TRAUMA TREATMENT
CHALLENGES
Daniel Mirea, 2022
JUNE 1, 2022
HTTPS://NEUROAFFECTIVECBT.COM/2022/06/10/TRAUMA-TREATMENT-CHALLENGES/
“What happened to you is not your fault, but your future is your
responsibility”
The topic of ‘trauma’ is much more controversial than one would
imagine. Research tends to indicate that approximately 25% of people who
have experienced a significant trauma go on to develop post-traumatic stress
disorder symptoms or PTSD, but that percentage varies. Based on the nature of
the trauma those rates are going to be higher, for example for someone who’s
experienced rape or sexual assault more like 50% or lower for other kinds of
traumatic events like for example a fireman dealing with a fire. An interesting
question following on from this data, would be centred around the 25 to 50%
people that resume their normal activities, symptoms free after a frightening
incident. Such a significantly high percentage might suggest that therapists are
presented with an interesting opportunity during treatment, if and when
therapy focus is re-directed towards a key aspect of trauma recovery –
RESILIENCE. Dr Meichenbaum, one of the CBT pioneers, aka the Freud of CBT,
has been talking about this area for decades. Therefore, a justified question
would be, how do the up to 75% people deal with their symptoms post-trauma
in order to, not develop chronic PTSD? And if resilience is at least one of the
answers then what helps improve resilience during treatment?
Whilst there is no agreed definition on what ‘resilience’ means, it is clear
that being resilient could describe an individual’s ability to bounce back in face
of adversity and according to Dr Meichenbaum it is also relating to an
individual’s inner resources and outer immediate support network. His
conclusions are backed up by neuroaffective research which describes
resilience as the capacity to deal with external challenges, also called
‘exteroception’ or sensitivity to external stimuli, by managing any resulting
internal changes, also known as interoception or the perception of internal
sensations. Dr Meichenbaum posits that trauma symptoms and resilience
engendering behaviours can coexists. The data must not be misinterpreted; it is
not that the 75% do not develop some symptoms of PTSD but victims evidence
the ability to bounce back and cope with ongoing challenges as such with time
symptoms can subside. Moreover, people can be resilient in one area of their
lives and not in others. As Bonanno (2022) highlights in his book “The end of
trauma”, a key feature of the 75% that are impacted but who engage in resilient
engendering behaviours is that they have developed a resilient mindset, a set of
optimism and self-efficacy and have ongoing social support (Meichenbaum
Roadmap to Resilience).
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In cognitive-behavioural terms the implications for treatment are
significant; although there is no magic bullet and there seem to be multiple
ways to developing resilience, these findings could be translated into high levels
of psychological flexibility and adaptability, good problem-solving skills, and an
ability to learn and implement new coping strategies which would have to be
rehearsed under pressure and in real life experiments.
Trauma characteristics
So, if being resilient is one of the ingredients that could help almost 75%
of people exposed to different levels of threat, not to develop symptoms of
trauma, how do we identify the remaining 25%?
When it comes to the label of trauma, much like depression, it seems the
over-use of the term itself becomes problematic. The label ‘trauma’ is
commonly used to describe a range of situations and experiences that might not
fall under that definition.
A traumatic experience may be defined by five main characteristics.
1. An experience that is far beyond what may be considered a normal
human experience and during which a person feels a significant risk
to self or even death; intense fear or helplessness during an attack
may also be part of this experience
2. This experience would extend to witnessing an event where
someone is threatened with serious injury or death
3. This experience is followed by extensive reexperiencing and
significant changes to memory
4. This experience is also followed by increased and frequent states of
hyper-arousal
5. The negative arousal is associated with safety-seeking and other
avoidant behaviours
Such experiences are more complex than the stress one would experience
during a driving test which might have even resulted in failure and subsequent
self-criticism. As upsetting as that can be, it does not amount to a traumatic
experience, not unless you had a serious car crash during your test and
subsequently kept reexperiencing scenes of the crash, you had become
hypervigilant in traffic, and this had also led to avoidance or even social
isolation. Waiting for two hours in line at the petrol station during the petrol
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crisis would not qualify as a traumatic event. Not unless you saw someone get
attacked and hurt while waiting in line.
The inconvenience can create distress, but most events we go through
daily are not traumatic. One might argue that, to qualify everyday occurrences
or even major inconveniences as traumatic is to minimise and trivialise the
experience of people who are living with PTSD every day and whose lives were
turned upside down by past horrific experiences. It is therefore important to
watch over the use of the term because it misses the boat by miles, on how
much trauma affects people both psychologically and physiologically.
