A Trauma Case History | SOMATIC TRAUMA THERAPY

A TRAUMA CASE HISTORY

Part one of this article is published in Somatics, Fall 1996, part two in Spring 1997

There is a growing body of literature on Post-traumatic Stress Disorder (PTSD) that suggests that PTSD has physiological elements – that is, heightened activation of the autonomic nervous system (ANS) – as well as psychological elements. Articles and books about the physiology and psychobiology of stress and PTSD abound (see, among many others: Figley 1985, Loewenstein 1993, Puglisi-Allegra & Oliverio (Eds.) 1990, Scrignar 1988, van der Kolk 1993). PTSD may be the condition that finally convinces both the medical and psychological communities that there is a connection between the mind and the body.

The following case history is particularly illustrative of this connection and demonstrates a sampling of techniques that address, support and heal this connection as a part of an integrated therapy for the treatment of trauma.

NOTE 1: This is a single case that illustrates certain general principles and techniques. It is in no way meant to comprise a complete instruction or theory in somatic trauma therapy. Each individual and his/her trauma history are different and must be treated on an individual basis.

NOTE 2: R’s identity has been protected. She has given permission to write about her case. She has also reviewed and approved this manuscript for publication.
Case Introduction

R is a Western-European woman in her mid-thirties who at 19 was raped during a student vacation in a middle eastern country. She works as a social worker for immigrants and often comes in contact with refugees from the Middle East. She sought therapy after noticing that over the previous few months she had growing anxiety at work which was beginning to interfere with her ability to continue her job. She was having increasing flashbacks of the earlier rape, difficulty concentrating, and periodic nightmares.

The symptoms cited above indicate posttraumatic stress, but technically, R’s is not a case of Posttraumatic Stress Disorder (PTSD) (APA, 1994) as she does not meet the criteria; she is too functional in her daily life. I evaluate R to be otherwise relatively stable and well functioning.

I have chosen to write about R’s case for several reasons. First it is a good example of a limited (11 session) somatic trauma therapy with a single-standing, non-complex trauma (Herman, 1992). Second, I found the cultural aspects both interesting and challenging. And, third, therapy with R demonstrates both the psychotherapy and body therapy aspects of somatic trauma therapy and is, therefore a good example of the mind/body integration work possible with body-psychotherapy.

Intake Interview

I began with R by taking a careful case history. As we discussed her past and current situation, it became clear that her current anxiety had been set off after she had been threatened by one of her Middle Eastern clients several months earlier. She hadn’t thought much about it at the time, but could now see the connection. She had no other incidence of sexual assault in her history.

I always take a complete case history to provide a three-dimensional picture of a trauma client. This helps to assure that I will treat the client as a person with a history and personality of which the trauma is just one aspect. Sometimes there are non-traumatic family dynamics, patterns or personality traits that could make the client more vulnerable to trauma. It is also possible that there could have been other traumas that were or became connected to the presenting trauma.

I established the frame of the therapy which includes my fee, cancellation policy, and an agreement that R will work with this trauma until finished, (not quit in the middle). R discussed some financial problems, but as she had gotten financial support from her employer, felt she could agree to this.

It is a good idea for the trauma client to agree to complete the therapy. Trauma therapy is very difficult – who wants to remember a trauma? – and such a contract provides some degree of protection. It is not a good idea to begin a somatic trauma therapy, triggering the bodily responses and emotions involved, unless there is good chance the client will see it through.

Somatic trauma therapy is most productive in two-hour sessions where there is ample time for the client to confront issues, integrate material and recover. Some clients prefer to come weekly, some biweekly to have more time to process the material raised in the therapy.

We also briefly discussed R’s situation at work and she agreed that for the time being, she wouldn’t take potentially violent clients – she was already receiving support for this from her colleagues.

Therapy Session #1

R outlined the story of the rape.

I kept R from going into detail at this time, as I could see signs of sympathetic nervous system activation (dilated pupils, pallor in face, increased respiration), and wanted to keep that at a minimum. At this point I only wanted to be oriented on what we were to work with, and didn’t want her experiencing the trauma. (With a more frightened or less stable client, I might have waited many sessions before asking for information about a trauma, focusing instead on establishing the client’s sense of safety both in and out of therapy. R is not anxious about the therapeutic process, itself.) I expected to be told only a partial story. Dissociation in varying degrees is typical in trauma. The relationship between trauma and dissociation is well established (Loewenstein, 1993; Herman,1992; Braun, 1988). Traumatic events, if remembered at all, are often remembered only partially. Missing events, details, physical sensations, etc. are common.

R had been traveling with a group of friends, but had chosen to go off by herself one day with a polite young Arab, M, who offered to show her the city. No one thought much about it. M was very knowledgeable and showed her much of the city she wouldn’t have otherwise seen. Towards the end of the day they encountered one of M’s friends, and went back to M’s apartment. As night fell, she was told by M that he would have sex with her, but would not allow his friend to because M was “in love” with her. She protested and asked to be taken back to her hotel, but was told that if she didn’t allow it, they would both have sex with her. R reported she then went dead in her body. The next morning M showed her back to her hotel, stopping to buy her breakfast on the way. When they arrived, her friends expressed concern for where she had been. R was so embarrassed and ashamed about what had happened she didn’t say a word about the rape; she told her friends she had spent the night dancing.

I decided that the BODYnamic running technique would be useful in R’s therapy. I suspected that her “going dead” was in response to feeling trapped (suppression of flight reflex (Levine 1992; Bloch 1985)). I also judged that she was stable enough to be able to benefit from the running technique as an aide both to reduce her anxiety and to loosen some of the freezing/deadness in her body.

