In the first part of this article, I looked at how triggers are an everyday occurrence for many trauma survivors and what an impact they can have on us. But as well as being unwelcome intrusions, triggers are also clues to our dissociated trauma, little ‘pop-up’ reminders of things from the past that our brains have interpreted as danger. They can therefore point us towards what we still need to process. So whilst being difficult to deal with, they can also become useful guides on our therapeutic journey of recovery. Rather than being ashamed of triggers, we can start to see that they are our brain’s best attempt to keep us safe by giving us maximum warning time to respond to potential threats. The problem lies in the fact that our amygdala, which functions as a kind of ‘smoke alarm’ in the brain, responds so quickly and so automatically to potential threats (within 7 milliseconds and outside of conscious thought), that if we were in a lot of ‘fires’ as a child, we react without even thinking to the merest ‘whiff of smoke.’
This automatic, hardwired survival response is built into every single human being, but it has become over-responsive in the case of people who have suffered repeated trauma, especially in early life. In the second part of this series on managing triggers, I am going to look at what we can do to turn off the smoke alarm once it has been triggered, or in other words how we can develop strategies for turning our front brains on and our back brains off. We will also look at what we can do to turn down the sensitivity of the amygdala, or the brain’s ‘smoke alarm’ over time so that we are less likely to react unnecessarily to ‘burnt toast.’
The brain and triggers
Of course our brain is a single yet highly complex organ with many interrelating parts or areas, and yet it can be helpful to think of it in terms of two separate units: front and back. As I have said before, some of the problems that we face as dissociative survivors is that the connections between different parts of our brains are not as well developed as they might be, and that is certainly true for the highway between the ‘front’ and the ‘back’ brain. Our front brain plans and considers and assesses and thinks; and our survival-based back brain, which is mainly unconscious, acts to keep us safe with automatic responses in the face of threat and danger. When we are triggered, we could say that our back brains light up and our front brains go dark. We become panicky, impulsive, unable to think, even unable to speak. That can be a lifesaving response when the danger is for real, like a mugging or a near-miss on the motorway, but it’s not so helpful when our smoke-alarm smells ‘smoke’ that is a reminder of a traumatic episode from years ago and where there is no actual current danger. (Whatever we feel, memories can’t actually hurt us.) So it is imperative that we know what we can do at that moment of being triggered to get our thinking, front brains back online and to turn down the emergency response of our back brains.
Of course, the first and most important thing to realise is that we can actually do something. I believe that the core essence of trauma is helplessness – it is being overwhelmed and powerless where there is absolutely nothing that we can do to stop what is happening to us. For many of us who have gone on to develop a dissociative disorder, that sense of helplessness lives on in a very powerful but often unconscious way, infecting everything that we do with a sense that we can’t. It is a habit that our brains developed in childhood because chronically, over years and years, perhaps hundreds or even thousands of times, we experienced traumatic events where we experienced intense helplessness. Our brains grow and develop in response to our experience, especially repeated experience. And so quite without any sense of choice, most of us developed a chronic sense of learned helplessness: this can become a default state that we are triggered back into, either when we are reminded directly of our original trauma or when we are hit by a circumstance in the here and now that renders us helpless again.
And being triggered – being hit by an automatic body-brain response where adrenaline is pumped into our bloodstream, our thinking brains shut down and our survival-based back brains light up – can also make us feel helpless! After all, it all happens outside of our control, without our permission, even when we are doing our best to stop it. So it is easy to believe that there is nothing that we can do about it, and we can start to restrict our life to cater for it – we give up work, we don’t bother to try to sleep at night, we rely on prescription medication or other drugs, or alcohol, to try to numb things down. But the good news is that although triggers happen within 7 milliseconds, we can be ready for them, we can develop a strategy for managing them, and we can even begin to turn down the sensitivity of our ‘smoke alarm’ over time so that we are less likely to be triggered in the future. The net result, of course, is that life then starts to become a whole lot easier and we can concentrate on more than just surviving an hour at a time.
So what therefore can we do when we are triggered? I believe that we need a ‘go to’ strategy, something that is easy to remember even when our front brains are screeching to a halt, and something that works in a variety of settings. What I developed for myself was something that came out of understanding a little bit about the front brain, and how three general areas of the front brain, with their own particular characteristics and peculiarities, can be engaged to help us get back in control again when an unexpected trigger knocks us off course.
