Effective treatment for trauma
Updated: Jun 30, 2022
Trauma is relived via a smell, a word, an image or else just appears from nowhere. It ranges on a scale, which at one end, is typified by mildly distressing thoughts, images and memories to the other end which is, absolutely debilitating and is typified by a person who is no longer functioning. Here we consider trauma in brief and focus especially on effective treatment including a brief lived experience of a frontline treatment for trauma.
Trauma is often associated with post-traumatic stress disorder and natural disasters, war, sexual abuse, assault and torture are of course highly correlated with the presence of PTSD. Additionally, there is also significant trauma with a smaller t. Trauma which colours how we behave, upsets us when we think about it and is subject to ‘stuck’ memories and perhaps flashbacks. Instances of bullying as a child or adult, accidents, bad relationships are all common, that isn’t to say that these events can’t also be trauma with a big T, it’s just that clients may often feel their trauma isn’t big enough to be validated by treatment especially when they hear about the horror of what others have faced. So How do you know if it is traumatising enough or in effect ‘qualifies’? Ask yourself: ‘have I thought about this in the last month?’ and: ‘was it/is it still upsetting?’ If the event(s) happened some time ago and you are still answering yes to these two questions, then it probably qualifies.
Why doesn’t my trauma just go away?
Talking to someone can help (but does not always) just In the sense of clarifying what happened and starting to help process the memory/trauma. It is ‘Processing’ which really helps. Processing in this case means moving a memory from a stuck position (it keeps recurring, is subject to flashbacks, is triggered by a number of things e.g., smells, sounds, sights etc.) to one where the memory if processed i.e. it does not affect you any longer in those ways, you still remember it, but it does not come accompanied by dread, anxiety, physical sensations of fear but is in fact, well processed… as if it’s been assigned to the right draw in the filing cabinet.
‘in PTSD reliving the trauma repeatedly in therapy may reinforce preoccupation and fixation’
Van Der Kolk (2014)
Serotonin may help trauma i.e., in the form of selective serotonin reuptake inhibitors or SSRI’s like Prozac (fluoxetine) the drugs may help in reducing symptoms altering the way people function day to day. The downside to this, of course, is that drug treatment does not treat the underlying cause of the trauma. We now have decades of experience of people using anti-depressants and record high levels of depression… the anti-depressant industry is akin to the diet industry i.e., obesity soars while we eat more and more low fat, low sugar food… So, while the SSRI’s may play a role in calming an emergency situation the problem absolutely needs psychologically treating, with the anti-depressant’s being ‘first aid’ or a sticking plaster while the wound is carefully tended to by treating the underlying cause. In depression that is a lot easier said than done as often the underlying cause is: ‘shit life syndrome’ meaning the social life, friends, experience, educational background, tragedy and geographical bad luck are amongst some of the potential factors feeding into the underlying cause.
With distinct and specific trauma instances, however, it goes back to processing and thanks to the development of technology such Positron emission tomography or PET scanning and magnetic resonance imaging (MRI) we can see the areas of the brain affected when negative memories are stimulated and also the areas which light up when calm, logical or neutral thinking occurs. To cut a long story short; the bit of the brain designed to assess threat: the amygdala is activated not just when there is actual threat but also when there is re-experiencing via memories of threat/trauma and going along with this there is the production of the hormones associated with fight, flight or freeze mechanism. When the neutral memories or non-threatening memories occur it is the pre-frontal cortex which is in operation. I have written before about the ancient, or to quote Psychiatrist Steve Peters, ‘Chimp’ part of the brain and the accompanying ‘human’ (logical/calm/rationale) areas and although this is overly simplified here these are the Limbic system where the amygdala is located and the more modern pre-frontal cortex.
‘no matter how much insight and understanding we develop, the rational brain is basically impotent to talk to the emotional brain out of its own reality’ Van Der Kolk (2014)
The limbic system where our emotional responses come from is of course stronger in general than a calming rational voice coming from the pre-frontal cortex. Think about the last fearful, or rage fuelled incident you can remember vividly, how rational, and calm where you? Usually when and if calm does come it is when you are thinking about the incident later, after the threat has disappeared.
