Trauma Processing: When and When Not?

How do you lay a foundation for trauma processing?

Posted Apr 11, 2018

Photo by Leio McLaren on Unsplash
Source: Photo by Leio McLaren on Unsplash

Clients are often surprised when I tell them that we won’t be actively working to bring their trauma history to the surface in therapy.  It’s not that we wouldn’t ever want to do that - when the time is right, trauma processing* in a safe, supportive environment has a role to play in the journey of trauma integration. 

But research has found that telling the trauma story is ineffective in bringing relief from symptom of trauma and sometimes can be harmful (retraumatizing).  Careful preliminary work with other strategies needs to take place before working with the trauma story itself.

A heavy focus on telling the traumatic story reflects outdated notions of what trauma does to people and how to treat it. Traumatic memories are not stored in a way that they can be deeply accessed by verbal interactions based on cognitive or logical processes.

Trauma is stored somatically, that is, in the body.  Its most disruptive consequences play out in sensory networks, the nervous system and the vagus nerve that connect many parts of the body including the brain and the gut.  We have to involve all of those systems to get to the root of trauma.

Trauma puts survivors on constant high alert, a survival response useful to protect against additional trauma.  But this sense of alertness also blocks access to the deep roots of trauma in the body.

Traumatic memories reside as frozen experiences within.  They take away spontaneity, one of the most important resources for survivors in moving on.

Start therapy with laying a foundation
If we begin therapy by focusing on the trauma story itself, the risk is high that we will add to the injury and pain.  Early work should focus instead on restoring a sense of safety, on helping the survivor to discover and draw on their resources, and on self-regulation.

Only after a client has been able to achieve a reduction in the alertness that typically follows trauma and a strengthened awareness of resources for coping with stress should we consider strategies that directly deal with the trauma story.   Such preparation reduces the odds that reviewing the trauma will cause emotional flooding and retraumatization.

Trauma is complex in its impacts, and therefore treatment needs to be complex as well. In a gradual way we need to strengthen various aspects of a survivor’s well-being: emotional, physical, cognitive, spiritual and social.

ETI
Source: ETI

The ETI framework provides such a complex, whole-person approach by designing trauma treatment around six components: (1) psychoeducation; (2) individual sustainability plan (ISP); (3) grounding; (4) resilience awareness; (5) taking action; (6) trauma integration. (When working in the context of developmental trauma, the framework is a bit different, giving priority to secure attunement).

In this blog I focus on Stage Four,  Resilience Awareness, and Stage Five, Taking Action, in the ETI roadmap.


Is resilience a trait, a process, or an outcome?
Resilience is such a buzzword now that the term can be confusing.  Everyone wants, of course, to be resilient.   But what is it?
When it began to be widely used in late 90’s early 2000’s, “resilience”  seemed to be understood as a trait, a capacity to bounce back from adversity that some people had and others didn’t.   That wasn’t much help for those who don’t seem to have it.

Gradually the definition broadened to understand resilience as a capacity.   One author, for example, defines it as “capacity to cope, adapt, and maintain psychological and physical performance following a traumatic event” (Scali et al., 2012).  This was an empowering shift - a capacity can be learned and expanded by anyone.  

How to discover resilience?
A valuable conversation among leading theorists and researchers of resilience published in 2014 (Southwick et. Al) takes this further, suggesting what I believe to be an even more realistic and useful understanding.  I now see resilience as a continuum from low to high, and I think that everyone functions at various points on this continuum from time to time. 

A benefit of viewing resilience as a continuum  is that makes it easier to recognize forms of resiliency in survivors that are easy to miss.  My premise as a therapist is there was and is resiliency functioning in this client; my job is to help them recognize it and reconnect to it.

By the time a client has found their way to my door, an enormous amount of resiliency has already been demonstrated, just by the mere act of surviving the event and continuing with life.   The fact that they have gone further and somehow found a therapist is yet another display of resiliency, as is the fact that they continue to show up over and over again for sessions.

These resources have enabled the trauma survivor to endure, to persevere, to continue with life, to try to make things better in the midst of pain, to reach out for help, to seek meaning and hope. 

When you add up all the small displays of resources demonstrated across hours, days, weeks, and months, all the small choices to keep on trying in spite of the difficulties, you’re looking at a rich, ongoing web of resources. 

That is resiliency.  Clients don’t recognize it or feel it as such yet, of course, and a key part of the therapist’s role is to help them claim it. 

Scan the survivor’s life post-trauma with an eye for strengths
Discovering previously unused personal resources is one of the keys to trauma integration.  This is an essential foundation for nobody is ever quite the same after trauma.   Recovery requires a significant amount of rebuilding of the self and renewing a sense of connection to the foundations of life. 

The goal in rebuilding and renewing cannot be to throw out everything from the past, or try to get back to things they way they used to be.  Rather it must be to reclaim familiar and enduring elements of the past and reframe them in a new configuration of purpose and meaning. 

This new configuration must somehow incorporate the injury, loss, pain, and changes caused by trauma and its aftermath.  This becomes possible, and surprisingly, life-giving, when the primary handles for incorporating the trauma experience into on-going life are the personal strengths exhibited by the survivor in coping with it.

In the same way that stress and trauma are cumulative, so too are reactions, responses, and coping mechanism that keep us alive.

From the moment trauma takes place, we are wired with  survival mechanisms that mobilize special resources for coping.  Commitment to life, determination, persistence, and courage often show up in a survivor’s life during and after trauma in new ways. 

Other reactions show up as well, some quite troubling. Early arrivals often include hyper- or hypo-alertness, anxiety attacks, anger, shame and guilt.  Later we may see depression, avoidant behaviors, addictive behaviors, etc. 

