Level 1 Manual Modules 16 PDF

Rehab Kids
Janina Fisher’s Certified

Clinical Trauma
Professional Training
Level 1 (CCTP)
Working with the Neurobiological
Legacy of Trauma
Janina Fisher Ph.D.
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Janina Fisher’s Certified
Clinical Trauma
Professional Training
Level 1 (CCTP)
Working with the Neurobiological
Legacy of Trauma
Janina Fisher Ph.D.
Rehab Kids
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MATERIALS PROVIDED BY
Janina Fisher, Ph.D., is a licensed clinical psychologist and former

instructor at The Trauma Center, a research and treatment
center founded by Bessel van der Kolk. Known as an expert
on the treatment of trauma, Dr. Fisher has also been treating
individuals, couples and families since 1980.
She is past president of the New England Society for the

Treatment of Trauma and Dissociation, an EMDR International
Association Credit Provider, Assistant Educational Director
of the Sensorimotor Psychotherapy Institute, and a former
Instructor, Harvard Medical School. Dr. Fisher lectures and
teaches nationally and internationally on topics related to the
integration of the neurobiological research and newer trauma
treatment paradigms into traditional therapeutic modalities.
She is co-author with Pat Ogden of <em>Sensorimotor

Psychotherapy: Interventions for Attachment and Trauma (2015)
and author of Healing the Fragmented Selves of Trauma Survivors:
Overcoming Internal Self-Alienation (2017) and the forthcoming
book, Working with the Neurobiological Legacy of Trauma (in
press).
Speaker Disclosures:
Financial: Janina Fisher is in private practice. She receives a speaking honorarium from PESI, Inc.
Nonfinancial: Janina Fisher has no relevant nonfinancial relationship to disclose.
Materials that are included in this course may include interventions and modalities that are beyond the
authorized practice of mental health professionals. As a licensed professional, you are responsible for
reviewing the scope of practice, including activities that are defined in law as beyond the boundaries of
practice in accordance with and in compliance with your professions standards.
Working with the Neurobiological Legacy of Trauma Certification Program
Trauma: “Trauma and the Body”
Working with the

Neurobiological Legacy
of Trauma
Trauma and the Body
Janina Fisher, Ph.D.

www.janinafisher.com
Having a trauma lens...
Jenni Thompson, 2013
Copyright 2017: Janina Fisher, Ph.D. Do

Not Copy without Permission 1
What is a “trauma” ?
“Psychological trauma is the unique individual
experience of an event, a series of events, or a set
of enduring conditions, in which:
•The individual’s ability to integrate his or her
emotional experience is overwhelmed
and/or
•The individual experiences (subjectively) a
threat to life, bodily integrity, or sanity.”
Saakvitne et al, 2000
Sensorimotor Psychotherapy™ Institute 2012
“Trauma” is relative: what is traumatic depends upon
our vulnerability
Because children are so dependent on their caretakers

for survival and safety, they are vulnerable to
traumatization by:
•“Frightened and frightening” caregiving (Lyons-Ruth)
•Neglect, separation, abandonment (Perry)
•Exposure to domestic violence, witnessing violence
•Parental fighting
•Threatening words and behavior: “I’ll kill you if you . . .”
•Secondary effects of parental PTSD (Yehuda)
•Accidents, medical crises, surgery, invasive procedures
•Death of a parent or parent figure Fisher, 2009

Nightmares
Nervous Flashbacks Hypervigilence
system Foreshortened
future, Mistrust
dysregulation
Hopelessness Shame
Self-loathing
Social anxiety
Decreased Panic attacks
concentration Insomnia
Chronic pain
Decreased Numbing Eating disorders

interest
Irritability
Trauma Suicidality and
self-harm
Depression
tic Addictions
Event
“Trauma survivors have symptoms instead of memories”
Harvey, 1990
WHY do
trauma
survivors
have
symptoms
instead of
memories?
Carter, 1998

The Triune Brain [McLean, 1967]

Mammalian Frontal Cortex:
Regulatory abilities,
Brain: or cognitive and
Limbic System: executive functioning
emotional and
somatosensory Uses verbal
memory, language and
attachment analytical
reasoning
Speaks the
language of
emotion
Reptilian Brain:
Autonomic arousal,
instinctive responses
Speaks language
of sensation and
impulse
Sensorimotor Psychotherapy Institute
Threat and the Brain

Limbic
System or Frontal
Emotional Cortex:
analyzes,
Brain: perceives problem-solves,
and reacts to learns from
threat experience
Reptilian Brain: Threat

controls our instinctive
responses and functions Amygdala
Fire Alarm and Emotional
Memory Center

The Emergency Stress Response
Fight- Freeze-
Flight Submit
Cortisol release
triggers
Parasympathetic
System
Sympathetic Nervous Parasympathetic Nervous

System: noradrenaline release, System: decreased autonomic
increased heart rate and activation, shaking and trembling,
respiration, rush of energy to rebound gastro-intestinal activity,
muscle tissue, suppression of exhaustion, depletion, shutting
non-essential systems, frontal down, numbing, total collapse,
lobe inhibition “licking the wounds”
Fisher, 2008
After the threat has passed,

•Consolidation and retrieval of a clear event memory is
compromised: activity in the hippocampus (which
processes experience prior to its being ‘remembered’) is
inhibited under threat, and the frontal cortex fails to witness
the experience
•The unprocessed “raw data,”encoded in the amygdala.
Feeling memories, sensory memories, muscle memories,
autonomic memories provide the record of what happened
divorced from a narrative that could explain them
•Since the amygdala is the brain’s “smoke detector,” the
result is sensitization to even subtle reminders of the
traumatic event Fisher, 2009

“Under conditions of extreme stress, there is

failure of . . . memory processing, which
results in an inability to integrate incoming
input into a coherent autobiographical
narrative, leaving the sensory elements of the
experience unintegrated and unattached.
These sensory elements are then prone to
return . . .when a sufficient number of [them]
are activated by current reminders.”
Van der Kolk Hopper & Osterman 2001
Sensory elements without words = implicit memory
•Brain scan research demonstrates that traumatic memories

are encoded primarily as bodily and emotional feelings
without words or pictures—detached from the event
•These implicit memories do not “carry with them the
internal sensation that something is being recalled. . . . we
act, feel, and imagine without recognition of the influence
of past experience on present reality.” (Siegel, 1999)
•“Emotional memory converts the past into an expectation
of the future. . . [and] makes the worst experiences in our
past persist as felt realities.” (Ecker et al, 2012, p. 6)
Fisher, 2015

Triggers and Triggering
•The human body is self-protective: it automatically reacts

to any cue indicating the possibility of danger.
•The brain is biased to respond to any danger signal it
has known before: times of day, days of the week. times of
year, gender and age, facial expression, colors, smells or sounds,
weather conditions, a tone of voice or body language, touch, even
our own emotions and body sensations
•When we get triggered, we experience sudden and
overwhelming feelings, sensations, and impulses that
convey, “I AM in danger—right now!” not “I was in
danger then” Fisher, 2015
Common Post‐traumatic Triggers
Therapy and therapists Recall of traumatic events

Being asked questions Therapist silence
Self-disclosure Not allowed to speak
Being put on the spot Being ignored
Being center of attention Emotions, vulnerability
Loud noises Unfamiliar stimuli
Authority figures Performance demands
Being told “No” Having to say “Yes”
Males/females Nightime, sleep
Criticism, feedback Confrontation
Home and family Intimacy
Eye contact Commitment

Implicit memories take many different forms
•Intrusive emotions disproportional to the stimulus: fear,

anger, shame, dread
•Thoughts the predict threat or failure, as well as
intrusive, contradictory, or ruminative thoughts
•Impulses: to run, to hurt the body, drink or drug, hide
under the bed, avoid going out
•Somatic sensations: spinning, dizziness, pain, heaviness,
floating, tingling, numbing, ‘noise’ in the head, loss of
hearing or vision
•Attachment symptoms: yearning for contact, painful
loneliness, and a felt sense of abandonment Fisher, 2015
Autonomic Nervous System is Shaped by
Parental Attachment Behavior
High Activation
A
R Optimal Arousal Zone
O Window of Tolerance*
U feelings can be tolerated
S we feel safe
A
L
Low Activation

Autonomic Adaptation to a Threatening World

Hyperarousal-Related Symptoms:
Impulsivity, risk-taking, poor judgment, racing thoughts
Perceptual and muscular hypervigilance, post-traumatic paranoia, states of frozen terror
Intrusive images, sensations, emotions; flashbacks and nightmares
Self-destructive and addictive behavior
Hyperarousal
Optimal Arousal Zone:

feelings can be tolerated
able to think and feel
Hypoarousal-Related Symptoms:
Hypoarousal Flat affect, numb, feels dead or empty, “not there”
Cognitive functioning slowed, “lazy”
Ogden and Minton (2000); Preoccupied with shame, despair and self-loathing
Fisher, 2006
Disabled defensive responses, victim identity
*Siegel (1999)
“One of the most robust findings of the

neuro-imaging studies: under stress, the
higher brain areas involved in "executive
functioning”—planning for the future,
anticipating the consequences of oneʼs
actions, and inhibiting inappropriate
responses—become less active.”
Van der Kolk BA: Clinical applications of neuroscience
findings in PTSD. New York Academy of Sciences, 2006.
Sensorimotor Psychotherapy® Institute 2012

Not understanding trauma, individuals come to
identify with their symptoms and implicit memories:
“Itʼs who I am”
Pervasive, chronic fear = “Iʼm not safe anywhere”

Loss of energy and ability to feel= “I have no motivation,” “Iʼm a
fraud”
Addictive behavior= “Iʼm a loser—Iʼm just a drunk”
Chronic irritability = “Iʼm an angry person”
Mistrust and fear of people = “I donʼt like people”
Shame = “I am a loser--a failure--Iʼm worthless”
Wanting to die = “I deserve to die”

Copyright 2000 Janina Fisher, PhD
AND other symptoms develop as valiant
attempts to cope with the dysregulation
• Self-injury and self-starvation to
discharge tension somatically
• Suicidal thoughts and impulses to “control” overwhelm by
combating feelings of helplessness
• High-risk behavior to activate the adrenaline response
• Re-enactment behavior to keep memories “in their place”
• Caretaking of others to combat a sense of worthlessness
• Addictive behavior to alter consciousness and to “treat” specific
traumatic symptoms Fisher, 2004

Judith Herman’s (1992) Three-Phase

Model of Trauma Treatment
PHASE I: Safety & Stabilization: Overcoming Dysregulation
•Establishment of bodily safety and control of the body
•Establishment of a safe environment
•Establishment of emotional and autonomic stability
PHASE II: Coming to Terms with Traumatic Memory
Since “remembering is not recovering”, it is only necessary to come to
terms with the traumatic past, rather than trying to uncover all details.
PHASE III: Integration and Meaning-Making

As the survivor’s life become increasingly consolidated around a
healthy present and a healing self, the trauma gradually becomes
farther away Adapted from Herman (1992)
To Stabilize, Frontal Lobe Inhibition

Must Be Reversed
“In order for the amygdala to respond to
fear reactions, the prefrontal region has
to be shut down. . . . [Treatment] of
pathologic fear may require that the
patient learn to increase activity in the
prefrontal region so that the amygdala is
less free to express fear.”
LeDoux, 2003

What are therapists trained to do?
•Listen empathically
•Communicate unconditional positive regard
•Adhere to the principle of neutrality
•Be non-directive
•Foster experiences of direct connection with affect
•Encourage the expression of affect, especially in therapy
•Teach how to use affect to interpret personal reality
•Encourage connection to painful past experiences as a way
of understanding present conflicts and symptoms
•Discuss and interpret transference phenomena Fisher, 2009
What should the trauma-wise

therapist do?
•Offer unconditional acceptance of the client but not the
symptoms: those are ‘red badges of courage’
•Take an active role in the treatment, recognizing that the
client’s prefrontal inhibition interferes with self-direction
•Teach the patient how to distance from affect, how to
modulate and titrate affects, before connecting to emotion
•Teach the patient that feelings and sensations are the most
useful guides for interpreting her past reality, but cognition is
a better guide to understanding present reality
•Instead of interpreting the transference, offer education
about trauma and its effects on relationship Fisher, 2009

“The therapist’s role is both intellectual and

relational, fostering both insight and
empathic connection. Kardiner notes that
‘the central part of the therapy should
always be to enlighten the patient’ as to the
nature and meaning of his symptoms, but
the same time ‘the attitude of the physician
in treating these cases is that of the
protecting parent. He must help the client
reclaim his grip on the outer world. . .’”
Herman, 1992, p. 137-138
Psychoeducation
•Offer a “crash course” on the effects of trauma on the mind
and body: “body memories,” the nervous system, cortical inhibition
•Normalize feelings/behavior that have been sources of shame
as ingenious attempts to cope
•Label the symptoms as “symptoms:” poor judgment and
impulse control, self-loathing, self-neglect
•Increase awareness of post-traumatic triggering and
habitual triggered survival responses: “getting” the logic of
trauma decreases shame/increases understanding of cause-and-effect
•Encourage curiosity and compassion: “That makes sense,”
“Of course you feel trapped,” “No wonder you had to cut [drink,
restrict, act out]—you were trying to get some relief”
Fisher, 2003

Transforming Trauma‐related Responses
Requires Curiosity and Mindfulness
“Where attention goes,

neural firing goes. And
where neurons fire, new
connections can be made.”
Siegel, 2006
Ingredients of Mindfulness
•Awareness or recognition of sensation, thought,

emotion, movement, external stimulus (medial prefrontal cortex)
•Detachment: noticing it but ‘not participating’ in it or
getting swept away by it (medial prefrontal cortex)
•Labeling: putting neutral language to what is noticed
(e.g., “I’m having a thought—some emotion is coming up”)
•Mindfulness can be directed or directionless:
following the flow of thoughts, feelings and body
experience as it unfolds or deliberately focused on an aspect
of experience (e.g., the breath) Fisher, 2009

Facilitating Mindful Awareness
•Mindfulness in therapy depends upon the therapist
becoming more mindful: slowing the pace, refraining
from interpretation or direction in favor of neutral
observation, helping the patient begin to focus on the flow
of thoughts, feelings, & body sensations
•Mindful attention is present moment attention. We use
“retrospective mindfulness” to bring the client into present
time: “As you are talking about what happened then, what
do you notice happening inside you now?”
•Curiosity is cultivated because of its role as an entrée
into mindfulness: “Perhaps by binging and purging, you
were trying to help yourself get to the wedding. . .”
Fisher, 2009
Distinguishing Thoughts, Feelings,

and Body Sensations
In traditional talking treatments, we do not always clearly
differentiate cognition, emotion, and body responses:
For example, when we say, “I feel unsafe,”
•It could reflect a cognition: “I am never safe,”
“The world is not a safe place”
•It could mean an emotion: “I’m feeling frightened”
•It could mean bodily sensation: “My chest is tight;
my heart is racing; it’s hard to take a breath”
•It could mean action: “I want to hurt myself”

On what do we focus?
•Trauma patients generally come to treatment because of
post-traumatic triggering: trauma-related stimuli have
stimulated anxiety symptoms, intrusive memories,
overwhelming emotions, depression, and/or suicidality
•The first goal of trauma treatment is to help patients
recognize the role of triggering in causing and
perpetuating their symptoms in order to empower them
•With greater understanding comes decreased fear and
shame when these responses are triggered. With more self-
awareness and a language to describe what is happening, the
capacity for self-regulation in the face of triggering can
potentially increase Fisher, 2008
Prioritize Past/Present Differentiation
•Traumatized individuals generally come to treatment

because of post-traumatic triggering: trauma-related stimuli
have stimulated anxiety symptoms, intrusive memories,
overwhelming emotions, depression, and/or suicidality
•The first goal of trauma treatment is to help patients
recognize the role of triggering in causing and
perpetuating their symptoms in order to empower them
•With greater understanding comes decreased fear and
shame. With more self-awareness and a language to
describe what is happening, the capacity for self-regulation
in the face of triggering can potentially increase Fisher, 2008

Connecting Symptoms to
Triggers
In the context of client’s having cut herself, therapist tries to evoke curiosity:
And you probably
I hear you What feelings couldn’t tell
cut last and thoughts anyone because
What was came up when
night—what you felt ashamed?
going on just he didn’t call?
might have before?
triggered
you?
“Yeah, I thought,
“I was mad at “What
“I don’t “My boy friend
myself for kind of fool am
know—I was supposed
trusting him— I for trusting
just hate to call me, but
that’s why I him?”
myself” he didn’t”
hate myself”
Fisher, 2006
Triggers, cont.
Therapist continues to ask mindfulness questions: Do you want me
Well, cutting triggers
to show you
adrenaline so you feel
something else to
calmer—you were just
When you had How do that will help
trying to get control
that thought, overwhelmed you feel less
back, huh?
what feelings were you? overwhelmed? It
came up? won’t work as
well, but it
doesn’t get you
in trouble!
“Completely “But now I’m
“I wanted
overwhelmed feeling stupid,
to kill him,
—I couldn’t and my arm is
and I “Sure. . . I’d like
stand it” killing me”
wanted to to survive this
kill me” weekend!”
Fisher, 2006

How can you tell when you are triggered?
• Triggered reactions = sudden, intense, and hard to shift
• Anxiety, fear
• Increased heart rate
• Pit, tightness, clenching in stomach
• Shallow breathing, hyperventilation, holding the breath
• Obsessive thinking
• Response disproportional to event, major change in previous state
• 0-to-60 reactions
• “I’m doing something I shouldn’t/didn’t want to do”
• Muscle tension (either whole body or specific areas)
• Twitches, tics
• Jumping to conclusions
• Jumping to “worst case scenario”
• Feeling that ‘the sky is falling’
• Sense of not belonging, being on the outside looking in
• Fear of abandonment or aloneness, feeling small
Dis-identifying from Symptoms

•When we preface a self-observation with the pronoun,
“I,” we identify with that feeling or symptom, rather than
just noticing it. But identifying with states of shame and
self-loathing or helplessness and hopelessness is not
adaptive. Thus, we must help the client to dis-identify
with the symptoms
•By separating self from symptoms: “When you feel
stressed, that old belief, ‘I’m a loser,’ gets more intense
and feel real—isn’t that a coincidence?”
•By labeling symptoms as ‘just’ symptoms: “That
anxiety is meant to be your early warning signal for
danger—I wondered what triggered it . . .”
Fisher, 2008

Re‐framing the Symptoms
•We should assume that every symptom is a valuable

piece of information about how the client survived,
adaptive instead of pathological
•Use psychoeducational material to wonder about the
meaning of each symptom: is this a feeling memory? Or a
valiant attempt to cope or self-regulate?
•Heighten curiosity about what the symptom is trying
to accomplish: Increase hypoarousal? Decrease
hyperarousal? Regulate feelings of emptiness or
loneliness? Restore a sense of power and control over
one’s own experience? Admire the symptom as a
survival resource! Fisher, 2006
What Symptoms Try to Accomplish
Generally, these secondary symptoms reflect unconscious,
instinctive efforts to regulate autonomic arousal:
•Suicidal symptoms: “You found a way to live by always having
a way out, a bail-out plan, that gave you some control over your fate”
•Cutting or self-injury: “Hurting the body when you feel
overwhelmed is an ingenious way to get relief because it triggers
your body to produce adrenaline and endorphins”
•Mistrust and paranoia: “You learned the hard way that it was
safer to assume the worst in people . . .”
•Eating disorders and addictive behavior: “You found that
alcohol took away the fear of being around people. . .” “Yes, when
you restrict, you can’t feel … it lowers your activation.” Fisher, 2008

Trying to stay here, not ʻgo thereʼ
Stay here
instead of
Symptoms
Curiosity Validation ‘going
or
(Re-framing) there’
crisis
“Let’s both be “OK— just keep

“I can’t handle “I wonder if curious: how could saying, ‘It’s just
this anymore— you’re wanting to give up body memory—
I’m triggered—there have helped you just triggering—
overwhelmed—I must have been a survive in an I’m just
give up!” trigger for you to unsafe world? How remembering how
get so freaked was that smart?” it felt then.”
out…”
Fisher, 2009
“Long-lasting responses to
trauma result not simply
from the experience of fear
and helplessness but from
how our bodies interpret
those experiences.”
Yehuda, 2004

Brain and body organize to adapt to our

circumstances
•In childhood, the brain undergoes numerous growth

periods followed by “pruning.” Frequently-used neural
pathways become automatic and less-used pathways are
eliminated. These brain changes are called “neuroplastic”
•When adaptation is shaped by trauma, the brain and body
develop patterns of response most likely to ensure
survival under threat. The resulting pathways become
“kindled” or sensitized, increasingly habitual and efficient
•When these patterns are no longer effective years later,
they are no longer “plastic” or under conscious control:
they are automatic responses Fisher, 2017
Another kind of memory: habits of action and
reaction
•Procedural memory is our implicit memory

system for functional learning: skills, habits,
automatic behavior, conditioned responses.
•Driving a car, playing an instrument, dance, swimming or
playing tennis, riding a bike, shaking hands and making
eye contact and other social behavior, are all examples of
procedural learning.
•Procedural learning allows us to respond instinctively,
automatically, and non-consciously, increasing our
efficiency at the cost of a loss in reflective, purposeful
action Fisher, 2012

“The neural substrate for procedural learning appears to develop prior to

the capacity for declarative learning. This means [that] templates for
habitual behaviors may be acquired, and the behaviors become
relatively automatic and routine, before the child has an episodic
memory system capable of remembering the events that produced these
behaviors. [Thus,] very young children are likely to experience a kind
of learning . . . that is dissociated from the content.”
Grigsby & Stevens, 2002
Trauma-related Procedural Memory

•Social behavior: difficulty making eye contact, asking for
or accepting help, expressing feelings in words
•“Default settings:” tendencies to automatic self-blame,
shame, anger, shutdown, dissociation
•Behavioral responses: impulsive acting out, isolation and
avoidance, help-seeking, inability to say ‘no,’ collapse
•Emotional expression: emotional disconnection, cathartic
expression, overwhelming intrusive emotions
•Interpersonal behavior: gets too close too quickly and
expects too much from others, becomes the caretaker, or
avoids closeness, dependency Fisher, 2014

The nervous system learns to stay mobilized

Freeze: Hyperarousal:
“The deer in the headlights” Hypervigilant, restless, ready to act
Mute, physically immobilized Anxiety and fear prime the body to defend
Fight/flight responses
Still, ‘invisible’
Angry, self-destructive behavior
Sympathetic Hyperarousal
“Window of Tolerance”*
Optimal Arousal Zone
Hypoarousal:
Parasympathetic Hypoarousal Compliant, weak, no energy, cannot defend
Numb, “empty” or “dead”
Cognitively dissociated, unable to think
Ogden and Minton (2000)
Helpless and hopeless
*Siegel, D. (1999) Sensorimotor Psychotherapy Institute
Post-traumatic stress = the trauma is re-

enacted or re-lived.
It never ends
Pierre Janet
1859-1947
“[Traumatized] patients ...
are [repeatedly] continuing
the action, or rather the
attempt at action, which
began when the thing
happened, and they exhaust
themselves in these ever-
lasting recommencements.”
1919/25, p. 663

The Expectation of Danger is a

Procedurally Learned Response
“[Procedural] memory shapes how we
experience the present and how we
anticipate the future, readying us in
the present moment for what comes
next based on what we have
experienced in the past.”
Siegel, 2006
Focusing on the past or present?

