Dr. Ernst Feistauer
Trauma treatment, approaches using the example of PTSD
Accompanying people who have had a traumatizing experience and are perhaps still currently exposed to threatening situations according to objective and subjective criteria is a particularly challenging, but also very rewarding task of psychotherapy; here a great deal of suffering can be absorbed and alleviated.
Even if you have not chosen the specialty of psychotraumatology, it is still helpful to have dealt with the phenomena of traumatization, because even in so-called conventional therapy situations it can happen that previously unconscious injuries are actualized. In addition, the number of people who have experienced war, torture and flight and are now seeking and urgently needing help in institutions will continue to rise. Basic knowledge of trauma therapy and practical skills should therefore be in the repertoire in any case.
Of course, this therapeutic encounter is also challenging for those affected. Coping with trauma sequelae, dealing with the trauma itself and ultimately integrating what has been experienced into one’s own biography requires a great deal of courage and a great deal of trust. Trust in this context means the ability to give up control over one’s vulnerabilities.
Explanatory models for the development of PTSD are many, from different schools and models of thought. Therefore, there are now also very many, well-documented and very effective treatment methods and interventions from different approaches.
The following explanations are based on models from the tradition and developments of behavior therapy. However, the choice of methods in the individual therapy, coordinated with the client, remains – as always – free calculation.
The structure of this article:
V.9.1.Theoretical part:
Dream definition
Diagnostics
Possible explanatory models of PTSD
Two factor theory, Mowrer
Trauma and brain functions
Dissociations as a consequence of traumatization, manifestations
Basic assumptions violated by taumata
Cognitions / Emotions / Interpretations
V.9.2. Practical part
Basic
Methodology:
Stabilization
Trauma Processing
Cognitive restructuring
PE Prolonged exposure
EMDR Eye Movement Desensitization and Reprocessing
Practical approach to dissociative disorders
Integration
V.9.1. Dream definition:
The term trauma actually means injury or wound, and originally comes from the medical field.
An example of a physical injury is a good way to explain this:
our body is designed and quite capable of compensating for minor injuries without long-lasting damage.
But when we suffer injuries that break through the stimulus protection, that is, the organism’s ability to compensate, we suffer trauma, from bruising to fracture to life-threatening wounds.
This image can be applied to the consideration of psychological trauma, and the concept of trauma is now also very broad. A lasting shock is given when our psychological stimulus protection is broken.
Thus, psychological trauma can be defined as a `discrepancy experience’ between a threatening situation and the respective current individual coping capabilities.
So what are the more specific conditions defined for psychological trauma:
it is one or more events, where the threat consisted of a situation or situations perceived as life-threatening. The situation involved death, imminent death or an injury, there was a danger to physical integrity – for oneself or for others.
The immediate reaction to the event includes: intense fear and horror and the feeling of helplessness.
The criteria are thus: Intensity, duration, frequency and subjective importance.
A further distinction is made between stress trauma ( type I trauma ), in which the stressor is a usually one-time, sudden, uncontrollable event in adulthood, often experienced with fear of death.
Developmental trauma ( Type II trauma ) occurs when the stressor consists of repeated, different individual events. The course and outcome is unpredictable, usually extends over a longer duration, and the onset is usually in childhood.
A further and very important distinction for the effects and treatment results from whether the trauma was caused by an accident or a misfortune (e.g. natural disaster), or whether the traumatic experience was caused or inflicted by a human being, so-called ‘man – made disasters’.
Especially in this category (man-made) it becomes very clear that the physical and emotional reactions of victims to violence, persecution and torture, for example, run in line with our physiological possibilities and endowments, i.e. are basically intended to be that way. Pain and fear cause natural defense reactions. But in addition to this experience, those affected usually experience a deep and also lasting shaking of their world view.
In each case it must be considered and clarified whether the traumatization and the trauma consequences were caused by the event itself, or by the way and above all – by whom – the event was caused.
However, suffering a trauma does not mean that an affected person should automatically develop PTSD!
Therefore, the question arises: how is it that different people react to stresses more strongly or even less strongly than others?
Essentially, this depends on two components, namely vulnerability and resilience.
Vulnerability means vulnerability and depends on factors such as age, gender, socialization, the nature of the exposure, previous experiences and the like.
Resilience, on the other hand, describes the ability to develop psychologically healthy and even become stronger despite serious stresses or adverse life circumstances.
Vulnerabilities and resiliences are thus in a context-dependent interplay.