Such Withdrawal reactions (Stage 4 ETI roadmap) are at root resources for survival. They are defense mechanisms that enable a survivor to stay alive in a time of crisis.

By scanning the chaotic personal aftermath of trauma with an eye for strengths, survivors can reclaim the energies unleashed but rarely recognized as such in the struggle with fear, pain, and loss.

Embodied resilience: self-regulation
According to Panter-Brick (in Southwick et. al. 2014), some indicators of resilience are physical biomarkers such as blood pressure, stress hormones, immune functions etc. These markers are easy to measure and can demonstrate progress of self-regulation.  The more a survivor is able to self-regulate in response to stress the more likely that these biomarkers of resilience will show up.    

In working on self-regulation the challenge is to reconnect to the body and regain a sense of control within. One approach is for a therapist to invite the survivor to fully experience the stress without trying to reduce or eliminate it. The therapist might encourage the client to instead expand the uncomfortable symptoms, in order for the survivor to experience a sense of control over them.

The underlying principle is that, in order to regain access to memories and responses of the body that have been frozen by trauma, survivors need to expand their control over the instinctual (ie: spontaneous) stress response to the trauma. However, this needs to be achieved without activating a shutdown response (fight/flight/freeze) that is often triggered by reminders of the traumatic story.

An active decision to act
In the ETI roadmap, the fifth stage is action.  Three things need to be part of action for it to be effective: (1) The timing of action needs to be chosen by the survivor, not imposed by life, by other people, or by the therapist; (2) Action needs to engage with the trauma story or the pain and injury that resulted from the aftermath of it; (3) Action needs to involve some element of emotional risk for the survivor, no matter how small (thereby expanding the window of tolerance).

Risk, for a trauma survivor?  Yes! 
In the third point above, I highlight the importance of risk.  This may seem surprising in work with people who’ve endured great loss.  But risk is unavoidable for living well and one of the greatest damages trauma inflicts is deep fear of it.  Since risk is so intertwined with life itself, that translates, in practical terms, into something pretty close to deep fear of life itself.  

Part of the therapist’s task, then, is to assist a client to reclaim living with risk as part of life.  This is assisted by consciously choosing engagement with risk under the supervision of a therapist in a therapeutic setting. The goal is to assist the client to consciously make a decision to take a risk, and thereby to rediscover that vulnerability increases engagement with life.

The action chosen varies widely from one person to another and it need not be big.  I point out to clients that they’ve already taken an action involving risk by entering the door of my clinic, not just once but over and over again.  In this space they are able to be vulnerable.  Not only are they discussing an experience that has brought them great pain, they are doing so with a new person who, in the beginning at least, is largely unknown to them.

Other risks follow as therapy proceeds.   One of the therapist’s most important contributions is creating spaces that allow for incremental risk-taking as the client’s journey proceeds.   This can be done in many ways, but as a practitioner of experiential modalities, I find the use of imaginal space** particularly effective. 

In imaginal space the survivor is guided through a short vignette in which she enters a spontaneous state and chooses any type of activity to explore the traumatic story.  The goal is to help the client regain a sense of control over the trauma experience by choosing a response to the trauma event. It could be to create a drawing and embodied sculpture, a dramatic vignette, narrating a script, a letter, a poem, a song, a dance, etc.

Not all trauma survivors need to do trauma processing
Trauma processing requires a strong and safe bond between the client and therapist. It also requires self-regulation for the client to be in the present in the face of what comes up. For some clients, work on improving self-regulation increases their quality of life enough that they feel little need to do extensive processing of the trauma event itself. This may suffice for now, and in the future they can engage further with more deep trauma processing if the wish arises.

Other clients feel a need to go over certain aspects of their trauma experience experientially, again and again, until they are able to gain a sense of control over this pivotal event that separates life for them into two phases, before-trauma and after- trauma.

Narrative processing is Stage Six, the final stage of the trauma integration process, when the client processes their emerging narrative, using a talk-based, top-down modality.

It’s about trauma integration, not happily ever after
Trauma is painful. Pain is a part of life and we all carry it with us all the time. The hardest part of trauma therapy, as in many other kinds of therapy, is coming to terms with the fact that the pain that brings clients to seek help will not necessarily go away.

But in effective therapy, the relationship of survivors to the pain of trauma changes, so that it no longer dominates consciousness and monopolizes resources for living.  Trauma and the resulting pain become but one part (or parts) of the rich, ongoing tapestry of life.

Endnotes:

*I differentiate between two types of trauma processing. The first, which I mostly have in mind in this post, is experiential, using imaginal space. The second is narrative processing, which takes place later, after we engage with the trauma experientially.

**Imaginal space is an abstract creative space of play, fantasy, and spontaneity in which a client can explore and engage with different aspects of personal experience through art, play, movement, dance, drama, music, etc.

References

Scali, J., Gandubert, C., Ritchie, K., Soulier, M., Ancelin, M. L., & Chaudieu, I. (2012). Measuring resilience in adult women using the 10-items Connor-Davidson Resilience Scale (CD-RISC). Role of trauma exposure and anxiety disorders. PloS one, 7(6), e39879.

Southwick, S. M., Bonanno, G. A., Masten, A. S., Panter-Brick, C., & Yehuda, R. (2014). Resilience definitions, theory, and challenges: interdisciplinary perspectives. European Journal of Psychotraumatology, 5.

Yehuda R, Flory J. D. Differentiating biological correlates of risk, PTSD, and resilience following trauma exposure. Journal of Traumatic Stress. 2007;20(4):435–447.