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This is an intermediate course. After completing this course, the mental health professional will be able to:
The materials in this course are based on the most accurate information available to the author at the time of writing. The field of trauma psychology grows daily, and new information may emerge that supersedes these course materials. This course material will equip clinicians to have a basic understanding of trauma and its effects, and how to assess those effects across a broad range of diagnoses. This content may provoke painful feelings for some readers, or bring the reader’s own personal trauma experience to mind.
This is the second of three courses in a series about trauma, which is a biopsychosocial/spiritual-existential phenomenon whose effects can be seen in the forms of distress and dysfunction on almost every variable of human functioning. The first course, Becoming a Trauma-Aware Clinician: Definitions and Assessment, covers questions of what constitutes a trauma, and how to assess for its effects in a range of ways. This second course, After the Trauma: Skills and Treatments, introduces an overarching framework for trauma treatment, and then reviews the large variety of specific treatments for trauma that are now available. The third course, Cultural Competence and Sensitivity in the Trauma-Aware Clinician, explores being sensitive to the patient's multilayered cultural identities when being treated for trauma, as well as that of the clinician working with the trauma patient.
Once the clinician has determined that trauma constitutes an important aspect of what is troubling a client, there are a number of considerations to take into account when moving forward with treatment. Clinicians working with trauma survivors should become familiar with the overarching paradigm for trauma treatment, which serves as the foundation and framework for the application of specific interventions. The choice of a specific intervention will, in turn, reflect the nature of the trauma (e.g., complex trauma), as well as considerations regarding effectiveness and client capacity to tolerate a particular approach to treatment.
Once the clinician has determined that trauma constitutes an important aspect of what is causing distress for a person, there are a number of considerations to take into account when moving forward with the process. Clinicians working with trauma survivors should become familiar with what has become a well-accepted overarching paradigm for trauma treatment. This construct serves as the foundation and framework for the application of specific interventions when one is deemed potentially helpful. The choice of a specific intervention will, in turn, reflect the nature of the trauma (e.g., complex trauma), as well as considerations regarding effectiveness and survivor capacity to tolerate a particular approach to treatment. The choice will also be affected by a closer reading of the literature that has supported these interventions, which has raised concerns about the applicability of specific treatments to survivors who, unlike those in RCTs, tend to have many co-morbidities, often those associated with attempts to cope with distress caused by trauma exposures (Brown & Courtois, 2019; Courtois & Brown, 2019). Finally, we will explore in depth the importance of the Evidence-Based Psychotherapy Relationship Variables (EBRV), as their importance in working with traumatized persons has become more prominent in the last half decade.
Best practices in trauma practice today, no matter what else a clinician does, tend to be guided by a meta-model. This “ecological model of trauma treatment” (Harvey, 1996) used by Herman, Harvey, and their colleagues at the Cambridge Victims of Violence Program reflects much earlier recommendations made by Janet regarding working with complex trauma, and Kardiner and Spiegel’s descriptions of effective treatment of soldiers with combat-related PTSD, as well as more recent work by colleagues such as Putnam. This model, because of its broad dissemination in the field of trauma therapy, serves as a paradigm for other transtheoretical treatments for trauma, and has been integrated into the work of many psychoclinicians working with trauma survivors. Before going on to any specific intervention, trauma-aware psychoclinicians must familiarize themselves with this model to ensure that they are guided by its parameters in their work.
While this model posits three phases of treatment, trauma-exposed persons rarely proceed in a linear fashion through these phases, as there is no typical trauma survivor. The individual with a positive developmental experience and solid attachment, as well as few to no marginalized intersectional identities, who then experiences an adult-onset trauma may need to spend less time in the stabilization and safety phase of treatment as they will likely have had an experience of safety in their life. Conversely, a person with a complex developmental trauma history may spend almost the entire course of therapy there, working to achieve something that more closely resembles safety, but takes into account the person’s lived experience of never having yet been safe. I refer to this as “getting closer to safe,” or “getting to safe enough” (Brown, in press). Traumatized people move in and out of these stages; they often enter the therapy office with florid intrusive or dissociative symptoms which call for the clinician to work with that person in ways that directly target and reduce those distressing experiences. While those experiences are occurring, the person does not feel safe with themselves, let alone with anyone or anyplace else in the world (dogs and cats usually excepted). However, as will be discussed below, it is more clinically prudent to do whatever possible to focus on safety and stability, by which I mean the capacity to maintain in some non-dissociated state of adequate function more of any given day than not, prior to, or simultaneous to, dealing with the overtly distressing intrusive trauma materials. Keep in mind, as well, that many very traumatized persons present with a faux calm that, as therapy moves forward, turns out to be deep dissociation; that dissociation, when pierced, opens up the door to intrusive distress.
I use the metaphor of a slinky-toy for trauma work (and kept one on my desk where survivors could see it in the pre-telehealth era). Trauma work involves moving through a continuous spiral of levels, sometimes so tightly packed that they seem to be a circle rather than a spiral, other times more clearly separate from one another so that moving through a level gives more obvious evidence of healing. Similar material is addressed in trauma work at each step along the spiral, but addressed differently at each level as the spiral progresses forward.
The initial stage is that of establishing safety and stability. Safety, like trauma, would appear at first glance to be a neutral, easily agreed upon construct. However, there are likely to be many specific variables that delineate, or serve as a barrier to, a sense of safety for a given trauma survivor. There are other aspects of this phase of treatment that are foundational and must be established with every traumatized person in order for trauma work to proceed. For some survivors, these boundary conditions are more or less in place when they enter therapy; this is most likely true for individuals with single-episode adult-onset traumas who have good social supports, or for children whose single-episode trauma occurred outside of the family system and thus did not undermine their primary attachment relationships. These boundary conditions are also more likely to be present for persons who do not have marginalized intersectional identities, and are thus not at risk of continuous trauma exposure from microaggressions or insidious traumatization.
The child trauma outside the family situation is not always one in which the person has felt a sense of safety in the world before the index trauma. For example, in the infamous case of sexual abuse of hundreds of child and adolescent gymnasts by Dr. Larry Nassar, parents were often in the exam room, unaware of the abuse taking place in front of their eyes. This had the effect of disrupting attachment relationships with that parent for some of his many victims, who were delivered into the violating hands of Nassar by unwitting parents. For other people, safety and stability are dimensions on which they have always experienced deficit due to the disorganizing or unpredictable nature of their familial or early psychosocial environments. For this group of survivors, a significant component of the work may consist of ensuring that these elements of safety and stability are reliably in place before proceeding, to more directly address the specific material of the trauma.
Finally, as mentioned earlier, marginalized individuals in a culture are exposed to almost daily reminders that they are not truly safe. Like people with histories of trauma in childhood at the hands of caregivers, marginalized persons require the practitioner to leave aside the word “safe” and instead speak of “closer-to-safe” or “safe-enough-for-now” in order to be credible to these groups of traumatized individuals.
Some aspects of safety are basic and resemble the bottom layers of Maslow’s famous pyramid of needs: safe food, safe water, safe air to breathe, and safe housing. For many trauma survivors, these basics cannot be taken for granted. Depending on the type of trauma involved, survivors often have both immediate and longer-term, chronic challenges to their basic needs for safety. Disaster survivors may not have a roof over their heads or water to drink – or worse, may be domiciled, but in unsanitary and unsafe conditions, like the Katrina survivors placed in the toxic FEMA trailers, or Hurricane Maria survivors left in flimsy tents for many years after the hurricane has occurred. Combat veterans who have experienced multiple types of trauma exposure have among the highest rates of unemployment in the U.S. and are at significant risk of being homeless, with the attendant risks to safety. Trauma-exposed persons are generally over-represented among the unhoused, among those using substances unsafely, and those engaging in other behaviors that mean that safety is a foreign concept in their lives.
Survivors of complex trauma are often engaged in trauma reenactments in their adult lives. This means that they are frequently embroiled in relationships that are physically or emotionally dangerous – or both – and often have difficulty understanding that this danger is not the price they must pay in order to have something resembling attachment. Many persons who have been trauma-exposed are also not safe with themselves, engaging in a range of self-injurious behaviors as strategies for attempting to manage trauma’s neurobiological dysregulatory effects. Safety in trauma therapy must, consequently, focus on addressing questions of strategies that people have adopted in order to soothe themselves and manage intolerable affects and somatic experiences in the wake of trauma. Many of the types of distress associated with post-traumatic presentations represent some component either of those intolerable effects or of people’s self-help strategies for trying to deal with them. Some of those strategies are problematic and risky for the survivor, such as consumption of risky amounts of mind-altering substances, cutting or burning oneself to evoke either heightened or numbed states of awareness, over-exercise, over-work, eating less or more than nourishes the body, being sexual in unsafe ways or with unsafe partners, and so on. An astute trauma clinician pays attention to how the survivor has been dealing with their distress, as questions of whether it’s numbing or activation, insomnia or general dissociation, can guide a clinician to a collaborative discussion with a trauma-exposed person about other, lower-risk ways to address the suffering caused by their traumatic experiences.
A component of safety rarely addressed in the trauma treatment literature, but one that takes into account the explicit presence of possible insidious trauma in the psychosocial environment, is extending the definition of safety to include considerations of ways in which systemic oppression and bias may be creating inherent and difficult or impossible-to-avoid unsafety for the survivor (Nadal, 2018). The presence of such systemic challenges to safety for members of marginalized groups must be addressed and identified, given that some individuals may be chronically responding to these embedded phenomena, some of which have become more prominent in their daily lives. The overt manifestations of these signs of danger have increased markedly since 2016, according to such organizations as the Anti-Defamation League and the Southern Poverty Law Center, which track episodes of hate crimes and increases in the violent militia movement. This is occurring as violent nativist, Christian Nationalist, and white supremacist groups have become more visible and active in the second decade of this century in the US and all over the world, as active as fascist groups were in post-WW I Europe and the US in the 1920s and 1930s (Maddow, 2023). A trauma-aware clinician who is also culturally attuned will add to the discussion of standard safety issues discussions of the presence of systemic safety-undermining life experiences that may not be avoidable or changeable due to their ubiquity, and will collaborate with their marginalized survivors in integrating awareness of these realities into strategies for coping with these unavoidable microaggressions and insidious traumas. Clinicians working with people who cannot experience full safety due to such environmental realities can, however, have the goal of assisting the survivor to make life as safe as possible. Getting “closer-to-safe,” or “safe-enough-for-now” become the goal, with the traumatized person taking the lead on defining what the boundary conditions of those terms are in their lives, conditions which may shift with changes to social and political realities.
At such times, it can be particularly important for the clinician not to join with a survivor’s learned helplessness and hopelessness, the “sense of a foreshortened future” with which many trauma-exposed people are left after their assumptions about a somewhat safe, somewhat just world have been shattered. Rather, a clinician must insist that neither the clinician, nor whatever they offer to this suffering person, will settle for any less than is fully possible for that person, and will not agree to a less-than good-enough outcome. This is because to do otherwise is to collude with the systemic forms of oppression affecting this person, systems that will persist in making the world unsafe in some ways for the traumatized individual who is a member of a marginalized group. While clinicians cannot yet eradicate systemic racism or xenophobia, nor any other form of systemic and ubiquitous oppression, they can certainly work with traumatized people to strengthen bonds within their own communities, reduce, if at all possible, exposure to overtly and insidiously racist or xenophobic experiences, and validate traumatized peoples’ experiences of those daily exposures so that those individuals feel allied with, seen, and heard rather than alone in the therapy office with their experiences of feeling unsafe in their daily lives.
