How to Help Clients Break the Cycle of Traumatic Memory Peter Levine, PhD - TalkBack - pg. 1. Rethinking Trauma

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1 How to Help Clients Break the Cycle of Traumatic Memory Peter Levine, PhD - TalkBack - pg. 1 Rethinking Trauma How to Help Clients Break the Cycle of Traumatic Memory a TalkBack Session with Ruth Lanius, MD, PhD; Ron Siegel, PsyD; and Ruth Buczynski, PhD

2 How to Help Clients Break the Cycle of Traumatic Memory Peter Levine, PhD - TalkBack - pg. 2 TalkBack Session: How to Help Clients Break the Cycle of Traumatic Memory with Ruth Buczynski, PhD; Ruth Lanius, MD, PhD; and Ron Siegel, PsyD Table of Contents (click to go to a page) What Stood Out Most... 3 How Community Can Help Overcome the Effects of Trauma... 6 Strategies for Working with Implicit Memories... 9 The Future of the Field of Trauma Treatment About the Speakers... 13

3 How to Help Clients Break the Cycle of Traumatic Memory Peter Levine, PhD - TalkBack - pg. 3 TalkBack Session: How to Help Clients Break the Cycle of Traumatic Memory with Ruth Buczynski, PhD; Ruth Lanius, MD, PhD; and Ron Siegel, PsyD Dr. Buczynski: I am back now with my two colleagues. Now we are getting into the TalkBack portion. We are going to chew on the ideas that we have heard from Peter, think about them more, and give you some ideas and ways of thinking about them. I am joined by Dr. Ronald Siegel and Dr. Ruth Lanius. Ron is a licensed psychologist in Boston and the Assistant Clinical Professor of Psychology at Harvard Medical School. He is the author of many books, and tonight I will mention Wisdom and Compassion he is coauthor of Wisdom and Compassion in Psychotherapy, and that has a foreword by His Holiness the Dalai Lama. Ruth is a physician and a Professor of Psychiatry at the University of Western Ontario in Canada. She is also coauthor of the book: Healing the Traumatized Self: Consciousness, Neuroscience and Treatment. So, I can t wait to jump in with you both and get your thoughts on this. There were a lot of interesting ideas here. I am going to start the way I always do with the question: What stood out to you? and we ll start with you, Ron. What Stood Out Most Dr. Siegel: Peter Levine has been such a pioneer, and what stands out to me most is his pioneering observation that animals, when they are involved in some kind of a threat situation will, at a certain point, often move into a freeze response. When they come out of this freeze response, they have some sort of discharge: they are either shaking in some way, or panting, or very often they are continuing whatever the motor response would have been in the moment in which the trauma had occurred. His fascinating observation is that we are animals, too clearly, we are mammals but we don't see ourselves doing this, at least not readily, not fluidly and not reliably. So, what s up? His conclusion is that we

4 How to Help Clients Break the Cycle of Traumatic Memory Peter Levine, PhD - TalkBack - pg. 4 learn not to do it. For us, the discharge involves things like crying, or shaking, or continuing whatever the procedural memory might be of the motor sequence that would be involved in what had gone wrong and yet we don't play that out. We tend to inhibit that. And he raises the question, Could that be curative of trauma, if we could help people to connect with that? and he s discovered that indeed, it seems to be. That s a masterful contribution, which has then come up in Pat Ogden s work, in Bob Scaer s work, and in the work of many other people who have expanded on this core discovery, which is very important. Also, we see the vital importance of other people. We have seen that come up over and over in different elements of the trauma series. We see this in neurobiological research. Stephen Porges s work about For us, the discharge involves things like crying, or shaking, or continuing whatever the procedural memory might be of the motor sequence that would be involved in what had gone wrong and yet we don't play that out. the mammalian branch of the vagus nerve that is involved in facial expression is about the way in which our interpersonal connection that is done in part through facial expression is part of the curative process of healing trauma. Peter brings in very interesting anthropological evidence from Navajo and Hopi tribes, and shows how, when people experience trauma, the way that they come back the way they heal is through reconnection to the Our interpersonal connection is part of the curative process of healing trauma. tribe. So that is a very important contribution. I ll just mention a couple of other things. Peter warns about the problems of being too attached to declarative or explicit memory, and he speaks so nicely about how we learn to do that, starting in elementary school this idea that, Don't tell me about your subjective experience; tell me about some objective fact. I m always thinking of for those of you who are old enough to remember Sergeant Friday in Dragnet. People would be talking about their implicit memories they d be talking about powerful subjective experiences, and he d go, Just the facts, ma am! That captures this bias and Peter does a really nice job of highlighting the dangers of that, particularly the

