How Does Trauma Get Treated Anyway?
Despite a robust research base surrounding effective interventions for psychotherapeutic treatment of trauma (usually specifically PTSD) there is somewhat limited agreement on what psychological mechanisms are improved as a result of treatment and even less agreement about which neurobiological mechanisms (if any) are improved as a result of treatment (Childhood Trauma Meta-Analysis Study Group [CTMASG], 2022; Giotakos, 2020; Manthey et al., 2021). One reason for the lack of consensus around the impact of trauma-focused treatment is the relatively heterogeneous presentation of clients who have experienced trauma (CTMASG, 2022). Often, those coming to therapy are not coming to therapy to treat their trauma or even the symptoms of their trauma (Flynn et al., 2023). Instead, many folks come to therapy to treat a more primary concern— such as difficulty sleeping, anxiety or depression, interpersonal conflict, substance use disorder, or behavioral difficulties— and find out in the course of treatment for these symptoms that some form of trauma may undergird the development or maintenance of these symptoms (CTMASG, 2022; Flynn et al., 2023; Lee et al., 2022; Zettler, 2021). Because of this commonality, attempting to discriminate symptoms which may be caused by trauma from those that may be attributed to a mood disorder for example, can be difficult (CTMASG, 2022). Some comorbidities, such as substance use disorder, can also create confounding variables when attempting to describe the neuroanatomical or neurobiological impact of past traumatic experiences as both substance use and exposure to trauma can impact brain functioning and structures in ways that require more precise tools than are available to us presently in order to parse out (Manthey et al., 2021; Najavits et al., 2020). Adding to this complexity is the impact of environmental, social, and cultural factors— such as familial dysfunction, systems of oppression, and limited access to care— which can augment the impact of trauma is ways that are starting to be described but are not yet fully understood (Zettler, 2021; Lee et al., 2022).
However, the state of research around effective interventions for trauma, although imprecise and somewhat nascent, is not without useful suggestions. Most interventions that have research support help clients who are impacted by past traumatic experience decrease the intensity and severity of their symptoms through some element of exposure to an inciting or activating stimulus (Lee et al., 2022). Clients are taught coping strategies— usually behavioral or cognitive techniques which help them to manage their physiological response to threat and engage in behavior that is adaptive to their environment instead of disproportionate or maladaptive— and are given opportunities to practice using those copings strategies in a variety of different circumstances which elicit trauma reactions (Lee et al., 2022). Through repetition of this process, clients are able to better learn how to regulate their emotions, develop new habits of thoughts and behavior which reinforce more accurate discrimination of real versus perceived threat, and are more able to adjust their daily behavior choices to be less avoidant and restrictive (Lee et al., 2022; Zettler, 2021). From a neurobiological perspective, it is hypothesized that creating new behavioral patterns may allow new neural connections to develop which increase the likelihood of clients engaging in behaviors which are adaptive and not likely to create or maintain symptoms (Giotakos, 2020). Continued exposure in this way may also reduce the level of activation of some of the hormonal and biochemical aspects of the autonomic nervous systems which can lead to symptom reduction and stabilization of biochemical processes across the whole body (Giotakos, 2020; Manthey et al., 2021).
More specific interventions have been developed which include other elements which are thought to be helpful in treating trauma in that they are believed to work on different mechanisms such as Eye Movement Desensitization and Reprocessing (EMDR) which is through to improve communication between the left and right hemisphere of the brain and allow easier access to long term memory using visual bilateral, stimulation and Family Functional Therapy (FFT) which is thought to help children and adolescents with a history of trauma to be better supported by their families through the use of psychoeducation and structured family therapy which can lead to more effective emotional regulation and integration of traumatic material (Gainer et al., 2020; Lee et al., 2022; Zettler, 2021). Approaches to help address clients who are impacted by trauma as well as other disorders have also been developed (CTMASG, 2022). Examples include the use of group therapy and particular kinds of Narrative Exposure Therapy (NET) to help veterans with combat exposure and military sexual trauma address shame which can exacerbate symptoms of trauma and integrative models such as Seeking Safety (SS) which was developed to help those impacted by substance use disorders and PTSD to learn, individually or in a present-focused group setting, coping strategies to help decrease symptoms (Najavits et al., 2020; Lee et al., 2022; Flynn et al., 2023).