The tasks of the clinician during the stabilization and containment phases of trauma work may begin by not looking very much like what trauma work is generally imagined to be, because it’s not about the eradication of intrusions. Instead, it’s about addressing the secondary effects of trauma exposure, the so-called co-morbidities, and the real problems in life that arise from all of these. Case management skills, such as knowing what forms to fill out and how to get them filled out correctly and on time, and a willingness to collaborate with survivors in navigating the confusing systems of social welfare, public housing, transportation, and other systems supporting closer-to-safe lives for traumatized people are often necessary in working with all but the most privileged and apparently functional of trauma survivors. In the trauma-focused training clinic that I directed between 2006 and 2015, interns acquired skills such as learning how to get people into the social security disability system; what the correct language is for a letter requesting a trauma service dog, and how to find low-cost or free veterinary care for the animal; how to deal with the crime victims compensation system; how to lobby legislators to fund services for crime victims on Medicaid; and how to deal with the vicissitudes of the paratransit system, which routinely arrive too early or too late. They also learned where the safest homeless shelters were located, where survivors could find clothing banks and food banks, how to get acupuncture services for poor people, and how to get specialists to be willing to see patients who can pay very little or who are covered by Medicaid. This was all stabilization work, sometimes going on for months. These kinds of skills are needed more today, in the wake of the Covid-19 pandemic, which left more people unhoused, more with tenuous employment and childcare situations, and more dealing with the effects of Long Covid, which disables a person’s functioning across many dimensions, even if they were previously well-functioning on most.
Trauma-informed clinicians working with survivors in the safety and stabilization phases of treatment need to be willing to master these and similar skills, or work in a practice context where there is someone who will offer those case management skills to the survivor. Such engagement by the clinician is, in fact, trauma treatment with powerful symbolic implications for survivors. As Ochberg (1988) noted on working with trauma survivors, clinicians with this population cannot behave in a distanced, neutral manner. A component of creating safety for survivors is demonstration of our willingness, in a boundaried, professional way, to collaborate with them on genuinely creating as much safety as possible in their lives. Such engagement with these very practical problems and solutions is a therapy intervention that challenges hopelessness about the world and people in it, and enhances trust in a population of survivors who are notorious for (reasonably) having difficulties trusting their clinicians. Gold (2020) has made similar observations based on three decades of work with people who have experienced neglect and attachment disruptions instead of, or in addition to, the kinds of fear-based trauma that earlier trauma practice literature refers to.
No matter to whose work one turns, the emphasis on examining safety as a multidimensional and ever-changing component of a traumatized person’s prior and present lived experience has emerged more clearly over time as a foundational component of any and all practice with traumatized persons (Brown, in press). Historically, the practices that emerge in this phase of trauma work focus on aspects of personal safety other than those that are systemic, or based in the recurrence of historical or intergenerational trauma. There must be time spent on assisting a traumatized person to become free of relationships that are identified by either party as dangerous to or exploitative of the traumatized person. Being in a relationship where there is intimate partner violence, being harassed or discriminated against in the workplace, working in dangerous conditions where occupational safety considerations are not adhered to, or living in dangerous housing or in a neighborhood where violence is endemic, all may become a focus of trauma work as the clinician works together with the traumatized person to empower the survivor to move into situations of greater material safety. So long as a traumatized person continues to live in conditions where they are unsafe, they will be unable to experience any long-lasting biological changes to the stress response system of the SNS and amygdala and the dissociation/shutdown system of the dorsal vagal, each of which is necessary for a fuller recovery from post-trauma distress. Development of safety plans that are both short-term, as in how the survivor will stay reasonably safe-enough, or closer-to-safe from session to session and longer-term, and as in how a person will make a safe exit from an intimate partner violence situation they are currently in, should be occurring early, and then repeatedly, during the safety and stabilization phase of treatment, as Gold (2020) and Brand, Schielke, Schiavone & Lanius (2022) have pointed out in their recent books on working with multiply traumatized persons.
An element of safety that is rarely discussed in the trauma treatment literature, but which reflects a commitment by the clinician to cultural responsivity, as well as trauma itself, is that of spiritual and/or existential safety. When trauma has involved moral injury, or has been meted out at the hands of religious institutions or leaders, constituting Institutional Betrayal Trauma, the traumatized person’s most painful concerns are likely to have to do with the loss of the safety of beliefs or institutions, or in one’s own decency, leaving the morally injured person wondering if they are safe to be with.
Issues of safety may also raise cultural dynamics when culture speaks directly to what constitutes safe ways of living and the means by which such safety is achieved. Some examples are offered here not as a comprehensive list, but rather to evoke a clinician’s capacity to think about how and where their cultural responsivity might lead them to a non-traditional path for healing with a particular traumatized person. A traditional Navajo person may, for instance, feel safe only after going through a ceremony with a traditional healer and may feel unsafe in the world no matter what the material circumstances surrounding that person may be until able to perform such a healing ritual. The observant Muslim survivor of domestic violence who is in a physically safe shelter environment may feel unsafe if not able to eat halal food, as the safety of that person’s soul will feel in jeopardy. The morally injured combat veteran who cannot bring themselves to take the Eucharist, believing that their actions in combat rendered them outside of the care of a loving Divine, will not be helped by all the official trauma interventions available unless this profound wound is addressed.
Spiritual safety can often transcend physical safety in a particular trauma survivor’s personal hierarchy of needs. Its absence can undermine the possible healing effects of apparently safe settings. Conversely, when there is spiritual safety, an individual may code an experience of trauma differently because of the belief that they were accompanied through this terror or betrayal by a loving Divine. When traumatized people raise this kind of safety issue, a trauma-informed and culturally responsive clinician will listen carefully to whether a survivor is using spiritual or religious language to excuse remaining in unsafe conditions versus expressing a powerful need for spiritual authenticity that trumps personal safety, not excuses personal unsafety.
Clinicians must also attend at this phase of treatment to their own biases about what constitutes safety. An example of this clinically was the case of a woman who had never worked as anything other than a sex worker. She had been pulled from school in early adolescence by her step-father to be trafficked for sex with his friends, and had no other skills with which to earn a living, even when she was able to escape the dangerous and neglectful environment of her family. While the clinician’s own bias was that prostitution was always a form of victimization, the clinician was aware that this traumatized person did not share that perspective, and moreover was unprepared to function in the “straight” world. A single parent with two small children, she needed to keep a roof over her head and theirs, and wanted her children to have the safe life that she had not.
The clinician, after consultation with a trauma-informed supervisor, shared her concerns with the survivor about possible risks from the men who bought sex from her, opening a more productive collaborative conversation, framed as it was in the clinician’s genuine concern for this person’s safety and welfare. She then offered an idea; consider a move toward increased safety by working in those aspects of the sex trade that would be least dangerous to this traumatized person, both physically and legally. The survivor agreed to this safety plan, and took a job working for a phone sex line, as well as one doing sexual webcasting. These forms of sex work got the traumatized person out of direct physical contact with customers for the first time since her step-father had trafficked her. This reduced to zero her risks of being beaten or infected, and greatly minimized her legal risks as well. Having this new experience of greater physical safety for the first time in her life allowed this traumatized person to see how she could set the bar for safety in her life even higher, and provide higher income, allowing her to seek education in an even lower-risk occupation that would pay well enough to support herself and her children.
The clinician’s focus on “as safe as possible” allowed the traumatized person herself to set a goal of even more safety – in this case, emotional safety as well. This harm reduction model, familiar to psychoclinicians who work in the field of substance abuse, applies equally well to working with trauma survivors who may not have seen options to their various highly effective, but high-risk coping or occupational strategies.
Stabilization refers largely to the ways in which people become safe in relationship to themselves. This work focuses on the phasing out of problematic and risky coping strategies that create interpersonal difficulties or dangers to the health of the body and replacing them with other ways of relating to self that are non-harmful, less likely to undermine the traumatized person’s interpersonal field, and may even be health-inducing. In order for traumatized persons to directly approach the painful memories and powerful effects of their trauma experiences, they must be equipped with the emotional and cognitive capacities to do so without becoming further destabilized, as Gold has so cogently discussed in his descriptions of failed trauma treatments that ignore these factors of safety and stability and had the effect of retraumatizing people. One of the very difficult learning curves of the trauma treatment world in the 1980s, a curve that continues to move toward safer practice for traumatized people, was the discovery that the exposure and abreaction models of trauma treatment that had emerged from work with adult-onset, otherwise well-resourced trauma survivors were badly decompensating those persons in these groups whose developmental trajectories had, for reasons of trauma or other causes, not equipped them with skills for soothing themselves or quieting their levels of painful arousal after directly confronting trauma materials in session. This was one of the ways in which trauma clinicians became aware that the apparent capacity to function in daily life was not necessarily a predictor of whether a person could tolerate direct exposure to trauma material. Rather, what is clearly more predictive – recalling our earlier discussion of developmental factors – had to do with what developmental capacities had been undermined in some way by trauma in early life (Gold, 2020).
At this stage of treatment, clinicians can offer practices that enhance or improve traumatized persons’ capacities to regulate emotion either up, from dissociative freeze, or down from SNS arousal, to self-soothe, to use their safe-enough relationships effectively as a source of soothing attunement and positive connectivity, and to develop self-compassion. As we will be discussing in the segment on specific approaches to trauma treatment, those practices developed for enhancing or growing this skill set in traumatized people have not always been trauma-aware, but they are highly suited for, and of assistance to, survivors struggling to master these capacities, so long as the reality of trauma is always taken into account.
Goals of trauma work that is centered on stability include reductions to extinction or to very low levels of all forms of self-harmful behaviors. This may take extended periods of time, because these coping strategies have been so effective for a trauma survivor that they fear that they cannot exist without them. Because many trauma survivors struggle with suicidality, both chronic and acute, as it offers a sense of escape when people feel trapped, and many engage in self-inflicted non-suicidal violence because it regulates emotion, calming or numbing depending on the person, strategies that give survivors non-violent means of tension reduction or anti-numbing will be important. One of the messages that I gave to traumatized people is that most of what therapy offers to them will not be as effective, as quickly, as their self-developed soothing strategies. This is both a validation of a clinically observed reality and their lived experiences, and a relapse prevention strategy, giving the survivor the expectation that the newly acquired self-care strategies may eventually become more effective when practiced as many times as the homegrown self-soothing behaviors have been. Predicting up front the difficulty of acquiring and using skills that the survivor did not have to develop in isolation, at a young age, while being repeatedly subjected to more trauma, can help to reduce the perfectionism and rigidity, forms of internalized self-hatred with which many trauma survivors approach the task of their own recovery. This prediction that “this will be hard” also models self-compassion via the clinician’s compassion and empathy for their struggle. This kind of caring statement is a bit like what a good-enough parent says to a child attempting to learn a new skill; this could be hard, this will take time, I will catch you when you fall, never ridicule nor criticize you for how long you take, and how imperfectly you demonstrate it. This approach conveys the message that the homegrown self-soothing behaviors are simply one set of coping skills, learned or acquired in situations of extreme duress, and that new self-care skills can similarly be learned, without the duress or danger that necessitated the more problematic coping strategies. Additionally, the message in this component of trauma practice is that the traumatized person deserves better treatment than they had meted out to them – and that they can thus treat themselves, as deserved, with more kindness.
Survivors during this phase also need assistance to modify their relationship to harmful substances and to risky compulsive behaviors. Trauma practice should be informed by a harm reduction model when possible, with a focus on safety however that person defines it, rather than on some external measure or set of rules about what constitutes the “right” relationship to any of these self-soothing practices. Programs aimed at assisting people to become sexually safer report that many of their more challenging participants are those with a trauma history, who may be using the risks of unprotected sex as an emotional high, or as a means of inflicting punishment upon themselves. Clinicians working with trauma survivors must thus become minimally conversant with the pathophysiology of substance abuse, with norms for sexual safety, and with adjunctive treatment options for survivors with addictions or risky compulsions. Trauma practice may integrate a 12-Step abstinence model, but cannot be bound by it, particularly given both its very low success rates, and the risk that a sudden plunge into detox will become the door through which nearly intolerable intrusive trauma symptoms emerge.
