The Polyvagal Theory (PVT), developed by Dr. Stephen Porges, is a neurbiological theory that brings significant shift in our understanding of the treatment of trauma, helping therapists understand how the Autonomic Nervous System (ANS) influences our responses to trauma, stress, social interactions, and affective and physiological regulation. Most significantly, it introduced therapists (and the world) to the concept that trauma forces the ANS into a neural state of immobility by involuntarily inciting the Dorsal Vagal System (DV), the unmyelinated, ancient part of the vagus nerve that is associated with immobilisation. Prior to Porges’ PVT, trauma was (and in some cases still is) misunderstood simply as an engagement of the fight flight response of the Sympathetic Nervous System (SNS).
In speaking or thinking about trauma, we understand that the neurophysiological self responds to traumatic experience by involuntarily shifting the ANS state. This shift is incited through the perception of threat that overwhelms the ANS and psyche, therefore it is not necessarily caused by the event, but is the result of our inability to stay safe, or feel safe, during the experience. There is an overwhelm to the system and its integrative capacities which disrupts the ability for the individual to metabolise the experience at the time.
We used to understand the ANS as two systems, the sympathetic and parasympathetic, but the PVT indicates that there are multiple states (poly) within the parasympathetic. To understand trauma we want to think about two of those states, the ventral and dorsal vagal states, both part of the parasympathetic system.
The PV theory proposes that our bodies use a hierarchical system of responses, with the ventral vagal system being the most evolved and socially engaged, followed by the sympathetic system for more intense stress situations, and finally the dorsal vagal system as a last resort in extreme danger. It also includes two hybrid systems which combine states of the ANS as in play and intimacy (see image below). The Polyvagal Theory asserts that the psyche operates out of different ANS states – in the moment of experience, as well as an overall generalised pattern or tendency, and our autonomic state is “a neural platform for behavior and psychological experiences, including feelings of being safe” (Porges, 2017, p.41). We also know that our autonomic state correlates with probabilistic behaviour and psychological feelings (Porges, 2017). We use unconscious neural processes to evaluate risk/safety in our environment.
Social Engagement (Ventral Vagal) System: This branch is associated with feelings of safety and connection. When it’s active, we are more likely to engage with others, communicate effectively, and experience positive emotions. It supports social interaction and emotional regulation. We use engagement of this system to downregulate or upregulate the ANS in trauma therapy.
Fight or Flight (Sympathetic Nervous System): In this state of high sympathetic arousal we move into fight and/or flight behaviour. Our heart rate increases and our body mobilises in ways to defend & protect ourselves.
Immobility (Dorsal Vagal) System: This branch is associated with immobilisation – ranging from the feigning of death to the inability to mobilise a response/defend or escape and dissociation. When this system is dominant, it can lead to feelings of helplessness, dissociation, and emotional shutdown. It’s a survival response to extreme threat or trauma.
Play (Ventral Vagal and Sympathetic) : This is a hybrid state, engaging both sympathetic arousal and ventral vagal, however defensive mobilisation is down-regulated through face-to-face connection or vocalisations that maintain the connection and neuroception of safety – indicating that play has not shifted into aggression.
Intimacy (Ventral Vagal and Dorsal Vagal) : This is a prosocial state, a state of social/self engagement but requires a reduction in movement. When we involve the social engagement system, “we can even use the oldest system, which is immobilization, and we can be in the arms of someone we feel safe with” (Porges, 2017, p. 129).
We have to remember that these systems regulate the ANS in adaptive responses from the most recent to the most ancient – social engagement (the ventral vagal – VV), mobilisation (SNS), immobilisation with fear (DV). The PVT tells us that under threat or when unsafe, the ANS involuntarily shifts into a dorsal vagal dominant state which decreases arousal in terms of mobilisation and reflects a survival response (Porges, 2004).When the DV system is dominant, we can see a range of effects from a collapsed sense of self to tonic immobility depending on the event; the history, and the experience(s) of the person, and can lead to feelings of helplessness, hopelessness, shame, and dissociation. Porges refers to this as a portal to the death state (2017), however, when people survive the trauma (as most do), their DV often remains active in the ANS. Porges tells us that once the survival system (DV) is engaged, it “doesn’t have an efficient pathway to get out of it” (Porges, 2017, p. 106) thereby wreaking havoc in the ANS, and can create ongoing emotional, relational and physical or physiological symptoms.