I would like to caution that the BODYnamic running technique, while extremely useful and powerful, is contra-indicated in many instances of somatic trauma therapy. It is not appropriate for use with clients who have psychosis, dissociative disorders or borderline personality disorder; where the traumatic experience included fever, drugs or unconsciousness – head injury, anesthesia, fainting, etc.; with actual/current traumas, especially where there is a history of trauma; and any time the client becomes more rather than less anxious from its use. It can be used in cases of Complex Posttraumatic Stress Disorder if not complicated by any of the aforementioned limitations. However it should not be used before the client has achieved relative stability in his/her life, is able to contain powerful emotional release, and is able to differentiate the traumatic event as something that occurred in his/her past. For in depth discussion of the BODYnamic “running technique” see:Jørgensen, 1992.

The client “runs” lying down with feet pummeling into a mattress with arms swinging and head pointed forwards as s/he imagines running along a route to a “safe place”. It is important that the movements be running movements and not allowed to become a kicking/hitting “temper tantrum” – one of the reasons for keeping the head pointed straight and not rolling from side to side.

The client chooses the safe place (Jørgensen 1992). It must be a real place with a real person(s) the client has or had a close relationship to. One reason a trauma sufferer remains affected, is because s/he lacked appropriate support and contact at the time of the trauma. Running to the safe place accomplishes several goals: 1) it helps to physically loosen traumatic freezing, 2) it helps re-establish the reflex of flight, 3) it creates an imprint of contact rather than isolation as a result of the trauma.

We then used a good amount of time to establish her “safe place” to run to. She chose to run to her home at the time of the rape, and chose 4 of her current friends to be there. We went over the route to the safe place, springing from the Mid-Eastern country to a landmark close to the house and continuing along a route that would eventually lead her into the house and to her friends who would be waiting for her. She drew a map and named the other landmarks along the way so I could help guide her as she “ran”. She decided how she wanted to be greeted: for the friends to ask “What happened?!”, but not to touch or hug her unless she reached out for contact. She then practiced running to the safe place. Before we ended this first session, we discussed if there were any of her current friends she might like to invite to future therapies, as in-person supports – “helpers”. R choose one of her colleague/friends, a young Middle-Eastern woman whom R felt very close to.

It is often a good idea to have a client invite one or more “helpers” to shock therapy (Jørgensen 1992). It is important that the helper be instructed not to do anything unless told to, including giving comfort to the client. S/he is there as a witness and support. It is important to decrease the isolation of trauma as much as possible. Of course, the use of helpers will also decrease transference to the therapist – which can be an advantage in a limited trauma therapy, but contra-indicated when trauma therapy is a part of a longer, dynamic or characterological psychotherapy, or body-psychotherapy. In R’s case use of a helper was serendipitous, which will be illuminated as the therapy progresses.

Therapy Session #2

I suggested that R begin the therapeutic work with events that occurred after the actual rape. An important source – perhaps the most important – of lost resources lie after the traumatic event, as resulting PTS or PTSD usually indicates that a person was not met, supported, helped as they needed to be during the trauma and after it. This case study illustrates this principle well: how grasping the resources lost (hidden) after the traumatic event, in this case, rape, made approaching the rape situation itself, much less difficult and anxiety provoking. There are also important resources in the events before a trauma. Often a ping-pong approach is best: slowly nearing the core of a traumatic event from events both after and before, going back and forth.

I listened to R’s words and observed reactions of her body. I was especially interested in noticing somatic signs of autonomic nervous system (ANS) activation – both sympathetic (SNS) and parasympathetic (PSNS) – (changes in skin color or temperature, sweat, pupil size, breathing patterns, muscular tension, pulse rate, etc.). I didn’t just rely on my observations, but also periodically asked R what she was aware of in her body. This was both a feedback for me, and an encouragement for R to sense her body and it’s changes. It was helpful for R to connect with her body as she might have fully or partially dissociated from it because of her trauma. Body awareness is also one of the most valuable tools of somatic trauma therapy (Rothschild and Jarlnæs, 1994; Rothschild, 1993). It is the changes that occur in the body that indicate both what is happening within the client and what needs to happen. For example, when R becomes stiff in her legs (PSNS activation), or shows signs of anxiety (cold sweat, wide pupils, increased heart rate – SNS activation), this is the time to run to the safe place. It isn’t usually a good idea to have the client run when dissociated (i.e., spaced out, areas of physical numbness, feeling of depersonalization, etc.). If dissociation increases, that must become the focus of the therapy – what happened that the client dissociated? – with association accomplished before continuing use of the running technique. Additionally, you shouldn’t use the running technique with clients who have dissociative disorders (depersonalization, multiple personality, etc.), as this technique could increase the dissociation.

R talked about what happened after she returned to her home country. She had still not told anyone that she had been raped, but a vaginal infection forced her to seek medical treatment. A gynecologist was the first person she told about the rape. His response was cold and clinical, with an edge of sexual interest that increased her feeling of shame.

When reviewing a trauma there is a choice of using past or present tense, dependent on the stability of the client and the type of techniques used. Use of present tense will bring the client closer to the trauma, traumatic reactions, and activation of the ANS. Often when using the running technique, it is useful to have the client talk of the trauma in the present tense as she gets in touch with it, and then change to past tense when she reaches the safe place. This can help attend to both the inner sense that the trauma is occurring now, and the external reality that the trauma is over and survived. The goal of therapy is, of course, to clearly separate past and present and relegate the trauma to the past.

As her legs began to stiffen, or she began to become anxious (both ANS signs of trauma), I had her run from the scene, to her safe place. In the safe place she told her helper what happened, then, and how that has affected her till now. She expressed anger at the doctor’s insensitivity, and she related difficulties with her current doctor and made a decision to switch to another one, before having her next examination. She felt the impact of not having told any friends, how alone she was at that time, and how ashamed. She cried deeply.

