Introduction to therapy for trauma
Trauma is one of the most common issues that I see in both my private practice and my NHS work. Often people who come for help with trauma don’t know what is happening to them or why they are having nightmares, flashbacks or feeling scared a lot of the time. I am writing this article so people experiencing trauma can better understand how therapy can help them to overcome this often frightening and overwhelming situation.
Trauma and anxiety
The first obstacle people face when getting help with trauma is realising that they are suffering with this specific issue and not a more general experience of anxiety. Without specific training or knowledge it is easy to confuse the two. Awareness about trauma is improving however, partly due to media attention focused on celebrities like Prince Harry. Healthcare professionals like GPs, nurses and psychologists are also becoming more knowledgeable about the issue and the need for specialist trauma therapy.
It is no surprise that people struggle to tell general anxiety and trauma apart as one of the main ‘symptoms’ of trauma is intense anxiety. Indeed, psychiatrists used to consider trauma to be a type of anxiety disorder1. The distinction between anxiety without trauma and anxiety as a result of trauma is important however because they require different types of therapy.
For people experiencing trauma, anxiety can be thought of a consequence of living with traumatic memories. Traumatic memories aren’t just remembered, they are re-lived and can be incredibly vivid and upsetting. Even if people are able to learn effective ways of coping with moderate anxiety in their everyday lives (e.g. breathing exercises or refocusing techniques), their mind can still feel paralysed when a traumatic memory is activated by a trigger.
Anything which reminds that person of the traumatic event (or series of events), such as an advert or story line on TV, a smell, a thought or a noise can act as a trigger which ‘turns on’ the vivid traumatic memory. In these moments the helpfulness of breathing exercises or similar to manage anxiety can feel limited.
What is trauma?
This article is only going to briefly touch on what trauma means in terms of psychology, but if you would like to find out more ‘The Body Keeps the Score’ is a popular book which outlines the concept in more detail2. For our purposes a basic definition of trauma is: a person is exposed to an event which causes an overwhelming amount of anxiety (it could be that they or someone they care about is in danger). After this event, the person re-experiences the trauma through nightmares, flashbacks and intrusive memories. In other words, they have times when they feel like the trauma is happening to them again and they may find it hard to remember that it is just a memory.
People often feel highly anxious and like they are constantly on the lookout for danger. They may find it hard to relax and can be easily startled or frightened by things like loud or unexpected noises. Because this experience of reliving trauma is so horrible, the person likely begins to avoid things which trigger off their memory (e.g. people, places, objects) and so their life begins to contract around them. People suffering from trauma can also come to feel very negatively about themselves and their place in the world. They can blame themselves, feel like a burden to others, or like they don’t fit in3.
How does trauma therapy help?
Trauma therapy aims to help people to process their traumatic memory so that they don’t feel like they are reliving it whenever they are reminded of the event. Their body does not react as strongly to triggers and so they feel less anxious. They can start to do more of the things they enjoy and feel more positively about themselves.
There are two main models of therapy which are proven to be effective in processing trauma: trauma focused CBT and EMDR (Eye Movement Desensitisation and Reprocessing). Both are effective4 but I have chosen to specialise in EMDR, partly because it requires clients to talk less about their trauma to achieve a positive result, and often this is something which people find very difficult to do.
During doctoral training for Clinical Psychology, we are taught multiple models of therapy. Trauma therapy is special in that it requires additional training after the standard doctorate. This is because it has its own specific nuances and skills which can take a long time to learn and master.
For EMDR there are multiple phases that a therapist and client must go through. To begin with they discuss the traumatic memories, what triggers them off and how they are getting in the way of the client living the life they want to live. Then the therapist and client prepare for processing of memories by practicing exercises which help to calm and relax the client so that they have a way of bringing themselves back to the present and feeling safe after thinking about the traumatic memory. The ‘preparation phase’ normally takes 2-3 sessions and is essential for the work to be carried out safely and effectively.
The preparation phase is followed by the ‘processing phase’ of therapy which is usually the longest part of therapy, taking anywhere from 2 to 12+ sessions depending on how many and how challenging the memories are. During the processing phase of therapy, clients follow the hand movement of the therapist, or alternate tapping left and right on their own bodies (a YouTube search will show you videos of how this looks in practice, as well as more detailed explanations of the different phases of EMDR). This is called ‘bilateral stimulation’ and is done whilst the client thinks about the traumatic memory.
Finally, after the traumatic memories are processes, the therapist and client will think together about the future and do some work to help the client to maintain their progress, and expand their life out to include more of the things they enjoy and care about.
Typically at the start of therapy the client feels highly anxious when thinking about the memory and can experience a temporary increase in anxiety and other effects of trauma. However, when therapy works well, this anxiety reduces dramatically over time. As the memory is processed over the weeks, clients can experience fewer nightmares, less intense responses to triggers and feel more relaxed in their everyday lives.
Why does trauma therapy work?
Although we don’t often like to admit it, in all honesty, scientists don’t really know why trauma therapy works so well. The positive results of trauma therapy are clear, but the psychological and biological mechanisms at work are still hotly debated5. As usual with psychological science, we tell a simplified story about how the brain works which makes sense to us: when we are using bilateral stimulation we are allowing the mind to explore new connections between the trauma and other, happier memories.
When done in a safe, supportive environment like the therapy room, this allows our minds to process the traumatic memory in a way which knits it together with the rest of our life story. Instead of feeling helpless or hopeless when we remember the challenging memory, our minds draw on other experiences where we overcame problems to give us a more positive and helpful story which makes us feel like we can cope with the past.
After trauma therapy, we are left with a sad or painful memory, but one which does not jump out and terrify us when we see a related advert on TV, or leave us drenched in sweat upon waking from another nightmare. Given how complex the brain is, I believe we might never really know why trauma therapy works as well as it does. I also believe that as long as we continue to be honest about this and conscientious in terms of the research which proves that it does work, then we can continue to help people in a productive and safe manner.
In my opinion trauma therapy is one of the most challenging therapies for clients and anyone who wholeheartedly engages with it deserves the utmost respect. The fact that I see so many clients who are willing to give it their all, despite how demanding it can be, just shows how difficult living with trauma is and why having specialist therapies like this is so important.
Thanks for reading,
Andrew
Dr Andrew Morgan, Clinical Psychologist
References
1: Pai, A., Suris, A. M., & North, C. S. (2017). Posttraumatic Stress Disorder in the DSM-5: Controversy, Change, and Conceptual Considerations. Behavioral sciences (Basel, Switzerland), 7(1), 7.
2: Van der Kolk, B. (2014). The body keeps the score: Mind, brain and body in the transformation of trauma. Penguin UK.
3: American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders (5th ed.). https://doi.org/10.1176/appi.books.9780890425596
4: de Jongh, A., Amann, B. L., Hofmann, A., Farrell, D., & Lee, C. W. (2019). The status of EMDR therapy in the treatment of posttraumatic stress disorder 30 years after its introduction. Journal of EMDR Practice and Research, 13(4), 261-269.
5: Landin-Romero, R., Moreno-Alcazar, A., Pagani, M., & Amann, B. L. (2018). How does eye movement desensitization and reprocessing therapy work? A systematic review on suggested mechanisms of action. Frontiers in Psychology, 9, 1395.
