F From my point of view, the polyvagal theory has so far provided us with the best working model for how trauma affects the brain and the body. According to this model, trauma affects both branches of the autonomic nervous system (sympathetic and parasympathetic), which include both branches of the parasympathetic (ventral and dorsal).
The sympathetic branch of the nervous system is associated with physical and emotional acceleration (such as increased fear, anger, breathing and heart rate); in case of danger this means "fight or flight". In contrast, the parasympathetic branch of the nervous system is associated with physical and emotional deceleration. More precisely, the ventral branch of the parasympathetic nervous system is associated with social commitment, while the dorsal branch is responsible for "resting and digesting" functions and for "freezing" in extreme threats. Freezing occurs when the organism is either mentally dissociated or, in more extreme cases, passes out.
In the event of danger, the various branches of the autonomic nervous system are affected in a certain order. The first branch affected is the ventral sub-branch of the parasympathetic nervous system, which is responsible for social engagement. In other words, when faced with a threat, social connectivity-related functions – laughter, smile, empathy, attunement, the ability to acknowledge – go offline. If the danger persists, the next affected branch is the sympathetic nervous system, which leads to fight or flight. When neither fight nor flight can mitigate the threat, the dorsal sub-branch of the parasympathetic nervous system is activated, resulting in freezing (a type of either mental or physical breakdown, such as dissociation or fainting). The following actions summarize this process:
Danger is felt.
Social engagement goes offline (ventral parasympathetic nervous system).
The danger remains.
Fight or flight is triggered (sympathetic nervous system).
The danger cannot be alleviated by fighting or fleeing.
Freezing reaction activated (dorsal parasympathetic nervous system).
The two pedals
Imagine the sympathetic as an accelerator and the parasympathetic as a brake. We need both functions on the motorway. If the ride is smooth, sometimes we will accelerate gently and sometimes we will brake gently. The same process applies to our physical, mental, and emotional functioning. When the "drive" is smooth, our mind and body enjoy a gentle oscillation between acceleration and braking.
This is even reflected in our heart rhythm. A healthy rhythm is indicated by a consistent repetition of fast / slow, fast / slow, fast / slow. The reason for this gentle oscillation is that the entire organism can accelerate further for a moment or break further, depending on the need. A heartbeat that is either constantly fast or constantly slow or irregularly fast / slow is not a healthy rhythm because these circulatory styles cannot account for the gentle oscillation between acceleration and braking required for a smooth ride.
Let us return to our driving analogy. If you are driving on the freeway and a truck is carelessly swerving in front of you, you will likely have all of the reactions the polyvagal theory represents: you can swear and flash your fingers (social engagement goes offline), you can suddenly step on the gas, or you can strike the breaks. But after the threat is over, you will most likely return to your baseline, gently swinging between accelerating / braking as needed – until the next threat again calls for more extreme action.
Now suppose you have seen so many roadside hazards that you choose never to be on your guard. At any moment you are ready to yell and yell at other drivers, accelerate unpredictably and brake unpredictably. If you are really exhausted, you can even try to accelerate and brake at the same time. Over time, this will become your new standard driving style, regardless of the driving conditions: berating everyone, suddenly accelerating, suddenly braking. (You may have noticed that this type of driving is common in some major cities.) See how this makes for a wild ride? Even if the driving conditions had otherwise been relatively calm, they will no longer be. And even if there would have been no other danger, now it is there. You go to the races …
A breakdown in the dialectic
This driving metaphor describes what happens to people who have experienced a chronic trauma: too much acceleration, too much braking and, on top of that, a loss of social commitment. This leads to a variety of responses that are either "too much" or "too little", leading to a variety of life complications. This tendency to too much or too little affects the following areas in particular:
awareness
Thoughts
Emotions
Reactions
Relationships
For each of these domains there can be either too much (overuse of the gas pedal or the sympathetic system) or too little (overuse of the brakes or the parasympathetic system). Too much awareness leads to hypervigilance, while too little leads to dissociation. Too much thinking leads to compulsive brooding, while too little leads to impulsive decisions. Too much emotional stimulation leads to overwhelm, while too little leads to numbness. Too much reactivity leads to even more crises, while too little leads to paralysis. Even relationships can be either too much or too little, resulting in either over- or under-dependence on others.
In short, trauma leads to all of the following possibilities: superconscious versus subconscious; Overthinking versus underthinking; Overemotional versus underemoting; Overreaction versus underreaction; and over-relationship versus under-relationship. Since both the sympathetic and the parasympathetic nervous system have been hijacked, the driver constantly over-accelerates and brakes in each of these areas – and often both at the same time.
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Restore credit
Dialectical behavior therapy (DBT) developed by Marsha Linehan aims to reconcile “dialectical dilemmas” (binary extremes that lead to dysfunction) by teaching specific behavioral skills to find a “middle ground” between to forge these extremes. In particular, DBT teaches the following five skills: mindfulness, stress tolerance, emotion regulation, dialectical thinking, and interpersonal effectiveness. These skills teach the middle ground between each of the dialectical dilemmas mentioned in the previous section.
