What is Processing?

Processing involves acquiring new learning and connecting adaptive neural networks with dysfunctionally stored information through activation of emotions associated with traumatic memories. Processing, represented toward the top of the Treatment Hierarchy Triangle (see Chapter 1, Figure 1-4), reflects access of all dimensions of memory: behaviors, affect, sensations, cognitions, and beliefs associated with the trauma (Shapiro, 2001). Briere and Scott (2006) say that this learning is primarily emotional, involving implicit, nonverbal, relational memories, and that cognitions do not necessarily need to be addressed. Briere and Scott’s (2006) trauma model emphasizes counterconditioning. This means that the activated, trauma-related emotional responses of fear or danger are not reinforced in the external environment of therapy and are consequently extinguished or processed.

Current triggers activate unprocessed memories, and the person feels the attending emotions and sensations of the stored traumatic memory. For example, a patient who has an early attachment trauma history may repeatedly be triggered by her relationship with the therapist and expects to be emotionally abused and criticized. Because the therapist is consistently caring and nonjudgmental, this expectation is eventually diminished through counterconditioning without the person being explicitly aware that this has happened. Chapter 8 describes how to work with and process this type of attachment trauma using psychodynamic psychotherapy.

Processing promotes neural integration and association of dysregulated memory, removing blocks to flow in information and energy. This is a basic tenet of the Adaptive Information Processing (AIP) model (Shapiro, 2001). AIP posits that dysfunctional information is blocked from adaptive resolution and connection to other memory networks. The other important tenet of AIP is that this integration can occur much faster than previously thought possible with appropriate accessing of information. Nonadaptive self-beliefs, negative emotions, bodily sensations, and intrusive images that contribute to psychopathology can be positively integrated as fast as these elements were disturbed in the first place.

In psychopathology, dimensions of memory are improperly stored, fragmented, and dissociated from one another and are not linked to adaptive memory networks. As discussed in Chapter 2, high levels of disturbance with the resulting physiologic changes contribute to traumatic experiences or memories being stored in dysfunctional memory networks (Shapiro, 2001; 2006). The person may experience anxiety without the attending context for the anxiety or experience a body sensation, but this may be disconnected from other, more adaptive memory networks. For example, one man came to psychotherapy for depression and subsequently had a panic attack after undergoing sinus surgery. On exploration in psychotherapy, he discovered that the panic attack was triggered by an earlier body memory of swallowing blood after a tonsillectomy when he had almost died as a child. He had no memory of this incident as particularly disturbing before this (Broad & Wheeler, 2006). Another patient “heard” only sounds without understanding the context but knew that these sounds were associated with disturbing memories that occurred when she was a child. These dissociated memory networks may also manifest as behaviors or personality traits that are compartmentalized and triggered in specific situations or contexts. For example, in intimate relationships at home, a woman is emotionally and physically abused by her husband, but at work, she is decisive and assertive. All these examples reflect state-dependent memories or states of consciousness that are physiologically based and triggered by stimuli in the present. The latter example illustrates that resources, like trauma, may be stored in one state of consciousness and not available in another state.

Transforming traumatic memories through processing opens up access to positive emotions and thoughts as the negative event is integrated into the larger networks where positive memories are stored (Shapiro, 2001). The traumatized person is often alexithymic, and strategies for working with those who do not have access to feelings are delineated in Chapter 2. The person may be numb to both positive and negative emotions. We cannot numb emotions selectively; that is, we cannot numb negative emotions without numbing the positive emotions as well. As emotional awareness increases and the attending anger, sadness, and hurt are experienced, the person also will have access to more positive feelings. Experiencing all emotions fully is thought by many to be synonymous with being fully alive and salubrious to health (Pert et al., 1998). Having intense emotional reactions and experiencing peak experiences, according to Maslow, is a dimension of the self-actualized person. This also helps the person problem solve more efficiently because new information enhances development of the frontal cortex.

