Primitive Reflexes and Righting Reactions

A Look Through the Lens of Survival, Emotions, and Memory

A critical aspect of the SE® model is the restoration of protective responses (orienting, survival/defensive responses and attachment/bonding). Motor reflexes, which provide for optimal self-protective responses, may be disrupted as a result of trauma, but may also be disturbed in the course of otherwise normal motor development. These developmental disturbances may then be the underlying source of disrupted capacities for self-protection and healthy attachment or may be intertwined with disruptions caused by traumatic incidents. Proper functioning of the sensory systems (visual, auditory, proprioceptive, tactile and olfactory) is another critical element in the overall mechanism of self-protection. As with motor reflexes, sensory systems may be disrupted due to trauma, or via disturbances in the original developmental process for these systems. In this article, the physical processes of orienting, attachment and defense, and their underlying developmental progressions, will be described in the context of the SE® model.

Orienting defensive responses and attachment systems cannot be completely separated because orienting is a primary part of our capacity to defend and to bond. Likewise, the sensory and motor functions, which are critical for self-protection often, serve to support orienting, defense and attachment.

Introduction

Physical therapists, physicians, occupational therapists and some somatics practitioners who utilize movement therapies understand and use primitive reflexes (PR) and righting reactions (RR) differently. For example, a pediatric physical therapist might evaluate an infant’s motor development by looking at both gross motor patterns (rolling or creeping, for example) and her primitive reflexes or righting reactions to assess developmental level, functional ability and neurological status. A somatics practitioner might look at how well PR and RR are integrated into more mature and complex movement patterns to help direct interventions based on what is missing or inefficient.

It is generally agreed that PR and RR underlie, or form the foundation for, more complex and integrated movement patterns and sequences. This is described clearly by Nancy Start Smith (1). However, I want to propose an additional way of considering the functional importance of PR and RR. I suggest that the PR and RR are hardwired in our nervous systems as instinctual implicit memory and underlie or lay the foundation for flight, fight and attachment/bonding strategies so important for our survival.

The first order of being alive, starting from the moment of conception, is survival. In order to survive, and thrive, mammals need bonding/attachment with those who can nurture them. We also need the physical ability to protect ourselves. The ability to flee a dangerous situation, fight back if threatened, or freeze (shut down in shock if overwhelmed and unable to engage the flight and fight abilities successfully), is also imperative for our survival.

If we look at PR and RR through the lens of survival, we can understand how they form the foundation for our physical, functional abilities of bonding and defense. In the first part of this article is a description of PR, RR and equilibrium responses (ER). In order to place them in context of gross motor development I have listed the expected ages of some gross motor development patterns of movement.

The second part of this article is a theoretical categorization of the PR and RR based on the functional relationship they have with survival/defensive and bonding strategies.

In the part 3, I detail most PR and RR, describing how they are elicited and how I understand their function based on our need and imperative to survive and thrive.

This is followed by a case example to demonstrate how to track for the emergence of motor reflexes and support completion of the thwarted impulses and allow for deepening of the potential for healthier bonding.

Part I: Reflexes, Righting Reactions and Equilibrium Responses

Primitive Reflexes (PR)

Primitive reflexes are stereotypical movement patterns in response to specific stimuli. In other words, each time a stimulus is provided, the same movement pattern is elicited with no or limited variation for typically healthy development. They appear at or before birth, normally developing in utero, while the postural reactions of righting, and movement responses to maintain equilibrium or balance develop later in infancy. Most PR integrate by 4-6 months of age although a few remain as reflexes throughout life. Integration is accomplished when equal and opposite reflexes modulate each other for more variable and mature movements. The PR may not be noticeable in the execution or performance of complex mature movement patterns. During stressful situations, however, they may be distinguishable. An example of this is when a person looks over his right shoulder to determine if it is safe to change lanes on the highway. The car may start to veer to the right because an Asymmetrical Tonic Neck Reflex (ATNR) [see part 3 for details] is present in this relatively stressful environment.

PR are mediated at the levels of the spinal cord and brainstem (reptilian brain) and underlie all movements including righting reactions, equilibrium responses, orienting and survival defensive responses of fight, flight. They are utilized by all movements of the head and neck, underlying orienting and the ability to turn the head and make visual contact in, for example, bonding with mother.

If PR are absent or deficient, development of more advanced movement patterns will be absent, weak or deficient. This includes survival defensive responses and higher-level complex movement patterns. This can result from trauma in-utero, pre- or perinatally or later on in life and can manifest in a failure of physical defense.

