When trauma hides in plain sight
Therapy Today, November 2024

My long-held fascination with trauma was further ignited in the first pandemic lockdown. When many of us were separated from each other and facing the existential threat of an unknown and unseen disease, I noticed an array of responses as disparate as anxiously washing lemons to disregarding potential infection completely. So I started to think about trauma symptoms more deeply – what is it that we humans do when under threat and challenge?

In counselling training, working with trauma is often described as an advanced specialism, while students on placement inevitably discover that trauma is alive and present in the individuals they work with. For that reason, I believe all therapists need an understanding of trauma, even if they are not intending to specialise in working with it. As trauma can be elusive and easily missed, hiding in plain sight, it may not be what many clients initially come to us for help with, only emerging as the work progresses. In more serious cases, this may mean referring the client to a specialist. 

Trauma is a set of responses within us, part of our inner worlds – in the words of trauma specialist Peter Levine, it is ‘a highly activated incomplete biological response, frozen in time’.² However, the term is not ubiquitous, a hold-all for general bad experiences. Thanks to growing awareness, most of us now know that trauma is not the event itself – trauma is what is left behind from an overwhelming experience in our bodies and minds. As Myira Khan puts it, with trauma we are often treating the wound, not the weapon.¹ 

However, it does not follow that every curveball that life throws at us will necessarily be experienced as trauma. There are also two distinct types – incident trauma and cumulative trauma. Incident trauma unseats our worlds and changes everything from then on. By contrast, cumulative trauma can be slow and subtle – we can experience it, for example, if we live in an ongoing unsafe or uncertain environment. We can miss it if we have no space to recognise our own experience because we are too busy surviving. Cumulative trauma can happen to us if someone we love becomes unpredictably and unexpectedly frightening, if we feel dismissed, diminished, dispossessed or disregarded, or we are not loved in the way we need. We can also experience second-hand cumulative trauma in a variety of ways, including when we witness societal systems subtly ignoring the needs and afflictions of others, which is why it’s a protective mechanism to avert our gaze from distress or suffering. 

The manifestations of trauma can frequently be both powerful and elusive – as one client said, maybe those who are traumatised need to wear a wristband, an outward and visual sign of inner and frequently missed and underestimated struggles and sufferings. A version of this was recently piloted in Essex, developed by the University of Essex in conjunction with individuals with lived experience who were offered trauma cards to be presented in health and care settings to let people know what may trigger and what may help them (For more information please see What is the trauma card). 

However, more often trauma remains unacknowledged and unrecognised, allowing its tentacles to reach into surprising crevices within us, as I aim to show in the following two illustrations. 

Manifestation 1:
Thrill-seeking as a trauma response

Keisha’s* adored father died in a car crash when she was 11. Afterwards, her mother emotionally collapsed and was unable to function for more than 10 years. For young Keisha, her mum’s mental illness always dominated – there was never much space for her feelings and she never felt properly safe. Now in her 20s, Keisha worked in a bank, a job where she excelled and was popular, although she was careful never to tell colleagues much about herself. At night, without the distraction of her daily tasks, she felt a pressure-building energy – her heart pounded, her muscles twitched. Intrusive thoughts told her she was not safe in the house and that she urgently needed to get out, so she leapt into action. She took long walks, striding in the dark through the populated areas. Always alone, she sometimes met lone men but she didn’t feel afraid. She ignored them and pressed on. Keisha was compelled to keep taking her night-time walks. The more danger she was in while outside, the better – it matched what she was feeling inside. 

When we are experiencing trauma, our nervous system becomes dysregulated. This means we have too much stress in our system that we are then unable to control. It may seem strange that seeking thrills was the trauma solution Keisha came to, but this is a very common response. There are two reasons for this. One reason is that the hormones released in trauma, such as adrenaline and cortisol, can be addictive. 

There can be logic to this kind of response – maybe we learned to ‘run’ or ‘get busy’ long ago. Hidden in the running and activity is often an unacknowledged desire – ‘if I just do this maybe then I can rest’ – but the thing has caught us on its spikes, we are so out of control and compelled that we never quite find the green zone of safety. For people like Keisha, allowing themselves to rest can feel a great challenge. 

