This blog post introduces trauma therapy for chronic illness drawing from a video example with a dog named Kane.
The video offers an example of how trauma therapy for chronic illness can work with nervous system perceptions of threat that drive symptoms. It’s not psychological and the science is showing that adverse events affect symptoms by altering our physiology, nervous system, cell danger response and epigenetics. On my blog I share the research about adverse events in babyhood, childhood and later in life that trigger the onset of symptoms to influence health and why it’s not in our heads. I also share the personal work I’ve done healing from my own chronic illness using these perspectives. Trauma therapy for chronic illness, it turns out, supports healing for many different kinds of symptoms and chronic diseases.
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Kane is a 2-year-old great dane who developed a trauma response after sliding into a glass door. His owners consulted dog whisperer Cesar Milan, as you’ll see in the 13-minute video from the TV series “The Dog Whisperer” (1)The Dog Whisperer, with Cesar Milan, National Geographic Wild, Series 1, Episode 1, part 2; September 13, 2004.
I’ll chunk the steps down and highlight principles about symptoms, nuances of trauma therapy for chronic illness, and what the process of recovery looks like.
The beauty of this example is that these principles apply to working with people as well as animals. And as you’ll see, they are relevant for working with mental health such as fear or panic, anxiety and PTSD. At the end of the post are references and approaches for helping people recover from trauma.
The videos I originally used have been deleted and hopefully the one below will be available for a while. Kane’s is the second story, starting at about 12:52 minutes and the video should begin then. If you have trouble seeing the video, try this other link.
If the video is not available, the pictures in this post will give you an idea of what I am referring to.
Marina, Michael and Emmett have had their dog Kane since he was an 8-week-old puppy (00:13). Marina is a teacher who has always loved bringing her dogs to class and to school on weekends. Kane is sweet and gentle and loves to play. His fears since his accident, however, limit where they can go as a family. Marina can no longer get him into her school, for example, and now that he weights 160 pounds she can’t force him to do so either. This is why Cesar Milan has been consulted.
I. How Trauma Happens
A year ago when Kane was a one-year-old (2)this is the equivalent of 15 years in human terms he was acting rambunctious one day at Marina’s school when he ran towards an exit that was actually a glass door (1:23). He lost his footing on the shiny, slippery floor and couldn’t prevent himself from crashing into the door (the accident is not shown in this video). When Cesar gets information about Kane’s history he asks Marina how she reacted at the time of the accident (3:54). She describes with insight that she went over to pet him and “overreacted and jumped all over him.” Cesar explains that her behavior nurtured the trauma and stress rather than helping him recover. Cesar’s belief is that Kane’s trauma response is repairable.
The Healthy Response of Adaptation
Our nervous systems are designed to maximize our chances of survival by learning through experience. When we got through something scary we learn what to avoid and how or where to be more careful.
Fear is an important aspect of normal learning.
Fear is designed to maximize our chances of survival in the future.
The Trauma Response
Instead of learning to be more cautious or to walk more carefully on slippery floors, Kane has developed a trauma reaction: he has come to fear shiny surfaces. There are a number of factors that prevented Kane from recovering and learning from his accident and that instead lead to a trauma response. Risk for trauma is increased:
When escape is not possible
Successful escape from threat involves fighting, running or even negotiating and talking our way out of some dangers. Kane could not stop himself from sliding into the door: he was unable to prevent the painful impact by running away; he could not fight with the door as a way to avoid being hurt; barking, growling and whining were not effective for warning the threat away either.
Experiences that lead to overwhelm and helplessness increase risk for trauma
When events are perceived as life-threatening, whether life is actually at risk or not
When we are overwhelmed with fear and helplessness, it prevents us from recognizing that he have actually survived. Our nervous systems perceive that we are still in danger.
When there is a lack of resource
Kane had little time to prevent or avoid his accident.
When Marina got scared, her own overwhelm conveyed a sense of danger to Kane.
Kane, still a young dog learning many lessons about life and his environment at the time of his accident, did not have a reference point of calm reassurance during or after the event.