Clinicians must also be prepared to directly collaborate in discussions with traumatized people about behaviors that risk this person being pushed into the retraumatizing carceral system. Doing things that can get one arrested, be it violent or so-called white-collar crime, is a very therapy-interfering activity. It is a coping strategy putting a traumatized person in the path of further harm. This collaboration requires a trauma clinician to maintain a stance of compassion and care with respect to these behaviors rather than of any judgment, the exception to this being behaviors that are violating of others bodily integrity or life. As I have pointed out to more than one survivor, I cannot do treatment with them if they are in prison for theft, drug sales, or sex work. I add that I care enough about the survivor that I do not wish to see them spending time locked away behind razor wire in another setting where they will be chronically unsafe. The predominance of trauma survivors in U.S. prisons, and of people from historically marginalized, and thus systemically traumatized groups of people, speaks volumes to the importance of collaborating with trauma survivors on finding ways to work toward becoming legally safe. Our assertion of our relational caring for them introduces the element of compassion and underscores the anti-relational nature of other-than-legal coping strategies. Of course, being anti-relational was often a goal for these survivors, some of whom developed a dangerous persona that mimicked that of those who had harmed them, while also having a personal ethic of protecting vulnerable people, such as children and elders, from other dangerous people with this dangerous persona. Thus, their other-than-legal behaviors need to be contextualized as having been attempts to keep people at a distance rather than as per se evidence of sociopathy.
A very public example of this kind of self-care initiative gone terribly wrong is the life of Hunter Biden, who experienced severe trauma at an early age while being injured in the car accident that killed his mother and younger sister. He then was retraumatized as an adult by the death, from an aggressive glioblastoma, of his beloved brother, the only other survivor of that car crash. While his father clearly loves him, his father’s work made his presence in Hunter’s life, of necessity, less persistent and steady, even though always loving. Reading Hunter Biden’s descriptions of his own desperate attempts to quiet the terror inside of him with substances and actions that put him at risk, sometimes risk of death and certainly, now, risk of incarceration, while he was presenting a façade of being a high-functioning person, provides a painful and public example of the necessity of trauma work addressing these attempts at self-care that eventually turn into self-harm.
Compulsions that do not put a person at risk of incarceration, such as over-work and over-exercise, must also be addressed during the stabilization component of trauma work. These can be more difficult to interrogate collaboratively, as they are a distorted use of culturally valued and potentially positive coping methods, such as excelling at school or work, or engaging in exercise at healthy levels. Traumatized people who use these strategies are usually apparently higher functioning, and thus more able to rationalize and intellectualize their actions. This is often pseudo-stability, however; many experienced trauma clinicians find that this set of people seek care when life circumstances have curtailed their abilities to over-work or over-exercise, and the self-soothing function of these behaviors becomes painfully and intrusively apparent. Once again, a trauma-aware clinician does not equate the appearance of superficial functional capacities with the capacities to self-soothe in self-loving and self-compassionate ways.
Therapeutic experiments can be helpful in assisting both clinician and survivor to determine whether survivors are using these modalities to avoid intrusive materials or reduce anxiety, or whether they genuinely need to work fifteen hours a day or run with a stress fracture in their foot, which is often the rationale offered by these traumatized people, “I really need to do it this way.” In this part of trauma work, we request the traumatized person do the experiment of going without the socially acceptable compulsion for a brief period, usually no more than a week, and observe the effects. Traumatized people frequently discover that they are experiencing the trauma-related distress that the over-activity has been warding off, particularly of the anxious and intrusive forms, given that numbing and dissociation are already being accomplished.
Another central therapeutic task of the stabilization phase is assisting traumatized people in reducing numbness and avoidance, both of which may have been protective, but are now limiting for the person, and may make a healing process difficult. As Bailey (2023) has noted, simply the act of saying “Hello” to a frightened, avoidant trauma survivor is at times sufficient exposure so as to activate intrusive forms of distress. Avoidance of anything resembling the trauma, and dorsal-vagal freeze responses, are among the hallmarks of post-traumatic distress. Retreat into dorsal-vagal shutdown and avoidance of anything reminiscent of the trauma both represent at-the-time reasonable ways to not expose oneself to more of the trauma, nor to be overwhelmed by intrusive symptoms that interfere with sleep, cognition, and the capacity to participate in daily life. However, such coping strategies becoming over-generalized and pervasive. This may, in turn, poorly equip some trauma survivors for handling even non-trauma-related affects, much less those associated with the trauma experience that may emerge during therapy. Graduated strategies for assisting a survivor in reducing numbness and avoidance and tolerating the experiences of bodily sensations and emotions without becoming overwhelmed or dissociative, are another aspect of creating intrapsychic safety and stability. The work of Dana (2020, 2021, 2023), who has created a range of ways for trauma survivors to work with themselves to move out of dorsal-vagal shutdown without being thrown into SNS arousal, can be extremely helpful companions to clinician and traumatized person alike. I have found it especially useful to initially do these exercises together, integrated into the therapy, rather than sending a person home to read or listen to a book and venture into this frightening territory alone. Schielke, Brand, & Lanius’s (2022) workbook for highly dissociative trauma survivors may also be helpful at this juncture in trauma work, especially when a person’s avoidance is of a dissociative nature.
Safety interventions such as the one described above also commonly involve health of the body, which is an important component of safety. Although few Complementary and Alternative Medicine (CAM) treatments have been scientifically studied for their effectiveness, many of them are founded in long-standing non-Western systems of healthcare and have extensive clinical evidentiary support for their use. CAM approaches have been studied with regard to certain ethnic groups within the U.S.; for example, studies of collaboration with traditional curandero, as in Hispanic communities (Comas-Diaz, 2006, 2023, 2024), or with traditional healers in American Indian communities (Robin, Chester & Goldman, 1996) seem to indicate that integration of these CAM approaches into the psychological healing process can be extremely helpful. A trauma-aware clinician working with people on issues of safety and stability is encouraged to be open to methods of health management that are congruent with traumatized persons’ beliefs, even when those beliefs run counter to those held by psychoclinicians, many of whom are trained within Western models of medical care and standards of proof. Such survivors are not always from the cultures in which these somatic interventions are most common.
The safety phase is also one in which a traumatized person is supported in developing a sense of resilience and capacities. All trauma survivors have some resilient coping strategies and capacities or they would not have survived to walk into our offices or onto our telehealth screens. Many do not experience their capacities and have a damaged self-perception as “weak” or “crazy.” Others have lost their usual resilient strategies in the wake of an adult-onset trauma and are struggling to identify how they are still capable, seeing themselves as “damaged goods.”
Trauma survivors need to learn that they can depend on themselves, and that they are safe with themselves. Consequently, trauma practice at this phase will include a focus on experiencing, building, and reinforcing a sense of oneself as competent, capable, and able to interdependently care for oneself. Rigid internal rules about who and how one should be in the world often emerge at this point, particularly as pertains to what is perceived as socially acceptable for a person who has particular intersectional identities that were shaped by rigid systemic forms of oppression.
The second stage of Harvey and Herman’s model is that of “mourning and remembrance.” This is the component of trauma work in which a survivor tells the story of what happened, and begins the process of integrating that narrative into the narrative of life, grieving for what was and what could not be as a result of the trauma so as to create the emotional space in which a life and a future can be constructed. At this phase of trauma work, survivors address what they remember, as well as what they cannot recall. Issues of post-traumatic amnesia, delayed recall of trauma in which attachment needs fought with awareness of danger, and the impact of any trauma on memory, are all generally relevant topics for the trauma-aware psychoclinician to be familiar with.
Cultural responsivity and attention to issues of a survivor’s intersectional identities can be centrally important to the successful accomplishment of this component of therapy. As discussed in the segment of this course about cultural responsivity and humility, trauma frequently insinuates itself into multiple aspects of a person’s intersectional identities and self-constructs in ways that they may not, at first, detect because that trauma is the emotional water in which they have always been swimming, and it does not feel wet.
Inviting trauma survivors to tell their stories is the process of gradually rewriting their life narratives so that two things might occur. First, the reality of the experience of trauma is acknowledged, not in the form of intrusive symptoms representing dissociated affects and sensory stimuli, but rather as part of the individual’s autobiographical narrative. Recall the discussion of trauma’s effects on the brain and the way in which Broca’s area is deactivated during a survivor’s experiencing traumatic memories. Related research has demonstrated that after working with the trauma to the point where it can be told as a story rather than experienced as intrusions,, at which point the trauma experience is well-integrated into the personal narrative, Broca’s area is activated. The survivor can now give voice to the truth of their experiences.
A component of this process of rewriting the personal narrative is unpacking, interrogating, and disrupting those cultural and contextual master narratives emerging from systemic forms of oppression that have informed and distorted a survivor’s experience of self. Such a process of disentangling oneself from the trauma narratives of a culture that has marginalized the traumatized person in other ways can be tricky and fraught with pitfalls. A trauma-informed psychoclinician cannot simply dismiss systemic and problematic dominant cultural lenses on the trauma experiences as irrelevant to the survivor’s realities by naively challenging them as irrational thoughts or beliefs that are not relevant within the immediate cultural surround. This is a “technique” guaranteed to worsen distress, or lead to the traumatized person simply abandoning therapy as harmful at worst, useless at best.
At times, the collective cultural survival and safety of a particular marginalized and subjugated group has appeared to require the suppression of individual narratives and experiences of trauma that are not part of that marginalized culture’s particular dominant trauma narrative. In cultures where certain kinds of trauma exposures are endemic, cultural and personal survival may have led to the development of a cultural narrative that minimized the importance of those apparently normative and usually inescapable events. Such endemic experiences are often referred to dismissively; for example, “It’s no big deal. This happens to all of us. It’s the way of the world.” These cultural numbing strategies may also need to be compassionately challenged as the survivor rewrites the story of what his life means with trauma in it.
Traumatized people who encounter a pre-existing narrative about their particular sort of trauma can find their healing process to be complicated. This phenomenon is easy to observe in the ways in which veterans with combat-related trauma symptoms, particularly assigned male at birth veterans, fail to report them because of how those symptoms interfere with the narrative of the warrior, as well as with their ability to continue on a career path in the military should that be their goal. This master narrative of masculinity has consistently undermined the military’s attempts to screen for and treat combat-related trauma dynamics in personnel returning from deployments, with many anecdotal reports of returning military members lying on screening questionnaires because the motives of such documents are transparent, and the veteran does not wish to be labeled as having trauma-related distress and derailed in their career.
Consequently, one aspect of this second general stage of trauma practice invites trauma survivors not to reject the narratives of their culture and context out of hand, but rather to think critically yet compassionately about those narratives in order to develop their own healing stories about the trauma in their lives. Some of the grieving that occurs at this juncture is for the lost mythologies of trauma survivor’s lives, the mythologies about “how it was supposed to be” woven into the dominant narratives of their cultures.
One of the more contentious aspects of trauma treatment since the early 1990s has been the issue of memories for trauma that emerge after having been unavailable to conscious awareness for periods of time. The focus of the so-called “memory wars” of that decade was delayed recall of childhood sexual abuse. Despite the well-documented phenomenon of delayed recall of all kinds of trauma (Courtois, 1999), the discourse about this issue became heated, adversarial, and polarized, with an entire movement of individuals who claimed to have been falsely accused of childhood sexual abuse by adult offspring. This movement insisted that it was impossible for traumatized people to forget trauma, that all memory science agreed with this assertion, and that any report of a delayed recall of childhood trauma represented a confabulation arising from suggestions made by clinicians or self-help books. As of early 2020, however, the organization that generated the so-called “false memory” narrative closed it doors; the data about trauma’s effects on memory and the typical nature of delayed or disorganized recall of trauma had become too overpowering to be ignored. As Freyd (1996) demonstrated early in this debate, the necessity for people to maintain connections is so much stronger than their need to know that the people to whom they are attached are violating them, that knowing/remembering is fraught, and thus complicated, when betrayal trauma is involved.
One of the few productive aspects of the “false memory” narrative was that it spurred an outpouring of research examining the question of what cognitive and/or biological mechanisms might underlie a clinical reality that had first been described by the British psychiatrist W .H. R. Rivers in a scholarly publication about combat-related traumatic distress in 1918. In the second decade of the 21st Century, several different cognitive psychology models were empirically tested and shown to explicate a number of varying mechanisms that will produce delayed recall. Readers wishing to read in detail about some recent findings on this topic are referred to the proceedings of the 2010 Nebraska Symposium on Motivation, which took the memory debate as its topic (Belli, 2011). While it is equally clear that it is possible for people to represent as memories of their life things that have never happened, it is now well-accepted that delayed recall of trauma is a normative aspect of post-trauma experiences for some individuals, and that for many, the memory of the trauma, no matter how recent, is obscured by the physiological phenomena of terror, disgust, or tonic immobility that accompany the events of the trauma. Although it is possible to still find a few partisans of the memory debate who insist that either no recovered memories or all recovered memories are true, the most scientifically supportable position on this occupies a middle ground in which trauma’s effects on memory can be acknowledged as simple neurological and interpersonal phenomena, and in which the experience of trauma as shaping both retention and recall of memory is recognized as affecting those dynamics differently than the events of every day.