It is crucial to prevent re-traumatizing of the client. Therefore, as soon as the client begins to show even small signs of ANS activation (stiffness, anxiety, pallor, cold sweat, etc.) that s/he run to the safe place. This will often (but not always) trigger an outpouring of blocked emotion. The client gets contact from both therapist and helper(s) and tells about the past events that led up to the reaction. Memory expands and events and emotions can be associated. This is a critical opportunity for the client to assign the trauma into it’s rightful place in time, the past, separating past from present. The trauma sufferer hasn’t fully realized that the trauma is past, and, therefore, survived.

The associated memory and emotional impact of the insensitive doctor who examined her following the rape helped R to claim more control in her life by deciding to replace her currently inadequate doctor. This is one of the best results of trauma therapy: when the client is able to use the therapy to positively impact on his/her current life.

At this point she remembered eventually telling one of the friends she had traveled with, both with relief and shame and fear of being judged. I asked her to make eye contact with her helper and see how the helper would receive her – testing the reality of her feeling that everyone would judge her.

The helper, was very touched by R’s feelings, and their contact was intense. R reached out and took hold of the helper’s hand several times throughout the session.

At one time R looked at the helper and realized that the helper’s nose resembled the nose of the rapist. They laughed about this and R said she didn’t feel this was a problem. The next time R ran and arrived at her safe place, the helper covered her nose with her hand – half in seriousness and half as a joke. R first laughed, almost hysterically, then the laugh deepened into sobbing – the impact of the rape associating closer. I later talked with the helper about not making further spontaneous gestures, that she was just to be there and not do anything unless asked.

This illustrates both advantages and disadvantages of using a helper. This helper inadvertently triggered a deepening of the therapy process. But she also acted without instruction from the therapist. Helpers who cannot follow the therapist’s instructions, can not be allowed.

Before we ended this session, R commented that the noise from the street outside my office window reminded her of the busy streets of the city in which she was raped. I suspected she was confusing past and present, so I had her run again to her safe place. This time she ran full-out, with the flight reflex fully engaged, and sobbed when she arrived at her safe place, releasing a large portion of her anxiety.

It is not a good idea to let a client leave a session in the trauma. Sometimes a session must be extended to prevent this. The therapist must listen to the client’s words and look for signs of ANS activation.

R was tired and felt a little “stoned” when we ended and I intervened to insist she take the train home, instead of driving (an hours trip). Her helper agreed to assist R in securing her car (she could fetch it the next day on her way to work) and accompany her to the train station.

It is often necessary for the therapist to present safety limits for the client. At this point it would not have been safe for this client to drive such a long distance home.

At the end of this session I had R and her helper “de-role” to keep their out-of-therapy relationship clean of transference and rescue (Jørgensen, 1992). It’s a good idea to do this after each session with client and helper(s). It’s a simple ritual. The client says, “you are no longer my helper, you are (helper’s name), my friend (colleague, etc.).” The helper responds, “I am no longer your helper, I am (name), your friend (colleague, etc.).”

Therapy Session #3

R reported that after the helper had departed the train station, she found a man in the women’s toilet. R became instantly angry and demanded he leave. Luckily he was only a passive drunk who had chosen the wrong door, but she was quite shaky after. We discussed issues of getting help vs. doing things herself. She made a contract that until we were finished working on her shock, if anything like that occurred again, she would seek help, and not handle the situation herself. I explained that while working on shock, one isn’t always able to evaluate what is and isn’t safe in the area of the shock one is working with. She agreed to do this. We also discussed the coincidental nature of what had occurred, and joked some about how it seems the universe arranges for us to be challenged as we work through our issues. (It happens a lot!!) She then remembered – with both fright and fascination – that as a child she had met a flasher on a train.

It may be necessary to make protective contracts with clients during trauma therapy. It is not uncommon to make a safe driving contract with a client working with a car accident, for example, or a contract for extra caution at night with a client who has been assaulted. This action supports possibly reduced orientation resources. This is another instance of the therapist intervening to provide safety for the client. It might have been better if I had first explored with her what she’d like to do in a similar situation, but the contract is a good idea. It is a common occurrence that a trauma client is confronted with situations that mirror the issues being worked with and that illuminate some of the themes involved. The popular term for this phenomenon is “synchronisity”. Here the theme of handling a, possibly, dangerous situation on her own and not seeking help was demonstrated.

It is important for the client to feel in charge of the therapy process, and at the same time the therapist must provide his/her expertise. Steering of the therapy process is more common with a somatic trauma therapy then in a dynamic or characterlogical therapy. But no step is taken without the full understanding and consent of the client. Trauma occurs because of a loss of control (of the car, at the hands of the assailant, under anesthesia, etc.). Having a large degree of control over the therapy process – i.e., trusting that all “no”‘s and “Stop!”‘s, as well as the client’s own ideas for direction will be respected, etc. – will increase his/her sense of safety in the therapy and in his/her life.

I suggested that today’s therapy should focus on the events before the rape. How did she choose that trip, with those people, to that country? How was the travel, what were problems and enjoyments along the way?

They traveled through Europe and then into the Mid-East. The contrast of cultures was intense. Over and over as we discussed how it was to be in the country where she was raped, she remarked that she hadn’t remembered how tense, and often uncomfortable the atmosphere had been for her – she had only remembered the excitement. It became a true asset that her helper was also from the Mid-East, as we were able to utilize her expertise in establishing a true sense of the difference of energy, norms and values compared to Western European countries, and how that also effected attitudes about women, especially western women, something that may have contributed to the rape.

There can be much forgotten in the time before a trauma. It is important to associate these memories and extract the resources – often clues to orientation – contained in them. Sometimes a sense of curiosity, self-confidence, joy, etc., can also be lost when it seems that such traits or feelings resulted in a trauma. This must also be reclaimed. Decisions like, “I’ll never ________.” are often based in events before a trauma.