Diagnostics:
The previous definition of PTSD in ICD – 10, F 43.1 is extended in some points by the new version ICD – 11:
Stress trauma: the stressor is an extremely threatening or horrifying event or series of events
Developmental trauma: the stressor is an extremely threatening or horrifying event or series of events, usually prolonged or repeated events, in which escape was difficult or impossible (e.g., torture, slavery, genocide attempts, prolonged domestic violence, repeated sexual or physical child abuse)
A new aspect is that even people who have not been directly threatened themselves can also suffer post-traumatic disorders (police officers, rescue workers, train drivers, etc.)
The previously existing other main criteria of post-traumatic stress disorder ICD – 10, F 43.1 have remained essentially unchanged. Re-experiencing, avoidance, and heightened vigilance must still be met for a diagnosis of PTSD.
In detail:
Re-experiencing the traumatic event(s) in the present in the form of vivid intrusive memories, flashbacks, nightmares, typically associated with strong and flooding emotions such as fear or horror and strong physical sensations, or feelings of flooding or immersion with the same intense emotions as during the traumatic event.
Avoidance of thoughts and memories of the event, or avoidance of activities, situations, or people related to the event or events.
Overexcitation: Persistent perception of increased present danger, for example, with hypervigilance or increased startle response to stimuli such as unexpected sounds.
Symptoms must occur for at least several weeks and involve significant losses in various areas of life (personal, family, social, educational, work, or other).
In addition to PTSD, ICD – 11 introduces Complex Posttraumatic Stress Disorder. Here, the fact that there are repetitive experiences of violence (e.g., organized sexual violence, incest over years, etc.) and their particular post-traumatic consequences was taken into account. Repeated traumatic experiences cause particular psychological consequences.
The disorder is characterized by the core symptoms of PTSD as previously described. All diagnostic conditions for PTSD were met once during the course of the disorder.
In addition, kPTBS is characterized by: severe and profound problems with affect regulation; persistent views of self as diminished, inferior, or worthless; associated with severe and profound feelings of shame, guilt, or failure related to the traumatic event; and persistent difficulties in sustaining relationships or feeling close to others.
An experience that is deeply disturbing leads to an acute stress reaction, of course with physical symptoms such as increased heart rate, sweating, trembling, dry mouth, etc.
Psychological symptoms such as those mentioned, which occur immediately after traumatic events, are also a completely normal phenomenon, but they subside over time in most affected persons.
However, if these symptoms persist within six months of the stress event, they become chronic and significantly impair everyday functioning.
If these two criteria now coincide, i.e. a traumatic event on the one hand and the persistent, described symptoms on the other, one will consider the diagnosis of post-traumatic stress disorder.
Summary:
So, in essence, PTSD and cPTBS are about the following criteria:
Trauma was experienced (triggered by a stressor)
The feeling of helplessness was experienced
There is a vivid recollection
Psychological and physical excitement is shown
Avoidance actions have been established
The time factor plays a role
Differentiation of PTSD from other trauma sequelae disorders ( ICD – 10 ):
Acute stress disorder F 43.0
Adjustment disorders F 43.2
Personality change after extreme stress F 62.0
Other common other problems with PTSD include: Depression, other anxiety disorders, relationship problems, sexual dysfunction, substance abuse, physical complaints/somatization disorders.
Possible explanatory models of PTSD:
How can we understand that an event, or a series of events, can change a life so permanently? The way we think about and define a problem in our socio – cultural environment in psychotherapy naturally has implications for how we want to manage the problem.
However, the real basis for working with patients is to explore how they explain the causes of their difficulties to themselves.
Two – Factor Theory , Mowrer 1960
PTSD is classified as an anxiety disorder. According to Mowrer’s theory, the first factor represents classical conditioning: an initially neutral stimulus (any) becomes associated with an aspect of the traumatizing situation due to its temporal and spatial proximity to the trauma event.
In the worst case, this can lead to a generalization of the response to different stimuli that were coupled or associated with the traumatization (classical conditioning).
The second factor is operant conditioning: avoidance of fear-inducing stimuli leads to so-called negative reinforcement, as a negative state is interrupted. Avoidance `makes it feel easier’. A so-called ` deletion ‘ of the conditioning thus becomes unlikely.
The high pressure of suffering thus arises in the field of tension between the vivid re-experiencing on the one hand and the desperate attempts to avoid these intrusions on the other!
For the treatment of anxiety disorders, this theory is very helpful, because it is very simple and impressive In PTSD, however, we find highly complex re-experiencing phenomena that cannot be explained by this theory alone.
One phenomenon of PTSD, for example, is an increased occurrence of threatening intrusive memories, but at the same time, partial amnesias related to the traumatic events or their chronology often appear.