Another common issue would be convenient access to a lot of online
information at a time when unfortunately, not all online resources are
legitimate sources of information. The answer is often a lot simpler. It is wise to
try to access a professionally trained clinician or therapist, preferably a trauma
specialist. Even though many schools of psychotherapy reject the medical
model the evidence stands out. According to Dr Meichenbaum, trust in the
therapist, in the therapist’s expertise and in the therapeutic method used, is
associated with positive treatment outcomes (e.g., Therapists’ Core Skills by Dr
Meichenbaum 2022, BABCP competencies on BABCP).
Irrespective of their school of thought, psychotherapists need to
familiarise themselves with the psychopathology of trauma, the risks and
maintenance factors and feel confident in delivering a variety of therapy
methods in response to a traumatic experience or else they are faced with a
situation where the blind is leading the blind. In this regard, it seems that
choosing the right therapist can be a challenge since a lot of psychotherapists
are often led by their personal beliefs or what they might consider healthy
scepticism and miss out, on the real symptomatic impact that a traumatic
experience can have on an individual (Mirea, 2012).
Understanding the symptoms of trauma and how these symptoms are
being maintained can also facilitate the process of psychoeducation which is yet
another important aspect of the trauma treatment. Recovered trauma patients
frequently report that if they knew what trauma meant and how it ‘worked’ they
would have chosen the right support a lot sooner, they would have had faster
results, they would have saved money on treatments and would have resumed
their normal lives a lot faster.
Misdiagnosing trauma is surprisingly common for a variety of reasons, not
least comorbidity. It seems that 8 out of 10 people with PTSD are more likely to
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have a comorbidity such as, another anxiety or depressive disorder, or a
substance use disorder. Cognitive intrusions and reexperiencing are common
across a range of disorders including PTSD, OCD, schizophrenia, or even bipolar
disorder, this is where having the skills and the correct training would help
therapists peel back all the complex layers of a mental disorder.
An interesting trauma myth is that trauma is only defined by something
happening directly to you. You would have to be assaulted or raped or
something bad has to happen to you. In fact, trauma can also be defined by
witnessing something violent like a crime, an assault, a rape or a murder.
Common beliefs associated with this type of guilt or shame-based trauma are
loud with a strong internal critical or blaming tone: “I’m being ridiculous… I
must be weak… I could have done more… How dare I say I have trauma… I am
not the real victim here”.
Trauma reexperiencing and processing methods
Going through a traumatic experience can lead to a very confused
memory data base. At the time when the trauma occurs the individual does not
get a chance to fully process the event and therefore a range of problems would
rise from there. On an ordinary day, memories are coded and laid down in
specific structures of the brain, specifically via the hippocampus, and the
neocortical system, best viewed as our long-term memory storage. Here we
have access to an event in a narrative format, something one can talk about
comfortably, distant stories from our past, which eventually would fade with
time.
During a traumatic event this natural process is interrupted by a
narrowed and focused attention onto the threatening stimulus, facilitated by
high levels of cortisol and adrenaline. The traumatic memory is saved by our
internal alarm system called the amygdala, a peanut size brain structure
located just anterior to the hippocampus in the medial temporal lobe. The
amygdala is a different kind of data storage, in charge with our safety and
responsible for keeping us alerted to new similar threats. This is basically part of
our fight-flight system, essential to our survival. Because of this, memories
about threats or dangers, do not fade with time. Such memories capture all
sensory modalities, they feel real, current and relevant. Traumatised victims
would find it difficult to share memories of trauma even decades later.
So, traumatic memories are saved in the amygdala ready to be activated
at a moment’s notice, if a similar emergency should arise again. With assistance
from the Autonomous Nervous System (ANS), all mammals have the ability to
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re-orient attention toward a potential threat and scan the database in 0.025
seconds. This would lead to an immediate series of reactions designed to
preserve life.
Unfortunately, the ANS is far from perfect and impacted on by a variety of
unhelpful habits very well-rehearsed by other parts of our brain, such as the
tendency to ruminate and worry over unpleasant or scary events. Ruminations
and worries in particular seem to confuse our internal processing systems and
therefore memories are generalised and constantly updated with more
threatening material. As a result, the amygdala would get frequent imprints and
the sympathetic response gets easier and easier activated by a variety of
sensorial triggers. For example, a lady who was raped by a bald man, years
later, she would feel threatened by all bald men she would come in contact
with, irrespective of ethnicity, age or size. At least 25-50% of people exposed to
a threat describe flashbacks of the traumatic events as a frightening experience,
they feel they are right back there, reliving the traumatic experience. As such,
significant efforts would go into suppressing and neutralising flashbacks as well
as avoiding places or situations that act as reminders and might trigger the
flashbacks.