Hopefully, this brief overview of the PVT has offered some insight into the workings of the ANS, particularly as it relates to trauma. Of course, understanding it and integrating it into your clinical practice are two different things. If this has piqued your interest, know that we work intimately with the PVT in our Bringing the Body into Practice trainings and workshops.
References:
Mortimore, L. (2018). Porges’ Polyvagal 5 States Made Simple Image, Somatic Attachment Psychotherapy Training Curriculum, The Savoy Clinic, Ltd.
Porges, S. (2004). Neuroception: A Subconscious System for Detecting Threats and Safety. Zero to Three. 24, 19-24.
Porges, S. W. (2017). The pocket guide to The Polyvagal Theory: The transformative power of feeling safe. W.W. Norton & Company, New York.
We met with our web guru David Michels fromGeeks on the Beach and he invited us to give our readers a peek behind the scenes. We thought, hmmm, this might be fun, and even more fun, we decided to write each other’s bios and include a glimpse from behind the scenes. So, here it goes, meet Lisa Mortimore, PhD and Stacy Adam Jensen, MEd and Riley …
Lisa Mortimore is the driving force behind the Bringing the Body into Practice, Somatic Attachment Psychotherapy training- a training that is the ever-evolving synthesis of her clinical will and wisdom. In addition to weaving her heart and soul throughout her teaching, she brings to the program clinical and academic rigor, a tremendous capacity to work relationally and translate that into her clinical teaching, and a strong side of laughter. I appreciate the way she’s always pushing her clinical understanding- forging new connections and bridging between diverse clinical knowledges. It is a true pleasure to witness Lisa’s capacity to bring her heart and care into her clinical teaching, and see the fruit come to bear as students embody and deepen their practice across the two-year training. On the one hand she holds the vision what is possible, and in the other hand she lets it unfold, inviting therapists to make the material their own.
When Lisa isn’t teaching, writing, or formulating new clinical connections, you’ll find her with her hands in the mud on her pottery wheel, riding her bike, or practicing culinary alchemy in the kitchen (that’s a fancy way of saying- cooking without a recipe).
The first thing I want to say about Stacy is that he’s all heart, clinically and personally. What I mean by that is that he leads, understands, and relates through his heart. I think this is what sets him apart from other therapists and educators that teach about insecure attachment and chronic shame. Stacy works hard to bridge learners into not only relating to those who have chronic shame, but as he says, “the goal in my teaching is to humanize those who suffer with chronic shame”. Over and over again, I’ve seen how this stance, his orientation, opens therapists’ hearts as they engage with the material and that open heart extends into their practices. It’s like he pedals kindness and preaches belonging, definitely salve to those who suffer from such difficult experiences of non-recognition, misattunement, and shame.
As an educator and therapist, I see the way Stacy formulates and responds to human suffering in ways that relay, I get it and I get you, but there’s a way that he goes beyond that, to relay, and together we can find our way to solid ground. I appreciate that ground because he also brings it to our work, so when things get a little chaotic behind the scenes, when the cat needs feeding, someone’s at the door, and we are teaching online, oh, and what are we going to eat for lunch, he brings it down a level, and Riley (the cat) gets fed, and so do we 😊
When Stacy’s not mucking about with clinical material, teaching, or in his practice, he’s living life on two wheels, bicycle wheels that is.
You’ll also note the black feline in the illustration, that’s Riley, she’s pure sweetness, and occasionally makes an appearance at the trainings (online), to make sure us humans have things under control.
So that’s us, a little peek behind the scenes of the BBP trainings.
As a lifelong cyclist I know the harrowing things that can happen when we live life on two wheels. The good thing is that as a psychotherapist specializing in trauma, I know some of what it takes to process the trauma of accidents and near misses. I’m going to outline the simplest thing that we can do so that the fright of a near miss doesn’t get stuck inside our body, and compromise our ability to be safe on the bike.