This suggests that our memory and the way we process experiences in our memory have a very large impact on the development of PTSD.
Trauma and brain functions
In life-threatening situations, we `tribally’ have two choices in principle to deal with the danger: flee or fight. If neither is possible (or seems to be), a kind of dead stop reflex is triggered.
In this state, processes are reduced to a basal processing level, perceptions pass from the brainstem to the limbic system, stress hormones are released but transmission to higher brain regions (cerebrum) is largely interrupted.
Analyzing, organizing, linking with what has been experienced or known so far cannot take place. No logic can be derived, even the speech center is partially blocked.
This explains why many of those affected are unable to put into words what they have experienced and often also have gaps in their memory with regard to the chronology of events. A linguistic examination of the experience is therefore already hindered at the neurobiological level. Finding words or even symbols together in a therapeutic relationship can therefore already be a first, important step.
A good further step would be if the patients succeeded again in living fully and above all safely in the present. For this to succeed, it is necessary to reactivate the brain structures that were `shut down’ during a traumatic experience.
With psychological trauma, our brain is overwhelmed. The events cannot be processed and stored in an orderly manner, but are temporarily stored in an unordered manner in different regions of our brain.
The incomplete processing of traumatic experiences has lasting consequences for those affected – unprocessed traumatization leads to the re-experiencing of strong emotions and bodily sensations, which – triggered by ‘triggers’ – give the impression that the trauma is taking place again in the ‘here and now’.
Understanding the processes that take place in the brain during trauma also makes the symptoms of PTSD more understandable. They are probably not less stressful because of this, but perhaps a little easier to accept.
In order to process the trauma, it is therefore necessary to be able to put the traumatic event into an overall context and to place it in one’s own biography.
Dissociations as a result of traumatization
In order to be able to explain what dissociative phenomena are about, we must first deal with the concept of integration: in our context, integration can be understood as the unification of all our personality aspects into a whole that functions in a coherent way.
We have the natural tendency and also the ability to integrate our experiences into a coherent, complete life story and develop a stable sense of self. This ability helps us distinguish the present from the past and also allows us to stay anchored in the present even when we think back to the past or think about the future.
Self-feeling
The more secure and reliable the emotional and external environment is, the better this ability to integrate can develop. So we gradually learn to relate our life experiences to our sense of self. In other words, we gain an idea of who we are and are able to insert our experiences into our life story as an integral part of our biography. Ultimately, the sense of self is part of the personality and remains in a wide variety of situations: I am me, and all my thoughts, feelings, behaviors, sensations and memories belong to me.
Dissociation
As we have already heard, traumatic experiences often cannot be processed in our chronological memory. Dissociations result from a severe disturbance in the ability to integrate, which ultimately affects and also changes our personality.
For example, trauma in childhood can drastically reduce the ability to integrate experiences into a coherent, internally consistent life story, because in the early years of life this ability to integrate is much more limited and not yet fully developed.
Dissociation can be explained as if we recognize an experience as our own and at the same time we do not. Memories, thoughts, feelings, etc. are experienced as foreign and atypical, i.e. as something that does not belong to one’s own personality at all. As a result, people with dissociative disorder feel fragmented rather than integrated within themselves.
Dissociated personality traits
Thus, split-off self-feelings and reaction patterns are called dissociated personality traits. For example, a person suffering from dissociative disorder may have the impression that certain distressing memories are not his or her own. This lack of realization, this ‘not-me’ experience, is the actual characteristic of dissociative disorders.
Dissociation as a way to survive threatening situations
Torture victims often report that they felt they had left their bodies and were watching themselves from the outside. Thus, splitting off in severe psychological and physical moments also serves a quite useful purpose. It becomes problematic, of course, when one part of the personality gets ‘stuck’ in that situation, the part lives in the trauma period and is activated again and again by triggers.
Possible formations:
A prerequisite for establishing a dissociative disorder is that no physical illness can be proven that explains the symptoms.
Dissociative amnesia
In dissociative amnesia, the person lacks all or part of his or her memories of the past, especially of stressful or traumatic events. The amnesia goes far beyond the level of normal forgetfulness, i.e., lasts longer or is more pronounced.
Memories can also become mixed and thus distorted. The affected person then cannot distinguish whether memories are true or not.
Dissociative Fugue
Dissociative fugue is the unexpected departure from familiar surroundings. The trip is outwardly organized normally, self-sufficiency is largely maintained. Occasionally there is confusion about one’s identity or another identity is assumed. When this is the case, the new identity is usually characterized by more sociability and less reticence. The duration can be from a few hours to several days.
