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STM8282 - SECTION 9: STRESS MANAGEMENT WITH DEEPER LEVELS OF STRESS



Stress management approaches are different for clients without early or severe trauma than for clients who have experienced early, severe or ongoing trauma and/or severe stress. Recalling our early diagram on the different levels of stress perception, the more primitive areas of the brain store information concerning stressful events differently than do the more conscious areas of the brain.

This has important implications for clients who have experienced trauma, deprivation, and abuse early in their life, or for clients for who exhibits signs and symptoms of post-traumatic stress disorder from circumstances later in their lives.

Normal amounts of stress are generally able to be processed by adults through the conscious application of stress management resources and techniques, whereby the person works to maintain a successful stress balance. Abnormal amounts of stress, or stress experiences that exceed the resource capacities of the individual at early times in life, create responses that are processed through more primitive perceptual and response equipment.

In such instances, the conscious attempts by the client to manage the stress may not be sufficient to keep an adequate stress balance. Stress management will therefore require the application of other approaches to bring the person's stress response systems to a more stable place.

In order to study this aspect of stress management further, it may be helpful to return to a study of the physiological responses that occur in instances of trauma. This will include a look at the Autonomic Nervous System, and the changes that occur in situations of trauma or extreme stress.

In the mammalian part of our brain, there exist the structures responsible for the Autonomic Nervous System, the part of the brain involved in a great number of body regulatory functions. This system is further separated into the sympathetic and parasympathetic systems. The sympathetic system is responsible for the release of epinephrine (or, adrenaline) in the face of a threatening situation. This release provides fuel for fighting or running.

The parasympathetic system serves as a regulator to reverse the effects of stress on the individual, through the release of norepinephrine. The actions of this system are automatic. The primary effects of anger on the body are the stimulation of the Autonomic Nervous System, which prepares the body to run or the fight. They can be broken down into two main response sets, physical responses and mental / emotional responses. These are shown below.

Physical responses include:

- Extra adrenalin secretion
- Muscle tension
- Blood diverted from the liver, stomach and intestines to the heart, central nervous system and muscles
- Increased breathing, heart rate and blood pressure
- Cortisol production increased, depressing the immune system
- Increased supply of testosterone in men
Spleen contraction, discharging chemicals into the blood
- Sharpened senses
- Heightened physical energy and reactivity with jumpiness, shakiness, restlessness
- Clammy skin

Mental/emotional responses include:

- Increase in alertness
- Strong feelings, with urge to attack or run, or to freeze and go unnoticed
- Racing thoughts and sense of urgency (or brain freeze), making clear thinking more difficult
- Recall of past stressful situations
- Experience of the onset of loss of control
- Shift in thinking shifts to black and white; able to see fewer options
- Feelings of power and certainty in some people
- Feelings of energy and warmth
- Desire to yell, urge to move limbs quickly and forcefully

The sympathetic and parasympathetic nervous systems are part of the autonomic nervous system which functions continuously in the body - without conscious control - much like a knee jerk response to a stimulus.

Individuals exposed to early or excessive and continuous stress can develop an over-active sympathetic nervous system and/or an under-active parasympathetic nervous system.

With enough repetition and ongoing use, the over-active responses of the autonomic nervous system can become chronic and relatively difficult to reverse. It is as if the “fight or flight” response has become jammed, always turned to the “ON” position. As the person operates poorly in interaction with a challenging world, stresses mount, leading to a state of ever-increasing stress and continuously over-active response.

This state of chronic stress is more readily acquired by individuals who are biologically pre-disposed to sensitivity to stress. However, people who are in constant environmental stress can also acquire this biological short-circuiting. This is the case for persons who are exposed to extreme trauma in their environmental circumstances - even when those circumstances are short-term in nature.

Individuals with overly sensitive mechanisms in this area may not be able to handle normal amounts of stress in a controlled way. They may consistently have problems handling life’s normal ongoing challenges. This can lead to problems with anxiety and depression at an affective level, as well as uncontrolled anger and other problems at a behavioral level.

As is the case in most areas of functioning, this autonomic sensitivity will fall on a continuum. For those unfortunate few at the far end of the continuum, the susceptibility to all kinds of problems is very real. Psychiatric hospitals, emergency rooms, and the legal system all have a great deal of contact with these individuals.

When this increased sensitivity operates in interaction with the internal and external world, secondary problems often result. Relationships become more complicated, self-esteem more difficult to maintain, feedback from the world more negative, and internal resilience more problematic.

There are other biologically produced problems that lead to difficulties with stress management. Low levels of the neurotransmitter serotonin are also associated with irritability, impulsive volatile outbursts and hypersensitive responses to agitation or stressful situations. Researchers find that violently impulsive patients have significantly lower levels of brain serotonin compared to normal or control groups.

There is strong evidence that the brain serotonin levels can be strongly affected by environmental factors as well as biological factors. In both rat and monkey studies, deprivation of normal nurturing from the mother early in life is associated with decreased brain serotonin functioning that lasts into adulthood.