Again we worked with the memories, and she ran when signs of ANS activation appeared, using the safe place for processing of information and feelings – relegating the rape into the past. At the end of this session R was surprised to realize how much she had repressed/dissociated her emotional memories of that trip. She realized that, on the whole, she had sugar-coated her memories. She had not enjoyed her visit to the Mid-East!

PART II

Therapy Session #4

R reported encountering a strange man on the train. He seemed to nap with his head on her shoulder while brushing her leg with his (seemingly asleep) hand. When she realized he wasn’t asleep, she became frightened and appalled, but was afraid to move, lest she offend him. She was not able to keep her contract of getting help. We discussed options: choosing populated cars to sit on, and moving if she is uncomfortable, etc. She thought it might be good to say, out loud: “What do you think you are you doing?” or “Stop that!” – such protests will both stop an offender, and draw attention to the situation – and I had her practice this a couple of times.

Again, she encountered synchronistic situations. Some of her paralysis (inability to move) was directly related to the rape and I suspected she would be able to move in a similar situation when she had finished her therapy. How much of these encounters were a magnet of her personal process, and how much of her heightened awareness – have these kinds of things been happening before without her noticing? – was not clear. At any rate it was important to discuss her options for response and train her in them.

We decided, in this session, to take a look at the situation immediately following the actual rape. Here the connections to her inability to act against an offender or seek help gradually became clear. I gave continued attention to R’s body awareness and signs of ANS activation.

When R and M left his apartment after he raped her, R felt she had to be nice to him. She didn’t know where she was or how to get to her hotel. She didn’t speak the language. She felt dependent on M to get her back to safety – dependent on the man who had raped her! So she let him hold her right hand. As she remembered she could feel the tension in the hand and the impulse to draw it away.

As R approached her friends with M, she had an urge to scream out, “Call the police, he raped me!”, but stifled it, by tensing in her throat; she feared the reaction of the crowd.

Here the helper’s culture was, again, an asset as we discussed if R should or shouldn’t have yelled out – what kind of reaction was R likely to have gotten if she had?

The helper was sure that a Mid-Eastern crowd would have considered R, a young European woman accusing a Mid-Eastern man of rape, to be a whore and would have, at best, ignored her, at worst accused her or hit her. The police, the helper was sure, would not have taken the situation seriously, and may have arrested her, instead.

This cultural insight is important in alleviating R’s guilt about not seeking help or retribution. If R had not had this helper, it would have been appropriate for us to do some research with regard to cultural norms. Here, supporting her intuitive defenses is of utmost importance. In trauma, people call on unconscious defenses and make unconscious decisions based on the knowledge they have at the time. These trauma decisions and trauma defenses have, also, a trauma logic (Rothschild and Jarlnæs, 1994). They are always appropriate to the situation when judged from that angle, but can carry much guilt and be harshly judged when viewed from a non-traumatic perspective.

I had R return to her memories. I had her sense what she had to do in her body to make herself hold the rapist’s hand and not cry out: tense her arm while relaxing her hand, tense her throat, not run, etc. At the same time I encouraged her to consider how smart she had been – how she had likely saved herself further harm, shame and anguish.

Trauma decisions are two sided. They are made in the service of survival, and sometimes require compromise of normal instincts and feelings.

But when she ran to the safe place, I urged her to yell out, “I’ve been raped!!” – it is now safe to dissolve this defense! -, timing my intervention as her anxiety rose, but before it became so high she again froze. With her shout came a strong outpouring of emotion: fear, shame, rage. She swore at the rapist, and began hitting with her right fist, finally taking back her hand. For the first time she became angry at the rapist (she’d always been angry only at herself) and how he had set her up. Now she was ready to begin to separate her guilt and place blame with him. For the first time she realized that it was he who was in the wrong. (She knew – and we still needed to work on – that there was something amiss in her judgment that she walked into the situation, but she realized at this point that the responsibility for the rape, itself, clearly was M’s.) R had clearly said “No!” to his sexual advances, and she then remembered that M had attempted to strangle her when she resisted.

This is an important step. It is crucial to assign guilt. A trauma survivor is all too ready to take all blame, and many therapists are too quick to place all blame on the offender. For the client to reclaim all his/her power and sanity, the truth of guilt must be illuminated. A rapist is responsible for a rape. Period. And, s/he who is raped must be willing to look at how s/he came into the situation – SO THAT S/HE CAN PREVENT THE SAME FROM HAPPENING IN THE FUTURE. Orientation is a first response to threat: where is the danger? what is it? how do I react? When one has been traumatized, often it is because there was something missing in this stage. And orientation for future safety is always reduced in trauma – often resulting in a traumatized individual being more vulnerable to future trauma. It is important that this resource be restored. In all animals, orientation is a reflex that involves stopping and locating the source of threat. Physically this requires sharpness of eyes and ears and mobility in the neck (Levine 1992). In humans, orientation additionally requires being able to process information and intuitive signals.

R wanted to further express her rage through hitting a pillow. As a part of setting up a safe situation for this, I required that she stay in contact in the here and now and cautioned that she shouldn’t expect to “get rid of” all of her rage. I suggested that she needed to keep some of it and contain it, as a part of her power, and to help her to react more protectively on the street, in trains, etc.

It seems a common misconception of Body-psychotherapy, that one can or should “get rid of” feelings. I have heard many therapists state this, and it is often a goal of clients. I don’t believe this is possible, nor, necessarily desirable. One can become better at expressing or releasing feelings, but humans continue to have emotions. Containment of emotion is an equally desirable goal of therapy. One needs both the ability to release and the ability to contain emotions. Ideally the individual should be able to choose expression and containment in differing situations. Containment of emotion requires a certain amount of body tension, which is desirable as an additional aid to personal defense.

