A novel theory of trauma offers new treatment possibilities

Childhood trauma is a major risk factor for adult illness, including liver disease, chronic obstructive pulmonary disease, coronary artery disease, autoimmune disease and psychiatric illness. Individuals with adverse childhood event (ACE) scores higher than six have a life expectancy two decades shorter than healthy, untraumatised children.¹ A New Zealand community survey found that 51% of people had experience of traumatic events, 9% in the last year, including such events as accidents, medical treatment and violent attacks. Traumatic exposure correlates with symptoms of post-traumatic stress disorder (PTSD) and psychological distress.²

The best treatments for PTSD, according to experts such as Bessel van der Kolk, involve some form of exposure followed by trauma processing, such as eye movement desensitisation and reprocessing (EMDR), yoga or other somatic therapies.^3,4 EMDR is well validated in systematic reviews as a treatment for PTSD, although the therapy is empirical and the mechanism of action is not established.⁵ Havening Techniques® appear to accelerate trauma processing through the action of delta waves on molecular mechanisms that erase the exposed traumatic memory in the amygdala. A similar mechanism is now postulated for EMDR, as researchers have noted the similarity of delta waves recorded by electroencephalogram (EEG) during the lateral eye movements of EMDR and those occurring during the slow-wave (deep) sleep implicated in memory processing.⁶

Trauma mechanisms are more easily understood when we consider their purpose. Why did the brain evolve mechanisms for encoding trauma when this causes human suffering, including traumatic flashbacks, anxiety, panic, PTSD, depression and serious physical illness? Because it’s a built-in safety system designed to protect us from threats to our survival and wellbeing.

Our environment presents many threats to life. The human body therefore has multiple defence mechanisms including our immune system, protective reflexes and the trauma system.

Just as the immune system has memory and rapidly responds to reinfection, traumatic memories exist to remember past threats and to instantly alert us to potential danger. The relevant part of our brain—the right amygdala—continuously scans sensory signals for potential threats. It is part of the limbic system, which subconsciously processes sensory information, emotions and memories at a rate of billions of bits per second (bit/s). In contrast, our conscious, thinking brain only manages 10 bit/s.⁷

The amygdala is directly connected to multiple body systems: the autonomic nervous system, somatosensory system, hypothalamic-pituitary-adrenal (HPA) axis and emotional and cognitive systems. When a traumatic memory is subconsciously triggered, we mount a fight-or-flight reaction within 75 milliseconds—four times faster than our conscious thought. Thus, if we were once mugged on a dark street, this mechanism causes us to feel anxious walking in the dark and will trigger an acute fear response when approached by a potential attacker.

The proposed physiology of traumatic memories

Ronald Ruden is an internal medicine specialist in New York with a lifelong interest in addictions and trauma. His sentinel paper describing his proposed mechanisms of trauma was published in EXPLORE in 2018.⁸

According to his theory, traumatic memories are stored in the (right) lateral amygdala, in the first synapse connecting neurones conveying sensory information from the thalamus. The neurotransmitter is glutamate, which binds to a-amino-3-hydroxy-5-methyl-4-isoxazolepro-pionic acid (AMPA) receptors. During a traumatic event, sensory neurones from the thalamus release glutamate, which also activate N-methyl-D-aspartate (NMDA) receptors in the synapse, activating voltage-gated calcium ion channels and de-polarising the post-synaptic membrane.

In the presence of a major stress reaction and fast gamma brain waves (up to 100Hz), the frequency-sensitive enzyme calmodulin reacts to the rapid intra-cellular oscillation of calcium ions and activates protein mechanisms that push AMPA receptors onto the post-synaptic membrane. Calcium oscillations are ubiquitous signals present in many cells that provide efficient means to transmit intracellular biological information.⁹

The upregulation of AMPA receptors thus forms new synaptic connections with the many neurones that contain sensory information specific to this traumatic event. Then a phosphokinase called PKMZeta phosphorylates a subunit of the AMPA receptor, anchoring it permanently in the cell membrane.¹⁰ These upregulated synapses create a permanent “alarm circuit” connecting the sensory information about the threat to the traumatic stress reaction. See Figure 1 (reproduced with permission from Ruden).

While information directly about the threat (unconditional threat stimulus, UTS) is relayed directly from the thalamus, more complex sensory information is processed in the hippocampus and sensory cortex, entering the basolateral nucleus of the amygdala. Thus, the context of the event and associated sensory information can be assessed and stored. Outflow tracts from the amygdala connect to the autonomic, cognitive, somatosensory and emotional systems. See Figure 2.