Dissociative stupor
In dissociative stupor, voluntary movements, speech, and normal response to light, sound, and touch are diminished or absent. However, normal muscle tone, upright posture, and breathing are maintained, and coordination of eye movements is often impaired.
Time distortions
Those affected have the feeling that time passes much too slowly or much too quickly. Some personality traits are disoriented and cannot indicate where they are in space, time, or believe they are still in the past.
Dissociative movement disorders
Dissociative movement disorders involve either a loss or limitation of movement or speech, incoordination, ataxia, or the inability to stand without assistance.
Dissociative seizures
Dissociative seizures involve sudden and unexpected convulsive movements that may resemble an epileptic seizure. However, there is no loss of consciousness. However, a stupor or trance-like state is possible instead.
Dissociative sensory and sensory disturbances
In dissociative sensitivity and sensory disorders, there is a partial or complete loss of normal skin sensations (one part of the body or all over the body) or of vision, hearing, or smell.
Dissociative identity disorder
There are two or more separate identities or personality states that alternate to determine the behavior of the same person. This disorder is to be distinguished from psychotic illnesses, such as schizophrenia.
This is a change in self-perception: the person feels alien in his own body – he observes himself from the outside. In doing so, the individuals react completely appropriately to their environment.
In the process, a feeling of unreality causes the environment to be perceived as alien or altered. Both depersonalization and derealization are rarely isolated. Most often they occur as a symptom of other disorders, for example, in the context of panic attacks.
Strangeness and unreality symptoms are sometimes linked to personality traits that live in a time of traumatization, that is, they cannot distinguish between the past and the present and therefore cannot perceive themselves and the environment as familiar.
Basic assumptions violated by trauma
Our basic assumptions are the sum of our conscious and unconscious `knowledge’ about the world, i.e. our basic assumptions formulate the picture we have of the world and they determine our thinking, feeling and acting. Naturally, this knowledge is very individual and can be fed from very different sources: philosophy, psychology, sociology, empiricism (attachment theories, education, role models) and of course religion etc. Although basic assumptions are a very personal construction, there are certain overlaps across all cultures.
Therefore, a good first step in approaching the effects of trauma is to realize that almost every traumatic experience deeply violates our basic assumptions, the validity of which we all take for granted. With these implicit (automatic) basic assumptions, we were able to move through everyday life without having to re-evaluate every situation. But trauma can profoundly and permanently shake our worldview.
Shaken basic assumptions could be, for example:
The belief in one’s own inviolability
The world has an understandable order (control, predictability)
I am valuable as a human being
I have a right to physical integrity
I can trust other people
If I follow rules, nothing can happen to me, I belong
I can essentially determine my own life
The degree of shock can vary, as in the case of natural disaster or, for example, an accident. Trauma caused by a human, such as an assault or battery or maltreatment is more likely to have a greater impact.
Of course, the most serious effect of an aggressive, personal physical assault is when the perpetrator is a partner, a close relative, or even a parent, that is, someone from whom a child or even an adult might expect affection and protection.
Cognitions / Emotions / Interpretations
Of course, many models also attach great importance to the cognitive processing of trauma experiences and, as a consequence, to their interpretation.
For example, a `surrender’ during an act of sexual violence or torture or political imprisonment describes the perceived loss of all autonomy, often associated with a sense of no longer being a human being. Individuals who have given up on form often interpret trauma as evidence of a negative view of themselves, that they are worthless and have suffered permanent damage.
On the cognitive level, dysfunctional conclusions are found as a result, such as:
I have only myself to blame
I probably deserve it
I could have prevented it
I could / should have behaved differently
The trauma has changed me forever
I will never be able to feel close to others again
If I talk about the trauma, I will break down, etc.
Emotions:
Equally significant, of course, are the emotions that arise in those affected when they think back on the experience.
The moments that trigger the strongest feelings in the memories (`hot spots’) should be asked in detail in order to capture their individual meaning. Of course, the same goes for images that keep popping up.
The nature of the predominant emotions (such as guilt, anger, shame, sadness, or fear) provides clues to the underlying interpretations.
Emotion / possible dysfunctional interpretation
Blame – I am responsible for the event or its outcome myself
Anger – an injustice has been done to me, others have persistently violated my sphere
Shame – I have broken rules through my own behavior
Grief – I have lost something significant irretrievably
Fear – overgeneralizations of danger
Disgust – feelings of disgust are defined as disgust at the expectation of direct contact with an object experienced as strongly repulsive
V.9.2. Practical part
Basic information on the therapy of PTSD
Prompt and comprehensive treatment in psychotherapy is favorable for the course of PTSD. As a rule, such therapy can be performed on an outpatient basis, if necessary with the support of medication. Hospitalization may be necessary if, for example, the patient is suffering from severe depression, has an acute psychotic disorder, or is in acute danger of suicide.