Righting Reactions (RR)

RR develop at or shortly after birth in response to the new environment of gravity. They are most distinguishable at 10-12 months old and remain active throughout life, providing integrated movement between the head and trunk, and the body and gravity. They are under control at the mid-brain level and have to do with the relationship to gravity and the relationships between body segments. They underlie one’s ability to orient to our environment and to one’s own body.

There are 2 general categories of RR:

  1. Bringing the head into upright or vertical orientation in space in relationship to gravity

  2. Bringing the head and trunk into mutual alignment with each other

RR underlie movement transitions from lying to upright and turning in relationship to gravity and space. They are required for head lifting, rolling, sitting, crawling, creeping, standing, walking, running, etc., and maintaining postural alignment or tone. They are automatic reactions to a rapid loss of balance and weight shifting.

Equilibrium Responses (ER)

(While this article proposes a theoretical understanding of the survival functions of RR and PR, a description of equilibrium responses is important as they are directly related to integrating PR and RR, and are a functional outcome of integrated PR and RR)

ER appear around 6 months of age and last throughout life. They appear as the infant is beginning to develop the ability to transition from a horizontal position to vertical or sitting. They are automatic, varied patterns of movement to maintain balance by shifting the center of weight and/or base of support. They are elicited by:

  1. Internal change of movement, such as shifting weight from one leg to another while climbing up a flight of stairs

  2. External change or movement of support, such as when a rolling stool being pushed by a toddler rolls faster than she can ambulate or when a dancer is lifted into the air and her partner moves along the floor.

  3. Outside force on body, such as when a football player is hit while running down the field but stays on his feet to continue running.

  4. Enticement outside one’s kinesphere, such as when one partner slowly leans in and the other partner is drawn toward an embrace without falling over.

ER underlie and allow or support turning of the body through space and the ability to have a multidirectional relationship with gravity. They are mediated by higher brain centers, integrative centers such as the cerebellum, and they coordinate with, or are supported by integrated PR and RR.

Functionally, there may be a coordinated, sequential strategy to reflexes, reactions and equilibrium responses. These three are progressively more complex and allow increasingly varied outcomes, but the progression of functional use may be the opposite from their appearance developmentally. Remember, however, when under stress, we regress. The progression would be equilibrium responses, righting/orienting reflexes and then primitive reflex, specifically protective extension. The immediacy or speed with which the movement pattern is needed also determines the order in which they will be executed.

For example, a quick fall while ice-skating may allow the skater time to reflexively put her arm out to try to soften the landing (protective extension) as the only physical defensive movement. However, standing upright on a moving train requires continual slow postural adjustments to maintain one’s balance (equilibrium responses). As the train accelerates righting/orienting reactions take over to allow the person to stay vertical. If the train suddenly and quickly slows down the primitive reflex of protective extension of the leg and/or will be rapidly elicited.

Gross Motor Developmental Sequence (of some gross motor skills)

As an infant develops the ability to achieve and maintain an upright position such as sitting, s/he develops a new relationship with gravity, the environment, and her capacity to interact relationally. (Typical motor development happens in age ranges, not at a specific age.)

  • Rolling—beginning of independent mobility:

  • 3 months—begins to roll back to/from front, more incidentally than purposefully

  • 4-6 months—intentional rolling with immature movement patterns. This may correspond with the beginning of Separation/Individuation stages of psychological development called.

  • 6-8 months—mature segmental pattern of rolling with intention and purpose

Crawling (on belly) and Creeping (on all fours) {I know, this sounds backward but it is the accepted conventional lingo}

  • By 6-8 months purposeful, functional creeping allows independent mobility

Walking—development of the ability to move toward and away from others. Achievement of independent ambulation coincides with the rapprochement and object permanence phases of psychological development.

  • 6 months—bears full weight on legs when held

  • 7 months-may bear full weight independently when holding onto something

  • 9 months—pull to stand and bears full weight

  • 10 months—stands independently and cruises by holding on to something but still cannot get down to sitting independently

  • 11 months—walks holding on to someone’s hand

  • 12 months—stands alone well and sits down independently

  • 13 months—walks without support

  • 14 months—steps off 1 step

  • 18 months—runs without falling and climbs down steps. This may coincide with the beginning of autonomy stage of development.

Hopping, Skipping and Running all develop after walking, between 18 and 36 months.