As long as clients exist and operate in these extremes, it is extremely difficult for them to do even basic counseling – much less trauma work and much less life. It is for this reason that DBT, as a treatment model, is entirely skills focused. DBT teaches the basic skills you need to optimize counseling, stabilize yourself for trauma work, and then thrive in life – "building a life worth living," in the words of Linehan. Among dozens of skills that might be highlighted, I would like to introduce five simple acronyms that will help clients find – or forge – any of these middle paths.
The RAIN dance: A path to mindfulness
By definition, mindfulness is always a combination of awareness and acceptance. The RAIN dance helps clients increase both awareness and acceptance of intense emotions and other triggers in a very practical and applied way. RAIN stands for Recognize, Allow, Inquire and Nurture.
The purpose of this acronym is to help clients know exactly how to use mindfulness in a real situation. Let's say you want to help a client become more aware of their anger. First, teach your client to recognize their anger – and especially where it is felt on their body (e.g. when their jaws are clenched). Next, teach your client to let in their anger (instead of judging or resisting it, which will only make it harder to deal with in the long run). Then teach your client to inquire about their anger – with curiosity, empathy, and maybe even humor. (Fear and anger are neurologically incompatible with empathy, curiosity, and humor.) Finally, teach your client to be nourishing (i.e. walking through the woods) in a way. The emotional energy must be adequately discharged, especially if the intense emotion results from a fight-or-flight response; otherwise this energy is simply frozen – and then continues to emerge when it is triggered.
The basic idea behind this skill is simple: learn to "dance" with your emotions instead of avoiding them, resisting, suppressing or judging them.
TIP for the balance: A way to stress tolerance
DBT exercise tolerance is about learning to manage the moment without making it worse. The point is to replace impulsive, addictive, risky or self-harming behavior (i.e. any behavior that leads to an even stronger crisis orientation) with more effective coping strategies.
One of my favorite stress tolerance skills has to do with finding ways to upset my balance. Because there is such a direct and obvious connection between the mind and body, often the quickest way to change your mood is by quickly changing something in your body. If you can "tilt" your body chemistry, you can also "tilt" the balance on your emotions. There are three ways to quickly TAP your body chemistry: temperature, intense exercise, and gradual breathing / pairs of muscle relaxation (this refers to tensing your muscles when you inhale and relaxing your muscles as you exhale).
Although each of these techniques is effective on its own, they can be even more effective together. For example, I personally type to balance my life by riding a bicycle. This activity helps me to change my body temperature quickly, requires intense physical exercise and helps me to synchronize my breathing (inhale / exhale) with my muscles (tense / relax) through the cyclical nature of pedaling.
Saat your SEEDS: A way to regulate emotions
While stress tolerance refers to short-term coping in the moment, emotion regulation refers to a long-term change in lifestyle that ultimately supports a much healthier emotionality. When teaching clients emotion regulation skills, I use an extended garden analogy. For example, if you wanted to have a healthy flower garden, would it make sense to yell and curse at the flowers? Are you ignoring the flowers? What a shame about the flowers? Forcing or manipulating the flowers? Of course not. Your flowers do not have to be controlled – they have to be cultivated.
The same concept applies to our emotions. Instead of trying to control them, we need to take care of them – like beautiful, delicate flowers. (By the way, it makes me wince every time I hear therapists – and even DBT practitioners, no less – rewrite emotion regulation as "controlling your emotions.") There are several things you need to do to create a real garden To care for: sow the correct seeds, weed, check the soil, continue to care for the garden even if you are about to give up, and fertilize. Each of these activities represents a specific way of caring for our emotions. Here I am just introducing the first one: you need to plant the right SEEDS.
Planting the right SEEDS relates to five ways of taking care of your physical body: symptoms, food, exercise, drugs and sleep. If you want to have a healthy garden of emotions, you need to plant each of these seeds by addressing physical symptoms, finding healthy eating habits, getting moderate exercise, monitoring what drugs are getting into your body, and getting adequate sleep. After helping my clients develop a specific plan for each of these "seeds", I often send me a short SEEDS report at the beginning of each session as part of their weekly check-in.
Working on the TOM: A Path to Dialectical Thinking
Dialectical thinking is about letting go of the extremes, thinking more in the middle, being more flexible with one's cognitions, seeing things from someone else's perspective, learning to see things from multiple perspectives in one's own head and learn to update your beliefs as new information is presented to you.
When I teach clients dialectical thinking, I use a very simple process: We work with the TOM, which stands for Thought, Opposite and Middle. First, we identify the original problematic thought. Next, we identify the completely opposite extreme of this realization. Finally we consider a possible belief somewhere in the middle.
Suppose a client has the original problematic thought “I am not good at anything”. The complete opposite would be: “I've never made a mistake. I am absolutely flawless. I'm the most competent human specimen that has ever existed. ”And something in the middle could be,“ There are some things that I'm good at, but there are also many things that I have to work on. ”
The purpose of this exercise is to help clients quickly identify a finding that is most likely much more accurate than the original belief. Clients may not always be able to come up with a middle thought on their own, so it is perfectly okay to help them first. Ultimately, however, it is better if clients can generate their own middle thoughts, since everything they produce is inherently more believable than anything you can come up with. Even if the client insists that they don't believe the middle thought they generated, chances are that part of them does – because those words came out of their head. Regardless, your job is not to convince your customer that the middle thought is more accurate; it is easy to plant the seed for this thought and then let it germinate on its own.