Throughout the research on effective interventions for symptoms of trauma, similar ethical considerations and methodological shortcomings were identified. Most notably, it is challenging to balance internal validity with external validity in studies of effective treatment for trauma as all groups of study participants experienced their kind of trauma differently than those in other groups (Flynn et al., 2023). Particular kinds of trauma also seemed to impact the client different and were more or less amenable to particular forms of treatment (Flynn et al., 2023; CTMASG, 2022). Additionally, many studies separated research groups into binary gender groupings or by other identity demographics which may leave a particular group of prospective patients without clear evidence to suggest effective treatment (Lee et al., 2022). Many forms of therapy, such as EMDR, also require training which is costly and time consuming for the clinician and may result in treatment outcomes which are similar to other, more cost effective, and efficient forms of trauma therapy (Lee et al., 2022). The comfort of participants and their willingness to continue in therapy also depends on specific interventions (Lee et al., 2022). For example, Prolonged Exposure Therapy has evidence to show it is widely effective and is relatively easy for practitioners to learn but is reported to be quite uncomfortable for clients to participate in and has a relatively high attrition rate (especially compared to other types of interventions, like those used in EMDR which are rated as relatively comfortable and have high levels of patient participation) (Lee et al., 2022; Zettler, 2021). Because of these factors, it is imperative for clinicians to identify what kinds of trauma their clients have experienced, what other potential comorbidities may be present, and to be thoughtful about how they want to intervene in order to help their clients gain new skills and not add to their negative experiences (Zettler, 2021).
References
Childhood Trauma Meta-Analysis Study Group (2022). Treatment efficacy and effectiveness in adults with major depressive disorder and childhood trauma history: a systematic review and meta-analysis. The Lancet. Psychiatry, 9(11), 860–873. https://doi.org/10.1016/S2215-0366(22)00227-9
Flynn, A. J., Puhalla, A., & Vaught, A. (2023). The role of shame and trauma type on posttraumatic stress disorder and depression severity in a treatment-seeking veteran population. Psychological Trauma: Theory, Research, Practice, and Policy. Advance online publication. https://doi.org/10.1037/tra0001495
Gainer, D., Alam, S., Alam, H., & Redding, H. (2020). A FLASH OF HOPE: Eye Movement Desensitization and Reprocessing (EMDR) Therapy. Innovations in clinical neuroscience, 17(7-9), 12–20.
Giotakos O. (2020). Neurobiology of emotional trauma. Psychiatriki, 31(2), 162–171. https://doi.org/10.22365/jpsych.2020.312.162
Lee, E., Faber, J., & Bowles, K. (2022). A review of trauma specific treatments (TSTs) for Post-Traumatic Stress Disorder (PTSD). Clinical Social Work Journal, 50(2), 147-159. https://doi.org/10.1007/s10615-021-00816-w
Manthey, A., Sierk, A., Brakemeier, E., Walter, H., & Daniels, J. K. (2021). Does trauma-focused psychotherapy change the brain? A systematic review of neural correlates of therapeutic gains in PTSD, European Journal of Psychotraumatology, 12(1), DOI: 10.1080/20008198.2021.1929025
Najavits, L. M., Clark, H. W., DiClemente, C. C., Potenza, M. N., Shaffer, H. J., Sorensen, J. L., Tull, M. T., Zweben, A., & Zweben, J. E. (2020). PTSD / substance use disorder comorbidity: Treatment options and public health needs. Current treatment options in psychiatry, 7(4), 544–558. https://doi.org/10.1007/s40501-020-00234-8
Zettler, H. R. (2021). Much to do about trauma: A systematic review of existing trauma-informed treatments on youth violence and recidivism. Youth Violence and Juvenile Justice, 19(1), 113-134. https://doi.org/10.1177/1541204020939645