From the Body Remembers Flashcards
1
Q
What is the HPA Axis
A
The hypothalmic pituitary adrenal axis.
2
Q
What sets the HPA Axis in motion?
A
The limbic system, responding to extreme trauma/stress/threat, sets the HPA axis in motion, telling the body to prepare for defensive action.
3
Q
What chemicals are released when the HPA Axis is set in motion, and what is the effect on the body?
A
Repenephrine and norepenephrine, quickening heartrate and respiration, skin pales as blood flows from the surface to the muscles, and body prepares for quick movement.
4
Q
How does the limbic system respond when flight and flight are both perceived to be impossible?
A
The limbic system commands simultaneous heightened arousal of the parasympathetic branch PNS of the autonomic nervous system ANS, and tonic immobility.
5
Q
What bodily mechanism halts the alarm response, but is insufficient in people with PTSD?
A
Cortisol secretion.
6
Q
People with PTSD live in a chronic state of ____ activation.
A
Autonomic nervous system (ANS) activation, or hyperarousal.
7
Q
In PTSD sufferers, what is the cause of the distressing, and disabling symptoms of heightened pulse, paled skin, cold sweat, etc.
A
Repeated recall of autonomic nervous system (ANS) activation, the body’s high alert that occurred during the original trauma.
8
Q
Under normal circumstances, what is the relationship between the SNS and the PNS?
A
Balance. Both are always activated, but when one is up, the other is down. SNS is usually aroused by positive / negative stress (exercise, danger) and PNS aroused by rest, sexual pleasure, etc.
9
Q
What would indicate the successful processing of trauma?
A
Can recall and describe the event; can make meaning of it; have appropriate emotional reactions; and can perceive it as clearly in the past
10
Q
Generally speaking, people with PTS/PTSD remember trauma in two different ways. Describe them and note what they both have in common:
A
- Clear, film-like memory of the trauma, with either powerful and innappropriate emotions or numbness and deadening.
- Vague, or lack of memory of trauma accompanied by physiological sensations that don’t make sense.
(In common): both experience danger as present, not in the past.
11
Q
What is the difference in malleability between different brain systems?
A
More complex systems are more malleable. The cerebral cortex is very malleable and influenceable, while the brain stem is less so.
12
Q
Define resilience
A
Being able to swing with the punches dished out by life
13
Q
Why is healthy attachment good for the brain?
A
In babies, healthy attachment relationships with caregivers stimulates key brain development, helping to develop resilience
14
Q
What are synapses?
A
The electrical or chemical (neurotransmitter) link between neurons (nerve cells)
15
Q
What are some examples of basic synapse strings and complex synapse networks?
A
Basic string: a feeling, a blink, a basic action
Complex: walking, speaking with someone
16
Q
What are two chemical synapses and what systems do they come from?
A
Epinephrine: Adrenal
Nor-epinephrine: the other sympathetic nerves
17
Q
What does a buildup of norepinephrine lead to?
A
Fight or flight
18
Q
What type of nerves are Brain -> Body, sending messages about behaviours?
A
Efferent nerves
19
Q
What type of nerves are Body -> Brain, sending messages about body position?
A
Afferent nerves
20
Q
What is the lower brain, and what functions is it implicated in?
A
The brain stem: breathing, heartbeat, etc.
21
Q
What are some of the main parts of the mid-brain and what fuctions?
A
Limbic system, hypocampus, amydala, ANS. Instincts, reflexes related to safety, danger, sex, food, etc.
22
Q
What is the upper, most advanced part of the brain?
A
Cerebral cortex
23
Q
Describe some differences between the functions and development of the amygdala and the hippocampus
A
Amygdala: responsible for processing emotional reactions and sending that to the cortex. Functional at birth
Hippocampus: Makes sense, provides context, sequencing on a timeline. Develops from 1-3 years
24
Q
What is unique about the hypocampus regions of PTSD survivors?
A
It is smaller, although not clear if it got smaller from PTSD, or if PTSD resulted because HC was already smaller
25
Why does extreme stress have the potential to distort memory and make processing experience difficult?
Stress hormones, like cortisol, may suppress the function of the hippocampus
26
Explain how bi-lateral brain function may contribute to the "speechless terror" of trauma?
The amygdala is associated with the right hemisphere, while the hippocampus is linked with the left hemisphere. The left hemisphere also contains Broca's Area, believed to be responsible for speech. Both Broca's Area and the hippocampus are suppressed in trauma.
27
Explain how a mother helps a child build resilience (in the context of amygdala and hippocampal function)
The early attachment bond with baby are right brain focused, where the mother helps baby regulate in response to stimuli, by soothing, regulating, and calming the baby who is being newly and overly stimulated. Later, the mother helps a toddler by setting rational limits, socializing, using language to make sense of experience.
28
What early life conditions are PTSD risk factors, and why might this be (in relation to brain function)?
Early trauma and lack of a healthy attachment bond. Both mean that child will be less able to self-regulate, because there is reduced hippocampal activity, either from lack of attachment bond stimulation, or because it was suppressed by trauma.
29
What is the key brain structure to making sense of and moving on from trauma?
Hippocampus
30
Can anything be done about lack of a healthy attachment bond?
Yes. Healthy attachment can come later, in the form of a friend, counsellor, etc.
31
What are the three main functions of memory?
Encoding, storage, retrieval
32
What are two main types of memory, and what are the differences (esp in relation to brain function)
Explicit (declarative): connected with hippocampal region and involves concepts, language, narrative sequencing, steps, etc.
Implicit (Procedural or non-declarative): Connected with amygdala, Unconscious, automatic, emotions, sensations, bodily impulses
33
What type of memory functions better under stress and why?
Implicit (Procedural or non-declarative) functions better under stress than Explicit (declarative) because the functions of the amygdala are not suppressed under stress
34
What are the 4 main components of classical conditioning and the classic example?
Stimulus (S), Response (R), Conditioned Stimulus (CS), Conditioned Response (CR). Pavlov's dog drooled (R) when presented with food (S). Pavlov paired food with bell (CS). Now when bell rings (CS), even in the absence of food, the drooling still happens (CR).
35
Describe how classical conditioning might play out in trauma triggering, and how a secondary stimulus/response might come about?
A trauma (S) provokes intense fear (R). That trauma is paired with something like a color or smell (CS) that now also provokes fear (CS). Running into that color or smell (CS) might be then paired with the street on which it happened (SCS) and provoke fear (SCR). This could eventually generalize to "all streets" leading to agoraphobia for example.