Here’s a common scenario- you are riding and someone opens their car door right in front of you. Your natural reflexes take over and you slam on your brakes, swerve into the next lane, or so some variation of the two. Thank goodness, you don’t hit the door and there was no car in the next lane, so you were lucky and had only a close call, not a physical collision and trauma. As you stop, your heart is racing, and you may be enraged, or afraid, or even terrified; your heart pounding and pulse racing, and your body feeling both shaky and energized. Your sympathetic nervous system has mobilized to get keep you safe (fight/flight), and it has been fused with the shock from the opening of the car door. The evasive action that you took in that split second to avoid injury or possible death, though successful, isn’t enough to discharge (release) the tremendous amount of energy created by the situation, which gets bound up in the body and nervous system.
If you do as many of us probably have done, many times- you say ‘phew’ (or some variation), or educate the driver about how to open a car door properly, or pause for a few moments, then continue on with your ride. As you ride, you may feel shaky, nervous, easily startled, like your balance is a bit off, or maybe a bit ‘out of it’- like you can’t take in all the information in your surroundings, be it cars (moving or parked), potholes, etc., and things can startle you. If you have a close call while riding gravel, cross or mountain biking, you may find that you keep crashing, or almost crashing. All of these things add up to having a bad ride, and being at increased risk of injury.
The culprit for this strong reaction and resulting vulnerability is your nervous system- which did what it was meant to do- to keep you safe, but hasn’t had the time to come back to equilibrium. After the shock of the incident our nervous system needs time to settle, to metabolize, to discharge all of the shock and survival energy that was just created, and we don’t often allow this to happen, interrupting the body’s natural rhythm. In the above example, we halted the discharge/settling process by simply continuing the ride, or it could be by checking Strava, or sending a text, etc. All of which keep us distracted, and unaware of what is happening in our body- unaware of or disavowing the intense activation present in our nervous system.
Here’s how to do it differently. The next time you have a near miss or something else that frightens you- get to safety (so off the road or trail), and take a moment to notice things that help you orient to the here and now (I see a tree, I feel the cool breeze, I smell cut grass, I hear a crow calling, my friend is sitting with me, etc.). Now, take some time to give your body and nervous system space- be curious about what is happening inside, and give it space to express itself. This process may feel very odd and vulnerable, and as you do this, you may experience a rush of heat or cold, or you may feel some shaking, your face may flush, or you may feel some fear- some tears may come, or even some nervous laughter. All of these are signs that the shock to your system from the near miss is processing and your body is moving it through. The point is to give your body space to express itself- to do what it naturally wants to do- to allow the bound-up survival energy to come out, so that you don’t have to carry it with you for the rest of the ride, and possibly beyond. The good thing is that this process described above only needs a few minutes to happen, and once this wave has come through, your system will naturally settle- you will feel more grounded, present, focused, and ready to go on with your ride. The discharge of the energy may not be entirely complete, so when you get home, give your system some space to see if anything residual is left, by repeating the process I’ve laid out above.
I’m aware that the process I’ve laid out above doesn’t fit well with the culture of many group rides, and it would be great if this could shift. Educate your riding friends, and if you are on a group ride and are unable to give your nervous system time to discharge in the moment- do it as soon as you can afterwards, once you get home, or at the post ride coffee- before the energy has become really rooted inside your system.
If you do get hit or injured, or have a bad crash on your bike (or anywhere) and are dogged by the incident, reach out to a trained therapist that can help you move the residue from the accident – check out our referral list – https://bringingthebody.ca/referrals/.
I hope that this information is helpful, and that you take up the challenge to listen to your nervous system after your next close call- your nervous system will thank you for it. Have a safe ride.
I sat down, (well zoomed), with Stephanie Davis at the end of August. Having a PhD in leadership studies, I am always interested in how people lead, whether that be in a larger clinical setting, a teaching practice, or in the ways they run and show up in their clinical practice. Knowing Stephanie from the BBP community, and as the co-owner and director of a large teaching clinic, I was curious to hear what she had to say about this next evolution of her work, as a counsellor’s coach, and now offering two groups for therapists: Private Practice 101 and The Art and Business of Therapy, both starting this September. Here’s what I found out: (Stephanie’s words are italicized)
Tell me about the why behind you creating the workshops – what was the need you were seeing?