In fact, the more the client struggles with the middle thought, the more he thinks about it, and therefore reinforces the new knowledge.
Dear adult: A path to interpersonal effectiveness
While all the other abilities mentioned so far relate to self-regulation, interpersonal effectiveness naturally involves both the self and someone else. Hence, interpersonal effectiveness naturally subsumes the other abilities. After all, you cannot possibly deal with another person if you cannot even deal with yourself.
Here I would like to introduce what is perhaps the most comprehensive ability for interpersonal effectiveness: DEAR Adult. D stands for Describe: First, describe the situation that needs to be addressed. Just give the facts and really focus on the situation, not the person. Next, express how you feel about the situation. Use “I feel” statements. Again, really express what you think of the situation, not the person. Sometimes it can be helpful to use a “float back” and express how you have felt in similar situations in the past, so that both you and the other person understand that it may go beyond the current situation. If you want to be extra dialectical, use that E to empathize with each other's perspective as well.
Now you can continue with A, which stands for Assert. Use “I need” statements when making the statement. Specifically, explain what you need positively, not negatively; Explain exactly what to expect from the other person, not what to stop. Also, if you want to be even more dialectical, use the A to appreciate the other person's perspective and even to apologize for your role in this situation.
R stands for reinforcement. You want to end on a positive, upbeat note by affirming both your request and the relationship itself. In my opinion, the best way to reinforce both is to explain that what you are asking for is a win-win offer. They just want what's best for both parties. Hence, you are ready to continue negotiating and compromising if necessary.
After all, you want to do all of this with the adult voice, which is the dialectic (the middle ground) between the parent's voice (screaming, teaching, abusing) and the child's voice (whining, pouting, a fit of anger). . The adult's voice is when you communicate calmly, collected and collected.
Abstract
Persistent trauma leads to an overstimulation of both the sympathetic and the parasympathetic nervous system (accelerator and brake), which leads to a large number of reactions that are either “too much” or “too little”. The five skills taught in DBT help restore the balance between these extremes by providing a middle ground that involves reactivating the social engagement system. Therefore, when I explain DBT to my clients, I mostly avoid clinical jargon and simply refer to this model as the “development of balance therapy”. In this article I have briefly presented five skills (under Legion) as examples of these middle paths: RAIN dance as a form of mindfulness; TIP balance as a form of stress tolerance; Sow your SEEDS as a form of emotion regulation; edit the TOM as a form of dialectical thinking; and DEAR Adult as a form of interpersonal effectiveness.
To be clear, DBT was not designed to resolve the original trauma. Countless models have been developed for trauma processing. Some models are more focused on verbal processing and are commonly referred to as "top-down models". Other models focus more on somatic processing and are commonly referred to as "bottom-up models". Some clients prefer verbal forms of processing, some clients prefer somatic forms of processing, and most clients can benefit from both, so there is (in my opinion) no need to have endless debates or pointless turf wars on this point. My recommendation is simple: get trained in at least one form of trauma processing, which is mostly top-down, and at least one form of trauma processing, which is mostly bottom-up – and master both. (Another dialectical dilemma has been solved.)
However, no form of trauma processing can be fully effective if the individual is actively in a crisis, experiences a persistent danger or is constantly dysregulated. This is where DBT comes in. DBT (which I like to call "Balance Therapy Development") provides the skills necessary to help the individual stabilize or self-regulate sufficiently to then move on to deeper trauma work.
If you want to learn more about the use of trauma-focused DBT for a variety of trauma-based disorders, I recommend the following resources to get you started:
The Dialectical Behavior Therapy Skills Workbook for PTSD: Practical Exercises to Overcome Trauma and Post-Traumatic Stress Disorder by Kirby Reutter, 2019
"DBT for trauma and PTSD" (DBT expert interview series on psychotherapyacademy.org/dbt-interviews)
Survival Kit: Treatment Guide for Individual, Group, and Family Counseling by Kirby Reutter, 2019
Webinar "The Journey from Mars: Brain Development and Trauma" (youtube.com/watch?v=WSFqHS_axOc)
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Kirby Reutter is a bilingual clinical psychologist and licensed mental health consultant who has signed an agreement with the Department of Homeland Security to provide mental health services to international asylum seekers has completed. He has conducted four training sessions for the U.S. military, is a TED spokesperson, and is the author of The Dialectical Behavior Therapy Skills Workbook for PTSD: Practical Exercises for Overcoming Trauma and Post-Traumatic Stress Disorder. Contact him at [email protected] or through his website at drkirbyreutter.com.
Counseling Today reviews unsolicited articles written by members of the American Counseling Association. For writing guidelines and tips for accepting an article for publication, visit ct.counseling.org/feedback.
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Opinions and statements in articles appearing on CT Online should not be construed as the opinions of the editors or guidelines of the American Counseling Association.