Animals deprived of normal nurturing early in life:

Are more aggressive
Are more fearful
Have higher levels of the stress hormone, cortisol
Prefer liquids with alcohol over liquids without alcohol

Animals given extra attention have an increase in serotonin release in the hippocampus of the brain. This is the part of the brain where experiential memory formation is created and where the receptors for the stress hormone, cortisol, reside as well.

When stress stimulates these receptors through a surge of cortisol, a protective message is sent down to the hypothalmus from the hippocampus to turn off the stress response. This is a negative feedback loop that helps us to avoid excretion of a constant, chronic amount of the harmful stress hormone, cortisol, in our bodies.

Deprived animals do not seem to be able to develop this shut off mechanism. As noted previously, there are some individuals whose “fight or flight” response seems stuck in the “ON” position. Deprivation can lead to this condition in the human animal, as well.

Further, there seems to be an effect on the genetic messaging within the cells. When there is extra nurturing attention given, chemical messages go to the genes in the nucleus of the cell. Here, these messages actually switch on the gene that makes the receptor for cortisol.

In this manner the cortisol becomes more functional in the hippocampus, producing a more stress-resistant animal in adulthood. Research seems to indicate that these genes are not switched on in the animals who are deprived of caring. This is an example of the complex relationship between nature and nurture.

In the animal research, moreover, enhancing maternal attention raised brain serotonin. Researchers believe that the effects of nurturing - in terms of altering the genetic set point for serotonin function - are critical from birth. Some scientists argue that if too much deprivation and damage occur in a person’s early experience, positive, corrective experiences may not be able to create effective changes later in life. Some therapists, however, believe that the right kinds of targeted therapeutic approaches are able to provide important and deep corrective experiences to this early deprivation.

There are other factors that have been studied with regard to individuals who grow up in dysfunctional families. Hans Selye, a founder of stress theory, theorized that each individual is born with a finite amount of stress/coping chemicals in the body. He noted that traumas and extreme stressors tended to “use up” these factors that provide the body with its protection.

Thus, those individuals who struggle to survive the chaos of their early childhood experiences are, in all likelihood, depleting their bodies of protective substances, and may not have the benefits of nurturing which raises serotonin responsiveness.

The effects of early childhood chaos can include a sense of helplessness, hopelessness, victimization, low self-esteem, fear and other self-defeating feelings and behaviors which are at the core of depressions and other DSM 5 diagnoses. Particularly when children experience anger and violence in their environment, they usually feel anger, fear, hurt and shame. This creates an increased risk for problems managing stress.

Current research on stress is highlighting some additional problems with the neurochemistry involved in the stress response. While we have touched on this briefly in an earlier section, it may be appropriate to expand on this hear.

Studies of brain scans of patients who are under chronic stress are revealing changes in the structure and even size of the brain. In particular, two important areas of the brain appear to be affected by stress: the amygdala and the hippocampus. Brain images appear to suggest that these two brain areas are literally caused to shrink through the effects of stress.

It is believed that the primary culprit for this shrinking effect is the stress chemical cortisol, which apparently kills brain cells in these regions of the brain, and also prevents the formation of new brain cells that can migrate to the hippocampus and amygdala to replace the cells that have been damaged and destroyed.

The importance of these effects can be better understood when the functions of these two brain areas are explained.The Hippocampus lies tucked in the temporal lobes of the cerebrum and appears to be responsible for adjusting moods and emotions to incoming environmental information and plays a critical role in memory formation. It is the hippocampus that is inhibited, i.e. blocked, by the neurotransmitter, serotonin.

The Amygdala is one of the main nuclei of the limbic system. It is involved with associative memory, long-term memory and memory retrieval. It is part of the pleasure and pain system with the pain component being more significant. Aggression, rage and fear reactions are produced when the amygdala is stimulated. Fight and flight reactions from the Autonomic Nervous System are at least partially directed by the Amygdala.

Traumatic memories that lead to Post-traumatic Stress Disorder are generally thought to be held in the hippocampus. The memories stored in this part of the brain are stored in a more primitive - and more durable and persistent - way than are memories that are stored in the neo-cortex of the brain.

Because of the position of the hippocampus – deep in the limbic system – memories stored here can generate a faster and more powerful emotional and physiological response to threatening and challenging stimuli. The memories are also less accessible to revision from the conscious understanding of the cognitive processes of the neo-cortex.

The individual who has experienced early trauma is likely to have deeply rooted memories of both the trauma and the emotional state that was created with the trauma. These deep memories can significantly influence the patient's perception of the level of threat or challenge posed by external and internal events.

The movement to emotion can be so fast and so powerful that it is difficult for the reasoning abilities of the neo-cortex to prevent emotionally influenced misperceptions from determining the level of stress response. Moreover, if the trauma is severe enough, the emotional discomfort can be so severe that the person is not able to restructure the memory – because it is too painful to face.

In essence, their perceptions may get "stuck" as the result of their trauma. The result of this is that they may find many normal internal and external challenges too difficult to handle – based upon their faulty perceptions. This will contribute to a persistent sense of being under constant siege - and constant stress.

