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How to Work with the Traumatized Brain Bessel van der Kolk, MD - TalkBack - pg. 1

Rethinking Trauma

How to Work with the Traumatized Brain

a TalkBack Session with

Ruth Lanius, MD, PhD; Ron Siegel, PsyD; and Ruth Buczynski, PhD


Table of Contents

(click to go to a page)

What Stood Out Most ........................................................................................... 3

How Practitioners Can Help Patients to Re-Connect .............................................. 6

Viewing Trauma as an Interpersonal Issue ............................................................. 9

How to Best Teach Our Patients about the Functioning of the Brain .................... 11

About the Speakers ............................................................................................... 13

with Ruth Buczynski, PhD; Ruth Lanius, MD, PhD; and Ron Siegel, PsyD

A TalkBack Session: How to Work with the Traumatized Brain


Dr. Buczynski: That was an incredible webinar. I can't wait to hear what the two of you think about it and get

your insights – there was so much there.

We're starting our TalkBack session now. I am joined, as I have been for the last two weeks and will be

throughout this series, by Ron Siegel and Ruth Lanius.

Ron is a psychologist and assistant clinical professor of psychology at Harvard Medical School. He's also

author of The Mindfulness Solution: Everyday Practice for Everyday Problems.

Ruth is a physician as well as a neuroscience researcher. She is professor of psychiatry at the University of

Western Ontario in London, Canada. She is the author of Healing the Traumatized Self: Consciousness,

Neuroscience, and Treatment.

What Stood Out Most

Dr. Buczynski: Let's start like we always do and I'll ask you both about what stood out to you most in the

webinar tonight. We'll start with you, Ron.

Dr. Siegel: Having followed Bessel's work for some time now, since he's such a leader in the field, I'm just so

impressed by how he continues to grow in scope and continues to

be more and more integrative in a way that not only makes sense

out of so many aspects of trauma, but gives us such a wide toolkit

for how to approach people who are suffering from trauma.

He shows us in such clear ways why folks who've been traumatized

have this enhanced threat perception – they see the world as frightening and they're on alarm. They have a

reactive alarm response to ambiguous stimuli across the board.

He shows us how they wind up dampening their reactions to pain, and not really feeling pain very well, at the

most extreme end, which is a kind of vagal nerve shutdown. He resonates with and draws on the work of

“Bessel’s work gives us such

a wide toolkit for how to

approach people who are

suffering from trauma.”

A TalkBack Session: How to Work with the Traumatized Brain

with Ruth Buczynski, PhD; Ruth Lanius, MD, PhD; and Ron Siegel, PsyD


Stephen Porges in regard to the shutting-down reaction. That makes so much sense out of people's

experience.

I also thought Bessel’s emphasis on imagination, which we don't hear so much about, was really interesting.

His study that he'd done years ago with the Rorschach where he found that many traumatized people see

very little in the Rorschach reminded me of many of my patients with trauma histories, who have a corollary

to that, which is, "I don't really remember my childhood."

Think of how often we hear that in clinical work – this kind of shutting-down, and yet that's not the only

response because sometimes people are visited by the demons. Sometimes they look at the Rorschach and

it's an "Oh my God" response. It's either hypersexualized or hyperviolent, or for that matter, they're flooded

with these kinds of memories.

Bessel helps us to understand how these things fit together.

He helps us understand, which doesn't get mentioned that often, what the analysts used to call repetition

compulsion, and how very often that is just an attempt to feel alive in some way.

When people are shutting down – when they're either having the

vagal response or just shutting down to pain, they desperately want

to feel alive in the world.

One way to get that juice going is to in some way approximate a re-

creation of the early trauma because that's still alive. We see that so

often in our patients.

Bessel also points out that while they’re doing that, it's not a great experience. As he put it, the thalamus isn't

online very often so they're getting bombarded by these different thoughts, images, and sensations, but

they're not well coordinated nor is a person really aware of where they are in time – if they’re in the present

or the past. So, it's certainly difficult.

I'll just mention a couple of other ideas – he was so comprehensive. His emphasis on Broca's area, where I

don't think he quite used this phrase, but he talked about the way people act like “a deer in the headlights"

when they become actually speechless when confronted with trauma or with the memory of trauma.

Finally, Bessel talked about the critical role of attachment, which I'm sure we'll talk more about, but he so

“When people are shutting

down – when they're either

having the vagal response

or just shutting down to

pain, they desperately want

to feel alive in the world.”


emphasizes the need for a responsive, caring, social interaction to

get us through the trauma.

