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Despite the fact that more agencies and mental health organizations are attempting to be “trauma-informed,” when CBT (Cognitive Behavioral Therapy) is the only treatment paradigm used, it’s disingenuous to say that they are truly approaching clients from a trauma-informed perspective.
Steps towards de-pathologizing clients’ issues and lessening their sense of shame
We are who we are in spite of and because of where we come from. Clients’ earliest attachment experiences profoundly impact their subsequent thoughts, emotions, and behavioral choices. These experiences shape and inform their core sense of self and the inner monologue that guides them throughout life.
When therapists only focus on re-framing negative or distorted cognitions or give clients a formulaic approach to changing their behavior without exploring the underpinning of those beliefs or self-destructive choices, it’s as if they are building a house on sand rather than a foundation of concrete. Helping clients to “connect the dots” between past experiences, formative relationships, and current struggles is essential. It helps clients make sense of their pain. It can be the first step towards de-pathologizing their issues and lessening their sense of shame.
Building the bridge between the past and the present gives clients the opportunity to recognize that some of their deeply held “truths” were never actually their own thoughts. It’s powerful and freeing for clients to process the fact that their beliefs were imposed upon them by caretakers they loved and trusted, and therefore the messages were never challenged.
Doing deeper, family-of-origin work gives clients the opportunity to re-examine, re-evaluate, and potentially let go of thoughts that have never been accurate or served them well. When clients are given the chance to safely identify and explore the origins of their negative thinking, self-effacing beliefs, or self-destructive behaviors the process of cognitive re-framing and the ability to embrace new behaviors will certainly be a more organic, authentic, and effective endeavor.
Additionally, our newest understanding of the brain corroborates the fact that trauma is not stored in Broca’s area — the part of the brain responsible for language. As “trauma-informed” therapists, we must weave right-brain based, expressive modalities into the work. In this way, the deepest healing can occur. Simply “talking” about the issues that clients bring into therapy is not enough. Although there is absolutely a place to address negative, inaccurate beliefs and behaviors that are unsafe or promote shame, if therapy doesn’t take into consideration clients’ histories, their affective states, and the somatization of their trauma, then we are putting a band-aid on something that requires surgery.
In a world where we have become conditioned to expect and demand immediate, instantaneous results and quick-fix approaches, CBT can seem very appealing. It’s certainly still being promoted by insurance companies and, shockingly, the paradigm of choice in many mental health graduate programs. We are doing clients a terrible disservice when all we offer them is a “here and now” approach.
Helping clients to access, unpack, and heal from powerful childhood wounds is essential. It requires a therapeutic context that is safe and trusting. It means taking the time to resource clients with affect regulation skills and respecting the pace that clients establish so safety is always preserved. It means honoring the uniqueness of every client and incorporating a variety of treatment modalities that resonate with each person. It means taking the time to build a secure attachment, and safely reconnecting the client to their autobiography so their thoughts and feelings make sense. If we do anything less, we cannot call ourselves “trauma-informed” clinicians.
The Department of Veterans Affairs may today deliver the worst trauma treatment known to man or woman.
The diagnosis of PTSD is an outgrowth of the protests over the Vietnam War. Distraught and disillusioned Vietnam veterans, together with psychiatrists such as Robert Jay Lifton and Chaim Shatan, developed the “rap groups” that provided psychological support in a community of other vets who had undergone similar experiences. Rap groups worked because they provided a place to share common experiences, including terror and remorse. Rap groups provided community and social support.
The effectiveness of rap groups eventually convinced the American Psychiatric Association to include Post Traumatic Stress Disorder in the third edition of its Diagnostic and Statistical Manual, though this is a long and convoluted story (see https://traumatheory.com/whats-going-on-with-dsm-5/ for more details). For some time, rap groups were employed by the VA, often with reluctance, for their members were not always easily managed (Sonnenberg, Blank, Talbott).
No more. David Morris’ recent account of his experience with cognitive behavioral therapy at the San Diego VA tells of a sign on the wall of a waiting room for a small group of vets who were about to enter therapy (p. 195).
PLEASE REFRAIN FROM TELLING WAR STORIES. YOUR STORY COULD BE A “TRIGGER” FOR SOMEONE ELSE.
If the traumatized cannot talk with each other, but only through a therapist, even in a group, then therapy is no longer about creating a community of support for those who suffer. It’s about isolating those who suffer from each other, so they can be processed individually, their trauma chopped into bits.
I am not a veteran; I have not been subjected to the VA’s trauma treatments. My opinion is based on reading the publications of the Veterans Affairs National Center for PTSD, several good books, including The Evil Hours, by Morris, and my own understanding of trauma, which I have laid out in 30 posts this year.
First line treatments
The VA recognizes as “first line treatments” only versions of what it calls cognitive behavioral therapy (CBT). First line treatments means the only treatments that have been scientifically validated. The terminology is a little confusing, so stick with me. Under CBT, the VA includes highly focused small group therapy, designed to correct “distorted cognitions, which are derived from . . . dysfunctional beliefs.” (Clark and Beck, pp. 116-118)
CBT also includes prolonged exposure therapy, sometimes called flooding, in which memories of a traumatic event are rehearsed (retold) again and again. The idea is that the intense initial reactions of panic will be “extinguished” over time as the mind and body become used to being overwhelmed. Not everyone considers flooding a version of CBT, but the VA does.
