Definitions and labels are important when you are in pain and trying to figure what to do about it. An important step in my journey of trauma integration was to let go of “recovery” and “healing” as my final goal and to seek instead outcomes I could actually achieve.
I share the view of trauma scholar Robert Stolorow, that trauma recovery is an oxymoron. (Stolorow, 2011. p. 61). Things are never really the same after trauma. So what then to name the place that can be achieved, where trauma is no longer the center of experience and yet is acknowledged to be a part of ongoing reality? I call it Trauma Integration.
Trauma integration is not once-and-done, nor is it linear. It is on-going and sometimes cyclic. If that sounds discouraging, the good news is that movement begets more movement. Achieving a sense of integration – even just once, for just a short while - establishes the possibility of breaking the script of old responses and opens the door to more new responses. Gradually, experience with new, integrated responses accumulates and the rewards are felt, emotionally, cognitively, physically and spiritually.
Broadening the treatment approach of trauma
But a narrow treatment approach limits progress. A study from the Journal of the American Medical Association (Kearney & Simpson, 2015) provides evidence of this and calls for broadening approaches to post traumatic stress disorder and other consequences of trauma.
The two most common treatments for US veterans with PTSD are Cognitive Processing Therapy (CPT) and Prolonged Exposure (PE). The study reports that half to two-thirds of the participants experienced at least some improvement in symptoms following treatment with one or both of these approaches. But in addition to low follow-through and high dropout rates, the study found that about two-thirds of participants studied continued to experience post trauma symptoms so severe that they maintained a diagnosis of PTSD.
The authors point out that trauma affects survivors mentally, physically and emotionally. Thus they suggest that one strategy for improving the results of treament should be to address diverse symptoms in a variety of ways. (Kearney & Simpson, 2015).
Establish an expansive therapeutic arch
Diverse approaches exist, of course, across the therapeutic community. There are many different approaches and protocols for trauma therapy, each with particular strengths. But although it is accepted in theory that no one therapy works for everyone, in practice therapists tend to specialize in one or two approaches and apply them to all clients. Many therapists operate from a client-centered perspective, of course, which calls for providing therapies that are truly responsive to clients. But how many therapists are well-informed about treatments in the diverse aspects of human functioning that are implicated by trauma?
Integrated approaches
Several authors and practitioners have called for integrated approaches to trauma, but few such such approaches are backed by empirical research. One exception is SEE FAR CBT (Lahad et al., 2010), which was studied in a small sample of adults who suffered from PTSD and then received treatment. SEE refers to elements of somatic experience, FAR refers to the use of fantastic reality, specifically, elements of drama therapy, and CBT refers to cognitive and behavioral elements.
Lahad compared results of SEE FAR CBT with those of the more widely studied EMDR and found them nearly equally beneficial. SEE FAR CBT was found to be effective one year after therapy whereas the group receiving EMDR experienced a return of some trauma symptoms. This highlights, in my view, the necessity of establishing Cognitive and Behavioral Resolutions at the very core of trauma therapy, in order to sustain the benefits of therapy across time.
Expressive Trauma Integration (ETI)
Convinced that single-strategy approaches are unsustainable, I’ve sought for some years in my practice and research to find a wholistic framework that applies diverse approaches in a integrated way to trauma treatment.
Among the various strategies of treatment for which efficacy has been demonstrated in research, I find three to be particularly complementary: psychoeducation, expressive and experiential therapies and cognitive and behavioral resolutions. For several years now, I’ve been applying them together in a wholistic approach to trauma I call expressive trauma integration (ETI). While it is too early to make claims about efficacy, initial results show promise.
Psychoeducation in the context of trauma refers to education regarding the biological, emotional and physical effects of trauma on survivors and their surrounding relatives (individual trauma) and communities (communal trauma).
Many studies have investigated the effectiveness of psychoeducation (Gertel Kraybill, 2015). Phipps and colleagues (2007) suggested that psychoeducation alone, even if unaccompanied by other interventions, assisted trauma survivors to better understand their trauma symptoms and thereby contributed to a decrease in their stress symptoms.
A key goal of psychoeducation is understanding the brain’s responses to trauma in survivors and those who work with them (Raider et al., 2008). However, my own research has brought me to see that in order to make psychoeducation effective the information needs to be delivered experientially. I found that two months after a workshop providing psychoeducation in an experiential approach to learning, 92% of the participants retained the content whereas in the control group, who were taught in a purely didactic, non-experiential approach, retention was virtually zero! (Gertel Kraybill, 2015).