5 How to Help Clients Break the Cycle of Traumatic Memory Peter Levine, PhD - TalkBack - pg. 5 grievous danger of the therapist having some narrative for what happened and forcing it down the mind and the voice of the patient. Then finally, of course, there s the importance of staying with the body in the here and now, both as an avenue into implicit memory, There s the importance of Revisiting trauma rather than reliving trauma. but also as a way to get safety a way to have a sense of It s okay; it s just experience happening in the here and now. He puts it so eloquently: Revisiting trauma rather than reliving trauma. Dr. Buczynski: Thanks. How about for you, Ruth, what stood out to you? Dr. Lanius: Peter s groundbreaking work helps us to normalize the responses to trauma. As Ron talked about, the fight, flight and freeze responses that also occur in animals help to normalize this experience. So often our patients will tell us that when they had a freezing response, they felt useless they feel so guilty Peter s groundbreaking work helps us to normalize the responses to trauma. that they couldn t act to overcome whatever they needed to overcome at the time of the trauma they simply couldn t move. Putting this in perspective with what happens in animals and relating it to what happens in humans can be incredibly helpful. And then what I also really like and what stood out for me was this sense of empowerment he talks about. As we work with trauma and with the body, we can help to empower the person from the bottom up from body up helping them to move through very difficult experiences. Also, Peter touches on the extremely important concept of the intergenerational transmission of trauma. If a person has been traumatized has difficulty regulating their emotions or knowing what they feel this not only has huge implications on their offspring, but also affects the whole community. This is what we re seeing, especially with the veterans coming back from Iraq: they are dysregulated; they have anger outbursts; they feel numb; they can t have loving feelings; they get disconnected If a person has been traumatized this not only has huge implications on their offspring, but also affects the whole community. from their partner and their families and very often their marriages break up you see this intergenerational

6 How to Help Clients Break the Cycle of Traumatic Memory Peter Levine, PhD - TalkBack - pg. 6 transmission of the trauma. This has effects on the whole community on the entire country. Whenever we are talking about trauma, it is so important to realize that these effects can occur and we can intervene by treating the trauma. Peter beautifully illustrates how we can use the entire community to help overcome some of those intergenerational effects. How Community Can Help Overcome the Effects of Trauma Dr. Buczynski: Let s stay with that idea for a minute maybe we could look at the story he told about the tribal woman who was traumatized in Brazil, and how the tribe helped to treat the trauma using the entire community. We are not as tribally oriented in the United States and in many parts of Europe, but how can we make that useful in our more individualistic culture? Since you have both talked a little bit about this, I d like to hear from both of you on this. Let s start with you, Ron. Dr. Siegel: That s a great question. It reminds me of Chris Peterson before he passed away, who is one of the The whole hardwiring that we have for social interaction interfaces with what happens with trauma. leading figures in the positive psychology movement. He was looking over the last 15 or 20 years of research and said, In terms of what makes for human well-being, it s about other people. That was his summary conclusion. As a field, I think we re coming around to this and we re seeing it from so many different angles. Desmond Tutu, for example, says that in many African cultures, if you were to ask somebody How are you? the person would say, We re fine, or We re having a difficult time. The idea that one could even have well -being or the absence of well-being disconnected or autonomous from the rest of the community is absurd. And yet, as you point out, we have a culture that has such an emphasis on this kind of individuality.

7 How to Help Clients Break the Cycle of Traumatic Memory Peter Levine, PhD - TalkBack - pg. 7 I m also struck by the whole hardwiring that we have for social interaction and how this interfaces with what happens with trauma. We are talking about basically not having a sense of safe connection with others which is such a risk factor for adverse events later in our life becoming traumatic and leaving scars. We have so many different avenues pointing to the importance of this interpersonal realm. It behooves us to be warm, empathic and understanding. So, how do we deal with that in therapy? It begins, if we are doing therapy, in the nature of the therapeutic relationship. We know that the therapeutic relationships that are successful are those in which the therapist is experienced, warm, empathic and understanding, and it behooves us to be warm, empathic and understanding. Even though the literature doesn t say we have to actually be that way, it will certainly help if we are more empathic and understanding to be experienced in that way. And a lot of that has to do with our own work our own capacity to be with all of our own split-off traumas, all of our own fears, all of our own longings, so that when we are sitting with a traumatized person, we can actually be present because it is not easy to do that. Most of us, while not in full-blown dissociation, disconnect to some extent when somebody is talking about a really painful experience, because we don't really want to feel it. We need to do our own practice whether it is a mindfulness practice or our own therapy practice as a patient or a client in order to be able to be open to patient experiences. Interestingly, we can also help people to have a sense of interpersonal connection internally. Loving-kindness practices are now taught very much in the West, and we tend to teach them by saying, First, begin with a We need to do our own practice whether it is a mindfulness practice or our own therapy practice as a patient or a client in order to be able to be open to patient experiences. benefactor begin by imagining somebody who is naturally loving and kind, and imagine sending lovingkindness toward that person and then having that person send it in turn toward oneself.