One of the problems with trauma is accurately assessing whether a situation, person etc is actually a threat… the area of the brain including the amygdala termed the limbic system may well, following trauma, start to inaccurately assess threat and remember this is the part of the brain that always assesses any given situation for threat, the information goes their first and then if the threat does not seem too awful the pre-frontal cortex (PFC) may get a look in and offer some logic to calm the situation, thoughts like:
‘it’s ok, this is not a threat, you can just carry on’
So, in essence the PFC is our controlling mechanism, it inhibits us from saying and doing things which (when considered with any logic) we should not say or do as clearly the consequences would not be good. Even my angriest patients, in the cold light of day, or the calm of the counselling room can see their previous lack of inhibition. They are not under threat in the consulting room, they are also not being judged and so they are accessing the PFC and actively seeking control, they seek ways to master the impulses that overcome them at other times. Their actual rage is, of course, a response to threat, which is not just direct physical threat: ‘I’ll smash your face in’ threat but also inconsiderate violation of territory (e.g., queue jumping or cutting someone up when driving). It can also be threatening someone’s freedom or autonomy as in telling them what to do. The amygdala likes none of this, it does not want you to lose face, look bad or be threatened and when the stakes are high the logical watchful PFC does not get a word in. Trauma can mean that the assessment of threat by the brain is super-charged, and the person suffering is ever hyper-vigilant for threat around them, even when, in reality, no genuine threat exists.
Prolonged exposure/ desensitization
In prolonged exposure therapy the idea is that you gradually face trauma inflicted memories to learn to overcome them, it is an approach, for example, promoted by the U.S Department of Veteran Affairs. Typically, exposure therapy may go on for around three months with weekly sessions of an hour and a half. Evidence suggests exposure therapy is useful for reducing trauma symptoms (Rothbaum and colleagues, 2002). There is of course the side-effect of having to deal with the discomfort of the exposure as obviously this involves reliving uncomfortable and sometimes horrendous memories/images, but the counterargument is that someone living with trauma, relives these thoughts and images a lot of the time anyway and the contraindications/risk of harm from treatment appear to be very low (Van Minen and colleagues, 2012).
EMDR (Eye Movement Desensitization and Reprocessing)
In psychotherapy talking about traumas and coming up with new ways to deal with the experience, contain it, calm yourself etc are not new ideas. In terms of processing, it also becomes clear, to me as the therapist, that people do talk through a very upsetting experience and at least sometimes ‘process’ it seemingly by being heard, understood etc, although a word of caution here is that many do not. If you have felt the catharsis of ‘a problem shared’ but then felt like you are still just repeating the issue repeatedly with no resolution, then it may make you a good candidate for EMDR. EMDR is: eye movement desensitization and reprocessing. Thought of by Francine Shapiro In the late 1980’s EMDR has gained traction as a frontline approach for trauma, including both with trauma with capital and lower-case t’s.
A trained psychotherapist administers the therapy, and they need to be effective in clearly identifying the correct ‘target’ memories for treatment. Once that is done a protocol is followed which involves seeing and imagining the memory that causes problems and whilst thinking about it, simultaneously following the therapist’s fingers to affect lateral eye movements. Despite the years of research, the exact mechanism, by which EMDR works is still unknown, a plausible mechanism is mimicking the movement seen in rapid eye movement (REM) sleep. Indeed, REM is seen as an important part of processing information which has occurred during the waking day while we are asleep.
How it works, is not so well understood, but that it does work, is not so much under question with numerous strongly designed research trials showing an impressive reduction in symptoms for PTSD with as little as 3 x 90 minutes of treatment. A difference in the number of sessions, to some extent, will depend upon the complexity of the trauma, with a single issue/event trauma for example, people may get effective treatment from only one session but with multiple traumas (years of abuse, numerous awful events for examples) numerous target memories might need processing. It is not that someone who was abused for years needs to process every single memory they have- but rather a number (perhaps 4-5) to treat a ‘linked’ set of horrible events. In this case it is as if the events track, and the processing has a knock-on effect to many other similar or ‘linked’ events.