Let’s be honest, private practice is an idealized and popular path for those of us with training in counselling psychology and yet, none of the counsellor training programs offer any courses to support the visioning, launching or running of a private practice.
I have been in private practice as a solo practitioner, an independent contractor and now I am a group practice owner and have been extremely privileged to have found great mentorship and coaching that has helped (and continues to) support my development as a business owner and entrepreneur, but it was on me to find that support….or to even know what I was looking for.
I think that is where these workshops and the coaching work I do now, fits. As a counsellor’s coach, I see my role as helping to fill that gap for counsellors wanting to pursue the path of private practice – whether it be solo, as an associate or as a group practice owner. As a counsellor myself, I understand that the clinical and business components of private practice are not two separate hats we wear but rather, these two pieces create a tapestry that reflects who we are as counsellors, business owners and leaders within our communities. Together, these two pieces showcase our values and enable us to be authentic and congruent in both our clinical work and as the architects of a framework that sustains a growing and thriving business.
In our clinical training and ongoing supervision, there is much emphasis put on understanding ourselves, noticing the way we are showing up and how it supports or hinders the client, but that I see a lack of exploration when we are navigating the complexities of where the clinical meets the business. For example, the most common struggle that we see with our interns early in their training is knowing how to talk to clients about rebooking. Oftentimes clinicians feel worried about how it will be perceived by the client if they suggest rebooking: What if they didn’t like me? What if they don’t find what we talked about today helpful? What if I didn’t do enough? Alternately, others avoid conversations about rebooking because they feel it is important to honour the client’s autonomy, and trust they will reach out again when they are ready. Our individual motivations need to be explored.
I don’t suggest to know what is the best way fortherapists to rebook with clients, but what I do know about these two paths is that they are more about the therapist than the client, and that often the therapist is unaware of the underlying source of this anxiety, or that there is any anxiety at all. If this kind of discomfort occurred in the middle of trauma processing, therapists would more easily assume themselves to be engaged in some sort of enactment or transference dynamic with their clients, and would seek supervision to support this personal exploration, and yet when it comes to things like rebooking, cancellations, asking for payment, etc. my experience is that therapists don’t think about undertaking a similar process in the pursuit of congruence and authenticity….and good client care….
So…these workshops are about filling the gaps in supporting therapists to develop the leadership skills required to walk alongside their clients both clinically and while creating and maintaining a business framework that is value aligned and congruent. There will also be lots of tips and tricks that I’ve learned along the way.
Yes, I think there’s an unspoken discourse that being a therapist and running a business are somehow at odds…and I always think about sustainability because so many therapists ride the edges of burnout in their career. I get curious, what’s specifically unique about your approach?
I think what makes me unique is that as a counsellor and coach, I recognize the interconnectedness of the business and the clinical. Whenever I have sought out coaching to support my business development, the most challenging parts have been when (what I am sure is) sound business advice rubs up against some of the ethical or clinical complexities that come alongside doing clinical work and running a business. And the coach just didn’t get it. As a clinical supervisor and business coach, I honour and hold the clinical work with all the importance it deserves and that informs much of how I understand the business framework to be built.
Additionally, I think it helps that I don’t ascribe to a belief that there is a ‘right way’ to be a therapist in business, rather I aim to create a space for therapists to reflect with what it means to be valued, aligned and congruent, and then support them in evolving their business and clinical practice to be in alignment.
It sounds like you have a specific call that informs your coaching work.
I think at the core of what makes a good private practice clinician is leadership and there is a significant gap not only in training, but even in the role of therapist being seen that way in our larger society. We walk alongside some of the most vulnerable people in their time of need, and there is a responsibility in that to be able to maintain steadiness, authenticity and congruence (I know, I’m preaching to the choir…) alongside clear communication, integrity, and the like, regardless of whether we are in the middle of a piece of clinical work, hustling for clients or having conversations around payment, cancellations or rebooking with our clients.
