Updated: Feb 5, 2019
What you need to know about trauma, and trauma therapy.
Every week I am contacted by people struggling with the aftermath of trauma. Most have tried many forms of therapy and seen multiple therapists. Many describe themselves as desperate and ready to do whatever it takes to get help.
I have come to see that lack of good information about trauma is one of the biggest obstacles to dealing with it for most of these survivors.
So here’s a quick compendium of info, presented in the form of a loosely organized glossary of terms and concepts that every survivor and trauma therapist should know. Rather than alphabetical order, I’ve placed them in what I consider order of importance, starting with those terms I think I most urgent for people to understand.
Psychoeducation is education and information about mental health. In the context of trauma, psychoeducation should inform about the cognitive, physical, emotional, spiritual and social effects of trauma on survivors and families (individual trauma) and communities (communal trauma).
Why is this important to understand? Psychoeducation is so useful that even without additional intervention it has been found to increase quality of life after trauma among trauma survivors. Survivors need information about what happened to them, and how the injury of trauma affects them. Without this understanding survivors often feel that something is wrong with them, that they need to be "fixed."
Psychoeducation enables survivors to recognize that they are not broken, rather they are experiencing a predictable set of symptoms, a normal response to an abnormal situation. These symptoms can be difficult to live with but they evolved to assist human survival and are easier to manage when understood in this light.
Psychoeducation is also important to help survivors understand strategies required to sustain progress achieved in therapy. Trauma integration is not a matter of healing and moving on. Careful life management is required (see this blog).
Psychological trauma is a response involving complex debilitation of adaptive abilities—emotional, cognitive, physical, spiritual and social—following an event that was perceived by our nervous system as life threatening to oneself or others (especially loves ones).
Trauma can be a one-time event, a prolonged event or a series of events. Trauma that affects a community or a country is called collective trauma.
Traumatic injury shocks and changes all systems. These include:
-Cognitive: The trauma affects ability to process thoughts and make good judgments.
-Emotional: Looping with emotions of shame, guilt, fear, anger and pain.
-Physical: It affects muscles, joints, digestion and metabolism, temperature, sleep, immune system, etc.
-Spiritual: The trauma affects our worldview, the lenses with which we see reality (typically so we see it as unsafe), our understanding and meaning of life, society, and the world.
-Social: The trauma affects relationships with spouses, family, friends, colleagues and strangers (because it affects so many so deeply, it affects structures of societies).
Post-Traumatic Stress Disorder (PTSD) is a set of alarm responses that occur when a survivor’s nervous system remains on high alert after trauma in order to protect against further harm. The survivor’s alert systems respond to reminders of the traumatic memories as a threat. Often additional triggers are added to a growing list of stressors.
Developmental trauma occurs early in life and disrupts normal sequences of brain development. As a result, other aspects of development such as emotional, physical, cognitive and social are also impacted.
In the first years of life the brain develops from the bottom upwards. Lower parts of the brain are responsible for functions dedicated to ensuring survival and responding to stress. Upper parts of the brain are responsible for executive functions, like making sense of what you are experiencing or exercising moral judgement.
Development of the upper parts depends upon prior development of lower parts. In other words, the brain is meant to develop like a ladder, from the bottom-up. So when stress responses (typically due to persistent neglect or abuse) are repeatedly activated over an extended period in an infant or toddler or young child, sequential development of the brain is disturbed. The ladder develops, but foundational steps are missing and many things that follow are out of kilter.
Unaddressed developmental trauma can manifest in many ways. The most common psychological diagnoses that follow are: bipolar disorder, personality disorders (especially borderline), ADHD, Oppositional Defiant Disorder, learning disabilities, social disabilities, addictions, eating disorders, depression, anxiety, complex PTSD, PTSD and so forth (more in this blog).
Our Memories are stored in explicit and implicit ways:
Explicit memories are verbal ones, conscious. We are aware of the facts and can typically recall them in a way that has order - story (event), people that we know, certain location etc.
Traumatic memories are implicit (autonomic). These are stored in an unconscious, fragmented form. They bear no sense of order or even a connection among themselves. They can however be easily activated by inputs from our senses in the present moment, causing us to intensely experience reminders of something that happened to us in the past.
Since traumatic memories are implicit, trauma therapy should in the beginning focus on bottom-up modalities that target areas of the brain known to store implicit memories. As trauma integration progresses, it becomes possible to engage with top-down modalities to process the narrative of the traumatic event/s.
Bottom-up modalities are experiential ways of engaging survivors with a focus on enhancing self-regulation through body-awareness, and expanding a survivor’s sense of control and ability to tolerate inner and outer triggers.