The American Psychological Society lists Cognitive behavioural therapy and prolonged exposure therapies for traumas as ‘strongly recommended’ versus EMDR being conditionally recommended; although a recent review and meta-analysis (a study which pools a number of scientific experiments together) suggests that EMDR is better than CBT in lowering PTSD symptoms (Khan et al, 2018).
So, what happens in EMDR?
Initially it is important to identify with clarity the memories and worse events relating to the trauma we are discussing, to identify in essence how this has left you feeling. This feeling may well from an ‘I message’, for example: “I feel worthless’ when the way you were treated very much made you feel that way. Next, we also must carefully prepare the opposite i.e., the way in which you would really like to feel about yourself e.g., ‘I have worth’. The processing involves using memories and your negative belief and recalling/replaying these whilst conducting sets of rapid eye movements (typically following the therapist’s moving her fingers from side to side). Occasionally the therapist will check in what has changed in your physical sensation and the images/thoughts coming up during the eye movements. Scales to assess your feeling of disturbance and your feelings over the validity of the positive statement are used.
What is the experience like?
Strange to own the truth… during my own initial training I chose a trauma with a small t to work on for the purpose of trying out the protocol. My thoughts were: ‘well this isn’t such a big trauma, just a little upsetting’ and ‘therefore this is unlikely to have any effect’ (I was thinking of a time when I left a job suddenly without giving any notice and let people down). However, as the eye movement sets progressed my image of the building, the image of disappointed people faded and moved further away, happier times at the same place emerged and my own thoughts changed too: ‘you were doing the best you could under the circumstances, it was a difficult time etc.’ By 24 hours after the treatment the thought was so faded (my memory still fully intact) that the, albeit slight, trauma had completely gone and continues to be gone to this day… fellow trainees had more significant traumas and they too changed and all for the positive, I looked for one which flopped but amidst a room of about 30 people and more than a few tear-streaked faces there were only stories of success…
How does it work?
No one is absolutely sure but it seems likely that the exposure to the trauma through repeating the images/memories (and not shying away from them) is made easier by simultaneously concentrating on having to track with your eyes (doing two things at once or ‘dual processing’ as they call it in the business) and potentially the eye movements themselves are doing something physiologically or neurologically to help you literally process the memory and put it into a place where you are not triggered, re-traumatised every time you meet that smell, colour, type of person etc.
The desensitization referred to in EMDR is the process of remembering the negative memory/image including audio and olfactory sensations whilst carrying out the eye movements, something which is ordinarily very upsetting seems less so during the process. Not to say it does not upset people, it does, and then idea is, as much as possible, to keep going with the images/thought/physical feelings which come up and continue the eye movements. The therapist will ask you ‘what comes up?’ In between successive sets of eye movements and you just need to truthfully say what that is and keep on going. If the process becomes too upsetting you can stop, otherwise you push on through, like driving through a dark tunnel, pushing through will get you to the other side.
References
American Psychological Association https://www.apa.org/ptsd-guideline/treatments/eye-movement-reprocessing last accessed 14.03.22
Khan, A. M., Dar, S., Ahmed, R., Bachu, R., Adnan, M., & Kotapati, V. P. (2018). Cognitive behavioral therapy versus eye movement desensitization and reprocessing in patients with post-traumatic stress disorder: Systematic review and meta-analysis of randomized clinical trials. Cureus, 10(9).
Peters, S. (2013). The Chimp Paradox: The Mind Management Program to Help You Achieve Success, Confidence, and Happine Ss. TarcherPerigee.
Rothbaum, B. O., & Schwartz, A. C. (2002). Exposure therapy for posttraumatic stress disorder. American journal of psychotherapy, 56(1), 59-75.
Shapiro F Eye Movement Desensitization and Reprocessing (3rd edition) 2018 Guildford Press.
Van Minnen, A., Harned, M. S., Zoellner, L., & Mills, K. (2012). Examining potential contraindications for prolonged exposure therapy for PTSD. European journal of Psychotraumatology, 3(1), 18805.