These principles are also seen throughout the literature exploring risk between adverse life events and risk for chronic illness. This is why trauma therapy for chronic illness can be such a practical and helpful resource.
II. Symptoms of Trauma
After the accident, Kane developed symptoms of fear (1:46). At first, his fear was in response to seeing the shiny linoleum floors at Marina’s school where the accident happened. In time, however, he began to avoid all shiny floors and eventually, to avoid other shiny surfaces as well, such as wet streets.
Kane’s symptoms are hallmarks of trauma. We experience similar symptoms as humans:
Unresolved fear represents a trauma response
- Emotional Fear – You may be able to see the fear in Kane’s eyes in the video and picture. You may also notice fear when watching Kane because we pick up on emotions in others through our own bodies just by watching or being around them.
- Kane’s degree of fear is why he’s been so avoidant. It’s why we humans have the impulse to avoid talking about, thinking about or recalling traumatic events if we can help it. We do this because we are trying to avoid feelings of overwhelm and helplessness.
- Physiological Fear – when Cesar and Kane stand on the shiny floor just inside the school entrance, Kane’s physiological symptoms of fear become visible. Kane starts to breathe heavily and then to salivate (6:45). When they cross the floor, Kane tries to resist and eventually lies down (7:10). There is an element of giving up and this represents a state of collapse stemming from the accident. It is the freeze response, which is the normal reaction to inescapable, overwhelming threat and the only option left to Kane at the time of his accident. Having to resort to freeze increases our risk for developing a trauma response (3)It is possible to avoid triggering a freeze response by going even more slowly and gently in therapy. Force is not a useful tool to use with people. Information, education and guidance can be used instead while tuning into the pace that a person needs.
- Kane’s freeze tells us that he is still caught in the past traumatic event. This is a result of altered perception that leads Kane to assess shiny floors as an overwhelming threat.
- Behavioral Reactions of Fear – Kane’s avoidance of shiny floors (2:10) is out of proportion to the circumstance since linoleum floors are not actually dangerous. Kane’s resistance offers clues to his underlying trauma history. Avoidance is a natural way we all have of managing fear, although it does not actually treat the underlying cause.
Altered perception. Altered perception is a component of trauma. It drives the creation and perpetuation of symptoms and is outside of everyday awareness.
Duration of Symptoms. Kane is still expressing fear and avoidance a year after a single seemingly minor accident. This persistent reaction (emotional, physiological, and behavioral) is a hallmark of unresolved trauma and posttraumatic stress disorder (PTSD). My theory is that chronic illness represents a similar expression of unresolved trauma (learn more in The Chronic Illness Trauma Connection: a summary of the science).
Limitations. Symptoms lead to limitations. Kane’s PTSD limits where he and his family can go.
Triggers. Kane’s symptoms are stimulated by triggers, which increase over time (4)Here’s a more detailed description about trauma triggers. While the article focuses on triggers in men it applies to the rest of us as well.
The Number of Triggers increases. After the accident, Kane was afraid of the school’s linoleum floors. He then became afraid of other shiny floors. Over time, he developed fear of wet streets. This process is a hallmark of PTSD.
The Types of Triggers globalize. In the future, Kane’s symptoms could get triggered by increasingly unrelated events. Other shiny things, such as cars, toys, or refrigerators, could become triggers for example. So could glass doors or doorways in general. This is another hallmark of PTSD.
Symptoms. Kane’s most visible symptom is behavioral (avoidance). His physiological symptoms are less obvious. Some symptoms of PTSD are not highly visible either, are difficult to interpret if there is no history or context, and can be missed. Kane resists situations such as shiny floors because they trigger greater symptom intensity.
Management of Symptoms. Marina’s use of the carpet (2:50) to cover the shiny floors at her school is a way of trying to manage and work around Kane’s fear.
All of the examples above are also relevant when we consider trauma therapy for chronic illness.
Pulling or trying to force Kane is another way of trying to cope with a difficult situation, as is the end result of being unable to bring him to class with her even though Marina really wants to do so. Managing symptoms can help us function better in daily life but does not treat the underlying cause and may sometimes exacerbate symptoms by reinforcing the underlying fear pattern.