Examples of bottom up modalities are: expressive therapies (arts, drama, movement, dance, music), body-oriented therapies, certain mindful modalities, and certain neurofeedback protocols. These modalities include use of talk to process the dynamics of therapy but they do not rely on cognitive processing.
Body awareness means learning to detect and trace what is happening in the body. It’s particularly important to understand what sensations are associated with various triggers, emotions, movements, associations, images etc. (more info in this blog).
Self-regulation is the ability to control one’s emotional responses. Self-regulation in the context of trauma therapy focuses on three dimensions:
Sensory regulation (integration): Expanding control in response to sensorial triggers and alerts.
Emotional regulation: Expanding control over one’s emotions.
Cognitive regulation: Expanding control over thoughts, and increasing capacity to respond rather than to react.
Top-down modalities usually refers to talk based therapies, such as cognitive and behavioral therapy (CBT) modalities. Top down modalities focus on thought processing and reframing, behavioral modifications, emotional processing, and some forms of narrative processing. Some top down approaches combine modalities, for example, mindfulness based cognitive therapy.
Mindlessness vs. mindfulness. Both are practices that can increase ability to quiet an alerted nervous system. However, mindfulness is a mental state that focuses on awareness of what is here and now (present moment sensations, feelings, thoughts), whereas mindlessness brings attention to focus on a task or activity and seeks to be fully absorbed by it.
Mindfulness can be very challenging for trauma survivors since, along with awareness of the present can come expanded awareness of sensitivity to certain sounds, smells, or textures. These sensitivities, known as triggers and alerts, torment many survivors by bringing to the surface unwanted memories and a flood of emotions. If not developed slowly and gradually, mindfulness can cause more harm than good.
Intentional mindlessness that incorporates creative activity can be just as calming to the nervous system as mindfulness, and engaging in it enhances ability to be spontaneous. When practicing intentional mindlessness, we want to engage in activity that fully absorbs us (and during which the mind doesn't flit to other thoughts or to what we are thinking and feeling), and that increases our sense of joy. Typically activities: playing games, scribbling and doodling, exercise and so forth (see this blog).
“Imaginal Space” is an abstract, creative space of play, fantasy, and spontaneity in which a trauma survivor is able to explore and engage with different aspects of her experiences (including traumatic ones) through art, play, movement, dance, drama, music and so forth.
In imaginal space we encourage expanded spontaneity. If trauma is a frozen moment in time, then spontaneity is the antidote.
Trauma processing. Many trauma survivors seem to expect that, if only they will be able to tell their story, they will be “healed.” A heavy focus on telling the traumatic story reflects outdated notions of what trauma does to people and how to respond to it. Since traumatic memories are implicit and somatic, face-to-face, talk based processing of trauma is not the best way to go about therapy.
"Telling the story” of the traumatic event is not necessary to enable clients to bring up and process what they experienced. The pain of trauma will emerge in whatever modalities are being used. The key concern that must guide a therapist is how to enable it to emerge in manageable ways that do not cause more harm (see this blog).
Resilience is a set of individual responses that enable survival in the face of adversity. The mere fact of survival is evidence already of resilience and individuals display a variety of other survival responses depending on their circumstances.
A key challenge in therapy is helping survivors discover their existing resilience. Most survivors are more resilient than they give themselves credit for. When we add up all the displays of resources demonstrated across hours, days, weeks, and months, in spite of the difficulties of trauma, we see a rich, ongoing web of creative resources that have enabled survival. (more in this blog).
Post Traumatic Growth (PTG) is a meaning making process following trauma. Though the original definition (see link here) is different from my own, I have observed that some survivors come to terms with their experience through a process of meaning-making that typically includes:
Action – making a conscious choice to get help (including self-help).Reflection - finding meaning in what has happened to me, in what I am doing about it, and in valuing things that have resulted in my life from having to cope with trauma.Contemplation - how to incorporate the meaning I have gained into my daily and future actions.
What to do right after trauma takes place? Therapy should not be the first line of response after trauma takes place. Survivors cope better with the aftermath of trauma if they are given caring support and rest rather than encouragement to talk about and reflect on what happened. Just after trauma, telling and re-telling the story is now recognized to be counterproductive and even harmful.
As an alternative, Psychological First Aid (PFA) is a short-term set of support strategies that can be provided by anyone, clinician or not, who has gone through training for it, to support survivors. PFA has been found to be effective in mitigating stress responses and assisting survivors in developing skills for coping with the after-effects of trauma (more info in this blog).
Aspects of self-sustainability. Trauma integration is as much or more about building a stable, meaningful life in the present as it is about moving out of the grip of the past. It’s essential for survivors to develop and maintain practices that support meaningful life in the present. Key categories of routine practices include:
Experiencing the joy of immediate gratification, even if the purpose is no larger than feeling good in the moment, such as watching a movie, getting a massage, getting a mani-pedi, meeting friends, etc.