•Procedurally-learned habits or responses, representing
the safest strategies available at the time, continue to
operate as automatic “default settings”
•Procedural learning theory suggests that reactivating
memories by talking about old experiences “may
actually perturb procedural learning” (Grigsby & Stevens,
2001). When we recount an old experience, we evoke the
implicit aspects as well as the narrative memory
•To resolve childhood trauma and attachment failure, the
theory suggests that cultivating new experiences in
therapy may be more useful than talking about old
experiences! Fisher, 2017

Assumptions of Neurobiologically‐Informed
Trauma Treatment
•Under conditions of trauma and neglect, the human

body becomes self-protective: defensive responses of
fight-flight-freeze-submit-attach are automatic under stress
•Since triggered emotions and actions are not experienced
as memory, clients often lack any clear sense of “why”
they are feeling or behaving‘this way.’ Because trauma
responses are autonomically driven, they happen suddenly,
often without warning, taking the client by surprise
•Another consequence of trauma is that other human
beings, including therapists, feel threatening rather than
comforting, threatening rather than calming Fisher, 2009
Assumptions of Neurobiologically‐Informed
Treatment, p. 2
•The emotions, sensations, and impulses triggered by

traumatic reminders, divorced from their original context,
are misinterpreted as indicators that the individual is still
in danger, still powerless or helpless. Though the client
may be safe now, the body doesn’t know or believe that
•When traumatic activation is interpreted as a sign of life
threat, past and present become hopelessly confused. For
example, if the client was abused by a male parent, all male people
become suspect; if abused in the late afternoon, the late afternoon
stimulates panic and rage; if neglected and abused, others who seem
indifferent or who are slow to respond are experienced as ‘unsafe.’
Fisher, 2008

Years later, do we treat the

memories? or the body responses?
“While telling ‘the story’ provides crucial
information about the client’s past and current
life experience, treatment must address the here-
and-now experience of the traumatic past . . .
Thus, ‘in the moment’ trauma-related emotional
reactions, thoughts, images, body sensations and
movements that emerge spontaneously in the
therapy hour [must] become the focal points of
exploration and change.”
Ogden, Minton & Pain (2006)
Procedural Learning is Oriented to the Past, not
the Present [Scaer, 2006]
“The more the patient is driven by procedurally

learned, conditioned responses, the less time the
patient experiences the present moment:
•The ‘lived’ story: what is happening right here,
right now
•Moment-to-moment internal/external awareness
•Working memory: holding ideas and
information in mind and manipulating them
•Intentional, rather than automatic, responses”
Fisher, 2006

Sensorimotor Psychotherapy
•Sensorimotor Psychotherapy is a body-oriented therapy
developed by Pat Ogden, Ph.D. and enriched by
contributions from Alan Schore, Bessel van der Kolk,
Daniel Siegel, Onno van der Hart, and Ellert Nijenhuis.
•Sensorimotor work combines traditional talking
therapy techniques with body-centered interventions
that directly address the somatic legacy of trauma.
•Using the narrative only to evoke the trauma-related
bodily experience, we attend first to discovering how the
body has “remembered” the trauma and then to
providing the somatic experiences needed for resolution
“Small gestures and changes in breathing are

at times more significant than the family tree”
(Christine Caldwell, 1997)
• Sensorimotor Psychotherapy is less focused on the

narrative of what happened then
• Instead, the narrative is used to evoke the nonverbal
implicit memories: the autonomic responses, movements,
postural changes, emotions, beliefs, etc.
• The therapist looks for patterns, for habits of response: too
much or too little affect, movement or stillness, negative
cognitions, patterns of gesture or movement
• We observe the client “right here, right now:” how is the
client organizing internally in response to the narrative?
How is the memory being expressed somatically?

Sensorimotor Principles of Treatment
•Regulation of arousal is a prerequisite for successful

treatment. When clients are hyper- or hypoaroused, their
frontal lobes shut down instinctively, interfering with
therapeutic collaboration and integration. Whatever
intervention we are using, it must regulate arousal
•Keeping the frontal lobes ‘online’ must be a priority.
Both mindfulness and psychoeducation facilitate this.
•Procedurally learned patterns must be identified as the
“culprits” keeping the trauma ‘alive’ in the client’s
body. Whether we identify those to the client or not, they
must become the focus of treatment Fisher, 2010
“The most direct way to effect change is by

working with the procedural learning system,
rather than with declarative memories”
[Grigsby & Stevens, 2000]
We can address “procedural learning” in two ways:

•”The first is to …observe, rather than interpret, what takes
place, and repeatedly call attention to it. This in itself tends
to disrupt the automaticity with which procedural learning ordinarily
is expressed.”
•”The second therapeutic tactic is to engage in activities that
empathically but directly disrupt what has been procedurally
learned” and create the opportunity for new experiences
(Grigsby & Stevens, 2000, p. 325)

Sensorimotor Principles of Treatment, cont.
•Observation and disruption of procedurally learned

patterns must be done without dysregulating the client!
If we dysregulate the client, there is no new learning
•As we observe the client, we keep in mind at all times that
the habitual patterns of response represent once creative
adaptations to traumatic experiences. Rather than
becoming frustrated with the client who can’t feel anything,
we get curious about how that helped him/her to survive.
•Even self-destructive behavior is viewed as an attempt at
a solution, not just as a problem. Numbing, acting out,
self-judgment, shame are all ‘survival resources’ Fisher, 2010
Transforming Procedural Learning
“Change happens through discovering

how [the client’s procedurally-learned
responses] to selected stimuli and then
changing how that experience is
organized. . . The ‘tool’ that we use to
discover and then [transform] the
habitual organization of experience is
mindfulness.” Ogden, 2005

How does Mindfulness Challenge Procedural

Learning?
•To be mindful and curious requires activation of the
prefrontal cortex. Whereas traumatic activation inhibits
frontal lobe activity, mindfulness engages it
•Mindfulness has been shown to increase activity in the
thalamus and anterior cingulate, increasing awareness of
new perceptual data (via the thalamus) and sustaining
attention to it (via the anterior cingulate) (Lanius, 2005)
•Rather than responding to traumatic triggers with impulsive
action, mindful awareness allows the client to study what
happens as “data:” as ‘just’ body responses, ‘just’
emotions, ‘just’ trauma-related cognitions. Fisher, 2006
How does Mindfulness Treat Trauma?

Regulation
Medial prefrontal
Working cortex of arousal:
memory: depends upon
good attachment
verbal, analytical, Dorsolateral Right orbital in early life to be
holds ideas in mind, Prefrontal Prefrontal effective
has insights cortex
cortex
Mindful
awareness and
integration of Emotional
experience: has a Amygdala
memory center:
reciprocal relationship amygdala activation =
with the amygdala dysregulation
From van der Kolk, 2009

Mindfulness Skills
• “Notice . . .”
• “Be curious, not judgmental. . . “
• “Letʼs just notice that reaction youʼre having inside as we talk about your
boy friend”
• “Notice the sequence: you were home alone, bored and lonely, then you
started to get agitated and feel trapped, and then you just had to get out of
the house”
• “What might have been the trigger? Letʼs be curious—go back to the start
of the day and retrace your steps” Fisher, 2004
Introducing Attention to Somatic

Experience
Because somatic awareness can be threatening for trauma
survivors, as well as helpful, we introduce attention to the
body slowly and carefully and track the patient’s
response:
•“When you talk about feeling scared, how does that feel inside?”
•“That’s the thought that goes with that scared feeling: what’s the
visceral sensation that goes with it?”
•“What sensations tell you that you’re scared? How does your
body tell you that?”
•Throughout, attention is paid to signs that the patient is

becoming more, rather than less, dysregulated
Fisher 2004

Increasing Frontal Lobe Activity:

Offer a Menu of Possibilities
•“When you feel the panic come up, what happens? Do you feel more tense? More jittery?
Or do you want to run?
•“As you feel that anger, is it more like energy? Or muscle tension? Or does it want to do
something?”
•“When you talk about feeling ʻnothing,ʼ what does ʻnothingʼ feel like? Is it more like calm?
Or numbing? Or like freezing? ” Ogden 2004
Making it Even Easier:

Asking Contrasting Questions
•“Does that feeling/sensation feel good or

bad? Is it more pleasurable or
unpleasurable?”
•“Does it feel like something that will hurt
you from the inside or the outside?”
•“When you say those words, ‘I’m a loser,’
does the shame get better or worse?”
Ogden 2004; Fisher, 2005

Experiments Replace Suggestions

[Ogden, 1999]
Mindful experiments encourage thoughtful “trials” of new

responses and non-biased study of their impact. The experi-
mental attitude is one of openness, without investment in a
particular outcome:
•Let’s see what happens if you just take a breath—or sigh very
loudly. . . “ “Let’s see what happens if you lengthen your spine just a
little bit . . . What do you notice?”
•“Notice what happens if you assume that the depression belongs to
just one part of you . . . Does that feel better or worse?”
•“Let’s study what happens to your anxiety when you repeat those
words, ‘I’m a hopeless case.’ Does it go up or go down?”
Fisher, 2007
Experiments Move the Treatment
•Experimenting is sometimes done formally: e.g. the

client is asked to ‘study’the results of practicing a skill such
as taking a breath to reduce activation
•Sometimes, experiments must be spontaneous to avoid
triggering the client or evoking resistance. Eg, the client’s
narrative always leads to anger and blaming of others.
Rather than ‘talk about’ the tendency to assign blame, the
therapist might ‘experiment’ with what inhibits this pattern.
Does it help the angry client if the therapist matches his/her
energy and words? Or is it more helpful to help the client
notice what triggered the anger? Or to reframe it as a fight
response?

Common Kinds of Experiments

•Client is preoccupied with negative beliefs, such as:
“I am hopeless”
“I am worthless”
“I will never be loved”
•Therapist asks the client to “notice what happens in the

body when you say those words?” After getting a report,
the therapist suggests trying an experiment to see “what
could help you feel better. “Notice what happens when
you lengthen your spine?” “Notice what happens if you
focus on the ground under your feet?” “Notice what
happens if you place your hand over your heart. . .”
Treatments for Trauma Must

Attend to Regulating Autonomic
Arousal
“Because the stress response
disrupts general information
processing, survivors of trauma
live in a somatic world rather
than a world of language.”
McFarlane, 2005

Attention to Autonomic Arousal

•As the client begins to talk about emotional or traumatic
experience, we track signs of dysregulation: What
happens when she thinks about telling you what happened?
•When hyper- or hypoarousal responses are noticed, clients
are asked to pause, notice what is happening, and let the
arousal settle before continuing. Somatic resources are
used to increase the ability to “think about thinking about it”
without becoming overwhelmed and dysregulated.
•The key is thinking “bottom-up” (Ogden & Minton, 2002): taking
the time to regulate will facilitate inhibiting habitual
responses and remaining in a mindful, witnessing state
Sensorimotor Psychotherapy Institute Ogden, 2001; Fisher, 2003
Sensorimotor Experiments for

Hyperarousal
•Limit amount of material in mind: the more information to
process, the more overwhelmed the client will feel. Focus on “just
thinking about thinking about it” or one “sliver of memory”
•“Frame” the piece of work very narrowly: “Let’s just stay
with that part of the story when you began to feel angry” or “Let’s
just stay with that gesture—would that be OK with you?”
•Keep the client in mindful state: “Just keep observing your
heart rate . . . Your breathing . . . ” “What’s happening now as you
just stay with those body sensations?”
•Ground emotions or cognitions in the body: “Where do you
feel those feelings in the body?” “When you express that belief that
you are stupid, what happens in the body?” Fisher, 2005

Sensorimotor Experiments for

Hypoarousal
•Remember that hypoarousal is a survival response:
attempts to increase arousal will often backfire, causing either
increased hypoarousal or an escalation into hyperarousal
•Increase amount of information to be processed, rather

than trying to stimulate feelings: study the numbness; find out
what words or emotions go with it; what images
•Foster curiosity: study how ingeniously hypoarousal “works.”

Study its details: how far the numbing goes down or in, whether
there is any other sensation, such as fuzziness, fogginess,
heaviness
•Admire the hypoarousal! Fisher, 2006

Modulation of Hypoarousal, cont.

•Conduct small experiments to increase arousal: use
humor, raise your level of arousal, work multi-modally, use body
language, do something unexpected or silly
•Ask the client to evaluate how “pleasurable or

unpleasurable” the hypoarousal feels in the body: experiment with
what increases the arousal to a more pleasurable level
•Encourage movement: change posture, trade seats with the

client, or work standing up
•Strengthen the client’s resources before pushing for

more arousal: hypoarousal means that the client is dysregulated
and affect intolerant. Pushing for affect too soon will increase
hypoarousal, rather than addressing it Fisher, 2005

For further information, please contact:

5665 College Avenue, Suite 220C
Oakland, California 94611
DrJJFisher@aol.com

Working with the

Neurobiological Legacy of
Trauma
The Complications of Dysregulation

Human beings interpret trauma-

related activation as ‘threat’
“Feelings and sensations

will rise and fall and run
their course—unless we
assign danger to them.”
Recovery, Inc.

“Assigning danger” to sensations?
• “Assigning danger” = triggered body sensations and

feelings are interpreted as having negative meaning
• Accelerated heartrate, tightness or hollow feelings in the
chest, freezing, or muscle tension might be interpreted as:
“Iʼm not safe” or “Iʼm trapped” or “Iʼm alone”
• The activation or emotion might lead to fears of a
different kind of danger: “I wonʼt be able to function if I let
myself feel this,” “Iʼll be killed if I let my anger out”
• Or certain beliefs about the self may become connected
to emotional reactions, such as: “Iʼm stupid for reacting
like this,” “Iʼm weak to be so afraid,” “No one will ever
love me because Iʼm so defective,” “Itʼs shameful to feel
these things” Fisher, 2013
Autonomic Dysregulation Gets Worse, Not Better

Interpretations of danger fuel activation, impulsivity, risk-taking, poor judgment
Hypervigilance increases, leading to post-traumatic paranoia or frozen terror
Clients experience an increase in intrusive images, sensations, emotions; racing thoughts
Self-destructive and addictive behavior are used to regulate the intense reactivity
Hyperarousal
The frontal
Optimal Arousal Zone:
feelings can be tolerated lobes shut
able to think and feel down
Hypoarousal
‘Danger’ cues cause disconnection, numbing, shutting down
Patient interprets responses as evidence to support self-loathing
Ogden and Minton (2000); Defensive responses are disabled by shame, collapse, victim
Fisher, 2006
*Siegel (1999) identity

Fisher, 2005
Increased activation Clients start to engage

and overwhelm when in compulsive behavior
“drug effect” wears off or substance use to
lower arousal
Self-injury, more
rigorous
restricting,
harder drugs to
replace the
substances that And intrusive
no longer work images, panic
The only answer attacks, night
left terrors
now is suicide
Triggered by everyday Leading to

stimuli, survivor But isolation even more
The natural impairs stimulus strenuous
becomes
reaction is to discrimination, attempts at
uncomfortable,
isolate to avoid causing more avoidance
overwhelmed, reactive,
potential triggers triggering
impulsive
Addictions and Trauma

Addictive behavior arises not as a pleasure-seeking
strategy but as a survival strategy:
•To self-soothe and self-regulate
•To numb the hyperarousal symptoms: intolerable
affects, reactivity, impulsivity, obsessive thinking
•To combat helplessness by increasing hypervigilance
and feelings of power and control
•To “treat” hypoarousal symptoms of depression,
emptiness, numbness, deadening
•In the service of walling off intrusive memories
•As a way to function or to feel safer in the world
Fisher, 2008

How Unsafe Behavior ʻHelpsʼ
•Jan, recalling abuse at age five: “Every day, I would say

to myself, ‘I can die tomorrow.’ I got through each day by
promising myself I could die the next day.”
•Annie, recalling how cutting helped her to function: “I
would cut myself to get off the floor of the closet and go
downstairs and make dinner for my family.”
•Anita, recalling a hospitalization at age 13: “After I got out,
I went to a party and had my first beer. I thought, ‘If I have
beer, maybe I won’t have to go back there again.”
•Peter: “I survived as a kid by locking myself in my room
and eating and masturbating til I got numb.”
81
How Substances “Medicate” PTSD

Hyperarousal symptoms:
•Alcohol and marijuana induce relaxation and numbing, facilitate
social engagement by decreasing hypervigilence, and allow sleep.
Cocaine, speed, and crystal meth counteract relaxation effects or
maintain hypervigilance. Heroin dampens rage and impulsivity,
while ecstasy combines relaxation with increased energy
Hypoarousal symptoms:
•Speed, cocaine, ecstasy and crystal meth counteract feelings of
“deadness,” numbing, hopelessness and helplessness, while
marijuana and other downers maintain the hypoarousal. Alcohol, at
different “dosages,” can induce numbing or counteract it. Although
a depressant, alcohol in small doses has a stimulating effect
Fisher, 2003

Addictive Behaviors and Self-

Regulation
•Eating disorders: over- and under-eating both induce numbing
effects, while purging results in a temporary increase in arousal
followed by profound hypoarousal
•Compulsive sexual behavior: sexual addiction increases

feelings of interpersonal control, counteracts hypoarousal during
seduction phase and induces relaxation during post-coital phase
•Self-injury: self-harm produces both an adrenaline and endorphin

response in the body, increasing energy and feelings of power and
clarity and also buffering the pain
•As in substance abuse, prolonged use of these behaviors leads to
tolerance: more and more is needed to achieve the same effect
Fisher, 2003
Modulating Trauma Responses

Behaviorally
Hyperarousal is decreased by:
alcohol, marijuana, heroin, overeating or
restricting, cutting, planning suicide or
self-harm, self-sacrifice and caretaking
Hyperarousal
Hypoarousal Hypoarousal is decreased by:

cocaine, speed, high-risk behavior,
cutting, suicide planning, re-enactment,
Ogden and Minton, 2000, re-victimization, hyper-reactivity
Fisher, 2004

Core assumptions of integrated model

•Sobriety or abstinence only address the addictions issues.
When behavior has been a post-traumatic survival strategy,
new challenges now arise
•The client now faces not only the risk of relapse but the
risk of post-traumatic flooding, autonomic dysregulation,
increased impulsivity, overwhelming emotions, and
flashbacks, all of which predispose the client to relapse
• Treatment must address the relationship between the
trauma and the addictive behavior: the role of the addictive
behavior in “medicating” traumatic activation, the origins of
both in the traumatic past, and the reality that recovering
from either requires recovering from both Fisher, 2007
Unfortunately, sobriety brings more challenges,
not fewer
Hyperarousal: over-activation The addiction has facilitated a

creates chronic de-stabilization
“false Window of Tolerance:”
and desperate craving for relief
the client is missing any other
way to self-regulate
Window of Tolerance in sobriety
Hypoarousal: numbing,
‘deadness’ and passivity
contribute to need for substances
to either shift or maintain this state

Abstinence/Relapse Cycle
Sobriety or Abstinence
Increased loss of “chemical

support”
acting out, Increase in
unsafe negative emotional
PTSD
effects of overwhelm,
behavior addiction irritability, symptoms
reactivity,
flooding,
sensitivity to
as a panicked
triggers
attempt at
Substance self-regulation
or Increase in
matches increase in
behavioral PTSD symptoms addictive
relapse impulses or
behavior
Fisher, 2009
“First Things First”

Increasing the ability to be mindful rather than
judgmental: mindfulness regulates arousal, “wakes up”
the frontal lobes, increases self-awareness, and allows
observation of patterns that “feed” addictive behavior
Building curiosity: since curiosity regulates the nervous
system, it lessens needs to act out
Focusing on the relationships between trauma-related
emotions and body sensations and compulsive
behavior: e.g., by learning to observe overwhelming
feelings and impulses, increasing ability to notice the
relationship between triggers, symptoms, and addictive
behavior
Fisher, 2013

Psychoeducation
•Offer a “crash course” on addictions/eating disorders as
attempts to self-regulate and on the Abstinence/Relapse Cycle
•Normalize feelings/behavior that have been sources of shame
as ingenious attempts to cope
•Label the symptoms as “symptoms”: poor judgment and
impulse control (“I can’t help it”), self-loathing, self-neglect
•Increase awareness of post-traumatic triggering and
habitual triggered survival responses: “getting” the logic of
trauma decreases shame/increases understanding of cause-and-effect
•Encourage curiosity and compassion: “That makes sense,”
“Of course you feel trapped at AA meetings,” “12-step programs are
just another treatment, and all treatments have side effects”
Fisher, 2003
Mindful Awareness of Connection

Between Behavior and Triggers
That’s a pretty
In the context of having used:
How could you big trigger!
tell people were People who don’t
I’m so glad What was getting to you? do their jobs, so
you could tell going on just That they had you have to carry
me you used before you ‘no respect’? all the load
last night— used?
what triggered
you?
“Yeah, just like

“One after
“I don’t “People were I have
another, they
know—I getting to me— my whole
weren’t doing
just hate they have no life. . .”
their jobs—I
my job” respect”
can’t rely on
anyone”
Fisher, 2008

Triggers, cont.
In the context of having used: Well, drinking does We have to figure
calm the nervous out a way for you
So the system—you were to know you’re
When you got trauma just trying to make triggered. People
triggered, what trigger the feelings disappear are going to be
feelings came triggered the assholes
up? food trigger! sometimes—you
don’t want to
relapse over
them
“But now I’m
“I just
feeling stupid,
wanted a “F--- it! I and my head is
burger and don’t have to “That’s for sure.
killing me, and
a beer” feel this shit” They’re not
I don’t want to
lose my wife” worth it”
Fisher, 2008
Tracking the Relationship Between Addictive

Behavior and Arousal
“Got a voicemail
from my father” “My hands were shaking—
went into kitchen and
started eating ice cream” Hyperarousal
“Made a peanut
butter sandwich—
and then another” Window of Tolerance
“After I threw up, Arousal
Optimal I Zone
felt better”
“Came home
from training “I felt better, Hypoarousal
“And then I
feeling OK” “Felt sick
then the phone and curled up on the
rang again!” disgusting” couch and slept”
Adapted from Ogden and Minton (2000)

Fisher, 2009

Re-framing the Symptoms:

‘Entraining the Positive’ [Fosha]
•Re-framing asks: how might the symptom be adaptive
or have adaptive intent? E.g., using cocaine or pot before
going to work might alleviate anxiety; the anorexic part of the system
might be trying to numb overwhelming feelings and sensations
•Addictions capitalizes on body chemistry: “Of course,
weed gives you relief: your body starts making neurochemicals that
take the edge off the pain and make you feel more in control;”
“When your risk-taking part drives that fast, you pump adrenaline;”
“Speed really helps with the hypervigilance, did you know that?”
•Celebrate the “survival resources” (Ogden, 2000): appreciation
of survival strategies challenges habitual beliefs of inadequacy and
also allows the therapist to ‘befriend’ acting out and addicted parts
Fisher, 2008
Re-framing Addictive Symptoms

•Heighten the client’s curiosity about the role of addiction
in his or her survival: what was the timing of the initial
attraction to drugs? How did the eating disordered part help her to
cope? How did later stressors impact addictive behavior?
•Re-frame the history by assuming that the addiction had
meaning and purpose: “How did the addiction help you to be
less afraid? Able to go to work? Or go to sleep? To handle being
around people? To act like everything was normal?
•Re-frame the relationship between PTSD and addictive
behavior: “The cocaine helped you to feel less numb, didn’t it?”
“So, you drink in order to sleep at night—that makes sense—you
can’t sleep, but you can pass out,” “It makes sense that you needed
the speed to be hypervigilant enough to go out” Fisher, 2005

