed at self or others), and learning to sense the physical precursors to full-blown aggressive outbursts will extinguish the conditioned response, and therefore increase the person's feeling of safety. When we help the client achieve biological completion, i.e., discharge following activation, and unlock the constriction of the nervous system, he/she can then integrate the experience for future use with triggering events, replacing the dysfunctional autonomic pattern of response.
The capacity to bring the automatic reaction into a state from which choice is possible, to internalize new cognitive information, depends on having portions of the cortex activated, which, in turn, requires a state of mindfulness. Some effective techniques to increase this state are increasing conscious awareness to current emotions; having the vocabulary and the self-sensitivity to identify and label emotions; creating, acknowledging and anchoring positive emotional events; and using support and other resources to improve tolerance for stressful situations.
17. Increase the sense of personal safety through increasing the sense of internal locus of control and greater reliability of external forces.
Clients find that they can gradually slow down and maintain an integrated awareness from start to finish throughout the experience of re-living a traumatic incident, including the most invasive aspects. Then perceptually, the incident can move from seeming to be ever-present, or fixated in the future, back into the past where it belongs. Symptoms diminish. Triggers of fear, panic and anger are extinguished as continuity of self is reestablished and it is experienced as truly over.
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David Hartman and Diane Zimberoff *
* 3716-274th Ave SE Issaquah, WA 98029 800-326-4418
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|Title Annotation:||p. 38-75|
|Author:||Hartman, David; Zimberoff, Diane|
|Publication:||Journal of Heart Centered Therapies|
|Date:||Sep 22, 2011|
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