Bowel and Bladder control typically develop between 2 and 3 years old and coincide with autonomy stage of development. It is the first gross motor skill that requires maintaining control, holding it in and releasing at appropriate times. 

Part 2: Functional Relationship of Primitive Reflexes and Righting Reactions with Survival Responses

PR, RR and ER underlie, support and allow the more complex movement for survival and defensive responses, attachment, and intimacy. As I suggested earlier, there may be specificity of these relationships if we look at PR and RR through a functional lens of survival.

I. Orienting allows a person the ability to scan the environment visually, auditorily or with olfaction (smelling). Orienting requires the ability to move the eyes across the visual field, turn the head and neck, raise the head and hear clearly. Bonding and Attachment require these same abilities.

Underlying Orienting: Defensive Orienting, Exploratory Orienting and Bonding/Attachment

  • Labyrinthine Head Righting

  • Optical Righting

  • Body Righting acting on Body or Head

  • Landau righting

  • Oral rooting (exploratory and bonding/attachment)

  • Nuzzling or Neck Mobility Reflex (Exploratory and bonding/attachment)

  • Startle Reflex

II. Boundaries provide semi-permeable access to one’s body, sense of self and spirit. They allow for healthy connection and attachment with others. Like the membrane of a cell, some from outside can enter and some from inside can exit. All touch and tactile sensations provide the building blocks for development of healthy boundaries. (2)

Underlying Boundaries and Bonding

  • Moro Reflex (bonding)

  • Asymmetrical Tonic Neck Reflex (ATNR) (boundaries)

  • Reverse ATNR (hand to mouth)

  • Pull to sit/pull to stand (bonding)

  • Palmer Grasp (bonding)

III. Survival Defensive Responses of Flight and Fight require the ability to mobilize one’s extremities and stabilize one’s trunk or torso simultaneously.

  • Underlying Flight and Fight

  • Flexor Withdrawal (both)

  • Negative Support Reflex (flight)

  • Extensor Thrust (fight)

  • Crossed Extension (flight)

  • Positive Support (both)

  • Spontaneous Stepping (flight)

  • Placing Reflex (flight)

  • Tonic Lumbar Reflex} flight

  • Lumbar Reach Reflex} “

  • Asymmetrical Tonic Neck Reflex (ATNR) (fight)

  • Protective Extension of arms and legs—defense against a fall (fight)

IV. Other Postural Tone Reflexes (provides core stability upon which the extremities can mobilize)

  • Gallant Reflex

  • Amphibian (abdominal) Reflex

  • Anal Rooting Reflex

Part 3: How to Elicit Primitive Reflexes and Righting Reactions

primitivechart.jpg

٠ These reflexes are present as reflexes throughout life 

CASE Example

Case Example of the implicit memory of motor reflexes and responses emerging as a trauma experience is renegotiated with Somatic Experiencing

CC is a 57 year old Caucasian woman whose young adult daughter died 2 years after suffering a traumatic brain injury in an MVA. CC came in complaining of difficulties sleeping, anxiety, severe neck pain and depression. She also suffered severely from thoughts and images intruding into her everyday life—thoughts and images of her daughter while lying in a hospital bed comatose and totally dependent upon her mother for the last year of her life.

Session 4

CC is talking about her daughter, tearing up as she usually does. She opens her eyes widely but briefly and they begin a slight micromovement to the left. She is functioning at an implicit or procedural memory level—somatic memory. I ask her to notice if she is starting to look toward the left or away from the right. After a few moments, “toward the left” and she begins a small turn of her head toward the left (orienting). As she follows the sensation of her movement I notice the fingers of her left hand begin micromovements toward extension (implicityly straightening) and, again, ask her to notice them. They, combined with her eyes and head are the beginning/impulse of an Asymmetrical Tonic Neck Reflex—reaching out and orienting to the left. She surprises herself by saying, “That’s the side my daughter’s car was hit from. If only I could have been there and helped” (protective and attachment—reaching out). I encouraged her curiosity about this and to notice what happens next. She was able to follow her own movement impulses and sensations through a series of twisting, turning and rotating sequences (Righting Reactions and Orienting at an implicit memory level) eventually settling down and into what appeared to be resting. She tremored a bit, relaxed and said, “that is exactly what happened in my daughter’s car accident. I hope she didn’t feel any of that.”