Lipke (2000) differentiates complete processing from partial processing. He says that complete processing eliminates excessive negative emotion and fosters positive resolution, such as recognition of strength in surviving or taking steps to avoid such situations in the future. In contrast, partial processing may result in less emotional distress about the event, but patients may not deepen their understanding about the event or themselves. Other indications of incomplete processing include continued disturbance about similar events, although the person may be aware of what the original triggers are about. For example, a patient who has experienced an automobile accident may still be anxious when driving but understands that the fear is related to her previous accident and has learned strategies that assist her in decreasing arousal in these situations. She has learned how to manage her anxiety, which means she is more stable, but she still has unprocessed, dysfunctionally held information about the original event.

When processing in psychotherapy, dysfunctionally stored implicit memories are accessed, and this occurs in the context of a safe therapeutic relationship with adequate resources in place. This is important so that the person’s experience is safe and less painful and because activating the trauma memory has the potential to further entrench the negative memory network. The more the neuronal network is activated, the more likely it is that the trauma template is reinforced and the connection and pattern formed between neurons and networks of neurons is strengthened (i.e., long-term potentiation) (van der Kolk, 1989; 1994). Chapter 2 describes the neurophysiology supporting this phenomenon. This explains why the traumatized person is prone to re-enact the experience many times. To counter this, adaptive memory networks need to comprehensively link to the trauma memory during the unaltered arousal generated by the event so that processing and new learning can occur. This speaks to the importance of the stabilization phase and preparing the person so that positive neural networks exist that can be accessed spontaneously during processing so that state changes are possible. It also underscores the importance of additional training and supervision for nurse psychotherapists to use processing safely.

The Therapeutic Window of Processing

After stabilization has been achieved, the person is ready to move to the next stage: processing. Signs that the person is stabilized include no current life crisis, acceptance of the diagnosis, an ability to set and adhere to limits, can identify triggers, ability to self-soothe and to reach out to supportive people, and to communicate honestly with the clinician. In terms of mood stability, the person’s mood may be depressed but not labile (Davis & Weiss, 2004). The Stabilization Checklist provided in Appendix I-4 (p. 140) is a general guideline, and not all of these parameters must be met before processing. Clinical judgment is essential in assessing the patient’s ability to tolerate processing. Because of the intensity of the experience, the patient must have the ability to maintain a dual awareness during processing and sustain increased arousal with little or no dissociating or avoidance of the content. The person needs to be in the “here and now” of the therapy session while also in the “then and there” of the traumatic event.

In processing, the hypothalamic-pituitary-adrenal (HPA) axis needs to modulate sympathetic arousal so the person can regulate affect while accessing arousing memories that must be activated for neural reintegration to occur. Briere and Scott (2006) describe the therapeutic window of emotional processing and say that activation of emotion must accompany the narrative to process the trauma. This activation must occur in the therapeutic window; the person must not be too overwhelmed and hyperaroused (i.e., sympathetic dominant) but not be too underaroused (i.e., parasympathetic dominant) to engage in the emotional memory. Research has shown that high levels of arousal interfere with frontal lobe functioning (Siegel, 2002). It is thought that trauma is relegated to the right hemisphere and to its hormonal counterpart, the HPA axis (Scaer, 2005). The APPN helps the patient to modulate experience through questions that increase or decrease activation. This balance depends on whether the person is avoiding the material, is dissociating and has too little activation, or is hyperaroused with too much activation.

Some patients may need activation decreased, especially if they are hyperventilating, overwhelmed with emotion, and in a highly anxious state. Hyperarousal occurs sometimes with rapid eye movements, increased respirations, and increasing levels of anxiety. During processing, an abreaction, which is the intensive discharge of emotions related to the trauma, may occur. During abreaction, the person experiences some or all of the same sensations, thoughts, and emotions that occurred during the time of the trauma and becomes immersed in the event (Kaplan & Sadock, 2004).