Dr. Buczynski: How about you, Ruth? What stood out to you?

Dr. Lanius: I completely agree with what Ron is saying.

I also felt that the integrative approach that Bessel brings to his work and how he's able to push the

boundaries of the field are impressive.

I've known Bessel for a long period of time. I was actually a student with him in the late 90s in Boston, so it's

great to see how he's continued to push the boundaries of the field – to help us question what we're doing

and helping us to adapt or gain new information. That's really admirable.

He teaches us how people with a history of trauma lose their sense of curiosity – how they're just overcome

by fear and all they can do is pay attention to how to survive and how that kills any capacity for curiosity or

any capacity to experience pleasure, which are essential treatment components to help people overcome the

traumatized experience.

He does a beautiful job of giving us his brain analogy to trauma. He talks about the alarm detector as the

amygdala, the cook as the thalamus, and the watchtower as dorsal medial prefrontal cortex, and we'll talk

about this later on in one of the questions, but this kind of analogy can help people to understand what their

brain is going through.

It can help make an invisible injury, which mental health problems are, visible, and that can take away a lot of

the stigma.

It can also be extremely validating for people who have an out-of-control brain and out-of-control

experiences to understand that it’s OK – their experience may be related to an overactive amygdala. Their

experience may be related to their thalamus not being in proper contact with the outer mantle of the brain

cortex, and therefore, they I can't make sense of information.

The watchtower, or the dorsal medial prefrontal cortex, not being active or active enough is the reason that

they can't reflect on an experience, or the reason they get caught in these flashbacks or emotions.

They can understand why they can't take a step back. Bessel brings a lot of explanatory power to what

people experience with traumatic events.

“The integrative approach

that Bessel brings to his

work and how he's able to

push the boundaries of the

field are impressive.”


How Practitioners Can Help Patients to Re-Connect

Dr. Buczynski: I'd like to ask both of you about how many traumatized patients dampen their responses and

they do that to not experience – not to feel or re-feel all of the pain that they're in – but that also dampens

pleasure, their connection to the world and to the people in their world.

How can practitioners help patients reconnect?

Dr. Siegel: That's a great question and often neglected. The excitatory or the fear-based responses to trauma

are more obvious to us – we see it with the person with the exaggerated startle response or with the person

who's always having anxious fantasies and catastrophic fantasies

about what's going to happen to them.

Sometimes these more dampening responses are subtler, and

they're a little bit harder to see because they don't look

necessarily like a problem at first glance.

As you pointed out, they're a subset of the much larger human

tendency to want to avoid painful experiences – to have ways to step back or detach from, shut down or

dampen painful experiences.

As you and I have discussed in some other contexts, while typically it's nice in the short run, the long run

consequences of that aren't so nice.

While we manage to escape some pain, we also can get ourselves stuck in a disorder. Folks who've

experienced bad trauma get most stuck because it's very dampening, and as

you mention, the trauma experience shuts us off from connection.

It shuts us off from being with other people, and of course, this is natural.

How many of us after losing a love relationship think, "Oh, what I really want

to do is fall in love again and get a broken heart." None of us would want this.

So, it makes perfect sense to step back, detach, or shutdown. But

what we've learned from Bessel is that social interaction is the

critical, critical system for being able to regulate our emotions – we

need to feel held and we need to feel safe.

“If we’re dampening responses

are subtler, and they're a little

bit harder to see because they

don't look necessarily like a

problem at first glance.”

“The trauma

experience shuts us

off from

“Social interaction is the

critical system for being able

to regulate our emotions.”


If we're dampening down on social contact to keep, in essence,

our heart from being broken again or to keep from being violated

in some way again, we're going to lose this totally important

resource.

And worse or potentially worse is what Bessel points out to

counteract the dampening: people will be drawn to re-create the

trauma.

They will look for things that have a lot of excitement to them or have a lot of danger to them, and often

they'll put themselves in circumstances where they're actually re-traumatized. They get assaulted again or

they get involved in violence again – something terrible happens to them once again.

So, the alternative to this is to do what we've talked about before, which is to find a way to reconnect with

inner experience so as to be able to connect with outer experience.

One vehicle for this is doing some kind of mindfulness practice that gets us in touch with what's going on.

