Distress identification and awareness
“Tout le malheur des hommes vient d’une seul chose, qui est de ne savoir pas demeurer en repos dans une chambre.” (All man’s miseries derive from being unable to sit quietly in a room alone.)
– Blaise Pascal, Pensées
Mindfulness practices, through paying attention to difficult and painful thoughts, feelings, and bodily sensations, assist people to become more able to identify those stimuli when the actually occur, without the need for automatic distraction or avoidance. The purpose of distress identification is:
- Name distressing thoughts, feelings, and uncomfortable bodily sensations as they occur.
- Make sense of distress – by naming sensations they can be ordered and seen as other than random.
- Decrease dysfunctional avoidance behaviours – when distress is more quickly identified, there is less of a 'window' to escape into habituated avoidance behaviours.
Video: Trauma, Suffering & Mindfulness – John Briere, Ph.D.
Some mindfulness strategies that are useful in distress awareness are: body scan; awareness of difficult/painful thoughts; and awareness of physical discomfort.
Another useful way of enhancing bodily and sensory self-literacy is through the use of scaling. This can be useful as a distress thermometer to rate internal levels of fear, anxiety, anger, and other difficult emotions as they occur. A commonly used tool for this is the Subjective Units of Distress Scale (SUDS), which is a scaling tool that people can quickly rate themselves on from 0 – 100 (from completely calm and relaxed to the most distressed ever felt). One of its benefits is that people dealing with sudden rises in distress can also notice reductions, sometimes occurring just as rapidly. For other people who have become habituated to extremely high levels of distress – and this is often the case with men, who believe that their high levels of internal pain (both psychic and physical) are normal – it can be a useful tool for increasing motivation for change and developing increased self-awareness (See Appendix G: SUDS – Subjective Units of Distress Scale).
Distress tolerance and distress awareness, although separated for explanatory purpose, usually occur simultaneously. When we become aware, with non-judgmental acceptance, of our difficult and painful internal experiences as they are occurring, paradoxically they usually (but not always) decrease in their intensity. The key elements of Mindfulness in assisting clients to achieve distress tolerance are acceptance and awareness.
Distress reduction strategies, although they draw more from relaxation therapy - utilising forms of distraction, can be useful when a person’s high levels of distress are temporarily preventing functioning, or where they are attempting to replace maladaptive tension reductions strategies with something more sustainable and less damaging. Types of adaptive distress reduction might include adaptive distraction (exercise, social activities), relaxation strategies, as well as specific tools to improve quality of life, such as supporting good sleep hygiene and developing good sleep protocols, through pyscho-educational processes. (See Appendix F: Sleep hygiene protocol).
If a person is being plagued by night terrors and nightmares, or incessant intrusions of trauma memory network material during waking hours, then psycho-education around the use of nightmare and flashback protocols can also assist in distress reduction, through the person's increased confidence in their own agency in managing their distress through being able to both predict it, notice earlier warning signs, and utilise practical strategies to reduce once the distress is brought into awareness (see Appendices D & E: Nightmare protocol and Flashback protocol).
“You cannot finally hold on to anything, just as you cannot inhale and hold your breath indefinitely. The breath teaches you about the processes of life, of gathering in and giving out, of giving up the old in order to make space for the new, just as the stale air is expelled to allow a tide of fresh air and energy to flow in.”
– Vessantara, 2005.
Dealing with avoidance
Avoidance is one of the key elements of post-traumatic stress and is also a primary effect of complex trauma. It follows a core human impulse; when something is painful or distressing then the individual learns to avoid it. People who have experienced trauma actively avoid people, places, and things which may remind them of the traumatic events. This can often involve elaborate reworkings of the daily business of life, and in some cases can lead to both physical and social isolation. Ultimately, total avoidance of memory triggers is not possible (although many people try it for long periods of time and for most of their waking hours – which may actually involve making all hours waking hours).
Avoidance, paradoxically, increases the power of the memories of the trauma. Imagine, for example, looking at an object and then actively attempting not to look at, think about or notice that very object. Even the act of not thinking about it, and not seeing it requires a part of the brain to hold it in partial awareness and for the eyes to constantly notice it in order not to notice it.
The most effective way of dealing with avoidance is exposure and habituation to the things being avoided, in order to take the 'sting' out of the response. Cognitive Behavioural Exposure Therapy (Deacon et al, 2010) argues that by creating a hierarchy of feared phenomenon and constantly exposing oneself to those phenomenon, they will become less distressing, and therefore less actively avoided. There is a strong evidence base for this approach, however many therapists, and indeed many clients, are not comfortable with it and will probably never use it.
Mindfulness offers an alternative; by actively noticing physical phenomena, as they appear or unfold, on a moment to moment basis, nonjudgmentally and with gentle curiosity and awareness, including phenomena that have been avoided. Then they can be experienced simply as things, objects, images, sights, sounds, smells, movements, natural objects and people, held in awareness only in the moment that they are actively noticed. This awareness may not be pleasant and may even be distressing, but these sensations can also be noticed in their transience.
Useful mindfulness strategies for exposure to avoided phenomena are:
- Mindfulness of the external world (utilising physical senses).
- Alternating between mindfulness of the external world and mindfulness of internal experiences (body sensations, thoughts, emotions).
Working with avoidance and working with intrusive thoughts and memories (see below) mutually inform each other; when avoidance decreases intrusive thoughts and memories lose their force, and this sets up a feedback loop which then further negates the need for active avoidance. Many people report enormous relief when active avoidance decreases, because many people who have experienced trauma actively organise their lives around avoidance.