In essence, CC retraced the sensory motor experience her daughter was unable complete, or more accurately, her own experience of freeze/tonic immobility, orienting, action and discharge to settling in response to her imaged experience of what her daughter went through during the accident. Her Image (s i b a m) of events constructed in her mind by what she was told and read completed. The emotional agony her daughter might have been fortunate enough to avoid at the time by going into shock and having severe traumatic brain damage but probably ‘shared’ by her mother (mirror neurons??) had surfaced in her mother. Afterward, she was relaxed and curious, her neck was achy but relaxed and she could move it more fluidly. The overcoupling of the incomplete reflex responses with the intensity of her emotions was able to dis-associate or uncouple. She grieved and cried in a way she “had never done before.” (emotional implicit memory) She was able to track or self-witness the return of protective and attachment movements that had been thwarted earlier as they started with micromovements and became ‘functional’ again. Severe neck pain was gone, her sleep improved over the next few days and she felt a great degree of vitality in her life.

References 

1. Stark Smith, Nancy. An interview published in “The ABC’s of Movement: Primitive Reflexes, Righting Reactions and Equilibrium Responses,” by Bonnie Bainbridge Cohen’s book, Sensing, Feeling, Action, The Experiential Anatomy of Body-Mind Centering. Contact Editions, 1993.

2. Krueger, D, Body Self and Psychological Self: A Developmental and Clinical Integration of Disorders of the Self. Bruner/Mazel Publishers, 1989 

When Pain and PTSD Meet

How often have you seen a patient with pain? It is a new pain in a series of ‘new’ complaints. It started out relatively manageable and anti-inflammatory medication helped for a short time. As the days after your patient’s car accident progressed, though, she returned continuing to complain of more pain. You referred her for physical therapy and that, too, helped, but didn’t seem to cure her of her pain. Specialists might be tried over time as her pain began to spread. You are starting to think that she is psychosomatic.

In fact, perhaps she is. But not in the way you think. Patients who have seemingly innocuous injuries can find healing from them more difficult if they have a history of prior physical injuries, developmental trauma, prior medical or surgical interventions, anesthesia, emotional or physical or sexual abuse. The autonomic dysregulation resulting from trauma experiences otherwise held at bay can easily erupt with even seemingly ‘simple’ injury or fear. The result: PTSD, chronic pain, occupational problems, headaches, anxiety and depression, fibromyalgia, irritable bowel syndrome. The research supports this—children exposed to abuse or neglect, infants who experience pre- or perinatal trauma, and young children who have a trauma history are at greater risk for developing PTSD and chronic pain later in life after a shock trauma such as a fall, car accident, or emotional upset (Stevens, 2015).

Why? Initially, the autonomic, immediate response to perceived danger, flight or fight, gets disrupted resulting in freeze–deer in the headlights or fainting reflex (heightened and persistent sympathetic charge–anxiety, fear, tension, rigidity, etc., or heightened and persistent parasympathetic charge–depression, low energy, dissociation, etc.). Over time this first domino in a chain of events can affect the autonomic nervous system, endocrine system, fascial and musculoskeletal system, gastrointestinal system, family system, relationships, work ability, and self-esteem. Even executive processes can be affected. (Naviaux, 2014).

Complaints of chronic physical pain can have roots in either end of the continuum between purely physical or purely emotional. The overlap is typical in PTSD as well. Studies suggested correlation between these ends of the continuum and, perhaps, it is why both diagnoses are frustrating to treat. The bi-directional communication between the body and the brain is a significant factor in this challenge.

Somatic Experiencing®, developed by Dr. Peter Levine, is a somatic psychotherapeutic approach which facilitates the redevelopment of a self-regulating autonomic nervous system by addressing the bi-directional communication between body and brain. It includes sensory, affective, behavioral, memory and executive functions and is based on theories of neurophysiology, neuroanatomy, psychology, human development, animal behavior, trauma and normal physiology. It is a very refined and enormously successful exposure therapy that avoids dramatic catharsis and the potential for re-traumatization.

Body awareness is one key component of Somatic Experiencing®. Mammals, including humans have a safety mechanism to avoid the anguish and pain of being traumatized or feel the torture of being killed: we become numb with shock. Humans dissociate from our felt sense or physical sensation through the cascade of biochemical secretions such as endorphins, epinephrine (adrenalin), norepinephrine, and cortisol. When the actions these chemicals are intended to facilitate (flight, fight) fail the tonic immobility of shock sets in. We are meant to come out of this energy conservation state after a short time. If we don’t there will be significant autonomic ramifications that can eventually result in symptoms of PTSD, chronic pain and other problems. During a Somatic Experiencing ® session a client is carefully guided to a level of autonomic excitation in which the potential for the thwarted survival impulses toward action can be felt and completed without the threat present. This allows for a metabolic discharge of the tonic immobility and re-engagement in the present moment.