Re‐framing Relapses and ʻSlipsʼ
•Even relapse behavior can be re-framed as a “golden

opportunity” or as a “spiritual opportunity,” thereby
challenging habitual shame responses to relapses
•Clients are asked to assume that the relapse is sending a
‘message:’ “If this relapse was sending you a message,
what would it say? That you didn’t have enough support?
Or you missed the early warning signs? You didn’t see the
trigger? You didn’t want to deal with the scared part?
•Rather than focusing on the negative effects of the
relapse, the new learning is celebrated, and the client
asked to practice these new responses Fisher, 2008
Cognitive Over‐ride
•Because traumatic triggering activates inhibits prefrontal

activity, the therapist cannot expect the client to
remember the coping plan or to use a “cognitive map” or
generalize the skills and knowledge, unless there has been
consistent rehearsal in sessions
•In sessions, therapist and client must practice the art of
“cognitive over-ride:” e.g., practice using the language of
triggering to describe activation, practice the art of keeping
“three frontal lobe cells awake” and mindful to observe the
triggered experience, or practice the use of distraction or
container techniques in response to the feelings and
activation that arise in therapy Fisher, 2006

Anticipation Skills
•Trauma survivors typically have elevated hypervigilance but
poor anticipation skills. They anticipate the worst but fail
to prepare for it
•Clients can learn to anticipate by mindfully analyzing each
crisis: looking for triggers, early warning signs, self-
sabotage, failures to utilize appropriate coping skills
•In preparation for upcoming events, the therapist must
help clients anticipate potential triggers and “rehearse”
skills and responses needed to prepare for the challenge
•Anticipation also decreases the “negotiating currency”
of unsafe behavior: rather than focusing on the ‘crisis du
jour,’ the work is focused on prevention of crises with the
therapist as a guide and mentor rather ‘EMT’ Fisher, 2009
Talk About Safety and Sobriety

from the Client’s Point of View
•Articulate the conflict between safety and unsafety: the
loss of control, of familiarity; the prospect of intrusive feelings; the
fear of becoming overwhelmed or feeling “weak”
•Acknowledge what the patient is sacrificing in
choosing safety: loss of immediate relief, loss of control, loss of
the “friend who is always there,” loss of a social network
•Foster a “de-coding” approach to acting out or unsafe
behavior: finding the trigger, creating a frame-by-frame de-
construction of triggers and reactions
•“Bore the patient into health” (Kluft) by a relentless focus
on deconstructing crises, anticipating triggers, and developing
increased ability to separate self from the part or symptom Fisher, 2009

In Place of Survival Resources, We

Offer Somatic Resources
Traumatic Reactions: Somatic Resources:
Shaking, trembling Deep breath, heavy sigh
Numbing Relaxation, opening
Hypervigilance Lengthening the spine
Agitation, desperation Focusing on the sensations
Collapse, shame Making a movement
Impulsivity Physical support (eg, chair)
Pulling back from help Grounding on the floor
Cultivating “10% Solutions” to

Overwhelming Feelings
•Breathing, sighing, releasing tension or taking in calm
•Taking walks, being physically active, yoga, tai chi, jogging
•Watching calming TV shows: eg, the Nature channel
•Engaging in any safe activity that calms the body (taking a bath,
making cookies, ironing, knitting, drawing, playing with a pet)
•Engaging in activities that require concentration but not much
thinking (tanagrams, jigsaw puzzles, computer games, solitaire)
•Working with the hands (gardening, cooking, needlework, painting)
•Prayer and meditation, listening to guided visualization tapes
•Inspiration: finding one thing that makes you smile
•Using mantras or sayings: “This too shall pass,” “One day at a
time”

Create Safety Nets

Coping
with Read meditation book--call a friend---go
feelings over coping skills cards---go to a 12-step
meeting---watch “The Lion King”
Coping with Don’t be alone---go over “Ten Things to

impulses Do” list---call my sponsor---breathe---live
a minute at a time---call the hotline
Coping with
Call my therapist---make sure I am in a
action plans
safe place---go to the ER---re-read my
contract---use my Survival Kit
Fisher, 1999
Make a Coping Skills Chart

Starting to Wanting to Starting to feel Hoarding
A little hate myself, hurt myself, suicidal, pills, buying
depressed say bad feeling like having razor blades,
and things, feel no one cares: fantasies about know that I
anxious shaky and my funeral am not safe
I’m all alone
agitated
Use Remember to Find someone Use Safety Talk to staff,

distraction: breathe! Go to talk to, Nets, go to the ER,
go for a walk, over 10% even about remember that give someone
listen to solutions list, the weather. this is my anything
music, read a try to relax Try not to be way of coping that I
magazine alone. with pain. shouldn’t
Remember have right
that the pain now
will pass
Fisher, 1990

Or Create a Survival Kit

A “Survival Kit” contains a variety of objects that are
symbols of “a reason to live” or of “what keeps me
connected to the universe,” “what keeps me keeping on:”
•Poems or prayers or inspirational sayings
•Pictures of loved ones (family, friends, pets)
•Letters, cards, tapes given by friends or caregivers
•Crystals, stones, seashells, driftwood, beach glass
•A stuffed animal or other comforting, beloved object
•Coping skills chart, safety contract, “What to Do” list
Fisher, 1995
Differentiating ʻsafeʼ andʻunsafeʼ?
•If self-harm, eating disorders, addictive behavior and
suicidal ideation are all attempts to self-regulate, it is
important not to treat them simply as life-threatening. We
need to distinguish life-threatening unsafe behavior and
behavior aimed at self-regulation
•The therapist should not assume that all of these
‘addictive behaviors’ are intended to be life-threatening
but should inquire: “How does this help? What does it do?”
•Self-injury is rarely life-threatening. If we respond as if it
has suicidal intention, we may unintentionally exacerbate it.
We will dysregulate the client and over-protect, robbing the
client of the opportunity to regulate her- or himself
Fisher, 2009

Not All Suicidality is ʻUnsafeʼ
•Active suicidal ideation and creating suicide plans may
be indicators of unsafety, but not always. Some trauma
clients have suicide plans for many years without ever
making an attempt.
•With planning and active ideation, the therapist should be
curious and concerned without conveying alarm. Our
alarm increases dysregulation instead of modulating it
•What should we be curious about? Curious about how
long the client has had the plan, about what has triggered the
increased intensity of suicidal longing, about how impulsive
or desperate the client is feeling, about whether or not s/he is
seeking death or just relief from overwhelm Fisher, 2009
Learning to Contract
•Therapeutic contracting is complicated because of issues of power
and control: as therapists, we want to avoid becoming the
patient’s external locus of control, their ‘reason to live’
•Contracts also carry two risks: first, suicidal clients often
acknowledge that they would not feel bound by any contract, so
contracting can feel like a “lie.” Secondly, being asked to contract
can be experienced as entrapping
•Commitment to the work of recovery or to choices that
enhance safety are most helpful: e.g., committing not to
isolate, go to 12-step meetings, or go to appointments. Time-limited
commitments are also better than open-ended contracting: “I can
keep myself safe until tomorrow morning . . . Until I go to work. . .”
“I commit to using my Survival Kit . . . To not being alone . . . To
follow my safety plan” Fisher, 2009

Most common mistakes made by therapists

in working with unsafe behavior
•Failing to validate the relief offered by unsafe behavior
•Failing to understand the fear of relying on people and the
safety in relying on a substance or behavior under your own control
•Failing to see that care of the body is not a priority for the
trauma survivor: when your body only matters as a vehicle for
discharging tension, its care becomes meaningless
•Failing to convey that trauma-related shame and secrecy
will make it feel “normal” to lie/evade and “unsafe” to disclose
•Becoming engaged in a struggle in which the therapist
becomes the spokesperson in favor of safety and the patient the
spokesperson for unsafe behavior, neglecting the task of helping the
patient to struggle with the strong internal opposing forces
Instead, we need to calm the body

and activate the prefrontal cortex
“In order for the amygdala to respond to fear
reactions, the prefrontal region has to be shut
down. . . Pathological fear, then, may occur
when the amygdala is unchecked by the
prefrontal cortex, and treatment of pathologic
fear may require that the patient learn to
increase activity in the prefrontal region so
that the amygdala is less free to express
fear.”
LeDoux 2003

Psychoeducation
•Connecting activation to its triggers: what is a ‘trigger’?

De-coding triggered responses, anticipating and preparing
for triggering situations, seeing the ‘trauma logic’
•Autonomic Arousal: frontal lobe shutdown, ‘highjacking,’
hyper- and hypoarousal, expanding the window of tolerance
•Labeling traumatic reactions as “body memories,”
“feeling flashbacks,” “long slow flashbacks”
•Reframing the symptoms: reinterpreting the symptoms as
attempts to adapt, survive, regulate arousal
•Phase-Oriented therapy: on what should we be working?
Fisher, 2013
“Effectively dealing with stress depends

upon achieving a balance between
[activating the amygdala] and
[activating the medial prefrontal
cortex]. If you want to manage your
emotions better, the brain gives you two
options: You can learn to regulate them
from the top down or from the bottom
up.”
Van der Kolk, 2014, p. 63

Psychoeducational Flip Chart (Fisher, 2011)
This psychoeducational flip chart consists of 22 diagrams

with text summarizing the most current research and
theoretical concepts in trauma treatment in a simple graphic
format understandable for most clients. The use of these
simple diagrams increases the ability of the client to
understand the nature of the symptoms and engage more
Translated into French,
easily in the treatment. Clients feel a sense of relief as their Spanish, Dutch, and
puzzling and disturbing reactions begin to make sense, and German. Available at
therapists find the flip chart a support for not only the www.janinafisher.com
treatment but also the relationship.

“When you hear something, you will

forget it.
When you see something, you will
remember it.
But, not until you do something, will
you understand it.”
Old Chinese proverb
Trigger Log
Feelings, thoughts,
Date, time, Intensity: Trigger: what Coping behavior:
body sensations
location 0-10 scale was happening? what did you do?
that got triggered
Fisher, 2006

Tracking Your Nervous System
High Activation
A
R Optimal Arousal Zone:
feelings can be tolerated
O we can think and feel
U simultaneously
S
A
L
Low Activation
*Spiegel (1999)
What happens when you get triggered? What kind of
activation do you experience?
High Activation
Client: “I panic---feel like throwing up----jaw
clenches----want to run away---always feel like I can’t
take this anymore!”
A
R
O “Hardly ever here! Maybe when
U I’m with my daughter. . . “
S
A
L
“Or I go to bed, pull up the covers and try to
zone out---sometimes I can go into a “whatever”
state where I don’t care anymore”
Low Activation Ogden and Minton (2000)

Fisher, 2006

How do you know when you are

in your Wise Mind?
“In this realm, I can
think, plan, be
Frontal Lobes “Here, I feel like
somewhat rational---
this is where I do my (Wise Mind) a child or even
job and manage all an animal,
my daughter’s relying on
activities and keep instinct, not
the household trusting anyone,
running” Emotional having these
Brain huge emotional
storms”
“Chest feels tight,

my legs are jiggling,
hard to breathe
Reptilian Brain because my chest is
so tight”
Fisher, 2003
Differentiating Facts from Feelings
[Fay, 2003]
• Feelings • Facts
• “I’m in my own home; the
• “I’m not safe” doors are locked; my dog
barks at strangers”
• “I have three friends

• “No one cares about me” I’ve known since college
and I live with my
parents”
• “I should hurt myself” • “Hurting myself only

helps for short periods
of time”
Fisher, 2005

Reaction Cycles
Immediate somatic
response Automatic
thoughts:
“It’s not
safe,” “I blew
Feel more it again”
desperate, Emotional
Dark
more reactivity
depression
impulsive
and
suicidality
Gather
More evidence of
reactivity danger or
worthlessness
Start predicting the
future
Fay, 2004
Response Cycles
Breathe! Slow down reactivity
“Don’t have to Be curious: “Is

figure it out this familiar”
now: just have Immediate
“Have I been
to get somatic
here before?”
grounded” response
Step back:
“What’s
happening?”
Slowly coming back to

Stay in present
normal activation: “It’s
time: “I hate it
OK---I was just
when this
triggered”
happens”
Fay, 2004

Using “Stepping Stones” “I want to

connect with
people”
Going to
lunch
with Erin
Joining
church or
community
group
Disclosing a
Talking more little more
to my partner when I talk
Sharing a tiny
bit more with
friends and
“It’s not safe neighbors
Participating
to let people more in
know you” socializing at
work
Fay, 2004
“Words cannot integrate the

disorganized sensations and
action patterns that come
from the core imprint of
trauma.”
van der Kolk, 2004

Resources that Regulate Arousal Facilitate

an Autonomic Sense of Safety
For Hyperarousal, we need to:
Slow down reactivity, impulsivity
Relax hypervigilance, hyperdefensiveness
Decrease flashbacks, nightmares
Sympathetic Arousal
Diminish elf-destructive, risk-taking, acting out
For Hypoarousal, we need to:

Parasympathetic Arousal Increase affect, counteract numbing
Increase frontal lobe activity
Increase activity level and energy
Decrease passivity and helplessness
*Siegel, D. (1999)
“The regulating brain is helping

the body to regulate, and the
regulated body in turn provides
ongoing feedback to the brain to
stay regulated.”
S. Fisher, 2014, p. 274

Somatic Resources
Somatic resources are the category of
resources that emerges from a person's
physical and body experience. Somatic
resources consist of any and all anatomical
and physiological functions that support a
physically felt experience of self,
competency, and well-being at the body level,
which in turn, facilitates cognitive and
emotional processing.
Bowen, 2000
Make Use of Somatic Resources to

Address Traumatic Reactions
Traumatic Reactions: Resources:
Shaking, trembling Deep breath, sighing
Numbing Grounding
Hypervigilence Lengthening the spine
Agitation, anxiety Hand on the heart
Collapse Movement
Tensing, armoring Tensing, then relaxing
Freezing Relaxing arms and legs

GROUNDING
for both hyper- and hypoarousal
•Sitting in a chair, gently push feet into the ground.
Notice the sensations in the legs and in the back as
you are pressed back against the chair. Experiment
with finding just the right amount of pressure or with
stomping the feet instead of pushing.
•For dysregulated clients, this resource can be bite-sized:
“Just notice the feeling of the ground under your feet,”
“Notice what happens if you plant just one foot on the
floor,” “Would you be willing to let your other leg drop to
the floor?” “Can you feel your butt on the seat of the
chair?” Sensorimotor Psychotherapy Institute
ALIGNMENT for
hyper- and hypoarousal
•For hypoarousal: experiment with what happens when
client lengthens the spine just a little bit, then a little more.
What shifts? Does it feel better or worse?
•For hyperarousal: experiment with lengthening the spine
slightly more and noticing what happens
•Use alignment to help client study impact of negative
beliefs: “Notice what happens if you allow your spine to
slump, to collapse. . . How resourced are you? How true
does it feel that you are helpless?” “What happens if you
lengthen your spine? What do you notice? Is that better or
worse? More resourcing or less?”

CENTERING
for hyperarousal
•Place one hand on your heart, and one hand on your
belly, and notice what happens in the body when all
thoughts are dropped, and you focus just on your two
hands: observe the weight of the hands, temperature,
sensations, changes in breathing, energy of the hands
•For more dysregulated clients: “Place a hand just
over your heart, and notice what happens to your
heartrate, your breathing,” “Would you be willing to
place a hand over the place where you are feeling this
anxiety?”
ORIENTING
for hyper- or hypoarousal
•When clients go into flashback or start to dissociate or
‘fade out,’ orienting to the external environment can be a
helpful way to “come back” into the room. Have client
practice 360 degree turning movements through the head,
neck, and spine, and notice what happens in the body
•Ask the client to turn his/her head and neck and slowly
focus on objects around them: the window, the wall, the
door, the lamp, the bookcase. Or, clients can be asked to
focus on objects that might be regulating: their least
favorite object, most favorite, or cues that tell them where
they are

The Therapist as a Somatic

Resource
“[The therapist must act as an
auxiliary cortex] and affect
regulator of the patient’s
dysregulated states in order to
provide a growth-facilitating
[therapeutic] environment. . . .”
Schore, 2001
Being a ‘neurobiological
regulator”
•Being a neurobiological regulator requires that the
therapist stay attuned to both the regulating and
dysregulating effects of the therapeutic encounter. Like
a “good enough” mother, we must strive to create an
optimal level of arousal from moment to moment
•Effective neurobiological regulating on the part of
therapists requires paying more attention to how we
are affecting autonomic arousal than we pay to the
content of the patient’s communication and with how
to maintain an optimal level of arousal in the room
Copyright 2006 Janina Fisher, Ph.D.

Mirroring = Attunement
•To foster a “felt sense” of connection, we mirror the
client’s words and body language, hoping to evoke a
visceral sense of being joined, a shared space, a sense of the
therapist’s interest and ability to ‘get it’
•Mirroring is not about WHAT we say but HOW we say
it: interest, body language, choice of words, tone
•It is also ‘dyadic dancing:’ as we mirror clients for signs
of resonance, we adjust our words and presence to maximize
their ability to stay present and socially engaged. Like
parents, our moment-to-moment adjustments help clients to
regulate and keep their frontal lobes “online” as much or
more as any skill we could teach them
Fisher, 2013
Strategies for neurobiologically regulating

clients
•Varying voice tone and pace: soft and slow, hypnotic tone,
casual tone, strong and energetic tone, playful tone
• Energy level: very “there” and energetic versus more passive
•Empathy vs. challenge: does the client do better with empathy?
Or challenge? Does s/he need limits to regulate?
•Amount of information provided: noting the effect of
psychoeducation or therapist self-disclosure
•Titrating vs. encouraging affective expression
•Providing more vs. less support: does client become
dysregulated with more contact? Or less? Does s/he self-regulate
better with less or more support? Fisher, 2009

Noticing rather than interpreting,

playing rather than ‘working’
In collaboration, therapist and client “study what is

going on [for the client], not as disease or something
to be rid of, but in an effort to help the client become
conscious of how experience is managed and how
the capacity for experience can be expanded. The
whole endeavor is more fun and play rather than
work and is motivated by curiosity, rather than
fear.” Kurtz, 1990, p. 11
Dyadic Dancing with the Client
•“Dyadic dancing” with clients means “going with” their

resistance, rather than offering resistance to their
resistance! For example:
•“Yes, I can see why suicide could feel like the most
logical solution to feeling so out of control . . .”
•“Yes, I can see that you would be afraid to hope . . . Hope
was so unsafe when you were a child”
•“If you’re invisible, you fly below the radar—so much
safer that way”
•“Yes, it isn’t fair that you have to comfort yourself when
others are responsible for your pain . . .” Fisher, 2006

“Mirror Neurons” [Gallese, 2000] and the Practice of

New Actions
• The theory of “mirror neurons” proposes that we have a

type of motor neuron that does not just fire when we
actually move but also in anticipation of actions that
might be necessary: e.g., when we perceive others
executing a particular action or if we imagine an action
that we might want to execute
• “Animal studies show a striking similarity of neuronal
activity correlated with perceiving, imagining, and
executing physical actions. For example, when monkeys
perceive an object [being manipulated], they activate the
same neurons as when they actually manipulate the
object. . . ” (Gallese, 2000) Fisher, 2005
Mirror Neurons, cont.
•Many experts believe that mirror neurons are the “active

ingredient” in empathy: when we resonate to someone’s
experience, it is because our mirror neurons are firing
•This concept offers an intriguing avenue for th self-
regulation and new actions and reactions
•We can capitalize on the action of their mirror neurons by
providing opportunities for observation, visualization, and
practice of new actions. Rather than “talking about”
using new skills, the therapist’s demonstration or
modeling will stimulate the mirror neurons in the patient,
even as she is protesting that this is silly or useless
Fisher, 2005

For further information:

DrJJFisher@aol.com

www.sensorimotor.org

Working with the

of Trauma
Working with Traumatic Memory: Principles and

Techniques
“At first sight it seems extraordinary that events

experienced so long ago should continue to
operate so intensely—that their recollection
should not be liable to the wearing away process
to which we see all memories succumb. . . .
[A]nother remarkable fact: . . . these memories,
unlike the memories of their lives, are not at the
patient’s disposal. On the contrary, these
experiences are completely absent from the
patient’s memory when they are in a normal
psychical state or are only present in a highly
summary form. . .”
Breuer & Freud, 1893, P. 7-11

Phobia of Traumatic Memory

 “It’s too dangerous for me to put these
things into words. I am afraid they might
become gigantic and I be no longer able to
master them.”
 E.M. Remarque (1929/82, p. 165)
“The moment any [Holocaust] memory or

shred of a memory was about to float
upwards, we would fight against it as though
against evil spirits.”
 A. Appelfeld (1993, 1994, p. 18)
“Parallel Lives” [Deirdre Fay, 2002]

The danger feels
Here & Now like “NOW!”
There & Then

Implicit
Memory of
Fear/Terror
Fay, 2003

“The [traumatic]
past is not dead and
buried. In fact, it
isn’t even past.”
William Faulkner
The nature of memory
•When we talk about ‘memory,’ we generally mean

‘explicit memory,’conscious verbal memory, including:
•Declarative memory: verbal description, stories
•Autobiographical memories: the narrative of personal
experience
•Fund of knowledge: vocabulary, multiplication tables,
politics and current events
•Working memory: holding ideas in mind, problem-
solving, learning from experience
•Explicit memories are voluntarily retrievable: we can
choose to recall them or not recall them. Fisher, 2013

“State‐Specific Memory”
•Our memory system has both voluntary and state-specific
areas. Some types of information can easily be retrieved
voluntarily (e.g., the multiplication tables, old family
stories, acquired knowledge), while other types of
memory are more state-dependent (memory for faces and
names, procedural memory, implicit memories)
•As we tell a narrative, its state-specific aspects begin to
“bring alive” the experience: we start to feel the implicit
emotions and body sensations. E.g., “I can feel my
daughter’s tiny body in my arms and a warm feeling in my
heart,” “As I talk about this, my heart is pounding,” “This
is overwhelming to talk about,” “I laugh just recalling it”
Ogden, 2006; Fisher, 2008
Different “departments” for different memories

Frontal cortex: ‘the
story’ and beliefs
attached to it
Hippocampus: the
brain’s“filing cabinet:”
organizes,
contextualizes,
sequences
Putamen:
procedural
memories, what to
do, how to react
Amygdala: implicit
and emotional
memory
Caudate nucleus:
instinctual responses
(fight/flight/freeze)
Carter, 1998

The nature of memory, cont.
•The implicit nonverbal memory system is an even more
powerful influence on our behavior than declarative.
Implicit memories are “state specific.” We cannot choose
to retrieve them; they are triggered by associated stimuli:
•Emotional memory: feelings, emotions
•Visceral memory: internal body sensation
•Perceptual: olfactory, visual, auditory, tactile
•Muscle memory: posture, tension, movement, skills
•Autonomic: sympathetic-parasympathetic responses
•Vestibular: balance
•Procedural: memory for habit and function
Fisher, 2013
Memory System
Explicit Implicit
Memory Memory
Recall of Working Procedural Conditioned

facts memory habits responses
Autobiograph-
ical narrative Priming
Trauma impairs explicit memory functions and increases

vulnerability to situationally-activated implicit memories.

