Trauma and Psychotherapy
Carlos Durana, Ph.D. offers counseling and psychotherapy at A Caring Approach in Reston, Virginia, Washington, D.C., and Bethesda, Maryland.
The word trauma comes from a Greek word meaning wound. In psychiatry, the term refers to an experience that produces psychological injury or pain. Post-traumatic stress disorder (PTSD) sometimes occurs after one has been through a traumatic situation. A traumatic event is the experience of something horrible and scary happening to oneself, or witnessing it happening to someone else. The event may involve a threat of actual death, or serious injuries; and the experience that your life, or the lives of others, may be in danger. You react to what you have experienced with fear, horror, and helplessness.
After the event, if these and other feelings don’t go away or get worse, you may have PTSD. These symptoms may disrupt your life; they may disrupt the way you see yourself, your relationships, your life, and your daily activities.
These traumatic events may include: child sexual or physical abuse, serious accidents, combat exposure, physical or sexual assault, natural disasters and terrorist attacks.
The American Psychiatric Association in the DSM-5 diagnostic manual provides a set of criteria in the diagnosis of PTSD. Someone (for those older than 6 years) experiencing PTSD after a traumatic event may experience the following:
(1) Being exposed to actual or threatened death, sexual violence, or serious injury (in one or more of the following ways):
a) Direct experience of the traumatic events(s);
b) Witnessing the events(s) as it happened to others;
c) Learning that a close family member or friend experienced a traumatic event(s);
d) Experiencing repeated exposure to aversive details of the event(s).
(2) Intrusive (experiencing the traumatic event) symptoms (one of these is sufficient for the diagnosis):
a) Recurrent involuntary and intrusive memories;
b) Traumatic dreams related to the traumatic event(s);
c) Dissociative reactions such as reliving the experience of flash backs, spacing out or zoning out, feeling numb or feeling detached;
d) Intense or prolonged distress after reminders of the traumatic event(s);
e) Marked bodily reactions after trauma-related internal or external triggers or stimuli that resemble aspects of the event(s).
(3) Persistence avoidance of trauma-related triggers (one of these is sufficient for the diagnosis):
a) Avoiding trauma-related thoughts, feelings, or memories associated with the event(s);
b) Avoiding trauma-related external reminders that cause distressing feelings, thoughts or memories associated with the event(s). These may include activities, people, conversations, places, sights, smells, dates, objects, or situations.
(4) Negative alterations in thoughts and mood or emotion (two or more of these are required for the diagnosis):
a) Inability to recall important features of the trauma;
b) Distorted and persistent negative beliefs and expectations about oneself, others, life and/or the world (e.g., “I can’t do things,” “I can’t trust anyone,” “It’s hopeless”);
c) Distorted and persistent blame of yourself or others for causing the trauma or its consequences;
d) Persistent trauma-related emotions (e.g. anger, chronic guilt, fear, self-blame, helplessness, shame);
e) Markedly diminished interest in important activities;
f) Feeling estranged or alienated from others; or
g) Marked inability to experience positive emotions.
(5) Marked changes or worsening in physical and emotional arousal, and reactivity associated with the event(s) (two of these are required for the diagnosis):
a) Irritability or aggressive behavior towards people or objects;
b) Self-destructive, reckless or risk-taking behaviors;
c) Hypervigilance (being overly watchful);
d) Exaggerated startle response (you feel jumpy);
e) Difficulties with concentration; or
f) Sleep disturbances (falling or staying asleep).
To meet the diagnostic criteria for PTSD, the symptoms must have lasted for more than one month, and they must have created significant distress or impairment in social, occupational, or other important areas of functioning. In addition, the disturbance must not be caused by illness, medication, or substance abuse.
Symptoms of PTSD are more likely to endure in the absence of emotional support, if the trauma occurred early in life, and it was prolonged and interpersonal in nature. The good news is that trauma is treatable with counseling or psychotherapy.