III. Principles of Treating Trauma
In order to recover from trauma, one must perceive that the threat of danger is over and that we have survived. This process occurs in our brains. It happens outside of conscious awareness, so finding ways access things we aren’t fully cognizant of is an important way of treating the effects of trauma.
Trauma therapy for chronic illness and recovery in people can be accomplished by using art or music, for example, or by paying attention to sensations and impulses in the body, images and more. These are just a few examples of ways to access and work with patterns of the trauma response. There are key components to trauma therapy, however, and apply in all of these approaches.
Calm, Supportive Witness: (6:26) Cesar is calm, clear and steady, which imparts a nonverbal message of safety to Kane as well as to Kane’s nervous system. The presence of a “regulated,” supportive other is an important resource for working through trauma.
Trust and Safety. Cesar’s first step after getting Kane’s history is to establish basic trust by taking Kane for a short walk (4:35). Kane needs to have enough of a bond and rapport with Cesar to follow him as they work through his trauma response (5:08). Feeling “safe enough” is similarly important for people when choosing a therapist for working with trauma as well as with chronic illness.
Evoking the Sensations of Fear. In the next phase, Cesar takes Kane up the steps and just far enough onto the shiny floors to stimulate or trigger his pattern of fear (6:17). Small doses of fear are more manageable.
Attunement. Cesar pays close attention to Kane’s behaviors and is tuned in to his symptoms and experience. This guides the pacing of the process. Trauma therapy with people is similar. Sufficient connection, attunement and responsiveness are critical.
Allowing the Sensations of Fear: An initial step in trauma recovery is to stay present with the physical sensations of fear, rather than the emotion of fear (5)Emotions tend to be more overwhelming than sensations. Depending on the traumatic event, the emotion to be processed or worked with could be grief, loss, rage or other intense emotions in addition to fear., while maintaining awareness of the present moment. This keeps the process manageable and conveys information to the nervous system that safety exists and that we have survived. This process is like being an “impartial spectator” (6)the impartial observer or spectator is described by addictions specialist and former family physician Gabor Mate, M.D. in which we observe in a mindful way without reacting. As Cesar describes (6:52), the first few seconds for Kane were “the hardest seconds for his life.”
Trusting the Process. Symptoms makes sense when seen as an attempt by the body to survive an overwhelming experience. The intelligence that creates symptoms also guides recovery from these symptoms. Our bodies, brains and nervous systems are designed to go into and out of the freeze response with relative ease. Wild animals such as deer do it every day. Humans and domesticated animals, however, get stuck in freeze states more easily. Part of working with trauma involves trusting the body’s ability to recover as it is designed to do.
The qualities mentioned above are maybe even more important aspects of trauma therapy for chronic illness where going slowly and gently is key. This is because by the time symptoms of chronic illness develop there are many processes happening in our physiology that are maxed out or operating at extremes of capacity. Helping these processes decrease is most useful by going slowly and in small “doses.”
IV. The Recovery Process
Moving through the Eye of the Trauma. Once Kane’s initial fear starts to decrease (6:50), Cesar takes him further into the room. This evokes another cycle of fear. Cesar uses some force (7:00) (7)Using any kind of force is a tricky area to navigate and there may be other ways of getting dogs through this step. When working with people, the approaches I like use no force and instead focus on rapport and attunement, invitation, and pacing to support the process of working through these intense sensations and fears in small steps, yet he does so with a gentle, calm firmness. His goal is to move Kane through his fear and avoidance so he doesn’t get stuck again in the old patterns.
When working with a person, gentle firmness could mean inviting a client to stay with physical sensation such as a rapid heart beat for a few more seconds, or it could involve education and information about a sensation that might arise such as shaking, which is common when coming out of freeze. Here are additional important principles for trauma therapy and recovery:
- Recovering from Fear. Experiencing the physical sensations of fear in a safe context enables Kane’s nervous system to come out of the past.
- Returning to the Present. Coming into the present restores the ability of our nervous systems to perceive our environments with accuracy so we can know what is truly safe versus what is dangerous.