Keeping routines of self-care, including exercise, sleep, diet, interacting with loved ones, etc.
Reflection on practices of self-sustainability. Because trauma survivors are more vulnerable than others to the stresses of daily living, ongoing monitoring and adjustment of self-sustenance practices is important.
A therapist can contribute to this by working with a client in reflecting on what is working and not working and why, observing intentions, stimuli, and sensations, both internal and external, and learning from these observations.
Individualized Sustainability Plan (ISP) is a blend of strategies and practices to maintain the process of trauma integration. An Individual Sustainability Plan (ISP) provides ongoing structure after we’ve done essential preliminary work on connecting to inner resources and establishing a sense of safety. An ISP incorporates routines that target all aspects of wellness (emotional, cognitive, physical, spiritual and social) such as: mindfulness and self-compassion practices, sensory and bilateral integration, sport and movement, cognitive reframing, behavioral modifications, expressive arts, brain-training neurofeedback, diet and nutrition. (more in this blog).
Food-Mood, Brain-Gut. Stress affects gut balance and gut balance affects how we feel. Research about the impact of diet and nutrition on emotional functioning, and about the impact of stress on the gut, and impact of gut balance/imbalance is relatively recent, but the link is now too obvious to ignore.
After several years of study of this nexus, I am convinced it is impossible to achieve sustainable trauma integration without paying attention to the brain-gut-axis and inflammation as root causes to many physical and mental symptoms. I consider it essential to help clients learn about diet and nutrition, with a goal of identifying foods that for them have a triggering or calming effect. I also help clients, often in consultation with a medical practitioner knowledgeable in this area, to formulate nutritional routines and choose supplements and medication that help restore balance to gut microbiome, support the immune system, treat underlying infections, reduce inflammation, and facilitate overall wellness. (More info in this blog)
Self-Compassion is one of the most effective practices to manage the the aftermath of trauma and an essential requirement for sustaining progress after trauma. The goal here is to expand a client’s capacity to deal with post-trauma injury and pain (shame, guilt etc.) by incorporating the three elements of self-compassion: mindfulness, common humanity, and self kindness (see this blog).
Approach vs. Modality. There is no one trauma intervention (modality, technique) that helps all. A sustainable trauma treatment approach is a set of interventions that target different aspects of wellbeing. Together they can have great impact, but alone, the results of any one of them are inconsistent and limited in duration.
Most people seem to be looking for the one thing that will make their pain/trauma/injury go away. There is no such thing–most certainly not one that will work for everyone all the time (see this blog).
Finding a therapist. Every therapeutic relationship has a certain element of chemistry. It’s not possible for any therapist, no matter how good, to achieve that with every client. As a client, you will know a therapist is right when you feel deeply cared for and in the center of attention of your therapist when you are in sessions. Over time you will feel a growing sense of trust, both in your therapist and in yourself.
Why trauma "integration"? Since trauma is an injury, it is impossible to expect that it will go away completely. What one defines as “overcoming,” “healing,” and recovery” is subjective and may not apply to someone else. I find that “integration” is a word that serves the realities and purposes of trauma therapy.
If a therapist promises “full healing and recovery,” “full reversal of trauma,” or feeling better in 10 sessions, I’d suggest you keep looking, especially if you have a history of multiple traumas.
Trauma integration is a process in which trauma is acknowledged to be a part of an ongoing reality but is no longer at the center of experience, for it is now surrounded by awareness of resources for coping with past and present adversities.
Developmental trauma integration. In the context of developmental trauma, integration means internalization of a sense of safety, predictability, and connection to oneself and others. As survivors progress with integration, they will experience less time in a sense of misattunement and greater fluidity in returning to a sense of attunement.
Final note Trauma takes things away from us and some can’t be returned, ever. For some survivors, the losses are physical, and tangible, such as people we loved or a body that once functioned perfectly. For others, the losses are emotional or intangible, such as a sense of uncomplicated wholeness, pristine memories of beloved times and places. Either way, coming to terms with irreversible loss is an essential part of the trauma integration process.
Trauma therapy objectives: (1) symptoms mitigation—reduce the post trauma stress symptoms and increase your capacity to feel safe, (2) expand your ability to endure the pain that was caused by the trauma and its aftermath, (3) increase your capacity to self-sustain and experience joy with yourself and others.
Each of these objectives are complex and takes time. Most trauma therapy modalities focus on symptoms mitigation, but except for certain contexts, the complexity of trauma requires more than just symptoms mitigation.
No therapist, no modality, no medication or substance can fully remove the injury and pain of trauma. As trauma therapists our job is to guide you through the process of trauma integration. It is possible to help you integrate your vulnerabilities with your resources, and integrate your pain with your joy!