R expressed her anger and cried that it was not fair that M got off free and she had suffered all these years. I suggested that she allow herself a fantasy of what she would have liked to happen. She is very quick and clear: he should have been caught, tried, and castrated. “Men who can’t contain their sexual hormones, shouldn’t be allowed to have them.” She was sure she didn’t want him killed, and didn’t want him to suffer pain, just be deprived of the hormones that were a cause to what he did to her.

It is important to allow the client to fantasize desired outcomes – and for the therapist to help the client to keep the fantasy as fantasy especially when there are desires for revenge. Fantasy helps the victim to feel his/her power and relegate responsibility.

I told R that in the US, they call this “date rape” which is a classification of rape not as recognized in Europe at this time. I explained that date rape is rape that happens between known parties. Usually the encounter is friendly, even flirting, but becomes rape when the man presses his sexual desires over the woman’s protests. In parts of the US it is considered as serious as rape by a stranger.

R left this session feeling different. For the first time, she didn’t feel guilty that she was raped. Instead she felt angry at the rapist who did it.

This was a pivotal therapy. The issue of guilt in place, the rest of R’s therapy will be much easier. Now when she works with the rape itself, R will not be as plagued with doubts about who is in the wrong. And when she approaches looking at how she got herself in that situation, the guilt of the rape itself, will be separate from her guilt for not having been more cautious.

Therapy Session #5

Since the last session R had been ill twice, once with a stomach flu and today with a cold. It was unusual for her to be ill. I discussed with her some of the physiology of stress and its effect on the immune system.

It is likely that R’s illnesses are related to her therapy. Since stress affects the immune system, it is not unusual for a client to become ill during trauma therapy (Bloch, 1985).

She’s also been more irritable at home, and more assertive with her husband and family.

We agreed to focus R’s session on the events leading up to the rape. R carefully described how she met M. Several times I stopped her and had her go back and relate further details. I was wanting both to increase her association and to engage her orientation – were there danger signals she may have sensed, but ignored?

Since dissociation is a main feature of trauma, it is good to have the client repeat, especially when the therapist senses s/he is glossing over details. Memory of details is a part of increasing association. Remembered details may also hold clues to orientation or trauma decisions. I am also, of course, continuing to monitor activation in the ANS and help R to increase her body awareness.

R began by telling how she met M in a cafe while having coffee with a friend. M came to their table and started talking. R then skipped to another memory: the day before an older Arab man had approached R and her friends, offering to buy R. She says that this was only a joke, and she went along laughing. But as she discussed it with me, she began to feel irritated, remembering a male friend bartering with the Arab. She displaced this irritation towards me: why am I focusing on this unimportant joke? When I checked her body awareness she was beginning to get stiff in her legs, so I had her run to her safe place. There she began to associate her irritation to the Arab, and her friends. She then realized she didn’t think it was at all funny. Her irritation towards them increased, becoming anger. Remembering the cultural discussions we have had she became clear that this older Arab wasn’t joking, but actually testing the waters to see how far he could go. She became angry her friends went along with him, and irritated with herself for not stopping it. She had been afraid not to go along with the joke, afraid she’d dampen the group’s mood.

The therapist must be able to accept a client’s displaced feelings, and at the same time keep aware of the bodily signs of trauma. If I had begun to discuss or argue with R about the direction of my questioning, much would have been lost.

I had her go back to the scene, hear the “joking” and say “STOP, this isn’t funny!” – and then run to her safe place. Her sense of power increased. I asked her what she might have liked to say. “I’m not for sale! I’m going now!” I had her go back to the scene, sense it in her body, say her words, a couple of times, and then run to her safe place.

She now realizes that already the day before the rape, the sexual atmosphere was uncomfortable for her. She wonders how she could have been so naive. I point out her personality tendency to hold back anger and try to make jokes and peace at the cost of her own feelings and how she was already, from her upbringing, used to holding herself back, being one-down, and not making waves.

Here her orientation resource is increasing both from increasing memory and emotional association to the trauma, and in gaining understanding into her personality makeup. Some trauma clients might need to loosen a stiff neck to physiologically increase the ability to orient. This was not necessary for R as her neck mobility automatically increased as she worked with the rape.

It was important to work with this incident, because it was a place where she had seriously cut off her orientation to danger, which may have made her more vulnerable to the later rape situation.

R says she has become more protective. She now takes care to look over her shoulder and to avoid being followed at night – all reinforcement to her orientation and safety.

Therapy Session #6

R states that she can only afford this session and the next two. I remind her of our contract that she will work with the trauma until she is finished and explain it is not good to end in the middle, nor to rush the process. She agrees that if more sessions are necessary, she will seek further assistance from her work.

She’s been feeling fine, and wonders if it is resistance, or that the effects of the trauma have actually lessened. She hadn’t been nervous about coming to this session.

We agree to focus on when she met M and approach the actual rape. M’s tone was very friendly, non-sexual. He offered to show R and her friend around the city. I ask if this is normal, both because it is out of my experience to meet such foreign friendliness, and because I want to explore her orientation at that time. R explains that in the ’70’s it was common for foreigners to offer guidance to tourists without expecting anything except the pleasure of sharing one’s country. She had done it herself!

R’s friend declined the offer, but R accepted. M showed her around the city. R was careful not to let him buy anything for her (he wanted to buy her a necklace, which she bought for herself) – not to be in his debt. We agree this was smart! M sometimes held R’s hand, but R believed this was platonic. I point out that R’s considerations – not letting him buy her trinkets and allowing the hand holding because it seemed platonic – indicate that she was somewhat on watch, and somewhat discounting what could have been important signals. We discussed this to increase her orientation.