Abreactions indicate that the person has accessed the memory with all the attending emotions of the original event. The abreaction may be necessary but should be titrated and monitored so that the person does not re-experience the trauma with overwhelming negative affect, identity fragmentation, or feelings of loss of control (Briere & Scott, 2006). Instead, the person processes the experience to attain new learning. Chefetz (1997) says, “The management of abreaction is one which works steadily toward the development of coherent narratives of experience” (p. 206).

The key to re-experiencing the trauma with manageable affect so the person can form a narrative is the patient’s ability to maintain dual awareness. Horowitz (2003) says, “The goal of exposure is to achieve as much calm during the exposure as possible; with the repetition of heightened calm, the patient’s emotional equilibrium will be restored” (p. 62). Chapter 10 offers strategies to enhance dual awareness. Dual awareness is also cultivated during processing through the use of a metaphor, i.e., as if the person is on a train and watching out the window as the memories and experiences come up, much as scenery passes while on a moving train (Shapiro, 2001). This is explained to the patient prior to processing.

Titrating the level of arousal is extremely important. Processing only in the middle of the session and helping the person to leave in a calm state are essential (Briere & Scott, 2006). Asking the patient to rate the subjective units disturbance (SUD) on a 0-to-10 scale helps her/him to distance a bit during exposure while also reinforcing the fact that the distress is decreasing. When overactivation occurs, suggestions include shifting the focus away from the trauma with breathing exercises or relaxation techniques; directing the person’s attention to less disturbing material; distraction; using supportive communication techniques that are dearousing (see Chapter 3, Figure 3-1); supporting the intensity of emotion as doing “good work”; explaining activation before and after processing to normalize the person’s reactions; problem-solving with the person to help mediate hyperarousal; using safe place or container exercises; conveying optimism; and stabilizing with other affect management strategies (Briere & Scott, 2006). If the person is abreacting, do not touch the person or make any sudden moves, and allow for personal space.

Shapiro (2001) differentiates abreactions that occur with EMDR from those that occur with hypnosis or other therapies. In EMDR, abreactions occur more rapidly as processing is accelerated, and abreactions can be an indicator of movement toward healing. Helpful strategies during abreactions include a calm voice, detached compassion, changing the rate or direction of bilateral stimulation, allowing the process to unfold without judgment, grounding techniques (see Chapter 10), calling the person by name, and orienting the person: “It’s okay, Jeanne. You are at my office and can hear my voice. It is old stuff; let it go. You are right here with me, and you are safe.” The preparation and education about processing before the experience cannot be underestimated.

Chu (1998) delineates common phases that occur during abreactions: increased symptoms; intense internal conflict; acceptance and mourning; and mobilization and empowerment. Patients who do not have the capacity to withstand the intense feelings that occur during abreaction may instead use dissociation, substance abuse, distraction, and other avoidance responses (Chu, 1998). Avoidance responses may take the form of missing sessions, lateness to sessions, increased distress, or self-injurious or impulsive behaviors after sessions. Therapists who are not skilled in working with abreactions should heed these signs as obvious indicators that the therapeutic window for processing has been exceeded.

For a significant subgroup of patients, dissociation presents a barrier to processing trauma, especially for those who have suffered complex trauma. Dissociation is a right brain phenomenon and therefore may not be linked to declarative memory networks (see Chapter 10). For those who are victims of complex trauma, there may not be a felt sense of their whole body. Accessing procedural somatic memories through words and left brain activities may not be possible. For those who are mildly dissociating (see Chapter 10, Box 10-1, for signs of dissociation), the therapist may be able to bring the person back by asking questions and observing that the person seems to be “away.” Grounding techniques as described in Chapter 10 may be needed to bring the person back to the present.