As a less effective but still “first line” treatment, the VA includes eye movement desensitization and reprocessing (EMDR). EMDR is a version of exposure therapy in which the traumatic event is rehearsed while the eyes move back and forth, or the therapist taps your hand. No one quite seems to know how EMDR works. The eye movements may mimic REM sleep, allowing traumatic memories to be reprocessed, but there is no quality scientific research supporting this hypothesis, and it wouldn’t explain why hand tapping seems to work as well.
Why these are bad treatments
These are bad treatments because they assume that PTSD stems from a particular dramatic and traumatic incident, such as an explosion, rape, car accident, and the like. Trauma that develops over time, not just chronic PTSD, but the trauma of a long deployment, or a long illness, doesn’t fit. Trauma is reduced to an event. This represents
a fundamental misapprehension of the nature of trauma as I experienced it in Iraq, trauma that to my way of thinking was far more about the cumulative effect of living under fear of death for months and then coming home and realizing that no one cared in the slightest about it than it was about a single close call with an IED. (Morris, p. 192)
Yet, it is exclusively with Morris’ close call with the IED that his treatments focused on. They had to, for they are not designed for talking, but for programmed interaction.
Flooding is torture
Flooding, or prolonged exposure therapy, has taken the worst rap, as it essentially demands that the trauma victim reexperience his trauma over and over again. For this to work, it has to focus on a traumatic incident, not trauma as a process extended over time. Some therapists and researchers consider it dangerous. It’s a reasonable conclusion, considering that flooding essentially simulates the original trauma. Morris asks
What is it about post-traumatic stress that makes such sadistic methods seem reasonable? What is it about post-traumatic stress that so confounds the clinical mind that it resorts to methods that are virtually indistinguishable from torture? Could it be that there is some daemonic repetition-compulsion at work here? . . . A writer friend . . . mentioned offhand that PE seemed in some ways to resemble an exorcism. (Morris, p. 193)
Such a conclusion only makes sense if we adopt the following assumption. The traumatized person is someone who has seen and knows a part of the world that the rest of us cannot bear to know. “Trauma is the savagery of the universe made manifest within us.” If this is so, then flooding (prolonged exposure) would be not so much a way of driving the demons out as it would be tormenting the messenger until he or she is exhausted, or worse. This is a harsh conclusion, but exposing the traumatized person to his or her trauma over and over again is harsh treatment.
CPT is discipline
While flooding seems the most damaging, one should not underestimate the damage of what is usually known as cognitive behavioral therapy, what the VA calls cognitive processing therapy (CPT). In a small group, participants are asked to evaluate whether their extreme beliefs, from which their trauma supposedly flows (contrary to much evidence that trauma is not a cognitive experience), are really rational or normal. Morris gives this example.
When, in one of my first “A-B-C” sheets, I wrote that “A. The government lies. B. People in power are liars and their lies killed friends of mine. C. I feel sick and helpless about it,” I was urged . . . innocently, even sweetly, by Chloe [his therapist] to investigate whether my “B” belief was, in fact, “100 percent realistic.” (Morris, p. 203)
If PE resembles torture, then CBT resembles what Michel Foucault calls discipline, in which experts define what counts as normal, exerting pressure on the rest of us to conform. Discipline is the modern, or sophisticated, version of punishment.
Treatment that can be practiced from a handbook
The treatment of PTSD has become “manualized,” something that therapists with minimal training and experience can learn and practice from a handbook. Once again, this assumes trauma is a discrete event that can be managed by a psychological technique, rather than an assault on all that one has ever presumed to be right, good, just, and fair. Trauma destroys worldviews, above all the view that the world is basically a good, or at least decent, place to live.
When trauma professionals control treatment
Most people have heard about the long waiting lines for treatment at VA hospitals, primarily the result of the wars in Iraq and Afghanistan. The need to shorten waiting times has led to a preference for treatments for PTSD that can be completed relatively quickly, often in a dozen sessions, by therapists with minimal training.
But, there is a larger issue at stake: what happens when professionals get their hands on a treatment that was originated by veterans? Measurement of results counts more than quality, and what can be measured becomes what it real. Worldviews, and their destruction, can’t be measured, though perhaps their “side-effects” can. One study showed that even when CBT works to reduce anxiety, it has little effect on “the negative emotions,” including shame, guilt, and anger (Pitman et al.).
The originators of the rap groups that led to the diagnosis of PTSD saw the disorder as an indictment of a society that would send its young men to fight a pointless war. Today PTSD is the subject of professional discipline. The result is that a concept that helped many to make sense of their suffering by seeing it as a reaction to a brutal and senseless world, a concept that helped bring veterans together, has become a technical process to be applied to symptoms one veteran at a time.
References
David Clark and Aaron Beck, Cognitive Therapy of Anxiety Disorders: Science and Practice. New York: Guilford Press, 2011.
Michel Foucault, Discipline and Punish: The Birth of the Prison. New York: Vintage Books, 1995.
David Morris, The Evil Hours: A Biography of Post-Traumatic Stress Disorder. New York: Houghton Mifflin Harcourt, 2015.
Roger Pitman, Bruce Altman, Even Greenwald, Ronald Longpre, M. L. Macklin, R. E. Poiré, and G. S. Steketee, “Psychiatric complications during flooding therapy for posttraumatic stress disorder,” Journal of Clinical Psychiatry, 52 (1), 1991, 17-20.
Stephen Sonnenberg, Arthur S. Blank, and John Talbott, eds., The Trauma of War: Stress and Recovery in Vietnam Vets, pp. 167-191. Washington, D. C.: American Psychiatric Press, 1985.
United States Department of Veterans Affairs, National Center for PTSD. “Treatment of PTSD.” http://www.ptsd.va.gov/public/treatment/therapy-med/treatment-ptsd.asp