Affect tolerance, or the ability to feel the feelings and the thwarted movement impulses without becoming overwhelmed or numb, is another main aspect of Somatic Experiencing®. Emotions are varying states of physiology and posture, and they have somatic sensations associated with them. Following a traumatic experience these are often undercoupled or disengaged from one another. When reconnected new cognitions are often developed, with a new understanding of self, of what happened, and a shift in belief to more positive and life affirming.

The most important component of working with trauma that manifests as chronic pain and/or PTSD is that the work be done in manageable titrations (like mixing an acid and a base so there is no explosion) and does not overwhelm or retraumatize. This is the beauty (and art) of Somatic Experiencing ®. To facilitate this delicate balance the therapist must have detailed knowledge of the relationship between the various parts of the autonomic nervous system, comprehend the psychodynamics and neurobiology of relationship, be knowledgeable about human development, and understand anatomy, physiology, and neurophysiology of trauma. Knowing how to support and facilitate autonomic regulation with proper, healthy touch and understanding the anguish of PTSD and chronic pain are also essential for skilled therapists working with this population.

PTSD and chronic pain need to be addressed as aspects of a whole continuum and not as separate diagnoses ‘isolated’ from one another. The constant over association of physical sensations, intrusive images, avoidant behaviors and the constant search for a cure can perpetuate physical pain, emotional anguish, social disengagement (this alone is enough to drive the autonomic dysregulation), poor self-care (including nutrition), re-enactment and destructive beliefs about self.

When pain and PTSD meet, we need to address a patient’s complaints as part of a continuum that includes their body, emotions, spirit, cognition and trauma history. The physiological and behavioral symptoms experienced with PTSD and chronic pain are accompanied by suffering. At a minimum, the suffering can be alleviated and symptoms will be reduced. Complete alleviation, though, is possible with Somatic Experiencing®, proper nutrition, exercise, medication management, and social/emotional support.

References

Levine, Peter (1997). Waking The Tiger: Healing Trauma. North Atlantic Press.

Levine, Peter (2001). In An Unspoken Voice: How The Body Releases Trauma and Restores Goodness. North Atlantic Press.

Naviaux, R. K. (2014). Metabolic features of the cell danger response. Mitochondrion16, 7-17. doi:10.1016/j.mito.2013.08.006

Stevens, J. E. (2015, June 3). The adverse childhood experiences study - the largest, most important public health study you never heard of - began in an obesity clinic. Retrieved from https://acestoohigh.com/2012/10/03/the-adverse-childhood-experiences-study-the-largest-most-important-public-health-study-you-never-heard-of-began-in-an-obesity-clinic/

 

'B' is for Behavior

We usually consider avoidant behavior as part of the constricted behavioral patterns of PTSD. Avoidant patterns can appear in a multitude of ways, and I want to share one client story that points out how show up movement patterns.

Julie (not her real name) first came to me for physical therapy for treatment of her chronic ankle pain. Falling down a flight of stairs and fracturing the end of her fibula nearest her ankle caused this. She had clear structural stiffness with decreased passive and active range of motion. Her pain was worse with movement than when weight bearing. It required manipulative physical therapy (deep soft tissue mobilization, stretching and joint mobilization) as well as strengthening to balance her functional mobility. Manual therapy also focused on easing specific fascial (periosteum) constriction/activation. Her pain, strength, range of motion and walking all improved significantly with the appropriate physical therapy, but she continued to have a nagging ache when she walked.

So, I watched her walk. I do this with most clients, whether it is for physical therapy or psychotherapy because it gives me a general sense of how and where constriction (activation) is held bodily. I noticed that each time she walked passed a chair on her right she ever-so-slightly-leaned toward her left and compressed the right side of her trunk.

I pointed this out to her and asked her if she was aware of it. She was not (numbing/dissociation) so I had her slow her walking down and stop the moment she noticed she was leaning. “Are you leaning toward the left or away from the right?” I asked. She processed this question somatically and realized that, “I am leaning away from the right.” (Avoidance due to higher sympathetic charge, in other words, flight). I asked her to bring her awareness into her body and track whatever she noticed next—movements, images, feelings and thoughts. SEP’s will recognize the basic principles of SE: stretch time out/slow down, track sensation and other elements of SIBAM, defensive orienting, sympathetic activation in readiness for action, in this case a defensive response of flight.