M offered to show R a beautiful ruin outside the city. She agreed. Everything was fine until, on the way back to town, the mood changed. A friend of M’s drove by in his taxi and offered them a ride. R didn’t like it when they spoke Arabic and she couldn’t follow the conversation, especially when she believed them to be arguing.

The taxi driver ran a red light and the police stopped the car. When they saw a western woman with the two Arabs, they accused her of being a prostitute and wanted to arrest her. M defended her and convinced the police she was a tourist and they let her go. R was very scared. This is an important event as it was here she gained trust for M, as she felt he protected her from arrest. As we explore these memories, her legs periodically stiffen and I have her run to her safe place several times.

As a rule of thumb, it is better to have the client run many times too many than one time too few. But there needs to be some ANS activation before it can be relieved in running.

M then asked if R would like to see how he lived. Never having been in an Arab country before, R was very interested to see how he lived, and assumed the taxi driver would drop them off. But to her chagrin, he came with them to the apartment. She began to get nervous and asked to be taken back to her hotel.

At this point M announced that he would have sex with her. The taxi driver wanted sex with her too, but M said he would protect R if she would cooperate. M told her to take off her clothes and lie down. He then put his hands around her neck. R went dead in her body. She feels this deadness, also now, as she lies on the mat.

We are now at the center of the trauma, the place where she believed her life to be in danger. This is where she went dead in her body. This deadening response is common in trauma. It is a survival reflex of the ANS and can appear as either a stiff paralysis (as we’ve seen in R’s stiffening legs) or as a flaccid collapse (as we see with R now). It is the same biologic reflex an animal of prey will have when captured by a predator, like a mouse captured by a cat (Gallup and Maser 1977).

I structured the next steps with R’s agreement in an attempt to help R out of the deadness and restore a sense of power and control. I instruct her to select something she can use to symbolize the man’s hands (not me or her helper!). R chooses a rolled towel. She lays the towel on her throat and has a strong memory of his hands there – I instruct R to allow this experience only for one or two seconds. She is then to cast the towel off, yell any appropriate words, and run to her safe place. She throws the towel yelling, “Get your hands off of me!!” and runs with flight reflex fully engaged. This time when she gets to her safe place she is crying and shaking. When she calms, she is proud. After a pause, she agrees do it again. This time she is more spontaneous, more proud, more tired, and has a greater sense of control. She is also relieved. She wants to repeat the sequence, but is too tired. We agree we will come back to it.

This was a turning point in R’s therapy. The rest of her therapy will be easier.

There are several important principles to discuss here. First of all it is critical that I allowed R to choose a symbol to represent the rapist’s hands. It is not a good idea for the therapist to come into a role where s/he could be confused with the offender. There is potential for re-traumatizing the client when therapist and perpetrator become confused. In addition, the client needs a sense of increased power and control, not another fight that could risk re-traumatizing. With regard to the threat and deadness, I only want her to taste it, not become dead again. Having her sense the threat and deadness only a couple of seconds and then react, makes it possible to turn the imprint of the trauma around. It also gives the client a greater sense of control that she is in charge of the process: confronting her fear, choosing the symbol, determining where it should be placed, reacting where reaction was not possible before. Lastly, getting in touch with how and when she went dead, experiencing the deadness, being able to come alive and react, and then release her fear through crying and shaking will contribute to a reduction in the ANS activation that has contributed to her traumatic symptoms and kept a sense of deadness in her body and life.

PART III

Therapy Session #7

R has a cold. She reports feeling more confident. She’s more assertive, especially at work – with both colleagues and clients. She accepts her opinions, and moods more readily. She feels more connected with herself and less swayed by others. She’s not had any anxiety with clients.

R’s view about the rape has changed. It has less impact. It happened, but she doesn’t feel fear or ill when she thinks about it anymore. It means less to her life now. She doesn’t feel she is repressing. She has better judgment about which clients she will and won’t accept. And she has not had any weird encounters with strangers on the train or bus.

She had felt good since the last session, and she had a lot of energy.

A lot has changed since the last session. It is tempting to think that it is this last, dramatic session that has created such change. But it is actually the build up from all the work that has gone before that culminated in that session. It is easy in somatic trauma therapy to put too much emphasis on the dramatic, active sessions and discount the value of the careful discussion, integration, association, body awareness and contact between client and therapist.

We agree to work further with the rape scene. She asks, “why did I take off my clothes and lie down?” An area of guilt. She answers herself: M had a friend in the next room and threatened he would also rape her if she didn’t cooperate. Her hands become warm and sweaty as she talks about this, there are prickles at her inner knees, her feet are cold and she feels discomfort in her inner thighs.

I suggest she place a pillow between her knees and slowly squeeze it to build up tension in the thigh adductors. The left adductors feel “dead” and the right feel warm (according to R’s Bodymap®, her left adductors are slightly resigned – flaccid – and the right are resource filled – slightly tense). As she squeezes the pillow the left adductors begin to liven, and then to vibrate, and it gradually becomes easier to get the muscle to tense. She is cold in her calves and the skin feels creepy, she gets tense in neck and shoulders (muscles associated with orientation).

Certain muscles react to trauma with flaccidity – a physical sign of deadness or resignation. R couldn’t stop M from raping between her legs and the adductors (muscles that pull the legs together) gave up trying to stop him. Working with tensing these muscles helps re-develop her resource to hold her legs together, and protect her genitals.

After building up R’s contact in her body, we go to the traumatic scene where M tells her to remove her clothes and lie down. At this point R can feel she goes dead in her body and I have her run to her safe place. Here she talks about having been in fear for her life. She also expresses guilt she feels – it was stupid to get into the situation. And she is also disappointed she didn’t get psychological help sooner and has waited till now to work on it.