For an avoidant patient, asking detailed information about the specifics can increase activation and encourage comments if the patient is processing: “Stay with that. You’re doing well.” Using communication techniques that are expressive to increase arousal may be needed for avoidant patients. These may include immediacy, interpretation, observation, and focusing, depending on the psychotherapy approach being used. Figure 3-1 in Chapter 3 shows the continuum of expressive (i.e., arousing) versus supportive (i.e., dearousing) communication techniques. Another strategy to increase activation is to ask the person to go over the memory slowly in detail using the present tense. The amygdala is thought to hold memory in the present tense because it has not yet been processed. The narrative naturally shifts from what is happening to what did happen after processing has occurred. The greater the detail of the event in the present tense, the greater the activation and the processing of traumatic material (Briere & Scott, 2006).

Additional techniques to bring the body back into conscious awareness may be needed if the person has somatic problems. Scaer (2005) says these individuals are parasympathetic dominant and suggests a number of body-based therapies for healing. These include somatic experiencing (SE), as described in Levine’s book, Walking the Tiger (1997), and energy therapies, such as thought field therapy (TFT) and emotional freedom therapy (EFT), which use visual imagery, self-affirmations, and tapping on acupressure points. Movement therapies such as dance and other induced movement techniques, including touch, cranial sacral techniques, and gentle massage, may also be useful. Artistic endeavors such as sculpting, drawing, and painting can tap into right brain states and may assist the person in replicating the traumatic, event in symbolic form. None of these methods is considered a sole evidence-based treatment for trauma, but each may be a useful adjunct to CBT and EMDR, which do have a solid research base. The only evidence-based approach for trauma treatment that includes a somatic component is EMDR.

General Guidelines for Processing

Whether using CBT or EMDR for processing, the trauma recounted usually is connected to other dysfunctional memory networks and triggers of other traumas, so that there is not a discrete, coherent account of one specific memory but a collage of traumatic memories (Briere & Scott, 2006). For example, one patient was focusing on a recollection of an abusive relationship with a boyfriend and then had another memory triggered that reminded her of being bullied by her brother. This led to a memory of an earlier abusive relationship with her father. Following the narrative with empathic attunement and allowing the person to go where s/he needs to go is a good principle for all therapies but of paramount importance for the significantly traumatized patient. It is especially important when working with patients with significant trauma to honor their feelings, go slowly, and give them as much control as possible. The APPN empowers the patient by planning interventions collaboratively and allowing the process to unfold by staying out of the way so the person’s natural healing ability can be accessed. The person’s ability to follow though with the exposure in trauma processing depends on his or her affect regulation skills, support from others, and life stress at the time, as well as on the safety of the therapeutic relationship.

Processing involves exposure to the trauma and assisting the person in constructing a narrative through the exploration of the meaning of significant small and large traumas that impair functioning. The emotional dimension of the memory is essential for full processing to occur. Emotions are embedded in body sensations so that both in tandem are experienced during processing. Talking about the event without the attending emotions or body sensations may be an intellectual exercise only and preclude total processing. Briere and Scott (2006) emphasize that “much of trauma activation and processing occurs at implicit, nonverbal, often relational levels” (p. 123).

Siegel (2002) posits that coherent narratives facilitate interhemispheric integration. The left brain, which is language based, interprets the emotion-based autobiographical content of the right brain. Chapter 2 discusses right and left brain functions. The narrative in psychotherapy as told to an empathic other links self-states that have become dissociated due to trauma (Howell, 2005). This integration is considered the heart of mental health, with the successful resolution of trauma creating a deep sense of coherence (Siegel, 2002). The narrative helps the person to reconstruct a chronology to make sense of the experience by providing a context for time with a beginning, middle, and end. Research supports that through the reconstruction of the narrative, posttraumatic symptoms are reduced (Amir et al., 1998). Because the trauma event is disconnected from other dimensions of the person’s experience, it is important that the person integrate the event into his or her life and create meaning, allowing for closure. The literal recall of the event itself is not as important as the meaning of the event to the person and his or her sense of self or identity as impacted by the trauma. It is important to explore the discrepancies between how the world is perceived before the event and how the world is interpreted after the event (Horowitz, 2003).