Dealing with intrusive thoughts and memories
Yesterday is a memory
Tomorrow is the unknown
And now, is the knowing
– The Buddha
Intrusive thoughts, pursuant to traumatic events, are most commonly understood as the mind’s attempt to make sense of the senseless. Because the events contain disrupted meanings, the mind continually returns to the memory of the event in an attempt to create some sort of coherent narrative out of hitherto meaningless memory (Laing, 1999). In addition, because the memories contain intense fear and horror, they are actively avoided. So we have this paradox of the mind; it both attempts to return to the memory to categorise and make meaning of it and, at the same time, it attempts to avoid and suppress those same memories. Intrusive thoughts can come in the form of flashbacks during waking states (sometimes containing a full memory, but more often partial and piecemeal), or in the form of trauma nightmares during sleep, again sometimes as coherent narratives, but more often partial and often disguised in other narratives. For example, a person who experienced trauma in a tsunami may have water-related nightmares that are not necessarily about a tsunami. Intrusions can also be sensory, in the form of smells and odours, and body sensations (and these, in turn, can also be triggers for memories).
Useful tools for assisting people who experience distressing intrusions are:
- Nightmare protocols (see Appendix D: Nightmare protocol).
- Flashback protocols (see Appendix E: Flashback protocol).
- Sleep hygiene protocols (see Appendix F: Sleep hygiene).
Ultimately, the avoidance of memories and the active avoidance of people, places, images, and things serve to reinforce and make more frequent the memory that is being avoided. Many people learn or develop a suite of distraction strategies, yet these also ultimately serve to reinforce the power of the trauma memory network, even though they may provide temporary escape.
Mindfulness is often used by practitioners much the same way as relaxation or distraction techniques are used, but this is in fact a form of 'mindfulness lite'. One of the Buddhist teachings upon which much western mindfulness is based is the maxim that suffering is, by its nature, transient, as are all human experiences. When a person says that they have been sad all week, they are not lying, but their selective memory has de-prioritised the many moments during the week when they were lonely, or fearful, or even contented and joyful. Mindfulness of thoughts, feelings, and bodily sensations provides an opportunity to attune more closely to the transient nature of moment to moment emotional experience, as well as the observation that thoughts (and memories are simply recurrent and painful thoughts) are passing phenomenon of the mind.
Briere (2012) has observed that this form of mindfulness is, in fact, a form of exposure therapy without the high levels of distress that most proponents of exposure therapy would argue need to be necessary for habituation to painful and avoided thoughts and feelings requires. It is worth noting here that there is ongoing debate as to whether mindful exposure to distressing thoughts, including trauma memories, actually changes the trauma memory network. Further research needs to be undertaken in this area. Cognitive behaviouralists (Deacon) contend that mindfulness is only useful as a distress regulation process and does not change the way in which trauma memory is stored. Further research on mindfulness as an exposure strategy is still embryonic and needs to be further developed.
What lies behind us and what lies before us are tiny matters compared to what lies within us.
– Oliver Wendell Holmes.
Working with time
Trauma and time are uncomfortable companions; the very nature of a traumatic event is a disruption in time. The way that trauma memories are held in the brain means that they have a continuous present tense to them. It is as though the event is re-occurring every time it is remembered, whether that is voluntary or through a sudden intrusion. The effect of this is that the memory, which is experienced as the present, pushes out the actual present, so that the person can have the disorienting experience of knowing, at some cognitive level that they are in the present (although sometimes, as in the case of true dissociation, this drops out as well), yet experiencing a memory as if it is a present-moment experience. Although this is the subjective experience, of course trauma memories are of past events. One of the goals of all trauma work is for the trauma memory network to actually feel like it is in the past tense. Anxiety – one of the legacies of trauma – takes a person into a feared future and thus also out of the present.
Mindfulness – especially the elements of bare attention, awareness and curious observation of thoughts and feelings – is, in fact, a form of exposure therapy (Briere, 2011), in that it allows the person to habituate to a memory by noticing that its attendant thoughts, feelings and bodily sensations are all experienced in the present.
Some specific strategies to help a person to learn to anchor themselves in the present, even while remembering past trauma, are:
- Utilise appropriate language, making sure the tense is appropriate. When talking about the past then the tense should always be past. Obtain agreement from the client to correct their language if they slip into speaking about the past in the present tense. For example, changing 'he is coming towards me', to 'he was coming towards me'. Notice when a client moves tenses.
- Maintain intermittent eye contact.
- Encourage the client to look around, utilising their physical senses to ground themselves in the present. The 5 dominant physical senses (with the possible exception of olfactory, which is connected to the part of the brain that holds memory) can only be experienced with awareness in the present. (See our mindfulness exercise Mindfulness of the external world).
- Workers can modulate their body and voice energy, making themselves present to the client.
- Establish meanings around different ages – assisting the client to see the past always from the vantage point of the present, rather than the past in the present. For example: 'Looking back at that time with your adult hat on and as you are sitting here now with me, can you tell me what that child that you were back then would have believed/thought/felt?' (Notice use of tenses).
- Other signals to look for, to determine whether the client is in the present or the past are direction of the eyes (usually downcast eyes indicate being in the past), signs of physical arousal (shallowness of breath, muscle tension, flushing, sweating, etc.), changes in voice tone, pitch, and even vocabulary (sometimes reverting to the vocabulary of an earlier age).
At the still point of the turning world. Neither flesh nor fleshless;
Neither from nor towards; at the still point there the dance is,
But neither arrest nor movement. And do not call it fixity,
Where past and future are gathered. Neither from nor towards,
Neither ascent nor decline. Except for the point, the still point,
There would be no dance and only the dance.
– T.S.Eliot, Burnt Norton, 1935
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