Introducing Trauma and Tension Release Exercises (TRE) to support staff wellbeing at Addenbrooke's Hospital Cambridge

Our lives and workplaces have changed in myriad ways since February 2020. Things we once took for granted – mask-less coffee breaks, shaking hands, a reassuring touch to a distressed patient – seem alien now, and still we are finding our way through to establish the ‘new normal’.

Many of us have been using multiple ways to counteract the stress and the demands that the pandemic has placed on us, ranging from individually-sourced strategies to wellbeing initiatives offered through our workplaces. Typically, most wellbeing support offered to healthcare professionals by their Trusts involves talk therapy-type approaches that engage the higher brain functions, classed in psychotherapy as ‘top down’ approaches. We were keen to diversify the available wellbeing initiatives in order to reach a wider range of people who might be able to benefit, especially people who feel uncomfortable engaging in talk therapies. We therefore obtained funding to offer Trauma and Tension Release Exercises (TRE) to people in our anaesthetic department, theatres and ICUs.

We are embarrassed if we shake after a near miss, not knowing that this is a physiological response of the body to bring itself back into a more relaxed state.

TRE are a so-called ‘bottom up’ approach, which means working with the body to calm down the autonomic nervous system and help regulate some of the evolutionarily older parts of the brain, the brain stem and the limbic system, that are difficult to influence through cognitive therapies [1]. They are a series of simple physical exercises that aim to induce muscle tremors or shaking, thereby releasing stress from the autonomic nervous system. The fundamental idea is that stress, tension and trauma are both physical and psychological phenomena. Our bodies have a natural ability to release this tension through tremoring, and yet we have learned to suppress this most of the time. We are embarrassed if we shake after a near miss, not knowing that this is a physiological response of the body to bring itself back into a more relaxed state. TRE helps us to ‘re-learn’ this natural skill to tremor and thereby soothe the nervous system.

Stephen Porges’s polyvagal theory helps to explain the autonomic responses that underpin our stress response (Figure 1) [2, 3]. In a relaxed state we are operating predominantly in a ventral vagal arousal state, illustrated by the wavy green line. When stress levels increase we shift into a sympathetic nervous system-dominated arousal state, and eventually if we become totally overwhelmed into dorsal vagal shut down.

TRE comprise seven simple exercises that trigger a natural tremoring reflex. They can easily be modified to take into account any injuries or disabilities.

TRE were created by David Berceli, who had observed communities in the Middle East and Africa who had been traumatised by war. By inducing the body’s natural tremoring mechanism to release trauma, there was a reduced need for interventions such as psychotherapy or medication to manage those with PTSD. David Berceli has used TRE extensively to support US war veterans [4]. The tremoring achieved through TRE can help us to move from a heightened state of arousal back into a ventral vagal dominated state of arousal, lowering adrenaline and cortisol levels in the process (Figure 2, green arrow). We therefore feel calmer and more relaxed.

What does it actually involve?

Our TRE sessions are run by Samina Khan, a trained and certified TRE practitioner who is also a therapist. The sessions take place in very small groups in a large room so that we can adhere to the appropriate physical distancing to comply with COVID regulations. Apart from floor mats no other equipment is necessary, just the participants with their phones turned off. We have been fortunate at Addenbrooke’s to have had the use of a large fitness hall during lockdown. However, in more recent times we have used the patient physiotherapy gym out of hours - it is worthwhile to check out your own unused facilities locally if you are looking for spaces to accommodate wellbeing initiatives.

TRE comprise seven simple exercises that trigger a natural tremoring reflex. They can easily be modified to take into account any injuries or disabilities. Samina guides the group through the exercises. For the final exercise, one lies on the mat with feet drawn up and knees apart – the tremoring response begins as one brings one’s knees together. Lying on the mat also allows the mind and body to settle, and helps to integrate any emotions that may arise. TRE is always guided by a trained practitioner and it is important to take it slowly when first undertaking TRE. If the wish arises to talk informally with one’s practitioner about any emotions that might arise during the exercises there is time and space to do so, but it is totally acceptable to do the exercises without talking.

What do people think?

Over 170 people have attended TRE to date, with many returning for multiple sessions. We surveyed attendees to gain feedback: an overwhelming majority of 96% said that they were satisfied/very satisfied with the sessions; 75% felt better or more relaxed; 92% would recommend TRE to friends and colleagues. Almost half of participants reported that they slept better.

Further information:
Dr David Berceli
Trauma Prevention
TRE Association UK
TRE Australia

Ruth Fenton
Consultant Anaesthetist 

Amy Donnelly
Senior Clinical Fellow 

Heike Prinzhausen
Consultant Anaesthetist and Wellbeing Lead
Addenbrooke’s Hospital, Cambridge University Hospital Trust, Cambridge

Figure 1. Adapted with permission from reference [2]

References 

1. van der Kolk B. The body keeps the score. Mind, brain and body in the transformation of trauma. New York: Penguin, 2015. 
2. Porges SW. The polyvagal theory: phylogenetic substrates of a social nervous system. International Journal of Psychophysiology 2001; 42: 123-46. 
3. Porges SW. The polyvagal theory: neurophysiological foundations of emotions, attachment, communication and self-regulation. London: WW Norton & Co, 2011. 
4. Heath R, Beattie J. Case report of a former soldier using TRE (tension/ trauma releasing exercises) for post-traumatic stress disorder self-care. Journal of Military and Veterans’ Health 2019; 27: 35-40. 
5. TRE Australia. The shaking solution to stress, tension & anxiety, 2021. https://treaustralia.com.au (accessed 17/8/2021).

Read next: Thomas Boulton History Prize Essay: The ABCs of anaesthetic history – alcohol, beer and cocktails