(Content warning for frank discussion of trauma in this piece.)
Welcome back to Choose Your Own (Therapy) Adventure! In this episode, we’ll be covering some of the trauma therapies.
Trauma, perhaps more than any other issue for which one might see a therapist, needs to be handled with care. Before we even get into the many different therapy modalities that there are to choose from, some history: Trauma, within the field of mainstream psychology, is something relatively new. Trauma and suffering, of course, have unfortunately been around as long as humans have been around. But the various frameworks and approaches that therapists now have at their disposal to help counsel clients through their trauma healing journeys is new.
In Trauma and Recovery, Judith Herman describes the frustrating way in which the trauma therapies have gone through cycles and seasons within the realm of psychological research. Trauma has been a hot topic for certain stretches of time, and during other periods has fallen out of favor – sometimes for infuriating reasons. Freud, for example, studied trauma extensively in his earlier work, and even came to realize that many of the symptoms of so-called “hysteria” in women were actually manifestations of early childhood sexual abuse, which he wrote about in “The Aetiology of Hysteria” in 1896. However, “troubled by the radical social implications of his hypothesis,” Herman writes, Freud later recanted these findings. Herman continues, “Hysteria was so common among women that if his patients’ stories were true, and his theory were correct, he would be forced to conclude that what he called ‘perverted acts against children’ were endemic, not only among the proletariat of Paris…but also among the respectable bourgeois families of Vienna…The idea was simply unacceptable. It was beyond credibility.”
I find relatively little use for Freud in my therapy practice. Psychoanalysis – specifically, the power differential between client and therapist in a psychoanalytic framework – makes me uncomfortable. I’m not a silent and stony-face tabula rasa to my clients, and I don’t like to position myself as “the expert” in the room. My training gives me a specific skillset which I can offer to contextualize my clients’ experiences and which helps me provide psychoeducation to de-mystify the scary sensations we often feel in our bodies when we’re moving towards healing after trauma. However, I think approaching the work as a collaboration, and one that is careful and consent-based at that, makes for better therapy – especially for clients with a trauma history.
The historical origins of trauma therapy in the field of psychology illustrates some very important things about trauma therapy now. For Freud to have garnered the patient accounts from which to write “The Aetiology of Hysteria,” he would have had to, as Herman writes, “overcome his own defensiveness and [be] willing to listen” in order to develop enough of an empathic attunement toward his clients for them to be vulnerable with him. And for the brief handful of years that this type of investigation into trauma was in style, patients – oftentimes women – found that they were being listened to, truly listened to, about the violations they had survived, probably for the first time.
But talking about it usually wasn’t enough. More importantly, society at large, was not willing or ready to give credence to these accounts of trauma. It would have been too destabilizing of contemporaneous social norms to acknowledge the rates of violence against women and children that such profuse cases of “hysteria” implied. Freud’s philosophical and political contemporaries at the time were used to men being in the position of being benevolent stewards and caretakers of women and children, who were hardly seen as autonomous individuals with their own agency. There’s also a certainly no small amount of classism inherent in Freud’s apparent dismay that rates of sexual violence were reflected not only in the proletariat, but among the bourgeois as well. Freud, and others who were doing similar work at the time, responded instead by turning their backs on their patients. Freud, in his subsequent research, sought out evidence for his Elektra Complex theory, and from what Herman writes about the process, it sounds like much of his work henceforth was triggering, re-traumatizing, and would be considered by today’s standards to be unethical. Certainly, he was no longer “staying where the client is,” as they say in social work.
Sadly, the tides turned against trauma survivors – a social phenomenon that it’s important to remember today as well. While certainly since #MeToo there is more space for public discussion of what it means to be a survivor of sexual violence, violence against women and children is still widespread and prevalent. That’s why, no matter which trauma therapy you decide to explore, it’s important to couch your investigation into trauma therapists within the context of anti-oppression and intersectional practice. Some questions that you might consider asking a trauma therapist before you work with them include:
• How do you understand power and oppression, both on a societal level, and as it operates with clients?
• What is your definition of intersectionality, and how do you bring this into your work with trauma survivors?
• What is your understanding of intergenerational trauma, and how it impacts clients of marginalized identities?
• What work have you done to understand power, privilege, and oppression in your own life, and what your positionality is with a client like me?
These questions are important especially for clients of marginalized identities, who – due to the gatekeeping and elitism of academia – may often find themselves working with therapists who have more social power and privilege than them. If a therapist seems uncomfortably defensive with this line of questioning, take note.
(Some of) the Trauma Therapies
The biggest difference between trauma therapy and other kinds of therapy is that trauma therapy has to be doing more, especially for clients who have very long or complex trauma histories, or those for whom the trauma is very close to the surface. This includes those who may have diagnoses of post-traumatic stress disorder, whether chronic (long term, more than six months) or acute, but also for those who experience complex PTSD (C-PTSD) or developmental trauma (neither of which are included as diagnoses in the DMS-V, something Bessel Van Der Kolk recounts with frustration in The Body Keeps the Score).
Trauma therapy is not simply talking about your trauma, taking a deep breath, crying a little, and walking out the door. I wish it could be that straight-forward! A good trauma therapist will understand, as Peter Levine writes in Trauma and Memory, that the first step is often not talking about the trauma at all, but rather, attending to the symptoms of the trauma (anxiety, panic, flashbacks, dissociation, anger, rage, etc.) and helping clients build the skills necessary to be resilient and grounded when experiencing those symptoms, before delving too deeply into the details of the trauma itself. In fact, with some trauma modalities, you may not necessarily have to verbally describe your trauma at all.
