Nurturing Resilience

Nurturing Resilience:


The therapeutic work with clients who have experienced early and chronic stress and trauma is one of the demanding challenges facing the depth therapist and body psychotherapist.


Particularly, as these experiences are often preverbal, and before autobiographical memories are formed, there is a great need for specialized approaches that help these clients process their traumas, integrate them, and regain a cohesive sense of self. These authors focus on the developmental unfolding of the fetus, infant, toddler, and child so that we can map precisely where our clients have become stuck or thwarted in this intrinsic growth process.


This provides a way for therapists to find access points to reach their clients where they have become stuck and gently bring forth the healthy developmental processes.


There is a quiet revolution taking place in how we provide help to those who have experienced trauma in their earliest years. Theories relating to developmental trauma have been slowly moving to the forefront within psychotherapy communities, trauma therapists, neuroscientists, and perhaps most of all, clients who are seeking help for their lifelong challenges.


We now know from a growing body of research that early trauma takes a staggering toll on our physical, psychological, emotional, and social health. Those who have experienced developmental trauma struggle to receive treatment that adequately addresses their complex symptoms, which often cross boundaries between symptoms that require medical attention and those that require psychological treatment.


Although trauma plays out in very different ways for different people, the feeling of overwhelming helplessness lies at its core.


Utilizing our fifty years of combined clinical and teaching experience, Nurturing Resilience offers an introduction and foundational framework for mental health therapists and other care providers seeking more effective means for responding to people whose bodies or spirits have been altered by developmental trauma and attachment difficulties.


Trauma’s complex influence on development is sometimes, but not always, tied to faulty parenting. It can also be caused by medical procedures, birth difficulties, frightening events, and caregiving failures that have nothing to do with maltreatment.


The field of resiliency research is expanding rapidly, providing helpful new information, but also bringing into question how to define the concept of resilience itself, and how to know which factors directly influence it. For our purposes in this book, we can define “resilience” as the ability to achieve positive outcomes—mentally, emotionally, socially, spiritually—despite adversity.


Supportive adult-child relationships

A sense of self-efficacy and perceived control

Adaptive skills and self-regulatory capacities

Sources of faith, hope, and cultural traditions


Harvard University’s Center on the Developing Child suggests that “the single most common factor for children who develop resilience is at least one stable and committed relationship with a supportive parent, caregiver, or other adult” (Center on the Developing Child 2017).


(Insert Link to REsilience test)

(Insert Link to REsilience movie SCREENING promo)


The causes of developmental trauma are less important than how trauma manifests in a client’s life. We see that people in this demographic are often trapped in survival physiology. They develop management techniques to override their anxiety or perceived negative social behaviors. A chronic feeling of disconnect or “not belonging” gradually leads to a masking of their symptoms out of a very human desire to fit in. However, no matter what skills individuals may develop, the underlying symptoms of their early history still exist. As a result, many of the adults and children we work with struggle with activities of daily living.


Working with adults with severe early trauma histories almost always includes a process of sorting through complex and interrelated symptoms. This category of client often experiences what initially appear to be straightforward and separate physical issues: high blood pressure, autoimmune disorders, or diabetes, for example. But we now know that developmental trauma can trigger these somatic symptoms and conditions. Indeed, early trauma can activate genetic predispositions toward certain diseases, apparently “turning on” that genetic predisposition; it can alter the size of the developing brain; it can cause the immune system to create chronic inflammation; it can contribute to a wide range of physical, as well as psychological, disorders (Ellason, Ross, and Fuchs 1996; Felitti et al. 1998; Perry 2004a, 2006).


In our experience, treatment that addresses all levels of the wounds from early trauma is most effective. It is our belief that the somatic responses must be included as part of treatment in order to effectively address and resolve developmental trauma. The clinical realities we have experienced over decades have been illuminated, contextualized, and more deeply understood thanks to the trailblazing efforts of John Bowlby, Mary (Salter) Ainsworth, Bruce Perry, Peter Levine, Bessel van der Kolk, and others, particularly the theoretical contributions of Stephen Porges surrounding the polyvagal system, discussed in chapter 4, and the vast public health research based on the Adverse Childhood Experiences (ACE) Study, which informs the whole of our work and is described in chapter 6. The ACE Study, which has correlated early childhood trauma with later development of various types of diseases and disorders, along with the abundance of research that continues to spring from its conclusions, confirm how devastating trauma can be when it occurs at an early age. This study also underscores the importance of not separating a client’s physiological and somatic symptoms from their psychological struggles.


Safety and security are the underpinnings of resilience and are key in supporting the capacity for self-regulation.


Healthy development provides the foundation for the physiological capacities needed to accurately perceive safety and connectedness.


Healthy development also builds the capacity for productive self-communication.


Developmental trauma may disrupt and impact development.


Relational Development

Somewhere in the world, every 4.3 seconds, a child is born. Many factors then emerge to determine how the child will grow and create her own individual self with a sense of autonomy. Humans are born completely dependent on their caretakers.


Safety and Attachment

Attachment, according to Bowlby (1969) and Ainsworth (1973), is a deep, enduring emotional bond that connects one person to another across time and space. Attachment is not always mutual, however, and can easily travel in only one direction, when a child attaches to a parent, for example, but the parent doesn’t attach fully to the child, or vice versa.


It is impossible for infants to survive on their own, and we all need someone to provide safety and security for us to grow and develop throughout our lives. Survival becomes the common need we all share, and is the basic building block in development.


The idea that the infant and small child would be active in their survival efforts by how they bonded with their care providers had not been considered before. Prior to this, infants were considered passive in their role as dependents, and it was thought that bonding would happen as a natural side effect of their physical needs being met by the caregiver.


