Abuse and neglect are experiences of profound invalidation, of both one’s physical and emotional needs. Physical, sexual or emotional abuse or neglect thrusts one into survival mode. There is rarely space for feelings. The body goes into “fight, flight, or freeze” response, there may be overwhelming rage or terror, or there might be numbness in the form of dissociation. All these reactions have biological correlates. The client that comes to us, feeling either nothing, or overwhelming flashbacks, is in the throes of a storm they can’t control and often don’t understand.
Bessel van der Kolk was right: the body keeps the score. In his groundbreaking work on the biological impact of trauma (van der Kolk, 2015), Dr. van der Kolk brought to the field an understanding that trauma impacts us on a cellular level (Colich, et al, 2020). Those of us who work with trauma are aware that what the body and mind experience often become “hardwired,” in the form of startle responses, triggered emotional reactions, flashbacks, and nightmares. As Dr. van der Kolk has pointed out, trauma doesn’t embed itself in the brain as words – but rather images and sensations, so why should words be the primary mechanism for healing? As the field of psychotherapy learns more about the pathways to alleviating symptoms (including art, dance, and movement therapies, among other modalities) I would like to reflect on the power of psychoeducation in trauma. To be clear, if education were all it took to facilitate healing – we’d all eat right, exercise, and go to bed early. But as many of us know, insight has limited value when addressing symptoms and suffering as we’re trying to find a pathway to health.
Having noted the limits of insight and education, I’d like to reflect, paradoxically, on why it is so essential in trauma treatment, and how it becomes a tool of empowerment.
As clinicians, we are always listening for the information that will help us provide what people need to heal, feel safe, and move towards their goals. As Dr. van der Kolk has said, the goal of therapy is to be comfortable with one’s internal experience. As a therapist who has worked with trauma survivors for many years, my “go to” theory for this work is Relational Cultural Therapy, which posits that people grow and heal in the context of healthy connections. When a therapist can offer an authentic and healing connection with a client, they provide a space to integrate what has happened to them as well as to process how the memories and aftereffects of their experiences continue to impact them. As Pearlman and Saakvitne (1995) have pointed out, “The process of building the therapeutic relationship is the therapy with trauma survivors. This premise frames the psychotherapy as an evolutionary relational process, rather than a series of either crisis and their solutions, or dramatic mutative interpretations.” The relationship is the context for healing. But ultimately, the goal is to take back one’s internal experience from the imprint of the past.
An example of psychoeducation as a trauma tool is illustrated below.
Carri was referred to me for therapy in the middle of the pandemic. She was in her 70’s, a domestic violence survivor, a lung cancer survivor, and the child of parents who, in her memory, saw her as the “least” of their several children, despite her having had a successful career. She never felt loved by her family or appreciated for who she was. And while she felt loved in her brief marriage, she was also physically abused by her husband. She was currently single, riddled with anxiety, claustrophobia and depression, and dependent on a home health aide – who, as per Carri’s report, would endlessly discuss her own happy life and political views which were abhorrent to Carri. She felt trapped by her situation. Her presenting problems were bouts of panic that she would die alone, claustrophobia (she was having trouble getting into her own shower), and loneliness. Her recent history of breathing problems exacerbated her anxiety. We began her treatment by discussing her psychosocial history. Towards the end of the first session, we set aside some time to discuss the biology of anxiety. I explained the sympathetic and parasympathetic nervous system, how deep breathing is “a way for your lungs to tell your brain that you are safe,” that while anxiety affects the body by releasing adrenaline and cortisol, as well as inducing shallow breathing, the body can also tell the brain that it is safe by slowing down breathing and using movement to “burn off” the adrenaline. When I was done explaining this, she looked at me and said, “why hasn’t any therapist ever told me this before?” Apparently, no one had ever shared with her that you can be proactive in your biological responses.
As we continued our work together, I was able to provide a supportive relationship, I encouraged her to attend her local senior center (which she did when she was physically well enough to go), and we continued to work on how she could be intentional in teaching her body to communicate to her brain that she was safe. During our sessions she would reference experiences during the week in which she dealt with anxiety by doing deep breathing and distraction techniques. She would do this prior to getting into the shower and by combining deep breathing and reading, which she loved, before bed, which was a difficult time for her.
While the psychoeducation piece of therapy is something I do regularly, what makes it especially important for trauma survivors is the introduction of the idea that they can do more than just experience involuntary physical reactions (or triggers) from their brain (these are called “top down” messages). They can begin to direct the message that their body gives their brain (known as “bottom up” messages). As noted above, trauma is an experience that wrests control of our body, our thoughts, and our feelings. We begin to feel our own internal experience as something happening to us. Understanding what is happening in our bodies begins the process of taking back that control.
Some suggestions on what may be helpful for your clients to know:
- Therapists should understand the basics of the sympathetic (fight, flight or freeze) as well as the parasympathetic (“you’re safe”) nervous system. Deep rhythmic breathing activates the parasympathetic nervous system, which tells our body that we are safe. It curtails the fight or flight response.
- Therapists should understand that adrenaline and cortisol are released during times of stress and panic. These hormones are the biological correlates of fight or flight. This release of hormones will resolve without intervention within a short time but can be hastened with deep breathing and movement.
- Most panic attacks last a few minutes (although they can last longer). It is helpful to emphasize that once the panic attack starts – what they are feeling is a physiological response. Those with panic disorder are often experiencing a “false alarm.” They are terrified, but there is no actual danger. I have found it helpful to explain to clients that the exact same hormones of panic are also secreted during times of excitement when people are feeling joy. So, while the feeling is scary, it is the cognitive experience that sets the tone. It takes some time to integrate this information, but knowing that it is time limited, and breathing deeply will help the chemicals resolve faster, can often help people move through the experience quicker. (This can also reduce anticipatory anxiety in the future.)
- Distraction (music, reading, watching a comedy) uses a different part of the brain from where anxiety is generated. Distracting yourself with a pleasurable experience can calm down the nervous system more quickly. (It should be noted that “distraction” is an underutilized coping skill, but one of the most easily accessible and pleasurable ways to quell anxiety.)
- Movement (e.g., going for a walk, yoga, exercise) helps “burn off” these hormones. It is also a “bottom up” message to the brain that you are not trapped. It is a form of “flight.”
- It is very important to practice these skills (slow rhythmic breathing, distraction, exercise) when you are not anxious. This begins to create the synaptic connections that tell the brain, “It’s ok. I’m safe.”
While it is always helpful for people to be educated about how their body works and what helps them feel safe, teaching trauma survivors this information and these skills, as well as helping them put these principes into practice, begins the process of their taking back control of their body and their reactions. Education is always important. But being able to actively do something that alters one’s responses becomes a centerpiece of empowerment and control.
Elaine Edelman, PhD, LCSW, CASAC-Adv., is Professor of Practice at Kansas State University. For more information, email eleh@verizon.net or call (917) 494-1617.
References
Colich, N. Williams, E.S., Rosen, M., and McLaughlin, K. Aug. 3, 20202. Biological Aging in Childhood and Adolescence Following Experiences of Threat and Deprivation: A Systematic Review and Meta-Analysis. Psychological Bulletin published online Aug. 3, 2020.
Pearlman, L. & Saakvitne, K. (1995). Trauma and The Therapist. Norton: New York
van der Kolk, B. A. (2014). The Body Keeps the Score: Brain, Mind, and Body in the Healing of Trauma. Viking, or van der Kolk, B. A. (2015). The Body Keeps the Score: Brain, Mind, and Body in the Healing of Trauma. Penguin Books.