The three parts of the front brain that I am referring to are:
- the front left brain: the dorsolateral prefrontal cortex
- the front right brain: the right orbital prefrontal cortex
- and the front middle brain: the medial prefrontal cortex.
Of course this is a simplification, and is looking at the brain in metaphorical terms rather than strictly neuroscientific terms – because the aim is not precise brain surgery, but to understand generalised differences in the way that our front brains work which we can then tap into to manage triggers better.
Stored information and triggers
So firstly, there’s the dorsolateral prefrontal cortex: the front left brain. This is the part of the brain that holds information as facts: that Paris is the capital of France, that Shakespeare wrote Macbeth, and that I am safe here – the logical, factual part of that statement, not the emotional, experiential part of it. There are many people with dissociative identity disorder who have great, even highly-developed front left brains – we love knowledge and information and facts, and the more the better! And it is this part of the brain that gets ‘switched on’ by doing even just low-level mental activities such as counting or maths, logic puzzles, factual quizzes, Sudoku – which is why we include those kinds of activities in the Grounding and Resourcing Booklet that is provided as part of our Living and Working with Dissociation workshop.
Doing those kinds of things turns on the front left brain, and because the front and back brain operate like a kind of see-saw, just by turning your front brain on you will be turning your back-brain off. All too often we fight hard, by some huge effort of the will, to try to “calm down.” In fact we may be more successful if we don’t try hard to calm down – which often upsets us more as we become frustrated that we’re not succeeding! – but if we just focus our attention instead on switching our front left brain on. Conversely, of course, that is why it is hard to concentrate when we’re stressed and panicky. And that’s why something that doesn’t matter, something like Sudoku or a puzzle game on a smartphone, can help get our front brains more active again without even really trying.
That is also why work is so often a stabilising factor for many trauma survivors – work that isn’t too complex and stressful and full of relational conflict and high risk, but work that engages our front brains to come online and stay online. We really shouldn’t underestimate the role that work plays in keeping our front brains on and keeping us stabilised. Certainly my worst time after my breakdown in 2005 was during 2008 when I gave up work – because I felt I couldn’t cope any more – and without the demands of work to keep my front brain online, things actually got a lot worse for me very quickly. I went through a period of several months where I was what I might call ‘back brain activated’ most of the time, and where I was resorting to medication and self-harm as my principal methods of self-regulation. It was when I started work again at a low-level and on a voluntary basis that I was able to activate my front brain for several hours a day, which had the automatic see-saw effect of turning down my back brain. That was then a turning-point for me from which I was able to move forwards, and it is something that I am still very conscious of nowadays. I know that after a therapy session, I need to get my front brain online again by doing something menial like filing or checking the bank statement. I can’t do anything very complicated or creative, but even Sudoku or putting books back in alphabetical order is better and safer than descending into a back-brain fuelled dissociative state of crisis!
So the front left brain can be viewed as the facts-based, information centre of the thinking brain. However, even though the front left brain can say, “I know I’m safe here,” have you ever noticed how your therapist can tell you until he or she is blue in the face that you’re safe now, but you still don’t feel safe? This is because the front left brain has very few direct connections to the smoke alarm, the amygdala, which is the part of the brain as we have seen that makes that initial assessment of risk and danger. So the lack of connections between the front left brain and the amygdala means that although we can use the front left brain to turn down our panicky, survival back brain response once we have been triggered, just relying on cognitive facts won’t make any difference to the sensitivity of the smoke alarm over time. In other words, it helps in the short term but not in the long term. Two other parts of the front brain are much better for that.
Attachment in triggers
Firstly, there is what we can call the front right brain, the right orbital prefrontal cortex. This is the region of the brain that is involved in attachment, in human relationships, especially between a mother and her baby. Attachment theory is critically important to understanding and recovering from dissociative disorders, and I cover it in detail in my Working with Relational Trauma training day, but suffice to say here that the front right brain is switched on during what we might call ‘attachment moments’ – times when a mother soothes her baby with touch, with eye contact, with a reassuring tone of voice. And these ‘attachment moments’ can be replicated by a partner – someone with whom you have a close emotional bond – as well as the therapist who acts as a soothing presence to their client during times of hyperarousal or agitation. We all know how powerful it is to have someone who cares about us come alongside us when we are triggered and help us to down-regulate again, coaxing us to breathe more slowly, to come into tune with their calm presence rather than our terrified state of panic. And it is this right orbital prefrontal cortex that is being activated during these moments.
