Download developmental issues - Conference on Trauma, Dissociation and

Healing the Body,
Healing the Mind: a
Sensorimotor Approach to
Trauma Treatment
Conference on Trauma, Dissociation and Psychosis
31 May 2017
Janina Fisher, Ph.D.
www.janinafisher.com
If we use a trauma lens...
Jenni Thompson, 2013
What have we learned so far?
• Each speaker has asked that we look more clearly at
the longterm effects of trauma on patients and
evaluate symptoms based on an understanding of these
post-traumatic responses, rather than on DSM or ICD
• We should consider that a delusion could reflect
automatic “jumping to conclusions” based on actual
past events: “I will be killed,” “Someone is after me”
• Or “I will be killed” could be the implicit memory or
anticipatory dread being communicated by a very
vulnerable part in a structurally dissociated
consciousness
Fisher, 2017
Could we be talking about a new
Spectrum of Trauma-Related
Disorders?
•
•
•
•
•
•
•
•
•
Post-Traumatic Stress Disorder, Acute
Post-Traumatic Stress Disorder, Chronic
Borderline Personality Disorder
Dissociative Disorder NOS
Dissociative Identity Disorder
Acute Psychotic Episode
Schizoaffective Disorder
Bipolar I
Schizophrenia
What are the common
denominators?
• Affect dysregulation
• Sensitivity to environmental cues
• Tendency to experience those cues as “danger”
or “threat”
• Intense signal-to-noise responses, little ability
to identify non-threatening stimuli
• Tendency toward hypervigilant, automatic
“jumping to conclusions”
• Dysregulated, impulsive, unsafe behavior
Threat and the Brain
Limbic
System or
Emotional
Brain: perceives
Frontal
Cortex:
analyzes,
problem-solves,
learns from
experience
and reacts to
threat
Threat
Reptilian Brain:
controls our instinctive
responses and functions
Sensorimotor Psychotherapy Institute
Amygdala
Fire Alarm and Emotional
Memory Center
Autonomic Adaptation to a Threatening World
Hyperarousal-Related Symptoms:
Frontal lobe shutdown leads to impulsivity, risk-taking, poor judgment
Hypervigilance, mistrust, resistance to treatment
Anxiety, panic, terror, post-traumatic paranoia, racing thoughts
Intrusive images, sensations, emotions; flashbacks and nightmares
Self-destructive, suicidal, and addictive behavior
Sympathetic Hyperarousal
Diminished Window of
Affect Tolerance
Parasympathetic
Hypoarousal
Ogden and Minton (2000);
Fisher, 2009
*Siegel (1999)
Patient is affectively and
autonomically dysregulated
Hypoarousal-Related Symptoms:
Flat affect, numb, feels dead or empty, “not there”
Cognitive functioning slowed, “lazy” thinking
Preoccupied with shame, despair and self-loathing
Passive defenses, victim identify
Sensorimotor Psychotherapy Institute
Unsafe
Behavior
and Trauma
Leads to more selfinjury, more rigorous
restricting, harder
drugs to replace the
substances that no
longer work. The
client feels more
desperate, not less
Triggered by everyday
stimuli, the client
becomes overwhelmed,
reactive, impulsive
without awareness
reactions are ‘memory’
Increased activation
and overwhelm when
“drug effect” wears off
The client begins to
engage in compulsive
behavior or substance
use to lower arousal,
and it seems to work
at first
Finally, the fear of
the emotions is more
terrifying than the
fear of suicide or
homocide
S/he flees by
isolating, avoiding
potential triggers
As isolation impairs
stimulus
discrimination, the
client is more easily
triggered
Resulting in more
flooding, shame,
panic, rage,
hypervigilance
Even more
strenuous
attempts at
avoidance
Assumptions of NeurobiologicallyInformed Trauma Treatment
•Under conditions of trauma and neglect, the human
body becomes self-protective: defensive responses of
fight-flight-freeze-submit-attach are automatic under stress
•The emotions, sensations, and impulses triggered by
traumatic reminders, divorced from their original context,
communicate that the individual is still in danger.
Though clients may be safe now, the body doesn’t know it
•These experiences-without-words are then interpreted
by the client as proof of the danger: “I must be feeling
this way because you are dangerous, or the whole world is a
dangerous place.”
Fisher, 2017
To Treat Trauma, Frontal Lobe
Inhibition Must Be Reversed
“In order for the amygdala to respond to
fear reactions, the prefrontal region has
to be shut down. . . . [Treatment] of
pathologic fear may require that the
patient learn to increase activity in the
prefrontal region so that the amygdala is
less free to express fear.”
LeDoux, 2003
“Waking Up” the Frontal Lobes
•Increasing mindful differentiation of thoughts,
feelings, and body sensations: “When you say, ‘I’m in
danger,’ is that a belief? An emotion? Or is it a physical reaction?”