Bowlby argued that infants need a relational space in which the child’s need for attachment is satisfied by the caregiver, who provides protection, nurturing, and care. The child feels he can return to and rely on this space during high levels of stress in order to be soothed by the caregiver. At this stage of development, the child is not able to soothe himself on his own and therefore must rely on an adult to recognize and respond to his emotional needs. Within this space, the child begins to learn a sense of safety and connection.


Bowlby also categorized the development of attachment into four distinct time periods, or phases, providing insight into how each stage paved the way for the next and identifying opportunities where healthy development might be disrupted (Bowlby 1969):


Pre-attachment period / birth to six weeks: This is the phase when connection begins to develop between the caretaker and infant. The infant seeks proximity to the caregiver by crying or cooing. She recognizes her caretaker’s voice and smell and begins to respond when the caretaker holds her and interacts with smiles and whispers.


Attachment-in-the-making / six weeks to eight months: The infant begins to seek out and prefer her primary caregiver over other adults. Her verbal skills with the preferred caregiver begin to increase, and the infant responds differently to her caregiver, compared to the occasional visitor.


Clear-cut attachment / eight months to eighteen months: It becomes quite obvious from whom the toddler seeks comfort and to whom she feels most attached. Toddlers at this stage will perform for the primary caregiver in order to gain her attention. They climb and jump on the caretaker in order to remain the center of her focus. During this phase, toddlers will exhibit stress when separated from their primary caretakers, but they are also receptive to other caring adults who attempt to meet their needs and form attachments.


Formation of reciprocal attachment / eighteen months to two years: Words become more important to the child as she expands her capabilities and learns new techniques in terms of movement, communication, and play. Language helps facilitate this stage of learning. Though the child is aware that her caretaker will return from an absence, she may still show distress when left behind. The child will purposely speak, act out, or express frustration to prevent the caregiver from leaving. This is an important phase when the caregiver should slow down, listen to the child, and engage her so she can trust that her needs will be met consistently.


If John Bowlby is considered the father of attachment theory, Mary Ainsworth is considered its mother.


Early in 1960, while giving her first public presentation on her Uganda research, Ainsworth was challenged by developmental psychologists in the audience to more clearly define what she meant by “attachment.” This motivated her to more specifically articulate the elements that influenced the attachment process, and to identify the behaviors that would differentiate healthy attachment from unhealthy attachment. By 1965, Ainsworth and her assistant Barbara Wittig had designed the Strange Situation procedure. The goal was to study the individual attachment differences among children experiencing small moments of attachment distress.


For this study, a mother and her child of twelve to twenty-four months of age would enter the lab, and the child would be allowed to explore.


After one minute, a person the child didn’t know would enter, speak with the mother, and then attempt to establish a relationship with the child.


The mother would then “conspicuously” leave the room, leaving the child with the stranger. During this first separation, the stranger tries to interact with the child.


The mother is gone for three minutes and then returns. She greets and comforts the child, only to leave again—with the stranger—for another three minutes.


During the initial part of the second separation, the child is alone briefly before the stranger returns.


During the mother’s second absence, the stranger attempts to care for and comfort the child. After her brief time away, the mother reenters the room, she greets and picks up the child, and the stranger conspicuously leaves.


Throughout these interactions, researchers observed the child’s reaction to the stranger, as well as to the mother’s return. Based on these behaviors, researchers could draw conclusions about the nature of the child’s attachment relationship with his mother.


Secure attachment: During the study (Ainsworth and Wittig 1969), children in this category felt comfortable looking around the room and exploring their new environment with their mothers present. This echoed Bowlby’s idea of the secure base. The mother functioned as the secure base for the child, allowing her to safely explore and engage with the stranger while the mother was present. The infant began to cry when the mother left the room, but was excited to see her when she returned. This category of attachment is the one most strongly affiliated with the protective factors that foster resilience (Shonkoff, Boyce, Cameron, et al. 2004).


Anxious-avoidant insecure attachment: Children in this category seemed to avoid the mother or ignore her departure from and return to the lab. The children seemed uninterested in the room itself and typically chose not to explore the space. Their emotions were more limited and constricted, regardless of who was present in the room or any attempts made to comfort the children. As research continued, this group was later divided into two subsets: one group completely ignored the mother upon her return, and the other group attempted to approach the mother but tended to then turn away from or ignore her. At the time (in the 1970s), Ainsworth and Silvia Bell, with whom Ainsworth conducted some of her research, believed this avoidant behavior functioned as a form of emotional self-protection for the child. Later, using heart-rate monitors with the children, the researchers discovered this group was equally activated emotionally compared with the other groups in the study. This indicated that the anxious-avoidant children still had rich emotional responses to their mothers, but had, for some reason, learned to hide or withhold their emotions.


Anxious-resistant insecure attachment: These children showed distress even before the mother left the room. They became clingy and difficult to comfort upon the mother’s return. This group was later divided into two subsets: one showed signs of resentment toward the mother for leaving, and the second showed signs of helpless passivity. The level of stress among this group was so great in the original trial that Ainsworth had to end the study prematurely. There was also a group in this category with an even higher level of distress noted, which was not categorized until Mary Main, with Judith Solomon, added another category, noted below.


Disorganized/ disoriented attachment: This fourth category was noted by Mary Main and Judith Solomon (Main and Solomon 1986), who developed the Adult Attachment Interview. They noticed a group of children who didn’t meet the criteria of the original three categories of attachment behavior. The children in this group appeared not to possess coping skills. Some moved toward their mothers when they returned to the room, whereas others moved away. Their reunions seemed disoriented and inconsistent. This category is the one most strongly affiliated with the risk factors impairing resilience (Shonkoff, Boyce, Cameron, et al. 2004; Shonkoff, Levitt, Boyce, et al. 2004).


In studies of the three initial attachment classifications (secure, avoidant-insecure, and resistant-insecure), about 70 percent of American infants have been classified as secure, 20 percent as avoidant-insecure, and 10 percent as resistant-insecure (Ainsworth et al. 1978). Van IJzendoorn and Kroonenberg’s meta-analysis (1988) supports these earlier findings.


