A Therapist’s Guide to Understanding Trauma Therapy

Freud called psychoanalysis the third impossible profession (the other two being education and government). It may be as valid to say that psychotherapy is another impossible profession. Many therapists desire to master several of the countless therapeutic modalities available today in their endless pursuit to feel more adept at offering hope, especially to the large number of individuals looking to alleviate the despair rooted in the experience of traumatization. Trauma therapy requires mastering several modalities and unlearning most of what therapy was before. It’s not “impossible” but definitely a fascinating and arduous journey for the therapist — and for clients.

I wonder how therapists felt when psychoanalysis (and behaviorism) dominated the world of psychotherapy all through the first half of the 20th century.

I picture the beginning of this contest developing as the paradigm shifted to a person-centered school, and the appearance of humanistic psychological therapies in the 1950s and 60s. That, in tandem with the emergence of psychotropics and closing of mental institutions, must have been the reason why a revolution in the treatment of mental illness kicked off.

We are now in a very important moment in the history of psychotherapy, confronting another paradigm shift: traumatization. Foderaro (1995) stated it beautifully: “the fundamental shift in providing support using a trauma-informed approach is to move from thinking ‘What is wrong with you?’ to considering ‘What happened to you?’”

Traumatic Events

It was not until recently that trauma came to occupy a place among mental disorders, receive the attention that it deserves and obtain the recognition for the magnitude that it has. Yet, there are no official diagnoses for the several different types of traumatization, and the DSM-5 still requires the person have been exposed to death, threatened death, actual or threatened serious injury, or actual or threatened sexual violence to meet the criteria.

To understand the individual’s challenges and for therapy to serve them well, it is important to have in mind that how traumatic an event is rests on each individual’s resilience. The response of an individual to “traumatic events” depends not only on stressor characteristics but also on factors specific to the individual — out of their control, awareness and power.

Any event could be traumatic if the reaction to it exceeds the capacity of the person to stay regulated and to bounce back to “normal” functioning. Events that cause trauma can be of all sorts; to name a few, they can include:

• abuse of power,
• betrayal of trust,
• entrapment,
• helplessness,
• pain,
• confusion,
• loss,
• sadism,
• cruelty,
• criticism/bullying,
• rejection,
• absence of control,
• lack of attunement to the parent,
• and factors like oppression, discrimination, poverty, racism, or even malnutrition.

I hope this concept is clear: traumatization is about how a person experiences an event, circumstances or emotions and that each one’s experience is subjective. Traumatization depends on the person, not on the event itself.

Trauma Psychotherapy

This is a very interesting moment to be a psychotherapist. Many modalities are introducing neuroscientific concepts to elucidate their efficacy, and several of them are using neuroscientific discoveries as part of their core. Psychology, physiology, anatomy, technology and even Eastern and Western philosophies are all converging, and we are getting much better equipped to help people live more fully.

Trauma therapy is newer than the recognition of trauma as a disorder. Post-traumatic stress disorder (PTSD) is only 40 years old. Interdisciplinary debates involving philosophy, psychology and psychopathology are taking place constantly, contributing to our understanding of how the brain is related to our emotions; the report of the central role of mirror neurons on empathy just came out seven years ago.

Therefore, we can say that trauma therapy is still in the making.

So far, what we can say about trauma therapy is that it differs a lot from “traditional” therapy in the sense that it is less about thinking and talking, and more about doing and experiencing.

Trauma therapy is more structured and directive, it’s highly relational and it’s truly compassionate. It doesn’t pathologize the client; it gives the client the authority of owning their interpretations, and it sees the symptoms as a consequence of what happened to the client instead of identifying the client’s behavior as a sign of defectiveness.

Trauma therapy is not “talk therapy;” working with a trauma therapist is not talking about terrible memories as soon as the relationship starts. Trauma therapy is highly informed by neurobiology. For this reason, it has the understanding that exposing clients to their traumatic memories too soon is counterproductive and can even be retraumatizing.

If you work with a trauma therapist, you don’t need to go in prepared to constantly cry. Instead, you could prepare by wearing comfortable clothes because you may move around — many interventions include body movement, posture, sensations and physical interactions.

Be prepared also to learn about yourself inside out: from how your nervous system works to how society influenced your symptoms. Instead of spending your session talking about others, you’ll go in and develop a conversation with and about you. Instead of finding who to blame, you will be working on how to recover agency, confidence, self-esteem, sense of self and peace of mind.