The front right brain also has quite good links to the amygdala, meaning that human contact – especially at the level of an attachment relationship – can help to turn down the sensitivity of the smoke alarm over time. If there are repeated soothing moments, a neural network can develop in the brain and the front right brain can in effect ‘inhibit’ the smoke alarm, making it less likely to go off at just a whiff of smoke. This is what we should have developed in childhood – the ability of the front brain, in effect, to down-regulate and modulate the activity of the back brain, and intentionally ‘practising’ this relational soothing can have a tremendous impact over time. Many writers talk about the importance of ‘affect regulation’ – the ability to manage difficult or strong emotions – and how this can develop over time as the therapist and client form a ‘dyad’ which closely resembles, in neuro-developmental terms, aspects of the relationship between a mother and a baby.
This is what I have experienced a thousand times in therapy sessions when my feelings have suddenly hijacked me and I have been triggered into a high-anxiety state. Together with my therapists, I (or another part of me) has gradually learned to be able to turn the volume down on those feelings so that they are not deafening me anymore. My therapists have mirrored calmness to me, breathing slowly and deeply together (“Just sigh!” as Janina Fisher puts it), so that I have been able to manage the spikes of emotion when triggered. Over time this has helped to form a neural network between my front right brain and my amygdala, to turn down the sensitivity of the smoke alarm over time. At first I felt frustrated at being triggered during therapy, that I was wasting precious minutes by just “getting upset again” and therefore somehow messing up the session. But I eventually realised that “getting upset” in the session was a good thing, because through the coaching of my therapists I learned how to calm down, and by doing so I have been laying down new patterns in my brain, new neural networks that have meant that over the long-term I am less likely to fly into a panic when I am sniffing smoke but there is no fire to be found.
Neglect and triggers
The impact of neglect on the front right brain has perhaps most strikingly been seen in brain scans on the Romanian orphanage children highlighted by television documentaries in the 1980s. These children, victims of Ceausescu’s regime, received the most minimal levels of care and attention, many of them being washed and fed but otherwise ignored – no cuddles, no interaction, no play, no love. On brain scans, the area of the front right brain that we are talking about here, the region connected with attachment and emotional regulation, was more or less missing: ‘black holes’ showing the lack of development arising from extreme relational neglect. Although most of us with DID will not have such evidently absent right brains, many of us will however manifest some degree of underdevelopment. And we see the impact of this in our difficulties with relationships and especially attachment relationships, as well as our struggles with managing our emotions. And this is why we can’t just “get better” or “snap out of it” as many of us will have been exhorted: we’re actually ‘brain-damaged’ or at the very least ‘brain-missing!’ That is why recovery can take time, because we are literally trying to grow and develop these parts of our brains. That is also why some forms of cognitive therapy often prove inadequate on their own in treating DID – cognitive therapies may appeal to our front left brain with its facts, logic, information and knowledge, but may do little to develop our front right brain with its craving for human relationship and interactive affect regulation.
The good news is that attunement and empathy can actually ‘grow’ this front right part of our brains, and that is why attachment relationships including ones with partners and with therapists are so important. It also hints at why when we do develop secure attachments, it positively impacts our ability to cope better with adversity and manage our feelings within a wider ‘window of tolerance.’ For me personally, perhaps the greatest impact I have seen over the last few years has been the way in which my front right brain has helped to turn down the sensitivity of my ‘smoke alarm,’ meaning that I am much less often triggered nowadays, and much less severely. Even when I am, I can use what I have learned in therapy to coax myself back down to a more settled state.
Feelings and triggers
The other part of the front brain that we can tap into and which is helpful for modulating the smoke alarm is the front middle brain, the medial prefrontal cortex. You may be thinking, “But what do I do when my therapist or partner isn’t around? What do I do if I haven’t got a therapist or partner in the first place?” And they are very real concerns. But the good news is that the medial prefrontal cortex is part of the brain that everyone can tap into, at any time of night or day. It is a part of the brain that is concerned with self-awareness: of emotions, of body sensations, of thoughts. It is the part of the brain that can reflect upon itself, looking inside and thinking, “How am I feeling? What’s going on for me? What am I experiencing right now?”