8 How to Help Clients Break the Cycle of Traumatic Memory Peter Levine, PhD - TalkBack - pg. 8 It is an internal process, in a sense, but it is with an imaginary other that can bring some of this sense of connection and safety. Self-compassion practices can do the same thing: imagine, if we are feeling bad about ourselves, writing a letter to ourselves from the vantage point of a compassionate friend. That is done internally in that the live other isn t there, but yet we get the same feeling of love and connection that can be so healing. There are also the 12-step programs and how they can provide this sort of support they become the tribe, if you will, in an otherwise often alienated culture, because these are people who understand and with whom we can be honest. Group therapy can do this; certainly being part of a church or a temple or a meditation group can do this. We can write gratitude letters this is another positive-psychology intervention, and one that Martin Seligman found to be the most powerful single intervention you could do. You think of somebody who has been helpful to you who you never adequately thanked, and you write a letter to them thanking them, and then actually deliver the letter! All of these are ways to create a sense of connection in an otherwise easy-to-be-alienated culture. Self-compassion is really about creating a connection even if the other person isn t there. Dr. Buczynski: Thanks. I have found, in particular, that the more we explore the whole idea of selfcompassion and the research, the more we are finding that selfcompassion is a reparative experience. Dr. Siegel: Self-compassion is really about creating a connection even if the other person isn t there. Dr. Buczynski: Yes, and maybe more necessary in our individualized culture than it might be in a more tribally oriented culture. Ruth, what are your thoughts on that particular story and how we can use this idea even in our more individualized culture? Dr. Lanius: I want to continue this idea of self-compassion for a minute, which I agree is absolutely key that internal connection.

9 How to Help Clients Break the Cycle of Traumatic Memory Peter Levine, PhD - TalkBack - pg. 9 When we are working with severely traumatized individuals, establishing that self-compassion is often so difficult and takes a long while, but the lack of self-compassion is at the core of the pathology. What we often do and I m sure you do this as well is to work with the adult self and the child self to begin that process of self-compassion. When you first discuss it with people, often they are very hesitant and they are very anxious and frightened about it, and it s important to give them the distance and the space between these two states of self so they can slowly come together at a pace that feels comfortable for each person. That is the first step of reconnection within oneself, which then When we are working with severely traumatized individuals, establishing that self-compassion is often so difficult and takes a long while, but the lack of self-compassion is at the core of the pathology. helps to reconnect with all the things that Dan has already talked about. I can t stress group therapy enough, especially with people who have been chronically traumatized it is so Group therapy is so important to building that sense of community where it feels safe. important to first start by building that sense of community where it feels safe, because often interpersonal connections are so difficult for these individuals to maintain. To have a group of people who have gone through similar experiences where they can start to feel a sense of connection, where they can feel validated, where they can start to support each other, cheer each other on, and not judge each other, that kind of group therapy is absolutely essential for healing the traumatized self. Strategies for Working with Implicit Memories Dr. Buczynski: Moving on, Ron, what are some good strategies for working with patients implicit memories? Dr. Siegel: Yes, Peter does a nice job of stressing the importance of staying with the here-and-now, momentto-moment experience in the body and using this as a kind of base from which to then reach into the implicit memories. If we look at the wide variety of trauma interventions that are out there, some of which have good data to

