Understanding Trauma and Chronic Pain
For those living with long-term chronic pain, life often becomes a long, expensive and demoralizing search for relief. This was my journey, or odyssey really, for more than fifteen years. Over time, I lost confidence in my body and my life became more and more limited. By the late 90's, while I hadn't quite given up hope I had stopped actively searching for help. Then totally by chance, twice, I happened to turn on the radio at just the right moment and heard two interviews that changed the course of my life. The first was a conversation with Dr. Peter Levine, and a few months later I heard an interview with Eleanor Criswell Hanna. Both times my heart skipped a beat as I listened to them describe me. Levine described the unconscious, protective bracing that happens with trauma. Until then, I hadn't made a connection between my trauma history and my chronic pain. I knew my body was tense, but had had no success in stopping the reflexive holding. When Eleanor talked about sensory motor amnesia, I finally had an explanation for how and why the body forgets how to let go. Somehow the stars had finally lined up just right, leading me down a path not only to my own healing, but giving me the tools to help other people. In this short article, I will talk about what I have since learned about the intersection of trauma and chronic pain, and, in particular, some things bodyworkers should keep in mind about the peculiarities of working with a soma in traumatic overwhelm.
Although there are differing perspectives on what constitutes trauma, I will speak about it as it's defined by stress and trauma research pioneer, Peter Levine, author of Waking the Tiger and creator of the trauma resolution method, Somatic Experiencing. From this perspective, trauma is a normal survival reaction that has been prolonged beyond its original intended use. The body's innate biological survival mechanisms are designed to help us defend against danger or the perception of threat in the present moment. Trauma occurs when our ability to respond to threat has been in some way overwhelmed. This causes the nervous system to continue to respond as if it needs to brace itself against danger that no longer exists in real time, keeping the body stuck in survival mode. The soma has become disregulated and is no longer able to rebound from overwhelming experience. Trauma is thus a process occurring in the nervous system, and not in the event itself.
There is a tendency among both physicians and bodyworkers to look at the structural mechanics causing pain and leave out other aspects of the chronic pain experience, most notably what it is like to reside inside the soma of a person suffering from chronic pain. Once we understand the mechanisms of trauma, it's easy to see how it can generate ongoing pain. A surprising range of stressors can be perceived by the survival centers of the body as a threat to survival. The high charge experience of threat makes a deep imprint on our implicit (unconscious) body memory, even when we haven’t retained the experience explicitly in our conscious memory. According to Levine, the patterns we develop from navigating each threatening experience tend to become our ‘personal blueprint’ for how we will reflexively protect ourselves in the future. "When unresolved, trauma forms the bedrock of chronic pain. In the absence of a physical injury or other medical causes, most chronic pain is generated by our bracing against the physical sensations of pain. We begin to fear these physical sensations and (body) responses that were originally self-protective in nature, tightening up against them and causing them to become maladaptive. As told by the Buddha some thousands of years ago, it is as though we are shot by one arrow and then shoot ourselves again (in the same place) with another." Pain and the fear of pain are reinforcing. They generate a never-ending cycle of hypervigilance in the body so that pain becomes, in and of itself, a traumatic experience. Traumatized people often come to fear their own body. Their soma has become the enemy, the source of their suffering and their home at the same time. This is an impossible double bind, since our body is the container for our very life energy. Hypervigilance toward our own soma keeps us internally immobilized and unable to fully engage with life.
Survival-based energy is stored in the brain and throughout all of our body systems, including the neuromuscular system. Afterall, it is our muscles that enable us to flee from danger or fight to protect ourselves. Chronic muscle constriction becomes a traumatized soma's way of storing energy to mobilize itself to fight or flee. The imperative for survival summons the biggest energy surges humans are capable of. It is the type of energy that enables a 100 pound mother to lift a car off of a trapped child. These survival-oriented energetic surges are designed to have a beginning, middle and end. They are short-term strategies that enable us to get through a crisis in the moment, and are designed to complete. When these survival impulses get thwarted or interrupted midstream, the nervous system is left holding a reservoir of crisis energy. No living organism is designed to retain this kind of charge over time. Levine found that animals in the wild are able to make their way through these powerful energetic surges and return to equilibrium with relative ease. While we share the same primal physiology as wild animals, when humans are threatened by assault, loss or injury, our survival responses may not be able to complete because our higher brain structure (the cerebral cortex) tends to prevent us from surrendering to body impulses and disturbing sensations that feel out of control. Because the cortex tends to inhibit and override the complete unfolding of these primal survival cycles, we tend to retain crisis energy that was intended only for short term use.
