What to expect after trauma exposure and what to do
Psychological first aid is what we need. Background step by step
Step 1: How we choose to see the intrusive thoughts
The first step in psychological first aid is for all of us to understand and make friends with the sensations in our bodies.
Trauma memories are different from other types of memories. They are stored in the primitive fear centre of the brain and result in intrusive thoughts, dreams and memories, which are a difficult but entirely normal and rather clever attempt by the brain to try to trigger us to process and file them. They are like a messy wardrobe which, despite our best efforts to close the door, will keep bursting open, reminding us that it still needs sorting and tidying up.[i]
Intrusions include a lot of sensory information and are often easily triggered, involuntarily, by stimuli associated with the event. Participants in Harvard Medical School’s early fMRI studies in 1994 agreed to be retriggered in the scanner with a co-agreed script of their traumatic event. The results show major activation of Brodmann’s area 19 in the brain, an area in the visual cortex that registers images as soon as they enter the brain. Under normal circumstances these raw images would be quickly moved to other brain areas for interpretation, but here they show up as if the event is happening right now, in the present.[i]This can be devastating for those who have experienced trauma, as the brain makes us believe the threat is current, even in perfectly innocent moments, with a flashback triggered by a smell, a texture, a colour, a sound. In The BBC adaptation of This is Going to Hurt[ii] we see Ben Whishaw playing the Adam Kay registrar character open the fridge at home and barely see the shape and texture of some kind of meat before it becomes a picture in his mind (still at the back of his fridge) of the 25-week-old baby he delivered the previous week after a devastating misdiagnosis. These visceral responses are normal, and you could even say helpful, hard though they are. They are evidence of our brain trying to facilitate our survival.
The other discovery using fMRI imaging also helps us to understand why the experience is so vivid and visceral: recalling trauma activates the right brain hemisphere while deactivating the left. Psychiatrist and trauma specialist Bessel van der Kolk describes the right hemisphere as carrying ‘the music of experience’.[iii] The first hemisphere to develop in the womb, it is used in non-verbal communication with our primary carer – body language, facial expressions, tone of voice – and goes on to store memories of smell, sound and touch and associated emotions. In the midst of trauma, when we most need our left hemisphere to help sequence our experiences and put overwhelming sensations into words, it is offline.
Scans show, for example, Broca’s area, one of the brain’s speech centres often affected in stroke patients, completely deactivated during flashbacks.5[iii] There are no words. The body and memory is, in a sense, frozen in the experience of trauma, hindering any attempt to make ‘sense’ of it.
Step 2: How we choose to respond to the intrusive thoughts
Avoiding the thoughts themselves is the most common reaction: to block or numb or distract away from painful thoughts or memories. That is why in the immediate aftermath of an event we are prone to using alcohol or drugs to numb, destructive behaviour including in our relationships, anything to direct attention elsewhere. We might also avoid places or things that might trigger the memories, including work, or try to avoid talking about them.
So the memories stay where they are, in the primitive fear centre, stuck; less likely to be integrated, causing further hypervigilance or hyperarousal in us. We might then make meaning about the ongoing nature of these debilitating intrusions – that we are not strong enough, or resilient enough; that there is something fundamentally wrong with us feeling this way, especially when, after all, it’s ‘so much worse’ for the family involved. This self-criticism – and the guilt and confusion it creates – might make us even less likely to get the help we really need, including the support of our peers and that of trauma-focused professionals who can help sort the wardrobe so that everything is in its rightful place.
The amazing brain can heal well by getting help to:
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Manage the intrusions – by acknowledging them, labelling them, and allowing them to pass by.
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Understand and empathise with our natural responses – being compassionate rather than critical with ourselves.
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Avoid the avoidance – recognising our unhelpful patterns and mitigating them.
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Reduce our isolation – by being in places, even with our peers, and also with trauma-informed professionals, where we can process experiences safely with no risk or judgement.[i]
Is PTSI inevitable? Trauma and the brain
PTSI is not inevitable. But experiencing or witnessing trauma does require rapid access to
trauma-informed and focused psychological intervention in order to protect the person from potential longer-term effects.