36
Describe how Skinner's operant conditioning might play a role in development of PTS symptoms in an example of public speaking
Someone punished for assertive speaking as a child, might extinguish that behaviour. Then, later in life, faced with a public speaking challenge, may react with panic, dry throat, etc.
37
What is relationship between conditioning and stress?
Conditioning's ability to create or extinguish behaviour is much more powerful under stressful conditions.
38
Give some examples of how state-dependent recall plays a role in triggering PTS symptoms?
Heart racing from exercise or sex, assuming a similar posture to when the trauma occurred.
39
What are the two main branches of the human nervous system?
Central and peripheral
40
What are 3 divisions of the peripheral nervous system?
Autonomic, Somatic, and Sensory
41
What are the two branches of the sensory nervous system?
Interoceptive (vestibular, proprioception) and Exteroceptive (eyes, ears, nose, tongue, skin)
42
What is the difference in function between the somatic and autonomic nervous systems?
Somatic is related to voluntary control, while autonomic is largely involuntary.
43
What are the two branches of the autonomic nervous sytem?
Sympathetic (SNS) and Parasympathetic (PNS)
44
Describe the pathway between the senses and memory?
Stimulation of Intero (viscera, muscles, connective tissue) and Extero (eyes, ears, nose, tongue, skin) ceptive nerves, with signals travelling via synapses to the thalamus, then to the cortex where they are either encoded to memory or forgotten.
45
What are the two parts of interoceptive sense, and their functions?
Vestibular (balance) and Proprioception (body in space, kinesthetic state, internal state of the body)
46
Describe an example of the kinasthetic sense?
Touch finger to nose, knowing angle of arm, where finger is, where nose is in relation to it.
47
What type of memory is associated with the kinesthetic sense?
Implicit (procedural). Motor tasks are typically unconscious, but we can develop awareness of them.
48
What would be a way to challenge someones implicit memory of a motor task?
Have someone write with the wrong hand - writing in the unfamiliar way will mean they have to think about what they are doing.
Teach a child how to tie their shoe. What seems so simple and natural for you, might be a frustrating experience of figuring out, thinking about complex movements.
49
What is affect?
The biology of emotions and internal sense
50
What do we sense internally?
Temperature, breath, heartbeat, tension, pleasure, pain, relaxation
51
Summarize Damasio's Somatic Markers and provide an example
Internal sensory input -> sensations/emotions -> stimuli -> become associated (CC) -> encoded in implicit memory. Food poisoning leading to nausea at certain foods.
52
Where is the vestibular sense located, and what is its function?
Fluid of the inner ear. It tells us "I am upright," let's us know of changes. If it is disturbed, dizziness, vertigo, and motion sickness result.
53
What is a first impression, from a memory encoding perspective?
Intero and exteroception provides sensory information, and this is encoded as sensations (not words). Recalling a song, or smelling something can bring back a somatic memory.
54
What is the problematic memory encoding process in trauma?
The trauma is encoded in implicit and explicit memory, however, due to suppression of the hippocampus, some explicit info may be missing, and the victim cannot make sense of just the somatic memory.
55
State 3 goals of trauma therapy, as they relate to somatic memory
1. Feel sensations
2. Identify and describe them
3. Possibly (but not necessarily) clarify meaning related to trauma
56
What is a flashback, and what does it feel like?
Intense recall of implicit memory with or without explicit details. It feels real, like it's presently happening.
57
What kind of experiences can be triggering?
Both intero and extero ceptive. SIghts, sounds, body position, heart rate, etc.
58
What brain system could be called the "Survival Center"
The Limbic System
59
What part of the limbic system prepares the body for fight or flight?
The hypothalamus activates the SNS branch of the ANS, provoking it into a state of heightened arousal.
60
What are noticeable signs of SNS activation, and what is their function in the context of trauma or flashback?
Faster respiration, quicker pulse, higher blood pressure, dilated pupils, pale skin, increased sweating, cold possibly clammy skin, digestion decreases. This is to prepare for quick movement, and possible fight or flight reflex.
61
When is the SNS branch activated?
During positive and negative stress states, including sexual climax, rage, desperation, terror, anxiety, panic, trauma
62
When is the PNS branch activated?
In states of rest, relaxation, sexual arousal, happiness, anger, grief, sadness
63
What are noticeable signs of PNS activation, and what is their function in the context of trauma, flashback?
Slower, deeper respiration, slower heartrate, decreased blood pressure, pupils constrict, flushed skin color, skin dry and warm to touch, digestion increases. The PNS can activate concurrently with, and mask, SNS activation, leading to tonic immobility, a freezing reflex.
64
Provide an example of how the balance between PNS and SNS might play out?
Sleeping, PNS is active. Wake up, thinking you're an hour late, SNS shoots up. Racing to work you realize the clocks have changed, the PNS rises and SNS decreases. But getting to work, there is an angry client. PNS is suppressed as SNS rises again.
65
Describe "tonic immobility" in the context of cat and mouse, and what the evolutionary function might be.
The physiological dilemma of fight, flight or freeze. If a mouse spots a cat, its SNS will activate drastically, enabling it to run and escape. But if it perceives itself as trapped, its body will go limp, like a rag doll. While the SNS is still highly activated, the PNS is also actived and masks the SNS activity. This is an adaptive function in that a cat may lose interest in dead prey. Alternately, in the case that the attack continues, the analgesic and numbing effect of tonic immobility reduces the suffering for the mouse significantly.
66
What do reports from people who have been threatened with death, or rape survivors indicate about tonic immobility?
Survivors of great falls, animal mauling, and rape report an altered state where fear and pain is reduced greatly, and the body goes limp (a source of shame and guilt for rape survivors)
67
What problem exists in the justice system with respect to rape and tonic immobility?
Rape cases can be thrown out because the victim did not resist. However, this lack of resistance may have been a tonic immobility response to extreme threat and a state where fight or flight was perceived impossible.
68
Why are there differences in how people respond to threat, for example gender?
Reflexive and instinctive response depends on several factors including instinct, physical resources, psychological resources, and learned behaviour. For example, men may more often respond with fight or flight than women and children because they have greater physical resources and have been conditioned that way.
69
Is fainting related to tonic immobility?
Unknown, but fainting does appear to be a consequence of an overwhealmed ANS.
70
How does ANS function help us understand why someone with PTSD can't handle daily stress like others do, or like they used to?
