Bob Van Oosterhout

How I explain recovery from PTSD to clients
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How I explain the process of recovery from PTSD to clients
Bob Van Oosterhout

1.  I have come to believe that recovery from PTSD is a natural process, similar to recovery from a wide range of physical injuries.  I often tell the story of getting a deep cut in my hand from a piece of glass while gardening.  All I needed to do was remove the obstacles (in that case, dirt, by painfully scrubbing it) and my hand fully healed so that there isn’t even a scar.  I believe the same is true with PTSD.  When people who have suffered severe trauma remove obstacles to full emotional health, they recover naturally.

2.  I use the term “emotional tension” to describe what I believe to be the primary obstacle to recovery from PTSD.  When we experience trauma, especially in situations where we have little control, we tense up - there is a deep and sudden tensing of various muscle groups.  We get a burst of energy to our muscles in case fight or flight are reasonable options, and tension blocks the intensity of our emotions so our reaction doesn’t make things worse.  In many cases, this tension makes it possible for people to survive a traumatic experience.  

PTSD arises when we don’t discharge or let go of the tension and emotions after the event is over.  When I have worked with people shortly after very severe traumatic experiences, they tend to recover within weeks, once they resolve patterns of tension and allow emotions to run their course.  Recovery from PTSD usually involves a period of months.

3.  My experience is that recovery from PTSD is primarily an emotional process and that we recover by gradually resolving emotional tension that built up in response to trauma.  Emotional tension is a pattern of muscle tension and breath holding that restricts the full experience of emotion.

I find it important to explain the nature of emotions.  First, emotions are natural human experiences.  Every healthy person on this planet has the capacity to experience the exact same emotions and people from every corner of our world (even newly discovered tribes that never had outside contact for thousands of years) have the same facial expressions when they experience these emotions.  Emotions are simply a natural response to our experience.  People who say that emotion is a sign of weakness, simply don’t understand the nature of emotion.  Second, emotions are physical events.  This is most evident in facial expression but emotions also trigger movement in other muscle groups in our bodies.  We are able to stifle emotions by tensing various muscle groups and holding or restricting our breath.  Third, emotions occur in present time and are temporary.  Basically they give a read on the present moment.  Emotions that seem to last are actually as a series of similar emotions in response to new stimuli.  I was sad for many months after my parents died but each episode of sadness was triggered by a thought or memory of how much I missed them.  Emotions from PTSD are held in by muscle tension and ANS imbalance which puts them out of sync with the present time.  It’s like a thermometer that tells us what the temperature was six months ago - I wind up wearing shorts when I need a winter coat.  It is important to recognize that the thermometer will not be fully accurate until emotional tension is resolved.

4.  Emotional tension seems to “break loose” during times of high stress or in response to reminders of trauma.  That only tends to occur when there is still a significant build-up of tension, early in the recovery process.  As day-to day “surface tension” is resolved and balance is restored to the Autonomic Nervous system, emotional tension from past trauma seems to naturally come up in a time and place where we can deal with it appropriately.  (I believe recovery only takes place during parasympathetic nervous system activation)

Clients gradually recover as they allow emotions to move without resistance through tensing and breath holding.  In my experience, episodes of emotional intensity do not last more than a few minutes (although they are extremely uncomfortable minutes.)  They only last longer when people  tense as they let go.  It’s like filling a cup of water when we are trying to empty it.  As long as we empty it more than we fill it, we eventually resolve deep patterns of emotional tension over time.  My experience is that this process takes a number of months.  It very rarely resolves in a matter of weeks and only takes longer than a year when circumstances lead to the creation of significant new tension.  

When clients experience these emotions during a session, I encourage them to continue breathing and to put their body in a “neutral” position to help them be aware of how they are tensing so they can let it go  (see#7 below).  I remind them that “These are normal emotions in response to past trauma;” “You have survived, you are now safe” “This is exactly what you need to do to recover;” and “If you don’t resist, it will pass in minutes.”  I encourage them to repeat them to themselves when emotions arise at other times.

5.  I have found that it is critical to create circumstances where one feels safe and in control for recovery to proceed.  Failure to do so creates experience that remind one of traumatic experiences and leads to additional emotional tension.  I have found that it is not only not necessary, but that it can be harmful to discuss memories of traumatic events.  Emotions and language are activated by different parts of our brain.  Thinking or talking about trauma tends to trigger new emotions that remind us of the trauma.  That may be a helpful (but inefficient) way to resolve some tension if we let go of more emotional tension that we build through that process.  But it is much more effective, in my experience, to allow emotions to run their course without adding to the cup.  I have seen a number of people seem to fully recover from PTSD without ever talking about what actually happened.  (A lot of clients heave a sigh of relief when I tell them this.)

In the case of sexual abuse, safety requires that we feel that we are fully in control during intimate encounters.  Helping one’s partner understand the process of recovery and recognizing that it is a good sign when they ask to stop at any point during intimacy seems to greatly facilitate the recovery process.  The same is true in dealing with panic attacks or phobias.  Any time we force ourselves to do something that is uncomfortable, we build tension that interferes with the recovery process.