Memory formation in children
•Just as verbal receptive language develops prior to

expressive language, implicit memory formation precedes
encoding of explicit declarative memories
•In addition, there is evidence that the ability to formulate
declarative or autobiographical memory is ‘experience-
dependent,’ i.e., we remember narratives earlier and
more consistently when remembering is encouraged
•Parents who support early acquisition of narrative memory
ability are described as focusing children on their positive
experiences and recounting them for the child, re-stating
what happened multiple times, and communicating positive
feelings about events to be remembered Fisher, 2013
Memory formation in children, p. 2
•Implicit memory is dominant during the first two years

of life and when adaptation to the environment requires
procedurally learned responses, not verbal dialogue.
•Nonverbal memory is more helpful in survival
situations because it “primes” or conditions the body to
respond to danger automatically
•Van der Kolk’s landmark brain scan study was the first to
demonstrate that, when subjects recalled traumatic
experiences, implicit memory areas in the limbic system
were activated and explicit memory areas in the prefrontal
cortex were de-activated Fisher, 2013

Encoding of Traumatic Memory

Van der Kolk, 1995; Fisher, 2008
Hippocampus: Inhibited
also inhibited during the
during threat event, it fails
response, how can
to witness
it process a
what
trauma?
happened,
complicating
the encoding
of a narrative
memory
Threat Amygdala: the unprocessed

implicit traumatic memories are
encoded here and are activated
by triggers
Sensorimotor Psychotherapy™ Institute
2012
Addressing declarative memory

doesn’t resolve implicit memory
“[It] is in the very nature of traumatic memory to
be dissociated, and to be initially stored as
sensory fragments without a coherent semantic
component. The persistence of intrusive
sensations related to the trauma [even] after the
construction of a narrative contradicts the notion
that learning to put the traumatic experiences into
words will reliably help to abolish the occurrence
of flashbacks.”
van der Kolk & Fisler, 1995

ʻModalities of memoryʼ associated with trauma
In their 2001 study of traumatized adult patients who had

awoken from anesthesia in the middle of surgery, van der
Kolk et al (2001) found that, even after recalling a
narrative, they reported that they kept re-experiencing
the traumatic event via the following additional “channels”:
Visual
Affective
Tactile
Olfactory
Auditory
Fisher, 2013
Non-verbal memories don’t feel

like memory—they feel like “me”
“When the images and sensations of
experience remain in ‘implicit-only’
form . . ., they remain in unassembled neural
disarray, not tagged as representations
derived from the past . . . Such implicit-only
memories continue the shape the subjective
feeling we have of our here-and-now
realities, the sense of who we are moment
to moment. . .” Siegel, 2010, p. 154

Traumatic implicit memories are experienced as:
•“Feeling flashbacks” of desperation, despair, shame

and self-loathing, hopelessness and helplessness, rage
•Chronic expectation of danger: hypervigilance and
mistrust, fear and terror, “post-traumatic paranoia”
•“Body memories:” numbing, dizziness, tightness in the
chest and jaw, nausea, constriction, sinking, pain
•Impulses and movements: motor restlessness, ‘hang-
dog’ posture, frozen states, impulses to “get out,” violence
turned against the body, huddling or hunkering down
Fisher, 2013
The ʻNegativity Biasʼ
•Presented with negative and positive stimuli, the human

brain is biased to attend to the negative. While the
emotionally neutral left brain is biased toward the positive,
the more emotional reactive right brain is biased toward the
negative, as is the amygdala, two thirds of whose cells are
dedicated to scanning for negative or threatening stimuli
•Hamlin et al (2010) observed the negativity bias is
operative at ages as young as six months
•When limbic activation “highjacks” higher levels of the
brain, the prefrontal cortex can no longer dispute the
negativity bias with logical data, leaving the limbic system
“in charge” of our perceptions Fisher, 2013

The ʻNegativity Biasʼand Trauma
•One of the first observations made about post-traumatic

stress by Kardiner in treating World War I ‘shell-shock’
patients was the tendency for their attention to keep
returning to the trauma. It was as if they could barely keep
their attention focused on present moment or neutral stimuli
•It is quite possible that post-traumatic hypervigilance
coupled with the negativity bias accounts for this
phenomenon. It is equally possible that patterns of
avoiding traumatic memory or emotion reflects the same
•But the chronic intrusions of traumatic images and
emotions interfere with processing by activating the implicit
memories and the sense of ‘danger now’ Fisher, 2013
The Nature of Traumatic

Memory
“[It] is in the very nature of traumatic memory to
be dissociated, and to be initially stored as
sensory fragments without a coherent semantic
component. . . . The persistence of intrusive
sensations related to the trauma [even] after the
construction of a narrative contradicts the notion
that learning to put the traumatic experiences into
words will reliably help to abolish the occurrence
of flashbacks.”
van der Kolk & Fisler, 1995, pp. 515-16

Sensory Fragments without Words = Implicit
Memory
•All experiences are remembered implicitly but not all are
encoded explicitly. Traumatic experiences typically fail to
be encoded as autobiographical memories (“I remember it
happening”) because of frontal lobe de-activation
•The victim is left instead with easily activated implicit
memories: automatic emotional, physical, and somato-
sensory responses disconnected from the events
•Verbal recall re-activates these implicit memory
networks, rather than processing them, but more frequently
implicit memories are evoked by everyday triggers and
interpreted as information about “now” Fisher, 2017
These implicit emotions, overwhelming

images, and body sensations can threaten
safety and stability
“As the survivor summons her memories [to
try to create a narrative of what happened],
the need to preserve safety must be balanced
constantly against the need to face the past. . . .
Avoiding the traumatic memories leads to
stagnation in the recovery process, while
approaching them too precipitously leads to a
fruitless and damaging reliving of the
trauma.” Herman, 1992

“Working with traumatic memories is

destabilizing. There is no way to get around this;
opening up to memories of terror and
helplessness will unglue anyone. The person who
lives with the aftermath of traumatic experience
develops . . . defenses that enable them to live with
the fact of whatever it is that they have endured.
Defenses may include dissociation, avoidance,
repression, and so on. Some defenses will be more
effective than others, but all of them help an
individual to cope.”
Rothschild, 2017, p. 4
Establishing a relationship to oneʼs traumatic
memories
•Brewin et al (1996) observed three types of

relationship to memory in trauma patients:
•Completed, successful resolution: client may get
triggered but recognizes it and can re-regulate
•Chronic incomplete emotional processing: client
ruminates about the past, is emotionally flooded,
preoccupied with trauma, unable to focus on normal life
•Sustained and automatic suppression and
avoidance: client avoids talking about the past,
minimizes or is disinterested in it Fisher, 2009

What should be the goal when

we address event memories?
“[Successful treatment of traumatic memory]
consists of helping patients to overcome the
traumatic imprints that dominate their lives:
the sensations, emotions, and actions that are
not relevant to the demands of the present but
are triggered by current events that keep
reactivating old, trauma-based states of
mind.” van der Kolk, 1996
Truth be told, the past is stable. What happened, happened.
No matter what we do in therapy, no one can change

history. How it is remembered, how it is reported, how it is
felt or interpreted, how we regard it, and different
viewpoints can all change, but the facts of the past are
permanent. We can not change the past, no matter how
hard we try or how good our tools. It is just not possible.
The past is, literally, out of our control. . . . The good

news is, we can change the effect the past continues to
have on ourselves and our clients now and in the future.
That is really the aim of trauma recovery. . .”
Rothschild, 2017, p. 13

‘Talking About’ versus ‘Processing’ Memory
•“Talking about” what happened (i.e., accessing

narrative memory) does not process or metabolize the
memories. It establishes a context for the symptoms,
validates the suffering, and increases self-compassion
•And because narrative re-telling activates implicit
memories (emotions, body sensations, autonomic arousal), it
risks autonomic dysregulation and re-traumatization
•“Processing” memories refers to interventions that
transform or digest the experience in some way and do
not always include attention to the narrative. In
processing, we seek interventions that promote a sense of
mastery, even if they elicit strong emotions Fisher, 2009
Why do clients want a ʻwitnessʼ?
•A cornerstone of trauma treatment for decades has

been the telling of the story to a “witness.” But telling
“what happened” is not just a drive to be “witnessed”
•Human beings want to be heard when they are frightened,
distressed, angry, hurt, or lonely because they want
someone to “do something” to shift their state
•The animal defense of “cry for help” is an instinctive
response for children and other vulnerable beings.
Therefore, “wanting to be heard” in the treatment of
trauma is a feeling memory of the longing to be helped,
not just a longing to be acknowledged Fisher, 2012

“Telling the story to

ourselves is more
important than telling it
to someone else.”
van der Kolk, 2009
Transformative Witnessing
•Witnessing of an adult’s story of the past will not

resolve the implicit memories of no one hearing, no one
doing anything to protect, no one seeming to care. The
goal of witnessing should be to evoke an experience of “it’s
different now . . . Someone is here now”
•But telling the story activates the implicit memories
associated with it, causing clients to automatically
disconnect emotionally and default to a dissociated state.
The therapist is present but not the client
•For those who need witnessing, we need to use
transformative techniques that allow clients to stay
present and experience a ‘felt sense’ of being witnessed
Fisher 2014

Transformative Witnessing, p. 2
•Set the stage: “Today, you are going to tell me about what
happened when you were 6—no one was there to listen
then, so it’s very important that 6-year-old feels both of us
listening very carefully today. As you tell the story, I’m
going to pause you every so often to make sure you and she
both know that someone is here, listening . . .”
•Slow the pace: don’t let the client tell the story detail by
detail or very quickly. Detail activates more of the implicit
memories; the fast pace leads to disconnection. Don’t be
afraid to “empathically interrupt” to regulate pacing:
the interruptions are necessary to the experience of keeping
the client in the room to feel witnessed! Fisher, 2014
Transformative Witnessing, p. 3
•Bring the client’s attention to what’s happening:
“Notice that as you are speaking, I am listening. I’m right
here with you. Can you feel me here?”
•Bring his/her attention to what’s different: “It’s really
different, huh? Back then, that 6 year old had no one to
listen, no one to help her, and right here, right now, we’re
both here. Can she notice the difference?”
•Try to evoke a felt sense that can be remembered as a
new experience: “What’s that like for her? Is it
emotional? Or more calming and reassuring? How do you
feel different inside when you can see and feel someone’s
here with you now?” Fisher, 2014

Memory Processing and the

Therapeutic Relationship
“Modern memory research is clarifying that
the painful edge of affectively negative
memories may be dulled substantially if they
are followed by intensification of positive
feelings (Donovan, 2010; Nader and Einarsson, 2010),
including the positive affective aspects of
supportive therapeutic settings.”
Panksepp et al, 2012, p. 15
Memory Processing and the

Therapeutic Relationship, cont.
“For instance, if therapists are able to evoke
positive, even playful feelings, there is a
reasonable chance that the subsequent
memory-reconsolidation process will carry
along the new positive affective [elements],
thereby dulling the aches of painful
memories. . . .” Panksepp et al, 2012, p. 15

A ʻRepairʼ Model for Trauma Work
•If the issue in trauma is not ‘just’ the events but the
implicit memories, “pathogenic kernels,” and autonomic
dysregulation, how does that change our approach to
working with memory? Should treatment focus on
processing memories?? Or on ‘repairing the damage’?
•A repair model is premised on the assumption that any
intervention that successfully resolves the ‘pathogenic
kernels’ or implicit memories is ‘memory processing’
•Should we focus on what happened?? Or on what
‘happened’? What happened to the ability to feel safe in
the world? What happened to the nervous system? What
happened to intimate relationships? Fisher, 2008
ʻPathogenic Kernelsʼ of Memory [van der Hart et
al, 2006]
•‘Pathogenic kernels’ are the symptoms, responses, and

difficulties left as a legacy by traumatic events. To identify
them, we ask: what stands in the way of resolution?
•The most common pathogenic kernels seen in complex
trauma and dissociative patients include:
•Chronic dysregulation
•Post-traumatic cognitive schemas
•Attachment and social engagement
•Phobia of the traumatic memories
•Phobia of the parts
•Phobia of change and/or pleasure Fisher, 2009

ʻPathogenic Kernels,ʼ cont.
•Chronic autonomic activation and dysregulation: the

trauma always feels ‘now,’ not ‘then.’ Normal life and
states of calm or well-being can be as triggering as memory
•Post-traumatic cognitive schemas reflect an
internalization of the perpetrator’s value system and
treatment of the client.
•Effects of trauma on attachment and social engagement
interfere not only with relationships but with the therapy.
•Phobia of traumatic memory = fear of becoming
overwhelmed by both the sensations and acceptance that ‘it
happened, and it happened to me’ Fisher, 2009
Neuralplasticity vs. Processing
•If trauma responses are driven by an irritable amygdala,
overactive hippocampus and inhibited prefrontal cortex, a
‘repair’ model helps us focus on neuralplastic change
• “Neuralplasticity refers to the ability of neurons to forge
new connections . . ., even to assume new roles. In
shorthand, neuralplasticity means rewiring of the
brain.” (Schwartz & Begley, 2002, p. 15)
•“Neurons fire whenever we have an experience. With
neural firing, the potential is created to alter synapses
by growing new ones, strengthening existing ones, or
even stimulating the growth of new neurons that create
new synaptic linkages.” (Siegel, 2007, p. 30) Fisher, 2009

A neuroplastic approach to trauma treatment
•Neuroplasticity is fostered by inhibition of old responses

coupled with repetition of new, more adaptive responses.
“Attending to one sense . . .does not simply kick up the
activity in that region of the brain. It also reduces activity in
[other] regions . . .” (Schwartz & Begley, 2002, p. 333)
•Sensorimotor Psychotherapy encourages neuroplastic
change by asking the client to pause, inhibit old responses
for a moment, and then “notice what’s happening right
now in your body as you focus on this ______________”
•That noticing opens up choices of new responses: new
words, new movements, new resources that can be practiced
repetitively until well-integrated Fisher, 2015
Dual Awareness: Keep the

Frontal Lobes “On Line”
•Dual awareness refers to the mental ability of divided
attention: to be both the observer and the observed
•In states of dual awareness, we can hold past and
present in consciousness simultaneously: eg, we can recall
a “sliver” of memory and observe with curiosity what
sensations, affects, and cognitions are activated
•The transformative effect of dual awareness stems from
recalling a traumatic event in a self-witnessing state,
rather than re-experiencing it as if it were happening now.
Dual awareness creates a separation between past/present
that helps to integrate the two realms of experience as
separate Fisher, 2015

“[E]motional learning usually consists of

much more than stored memory of the ‘raw
data’ of what one’s senses were registering
and what emotions one was experiencing
during an original experience. Also [stored
in implicit memory] is a constructed mental
model of how the world functions, a template
or schema that is the individual’s sense-
making generalization of the raw data of
perception and emotion.”
Ecker et al, 2012, p. 6
“This model [was] created and stored with no

memory of doing so. It does not exist in
words. . .”
“Emotional memory converts the past into

an expectation of the future, without our
awareness, and that is both a blessing and a
curse. It is a blessing because we rely daily
on emotional implicit memory to navigate
us . . .”
Ecker et al, 2012, p. 6

Mindfulness and Parallel Processing in the
Treatment of Trauma
"As long as you are able to have parallel processing, you will not be
traumatized...The prefrontal cortex allows us to have this observing
presence...and that is something we have to cultivate with our clients.
But we don't cultivate it by having them relive the traumas over and over
and abreact them... [When we encourage reliving,] we often…injure the
client more...”
van der Kolk, 2001
Resolving Trauma by “Repairing” Traumatic
Dysregulation
•“Uncoupling” autonomic arousal from the story of

what happened until it is no longer overwhelming to tell
•Increasing the client’s mastery over states of dread,

terror, panic, rage by cultivating somatic resources
•Expanding the capacity to feel safe in the body

through practicing actions of setting boundaries, engaging
defensive responses, or maintaining dual awareness
•Expanding the capacity to tolerate states of calm,

peacefulness, well-being, and joy Fisher, 2007

Uncoupling ʻOver‐Associatedʼ Sensations and
Dysregulation
•At the moment of threat, trauma-related stimuli and

neutral stimuli become “coupled” or “over-associated.”
Time of day, weather, a smell, the wallpaper, a tightening in
the gut or sinking feeling, increased heart rate become triggers
• Because these intense sensations, movement impulses,
emotions, and autonomic activation are not recognizable
as “memory,” they feel and out of control.
•In order for clients to feel a sense of mastery over their
symptoms, it is essential for teach them to “uncouple” the
physical experiences from the traumatic content or the
interpretation of them, to uncouple past and present
Fisher, 2007
How Do We Know When Trauma is

‘Processed’? [Steele, van der Hart & Nijenhuis, 2001]
•When past and present and the implicit and explicit
memories have been integrated, and the client can make
meaning of what happened, recall the past in context
without becoming dysregulated, and differentiate past and
present
•When clients achieve “personification,” the ability to
“own” the trauma: “It happened, and it happened to me”
•And achieve “presentification,” finally relegating the
traumatic events to the past: “It is over now. That was a
long time ago. I survived. And I am safe now.”
Fisher, 2009

Increasing Ability to Modulate Arousal

Decreased impulsivity and risk-taking, greater control over actions
Relaxation in hypervigilance and post-traumatic dread
Diminished flooding, less emotional overwhelm
Decreased obsessiveness and compulsive behavior
Hyperarousal
Hypoarousal Hypoarousal-Related Symptoms:

More present and responsive, more ‘there’
Greater ability to think and plan
Increased energy, decreased hopelessness
Ogden and Minton (2000);
Fisher, 2006
Less helpless and passive
*Siegel (1999)
Principles of Memory Work

•“Remembering is not Recovering” (Courtois, 1999): the
trauma survivor must overcome the fear of memory and
address the “pathogenic kernels” (van der Hart, 2000) that
continue to exert an influence over current experience
• Because even “thinking about thinking about it” can
activate autonomic arousal, focus on “event memory”
may increase vulnerability to dysregulation. Working with
“slivers” of memory or triggered memory is more effective
•Traumatic memory does not have to be deliberately
“retrieved” because it cannot be avoided: it is constantly
being re-activated by normal life triggers. Processing
triggered memory is also “memory work” Fisher, 2005

Primary vs. Secondary Memory

[Hoffman, 2003]
Must always be
addressed first after
Addressed chronic or
first after childhood trauma
recent or
single-
incident until
trauma Primary Secondary there is
or Event or sufficient
stability
Memory Triggered and
but can be Memory capacity to
destabilizing integrate
for childhood experience
trauma
survivors
Fisher, 2003
Principles of Memory Work, cont.

•Repetitively triggered implicit memory fragments that
threaten normal functioning need to be integrated first:
•By welcoming the symptoms as ‘feeling’ or ‘body
memories’ that “tell the story” of what happened equally
as well as event memories or images
•By re-organizing the patient’s relationship to the
memories through mindfulness, modulation of arousal, past-
present differentiation, working with the body, meditation, yoga,
tai chi or chi kung, or empowering activities/actions
•By changing patterns of response through the
practice of new responses: mindfulness, grounding,
cultivating curiosity, alignment, boundaries
Fisher, 2009

An Integrated Approach to
Working with Traumatic Memory
•Look for the “pathogenic kernels” (van der Hart, 1999) rather
than focusing chronologically: work with the memories that
still have somatic, emotional and cognitive “power” over the client
•Emphasize survival aspects in place of terror: highlight
survival resources, courage and ingenuity in the face of danger
•The goal is integration and mastery: whether it is reached
via a restored comfort in social engagement, a re-negotiated somatic
sense of self, or new meaning-making
•Work toward personification, presentification, and re-
negotiated sense of identity: who am I now in the light of the
past? Who is the person I was always meant to be? Fisher, 2003
Acknowledging Triggering
• Triggers are not best acknowledged by connecting them

to a past narrative since the memory will increase the
activation, not resolve the memory. Triggers are best
acknowledged by referencing the traumatic past
without exploring it.
• The goal is recognition that the body or emotions are
remembering the past—in a moment when clients can
look around to see that nothing dangerous is happening
• When they relate to triggering by remembering specific
events, clients can exacerbate their state-specific
symptoms. When they relate to triggering as just a
symptom, its power is reduced! Fisher, 2014

Re‐framing aids acceptance of implicit memory
• Implicit memories are a potent contributor to the

trauma survivor’s fears that s/he is crazy, defective, or
“losing it.” Overwhelming emotions, involuntary
shaking, moans, or movements feel “out of control”
• Although it is helpful to observe and name them as “body
memories” or “feeling flashbacks,” interpreting implicit
memories as information about how the client survived
gives them new meaning and purpose
• The sudden sensation of fear or dread was once a
warning signal of real danger, not a false alarm. The
twitch in her arm is a sign she wanted to fight back
Re‐framing aids acceptance of implicit memory,
cont.
• Re-framing also draws a clear distinction between the

past and the present: “It helped you survive then to mistrust
all human beings over the age of 25, and now, it makes it
harder to be in the world. . .”
• Often, clients have failed to encode their stories past
the trauma: new, safe, pleasurable or honorable experiences
have been interpreted negatively, not owned as real
• If we want them to ‘own’ the story of what happened
after the trauma, re-framing will aid in their seeing how even
rocky periods, unsafe behavior, or self-hatred were ways of
surviving the aftermath of what happened Fisher, 2014

The treatment of implicit

memory as “memory”
•When clients are avoidant of event memories, have little
access to them, or are troubled by the implicit memories
more than explicit, the ability to identify implicit
memories and process them becomes crucial.
•“Processing” = changing our relationship to a memory.
After processing, it feels further away, less overwhelming,
more settled and in the past. We feel safer inside or have a
felt sense that “it’s over and I’m safe now”
•To change the relationship to implicit memory, we have
to name it: “This is very triggering to talk about, huh?”
Fisher, 2013

memory as “memory,” p. 2
•To change the relationship to implicit memory, we can
also make a connection to a past event: “Where does this
feeling of shame fit in your childhood past?” “What does
this feeling tell you about this young part’s experience?”
“Does this feeling make more sense in your life now? Or
back in the cold, scary world of your parents?”
•An implicit memory can also be transformed by
connecting the “feeling or body memory” to a child
part: how does client feel toward this part who is feeling
so scared? So ashamed? So hurt? Compassion for self
and part is a powerful processing agent. Fisher, 2013


memory as “memory,” p. 3
•In Sensorimotor Psychotherapy, implicit memories are
noticed as a collection or series of sensations, emotions,
images, impulses, and thoughts, each a discrete entity. Or
we can ask the client to notice them as “just body
memory” uncoupled from the explicit memory of the event,
no longer frightening.
•Or an implicit memory can be transformed by a change
in procedural learning: by helping clients inhibit
automatically triggered actions and reactions and practice
different responses: re-framing them, tying the old
responses to child parts, befriending their parts
Safely Accessing Event Memory
•In Sensorimotor Psychotherapy, we start just BEFORE

the traumatic event occurred. As the client ‘accesses’
that moment, the therapist asks:
•“What happens inside when you remember that moment
just before things went bad? What do you notice?”
•“How can you tell you are afraid? How is your body
telling you that? If that fear had words, what would it
say?”
•“Is there an image or memory that goes with those
words? What happens when that image comes up?”
Fisher, 2012

Safely Accessing Memory, cont.
•Note the slow pacing and attention to each aspect of

experience as different and separate.
•Body sensation, activation, felt sense
•Emotions
•Thoughts
•Images
•Impulses or movements
•Also notice that the client is kept focused and mindful to
keep the medial prefrontal cortex online Fisher, 2012
Safely Accessing Memory, p. 3
•To increase dual awareness, the implicit and body

memories can be connected to the young child we once
were. We can transform the pain of the past by observing
the memories compassionately as those of the child
•Processing the emotional and body memories of child
parts creates a greater sense of internal safety: there is a
felt sense of the present being different than the past that is
the essence of transformation
•In these ways, we facilitate ‘missing experiences’
unavailable at the time: the experience of safety,
compassion, being heard or seen, protection, someone there,
being welcomed Fisher, 2014

Safely Accessing Memory, p. 4
•If a memory or image causes dissociation or loss of

mindfulness, the therapist shifts the focus to just staying
present, grounded, orienting to ‘right here, right now’
•If the client can remain mindful, then the therapist might
work with the implicit memory activated by the story:
“What happens when you just notice the activation as
‘body memory’? Really appreciate how dissociation and
disconnection saved you then from overwhelm. . . It’s so
automatic to just go away, huh?”
•The key in memory work is have no other goal than
helping the client to have a different experience of an
old event. That is transformation. Fisher, 2014
“If the problem with PTSD is dissociation,

then the treatment should consist of
association” (van der Kolk, 2001)
•“Association” could mean connecting distress to triggers
•Or the ability to stay associated to one’s own body: to stay
present, to feel safe in one’s own skin
•Or associating positive feeling states to the safety of the
here-and-now, being able to tolerate positive feelings
•It can mean taking on previously avoided normal challenges
•Or it can mean experiencing one’s talents or competencies
or deeply held values or ability to love as one’s own
•Or it can mean experiencing a deep sadness and sense of
compassion for the wounded child s/he once was Fisher, 2007

“No matter what

modality we use,
the goal of trauma
treatment is finally
to be ‘here’ and not
‘there.’”
van der Kolk, 2001

DrJJFisher@aol.com

office@sensorimotorpsychotherapy.org
www.sensorimotorpsychotherapy.org

Finding a new language for symptoms
•It is our job to translate descriptions of triggered
implicit memories into a language that changes the client’s
relationship to trauma-related responses
•“Body memory” helps to capture the ‘whole body’ aspect
of implicit memory, the constellation of cognitive,
emotional and bodily reactions
•“Feeling flashback” is a term that capitalizes on a familiar
term and expands it from visual to emotional
•“Thought memory” for negative cognitions changes their
believability, while “long, slow flashback” helps put words
to traumatic states that last hours or days Fisher, 2013

Working with the

Neurobiological Legacy of
Trauma
Disorganized Attachment, Borderline Personality
Disorder, and the Traumatic Transference
When the source of

threat is the
attachment figure,
an internal conflict
is created for the
child: is it safer to
attach? Or to push
other away?
Neither separation
nor connection feel
safe. . .

