Traumatic injuries - a major challenge for psychotherapy

Leitmotif: There is no present and no future. Just the past repeating itself over and over again.

1. Introduction

In our work as therapists, we are increasingly confronted with patients with repressed trauma. In the following lecture I would like to show a path in trauma therapy which is significantly influenced by the knowledge of neurobiology and early developmental psychology.

In the following lecture I will primarily refer to the books by Peter A. Levine, «Trauma and Memory, How we understand and process traumatic experiences», published in Germany by Kösel in 2016 (the original title of the English edition from 2015 is "Trauma and Memory: Brain and Body in a Search for the Living Past: A Practical Guide for Understanding and Working with Traumatic Memory), and Joachim Bauer, «The Empathic Gene», published by Herder in 2021.

It is imperative that we spread this knowledge more and more, because traumatic experiences bring unspeakable suffering to children and adults in many different ways. Often these people get stuck in their traumatic experience without therapy and suffer from the worst mental illnesses. At the beginning of the therapy we are confronted with post-traumatic syndromes and our first task is to really work our way up to the experienced trauma.

In the lecture I will first describe the devastating physical and mental destruction. Then I will show how the memories of trauma are pushed down into the depth of our brainstem and are no longer accessible to us. Finally, I will provide a way to help a person process their trauma so they can live their own life.

The goal of the therapeutic work is for traumatized people to be able to self-regulate the flood of emotions with the help of the therapy, should the trauma unexpectedly reoccur.

2. Experienced trauma severely destroys the soul, body and spirit.

As early as 100 years ago, the neurologist Jean-Martin Charcot made the strange observation that his hysteria patients showed behavioral patterns that he and his colleagues could not make sense of. Gradually, Charcot realized that the signs of paralysis, convulsions, fainting, the sudden collapse, the mad laughter and the dramatic outbursts of tears did not fit with the disease known as hysteria.

Charcot concluded that these strange movements were the physical and psychological aftermath of experienced trauma. As a result, his student Pierre Janet was the first to write a book (L'automatisme psychologique), in which he gave an early description of post-traumatic stress disorder.

Janet considered the topic of recollection the first and foremost question in dealing with trauma:

An event becomes traumatic only when overwhelming emotions interfere with the proper processing of memory.

After experiencing trauma, people react with panic fear, although the current situation does not justify such reactions. Unprocessed trauma keeps returning through inadequate behaviors that represent the traumatic memories.

Traumas are not stored as normal narratives from the past, but as bodily sensations that we experience as an imminent threat to our present life.

The difference between ordinary memories (everyday events) and traumatic memories (recurring bodily sensations and movements accompanied by intense emotions of fear, shame, anger, and resignation) is that the latter damage the brain areas responsible for creating autobiographical memories.

Janet's revolutionary conclusion, which is still valid today, is that traumatized people remain stuck in the past and relive the horror of the trauma over and over again. Unable to relegate their bad experience to the past, the traumatized are preoccupied with channeling all their energies into constantly keeping the threatening emotions in check. They are thus unable to focus their attention on present demands.

An experience is traumatic when the human organism does not have the necessary resources to integrate the experience, but is overwhelmed and reacts with helplessness and paralysis.

If you can do absolutely nothing to change the outcome of events, the whole system collapses.

At the time, Sigmund Freud also worked with Charcot, and at the beginning of his career he also pursued research into trauma theory. He said that traumatized people could no longer remember their traumatic experiences, but would act them out in their current behavior. Acting out causes the trauma to reoccur over and over again. Freud suggested that acting out was a form of remembering the trauma.

Unfortunately, Freud left this path of trauma research and turned to drive theory (Oedipus complex).

Peter Levine believes that the path to trauma resolution is both coming to terms with the physical paralysis and turmoil and the essential need to confront the helplessness experienced. In addition to physical activation, it is important to report on what was experienced. This verbal measure creates a narrative, a story that is told, that helps a person understand what happened.

Later in my lecture, I will describe this way of resolving traumatic experiences in more detail.

Today, if one takes traumatic injury seriously, one must recognize that the entire organism—body, mind, and spirit—is stuck in trauma, so to speak, and it continues to behave as though there clearly were a danger in the present.

3. The relation between memory and recollection (memories)

We have known for a number of years that we do not store our memories in just one place in the brain, but that the system is complex.