- Titration: Working with trauma is done in increments. This keeps the experience manageable, prevents overwhelm, and allows the natural cycle of rising and falling of arousal to occur.
- Time: Timing and pacing are important resources and components of trauma therapy.
- Moving through Time. Cesar moves Kane through the process without spending too much time in each step. This prevents overwhelm from happening since there is a tremendous amount of survival energy that is moving through Kane’s nervous system with each phase of the recovery process (8)Horseman Jonathan Field, who worked through a traumatic experience of nearly losing his hand and dying from blood loss, describes a similar process of how there is often a tremendous amount of built up or stored energy in horses when they come out of freeze, (9)Peter Levine, Ph.D., founder of Somatic Experiencing, describes the presence of tremendous amounts of energy lying beneath the freeze response in people and how this can increase our avoidance and fear of trying to resolve or work with trauma. See Chapter 4, “Immobilized by Fear,” in Peter’s book In an Unspoken Voice.
Collapse and Freeze. Kane’s footing is noticeably unsteady as he slips and resists Cesar pulling him across the front room (7:15). When Kane gets to the second doorway and collapses (7:10) into the freeze response (see more on wiki), Cesar lifts him up (7:14) to prevent him from staying in the old pattern. Cesar remains steady and calm as he once again stands with Kane and waits for the fear to cycle through and begin to diminish. This is the final step before we see Kane start to recover, which happens quickly from this point forward.
Coming into the Present Moment. In the moments after Cesar pulls Kane to standing (7:21), Kane’s stance and demeanor become a little less shaky. He is still experiencing intense fear (seen in his eyes, panting, and drooling at 7:25) but he looks a little less afraid and a little more present. This is a sign that Kane’s nervous system is coming out of the past and out of the trauma response.
Orienting. The moment Kane starts coming back into the present (7:21) he starts to look around the room. He has moved through enough fear that he can now begin to notice his surroundings. This is called orienting. Wild animals orient all the time with their ears, eyes and noses to look for threat or to assess for safety. So do humans. This process of orienting is another clue that tells us Kane is coming out of his trauma response. Cesar explains, “He knew I wasn’t going to give up. I knew if I stayed there with him and did not allow him to back away that he was going to move forward.” Cesar is emphasizing the importance of a calm attuned presence, which helps us stay with difficult sensations just long enough to get to the other side. This, too, is a part of trauma therapy for chronic illness.
Moving Forward. From this point on Cesar invites Kane forward (7:30). He can now guide Kane through the process because Kane is no longer completely immobilized or frozen in fear.
Discharge. As Kane stands in the inner doorway panting heavily and salivating with his tongue hanging out (7:25) we see how working through trauma can feel like an intense workout. Trauma recovery is a process where the nervous system discharges states of high arousal, which are what drive symptoms. The sensations come from the fight and flight impulses Kane had but could not engage in to prevent his accident. Discharge is a way of releasing these natural impulses that got inhibited in the freeze state.
Symptoms of discharge can look similar to sensations experienced with fear, but the physical experience is different. In humans, the sensations of discharge feel either neutral or pleasurable. Examples of discharge include tingling, shaking, deep releasing breaths, burping, and gentle intestinal gurgling. These changes reflect the return of our capacity for rest and recovery as our systems of defense and protection shut off because they are no longer needed.
Orienting Continues. (7:34, 7:45, 7:56) As Kane moves into the hallway with hesitant steps he begins to look around him with an increased level of interest. This is another cycle in the process of healing.
It is a Process. The process of recovery takes time, patience, and practice. (8:15) Kane walks down the hallway with Cesar on legs that are still unsure but much less shaky and without collapse. (8:25) Cesar says, “he’s doing it.” and at 8:30 you see Kane reach down to sniff the floor. He is beginning to orient to his environment now with his sense of smell. He begins to walk with a greater sense of confidence and ease and he no longer slips as much on the floor. You can see Kane literally moving further into full recovery.
Practice using Calm Energy. (8:58) Cesar describes to Marina and Emmett how to be with Kane to keep helping him move through his fear pattern, “You can share all the happiness and excitement and the relief in a quiet way … leading him with calm energy, not tense energy (9:25).” This is what we learn to do more and more with ourselves as well when we work through the effects of trauma in our lives.