Another reason is that trauma can affect our capacity to think properly about consequences. In the overwhelm of trauma, the whoosh of fear that surges upwards through our limbic brain affects linkages in the prefrontal and frontal cortex. This causes our brain functions to be temporarily disabled. We cannot think strategically or logically; we cannot think and we cannot link. 

Therapy Today, December 2024

Working with red zone clients 

Many practitioners find Dan Siegel’s ‘window of tolerance’ a helpful resource for psychoeducation with clients. One way of explaining the ‘window’ is that we all have a zone of optimal arousal, our ‘just right space’ when we can both feel and think. Too much emotion or sensation (red zone – hyper or too much arousal or activation) inhibits thinking and so does being disconnected (blue zone – hypo or too little arousal or zoned out) from our feelings and experience. When at either polarity our availability to be aware of what is happening to us in the present, our window, is limited, but with awareness our toleration of feelings and our window can expand and open. The image of a thermometer, as shown on page 41, is a useful visual of this that clients often connect with, shared with me by my colleague Sue Wright.³ 

Keisha’s red zone activation, and her misfiring amygdala and short-circuited brain functions, lead her to come up with a solution – to leave the house and walk alone at night. The walking activity both releases and expresses the trauma charge, but danger begets danger. At the same time Keisha was operating in the disconnected blue zone, disconnected from understanding any danger she was in. This is typical of trauma – the parts of Keisha’s brain that can think properly, helping her to reflect, assess a situation and care for herself properly, were taken over by the overwhelming trauma reaction that eclipsed everything else. 

As the story unfolded, a friend spotted Keisha and gently voiced her concerns. Her kindness and determined engagement allowed Keisha to access her green or safe zone once again, at least for some moments to start with. The part of Keisha that was dominating – the exaggerated stress response of her trauma – was challenged by the caring of another person. This enabled her to seek therapeutic help with me. It was enormously relieving for Keisha when I was able to explain that her red zone behaviour was a trauma response directly connected to her being overwhelmed and powerless in response to her mother’s mental health. Connecting with ‘young Keisha’ enabled her to understand how difficult this had been for her and safely process her grief. 

Manifestation 2:
Going under the radar to survive 

Jade* was a single mother to teenagers, one of whom had special needs. She worked in a full-time job and had also become a carer for her mother who had dementia. At first Jade became weepy when her mother lashed out at her or became like a needy child. After a while she felt nothing, hardly registering any emotional response at all. In the netherworld of her existence, Jade lived in a kind of psychological fog. It reminded her of the ‘baby brain’ she felt after giving birth – she found it hard to think clearly about anything or make decisions. She just ploughed on. 

For Jade and for many facing unbearable situations, disconnecting from emotional distress and pain is necessary for survival. In war zones the incessant sound of gunshots or explosions can become like background noise, and it may be hard to register emotionally. It can feel as if we stop caring. Blanking out our responses to the traumatic event allows us to function or simply survive what is in front of us in every day. 

Traditionally, Jade’s response has been called ‘dissociation’. There are various ways dissociation can manifest, including experiencing an emotional fog, slumping into a powerless state and sending parts of ourselves into compartments for safe keeping, also known as fragmentation. 

Imaging tests show that the brains of individuals with dissociative symptoms are smaller in the hippocampus and amygdala regions that affect memory and emotional responsiveness. This mechanism protects us from too much reality. Studies on war veterans show lower levels of the stress hormone cortisol in their systems, as they have become physiologically unresponsive to stress. At the more severe end of the dissociative continuum, we can be so cut off in our everyday life that we regularly lose whole chunks of time. A more moderate manifestation might be feeling emotionally unresponsive and seeing life as though we are looking through a pane of glass. 

Working with blue zone clients 

In clients, this kind of blue zone trauma presentation might manifest in a glazed look that comes and goes in the session, or an emotional flatness and unresponsiveness, both with us and with others in their lives who might find the way they are understandably difficult and perplexing. Understanding the ‘too little’ aspect of trauma means we can let clients know that their response to life’s wounding has been to go under the radar, to feel too little rather than too much, to protect themselves from pain. I explain that our minds have a circuit breaker, like the protective mechanism that protects an unstable electricity supply. When we are overwhelmed by trauma we can become spaced out or not quite present, becoming blue zone activated. This mechanism could be considered to be one of ‘nature’s small mercies’.⁴ The disconnect protects us from unbearable or unmanageable feelings, from being too vulnerable, and helps us carry on living and surviving when something is too frightening for us. Disconnect can happen in an instant if something triggers us, or as a response to something that feels too risky. It can also become a state we live in all the time. So we are left feeling alone and cut off, even from ourselves. In my experience, this information can be enormously relieving to clients. 

