Trauma and Trauma-Focused Therapy
Psychological trauma is an emotional response to a distressing event (or set of events) resulting in symptoms that are outside of the normal human experience. The following provides some basic information about mental health diagnoses that are related to psychological trauma.
Those who are exposed to actual or threatened harm or violence often develop trauma symptoms. PTSD is commonly diagnosed following experiencing, witnessing, or learning about such an event. It has the following characteristic symptoms:
- Intrusion symptoms: flashbacks, nightmares, negative thoughts, and sudden increases in unpleasant emotions, or physical sensations
- Hyperarousal/reactivity symptoms: feeling on edge, on the lookout for danger, difficulty focusing concentration, difficulty feeling relaxed or sleeping, and irritability or quick jump to aggression with little provocation
- Triggered responses: intrusion or hyperarousal/reactivity symptoms may be triggered by external or internal reminders of a past traumatic event
- Avoidance symptoms: persistent efforts to avoid external reminders of past traumatic event/s (e.g., avoiding the place that the event occurred), and/or suppression of thoughts, feelings, or emotions associated with the event
- Negative alterations in thinking or feelings: This cluster of symptoms closely mirrors depression/anxiety and may include negative beliefs, inappropriate guilt/shame, persistent low or anxious mood, withdrawal from others, and difficulty experiencing positive emotions
Dissociative symptoms are commonly associated with trauma and generally involve some kind of disconnection from present moment experience. Some common dissociative symptoms include:
- feeling zoned out
- frequently or persistently staring off into space
- feeling disconnected from yourself or your environment
- difficulties remembering large chunks of your personal history
- memory lapses in your day-to-day life
- feeling as if time is moving very fast or slow
- having thoughts, feelings, or urges that do not appear to be your own
- images popping up in your mind’s eye that you do not understand
- hearing internal voices
There is some debate about how complex PTSD should be defined and how it should be differentiated from PTSD. When PTSD becomes more “complex” it generally means that some (or all) of the following is present in addition to a more classical PTSD presentation:
- Distressing events that occurred frequently over an extended period
- Multiple traumatic events occurred during childhood
- Childhood was frequently (or always) unsafe, abusive, neglectful, or unstable
- Trauma/s had an aspect of relational betrayal – traumatic events were perpetrated by a person who was trusted or was in a protective role
- Intrusion and hyperarousal/reactivity symptoms may occur in response to a wider range of triggers and those triggers may be more generalised (e.g., people in general are the trigger as opposed to a person with a particular appearance)
- Perception of threat more highly generalised – person feels perpetually unsafe, on edge, or expecting harm or mistreatment from others
- Dissociative symptoms more likely to be present and more pronounced
- Significant relationship difficulties and difficulties in feeling close to others
- Going back-and-forth between feelings of extreme closeness and extreme isolation in relationships with others
- Intense mistrust of others
- Frequent and intense feelings of helplessness, worthlessness, guilt, shame, blaming self, and failure
- Difficulties in regulating emotions and behaviour especially when triggered or distressed
- Intense mood swings lasting a few minutes to a few hours.
- Extreme emotional reactions
- Self-destructive behaviours: self-injury, alcohol and drug misuse, disordered eating, casual sexual encounters, excessive spending, gambling etc.
- Multiple prior diagnoses or multiple competing diagnoses that explain some but not all symptoms experienced. These may include depressive, anxiety, bipolar, personality, eating, substance use, or sleep disorders
Some people have early relationships and key events in their relationship with others that they still find highly distressing. Although these relational events are not life-threating, they can have an effect that is similar to a trauma response. When upsetting relational events are frequent early in our lives, it can result in a fixation on these past events and an increased sensitivity to similar events in the present. The present events “trigger” the past distressing events. When “triggered” a person experiences emotional distress and can react with specific thinking and behavioural patterns. These responses may have helped the person maintain a sense of safety, restore their self-esteem, or manage social difficulties in the past. But these responses can get locked in and keep occurring in the same way when “triggered”. This is what we call a “personality disorder”. Oftentimes the difference between those diagnosed with PTSD or complex PTSD and a personality disorder is that the type of trauma experienced was mostly “relational trauma”. Therefore, personality disorders can be usefully understood as a special form of trauma disorder.