To Julie’s astonishment, she fearfully (upward constriction of her pelvic floor, faster and shallower breathing, slightly widened eyes and verbally expressing, “This is weird, almost scary”) recalled how, just before she fell down the stairs holding the laundry basket (left hand/arm), she reached for the banister on her right side. The problem was that the banister had been removed for painting and the lack of banister became the threat from which she fled (leaned away). This was complicated by being off balance. Her next comment reflected how her attachment strategy or developmental trauma overcoupled with the shock trauma: “There was no banister to grab onto just like there is never anyone there to help me.” Since she was in the midst of feeling the thwarted protective and postural reflexes unavailable when she fell, I chose to stay with the shock trauma and return to the developmental trauma later. This started the process of uncoupling the two.

Julie’s movement pattern of attempting to reach to the right (frozen impulse) with her arm but falling to the left created a local tonic immobility of her righting reactions (orienting to body) and equilibrium responses at her ankles. Protective extension was useless because “Everything happened so fast.” In other words, her defensive responses were thwarted. The impact injury or the fracture was painful, but the traumatizing ‘stuckness’ or tonic immobility of her autonomic nervous system was from the moment she was unable to protect herself from falling. It manifested in a dysregulated, dysfunctional movement pattern and chronic pain. From the moment of her realization about the banister and attempted but incomplete protective response we ‘worked the fall’ as a Somatic Experiencing® Practitioner typically does—slowly and gradually facilitating her capacity and ability to manage protecting herself with a greater sympathetic action by uncoupling her fear from the immobility. She was guided to feel the impulse to reach, the micromovements of her ankles and the righting or orienting strategies of her neck, head and eyes, and the rotation of her trunk (the frozen compression I had observed when she walked past the chair initially). As these came back ‘online’ her fear diminished and the activation associated with it discharged and settled. She needed only two rounds or titrations to feel complete with this. Her pain alleviated as her somatic protective reflexes came back online and her tonic immobility patterns, particularly the more complex ones of her ankles and trunk thawed.

I had her walk across the room a few more times and she walked with flow and balance deviating neither left nor right when she waked past the chair. After this session she was pain free, and, needless to say, felt greatly relieved. She was also able to walk down the staircase in her house without holding the new banister.

Her attachment strategies of life included avoiding intimacy. She was unable to trust that her mother would ever understand her needs, and her father, whom she longed to be with, was often traveling for work. Her psychophysical interpretation: “no one is there for me so don’t bother reaching out for help”. Of course, this manifested as a belief and in her experience falling down the stairs. While this might make little logical/rational sense, it makes perfect somatic sense. As we ‘worked’ the fall and I asked her to notice how it was for her to accept my help, she

initially felt simultaneous dueling impulses. “I can do this by myself” and, “but I guess I need him to help me.” Her capacity to verbalize these dueling impulses helped to further uncouple the shock from the developmental trauma and the affect (fear) from the tonic immobility. In the transference relationship, she came to understand somatically and affectively that she does not have to experience herself as alone in the world and that help can be had. Her belief started to change.

The ‘B’ of SIBAM includes movement behaviors. Observing movement patterns opens powerful lenses through which to see affects and behaviors associated with PTSD. This is essential with all categories of trauma.

 

Preparing for Surgery or Other Medical Procedures

(Adapted from Trauma Through a Child’s Eyes by Peter Levine and Maggie Kline)

 

Preparing a Child for Surgery or Other Medical Procedures

Your presence during the procedure can be helpful if you are not visibly anxious yourself.

Medical personnel may not allow parents to be present for all procedures. It is best to work this out in advance if at all possible so there is no argument in front of the child. Two procedures that can be particularly terrifying to a child are: 1) being strapped down to an examining table, and 2) being put under anesthesia without being properly prepared.

Before the day of surgery:

  1. Be sensitive to the child’s needs.

  2. Prepare the child for what will happen. Tell them the truth without unnecessary details.

  3. Some hospitals have programs that allow the child to visit the hospital prior to the surgery, meet the doctors (or see pictures of them), and do some role-playing. Ideally, the child should at least be shown photographs of what the doctors and nurses will look like with surgical masks on.

  4. Staff and parents can arrange a time beforehand so the child can meet the surgical staff when they are wearing normal attire.

  5. If the hospital does not have a program for child education, you can prepare your child by having them dress up and play “hospital,” going through all the steps in advance.