Chronic ANS arousal means there is less room to swing between SNS and PNS arousal in response to stress. When SNS is constantly aroused, as in the case of PTSD, there is little room left when additional stress is added.
71
What is the SomNS responsible for?
Voluntary movement via contraction of skeletal muscles.
72
What are the different functions available to a muscle?
Active function: contract. Passive function: relax.
73
What are the three types of muscles in the body? What NS branch controls each one?
Skeletal: Voluntary (Conscious), Controlled by SoNS
Smooth (visceral): Involuntary (Unconscious), wrap veins, arteries, intestines, controlled by ANS
Cardiac: Involuntary, Controlled by CNS
74
What nervous system activity will cause the contraction / relaxation of a skeletal muscle?
Nerve signals (neural impulses) in the SoNS cause contraction, absence of nerve signals in the SONS cause relaxation.
75
When you reach out to touch your own nose, what are the roles of the SoNS and the kinesthetic sense?
The SoNS commands the movement by contracting certain muscles and leaving others relaxed. The kinesthetic sense ensures accuracy of movement.
76
What nervous system functions are required to learn and perform a movement?
SoNS nerves cause the movement,
The interoceptive and proprioceptive nerves perceive it, give you a feeling about it, by relaying sensory information from the body to the brain via afferent nerves.
Efferent nerves relay learned actions to muscles to recreate movement in the SoNS and proprioceptive system.
77
What are the roles of the SoNS and ANS in threat situations?
The ANS directs blood flow away from viscera and skin to muscles, and the SoNS directs muscles to carry out fight, flight, or freeze response.
78
Can instinctual defensive behaviours be taught?
In some cases yes. For example, premature babies sometimes lack falling reflex, which can be later taught to extend their arms.
Self-defense training reawakens normal fight responses for victims of assault and rape, by building synaptic movement patterns of defense that will repeat spontaneously.
Earthquake and fire drills are another example
79
How does operant conditioning play a role in defensive behaviours?
Previous success/failure of a behaviour like fight or freeze will increase the chance of it being used in the future. If someone successfully defends themselves in a fight they are more likely to use it again. If not, and he has to resort to tonic immobility, that becomes a more likely response.
80
How many repetitions are req'd to encode/extinguish a defensive behaviour in a trauma scenario?
None. One instance of a failed defensive behaviour can be instantly encoded via the SoNS and can extinguish it from one's defensive repetoire.
81
How might the SoNS be implicated in state-dependent recall?
Assuming a posture. For example, sitting in the same way to remember a thought; a posture assumed in a traumatic situation can invoke panic when assumed later (ie, arm pinned behind back, turning head to look at devastating news, etc.)
82
Explain how emotion is an interplay between the body and brain?
Each emotion has a discrete pattern of skeletal and visceral muscle contracts, giving the emotion a visible signature to others, and a feeling on the inside of the body. Proprioceptive nerves communicate the feelings of an emotion to the brain to be named and interpreted by the cortex.
83
Why might "feel" refer to both emotions and sensation?
Perhaps a semantic acknowledgment of the fact that emotions comprise body sensations.
84
How does Donald Nathanson address the dilemma of feelings, emotions, and affect?
He suggests affect is the biological aspect of emotion, and feeling is the conscious experience of it. Memory is necessary to create an emotion, while affects and feelings can exist without memory of a prior experience.
85
What are some English phrases that reflect how body is connected with emotions like anger, sadness, disgust, happiness, fear, shame.
```
Anger - he's pain in the neck
Sadness - I'm all choked up
Disgust - she makes me sick
Happiness - could burst
Fear - I have butterflies in my stomach
Shame - I can't look you in the eye
```
86
What are some commonalities in physical sensations of emotions like anger, sadness, disgust, happiness, fear, shame.
Anger - muscular tension, in jaw and shoulders
Sadness - wet eyes, 'lump' in the throat
Disgust - nausea
Happiness - deep breathing, sighing
Fear - heart racing, trembling
Shame - rising heat, particularly in the face
87
What are some typical behaviours associated with emotions like anger, sadness, disgust, happiness, fear, shame.
```
Anger - yelling, fighting, gesturing
Sadness - crying,
Disgust - turning away, gagging, scrunching face
Happiness - laughing, smiling,
Fear - flight, shaking,
Shame - hiding
```
88
What are some recognizeable facial and postural expressions associated with emotions like anger, sadness, disgust, happiness, fear, shame.
Anger - clamped jaw, reddened neck
Sadness - flowing tears, reddened eyes
Disgust - wrinkled nose with raised upper lip
Happiness - smile, bright eyes
Fear - wide eyes with lifted brows, trembling, blanching
Shame - blushing, averted gaze
89
What is the range of a newborn baby's emotional expression?
Wailing at discomfort, calming down at comfort.
90
What are four important theoretical models of emotion?
Darwin's Cross-cultural survey
Silvan Tomkins's Affect Theory
Joseph LeDoux's Emotional Brain
Antonio Damasio's Somatic Marker
91
What did Charles Darwin's cross-cultural survey reveal about emotions, and who did he study?
Looking at various cultures including aboriginal, indian, african, native, american, chinese, malayan, and ceylonese, he found that the ranges of emotion and somatic expression of emotion had great commonality across cultures.
92
What was Tomkin's affect theory concerned with?
Identifying similarities in emotional expression across generations, and categorizing affect by physical expression including facial characteristics and changes to body posture.
93
According to LeDoux's Emotional Brain theory, what is the evolutionary function of emotions?
Survival, by dealing with hostile environments and procreation.
94
Who did Damasio study in relation to his somatic marker theory, and what were some of his discoveries? Esp related to 'gut feelings'?
People with brain damage to emotion centers. He found that rational thought requires emotion, that body sensations cue emotional awareness. A rational decision requires a feeling of the consequences, not just the thought of it. Positive and negative sensations, somatic markers, guide decision making.
95
What is an exercise to explore the somatic basis of emotion?
4 parts. 1) Survey current sensations, breathing, skin temp, heart rate, shoulder position, tension, gut feelings, and body position. 2) Remember an angry moment, what you were angry about, who it was with, what you said / thought, and then repeat the above survey to notice differences. 3) Repeat with a time that was happy, safe, recalling as much sensory info as possible. 4) Repeat with a time that was scary (not worst trauma, but a small amount of fear). To finish, return to memory of happy and safe.