More recent studies show worrying declines in secure attachment, with percentages in the general population now closer to 60 percent (Andreassen, Fletcher, and Park 2007).


Percentages related to the disorganized attachment category depend on the particular sample studied (Greenberg, Cicchetti, and Cummings 1990; Andreassen, Fletcher, and Park 2007).


-The prevalence of disorganized attachment among middle-class, white American children is 12–15 percent in the Mary Main studies (Main and Solomon 1990).


-Infants of adolescent mothers have a rate around 30 percent (Broussard 1995).


-And infants of abused mothers and psychiatrically ill or substance abusing mothers can be as high as 70–80 percent (Carlson et al. 1989).


We again see a correlation within these different population samples in relation to resilience. Children of mothers with psychiatric illnesses or substance abuse issues have more risk factors that are correlated with poor resilience (Shonkoff and Eisels 2000; Shonkoff and Phillips 2000).


Bowlby opened the door to considering that regulation of the infant/ child’s physiology is one of the key elements that occurs within the attachment process, and we now understand more fully how critical this element of the co-regulatory function of care providers is.


Regardless of the influences on the child’s attachment style, the four components of attachment that Bowlby articulated (safe haven, secure base, proximity maintenance, and separation distress) provide a helpful structure for understanding which elements of connectedness and safety provide the foundation for attachment. Likewise, the attachment styles themselves can provide therapists with useful information about what may have gone awry in the early attachment and bonding process, and how best to structure their interventions.


(INSERT ATTACHMENT BOOK SUMMARY)


Understanding how early attachment ruptures caused by trauma can affect the capacity of the client to interact relationally is critical when working with developmental trauma.


Regulation


Regulation is the term used to describe our ability to manage our emotional state, to calm ourselves during times of heightened emotion—when we become fearful, deeply sad, angry, or frustrated. Regulation is a learned process, one we integrate into our own lives by observing others and, importantly, through the attachment phases with our early caregivers.


For example, an infant may hear a loud noise or become spooked by the sudden movement of a pet that wants to play. The infant perceives these small disruptions as potential threats to his survival. Unable to “fight back” (or do anything to stop the pet), the infant cries out for a caregiver to intervene and rescue him from the situation. If the parent is attuned to the infant, she will pick up the baby, provide a physical embrace, and use soothing language to help calm the child’s neurological fight-or-flight response.


These interactions between parent and child will shape the child’s ability—or inability—to regulate his own emotions later in life. This process is called co-regulation because the parent steps in as a mentor and external source of soothing when the child feels distressed.


This process of co-regulation creates a foundation for neurosequential development for the child (Schore 1994). Dr. Allan Schore (2001) sees the transfer of regulation from external (relying on others) to internal (developing the capacity to self-regulate) as the primary task of early development. Regulation is not only about regulating the physiology of the autonomic nervous system. It’s also about regulating levels of arousal, and eventually being able to regulate our affect.


Our ability to regulate during times of stress is one of the key elements for responding in healthy ways to challenges, and in building and maintaining both resilience and a sense of safety.


The loss of regulatory capacity is one of the consequences of traumatic stress. With the loss of regulation comes loss of healthy functioning in many physiological, behavioral, and social processes.


Healthy bonding, access to co-regulation, and the eventual development of self-regulation inoculate us against traumatic stress (Stroufe 1995). Social engagement supports and builds early developmental neurological “programs” that help us feel a foundational sense of safety. Healthy bonding and attachment allow us to develop the early ability to self-regulate our systems and trust the shared experience of co-regulation and connectedness. Resilience research indicates that the interplay between caregiver and child promotes healthy brain development (Schore 2001; Shonkoff, Boyce, Cameron, et al. 2004) as well as resilience. Experiences of safety and connectedness impact us deeply, supporting important physiological benefits, such as strengthening our immune system and increasing our chances for better health overall by promoting homeostasis. It would not be an exaggeration to say that a strong sense of connectedness is one of the best ways to prevent developmental trauma, and one of the remedies that should be brought into play for repair of early trauma (Felitti et al. 1998).


As our sense of connection develops with our care providers, so too does our ability to recognize cues that indicate safety. One key area in which our care providers help us develop involves the differentiation between threat and excitation—understanding when something is exciting but enjoyable versus when something causes excitation because a real threat is present. Worried parents tend to produce children who are more prone to anxiety and worry themselves (Eley et al. 2015).


As infants and small children, we are exposed to so many new experiences that we need an attentive parent or adult to help us understand how to sort through those experiences and respond to them. Play can be a valuable form of support to help children differentiate between excitation and threat or alarm.


To build the healthy ability to differentiate between threat and excitation, we need the foundational capacities—the foundational architecture—to activate this ability to perceive accurately, to understand what we are perceiving, to make meaning of it, if necessary, and to respond in nuanced ways. These foundational capacities are developed contextually, strongly influenced by our social interactions (or lack of interactions), by our external environment, and by our own physiology.


When our social environment is chaotic and lacks consistent feedback about safety versus threat, our differentiation between these two possibilities can become confused or even absent, tuning us more acutely toward assessment of danger and perhaps limiting our ability to recognize safety.


(Insert Link to discussions about safety zone, comfort zone, unknown and fear)


Interoception


Interoception is the process by which we notice our internal state. We evaluate a combination of sensations and perceptions of physical processes to assess our interior milieu and decipher what it’s telling us about what we are feeling, how we are, and even who we are.


This includes our perception of physiological processes, such as heart rate, the digestive process, sensations of the skin, and any other internally experienced sensations of our own bodies. Using our evaluations of these sources of bodily information, we take action, make meaning, make predictions (like predicting our own illness by feeling the initial sensations associated with the onset of a cold), and make judgments about who we are and how we are—are we hungry, are we safe, are we loved?