As a consequence of the known problematic effects of the neurobiology of trauma on the recall process, many survivors of almost every kind of trauma will, during this phase of their healing process, struggle with questions of “Did this really happen?” So much of trauma is both so common and yet extraordinary that the simple facts of what has happened can beg belief. For example, accounts of the survivors of the October 7th, 2023, Hamas attack on the Nova music festival in Israel were called into question until the attackers posted the videos they had taken of multiple sexual assaults and murders online for the world to see.
The pull for a clinician to simply say, “I believe you” when there is no evidence aside from the survivor’s own recollections, can be powerful, but not necessarily helpful. As Pope and Brown (1996) and Courtois (1999) note, the clinician at this point must assist survivors in holding the ambiguity and lack of clarity in what is consciously known so as to empower the survivor to come to their own understandings of what has happened to them. Clinicians must refrain from drawing conclusions about the details of a survivor’s experiences based on the sort of distress that the survivor manifests. Similarly, because all memory, including that for the quotidian, contains some distortions and inaccuracies, clinicians must refrain from enthusiastically endorsing the specific veracity of material presented as a continuous memory, since research indicates that continuous memories are no more likely to be completely accurate than those that are delayed.
Psychoeducation can be a very important component of addressing questions of the survivor’s memory for the trauma. Trauma-informed clinicians need to add to their repertoire the emerging science of how memory systems work, including information about when anyone’s continuous narrative memory is most likely to emerge. Memories for life experiences prior to this offset of infantile amnesia, which is usually associated with the development of language skills with which to encode memory in narrative form versus as a somatic or felt sense, must be seen as less likely to represent personal recall of events than reports of memories from later in life. The effect of trauma-related effects on the process of memory retention, storage, and retrieval should also be understood by the trauma-aware clinician, and conveyed in a clear and compassionate manner to the survivor who is struggling with fragmentary or clouded memories.
One of the shibboleths of the false memory movement has been that adults have reported remembering events that could have never occurred, as they were fantastical or violated laws of physics. However, Dalenberg (1996), in a study of materials reported by children whose sexual abuse was extensively corroborated, found that such fantastical, impossible material was more likely for children known definitively to have been abused than for children whose reports of abuse could not be corroborated. Thus, clinicians at this juncture in treatment should avoid becoming attached to issues of veracity or proof, or of whether what the survivor reports could have really happened. These are forensic questions, useful when there is a legal matter at hand, but problematic in treatment.
Instead, the focus of the remembrance process for the trauma survivor must be on coming to terms with what both is remembered and what cannot be recalled, and integration of those experiences into the survivor’s life narrative in an empowering manner. Courtois’s description of this is particularly felicitous, “Safe, self-reflective disclosure of traumatic memories and associated reactions in the form of progressively elaborated and coherent autobiographical narrative is the primary task of this phase.” (2009, p. 93).
Finally, it is not unusual for a survivor of interpersonal trauma, at no matter what stage of life, to be told, “this never happened,” or, “if you ever tell someone what I did, I will kill you/your family.” This sort of witness-tampering isn’t considered unusual in the case of other kinds of crimes; sexual and intimate partner violence are in fact crimes as well. Consequently, for a perpetrator of this kind of trauma to have tampered with a survivor’s memory in order to protect the perpetrator from being identified as a criminal should be seen, by clinicians, as also having effects on survivors’ recollections. Sometimes the “false memory,” so to speak, is that “nothing happened,” a false narrative implanted with threat by a criminal perpetrating an interpersonal crime.
Trauma is always a loss of some kind. The losses can range from apparently small and transient – a broken arm from a serious car accident that affects the person’s ability to do valued activities for a brief period of time and that leaves a healed arm that aches in cold weather – or it can be profound and enduring – the realization that one was raised by adults who were malevolent and predatory rather than loving and caring. Grief for the loss of what was, and grief for what one had wished for, and now realizes never was or never could be, emerges as the coherent life narrative forms during trauma work.
As with other kinds of grief and loss, grief emerging from trauma can be destabilizing, and may appear to the naïve clinician as evidence of regression in the therapy. Remember the slinky toy; the survivor will need assistance to reinstate safety and stability while not avoiding the painful affects associated with loss and mourning. Such grief is also likely to emerge at important developmental points throughout the trauma survivor’s life, as events occur that evoke the losses inherent in the particular trauma. The Hurricane Katrina survivors who cannot visit their mother’s grave on the anniversary of her death because the grave was swept away in the flood re-experience the grief of her death, the loss of home and safety associated with the hurricane and its attendant systemic betrayals, and the continuing exile to a new home. The adult sexually and physically abused as a child by a parent who has just died feels not only that death, but also the death of hope (Brown, 2012). The griefs associated with trauma are often complex. A trauma-aware clinician working with any survivor whose current level of grief seems inconsistent with the most recent loss will explore whether and how this loss is evoking previously unexamined post-traumatic losses. When the bereavement is specifically trauma-related, the clinician needs to have a paradigm for grief that integrates both post-traumatic and grief dynamics (Pearlman, Wortman, Feuer, Farber & Rando, 2014).
The third stage of this overarching model of trauma work is about reconnection with self, body, social world, and meaning-making. A theme of this stage is of “radical acceptance,” (Linehan, 1993) an engagement with the reality of the trauma, so as to be able to make a commitment to move forward in life, with the reality of all of the losses and changes inherent in trauma now more fully integrated into the life narrative. It is a stage in which post-traumatic growth (PTG) is most likely to be observed, as survivors begin to make the experience of trauma less foreground to their lives, and to look for the recipes for making lemonade out of the lemon of trauma. Herman refers to this component of the process as the development of a “survivor mission,” wherein trauma survivors search for ways to transform their experiences in an empowering and meaning-making manner.
In this stage, trauma survivors create active engagements with their interpersonal and relational worlds, and come to experience themselves as more empowered and fully alive, able to heal others, their communities, or the larger world. They may try out new activities, new kinds of relationships, or new vocations. Disappointment over highly idealized visions of what recovery from trauma will be like is not unusual at this juncture, requiring the development of acceptance for what life after trauma actually can be, and what healthy-enough, emotionally meaningful relationships can offer (Brown, 2015). This is a phase of the healing process in which connections to culture can become particularly valuable to the survivor. Trauma work at this place on the slinky toy’s circle centers around assisting survivors to deepen their own systems of meaning-making, and to make intentional choices about how to craft an identity as a “thriver,” the person who has moved from surviving into a new identity of a person with an understood history of trauma.
For some trauma survivors, this phase of trauma work centers on how their old life is still available, yet transformed. This is a common theme for survivors of adult-onset trauma. For complex trauma survivors, who have had to come to terms with the chaos and destructiveness of their childhoods (Gold, 2020), this component of trauma work may entail learning how to live well in the life they do have, one in which most aspects of daily existence work well enough, and safe-enough is a norm rather than a fiction. The end of the tunnel can be full of surprises, and the goal of therapy at this point is to strengthen and deepen survivor’s capacities to blend with those surprises rather than struggle against them.
Strategies during this phase of trauma work are more likely to be helpful when they assist trauma survivors to directly encounter the existential issues inherent in their lives in the wake of trauma. Integration of self-care strategies into the norms of life, and deepening resilience for the unknowns that lie ahead, are also common threads of this final phase of trauma work. Inoculating survivors at this point against the notion that they are “fixed,” by reminding them that they were never broken, but were simply humans, having human responses to terror, betrayal, and loss, will include the invitation for the survivor to return for booster shots of work with a trauma-informed clinician as needed throughout their lifespan. Some survivors in this stage of trauma work have found it helpful to look intentionally at the future and use the trauma work to strengthen capacities for predictable events. A survivor of sexual assault by an acquaintance might decide to review skills for dealing with her daughter beginning to date. A survivor of a terror attack may wish to plan for coping with the news of the perpetrator’s trial, or of a similar attack elsewhere in the worldl. A component of radical acceptance is integration of the reality that trauma has happened and life has been inalterably changed; a theme of this phase of trauma work is that the changes need not be for the worse.
An important take-home message of this model is how it informs the choices of specific interventions that a clinician utilizes. A survivor who is early in the safety and stability phase would likely do very poorly with exposure therapies. Conversely, survivors who have not experienced complex trauma are unlikely to find treatments zeroing in on emotion regulation and self-soothing to be germane to their needs. Survivors in the existential crisis over life narrative may need more interpersonally-focused treatments. As Norcross (2002) has noted, therapies and interventions must be tailored to where a survivor currently locates in stages of change. A trauma-informed clinician integrates that overarching model of change into this superordinate paradigm for trauma treatment in determining what direction to take in treatment.
As is the case for other transtheoretical models of psychotherapy, the three-phase model for trauma treatment can be integrated into a clinician’s own particular paradigm for clinical work. However, it is rarely effective for clinicians to be rigidly adherent to their preferred theoretical orientation when working with trauma survivors. Classical psychodynamic treatment may be too destabilizing for a survivor inundated by flashbacks and intrusive thoughts, although entirely appropriate for the third stage of treatment where existential issues are being addressed, while a purely cognitive processing model will be unlikely to assist a survivor with existential meaning-making questions. A trauma-informed clinician will of necessity become somewhat more integrative in order to competently assist survivors who have experienced trauma. This is not a call for trauma-informed clinicians to abandon their frame or theoretical orientation. Instead, the trauma-informed clinician uses the three-phase model to integrate trauma-specific care into her usual treatment strategies. Readers wishing to learn more about this model are referred to Herman (1992) for an in-depth discussion. The next section of this course will discuss specific treatments for trauma-related symptoms, organized around how they are likely to be most applicable to the three stages of this model.
This section of the course will briefly review some of the strategies for working with trauma survivors in therapy. Some of these were developed specifically for PTSD; others address the range of types of distress described earlier in this course that are also common post-traumatically, and these practices may or may not have originally been developed to take trauma into account. All of these approaches have a strong evidentiary base for their use with at least some groups of trauma survivors. A caveat, however: the most current meta-analyses of even the best of the specific evidence-based treatments finds that their effects are mostly in the moderate range on a variety of outcome measures. Additionally, as the work of the APA Task Force for Treatment Guidelines for PTSD in Adults discovered, most of the evidence-based methods have not reported drop-out rates, exclude people with any forms of distress that are not simply those of the pure diagnosis of PTSD as described in any version of the diagnostic manuals, and under-included participants from marginalized groups (Brown & Courtois, 2019; Courtois & Brown, 2019). Readers should, consequently, proceed with caution when assuming that simply because a particular practice has been subjected to Randomized Controlled Trials (RCTs) that it will be effective for many survivors, especially when the trauma is not of the single-episode, fear-based, adult-onset variety.
A review of trauma treatment outcome literature performed for the APA Working Group for the PTSD treatment guidelines found a paucity of studies for almost all commonly used trauma treatment modalities. While the Guidelines eventually adopted by APA more strongly supported cognitive behavioral models (APA, 2017), thoughtful critics of the process that led to those Guidelines, including the chair of the working group, and this author (also a member of the group), indicate that the simple scarcity of research on most non-CBT treatment methods biased the outcomes of the working group’s findings (Brown & Courtois, 2019; Courtois & Brown, 2019). Simply put, not enough research has been done on what might actually help survivors to make any definitive statements about what will clearly help all. Courtois and I were so sufficiently concerned about the possible uncritical adoption of the Guidelines that we developed special issues of two journals (Psychotherapy: Theory, Research, Practice, Training and Practice Innovations) with contributions from researchers and clinicians in both the field of trauma practice and psychotherapy outcome, so as to offer peer-reviewed critiques of lacunae in the guideline development process.