To bring leadership into therapy is at the essence of what we do as clinicians, to create the space and place for people to grow and thrive. This is the quintessential quality of leadership. We seem to have no qualms about investing in clinical training, but neglect training and support in the business of therapy. The business of one’s private practice is so interwoven into the clinical, that having training in how to navigate that piece, within a larger conceptual framework that is both value aligned and oriented to a process of change, is integral.
Okay, now I want to know about these workshops! – tell me about them.
Both workshops I am offering this fall are running 2 hours bi-weekly for 6 weeks.
Private Practice 101 asks: ‘what does it mean to be a therapist in business?’ In answering that question for ourselves, the emphasis will be on exploring the values of the therapist as they pertain to their clinical work and the ways in which those help to inform the foundation of their business development. We will address many of the common challenges and struggles facing new private practitioners, and explore the patterns that may be creating obstacles to overcoming those challenges. We will explore the concept of leadership and how it lives in the counselling space as we work with our clients clinically, while maintaining a sound framework to make our practice viable, successful and sustainable. We will also build community, hold each other accountable and celebrate wins together. There will also be lots of logistical tips and tricks that have been shared with me, and that I value immensely, and that I am paying forward.
The Art and Business of Private Practice asks: ‘what comes next for me?’ for those in solo practice or those working as associates in a group practice. This question is meant to broadly address both the little changes that we can implement to help us move forward in an area we’ve been stuck or to address the larger questions that are standing in the way of us growing our practices. In answering that question, we will be auditing the values that live at the foundation of our individual practices. We will be reflecting on strengths – what has worked or is working well – and explore where folks are finding themselves stuck. We will explore how our own patterns – often invisible to us – can be limiting us and leaving us unclear about how we want to grow as therapists in business. As in Private Practice 101, we will explore the concept of leadership and how it lives in the counselling space as we work with our clients clinically, while maintaining a sound framework to make our practice viable and successful. We will also build community, hold each other accountable and celebrate wins together. There will also be lots of logistical tips and tricks that have been shared with me and that I value immensely that I will be paying forward.
Your workshops sound great. How do folks know if they need them?
My invitation is to ask yourself what values lie at the heart of why you work in private practice (since it isn’t the only way to engage with this kind of work) and how are you working in alignment with those values when it comes to making decisions that pertain to your business and livelihood, and not only your client’s clinical care?
I also think this is for folks who are struggling with having challenging conversations with clients around booking, cancellations, payment, fee structure, or even laying out a clear treatment plan. This workshop is an invitation to explore what patterns are contributing to these obstacles. Lastly, if you love the idea of private practice, are feeling confident in your clinical training, but are feeling really lost in how to set yourself up to run a business that can be authentic and congruent, these would be great workshops for you.
One last thing, tell me five things people will get from the workshops?
Greater insight into their values as a business owner/therapist and how they are working in alignment with those or not and what challenges need to be overcome in order to feel more congruent
Greater understanding of how leadership skills and the embodiment of leadership within private practice can increase confidence and create greater congruence between the business and the clinical
A greater sense of confidence in having challenging conversations with clients around the administrative or business pieces required to run a sustaining practice
A community of support alongside other private practitioners navigating similar challenges and with similar questions
Lots of tips and tricks from my years of experience in solo practice, as an associate and now as a group practice owner.
Wow, it sounds like you are opening the space for therapists to unravel their shame (or the collective shame) around creating and running a successful and sustainable clinical practice. Thanks Stephanie, I look forward to catching up and hearing how the workshops go.
If you are interested, book a discovery call with Stephanie, or learn more atwww.stephanieldavis.com
The following post is from the British Columbia Association of Clinical Counsellor’s Insights Magazine, Spring 2023, p. 34 -35.
What is Somatic Attachment Psychotherapy?
The heart of Somatic Attachment Psychotherapy (SAP) and SAP trainings is the reparation of early attachment injuries through a framework that weaves together: attachment theory and application to clinical practice, trauma research and practice application, affect and autonomic nervous system (ANS) regulation, somatic psychotherapeutic principles and practices, and relational/interpersonal psychoanalytic psychotherapy. SAP therapists are oriented to the reparation and regulation of the neurophysiological body and wounded psyche, by facilitating shifts in affect management strategies, attachment patterning, re-organization of the body and psyche, and, in supporting the maturation and development of complex right brain functioning. In the broadest sense, Somatic Attachment Psychotherapy is an embodied, relational orientation to psychotherapy that considers attachment and affect regulation as foundational for healing trauma, with the goal of integration and re-organization of the Internal Working Models (IWM) and neurophysiological regulation capacity. Additionally, the therapeutic relationship is paramount in offering dyadic regulation, completing absent or distorted affective communication cycles, and working psychodynamically with relational material.
