Action Systems

iBuilt In Action Systems

I knew nothing about this topic at all until I read the book, Trauma and the Body: A Sensorimotor Approach to Psychotherapy, by Pat Ogden, Kekuni Minton, and Claire Pain. In my opinion this is the best single book for mental health clinicians about trauma and trauma recovery. I have read it through cover to cover three times. I do not do that with any other books. It is that good. I have told colleagues that if I ran a psychiatric residency training program, I would not let any trainees see a single patient until they had read that book and discussed it with me. It is that good. If you haven’t read it, I strongly recommend it. It can change your practice in ways you will always be grateful for. It is that good. I have recommended it as a priority book to read for everyone I have clinically supervised after I read it for the first time. It is that good. Enough said. Now if you read it and don’t find it useful you can e mail me at james.seymour@somaticresiliency.org and tell me I’m full of crap. But I really hope you like the book. 😊

There is an entire chapter in the book on action systems. I cannot do it justice. So, I will describe this concept as I do for my patients and talk with them about the practical implications for them.

Action systems are basically wired in behavioral patterns that allow our brain to simplify some areas so that we don’t have to think about them. Action systems are not learned behaviors. We all have them whether we want them or not. There are many of them but Dr. Ogden and her team initially described the following:

The Defensive System

The Attachment System

The Exploration System

The Energy Regulation System

The Caregiving System

The Socialization System

The Play System

The Sexuality System

Dr. Ogden has revised the ways she talks about these systems. She now talks about how trauma disrupts many of these systems and has changed her emphasis to how to heal these disrupted systems. Her view is very nuanced and I think more accurately describes the complexity of these systems. When I teach patients, however, I use the simpler model and make simple recommendations that patients can do on their own. By understanding these action systems patients tend to be more internally motivated to make these important but simple changes.

The first is the defensive system which we have been already been looking at as a wired in automatic system.

The second is the attachment system. I like the word attachment. I like it because when we are in the womb, we are literally attached through the placenta and the umbilical cord. We are one organism with our mother. And immediately following birth, the umbilical cord is cut. If all is well, we are then placed on our mother’s chest and soon begin nursing. This is as close as we can be to anyone outside of the womb and are as attached as we can get, so I really like the word. Now attachment is the greatest emotional need we have throughout our lives. The need for a close attachment figure in our lives is so strong it does what I call, “trumps” anything and everything. We will hold on to the person we are most attached to no matter how bad they may be or how abusive they may be. We often see this with our patients. The attachment to the unhealthy abusive person overrides our common sense, overrides our need for safety, overrides important values we may give up. It is really important our patients know how powerful this built in action system is. Everyone in their life thinks they are crazy, stupid, dumb, or cowardly for staying with an abuser. Our patients feel the same way about themselves and are calling themselves the same names everyone else is. But they are not crazy, not stupid, not dumb, and not cowardly. They stay in an unsafe relationship because attachment needs trump everything.

It is remarkable how learning this can improve their view of themselves. They can take pride in the crafty ways they have stayed alive by not fighting back, by fawning, or even by manipulation. Our patients in these abusive situations are not weak as many people tell them they are. They often can see that to satisfy the attachment action system they have been highly resilient.

A word of caution though for us as therapists. At times there are situations that need to be reported. At times we have to provide the insistence and the assistance to have them get away in truly dangerous situations. For most of us, unless we work a great deal in the field of domestic violence, this type of situation of emergent danger is fortunately not common. Our natural tendency is to get angry with the verbally abusive partner. At times we express outrage. This is generally a serious mistake for two reasons. The first is the patient often can have a real reduction in self-worth and self-efficacy. “My therapist is angry. What’s wrong with me that I can’t?”. The second reason is the more important one we really need to get through our heads. We should never vilify the abuser, no matter how bad or evil they may be. Why? The attachment trumps all. It does not go away just because they cognitively know they should leave. When we vilify the abuser, we can be pretty sure that the patient will go “underground”. They will no longer say what is really going on. They will lose trust in us. They will feel ashamed of themselves and that shame will block open communication with us. In addition, we will actually push them closer to the abuser and we increase the risk of the patient becoming despairing and suicidal.

Is there any case where it is not harmful to the patient to vilify the abuser? I can’t think of any. Even when the patient is no longer in the abusive relationship? Yes. Attachment trumps all. They may go back years later. If we work with patients who had severe early life abuse and have complex dissociation or DID, we have the experience when they really can trust us, when they tell us things like for the past 30 years, they have still been in regular contact with the abuser or continued a sexual relationship. I have had patients in their 50’s tell me they have maintained an intermittent or chronic relationship to their childhood abuser.