In addition to offering the psychoeducation described above, the therapy room can be a safe and attuned space to attend to this deficit and understand it sensitively as we draw close to our client’s experience, observing how they are in the room. While validating their pain and wounding, we can offer them a different experience than they have known or are used to. The defensive patterns can so often be woven in deeply in the fabric of who our clients are. We can teach our clients empathically to understand how risky it might feel to allow themselves to take in good things while offering them the idea that they can still practise finding their feelings in bitesized chunks, with us as their champions.  

Being a mirror 

If you have experienced being with a client who zigzags from the red zone, hyper and with too much activation, to slumping into shutdown, maybe several times within a session, you may have noticed their capacity to think and reflect is eclipsed in such states. 

As practitioners we are likely to feel the turbocharge of trauma as we sit with affected clients, so working with trauma is not easy, and we need to regulate and care for ourselves. What resources do we have to access our green zone? Our bodies are a huge resource as they can let us know about our client’s experience. I remember sitting with someone so fired by a trauma surge that I felt the constriction of breath in my own chest and a whirring sensation. After several sessions, I said, ‘When I am with you I feel like a truck careering along the motorway without brakes.’ The client broke down and said that was exactly how it was to be her. ‘Welcome to my world!’ she said. This was the starting point for a discussion about her inner life and how truly terrified she had always felt inside. 

Regulation 

How might we spot the compelling force of trauma in our clients? How might we think about it with them, respect trauma’s message, its imperative, its logic and its power? In pondering trauma deeply over the past four years I have considered the following two questions. In order to process their trauma and recover, do clients need to release or express the volcanic charge they feel, either directly or indirectly? Maybe the work is about both respecting the impetus and power at the centre of the ‘volcano’, while supporting clients in their external lives to develop practices that help soothe and dilute that charge in ways that work for them. 

Much Western trauma theory emphasises regulation, the task of bringing the hyper-activation down to the green zone of safety where we feel calm inside. Regulation is important but perhaps it is not all we need when turbocharged with trauma. Indigenous cultures around the world have much to teach us about rituals that help us release and express pain and dissipate the charge of trauma in the safety of groups. New thinking incorporates physical practices such as wild swimming as trauma treatment, where the body and mind are brought to an edge and frequently find release into calm on the other side.

Can we speak with our clients about finding a way to dissipate the charge, releasing some of the fizz in the cola bottle through creative means, such as sport, dance, movement, taking them to the edge, not compulsively but creatively and expressively completing circles of activation and dissipation? Can we be empathic with the clients who are passive in their response to life, understanding how difficult it can be to trust life again after feeling so betrayed and hurt by it? When clients rebuff us with their brittle hopelessness, it is important to consider that it can feel risky to let in our empathy and consistent regard for them. Can we also share with them what it feels like to be shut out? This may connect to the heart of their trauma. 

The challenge for us as practitioners is to both respect the hyper and hypo responses in our clients while modelling attentive and empathic calm. How can we discharge or attend to the overspill of their trauma that we pick up? If we have experienced the ‘too much’ of trauma, we might have defensive structures that cause us to hold our breath, brace and tighten. A simple regulation exercise drawn from yoga (see Red Zone Exercise, page 40) may be useful for both clients and ourselves, a way to touch base inside. When we have shut down or become defensive in response to the ‘too much’, gentle encouragement to open up physically and begin to take pleasure in the world again can become a useful practice (see Blue Zone Exercise, page 41). 

My clarion call is for greater understanding of the myriad ways that trauma manifests. If we as practitioners understand the breadth of trauma’s far-reaching tentacles, we can offer our clients understanding and information. From a place of compassionate observation, we can help clients with mitigations and ways to dissipate the impact of their trauma and to find ways through to more freedom on the other side of all that might trap and bind them.  

*Fictional case studies based on typical client presentations.