(INSERT LINK TO SOMATIC PSYCHOTHERAPY AS IT RELATES TO RECALABRATING INTEROCEPTION AFTER TRAUMA, C-TRAUMA, D-TRAUMA)


If an infant cannot accurately perceive whether or not he is hungry or thirsty, if he needs sleep, if he is too warm or too cold, then he cannot accurately communicate his needs (or distress) to care providers. That, in turn, can prevent care providers from responding properly to the infant’s needs, which may then increase the infant’s distress and instill a feeling that safety and connection are lacking.


(Insert the BioPsychosocial model of pain as it relates to those that have a history of TRAUMAHOOD and their inability to self regulate and a link to THE BODY KEEPS THE SCORE or LEVINE AS A EXAMPLE OF not FEELING THE BODY)


As we mature, our need for a nuanced, interoceptive vocabulary becomes even more critical. We need a reference system for understanding how we feel about different people, different circumstances, and different types of needs. It’s easy to assume that this system of reference develops of its own accord, but in fact it develops contextually, requiring regular feedback from our social system in order to calibrate points of reference and rely on them with confidence (Bermúdez, Marcel, and Eilan 1995).


(Insert excerpts from the secret life of the brain and the use of language and context for our more nuanced feelings as well as emotional education tools used in talk therapy.)


It’s helpful to understand how interoception informs our clients’ experiences of self and environment, both internal and external:


-Interoception provides a significant portion of the information we use to form our experience of self and our view of the self in relation to others. It provides a large portion of the self-communication we use to assess whether or not we are safe or unsafe and whether an external event or person is pleasurable, exciting, or threatening (Ceunen, Vlaeyen, and Van Diest 2016; Bermúdez, Marcel, and Eilan 1995; Cameron 2001; Craig 2015).

-Interoception develops in context; our day-to-day experiences inform our perceptions and evaluation of various internal sources of information. This includes our social context—our social group provides a significant amount of feedback, which we use to “calibrate” our interoceptive perception and interpretation.

-Interoception can be easily influenced, including by something as simple as our mood when we are asked to rate our pain levels: positive emotion increases our tolerance for pain, and negative emotion decreases our tolerance for pain (Carter et al. 2002; Zweyer, Velker, and Ruch 2004). Although it may seem there could be “objective” measures for physical sensations like pain, our interoceptive experience will shift based on many factors that have nothing to do with physical qualities, so it may seem there is not a stable “baseline” for any given interoceptive response (Craig 2015).

-The interoceptive system is meant to inform us in a predictive assessment of our internal and external environments, but it can mislead us if this system developed without congruent congruent context and feedback, in which case, our markers for perception and meaning-making may be overly sensitive or tuned to signals that don’t provide the most reliable information. In other words, our points of reference for making a judgment may be off-base and therefore lead to false conclusions (Bechara, Damasio, and Damasio 2000). Information gathered via interoception tends to be experienced as factual, not evaluative, because it comes from what many of us call “inner knowing,” or gut feeling. Part of our job as clinicians is to support our clients in changing and revising their interoceptive “conversations” with themselves. Because interoception remains plastic, it’s possible to help our clients change their interoceptive vocabulary and conduct more nuanced assessments of their inner world, resulting in more helpful self-conversations.


There are many bodily sensations whose origins could be internal or external: the perception of heat, for example. If we are in a warm environment, we will perceive heat. If we have a fever, we may feel just as we would if the room were hot. In addition, some biological systems, such as the skin, interface with the outside world and therefore therefore allow us to feel something that is clearly outside the body—a soothing touch, for example—while also providing sensations that most of us attribute to the internal body, such as pain.


(Insert the role of P-DTR and the idea of mechanoreceptors)


The interoceptive system’s flexibility also helps us hone our learning and survival skills, and keeps us responsive to changing circumstances and environments.


(Insert the monot-asking and the stepping off the curb example as it relates to the rubber hand and inflammation responses, pain and the nail in the boot example)


Exteroception

Our exteroceptive systems help us pay attention to our external environments.

There are many similarities between interoception and exteroception, but both systems:


-Develop in the context of environmental and social factors

-Contribute to our perception of safety and lack of safety

-Are influenced by day-to-day experiences

-Contribute to our predictive assessments of experience

-Contribute to meaning-making about our experiences


The traditionally recognized exteroceptive sensory systems are sight (vision), hearing (auditory), taste (gustatory), smell (olfactory), and touch (tactile)—what we might informally call the “paying-attention systems.”


However, the processing of information about the external environment does not derive entirely from our obvious paying-attention systems. There are additional sources of information that contribute to our overall assessment of our internal and external environments: the vestibular (balance) system; the proprioceptive system, which tells us where different parts of our body are in relation to each other and how fast they are moving; temperature perception; vibration perception; and pain perception.


(INSERT THE LEARNINGS FROM PAIN SCIENCE THERE IS NO PAIN RECEPTORS JUST A KNOWING OF SAFETY OR NOT)


We sometimes take for granted that our sensory systems simply develop to produce accurate perceptions of our environment, when in fact, these systems are strongly influenced by environmental factors, including trauma.


It’s important to remember that we cannot exclusively use cognitive processes when assessing our safety. Rather, our body’s holistic response tells us whether or not we are safe. We can certainly evaluate our external environment with conscious thought, but, as noted in the previous section, our inner responses to that information will provide the bulk of the information we’ll use to determine whether we are in fact safe.


(Insert learning process about experience vs understanding feeling vs thinking)


Neuroception


“Neuroception” is a term coined by Stephen Porges, who summarizes the term this way: “Neuroception describes how neural circuits distinguish whether situations or people are safe, dangerous, or life threatening” (Porges 2004, 19).


He also describes neuroception as a “dynamic and interactive process” whereby we respond to cues about safety and threat, while simultaneously transmitting similar cues in our social interactions.


