THE COMMON FACTOR IN van der KOLK’S TOP THERAPY RECOMMENDATIONS
There seems to be a tendency for systems of any kind to coalesce like a collapsing star into a fixed, compact, inward-looking phenomenon. Human groups also seem to have a need to see their own system (belief system, cultural system, healing system) as ‘the best choice’.
My experience through life has been that the need to espouse one’s group’s system as the best is usually driven by insecurity. If the whole group backs up the system, and numbers rule, the members of the group gain security in knowing that everyone is in agreement that their system is the right one to follow. Dissenters are usually pushed to the outer edges of the group, where it’s hoped they will just fall away, and the inner circles of the group bind even more strongly together.
Within the field of psychotherapy (of all its many kinds), this phenomenon is present of course, especially when a system or therapeutic intervention becomes attached to an entrepreneurial business involving payment for teaching the intervention. But what I see more often is a broader view being espoused, in which the task of healing C/PTSD is seen as involving a number of different types of therapy. The presentation by Bessel van der Kolk (under ‘Attachment’) demonstrates this approach very clearly. ‘Here are at least five different types of therapy, all of which have been shown to assist the healing process’, he says.
And if we look at the methods that are being recommended by large numbers of researchers, teachers and clinicians in the field of trauma and C/PTSD, what stands out at the top of the list are:
3. internal family systems therapy/inner child work/inner parts-of-self work,
4. somatic/body based emotional release work (which may take a number of forms, including psychodrama).
Note that I do not include CBT, even though it IS the primary intervention used by conventional psychologists in Australia. But it is a mistake to treat traumatized people with CBT techniques in the early and middle phases of healing, because CBT targets the cognitive brain and conscious emotional intelligence, but does not reach the hidden areas of implicit memory and dissociated parts of self. CBT is very useful in the final stages of healing, when strategies for living in the world and coping with relationships are needed.
Until about two years ago, my work with clients focused mainly on the 3rd and 4th interventions on this list, combined with talking therapy and creative arts therapies. In the last year I have added both mindfulness and EMDR to my toolbox. It is only since actually practising all four strategies that I’ve realized that all four, but especially mindfulness, EMDR and somatic/emotional release therapy, have a particular quality in common, which may account for why they have found their way to the top of van der Kolk’s recommendations. In other words, the key element that helps the PTSD healing process may be the aspect of these interventions that is shared by all four.
This common factor is what I would describe as :
“staying with the feeling”,
being able to tolerate the discomfort of traumatic memories
and stay present to them without dissociating.
Mindfulness teaches the client or ‘seeker after healing’ to be able to stay present to the present moment. This is done by focusing on a target, within the mind and/or in the body, in other words, developing awareness of the the physical state of the body, and of the mental state of the mind in the present moment. Psychology Today offers a description of mindfulness meditation that supports this view:
“. . . The man called the Buddha taught that the source of suffering is our attempt to escape from our direct experience. First, we cause ourselves suffering by trying to get away from pain and attempting to hang on to pleasure. Unfortunately, instead of quelling our suffering or perpetuating our happiness, this strategy has the opposite effect. Instead of making us happier, it causes us to suffer. Second, we cause suffering when we try to prop up a false identity usually known as ego. This, too, doesn’t work and leads instead to suffering.
Mindfulness, paying precise, nonjudgmental attention to the details of our experience as it arises and subsides, doesn’t reject anything. Instead of struggling to get away from experiences we find difficult, we practice being able to be with them. Equally, we bring mindfulness to pleasant experiences as well. Perhaps surprisingly, many times we have a hard time staying simply present with happiness. We turn it into something more familiar, like worrying that it won’t last or trying to keep it from fading away . . .”
[Karen Kissel Wegela, PhD, ‘The Courage to be Present” in Psychology Today, January 19th 2010. URL: https://www.psychologytoday.com/blog/the-courage-be-present/201001/how-practice-mindfulness-meditation%5D
EMDR involves a preparatory process of selecting a past traumatic target event that continues to intrude into one’s present life. The client identifies its accompanying emotions, body sensations and pervasive negative cognitive belief that is still dominant, even after many years. Holding these elements in mind, the client is assisted in activating bilateral brain activity. This may take the form of the eyes tracking the therapist’s finger movement back and forth, or finger tapping on alternate knees, or scribbling on paper with both hands simultaneously. This preparation and implementation often results in sudden surfacing of traumatic memory and/or strong emotional recall and/or strong physical sensations, followed later by a fairly stable sense of the event having been put in the past.
The therapeutic method involves pausing from time to time and debriefing the experience. The facilitator looks for a significant moment, insight, feeling or memory, and asks the client to ‘stay with that’, and they resume the bilateral stimulation. This ‘pause, identify and resume’ may be repeated for 15 or 20 minutes, encouraging the client to be able to stay with the memory recall process much longer than would normally be likely with a dissociative client.
