PSYC 423 Psychology of Trauma

Week 12
Burcu İldeniz Tan, M.A.

Antalya Bilim Üniversitesi, 2024

 CLINICAL INTERVENTIONS

The client’s trauma history and posttraumatic symptoms

Then
Trauma Therapy

• Integration of cognitive-behavioral, psychodynamic, mindfulness, and eclectic approaches.

• Effective therapy— irrespective of underlying theory—,

• can usually be broken down into a number of broad components,
• the exact combination of which varies according to the client’s specific clinical needs.
 CLINICAL INTERVENTIONS

• An overall approach that is respectful, positive, and compassionate, and

• that provides support and validation in the context of
• an empathically attuned therapeutic relationship.

How to do?
• Psychoeducation on trauma and trauma symptoms

• Some form of stress reduction or affect regulation training

• Cognitive interventions that address harmful or debilitating trauma- related beliefs,

assumptions, and perceptions
 CLINICAL INTERVENTIONS

• Opportunities to develop a coherent narrative about the traumatic event

• Memory processing, usually involving guided self-exposure to trauma memories

• Processing of relational issues in the context of a positive therapeutic relationship

• Activities that increase self-awareness and self-acceptance,

• including opportunities to reflect on one’s internal experience and
• change one’s relationship to the effects of one’s history
 A BASIC PHILOSOPHY OF TRAUMA, RECOVERY, AND GROWTH

1. Intrinsic Processing
• Innate tendency for humans to process trauma-related memories and, when possible, to move
toward more adaptive psychological functioning.

• Many of the “reexperiencing” symptoms of posttraumatic stress disorder can be conceptualized

as recovery algorithms that humans have evolved over time as a response to trauma exposure

• The intrinsic function of these reliving experiences appears to be, at least in part, a way to
process, desensitize, and integrate upsetting material.

• Intrusive trauma-related symptoms are, in a sense, attempting to metabolize or internally resolve

distressing thoughts, feelings, and memories.

• Many posttraumatic symptoms as, to some extent, adaptive and recovery-focused rather than as
inherently pathological.
 A BASIC PHILOSOPHY OF TRAUMA, RECOVERY, AND GROWTH

1. Intrinsic Processing

• That therapeutic exposure and other approaches to processing traumatic memories may
work by optimizing those activities in which the client is already engaged, as opposed to
imposing entirely new or alien techniques.

• Traumatized individuals are not collections of symptoms, but rather people who, at some
level, are attempting to recover—even not always successfully.

• This view allows the therapist to more clearly understand expressed emotional pain as “just”
emotional pain
• but rather as a process wherein the client can process her or his history and ultimately
experience reduced emotional suffering.
 A BASIC PHILOSOPHY OF TRAUMA, RECOVERY, AND GROWTH

• Trauma can result in growth.

• Adversity and distress—beyond their capacity to disrupt and injure—often help people to
develop in positive ways.
• New levels of psychological resilience,
• additional survival skills,
• greater self-knowledge and self-acceptance,
• a greater sense (and appreciation) of being alive,
• increased empathy, and
• a more broad and complex view of life in general
 A BASIC PHILOSOPHY OF TRAUMA, RECOVERY, AND GROWTH

• The recently widowed person may learn new independence,

• the survivor of a heart attack may develop a more healthy perspective on life’s priorities, and
• the person exposed to a catastrophic event may learn important things about his or her
resilience in the face of tragedy.

• Not all outcomes associated with adversity are inevitably negative.

• “Look on the bright side” ???

• Survivor’s life, although perhaps irrevocably changed, is not over, and that future good things
are possible.
 A BASIC PHILOSOPHY OF TRAUMA, RECOVERY, AND GROWTH

• Some traumatic events are so overwhelming that they make growth extremely difficult

• Impossible (if not disrespectful) to suggest any eventual positive outcomes to the client.

• Severe childhood abuse, torture, or disfiguring fire may feel that they have been permanently
injured, if not ruined for life.

• Even in these instances, however, treatment should not be limited to symptom reduction; it
may also include the possibility of new awareness, insights, and skills.
 A BASIC PHILOSOPHY OF TRAUMA, RECOVERY, AND GROWTH

2. Respect, Positive Regard, and Compassion

• The traumatized client should be seen as someone who is struggling to come to terms with his or her
history—and, perhaps, to develop beyond it.

• It is often hard to be in therapy, especially when such treatment requires one to feel things that one would
rather not feel and think about things that one would rather not consider.

• The easy choice - to block awareness of the pain and avoid the thought—to “let sleeping dogs lie.”

• It may be that the client must engage in some level of avoidance in order to deal with otherwise overwhelmed
memories, thoughts, and/or feelings during treatment.

• Such “resistance” does not contradict the fact that the client deserves considerable respect for being willing to
revisit painful event.
 A BASIC PHILOSOPHY OF TRAUMA, RECOVERY, AND GROWTH

• Visible therapist respect and appreciation assists

• greatly in establishing a therapeutic rapport,
• increasing the likelihood that the client will make himself or herself psychologically available to the
therapeutic process.