Stages of Psychotherapy
Stages of Support, Safety, Education, and Stability
Creating a safe, accepting, caring, and supportive therapeutic relationship is essential. Before any counseling work can be done on the issues related to the trauma, establishing safety is the primary goal of the psychotherapist. Safety also involves being able to prevent self- injury or being injured by others, and from being abused or from re-experiencing traumatic events. Safety means that you are able to identify beliefs, feelings and actions that protect you and lead you to making good decisions about your life. The understanding, support and safety provides an environment that helps the patient tell the story about the initial trauma and its lingering effects. Education continues throughout the therapy and involves learning about the nature of trauma, reactions, flashbacks and memory work, trauma management, triggers, re-scripting of the trauma story, relapse prevention etc. Strengths, internal and external resources are identified and developed in order to enhance a sense of calmness, grounding, confidence, personal control, and stability which help address the helplessness, fear, and lack of integration associated with the trauma.
A clinical assessment at the beginning stage of counseling helps identify: current functioning and stressors, self-injury, early abuse or neglect, mental, emotional and physical regulation, family and social support, history of traumatic stress, important life history patterns, familial relational patterns, relationship and interpersonal functioning, core beliefs about self, others, and the world, symptom management, life and stress coping skills, strengths, and resources.
Stages of Recovery and Healing From Trauma
The task in this stage is to regain ownership of yourself. Trauma hinders the integrative functioning of our being; re-integration of mind, body, emotion and soul is what repairs the trauma. The disruptions that occurred during the trauma and in memories of the trauma are manifested in our thoughts, emotions, physical reactions, and behaviors. In order to heal, the trauma needs to be revisited, but only after you feel stronger, calmer and safer so as to not be re-traumatized by the encounter.
The vehicles or methods for recovery are many, but they must address your physical, emotional, mental, and at times your “spiritual” nature (the questions of meaning and purpose of your life). The importance of using and developing physical and emotional inner resources cannot be overstated. Your rational brain is not sufficient for the healing process and changing post-traumatic reactions; it cannot by itself abolish the hyperarousal, the sensations, emotions and thoughts that are triggered, and the dysregulation of the nervous system. Trauma recovery involves a better balance between the “emotional” and “rational” brains.
The physical (somatic) work helps us re-inhabit our bodies; it involves the use of relaxation, breathing, imagery, grounding, and centering techniques. Body-centered psychotherapies can help you bridge the gap between your emotions, your body, and your thoughts. Adjunctive somatic methods may also include qigong, massage, body work, yoga, drumming, martial arts, or other forms of art or conscious movement that enhance your emotional regulation, and your ability to be grounded, more emotionally aware, and centered in the present.
The use of awareness or body mindfulness is helpful in learning to witness or observe the transitory nature of physical and emotional reactions; our ability to observe and disengage from habitual reactions increases our tolerance for them, and helps us learn to pay attention to the sensations and feelings of well-being. Mindfulness is also helpful in recognizing erroneous beliefs, and noticing the relationship between thoughts, physical sensations, and feelings.
Cognitive-emotional-behavioral approaches are also useful in addressing erroneous beliefs and assumptions. Exposure therapies for transforming memory responses can be useful in some types of trauma. Group therapy is effective for many people. Recovery is also helped by a good support network; relationships reconnect us to others and help heal shame, judgment and alienation. Relationship therapy is useful in healing the effect of trauma in intimate or family relationships. Medication may help make some feelings more manageable and less overwhelming. Religious and/or spiritual support and exploration is also essential for many people.
As therapy progresses, the client is helped to restructure the trauma story and the memories. A shift happens at first where the client moves from “victim” to “survivor” role, and eventually to a “thriving” role. Religious, spiritual, or philosophical questions may gain new meaning. Restoring social, familial functioning may play a role at this point. Occupational and career concerns may need to be evaluated and addressed. In the termination phase, special attention is place in recognizing ownership for gains made, discussing relapse prevention, and arranging for booster follow-up sessions that help cement the progress made.
The process of recovery from trauma is the road toward self-awareness, empowerment, integration, and life.
Carlos Durana, Ph.D. offers psychotherapy and counseling in Reston, Virginia, Washington, D.C., and Bethesda, Maryland.