Interoception and exteroception both inform neuroception. If we have a healthy, well-developed safety system, our interoceptive and exteroceptive systems will work in an integrated fashion to help us differentiate information and determine when we are safe and when we are not.


Likewise, our social systems will have helped us experience a sense of safety and security in our relationships, which reinforces our ability to perceive safety and experience a sense of belonging and security.


(INSERT THE BOOK SUMMARY OF CLINICAL APPLICATIONS OF THE POLYVAGAL THEORY)


Neuroception refers specifically to the neurophysiological processes involved in the perception of safety and threat, what Porges refers to as the neural platforms that support certain categories of behavior (Porges 2007). Porges differentiates the physiological processes from the behaviors themselves. This is important to understand as we work with clients whose perception systems may be inaccurately signaling them of false threats. That perceived lack of safety may in turn trigger the behaviors of threat response, even if there is no legitimate threat to respond to. This can then create a self-fulfilling process whereby others in the social interactions react to those threat behaviors with their own, and the client’s felt sense of lack of safety becomes reality, further justifying his initial reaction.


(Insert the hall of mirrors story and the puppy dog)

(Insert the four agreements story)


The development of neuroception can be influenced by trauma, and altered profoundly by developmental trauma. Clients who lack a “safety map” are primarily tuned to danger. They have well-developed filters and somatic narratives about what danger is and what it means—because danger has been an imperative in their lives—but they often have a somewhat limited ability to recognize safety, either within their interoceptive self-communication, or in the perception of their external environments.


To experience healthy neuroception, we must first be able to differentiate between safety and threat. Neuroception is about the detection of both, but to properly make the distinction between the two, we need: (1) reliable access to a sense of safety; (2) care providers who help us regulate our responses and understand environmental cues contextually; and (3) coherent feedback from our social group about how we ought to categorize our experiences. Together, these three elements support the development of necessary and healthy neural platforms that neurophysiologically help us differentiate between safety and threat.


(Insert comic about parents looking for monsters under the bed)

(Insert comic about parents being the monsters)

(Insert image of child watching a parent do amazingly bad stuff)


We learn and store information about emotional experiences with the aid of the amygdala. This type of learning and memory is often implicit, meaning we aren’t consciously aware of what we’re learning. (Explicit learning and memory—which, as the name implies, means we are aware of the process of learning and the source of the memory—is mediated by the hippocampus.) Although we know the most about the amygdala’s role in fear and threat response, it is also involved in reward learning and motivation, and in the modulation of attention and perception. It is thought that these processes are the result of the amygdala’s assessment of the emotional significance of external stimuli (LeDoux 2015).


(INSERT BOOK ABOUT LEARNING)

( INSERT TRAUMA MEMORY AND LEARNING WITH THE BODY)


Interestingly, the strong emotions felt during a certain experience seem to prompt the amygdala to signal the hippocampus to place a stronger “value” on that experience, so that it makes a greater imprint in our memory (LeDoux 2015). Our past experiences, particularly if they include strong emotional responses, accumulate as memories that inform our current responses to similar types of experiences.


If the environmental information is either unfamiliar or misunderstood, we then must turn to other evaluative and sensory systems to formulate a proper response. A classic example of this is the snake-or-stick proposition.


We’ve encountered an object that could be a snake (dangerous!) or could be a stick (harmless), but we need more information from our sensory systems in order to make a final determination about whether it is or isn’t a threat.


Is it moving?

Does it have a head?

Are we in an environment where there are usually snakes?


With neuroception, we will simultaneously make a contingent assessment based on previous experience—while the additional sorting of information unfolds—and quickly marshal a response to that preliminary assessment.


If we have previously encountered dangerous snakes, we will respond physiologically with more immediacy and greater arousal, and perhaps back away without consciously deciding to do so. From a survival perspective, we can’t risk not responding just in case it’s a snake. Our neuroception is signaling us that there is indeed the possibility of threat, and we must respond accordingly.


(INSERT THE TED TALK ABOUT PAIN INFLAMATION AND SNAKES FROM NEUROSCIENCE)


Healthy neuroception develops in the context of healthy social engagement. Our social group provides a great deal of information about what is safe and not safe. The people in our social group—family, friends, and peers—help us learn by modeling various responses and ways of sorting the information we receive.


If that social support and instruction have been missing, or if our social system was the source of danger or did not protect us from threat, we can assume our neuroception will not have developed in a healthy way.


(Insert pictures of kids in safety seats and kids in tuK-Turks)


Forming a Narrative


The somatic, body-oriented narrative of safety, lack of safety, connection, awareness of self, and meaning-making of our experiences is informed by our early development. In our infant and childhood years, our brains are not fully developed, and are unable to acquire and assimilate memories in a narrative fashion, the way we can as adults.


We are little somatic beings, responding to our experiences in a noncognitive way. We may later overlay our early experiences with narratives that express our more mature understanding, or simply make our best attempt to explain our experiences by formulating or reconstructing a story that matches, but our earliest experiences will inform that narrative in a way that is largely invisible to us.


In our early developmental years, we form what could be termed “somatic narratives.” We respond to simplified information from our internal and external environment.


(Insert Image of grown man afraid of a puppy)

(INSERT ARTICLE ABOUT THE DIFFERENCE BETWEEN FEARS AND PHOBIAS)

(INSERT ARTICLE ABOUT HYPNOTHERAPY HELPING WITH BOTH)


We create our earliest foundations for narrative by developing a somatic vocabulary for understanding our experiences, often in relation to other people, namely our caretakers. If our development has been healthy, we will form narratives that are fairly congruent with the actual situation, and that include different categories of information, much like those within our neuroception: safe/ not safe, fun/ not fun, scary/ exciting.


(INSERT IT DIDN’T START WITH YOU INHERITED TRAUMA)


Each of us will have a different narrative for how we understand our experiences—even the same types of experiences—but the foundation for those narratives is built on early experiences that hopefully enabled us to develop a nuanced and wide-ranging somatic language.