• Compassion
• nonjudgmental, nonegocentric awareness and appreciation of the predicament and suffering of another
• with the directly experienced desire to relieve that person’s distress and
• to increase his or her well-being.

• Unconditional caring that is directed to the client regardless of his or her actual or presumed good or bad
qualities.

• Compassion is not equivalent to pity.

 A BASIC PHILOSOPHY OF TRAUMA, RECOVERY, AND GROWTH

3) Hope
• Hope is critically important to effective trauma treatment.

• Repeated experience of painful things (including symptoms) may cause the client to expect continuing despair as an
inevitable part of the future.

• The task of therapy is to reframe

• trauma as challenge,
• pain as (at least in part) awareness and growth, and
• the future as opportunity

• Not being Pollyanna-ish

• Instead, the challenge is
• to acknowledge the sometimes incredible hurt that the client has experienced, while, at the same time,
• gently suggesting that his or her presence in treatment signals implicit strength, adaptive capacity, and hopefulness for
the future.
 A BASIC PHILOSOPHY OF TRAUMA, RECOVERY, AND GROWTH

• Instilling hope does not mean that the therapist promises anything.

• Yet an overall positive view of the client and his or her future is often justified and helpful.

• Even when not treated, many of those individuals exposed to major trauma will experience significant
symptom reduction over time (Freedman & Shalev, 2000).

• Even more important, having completed trauma-focused treatment is associated with greater symptom
reduction than not having done so.

• Instilling hope is not a therapeutic goal, the instillation of hope is a powerful therapeutic action.
 THE PAIN PARADOX

• Traumatized or otherwise suffering people sometimes inadvertently engage in pain-enhancing or sustaining

behaviors while trying to reduce painful or upsetting states.

• Survivors may do things that specifically increase, not decrease, posttraumatic distress, and that often make
them more chronic.

• According to general opinion of society, feeling good often arises when one has done things to stop from
feeling bad.

• But modern psychology (and, as it turns out, philosophies such as Buddhism) suggests that avoiding
unwanted thoughts, feelings, and memories actually increases or sustains pain, symptoms, and distress
• whereas directly experiencing and engaging pain ultimately reduces it.
 THE PAIN PARADOX

• Using drugs or alcohol, dissociate, avoid discussing what has happened to them, and/or engage in other
avoidance behaviors such as denial or thought suppression are more likely to develop intrusive and chronic
posttraumatic problems and syndromes.

• In contrast, those who are able to more directly experience distress, or engage in psychotherapy, mindfulness
training, therapeutic exposure, or other ways of accessing traumatic memory, are likely to have improved and
experience less chronic outcomes.

• “What we cannot hold, we cannot process. What we cannot process, we cannot transform. What we cannot
transform haunts us” (Bobrow, 2007).

• Trauma-related problems in affect regulation and tolerance, especially in the context of overwhelming
memories, and/or a lack of sufficient social support, may mean that the survivor essentially has no choice but
to avoid, in order to maintain some degree of internal homeostasis.

• Offering an invitation to engage when it is safe and appropriate to do so, and only to the extent possible.
 PSYCHOEDUCATION

• Psychoeducation is also an important aspect of trauma therapy

• Many survivors of interpersonal violence were victimized in the context of
• overwhelming emotion,
• narrowed or dissociated attention, and, in some cases,
• a relatively early stage of cognitive development

• all of which may have reduced the accuracy and coherence of the survivor’s understanding of these traumatic
events.

• A more powerful figure who justifies his or her aggression by distorting objective reality
• for example, by blaming victimization on the victim.

• These fragmented, incomplete, or inaccurate explanations of traumatic events are often carried by the survivor
into adulthood, with predictable negative results.
 PSYCHOEDUCATION
• Therapists can assist in this area
• by providing accurate information on the nature of trauma and its effects, and
• by working with the survivor to integrate this new information and its implications into his or
her overall perspective.

• Individual treatment or support groups

• Support groups
• a small number of people with similar trauma histories
• compare stories,
• give each other advice, and
• discuss interpersonal violence and its effects.

• Support groups may be less efficient than face-to-face psychotherapy for the client’s own processing,
integration, and personal application of whatever he or she learns from such information.
 PSYCHOEDUCATION
• Handouts
• the prevalence and impacts of interpersonal violence,
• common myths about victimization, and
• social resources available to the survivor.

• Therapist should be careful about;

1. The quality of the materials.
2. The language of the materials.
3. The cultural appropriateness of the information or depictions.
4. The risk of insufficient cognitive-emotional integration.

• Didactic material alone may not be especially effective in changing the beliefs or behaviors of victimized
individuals.
• Instead, the clinician should ensure that the information is as personally relevant to the survivor as possible.
 PSYCHOEDUCATION
• Books
• Clinicians may also refer clients to readily available books that are “survivor- friendly,” such as Judith
Herman’s Trauma and Recovery.