The attachment action system trumps everything. We should never vilify the abuser. The patient has to come to their own realization about the nature of the relationship. I want to reiterate that there are times we must intervene for our patient’s safety but even then, we should avoid vilifying the abuser. How do I know this? I have done it way too many times and it has backfired every time to the detriment of the therapeutic alliance.

There is a lot more to say about attachment. That is covered in the complex concept section under Attachment Issues.

The third action system we will look at is the exploratory system. We humans are wired to explore, to find new sources of water, of food, of shelter, and safety. We are still wired that way, but in our time, we can better call it the curiosity system. People tend to be curious about almost anything and everything. But for many of our patients they are too focused inward with their own pain so this system is not as strong. One thing about the action systems is when we are in the midst of choosing to be using some of these systems, we are much less likely to be in the defensive system. The way I put it is while we are actively curious, we are for that period of time “not in our trauma”. There are two helpful ways to use this. One is the psycho-education we do. That system is activated while they learn new things and ask questions. Another way is to strongly encourage them to explore a topic they have been interested in but for whatever reasons have never looked in to. Getting them to briefly share the new knowledge with you can be helpful as they are more likely to continue learning.

The next system is the energy regulation system. This is the system that drives us to take care of ourselves. The three areas here most of our patients have had disrupted are sleep, appetite, and exercise. Unless our patient has an eating disorder, I leave that area alone for a while. I do the same for exercise. We know that exercise is good for us physically and mentally but a lot of us don’t do it anyway. Sleep, however, is one which is nearly always disrupted and the one of most importance to our patients to be “fixed”. This a very difficult one. There are multiple difficulties in addressing this. It is sometimes amazing to me how much time as a psychiatrist I deal with sleep issues.

One of the difficulties is that while our patients are very motivated to have their sleep normalized, in my experience they tend to have almost no motivation at all to make any behavioral changes which might help them. I find that it seems I am wasting my breath and our time together by even trying. Why? Because most of our patients see the only answer in medications. This makes it nearly impossible for non-medical therapists to address. The reason is not lack of knowledge. The reason is that so many patients are on benzodiazepines or the “Z” drugs Ambien and Lunesta prescribed by their primary care provider or their psychiatrist. Or they are dependent on over-the-counter sleep medications, which are primarily diphenhydramine (Benadryl) which wreaks havoc on the sleep cycle when used regularly.

So, what are my recommendations? First, if they are on any of these medications provide education about how they don’t work and cause harm. Secondly, have them talk to their doctor (who usually won’t do anything at all about getting the patient off any of these medications) and then be done with the issue altogether. Now there are patients who are not on these medications and they can be very responsive to the cognitive-behavioral methods which really do work. I think for these patients it is definitely worth the time and effort to help them with these methods.

Next up is the caregiving system. This is the maternal instinct. We all have it – except psychopaths. We tend to love babies, little children, puppies, kittens, cartoon characters with big round eyes, and other cute little animals. This also is the system which drives us to care for one another, to love one another and want the best for them. This is the system that causes us to hurt when someone who we care about is hurting. This is the system which drives doctors and nurses to do what they do. This is also the system which drives us as therapists to do what we do. If our caregiving system wasn’t highly activated, we would never have gone into this field.

What I have to say next I am sure will be controversial and many of you will strongly disagree with me. We often put down this system as pathological. We call it “co-dependence”. We really confuse patients with this concept. I have heard some therapists say that co-dependency is a major part of many of our problems. It’s not. In fact, the concept is too broad. I have never heard anyone or read anything that is a coherent definition. I have seen handout sheets given to patients on what is co-dependence which list many, many normal human behaviors. There is one exception. That is it’s original meaning. Co-dependence is the description of the behavior of a spouse which enables an alcoholic to continue drinking. Using the term for anything else is, in my opinion, not a good idea. Many patients come to see the normal caretaking system as unhealthy and pathologizes many behaviors which have been adaptive strategies, to allow them to continue to function.

But what about all the times someone has problems ending a difficult relationship? What about the person who does everything for everyone and doesn’t take care of themselves? What about the therapist who “takes their patients home with them”? What about the person who feels guilty when they do anything for themselves? What about the person who engages in behaviors so everyone likes them? What about the person who never stands up for themselves? What about the person whose sense of self-worth depends almost entirely on how others see them? What about the person stuck in fawning behavior? I could go on. Aren’t these codependent behaviors? No. They are all adaptive strategies and each person who has such behaviors are different. The same adaptive strategy may be used by different people for vastly different reasons. By lumping them all into the concept of co-dependency and teaching our patients about it what have we gained? Also, what are our interventions we use with a patient who is co-dependent? Usually, we just recommend they just stop it.