  6. Prepare the child for entering, and coming out of, an altered state by telling (or making up together) a fantasy story.

  7. Healing from surgical wounds is more rapid when a local anesthetic has been used at the incision site. Make this request in advance of the surgery.

On the day of surgery:

  1. Parents and medical personnel should work out a system by which parents can stay as much as possible with the child.

  2. A child should never be strapped down to an examining table or put under anesthesia in a terrified state.

  3. Ideally, parents should be in the post-operative room when their child is waking up. The child should never awaken in the recovery room alone.

After the surgery:

  1. Rest speeds recovery.

  2. If your child is in pain, have him or her describe the pain, and then find a part of the body that is pain-free, or at least less painful.

  3. If the child appears fearful, assist him by using storytelling, drawing, and other expressive activities. 

Preparing an Adult Client for Surgery or Other Medical Procedures

There are a number of things that can be done pre-surgery that will assure that your client has the best possible chance of coming through with minimal traumatization:

  • Learn about what will happen; determine who can be your advocate or helper at the hospital; learn about what is needed after the surgery (home help, rest time, help with mobility).

  • Be assertive, so that you are able to ask the doctor all the questions you have so you can make an informed decision.

  • Identify resources for the O.R. (music, photographs, security blanket/item) – it’s best to clear this with the hospital staff in advance to ensure that any items can be taken into the O.R. to avoid client having these items confiscated at the last minute.

  • Write down instructions you wish to give surgeon, anesthetist or O.R. staff prior to surgery (asking for reassurances as you go under anesthesia, have surgeon give news of successful surgery immediately, etc.).

  • Visit the hospital and recovery room prior to surgery. Minimize surprises.

  • Become accustomed to going in and out of altered states of consciousness. Practice letting go into the anesthesia without activation.

Let’s discuss other surgeries you have had and renegotiate them if there is time. However, if the upcoming surgery is an emergency or is set up for the near future, we will work on relaxing, anchoring yourself and preparing in other ways. 

Requests for the surgery itself:

  • Preemptive anesthesia - Preemptive anesthesia means that in addition to the general anesthesia, the patient is given a local anesthetic at the site of the incision. This has been shown to greatly diminish post-operative pain.

  • Some hospitals can arrange for you to receive Reiki immediately before and after getting anesthesia. Ask about this.

  • If possible, bring an mp3 player with music you choose to listen to—calming and relaxing

  • Request that any talking in the operating room be reduced to the necessary and positive or neutral—thus reducing the possibility of complications from the fact that the patient’s unconscious, at that time is highly open and suggestible.

If at all possible, arrange to be accompanied by someone that you love and trust, someone who can help you stay calm.

  • At the time anesthesia is administered

  • In the recovery room (the time when you first wake up)

  • If you have a friend who is a doctor or a nurse this is best—it may even be possible for the friend to be present in the operating room.

Some clients have taken advantage of this supportive presence and the highly suggestible quality of the anesthetized state to come up with a list of positive suggestions, and have their friend read them aloud during the surgery.

In the recovery room, when the patient is emerging from the effects of the anesthesia, you may tremble, sometimes with considerable intensity. This is one of the very best things that can happen as it allows for the discharge of the activation from the surgery. However, standard medical practice is to medicate the patient at this time, because both patients and doctors tend to be afraid of the trembling. Some education about this before the surgery can create the space for this naturally healing response of the body to occur in peace.

Pre-schedule an appointment for after the surgery. That way you will know there is immediate help for any lingering after-effects.

Post Traumatic Stress Syndrome

What do car accidents, abuse, falls, surgery, rape and combat
have in common?

Thousands of people each year experience motor vehicle accidents, have surgery, are raped and physically abused, fall and suffer an injury or are emotionally abused. Traditional medicine addresses the resultant symptoms of these scenarios with medication and rest. Too often, the symptoms of post traumatic stress syndrome are overlooked, yet they contribute to, and are part of the individual’s larger health condition.

So, what do all of these experiences have in common? They can all result in a trauma response by the nervous system. A trauma response can best be described as the response a person has to situations perceived as threatening to life or self-integrity. For example, if a person is attacked she has 3 options: fight or run for it. Both of these choices are attempts to protect her life. If neither of these appear as though they will succeed, a third option is to freeze as prey does when a predator is about to pounce. The freeze option, know as shock, is a brilliant strategy by the nervous system’s lower or primitive centers to feign death since many predators prefer a live kill. It also numbs the individual to the overwhelming intensity of emotions and physical sensation. As the shock wears off and the heart rate and respiratory rate normalize, the “almost” victim gets up, orients itself, staggers as it finds its walking legs, shakes out the locked up energy; then it moves on, back into its normal routine.