How to safely integrate traumatic memories
Evidence-based psychological treatments such as the family of CBT
therapies rely on a few strong principles such as ACT: Assess, Conceptualise and
Treat. We have already understood how important it is to be able to separate
trauma symptoms from other unpleasant or stressful experiences that do not
come under the same umbrella. Therapy alliance, psychoeducation, new
learning, problem solving, installing new coping skills, exposure programmes
are all essential and well evidenced approaches across the range of CB
therapies.
However, with PTSD cases, traumatic memory processing plays a distinct
role. The theory that lies behind memory processing focuses on the influence of
the Autonomous Nervous System (ANS) our main survival mechanism which
gets activated when we are faced with a threat. The ANS has an ON switch called
the sympathetic response which leads to arousal and an OFF switch which is
called the parasympathetic response that encourages de-arousal or a calming
relaxed response. This sounds great, however one of the problems is that we are
not able to consciously switch the system On and Off, as we would more than
likely prefer, hence the label ‘autonomous’.
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With the risk of over-simplifying a process that is otherwise very complex,
it might be easier to understand by separating the hardware from the software
components of our brain. It may be important to remind our brain’s hardware
which includes structures such as the amygdala, hippocampus, the thalamus
and the neocortex. Part of the software include sensorial processing, memories
processing and the role of attention-orientation. The software communicates
via different hardware components with the help of neurotransmitters, such as
adrenaline and noradrenaline in the case of a threat, via neuropathways or
brain circuits that all together create our autonomous nervous system.
The role of the amygdala is to analyse and collect data about threats in
order to alert us and keep us safe when necessary. For example, the amygdala
would correctly alert us through the emotion of fear, that “snakes are
dangerous” if we come across a snake on a mountain trail but in fact, not all
snakes are dangerous in all situations and as such memory upgrading becomes
relevant in relation to threat recognition and threat identification.
Ironically, for at least 25% of the victims exposed to trauma the system seems to
be even less effective and therefore this is the category that requires trauma
memory processing and better integration in the longer-term memory systems
(hippocampus and neocortex), so that eventually when memories are recalled
the threat system will not be unnecessarily activated and instead past events
simply turn into stories or narratives from our past.
Updating trauma memories involves going over the traumatic event and
identifying specific moments that create the highest level of distress during this
detailed recall through imaginal reliving. Next, identifying positive or hopeful
messages, symbols or even other people that add new information and
meaning to the event.
In NeuroAffective-CBT at this stage, attention is also directed towards
feelings and physiological reactions by encouraging a focus on the location and
the intensity of the distress within the body. This is followed by clear but gentle
instructions at every step to keep track of the intensity of the distress and selfregulate through breathing and progressive muscle relaxation, in parallel with
the memory recall.
It is important to remember that memory recall in a state of high emotion
can increase the arousal to the point of overload sending new sensory
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impressions in the amygdala. In other words, upgrading the memory with more
traumatic material, which might have a negative effect.
As such, a precursor to this exercise would be a strong bond and a trusting
relationship with the therapist, which facilitates down regulation and selfsoothing during heighten states of arousal or dissociative states. Grounding
techniques, attention training techniques, practising safe place, progressive
muscle relaxation and body scanning are proven tools that help with selfregulation.
Safe place or grounding imagery can be introduce at different times in
order to establish distance and a sense of safety for example: ‘you are safe now
travelling on a train looking at the passing scenery, your memories are just
passing scenery…or… you are in your own private cinema, it feels safe,
comfortable and distant, you are watching your own memories unfold on the
screen, just like a movie, scene, after scene..’.
All the above present-focused exercises are essential, since trauma recall
is reported to dissociatively bring online a sense of being back during the event
that caused the trauma in the first place, even if/when this took place decades
earlier. Grounding exercises, safe place, bilateral tapping used in NA-CBT or any
other sensorial bilateral stimulation used in EMDR are all meant to
downregulate and create a sense of ‘hear-and-now’ by distributing, widening
and re-orienting attention during the recall (EMDR article Mirea, 2012).
In TF-CBT reading out the traumatic episodes are also common reliving
exercises though the risk for retraumatising is higher without specific memory
upgrading. According to Clark and Ehlers (NICE recommends their model for
PTSD treatments within NHS) negative appraisals of the trauma poses a special
challenge as much of the patient’s evidence for the problematic appraisals
stems from what they remember about the trauma. Thus, work on appraisals of
the trauma needs to be closely integrated with work directly on specific
traumatic memories. The disjointed intentional recall of the trauma in PTSD
makes it difficult to assess the problematic meanings by just talking about
the trauma, and has the effect that insights from cognitive restructuring may
not be sufficient to produce a large shift in affect and those are a precursor to
what is know as re-traumatisation.