Research has shown that this part of the brain also tends to be quite depleted in chronic trauma survivors – many of us struggle to know what is going on inside us! I suspect that some of the reason for that is because we are so focused ‘out there,’ being hypervigilant for threat, that we have never stopped to look ‘in here.’ And if we do, then the ‘in here’ bit is so often fraught with feelings of yuk and shame and horror – we don’t want to feel what we’re feeling; we don’t want to think about what we’re thinking. And that of course is the very essence of dissociation. Many of us, therefore, have ended up with a quite underdeveloped medial prefrontal cortex – which is a real shame as it has the best connections or pathways to the amygdala.
The most successful emerging therapies in working with DID seem to be those that employ so-called ‘applied mindfulness,’ such as the Sensorimotor Psychotherapy approach developed by Pat Ogden and others including Janina Fisher. This has helped me enormously – 7 or 8 years ago I had practically no ability whatsoever to be able to just observe what was going on in me. I was ‘in’ my physical experience, just swallowed up and consumed by it; I wasn’t able in any way to stand back from it and observe it. I was ‘in’ my emotional experience, domineered and hijacked by any emotion that wanted to come along and dictate to me, and I was utterly convinced that not only did I have to believe what that feeling was telling me, but that I had to obey it too. I couldn’t bear to sit with it. I just had to act on it. So I was forever mindlessly reacting to what was going on inside me, and yet through the practice of mindfulness and through Sensorimotor Psychotherapy approaches in particular, I was able to begin to be able to “just notice,” to “just be curious,” and to start to observe and comment on what was happening, seeing that it was “just a thought” or “just a feeling” or “just a sensation.” This was revolutionary for me. I began to realise that the Ithat I so struggled to define was separate to the feelings of panic, the compulsion to self-harm, the in-wash of shame, and that this I could stand back and “just notice” and comment on what was happening in an accepting-but-detached way, without judgement, without counter-emotion, but just with curiosity. I began to be able to develop what others have called a “third position” or a “mentalising stance.”
And perhaps most critically for me personally, it meant that I had a new strategy when I was triggered. When my back brain had switched on and my front brain had switched off, I began to realise that I needed to talk myself through it. At first I needed the support and coaching of my therapists to do it, for them to help direct my attention and for them to help me to step back from myself and just observe what was happening and to name it. So I began to learn to develop a self-narrative at these moments: “Oh look, my arms and my legs have gone all tense. What else is happening in my body? Let’s have a look. Oh, my breathing has speeded up and it’s gone quite shallow. What’s happening in my tummy? It feels like a tight ball of energy. What’s this all about? Oh, I think I’ve been triggered. This is an autonomic nervous system reaction. Something has tripped the switch; something has set the smoke alarm off. My amygdala has detected something that it thinks is a threat. My front brain has been shut down and my back brain has lit up and geared me up ready for fight or flight. It’s not because I’m being abused in the here-and-now. It’s just my body’s automatic reaction because the memory of that has been triggered. Now let’s look again at what is happening in my body … My fists want to clench. My legs want to run …” And so on.
And even by doing this – even by putting these things into words, we are automatically bringing our front brains online, by engaging Broca’s area, the speech and language centre. But the real key is to be able to turn our attention inwards and to observe what is going on in us so that it is just something that is going on in us: it is just a thought, just a feeling, just a sensation. It’s not the entirety of our experience. If it is something separate from us, then it need not define us or control us, or be the be-all and end-all of us. It can come, and it can go, and we can be certain that it will only be temporary. There is a difference betweenbeing anxious and having an anxious feeling: the latter will pass, whereas by thinking the former, we have begun to attribute meaning to it (“This is who I am”), with a sense of certainty and finality and enduringness to it.