As patients begin to accept what has happened, new perspectives about long-held assumptions begin to shatter. Those who have suffered abuse typically have conflicts in many areas of life. For example, one young woman who had been sexually abused by her father as a child felt intense shame about not having been “good” enough to stop the abuse. She had both love and hate for her father and, consequently, for herself. Her ambivalence was reflected in many areas: “I was loved/I was hated; I was powerless/it was my fault.” These intense ambivalent feelings were extremely painful, repressed, and reflected entrenched neural networks of thought, emotion, and sensations. As she began to see her father more realistically, she was able to reformulate a more accurate view of herself. Over time, she began to see herself as a survivor instead of a victim. The reworking of traumatic material occurs over time in different ways. The person begins to understand the various elements of what happened and then understands the same event and sense of self in a different way at a later date.

For example, one man who suffered horrific physical abuse from his sadistic father examined various aspects of this situation. First, he understood and experienced the betrayal and pain he felt because of his father, and subsequently, he also understood the event as betrayal and humiliation by his neglectful mother, who did not intercede and passively witnessed his abuse. He then examined how this reverberated into all areas of his life, such as his feelings about himself in relationships, difficulty setting boundaries, inability to make decisions, lost job opportunities, self-esteem issues, somatic symptoms, difficulty managing feelings and self-soothing, and poor coping skills. Changes in physical and emotional responses occurred as the fragments of the traumatic memory from the past were integrated with other more adaptive networks. The emotions elicited from the retelling are likely to be intense, and this expression is encouraged (Horowitz, 2003). Eventually, the events no long increase emotional arousal after they are fully processed. Over time, memories are woven into a narrative reflecting the integration of neural networks as new information is learned.

Most people are not eager to re-experience upsetting material, and this is essentially what we are asking the traumatized person to do. Trauma survivors have spent considerable effort avoiding thinking about the traumatic event/s and naturally question the wisdom of this idea. It is essential for the therapist to educate the person about how the flashbacks, symptoms, and intrusive memories are the brain’s effort to heal and how the avoidance serves to keep the trauma alive. The memories need to be integrated with other memory networks to dissipate. Reassure patients that you will teach them methods of managing arousal so they will not be overwhelmed and assure them that they can stop or take a time out anytime they wish. However, it is more than the therapist’s reassurance that enables the patient to trust that processing trauma will be helpful. It is the psychoeducation in tandem with the safety and trust that has been built up over time in the therapeutic relationship that allows the person to process traumatic material.

Patients who have been processing may need special closure at the end of the session so they can leave in a comfortable state. It may be helpful for the therapist to summarize the work of the session. For example, reframing the emotional distress with a statement such as, “You did some good processing today,” or returning to the safe place, using the container exercise included in Chapter 10 for negative feelings, visualizing a healing image, or using art to draw a new belief or feeling are ways to soothe and contain at the end of processing. Immediately after processing, patients often report that they feel “scattered” or “spacey.” The APPN should suggest that the patient walk around first or sit quietly before driving home. It is important to inform the patient that processing may continue between sessions. Summing up the session at the end and telling the person the date of the next session helps to provide closure.

Suggestions for assisting patients in managing emotions between sessions include asking them to call you in a day or two to let you know how they are doing; homework, such as journaling, walks in nature, artwork, or meditation; stress-reduction strategies; group work; exercise; eating well; and other resource enhancing skills. These are all skills that have been learned before processing in the stabilization phase. Sometimes, patients report a deep sleep after a processing session, and perhaps this heralds the healing that is taking place. Ask the person to keep track between sessions of any increase in flashbacks, nightmares, and disturbing feelings or memories and bring this information to the next session. It can also help patients if the APPN makes tapes for relaxation and guided imagery in the APPN’s own voice so the patient can play these audiotapes in between sessions to reinforce stabilization outside of sessions. These strategies help the person to stay connected and feel supported between sessions by providing a link to the “holding environment” of the therapeutic relationship.