The goal of trauma therapy is not to make our trauma disappear entirely. Trauma is a big deal, symbolically and in the narratives of our lives but also, simply, physiologically. It changes our bodies, and it changes our relationships (epigenetics, in fact, studies how trauma literally alters genes that get passed down from generation to generation). Healing, in trauma therapy, is not about erasing and starting over, but rather, in making room for our trauma non-judgmentally as something that is a part of us, but not all of us, and helping us to feel more empowered, safe, whole, and embodied and – this above all – in the present – rather the held captive to the worst or most overwhelming moments of our lives.
So, what are some of the trauma therapies?
Brainspotting and EMDR
Brainspotting and EMDR (eye movement desensitization and reprocessing) are two related trauma therapies (in fact, brainspotting was developed from EMDR) that are highly effective in trauma work. Both require very little actual retellings of trauma – unlike prolonged exposure therapy, a cognitive behavioral therapy which has been used with trauma survivors and can risk retraumatizing them as they’re made to recount their story over and over again. Discussion of the events themselves are usually limited to less than a minute, and both therapies use some form of brain stimulation (rapid back and forth eye movements in EMDR, which stimulate both hemispheres of the brain; or a fixed gaze, in brainspotting), “to localize the source of negative memories and process them appropriately.” This is where the emotional rewriting comes in, and therapists encourage clients to relate to their trauma from the safety of present moment, rather than feeling so swept away in the remembering of the trauma that it precludes them from living their lives.
Somatic experiencing was developed by the above-mentioned Peter Levine. The main component of somatic experiencing is that it underscores the importance of embodiment in healing from trauma – no easy feat for clients whose bodies, in the aftermath of trauma, are often painful and frightening places to be. Somatic experiencing underscores the importance of understanding and proactively interacting with your stress response – fight, flight, or freeze. Trauma is what happens when our fight and flight responses are totally overwhelmed; in these moments, we are frozen in horror, helpless or dissociating. It is these moments in which clients often find themselves “stuck,” and somatic experiencing seeks to get them unstuck.
How does it do that? In a somatic experiencing session, a client will be asked to recount their traumatic experiences slowly, and in small amounts of detail, while the clinician pays careful attention to changes in the client’s body and breathing. Do they change their position, hunching forward to protect their core, or stiffening up as if bracing for impact? Does their breathing change? Do they start to fidget with their hands? What are the sensations that are present in the client’s body (heaviness, tightness, jitteriness, warmth, a floating sensation, dizziness?) and where are they present? Paying extra care and attention not to move too quickly out of the client’s “window of tolerance,” the clinician encourages to client to “pendulate” between the sensations associated with the traumatic memory or experience, and sensations that provide soothing, relief, strength, and comfort.
When I read about neurofeedback in The Body Keeps the Score, it seemed like one of the most futuristic forms of therapy I’d ever heard of – but in actuality, its origins just might be ancient. Neurofeedback works by asking the questions “Where are you now?” and “Where do you want to go?” In terms of trauma, this might mean wanting to go from the place of traumatic memories intruding and interfering with everyday life, to being able to relate to those memories differently, while bringing ourselves back to the present more readily and with more confidence. Then, brainwave patterns are “mapped” using a qEEG (quantitative electroencephalograph), “dysfunctions” (denoting dysregulation) are identified, and therapeutic treatment is devised which includes new patterns in brainwave stimulation.
How to Pick Your Trauma Therapy
With the trauma therapies, unfortunately, where you’re located an what your insurance covers will probably play at least as large a role in what therapy you choose as the ones which really interest you. This, quite frankly, sucks, because – as discussed above – trauma is pervasive, and effect trauma treatment really should be accessible to all. If you live in a big city, specifically a city like New York City, which is a psychotherapy hub, it will likely be easier to have your choice of trauma therapies. For those living in more remote locations, access may be more difficult.
Financial access, too, is a barrier, which, when considered from the standpoint of intersectionality, is a real problem. Folks for whom survival needs – food, housing, health care – are perpetually breathing down their necks are likely to be more exposed to traumatic events. Ditto for people of multiple marginalized identities. And yet competent care for this demographic is oftentimes upsettingly out of reach.
The good news – if there is any good new to come out of the COVID19 crisis – is that therapists have been able to practice some of the trauma therapies via remote practice and telehealth. EMDR, for example, can be done remotely, and with some finagling, perhaps somatic experiencing can also adapt (though the clinician would need to be able to see more than just a thumbnail of the client’s face in order to practice most effectively).
No matter what, if you’re looking to start trauma-specific therapy, it’s important to work with a clinician who is trained and competent. I don’t list myself as certified in any of the above therapies, because I haven’t gone through that process yet, though I do consider my practice to be trauma informed, by which I mean, I am well-versed and constantly learning more and more about the somatic and physiological, as well as the mental, emotional, and sociocultural impacts of trauma and bringing that into the work that I do with clients. Ask about a prospective therapist’s training, how long they have been using whichever intervention you’re seeking, why they chose that specific type of therapy over any of the others, if they’ve undergone that same treatment themselves, and how they’ve seen it used with whichever specific experience you are seeking support around.
Trauma takes our power away and makes us feel like we don’t call the shots in our own lives. But we do. And any trauma therapist worth their salt will answer your questions thoroughly, guide you gently and at your own pace, and remind you of your agency every step of the way.
Next Up: Somatic and Movement Therapies