We distinguish between explicit and implicit memory. In explicit memory we store memories that we can access more or less autonomously and consciously. But here, too, we are selective. The psychoanalyst Alfred Adler had the following to say about this procedure: "There are no 'chance' memories: Out of the incalculable number of impressions that an individual receives, he/she chooses to remember only those which he/she considers, however dimly, to have a bearing on her problems."

Research has been underway for some time on whether memories remain unchanged and correspond to facts. It has now been found that memories are more ephemeral and constantly changing shape and meaning. Memory is not a circumscribed phenomenon, not a solid edifice anchored in a stone foundation and set to stand there permanently. Memories are at the mercy of interpretation and confabulation.

Remembering implies constant reconstruction. Reconstructing entails a process of continually selecting, deleting, rearranging, and updating information. This occurs as a normal process of adaptation to enable life and survival. Our current emotional state is the main factor that determines what we remember and what sticks in our minds about a particular event. Our feelings, our sensations and physical experiences are thus the main triggers that activate our memories.

Before we get into the specifics of how traumatic memories work, I'd like to describe the graph above in more detail.

Our memory system is divided into two main areas: explicit memory and implicit memory.

Explicit memory is divided into declarative memory and episodic memory.

Facts are primarily stored in declarative memory. They are not emotional. Our experiences are stored in episodic memory. It's about a story that we experienced. These stories are emotionally colored and more exciting than the facts. But we also don't function without neutral knowledge. The stories of episodic memory are subject to the changes described above. So it often happens that we make up narratives and actually believe they happened. All that remains is the sober realization that we store our stories in our minds as we please and then play them back. Our episodic memory is not a video recording.

Bottom line: Memories form the foundation of our identity. Among other things, we attach our humanity to them. Memories are a magnetic compass that guides us in unfamiliar situations. They help us by providing context for newly emerging experiences. This foundation enables us to secure our future, even if it is influenced by our history but not unduly constrained by it.

Continuity is created through recollection by which we create a thread connecting the present and the past.

This way we can learn from our history and shape a more beneficial future for our lives.

These memories are colored by emotions (negative and positive), but they are responsible for triggering and promoting learning processes.

Episodic memories are often colored with all shades of emotions and bursting with vitality, whether positive or negative. They are richly encoded concentrates of our personal life experiences. Owing to this property, episodic memories form an interface between the rational and the implicit, emotional dimension. Forming coherent narratives is due to the ability to compose episodic stories.

The therapy goals with regard to traumatized people are to link and process raw emotions with nuanced feelings, with facts and with communication with people of our choosing.

The second memory formation is called implicit memory. This area of memory is unconscious and not accessible to us cognitively. On the one hand there is emotional memory and on the other hand procedural memory.

Implicit memories are radically different from both 'cold', declarative and 'warm' episodic memories: they are 'hot' and irresistibly pull us along.

Implicit memories elude our consciousness. They cannot be called up in a targeted manner; rather, they suddenly rise up in an amalgam of bodily sensations, emotions and behaviors.

They organize themselves around emotions and trigger bodily sensations called "action patterns". There are primary constitutional emotions such as surprise, fear, panic, aggression, disgust, sadness and joy. These emotions have an evaluative and action-triggering function. They are closely related to procedural emotions. Emotions provide information relevant to survival as well as information of a social nature. The mind would be far too slow for that (relative illustrations in Joseph Le Doux, 1996). Therefore, emotional memory is central to our personal survival and that of our species.

Bottom line: Emotional memories are generally triggered by features of a present situation (somatic markers, Antonio Damasio).

As a rule, the purpose of these emotions is to store memories from the past in the procedural memory, so that fixed patterns of action are formed that ensure survival.

Positively, emotions also have a social meaning. On the one hand they signal to others what we feel and need, on the other hand they are a signal to ourselves by being able to perceive what we feel and need. These emotions are the basis of empathy. Through intersubjectivity we relate to other people by creating resonance in the other.

Emotions are a concise form of exchange in relationships of any kind, they are primal knowledge. Through the central role of social emotions, we facilitate relationships with others and with ourselves.