10 How to Help Clients Break the Cycle of Traumatic Memory Peter Levine, PhD - TalkBack - pg. 10 support them, they all do this in one way or another. EMDR eye movement desensitization and retraining is one, and what does that do? The theory is you are helping to cross the corpus callosum because implicit memories are stored in one side of the brain and declarative memories more on the other. So, therapists will use either flashing lights, a moving object, or tapping on one side or the other basically We are bringing attention to the present, and out of the safety of the present, we are dipping into these traumatic experiences. bringing attention to some sensory experience in the present, and once doing that, giving in to implicit memory what comes up about the trauma (which is mixed with declarative memory in EMDR) and then coming back to the sensation in the present. Whatever the research winds up telling us eventually about the importance of crossing the corpus callosum whether that is important or not or whether this would work vertically what we are doing is we are doing what Peter is talking about: we are bringing attention to the present, and out of the safety of the present, we are dipping into these traumatic experiences. Many people use EFT techniques emotional freedom techniques to work with trauma successfully. The particular places in which people are doing tapping are supposed to be connected to the meridians from Chinese medicine and Vedic traditions. But again, whether or not that pans out in the research, we are having this idea of bringing attention into the body in the present and using that as a kind of secure base. We even see similarities to this in Gendlin s Focusing where the first move is always called clearing a space, which is finding some way to find We re working with the idea of titrating between the intensity of what we are trying to reintegrate and the safety we get from the present. the right balance between the intensity of a traumatic memory and whether it is implicit memory or explicit memory the safety of the present moment. We re working with the idea of titrating between the intensity of what we are trying to reintegrate and the safety we get from the present, which is part of all these techniques. Peter does a really nice job of talking about the importance of doing this kind of titration so that people can

11 How to Help Clients Break the Cycle of Traumatic Memory Peter Levine, PhD - TalkBack - pg. 11 indeed revisit but not relive the trauma. We don t want the trauma to be re-traumatizing. He talks about the dangers of it being re-traumatizing, which is very important, because many clinicians attached to the idea of I m going to help this person reintegrate have unfortunately injured folks by bringing up material without sufficient safety in the present. Dr. Buczynski: Yes, that is clearly something that can happen without enough training or care unintentional consequences. The Future of the Field of Trauma Treatment Dr. Buczynski: Ruth, where you see the field going the field of the treatment of trauma. What will we be thinking about? What is most promising? We will be seeing, exactly what you have created through this session, which is an integrative approach. Dr. Lanius: We will be seeing, hopefully, exactly what you have created through this session, which is an integrative approach. We need to keep this sort of integrative approach in mind when we see patients or clients, and we need to individualize the treatment. People will require different approaches at different times as Ron just talked about. When we think about trauma and the treatment of trauma in stages or as an approach, we need to create safety, and that can be through mindfulness, through emotional regulation, through safe relationships and through empowerment within the body, and then we can move on to trauma processing. Again, we want to use various techniques, including the body and exposure-based treatments such as EMDR. Throughout this whole process, we want to always foster reconnection. I can t stress enough how important it is to be familiar with a When we think about trauma and the treatment of trauma in stages or as an approach, we need to create safety, and then we can move on to trauma processing.

12 How to Help Clients Break the Cycle of Traumatic Memory Peter Levine, PhD - TalkBack - pg. 12 Our trauma patients are very complex patients. One technique alone is unlikely to help these complex disorders. variety of treatment techniques. Our trauma patients are very complex patients. One technique alone is unlikely to help these complex disorders. It s important to have an integrative treatment approach that we individualize we can win with that, and I think you have done a wonderful job in bringing all of these approaches into your courses. Dr. Buczynski: Thank you and let me just say thank you to the two of you. It has been so much fun working with you and sharing our mutual thoughts. See you soon.

13 How to Help Clients Break the Cycle of Traumatic Memory Peter Levine, PhD - TalkBack - pg. 13 About the speakers... Ruth Lanius, MD, PhD is a professor of Psychiatry and the director of the PTSD Research Unit at the University of Western Ontario. She established the Traumatic Stress Service and the Traumatic Stress Service Workplace Program, both specializing in the treatment and research of PTSD and related comorbid disorders. She currently holds the Harris-Woodman Chair in Mind/Body Medicine at the Schulich School of Medicine and Dentistry at the University of Western Ontario. She has authored more than 100 published papers and chapters in the field of traumatic stress, regularly lectures on the topic of PTSD nationally and internationally, and has published Healing the Traumatized Self: Consciousness, Neuroscience, Treatment, together with Paul Frewen. Ron Siegel, PsyD is an Assistant Clinical Professor of Psychology at Harvard Medical School, where he has taught for over 20 years. He is a long time student of mindfulness mediation and serves on the Board of Directors and faculty for the Institute for Medication and Therapy. Dr. Siegel teachers nationally about mindfulness and psychotherapy and mind/body treatment, while maintaining a private practice in Lincoln, MA. He is co-editor of Mindfulness and Psychotherapy and co-author of Back Sense: A Revolutionary Approach to Halting the Cycle of Chronic Back Pain.