We've discussed at another point using the body scan to do this as a kind of safe and structured way to go

through the different parts of the body to help the person to get in touch with their inner experience.

The key here is to either make it structured enough with the interpersonal contact with the therapist, or

structured enough with contact with nature or the outer world so the person doesn't become overwhelmed.

If in a sense they have a good reason for having shut down on their experience because at one point,

certainly, it was too painful for them, then we need to be mindful as we're helping them to be more mindful

that they do it in an incremental way with a lot of structure and support.

It’s important that clients who have been traumatized don't get lost in the opposite of shutting-down and

become triggered by a flood of memories and feelings that would

be too difficult to bear.

All of this is toward the goal of getting in touch with oneself in

order to be able to get in touch with and connect with others.

Dr. Buczynski: Thanks. Ruth, how about your thoughts? How can

practitioners help patients reconnect after shutting down?

“If we're dampening down on

social contact to keep our

heart from being broken again

or to keep from being violated,

we're going to lose this totally

important resource.”

“It’s important that clients

who have been traumatized

don't get lost in the opposite

of shutting-down and

become triggered by a flood

of memories and feelings.”


Dr. Lanius: I agree with the fact that the lack or the inability to experience joy and pleasure is one of the most

devastating consequences of trauma. So how can we help people to re-engage with those experiences?

We also need to think about the sense of self people often experience as a result of chronic traumatization

and the incredible self-loathing experiences that we often see.

Doing something negative or repeating the trauma is very

congruent with how people view their sense of self.

How can we bring positive experiences online?

Psychoeducation is absolutely the key to helping people

understand that what they are feeling is normal.

We also, as Ron was saying, have to bring these positive experiences online slowly – warning them that if

they bring them on too fast, that often what we see is a negative effect of interference where they start to

experience something positive and all of a sudden, they are flooded by negative emotion.

It's really important in therapy to prevent that, so how do we go about this in a matter of fact way?

When we take a history, it’s important not only to ask people what's wrong with them, but to take a detailed

history of what some of their positive experiences have been. Was

there a teacher at school? Was there a secure care-giver you had at

any point? Or was there a friend who you felt safe with?

These are histories of safer attachments, but it’s important also to get a

history of when the person may have felt competent in their lives. For

example, was there a sporting activity that you felt you were really

good at?

We can then use imagery to help people bring back those memories and start to reconnect to those positive

emotions. Again, we want to keep in mind that it has to be, as Ron

said, titrated very carefully because we don't want them to get into

those negative emotional states.

Over time, what we often see clinically is that people slowly learn to

tolerate those positive emotions, step-by-step – bit-by-bit.

“When we take a history,

it’s important not only to

ask people what's wrong

with them, but to take a

detailed history of what

some of their positive

experiences have been.”

“Psychoeducation is absolutely

the key to helping people

understand that what they are

feeling is normal.”

“We can then use imagery

to help people bring back

those memories and start

to reconnect to those

positive emotions.”


This is also when we see their bodily sensations really changing and moving from a sense of heaviness – a

leaden feeling – to a feeling of lightness, feeling happy sensations of warmth in their whole body and their

whole being – and not having constipation anymore.

Often that also translates into people wanting to move more – people wanting to dance. Again, this is a

whole-person approach.

We’re working with the mind-brain and always connecting it with the body.

Viewing Trauma as an Interpersonal Issue

Dr. Buczynski: Ron, what are your thoughts about viewing trauma as an interpersonal issue? That's one of

the thoughts that Bessel suggested.

Dr. Siegel: That's absolutely critical. We were discussing this a little bit in the context of Stephen Porges when

he points out an important part of what the vagus nerve does.

It controls facial gestures that help us to communicate interpersonally – it is the social support that helps us

regulate our emotion.

So often when people experience trauma, they're cut off from that

social support. An example that comes to my mind of somebody I've

worked with recently, who unearthed a photograph of himself as a

relatively young boy, in which his older brother was forcibly pulling

down his pants – and somebody took a picture – and everybody in the

family is laughing, thinking that, "Oh, isn't this great fun?!"

It was quite painful for my patient to look at the photo because it brought up all these memories of moments

in which he basically felt abused, including some frank sex abuse on the part of the older brother and nobody

seeming to care – nobody seeming to provide any social support.

In fact, it was quite the opposite. He had a lot of traumatic childhood memories of being told he was too

sensitive, "Don't cry or I'll give you something to cry about," and the words, "You're a pussy," would always

rattle around in his mind as the ultimate insult.