Understanding trauma triggers is equally important. The aim would be to
break the link between the triggers and the trauma memory. This could be
achieved in several ways, including teaching the patient to distinguish between
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the past – ‘Then’ and ‘Here & Now’; i.e., the patient learns to focus on how the
present triggers and their context ‘Here & Now’, are different from the trauma
(‘Then’). This can be facilitated by carrying out actions such as movements or
bringing to mind positive images or touching objects that grounds and connects
the patient within present moment. Patients would practice these strategies
in their natural environment during sessions. When reexperiencing occurs, they
remind themselves that they are responding to a memory, and this is not the
current reality. They could focus their attention on how the present situation is
different from the trauma and may carry out actions that would have not
been possible during the trauma.
In NeuroAffective-CBT, imaginal reliving is not presented as an
intervention aimed at enhancing emotional habituation to a painful memory
but instead this is a moment-to-moment detailed reliving, which could and
often should be time framed. This helps to identify specific traumatic memories,
highly dissociative moments, which would be addressed through cognitive and
somatic processing. Bilateral stimulation does not have to be used, not least
because tapping is an unusual technique and for some people even
inappropriate, as long as attention training, memory upgrading, and cognitive
restructuring is carried out in parallel with emotional regulation with the scope
of achieving a renewed sense of distance between the traumatic episode and
the present moment. Comments such as, ‘I now feel this happened a few weeks
(or years ago) and I am no longer in danger… that moment is less clear…’, ought
to be the principle aim with this type of processing.
In summary…
Trauma processing is just a small part of the treatment protocol for
trauma, a constant focus on therapeutic alliance, problem solving skills and
new coping skills ought to be part of the repertoire that enhances individuals’
resilience. Cognitive and Behavioural therapies have a range of methods and
interventions available. For the newly trained CBT therapist, it is important to
study as many as possible, and work under CBT supervision with various
interventions, constantly developing and refining their ability to tailor the
treatment to each individual’s needs, abilities, learning style and personal
values.
This article is focused on traumatic memory processing and only briefly
outlines other essential interventions. A comprehensive trauma treatment
would have to address all mechanisms that predispose, precipitate and
perpetuate symptoms of PTSD. This suggests that a series of bio-psycho-social
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traps would have to be identified and disrupted. According to Dr Meichnebaum
positive outcomes are further enhanced by developing resilience rooted in
individuals’ culture, personal values and strengths. Meichenbaum has reminded
us in his characteristic manner that we are not only homo sapiens but
also homo-narrans or story tellers or narrators, therefore the stories that
individuals tell will determine if victimised individuals will fall into the 25% or
75% group (Meichenbaum, lecture notes 2022).
For online training in trauma with either Dr Donald Meichenbaum or Daniel Mirea please click on
this link
REFERENCES
Hackmann A, Ehlers A, Speckens A, Clark DM. Characteristics and content of
intrusive memories in PTSD and their changes with treatment. J Traumatic
Stress. 2004; 17:231–40.(30).
Ehlers A, Clark DM, Hackmann A, McManus F, Fennell M. Cognitive therapy for
PTSD: Development and evaluation. Behav Res Therapy. 2005; 43:413–31.(32).
Ehlers A, Steil R. Maintenance of intrusive memories in posttraumatic stress
disorder: a cognitive approach. Behav Cogn Psychotherapy. 1995; 23:217–49
Meichenbaum D (2022). Lecture notes donated by author.
https://neuroaffectivecbt.com/2022/06/10/bolstering-resilience-with-drdonald-meichenbaum/
Meichenbaum D (2022). https://neuroaffectivecbt.com/2022/06/10/bolsteringtherapists-resilience-at-work-with-dr-donald-meichenbaum/
Meichenbaum D (2012). Roadmap to resilience: a guide to military, trauma
victims and their families. Available on Kindle Amazon and on the
websites: UKCHH and Melissa Institute.
Meichenbaum D (2004). Stress Inoculation Training. Pergamo.
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Mirea D (2012). How to stress yourself when you are already stressed.
https://neuroaffectivecbt.com/2018/07/25/how-to-best-confuse-yourself-whenyou-are-already-stressed/
Mirea D (2012). EMDR, not just another therapy with a funny name.
https://neuroaffectivecbt.com/2018/10/11/why-emdr-is-more-than-justanother-therapy-with-a-funny-look-and-a-strange-name/
Bonanno G (2021). The end of trauma: How the new science of resilience is
changing how we think about PTSD. Amazon.
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