96
What is the emotion of self-protection? What might provoke this emotion?
Anger, which might be provoked by being threatened, hurt, or scared. Threat of injury or violation of boundary can provoke anger.
97
What escalates anger? What is the result?
Extreme threat, repeated violations of boundaries despite efforts to say 'don't' or 'stop.' This escalates to rage.
98
How might anger play out for someone with PTS / PTSD?
Chronic anger / rage, inappropriate, misdirected expression (e.g., road rage), short temper, has consequences for personal relationships, job stability
99
What emotion does LeDoux see as the driving force behind phobias, anxiety, panic disorders, and obsessive compulsive disorders?
Fear.
100
According to LeDoux, what is the difference between fear and anxiety?
Fear is stimulated by something in the environment (e.g., dog attacking), anxiety originates in the self (e.g., anxiety that a dog might be waiting around the corner, or what would happen if a dog attacked)
101
What extreme emotion is the central experience of trauma, and what does it result from?
Terror (extreme fear), resulting from perceived threat to life / self.
102
For PTSD sufferers, why is persistent fear a problem?
The alarm bell that won't stop ringing. The persistent fear, originally attributed to a genuine threat, becomes associated with many other stimuli and gets generalized to debilitating anxiety. When everything appears dangerous, and discernment is gone, fear is no longer protective. Those with PTSD "fall prey to dangerous situations"
103
What might be a biological cause of persistent fear in PTSD?
Insufficient cortisol production.
104
Why might shame by such a common feature of trauma constellations?
In addition to sexual abuse and rape, all victims of trauma might question "why couldn't I stop that... what is wrong with me that I became a victim of that trauma?"
105
In terms of processing shame, how is it different from other emotions?
It is not expressed and dispelled like other emotions, like crying for sadness, yelling for anger, screaming and shaking for fear.
106
What are the keys to alleviating shame?
Acceptance and nonjudgmental contact.
107
What is the possible adaptive value of shame?
From an evolutionary perspective, shame may serve to keep people in line with cultural norms, to socialize, and to prevent behaviours that are a threat to self, and the group.
108
What might be the generative upside to shame?
It underlies the formation of a conscience.
109
What is the value to investigating the adaptive nature of shame?
It may help us accept the shame, with acceptance understood as the first step to resolving unwanted emotional states.
110
What is grief a response to?
Loss or change
111
What does grief signal in trauma work?
That an aspect of the trauma has been relegated to the past, a positive part of the healing progression. "I was really scared" as opposed to "I am really scared."
112
In trauma work, what is the phenomenologial somatic experience of grief?
More solid, less fearful, if more sad.
113
What is a clinical trauma-work term often used interchangeably with 'catharsis'? What is the difference between the two?
Abreaction, emotional discharge that accompanies
| Catharsis is "the cleansing power of emotions" when disturbing memories are brought forth.
114
What is the ongoing clinical debate surrounding abreaction in trauma work?
Is it helpful or re-traumatizing? When does it help, when does it not?
115
What are the two variants of abreaction possible in trauma work, and how might we distinguish them in a client?
Integrating and disintegrating abreaction. Integrating abreaction might be distinguishable by visible hallmarks of parasympathetic arousal, like deep breathing, colored skin, emotional sounds on exhale. Disintegrating abreaction might be distinguishable by hallmarks of sympathetic arousal, like pale clammy skin, rapid respiration, jerky, emotional sounds on inhale.
116
What are two salient features of PTSD at the root of the most distressing symptoms? Which requires the occurrence of the other?
Traumatic dissociation and flashbacks. Flashbacks require some form of dissociation, though dissociation can occur without flashbacks.
117
What is traumatic dissociation? What are some examples?
A splitting of awareness; during a trauma, the victim separates aspects of the experience (partially or totally) to reduce the impact. These reactions may continue after the trauma, and reoccur under stress. Examples include amnesia, anesthesia (no pain), cut off emotions, loss of consciousness, feeling disembodied, or complete separation of personalities.
118
What are two commonly referred to types of flashbacks, and an additional type relevant to trauma? What is common across types?
Visual and auditory are often thought of, but any somatic symptom that replicates traumatic experience can be considered a flashback. They are all highly distressing because they feel as if trauma is beginning again, or continuing.
119
What is the difference between a flashback and a memory, in terms of the way they are remembered?
Memories exist on a timeline, in the past. Flashbacks are dissociated and free-floating, and are present moment experiences.
120
Who coined the term dissociation and when? What were they attempting to understand?
Moreau de Tours in 1845, looking at hysteria.
121
Who is considered the 'father of dissociation'? Why?
Pierre Janet, who's work on this topic is the foundation for current thought. His work has been rediscovered and applied to theories of dissociation and PTSD.
122
What are some possible explanations for the occurence of dissocation?
A neurobiological phenomenon which occurs under extreme stress, which may be an attempt to dampen the impact of trauma, or it may by a secondary result of trauma, or it may be "the mind's attempt to flee when flight is not possible."
123
How might trauma-related dissociative phenomena be reported?
I left my body; time slowed down; I went dead; I felt no pain; I felt beside myself; all I could see was the gun
124
How might trauma-related dissociative phenomena be identified, and when?
For years following a traumatic event, or even beginning years after a trauma. Identifiers include numbing, flashbacks, depersonalization, amnesia, out-of-body experiences, dead emotion, "irrational" behaviours, and emotional reactions not based in reality.
125
What is Peter Levine's model of dissociation?
Five parts to experience: SIBAM: Sensation, Image, Behaviour, Affect, and Meaning. Complete recall of an experience involves integrated recall of all the above parts.
126
According to Levine's dissociation model, what happens during episodes of traumatic stress? Provide an example?
Some elements of experience (SIBAM) become dissociated. Typically each of the five elements will be associated with the other 4, but some may be dissociated or absent. Someone with PTSD may report a visual memory (image) and an emotion (affect) but not be able to make sense of it (meaning). A child may repetitively play (behaviour), but not display affect, or recall the event (image).
127
According to Babette Rothschild, what is a shortcoming of SIBAM model?
There is no way to distinguish dissociation from forgetting.
128
What SIBAM elements might be associated / dissociated in a case of panic attack?
Associated: Sensation and Affect (feel the disturbing sensations of high alert, feel terrified)
Dissociated: Image (no memory of causal event); behaviour (don't know what to do to reduce anxiety); meaning (can't understand the panic onset)
129
What SIBAM elements might be associated / dissociated in a case of avoidance?