Clinically, processing has been achieved after relationships are adaptive, work is productive, self-references are positive, there are no significant affect changes on exposure to trauma triggers, affect is proportionate to events, and there is congruence among behavior, thoughts, and affect (Davis & Weiss, 2004). Shapiro (2006) says that the clinician can tell that processing has occurred by positive somatic, behavioral, and cognitive trait changes that occur after treatment. These changes are not temporary state changes, but enduring trait changes with the person able to talk about the event without the attending hyperarousal that was present before processing (Shapiro, 2006). The patient will not feel the trauma in the body after it has been processed. Asking the patient near the end of processing to scan his/her body is useful to determine whether processing has occurred. Significant body changes will be noticed after trauma is processed and the dysfunctional memory is integrated. Appendix I-5 (p. 141) provides a processing checklist to assist the therapist in determining whether processing has led to adaptive change. The traumatic memory should be re-accessed at the next session after processing and again before termination to determine whether the changes reflect trait changes (Shapiro, 2006). Asking the person to rate the SUD of the memory at these times assists the therapist and patient in determining the degree of processing that has been accomplished.

Periods of processing are sometimes followed by periods of destabilization. The APPN paces and structures treatment so work on traumatic material alternates with resources, such as grounding and containment. “Trauma should not be the focus of session after session. Instead, as material is retrieved, it is much more important to process that material in a manner that allows the patient to remain stable than it is to move on to find and/or deal with more material” (Kluft, 1999, p. 15). As Kluft points out, “slower is faster” because the overall therapy time is reduced if treatment is relatively stable. Periods after processing may include feelings of increased sadness, anxiety, loss of control, or confusion. Sometimes, normal functioning is impaired, and the person may become suicidal or unable to function, especially if there are memories of childhood abuse. More sessions per week sometimes offer more support, and the person then can have the opportunity to move beyond crisis intervention to address deeper underlying difficulties (Kluft, 1999). The APPN emphasizes the importance of maintaining supportive relationships and regular activities because these provide a positive sense of self and allow the work to continue. If the crisis is not averted quickly, this is an indication that the patient is not ready to continue with emotional processing. Hospitalizing the person to process trauma only furthers regression and is counterproductive unless needed to ensure patient safety.

After processing, the APPN should return to stage 1 interventions, such as somatic awareness, safe place, anchors, dual awareness, progressive muscle relaxation, establishing boundaries, and bridging the implicit with the explicit (Rothschild, 2000). Briere and Scott state, “Effective trauma therapy provides titrated exposure to traumatic material while maintaining the safety necessary to eventually extinguish conditioned emotional responses” (p. 126). As illustrated in Figure 1-6 in Chapter 1, the treatment process often looks more like a spiral alternating interventions aimed at stabilization and then processing leading toward self-actualization and future visioning. As “life happens” and job loss, serious illness, and other events may lead to destabilization, it may be necessary to stop processing and move to stabilizing again in the course of treatment.

As the trauma loses its arousal capacity, and losses are mourned, the person is able to be more future oriented and may decide to pursue life goals such as relationships, education, or professional goals that previously were not thought about. Remediation of life skills that were missed during crucial developmental periods because of trauma may be needed. For example, one patient who suffered incest as a child processed this trauma in psychotherapy, and only then began to envision a future for herself with a partner. The therapist taught her basic skills about dating and how to develop, pace, and deepen a relationship safely. Educating the person about relapse prevention is important. The patient may always be vulnerable to trauma symptoms when re-exposed to stress because high states of arousal may promote retrieval of state-dependent memories, sensory information, or behaviors associated with prior traumatic experiences that have not been fully processed. A plan for how to manage these times should be discussed, and this includes reviewing resource materials to enhance coping skills and booster sessions at vulnerable times. Explain to the patient that these high-risk periods may include developmental changes, periods of elevated stress, or reminders of partially processed traumas. Traumas that have not been previously identified may also be triggered at these vulnerable times. Resources should be increased prophylactically during these times.