• Such books allow clients to “read up” on traumas similar to their own.
• Other books can contain advice as well as information.
• Some may be too emotionally activating for some survivors with unresolved posttraumatic difficulties.
• Other books may contain erroneous information or suggest self-help strategies that are not helpful.

• The clinician should personally read any book before recommending it to a client.
 PSYCHOEDUCATION
• Verbal Information During Therapy

• More typically information is provided verbally by the clinician during the ongoing process of psychotherapy.

• Because the educational process is directly imbedded in the therapeutic context, it is often
• more directly relevant to the client’s experience, and thus
• more easily integrated into his or her ongoing understanding.

• Psychoeducation allows the therapist to more easily monitor the client’s responses to the material and to clear
up any misunderstandings that might be present.
• Over- or misapplication of psychoeducation during treatment can also impede therapy progress.

• Correct balance of content versus process

 PSYCHOEDUCATION
• General Focus of Psychoeducation

• The prevalence of the trauma

• Common myths associated with the trauma
• The usual reasons why perpetrators engage in interpersonal violence
• Typical immediate responses to trauma
• The lasting posttraumatic responses to victimization
• Reframing symptoms as trauma processing
• Safety plans
 DISTRESS REDUCTION AND AFFECT REGULATION TRAINING

• Trauma survivors often experience chronic levels of anxiety, dysphoria, and posttraumatic arousal.

• Many also describe extremely negative emotional responses to trauma-related stimuli and memories-feeling
states that are easily triggered and hard to accommodate internally.

• The survivor is often forced to rely on emotional avoidance strategies such as dissociation, substance abuse,
or external tension reduction activities.

• To avoid trauma-related material during therapy, or to drop out of treatment altogether.

• Two sets of interventions:

• to reduce acute, destabilizing emotions and symptoms that emerge during the treatment process
• focused on the client’s more general capacity to regulate negative emotional states.
 DISTRESS REDUCTION AND AFFECT REGULATION TRAINING

DEALING WITH ACUTE INTRUSION: GROUNDING

• In response to some triggering stimulus or memory, the client may experience sudden panic, flashbacks,
intrusive negative thoughts, dissociative states, or even transient psychotic symptoms during therapy.

• These internal processes can be frightening—if not destabilizing—to the client and can diminish his or her
moment-to-moment psychological contact with the therapist.

• At such times, it may be necessary to refocus the survivor’s attention onto the immediate therapeutic
environment (with its implicit safety and predictability) and the therapist-client connection.
 DISTRESS REDUCTION AND AFFECT REGULATION TRAINING

DEALING WITH ACUTE INTRUSION: GROUNDING

1. Attempt to focus the client’s attention onto the therapist and therapy
• Shifting one’s chair slightly closer to him or her, moving into his or her visual field, or slightly changing one’s voice
so that it compels more attention.

2. Ask the client to briefly describe his or her internal experience.

• “Susan, is something going on/upsetting you/happening right now?”

3. Orient the client to the immediate, external environment.

• (a) that the client is safe and is not, in fact, in danger, and
• (b) that he or she is here (in the room, in the session, with the therapist) and now (not in the past, undergoing the
trauma).

4. If indicated, focus on breathing or other methods of relaxation.

5. Repeat Step 2, and assess the client’s ability and willingness to return to the therapeutic process. Repeat
Steps 3 and 4 as needed.
 DISTRESS REDUCTION AND AFFECT REGULATION TRAINING

INTERVENING IN CHRONIC AFFECT DYSREGULATION

• It contains psychological interventions in the sustained hyperarousal and anxiety experienced by many
survivors of major, chronic trauma.

1. Medication:
• Pharmacologic agents that target anxiety and/or hyperarousal, or stabilize mood, sometimes may be helpful in
reducing such symptoms during trauma-focused psychotherapy.
• Such medications are not a cure-all for dysregulated emotional states and have side effects.
• The best approach to high pretreatment arousal and anxiety is to use psychiatric medication, if necessary, but
also to apply psychological interventions that reduce anxiety and increase affect regulation skills.
 DISTRESS REDUCTION AND AFFECT REGULATION TRAINING

INTERVENING IN CHRONIC AFFECT DYSREGULATION

2. Relaxation and Breath Control

• One of the most basic forms of arousal reduction during therapy is learned relaxation.

• Strategically induced relaxation can facilitate the processing of traumatic material during the therapy session
by reducing the client’s overall level of anxiety.

• Reduced anxiety during trauma processing both lessens the likelihood the client will feel overwhelmed by
trauma-related distress and probably serves to countercondition traumatic material.

• Relaxation can be used by the survivor outside of treat- ment as a way to reduce the effects of triggered
traumatic memories.
DISTRESS REDUCTION AND AFFECT REGULATION TRAINING

INTERVENING IN CHRONIC AFFECT DYSREGULATION

2. Relaxation and Breath Control

• There are two general approaches to relaxation training:
• Progressive relaxation
• Breath training

3) Meditation and Yoga