There may be some of you that may think I am way off base. But every time I have asked a patient to forget about the co-dependency concept all together and just examine their own individual behaviors, they express relief. They often say something like, “So there’s not anything wrong with me?” In the Somatic Resiliency approach I say, “No. There is nothing wrong with you. These behaviors are adaptive strategies you learned to deal with your trauma or the traumatic situation you were in. Let’s take a look at where those adaptive strategies continue to help you and which ones you might not need anymore?” Then, we can explore the purpose of that individual’s behaviors and examine how they might go about changing what they no longer want or need.

My opinion then is that the use of the concept of co-dependence harms our patients, causes loss of self-worth, self-efficacy, and confidence, pathologizes the behaviors and does nothing to help them to change the behaviors which trouble them and for which as therapists we are trying to help. I really do welcome feedback. This is my opinion. Like anyone’s opinion I may be wrong. Let me know at james.seymour@somaticresiliency.org

The next system to look at is the socialization system. This is an interesting system. It involves other people but is very different from the attachment system. This system has to do with us belonging in a group. As humans we lived for thousands of years in small groups of 150-400 people at a time. We have referred to these groups as tribes. Though our society is very different, the need remains to belong to a group. This is a powerful need and our society doesn’t respect that. In the United States we live in one of the strangest and unique societies in all of human history. I call it the “box society”. We tend to live in separate boxes from one another in an apartment or house by ourselves or with one other person or a small group (family). Our brains, bodies, and nervous systems did not evolve to thrive in such a situation. Now family or other people in our home don’t count in this regard – that is the attachment system. We then get in our box with wheels and drive to another box – our place of work. There we may or may not have a lot of contact with our co-workers. Our co-workers are a small community to which we belong and many people who retire fall apart when they retire. Nowadays many of us work from home. A zoom community does nothing for our neurobiology. If we work away from home we get in our little boxes with wheels, drive home to our own little box and then turn on a box called

Netflix (or something similar).

When you think about it, it is downright absurd. It’s really nuts. It goes against one of our very basic needs, to belong to a group or small community. I believe many people who we treat for depression and anxiety “illnesses” would not be coming to see us if they belonged. Not only many do not belong, but the depressive and anxiety symptoms stand firmly in the way of them having access to what they need. I am a psychiatrist. I have always worked with medication. I believe they help many people. I think they are essential when the mental or emotional problems are severe. But I also believe that many millions of people in our country would not need to be on antidepressant or antianxiety medication if they belonged. I am not suggesting in anyway people stop their medication. We don’t live in a society strong enough to support them.

We live in an extremely unnatural and weird society. The two main human needs that most support our resiliency are attachment and belonging. The divorce rate now is over 50 % of all marriages. We tear apart attachments and we don’t respect the need for belonging. I have no clue as to what we do about it. In our society, divorce is often necessary even though it hurts both the adults and the children. I have little hope that we address the belonging issue in my lifetime, if ever.

So, what do we do? We identify with sports teams. We wear our team’s jerseys and hats. Young people join gangs. We go to church, synagogues, temples, mosques, and ashrams. But less and less over time. And now many of us watch services on line. We take our computers and go to Starbuck’s to not be alone. The COVID epidemic harmed many community activities that gave some sense of belonging. Streaming television, sports, and movies encourage isolation. We may not be able to change much of this but I do believe we can help our individual patients quite a bit.

This is the way that I talk with my patients. I teach them about the socialization system. I tell them that activating this system in some way is vital for their recovery. But this is not enough. So many internal and external forces are against this. This is one area where the right intervention is me telling them exactly what to do. The mental health provider’s ethic of beneficence tells me that to do otherwise is a form of abandoning my patients. There are three major groups of people we deal with in this matter.

One is those with alcohol and drug problems. The belonging community is already there. They can go to 12 step or Rescue Recovery Groups. Smart Recovery doesn’t count for this as it is mostly on line. But many people hate AA and other self-help groups. What about those people.? I tell them I do not care whether they like it or not. They need to do at least once per week. This going has nothing to do with them staying sober. It is taking advantage of a built-in community to belong to. It only takes the effort to go. I tell them it is ok if they sit in the back and never say anything. If someone asks them why they are there, they can say, “Dr. Seymour told me I had to come”. They can if they want to socialize if they want to. But they do not have to. It is enough for the nervous system to know they are in a group.