It is important to note that trauma therapy can only take place if the person is no longer exposed to any current danger and is emotionally stable enough to deal with the issues.
The basic conditions of therapy therefore require: security, safety and trust. The strongest impact factors are: Relationship and time.
The goal of trauma-focused psychotherapy is to support those affected in this process:
To (re)gain control over unintentional memories,
Reduce accompanying symptoms such as anxiety, depressiveness, sleep problems, aggression, addictive behavior, concentration problems, etc,
to integrate the traumatizing events into the chronological memory and thus as a part of one’s own life story.
At the beginning there is a detailed explanation about the disorder, its origin and effects. Afterwards, a suitable therapy concept is worked out with the patient and, provided that the patient is stable enough, he will – together with the therapist – deal with his traumatic experiences and the associated memories step by step.
One can describe four steps:
Anamnesis, diagnosis, psychoeducation, relationship building: here it is a matter of conveying to the patient that the therapist can bear the descriptions of the traumatic experience and that she can accompany him with her reassuring and competent presence into and out of this situation, i.e. provide reassuring support. ( Zarbock 2019 )
Stabilization: this includes not only ensuring a safe environment in the practice/institution, but also clarifying whether current threats still exist and addressing any existing comorbidities, such as anxiety and depression, using appropriate disorder-specific strategies.
Trauma processing: there are different aspects here. The work on trauma sequelae on the one hand and the direct work on trauma in the sense of exposure on the other hand. If the patient is noticeably unstable or in a particularly difficult psychosocial situation, direct processing of the trauma is not indicated. But patients often have a very clear idea of whether they want to confront the experiences or not.
Thus, the ultimate goal in the work is to bridge the experience of loss of control to a new experience of control. The patient’s coping skills must therefore always be stronger than the intensity of the trauma (re)experience evoked in confrontation.
So, if the first step is that the patient is able to regain a stable self-esteem and good impulse control, and the trauma sequelae are back in the background, one can then consider the next steps.
In any case, trauma confrontation should always be linked to coping experiences. Of course, this also includes learning strategies to prevent possible relapses.
Integration can have several meanings in our context: Ideally, integration is the incorporation of the experiences and their consequences into one’s own life story, which also brings grief and perhaps reconciliation with oneself and others. In any case, integration is reorientation in the sense that violated basic assumptions and resulting dysfunctional behaviors can be overcome and the patient can regain confidence in his or her own self, relationships, and worldview.
Of course it is true that there is not ‘the one’, always effective therapy method, which should always be applied, but the respective method should be adjusted according to the always very individual needs and also often different approaches of the persons concerned.
Patients have very different explanations of what their difficulties are, what causes them and how they can be alleviated. Of course, this must always be taken into account in joint therapy planning.
Methodology
Stabilization
At the beginning of trauma therapy, as mentioned at the beginning, the focus is on establishing a relationship, anamnesis and diagnostics as well as psychoeducation regarding the development of symptoms. Subsequently, the focus is on learning and practicing stress – coping strategies, clarification / development of inner and outer resources. Medical and social stabilization is equally important.
Stabilization techniques include imaginative, cognitive, and affect-modulating interventions; these are described in detail in the literature.
It is favorable to introduce already in this phase proven models such as a `safe place ‘, a `healing place’ ( if the patient has the impression that she cannot be safe anywhere – Robin Shapiro, Ego-State Interventions, Probst Verlag, 2017, pages 52ff.), as well as body-oriented relaxation methods, for example `PMR’ according to Jacobson or relaxation methods according to P.Levine or Jon Kabat-Zinn. Here, too, there is a great deal of literature.
For the alleviation of the trauma sequelae disorder ‘overexcitement’ these interventions are very helpful.
For working on the trauma sequelae disorder `avoidance ‘ all behavioral exposure methods are suitable (of course depending on what is being avoided).
Trauma Processing
The therapy methods described below are of course very complex, but can only be presented compactly in this framework. In any case, further deepening through appropriate literature and relevant training is therefore recommended.
The cognitive processing of dysfunctional interpretations after trauma experiences and their consequences is a core part of behavioral trauma therapy.
- The cognitive restructuring
Model of Ehlers and Clark, 1999
The general procedure of `cognitive restructuring’.
First, we discuss how the patient interprets the trauma and its consequences. Reminder: in question are guilt, shame, anger, sadness, fear.
