Effective Treatment for Trauma

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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 Overview

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, and 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.

How do you know if it is traumatising enough, or in effect ‘qualifies’?Ask yourself:

• ‘Have I thought about this in the last month?’

• ‘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 is 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, or physical sensations of fear, but is, in fact, well processed… as if it’s been assigned to the right drawer in the filing cabinet.

‘In PTSD reliving the trauma repeatedly in therapy may reinforce preoccupation and fixation’— Van Der Kolk (2014)

Medication and Limitations

Serotonin may help trauma, i.e., in the form of selective serotonin reuptake inhibitors or SSRIs 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 SSRIs may play a role in calming an emergency situation, the problem absolutely needs psychological treatment, with the anti-depressants 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 social life, friends, experience, educational background, tragedy, and geographical bad luck are amongst some of the potential factors feeding into the underlying cause.

Trauma Processing and The Brain

With distinct and specific trauma instances, however, it goes back to processing — and thanks to the development of technology such as Positron Emission Tomography (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. Along with this, there is the production of the hormones associated with the fight, flight, or freeze mechanism.

When neutral memories or non-threatening memories occur, it is the pre-frontal cortex (PFC) 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/rational) areas.

Although this is overly simplified here, these are:

• the Limbic System (where the amygdala is located)

• the Pre-Frontal Cortex (more modern, logical area)

‘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 were you? Usually, calm comes later, when you are thinking about the incident after the threat has disappeared.

Threat Assessment Problems

One of the problems with trauma is accurately assessing whether a situation or person is actually a threat. The amygdala, following trauma, may start to inaccurately assess threat — and remember, this is the part of the brain that always assesses any given situation for threat.

Information goes there first, and then, if the threat does not seem too awful, the 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.’

In essence, the PFC is our controlling mechanism — it inhibits us from saying and doing things which, when considered logically, 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’), 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 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 — 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.

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, and calm yourself 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 sometimes ‘process’ it simply by being heard and understood — although 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 — thought of by Francine Shapiro in the late 1980s — has gained traction as a frontline approach for trauma, including both with trauma with capital and lowercase 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 — which is seen as an important part of processing information during sleep.

How it works is not so well understood, but that it does work is not so much under question — with numerous well-designed research trials showing an impressive reduction in symptoms for PTSD with as little as 3 × 90 minutes of treatment.

The number of sessions depends on the complexity of the trauma — a single event may be resolved in one session, while multiple traumas may require processing a few ‘linked’ memories to create a knock-on effect.

The American Psychological Society lists Cognitive Behavioural Therapy and prolonged exposure therapies as ‘strongly recommended’ versus EMDR being ‘conditionally recommended’; although a recent meta-analysis suggests that EMDR may outperform 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 worst events relating to the trauma, and to identify how this has left you feeling. This feeling may form an ‘I message’, for example: “I feel worthless” when the way you were treated made you feel that way.

Next, we must prepare the opposite — the way in which you would really like to feel about yourself, e.g., “I have worth.”

The processing involves recalling these memories and negative beliefs 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 the 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. (n.d.). Eye movement desensitization and reprocessing. https://www.apa.org/ptsd-guideline/treatments/eye-movement-reprocessing (Last accessed: March 14, 2022)

  
  

• 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). https://doi.org/10.7759/cureus.3250

  
  

• Peters, S. (2013). The Chimp Paradox: The mind management program to help you achieve success, confidence, and happiness. TarcherPerigee.

  
  

• Rothbaum, B. O., & Schwartz, A. C. (2002). Exposure therapy for posttraumatic stress disorder. American Journal of Psychotherapy, 56(1), 59–75.

  
  

• Shapiro, F. (2018). Eye movement desensitization and reprocessing (3rd ed.). Guilford 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. https://doi.org/10.3402/ejpt.v3i0.18805