Evolutionary Role of Attachment

(Hesse, Main, Abrams & Rifkin, 2003)
Throughout history, independent of culture, the

markers of attachment-seeking behavior have
functioned to maximize safety under threat:
•“An insistent interest in maintaining proximity
to selected others”
•“Tendency to use these individuals as a secure
base for exploration of the environment”
•“Flight to the attachment figure(s) as a haven of
safety” Fisher, 2004
Attachment and Brain Development

[Schore, 2003]
•In addition to ensuring survival, attachment

also plays an essential role in the “experience-
dependent maturation” of the infant’s mind and
body: “The early social environment,
mediated by the primary caregiver, directly
influences the final wiring of the circuits in
the infant brain that are responsible for the
future social and emotional coping capacities
of the individual”

“Attachment behavior. . .
is important far beyond the
provision of a fundamental sense
of safety and security.. . . In fact,
it may carve a permanent trace
into a still developing [brain].”
Schore, 2006
“Stress [or trauma]

sculpts the brain . . .
Stress can set off a
ripple of hormonal
changes that
permanently wire a
child’s brain to cope
with a malevolent
world.”
Teicher 2002

The Development of Self-

Regulatory Ability
(from Allan Schore)
Interactive regulation involves the ability to utilize

relationships to mitigate breaches in the window of tolerance
and to either stimulate or calm oneself. Infant are dependent
upon interactive regulation to survive, as well as develop.
Auto-regulation is the ability to self-regulate,

independent of other people. It is the ability to calm oneself
down when arousal rises to the upper limits of the window
of tolerance or to stimulate oneself when arousal drops to
the lower limits.
Ogden 2002
What happens when the source of safety is

also the source of threat?
“[Instead of contact providing soothing and

regulating,] approaching the attachment figure
who is also neglectful, abusive, or otherwise
frightening creates an experience of threat, and
therefore evokes the same succession of defensive
responses to danger (fear, fight/flight, collapse
and submission) as any other traumatic
experience.”
Van der Hart, Steele, & Nijenhuis 2001

Childhood Attachment Strategies
Secure attachment: infant shows clear preference for

interactive regulation, but after being re-regulated by caregiver, is
then able to self-regulate for short periods
Insecure-ambivalent attachment: infant anxiously seeks
proximity to caregiver, cannot auto-regulate without the caregiver,
and is not soothed by reunion
Insecure-avoidant attachment: infant shows clear

preference for self-regulation, often actively avoiding interactive
regulation and preferring books or toys to caregivers
Disorganized attachment: infant has difficulty with both
interactive and auto-regulation, exhibiting proximity-seeking
coupled with freezing, distancing, or avoidant behavior
Fisher, 2003
Secure/Autonomous Attachment in
Adults [Ainsworth, et al, 1978]
• Easily seek proximity and contact to others with little or
no avoidance or angry resistance when frustrated or
disappointed
•Able to receive soothing and calming and able to return to
auto-regulatory strategies when support is unavailable
•Exhibits the capacity to self-reflect, hold a balanced
perspective, see “the shades of gray”
•In therapeutic relationships, able to carry internal
representation of the therapist and use that for self-
regulation and self-soothing Ogden, 2002

Secure/Autonomous Attachment in
Adulthood
Suboptimal attachment leaves infants

without consistent sources of regulation
in the face of stress or distress
“The infant whose caregiver has been
unable to provide basic regulation . . . fails
to develop a coherent attachment strategy
for reducing physiological arousal in the
face of even moderate stress, leading to
under- or over-activity in the stress
response system.”
Lyons-Ruth et al, 2005

Insecure-Avoidant Attachment
•Researchers have observed that mothers of avoidantly
attached infants exhibit little affect or interest in the
infant. They withdraw or engage reluctantly, ignoring the
child’s cries, turning away when approached, minimizing
the importance of proximity (“she’ll be fine”), seemingly
averse to physical contact or even eye contact
•The avoidantly attached infant is observed to exhibit
little emotion in response to the parent as well as little
proximity-seeking. He or she has limited capacity for
either positive or negative affect, internalizes experience,
has difficulty making eye contact, and often appears
lethargic Fisher, 2009
Avoidant/Dismissing Attachment
in Adults
•Limited access to or interest in their internal emotional and
somatic states, little insight
•Out of touch with unmet attachment needs, they often
develop unrealistic, positive portrayals of their families
•Tend to avoid situations that stimulate attachment needs
and often find dependency repulsive
•Strong preference for auto-regulation, even in intimate
relationships or in therapy
•In therapy, they tend to be intellectualized, resistant to
emotional expression, confused about why they are there
Adapted from Steele and Ogden, 2002; Fisher, 2006

Intimacy issues cartoon
Insecure/Ambivalent Attachment
•Mothers of what is now called insecure/resistant infants
provide too much stimulation: e.g., they tend to be labile
and unpredictable, sometimes playful and engaging and
sometimes unavailable or irritable. These mothers fail to
regulate distress or repair disruptions
•Often warm and affectionate, they show more “interest”
but have ambivalent responses: e.g., letting a child cling
while simultaneously ignoring her; displaying affection in
public but then becoming suddenly unavailable in private
•Insecure/resistant infants are hypervigilently attentive
to the mother’s proximity and less interested in the
environment because exploration means loss of proximity
Fisher, 2006

Insecure/Preoccupied Attachment
in Adults
•In adulthood, preoccupied attachment results in excessive
focus on internal distress states, with frantic pursuit of relief
•Because they are so dependent on others for interactive
regulation, they are unable to distinguish safety within a
relationship: safety comes to be equated with proximity
•Relationships tend to become intense and enmeshed,
with poor boundaries and preoccupation with the other’s
availability
•Need for interactive regulation results in external locus
of control Adapted from Steele & Ogden, 2002; Fisher, 2006
Ambivalent-Preoccupied Attachment

The Memory is Held by the Body

•Memories of helplessness, the desperate cries for help, and
the caregivers who threatened rather than comforted, remain
encoded in the client’s body, nervous system, and emotions.
The phenomenon is at the heart of trauma survivors’
sensitivity to misattunements or empathic failures
•These nonverbal responses are not experienced not as
memory but as reactions, feelings, dysregulated states.
Body and emotional memories do not “carry with them the
internal sensation that something is being recalled. . . . We
act, feel, and imagine without recognition of the influence of
past experience on our present reality.” (Siegel, 1999) The
client’s experience is: “YOU are making me feel this
way.” Fisher, 2011
Traumatic Attachment Patterns as ʻBody

Memory,ʼ cont.
•Whether infants learn to turn toward or away from the
caregiver’s voice, to melt into her arms or freeze, shut
down or cry louder, they are engaged in a process of
procedural learning that will lead to the formation of an
attachment style: ie, a body memory of the “optimal”
strategy for maintaining connection to those on whom
survival depends
•Each attachment style consists of a particular blend of
approach vs. avoidance, a pattern of emotional expression,
habits of behavior and action, and later in development,
cognitive schemas about relationships Fisher, 2011

Disorganized Attachment
•The mothers of the disorganized infants characteristically

report their own histories of trauma, loss, attachment failure,
or separation. Even in the absence of traumatic memories,
they often exhibit PTSD and dissociative symptoms
•“. . . the activation of the attachment system [e.g., when
babies cry] arouses in these parents strong emotions of
fear and/or anger. Thus, while infants are crying,
‘unresolved’ parents may interrupt their attempts to soothe
them . . . with unwitting, abrupt manifestations of alarm
and/or anger.” (Liotti, 2004, p. 477)
•Rather than being soothed and regulated, the infants are
exposed to “frightened and frightening caregiving. Fisher,
2007
“Frightened and Frightening”

Caregiving
Frightened Behavior Frightening Behavior
Looming, attack
Backing away
postures
Frightened voice
Sudden movements
Dazed expression
Mocking, teasing
Exaggerated startle
Intrusive
Withdrawn
Emotionally reactive
Non-responsive
Loud, startling noises
Lyons-Ruth, 2000; Fisher, 2003

The Result is Disorganized

Attachment
•“Disorganized attachment” patterns observed in young
children show a correlation with maternal behavior
characterized as “frightened” or “frightening” (Liotti, 1999).
•Children with disorganized attachment demonstrate the
same patterns of autonomic dysregulation seen in abused
children: elevated heart rate, intense alarm reactions, higher
cortisol levels, and approach-avoidance behavior
•Disorganized attachment is also a statistically
significant predictor of dissociative symptoms by age 19
and diagnoses of Borderline Personality Disorder and
Dissociative Identity Disorder in adulthood (Lyons-Ruth, 2001)
Disorganized/Unresolved
Attachment in Adults
•Autonomic dysregulation: easily dysregulated, alternate between
hyper- and hypoarousal responses
•Proximity-seeking or clinging alternating with avoidance,
distancing and angry outbursts or threats to leave
•Internal conflicts re. distance and closeness: idealizing and
devaluing, preference for multiple or long distance relationships,
•Deficits in object permanence and object constancy:
yesterday’s good experience isn’t integrated and trusted
•Tendencies toward hypervigilant avoidance alternating with
attachment-seeking OR desperate clinging/pursuing alternating
with distancing and hypervigilance Fisher, 2011

Worse yet, abuse and neglect ʻpairʼ

attachment yearning with animal defense
responses
“[Instead of contact providing soothing and

regulating,] approaching the attachment figure
who is also neglectful, abusive, or otherwise
frightening creates an experience of threat, and
therefore evokes the same succession of defensive
responses to danger (fear, fight/flight, collapse
and submission) as any other traumatic
experience.”
Van der Hart, Steele, & Nijenhuis 2001
Disorganized/Unresolved
Attachment

Two “Flavors” of Disorganized

Attachment
•The essential characteristic of disorganized attachment

is an internal struggle between the drive to attach/connect
versus drives to fight or flee connection
•Some of our clients have disorganized/unresolved
attachment with preoccupied tendencies: they pursue,
long, experience intense fears of abandonment and
rejection while also mistrustful, suspicious, quick to anger
•Others have disorganized/unresolved attachment with
avoidant or dismissing tendencies: they may long for
relationship but keep their distance or push away those who
come too close, including the therapist! Fisher, 2011

Ambivalent-Preoccupied
Attachment
“Though the traumatized patient feels a

desperate need to rely on the integrity and
competence of the therapist, she [or he]
cannot do so, for [the] capacity to trust has
been damaged by the traumatic experience.
Whereas in other therapeutic relationships
some degree of trust can be presumed from
the outset, this presumption is never
warranted in the treatment of traumatized
patients. . .’”
Herman, 1992, p. 138

Disorganized Attachment in the

Transference = ‘Phobia of
Therapy and the Therapist’
“Contact itself is the feared element

because it brings a promise of love,
safety, and comfort that cannot
ultimately be fulfilled and that
[therefore] reminds [the patient] of the
abrupt breaches of infancy.”
L.E. Hedges (1997, p. 114)
Ogden, 2002
“[For trauma patients,] to be known

or recognized is immediately to
experience the other’s power. The
other becomes the one who can give
or withhold recognition: who can see
what is hidden; who can reach,
conceivably even violate, the core of
the self.” Benjamin, 1994

Manifestations of Disorganized Attachment in

the Transference
•Intense proximity-seeking behavior alternating with

devaluing, distancing, or increased de-stabilization
•Flights from treatment, chronic ambivalence about seeking
treatment, coming in and out of therapy
•“Clinging:” difficulty leaving at the end of sessions,
disproportionate distress around therapist’s absences
•Difficulty using therapy: coming but not being able to articulate
issues/feelings; becoming mute or distracted in sessions, “good”
sessions alternating with “bad”
•Need for repeated proof of therapist ‘caring:’ failure of object
constancy and often object permanence
Fisher, 2009
Manifestations of Disorganized
Attachment, cont.
•Hypervigilant attention to the therapist’s manner and tone
of voice, policies, therapeutic appproach, or office environment,
misinterpretations of therapist behavior or verbalizations
•Strong, out of proportion reactions: unable to tolerate
therapist imperfections/limitations
•Repeated requests for changes in treatment frame: anger
and disappointment, “it’s never quite right”
•“Destructive entitlement” to special treatment, use of crisis
and self-harm as relational “negotiating currency” (Rivera, 1996)
•Inability to collaborate: client resists therapist interventions,
cannot formulate goals for treatment, fights for control of the
therapy and/or insists that therapist must direct it Fisher, 2011

Traumatic Countertransference
“As a defense against the unbearable feeling of

helplessness, the therapist may [unconsciously]
assume the role of rescuer. [S/he] may take on more
and more of an advocacy role. . . . The therapist
may feel obliged to extend the limits of therapy
sessions or to allow frequent emergency contacts
between sessions. . . . Rarely do these
extraordinary measures result in improvement; on
the contrary, the more helpless, dependent, and
incompetent the patient feels, the worse her
symptoms become.” Herman, 1992, pp. 142-143
What is the answer?

•As therapists, we must be keenly attuned to the effects
of disorganized attachment on the therapeutic
relationship: accepting that, instead of being “the answer,”
we and the therapy pose as much threat as hope to the client
•Recognition and acceptance of disorganized attachment
dynamics in the transference as normal and natural
consequences of trauma. We must give “equal opportunity”
to both the defense AND attachment
•Mastery and control: when we de-emphasize the value of
the therapeutic relationship, we increase the client’s
opportunities to experience self-mastery and self-regulation
Fisher, 2005

How then do we treat the clientʼs intense

internal struggles?
•By concentrating on reduction of dysregulated arousal
and/or intense attachment striving: not pulling for too
much relationship or too little. This requires the therapist
to prioritize neurobiologically regulating distress,
capitalizing on moments of positive affect and avoiding
either too much distance or too much closeness
•“Right brain to right brain” communication: paying
less attention to our words, to how we “talk about” what is
happening. Instead, we must use our tone of voice, facial
expressions, and body language to shift the nonverbal
experience of the patient Fisher, 2010
Working with Phobia of Therapy

and the Therapist
•Name and normalize the phobia as an adaptive response
to relational trauma perpetrated by caretakers or authority figures
•Maintain a “optimal distance:” offering empathy and support
while not becoming the client’s external locus of control/sole support
•Validate the evidence of the internal struggles: give the
client permission to long for closeness AND distrust or distance
•Encourage awareness of these struggles without trying to solve
them. Try to find just the “right” relational distance
•The key to overcoming this phobia is the therapist’s
consistency, NOT the therapist’s caring. Consistency reduces
fear whereas caring can arouse it! Fisher, 2010

Treating the Effects of

Insecure/Preoccupied Attachment
 Distance and proximity: “desensitize” separation anxiety by
using transitional objects; increase client ability to tolerate less
contact with therapist, to end sessions on time
 Boundaries: increase client’s tolerance for healthy boundaries
by starting and ending on time, be “relentlessly consistent” around
between-session contact, self-disclosure, etc.
 Distress tolerance: though client may protest, insist on practice
of coping techniques that provide calming and containment or a
sense of mastery over intense feelings (eg, somatic resources,
breathing, journaling, safe place)
 Validate the survival resources inherent in Preoccupied
Attachment: the ability to ask for support, to depend, to tolerate
closeness Copyright 2006 Janina Fisher, Ph.D.
Treating the Effects of

 Increasing ability to receive interactive support: naming the
preference for auto-regulation, using humor, supporting their auto-
regulation as an interactive regulatory technique
 Experiment with proximity and distance: increase client’s
felt sense of control over distance; offer more physical and
emotional distance, rather than less; allow the client enough distance
to feel the pull toward instead of the pull away
 Experiment with slowly increasing tolerance for emotions:
but only with consent of the client and at client’s pace
 Honor their auto-regulatory abilities as survival resources:
notice them for the client, encourage the client to notice and feel the
sense of mastery inherent in self-regulation Copyright 2006 Janina Fisher, Ph.D.

Strategies for Working with Proximity and

Distance
•Whether the client wants emotional or physical distance,

the first priority with the distancer is to honor the distance
and offer MORE distance than s/he wants: by moving your
chair further away, being more boundaried and less self-disclosive,
giving the client permission to intellectualize or avoid emotion
•The first priority with the pursuer is to acknowledge the

wish for more closeness or contact or support without
gratifying it. Allowing the client to sit closer in the session or
suggesting transitional objects for extra support are ways of
acknowledging the wish, while giving less contact than the client is
requesting encourages slowly increasing tolerance for distance
Traumatic Attachment = “Enduring

Conditions,” not Events
“[While] traumatic events are discrete
occurrences, . . . disturbed parental affective
communications are often an enduring, day-in-day-
out feature of the childhood years. In contrast to a
more discrete traumatic event, the parent’s
responses to the child’s foundational needs for
comfort and soothing are worked into the fabric of
identity from a very early age. They are also worked
into the fabric of the child’s biological
organization. . .”
Lyons Ruth et al 2006 p 15

Traumatic Attachment =
“Enduring Conditions,” p. 2
“Therefore, the resolution of discrete
traumatic events in treatment may come
about more quickly than the resolution of
long-standing patterns of role-reversal,
disorientation and disrupted forms of
affective communication [that arise] in the
transference.”
Lyons-Ruth et al, 2006, p. 15
Relationships are Threatening, even Therapy

Desperate need to proof of caring, fears of abandonment
Hypervigilance, post-traumatic paranoia, angry outbursts or impulsive reactions
Rejection sensitivity, emotional overwhelm worsens in presence of others
Pursuing alternates with distancing and/or fight/flight responses (eg, self-harm)
Hyperarousal
Window of Tolerance
fails to develop in disorganized
attachment
Hypoarousal
Flat affect, numb, “not there” in relationships
Yearning coupled interpersonal avoidance, isolation
Preoccupied with shame, despair and self-loathing
Ogden and Minton (2000); Relationships = self-sacrifice or victimization
Fisher, 2006
*Siegel (1999)

Disorganized Attachment in the

Transference = ‘Phobia of
Therapy and the Therapist’
•Disorganized attachment is a serious complication in
trauma treatment, causing preoccupation with
abandonment, pervasive mistrust, obsessive focus on the
therapist (as source of either rescue or threat), regression,
therapy-destructive behavior, and/or chronic crises.
•The yearning for connection may initially seem like
collaboration but then reveals itself as an impediment.
How can the client work on ‘issues’ if the real issue is:
“Does s/he love me?” Or, conversely, if the issue is:
“ When is he/she going to betray me?” Fisher, 2012
“At the moment of the trauma, the victim is

utterly helpless. Unable to defend herself,
she cries for help, but no one comes to her
aid. . . . The memory of this experience
pervades all subsequent relationships. The
greater the patient’s emotional conviction of
helplessness and abandonment, the more
desperately she feels the need for an
omnipotent rescuer. . .”
Herman, 1992

“[But] because the patient feels as if her life

depends on her rescuer, she cannot afford to
be tolerant; there is no room for human
error. . . Because she has no confidence in
the therapist’s benign intentions, she will
consistently misinterpret the therapist’s
motives and reactions.”
Herman, 1992
The “Drama Triangle:” Victim-Rescuer-

Perpetrator Dynamics [Liotti, 2004]
Rescuer: a role typically played

by the therapist but one that can also
belong to the client
Trauma
Perpetrator: client may perceive
therapists as a perpetrators or therapists
Victim: clients tend feel in the
may inadvertently perpetrate. The client victim position, but the therapist
can also play the perpetrator role. may inadvertently end up in the
victim role

The “Drama Triangle” [Liotti, 2004]
Therapist-Rescuer:
“I will call you tonight, and I can see you
for an extra session on Tuesday”
Trauma
Therapist-Perpetrator: Client-Victim:
“If outpatient care doesn’t keep “I am feeling so hopeless—I
you safe, perhaps we should don’t want to live anymore—
consider hospital” I’m not safe”
The “Drama Triangle” II
Therapist-Rescuer:
“I must prove to her that I do
care”
Trauma
Therapist-Victim:
Client-Perpetrator:
“I’m only trying to do what I think is
“How dare you decide what
in your best interests—I’m sorry if it
care I ‘should’ get?!”
doesn’t feel that way”

The “Drama Triangle” III
Therapist-Rescuer:
“I’ll speak to him for you—
perhaps he didn’t mean it quite
that way”
Trauma
“Dr. Smith thinks that you have “Once again, I’m just a
bipolar disorder” category to you people”
The “Drama Triangle” IV
Therapist-Rescuer:
“Perhaps we can check in by
email during my week away.”
Trauma
“I’m going on vacation next month, and “How could you leave me?
Julie Smith will be covering for me” Don’t you care?”

How do we address these

attachment-related challenges?
•As therapists, we need to accept that
disorganized/unresolved attachment is an integral part of
trauma treatment: rather than seeing it as an impediment
to treatment, we must see it as part of therapy
•We need to understand attachment patterns and the
‘Drama Triangle” as body memory: because clients
experience body and emotional memory as “happening now,”
they assume that we are the cause.
•We need to remember that disorganized/unresolved
attachment is inherently an expression of conflict
WITHIN the client, not between the client and us
Fisher, 2012
Addressing the challenges, cont.