So the goal is first to establish a connection between these thoughts, feelings, and the symptoms the patient is experiencing. As a consequence, there is a need to talk about these thoughts or interpretations and to check to what extent they represent a realistic assessment of the world or of oneself. Possible `thinking errors’ should be corrected.
Methods to consider are: Plausibility checks, a `thinking to the end’ of situations, Socratic dialogue, etc.
It is important to keep pointing out that such negative thoughts and assessments are completely normal reactions to an abnormal situation.
The patient and therapist work together to check the patient’s interpretations and beliefs for consistency with reality. In the process, the patient learns to identify his thoughts and his interpretations and to question them for their reality content, i.e. to no longer automatically regard them as true, with the goals:
the problematic interpretations of the trauma and / or its consequences, which create a sense of current threat or self-deprecation, should be changed,
the trauma experience should be well elaborated and placed in a temporal sequence in order to reduce intrusive re-experiencing,
sufferers should ultimately recognize and abandon the dysfunctional strategies they use to try to control the perceived current threat and PTSD symptoms.
Therapy thus ultimately aims to cognitively restructure the partial aspects of the trauma and the trauma consequences with regard to their interpretations and meaning-making
Example: Some victims of an act of violence feel that they did not defend themselves sufficiently. Work could be done here to see if a stronger defense would not have resulted in an even more dangerous threat.
Many of these dysfunctional thinking patterns are based on the fact that, in today’s terms, the outcome of the event is completed and known. At the time itself, however, the outcome was of course not foreseeable.
The steps:
Identification and processing of guilt cognitions of the memories (sometimes incomplete) with the following therapeutic aspects:
Processing the moments that are processed culpably,
the modification of guilt in the sense of relativizing one’s own part in the traumatic experience and its outcome,
a reformulation of the ‘own’ part.
Guilt cognitions can arise from, for example:
suspected own norm violations
subjectively perceived / overrated own responsibility
lack of justification for one’s own actions
Misinterpretation of predictability / avoidability = hind-sight bias
`Hind – Sight Bias’ describes the fact that knowledge about the outcome of an event influences the memory of that event, with a distorted perception of knowledge prior to the event, giving us the impression that it could not have happened any other way. This leads to conclusions such as: ‘I should have known/could have known that it would turn out terribly and I should have prevented it/could have prevented it’.
Typical `thinking errors’ in guilt are thus:
Interpretation in retrospect
exaggerated perception of one’s own responsibility
excessive sense of responsibility for actions of others
Double standards
Conviction that one’s own behavior was not justified
emotional conclusion: I feel guilty, so I am too
Possible therapeutic questions for guilt
Are there any other explanations, was anyone else involved?
How much influence did you actually have on what happened back then?
How did things / the situation seem to you at the time?
What was the reason for behaving like that at that time?
How exactly could you have known what would happen?
How much time did you have to decide how best to act?
What physical and mental state were you in at the time?
Helpful questions for victims who have already been traumatized in childhood
How did the adults’ behavior strike you?
Did you know it was wrong?
Once an incident was over, did you have the opportunity to protect yourself from further assault?
During the time you were safe, did you even know about the assaults (dissociation!)?
Did you have someone you could have confided in?
What did you want back then as a child?
What was important to you at the time?
Who is responsible for how contact should be made between a child and an adult?
Are children responsible for the actions of their caregivers?
Who betrayed whom?
Literature: Anke Ehlers, Posttraumatic Stress Disorder, Hogrefe, 1999
Trauma Processing
- Prolonged exposure PE
Model by Edna Foa and M.J.Kozak
Prolonged exposure is intended to enable victims to emotionally process their traumatic experiences. The name prolonged exposure derives, first, from the long tradition of exposure theories for the treatment of anxiety disorders. They are designed to help clients confront situations that are normally anxiety-provoking for them in a non-threatening context, thereby reducing their intense fear of them.
Second, PE is rooted in the theory of necessary emotional processing of events because, as discussed, special processing and incorporation of traumatic events into chronological memory is required.
The Emotional – Processing – Theory is based on the assumption that fear is represented in memory as a ‘program’, which enables escape in case of danger. This program contains information about what we are afraid of – fear stimuli (e.g., a wild animal), fear responses (e.g., increased heartbeat), as well as the meaning associated with these stimuli (wild animals are dangerous) and ultimately the corresponding responses (fight, flight, play dead).
All these processes are (over -) vital and therefore highly useful and helpful!