Associated: Affect and behaviour (feel scared; don't go outside)
Dissociated: Sensation, image and meaning (No sense of what happened, numbing, and no understanding of why
130
What SIBAM elements might be associated / dissociated in a case of flashbacks?
Associated: Affect and image (moving between images and the terror)
Dissociated: Meaning, Sensation, Behaviour (Can't feel body in present moment, can't move to break spell, can't make sense of it)
131
How can SIBAM model help with trauma treatment?
Identifying dissociated aspects of the experience can indicate areas to carefully work back into consciousness when client is ready.
132
If a client indicates they are 'having nightmares when awake', what might they be experiencing?
A flashback
133
Why are some types of flashbacks more easily recognized than others?
Auditory and visual flashbacks can easily be described as what I'm seeing and hearing. Emotional, behavioural, and somatic flashbacks are less easily recognized as they may comprise hyperarousal, hyper-startle reflex, unexplainable emotional upset, physical pain, or intense irritation.
134
What is meant by "somatic re-enactment" of traumatic events? Provide an example.
Sensory and behavioural flashbacks. For example, a woman who was compelled to urinate repeatedly, after a trauma where her life was spared because she was the only one who did not need to use the washroom in a building fire that killed her friends.
135
When a child acts out a traumatic experience, what kind of trauma expression is this?
It could be a behavioural flashback.
136
Which memory systems are active in flashbacks?
Both implicit and explicit can be active, but explict can also be absent.
137
What role do the amygdala and hippocampus play in flashbacks?
The amygdala is active, and emotional and sensory aspects of experience are almost always present in a flashback. The contextual features associated with hippocampul activity are absent
138
Flashbacks are usually set in motion by what kind of triggers? What does that mean about nervous system involvement? Provide some examples.
Classically conditioned / state-dependent triggers, meaning the entire nervous system is involved.
For example, cop who kills man gets triggered by seeing blood flowing from another man's chest and begins yelling as if he were in the previous situation.
Or a woman panics every time she has to drop her child off at kindergarten. Realizes later that she was molested at school when she was that age.
Or a woman who received many invasive medical treatments as a child, being triggered and fainting when being examined by a docter (sensory flashback, triggered by sensation and posture)
139
Explain flashbacks in light of the following concepts: state dependent recall, interoception / exteroception, ANS, SNS, dissociation, implicit/explicit memory
Flashbacks involve dissociated, implicit memories of traumatic experience, elicited by state-dependent conditions, triggered by interoceptive/exteroceptive cues, and involve hyperarousal of the SNS and behaviours directed by the SNS.
140
What are the risks for trauma clients in psychotherapy?
Being overwealmed, decompensating, anxiety and panic attacks, flashbacks, and retraumitization. Having a flashback in the treatment room, and perceiving it as the site of the trauma, or perceiving the therapist as the perpetrator. Being unable to function in normal life during therapy. Requiring hospitalization.
141
What is decompensating?
Someone who has an illness that they have been compensating for (with medications, treatment, family support and all the other strategies they might be using) begins to show symptoms again, so they have “decompensated” – fallen backward from the level of compensation they had previously experienced.
142
What are alternatives for clients who cannot tolerate memory-oriented trauma work?
Symptom relief, improving coping skills, improving daily functioning
143
When might therapy become retraumatizing for clients?
Therapy process accelerates faster than client can contain; when more memories (images, facts, body sensations) are pressed or elicited into consciousness, than can be integrated. When the ANS is aroused beyond the clients ability to stop it.
144
How is trauma therapy akin to learning to drive?
The most important first step is learning to reliably and confidently apply the brake, so that the driver can safely accelerate and brake at an appropriate speed.
145
Other than being able to ward off retraumitization, why is braking important in trauma therapy?
PTSD symptoms are depleting, with client swinging between periods of wild energy and exhaustion. Therapy can be difficult if the client doesn't have the energy to confront issues at hand. Being able to reduce hyperarousal in therapy and in life will enable rest which will increase capacity to do the work.
146
How is PTSD like a pressure cooker?
The ANS hyperarousal builds pressure in the body and mind. Opening the lid will result in an explosion. Releasing the built up energy one pft at a time leads to being able to open it up. Opening the client to trauma at high pressure increases risk of decompensation, breakdown, illness and suicide.
147
According to Lenore Terr, what are the two types, and sub-types of trauma?
Type I: Experienced a single traumatic event
Type II: Experienced multiple traumas
Type IIA: Have stable backgrounds, enough resources to separate the individual traumatic events. Can speak about one at a time.
Type IIB: Overwealmed by multiple traumas, unable to separate one from the other, "begins talking about one, quickly links to another"
Type IIB(R): Stable background, but complexity of trauma that has broken down their resilience (e.g., Holocaust survivors)
Type IIB(nR): Someone who has never developed resources for resilience.
148
Which of Terr's trauma types will involve more, and which will involve less, transference work in therapy?
Type I and Type IIA - have resilience, require less attention to the therapeutic relationship
Type II B(R) - Therapeutic relationship will help reconnect with past resources
Type II B(nR) - Therapeutic relationship may be the whole of therapy, building resources and resilience.
149
What is Scott and Stradling's PDSD? Which of Terr's trauma type are they most likely to resemble.
Prolonged duress stress disorder. (PTSD symptoms, but no identifying events) Chronic, prolonged stress during developmental years from neglect, chronic illness. Resembles Type IIB(nR)
150
What are Levine's "intentional movements"?
Slight muscle contractions that indicate a possible unfulfilled behavioural intention
151
How might the body play into the therapeutic relationship in trauma work?
Observing for signs of ANS arousal, tension, intentional movements while considering client-counselor interaction may indicate the impact of the relationship.
152
According to Shore, how does the therapeutic relationship impact the implicit memory system?
Experiences of the therapeutic relationship are encoded in the implicit memory system, and make changes to existing synaptic pathways with regards to bonding and attachment. It creates a new somatic marker of a relationship.
153
What are two examples of situations that might benefit from successful positive therapeutic attachment?
Habituated avoidance; fear of interpersonal relationships
154
What must be in place before beginning to work directly with traumatic memories?
A secure therapeutic relationship. The client must feel safe with the therapist.
155
What is the approach with clients for whom developing the therapeutic relationship takes a long time and becomes central to the therapeutic process?
Direct trauma work to the sidelines, and building resources like body awareness, braking, muscle toning, resource building, boundaries, dual awareness, etc.
