Conference on Trauma, Dissociation and Psychosis 31 May 2017 Janina Fisher, Ph.D.

1. 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

2. If we use a trauma lens... Jenni Thompson, 2013

3. 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

4. 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

5. 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

6. Threat and the Brain Limbic System or Emotional Brain: perceives and reacts to threat Frontal Cortex: analyzes, problem-solves, learns from experience Threat Reptilian Brain: controls our instinctive responses and functions Amygdala Fire Alarm and Emotional Memory Center Sensorimotor Psychotherapy Institute

7. 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 Patient is affectively and autonomically dysregulated Parasympathetic Hypoarousal 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 Ogden and Minton (2000); Fisher, 2009 *Siegel (1999) Sensorimotor Psychotherapy Institute

8. Unsafe Behavior and Trauma 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 Leads to more self-injury, more rigorous restricting, harder drugs to replace the substances that no longer work. The client feels more desperate, not less Resulting in more flooding, shame, panic, rage, hypervigilance Finally, the fear of the emotions is more terrifying than the fear of suicide or homocide Triggered by everyday stimuli, the client becomes overwhelmed, reactive, impulsive without awareness reactions are ‘memory’ Even more strenuous attempts at avoidance As isolation impairs stimulus discrimination, the client is more easily triggered S/he flees by isolating, avoiding potential triggers

9. Assumptions of Neurobiologically-Informed 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

10. 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

11. “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 curiosityby 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 symptomsFisher, 2017

12. 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

13. 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

14. 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

15. 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

16. Therapeutic Bottom Up Processing S Clients learn to observe & describe present experience in simple words Instead of talking about experiences We teach the client to notice the habitual movements, postures, or inner body sensation as these unfold in the moment Clients are taught to be curious about what they notice & experience Instead of interpreting 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. Sensorimotor Psychotherapy Institute™

17. “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

18. 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 (Grigsby & Stevens, p. 325) Sensorimotor Psychotherapy Institute

19. 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

20. 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

21. 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

22. 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

23. 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

24. “[The restoration of] competence is the single biggest issue in trauma treatment” Bessel van der Kolk, 2009

25. Teaching the Skills to Regulate Arousal Within the Window of Tolerance Interventions Hyperarousal • Psychoeducation • Curiosity • Mindfulness • Differentiating body, thoughts, feelings • Identifying triggers • Tracking patterns as ‘interesting’ data (EMS) • Tracking arousal • DBT/CBT skills • Somatic skills Then regulate the arousal Notice the triggering Hypoarousal Ogden 2006; Fisher, 2009 Sensorimotor Psychotherapy Institute

26. Experimenting with Somatic Resources for Traumatic Reactions Traumatic Reactions: Shaking, trembling Numbing Muscular hypervigilance Accelerated heart rate Collapse Impulses to hurt the body Disconnection, spacing out Resources: Slowing the pace Sighing, breathing Lengthening the spine Hand over the heart Grounding with the feet Clenching/relaxing Movement, gesture Sensorimotor Psychotherapy Institute Ogden, 2000

27. 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 . . . butto avert distress by maintaining the infant’s interest and engagement in a positively toned dialoguewith the social and physical environment.” Hennighausen & Lyons-Ruth, 2005

28. “Maximizing positive states” Picture: Interactive psychobiological regulation

29. 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

30. 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 tocalm 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

31. “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

32. “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

33. “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 BobrowComing Home Project

34. For further information: Janina Fisher, Ph.D. 5665 College Avenue, Suite 220C Oakland, CA 94611 USA DrJJFisher@aol.com www.janinafisher.com Sensorimotor Psychotherapy Institute www.sensorimotor.org