Grieving is an important part of trauma therapy. How hard it was, how scary it was, how hard it’s been since.

Her hands were warm and feet cold. I encouraged her to feel this temperature split – focus on both sensations at the same time. When she did this she felt a split in her body. It was a familiar feeling that she recognized from times she has had sex when she didn’t want to. She felt leg-less, ice cold and rejecting. She talked about sex vs. violence. She thought about how it was for M to be sexual like that. She felt she understood him better and felt less anger, but thought he was pathetic. She caught herself being too understanding and wanted to feel her anger.

It is often very productive in somatic trauma therapy to have the client feel opposing sensations. This “splitting” is related to dissociation, bringing these splits into awareness is usually an aid to association. In this case R associates these sensations to her current life. Here R also makes an important distinction between sex and violence. When dealing with rape, this is an important difference to understand. Rape is an act of violence, not sex (Brownmiller, 1975).

R was still experiencing some temperature split in her body. I suggest she return to her memories of the rape scene. R now remembers that she didn’t just lie down. – she protested and M threatened her again. She remembers his eyes got wild and he grabbed her throat. It was only then she said “ok”. She had felt trapped and feared he would kill her, and that no one would know.

With the aid of her helper, R came to see she had been naive. R had grown up learning to always be polite and sweet and to not expect people to hurt her. We discussed cultural differences – I’d grown up learning to never talk with strangers. We talked about “healthy paranoia”. R warms in her legs, but her feet remain cold.

It is important to discuss cultural differences. Here we are also addressing R’s character pattern of always being friendly, agreeable and helpful.

R had hoped this would be her last session, but I insisted there be 2-3 more times explaining there are some important aspects of the rape still not addressed, as well as somatic signs of remaining ANS activation. She agreed.

Even though much in the center of the trauma has been dealt with, I still sensed there was more. There are still body splits as evidenced by her temperature differences, and there needs to be more tie in to her life now, especially her sexuality, and areas of boundary and limit setting. It is important to associate as much as possible – not only in mind, but also in body. And it is important to tie the trauma therapy as much as possible to the client’s life. Additionally, a trauma is not completely worked through until the client can talk about it without signs of ANS activation.

Therapy Session #8

R’s anxiety continued to lessen and she felt more aware of strangers when she was out in public – more orientation.

I suggested we discuss her current sexuality. She joked about it, and felt tensed in her solar plexus. There were sexual problems as a result of the rape, but they seemed better now. We explore this somewhat. She can lose concentration during sex, but thought this was not only a result of the trauma, but also of stress in her life. R appreciated her husband as a sexual partner. She continued to be relaxed through the discussion, breathing evenly.

R’s body signals told that her current sexuality is not much of an issue now, so we continued.

R brought up the rape and commented that M had raped her orally and anally as well as vaginally. This was new information. We discussed how this affected her sexual preferences now and then decide to review the rape scene once more, though it seems much is worked through. R became clear that when she went dead, it was in the hopes of surviving with the least damage,- a usual reason for any defense.

She discussed her confusion about M: good and bad in the same man. He protected her from being raped by his friend, he said he “loved” her. And, yet, he threatened and raped her. He was both sweet and evil, violent and protective.

I asked if she had such confusion in her life now? She said that the client who had attacked her at work was also a mixture – of aggression, desperation and sex. He had said he only wanted to “feel her good energy.” R says he was a very sweet man and very polite, not the type she’d expect to be afraid of.

If R had had a Borderline personality (or had a strong tendency in that direction), I would have spent much more time exploring this area of splitting.

We talked about different publicized cases of alleged rape: Bobbits, Ted Kennedy’s son, Mike Tyson, and “date rape”. This led to a greater orientation sense, and understanding of how rape victims become vulnerable to be raped again – if they don’t regain/repair lost or damaged orientation resources.

R mentioned a man on a train who followed her recently. She didn’t want to reject him, but tried to ignore him. She was aware there is a boundary problem here, as she hasn’t been effective in keeping him away. We planned to work with this at the next session.

“Boundary” refers to one’s personal – physical and energetic – space. The physical boundary of the skin is constant. Energetic boundaries (i.e., comfort distances during conversation) change all the time. Boundary can also refer to the limits we have of what we will and won’t do.

This session focused on integration, understanding and stabilization – all important processes to balance with the somatic work. I noted her comment about being raped vaginally and anally and suspected this should still be looked at.

Therapy Session #9

We agreed to go through rape scene with an eye to boundaries. She quickly reacted, said “no”, pulled her legs together and ran to her safe place. I suggested and R agreed to work with kicking and pushing in various directions, and ways – saying “no” with her body. She wanted to kick/push up and forward and her helper agrees to sit on R’s feet and be pushed up in the air and forward – flying. There is some fun in this training of a protective movement.

Training a trauma victim in movements that could be used to protect herself is an important aspect of somatic trauma therapy. This is not self-defense training, but a movement specific training: pushing and kicking in different positions to wake up possibly dead muscles or movements. In many cases it would be appropriate to supplement this with recommendation that the client take a class in self-defense. It is not necessary that such training be done with anger. The purpose is to enliven and tense, not to express emotion. If a helper is willing, they can often be used to provide physical resistance. The therapist must direct all steps and make sure no one gets hurt.

Kicking behind her, R becomes spacey (likely ANS activation) and I have her run to her safe place. She cries that it hurt when M anally raped her, she thought she’d die. She has a fantasy of cutting off M’s penis. R then gets itchy over her back and buttocks (deadness coming alive) and asks that her helper and I scratch her gently over her back. Then she rests on her back.

The rear directed kicking clearly provoked memory of the anal rape. This was an important aspect to have included. Her reaction of itchiness seemed to indicate a waking up of her skin.