I follow the leads of Norcross, Beutler & Levant (2005) and Norcross & Wampold (2019) in defining evidence-based in a very broad manner that includes not only those specific interventions studied through randomized clinical trials, but also evidence on relationship variables and clinician and survivor characteristics. The brief overviews below are not an endorsement of a particular trauma practice. They are, rather, meant to give a synopsis of how a particular treatment is hypothesized to work, and for whom it is most likely to be indicated, given the types of trauma and developmental variables in play, as well as those of intersectional identities and social context. Additional specific training in any of these practices may be necessary in order to competently implement them with survivors.
Underlying all work with trauma survivors, no matter what specific intervention is employed, is the foundation of the Evidence Based Psychotherapy Relationship (EBRV) variables. Ellis, Simiola, Brown, Courtois & Cook (2018) reviewed the extant literature on the application of the EBRVs to trauma work, finding that neither the psychotherapy research field nor the trauma treatment field have paid very much attention to the overlap of these concerns. Nonetheless, EBRVs need to be taken into account in trauma-informed care (Norcross & Wampold, 2019). That is because these variables are factors that have been determined by a preponderance of decades of evidence to affect psychotherapy outcome and survivor satisfaction. They consequently constitute an important component of the evidentiary base of trauma treatment. The findings described below derive in the most part from a series of meta-analytic studies conducted by APA’s Division of Psychotherapy under the leadership of John Norcross; more details can be found in the third volume of the edited text Psychotherapy Relationships That Work (Norcross, 2019).
The EBRV literature indicates that many of the interpersonal factors that can undermine work with trauma survivors (Gold, 2020) can meaningfully affect the outcome of treatment. Factors of the therapeutic relationship such as empathy, collaboration, genuineness, positive regard and respect, and the nature and quality of the therapeutic alliance all have demonstrated effects, which are estimated to account for as much as 48% of the outcome variance of any approach to psychotherapy (Norcross & Lambert, 2005), while the specific intervention used typically accounts for only 8% of the outcome variance (Norcross, 2019). As noted by Najavits and Strupp in their study of psychotherapy process variables contributing to good and bad therapy outcomes, “…basic capacities of human relating – warmth, affirmation, and a minimum of attack and blame – may be at the center of effective psychotherapy intervention.” (1994, p. 121)
Several EBRVs are particularly relevant to effective practice with trauma survivors. Positive regard, which can be expressed in terms of respect, liking, and giving honor to the survivor, generally accounts for significant percentages of the variance of therapies having good outcome. This is particularly the case, according to Farber & Lane (2002), when the survivor’s viewpoint about whether or not the clinician communicated these emotions to the survivor successfully is used as the metric for measuring this variable. For treatment of trauma survivors, many of whom have a damaged sense of self-worth, this ESR can be powerful. If survivors know that the clinician sees them as courageous survivors, a person of honor, worth, and dignity, whose experiences are attended to and respected, the entry conditions for formation of a therapeutic alliance have been met. Farber & Lane suggest that ruptures in the therapeutic alliance are more likely to occur when the clinician is not perceived by the survivor as offering this care and dignity. Since ruptures in the alliance are quite common with many trauma survivors due to dynamics of mistrust and hypervigilance, the value of positive regard’s role in trauma treatment receives even more emphasis.
The clinician needs to reflect back to the survivor a view of the survivor as a decent and brave human being. In attempting to convey this to survivors whose intersectional identities are likely to have introduced them to the work of J.R. R. Tolkein, I frequently use the metaphor of Bilbo Baggins, the eponymous hero of The Hobbit, and his nephew Frodo, the protagonist of Lord of the Rings, who, as I note, are terrified of the quests on which they have been sent, and frightened repeatedly throughout them – yet each one gathers his courage and goes forward. As it happens, Bilbo and Frodo are traumatized by these quests, and exhibit the kinds of pain and struggles typical of some trauma-exposed people (Tolkein having based these characters on some of his fellow veterans of the trenches and slaughter of WW I). When a person’s intersectional identities might find these stories alienating, I might ask the survivor what stories from their own identities might carry a similar message, as many cultures have such narratives. The message of these and similar stories is that being brave does not foreclose wounding. Rather, it is that the wounds are the evidence of courage – and the survivor’s participation in a healing practice is further evidence of that courage. Since the mythology of dominant cultures in the Western world is that heroes feel no fear, and that those who experience fear are cowards, a narrative thrown at the men traumatized by that first world war, positive regard communicated as a disruption of this untruth about the relationship between courage and the wounds of trauma lays a foundation to which the clinician-survivor pair will need to return repeatedly as the survivor faces new challenges of metabolizing the trauma material.
Empathy was defined by Rogers as “the clinician’s sensitive ability and willingness to understand the survivor’s thoughts, feelings, and struggles from the survivor’s point of view…It means entering the private perceptual world of the other.” (1980, p. 142) Three types of empathy have been measured in the research literature: the clinician’s self-perception; the degree of empathy rated by an external observer; and received empathy, what the survivor experiences. Levels of received empathy rated by the survivor are another predictor of good outcome in psychotherapy. Greenberg, Watson, Elliot, and Bohart (2001) found that across studies in a meta-analysis, empathy accounted consistently for 10% of the variance of outcome and routinely was found to account for a higher percentage of outcome variance than did any specific intervention (Wampold, 2005). When the clinician was not experienced, empathy had an even larger role in leading to good outcome.
Again, with trauma work, a clinician’s capacities for empathy take an even larger role as an important EBRV. The clinician must demonstrate the capacity to witness and resonate with the painful experiences that the trauma survivor has lived through. Trauma survivors often feel as if no one can possibly understand what they went through, and indeed, much of what any given trauma survivor has suffered will be beyond the life experiences of many clinicians. However, strong emotions – fear, suffering, confusion – are not beyond the experiences of most practicing clinicians. As will be discussed below in the section on countertransference and other clinician emotional responses, clinicians often numb and distance themselves from their survivors’ stories, in parallel to how the survivors themselves are numbing and distancing. Staying in empathic connection models the capacity for engaging directly in some way with traumatic materials. Such engagement, whether in the form of formal exposure or some other method for approaching the trauma material, appears ultimately necessary, in some form or another, for post-trauma symptoms to resolve in many survivors. In the empathic connection, the trauma survivor becomes less alone, and feels joined and allied -with when revisiting the dark passages of his life.
Empathy also has specific positive effects on trauma work. Survivors who experience high levels of received empathy are more likely and able to collaborate with the clinician on difficult work. Some findings from the attachment literature suggest that empathy mimics the attunement of healthy attachment between young children and good-enough caregivers, thus providing an emotional and neurobiological experience of soothing and connection that assists the survivor to self-regulate. Empathy also empowers survivors to think more clearly and critically, and to become engaged as active self-healers. For trauma survivors who often feel utterly powerless and disconnected due to trauma, empathy has the potential to have specific therapeutic effects to counter those post-trauma symptoms.
Genuineness is yet another EBRV that has implications for trauma work. Genuineness is defined as clinicians’ capacities to exhibit congruence, and to be transparent in the present about their feelings and responses to the survivor. This mode of therapeutic functioning can be seen in a number of different therapy paradigms; for instance, Stark (2000) gives examples of genuineness in a relational psychoanalytic treatment. Self-disclosure of a particular sort can be a component of genuineness; in fact, self-disclosures of the clinician’s here-and-now feelings about the survivor and what is happening in the work of healing has been found to be the variety of self-disclosure rated as most helpful by survivors (Hill & Knox, 2001).
The trauma treatment literature has, from the very first, been replete with the recommendation that to be successful with trauma survivors, the clinician must be “real.” Ochberg (1988) and Herman (1992) both speak of the importance of not being morally neutral about what has happened to the survivor. To say to a trauma survivor, “my heart breaks for you when I hear what you experienced” can, when sensitively timed, create the necessary feedback that what happened was not acceptable, that the survivor did not over-react, and that the clinician grieves with the survivor for the losses inherent in the traumatic experience.
Many trauma survivors feel as if their lives are treated by others as if they are simply a TV drama, and that they are an object of curiosity, a “fascinoma,” as one survivor of my acquaintance dubbed her experience of being non-empathically related to by another clinician. The clinician’s capacity and willingness to express concern and interest in the survivor as a human being makes genuineness and congruence into means by which empathy and positive regard are communicated to the survivor as well. While meta-analysis did not yield a specific portion of outcome variance for this EBRV, the research indicates that when survivors rate their clinicians as high on this variable, they are more likely to be satisfied with the outcome of therapy (Klein, Kolden, Michels, & Chisholm-Stockard, 2001).
Another EBRV that has been found to generally positively affect outcome in psychotherapy is the clinician’s ability to recognize ruptures, initiate their repair, and make amends for errors. Safran, Muran, Samstag & Stevens (2001) found that this capacity was a more potent predictor of positive outcome when the survivor had fearful, angry, or ambivalent attachment styles – in other words, the common relational dynamics present with a trauma survivor. Ruptures that are unattended to by the clinician predict premature exit from treatment.
These authors note several important clinician characteristics that enhance the capacity to notice ruptures. One of them is the clinician’s attunement to the very high likelihood that the survivor is being compliant and deferential, not letting the clinician know when they have done something that feels painful or betraying. This issue of silent compliance as a means of avoiding conflict, which is often frightening to trauma survivors, can be a challenge, especially in trauma work. One study found that clinicians correctly identified only 17% of the ruptures that survivors reported. Clinicians tend to be particularly challenged by noticing survivors’ negative feelings; when they do notice them, clinicians are likely to be defensive, or become more rigidly adherent to their model, thus becoming less empathic, genuine, and positive. As discussed in the section of this course on countertransference, trauma survivors, particularly those with complex trauma, are, by virtue of their post-traumatic adaptations, less likely to risk telling a powerful authority figure (the clinician) of displeasure or disagreement.
However, when clinicians are attuned to possible ruptures in the relationship, actively solicit feedback from their survivors, and then take responsibility for the rupture and its repair, the impact on the trauma work can be quite salutary. Early encounters with heartfelt, non-defensive clinician responses to relationship rupture have been shown to lead to survivors feeling more fully engaged in the relationship, and also to improve trust. Safran, et al. note that for some survivors, a “tear-and-repair” dynamic in the therapy relationship can predict improved outcome. For trauma survivors, this pattern may hold special meaning. It teaches, in a very present and embodied fashion, that errors, disconnections, and losses are not forever, and that repair and healing is possible.
Briere & Scott (2012) add to this list of EBRVs a relationship variable that has not been formally tested, but which every trauma clinician and survivor of my acquaintance would agree is an essential foundational component of trauma therapy. That variable is hope. Trauma wounds hope, sometimes almost fatally. Many trauma survivors begin trauma work feeling ground down by their distress and its intensity, and by the belief that they cannot be helped – a belief that has in some instances sprung from having participated in therapies that ignored trauma or stigmatized the survivor’s symptoms as evidence of severe psychopathology – or that were official trauma treatments that did not take the nature of this survivor’s trauma into account, as described poignantly by Gold (2020) in his writing about failed trauma therapies with survivors of complex and developmental attachment traumas. Despair is such a common consequence of trauma, particularly complex trauma, that to not encounter it in a trauma survivor is remarkable.