156
For which type of client is the therapeutic relationship the most important; why?
Type IIB(nR). Complex trauma is captured under this category, and they do not have resilience nor resources to confront trauma directly. Neglect or victimization mean trust in others is a major issue, and must be developed or re-established. Developmental deficits like attachment failures or neglect can be factors.
Interpersonal trauma makes therapeutic relationship more important.
157
According to Shore, what are the 3 critical phases of attunement in an attachment relationship relevant to developing the ability to regulate emotions, and forms the basis of attachment?
Attunement: Face-to-face contact between child and caregiver
Misattunement: High arousal level, through excitement, or disapproval/anger from the caregiver leads child to break attunement.
Reattunement: When the arousal level drops to a tolerable level, child will reattune with the caregive, usually at a higher level of arousal than was previously tolerable.
158
What are two ways misattunement can play out in therapy with Type IIB clients? What are strategies a therapist might employ in these situations?
1. A conflict could lead a client to perceive betrayal or injury and misattune and break off therapy. One strategy would be to address the possibility of this occuring beforehand, and lay the ground work for a possible repair to the relationship and reattunement. (e.g., client mentions he left previous therapists in anger; check why)
2. In a case of interpersonal trauma, a victim may have difficulty distinguishing between perpetrator and therapist, and this transferrence leads to the inability to trust the therapist. (e.g., Feldmar "you don't see my face, you see the attacker"). A strategy is to address this relatively quickly, and challenge that view with reality testing.
159
What is the first rule of trauma therapy?
Safety, both in the therapeutic relationship, and in the client's life.
160
Why is safety in a client's life a pre-requisite for trauma work?
Trauma work involves the lowering and releasing of defenses
161
What are some examples of ways that safety can be established in a client's life?
A battered wife must be safely separated from her husband; someone assaulted in their home might install locks on doors and windows; a rape victim may need to wait for the rapist to be incarcerated.
162
Are triggers a good or bad thing for trauma clients?
Initially, when trying to establish safety, it may be wise to remove triggers, to cultivate that baseline sense of safety. Sometimes by removing the trigger temporarily, it can later be learned to be tolerated.
163
What is the difference between derealization and depersonalization? (not from book)
Depersonalization can consist of a detachment within the self regarding one's mind or body, or being a detached observer of oneself. Subjects feel they have changed and that the world has become vague, dreamlike, less real, or lacking in significance. It can be a disturbing experience.
Derealization is a detachment from one's external environment, and can be described as an immaterial substance that separates a person from the outside world, such as a sensory fog, pane of glass, or veil. Individuals may report that what they see lacks vividness and emotional coloring.
164
What might be a way for a client suffering from depersonalization where they don't feel their own skin to reconnect with the feeling of their own body?
Take a cool shower, to gain a sense of the periphery of the skin. (Not recommended if this causes significant fear)
165
What might be a recommendation for someone who reports significant fear at an activity?
Suspend that activity and find an alternative. Constantly putting oneself in a terrifying situation will maintain high arousal levels and getting relief from that will help re-establish resilience.
166
How much time should be spend on building rapport and relationship in trauma therapy, before beginning with therapeutic techniques?
At least 1-3 sessions, but could also go on for years.
167
When taking a case history, what are two important things to be on the lookout for?
Indications of traumas and resources. (Resources should be evaluated and built upon before beginning difficult therapy)
168
What are the five major classes of client resources? What are some examples of each and ways to build them?
Functional: Practical, safe place to live, reliable car, establish a protective contracts
Physical: Strength, agility. Do self-defense training, weight training.
Psychological: Intelligence, sense of humor, curiosity, creativity, defense mechanisms. Develop the opposite of the defense mechanism for balance.
Interpersonal: Current social network, recalling significant people from the past, pets
Spiritual: Belief in a higher power, religious practice, communing with nature
169
Explain the idea of a protective contract (which originated in Transactional Analysis) in trauma therapy,
Synchronicity. Trauma client is often faced with issues being explored in therapy: being followed at night following a rape, close call in a car following an accident. Make a contract with a PTSD client for extra safety - extra caution at night, extra safe driving.
170
How might one cue the practice of defensive movements for an earthquake victim?
For someone who cannot relax, and is always preparing for the worst, ask them if they have practiced the movements they are preparing for. Suggest they follow the impulse in their defensive posture; run for the door, crawl under a table. Encourage them to practice them if it seems to reduce symptoms. Check in with physiological symptoms.
171
Explain how psychological defense mechanisms are a positive resource? How might one work them?
Unless they harm other people, they are positive because they are (or were originally) successful attempts to protect the self. Defense mechanisms are not problematic in and of themselves, but are a problem in their one-sidedness. Rather than trying to remove a defense mechanism, build up its opposite for balance and choice.
172
What are some examples of defense mechanisms, and how their opposite is missing?
Withdrawl - a problem only if engaging with others is not possible
Fear of solitude - connecting with others is great as long as it doesn't handicap your ability to spend time alone
Expressing anger can be alienating - while inability to express anger can leave one defenseless
Dissociation is useful when at the dentist - being present is helpful when driving
173
What is one way memories of healing can be brought into the therapeutic process?
Vividly recall being nurtured, by a pet, a loved one, etc.
174
What can happen to spiritual beliefs in trauma and what is the implication for therapy?
A trauma can lead one to feel betrayed by their beliefs. Reclaiming that relationship to spirituality can be an important healing step.
175
What is a question we could ask a client w PTSD that could prevent despair/hopelessness and invite discovery of resources?
How did you survive your life / trauma?
176
In terms of resourcing, what is an "oasis"?
An activity that gives the client a break from their trauma. It should be challenging enough to be absorbing, so not TV, or knitting if you are familiar with knitting, but car repair, solitaire, or computer games would work. It helps reduce internal monologue and hyperarousal.
177
In terms of resourcing, what is an "anchor" and how is it used in trauma therapy?
An anchor is a concrete resource from the client's life, preferably one that triggers pleasant memories in both body and mind, and could be the image of a family member, friend, animal, object, place, or activity. An anchor is used for braking.
178
From what theory did "anchors" originate?
Neuro-linguistic programming
179
How can we identify anchors in assessment?
Watch the client's physical indications of arousal. If they appear to calm, relax, brighten, sit up at the mention of someone or thing, make a note of that as something that could possibly be invoked for braking purposes.