But if the feeling is just a feeling, then I can watch it come towards me, as if hurtling in my direction on the motorway at 70 miles per hour, and I can choose to watch it go past me – I just need to wait and watch it zoom past. I can step out of the way of it. And I don’t need to make matters worse by feeling not just anxiety, but frustration at my anxiety. If I just observe the single juggernaut of anxiety and watch it roar past me, I don’t have to add on a lorry-load of frustration. Too often in the past I have allowed one emotion to spawn a whole car-crash of others. And all the time, while I’m just observing and commenting and noticing this feeling of anxiety, I am engaging my thinking, assessing, pondering, wondering front brain and the see-saw effect will mean automatically that my back brain will be calming down.
A Sensorimotor psychotherapist with whom I worked for a number of years used to say to me in the kind of sing-song voice that surely you can only pick up through very many years of therapy school: “Just notice! Just be curious!” It was pretty annoying at first, especially when I was consumed in a back-brain state of red alert, with everything screaming at me that the house was on fire and I was imminently going to die. But with just those two or three words she was in effect saying, “It’s ok, it’s just a false alarm. It’s just burnt toast. The house isn’t really on fire. Don’t panic. They are just feelings of panic, but there’s nothing to panic about. It’s just your body’s smoke alarm going off, that’s all. There isn’t really a fire. Just notice what the panic feels like in your body. Let’s just observe it. Let’s just be curious …”
Conditioning and repetition in triggers
It took many months of annoying repetition but eventually I started to be able to do it for myself. So when I had a very serious near-miss on the motorway some months ago, and I went into genuine survival mode, I talked myself through it. “Just notice!” I said to myself internally (in the same sing-song voice – I’m sure the magic is in the voice), “Just be curious!” And I started to recount to myself what was happening in my body – my shaking arms, my tense legs, my chest feeling crushed like there was no breath in it, my sweating palms, my feeling of nausea, everything distant and slow and unreal. I could feel myself being pulled off inside, to ‘check out,’ to dissociate and switch to another part, but like staring down a tunnel I just kept up my self-talk: “It’s just your amygdala sounding the alarm. Well done me for responding so quickly with that adrenaline. Well done me for releasing glucose into my bloodstream. I can stay present. I can just notice and be curious.” And I did, and it was one of those moments when I looked back afterwards and realised what progress I’d made, and how a few years ago I would have been lost maybe for hours afterwards; the emotional aftermath could have lasted in fact days; and worst of all, I would have beaten myself up for someone else’s driving error, and heaped torment and abuse on myself for someone else’s lapse of concentration. Instead I was able to stay in control; I didn’t have to switch or dissociate to manage the situation; and the aftermath was one of gratitude and thankfulness that I was alive and unhurt rather than the savagery of self-blame.
So there we have then the three parts of the front brain – front left, front right, and front middle, each of them with their own characteristics and their own specific ways that we can utilise to manage triggers and turn down the sensitivity of the smoke alarm over time. And using these three metaphorical regions, I have developed three strategies for turning my front brain back online when I have been triggered:
- using my front left brain, I get myself thinking – with Sudoku or word-searches or games on my phone, with counting backwards in 7s, with filing or reconciling bank statements, with reading and journalling.
- using my front right brain, I get myself connected – preferably to an attachment figure, such as a therapist or my husband, in order to allow them to help me be soothed and calm down.
- using my front middle brain, I get myself noticing – I turn my attention inwards and I am “just curious” and I “just notice” the feelings and the physical sensations of panic, and I name them and observe them and watch them pass by without judgement or meaning-making.
The important thing is to find activities that help us each personally to ground ourselves when we are triggered, but using this simple matrix of three parts of the brain and the three strategies to go with it, it can help us when our front brain has gone offline and we have become foggy with panic and we can’t remember what to do. For that purpose, quite some time ago PODS produced some laminated posters of this grounding technique that I have described here, with the three parts of the brain relating to the three strategies for grounding, and these are available to purchase either via the PODS website at www.pods-online.org.uk/resources.html or at any of our training days or events. They are ideal for sticking on the fridge or a kitchen cupboard or wherever you need to put them to help you through those inevitable times when, against our will, at the most inconvenient of times, we are triggered by our oversensitive smoke alarm.
But the promise is there that if we will develop these grounding activities and repeat them and repeat them and repeat them some more, then we will develop new patterns in our brain, new neural networks, that over time will reduce the sensitivity of our smoke alarm which has become over-reactive, not because we’re bad or stupid or pathetic or lazy, but simply because we were in way too many fires as children.
© PODS 2013