To genuinely assess chances for recovery and a good life after trauma is not leading on the survivor. Clinicians should, of course, make no guarantees; we cannot promise anyone what the outcome of trauma work will be. However, at this point in the development of ways for working with post-traumatic distress, it is reasonable for a clinician to predict that, if the clinician and survivor work diligently together, create a solid relationship in which the survivor feels genuinely seen and heard by the clinician, and are able to collaborate on choices of possible treatment strategies wisely, carefully tailoring them to the survivor’s specific dynamics and difficulties, as well as their intersectional identities and the sociopolitical contexts in which the survivor is living, the survivor will be able to experience significant relief from distress, gain or regain a sense of being safe-enough, establish their capacity to assess how and what to trust in the world, and find ways to have a life that has meaning and purpose. The research on recovery from exposure to trauma indicates that even without engagement in formal trauma work, some percentage of individuals experience relief from trauma-related distress over time. With complex trauma, although there are many more variables at play, the trauma work is likely to be, of necessity, of longer duration. The data emerging from studies of longer-term therapies with complex trauma survivors (see Brand, 2011; Brand, Schielke, Schiavone & Lanius, 2022; Cloitre, Cohen, & Koenen, 2006; Gold, 2020) indicates that survivors of complex trauma can experience substantial recovery as well. It is impossible to overstate how powerful this variable of relationship is to trauma work, and how difficult it can be for a clinician to maintain hope in the face of what can be lengthy periods of slow forward motion or even apparent absence of what the clinician defines as progress in work with a trauma survivor. For trauma work, hope is the “thing with wings,” to rephrase Emily Dickinson. Like the butterfly of chaos theory whose flapping wings on one continent cause a tornado on another thousands of miles away, hope, expressed early and then as needed by the trauma- informed clinician, will add potency to whatever other attempts at assistance, in the form of formal trauma therapies or other, less formal options, are offered by a clinician to a survivor.
Integrating and synthesizing these commentaries on the relationship in therapy, it becomes apparent from these findings that quality of relationship has been empirically demonstrated to be necessary in trauma work, and likely even more central to working clinically with trauma survivors than with individuals who have never experienced trauma. Individuals living in the emotional, biological, spiritual, and psychosocial aftermaths of trauma exposure can often challenge clinicians with the complexity of their distress, and with their apparent difficulties in making change. Avoidant strategies have been effective enough to stave off some of the painful images and affects; inviting survivors to stop avoiding, at a speed that does not re-activate their distress, and jump, with a harness and crampons, into the abyss with us is difficult at best. It can feel almost unbearable for people to let go of coping strategies, even apparently dangerous and deeply dysfunctional coping strategies that were developed by a survivor as a response to the need to contain trauma-induced terror, helplessness, shame, and disgust. It is difficult for many clinicians to be co-present with those coping strategies, and a clinician may feel strong pulls, both internal and interpersonal, to overpower the survivor’s process and speed in order to more quickly produce a particular behavioral outcome. Worse, this is often a point at which a clinician abandons the survivor as a “treatment failure” (Gold, 2020). In this difficult emotional exchange, the relationship and its quality become paramount. The EBRVs are foundational to trauma work, and to anything else a clinician may do, no matter how manualized the clinician’s actions are. Additionally, the contribution of the EBRVs to outcome of psychotherapy appears to account for a larger percentage of the variance than any of the specific interventions reviewed below.
Let us begin by reviewing therapies that are known to be helpful for the treatment of classic PTSD. Some of these interventions will also be helpful with Complex Trauma, although may require tailoring to the needs of survivors with low levels of self-soothing capacities.
EMDR was first proposed by Shapiro (2001) as a trauma-specific treatment whose goal was the reduction of intrusive symptoms. The model of PTSD on which EMDR is based, Adaptive Information Processing (AIP), posits that much of the symptom picture of PTSD is due to the maladaptive encoding of and/or incomplete processing of traumatic or disturbing adverse life experiences, impairing capacities to effectively process the information. It instead becomes an emotion-driven introject that is experienced in the present tense as if the trauma were continuing to occur. EMDR targets how memories for trauma are encoded to transform them from intrusive to a coherent verbal component of that narrative. While initially controversial because of the form that treatment takes, sufficient empirical research on its effectiveness in the past decade has led to it being designated as a Level A treatment (evidence for the treatment is based on randomized, well-controlled clinical trials) in the Guidelines of the International Society for Traumatic Stress Studies. Use of EMDR generally requires completion of a sequence of training classes. Recent research comparing EMDR to Prolonged Exposure (PE) found no significant difference in effectiveness between the two treatments.
EMDR has eight components. In the initial stage, a careful clinical history is taken, including screening for the presence of a dissociative disorder. Basic (Level I) EMDR is considered potentially destabilizing to individuals with dissociative disorders, who should only be treated by clinicians trained at EMDR Level II. The clinician next works with the survivor to ensure adequate capacity for self-soothing during and between EMDR sessions. A component of this phase of treatment is the establishment of an effective working relationship between clinician and survivor; a clinician may take considerable time with some survivors, particularly those with complex trauma, in establishing this secure base before proceeding to trauma processing.
Clinician and survivor next move into an assessment phase. Reviewing the survivor’s history, they collaborate on the development of a target image or images with which to begin reprocessing. The survivor is also asked to develop a self-statement, called the Negative Cognition (NC) that is based in the target trauma image. She is then requested to come up with a new statement, the Positive Cognition (PC), that would be true when treatment has been effective, the goal of which is to stimulate a connection between the experience as it is currently held with the adaptive memory network(s) and the validity of the positive belief. The survivor is asked to rate the subjective truth of the PC on a scale from 0 (feels not at all true) to 7 (feels completely true); this rating is known as the Validity of Cognition (VOC).
Survivors are next asked to scan their bodies and rate the Subjective Units of Distress (SUDS) that they experience emerging from the target image on a scale of 0 (no distress) to 10 (worst distress). This completes the assessment phase of treatment.
Survivors are then asked to hold the target image, NC, and current bodily state of distress together, and are exposed by the clinician to bilateral sensory stimulation. This is the reprocessing stage of treatment. EMDR initially used side-to-side eye movements, and has now expanded to include bilateral physical touches or taps, and bilateral tones. In the standard EMDR protocol, survivors are exposed to 24 sets of bilateral movements, then asked to stop, reflect on what has emerged, and develop the next target for the reprocessing activity. A variety of strategies are available to the clinician for use if survivors become stuck in trauma material, including changes to the direction, speed, or intensity of the bilateral stimulation, and the use of Socratic questioning, called “cognitive interweave” between reprocessing sets. During the reprocessing, survivors are instructed to allow whatever material that emerges to do so, and to be treated as objects passing by the windows of a moving vehicle, rather than focused on.
When a target image has been processed to as low as possible a SUDS (preferably 0 or 1), the clinician then begins the installation phase of treatment. In this component of EMDR, the PC is paired with the target image and processed up to as high a VOC as possible, with attention to ecological validity (e.g., is it reasonable for the survivor to have no negative emotions about their trauma). Next, the survivor is directed to scan the body, and treatment sets are utilized so that eventually neutral or positive emotionality is associated with the image. Survivors generally move freely between the reprocessing, installation, and body scan phases of treatment. The last two components of EMDR focus on reorienting the survivor to the here and now, and revisiting the target image for possible unprocessed trauma material.
EMDR has been found effective in sharply reducing intrusive trauma symptoms in persons with PTSD. For individuals with complex trauma, EMDR can be modified in order to focus almost exclusively on the safety and stability aspects of the treatment, using protocols that have been specifically developed to strengthen inner resources and resilience. It can also be effectively utilized to target and reduce problematic self-statements and beliefs that have been resistant to more direct cognitive challenges. Because it can be destabilizing, it must be employed with attention to the survivor’s specific functional capacities. Clinicians wishing to use EMDR are advised to complete formal training in its applications. For use with complex trauma, clinicians should have completed the second level of EMDR training, which addresses specific protocols for work with these survivors. A recent review of the literature on EMDR (R. Shapiro & Brown, 2019) indicates that an expanding body of literature supports its effectiveness. Parnell (2013) has developed a specific model of EMDR for use with survivors of attachment-based traumas, which supplements the basics of EMDR practice.
A wide range of cognitive and cognitive-behavioral therapies have been adopted to and studied with trauma survivors. Almost all of these interventions have been taken from those used with anxiety disorders and depression, and reflect a number of different paradigms for how PTSD symptoms develop and ameliorate. An in-depth description of each of these techniques can be found in the Guidelines for Treatment of PTSD promulgated by the International Society for Traumatic Stress Studies, summarized in the volume Effective Treatments for PTSD (Foa, Keane, Friedman & Cohen, 2009).
The exposure therapies for PTSD posit that the avoidant symptoms of the disorder lead to a failure to recondition cues related to the trauma to new, non-traumatic experiences in the present. A variety of strategies are utilized to reduce avoidant behaviors and increase the survivor’s exposure to trauma-related material.
The most basic of these exposure strategies is imaginal systematic desensitization. In this intervention, survivors are taught deep muscle relaxation, and then directed to construct a hierarchy of imagined feared materials, which are then paired with relaxation under the theory of reciprocal inhibition. These procedures can also be done in vivo. Given the difficulty in reproducing the situations in which some traumas occur, recent developments in computer-assisted technologies have led to the growth of virtual reality exposure therapies in which the survivor is not quite in vivo, but has the closest thing, given the possibilities of a VR environment.
Exposure therapies are also employed without the use of relaxation techniques. Prolonged Exposure (PE), developed by Foa and her colleagues from interventions used with other anxiety disorders, stems from the emotional processing theory of PTSD, which emphasizes the importance of changing emotional reactions to the trauma cues, and interrupting the avoidant behaviors that maintain the association between the original trauma exposure and cues associated with it. It is the most-researched specific intervention for trauma. In PE, the survivor is first educated as to the nature of the trauma response, and to how and why PE works. Survivors are taught to attend to their breath as a strategy for self-regulation although, unlike in systemic desensitization, survivors do not use this self-soothing strategy during the exposure components of the treatment itself. Survivors are then introduced to in-vivo exercises in which they expose themselves to something in the present that they have been avoiding due to its potential to stimulate PTSD symptoms, but which is not directly related to the trauma itself. So, for example, a person who was traumatized by a hurricane might be asked to spend time outside in bad but not dangerous weather, instead of going into the house and closing off all evidence of wind and rain.
Finally, survivors are requested to write a detailed script of their trauma experience, which is then utilized for imaginal exposure. With both in vivo and imaginal exposures, survivors are led repeatedly through the exposure experience or script, telling and retelling the story of the trauma, and classically reconditioning their response to it in the context of the safety of the therapy office. Therapy sessions for PE are generally 90 minutes in length so as to accommodate the need to go completely through the trauma experience and have survivors remain exposed for an extended period to the trauma-related material. Extensive research on the use of PE has found it to be highly effective in the treatment of combat and adult onset single episode sexual assault trauma. Concerns have been raised about the use of PE with complex trauma survivors, given that many of them do not have sufficient self-soothing skills available to cope with exposure to painful post-trauma affects. Teaching of emotion regulation and affect tolerance skills are a necessary precursor to doing PE with the complex trauma population. Simply teaching relaxation has been found to be less effective than adding the exposure component; thus clinicians using PE must be sure to include all components of the treatment protocol.
Cognitive Processing Therapy (CPT), also a very frequently researched intervention for trauma, was developed by Resick and her colleagues (1993, 2008) for the treatment of rape survivors, and has since been applied to work with other adult trauma populations. Although CPT incorporates some exposure elements, it is largely a cognitive treatment that focuses on problematic belief systems and self-schema developed by the trauma survivor in the wake of the experience. Two kinds of beliefs are targeted for challenge; what the theory refers to as “assimilated beliefs” having to do with how the trauma changes self and other schemata, and what are called “overgeneralized beliefs” about a variety of factors symbolically associated with the trauma. The survivor is asked to write a detailed account of the trauma and read it back to the clinician, as well as practice reading it between sessions. The goal of this is not simply exposure, but to identify the points in the trauma experience where the survivor made decisions about herself due to violations of pre-existing belief systems. Such beliefs and schemata are then targeted during the cognitive therapy component of treatment. Resick urges clinicians to combine the challenges to the cognitive schema with exposure to the affects of the trauma, so as to maximize the likelihood that the survivor will have access to the trauma-related thoughts and emotions that occurred while the traumatic event was in progress. CPT has been found to be equivalent in its effectiveness to both PE and EMDR.