Psychotherapy for Trauma
There are several therapies that have been effectively applied to trauma including:
- Trauma-Focused Cognitive Behavioural Therapy (TF-CBT)
- Eye Movement Desensitisation and Reprocessing (EMDR)
- Schema Therapy
- Sensorimotor psychotherapy/Hakomi
- Internal Family Systems (IFS)
Across these trauma-focused therapies a three-stage process is generally followed. These stages include:
Stage 1: Stabilisation and preparation
This stage involves:
- Learning about trauma and how and why it occurs
- Developing an understanding of the specific trauma/s and its impact
- Ensuring or developing personal safety within the current environment
- Developing and practicing emotional regulation strategies
- Identifying unhelpful thinking and behavioural patterns that have arisen because of trauma
- Identifying a set of important traumatic or distressing memories for processing
Stage 2: Processing
This stage involves:
- Bringing focused attention to a specific traumatic memory including focusing on the image of the memory in the mind’s eye, and the emotions, thoughts, and physical sensations that the memory brings with it
- Experiencing some distress (but not overwhelming distress) without trying to suppress these feelings
- Some technique (e.g., rapid eye movements, imagined narrative) designed to assist in reducing distress and discharging the emotional energy that the traumatic memory brings up
- Developing a new relationship with the traumatic event that is more realistic and based on an understanding that the event is now over and creating a sense of personal safety
Stage 3: Moving on
This stage involves:
- Developing and working towards new goals for life after trauma
- Developing and practicing new patterns of thinking and behaving
- Relapse prevention: avoiding falling back into old and unhelpful patterns of thinking and behaving
Trauma Focused Therapy:
Its not just for Trauma
Trauma-focused therapies can obviously be applied to PTSD and other trauma presentations, but they can also be applied to a number of other mental health diagnoses and symptoms – many of which can have trauma as a root cause.
Mental health symptoms can often be understood as responses or adaptations to distressing or traumatic early experiences. The emotional distress, negative thinking, and behavioural difficulties may be driven by unresolved trauma or distress. Therefore, working through this unresolved trauma is often important to effectively manage these symptoms. If you do not work on the root cause of your distress, the same problems will often keep arising again and again.
Trauma-focused therapy can help you to uncover the origins of your distress, how it’s triggered and why it keeps happening. It can also help you to identify and change your unhelpful thinking and behaviour patterns. Making meaningful and lasting change often involves some trauma-processing work around the origins of past distress. After processing trauma in this way, it is often much easier to break previous unhelpful patterns of responding.
See below how some other common mental health problems can be related to trauma. Often resolving trauma can be an important step in effectively managing these problems.
Stress is a protective nervous system response (the “fight or flight response”) which may be overactive if you have experienced trauma. Anxiety is like stress, but it helps us to anticipate things that could go badly in the future. For some people anxiety works too well and they find themselves worrying about things that are unlikely to happen, or avoiding too many things because they predict they will go badly.
Depression can leave you feeling low, tired, unmotivated, and hopeless. These feelings may have resulted from earlier experiences of being unable to achieve your goals or affect positive changes in your life. For others they may be dwelling on past failures, or had some invalidating or critical experiences earlier in life that loom large in their mind. Symptoms of depression are also common in those with PTSD often following on from missed opportunities that have been avoided or feelings of guilt and shame.
Many people with trauma can struggle with emotional regulation. They may have intense mood swings, struggle to calm themselves down after becoming distressed, or struggle to control their behaviour. This is because of their heightened stress and anxiety, and the emotional overwhelm that occurs when they are triggered.
Executive dysfunction is common with trauma and is a result of the heightened stress response. With heightened stress your mind often races with 1000 things all at once affecting your ability to make good decisions, remember important information, effectively plan and organise your day, and concentrate on one thing for extended periods. Trauma-focused therapies can assist with these difficulties which should naturally improve as you reduce your day-to-day stress levels.
Difficulties with sleep are common with trauma and are often related to a heightened stress response. Your stress response is designed to keep you safe from a physical threat (i.e., a predator). If you are chronically stressed, you are signaling to the nervous system that you are in danger. This naturally affects your ability to sleep well as it would be dangerous to sleep if you are in physical danger. Trauma-focused therapies can assist with sleep difficulties which should naturally improve as you reduce your day-to-day stress levels.
Alcohol and drug use are frequently used as a means of coping with the increased stress that may arise from trauma. Trauma-focused therapy can assist with understanding the distress you may be attempting to manage through alcohol and drug use and developing alternative coping strategies for managing distress. Following trauma processing you may find that your levels of emotional distress are not so intense that you feel the need to rely upon substances to manage.
If alcohol and drug use are severe, they may need to be addressed before any active trauma-focused therapy can begin.
Similar patterns can apply to other potentially addictive behaviours such as gambling, internet pornography use, video-gaming, spending, or even excessive working.
