When therapy clients are flooded or in a state of dysregulation, little progress can be made. The focus of the work needs to be bringing the level of arousal down. An oft-repeated dictum is that therapy requires regulation of arousal within a window or range that is neither too high, nor too low. But what, exactly is involved in accomplishing that? The answer is both more complex and simpler than one might think. Let’s review some well-worn, but helpful observations about hyper-arousal:
- Fight, flight, and freeze responses go far back in evolution when survival meant preparation for immediate action. If only our human problems were that simple. Such responses often put us out of sync with what is optimal in modern life.
- As Stephen Porges has emphasized, extreme stress goes further to bring out complex physiological responses, such as sweating, agitation, screaming, tears, production of adrenaline and stress hormones, and GI effects.
- Responses to life and death situations can be highly focused and effective, for example, avoiding an automobile accident or defending against attack. In others, especially emotional or attachment threats, extreme responses are more likely to be dysregulated and ineffective.
- Dysregulated, chaotic stress responses are more typical when the person is faced with a problem that has no solution. This may be due to lack of power, skills, or resources, or it may be in response to an insoluble conflict such as extreme rage at someone we absolutely need.
- During states of extreme stress, people are focused only on themselves and their survival. They have a kind of tunnel vision. As Porges points out, systems of social engagement are disabled, as are frontal lobe functions of judgment and self-regulation, in part due to locally lowered blood flow.
When these conditions come about in psychotherapy, our focus is to bring down the level of arousal. A more sophisticated and helpful way to look at it is that we are trying to support the return of prefrontal lobe functions of social engagement and self management. Let’s focus now on what that entails.
The temper tantrum: A prototype
Almost all children have at least an occasional temper tantrum during early years. Typically, this happens when the child’s personal desire runs headlong into the objections of the primary caregiver. This can’t happen until development reaches a point where the child has a well enough formed concept of the other so that the one who says “NO!” is recognized simultaneously as the one whose love is essential to life. At that point, the child has no way to be sure their rage will not destroy a relationship that is essential for survival. This constitutes a quintessentially vital, yet unsolvable problem and naturally leads to a primitive and disorganized survival response.
We can imagine that the child’s mental appraisal of this desperate circumstance yields simultaneous emotions of rage and terror deep in the limbic system. Limbic emotions are the ones that trigger both adaptive and maladaptive responses. In this case, there are two contradictory responses, one of attack and the other of fear, each one amplifying the other. The temper tantrum is a perfect example of dysregulation. It is entirely involuntary and fails in any direct way to solve the problem.
Interestingly, the tantrum actually does function in an adaptive way when we look at it from a relational point of view. Hopefully caregivers instinctively respond in just the way the child needs. What is that? First, the caregiver will stop the child from doing any harm. Next, physical holding and a soft, steady voice communicate that it’s going to be OK. Perhaps evolution has also given us access to parenting skills not only adapted to bring calm to the situation, but also giving something the child can eventually internalize. Ultimately it is the knowledge that the child’s rage cannot break the relationship that makes possible internalization of basic trust, a major source of resilience (See also, TIFT #46).
The childhood temper tantrum and its resolution give us a template for understanding both how clients become dysregulated and how to help them.
Why some adults are more susceptible to dysregulation
Freud coined the term “fixation” for points in development that the individual may revert to under stress. Where more advanced skills fail, the individual reverts to an earlier era of development and the response patterns that go with it. In at least some cases, Peter Levine sheds light on precisely how such a failure point can become established. The difference between successfully processing a trauma and developing PTSD can lie in the human capacity to inhibit action. When the more instinctive response might be to fight, but the mind knows not to, action becomes frozen in time. Processing of the event can’t take place until the instinctive action can, at long last, be released, at which point the body goes through steps leading to lasting resolution. In a more general way, the difference between healthy coping and PTSD is that in the latter, the person is not able to achieve an emotional resolution and the mind remains in suspended animation. The trauma is held as an unsolved problem, while the individual may go on functioning in other ways. This can continue for a lifetime or until the problem is re-activated and worked through to the point where the retained tension can be let go.
For many individuals, especially those who have experienced neglect or have been unable to work out a satisfactory relationship with parents or primary caregivers, similar stuck points will have prevented internalization of expectations of safety and confidence that a threatening situation will end in successful resolution. The result is naturally a reduction in resilience. The individual responds in ways that bear characteristics of a more childlike mode. Especially when circumstances remind them of previously unresolved problems or needs, the natural tendency is to revert to a state of dysregulation similar to that of a childhood temper tantrum.
The first phase of re-regulation
As hinted above, when clients are in a state of dysregulation, cognitive interventions are pointless. That channel is currently blocked. As in the nursery, it is the tone of voice, not the words that soothe. Just as in early years, this soothing can’t come from within because, as described by Margaret Mahler, whatever might have been successfully internalized has been disrupted by stress and is not available. Some form of soothing from outside is a requirement. In describing his own experience of physical trauma, Peter Levine gives a vivid example of an adult intervention when he describes the effect of a bystander’s voice and touch when he, personally, was in a state of mental dysregulation from being hit by a car as a pedestrian.
In my view, many of the “skills” recommended for people who regularly experience dysregulation can best be understood in the light of the temper tantrum. While they produce changes in physiology, they may do so in large part through their interpersonal impact. Remembering to breathe has a physiological effect, but it also re-creates the relationship with a trusted source of support and stability. As the individual pays attention, in the midst of intense distress, to putting into practice a method learned from some trusted source (therapist, author, video, etc.) an interpersonal connection is re-established. Like the soothing voice and touch of mother, practicing a learned act pulls the person out of their state of mental isolation and into relationship with the outside. Social engagement is re-established, as is the goal of self-management.
Similarly, practicing mindfulness draws the mind into a position of looking at oneself from outside, akin to the way a parent’s reassurance draws attention outward, viewing the self from the other’s point of view. The outside perspective that is at the center of mindfulness re-awakens a soothing mother-child connection.
When clients remember to make use of skills they have been taught, they are opening themselves to a soothing act received from outside themselves. These skills help accomplish the therapeutic goals of re-awakening social engagement and breaking the isolation, typical of the dysregulated state.
Hyper-arousal in slow motion
As described in TIFT #45, dysregulation can be chronic in the form of persistent self-harming behaviors, unresponsive to common sense. The client is likely to say something like, “I don’t know why I do it, I just do,” leaving the therapist feeling left out and helpless. Viewing these patterns as drawn-out temper tantrums can be a key to resolution. In that case, the job of the therapist combines the same elements as the childhood temper tantrum: bringing destructive behaviors under control, then providing steady assurance of safe connection even in the presence of rageful emotions. The goals are the same, re-activation of social engagement in the area in question and the return of self-management.
Surprisingly, once social engagement is re-established, dysregulation no longer stands in the way of therapeutic progress. The process of healing or resolution remains to be done, but the hyper-arousal that prevented therapeutic work is no longer the obstacle. Once the client is able to make use of the therapist as a source of reliable connection, the remaining process of resolution is the same as it at other moments of emotional healing in psychotherapy. The essence of what works is the magical juxtaposition described many times in these writings. The remaining unresolved affect and surrounding circumstances need to be brought to light while the client is exposed to an antidote, some surprising new information or experience that resolves the unsolvable dilemma. Once again, as therapists, we can facilitate bringing together the universal elements that lead to enduring change.
Jeffery Smith MD
Reminder: Dear readers, please write me about your most challenging situations in clinical psychotherapy. I’d be interested in discussing principles and what might be helpful.