The second group of patients are those with some form of communal spirituality. I will use the example of a church as that is what I know. The same principle applies for any organized religion. After all, what really is a religion all about? A way to experience spirituality in a community. I tell them they must go to a church weekly. On-line services don’t count. I tell them go someplace where they can at least stand it for one hour. I tell them I don’t care if they hate the preacher or priest, if they disagree with everything in the service, if they are uncomfortable and don’t think they are good enough to go, or if they sit in the back with their arms crossed, say nothing to anyone, and if someone asks the why they came, they can say, “Dr. Seymour told me I had to come”. Their nervous system will feel they are in a group.

Now the tough one. Those with no substance abuse problem and their spirituality is private and not part of any religion. They are the patients that have to work at it. There is nothing built in. They have to find it. But they don’t want to and they don’t know how. The only way I know is to join any common interest group. There are groups for almost any interest or any activity. It is very important they know that going is not to make friends. They don’t need to. They just have to be there. They don’t need to see anyone outside the group activity at all. They can if they want to. But it is not necessary. During the COVID epidemic this was not possible. It generally is now. I use myself as an example. I used to play a very nerdy card game once per week at the game store. I never made friends outside the group at all. But when I entered, I would hear, “Hi Jim!” You want to go where everyone knows your name.

Or you could facilitate a regular group.

All this may sound like too much. It may sound like this is not important as our patients have so many different stresses already, or so many things in life that are causing them problems or drag them down, or are way too busy. This is true. Many obstacles are very real. Many obstacles are very hard to overcome. But it is worth trying. Full maintained recovery is unlikely in the absence of belonging somewhere. I encourage you, in your own way, to assist your patients to belong somewhere.

The last action system we will look at here is the play system. The sexuality system is very complex and requires its own topic space. Right from the beginning of our lives we are involved in play, first with our mothers and then expanding as we get older. Trauma squelches this system. For many of our patients it destroys and blots out all expression of this system. The system is still there though, and needs expression for full recovery. Many of our patients already have the play system active in singing, dancing, games, athletics, and other fun activities. But for a number of our patients, they have none of this in their lives. I believe it is our job to help them find it. We can do so with almost any patient if we are flexible, allow our own spontaneity and creativity and we don’t worry if we look silly doing it. It can be done. It can be fun. I am not a creative or spontaneous person generally.

I will give you an example from my own practice. While working in a psychiatric hospital I worked with a man who was in a state of catatonia. He was sitting up but was immobile. There was no movement, no facial expression and no eye contact. I have no idea what came over me but I wondered if he would move if I tried something. I took his hand and moved them along with mine as if we were playing patty cake. Shortly he started to move his hands mimicking mine and made brief eye contact and smiled. This did not last. After we stopped. he reverted back to the catatonic state. What is showed me however, was that this catatonia was not caused by a dangerous physical problem affecting the brain (which a large part of catatonic patients have). Instead, his response told me his catatonia was because of a severe depression (the second most cause of catatonia) so we were able to get him into ECT fairly quickly and he made a rapid recovery. The real lesson for me was seeing that play can help even the most ill psychiatric patients. Those with psychotic mania love word play. Those with paranoid schizophrenia will often automatically be social if I ask them to do a puzzle with me or if we have markers and draw together.

So, we can help our severely traumatized patients activate the play system if we creatively find something the two of you can do together. It can be tossing a ball. It can be drawing together. It can be playing Jenga. I have a colleague who has a giant size Connect Four in her office. She works mostly with military trauma and finds that after playing this game with her they tend to open up more. I am so far from being a cool guy. I am old and clearly nerdy if you saw me. Women in their late teens and early twenties did not want to talk to “this old dweeb”. I found that by asking them what music they liked, and listening to it together with my phone by You Tube, the music really broke down barriers. Then, as time went on if they liked and we played any type of rocking song. I started getting up and start dancing to the music. This usually results in laughter. I find it is even better if I know the words and sing along while I dance. Having done this and seen my silliness, it is far easier to learn what’s really going on in their lives. I am not recommending you sing and dance with your patients. You certainly can try. But each one of us, with our own different creativeness can help our patients safely and relationally activate a long dormant play system.

The bottom line is if we help our patients activate their:

Exploratory/Curiosity action system

Energy Regulation action system

Caregiving action system

Socialization/Belonging action system

Play action system

This can go a long way towards helping them spend less time in the defensive/trauma system.