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Three or so decades ago, one of my clients, Greta, after much preparation, was ready, we agreed, to process memories of a very traumatic childhood incident.

This was the first time she had wanted to talk about it and I was interested. Too interested. We both became so engrossed in her account that it was only when she was finished that either of us realized something had gone terribly wrong. Rather than feeling better from the telling, she was extremely anxious and so stiff she could barely move. During the next week she was plagued with panic attacks and called me multiple times for support and stabilization. For her, what should have been an exciting progression in her therapy backfired into regression.

In another situation, a new client, Hans, easily answered all of the usual intake and assessment questions and told me he was “fine.” Nonetheless, when he left my office he became very confused and lost his way several times on his familiar route home. He was so distressed that he canceled the next appointment we had scheduled and never returned.

Could I have prevented these therapeutic disasters? I believe so. In those days I was brand new to traumatic stress studies and had not yet been exposed to theory or tools that would have helped me to monitor autonomic nervous system (ANS) arousal. I wish that I had that knowledge then. Likely, I would have noticed as Greta’s facial expression gradually lost its animation, her respiration quickened, and her skin tone slowly blanched. Those observations would have led me to slowing down or stopping her narrative, putting on the brakes, to reduce arousal and stabilize before she went on. It might even have meant pacing her memory processing in a different way, taking it slower and in smaller pieces. Likewise, with the necessary information and greater understanding, I might have seen that Hans was not “fine,” that his pupils were dilating. I could have inquired about the temperature of his hands and feet, and I may have noticed as his posture became more collapsed. Nevertheless, I did learn from those costly mistakes and, as a result, became interested in knowing more about identifying the effects of ANS arousal. My observational skills gradually improved—for example, for a long time I just could not see changes in skin tone, but did eventually with persistence. And I learned, as well as created, interventions for putting on the brakes. Consequently, the therapy I provided became safer and more digestible for my clients and, as a side effect, my own professional balance benefited from self-observation as well.

Such experiences piqued my interest in passing on what I learned about making trauma treatment safer through observation and modulation of the ANS. Therefore, the purpose of this chapter is to review and then update and integrate current understanding and observation of the ANS. In particular, I aim to give trauma therapists a new and improved tool that they can use to gauge and monitor their clients’—and their own—level of autonomic arousal at any given moment in time. By doing so, therapists will always be in the position to know whether their clients are able to safely manage what is happening and if they are able to integrate what is being worked on in therapy. Likewise, the therapist will also know if she herself is able to think clearly despite the level of stress in her- self and her client. To this end, I want to expand your knowledge of what to look for and what to do about what you see and hear from the client, as well as what you sense in your own body. There is, in this article and in my book, a full-color insert that contains one table and one chart that I fully explain. I hope they will contribute to the understanding of ANS arousal states so that clients can be better monitored, evaluated, and regulated.

You may want to take your time with this chapter. Many of my colleagues read earlier versions of it, helping me to better explain the concepts and make it more accessible without diluting it. Nonetheless, it is dense. Do not be concerned if you need to read it more than once to grasp the particulars.

At least where the treatment of trauma is concerned, there needs to be a great deal of precision in the therapy, perhaps even more than with other types of counseling and mental health issues as in the examples, above, of what can go wrong. You have probably already encountered the volatility of trauma treatment. Clients can easily get triggered, come unglued, and flip into flashback and other types of dysregulated states. That is because traumatized individuals are prone to extreme disruptions of their nervous systems which can sometimes lead to unpredictable emotional and somatic responses. ANS arousal levels can suddenly skyrocket or plummet, causing enormous discomfort, threatening emotional stability, and risking retraumatization. On the emotional side these responses may include anxiety, panic, dissociative episodes, confusion, and flashbacks. Examples of bodily disruptions can consist of extremely high or low heart rate or blood pressure, palpitations, hyperventilation, fainting, and the like. Over the last few decades, multiple methods for helping individuals recover from traumatic incidents have been developed. Though they emerged from divergent disciplines, these methods all have at least two things in common: structure and precision. To heal trauma, many in the field of traumatic stress have independently discovered that a therapist must be able to monitor and direct the process at all times. That includes being able to quickly identify when ANS arousal is at a safe or dangerous level, and then having the knowledge and tools to quickly intervene to maintain emotional and physical safety as well as optimal integration of the treatment process where required.

To assist with the care necessary for effective and responsible trauma treatment, more precise tools are required to help practitioners in their work. They need to be able to assess the client’s state of nervous system regulation from minute to minute, and repeatedly intervene to keep ANS arousal within manageable levels. Moreover, the therapist must constantly observe his own internal state lest a trigger, vicarious trauma, or countertransference overactivate his own nervous system. If that happens, it could render him incapable of the clear thinking necessary to conduct safe, precise, and effective trauma therapy. No matter which method of therapy or trauma treatment you are using, being able to track your client’s and your own arousal level will make the therapy safer for you both. In this chapter, I hope to clarify questions such as:

  • When is arousal at a level where integration is possible?
  • How will I know when my client is on the verge of a freeze state so that we can avoid it?
  • When is it okay to continue what we are doing in the therapy?
  • What would indicate it is time to put on the brakes?

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This has been an excerpt from Precision ANS Regulation – What To Look For by Babette Rothschild. For more excellent material for the psychotherapist, please subscribe to our monthly magazine.

Babette Rothschild, MSW, has been a practitioner since 1976 and a teacher and trainer since 1992. She is the author of six books, (translated into more than a dozen languages including Danish, German, French, Spanish, and Japanese) all published by WW Norton. Her newest, The Body Remembers, Volume 2: Revolutionizing Trauma Treatment; her classic bestseller, The Body Remembers, Volume 1: The Psychophysiology of Trauma and Trauma Treatment; The Body Remembers CASEBOOK: Unifying Methods and Models in the Treatment of Trauma and PTSD; Help for the Helper: The Psychophysiology of Compassion Fatigue and Vicarious Trauma; 8 Keys to Safe Trauma Recovery; and Trauma Essentials: The Go-To Guide. She is also the Series Editor of the WW Norton 8 Keys to Mental Health Series (12 titles and growing!). After living and working for 9 years in Copenhagen, Denmark she returned to her native Los Angeles. There she is writing her next books while she continues to lecture, train, and supervise professional psychotherapists worldwide. For more information, visit her website: www.trauma.cc