Recovery. (10:15) Marina celebrates a few days later by bringing Kane into her classroom. Each step that Kane makes gives him positive feedback and helps to further complete the shift out of the old pattern. You know that Kane has recovered when Marina walks easily into the school with Kane in the lead and actually pulling her forward.
Celebration. (11:25) After seeing Kane’s recovery Marina describes how “this is the most exciting thing that’s happened to me in a long time.” Her exhilaration is another component seen in trauma therapy and recovery. We feel energized when we come out of freeze (and often so do our loved ones), for we finally KNOW that we have made it through the ordeal. We feel ALIVE. There’s actually a term called “pronking,” which refers to the bouncing, lilting jumping that deer exhibit, sometimes after escaping from danger (10)here’s a description of pronking on wikipedia and a BBC video of gazelles (springboks) pronking. From his time learning about trauma from animals in the wild, Dr. Peter Levine (11)trauma therapist and founder of Somatic Experiencing has come to see and refer to pronking as a celebration of survival.
Here’s a charming video of a dog bouncing (pronking) around in the grass in an expression of pure joy.
Summary. Cesar summarizes what we know about trauma at the end of the video, “We don’t have to live with phobia, we just need sometimes somebody who helps us break that vicious cycle… I think we transfer our phobias to the dogs and if we can let go of that, then they can too. You don’t have to live unstable your whole life. There are ways you can rehabilitate and let go of any kind of issue you have.”
11 Keys to Trauma Therapy and Recovery
- We are designed to recover and heal from trauma.
- If we can heal from trauma, we can also begin to heal from chronic illness.
- The presence of a calm, steady, supportive person is important.
- Being present with sensations without reacting allows trauma patterns to resolve.
- Timing, pacing and support allow us to discharge old fears and emerge from freeze.
- Working in small steps prevents overwhelm and keeps the process manageable.
- Attunement, nonjudgment and perspective are important tools in trauma therapy.
- The body is intelligent. So are symptoms.
- Symptoms are guideposts. They show us patterns to attend to so we can come back to life.
- Each positive experience reinforces the body’s capacity for recovery.
- Exhilaration, joy, and “pronking” come from realizing we have survived.
Trauma Therapy for Chronic Illness
Research and personal experience suggest that trauma is an important risk factor for chronic illness. Working with trauma may therefore be a valuable and under-recognized tool for treating chronic illness, chronic pain and unexplained symptoms. I suspect that the pathway to understanding and working our way through chronic illness involves learning to better speak the language of the body. Maybe, like dog whisperer Cesar Milan and horse whisperer Jonathan Field, it’s about becoming “body whisperers” or “Self whisperers” in our own right.
The references in the next paragraph link to approaches and lists of practitioners who specialize in trauma therapies for working with people. They differ from the more traditional approaches of cognitive behavioral therapy and others often referred to as “talk therapy.” Here’s a full blog post on books and therapies for chronic illness and healing nervous system responses to stress, trauma and perceptions of threat.
The first sense that trauma might play a role in chronic illness came from training in body oriented psychotherapy after I left medicine (12)I studied at Naropa University in Somatic Psychology. The director of the program, Christine Caldwell, Ph.D‘s work and book “Getting our Bodies Back” planted the seeds of inspiration for my research and theories about chronic illness.. I’ve continued exploring and refining these perspectives through approaches that I’ve trained in (13)Somatic Experiencing (SE); here’s a list of SE practitioners around the world and founder Peter Levine’s excellent books introducing the concept of trauma and how to work with it called Waking the Tiger and In an Unspoken Voice, (14)Sensorimotor Psychotherapy; here’s a list of their practitioners around the world and their book (which I have not read) Trauma and the Body and/or experienced as a client in working with my chronic fatigue (15)EMDR (Eye Movement Desensitization and Reprocessing) has some similar perspectives and is described on wikipedia; here are lists of practitioners with the EMDR Institute and practitioners with the EMDR International Association, (16)Brain Spotting (BSP) described on wikipedia and here’s a list of BSP practitioners, (17)Internal Family Systems and their list of practitioners, (18)Biodynamic Craniosacral Therapy Association of North America: the National School and list of practitioners; an influential teacher Franklyn Sills with a detailed website; and a local school The Colorado School of Energy Studies where I’ve received introductory training and whose skillful faculty I’ve worked with. These approaches work with brain plasticity by attending to sensations, images, subtle impulses and other ways of working with experiences that aren’t in our conscious awareness. It’s about learning to speak and understand the language of the body (19)Scaer, R. (2005). The Trauma Spectrum: Hidden wounds and human resiliency. New York, W.W. Norton., (20)Scaer, R. C. (2001). The body bears the burden: trauma, dissociation, and disease. New York, Haworth Medical.