Trauma Therapy Phases

Most of the literature for trauma treatment suggests a three-phase treatment based on how Pierre Janet envisioned — more than a hundred years ago — a phase-oriented way to treat trauma. Despite the steps being defined so long ago, trauma treatment was not implemented until the late ’90s by Judith Herman’s book “Trauma and Recovery.” That design consists of:

Phase I: Stabilization
Phase II: Processing
Phase III: Reprogramming

The model has been modified a little to include more development of resources and emotional capital, and it’s seen now as more circular than linear, but the philosophy is basically the same:

Stabilization

Probably the most important phase of the trauma treatment; even more important than processing the traumatic memories. If this phase is done in an effective way, the processing of the emotionally loaded material from the past could go smoothly and fast. It has several steps:

• Establishing safety,
• Psychoeducation,
• Self-regulation.

Establishing safety (living situation, health, habits, income, well-being, etc.) is one of the steps that many other therapies don’t include. It comes more from a biopsychosocial model than from a psychological one. Traumatization is rooted in a lack of safety; therefore, it’s just logical to see how individuals can’t heal from the fear of feeling at risk if they are at risk. Trauma therapists work on safety from checking on the client’s diet and addictions, to abusive relations, to risky behavior, to ownership of weapons.

Psychoeducation is also a pretty novel in the therapy world. A trauma therapist could have a whiteboard at the office, and will give handouts with charts and explanations learning to instruct on how to develop:

• regulation skills,
• tolerance to affect,
• awareness of emotions-reactions-triggers,
• resilience,
• reaching a point where emotions and memories are manageable without overwhelming the system.

Self-regulation is about developing regulation skills to deal with the dysregulation of the autonomic nervous system caused by traumatization. We know that the nervous system emerges from the assemblage of neurons and nerve cells that are connected to each other and that the core component of the brain is the neuron. To understand trauma and how to treat affect regulation it becomes helpful — if not necessary — to have some knowledge of the sophisticated activity of brain, the neurons and their circuits. Self-regulation is the point where the individual acquires enough capacity to control emotional reactions, and the reprogramming of the brain starts. The alterations left by the traumatization begin to return to the previous way of operating and equilibrium gets recovered.

If the trauma is developmental — or complex (C-PTSD) — there is a need to strengthen the prefrontal cortex, to develop trust, to discover how to attach securely and to learn how to reparent the infant’s wounded self-parts.

Processing
This phase includes integrating the story of the traumatic event into a cohesive narrative by achieving memory reconsolidation, which means replacing the negative emotional charge of the original memory with a more appropriate emotional significance, according to the actual circumstances. Processing helps to recall — or not — the events, finally making sense of the past, and not carrying the dread that has been there all the time since the traumatic event(s).

Reprogramming

This stage is where the individual reconnects with others, rewrites the story, develops social skills and mourns all the losses from the years spent in survival mode.

Trauma Modalities

Since trauma is a disorder based on the dysregulation of the nervous system that affects the personality, the memory, the mood, the behavior, etc., it needs more than one modality to go through the healing process. Modalities are a series of techniques adhering to a specific philosophy about how to target specific problems, to solve them. Most trauma therapists train in at least two and attend countless workshops to become proficient in the three phases. What the sessions look like depends on the modality that the therapist is using. They can be top-down sometimes, or bottom-up others. They can be body-based, or more cognitive, or more energy-oriented, or they can even use computers and cables connected to your skull.

The most common modalities for each phase are:

Stabilization:

• Mindfulness
• Yoga, Tai Chi, Theater, EFT, etc.
• Hypnosis, EFT, Hakomi, Gestalt, Schema therapy, etc.
• Parts language (from IFS, sandbox, etc.)
• Biofeedback (breathing, HRV)
• Neuromodulation (Entrainment, brain stimulation)
• Neurofeedback

Processing:

• Eye movement desensitization and reprocessing (EMDR)
• Somatic Experiencing/Sensorimotor Psychotherapy
• Accelerated Experiential Dynamic Psychotherapy (AEDP)
• Internal Family Systems

Reprogramming:

• Narrative therapy
• Positive psychology
• Grief and loss counseling
• Social skills training
• Hypnosis

Trauma therapy is empowering.

Trauma therapy is not about coping with symptoms, it is about healing. It’s about helping individuals to recover their whole self, and to get their lives back.

A version of this article originally appeared on PsychCentral.