What client concerns is it especially effective for?
This orientation leans into clinical application of multiple theories and principles, giving it wide application to diverse practice populations, with SAP students and graduates creatively applying it across diverse settings and populations, including: private practice, clinical mental health, addictions, sexualized abuse and violence work with adults and children, work with neurodiverse folks, the 2SLGBTQQIA+ community, Indigenous communities, school and university counselling centres, cancer care, and group work, to name a few.
How does it work?
This orientation responds to clients wishing to heal injuries of the psyche and bodyself that inhibit how they imagine and live their lives. With a focus on disrupting and processing that which is distorted, dysregulated, or disavowed, the SAP orientation seeks to facilitate emerging, expanding, and flexible ways of relating—to self, others, and the world. For many folks with relational trauma, their integrative capacities have been significantly impacted by their early relational experiences (insecure attachment), about 42% of the non-clinical population (Bakermans-Kranenburg, & van IJzendoorn, 2009). This inhibits clinical work, as the psyche unconsciously thwarts affective processing of the unbearable affect of trauma, both relational and incident. The SAP orientation works to build integrative capacities over time by working with the distorted and fragmented IWM of insecure attachment; facilitating increased affect and ANS regulation, and; attending to, and bringing into awareness the recapitulation of early unconscious relational patterns that continue to reinforce (mal)adaptive relational strategies in current life.
While back and forth dialogue is essential, there is a bias towards working directly with the body, and with right hemispheric (RH) processes, seeking to build congruence between the explicit (narrative) and implicit (body) systems. In this way, this work departs from traditional left hemispheric (LH) therapy by consistently returning to the bodyself and the RH, where trauma is held and needs to be processed.
How long have you been using it and what do you like best about it?
The SAP orientation to clinical practice and psychotherapist training is the culmination of my evolution as a therapist, learner, and educator over the past 19 years, and continues to evolve as I deepen my personal and clinical understandings of what it takes to sit with, and deeply witness suffering—to traverse into the abyss of trauma, and return to the living. Essentially, this work seeks to hold, witness, and help metabolize the unbearable within a collaborative, therapeutic relationship. In this process, I have had to reach beyond different psychotherapeutic disciplines, and find bigger and bigger canvases to practice this art we call psychotherapy. SAP is an orientation where heart and academic rigour meet. I have been offering the two-year Somatic Attachment Psychotherapy training program since 2016, and we are currently registering for our 9th cohort.
SAP is a relational psychotherapeutic orientation and not intervention driven, so as a clinician, I value the diversity, creativity, and depth of contact that it supports in service of reparation of early attachment injuries, as they present across the lifespan. I also rely on and appreciate the focus on embodied experience in terms of regulation and tracking my own internal responses. I find this sophisticated information invaluable to clinical practice and it is essential in terms of preventing vicarious trauma. Because this is so important, we begin the process of embodying this on day one of the SAP two-year training.
Which other modalities does it pair well with?
With such diversity and breadth in the theoretical underpinnings (attachment, relational/interpersonal psychoanalytic psychotherapy, affect and ANS regulation, and body-centred/somatic practice with RH processing), SAP pairs well with numerous modalities, and can often provide a framework to understand what is happening in the body and ANS, the attachment system, and the therapeutic dyad, that can deepen the clinician’s understanding and increase the traction and effectiveness of clinical work. I see many creative pairings where students apply SAP to: art and play therapy, family systems work, couple therapy, narrative therapy, EMDR, and analytic or psychodynamic oriented work.
If applicable, are there any clients/client concerns it should NOT be used with?