Cognitive therapy for PTSD very much mirrors treatments for anxiety and depression as described by Beck and his colleagues, and is one of the treatments for which evidence for efficacy in trauma treatment is strong. The special emphasis of CT with trauma survivors is on dysfunctional cognitions and schemata related to the trauma itself such as beliefs about one’s own judgment, the trustworthiness of other people or institutions, and the fundamental safety of the world. Several authors (Briere & Fox, 2006; Courtois & Pearlman, 2005; Gold, 2020) have observed the manner in which survivors will have complex schemata about being betrayed, abandoned, or harmed, and about other people being rejecting, critical, contemptuous, and shaming.
What distinguishes CT with trauma survivors from CT in general is the very real presence of the very real trauma. It is not a distortion or irrational for the trauma survivor to have beliefs that the world, certain situations, or people in it are likely to be unsafe. In fact, the trauma survivor, unlike people outside of the invisible world of trauma, has no illusions about the justness or safety of the world. Thus, it is usually more productive to bring CT to bear on the ways in which such founded beliefs have become over-generalized and function in the service of avoidance, or have led to unfounded and distorted perceptions of self.
Mindfulness-based approaches to therapy take the approach that they are not attempting to change a survivor’s beliefs or symptoms. Rather, they attempt to change the survivor’s relationships to their beliefs or symptoms through the use of mindfulness strategies. Many of these strategies, which derive from Vipassana Buddhist meditation methodologies, teach their practitioners to compassionately observe their experiences without judgment or reactivity. Clinicians using Vipassana mindfulness meditation should be themselves mindful that this is simply one component of a larger Buddhist belief system, and avoid cultural appropriation by treating this as a tool of Western psychology.
ACT was developed by Hayes and his colleagues initially as a non-drug intervention for individuals with psychotic symptoms such as hallucinations and delusional thoughts. The slogan of ACT is “get out of your mind and into your life.” A mindfulness-based approach to treatment, ACT teaches that the productions of the mind, including thoughts, obsessions, feelings, intrusive images, and so on, are not real things, and need not be reacted to or serve as sources of guidance for the individual experiencing them. The mind itself is identified as a construct that is a metaphor for language, where language has been used to make schemata about self, others, and world. ACT has as its goal changing how people relate to the productions of their minds, freeing themselves from being reactive to and controlled by those productions.
ACT assists survivors in identifying their values, and what their goals are for life, and through the development of skills of mindful observation of self and others, in developing behaviors that are congruent with those goals and values. Survivors are taught skills in mindful observation, with an emphasis on compassionate, non-judging, non-reactive awareness of self. The therapy has six “core therapeutic processes” (Harris, 2009). They are:
An overarching principle of ACT is the development of psychological flexibility. Survivors are offered strategies to be fully present, be open to their realities, and act in ways that make valued differences in their lives, rather than rigidly avoiding or protecting against experience.
Because ACT was originally developed with individuals who had psychotic symptoms, it is easily transferable to the intrusive and avoidant symptoms of PTSD. Walser & Westrup (2007) have developed a specific variant of ACT for PTSD that addresses some of the more challenging aspects of ACT for trauma survivors, particularly the notion that survivors must give up their attempts to change or get rid of their post-trauma symptoms, and instead focus on learning to have a new relationship with those symptoms. Assisting survivors to be in the here and now, and to observe their intrusive and avoidant thoughts and feelings without reacting to them, changes the survivor’s relationship to her own insides. Rather than, “I am having a flashback, this is really scary,” an ACT intervention might assist a survivor to mindfully observe the flashback and note, “I am having a flashback. It’s information about the past; it’s not information about the present.” ACT forcefully does not attend to symptom reduction, which distinguishes it from almost every other treatment modality developed by cognitive-behavioral clinicians. ACT relies on research showing that such a focus can increase experiential avoidance, and may increase distress as the survivor develops secondary distress over the failure of a symptom to remit. Rather, its emphasis is on simply accepting, mindfully, that the symptom is there.
ACT’s emphasis on the development of values and having a life that is informed by values also has special usefulness in work with trauma survivors. Trauma is often an existential/spiritual crisis, and some persons respond to trauma exposure with nihilism, alienation, and the expression of foreshortened future that says that nothing matters anymore. Therapy that explicitly attends to questions of values, and of building a life that reflects a survivor’s value rather than one that is reactive to the experience of trauma contains a powerful message about the worth of the survivor’s life.
Cloitre, Cohen, and Koenen (2006) have proposed the STAIR/NST (Skills Training for Affective and Interpersonal Regulation/Narrative Story Telling) model aimed specifically at working with survivors of childhood trauma. This model, which is a technically integrative one, utilizes interventions from exposure therapies, attachment therapies, and narrative therapies, each configured to address specific components of the distress experienced by survivors of childhood sexual trauma. STAIR/NST exists as two modules. STAIR focuses on the reduction of specific post-traumatic symptoms and the development of healthy relationship patterns, while NST targets the narratives developed by trauma survivors and aims at their transformation into narratives of recovery. Similar to the TRIP model, STAIR/NST prioritizes assisting survivors in developing skills of affect regulation and life management before attempting exposure to the memories and narratives of the trauma itself.
STAIR/NST is a semi-manualized treatment; although the authors give a specific framework for how it is to be employed and steps that are to be followed, they also emphasize early in their work that flexibility and clinical responsiveness are important, as the therapeutic alliance is core to work with survivors of trauma. A theme and curriculum for each session of a 12- to 16-session treatment are described, with examples of how survivors might respond to each theme and how clinicians can utilize the themes and curriculum in manners responsive to the particular survivors with whom they are working.
While the goal of debriefing strategies – to prevent PTSD by giving large natural groups of trauma survivors an opportunity to process their response as quickly as possible after the event – has always been a laudatory one, the findings from two decades of research indicate that individual debriefing is clearly not helpful and may be harmful, and that group debriefing can be helpful if it is chosen, rather than required. In consequence, this segment of the course will not discuss the use of debriefing strategies. Meta-analyses of various debriefing protocols have not found them to be effective in reducing PTSD symptoms.
Dialectical Behavior Therapy (DBT) was developed by Linehan (1993a) as a treatment package for individuals who engaged in non-lethal self-inflicted violence, and was eventually marketed as a treatment for Borderline Personality Disorder (BPD). Because persons with a complex trauma picture are frequently misdiagnosed with BPD, and because many trauma survivors struggle with affect management, relationships with others, self-care and self-soothing, many components of the DBT treatment model are extremely helpful in work with trauma survivors, particularly those with Complex Trauma histories. Linehan’s model focuses on survivors’ experiences of validation, positing that the behaviors that are diagnosed as BPD arose from the context of highly invalidating environments; this would be another way of framing the disorganizing or dangerous environments common in the childhoods of survivors of complex trauma. Consistent with the goals of a trauma-informed therapy, DBT clinicians are encouraged to see themselves as the survivor’s ally and a source of validation for their personhood, while simultaneously working with the survivor to change ways of behaving that create difficulties in life. The dialectical tension between compassionate acceptance and validation of survivor’s realities and their humanity, and the emphasis on the necessity for making specific behavior change in order to have a life that is more powerful, effective, and enjoyable lies at the foundation of this approach. The balance of acceptance and change is at the heart of the DBT paradigm.
DBT as a complete package has two components. The first is individual psychotherapy; the second is a skills training curriculum, generally taught in groups. Both group and individual treatment focus on ameliorating specific categories of behavior, with distinct stages for treatment and targets for intervention that standard DBT clinicians use in the order specified by Linehan. The rationale for this very structured approach is to avoid a focus on survivor crises, and to ensure that the survivor is alive and coming to therapy in order to develop new skills for having “the life worth living.” PTSD is directly addressed by DBT, with its treatment described as one of the specific goals of the second stage of DBT treatment, in which a focus is on non-avoidant emotional expression.
The specific targets of DBT are, in the order of priority, self-inflicted violence and other risk-to-life behaviors; behaviors that undermine therapy, referred to as “therapy-interfering behaviors” and which, from a trauma-informed perspective, can be construed as attempts to manage distance and closeness with the trauma cue of another human being, behavior which can include avoidance, persistent non-participation in homework, missing sessions, or actions that undercut the therapeutic alliance; and behaviors that reduce quality of life. The treatment is grounded in a mixture of behavioral principles, including the use of self-monitoring through diary cards, relapse prevention strategies such as behavioral chain analysis, exposure exercises, and mindfulness skill building. Linehan’s model closely mirrors the general principles of trauma treatment, in that there is an initial emphasis on stabilization, the processing of material, and then on exploration of existential concerns, although she sees the last as optional, rather than core, to DBT.
DBT skills training groups focus on the same set of problem behaviors, with curriculum divided into four modules: core mindfulness skills, which are practiced at the start of every DBT group; interpersonal effectiveness skills; emotion regulation skills; and distress tolerance skills. DBT uses a variety of helpful mnemonics to assist people in acquiring and utilizing the various skills (e.g., the interpersonal effectiveness skill set DEARMAN, used to negotiate for what one wants, stands for Describe your situation, Express why this is an issue and how you feel about it, Assert yourself by asking clearly for what you want, Reinforce your position by offering a positive consequence if you were to get what you want, Mindful of the situation by focusing on what you want and ignoring distractions, Appear Confident even if you don’t feel confident, and Negotiate with a hesitant person and come to a comfortable compromise on your request (Linehan, 1993a).
Although mindfulness is a core component of DBT, it is, unlike ACT, very focused on behavioral change in relationship to self and others. What differentiates DBT from other CBT-based approaches to therapy, and makes it particularly useful in work with trauma survivors, is that it combines the notion of mindful radical acceptance of what is (i.e., that the trauma has happened) and mindful skills at observing and relating compassionately to one’s own distress with specific skills focused on empowering survivors to change their intra- and interpersonal behaviors from trauma-generated coping strategies to ways of being that are life-enhancing at best, and neutral at least. Most of the focuses of DBT are those that are germane to trauma survivors, who struggle with emotion regulation and self-soothing in the face of trauma’s powerful affects and intrusive images.
Some clinicians have found the standard DBT protocols problematic because they require that survivors must have a DBT clinician to participate in a skills group. DBT clinicians are required to participate in DBT consultation teams, with the goal of supporting clinicians and improving their own self-care, in part because of the high demands of DBT on both clinician and survivor. While there has not been research on the adaptation of components of the DBT model, and Linehan and her research teams are careful to indicate that only the complete package of individual DBT and a DBT skills group has been empirically supported, many of the strategies in DBT map onto the treatment needs of traumatized individuals, particularly those with complex trauma and any of those with serious challenges of emotion regulation and interpersonal relatedness.
Gold (2020) has proposed a similar model for working with survivors of complex trauma within the family context, the Contextual Trauma Therapy model. This model applies largely to work with complex trauma, and is designed around the specific needs and challenges of persons who have been neglected, betrayed, and deprived of helpful experiences in childhood by their caregivers, in addition to having experienced other forms of trauma, such as sexual or physical violations. He argues that trauma as typically defined, for example, by Criterion A of PTSD, is not an adequate conceptual framework for understanding the difficulties faced by these individuals, who also fall under the general rubric of complex trauma, and whose trauma exposures were usually the fabric of their early lives, and thus central to their sense of self and coping strategies. Although he divides his model into more specific component parts, the directions taken by treatment in his paradigm are quite similar to those proposed by Herman. Gold focuses on the task of assisting the survivor of intrafamilial abuse to identify the effects of the chaotic family context, and to understand how those are both interactive with and distinct from specific abuse that may have occurred, as a first step in developing a collaborative relationship with shared, clear treatment goals and priorities. He then identifies the importance of working with survivors to learn how to manage and modulate distress, reduce dissociative coping, engage in critical thinking, changing problematic behaviors, and titrating exposure to the trauma narrative. Gold de-emphasizes the importance of thorough scrutiny of and exposure to the process of remembering trauma, but emphasizes the value of creating a post-abuse narrative with survivors that emphasizes the shift from post-abuse functioning to liberation from the power of the abuse and abusers.
