Lots of guys have asked what trauma treatment is, and how it might be different than brief counseling or psychotherapy. As discussed in another article, brief counseling is often provided by counselors or social workers, and usually consists of a few sessions where you talk about what's on your mind. For some this is enough to resolve distress, for others more intensive treatment might be necessary.
Psychotherapists can be either psychologists or social workers who have had more extensive training in the provision of therapy. This training occurs after the completion of either the psychology or social work degree and involves several years of training and supervision, often at a psychoanalytic institute or a family therapy institute. Psychotherapists tend to do more long-term treatment that focuses on issues that may underlie the presenting symptoms.
Trauma therapists can be either psychologists or social workers who have had extensive training and supervision by leaders in the field of traumatic stress for which they have received a Certificate or other documentation of additional credentials. They are usually members of one or more of the associations of trauma therapists listed in the Helpful Websites link. The goal of trauma therapy is to reduce or eliminate symptoms and enhance resilience.
Bear in mind that since it is popular to call oneself a "trauma therapist" or a "trauma expert" you need to ask what specific training the clinician has had in this area and what type of trauma treatment they offer, as there are several types.
A crucial factor in successful treatment is the connection you feel to the therapist. Also important is whether or not the symptoms you came in with are starting to clear up.
What I will be describing is what trauma therapy should look like in general:
1.) At the first session the clinician should ask you which of the following symptoms of traumatic stress you are currently experiencing. Some therapists will use a trauma scale to gather this information. Symptoms are grouped in four clusters:
¨ Hyperarousal: Increases in heart rate, respiration and blood pressure; psycho-motor agitation, physical tension, difficulty sleeping, remembering and concentrating, anxiety, fear, irritability or anger.
¨ Avoidance: Avoiding reminders of the trauma including talking about it, thinking about it, visiting places where it occurred, or being around people who shared the experience. Other avoidant symptoms include withdrawing from friends and family, or being unable to work.
¨ Intrusions: Intrusive thoughts or memories of the traumatic event; flashbacks (in which people feel they are reliving the event with great intensity); and nightmares (although sometimes people wake themselves up to not dream – which causes frequent waking throughout the night).
¨ Hypoarousal: A sense of being emotionally numb, not feeling, (sometimes not smelling or tasting), having a sense of “unreality” or amnesia about the event or in general; being “spaced out” a lot. Concentration problems can also be a symptom of hypoarousal. People can be tense and agitated at the same time as they feel numb inside.
These symptoms can be so distressing that people overuse alcohol or other substances in an effort to feel better. This can become a habit, especially when the very nature of the work environment exposes people repeatedly to traumatic stress.
Or, people find themselves engaging in high-risk activities, taking unnecessary chances at work, or being careless and having unusual “accidents”. This can be extremely dangerous for people whose work is high risk anyway – especially if they are frequently not sober.
A good way to know if your therapist is trained in the treatment of traumatic stress is if they focus on your specific symptoms. This is the way the therapist determines what to work on. It is also a way for you to know if you're getting better - you can do periodic trauma scales (rating the distress level) and compare them to follow your progress.
Also, trauma therapists know that talking about what happened is generally not enough to heal posttraumatic stress symptoms. In fact, sometimes talking makes people feel worse. That is why trauma therapists use a wide range of techniques that help the traumatic experience to be processed so that it no longer causes distress in everyday life.
These techniques address the core problem with trauma - people develop symptoms because during the traumatic experience they felt helpless and unable to change the outcome.
So the goal of trauma therapy is to enable you to get back in control - by learning how to calm yourself down when agitated or to feel things again if you have been numb.
2.) Good clinical treatment of traumatic stress should be planned between you and your therapist in order to treat your specific symptoms:
Your therapist should share with you what the plan is to resolve your symptoms;
Your therapist should be helping you learn how to calm yourself down if you are agitated, or start to feel more if you are numb;
Your therapist should have a variety of tools in his or her toolbox to teach you in the office so that you can use them at home or at work;
Your therapist should be willing to collaborate with other therapists who have tools they don’t have (i.e. – refer you to have EMDR);
Your therapist should be willing to re-assess what’s going on, make changes and listen to you.