While humans demonstrate the same responses, we don’t always come out of the shock state so easily. We don’t actually remain frozen or paralyzed as far as our ability to walk, talk or function routinely or even at work. However, traumatized individuals often use descriptions such as, “I can’t think straight,” “I feel paralyzed in my decision making,” “I feel shaky,” “I can’t go back there yet,” “I see the (event) over and over in my dreams,” “I’m always looking over my shoulder,” “It’s like I’m still there (at the scene),” “I can still feel his hands on me.” The result is known as Post Traumatic Stress Syndrome, with variations in stress and anxiety related problems. Victims of car accidents, abuse, falls, rape, surgery, combat and other situations perceived as threatening or frightening may respond similarly: Freeze in shock to prevent overwhelm emotionally and sensorial. These results may last for years. In fact, 25% of people who have had whiplash injuries have diagnosable post traumatic stress disorder or acute stress disorder. Many people with chronic pain have significant trauma histories, which are often overlooked in the course of treatment.

Many people who suffer from panic attacks have histories of experiencing or witnessing traumatic events. Why don’t humans discharge the energy of trauma so easily? There are a number of factors involved. The feelings of helplessness and hopelessness are often at the base of freezing and result in the belief that “I can’t do anything to save myself.” Anger, fear and other high intensity emotions can overwhelm the nervous system and “lock” in trauma. Usually, these feelings are unconscious but guide conscious behavior.

Commonly, the physical signs of discharging energy are not recognized as connected with the response to the traumatizing event. Socially, shaking or tremoring, as a person often experiences in her body after feeling threatened, is not consider appropriate behavior and may feel embarrassing. Depending on the severity, it can affect vital functions of the body and, so, is inhibited medically in the emergency room. Repetitive trauma can cause the nervous system to remain in a hyper aroused state, thereby making it harder to return to homeostasis or a normal state.

People suffering from stress and anxiety related problems and post traumatic stress syndrome may experience it somatically with chronic pain, gastrointestinal problems, fibromyalgia, neck and back pain, dissociation, etc. They may have flash backs to the event. Emotionally, a person may feel detached from the present moment, forgetful, stressed-out, wondering when the next “attack” or accident will occur, difficulty sleeping, irritability, difficulty in relationships, etc.

These challenges can be overcome. Relaxation and meditation techniques go a long way in reducing the symptoms of incomplete trauma responses. However, these techniques only quiet the nervous system. The nervous system wants to finish what it started: feel, hear or see the presence of threat, orient toward it to decide to run or fight, dissipate the energy stuck form freezing, then move on its way in life. This way, the five components forming a person’s gestalt of everyday life, sensation, image, behavior, affect and meaning can come together once again.

The language of the body, the felt sense (physical sensation) is a key to moving through the incomplete trauma response. In a slow, facilitated process called Somatic Experiencing, a client is helped to consciously re-connect with the physical sensations of her body, reintegrate the 5 components of experience and overcome the freeze response. Somatic Experiencing is a systematic method of unfreezing out of the feelings of helplessness and hopelessness. The process is gradual, not cathartic in nature, allowing a time frame for healing that does not overwhelm the nervous system and throw it back into shock. It allows for individual situations and histories rather than protocol for a diagnosis. It facilitates the body’s natural healing abilities using the individual’s own felt sense with the skilled facilitation of a trained practitioner.

One might wonder about using the felt sense in the healing process when it was exactly that sense that caused freezing initially. Felt sense is used because it is a building block of all developmental progressions in life and because dissociation from felt sense is a common resultant in a trauma response. It is not uncommon for someone with post traumatic stress symptoms to be afraid when consciously experiencing her body. However, this is the gateway to healing. Learning to discern symptoms from good sensations allows strong, inner healing resources to be developed. These, in turn, allow the individual to move through the trauma response and symptoms.

Dave Berger, LCMHC, PT, MA is a Psychotherapist, Physical Therapist, Somatic Experiencing 
Practitioner and Rosen Method Bodywork Practitioner. He specializes in trauma and life transitions and works with individual and couples. This article was published in “Convergence Magazine,” Fall 2000, Vol. 13, Issue 4.