However, this fear structure becomes a problem when:
+ the information contained in the structure does not adequately represent the real world,
+ physical reactions, flight tendencies and avoidance actions are activated by actually harmless stimuli,
+ Fear reactions hinder the ability to cope with everyday life,
+ harmless stimuli and reactions are experienced as dangerous,
+ Avoidance actions restrict the affected persons
According to Foa and Kozak, however, two conditions must be met for an unrealistic and abnormal fear structure to change:
First, the fear and anxiety of the affected person must be activated. This is indispensable, because otherwise a change of the fear structure is not possible
Second, the original unrealistic information must be replaced with realistic information. This new information is transmitted during exposure sessions, and the fear structure may change.
Exposure therapies meet both of these requirements.
Thus, the PE – treatment program includes the following aspects:
+ Comprehensive psychoeducation on common trauma reactions.
+ Breathing training, or exercises that calm down.
+ Repeated in vivo exposures (real exposures) related to situations or activities that are avoided.
+ Repeated, prolonged imaginative confrontation with trauma memories.
The concept is that by dealing with trauma memories or with various triggers, people will realize that they can cope with such situations and nothing bad will happen to them in the process. Moreover, they may experience that when they confront what they fear, their fear actually decreases.
So the exercises, in terms of imaginative exposure and in – vivo exposure help to see the difference between the traumatizing event and other similar but harmless situations.
Furthermore, repeated imaginative exposures can help clients think differently about what they have experienced (cognitive restructuring). Here again is the example of a client who feels guilty because she believes she did not defend herself enough against an attacker. It should become clear that even worse things could have happened to her if she had fought back even harder.
The core of this therapy is therefore that the affected person imaginatively puts himself in the traumatic situation in the therapy session, relives the trauma and the unpleasant feelings. Therapy sessions are recorded and patients are given the task of listening to these recordings at home on a daily basis. With repeated use of this technique, the initially very violent emotional reactions slowly subside and the symptoms fade into the background.
Literature: Foa, Rothbaum, Hembree, Workbook Prolonged Exposure, G.P.Probst Verlag, 2014
Trauma Processing
- EMDR – Eye Movement Desensitization and Reprocessing
Francine Shapiro
Regarding EMDR, it is assumed that through bilateral stimulation by means of certain eye movements (or also acoustic or tactile stimuli), a synchronization of the cerebral hemispheres or an internal reorganization of the dysfunctional trauma experience is made possible.
We had already discussed that trauma, for example, can cause `voiceless horror’. This means that in parts of the brain experiences are stored in a stressful way and are also experienced by the client in a stressful way because the speech center was blocked or suppressed.
These blockages are to be dissolved by the new synchronization.
An EMDR session typically proceeds in 8 phases:
1st phase:
A detailed history of the stressful events / incident
Good information about the treatment method
Preparation of a treatment plan
2nd phase:
Stabilization and preparation of the patient, i.e. typically the establishment of a `safe place’ to which the patient can retreat at any time if the work becomes too stressful
3rd phase:
The stressful memory/memories are evaluated in terms of the intensity of the feelings, thoughts, body sensations, and images that emerge.
Then a negative inner evaluation takes place, e.g..: `I am to blame for this myself’ and in each case a positive countervailing evaluation, e.g..: `I could not have done anything about it’, each on a scale of 0-10.
4th phase:
This is the actual core phase of the treatment: the patient is asked to get in touch with her memories, and then to follow with her eyes the two fingers (or the pencil, or…) of the therapist, which are moved back and forth in front of the patient’s eyes. The head should not be moved during this process.
These movements are interrupted again and again and the patient is asked about her feelings about the memories, or about what has already changed or decreased in intensity.
5th phase:
The positive thoughts/images discussed prior to this sequence are again discussed, any changes are anchored in the scaling (0-10).
6th phase:
In this phase a ‘body scan’ takes place (for example according to Kabat-Zinn)
7th phase:
The conclusion of the session, with an intensive debriefing of the sensations or the changes
8th phase:
The reflection of the last hour in each case
Literature: Francine Schapiro, EMDR Fundamentals and Practice, Junfermann, 2013.
Trauma Processing
- Practical approach to dissociative disorders
There are very helpful explanatory models and effective therapeutic approaches to this topic from different schools. In the following I would like to describe some behavioral approaches again, but I strongly recommend a further examination of – for example – psychodynamic approaches.
The approach to treating dissociative disorders is fundamentally dependent on the type and severity of the dissociation and the presence of possible comorbid disorders.
Interventions that specifically address dissociative symptoms should therefore be embedded in an overall treatment plan.
