Titration in Trauma Therapy

Titration is a chemical term that was taken out of context to explain a technique to approach psychological problems.

Say we want to neutralize HCl with NaOH. Mixing the acid with the base should, with an easy calculation, give us H2O and NaCl, harmless water and salt.

The problem is that an acid and a base don’t mix like that. If you just poor them together the reaction looks pretty much like a volcano erupting, it boils over in an intense reaction, with a high enough concentration it explodes.

So what is done instead is adding only one drop at a time, giving the solution time to react, until the mixture is neutralized. There is only a small reaction visible, a sizzle, nothing gets out of control or boils over. But with every new drop we get a change in ph value and our chemicals get less dangerous. This process of neutralizing a potent substance one drop at a time is called titration.

We need this concept in various places when we try to heal from cPTSD. There are some psychological conditions that don’t mix well, but they need to be neutralized anyway.

 

 

Dissociation and mindfulness

When we dissociate we separate ourselves from the present. Mindfulness is the practice of being fully aware and present. If we live in chronic dissociation, always in a cloud, detached from our body, emotions, life and self, and we try mindfulness we will get overwhelmed. The mixture boils over. Most chronically dissociating patients report that doing a body scan or trying to be mindful of their breath or meditating makes everything so much worse. A short moment of being present makes them spin back into even greater dissociation because they don’t have any tolerance for being present or feeling themselves.

That doesn’t mean that mindfulness is the wrong tool. It is a valid way to neutralize dissociation, but we need to take smaller steps. Much smaller. Only a drop at a time. A lot of the regular mindfulness exercises start way too big.

When we started to make our way out of chronic dissociation we tried small.

Taking one foot in our hands and trying to sense that for a few moments. Feeling one breath, not in our belly, that is too difficult already, but in the lifting of the shoulders. Trying to stay present while washing this one cup. While eating this one cookie.

It doesn’t need more to start a mindfulness practice. When we come from a place of chronic dissociation it actually can’t be more and it wouldn’t make sense to push ourselves to do more. That would just end in another intense chemical reaction. We are looking for the tiny step, the drop, that will be a little challenging but won’t stir up too much.

 

 

Trauma memories and the present

We get another strong reaction when we look back at trauma memory. The nature of the intense memories will overwhelm us when we just try to face them. All the emotions, hyperarousal, immobility and pain just boil over. When we work with exposure techniques to neutralize trauma memories we often experience a strong reaction. Some techniques are more gentle than others and reduce the risk of an abreaction or re-traumatization that happens when we get fully overwhelmed. The most gentle techniques work with titration. We face our memory one drop at a time, let our body and mind integrate that and then face the next drop. We see this in somatic experiencing.

I believe that more trauma techniques will move towards using titration for exposure in the future. It is a lot safer, even if it takes a little longer. The integrative capacities grow with time. It doesn’t need the intense eruptions of extreme exposure to neutralize a memory. Treatment that can only be endured with the support of hard DBT Skills and that confirms our core trauma mindset of barely surviving will eventually belong to the past. (I was told that I am a helpless idealist but this is a trend I see in developmental trauma research)

 

 

ANPs and EPs

The front people of a DID system can be in intense denial when it comes to having parts. They often don’t remember any trauma, so there is no reason for them to expect anything like that. A sudden confrontation with the truth can be overwhelming and lead to a major crisis. We have made good experiences with integrating one part after the other, like drops. It means that we stabilize the known system as much as we can and then open the inner doors for one new part to join the team. We then work hard to integrate that part before we invite the next one in. That way we are exposed to new memories and traumatic experiences in small doses that are easier to handle. Because the whole system can focus on one part (and keeping our life stable) it is much more organized and less messy. This might not work for every system but it could be worth a try.

EPs might profit from small steps as well. Being confronted with a whole new world and time to live in, new people, new rules, a new life, can be a lot to take in. When we integrate a new part into the team they get invited to share small moments of co-consciousness. To be there to smell freshly baked cookies or pet a dog. Just one drop of our new life in the present at a time. Starting with all the goodness we have now. That way they can reflect on it and get used to it without getting overwhelmed. How much of the current reality they can handle depends on the part and our exercises can be adapted to their capacities.

 

With chronic dissociation, trauma and DID, the slower you go, the faster you reach your goal. When we take the tiny steps and use titration we protect ourselves from crisis. We couldn’t successfully take bigger steps even if we tried. There are places where pushing doesn’t get us very far and 2 minutes a day practicing something small can change our world.

 

More about the problem with emotional regulation