As we continue to mature, our somatic narrative supports more complex and mature cognitive narratives of our experience. Unhealthy formative experiences, by contrast, will stand in the way of developing a fully formed somatic language.


They skew our vocabulary and interpretative skills, causing us to view most situations as suspect or potentially threatening. This greatly limits our opportunities for connection and accomplishment, and creates a cycle that becomes difficult to break.


(INSERT RICHARD BARRETS WORK ON LETTING GO OF FEARS, TO CYCLE UP)


Fortunately, most people experience a healthy childhood that provides the foundation needed for healthy functioning to support them during adulthood. A majority of children experience “good enough” care from their care providers, feel a consistent sense of safety, form secure attachments, and do not experience the types of trauma that interrupt normal development.


While some sources of research indicate that 7–12 percent of the population experience developmental trauma, more than 60 percent of adults report having experienced some form of abuse during childhood (Felitti et al. 1998), which indicates that there will be a range of experiences that might fit into a somewhat gray area in terms of the lasting impact on any given individual, who might not meet the threshold to be clearly defined as having experienced developmental trauma, but resiliency may have been compromised and other impacts felt.


(INSERT ACE STUDY SCORES ARTICLE)


Because developmental trauma occurs prior to, and during, the times of our most rapid development, its effects impact every area of our developing selves and imprint us in sometimes unique ways. This means those with developmental trauma, particularly severe developmental trauma, will experience symptoms that don’t fit easily into a single category. The effects often seem so deeply rooted that they have become habituated and therefore masked. The individual living with the effects comes to accept his difficulties as “the way life goes” or “the way I am.”


The ACE Study has specifically correlated childhood neglect and abuse with the later development of diseases, such as diabetes, heart disease, and asthma, in adulthood. This study has been critical to our understanding of developmental trauma—and there’s still more to discover beyond this landmark study.


It’s important for clinicians to understand that trauma may not be expressed primarily through the client’s own narrative or his apparent trauma history. Not only may there be transgenerational impacts the client is unaware of, but the client may also simply be unaware that his experiences, which he sees as normal, may actually constitute trauma.


A new body of research is developing to help us better understand the environmental, cellular, and biological mechanisms that make these alterations possible. Although we don’t fully understand these mechanisms yet, we do know that early trauma is one of the factors that can cause epigenetic changes. Furthermore, those epigenetic changes can then influence the genetic makeup and development of the next generation and beyond (Elsevier 2016; Kellermann 2013; Yehuda and Bierer 2007; Yehuda et al. 2016).


Children of Holocaust survivors, for example, are more likely to develop PTSD and other mood and anxiety disorders, whether or not they’re exposed to traumatic events in their own lives (Yehuda et al. 1998).


Ongoing research suggests that greater vulnerability toward epigenetic impact exists for children of those with PTSD, of war veterans or survivors of war trauma, of refugees or torture victims, and of those who experienced childhood sexual abuse (Zerach 2016). This transmission of epigenetic changes did not appear to stop with the first subsequent generation, but also affected grandchildren and great-grandchildren.


Animal studies have already pointed out that the HPA axis (hypothalamic–pituitary–adrenal axis), which is often referred to as the stress axis, is affected by prenatal stress—the mother’s stress during pregnancy directly impacts stress responses in her offspring. (The interplay between the hypothalamic region of the brain and two of the endocrine glands—the pituitary and adrenal—creates the major neuroendocrine system that not only controls response to stress, but also regulates many body processes, such as digestion, immune response, sexuality, mood and emotions, and energy storage/ usage.)


Male adult mice whose mothers were subjected to mild stress early in the pregnancy had higher levels of chemicals, such as corticotropin-releasing hormone (CRH), that activate the HPA axis, and fewer receptors in the brain region that helps regulate the HPA axis. These mice also exhibited behaviors affiliated with depression, and, when subjected to stress, had higher levels of stress chemicals than did mice whose mothers had not been exposed to early prenatal stress. Early postnatal stress has also been linked to enduring epigenetic changes that alter the reactivity of the HPA axis.


Plasticity accelerates our ability to adapt to our environments more rapidly than if genes alone determined our wiring. In the case of healthy development, this is good news, because we can grow and change in direct response to the environmental inputs and demands we encounter as we mature. However, this also leaves us more susceptible to severe stress and its impact, which may then alter our genetic expression to the point that we may develop diseases, such as heart disease, that we might have otherwise avoided.


The ACE Study mentioned above proves that exposure to neglect and abuse in childhood can dramatically increase one’s vulnerability to disease, and creates an increased risk of early death.


Children who “inherit” parental trauma and also experience trauma themselves experience a double-whammy of sorts, and may face symptoms that arise out of two sources of trauma and either commingle with, complicate, or contradict one another. As a result, some clients have more trauma to sort through, separate, and address than they might have ever expected.


Plasticity has another upside—we can heal from the effects of trauma by altering neural pathways in new directions. For example, baby rats bred with a tendency toward anxiety did not end up expressing this anxiety when they were paired with especially competent mother rats (Weaver et al. 2004).


Neurobiological development is most directly influenced by what occurs to the infant/ toddler emotionally and psychologically within the first two postpartum years. The first nine months will have the most powerful impact on growth in the brain. As Schore points out, “Certain experiences are needed. Those experiences are embedded in the relationship between the caretaker and the infant” (Schore 2013). These experiences directly affect the part of the brain that involves the “emotional and social functioning of the child.” Schore continues, “There’s something necessary . . . that the human brain needs in terms of other human contact, for it to grow. It’s a ‘use it or lose it’ situation. Cells that fire together, wire together. Cells that do not, die together.”