If, in the future, any sensory signal arrives at the amygdala that correlates with the experience of the original trauma—a subconscious trigger—then the upregulated receptors generate an immediate autonomic stress reaction, emotions, bodily sensations and thoughts. For instance, a client who suffered a major assault from a man developed a severe phobia and was unable to enter a hardware store for fear of meeting a strange man.

View Figure 1–4.

How can we recognise a traumatic event?

Ruden’s theory also includes the conditions that must be met for a challenging life event to be encoded as a trauma. Trauma depends not on the nature of the event but how the individual perceives it. When we are truly resilient, we can marshal the resources to overcome a challenge without being traumatised. Conversely, when we are emotionally vulnerable as a result of prior trauma, major life stresses, sleep deprivation or physical illness, then we are much more easily traumatised. The key psychological factor is whether we feel capable of escaping the potential trauma or feel powerless, helpless and trapped in the moment.

The theory of Havening formulates this condition for traumatisation as an acronym, “EMLI”. “E” is the distressing event. “M” is the meaning of this event for the individual, which must represent a threat to the person for trauma to be encoded; the same event might not be threatening to a different individual. “L” is the landscape of the mind; an expression of pre-existing emotional vulnerability. “I” is inescapability, or a sense of being powerless or trapped. All elements of EMLI must be true for a challenging life event to be encoded as a trauma.

I remember when, as a young man, I was caught in a storm in the Arctic Ocean, in a small open boat, far from rescue. While the event was truly frightening, I was fortunate to be at the helm, and I navigated to safety. I felt in control and was not traumatised. In contrast, I remember one day as an anaesthetic registrar when a young mother died despite my best attempts to save her. The final image of that event was seared in my mind and reminders of that day, for instance watching a TV drama, made me sob in distress. This is a traumatic memory (since healed).

Ruden adds a second framework, using the acronym “CASE”, to remind us that trauma is a full mind-body experience. The letters stand for the cognitive, autonomic, somatosensory and emotional elements of a trauma. When a traumatic memory is triggered, all elements of CASE may be re-experienced including painful images, autonomic stress reactions, bodily symptoms and emotional reactions.

A mechanism to erase trauma

Fortunately, the paper by Ruden also identifies an innate brain mechanism that may rapidly erase the encoding of a memory in the amygdala (a traumatic memory) and reverse all the negative consequences of said memory.

If a client recalls a traumatic event, the neural network encoding this trauma is activated and the post-synaptic membranes are depolarised; voltage-gated calcium channels are opened, and intracellular mechanisms can now act on the receptors. If the brain is flooded with delta waves (low-frequency brain waves) then the slow intracellular oscillation of calcium ions is decoded by calmodulin and activates calcineurin, which is a phosphatase. The phosphorylation of the AMPA receptor subunit is reversed, breaking the chemical anchor to the cell membrane, and then dynamin and clathrin remove the receptors by endocytosis. This action of delta waves on the amygdala only impacts depolarised neurons; thus the action is specific to the neural network encoding the trauma, which has been activated by imaginal recall (traumatic exposure).

Many other researchers have linked delta waves to memory processing in different parts of the brain.¹¹ But how can we stimulate delta waves in a subject when they are usually only present during slow-wave sleep?

In a leap of intuition, Ruden linked soothing touch to the upper arms, the face and the palms of the hands, the generation of delta waves and stress regulation. He noted the primacy of touch in the secure mother–baby relationship, and how we all intuitively express empathy by rubbing the shoulder of a person in distress. We also spontaneously touch or rub our faces when feeling distressed or overwhelmed. Recent research has highlighted the importance of affective touch in stress regulation and has described C-tactile afferent nerves that are velocity and temperature sensitive, signaling a soothing touch to the skin.¹²

Ruden found research by Harper, who measured the EEG response to cutaneous stimulation.¹³ Aligned with Ruden’s intuition, Harper showed that stimulation of the palms of the hands, the shoulders and upper arms and the face generates high levels of delta waves (0.5 to 2Hz).

Ruden then synthesised an elegant protocol for erasing trauma. The client is asked to recall a traumatic moment and then to assign a subjective rating of distress, where 10/10 is the worst imaginable. Soothing strokes are applied to the client’s palms, upper arms and face, either by the practitioner or the client doing self-touch, which rapidly induces a feeling of profound safety and connection. Mental distractions are used to divert the client’s thoughts away from the trauma and the touch is continued for 5 minutes. The client then recalls the traumatic memory, which often now feels more distant and less distressing. The cycle is repeated until there is no emotional reaction to the previous trauma, which typically takes 15 to 20 minutes.