For dissociative disorders such as amnesias, fugue, stupor, depersonalization, or derealization, one can begin to work on the triggering situations (themes, contexts,etc.). If the patient has already shown a tendency to dissociate during the case history, agree on a sign, ritual or similar to be able to `retrieve’ the patient if necessary. In these cases, even the establishment of a ‘safe place’ for female patients is of little help because the temptation to avoid confrontation is too attractive.
The approach aims to re-perceive split-off memories or even personality parts, to endure the associated affects and fears, and to enable integration into a unified sense of self. From a psychodynamic perspective, this means developing integrated psychological functioning by overcoming conflicts, as well as developmental deficits that have resulted from repeated traumas.
Resolution of these conflicts and post-maturation of deficits reduces the need to maintain or act out dissociative defenses. (Citation: Dr. Ursula Gast, Vierwaldstätter Therapietagung 2016)
Underlying the idea of identifying and processing triggers of dissociation is the experience that patients regularly respond with dissociation in the absence of other coping mechanisms. Thus, a former, very useful, protective mechanism becomes an avoidance mechanism, which is a hindrance to adequately cope with a current situation. Habitual dissociation, e.g., in the form of depersonalization and derealization, also frequently prevents the integration of new emotional experiences during therapy (Ebner-Priemer et al. 2009).
Dissociative reactions basically serve – in a meaningful way – to avoid painful affects. It is therefore necessary to gradually abandon the coping mechanism of dissociation and replace it with other strategies. It is helpful to convey that dissociative coping was useful as an emergency measure in the traumatic situation, but then became increasingly independent and dysfunctional for the current life situation.
Depending on whether the trauma is one-time or structural, the approach differs. Patients who did not have reliable primary caregivers available to help them regulate and modulate their affects simply could not learn to manage affects. In traumatic situations, affects were experienced as overwhelming and distressing, so that feelings of any kind were often excluded and compartmentalized from normal life. This means that opportunities to regulate their needs are fundamentally unavailable to them. Thus, building a secure, sustainable relationship in the sense of `reparenting’ (Jeffrey E. Young) is a core issue in therapy.
However, working on the triggers, naming and enduring affects, appropriate confrontations and restructuring are essential elements for processing the symptoms and the trauma itself, even in the case of one-time, upsetting experiences. Here, too, it must be clarified, by means of appropriate anamnesis, whether the basic abilities to cope with crises existed before the shattering event.
Integration
Integrating what has been experienced, with all its implications, into a coherent self-image is thus the central theme of any trauma therapy. When planning therapy, it always depends on whether the patient wants to get involved in working on the trauma itself or whether it is sufficient – for the moment – to better understand the trauma consequences and to be able to control them better.
Grief and anger also fulfill an important function here, but it is also a matter of restoring lost trust in relationships, or – as in the case of early injuries – of establishing for the first time a relationship experience that has never been experienced.
The traumatic experiences should eventually become part of the autobiographical memory. Trauma either shapes a person or changes a person. In his worldview and his self-image. In any case, the question of the next, meaningful step arises: ‘Who am I now, after all these experiences, how do I experience myself, how do I cope with my present and what are my wishes for my future’. Whereby of course applies: `You can not get into the same river twice’ ( Heraclitus, 6th century BC ).
Literature:
Anke Ehlers, Hogrefe Verlag 1999: Posttraumatic Stress Disorder
Edna Foa, Elizabeth A. Hembree, Barbara Olasov Rothbaum, G.P.Probst Publishers 2014: Workbook Prolonged Exposure.
Liedl, Schäfer, Knaevelsrud, Beck Verlag 2014: Psychoeducation in post-traumatic disorders.
Gerhard Zarbock, Pabst Verlag 2008: Praxisbuch Verhaltenstherapie
Seidler, Freyberger, Maercker ( Eds.), Klett-Cotta 2011: Handbook of Psychotraumatology.
Busch, Hermann, ZBM 2019/5: Finding words for the unspeakable
Jan Gysi, Sollievo.net 2018: changes in ICD-11 in the area of trauma and dissociation.
Boon, Steele, Van der Hart, Junfermann 2013: Coping with trauma-induced dissociation.
Burkhard, Schattauer 2012, Mindfulness
Ulrich Sasse, Schattauer 2011,Trauma-Centered Psychotherapy
Storch, Cantieni, Hüther, Tschacher, Huber Verlag 2011, Embodiment
Rießbeck/Müller, Kohlhammer Verlag 2019, Trauma Confrontation-Trauma Integration.
Robin Shapiro, Probst Publishing 2019, Ego-State Interventions.
Anne Boos, Hogrefe 2005, Cognitive behavioral therapy after chronic traumatization.
Peter A. Levine, Kösel 2010, Language without words