Most importantly – it is your therapist’s responsibility to take care of you – not the other way around. If you are feeling in any way “used” by your therapist - this is a red flag that something is wrong – and not with you. Trust your gut.
3.) Good clinical treatment of traumatic stress follows what is called “Phase-Oriented Treatment”:
Phase One: Re-establishing safety and stabilization. Similar to what you do at the scene of an accident or a fire with people who are physically injured – they must be moved to a safer place, physically, so that they can feel safe again – but first their injuries must be stabilized so they can be moved. With traumatic stress the same principle holds true – before working on or talking about what happened, people, especially firefighters, cops and soldiers, need to feel in control again. Talking about what happened before the person is safe and stable (in control) can be re-traumatizing and can lead to people dropping out of therapy.
Phase Two: De-sensitizing and processing the traumatic memories. This is where talking about what happened is more a part of the treatment. It is a re-exposure to what happened with the idea that the more it is gone over, the less disturbing it becomes. During this phase some of the cutting edge treatments like EMDR can be most helpful because they enable the memories to be processed while the person is in a more relaxed state. This allows for resolution – the memories become regular memories, not traumatic ones.
Phase Three: Re-connection and Integration – reconnecting with family and friends and re-establishing the capacity to enjoy your lives and have fun again. This is the end of treatment – and you know when you’ve gotten here because you feel more like yourself again. The trauma has become integrated - it is now a part of your life – not all of your life.
4.) Remember – trauma is in the body, not just the mind:
¨ When a person is faced with a situation in which there is a threat to life, theirs or others, certain mechanisms in the body prepare for either fight or flight, or freeze. This is governed by brain chemistry – it is not a choice or an act of will.
¨ What happens is that the most primitive part of the brain (the reptilian brain or brain stem), which controls basic functions – breathing, eating, sleeping, etc. – goes into overdrive in the service of survival. Everything else is subordinated to survival needs.
¨ When this system is in overdrive people become hyperaroused – as if they need to be prepared for danger at all times. This is why after trauma people are unable to sleep and are sensitive to “triggers” (loud noises, specific locations, and other personal reminders).
¨ Another part of the brain, the limbic system, is also in overdrive. The amygdala, the part of the limbic system known as the body’s “smoke detector,” enables us to tell the difference (emotionally) between what is real danger and what may be a reminder of something that occurred in the past and is over. Because it is overreacting to the current environment and not discriminating between past and present, people react as if the danger is happening now.
¨ The pre-frontal cortex, however, which is the seat of cognition (thought processes and language) is suppressed during trauma. This is because during a traumatic event thinking would interfere with instinctual “animal defensive” responses and this would be a threat to life. So, the pre-frontal cortex shuts down in the interest of survival. Unfortunately, it often remains in that state.
¨ With some brain systems shut down and others in hyper drive , people over-generalize what represents danger and are unable to think clearly – this is why lots of people have problems post-trauma with concentration, memory, decision-making, and talking about what happened to them.
¨ This is physiological. But it obviously creates psychological and social problems – not the least of which is the feeling of going crazy.
Basically, since trauma is in the body the most effective treatments are those that treat the body’s response, which talk therapy alone does not do. Some of the therapies that treat the body as well as emotions and thoughts are:
EMDR (Eye Movement Reprocessing and Desensitization)
CBT (Cognitive-Behavioral Therapy)
TFT (Thought Field Therapy) (tapping on acupressure points)
Body-based trauma therapies (Sensorimotor Psychotherapy and Somatic Experiencing)
The best therapists to work with after a traumatic experience are those that use some of the above treatments in their practice and/or are willing to refer you to a colleague who has expertise in areas in which they do not.
A lot has changed in our understanding and treatment of traumatic stress in the last few years. Try to get connected to therapists who have taken in these new ideas, and have incorporated them into their clinical practice.
There are many qualified trauma therapists in New York City and elsewhere…they can be located by checking out the resources listed in the Helpful Websites link, or contacting me directly for a referral.
It has been said that “Hurt people, hurt people”. So, before you let this happen to you, get some help. You deserve it and so do your loved ones.