Peter Levine describes the nature of procedural memories with this memorable quote:

What the mind has forgotten, the body has not, thankfully (Sigmund Freud)

Procedural memories are impulses, the movements and sensations within the body that guide us in how we act, in our abilities, and in attraction and repulsion. Procedural memories can be divided into three broad categories:

a.Learned motor processes: For example, cycling

b.Well-established contingency measures that spring into action in the face of a threat, namely basic survival instincts. If these emergency programs go haywire, this breakdown plays a crucial role in the creation of traumatic memories.

c.A third category of procedural memories produce organismic response tendencies towards approach or avoidance, attraction or repulsion. We also describe these reaction patterns as the most important motivational systems: approach and avoidance. In the avoidance mode we tense up physically, withdraw, in the approach mode we have the need for expansion, going outwards and actively turning to the environment.

These movement patterns in the direction of approach or avoidance are the most elementary and primitive rudders in our lives. They are a compass that guides us through life.

Procedural memories are the supremely essential basis of our bodily sensations as well as many of our feelings, thoughts and beliefs.

It is important to note in trauma therapy that of all the subsystems of memory, the instinctive survival responses are the deepest and most indomitable, and in threat and stress these generally override the other implicit and explicit subtypes of memory.

Bottom line: The fact is that persistent, maladaptive, procedural and emotional memories provide the core mechanism underlying all trauma and many social and relationship issues.

4. The Destruction of the Self - From a Psychological and Neurobiological Perspective

In all of trauma theory and trauma therapy, the aspect that is most important to me is that the experience of trauma destroys the self from one moment to the next. Suddenly the victim no longer knows who he/she is. My self, my identity as a person no longer exists. My self, I as a person, represent the interface between the biological inner world and the social outer world.

Every self has a self-conception, an own inner life and is able to reflect its inner experience. Thanks to my self, I have access to the outside and inside world.

a.The self from a psychological perspective:

Heinz Kohut, the founder of self psychology, made a major contribution to the theory of the self. He believed that the child is not yet born with a coherent self. It is in a fractioned state. Through the appreciative perception of the mother, one's own self is strengthened and developed. If the child's self-perception is neglected, it develops a narcissistic personality disorder.

The characteristics of a self described above are absent, and when traumatized it so happens that the victim reverts to the infant's fractionated state of the self.

Donald Winnicott developed an important self-psychology as well. The child is born with a True Self. The True Self includes the innate abilities that strive for development. If the abilities are not nurtured by a sufficiently good-enough mother, the child develops a false self that develops through compliance, and eventually the child and later adult believes that the false self is their true self.

Here, too, traumatization can severely impair a normal developmental process and evolve into the above-described symptoms.

b.The self from a neurobiological perspective (from Joachim Bauer, The Empathic Gene, 2021 - in German only) The self-networks

Only in the last few years has the interest of neurobiology as regards the self become central in research. Above all, neuroscience was interested in the inner terrain of the person, because the person has the ability to self-reflect. In psychology, the psychologist Peter Fonagy coined the term mentalization. Every person has opinions, beliefs and convictions about him or herself. Neuroscience assumes that there must be neural networks for this, which would have to store the mentalization in the brain. These are "self-networks" that were localized in the frontal lobes on the one hand and an autobiographical area in the rear area that is networked with the self-areas in the frontal lobes. Stored in these neurobiological correlates of the "self" is how we currently feel, which character traits we attribute to ourselves and which physical characteristics we call our own.

Furthermore, the self-networks also store our values, the ones we hold most dear, and further, that which is most meaningful to us, and then which life goals we prioritize.

The self-networks are not only the neural correlate of self-awareness, but they also encode the core of a person and are the locus of the beliefs that make up the meaning of life.

An important integral part of the person besides the self is empathy. Because by nature we are not only egomaniacs, but social beings. In order to understand each other, to understand why someone behaves a certain way, we need a neural setup in the brain that allows us to move in social space. In order to be able to understand each other, we also need a neural system of empathy. Empathy has a cognitive (mental-intellectual), a feeling (emotional-intuitive) and an action level.

a.The cognitive level of empathy concerns the ability to consciously consider another person's internal situation. We can explain the motives behind their thoughts and even their behavior.

b.Emotional-intuitive aspects of empathy relate to the ability to empathize. Empathy takes place mostly intuitively. We can empathize with other people and often fall prey to emotional contagion. To compensate for this, we have the cognitive component of empathy.

c.On the action level of empathy, thanks to the mirror neurons, we simulate the actions of our fellow human beings and this process happens intuitively. We can thus anticipate the intentions of the other person to act.