(I also believe an atmosphere of safety is created when a therapist is open to and able to briefly experience the emotions that the client is resisting and that this is key to establishing a working relationship)

6.  Whenever possible, I find it is very helpful to ask my clients to set aside a period of time for recovery from PTSD much like we might when recovering from surgery.  Minimizing stress and pressure prevents the build-up of additional tension which complicates and lengthens recovery.  

7.  It appears that balance to the Autonomic Nervous system and awareness of patterns of tension are critical for the natural recovery from PTSD to proceed.  I have found a set of tools that seem to facilitate the recovery process and that people are more likely to use them when I explain how and why they work.  

Diaphragmatic Breathing:  I explain that our body gets stuck in patterns of escalating tension due to an imbalance in the Autonomic Nervous System and that this is the part of the nervous system that determines where energy goes in our body.  One part of this system (Sympathetic - SNS) sends energy to our muscles so we can be active and work, the other part (Parasympathetic - PNS) activates our internal organs so we can do maintenance.  These two parts of the nervous system work opposite each other.  (We don’t tune up a car when we are driving it, and we don’t eat a huge meal before running a race.)  I explain that anatomy shows that there is a loop between these parts of the nervous system which suppresses one when the other is activated, and that when muscles call for energy they win because that may be necessary for survival.  When there is chronic tension, the part (SNS) that activates the muscles works almost continually and seems to get stuck “on.”  I explain how stress hormones change the chemistry of our blood to give us an extra boost of energy and endurance in potentially dangerous situations and how the build up of tension seems to activate the release of stress hormones.  This becomes a self-escalating process as the added energy and endurance leads to the build-up of more tension, which then leads to the release of more stress hormones, etc..

The solution is to stimulate the maintenance part (PNS) of the nervous system.  The loop connecting the systems suppresses the activation of the muscles which allows maintenance and recovery to occur.  Clients consistently report a feeling of calm and relaxation when they do this for less than a minute when there is a build up of tension, and. If they don’t experience some relaxation, it’s an indication that their technique is not correct.  If you stop stimulating the PNS after a minute, the build up of tension resumes because of the stress hormones in your blood.  The key is to continue stimulating the PNS enough so your liver has a chance to clean the stress hormones from your blood.  (I explain how the liver produces sugar to give us more energy when the SNS is active and how it switches to cleanse our blood when the PNS is activated.)  In my experience, stimulating the PNS for three to five minutes, six to ten times per day gives the liver enough of a chance so that it can clean the stress hormones out of our blood within two to four weeks.  (I note that symptoms of anxiety and serious problems with temper and impulse control are consistently resolved when patients follow through on this regimen.)

I explain how the right vagus nerve, which is about the size of our thumb runs down the center of our body and passes through an small opening in the center of the diaphragm, which is located at the base of our lungs.  The key is to get the diaphragm moving in the proper rhythm so that the nerve is continually stimulated with a slow rhythmic movement.  The rhythm is critical.  Three to four seconds down and three to four seconds up is what works.  Too fast or too slow does not work and it doesn’t work when there are pauses between breaths.  Most people are able to get some movement in the diaphragm with a few minutes of practice and this seems to provide enough stimulation of the PNS so that the natural rhythm is easily established with regular practice.  Occasionally I will need to work out other techniques to stimulate diaphragmatic movement when there is a severe amount of tension in that area.  Practice is self-reinforcing because it provides a feeling of relief.  Using Diaphragmatic breathing when crying or experience strong emotion allows clients to release  emotional tension in brief (but very painful) episodes.

Putting the body in neutral - Grounding
I explain how patterns of tension are established in the body and note that every incident of chronic muscle tension is a deviation from what I call “neutral.”  I explain how opposing muscles groups work and show that when I bend and straighten my arm, opposing muscle groups either work or relax.  In neutral, neither muscle group has to work.  I encourage my clients to sit with their feet flat on the floor with their pelvis fully supported by the chair.  I point out areas of muscle tension which they then release to allow their skeleton to be their primary support.  I also explain how we seem always to tense up - muscles pulling up, away from the ground are involved in tension.  Keeping your feet flat on the floor undermines this process and gently pressing them down or lightly stomping them reverses it.   I often teach a grounding stance and simple exercises from Bioenergetics that help clients to become aware of and let of patterns of tension.  When grounding is practiced for even a few minutes, clients consistent report feeling “clearer,” and “more solid and secure.”  Regular practice at home becomes self-reinforcing and, in combination with diaphragmatic breathing, provides useful tools for resolving emotional tension and deal more effectively with stressful situations.

Putting the mind in neutral
I also teach techniques adapted from Yoga, Buddhism and Christian Monasticism that allow clients to develop the ability put their mind “in neutral” so thoughts do not intensify emotional memories related to trauma or increase tension during episodes when emotional tension is released and throughout their day.

I find that when people who suffer from PTSD understand the recovery process in simple terms and regularly apply the tools described above, they are able to effectively tolerate uncomfortable emotions and gradually resolve symptoms of PTSD.