180
How does the therapist use the anchor to brake?
When hyperarousal gets to high, simply change the subject: "Let's take a break/stop this for a moment. Tell me about (anchor)". By doing this repeatedly, the interruption to flow becomes acceptable and even welcome.
181
In the context of resourcing, what is a "safe place"?
A current or remembered site of protection, preferably real world with associated somatic memories attached to it. It can be used by clients during stressful times, or in the same way an anchor is used.
182
What can be done when a client has difficulty imagining a anchors / safe places?
Some clients images will become contaminated with fears, dangers, etc., and feel controlled by their fantasy, rather than the other way around. A frank discussion may be had, that client is in control of fantasy, and that it doesn't need to be perfect, just good enough. For example, limit the anchor to only good memories, or imagine protectors, sentries to keep it safe.
183
How can body awareness training help in the case of a client who has problems with positive affect tolerance?
For the small percentage of clients who become anxious imagining or experiencing positive affect states, because they can't differentiate them from nervous system responses related to anxiety, learning to tell the difference between the following helps:
Anxiety is linked with pallor and decrease in temperature of the face and extremities
Happiness and excitement are linked with increased color and temperature.
184
Why might a client fear positive affect? How can body awareness help?
Because he anticipates it will not last. Body awareness of the temporality of all somatic, bodily experiences can help, knowing that as sensations ebb and flow, so do emotions.
185
When might it be particularly helpful to teach trauma theory to a client?
When client has experienced multiple traumas and is not ready for the use of techniques.
186
What might be theoretical information to share with a survivor of complex trauma who feels 'dead inside' and is troubled by that feeling?
The adaptive nature of playing dead for a mouse, the autonomic nervous system and theory of freeze reactions. This theory can reframe the feeling as a natural and adaptive reaction to beatings.
187
What might be theoretical information to share with a survivor of complex trauma who blanks out?
Theory of the ANS function and dissociation.
188
How might a therapist help a client who begins dissociating in session?
Change the subject and focus on a previously-noted anchor (braking)
189
In trauma work, what is important to consider when an intervention fails?
No intervention works the same for two clients.
Timing may have been off, or the incorrect intervention may have been chosen.
Training in multiple modalities is helpful.
Sometimes the best technique is no technique; just be with the client talking about mundane things is the best approach sometimes.
190
What are Rothchild's 10 foundations for safe trauma therapy?
1. Establish safety in and outside therapy
2. Good therapeutic relationship precedes working with traumatic memories and techniques, no matter how long that takes.
3. Client (and therapist) must be confident in 'braking' before accelerating
4. Identify and build on internal and external resources
5. Defenses are resources. Don't try to exterminate coping strategies or defenses. Create more choices.
6. "Pressure cooker" analogy. Always reduce pressure, never increase.
7. Adapt therapy to the client by knowing several treatment models.
8. Broad knowledge of theory of psychology and physiology of trauma and PTSD
9. Clients don't fail at interventions.
10. Be prepared to put aside all interventions and just talk with client.
191
Why is body awareness such an important practical tool in trauma treatment?
Awareness of sensory stimuli is direct link to present moment, and to emotions. Body awareness enables the perception and self-regulation of hyperarousal, and the ability to separate past and present. It is also a first step in interpretation of somatic memory.
192
What is a working definition of body awareness?
The precise, subjective consciousness of body sensations arising from stimuli that originate both outside of and inside of the body.
193
What are terms that help identify bodily sensations associated with breathing?
location, speed, and depth
| contraction, expansion, yawning
194
What are some miscellaneous terms to help identify bodily sensations?
position of a body part in space; tears, crying,
195
What are terms that help identify bodily sensations associated with skin?
(humidity) Dry or moist
(temperature) hot, cold
shivers, prickles
196
What are terms that help identify bodily sensations associated with muscles, form, posture?
tense, relaxed, restless, calm, movement, still, pulling, rotation, twist, contraction, expansion, strong, weak, sleepy, awake, heavy, soft, hard, tight, loose, crooked, straight, balanced, unsteady, upright, tilted
197
What are terms that help identify bodily sensations associated with circulation?
Contraction, expansion, pulse rate, heartbeat,
198
What are terms that help identify bodily sensations associated with stomach?
Butterflies, shaky, empty, full,
199
What is a simple exercise to initiate basic body awareness?
Do not move. Notice sensations. Body scan.
Notice any discomfort. Before moving, notice sensations that tell you it is uncomfortable.
Where does impulse to move come from? What is first thing you would move? How do you know?
If no impulse, how do you know you are comfortable?
Change position, stand or sit on floor. Re-evaluate for comfort. Notice a change in alertness.
Try again in a new position.
Take some notes.
200
What is a strategy to help clients who cannot distinguish sensations in a body scan?
Be more specific: What is sensation in your stomach? What is temperature of your hands? Where does your breath go?
201
What is a body awareness strategy for clients for whom body awareness is frightening or frustrating?
Approach it indirectly. How is the temperature in the room? Is the chair too soft or hard? Are you thirsty, do you want a drink?
Or use kinesthetic sense: can you tell without looking how your hands/legs are positioned right now?
202
What are two examples of contraindications for body awareness in trauma work? What replaces body awareness in these situations?
1) Severe damage to bodily integrity, to the extent that sensing the body will accelerate contact with trauma leading to feeling overwealmed
2) Clients for whom body must be sensed "correctly", leading to performance anxiety.
Forgo body awareness in favor of building safety, attachment relationship, building resources, and finding oases. Develop calm before progressing towards the body.
203
What is a perspective-changing question one could ask someone with PTSD for whom body sensations all feel dangerous?
What would the consequences of not having sensations? How would you know pot is too hot to touch? How would you know the limits of exercise? How would you know not to walk on a deserted street or approach a dog?
204
What is the term for someone who cannot identify or name their emotions?
Alexithymic
205
What is an ongoing strategy to help clients identify emotions?
When therapist notices emotion expression via facial expression, posture, tone of voice, interrupt and ask "what are you aware of in your body right now?" or "did you notice your breathing change / heat rise in your face / how hard it was to swallow just now?" And then later, do you recall ever experiencing those sensations earlier in life? Or, "what would someone else be feeling if they experienced those sensations?"
206
How is the body an "anchor"?
Sensing the body pulls one into the present, and out of memories of the past.
207
What is the pacing when using body awareness as an anchor, and what is the goal of such an activity?