R asks to work with M’s strangling her again. We do, as we did before. Then she wants to push his hands away. Her helper and I give her resistance, one to each hand, placing a pillow between our own and R’s hand. She pushes and then runs to her safe place.

It is the pushing movement that is important – bringing tension, resource and strength to the muscles that push away (triceps brachii). It is also important that she not be in a position where she will “relive” the rape. By having her push with a hand each to me and the helper, we avoid a situation where there is one person over her that she must push off. If there had been no helper, I would have likely had her push towards me, but standing up.

Then she wants to push again, and I suggest she also push with her eyes – as well as her arms – towards me. We train this, pushing away contact/making boundary with her eyes. She recognizes this might help her with strangers who approach her.

I suggest that R train pushing from her eyes at home.

Learning to push away and keep out contact with the eyes can be an important aspect of learning to protect and hold on to one’s boundaries. Many children do this automatically, for example, by not making eye contact with people they don’t want contact with. Animals push and challenge with their eyes in threat. It is accomplished by tensing around the eyes and having the sense that any contact is pushed away from the eyes.

Therapy Session #10

R has felt great since the last session, relieved and relaxed at home. She felt a lot got cleaned out last time. She’s not so stressed.

She has practiced pushing with her eyes. She feels most successful when she makes her eyes cold and stares through people. She’s not been approached by strangers since she’s tried it.

The last session was profound for her. She’d known something had been there stopping her; the rear kicking cleared it. She’s taken more space and has enjoyed more quiet times alone.

R’s had success setting clear boundaries with a difficult Middle Eastern client. Her assertiveness was well received. She feels she is getting better at setting boundaries in positive ways. The client had wanted to kiss her on her cheek in greeting, which she did not want, but he accepted her limit that they just shake hands. She feels more confident.

She had to run for her train after the last session, and got a little nauseous. She thinks it’s connected to the rape and wants to work with the nausea. This leads to her memory of being mouth raped – forced to perform fellatio. We work precisely with this: how her head had to tip back, where jaw, neck, throat tenses, etc. I have her push away a pillow, and say “yuck” as she sticks her tongue out. She becomes nauseous. We work with this, with a bucket nearby, in case R throws up. R feels an impulse to bite. She needs something to bite. She tries a towel, but it’s not satisfying for her. I suggest sausages that she can bite and spit out; she likes the idea. (We take a break while the helper runs across the street to get them. She controls this process herself: sticking a sausage as deep in her mouth/throat as she needs to to release the nausea, then biting and spitting. She finally does throw up and feels better.

The symbolism here is obvious, although not a necessary stage in working with rape. I have never done this with a client before. Here it was effective in aiding oral aggression that was deadened in the rape. When working with trauma, one must be open to creative ideas that apply to the particular situation. For R this was important, if unpleasant work.

As we are ending, I tell R I think she is brave, and as she cries, she can finally feel how hard it was for her when she was raped and how hard it has been living with it.

R had expected this to be the last session, but I insist on one more. I believe that most of the trauma is worked through, but want to be sure, as this session was intense. A follow-up is a safety measure. I would always rather err on the side of safety – insisting on one or two sessions too many – than risk missing something important or leaving the client alone to handle an unpleasant reaction to the therapy. It can also be important to end with review of the therapy. The termination process need not be so long as in a dynamic or characterlogical therapy, but the principle of appropriate termination is the same.

(R canceled her next session because she had the stomach flu – came down with it only a few days after the last session. A kind of rinsing out, I think. Could also be an element of resistance to my insistence on one more session.)

Therapy Session #11 – termination

We discussed R’s flu, its cleansing features, and its connection to the last session which she left somewhat sad and tired.

R was very irritated I required she come today. I encouraged her to express this: She didn’t feel she needed it. She had needed, at the last session, to work with the nausea, now she feels done. But she does understand the logic of being required to follow-up the last session and end the course of therapy properly, and has accepted it.

The rape feels “so long ago”, clearly in the past. Her mode of reacting is no longer tied to the rape. She is pleased with herself and the therapy.

We do some review to integrate and tie-up loose ends from her therapy. I ask R what she would do differently, in a similar situation to see how she has integrated orientation resources: 1) Be quicker to realize and react to danger signals. 2) She wouldn’t, again, be interested in a man as superficial as M. 3) She’d not walk around after dark or in isolated places with a stranger.

To see how she had changed and integrated personality and culture aspects, I asked what she will, now, advise her own daughter when it is her turn to venture out on her own. R was clear she wouldn’t want to control or forbid an “adult” daughter, but would strongly advise her: 1) Don’t hitchhike. 2) Stay with your friends. 3) Use your eyes behind your head. 4) Don’t be pressured into doing something you don’t want to do. 5) Best to say “no” if you are unsure. 6) Don’t drink (or smoke hash or marijuana) with strangers. 7) It’s better to say “no” one time too many, than one time too few. 8) Take time to feel/sense if something is a good idea. 9) Stay with boys/men your own age.

After thoroughly exploring the above points and giving space to R to express any associated feelings to me – both positive and negative – we agreed we were finished , ended this session 1/2 hour early, and said “good-bye.”

I believe this to have been a successful, short-term somatic trauma therapy. In 11 sessions, R was able to expand her memory, associate the sequence of events during and surrounding the rape. She has been able to express emotions, enliven dead muscles and frozen movements, and thaw leg stiffness. She can now discuss and remember the rape without traumatic reaction (ANS activation). And her anxiety at work, the precipitating factor bring her to therapy, is gone.

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Babette Rothschild is the author of 5 books, all published by WW Norton & Co., including the bestselling The Body Remembers. She travels the world giving professional lectures, trainings and consultations. She can be reached through her website, www.trauma.cc and by email at babette@trauma.cc