“The vagus nerve controls

facial gestures that help us

to communicate

interpersonally—it is the

social support that helps us

regulate our emotion.”


The way we connect to other people when we're in pain is by

sharing that pain in some fashion, by telling somebody that this

hurts and having somebody say, in essence, "I understand” or “I

care about you."

He didn't have that kind of experience. In fact, he became completely afraid of that kind of social connection.

All of that became an interesting dynamic in setting up our

treatment because I try to be empathic and warm and not

judgmental in my approach: on the one hand, he craves and is

hungry for social support, but on the other hand, it makes him

feel weak, vulnerable, and he cuts it off and pulls back from it.

And that response is directly the result of all of those messages

that were given in and around his traumatic experience. What he

wound up doing much of his life was turning to substances to try to get comfort, and those, of course, have

all their own problems.

Interestingly, we talked about that. I remember being in a session with him and he was really feeling flooded,

and I said at one point, "Is it hard for you to have me be kind to you in this moment because it's going to

mean you're going to feel closer to crying?"

And he said, "That's exactly what's going on."

It's very, very difficult – he's so caught between wanting the social

connection and fearing the social connection that creates the

vulnerability.

The interpersonal connection is so critical. It's a critical part of our

treatment and I think Bessel's contribution to this is very helpful.

“The way we connect to

other people when we're in

pain is by sharing that pain.”

“On the one hand, he craves

and is hungry for social

support, but on the other

hand, it makes him feel weak,

vulnerable, and he cuts it off

and pulls back from it.”

“The interpersonal

connection is a critical

part of our treatment.”


How to Best Teach Our Patients about the Functioning of the Brain

Dr. Buczynski: Ruth, Bessel used an analogy. He talked about the smoke detector, the cook, and the

watchtower, as a way of talking to patients about the effect of trauma on their brain. What are your thoughts

on how we can best teach patients about the functioning of their brain under stress or with trauma?

Dr. Lanius: Again, as we talked about earlier, it’s incredibly

validating for people to realize that there's actually something

wrong – what's happening in your brain can explain some other

symptoms.

Often people have been told, "It's just in your head – get over it."

Psychoeducation is such an important part of helping people

understand and make meaning of what's happening.

With regard to the amygdala or the smoke detector, it's really

important for people to become aware of what’s going on. Even

though they may not be conscious of something affecting them –

the amygdala can still be overactive, even if they're not conscious of the information, and affect the rest of

their brain and their level of hyperarousal.

The thalamus or the cook of the brain is really key as it relates to a couple of concepts, and one is in regard to

flashbacks.

It’s important to understand that the thalamus very naturally oscillates around forty hertz and through those

oscillations and its connections with the cortex of the outer mantle of the brain, they start to oscillate

together.

If that happens, this allows us to experience, for example, a memory as an integrated experience.

Of course, this is what our PTSD patients often can’t do. They have these flashbacks that are sensory flashes,

but they're not experiencing the memory as an integrated memory.

In terms of the thalamus, and Bessel talks about this very eloquently, he tells how all sensory information,

except for smell, comes through the thalamus and then goes to the outer mantle of the brain where it's

“It’s incredibly validating for

people to realize that what’s

happening in your brain can

explain other symptoms.”

“Psychoeducation is such an

important part of helping

people understand and make

meaning of what's happening.”


integrated.

When we think about the shutdown responses, a different problem occurs with the thalamus.

We basically get a functional disconnection between the outer mantle of the brain, the cortex, and the

thalamus – we get no more sensory input from our bodies.

We actually don't know what's happening in our bodies, and of course, when we're severely traumatized –

during the trauma – this can be very helpful. We don't want to experience pain, and this is why we don’t and

how we can completely disconnect from our emotions.

But if this happens in the aftermath of trauma, it can be profoundly inhibiting of normal experiences.

So, how can we reconnect the thalamus and the cortex, so people can feel those experiences?

We've talked a lot about this in a number of webinars.

Lastly, we have the watchtower, the dorsal medial prefrontal cortex that helps us to know what we feel, and

again, this is an area that traumatized individuals are really disconnected from as well.

To know what we feel, to make sense of the experience – to make meaning of it – and to bring that online

slowly at a pace that's comfortable for people is so important.

Dr. Buczynski: Thanks. We're out of time, but thanks for joining us tonight. Take good care.


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 teaches 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.

About the Speakers . . .

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