Somatic and Emotional Release therapies.
Somatic and emotional release therapies are both body-based therapies, although they are not identical systems. A website for Somatic Experiencing offers this description of their body-based psychotherapy:
“Somatic Experiencing (SE) is based on the understanding that symptoms of trauma are the result of a dysregulation of the autonomic nervous system (ANS) and that the ANS has an inherent capacity to self-regulate that is undermined by trauma. SE bases its approach on the science that mammals automatically regulate survival responses from the primitive, non-verbal brain, mediated by the autonomic nervous system. In the wild, animals spontaneously “discharge” this excess energy once safe. Involuntary movements such as shaking, trembling, and deep spontaneous breaths reset the ANS and restore equilibrium. Somatic Experiencing works towards restoring this inherent capacity to self-regulate by facilitating the release of energy and natural survival reactions stored during a traumatic event. According to founder Peter Levine, “Trauma lives in the body, not the event.”
Sessions are normally done face to face, and involve a client tracking his or her own felt-sense experience. Practitioners of Somatic Experiencing are often also mental health practitioners such as social workers, psychologists, or psychotherapists, but may also be nurses, physicians, bodyworkers, physical therapists, clergy, or members of other professions. Certified practitioners complete a training course that spans three years (216 hours of instruction) and must complete 18 hours of case consultations and 12 hours of personal sessions. SE is effective for Shock Trauma in the short term (typically one to six sessions) and Developmental Trauma as an adjunct to psychotherapy that may span years.
Somatic Experiencing attempts to promote awareness and release of physical tension that remains in the body as part of the aftermath of trauma. This occurs when the survival responses (which can take the form of orienting, fight, flight or “freeze”) of the ANS are aroused, but are not fully discharged after the traumatic situation has passed. The details of this sequence are described in all the literature cited here.
Somatic Experiencing involves a guided exploration of the physical dysregulation that is harbored in the body as a result of trauma. Sessions often do not focus on talking about traumatic experiences. Clients are educated about how the body regulates stress and learn to track the related physical sensations, feelings, thoughts, and images that arise from traumatic memories.
Techniques include “titration” of the client’s experience. Titration allows the client to experience small amounts of the event’s distress at a time in order to release the stored energy and allow their nervous system to return to balance. In this way the client does not become retraumatized and can move through their experience creating new meaning and experience successful resolution.
Another element of SE therapy is “pendulation”. “Pendulation” refers to the movement between regulation and dysregulation. The client is helped to move to a state where he or she is dysregulated (i.e. is aroused or frozen, often demonstrated by physical symptoms such as pain or numbness) and then helped to return to a state of regulation. This process is done iteratively (in small steps, each step building on the last one). The goal is to allow the client to resolve the difficulties, both physical and mental, caused by the trauma.
“Resources” are defined as anything that helps the client’s autonomic nervous system return to a regulated state. This might be the memory of someone close to them who has helped them, a physical item that might ground them in the present moment, or other supportive elements that minimize distress. In the face of arousal, “discharge” is facilitated to allow the client’s body to return to a regulated state. Discharge may be in the form of tears, a warm sensation, the ability to breathe easily again, or other releases of energy which demonstrate the ANS returning to its baseline. Through this process, the client’s inherent capacity to self-regulate is restored.
Somatic Experiencing is useful for shock trauma and developmental trauma. Shock trauma is loosely defined as a single-episode traumatic event such as a car accident, natural disaster such as an earthquake, battlefield incident, physical attack, etc. Developmental trauma refers to various kinds of psychological damage that occur during childhood development when a child has insufficient attention from the primary caregivers, or an insufficiently nurturing relationship with the parent.”
Emotional Release Therapy: The Jamillon Centre (alternatively known as Primal Therapy Australia) offers the following description of their rationale behind trauma therapy. What used to be labeled ‘emotional release therapy’ is now referred to on their website as ‘exposure therapy’.
“At Primal Therapy Australia we believe that post traumatic responses represent an inborn self-healing activity that is an evolutionary adaptation. Our inherent tendency to process repressed emotional memory through “symptoms” such as flashbacks, intrusive negative thoughts, and nightmares may represent the mind’s natural and automatic attempt to desensitise emotionally-laden memories by repeatedly exposing itself to (relive) small “chunks” of such material in a safe environment.
In primal therapy we use the body’s own natural tendency to heal itself through repeated exposure by reliving small “chunks” of emotional content in an environment that is safe and without threat or danger. This must be done at an individual pace and this pace will vary from person to person.
This is vital in healing post traumatic emotional responses and beliefs associated with childhood attachment traumas, since many of the trauma or pain related responses are no longer accurate in the current, non-dangerous environment. Once post traumatic responses are relived (at times repeatedly) in a safe environment, the brain, the central nervous system and the body will sequentially heal itself. This makes it much easier for you to learn new skills for living as a healthy adult in the present.”