Peter Levine has spent a lifetime developing body-based approaches to traumatic events. It is clear from his work that being able to come back into our bodies immediately after a traumatic event is a game-changer: we have to create a feeling of enough space and safety for people to experience the physiological shock itself (including helpful shaking, trembling, changing blood pressure, etc) before we can deal with any emotions – let alone try to access verbal processing of what happened or what it all means.[i] Going back to Stephen Porges’ polyvagal theory this makes sense: whether the person is locked in the fight/flight or freeze response they are functioning primarily in the brainstem, and the language of the brainstem is the language of sensations. So, if you are trying to help the person in that moment to mitigate the impact of the trauma (and also later in therapy), you have to talk to that level of the nervous system. Peter Levine has called it bottom-up rather than top-down processing.[ii]
In the immediate aftermath of an event, we go into a childlike state of feeling completely unprotected. We need direct contact with someone who is trauma-informed enough to know that they can’t ‘make it better’, distract us, talk about ‘it’, rationalise or succumb to any other tempting human instincts. Instead, they can either just be there with us or use something called verbal first aid. Judith Acosta and her colleague Judith Prager, in their book The Worst is Over, have shown the powerful effect of verbal first aid on the autonomic nervous system because, in the midst of a traumatic experience, we are in a suggestible state.[i] Scripts and pacing skills (of benefit to birthing families and maternity staff in and after the moment) could be learned by colleagues in mandatory training, backed up of course by a trauma-informed system with structures that support the second victim. Scripts might read something like ‘The worst is over… I am here with you now… I’m not going anywhere and there is nothing else to do now… Except be fully in your body, feeling and allowing all that’s there…’
Levine describes himself on the pavement after a car accident when, because of a kind paediatrician passer-by who sat down next to him and held his hand, he was gradually able to actually experience the sensations of what had just happened in his body as micro movements, which created an unexpected strength in his body. Minutes later, in the ambulance, as he let himself re-experience those movements and let his body shake and tremble (an important and helpful resetting of the autonomic nervous system) and feel the different emotions including visceral rage at the woman who had hit him, he was able to ground the sensations in his body and his blood pressure completely normalised.[ii] This grounding in the body is in stark contrast to the common experience of a traumatised person frozen in immobilisation/fight or flight, frozen in a bodily reaction to the event, often literally contracting muscles to respond to danger, which can create chronic illness or pain,
with or without PTSI. The basic principle is that if we're able to reset our physiological system, able to reset our nervous system, then we can avoid or mitigate the symptoms of trauma.
This is good news – and it is evidently vital that in midwifery education and practice we engage with comprehensive awareness campaigns and action to create trauma-informed, compassionate, relational environments for families and midwives alike. Only then can we move from cultures of fear and blame to trust, compassion and healing.
[1] Slade P. Spiby H. Together we can care for each other. Online RCM conference; 2021, Oct 5.
[2] Van Der Kolk B. The Body Keeps the Score: Mind Brain and Body in the Transformation of Trauma. London: Penguin; 2015.
[3] Kay A. This is Going to Hurt. Episode 2. BBC productions; 2022.
[4] Van Der Kolk B. The Body Keeps the Score: Mind Brain and Body in the Transformation of Trauma. London: Penguin; 2015: p.52
[5] Van Der Kolk B. The Body Keeps the Score: Mind Brain and Body in the Transformation of Trauma. London: Penguin; 2015.
[6] Cankaya S, Erkal Aksoy Y, Dereli Yılmaz S. Midwives’ experiences of witnessing traumatic hospital birth events: A qualitative study. J Eval Clin Pract [Internet]. 2021;27(4):847–57. Available from: http://dx.doi.org/10.1111/jep.13487
[7] Levine P. In an Unspoken Voice: How the Body Releases Trauma and Restores Goodness. Berkeley. North Atlantic Books; 2010.
[8] Levine P. In an Unspoken Voice: How the Body Releases Trauma and Restores Goodness. Berkeley. North Atlantic Books; 2010.
[9] Acosta J, Prager JS. The worst is over: verbal first aid to calm, relieve pain, promote healing and save lives London. CreateSpace Independent Publishing Platform; 2014.
[10] Levine P. In an Unspoken Voice: How the Body Releases Trauma and Restores Goodness. Berkeley. North Atlantic Books; 2010.
Copyright Flourish: A Practical and Emotional Guidebook to Thriving in Midwifery by Kate Greenstock 2023. Pinter & Martin Ltd. Illustrations by Jo Bradshaw. No reproduction without permission.
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