Trauma treatment challenges (and solutions) by Daniel Mirea

“What happened to you is not your fault, but your future is your responsibility”

For online training in trauma with either Dr Donald Meichenbaum or Daniel Mirea please click on this link

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).

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 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 is 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 (link to Therapist Core Skills by Dr Meichenbaum 2022, BABCP competencies – seee BABCP website).

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 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 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 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’.

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 self-regulate 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 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 self-soothing 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 self-regulation.

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 integratedwith 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 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 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).

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.

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.

Mirea D (2012). How to stress yourself when you are already stressed.

Mirea D (2012). EMDR, not just another therapy with a funny 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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