So, what does a soma do when it is asked to contain too much survival-energy over a long period of time? We inhibit movement and brace against the container of our body. We pull painful parts inward (away from the external world) toward the core for protection. We compartmentalize painful areas, trying to separate ourselves from them. We come to live "beside ourselves", instead of inside ourselves. In trauma work these responses fall into the category of dissociation, freeze or the immobility response. SMA is an example of such a response. All involve a breakdown in the dialogue within the soma, a loss of integration of the brain, body and psyche. While the bracing and protecting that occurs while healing from an injury is fulfilling an important, life-preserving function, when it becomes habituated our system is no longer able to recognize when it is safe to return to normal function.
The Challenges of Working with Trauma and Chronic Pain: A Delicate Dance:
Ultimately, the aim of body-oriented trauma work is to help clients reintegrate back into their somas. However for many traumatized clients this reintegration process can be tricky business since trauma energy is stored within the muscles (even more is stored in the joints, and the highest concentration of traumatic energy is held in the viscera). Releasing tight muscles (and the crisis energy embedded there) too much or too fast can feel threatening without the practitioner getting easily readable cues that this is happening in the moment. Remembering that trauma is stored implicitly and unconsciously in the body, your client may also not be aware that too much is happening during the session. Your indication that something went awry will generally happen later when you find out that your HSE work inadvertently reinforced their reflexive bracing patterns, and/or caused them to dissociate or check out as a strategy for avoiding too much charge in the system. Afterall, the function of protective bracing is to armor us against further injury or too much crisis-energy in the system.
That said, threatening events are not equally traumatic for everyone. Some somas are more resilient than others, so what may be traumatic for me may not be for you. So, you don't need to assume that someone who has experienced trauma cannot benefit from a standard HSE session. But it's a good idea to err on the side of caution in the beginning, and do just a little bit of work at a time until you get a feel for how your client responds in the days following sessions. In Somatic Experiencing, we call this process titration”. It means we do small bits of releasing, and then let the soma integrate this newly freed energy throughout the body before doing any more work. Titrating your work enables the client's nervous system to metabolize and make use of new sensory experience without bracing against the change that is unfolding in their body.
An Essential Key for Working with Trauma and Chronic Pain:
An critical tool for resolving chronic pain is helping traumatized clients befriend and remain consciously connected to their bodies. People who have been living in pain for a long time often come to feel that their whole being is pain. I call this the ‘drop of ink in a glass of water syndrome’. Using sensory awareness training to help them cultivate a sense of curiosity about their internal body experience can be a helpful antidote. “Body awareness is one of the most potent methods for shifting pain” says chronic pain specialist, Dr. Maggie Phillips. “If you are connected to all types of sensations, including pain, you will have a much better chance of finding permanent relief. At the same time, without guidance from the mind, our bodies can get lost in primitive, painful reactions. Cutting off access to either the mind or the body creates more overwhelming stress and further disconnection from the vital resources that could end the reign of pain.”
Because the body can be a sort of danger zone for people in chronic pain, sensory awareness training is an important tool for helping clients learn to differentiate body sensation from fear. Beginning a session by asking clients to see if any part of their body feels ‘neutral to pleasant’ can be quite useful. I have them locate these sensations in their body and feel into the different qualities of the sensations. How big are they? What is their density, their shape? How much space do the pleasant sensations want to take up in the body? Are there any images associated with these pleasant sensations (for example, it feels soft – like a pillow)? It’s important to help clients sense that, no matter how much pain they are experiencing, there is always some aspect of their body experience (even if almost imperceptible) that is not painful, or less painful. They are often surprised to discover that less territory than expected is experiencing pain.
Once their awareness of neutral to pleasant body experience has been established in their awareness, I usually move on to having them explore more uncomfortable sensations in a similar way. This is a complex process, however, and space doesn’t permit me to present it adequately here. However, any truly effective toolbox for helping people recover from chronic pain must include a theoretical understanding for helping clients “untangle the sensations, images and thoughts that co-create the fearful dragon of pain”, according to Dr. Levine. When we learn to practice creating some space between painful body sensations and our fearful reaction to those sensations, “the very energies that were ‘locked up’ in the belly of the beast (the ‘bracing’ patterns of pain) are freed to live again within us”.
If you are interested in exploring Somatic Experiencing, go to: http://traumahealing.com/somatic-experiencing/ where you’ll find a list of practitioners.
- Abby Rose