Experiential Methods. Since the late 1980s, a growing number of authors argue that trauma creates nonverbal mental activity that dominates verbal thinking (Gertel Kraybill, 2015). From this perspective, which I share, verbal psychotherapy addresses cognitive aspects of trauma but has little impact on those aspects of trauma that cannot be accessed by talk. (Koch and Weidinger-von der Recke, 2009).
Brain research indicates that traumatic memories are stored in physical locations in the brain that simply can’t be accessed by cognitive approaches and require engagement via lower parts of the brain. Talk based and cognitive approaches work top-down, seeking to enlist the higher parts of the brain in the task of calming the more primordial functions of the lower brain, whereas nonverbal approaches work bottom-upwards by aiming to engage directly with the lower parts of the brain.
Expressive arts therapies provide a well-established body of practices for engaging clients nonverbally, enabling access to traumatic memories in an indirect way, even when verbal expression is limited (James & Johnson, 1996; Johnson et al., 2009).
Expressive therapy tools that I find especially effective in helping clients progress in these stages are experiential and include surplus reality, mirroring, and embodied sculpture work, and other techniques such as role reversal, short vignettes, and an integrated art and movement technique I’ve developed called mindful expansion.
For working with clients in ways that reflect the insights above, I’ve devised a six-stage roadmap for expressive trauma integration, with stages: 1. Routine; 2. Event; 3. Withdrawal; 4. Awareness; 5. Action; 6. Integration. Working mostly with the expressive therapy tools described above, I help clients to locate themselves among the six-stages and, when they are ready, to explore in the safety of a therapeutic setting what it might look and feel like as they progress to further stages of integration.
Individualized Sustainability Plan (ISP). In my last post, I described the use of such a plan. ISP are a set of techniques and practices created for a particular trauma survivor to assist him or her to achieve a minimal level of functional on spiritual, physical, cognitive and emotional levels. ISP draw from various practices demonstrated to be effective in trauma symptoms mitigation, and sustain a sense of well-being. These include: the practice of mindfulness and self compassion, sensory and biliteral integration, stress management, expressive arts, diet and nutrition.
The future of trauma therapy While we have years of work ahead to understand exactly which mix of approaches is best for various clients and how to sequence them, I believe that many survivors and practitioners now recognize the wisdom of a wholistic framework that includes an array of approaches in treating trauma. A critical challenge for our field now is getting the resources required to take this simple awareness into practice, to educate responders with a wholistic framework and to establish preventive and resiliency enhancing programs that reflect such awareness.
What do you consider to be the key elements of a wholistic framework? What approaches do you use and blend, and how do you decide which ones to use in a given phase or with a particular person?
References:
Gertel Kraybill, O. (2015). Experiential Training to Address Secondary Traumatic Stress in Aid Personnel. (Doctoral Dissertation). Lesley University, Cambridge, MA.
James, M., & Johnson, D. R. (1996). Drama therapy in the treatment of combat-related post-traumatic stress disorder. The Arts in Psychotherapy, 23(5), 383-395.
Johnson, D. R., Lahad, M., & Gray, A. (2009). Creative therapies for adults. In E. B. Foa, T. M.
Keane, M. J. Friedman, & J. A. Cohen (Eds.), Effective treatments for PTSD: Practice guidelines from the International Society for Traumatic Stress Studies (pp. 479-490). New York, NY: Guilford Press.
Kearney, D. J., & Simpson, T. L., (2015). Broadening the Approach of Posttraumatic Sress Disorder and the Consequences of Trauma. Journal of the American Medical Association. 314(5): 453-455. JAMA. 2015;314(5):453-455. doi:10.1001/jama.2015.7522.
Koch, S. C., & Weidinger-von der Recke, B. (2009). Traumatised refugees: An integrated dance and verbal therapy approach. The Arts in Psychotherapy,36(5), 289-296.
Lahad, M., Farhi, M., Leykin, D., & Kaplansky, N. (2010). Preliminary study of a new integrative approach in treating post-traumatic stress disorder: SEE FAR CBT. The Arts in Psychotherapy, 37(5), 391-399.
Phipps, A. B., Byrne, M. K., & Deane, F. P. (2007). Can volunteer counsellors help prevent psychological trauma? A preliminary communication on volunteers skill using the ‘orienting approach’ to trauma. Stress and Health: Journal of the International Society for the Investigation of Stress, 23(1), 15-21.
Raider, M. C., Steele, W., Delillo-Storey, M., Jacobs, J., & Kuban, C. (2008). Structured sensory therapy (SITCAP-ART) for traumatized adjudicated adolescents in residential treatment. Residential Treatment for Children & Youth, 25(2), 167- 185. doi:10.1080/08865710802310178
Stolorow, R. D. (2011). World, affectivity, trauma: Heidegger and post-Cartesian psychoanalysis. Routledge.