•We must remember that we are triggers: our clients are
having “attachment memories” in therapy, ie, memories of
intense strivings for closeness and protection in conflict with
impulses to defend and protect, to fight or flee. Sadly, then,
we are often projections, not experienced as “us”
•If we can accept these internal conflicts as part of
trauma treatment, then it is easy to accept that therapy for
traumatized clients poses as much threat as hope
•We can equally validate defensive AND attachment
strivings: allowing distance, validating mistrust, not
heeding pulls to rescue or favor relationship over avoidance,
returning power to the client where possible
Fisher, 2011

Take Advantage of Somatic

Communication
“Not only is the therapist . . . unconsciously
influenced by a series of slight and, in some cases,
subliminal signals, so also is the patient. Details
of the therapist’s posture, gaze, tone of voice,
even respiration, are [unconsciously] recorded
and processed. A sophisticated therapist may use
this processing in a beneficial way, potentiating a
change in the patient’s state without, or in
addition to, the use of words.”
Meares, 2005, p. 124
The Therapist as a Somatic

Resource
auxiliary cortex] and affect
regulator of the patient’s
dysregulated states in order to
provide a growth-facilitating
[therapeutic] environment. . . .”
Schore, 2001

Being a ‘neurobiological
regulator”
•Being a neurobiological regulator requires that the
therapist stay attuned to both the regulating and
dysregulating effects of the therapeutic encounter. Like
a “good enough” mother, we must strive to create an
optimal level of arousal from moment to moment
•Effective neurobiological regulating on the part of
therapists requires paying more attention to how we
are affecting autonomic arousal than we pay to the
content of the patient’s communication and with how
to maintain an optimal level of arousal in the room
Strategies for neurobiologically regulating

clients
•Varying voice tone and pace: soft and slow, hypnotic tone,
casual tone, strong and energetic tone, playful tone
• Energy level: very “there” and energetic versus more passive
•Empathy vs. challenge: does the client do better with empathy?
Or challenge? Does s/he need limits to regulate?
•Amount of information provided: noting the effect of
psychoeducation or therapist self-disclosure
•Titrating vs. encouraging affective expression
•Providing more vs. less support: does client become
dysregulated with more contact? Or less? Does s/he self-regulate
better with less or more support? Fisher, 2009

Mirroring = Attunement
•To foster a “felt sense” of connection, we mirror the
client’s words and body language, hoping to evoke a
visceral sense of being joined, a shared space, a sense of the
therapist’s interest and ability to ‘get it’
•Mirroring is not about WHAT we say but HOW we say
it: interest, body language, choice of words, tone
•It is also ‘dyadic dancing:’ as we mirror clients for signs
of resonance, we adjust our words and presence to maximize
their ability to stay present and socially engaged. Like
parents, our moment-to-moment adjustments help clients to
regulate and keep their frontal lobes “online” as much or
more as any skill we could teach them
Fisher, 2013
Dyadic Dancing with the Client
•“Dyadic dancing” with clients means “going with” their

resistance, rather than offering resistance to their
resistance! For example:
•“Yes, I can see why suicide could feel like the most
logical solution to feeling so out of control . . .”
•“Yes, I can see that you would be afraid to hope . . . Hope
was so unsafe when you were a child”
•“If you’re invisible, you fly below the radar—so much
safer that way”
•“Yes, it isn’t fair that you have to comfort yourself when
others are responsible for your pain . . .” Fisher, 2006

Focus on using the body as a vehicle for

communication
•Monitoring our own arousal so that we do not

dysregulate the client nor pull for too much or too little
relationship: ‘tracking’ attachment-related internal struggles,
neurobiologically regulating client distress, capitalizing on
moments of humor and playfulness, avoiding too much
distance or closeness
•Prioritizing “right brain to right brain” communication:
paying less attention to our words and more to how we “talk
about” what is happening, using tone of voice, facial
expression, and our own affect and body language to shift the
nonverbal experience of the patient Fisher, 2011
Non-Verbal Contact
We need to use non-verbal contact as we instinctively do

with young children, including:
Body language Facial expression
Physical proximity Eye contact
Mirroring movements Echoing sounds
Changing voice quality Head movements
Gestures Verbal utterances
Leaning toward/away Making empathic sounds

Working with Phobia of Therapy

and the Therapist
•Name and normalize the phobia as an adaptive response
to relational trauma perpetrated by caretakers or authority figures
•Maintain a “optimal distance:” offering empathy and support
while not becoming the client’s external locus of control/sole support
•Validate the evidence of the internal struggles: give the
client permission to long for closeness AND distrust or distance
•Encourage awareness of these struggles without trying to solve
them. Don’t interpret, just try to find the “right” relational distance
•The key to overcoming this phobia is the therapist’s
consistency, NOT the therapist’s caring. Consistency reduces
fear whereas caring can arouse it! Fisher, 2010
Working with Borderline or Dissociative

Disorders
•According to the attachment research, a connection exists

between disorganized attachment and symptoms of
Borderline Personality and Dissociative Disorders, both DID
and DDNOS. In the past 25 years, research findings have
established a clear association between BPD and a history of
trauma—and BPD and dissociative symptoms.
•Therefore, we can expect clients with these diagnoses to
have disorganized attachment patterns AND difficulty
managing autonomic arousal. To work successfully with
these clients requires us to be attuned to our internal conflicts
and to regulate our own arousal! Fisher, 2012

Strategies for Dealing with

Chronic Devaluing
•Keep in mind that neither the patient’s idealization nor
devaluation is about you! Both are triggered responses indicating
intra-personal transference, not interpersonal
•Do not hesitate to set limits on anger or regression in the
therapy with empathic re-framing or psychoeducation
•Be compassionate but clear that, if this patient had not been so
badly mistreated, she could tolerate your imperfections or mistakes
•Be careful to neither over-value or devalue the wish for
rescue: re-frame it, express regret, avoid getting inducted
•Take responsibility for your limitations BUT without
implying that they are open to change
Copyright 2006 Janina Fisher Ph D
Avoiding Re-enactment in the Therapy

•Be absolutely “incorruptible:” avoid being seduced into
boundary changes, rejection, or promising more than you can deliver
•Avoid becoming the client’s external locus of control:

even if the client begs for expressions of caring, no matter how self-
destructive she becomes, no matter how depleted and helpless she is
•Learn to recognize “projective identification” manifested in

uncharacteristic or intense reactions of your own that precede client’s
appointment or interfere with your consistency or confidence
•Discussion of the therapeutic relationship “heats up” the

disorganized attachment dynamics: it is more helpful to
universalize or use the language of triggering: “Many people with your
life experience have these feelings in relationships.”

Strategies for Managing Crises and De-

stabilization
•If closeness and dependency are triggers for both devaluing

and self-destructive behavior, how does the therapist deal
with the risks? The dilemma: more therapist involvement
leads to more ‘backlash,’ while less involvement requires
a leap of faith. The answer lies in HOW the therapist can
be more involved
•The best solution is to support clients at a distance or
indirectly: email or voicemail messages, audiotaping
sessions or making relaxation or encouragement tapes,
giving clients index cards with psychoeducational or
encouraging messages or other transitional objects (eg, an
object that could symbolize coming back each week) Fisher, 2012
When the therapy becomes

“unbearably dramatic”. . .
“When the patient is guided by . . . a disorganized

attachment in construing the therapist’s behavior, the
therapeutic relationship may become unbearably
dramatic, changeable, and complex for both partners.
Untoward countertransferential reactions or premature
terminations of an otherwise promising treatment may be
the unfortunate consequence of a disorganized internal
working within the therapeutic relationship. The presence
of a second therapist to whom the patient is usually less
strongly and less dramatically attached may be of great
assistance in dealing with the difficulties. . .”
(Liotti, 2004, p. 484)

Addressing Traumatic Attachment

is a Prerequisite to Trauma
Treatment
“[When] the contribution of disorganized
attachment to the [trauma-related]
disorder is successfully dealt with,
traumatic memories become more easily
integrated and dissociative defenses are
less difficult to relinquish.”
Liotti, 2004, p. 27
“[P]atients’ interpersonal difficulties should receive

at least as much attention as their traumatic
memories, their dissociative experiences, and their
dissociative defenses. . . . [S]triving] for safety and
alliance within the therapeutic relationship should
take precedence, both temporally and in the
hierarchy of therapeutic aims, over trauma work. . .
Phase-oriented treatments in which stabilization of
the therapeutic relationship precedes trauma work
has been made necessary [because] trauma-
centered therapies . . . can exacerbate rather than
resolve the patients’ difficulties . . .” (pp. 24-25)
Liotti, 2004


510-891-1809
DrJJFisher@aol.com

Working with the

of Trauma
The Role of Dissociation in Trauma-Related
Disorders
“Dear “Carolyn”,
[Yesterday] it occurred to me that this was
the time of year that I took the overdose. . . I was
so distressed that morning. I remember I kept
saying out loud, ‘Mommy. . . Mommy,’ but at that
time I had no idea of the different parts of me and
when I would come to see you, it would only be the
quiet Adult Part. So when I think back to the
many times I thought I was nuts and out of control,
it was really my Small Part struggling to say,
‘Help, I’m in trouble here--you better notice me,
or we’re all in trouble.’

“WhenI think about it, I can recall so many

days when things were so mixed up, and she was
just hanging on in the best way possible.
It’s so sad, isn’t it?
For me, the abuse memories were too much
for my body and brain to absorb, so they got put
away in a different place than regular memories,
and then very slowly these feelings started coming
out of nowhere. . . until I was being ineffective in
the present and disrupting everyone around me.”
“Jenny”
What is ‘Dissociation’?
“The essential feature. . . is a disruption in the usually
integrated functions of consciousness, memory, identity,
or perception.”
(DSM-IV-R, 2000)
“Dissociation refers to a compartmentalization of

experience: elements of an experience are not integrated
into a unitary whole but are stored in isolated
fragments. . . . Dissociation is a way of organizing
information.”
(van der Hart, van der Kolk & Boon, 1998)
Fisher, 2004

Compartmentalization = Survival
Corpus Collosum does not
Left Brain mature until 12+ Right Brain
Seat of the The right brain is the
“conscious, survival brain, as
linguistic self” well as the playful
(Cozolino, 2002), the left and creative brain.
brain or “CEO Our right brains
Brain” reasons, plans, hold a sense of
organizes, learns “corporeal and
from experience, and emotional self” The
makes meaning. The right brain lacks
left brain is also the words but reads
self-witness: it has body language and
the capacity for both facial expression. It
internal and external has ‘street smarts,’
awareness not book smarts
Right and Left Brains Hold Different Aspects of
Experience
“[Traumatic] memories are recorded in the right

hemisphere outside of conscious awareness, and this
realm represents the traumatic memories in imagistic
form along with the survival behavior employed as a
result of the abuse. The [two] cortical hemispheres
contain two different types of representational
processes and separable, dissociable memory systems,
and this allows for the fact that [the] emotional learning
of the right [hemisphere], especially of stressful,
threatening experiences, can be unknown to the left
[hemisphere].” Schore, 2001

Primary Dissociation:
a single incident trauma
At whatever age we
are traumatized, we
Pre-traumatic Personality have a pre-traumatic
personality that begins
Trauma undivided
Apparently Normal Part Emotional Part of the

of the Personality Personality
A split now occurs between the And the part of the Self that
Left Brain part of the Self that holds the body and emotional
“carries on” with normal life memories of what happened
and adaptation during and and the survival responses
after the trauma needed to survive it
Van der Hart, Nijenhuis & Steele, 2006
Client-Friendly Language
Pre-traumatic Personality
“Going On with Normal Traumatized Part of the

Life” Part of the Personality Personality
This Left Brain part of the This Right Brain part of self
self “carries on” with holds both the traumatic
normal life and adaptation memories and the survival
during and after the responses employed
trauma
Van der Hart, Nijenhuis & Steele, 1999

What is a “part of the personality”??
“Neurons that fire together wire

together” (Hebb, 1958)
“In the developing brain, [autonomic,

affective, somatic and cognitive] states
organize [into] neural systems,
resulting in enduring traits.” (Schore, 2001)
Neuroscientific Support
“The left hemisphere functions best within the
middle range of affect and is biased toward
positive and prosocial emotions. Strong affect,
especially anxiety and terror, appear to inhibit
left hemisphere functions of language and logic—
hence, the experience of stage fright and
speechless terror. . . . The right hemisphere is
generally responsible for both appraising safety
and danger and organizing the sense of the
corporeal and emotional self.”
Cozolino, 2002, p. 109

Secondary Dissociation:
Complex PTSD, BPD, Bipolar, DDNOS

Fight Flight Freeze Submit Attachment

EP EP EP EP Cry EP
The Emotional Part of the Personality

becomes more split and
compartmentalized: separate subparts
evolve reflecting the different survival
strategies needed in a dangerous world Van der Hart, Nijenhuis & Steele, 2006
Going on
with
normal
life. . .

Tertiary Dissociation:
Severe DDNOS, DID

Worker Caretaker Fight Fight Freeze Submit Attach

ANP ANP EP EP EP EP EP
Social More parts are needed to survive even

ANP more dangerous conditions: parts that
hold survival responses and parts that
hold resources
van der Hart, Nijenhuis & Steele, 2006

Each part of the personality

contributes a defensive strategy
“I can’t afford to feel
overwhelmed. I have to
function!”
“Going on with Normal Emotional Part of the
Life” Part Personality
Fight: Flight: Freeze: Submit: Attach:

Protector Distancer Terrified Ashamed Needy
Fight is the Flight comes to The terrified Shame, self- The Attach part
hypervigilant the rescue by Freeze EP loathing, and uses
bodyguard, using addictive triggers other passivity of vulnerability and
holding ‘the behavior to get parts to Submit feeds desperate help-
suicide card’ if quick relief, to respond with helplessness, seeking to get
drugs don’t ‘turn off’ the alarm hopelessness protection
work body
Van der Hart, Nijenhuis & Steele, 2006; Fisher, 2009
The traumatized parts are not experienced
as ʻparts of meʼ but as:
•Overwhelming emotions: desperation, despair, shame
and self-loathing, hopelessness and helplessness, rage
•Chronic expectation of danger: hypervigilance and
mistrust, fear and terror, “post-traumatic paranoia”
•Body sensations: numbing, dizziness, tightness in the
chest and jaw, nausea, constriction, sinking, quaking
•Movements and impulses: restlessness, ‘hang-dog’
posture, frozen states, impulses to “get out,” violence
turned against the body, “sex, drugs & rock ‘n roll,”
huddling or hunkering down Fisher, 2010

“De-coding:” identifying “parts”

•Signs of internal conflict: inability to make decisions,
stuckness, trying to stay safe alternating with acting out, alternating
sobriety and relapse
•Emotions: intrusive, overwhelming and out of proportion
•Noticeable shifts in mood or behavior: e.g., from neutral or
fearful states to anger and acting out; asking for extra appointments,
then not showing up; trust alternating with mistrust
•Autonomic arousal patterns: collapsed, numb, passive states
versus angry or desperate or suicidal states
•Cognitions: “I am worthless and hopeless,” “I know you are
going to leave me,” “I can’t trust you,” “I trust you completely”
Fisher, 2014
Or the parts are experienced as:
•Loss of ability to communicate: client becomes mute,

shut down, unwilling to speak, can’t find words
•Voices: usually shaming, punitive, controlling
•Constriction: withdrawal, social isolation, agoraphobia
•Regressive behavior: loss of ability for well-learned
skills, personal hygiene, ADLs, social engagement
•Increasing preoccupation with helpers: the only
safe/unsafe place becomes the office/hospital/house
•Alternating dependence and counterdependence
•Unchecked self-harm, suicidality and addictive behavior
Fisher, 2014

Diagnosing Dissociative Disorders

“Hard Signs” of Dissociation
•Evidence of losses of consciousness: two or more parts of the personality
take control of the body and operate outside of conscious awareness (DSM-IV-R)
•“Missing time:” amnesia for periods of time after the age of nine, difficulty
accounting for actions, finding objects present or missing without a memory of
transporting them, reports of conversations one does not remember having
•Physical changes associated with mood states: deeper or higher voice,
shyness vs. assertiveness, more female or male, different clothing/hair styles
•Psychotic-like symptoms: hearing voices, internal dialogues, intrusive voices,
thoughts, or images, ‘delusions’ of the trauma
•Dissociative fugue experiences: finding one’s self somewhere with no
memory of intending to go there or in the company of unfamiliar people
•Identity alteration: using different names or handwriting, being known to people
one does not remember, age regression experiences Fisher, 2010
Diagnosing Structural Dissociation:

“Soft Signs” of Dissociation
•“Anything that doesn’t add up” may reflect a failure of integration due to
dissociative compartmentalization: e.g., the patient alternately idealizes and
devalues, overfunctions in some spheres and regresses dramatically in others,
pleads for help yet refuses the help that is offered
•Difficulties with memory: unable to give coherent account, coming late or

forgetting appointments, forgetting conversations, having different accounts
•Somatic signs: headaches, chronic pain, paradoxical/non-response to meds

•Childlike speech, affect or cognition: out of character with level of
functioning; perceptions or reactions consistent with younger developmental levels:
“Are you mad? Are you going to hurt me? Do you like me?”
•Chronic condition of being “stuck” in life development, unable to

grow professionally or relationally; each step forward followed by a step back

More “Soft Signs” of Dissociation

•“Terminal ambivalence” about even minor decisions: “undoing” decisions,
sabotaging them, failing to take the steps to carry them out
•A history of rocky or failed or prolonged therapeutic treatments

without much improvement or diagnostic clarity: the patient often becomes more
dysregulated and symptomatic in therapy instead of less
•Therapist disempowerment: the therapist feels incompetent, confused,

overwhelmed, helpless. It seems as if “nothing works” with this client
•Signs of identity confusion or conflict: remaining in therapy while

devaluing it or the therapist, feeling meek and submissive but perceived by others
as enraged or difficult, being both over-responsible and self-destructive, leading a
double life, inability to leave a relationship client knows is unsafe or unhealthy
•Chronic self-destructive, self-harming or addictive behavior: despite

patient’s hard work and good treatment, the self-destructiveness or addictive
behavior is either unremitting or constantly re-surfacing Fisher, 2009
Evolutionary‐Determined Internal Tensions
What threatens stability is not the compartmentalization or the disorder: it is

the conflict between competing survival responses:
 Attachment to the therapist competes with wishes to flee or resist the treatment
 “Submission” (for example, willingness to work with the therapist) is in conflict with
fighting for control
 Going on with normal life and putting the past behind competes with hypervigilence and
mistrust
 Wanting to live or be stable competes with wishes to die or impulses to get “fast and
dirty” relief Fisher, 2004

Stabilization = Resolution of Internal Conflicts
•Unresolved internal conflicts between competing

animal defenses interfere with resolution of traumatic
experience and current stability
•How can the patient ‘go on with normal life’ when
traumatic triggers keep activating traumatized parts?
•If Attach is desperately seeking rescue, Fight is pushing
people away, and Submit is feeling more and more
ashamed and hopeless, the patient can become stuck
•For resolution, the internal conflicts must first be
brought to the client’s awareness and mindfully studied
and processed. But HOW? Fisher, 2008
Step 1: Psychoeducation
•Offer psychoeducation on the Structural Dissociation
model: re-conceptualize symptoms as manifestations of
structural dissociation, help clients see themselves through
this lens. Ask: “Do you recognize these different states?”
•Radical acceptance of trauma-related parts: ask clients
to assume that all distressing thoughts, feelings, and body
sensations are manifestations of parts
•Teach the client to be a ‘detective:’ what part might have
gotten triggered? What happened next? “Detective work”
focuses on better understanding the interplay between parts
and symptoms AND keeps the frontal lobes online.
Fisher, 2011

Establishing Mindfulness of Parts

•Helping the client to“just notice” the unfolding of
sensations, thoughts, feelings of parts
•Cultivating curiosity: “Which ‘I’feels or thinks or acts in

that way?” “Why might a part of you feel that way?” “Why would
it make sense for a part of you to over-react in this way?” “I wonder
what triggered that part . . .”
•Noticing self-destructive behavior as a part: “How is that

part trying to help? What problem is it trying to solve?”
•Noticing inner chaos and overwhelm as parts: “Notice

the struggle that’s going on inside you. . .” “I’m noticing that a part
of you wants to go forward, and another part just wants me to know
how had it is.” Fisher, 2011
“Speaking the Language” of Parts
• Use of the “language of parts” facilitates mindfulness and

increases awareness of their internal struggles
• “The language of parts” decreases over-identification with
symptomatic parts: when the client says, “I want to die,” the
therapist responds, “So there is a part of you that wants to
die—hmmm. . . I wonder what triggered that part?” When
the client says, “Itʼs just hopeless,” we re-frame, “Is that the
same part or a different part?”
• “Relentless reframing” of traumatic responses as “parts”
helps to inhibit self-destructive impulses and cultivates the
ability to notice overwhelming affects or impulses, rather
than being overwhelmed by them
Fisher, 2015

Choose Language that Acknowledges the Parts
•“When you say those words, ‘I am so ashamed,’ I hear

the depressed part of you that hates herself so much”
•“It feels like a very young part of you is in the room. . .”
•“When you talk about your fears about my leaving on
vacation, I hear a young part who’s worried about being
left alone and unprotected”
•“I’m curious about the part of you that didn’t want to
come today . . .”
•“So there’s a part of you that wants so much to be loved
and a part that doesn’t trust that it’s safe to let anyone in
close to you . . . ” Fisher, 2010
Controversy about Parts Language

•The idea of using the language of “parts” often raises
therapist concerns about iatrogenic worsening of
symptoms or‘encouraging’ DID diagnoses. These
fears stem from irresponsible treatment approaches in the
80s and 90s that focused on treating parts as separate
individuals and encouraging memory retrieval
•In 2010, we know that use of parts language can facilitate
greater internal awareness and accountability if therapist
and patient use the language of parts to encourage
mindfulness of the internal struggles and states shifts.
•Mindful awareness is inherently integrative: it makes
associations and combats fragmentation Fisher, 2015

The contribution of the Internal

Family Systems model
Using a mindfulness-based approach, Internal Family
Systems (Schwartz, 1995) assumes that, in addition to parts
holding survival responses, including functioning, there is
always a Higher Self untouched by trauma and capable
of becoming a witness and self-healer:
A “Self”
curious, compassionate,
clear, creative,
courageous, calm,
confident, committed
Fisher, 2003
IFS Adds a Concept of Defenses

In the course of childhood adaptation, parts of us are exiled and
isolated, protected by other parts that engage in acceptable behavior or
cause crises to divert attention from the exiled parts.
Self
curious, compassionate, clear,
calm, creative, courageous,
confident, committed,
“Exiles” “Managers” “Firefighters

”
Hold unacceptable or “Stand in” for Exiles Protect Exiles with

unsafe feelings/memories and try to “carry on” emergency responses
Fisher, 2003

Case Example I never feel overwhelmed

or vulnerable, just pissed
off and suicidal !!
Managers Suzanne
“Standards” Hypervigilantly focused on
Part Firefighters unfairness and incompetence,
fights authority figures
Focused on maintaining Justice-

the household in perfect Seeking
order Part
Ashamed
Part
Angry Part
Mothering Fearful
Part Suicidal Part
Reacts strongly Part
to any change Sad and
Focused on dance in plan or Needy
recitals, homework, disappointment Maintains a plan Part
family vacations at all times, hurts
the body daily
Fisher, 2006 Exiled Parts
Transformation = Inner Healing