5. The Development of the Self-The Most Important Stations

Bonding and reflection through sensitivity: The infant is existentially dependent on a bond with the primary caregiver. The reference person gives the infant safety and security through his sensitivity. The infant immediately shows attachment behavior when it senses that the attachment is compromised. John Bowlby founded the attachment theory. His close collaborator, Mary Ainsworth, developed the concept of sensitivity. It describes the quality of the response of an infant's caregiver, through which this person influences the early attachment in such a way that a secure attachment results. Secure attachment allows for a healthy development of empathy.

●The intersubjective phase:

It starts at 9 months and lasts until about 24 months. Then the toddler begins to learn language. In the intersubjective phase, three important experiences are made that already enable the emergence of empathy. On the one hand, the shared attention, then, observing the mother's face to see whether something is scary or not, and experiencing feelings together.

●Theory of Mind: By learning language, the child acquires his/her own self and experiences the relationship between self and others. The development of the theory of mind enables social exchange and at the same time the child begins to explore his/her inner life.

6. The Therapeutic Process of Trauma

When destruction of the self is at the heart of a traumatic experience, the victim is deprived of their experiences during their infant development into a self of their own. The above-described aspects have shown that traumatic experiences and the associated emotions are suppressed into procedural memory, even split off.

We've also found that it's very difficult to reach the procedural, persistent emotions.

However, if we cannot resolve them, therapy fails. Some therapists use bodywork to reach these feelings. My route is different and also successful. I'll describe this path.

Instead of body work, which is certainly appropriate in various cases, I have found in my therapeutic work that the theories of early child development are more suitable. As described above, a traumatic experience instantaneously throws a person in development back to the state of early childhood. The symptoms, which Janet had dubbed posttraumatic disorder, resemble the helpless state of an infant dependent on the protection of its primary caregiver.

A good bond only arises when the infant is protected by sensitive behavior and feels safe and secure. In Winnicott this sensitive attitude designates the holding function. For me, building such a relationship is the basis of successful trauma therapy.

The concept of sensitivity is almost therapeutic: The following four points are crucial for sensitivity:

I am attentive and concentrated. I'm a good listener. I am also empathetic and put myself in the other person's emotional state. I feel what he/she feels. But I have to find the balance between compassion for the suffering of others and my profession as a therapist. I must not overburden the patient, otherwise he will react with fear and withdraw or act out his trauma even more vehemently.

If the trauma has not been processed, a simple trigger in the present will brutally plunge you into your procedural memories of the traumatic past. The victim remains trapped in these memories, and the traumatic response patterns I outlined above emerge.

The following graphic shows how the transition from explicit memories to an episodic narrative takes place. The patient is only willing to walk this path with me as a therapist if the already-described relationship has been established and the necessary basis of trust has been created. The patient must feel supported when dealing with trauma. Through this process from confusion to episodic history, a connection is made between past and present that brings about a long-awaited understanding of the trauma.

(reglose innehalten=motionless pause / Neuverhandlung=renegotiation)

The work then always consists of several steps: First, the patient is confused and the repressed trauma expresses itself completely uncontrollably, as described above. The victim is at the mercy of emotional violence and gets into an uncontrollable state of agitation. The process is a slow emergence from the implicit emotions into an episodic narrative. Through this work andthanks to the support of the therapist, the patient undergoes the positive experience of the trauma of the past ultimately no longer reappearing, and he/she gains agency over the event. He/she is no longer helplessly at the mercy of the trauma he/she has experienced.

7. The Goal of Therapy

It is logical that no one can forget the trauma they have experienced. Even the best therapy can't do that. When remembering one's trauma, arousal sets in. In the graphic below, at the beginning of therapy, the patient constantly oscillates back and forth between increasing levels of hypoarousal. The memory of the trauma is reinforced in the present and, in turn, the procedural memory is reinforced. In between is the psychic state of adaptive self-regulation.

We have no control over these brutal emotional eruptions, we are helplessly held captive. A healthy emotional level, an episodic story is out of reach. In a second step, with the help and support of the therapist, the patient achieves a significant reduction in arousal spikes. The goal of therapy, here, is that through this monitoring process and a growing understanding of the connections related to one's trauma, the patient can carry out the adaptive self-regulation independently. The more the patient experiences that he/she can differentiate between past and present and plan his/her future, the more liberated he/she is and no longer finds him/herself hopelessly entangled in his/her tormenting past.