Gold argues that if a survivor wishes to delve into their personal narrative of abuse then the clinician should support them in so doing, but notes that many of the survivors treated by him and his co-clinicians in the trauma clinic that he directed for three decades found that once survivors had behaviorally and emotionally freed themselves from the problematic coping strategies used for dealing with the sequelae of trauma, they were no longer very interested in engaging in a narrative exploration of those experiences. He suggests that when a necessary component of solving the problems of life is understanding the roots of difficulties in the trauma experience, then specific exploration of that experience can be useful, as it is in the service of empowering a survivor into improved functioning. He further emphasizes that this process needs to be survivor-driven and -initiated, a stance consistent with a culturally responsive approach to trauma treatment. In Gold’s model, the mourning and remembrance phase of therapy is set further in the background, with the greater emphasis being placed on disruption of the family culture of chaos and neglect that enabled abuse to occur. This model has its primary focus on the first component of the overarching trauma treatment framework.
The core model for trauma work with survivors, discussed earlier in this course, can be and has been integrated into a very wide range of theoretical orientations and modalities. These include psychodynamic treatments, somatically focused treatments, group psychotherapies, couples and family therapies, and expressive and art therapies, among others. Readers interested in learning more about any of these specific approaches to treatment, or in receiving training in one of the approaches discussed above, are referred to the websites of the International Society for Traumatic Stress Studies (www.istss.org) or the International Society for the Study of Trauma and Dissociation (www.isst-d.org).
Additionally, there are a number of emerging trauma treatments that have yielded good reports from practitioners, but have not yet been well-researched. These include Energy Psychology, Brainspotting, Somatic Experiencing, Sensorimotor Psychotherapy, Hakomi, and Somatic Integration. Readers interested in pursuing one of these emerging trauma treatments should keep in mind that anecdotal evidence of effectiveness is not the absence of evidence; rather, it is evidence that there have not yet been sufficient studies of a particular technique in academic or institutional settings, in which gold-standard random clinical trials can be conducted.
This course will not discuss treatment of post-traumatic dissociative symptoms. However, readers interested in this topic are directed to the ISSTD website cited above for further information, or to Steele, Boon, and van der Hart’s (2016), or Brand, Schielke, Schiavone & Lanius’s (2022) texts.
Because trauma exposure can lead to such a wide range of forms of distress, including the secondary distress arising from a survivor’s attempts to manage the initial onslaught of their own response to trauma exposure, and because these forms of distress affect almost all realms of functioning, clinicians working with trauma survivors must become conversant in a wide range of treatment strategies. Following the lead of Norcross & Wampold (2011, 2019), who have discussed the importance of tailoring the therapy to the survivor in terms of the survivor’s stage of change and her symptoms and capacities, trauma-informed clinicians will carefully assess and develop a treatment plan, in collaboration with the survivor, that reflects the survivor’s particular needs and difficulties. Each of the specific trauma treatments described above offers some interventions that may be helpful to some trauma survivors, and less so, or even potentially harmful, to others. Careful consideration of the overarching model of trauma treatment in the choice of interventions will always remain foundational to competent work with this population.
Readers should also consult with their professional organizations for practice guidelines as they emerge. ISTSS (istss.org), ISSTD (isst-d.org), and the American Psychological Association (apa.org), all have published, and continue to update, clinical treatment guidelines for PTSD, complex trauma, and dissociation.
The next course in this series addresses the person of the trauma-informed clinician. Issues of cultural competence and awareness, countertransference, and vicarious traumatization are necessary components of competent practice, particularly given the emotional effects of trauma work on clinicians.
Belli, R. F. (Ed.). The 58th Nebraska Symposium on Memory and Motivation: A reappraisal of the recovered/false memory debate. University of Nebraska Press.
Brand, B. J. (2011, August). Results of a longitudinal naturalistic study of treatment outcome for patients with dissociative disorders. In B. Brand and C. A. Courtois (Chairs). Traumatic Dissociation – Neurobiological, Assessment, and Treatment Implications – II. Symposium presented at the 119th Annual Convention of the American Psychological Association. Washington, DC.
Brand, B. L., McNary, S. W., Myrick, A.C., Classen, C.C, Lanius, R., Loewenstein, R. J., Pain, C. & Putnam F.W. (2013). A longitudinal naturalistic study of patients with dissociative disorders treated by community clinicians. Psychological Trauma: Theory, Research, Practice and Policy, 5, 301-308.
Brand, B. L., Schielke, H.J., Schiavone, F, & Lanius, R. A. (2022). Finding solid ground: Overcoming obstacles in trauma treatment. Oxford University Press.
Briere, J. & Scott, C. (2012). Principles of trauma therapy: A guide to symptoms, evaluation, and treatment (2nd ed.) Sage Publications.
Brown, L. S. & Courtois, C. A. (2019). Trauma treatment: The need for ongoing innovation. Practice Innovations, 4, 133-138.
Brown, L. S. (2015). Not the price of admission: Healthy relationships after childhood trauma. Kindle Digital Publishing Platform.
Brown, L. S. (2012). Your turn for care: Surviving the aging and death of the adults who harmed you. Kindle Digital Publishing Platform.
Brown, L. S. & Courtois, C. A. (2019). Trauma treatment: The need for on-going innovation. Practice Innovations, 4, 133-138.
Cloitre, M., Cohen, L. R., & Koenen, K. C. (2006). Treating survivors of childhood abuse: Psychotherapy for the interrupted life. Guilford.
Comas-Diaz, L. (2006). Latino healing: The integration of ethnic psychology into psychotherapy. Psychotherapy: Theory, Research, Practice, Training, 43, 436-453.
Courtois, C. A. & Brown, L. S. (2019). Guideline orthodoxy and the resulting limitations of the American Psychological Association’s Clinical practice guideline for the treatment of PTSD in adults. Psychotherapy, 56, 329-339.
Courtois, C. A. (1999). Recollections of sexual abuse: Treatment principles and guidelines. W.W. Norton.
Courtois, C. A. (2009). Healing the incest wound: Adult survivors in therapy (2nd ed.). . W.W. Norton.
Courtois, C. A. & Brown, L. S. (2019). Guideline orthodoxy and resulting limitations of the APA Clinical Practice Guideline for the Treatment of PTSD in Adults: Introduction to the Special Issue. Psychotherapy: Theory, Research, Practice, Training, 56, 329-339.
Dalenberg, C. (1996). Fantastic elements in child disclosures of abuse. APSAC Advisor, 3, 1:5-10.
Ellis, A., Simiola, V., Brown, L., Courtois, C., & Cook, J. M. (2018). Effect of evidence-based therapy relationships on treatment outcome for adults with trauma: A systematic review. Journal of trauma and dissociation, 19, 185-219.
Farber, B. A. & Lane, J. S. (2002). Positive regard. In J. Norcross (Ed.). Psychotherapy relationships that work: Therapist contributions and responsiveness to patients (pp. 175-194). ord University Press.
Gold, S. N. (2020). Contextual trauma therapy: Overcoming traumatization and reaching full potential. American Psychological Association.
Gold, S. N. (2000). Not trauma alone: Therapy for child abuse survivors in family and social context. Brunner-Routledge.
Greenberg, L. S., Elliott, R., Watson, J. C. & Bohart, A. C. (2001). Empathy. Psychotherapy: Theory, Research, Practice, Training, 38 380-389..
Guideline Development Panel for the Treatment of PTSD in Adults (2017). Clinical practice guideline for the treatment of Post Traumatic Stress Disorder in Adults. American Psychological Association.
Foa, E. B., Keane, T. M., Friedman, M. J., & Cohen, J. A. (Eds.) (2009). Effective treatments for PTSD: Practice guidelines from the International Society for Traumatic Stress Studies. Guilford.
Gold, S. N. (2020). Contextual trauma therapy: Overcoming traumatization and reaching full potential. Washington, DC. American Psychological Association.
Harris, R. (2009). ACT made simple. New Harbinger.
Harvey, M. R. (1996). An ecological view of psychological trauma and trauma recovery. Journal of Traumatic Stress, 9, 3-24.
Herman, J. L. (1992). Trauma and recovery: The aftermath of violence from domestic abuse to political terror. Basic Books.
Hill, C. E. & Knox, S. (2001). Self-disclosure. Psychotherapy: Theory, Research, Practice, Training, 38, 413-417.
Klein, M. H., Kolden, G. G., Michels, J. L. & Chisholm-Stockard, S. (2001). Congruence or genuineness. Psychotherapy: Theory, Research, Practice, Training, 38, 396-400.
Linehan, M. (1993a). Cognitive behavioral therapy of borderline personality disorder. Guilford.
Linehan, M. (1993b). Skills training manual for treating borderline personality disorder. Guilford.
Nadal, K. L. (2018). Microaggressions and traumatic stress: Theory, research and clinical treatment. American Psychological Association.
Najavits, L. M. & Strupp, H. (1994). Differences in the effectiveness of psychodynamic therapists: A process-outcome study. Psychotherapy, 31, 114-123.
Norcross, J.C. (Ed.). (2002). Psychotherapy relationships that work: Therapist contributions and responsiveness to patients. ord University Press.
Norcross, J. C., Beutler, L. E., & Levant, R. F. (Eds.) (2005). Evidence-based practice in mental health: Debate and dialogue on the fundamental questions. American Psychological Association.
Norcross, J. C. & Lambert, M. J. (2005). The therapy relationship. In J.C Norcross, L. E. Beutler, L, & R. F. Levant, (Eds.) (2005). Evidence-based practice in mental health: Debate and dialogue on the fundamental questions,(pp. 208-217. American Psychological Association.
Norcross, J. C. & Wampold, B. (2019). Relationships and responsiveness in the psychological treatment of trauma: The tragedy of the APA Clinical Practice Guideline. Psychotherapy: Theory, Research, Practice, Training, 56, 391-399.
Norcross, J. C. & Wampold, B. (2011). What works for whom: Tailoring psychotherapy to the person. Journal of Clinical Psychology, 67, 127-132.
Ochberg, F. M. (1988). Post-traumatic therapy and victims of violence. New Brunner/Mazel.
Parnell, L. (2013). Attachment-focused EMDR: Healing relational trauma. W.W. Norton.
Pearlman, L. A. Wortman, C. B., Feuer, C. A., Farber, C. H. & Rando, T. A. (2014). Treating traumatic bereavement: A practitioner’s guide. Guilford.
Pope, K. S. & Brown, L. S. (1996). Recovered memories of abuse: Assessment, therapy, forensics. American Psychological Association.
Robin, R. W., Chester, B., & Goldman, D. (1996). Cumulative trauma and PTSD in American Indian Communities. In A. J. Marsella, M. J. Friedman, E. T. Gerrity & . M. Scurfield (Eds.). Ethnocultual aspects of posttraumatic stress disorder (pp. 239-254). American Psychological Association.
Resick, P. A., Monson, C. & Chard, K. (2008). Cognitive processing therapy: Veteran/military version. Therapist and patient materials manual. Washington, DC. United States Department of Veterans' Affairs.
Resick, P. A. and Schnicke, M. K. (1993). Cognitive processing therapy for rape victims: A treatment manual. Sage Publishing.
Rogers, C. R. (1980). A way of being. Houghton Mifflin.
Safran, J. D., Muran, J. C., Samstag, L. W., & Stevens, C. (2001). Repairing relationship ruptures. Psychotherapy: Theory, Research, Practice, Training, 38, 406-412.
Shapiro, F. (2001). Eye movement desensitization reprocessing: Basic principles, protocols, and procedures (2nd ed.) Guilford.
Shapiro, R. & Brown, L.S. (2019). Eye Movement Desensitization and Reprocessing therapy and related treatments for trauma: An innovative, integrative trauma treatment. Practice Innovations, 4, 139-155.
Stark, M. (2000). Modes of therapeutic action. Jason Aronson.
Steele, K., Boon, S., & van der Hart, O. (2016). Treating trauma-related dissociation: A practical integrative approach.W.W. Norton.
Wampold, B. E. (2005). What should be validated: The psychoclinician. In J.C Norcross, L. E. Beutler, L, & R. F. Levant, (Eds.) (2005). Evidence-based practice in mental health: Debate and dialogue on the fundamental questions (pp. 200-207). American Psychological Association.
Walser, R. D. & Westrup, D (2009). Acceptance and commitment therapy for the treatment of post traumatic stress disorder and trauma-related problems. New Harbinger.
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