Healing is the outcome of a compassionate connection between
parts and Self that creates sufficient safety and trust that parts can be
‘unburdened,’ can let go of their legacies of the past
Self
curious, compassionate, clear,
creative, calm, courageous,
“Exiles” “Managers” “Firefighters

”
Fisher, 2009

Working in an IFS Paradigm

• The fundamental assumption is that all thoughts, feelings,
and body sensations lacking the qualities of a Wise
Minded ʻSelfʼ represent communications from exiled
parts. As these parts are heard or observed, the therapist
brings them to the attention of the client
• Like Sensorimotor Psychotherapy, IFS cultivates the
ability to be mindful and maintain [ʻSelfʼ] awareness of
parts. Dual awareness (feeling emotions while noticing
them without reacting to them) is considered to be a healing
ʻingredient,ʼ but it also helps regulate the partsʼ triggered
feelings and activation
• In IFS, healing is intrapersonal more than interpersonal
Fisher, 2013
Cultivating “Self-energy” [Schwartz] or “Mental

Energy” [Van der Hart, Nijenhuis & Steele]
•Self-energy = increased capacity for states of curiosity,
compassion, calm, courage, creativity, clarity,
commitment, and confidence provide a spiritual energy
which is an antidote to fear and shame
•The assumption is that ‘Self-energy’ will increase
organically as parts are noticed and identified, then
asked to “step back” to make “more room” for Self
•But some of our clients have too many parts, or parts that
are highly dysregulated and dysregulating. Some have
parts that are in conflict with each other or even with
‘Self.’ Those clients need to be taught how to become
curious, calm, compassionate, and committed Fisher, 2009

Building “Self Energy” one

“C” quality at a time . . .
“Self”
curious, compassionate,
clear, creative,
courageous, calm,
Fisher, 2003
“Identifying” vs. “Identifying with”
• When clients interpret the partsʼ intrusive feelings,

thoughts, and body sensations as “me,” they “identify”
with the parts. Thoughts like “I am hopeless” or “I am
afraid” can feel ʻtrueʼ when the client is “blended” with
parts and driven by their actions and reactions
• An important part of trauma work is helping clients to
identify (i.e., to notice or recognize) parts and then dis-
identify with them by learning to say, “That part is
afraid . . .” rather than “I am afraid”
• Dis-identifying with and reframing the symptoms helps
to cultivate curiosity rather than hostility. The
assumption must be that symptoms = parts using their
“survival resources” to cope with the trauma Fisher, 2014

We use parts language to bring

the client’s attention to the
following question:
“Which one of the many people

who I am, the many inner voices
inside of me, will dominate
[today]? Who, or how, will I be?
Which part of me will decide?”
Hofstadter, 1986
With “whom” will we work?
•Normally, we work with a client’s affects or reactions as
“her reactions” or “his,” not a part’s. But does it make
sense to work with individual parts as if they represented the
whole person? Which parts do we define as ‘her’? The
parts that want closeness? Or parts that push the therapist
away? Or want to die?
•In trauma work, we should assume the presence of
structurally dissociated parts and track for their
appearance in the client’s life. By deliberately using parts
language to differentiate a “Going On with Normal Life”
Self from traumatized parts, we support better functioning
and increase client capacity for mindful awareness Fisher, 2011

“In order to do what

you want, you have
to know what
you’re doing.”
Feldenkreis
Both client and therapist tend to

ignore ego state phenomena . . .
“Through the day, we regularly pass from
personality to personality. Because of the
speed and fluidity of this process for most
of us, and the fact that we have such a
limited vocabulary for distinguishing among
these inner entities, we do not usually attend
to the ways in which this inner community
conducts its business.”
Schwartz, 1995

Who should be attending to the inner

community?
•Trauma theory tells us that “noticing” or “attending” is
a prerequisite for successful treatment and that restoring
frontal lobe functioning helps manage impulsivity.
•For that reason, cultivation of a witnessing self, a part of
the self that can step back, become curious, notice patterns
and notice the parts, should be a priority in treatment
•Of all the parts, the Going On with Normal Life has the
most access to prefrontal cortex and therefore is the best
candidate. But because the Normal Life part gets
overwhelmed by traumatized parts, often we have to model
becoming more curious and observant first Fisher, 2014
Client awareness of the parts requires therapist
awareness
• To help the Adult Self be mindful, the therapist names

the parts and their interactions as we translate from the
language of “I” to parts language
• That requires our noticing the signs and symptoms of
different parts, being open to using the language of parts
rather than the language of “I,” and taking the risk to
verbalize what we notice: eg, “Notice the collapse in your
chest that just happened—maybe thereʼs a part that had a
reaction to your plan to ask for a raise in pay!”
• It is OK to be wrong! The essence of mindfulness is
noticing, not being “right.” When we evoke curiosity, we
support the part of the patient that wants to grow
Fisher, 2013

Use Relentless Reframing
•The key to overcoming compartmentalization is seeing

and naming it, making it recognizable or more concrete.
When we do so, we are co-conscious, more integrated
•Because the compartmentalization is procedurally encoded
and automatic for the patient, it can only be challenged by
consistent use of parts language. If we are not consistent
(i.e., relentless), the patient will ‘default’ to the old ways of
understanding and relating to it
•“Relentlessness” speaks to the need to discipline ourselves
to counteract the automatic assumption of a unified “I” by
consistently using the language of parts. We have to hold
the perspective that there is more than one “I” Fisher, 2013
The Problem of “I”
•“I” statements often describe parts activity, not the
integrated experience of an adult: “I’m shutting down—I
can’t look at you—I’m too ashamed.” Or “I’m a
fraud—people think of me as upbeat, but I’m not”
•In addition, “’I’ is generic—any part can use it to get her
point across.” (Annie) When we use “I” language rather
than parts language with structurally dissociated clients,
we may inadvertently be giving power to or ‘enabling’ the
parts that own the “I”
•In clients who are easily flooded and overwhelmed, “I”
can increase the tendency to flood: as the client talks
“from” the part instead of “for” the part Fisher, 2010

Which “I” ?
•When clients use “I” to speak “from” a part, ask: “Which

‘I’ feels that way? Are there any other points of view
inside you?”
•“Which I?” reminds the client that there is not just one
single perspective inside the mind. But differentiating
parts from “wouldn’t anyone feel this way?” isn’t easy
•Rather than trying to “figure it out” rationally, it is more
helpful to ask clients to take a leap of faith. We can’t prove
to the skeptical, but: Would they be willing to assume for
the purposes of the therapy that any distressing feeling,
thought, or body sensation represents a communication
from a part? Fisher, 2013
Cultivation of the Normal Life Self as a Witnessing
Self
•Neuroscience research tells us cortical functioning is a

prerequisite for trauma treatment and addictions recovery.
•So the first priority is the cultivation of a Going On
with Normal Life self, the part that can observe, be
curious, notice patterns, hold the “reality principle.” That
part is asked to become less disconnected or critical and
more curious, observant, and‘wise mind-ed’
•Psychoeducation is used to help clients identify their
Normal Life selves, whatever their age, experienced as
wanting to do better, have a life outside an institution, go to
university, or have a home and family. Fisher, 2015

A Neurobiologically-Informed Approach
to Working with Parts (Fisher, 2017)
 Assume that dissociation is a way of regulating arousal:
switching, “going away” and acting out all reflect
autonomic dysregulation
 Regulation of arousal is always a first priority to keep
the frontal lobes online and therefore an observing adult
 Maintain a parts focus: “Does that feel like the same
part? Or a different part?”
 Focus on increasing feelings of centered and grounded:
the Normal Life Self can use somatic resources to “help
the child parts” feel safer and better “held” Fisher, 2008
A Neurobiological Approach to
Working with Parts (Fisher, in press), cont.
Thoughts and beliefs are treated as communications
from parts: studying the body responses in addition to the
words is a way of “listening” to the parts
Increasing awareness of somatic markers of parts:
choosing on which part to focus, where that part is felt in
the body, what actions to take, what thoughts to entertain
The ANP learns to notice dysregulation or internal
conflict and to intervene somatically: e.g., by asking the
Fight EP to “go into” the backbone to increase the ANP’s
courage and reassure younger EPs or by having the ANP
lengthen the spine slightly to transform the collapse of the
Submit EP Fisher, 2008

Blending, Shifting, and Switching

•One of the key features in all dissociative ‘disorders’is the
shifting of states. This is the mechanism by which parts
assert power and have the ability to influence the mind, body
and Adult Self
•One state change is “blending,” in which a part’s thoughts
and feelings seep into or flood the body and mind. Blending
makes it hard for clients to distinguish “me” from “part”
•Clients also “shift” states: e.g., the Adult shifts into a sad
child state but is consciously aware of both states
•Dissociative disorder clients switch or get ‘highjacked:’
ie, the client “becomes” the part with little to no awareness
of the part’s activities or words or behavior or even feelings
Fisher, 2010
“Unblending” [Schwartz, 2001] Normal Life

Self from Traumatized Parts
•“Unblending” refers to any technique that decreases
merging with the emotions and perspectives of parts and
increases the ability to hold multiple perspectives in mind.
•The therapist’s job to just to name the parts and foster
empathy for them: “Yes, that annoyed part is worried
about the defeated part ruining everything, isn’t it?” “You
know, the teenager was really trying to help by lashing out”
•As the therapist’s Self communicates compassion, calm,
and clarity to the system, the client’s unblending efforts
are supported, and the nervous system regulates,
increasing the somatic sense of safety and calm Fisher, 2014

Unblending Annieʼs story
•“Again, I failed.”
“I hear a part who feels she failed again”
•“Today was horrible….empty and boring and
scary. So, I laid low, thinking that would be
calming . . .”
“So interesting—you didn’t realize it was the
parts having a horrible, terrible, very bad day?”
•“‘I’ keep making mistakes. I, we, are hungry but all
we have is beer. Where is dinner--how did I miss it?”
“Look—missing dinner makes you aware now that
you got highjacked—that’s great!”
Unblending Annieʼs story, cont.
•“I make so many mistakes in a day.”

“There goes that part who blames herself again”
•“I tried to get the right replacement for a part on my
weed whacker, but I didn't have the right info .......
sound stupid??? I bought clothes for Shannon’s two
older kids and now ‘I’ think they are stupid.”
“Someone is trying hard to stay on top of things, but
there’s a critical part who is never satisfied!”
•“‘I’ keep struggling to be good.”
“She sure does, that part—she tries so hard, but
notice she keeps thinking good = perfect”

Unblending Protocols: 5‐Steps
• Assume that any distressing or uncomfortable feeling is a
communication from a part of you: ‘It’s not my feeling.’
• Put the part’s feelings into words using “she” or “he feels
_________.” See what happens if you say, “She feels ashamed---”
or “He feels angry”
• Create a little more separation from the parts by sitting back,
changing position, lengthening your spine, or using an object to
symbolize the part so you can be in relationship to it
• Use your adult mind to reassure the part that nothing bad
is happening right now. Acknowledge the fear or hurt.
Imagine these fears belonged to __________: what would you say?
• Get feedback—ask the parts: am I “getting” it?
Personalize the steps

for each client. Write
them down in your
own handwriting to
provide a transitional
object as well as
directions for
unblending. They
will have more power
for the client if there is
personal touch

Teaching Parts to “Sit Back”
•In Internal Family Systems therapy, unblending and

mindful awareness of the parts is enhanced by asking
them to “step back” to “make more room for Self”
•The therapist asks, “Would you ask this part if it would
be willing to sit back a little to make more room for
you?” Often, there is an immediate softening or settling
of feelings and sensations, creating dual awareness.
•Sometimes, the part resists, and the client is instructed to
ask, “Would you ask that part what she’s worried about if
she sits back? What does she need from you to be able to
sit back?” “Oh, so she needs to know that you won’t
ignore her if she sits back—could you reassure her of
that?” Fisher, 2009
Teaching Parts to “Sit Back,” cont.

•“Sitting back” is a particularly useful skill for clients
who are overwhelmed or experiencing a lot of “noise”
in their heads. It quiets the noise and also helps to build
compassion for the parts. When they sit back, their
feelings are not so overwhelming and can be “heard”
more easily rather than just felt as flooding
•Because “sitting back” is a skill, clients are asked to
practice it at home between sessions, and the therapist
tries to be consistent in using it in sessions.
•When the therapist has confidence that this skill will
work and that it is key to successful trauma treatment,
clients (and their parts) respond accordingly
Fisher, 2009

Managing Dissociative Switching

•Asking parts to “sit back” presumes that there is an Adult
Self present. But if a client has switched into a younger
part, an Adult witnessing self is no longer present. To
facilitate co-consciousness, we must ask the Adult to “come
forward” and ask the young part to “go inside”
•Hypnosis experts agree that dissociative clients are
chronically in trance, so we can use hypnotic suggestion
techniques. If the child part says, “I don’t know how to,”
the therapist can reply, “I know that—I’ll teach you—just
relax a little bit, take a breath, and then relax inside—just
drifting inside while Susan comes forward.” When this is
repeated, generally the Adult does ‘come back.’ Fisher, 2012
Fostering Internal Communication

•Assumption that there “more than one ‘I’:” consistently
asking, “Which ‘I’ feels so hopeless?”
•Mental contents must be connected to “right self:” the
Structural Dissociation model can be used to predict which affects
and responses “belong” to particular types of child or adult selves
•The goal is co-consciousness: each time connections are made
between a feeling and a part of the self, dissociative barriers are made
more permeable, and the seeds of co-consciousness are planted.
•The therapist enhances co-consciousness further by
teaching the client’s Adult Self to gather information internally by
“asking inside.” I.e., by directing questions internally, asking, “What
part feels this way? What is s/he afraid of? What does s/he need
from me to be less afraid/angry/sad?” Fisher, 2011

Using Multimodal Techniques

“When you hear something, you will forget it. When
you see something, you will remember it. But only
when you do something, will you understand it”
[Chinese proverb]
•Multimodal techniques increase the integrative potential of

every intervention we use
•If we add a visual component to the auditory, or a
movement to the words we choose, or a visual image or
auditory cue to an abstract concept or quality, the chances
of retention and generalization are increased
Fisher, 2004
Externalizing Parts Can Facilitate

Mindful Noticing

Externalizing Parts Can Also Facilitate

Problem-Solving
Critical Part
Scared Part
Ashamed
Part
Attach
Part Protectors
Normal Life
Part

Using Diagramming to Promote

Internal Awareness
= Adult parts of self grounded in
the present
= Child and teenage parts still

living in the past
= Trigger of traumatic activation
= Impact of one part on another
= Empathic connection between parts
The Feedback Loop

Therapist away on
maternity leave: “I
“Don’t worry,
don’t think I can
make it by myself “ Critical. I can
take care of both
Adult Elizabeth of you”
These threats re-

trigger the child
part and re-ignite
the cycle
Little Critical Enforcer
One Part
“I’m scared--
“Get a grip! “You deserve to
sad—all alone”
Stop that die---your body
“Someone
whining! Shape is worthless
please help me!”
up, loser!” anyway”
Fisher, 2004

Internal Problem-Solving
Med doctor “I want to stop all
is moving Annie my meds”
to a clinic
9 Warrior 13
Little
Saint
Warrior Depressed,
suicidal: “I need
those pills”
“We don’t feel The Hypervigilent
safe there” Protectors: “We
will be exposed--it 3
“We just
“It reminds us isn’t safe” 7 want to feel
of those social 5 better”
workers”
Fisher, 2002
“Integration requires both differentiation and
linkage”
[Siegel, 2010]
•We cannot integrate aspects of ourselves that we have not

observed, acknowledged, and “owned” as part of “me”
•Integration approaches in which the fragmented client is
treated “as if” s/he were one integrated person always fail.
•The parts must first be noticed and identified, then
connected or linked so they become essential aspects of
one system that is adaptive and “flows.” As Siegel (2010)
says, “Failure of integration leads to chaos, rigidity or
both.” Fisher, 2010

The “Laws” of Dissociation
•“A part is just a part”

•“The system was designed for survival, not
destruction”
•“For every action, there will be an equal and
opposite reaction”
•“The therapist is the therapist for all the parts and
for the system as a whole”
Fisher, 2000

5665 College Avenue
Suite 220C
510-891-1809
DrJJFisher@aol.com

Working with the

of Trauma
Working with Fear, Shame and Anger
The Role of Fear, Shame, and

Anger in Trauma
“. . . The goal of emotions is to bring
about physical movement: to help the
organism get out of harmʼs way, in the
case of negative emotions, and to
move in the direction of the stimulus in
the case of positive [emotions].”
van der Kolk, 2006

Triggered and dysregulated, the body

continues to anticipate danger
“When neither resistance nor escape

is possible, the human system of self-
defense becomes overwhelmed and
disorganized. Each component of the
ordinary response to danger, having lost
its utility, tends to persist in an altered
and exaggerated state long after the
actual danger is over.”
Judith Herman, 1992
Humans depend upon the same

defensive responses as animals
We either Fight for
cry for our lives,
help,
Or flee
Or, if we
are small,
we freeze
to When there is no
become way out, we submit
invisible and ‘play dead’

Autonomic arousal drives both animal defenses

and emotional responses
Hyperarousal:
Fear, terror
Rage, anger, frustration
Defenses of freeze, fight, flight and cry
High Arousal for help
Hypoarousal:
Flat affect, numb, aleixythymia
Low Arousal Shame, disgust, depression
Animal defenses of feigned death and
Ogden and Minton (2000) total submission
*Siegel, D. (1999)
Fear and Anger are

Sympathetically-Mediated
•Activation of the sympathetic nervous
system drives hyperarousal symptoms, such as
elevated heart rate and respiration, hyperactivity,
hypervigilance, easy startle, and emotions of fear,
terror, and panic, all serving the biological purpose of
sounding the alarm and warning of danger
•Core beliefs driven by sympathetic activation

have to do with safety: “I’m not safe,” “I’m a
marked woman,” “You can’t trust anyone.”
Fisher, 2006

Shame is a Parasympathetically‐Mediated
Symptom
Activation of the parasympathetic nervous

system is associated with autonomic responses
of dissociation or disconnection, vegetative depressive
symptoms, emotional numbing, decreased heart rate, and
emotional responses of shame, disgust, despair, and guilt,
all of which serve the function of facilitating
submission responses and thereby maintaining
connection to attachment figures
Parasympathetic activation drives such core beliefs
as “I’m worthless/helpless/hopeless” Fisher, 2006
Emotions and Trauma [LeDoux, 2003]

•The parts of the brain that induce or store emotions
are subcortical (ie, below the level of words): the
amygdala, hypothalamus, ventromedial prefrontal cortex,
and brain stem. Most if not all of these areas are also
involved in storing or inducing trauma responses.
•Emotions often activate PTSD responses: simple
primary emotions (like grief) may feel frightening or
overwhelming when intensified by autonomic arousal.
Also, emotional responses to trauma-related triggers
become “kindled” and thus habitual; or emotions may
automatically trigger hypoarousal, numbing, and
disconnection Fisher, 2013

Trauma‐related Emotions
• Because threats to safety evoke survival defense
responses, it makes sense that fear, shame and anger are
the most common emotions in traumatized individuals
• Threats to life and safety mobilize fear responses to
alert the body to danger: fear is an adaptive response
when others might harm us
• Often misunderstood as “anger,” fight responses are also
an adaptive reaction to danger. Clients’ fight instincts
are heightened now because they could not
‘complete’ the impulse to fight back ‘then’
• And shame is adaptive in traumatic conditions, too,
when there is no recourse other than to submit
Body Remains Ready to Defend

“When the traumatized individual is faced with
reminders of the trauma and experiences a
defensive response, the function of that
defensive response has shifted from reacting
to an immediate threat to reacting to an
anticipated threat. What began as a
necessary defense in the face of a real threat
becomes a pervasive, unrelenting reaction to
the anticipation of a threat.”
Ogden, Minton & Pain, 2006

SHAME
Why does shame stick like ʻglueʼ for decades
after the trauma?
•Shame is a survival response, as crucial for safety as

fight, flight, and freeze
•Shame, however, feels “personal:” by its nature, it feels
as if it is about “me”
•Shame is a body response accompanied by cognitive
schemas that can also trigger shame and create a vicious
circle of shame
•Shame is often reinforced by other cognitive schemas,
such as “It’s not safe to succeed—to be self-assertive—
to have needs—to be happy” Fisher, 2010

How can we better understand

trauma and shame?
“[When] a relationship of dominance and
subordination has been established, feelings of
humiliation, degradation and shame are central
to the victim’s experience. Shame, like
anxiety, functions as a signal of danger, in
this case interpersonal or social danger.
Like anxiety, it is an intense overwhelming affect
associated with autonomic nervous system
activation, inability to think clearly, and desire to
hide or flee. Like anxiety, it can be contagious.”
Judith Herman, 2006
“Shame signals (e.g., head down, gaze

avoidance, and hiding) are generally
registered as submissive and [appeasing],
designed to de-escalate and/or escape from
conflicts. Thus, insofar as shame is related
to submissiveness and appeasement behavior,
it is a damage limitation strategy,
adopted when continuing in a shameless,
nonsubmissive way might provoke very
serious attacks or rejections.”
Gilbert and Andrews, 1998, p. 102

Shame and Self‐Doubt are Magnified by
Powerlessness
•Children have no control over the acts of their

caregivers: experiences of satisfying autonomy
or mastery are fostered by secure attachment
and absent in disorganized attachment relationships
•When the caregiver is the source of threat, it is
not surprising that, instead of experiences of age-
appropriate mastery, children are over-exposed to
experiences fostering shame and self-doubt: “I
can’t do it—I have no control—I’m little and
helpless and insignificant.” Fisher, 2007
Neurobiological Purpose of Shame [Schore, 2003]
•Allan Schore believes that shame serves the purpose of

helping the child inhibit behavior. When shame down-
regulates excitement and impulsivity, the child is able to
restrains from doing whatever action the parent just forbid
•In a healthy, safe environment, these normal experiences
of shame are repaired by the parent so that shame inhibits
but then is mitigated by soothing and clarification
•In an unsafe environment, shame must be over-used to
down-regulate states of fear/anger or any behavior
unacceptable in the environment. In these families,
shame states are not repaired by the caregiver Fisher, 2006

Shame as a Source of Safety
•As part of its role in downregulating activation, shame

helps to drive the animal defense of submission:
shame responses cause us to avert our gaze, bow our
heads, and collapse the spine
•In an environment in which self-assertion is unsafe for
the child, shame enables the child to become
precociously compliant and preoccupied with
avoiding “being bad”
•This avoidance of potentially dangerous behavior and
procedurally learned submissiveness is adaptive in
traumatogenic environments Fisher, 2006
Shame alerts us to what was dangerous then
•Shame is typically triggered by criticism, by normal

mistakes, less-than-perfect performance, or simply being
visible or noticed, or disclosing one’s needs—all logical
as precursors to abuse.
•What is more striking about trauma-related shame is
that it can also be triggered by positive experiences:
pleasure and spontaneity, healthy change or
accomplishment, feeling proud or happy, self-assertion,
setting limits, etc. Traumatized clients report these too
were all dangerous when they were young. Fisher, 2017