Disordered eating is commonly associated with trauma and in some cases may be a coping response for the distress associated with trauma. Binge eating releases endorphins which provides a feeling of calm. Starvation and heavily restricting eating can leave you feeling flat, unemotional, and in a dissociative haze (or “zoned out”) – which may be preferable to feeling emotionally overwhelmed. Some theorists also suggest that eating disorders may be a form of imposing a sense of control over an uncontrolled environment or situation. Understanding disordered eating as a coping response can assist in removing its stigma.
If body weight is dangerously low this may need to be addressed before any trauma-focused therapy can commence.
Body image issues can be related to trauma in a number of ways – but oftentimes the core of this is shame. You may have been criticised or shamed for your appearance in some way resulting in a fixation on changing some aspect of your body. Some people gain or lose weight, or present themselves in a certain way to avoid unwanted attention or make themselves unattractive or unappealing. Others may compulsively exercise, lift weights, take supplements, or engage in surgeries in order to make themselves appear muscular (often called vygorexia). Other cases may be based around cultural and societal ideals around attractiveness.
Trauma can be a root cause of some forms of sexual dysfunction. For some it may be related to early experiences of rejection or embarrassing early sexual experiences. For others it may be related to a history of sexual abuse.
These symptoms can be related to trauma and can be understood as attempts to cope through over-control of the environment. The function of these symptoms may be to prevent some distressing event from occurring through anticipating what could go wrong and taking action to ensure that it does not happen.
Often earlier traumatic events involve being betrayed or hurt by somebody close to you. This can leave you feeling insecure and mistrustful of others or having regular conflicts within your relationships. You may also feel unsure about your relationship even when most signs point to it being just fine. A positive, validating, and emotionally close relationship is an opportunity to work through earlier relational trauma – but it can only be helpful if you are able to effectively manage triggers that may occur within the relationship. Trauma-focused therapy can assist by helping you to identify your relational triggers, how and why they occur, and to be able to better recognise that these are not always signs that the relationship is not working.
Many people live with a sense of identity confusion – not knowing who they are or what they want in life. These feelings are common in those diagnosed with a personality disorder – but the origins of this identity confusion may be trauma. With trauma there is often an intense focus on avoiding perceived dangers. There may also be a fixation on relationships with others. This can leave the person not focusing on their own needs, values, or goals. Instead, they focus on maintaining personal safety and keeping their relationships intact at all costs. This can make it difficult for them to develop a consistent identity as they are always being who they need to be to avoid possible threats or to maintain their relationships.
Some physical symptoms can be related to stress or trauma. There is a category of mental disorders called “Somatic Symptom and Related Disorders” which are physical symptoms that do not have a medical cause. Some people experience their distress as intense physical discomfort or have multiple physical symptoms that do not have a medical cause (e.g., pain, gastrointestinal distress, numbness, sexual dysfunction, tension, seizures). These symptoms can be related to trauma and the related heightened stress levels experienced.
Often physical health issues can be exacerbated by heightened stress levels. Stress management strategies and processing trauma can reduce stress and thereby reduce these physical symptoms.
A medical cause for physical symptoms should be fully ruled out before these symptoms are treated with psychotherapy.
Sensory sensitivities and overwhelm are often associated with neurodivergent presentations (e.g., autism spectrum disorder/ASD, attention deficit hyperactivity disorder/ADHD). However, levels of sensory sensitivity are often related to stress – the higher the stress the greater the sensory sensitivity. Research indicates that neurodivergent individuals are more likely to experience trauma during childhood and adulthood. These traumatic experiences and the related increased stress can amplify the distress associated with sensory overwhelm. Managing stress levels can thereby help to manage sensory sensitivity and overwhelm.
Rejection sensitive dysphoria is a state of being highly sensitive to cues for rejection from others. This can result in low mood or distress when cues for rejection are perceived. It is very common in neurodivergent presentations (e.g., autism spectrum disorder/ASD, attention deficit hyperactivity disorder/ADHD). This appears to result from neurodivergent individuals commonly experiencing repeated rejecting and invalidating experiences as they grow up and into adulthood. Neurodivergent individuals often miss or misunderstand social cues, do things that may be perceived by others as strange or annoying, and are misunderstood by others. This can lead to them experiencing an increased number of rejecting experiences, criticism, abuse, or exploitation by others. This sets up an expectation of future rejecting experiences.
In effect, rejection sensitive dysphoria can be usefully understood as a special type of trauma response. But frequently the events experienced would not be traumatic if any one of them was experienced in isolation – they are “traumatic” in that they experienced very similar rejecting experiences everyday (or multiple times per day). Investigating the impact of these events and processing the related distress can assist in managing rejection sensitive dysphoria.
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