[Primal Therapy, introduced to the world in The Primal Scream, by Arthur Janov, gained a negative reputation as ‘the screaming method’, and was criticized as being too confronting for trauma survivors and potentially re-traumatizing. Spensely and Johnson, who founded The Jamillon Centre, adapted primal therapy to make it a safe and effective treatment method, re-labelling it as ‘emotional-release therapy’. It was a disappointment to see the new Jamillon Centre (founded after John Spensely’s death) return to the negatively-associated title of Primal Therapy.]
The two therapy systems just described, that encourage intense reliving and discharge of traumatic ‘memory’, are as safe and effective as they are, because the process includes the faculty of language. It is essential that emotional affect, after having been allowed to express itself, is converted into language, ie, given words. If all a person did was to weep or scream, and nothing else, there would be little healing. The right hemisphere experience must be helped to move across to the left hemisphere, where it can be consolidated into permanent memory, so that the survivor can experience it as feeling ‘in the past’.
Inner Child/ Internal Parts-of-Self/ Internal Family Systems Therapies
The fourth category, Inner Child therapy, Internal Parts-of-Self therapy or Internal Family Systems Therapy all work with the same principle, that humans naturally have ‘parts of self’ that at times feel quite different from each other. Examples in a normally integrated person would be: the angry part, the sentimental part, the introverted part, the wise part of self, the fun-loving childish part, the protective mother part, and so on. In a sense these are roles, or costumes, that we don to deal with various life needs.
This natural ability of the brain to compartmentalize aspects of self can be adapted to deal with extreme or chronic trauma during the developmental periods of childhood. Even when a traumatized child does not develop the full compartmentalization of multiple personality disorder (now called Dissociative Identity Disorder), there is nearly always a degree of splitting into dissociated parts. When this splitting is accompanied by a permanent observer self or ‘core self’ (and there is no loss of time experienced), the condition is known as Other Specified Dissociative Disorder (OSDD, formerly DDNOS) in the DSM V. I find both these labels so meaningless that I don’t use them. I simply talk about Dissociative Identity Disorder (DID) as existing on a sliding scale from completely distinct ‘alternative personalities’ (or ‘alters’) to multiple inner child parts that are contained within a stable core self, the self-aware ego state.
Inner Child work is the aspect of psychotherapy that works to externalize this inner world of split-off selves, with the aim of facilitating integration within the neural net. If this integration is achieved, the core self or executive self will perceive its internal world as a normally integrated person does – ‘there is just one me, and occasionally I have experiences that I know are coming from other inner parts, but it now feels like it’s just Me that’s experiencing it’.
Van der Kolk included this system in his top five interventions for healing PTSD. The particular version of an ‘inner parts of self’ system that van der Kolk is publicising is Internal Family Systems, developed by Dr Richard Schwartz. For any reader who is interested in the branch of psychotherapy that actively works with the split-off parts of self, I recommend reading Schwarz’s website:
and I quote from the section of Schwartz’s article that draws attention to the element of Internal Family Systems that is in line with the ‘wounded inner children/selves’ and other ‘Parts of Self’ approaches:
“What if people could get extreme voices to step back simply by asking them to, not only in negotiations with other parts, but with family members, bosses, anyone? What if the person who was left when the parts stepped back was always as compassionate as Diane and these other clients had become? When they were in that calm, compassionate state, I asked these clients what voice or part was present. They each gave a variation of the following reply: ‘That’s not a part like those other voices are; that’s more of who I really am — that’s my Self.’
. . . At the time, I was thrilled to have found a way to make therapy so much more effortless and effective for my clients, as well as for me. Diane and the others began relating to their parts in ways that the parts seemed to need. Their emergent compassion, lucidity, and wisdom helped them get to know and care for these inner personalities. Some parts, like Diane’s pessimist, needed to hear from her that, while at one time she had been very hurt and needed to withdraw, she no longer needed it to protect her in that way. Subpersonalities, like the pessimist, seemed like inner trauma victims, stuck in the past, their minds frozen around a time of great distress. Other parts needed to be held, comforted, loved, or just listened to. The most amazing thing of all was that, once in that Self state, clients seemed to know just what to do or say to help each inner personality.” [Dr Richard Schwartz]
Parts of Self work involves a blend of therapist/client dialogue, internal visualization and/or body focused feeling work and free-association, any or all of which can facilitate contact with inner parts of self. Once that contact is made, the client can experience a part or parts of self that hold traumatic feelings and are programmed with adaptive functions, such as holding anger or self-blame, or protecting self from overwhelming feelings. The focus of the work is then emotional and relational, as the executive core self learns to dialogue with inner parts, to develop a relationship with them and to help bring those parts out of their isolation deep within the self and help them to heal in a variety of ways.
The Parts of Self approach requires the same ability to stay present to the experience, to cope with the intense feelings that may arise and develop an observer self that can help the whole system heal.
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