How Experiences of Shame Become Cognitive
Schemas
•“The subjective experience of shame is of an initial shock

and flooding with painful emotion. Shame is a relatively
wordless state, in which speech and thought are
inhibited.” (Herman, 2007)
•The words put to these autonomic, non-verbal responses
naturally reflect the experience of feeling small, powerless,
and exposed. Over time, these become belief systems that
explain all subsequent experiences
•Trauma-related cognitive schemas are then inextricably
linked with affective and bodily states of shame, resulting in
vulnerability to shame and self-hatred Fisher, 2009
Shame and Cognitive Schemas, p.2
•Meaning-making childhood begins in the body: an infant
or small child can only make meaning at a body level.
Then, as children develop language, they begin to attach
words that seem to explain these emotional and body states
•The words not only reflect the body states but can also
trigger the body states each time they are used. A
collapse in the body accompanied by hypoarousal and a
heavy feeling in the chest may be ‘explained’ as “I’m
worthless” or “I’m stupid.” Each time those words are
repeated, the body feels heavier, more hypoaroused, more
collapsed. Thereafter, the body experience and the
cognition mutually reinforce and confirm each other
Fisher, 2009

Fear, Shame and Anger are Procedurally‐
Learned Responses
• “Procedural learning”refers to the acquisition of body

memory for how to “do things,” such as driving an
automobile or riding a bicycle
• In traumatic environments, children and adults alike
depend on procedural memory to acquire adaptive
physical and mental reactions, cognitive schemas, or
behaviors that promote optimal survival
• For the most part, procedural learning is
characterized by automatic, non-conscious
performance, making it more efficient and automatic
Fisher, 2006
“The neural substrate for procedural learning appears to develop prior to

the capacity for declarative learning. This means [that] templates for
habitual behaviors may be acquired, and the behaviors become
relatively automatic and routine, before the child has an episodic
memory system capable of remembering the events that produced these
behaviors. [Thus,] very young children are likely to experience a kind
of learning . . . that is dissociated from the content.”
Grigsby & Stevens, 2002

Emotions and Procedural Learning
•Over time, procedurally-learned responses become

automatic and unconscious: when threat stimulates terror,
shame regulates the fear response—or anger stimulates
protective action.
•Associated cognitive schemas evoke both increased
shame AND hope: “I’m stupid” provides hope of being
smarter; “I’m ugly” gives hope for being an Ugly Duckling
who grows into a Swan; “I’m not lovable” provides hopes
for improving one’s lovability. “I’m not safe” provides a
warning to hide or isolate; “I have to fight” reinforces
automatic fight responses to threat Fisher, 2017
Environmental
trigger
The Vicious Circle of Shame and
More Shame
Flushing, sick feeling “I’m
Which triggers
in stomach, impulse stupid/worthless/ina
to turn away, curl into dequate/undeserving
ball ”
Which triggers
Procedurally-learned
automatic beliefs
Physiological shame
responses

Ideally, as therapists, we help patients

“to accept and integrate certain
emotions, to acknowledge some but
bypass others, to regulate disruptive
emotions, to express those that will
enhance relationships, to contain and
soothe painful emotions, and to explore
and transform maladaptive emotions.”
Greenberg, 2007

working with the procedural learning
system. . .” [Grigsby & Stevens, 2000]
•The first [type of therapeutic challenge] is to …observe,
rather than interpret, what takes place, and repeatedly
call attention to it.”
•Empathy is not helpful with shame: it reinforces
identification with the shame, rather than challenging it.
[Note: Observing the shame or the body can also trigger shame]
•Empathy often may not be helpful with angry clients:
empathy tends to increase connection to vulnerability,
increasing anger. With fear, empathy can be
misinterpreted as “You should feel afraid!” Fisher, 2017


working with the procedural learning
system. . .” [Grigsby & Stevens, 2000]
• •”The second therapeutic tactic is to engage in activities
that directly disrupt what has been procedurally
learned.“
• “Disruption” refers to responses and interventions that
interrupt obsessive negative thoughts, that increase
curiosity, that are unexpected or playful.
• But the disruption cannot be triggering: it is better
done more indirectly than directly. For example,
responding to shame with playfulness, fear and anger
with energy rather than a soothing tone
Psychoeducation
Psychoeducation is a ‘good disruptor’ of all of the

dysregulated emotions:
•Psychoeducation about the ability of shame to inhibit
impulsive behavior, its role as a ‘brake’
•Psychoeducation about the contribution of shame to
enforcing submission for the sake of safety. Submission
must be understood as an ‘active’ defense at those times
when fight and flight would be dangerous or impossible
•Psychoeducation about shame and cognitive schemas:
“The belief that you are worthless is a story you told
yourself—it kept you alive” Fisher, 2009

Psychoeducation, cont.
Psychoeducation is a ‘good disruptor’ of dysregulated

emotions:
•Psychoeducation about anger as part of the animal defense
response of fight: how fight responses often have to be
inhibited and gain more energy as a result
•Psychoeducation about the role of anger in establishing
control over threats, a sense of empowerment, and
increasing courage and confidence
•Psychoeducation about fight and cognitive schemas: “The
belief that anger is bad benefits the perpetrator more than it
benefits you.” Fisher, 2009
Psychoeducation, p. 3
Psychoeducation is a ‘good disruptor’ of fear and

anxiety, too:
•Psychoeducation about fear as a “signal” emotion, meant
to warn us of danger and mobilize our defenses
•Psychoeducation about fear as an implicit body memory:
“This fear seems like a memory of old fears from when you
were young.”
•Psychoeducation about fear or anxiety and cognitive
schemas: “The belief that the fear means it’s dangerous
NOW just increases the fear. . . Notice how your heartrate
increases when you say those words.” Fisher, 2017

FEAR
Emotional Experience is
Always Embedded in Body
Experience
“All emotions use the

body as their
theatre”
Damasio, 1999

Chronic Expectation of Danger
• The legacy of trauma invariably includes persistent

fear, reflecting the mammalian tendency to increased
vigilance and preparedness for threat under dangerous
conditions
• Brain scan research corroborates that the amygdala
becomes “irritable” after trauma, sensitized to triggers
and threat cues, and easily triggered to “sound the alarm”
• Due to the phenomenon of triggering, the body becomes
repeatedly primed for “it” to happen again, rather
than more confident that the danger was long ago and
it is safe now Fisher, 2017
Chronic Expectation of Danger, cont.
• Anxiety is a ‘signal emotion,’ meant to alert us to
danger and evoke the emergency stress responses that
mobilize fight and flight instincts
• Though persistent fear is debilitating and constricting,
adaptation in times of danger is enhanced by easily
triggered fear responses.
• Like other emotions, fear is a non-verbal state to which
we later put words—words that reflect how we feel,
not the context in which we feel it. “It’s not safe” are
words commonly put to fear experiences, and then the
words themselves also evoke fear—of fear of fear.
Fisher, 2017

Environmental
trigger
The Vicious Circle of Fear and More
Fear
Rapid heart beat,
Which triggers “It’s not safe” “I’m
tightness in chest and
stomach, hyper‐ going to be killed”
arousal, trembling “I need help!”
Which triggers
Procedurally-learned
automatic beliefs
Physiological
anxiety/fear
responses
Working with the Bodily Manifestations of
Fear/Shame
• When we try to work with fear or shame verbally, we

often exacerbate the painful emotional responses.
Talking about fear and shame (or anger) triggers more
feeling, rather than resolving those feelings
• Or the cognitive schemas reinforce the fear or shame:
“I’m not safe” is a frightening thought; “I’m
defective” is a shame-promoting thought.
• Instead, we can re-frame the fear or shame as a body
response: “Your body is giving you a false alarm. . .
It’s saying ‘Watch out—danger—red alert.’”

Working with the Bodily Manifestations of
Emotion, cont.
• In Sensorimotor Psychotherapy, we ask clients to ‘put

the thoughts aside’ and “notice the fear as just body
sensation. . .,” instead of reacting to it.
• “Your body is giving you a false alarm. . . It’s saying
‘Watch out—danger—red alert.’ Notice how it’s
telling you that: is it your heart beat? Is it the tension
in your chest? Just notice the anxiety as body
sensation—that’s all it is. . . Just body memory.”
• It takes practice to focus away from the beliefs about
fear and just notice it as body sensation, but the
repetition is necessary for success Fisher, 2017
“Dropping the Content”
• An important sensorimotor skill for regulating emotions
and arousal is learning to “drop the content:” to focus
away from dysregulating thoughts, interpretations and
feelings and instead to focus attention toward the body
sensations OR just external stimuli
• For less mindful or more unstable clients, letting go of the
“content” is only possible when they focus on something
concrete, such as their feet, as an alternative
• Dropping the content to focus on the body challenges
negative cognitions: the words lose their power when
they are deliberately ignored. Clients can be taught to
ʻdropʼ the partsʼ shame or judgments or their own
Fisher, 2015

Re‐framing Shame and Fear
•Using the assumption that every symptom is a valuable

piece of data about how the client survived, shame or
fear can be re-framed as a valiant attempt to
cope in a dangerous world
•Look for what the shame or fear is trying to
accomplish now: Increase hypoarousal? Maintain
compliance? Combat anger and assertiveness? Keep the
client from being “out in the world”? Or prevent change?
Admire shame and fear as survival resources! “You
wouldn’t be alive today without the protection of shame. . .
Without that alarm system of fear. . .” Fisher, 2017
Other Challenges to Shame
•Mindfulness and self-study: “Let’s be curious about what

happens when those shaming thoughts come up? “Drop the
content, and notice the shame just as body sensation . . .”
“Don’t attach to it or avoid it with disgust. . .”
•Dis-identification: “The thought,‘I don’t deserve
anything,’ is just a theory from when you were young, huh?”
•Identifying shame and self-loathing as parts: Typically,
shame reflects a relationship between two parts: a part that
judges and a part that feels judged. When the critical part
echoes the negative messages heard in childhood, younger
parts feel the same sense of shame as if it were “then”
Fisher, 2009

Other Challenges to Fear
•Mindfulness and self-study: “Let’s be curious about what

the fears? How would that have made sense when you were
young?” “How did the fear help you survive?”
•Dis-identification: “Notice the thought,‘I’m not safe’ as
memory—it was true when you were young, wasn’t it?”
•Identifying fear and dread as parts: It makes sense that
fear-related parts would become fragmented and split off as a
legacy of the trauma—with different parts holding different
fears. An attach part might hold the fear of abandonment; a
freeze part might carry the fear of attack; a flight part might
embody the fear of being trapped; a ‘fire alarm’ part could
have the role of warning the others of danger. Fisher, 2017
Treating Emotions as Child Parts
•“So, there is a part of you that is feeling shame right now

because you’ve told me something so very personal. Is
there another part shaming the ashamed part? A part that
judges you or other parts? Or is the ashamed part
remembering being judged and shamed?” (Where there is
an ashamed part, there is generally a shaming part.)
•“There is a very fearful part of you that is so afraid of your
success at work---feels so exposed and unsafe. She’s really
scared, isn’t she?”
•The therapist’s job is to evoke the client’s empathy for
the part—the part is scared or ashamed, not the client
Fisher, 2017

Using a Parts Approach
Therapist is on
maternity leave
Adult Stephanie
These threats re-
trigger the child
part and re-ignite
the cycle
Scared Critical Suicidal

Child Part Part
“No one cares about “You don’t “What’s the

me—I’m not safe” deserve to be point in living if
cared about--- no one respects
“I just want to go to sleep why should you?”
and never wake up” anyone care?”
Fisher, 2006
Compassion for one’s parts

“Compassion [involves] a number of key abilities [and
processing systems]: . . . the desire to care for the well-
being of another, distress sensitivity/recognition related
to the ability to detect and process distress . . ., sympathy
related to being emotionally moved by distress, distress
tolerance related to the ability to tolerate distress and
painful feelings‘in another’ . . . , empathy related to
intuitive and cognitive abilities . . . to understand the
source of distress and what is necessary to help the one
distressed, and non-judgment related to the ability to be
non-critical of the other’s situation or behaviours. All
these require the emotional tone of warmth.”
Gilbert & Proctor, 2006, p. 358

A Solution for the Part
“It’s OK—I’m here for you.
You’re not alone. You haven’t
Adult Stephanie failed—your family just
doesn’t know how to be nice.”
Ashamed or Critical Suicidal

Fearful Part
Child Part
“I’m “You’re just Not needed now,

overwhelmed— ungrateful! You the Suicidal pari
I’m all alone owe your family can be on “stand
now—no one for all they’ve by” alert status
cares” done for you!”
Fisher, 2006
Combating Shame Through the Body
•If the shame is reinforced or exacerbated by body

experiences of collapse, loss of energy, feelings of
revulsion, curling up or turning away, then shame can be
mitigated by changing body posture
•Lengthening the spine and grounding through the feet
both challenge shame. If the client head is bowed or
averted, bringing the head up or asking the client to begin
to slowly turn the head and lift the chin can begin to
increase feelings of confidence and fearlessness. If these
movements are triggering, they can be executed more
slowly, piece by piece, over time Fisher, 2011

Combating Fear Through the Body
•If fear is reinforced or exacerbated by body responses, such

as increased heart rate, tension, shaking or trembling, then
fear can be mitigated by practicing somatic skills
•Placing a hand over the heart slows heart rate. This
simple movement can reduce anxiety. Or placing one hand
on the stomach and the other on the stomach.
•Orienting to the environment: turning the head and neck
in a 180 degree circle, noticing ‘What’s different?’ can be a
signal to the body to reduce anxiety
•Making a boundary: holding up hands in ‘stop’ gesture,
drawing a circle around the body can also decrease fear
Fisher, 2017
The Vicious Circle of Fear or Shame and
Anger
“I’m
Trigger
worthless/inadequate”
“I’m not safe”
Which reinforces trauma-

related beliefs
Feeling exposed,
vulnerable is
experienced as
Adrenaline
life‐threat
response, anger,
rage, heat, impulses
to violence, acting
out
Sympathetic
responses Fright responses

ANGER
“If an individual is born into a malevolent

and stress-filled world, it is crucial for his
survival . . . to maintain a state of vigilance
and suspiciousness that enables him to
readily detect danger. He will need to have
the potential to mobilize an intense flight-
fight response and to react aggressively to
challenge without undue hesitation [in
order] to facilitate survival . . .”
Teicher et al, 2002

“[These survival responses will]

markedly augment the
individual’s capacity to rapidly
and dramatically shift into an
intense aggressive state when
threatened by danger or loss.”
Teicher et al, 2002
FIGHT RESPONSE

Fight responses are active or mobilizing defenses
• Anger is the emotional component of the fight

response and characterized by a surge of energy,
mobilization of the arms and legs, and impulses to hit,
push, kick or scream. Whether we can safely defend or
have developed automatic submission responses, the
fight response is automatic under threat.
• But because our clients have experienced the misuse of
anger and violence, they are often phobic of their
anger. Or their bodies learned at an early age to
disconnect from angry feelings for fear of displaying
them and being punished for doing so
Fight responses are active or mobilizing defenses,
cont.
• When anger is re-framed as a ‘fight response,’ most

clients find it less frightening and distasteful.
• It also helps them to direct attention to the physical
effects of the anger rather than to the object of their
anger. I ask: “Do the sensations feel more like energy?
Or strength? Or do they want to do something?’
• Most clients report that the sensations feel more like
energy. Then they are asked: “Does the energy [or
strength] feel good physically?” Usually it does, and
then they are asked to keep focusing on the good feeling
Fisher, 2017

Fight responses are active or mobilizing defenses,
p. 3
• Harriet Lerner in “The Dance of Anger” wrote years

ago that most of us waste our anger by discharging or
suppressing it. She encouraged women to view their
anger as “rocket fuel,” to “save it up” and let it
mobilize confidence, courage, and the ability to stand
their ground
• Lerner’s views are now supported by the somatic
literature. Anger’s usefulness lies in its ability to drive
empowering actions. It is less useful and less
empowering when discharged via verbal expression, and
verbalization is more effective if supported somatically.
Fisher 2017
Using a parts approach with anger
Therapist fails her
empathically: “It
must be hard . . .”
Adult Jessica
The fight part’s
response re-
triggers the
child’s fear of
abandonment
Hurt Fight
Child Part
“She doesn’t “She is cold and

understand—she uncaring—and it’s her
doesn’t really care job to care! I’m going to
about me!” tell her a thing or two!
Fisher, 2017


auxiliary cortex] and affect regulator
of the patient’s dysregulated states in
order to provide a growth-facilitating
environment for the patient’s
immature affect-regulating
structures.”
Schore, 2001
Being a “neurobiological regulator”

•It does not mean convincing the patient “not to be
ashamed.” Our well-meaning attempts to encourage
clients to believe in themselves are often dysregulating
•What it means is that the therapist “regulates” or
“repairs” the shame, just as healthy parents do: i.e.,
experiments with making contact with the patient in some way that
mitigates the shame, such tone of voice, energy level, empathy vs.
curiosity, re-framing the shame as active and heroic
•Effective neurobiological regulating of shame also

requires a commitment to not letting clients “go there:”
interrupting the thoughts earlier, consistently challenging the
cognitions, re-framing over and over again Fisher, 2009

Resonating to and regulating trauma-

related emotional states
Hyperarousal:
Fear, terror
Rage, anger, frustration
Therapist’s response has

to ‘match’ client emotion Window of Therapist response has to
while remaining within Tolerance ‘match’ client emotion
the Window (ie, slightly while remaining in the
less hyperaroused) Window, ie, slightly less
hypoaroused
Hypoarousal:
Fisher, 2017
Shame, disgust, self-
Ogden and Minton (2000) loathing
*Siegel, D. (1999)
Social engagement is a prerequisite for co-

regulation
•The social engagement system as described by Steven

Porges is a neurobiological system governed by the vagus
nerve that relies upon the “muscles that give expression to
our faces, allow us to gesture with our heads, put intonation
into our voices, direct our gaze, and permit us to distinguish
human voices from background sounds.” (Porges, 2004, p. 21)
•The social engagement system comes online at 2-3
months and is naturally engaged when human beings feel
safe. It goes offline when we are not, requiring that
caregivers provide both safety and interactive
communication for its optimal development

Increasing social engagement in the

therapy as a prelude to resolution
•Neglect and trauma interfere with social engagement:
with parents who are ‘frightened or frightening,’ children
freeze, shut down, space out, don’t make eye contact
•Clients with social engagement difficulties are simply
telling us that they didn’t and still don’t feel safe: i.e.,
difficulty making eye contact, blunt affect, head bowed,
difficulty discriminating safe/unsafe, frozen facial
expression—increasing the chances of empathic failure!
•When we observe an inhibited social engagement
system, it is a communication that the patient feels
unsafe and a signal to turn on our social enagement!
Experiment with using the components of social
engagement
•Vary your voice tone and pace of speech: soft and slow,
hypnotic tone, casual tone, strong and energetic tone, playful tone.
The voice is the best regulator of the nervous system
•Experiment with facial expression: does the patient respond
differently to calm vs. warm, expressive, or playful expressions?
•Use your gaze creatively: soften your gaze, put a sparkle in
your eye, set boundaries with your gaze, communicate warmth
•Take advantage of the turning and tilting abilities of the
head and neck: tilt your head when saying something challenging
or potentially triggering; turn your head away very slightly if the
client is uncomfortable with direct eye contact Fisher, 2018

Experimenting with co‐regulation
• When you find yourself tensing, unsure what to say,
frustrated, confused, try just relaxing the body.
• If you feel defended or ‘armored,’ experiment with
opening your chest or heart area just a little (but not so
much that you will feel assaulted if s/he gets angry)
• When you need to set limits on how clients communicate
hurt, anger, or sadness, first become an “iron fist in the
velvet glove:” engage your core and relax periphery
• At times when you need courage, lengthen your spine
• When you want your boundaries respected, engage your
boundary muscles and relax your facial muscles!
“The therapist’s empathy is not in itself

curative of attachment problems, but rather it
serves to create new experiences that
disconfirm and dissolve troubled attachment
schemas. . . (p. 108). The therapeutic power of the
therapist’s empathy resides . . . in how the
agreeable experience very specifically
disconfirms the client’s particular,
problematic models of self, relationship, and the
world.” (p. 109)
Ecker et al, 2012, pp. 108-109

In the face of stuckness or resistance,

•Become more curious: how is the stuckness serving the
patient? What would s/he lose if the client felt worthwhile? What
might be threatening about feeling proud or deserving?
•Let go of your need for their progress: cultivate the ability
to just keep challenging the shame. It is hard for us to hear self-hate,
but understandable that they feel safer ashamed than proud.
•Consider fear or attachment issues: did they have to use
shame to maintain attachment bonds with caregivers? Or does the
shame indicate a phobia of active, assertive, emotional expression?
•Look for internal struggles between parts: stuckness often
= gridlock. Parts holding different survival imperatives cannot agree
on a common goal: the internal critic keeps attacking needy or
emotional parts, and shame shuts it all down Fisher, 2008
“The primary therapeutic attitude [that

needs to be] demonstrated [by the
therapist] throughout a session is one of :
P = playfulness
A = acceptance
C = curiosity
E = empathy
Hughes, 2006

“Leavening” Distress States with

Positive States
“Playful interactions, focused on positive

affective experiences, are never
forgotten . . . Shame is always met with
empathy, followed by curiosity. . . . All
communication is ‘embodied’ within the
nonverbal. . . . All resistance is met with
[playfulness, acceptance, curiosity, and
empathy], rather than being confronted.”
Hughes, 2006

DrJJFisher@aol.com

office@sensorimotorpsychotherapy.org
www.sensorimotorpsychotherapy.org

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Rehab Kids

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Janina Fisher, Ph.D., is a licensed clinical psychologist and former

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Working with the

Janina Fisher, Ph.D.

Having a trauma lens...

Jenni Thompson, 2013

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Because children are so dependent on their caretakers

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Decreased Numbing Eating disorders

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The Triune Brain [McLean, 1967]

Threat and the Brain

Reptilian Brain: Threat

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The Emergency Stress Response

Sympathetic Nervous Parasympathetic Nervous

After the threat has passed,

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“Under conditions of extreme stress, there is

Van der Kolk Hopper & Osterman 2001

•Brain scan research demonstrates that traumatic memories

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•The human body is self-protective: it automatically reacts

Therapy and therapists Recall of traumatic events

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•Intrusive emotions disproportional to the stimulus: fear,

Sensorimotor Psychotherapy Institute

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Autonomic Adaptation to a Threatening World

Optimal Arousal Zone:

“One of the most robust findings of the

Sensorimotor Psychotherapy® Institute 2012

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Pervasive, chronic fear = “Iʼm not safe anywhere”

Mistrust and fear of people = “I donʼt like people”

Shame = “I am a loser--a failure--Iʼm worthless”

Wanting to die = “I deserve to die”

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Judith Herman’s (1992) Three-Phase

PHASE III: Integration and Meaning-Making

To Stabilize, Frontal Lobe Inhibition

Copyright 2017: Janina Fisher, Ph.D. Do

What should the trauma-wise

Copyright 2017: Janina Fisher, Ph.D. Do

“The therapist’s role is both intellectual and

Copyright 2017: Janina Fisher, Ph.D. Do

“Where attention goes,

•Awareness or recognition of sensation, thought,

Copyright 2017: Janina Fisher, Ph.D. Do

Distinguishing Thoughts, Feelings,

Copyright 2017: Janina Fisher, Ph.D. Do

•Traumatized individuals generally come to treatment

Copyright 2017: Janina Fisher, Ph.D. Do

Copyright 2017: Janina Fisher, Ph.D. Do

Dis-identifying from Symptoms

Copyright 2017: Janina Fisher, Ph.D. Do