Quick and present tense. Focus should not dwell on a particular sensation for too long. Many clients experience relief from this quick scan approach.
The goal is to release / relieve pressure by coming into the present.
208
What is the pacing when using body awareness as an "accelerator"?
Going slowly, staying with a particular sensation can still up memories of the trauma.
209
How can client and counsellor use the ANS to guide the pace of therapy?
By monitoring the body's sensations, learning to recognize arousal, and avoid hyperarousal (ANS) overarousal.
210
What is the difference between ANS activation in dark skinned and light skinned people?
Dark skin darkens with blushing. It does not blanch white, but becomes more grey than brown when losing blood flow.
211
What is a solution for visual impairment, or the need to look away from a client in terms of monitoring ANS activation?
Have client report verbally: face temperature (warm = blush, cold = pale); where is your breath, more in chest or belly
212
What is a popular subjective scale of emotional disturbance?
SUDS (Subjective Units of Disturbance Scale)
213
What is a SUDS limitation when working with trauma, and a way for therapist to overcome the limitation?
Not uncommon for a client to give a low SUDS rating despite symptoms like racing heart and clammy hands, due to dissociation. Therapist can supplement with ANS observation.
214
What might gradually paling skin and increasingly immobile face indicate?
ANS overarousal / hyperarousal
215
What is Rothchild's 5 level scale of ANS arousal and the signs?
1) Relaxed system (PNS moderate) (breathing deep and easy, heart rate slow, skin tone normal)
2) Slight arousal (PNS moderate and SNS low) (Breathing, heart rate increase, skin tone stays normal; or skin tone pales and moistens without increase in respiration and pulse)
3) Moderate hyperarousal (SNS moderate) (rapid heart beat, rapid respiration, becoming pale)
4) Severe hyperarousal (SNS high) (accelerated heart rate, accelerated respiration, pale skin tone, cold sweating)
5) Endangering hyperarousal (SNS high, PSN high): Pale skin (SNS) with slow heart rate (PNS); widely dilated pupils (SNS) with flushed colour (PNS); slow heart rate (PNS) with rapid breathing (SNS); very slow breathing (PNS) with rapid heart rate (SNS)
216
According to Rothchild's 5 level scale, at which point should brakes be applied?
Brakes ought to be applied for moderate hyperarousal, and should definitely be applied for severe hyperarousal. For endangering hyperarousal, which we are trying to avoid in therapy because it can be retraumatizing, the client must be stabilized.
217
What are 2 possible directions for trauma therapy?
Focusing on the memory of past trauma or working with sensation of here and now.
218
What kinds of things can clients be invited to investigate about their sensation around trauma?
When, under what circumstances, how long does it last, what precedes it?
219
What kinds of diet decisions can impact PSTD symtomology?
Skipping meals, caffeine, chocolate, alcohol
220
In addition to awareness of ANS overactivation, what other kinds of body awareness can be helpful as a gauge in trauma therapy?
Tightness, stomach upset, vision changes, hearing changes
221
What is an analogy for monitoring ANS activation?
Systems check. Checking fluids, tires etc. before heading offroad.
222
On the 5 stages of hyperarousal, which stages need braking and stabilization?
Moderate to severe, breaking should be applied. Endangering requires braking and stabilization before proceeding further.
223
What is a client with endangering arousal likely experiencing?
Highly traumatized state, speeding out of control, flashbacks, panic, breakdown, tonic immobility, and emotions like rage, terror and desparation.
224
What is the relationship between detail and hyper arousal?
Greater detail = greater risk of hyperarousal
225
What are the 3 stages of trauma narrative?
1) Name trauma (bus crash)
2) Overview of trauma with titles to main incidents
3) Details of each incident, one at a time
226
If a client exhibits, reports hyperarousal when naming the trauma, what is the next step?
Not narration. Stabilization, muscle toning, building trust and safety.
227
If client can name the traumatic incident and there is not significant arousal, or it dispels in manageable catharsis, what is the next step?
Outline main titles of the trauma. Chapter titles without details.
228
Describe an intervention where SIBAM can be used with sensation to make sense of somatic memory, in a case of chronic, unexplained pain?
Stay with sensation for a minute or more, while investigating the SIBAM elements -> like other sensations or emotions.
229
How can somatic memory be tapped as a resource in trauma therapy?
Remembering somatic aspects of a positive memory of safety and security (e.g., grandma's kitchen)
230
What is a question you can ask a client whose eyes appear to change?
"Can you still see me?"
"How do I look?"
"Have I become darker, father away?"
231
What is dual awareness, and how would it play into making sense of stomach pain?
Noticing more than one aspect of awareness simultaneously. Reconciling parts might help us determine whether stomach pain is related to what I ate, the tone of someone's voice, or fear for the future for example.
232
What distortion of perception occurs with PTSD? Why is this a problem?
Paying more attention to internal stimuli (sensations), and less to external. Sensations, associated with danger become means to evaluate situations. Without external stimulation to discriminate, danger is everywhere and constant.
233
What are two god gauges for monitoring pace of the trauma narrative?
Signs of hyperarousal, and the ability to make sense of responses to the events that caused those responses.
234
What strategy should be used to give clients a sense of control during the telling of the details of their narrative?
Periodic interruptions to check ANS arousal, and using established anchors during breaks to calm the client.
235
How might the body be used as a brake in a case of anxiety/panic?
Structured body awareness and tolerance. Learning to stay with sensations like anxiety until they subside.
236
What is a protocol for using the body to identify arousal triggers? (5 steps)
1) Notice body experience with precision, especially heart rate, breath, and temperature.
2) Identify last time you felt calm. (Point A)
3) Identify roughly when you began to feel disturbed (Point B)
4) Shuttle between these 2 points, recalling events, conversations, environmental conditions, objects, thoughts.
5) For each one, ask "Is this what upset me?" and observe bodily response. (An increase in arousal now may mean a likely trigger has been identified.)
237
What are some different terms that could explain the perceptual split between internal and external stimulation that's so important for people who've been traumatized?
Self / observing self
Core / witness
Child / adult
Experiencing self / observing self
238
What is the risk of delving into trauma memory for someone who does not have ability to maintain dual awareness (of arousal and current reality)?
Uncontainable arousal and possible flashback; retraumatization
239
What is an exercise to evaluate dual awareness capacity in a client?
Recall mildly distressing event. Notice body, muscles, gut, breathing, heart rate, temperature. Now bring awareness back to the room. Notice...