In conjunction with the formation of neural pathways in these early phases of development, attachment patterns become interwoven and extremely important in the continuation of that development. When attachment is disrupted or distorted, such as by extended separation from the caregiver, or by abuse, it will trigger a survival effort on the part of the infant or child. In such cases, the child’s behavior is driven by this unresolved survival effort (fear with no remedy), which further contributes to unhealthy attachment patterns, such as anxious clinging and unremitting distress even when in contact with the caregiver.


As an infant struggles to manage her arousal, she may be forced into attachment behaviors that help her limit and manage what feels like overwhelming levels of response.


(Insert picture from book)


They cry when they need food, water, comfort, or rest, and look for their caregivers to meet those needs. When the caregiver is consistently unable or unavailable to meet the infant’s needs, the infant constructs a new survival system to account for and accommodate the caregiver’s absence. A lack of ability on the part of the caregiver to show constancy in her response may move the infant into an ongoing state of fright and terror that she must begin to manage. The infant will no longer be able to perceive safety and will therefore treat most situations as though they’re riddled with possible threats. We also know from more current resiliency research that the lack of responsive care disrupts the development of the brain (Shonkoff et al. 2012), and has a limiting effect on the development of resilience.


These parents may have experienced early medical treatments that separated them from their parents, or experienced neglect, abuse, or unresolved trauma as young children. These early experiences reduced the parents’ ability to regulate their own responses when aroused, often resulting in a complete lack of impulse control.


Although studies show that disorganized attachment is the rarest of the four attachment styles, as much as 80 percent of children with abusive parents are at risk of developing disorganized attachment. Epigenetically, disorganized attachment can be passed on for generations. The parents’ limited capacity to regulate their responses can look like anger toward the infant/ child—and may in fact manifest as anger toward the child—while the child has no coping skills to help him tolerate the scary parent. He is instead constantly on the lookout or preparing for another outburst, attack, or scary moment, and is rarely able to let his guard down.


Mary Main understood that any given attachment style, including disorganized attachment, is not a life sentence. Her research showed—and subsequent research has confirmed—that an adult with disorganized attachment could in fact move toward what is often called earned secure attachment style regardless of her history, given the right circumstances.


The key factors in this transformation are a capacity to make sense of our past, and to create a new narrative that helps us understand our lives now. It is also often the case that those who move into an earned secure attachment have been able to establish a closer emotional relationship with someone who helps them develop more secure attachment patterns (Siegel 1999).


Children who experience limited safety and unreliable caring and connection also receive limited access to support that can help them differentiate between threat and safety. Their ability to accurately perceive safety and lack of safety may be distorted; the “filters” for determining whether something or someone is safe or unsafe don’t function properly.


Children also need access to a social group that provides congruent and consistent feedback about the environment so they can learn the cues and signals that indicate threat versus safety. Without that access, neuroceptive systems develop in ways that cause children (and later adults) to misunderstand or misinterpret internal and external environmental information. In other words, our interoceptive and exteroceptive processing provides misleading and inaccurate information.


For someone whose neuroceptive system is poorly calibrated, her experience of the environment may not match the objective level of danger or safety around her. She may experience a sense of danger even when the environment is relatively safe, or she may miss the cues in her environment that indicate threat. What makes this even more challenging is that this perception doesn’t arise from a cognitive process. A majority of this response system operates beneath the level of conscious awareness, driven by neurophysiological processes that developed over time in the context of the safety or lack of safety in which she was steeped during her early years.


We may be functioning primarily from a “danger map,” rather than having access to experiential and memory mapping of both safety and danger.


From a neuroception perspective, this means we are more likely to interpret any new stimuli, any change in our environment (internal or external), or anything that gives unpleasant sensations as possibly dangerous, which is why healthy interoceptive development is critical.


(INSERT DIANE DEBB POLYVAGAL THEORY IN THERAPY)

(INSERT SOMATIC PYCHOTHERAPY EXERCISES)


It’s important to note that the interoceptive sensations arising from the viscera are more diffuse than the sensations delivered to the brain via the spinal cord, such as information from the skin. This makes it difficult to accurately label visceral sensations, or locate a specific source of information that’s contributing to our inner experience. Visceral information is often sensed more as a general quality that imbues our perceptions with a felt sense that may take on important meaning, but for which we have little in the way of specific indicators, which makes the signaling process more prone to misinterpretation and misattribution.


(Insert Book Summary of The Highly Sensitive Person)


Our interoceptive systems enable us to make predictive assessments of our internal states. An example of this is knowing that we will soon need to use the toilet once we feel the first indicators of pressure in the bladder. This apparently routine process of information-gathering and responding to that information is part of a dynamic interplay between our physiology, behavior, and emotional state, which shapes our overall experience of self, and self in relation to other. Internal states, particularly visceral states, may provide motivational fuel for many behaviors, such as eating, drinking, and sexual activity, both implicitly and via cognitive awareness (Critchley and Harrison 2013).


With greater research being conducted on interoception, links with panic, anxiety, and other symptoms related to trauma are more firmly being established. Interoceptive sensitivity is correlated with social fear (Garfinkel and Critchley 2013), and the misattribution of bodily sensations is often implicated in panic and anxiety disorders—those with clinical anxiety disorders have a tendency toward interoceptive sensitivity, and even those whose anxiety has improved can still experience heightened interoceptive sensitivity (Ehlers and Breuer 1992; Garfinkel and Critchley 2013; Pollatos, Matthias, and Keller 2015).


The Neural Platforms for Regulation and Connectedness


There is a strong relationship between the development of our attachment styles and social systems, and the development of our physical, or somatic, systems.


Polyvagal Theory and Its Implications in Developmental Trauma


The ANS regulates the function of our organs, such as the lungs, heart, and digestive system, as well as various processes that are essential for life, such as maintaining blood pressure and regulating sexual arousal.


The ANS is critical in supporting our co-and self-regulation capacities, because it helps regulate the physiological systems that support both activity and rest.