I think what’s more apt is that the way in which the work looks will differ with different populations, presentations, and clinicians. For example, understanding what is happening in the ANS, (client and therapist), and how this impacts what is happening clinically is imperative no matter who we are sitting with. Having said this, the training is oriented to working with clients with relational and incident trauma. More severe presentations of mental health disorders are beyond the scope of the training, and additional specialization would be necessary for people working with these populations.
Where can I learn more?
Upcoming trainings and workshops can be found at www.bringingthebody.ca, where you’ll also find links to published articles about Somatic Attachment Psychotherapy, blogs, and a graduate referral list.
References
Bakermans-Kranenburg, M. J., & van IJzendoorn, M. H. (2009). The first 10,000 Adult Attachment Interviews: Distributions of adult attachment representations in clinical and non-clinical groups. Attachment & human development, 11(3), 223-263.
Incident trauma enters our lives unanticipated and uninvited. It ruptures the fabric of life and can be devastating—whether it be motor vehicle collisions, medical diagnosis, assaults of any kind, natural disasters, accidents, illnesses, loss, and the list goes on. As therapists, we need to be cognizant not only of the intense disruption and dysregulation to the autonomic nervous system (ANS), but we need to be aware of the disruption to identity that often comes with the experience. The loss of self, the loss of who I was, who I am, and who I can become, can be called into question, depending on the type and severity of the trauma, the disruption, and the injuries—psychological, neurophysiological, and physical.
One of the things I talk about as a trauma therapist and educator, is that the theory and process of metabolizing incident based traumatic material is relatively straight forward, particularly when there is a secure base, as there is with secure attachment—where there is a foundational integrity of the integrative functioning within the self. Often healing or resolution gets stymied when working with a person who has an underlying insecure attachment, where there is a deficiency in the integration capacity in the bodyself. This is when we as therapists, are called not only to travel to the abyss of trauma itself, but to negotiate that journey with a psyche and ANS that have foundational injuries that unconsciously thwart the integration of material. Kalsched (1998) aptly captures this dynamic: “for the traumatized psyche, integration is the worst imaginable thing, apparently equivalent in the ‘mind’ of the defending Self to some early horror—never to be repeated. It is as though integration threatens a re-experience of the ‘unthinkable’ affect. Therefore, connections among the components of experience are attacked in true ‘auto-immune’ fashion” (p. 89). These defenses are employed to maintain some stability in the system and to protect the psyche from re-experiencing the unbearable anguish of the affective experience of the trauma—the terror, pain, and unknown. For the insecurely attached system or psyche, the processing of traumatic material is threatening—too threatening for the systems to allow it to emerge, to surface, and involuntarily, unconscious defense structures emerge to shut down the process.
As clinicians, we also need to be cognizant of ramifications of what happens after a traumatic event, and the myriad of ways in which people’s early relational dynamics may be replicated as they navigate their post trauma reality. For some folks who have to interact with insurance companies (disability or otherwise), the medical and legal systems, employers, and other institutions, they may experience the recapitulation of their relational dynamics of early life. This can be particularly potent when interfacing with overburdened or profit driven systems, where they are left to languish unattended and in the unknown, a familiar abyss for some.
The Canadian healthcare system is a prime example, where people often wait for months to over a year for diagnostic imaging, access to specialists, and for adequate pain intervention and management, all of which can feel like there isn’t anyone to help them, evoking experiences that: no one cares, they don’t matter, no one sees them, etc., which may be reminiscent of early experiences wired into their internal working model. We can also see replication of early life experiences activating feelings that: there’s not enough for me, I have to manage this on my own, there is no relief, I don’t know what to do to make it better, to feel okay, to be safe—all of which can incite fear, anger, and/or helplessness for people, and complicate healing.
When people land in our clinical practice, we as therapists must be aware of the post trauma context in which people are living. For some clients, they may feel unmoored and unsafe, due to the recapitulation of early relational injurious experience, which destabilize them and needs to be attended to in the treatment process. In attending to our clients with this larger lens, and being tuned to the underlying relational security, or lack thereof (as with insecure attachment), therapists are better able to understand the complexity of processing traumatic incidents when there is underlying relational trauma.
References:
Kalsched, D. E. (1998). Archetypal affect, anxiety, and defence in patents who have suffered early trauma. Post-Jungians Today, 84 – 104.