Most clinicians are aware that a great deal of the work of therapy involves attempting to change some of the misperceptions that may exist as a result of the person's traumatic and faulty memories. However, most clinicians are also aware that this process can be very difficult for clients whose problems are manifested in conjunction with extreme and persistent states of stress.

This level of constant stress means that the very areas of the brain where the restructuring needs to occur – the hippocampus and the amygdala – are under assault from the overloading of cortisol arising from the stress response.

Furthermore, patients who have also experienced significant deprivation as children may also have disturbances in their ability to turn off their cortisol receptors, for reasons that were previously noted. This makes them more prone to continuous excretion of cortisol during the stress response.

The potent combination of these factors creates stress problems that can become circular in nature. It is for this reason that stressed-out, multi-problem patients can be slow to respond to stress management approaches, and difficult to engage in cognitive restructuring of their traumatic memories.

Ultimately, the secret to addressing and repairing this level of deep stress will consist of a program of therapeutic intervention with multiple parts. The long-term goal will be to reshape the client's misperceptions of the level of threat or challenge by developing the capacity to be able to think and feel at the same time.

This may first require that the cortisol level be brought under control. Medications that help decrease the level of cortisol, including the SSRI family of antidepressants, may be indicated, as well as anti-anxiety medications.

It may also be necessary to utilize experiential interventions to target the deep memories within the hippocampus that are to some degree inaccessible to purely cognitive change processes. (The counseling relationship – with its experiential messages of safety and security - is itself an essentially experiential process. In real time and real ways, the relationship creates an experiential counterbalance to the traumatic memories from the past. It is for this reason that studies consistently demonstrate that a trusting relationship is the most important component of therapeutic change.)

In addition to the relationship aspect of therapy, it may also be helpful to utilize progressive relaxation approaches to gain some experiential mastery over the physiological aspects of the stress response. (One note of caution in directing clients to use progressive relaxation - some clients with a history of serious trauma may experience flashbacks and intense anxiety when their defenses are lowered as they move to a more relaxed state. If this is the case, the clinician should carefully help the client exit the progressive relaxation and then conduct a trauma debriefing.)

In other cases, body work, EMDR or other experiential approaches may need to be considered as a method to lower the autonomic response sufficiently to allow for more cognitive restructuring approaches.

Clients who are amenable to and appropriate for Cognitive Behavioral Therapy or other similar cognitive approaches can then begin to restructure their traumatic memories in a planned and systematic way. This will ultimately occur through the pre-frontal cortex drawing together and integrating the information from the limbic system and the neo-cortex: thinking and feeling at the same time – so that reasonable perceptions can replace emotionally driven misperceptions.

This is a developed skill. Quite literally, the development of this skill requires that neural connections from the pre-frontal cortex be grown and strengthened, much like muscles of the body are grown and strengthened from exercise and conditioning.

Without these connections being made, behavioral responses will continue to be based upon reactions, formed in the more primitive areas of the brain, directed by the perceptions arising from the hippocampus and amygdala.

Furthermore, it requires that the neural connections be developed in both directions: between the pre-frontal cortex and the neo-cortex, and the pre-frontal cortex and the limbic system. Without sufficient bridges between the pre-frontal cortex and the neo-cortex, the person will be unable to bring reason into stress responses.

On the other hand, without sufficient growth between the pre-frontal cortex and the limbic system, the person may have a difficult time accessing his/her emotional resources. The traumatic memories – in order to be reprocessed and restructured – require that they be re-experienced in conjunction with other and better ways to perceive and understand the events that caused the trauma.

The requirement to engage in deeper levels of stress management with clients who have had traumatic experiences does not preclude the necessity to engage in other aspects of stress management. In fact, the client who manages day to day stresses is in a better position to engage in deeper kinds of stress restructuring.

A body that has a lower baseline level of stress will have more room to tolerate stress from re-experiencing traumatic memory. Relaxation approaches are more able to gain mastery over the autonomic responses if additional stress is not also being generated from work or family or other life stresses.

The overall stress response system should still be visualized as a kind of bank account. Maintaining control over the mundane stresses of day to day living may provide only a small measure of relief compared to the overwhelming stress of re-experiencing extreme trauma. However, that small amount may be the difference between a client who is able to engage in cognitive restructuring and one who is unable to think clearly enough to keep traumatic memories under control.

A final reminder as we close out this course on stress and stress management: good stress management will not be found in a single skill that you either have or don't have. It is like a quilt of a thousand small pieces, or an economy of nickels, dimes and dollars. Each one you add creates a fuller, more useful overall strategy. Each additional part of the strategy accrues towards a better overall stress balance.


Review Questions for Section 9

At this point in the training, the trainee should be able to answer the following questions:

What are some of the particular challenges of stress management with clients who have experienced severe or early trauma?

What is the effect of childhood deprivation on the ability to manage stress?

How will maintaining a lower baseline level of stress help clients with a history of severe trauma or childhood deprivation?



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