Many clients express astonishment that a memory that caused extreme distress and floods of tears 20 minutes earlier now seems like a distant, factual memory with no distress. This shift is often accompanied by laughter of relief and a profound relaxation response.

During therapy, marked changes in the client’s physiology are observed, as the traumatic stress response is removed. The factual memory of events is unchanged but the emotional and stress reactions are removed. Triggers that previously caused a strong reaction now have no effect.

Two randomised controlled trials (RCTs) have begun to validate this technique. Hodgson et al. examined the Type D personality profile in clients seeking treatment for trauma, which is a psychological indicator of illness-prone personality.¹⁴ Scores on the DS-14 scale fell significantly in the treatment group after one session of therapy. In a sub-group of 40 clients in the treatment group, salivary cortisol fell from 5.3ng/ml to 4.2ng/ml at 24 hours, and then to 3.7ng/ml a month later (p<0.001).

The same research group showed in a RCT that one session of Havening dramatically increased resilience in trauma-exposed clients, as measured by the Connor-Davidson Resilience Scale (CD–RISC).¹⁵ Pre-treatment resilience scores correlated with the presence of PTSD, and post-treatment scores, 30 days later, approached that of a healthy population (p<0.001).

Both trials used wait list subjects as controls, which is a limitation because previous trials of treatment for PTSD have shown a strong short-term placebo response when subjects are given regular attention by researchers.³ In contrast to EMDR, which might typically involve eight 90-minute sessions of therapy, the trials of Havening used one brief therapy session.

Clinical observations by many practitioners appear to validate the theory, the diagnostic criteria, the physiological consequences of trauma and the efficacy of Havening Techniques. Further research including well-designed RCTs and longitudinal studies is essential to evaluate the efficacy and underlying mechanisms of the technique. In addition to standardised measures of mental health outcomes, a range of biophysical markers, hormone assays, immunological markers and pain scores may be relevant.

The medical implications of trauma

While the treatment of trauma has major implications for mental health, including the potential cure of problems such as anxiety and depression, few doctors appreciate that trauma may also cause chronic physical symptoms long after a physical injury has been resolved. When a traumatic memory is created, all aspects of the sensory experience are encoded, including concurrent physical symptoms. If at the moment of emotional trauma the patient is experiencing physical pain, neurological symptoms, muscle tension, weakness, disability or mental confusion, these symptoms can become chronic because the traumatic memory is continually triggered in a feedback loop.

Many patients present to doctors with “functional illness” for which no physical cause can be found. However, this novel theory of trauma provides a potential mechanism for functional illnesses, and their possible relief.

A medical system that reduces patients to passive recipients of medical care renders them helpless. When threatened with serious injury or illness and not given emotional support the conditions for traumatic encoding are potentially set up. Thus, a patient experiencing high levels of anxiety and pain after surgery may encode this pain as part of their trauma, which might explain why 20–30% of surgical patients experience chronic post-surgical pain in the 6 to 12 months after surgery.¹⁶ Erasing the trauma may abolish the pain. Such approaches warrant investigating.

Childhood trauma is linked to adult obesity and diabetes.¹⁷ The emotional pain of trauma leads to addictive snacking and over-eating. Also, the inescapable stress caused by trauma leads to elevated cortisol levels, which greatly increase blood glucose. Trauma therapy may be an important strategy for addressing the epidemic of obesity and diabetes (see the case below).

Illustrative case histories

Clients with complex trauma, especially from childhood, may require extensive therapy by appropriately qualified mental health practitioners. The following cases illustrate the potential to work with resilient clients who have clearly identified individual traumas. These reports were all observed by the author in his clinical practice.

1. Post-traumatic stress related to an armed hold-up

A client in her 70s presented with 20 years of nightmares, anxiety and fear responses related to an armed hold-up in South Africa. In 15 minutes of Havening her trauma was completely erased—see this short video.¹⁸ In the 5 years following, she has never had a recurrence of the nightmares or the fear reactions.

2. Phobia of being in a motor car

A clinical psychologist drove her car to the clinic and was experiencing multiple fear reactions on the journey related to a head-on crash suffered 35 years before. That traumatic memory was erased, and when she drove home after the appointment she had no fear responses. They have never returned.

3. Chronic post-concussion syndrome

A young man presented with 18 months of severe post-concussion syndrome and was unable to work following a head impact during a rugby game. He experienced mental impairment, inability to concentrate, poor memory and his balance was affected. When the traumatic memory was erased, all his symptoms immediately resolved and he returned to work the next week.