•Evoking curiosity by observing and re-framing old schemas
and habitual responses as adaptive in intention: “How might this
have helped you survive?”
•Providing psychoeducation about trauma to help
patients develop new, more accurate schemas for their responses
•Helping patient achieve distance from the symptoms:
noticing them as information, using neutral terms (‘notice the
beating of the heart’), universalizing or reframing symptoms
Fisher, 2017
Fine-tuning treatments for trauma
•Psychodynamic and exposure approaches that encourage
remembering events and tolerating the affects require an ability to
regulate autonomic arousal to be effective.
•Cognitive-behavioral models and DBT offer concrete skills
for regulating autonomic arousal and “problem behaviors.” However,
without acknowledgement of the trauma or empathic resonance,
clients can feel unheard, unseen, or pathologized.
•Mindfulness-based models (Sensorimotor Psychotherapy,
EMDR, Internal Family Systems, ACT) are inherently regulating
and therefore facilitate cortical functioning. Mindful noticing is
easier cognitively than insight or skill-building. Mindfulness-based
compassion communicates safety, positive regard, and calming of
trauma responses
Fisher, 2017
Traumatic experiences are
difficult to address at a
cognitive level
“Words cannot integrate the
disorganized sensations and
action patterns that come from
the core imprint of trauma.”
van der Kolk, 2004
Sensorimotor Psychotherapy
•Sensorimotor Psychotherapy is a body-oriented therapy
developed by Pat Ogden, Ph.D. and enriched by
contributions from Alan Schore, Bessel van der Kolk,
Daniel Siegel, Onno van der Hart, and Ellert Nijenhuis.
•Sensorimotor work combines traditional talking
therapy techniques with body-centered interventions
that directly address the somatic legacy of trauma.
•Using the narrative only to evoke the trauma-related
bodily experience, we attend first to discovering how the
body has “remembered” the trauma and then to
providing the somatic experiences needed for resolution
Sensorimotor Psychotherapy Institute
Distinguishing Thoughts, Feelings,
and Body Sensations
In Sensorimotor Psychotherapy treatments, we clearly
differentiate cognition, emotion, and body responses:
When the client says, “I feel unsafe,”
•It could reflect a cognition: “I am never safe,”
“The world is not a safe place”
•It could mean an emotion: “I’m feeling frightened”
•It could mean bodily sensation: “My chest is tight;
my heart is racing; it’s hard to take a breath”
•It could mean action: “I want to hurt myself”
Sensorimotor Psychotherapy Institute
Therapeutic Bottom Up Processing
Instead of talking about
experiences
Clients learn to observe &
describe present
experience in simple words
We teach the client to notice the habitual movements, postures,
or inner body sensation as these unfold in the moment
Instead of interpreting
experience
Clients are taught to be
curious about what they
notice & experience
We teach the client to study the interaction of emotions,
thoughts, inner body sensations and movements; to inhibit
habitual trauma-related procedural tendencies and execute
new physical actions, somatic resources, adaptive defensive
responses, and self-regulatory skills.
S
Sensorimotor Psychotherapy Institute™
“Brain states and bodily
responses are the fundamental
facts of an emotion, and the
conscious feelings are the frills
that have added icing to the
emotional cake.”
Joseph LeDoux
Therapy must deliberately challenge,
rather than reinforce, conditioned
patterns of response
To challenge the patterns without further dysregulating
the client, the therapist uses two interventions:
•”The first is to …observe, rather than interpret,
what takes place, and repeatedly call attention to it.
This in itself tends to disrupt the automaticity with which
procedural learning ordinarily is expressed.”
•”The second therapeutic tactic is to engage in activities
that directly disrupt what has been procedurally
learned” and create the opportunity for new experiences
Sensorimotor Psychotherapy
325) Institute
(Grigsby & Stevens, p.
Old responses are challenged
using mindfulness rather than
insight
“Where attention goes,
neural firing goes. And
where neurons fire, new
connections can be made.”
Siegel, 2006
Facilitating Mindful Awareness
•Mindfulness in therapy depends upon the therapist
becoming more mindful: slowing the pace of thinking
and talking, refraining from interpretation, helping patients
to notice their bodily responses as “interesting” or
“curious” rather than threatening
•Mindful attention is present moment attention. We use
“retrospective mindfulness” to bring past into present time:
“As you are talking about what happened then, what do
you notice happening inside you now?”
•Curiosity is cultivated as an entrée into mindfulness:
“Perhaps by binging and purging, you were trying to help
yourself feel ready to go to work. . .”
Fisher, 2017
Mindfulness Skills
• “Notice . . .”
• “Be curious, not judgmental. . . “
• “Let’s just notice that reaction you’re having
inside as we talk,” “Notice that belief . . .”