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How Trauma Affects Risk for Chronic Illness: The Discovery Series Introducing the Science
|↑1||The Dog Whisperer, with Cesar Milan, National Geographic Wild, Series 1, Episode 1, part 2; September 13, 2004|
|↑2||this is the equivalent of 15 years in human terms|
|↑3||It is possible to avoid triggering a freeze response by going even more slowly and gently in therapy. Force is not a useful tool to use with people. Information, education and guidance can be used instead while tuning into the pace that a person needs|
|↑4||Here’s a more detailed description about trauma triggers. While the article focuses on triggers in men it applies to the rest of us as well|
|↑5||Emotions tend to be more overwhelming than sensations. Depending on the traumatic event, the emotion to be processed or worked with could be grief, loss, rage or other intense emotions in addition to fear.|
|↑6||the impartial observer or spectator is described by addictions specialist and former family physician Gabor Mate, M.D.|
|↑7||Using any kind of force is a tricky area to navigate and there may be other ways of getting dogs through this step. When working with people, the approaches I like use no force and instead focus on rapport and attunement, invitation, and pacing to support the process of working through these intense sensations and fears in small steps|
|↑8||Horseman Jonathan Field, who worked through a traumatic experience of nearly losing his hand and dying from blood loss, describes a similar process of how there is often a tremendous amount of built up or stored energy in horses when they come out of freeze|
|↑9||Peter Levine, Ph.D., founder of Somatic Experiencing, describes the presence of tremendous amounts of energy lying beneath the freeze response in people and how this can increase our avoidance and fear of trying to resolve or work with trauma. See Chapter 4, “Immobilized by Fear,” in Peter’s book In an Unspoken Voice|
|↑10||here’s a description of pronking on wikipedia and a BBC video of gazelles (springboks) pronking|
|↑11||trauma therapist and founder of Somatic Experiencing|
|↑12||I studied at Naropa University in Somatic Psychology. The director of the program, Christine Caldwell, Ph.D‘s work and book “Getting our Bodies Back” planted the seeds of inspiration for my research and theories about chronic illness.|
|↑13||Somatic Experiencing (SE); here’s a list of SE practitioners around the world and founder Peter Levine’s excellent books introducing the concept of trauma and how to work with it called Waking the Tiger and In an Unspoken Voice|
|↑14||Sensorimotor Psychotherapy; here’s a list of their practitioners around the world and their book (which I have not read) Trauma and the Body|
|↑15||EMDR (Eye Movement Desensitization and Reprocessing) has some similar perspectives and is described on wikipedia; here are lists of practitioners with the EMDR Institute and practitioners with the EMDR International Association|
|↑16||Brain Spotting (BSP) described on wikipedia and here’s a list of BSP practitioners|
|↑17||Internal Family Systems and their list of practitioners|
|↑18||Biodynamic Craniosacral Therapy Association of North America: the National School and list of practitioners; an influential teacher Franklyn Sills with a detailed website; and a local school The Colorado School of Energy Studies where I’ve received introductory training and whose skillful faculty I’ve worked with|
|↑19||Scaer, R. (2005). The Trauma Spectrum: Hidden wounds and human resiliency. New York, W.W. Norton.|
|↑20||Scaer, R. C. (2001). The body bears the burden: trauma, dissociation, and disease. New York, Haworth Medical|