Key to Porges’s model is the understanding that healthy attachment and its related sense of safety support the development of healthy functioning of the ANS.


When our early attachment is disrupted, so are those important neural platforms.


(Insert image of POLYVAGAL)


(Insert Poly Vaal pocket guide review)


The Ventral Vagus


During the first few months of life, and to a certain degree the first few years of life, we are dependent on our caregivers for many of the more nuanced functions of the ventral vagus system. Some of the methods for soothing via caregivers are built into normal parent-child behaviors.

-The muscles used for suckling and mastication are “wired” via the vagus system to downregulate our heart rate when they’re in use, which is partly why the infant will seek out the soothing activity of suckling and skin-to-skin contact to calm himself (Porges 2011a).

The infant or small child relies on its caregivers to provide active soothing and comfort behaviorally, providing a sense of safety and belonging within the relational bond.


The Dorsal Vagus


The dorsal vagus system is the aspect of the ANS that we associate with the freeze response, but it’s more helpful for our purposes to recognize this system as having been adapted to enable us to conserve bodily resources.

In times of elevated survival stress, we may require an extreme version of this conservation physiology, provoking a rapid slowing of our heart and breathing rates, immobilizing our muscles, and increasing our pain tolerance.

The dorsal vagus system performs two other critical, but sometimes overlooked, functions for our survival: it supports prosocial bonding behaviors and maintains health by regulating bodily functions, such as digestion.

Behaviors such as cuddling or nursing require a certain level of immobility. The dorsal system’s support of prosocial behaviors occurs using a process or approach that Porges refers to as “immobilization without fear” (Porges 2011a, 172).

By contrast, immobilization with fear induces the dorsal vagus system to alter the physiology in potentially dangerous ways, such as the precipitous reduction in heart rate. As with the ventral vagus system, we need a reliable experience of safety in social interactions in order to create the neural platforms needed for these social experiences of immobility without fear. In the absence of that safety, immobility will feel too risky, even dangerous, in which case our physiology will help us avoid that “vulnerable but cradled” feeling—because we don’t trust it—and this will further disrupt future opportunities for connection (Carter 2014; Kozlowska et al. 2015).

The dorsal vagus system helps regulate important functions that contribute to healthy homeostasis. It aids in the regulation of food intake, and the digestive process more broadly, by stimulating the secretion of gastric acid and other digestive substances.


The Balancing Act in Our Physiological Responses


When an infant is distressed and has moved into sympathetic dominance, she needs her caregiver to provide soothing via feeding, touching, making reassuring sounds, and responding to the specific source of distress by changing a wet diaper, or applying lotion to irritated skin, for example.


(Insert analogy about pain and the signals, that maybe when we are not attuned to our won bodies is it is from a learned behavior that we do not matter relative to the job, the relationship, the goal etc. explain pain, mastery of self)



If a caregiver becomes unavailable for extended periods of time, the infant faces increasingly limited options physiologically, in which case:


The child will continue to fuss and cry indefinitely, becoming inconsolable even when someone does eventually arrive, or until she is exhausted and falls asleep. This is based on sympathetic arousal.


Or the infant will cascade into the survival response of the dorsal system, moving into conservation physiology and becoming quiet and still. This is not immobility without fear, but the freeze physiology activating to conserve resources and preserve life—the tonic immobility that follows unresolved fear. This reaction originates in the dorsal vagus system, producing freeze or shutdown.


In either instance, the infant remains in a physiological state that is affiliated with survival effort. Survival physiology—either extreme sympathetic arousal or dorsal freeze—is meant to be a temporary state that serves the specific survival purpose of preserving life at all costs.


These types of physiological responses evolved to provide short-term protection, turning on and off quickly to increase the survival response.


The term used for this is “allostatic load,” a term coined by McEwen and Stellar (1993) that describes the physiological consequences of this stress exposure.


One example of allostatic load is the repeated rise in blood pressure that occurs when someone is regularly exposed to stressful work situations. The body makes changes in blood pressure to respond to the stressors, which, in short and infrequent bursts, would help the stressed person adapt to the stressful situation. In the short term, such allostasis helps us adapt to our environment in helpful ways. However, when these blood pressure changes become chronic—because the stressful situation has become prolonged—the physiological changes will produce allostatic overload (McEwen, Seeman, and Allostatic Load Working Group 2009). Porges uses a simple phrase to express this concept: “the cost of doing business” (Porges 2011a, 95).


(Insert study on blood pressure, and the mail room, vs the blue zones)


Individuals cope with challenges in a wide variety of ways, all of them influenced by factors such as genetic predisposition, exposure to early trauma or other life stressors, development of resilience, and lifestyle choices, such as smoking, overeating, or alcohol use. No matter the cause, allostasis comes at a price. The greater the intensity of our physiology in reaction to stressors, the higher the price we pay in wear and tear on our bodies and overall physiology. As the body is forced to adapt to repeated challenges, our physiological reactivity increases, which in turn increases the allostatic load, or the cost of doing business.


(Insert the tool guide to develop self-regulation practices for people)


When the sympathetic system is dominant, we inhibit other functions, such as digestion and immune response, sending the physiological message that we are fighting for our lives. As a result, the functions that contribute to longer-term survival are set aside in order to free up our available physical resources for the active efforts of survival.


Physiologically, this is the equivalent of setting aside a maintenance project like painting the house because the basement is flooding. There is suddenly an emergency that immediately needs our attention, so we divert our energy to respond to that emergency and pause the routine maintenance tasks. Likewise, we will set aside physiological “housekeeping” tasks so that we can respond to the emergency of survival. In this way, we can say that high sympathetic arousal brings with it a high cost of doing business, or a high allostatic load. As other areas of the metaphorical house continue to be ignored, they too begin to deteriorate.


(Insert the 3-1 solving principle vs the 1-1, with the urgent and important aspect of managing life)