• “Notice the sequence: you were home alone,
bored and lonely, then you started to get
agitated and feel trapped, and then you just had
to get out of the house”
• “What might have been the trigger? Let’s be
curious—go back to the start of the day and
retrace your steps”
Fisher, 2004
Increasing Frontal Lobe Activity:
Offer a Menu of Possibilities
•“When you feel the thought come up, what
happens? Do you feel more anxious? More
overwhelmed? Or do you feel less anxious?”
•“As you feel that anger, is it more like energy?
Or muscle tension? Or does it want to do
something?”
•“When you talk about feeling ‘nothing,’ what
does ‘nothing’ feel like? Is it more like calm? Or
numbing? Or is it fuzzy? ”
Ogden 2004
Sensorimotor Psychotherapy Institute
Making Mindfulness Even Easier:
Ask Contrasting Questions
•“When you express your anger, do you feel
better? Or worse? Is it more pleasurable or
unpleasurable?”
•“Does this danger feel like something is going
to hurt you from the inside or the outside?”
•“When you say those words, ‘I am stupid,’
does the shame get better or worse?”
Ogden 2004; Fisher, 2005
Sensorimotor Psychotherapy Institute
“[The restoration of]
competence is the
single biggest issue in
trauma treatment”
Bessel van der Kolk, 2009
Teaching the Skills to Regulate Arousal
Within the Window of Tolerance
Interventions
Hyperarousal
Notice the
triggering
Then
regulate the
arousal
Hypoarousal
Ogden 2006; Fisher, 2009
Sensorimotor Psychotherapy Institute
•Psychoeducation
•Curiosity
•Mindfulness
•Differentiating body,
thoughts, feelings
•Identifying triggers
•Tracking patterns as
‘interesting’ data
(EMS)
•Tracking arousal
•DBT/CBT skills
•Somatic skills
Experimenting with Somatic Resources
for Traumatic Reactions
Traumatic Reactions:
Resources:
Shaking, trembling
Slowing the pace
Numbing
Sighing, breathing
Muscular hypervigilance
Lengthening the spine
Accelerated heart rate
Hand over the heart
Collapse
Grounding with the feet
Impulses to hurt the body
Clenching/relaxing
Disconnection, spacing out
Movement, gesture
Sensorimotor Psychotherapy Institute
Ogden,
The therapist must maximize
positive states and repair negative
states
“The parent’s role in regulating negative
arousal during the first year is not simply to
respond with comfort . . . but to avert distress
by maintaining the infant’s interest and
engagement in a positively toned dialogue
with the social and physical environment.”
Hennighausen & Lyons-Ruth, 2005
“Maximizing positive states”
Increasing capacity for social
engagement creates a sense of safety
•The social engagement system (Porges) is a
neurobiological system: it relies upon the “muscles that
give expression to our faces, allow us to gesture with our
heads, put intonation into our voices, direct [or soften] our
gaze, and permit us to distinguish human voices from
background sounds.” (Porges, 2004, p. 21)
•Clients with histories of neglect and trauma come to
therapy with social engagement difficulties: difficulty
making eye contact, blunt affect, head bowed, gestural
language limited, and difficulty discriminating our kindness
from others’ cruelty
Ogden, 2004; Fisher, 2011
Experiment with the impact of
different styles of communicating
•Vary your voice tone and pace of speech: soft and slow,
hypnotic tone, casual tone, strong and energetic tone, playful tone
•Experiment with facial expression: does the client respond
differently to calm vs. warm, expressive, or playful expressions?
•Change energy level: very “there,” energetic vs. quiet, calm
•Does the child/adult respond better to empathy or to
challenge? Better to playfulness or seriousness?
•Amount of information provided: does s/he do better with more
explanation? Or does information cause overwhelm or spacing out?
•Is the client more comfortable with distance, closeness, or
neither?
Fisher, 2008
“The primary therapeutic attitude [that
needs to be] demonstrated [by the
therapist] throughout a session is one of :
P = playfulness
A = acceptance
C = curiosity
E = empathy
Hughes, 2006
“Leavening” Distress States
with Positive States
“Playful interactions, focused on positive
affective experiences, are never forgotten .
. . Shame is always met with empathy,
followed by curiosity. . . . All
communication is ‘embodied’ within the
nonverbal. . . . All resistance is met with
[playfulness, acceptance, curiosity, and
empathy], rather than being confronted.”
Hughes, 2006
“What we cannot hold, we cannot
process. What we cannot process, we
cannot transform. What we cannot
transform haunts us. It takes another
mind to help us heal ours. It takes other
minds and hearts to help us grow and
re-grow the capacities we
need to transform suffering.”
Joseph Bobrow
Coming Home Project
For further information:
Janina Fisher, Ph.D.
5665 College Avenue, Suite 220C
Oakland, CA 94611 USA
[email protected]
www.janinafisher.com
Sensorimotor Psychotherapy Institute
www.sensorimotor.org