4. A patient having panic attacks prior to an elective C-section

A patient presented with frequent PTSD symptoms related to a traumatic first birth, which had culminated in an emergency C-section. The thought of returning to the same hospital for an elective C-section caused uncontrollable panic attacks. After one session of therapy her PTSD symptom score dropped close to zero and she subsequently had a completely calm childbirth.

5. Severe pelvic and hip pain of unknown origin

A pregnant woman presented with severe pelvic pain, much worse at night-time. The chronic pain specialist was unable to diagnose the problem but prescribed methadone and clonidine, which the patient refused. A focussed history revealed she had been raped when she was 7 years old. The traumatic memory was erased and the pain vanished during the first session of therapy. It has not returned after several years.

6. Needle phobia and invisible veins

As the anaesthetist on-call, I was called to the emergency department because nobody could secure an intravenous line in an obese patient. I was unable to palpate or see any veins and considered using ultrasound-guided cannulation. I discovered that the patient had a needle phobia and empathised with her distress. In 10 minutes of Havening, she completely erased the trauma that initiated her needle phobia and became very relaxed. Her hand veins were now easily visible as the vasoconstrictive stress response was abolished. She accepted cannulation with no distress.

7. Patient with obesity and type 2 diabetes

This client had a 20-year-old son with a chronic disability as a result of a traumatic birth. The client had severe PTSD related to the birth, at a level that would predict immune suppression and high levels of cortisol (Impact of Events Scale score IES=56). She identified two other major traumas in her life. After the birth trauma was erased and the PTSD resolved (IES 6), her blood glucose fell by 40%, with no change in medication, exercise or diet. HbA_1c fell from 94 to 60. Two more sessions addressed other traumas. The trend is shown in Figure 4 (shared with permission).

8. Chronic depression

A nurse specialist presented with years of severe depression, multiple admissions to a psychiatric hospital and telling me she was “brain damaged”. The underlying cause of her depression, helplessness and low self-worth was sexual violence. After four sessions of therapy, the depression and mental confusion resolved. She had a setback during the COVID-19 lockdown but after several more sessions she was able to return to work, has had no episodes of depression for 4 years and is off all medication.

Implications for physician wellbeing

A recent survey in the United Kingdom found that 37.9% of physicians had symptoms of burnout, which include emotional exhaustion, depersonalisation and a reduced sense of self-actualisation.¹⁹ Burnout is associated with reduced patient satisfaction and care quality, higher rates of medical error, increased physician turnover, alcohol and drug abuse and physician suicide.

These symptoms of burnout correlate closely with the dorsal vagal response to trauma, described in the polyvagal developed by Steven Porges: dissociation, depression, feeling trapped, helpless and hopeless.²⁰ Life as a junior doctor creates the conditions for traumatisation: high levels of stress and anxiety, emotional vulnerability, sleep deprivation, exhaustion and traumatic events over which the doctor has no control—such as the sudden death of a young patient.

Because these traumatic events occur in the clinical setting, doctors are surrounded by subconscious triggers that may cause high levels of chronic anxiety and frequent traumatic stress reactions. In the face of this overwhelming stress, we tend to dissociate from our feelings and painful memories, which allows us to function in our professional roles. We may look OK on the outside while concealing high levels of internal stress, and we are no longer emotionally available to our patients and our spouses.

Dr Gabor Maté, a physician and renowned trauma expert argues, “We need trauma‑informed medical care, trauma‑informed education. If we had a trauma‑informed society, we would have a society that looks much more compassionate.” He describes how his own childhood trauma of abandonment still shapes his attitudes and behaviours as a physician and speculates that many doctors may be “wounded healers” with hidden childhood trauma. A comprehensive overview appears in his bestselling new book The Myth of Normal.²¹

In my clinic I have treated many mid-career medical specialists who appeared high-functioning yet had high levels of trauma and PTSD. Through Havening Techniques they substantially improved their mental and physical wellbeing and restored their resilience and work satisfaction. Trauma may thus be a major contributor to burnout.

Summary

The theory behind Havening Techniques provides an elegant and easily understandable explanation for the effects of trauma and offers the potential for relief based on a speculative mechanism for the rapid erasure of traumatic memories in the amygdala.

While clinical observations appear to support this theory, it is yet to be proven in major, placebo-controlled trials. A growing number of mental health practitioners are seeking training in Havening Techniques, based on their personal experience of having traumas erased.

The potential use of Havening Techniques by laypersons raises ethical and safety concerns. All practitioners engaged in trauma care require training in trauma therapy and must invest in their own reflective practices of self-development and clinical supervision. Practitioners must also be mindful of their safe scope of practice.

Footnote

Havening Techniques is a registered trademark of Ronald Ruden, 15 East 91st Street, New York.

More information may be found at havening.org.