Stop Focusing on Pathology
Let's refocus mental health in 2021 on resources.
Posted Dec 31, 2020
The topic of trauma has gotten a lot of attention in recent years. Yet trauma and the treatment of it remain on the outer fringes of psychotherapy, dealt with as a niche topic in which only certain specialists are trained.
In fact, trauma belongs at the heart of psychotherapy, and working in ways that are fully trauma-informed—what I call Trauma-Focused Psychotherapy—is key to the practice of all mental health care.
Already in 1895, Breuer and Freud recognized the long-lasting and hidden effects of trauma. “We must presume," they wrote, "that the psychical trauma—or more precisely the memory of the trauma—acts like a foreign body which long after its entry must continue to be regarded as an agent that is still at work.”
Trauma caused by emotional injury or cognitive, physical, spiritual, or social harm is the number-one root cause that brings people to therapy. Often, of course, trauma manifests in familiar symptoms, like burnout, anxiety, or depression. Or trauma shows up in more complex symptoms, such as eating disorders or addictions.
With few exceptions, symptoms like these, whether common or complex, are rooted in some kind of injury, often unrecognized. This requires that psychotherapy be, in essence, trauma therapy: that is, therapy conducted with a deep awareness of how trauma affects people and what they need to feel better. It also means that therapists must be trained to help clients deal with more than symptoms; they must have the knowledge and skills required to investigate and address root causes and to recognize and build on the resources for a meaningful life that clients carry within.
Enough with pathology. It is true, of course, that clinicians may be correct in diagnosing a trauma survivor as having depression, anxiety, bipolar disorder, personality disorders, RAD, addictions, eating disorders, or any number of other “disorders.” Some survivors, some therapists, and all insurance companies need a “diagnosis.” But it’s time to drop the language of pathology and the misleading assumptions that come with it.
Trauma triggers defense mechanisms, which are there to protect us and help us survive. The overactive nervous system that results has a mission—to spare us from existential pain and fear that for some reason we are not ready to face, often due to early life experiences with caregivers (misattunement) that signaled that reality is isolating, unpredictable, and often threatening.
When we diagnose and treat the responses that follow trauma as pathology, we compound the devastation of trauma. We launch into the chase of a problem that doesn’t exist in the way we imagine; as a result, even useful therapies provide only limited and partial relief. We divert precious resources of time, energy, and finances away from addressing the underlying issues that prevent an individual’s defenses from coping with trauma constructively.
When trauma is the root cause of someone’s difficulty, it’s tragically inept when our responses revolve around only the symptoms presented. In some way or other, all mental health symptoms have some kind of injury at their root. Therapists, therefore, have a duty to bring competencies that both treat the symptoms (self-regulation) and address root causes (attunement and sustainability).
This requires significantly more than familiarity with a few trauma therapy modalities. We need to understand trauma therapy as a resource-oriented approach that draws on all aspects of wellness to assist clients in developing a sustainable, life-expanding response to trauma.
Building on the understanding described above, here are pillars of what a trauma-focused approach to therapy needs to include:
- Experiential psychoeducation about the biological, emotional, physical, spiritual, and social effects of trauma on survivors and families (individual trauma) and communities (communal trauma). (Read more in the blog.)
- Individualized Sustainability Plan (ISP), a plan that develops over time in the therapy process and includes routines known to be effective in mitigating stress symptoms and enhancing capacity to endure pain and experience joy. When designing an ISP, we investigate and address the biological and medical root causes of symptoms (neuroimmune psychiatry and nutritional psychology) (Read more in the blog.).
- Attunement-Based Psychotherapy (Co-regulation). Attunement is a nonverbal process of being with another person in a way that attends fully and responsively to that person. A key aspect of the attunement is that it is a joint activity experienced in interaction with a caregiver. In therapy, the therapist attunes to the client with the goal of becoming a “co-regulator” with the client's responses. Over time, the client is able to transfer the sense of being co-regulated to self-regulation outside of the therapy room in everyday life. Through the attuned relationship, clients learn to expand their capacity to endure the pain and loss of trauma and its aftermath (read more in the blog).
- Self-Regulation. This refers to the ability to maintain control over one's sensory, emotional, and cognitive reactions. Therapeutic work with a client on self-regulation uses modalities and practices that mitigate stress symptoms and facilitate body awareness, such as expressive therapies (arts, drama, movement, dance, music), body-oriented therapies, certain mindful modalities, and certain neurofeedback protocols (read more in the blog).
- Narrative Processing and integration. Since this is not a linear process, aspects of trauma integration begin to emerge when clients are engaged with each of these pillars. As therapy progresses, clients are able to redirect many of their defense mechanisms to be more productive and expand their capacity to endure pain and experience meaning and joy. At this point, clients are able to look at themselves, their past, present, and future, in more favorable terms. (Not all the time, not happily ever after, but in a way that feels "good enough.")
In the coming blog posts, I will elaborate on each of these pillars. In the meantime, I wish you a happy, healthy, joyful, and meaningful 2021!
Breuer, J., & Freud, S. (1955). On the psychical mechanism of hysterical phenomena: Preliminary communication from studies on hysteria. In The Standard Edition of the Complete Psychological Works of Sigmund Freud, Volume II (1893-1895): Studies on Hysteria (pp. 1-17).