Our Evolving Understanding of Trauma (and its Treatment)

Trauma has been studied by physicians and psychologists alike for decades. Historical events and advancements in the field of psychology have changed our views on how trauma affects a survivor, our recognition of different clinical presentations, and our concept of how to best address varying symptoms in clinical practice. The rate of progress has increased in the last few years as new medical technology has allowed researchers and clinicians to better understand how traumatic experiences can cause long-lasting psychological and physical effects in survivors, in turn advancing the way we approach treatment.

Research beginning in the 19th century began to identify a link between traumatic events and symptoms that could not be easily explained in medical terms. This understanding was later refined by Pierre Janet, French psychologist in the field of dissociation and traumatic memory, who asserted that intense emotions interfere with appropriate or accurate appraisal of and response to an event, leading to sensory experiences, overwhelming emotions, and behaviors that make it feel like the trauma is being re-experienced. This concept became a foundation to our current understanding of trauma. Later, soldiers returning home from World War I displayed new unexplained symptoms related to trauma, which were referred to using terms such as shell fever, mental shock, war shock, shell shock, and war psychoneurosis. Additional phrases such as battle fatigue and combat exhaustion were developed during and after World War II to try to describe the trauma-related syndromes being seen so commonly in combat veterans. It was at this time that Abram Kardiner, American psychoanalyst, began to describe some of the specific symptoms in greater detail such as chronic vigilance and sensitivity to the possibility of threat in his book, The Traumatic Neuroses of War.

The understanding of a trauma-related syndrome became clearer with the publication of the first Diagnostic and Statistical Manual of Mental Disorders (DSM) following World War II. Here, the diagnosis of Gross Stress Reaction was introduced to describe the constellation of symptoms commonly seen in war veterans. This described the acute psychological responses following exposure to an extreme stressor, which was defined as anything that would be traumatic for most people. Of note, this psychological response was thought to resolve after the stressor ceased and there was no mention of longer-lasting symptoms following trauma. However, this view began to shift as further information was collected from Holocaust survivors, prisoners of war, and the survivors of mass catastrophes. Finally, in 1980, a group of veterans along with two New York psychoanalysts, lobbied the American Psychological Association to create a new diagnosis for the DSM-III which would account for the long term symptoms and sequelae of trauma. This diagnosis became Post-Traumatic Stress Disorder, which is still in use today.

Following the formal recognition of the long-term impacts of trauma on survivors, this concept has become widely accepted and thoroughly researched. The concept was expanded from its initial narrow focus on trauma related to war to include the aftermath of domestic violence, sexual assault, and child abuse. Researchers also began to probe and better understand the physiologic basis underlying many PTSD symptoms. New brain imaging technologies such as functional MRI allowed visualization of the Positron Emission Tomography and later functional Magnetic Resonance Imaging allowed scientists to probe how the brain processes information during trauma and to see how different parts of the brain are activated when people remember traumatic events from the past. One particular pioneer in this field, Bessel van der Kolk, Dutch psychiatrist noted for his research in the area of posttraumatic stress, studied which areas of the brain are activated when people are presented with events to purposely remind them of past trauma. In this work, he noted that when the memory from the traumatic event is triggered, the survivor’s sympathetic nervous system is also activated, which in turn creates a similar physiological state as when the trauma first occurred.

These new developments in our understanding of trauma have caused shifts in treatment models for survivors. Approaches in the 1970’s related to catharsis and the “letting out” all of the feelings and memories associated with the traumatic events gave way to exposure therapy and cognitive behavioral therapy in the 1990s. These treatment modalities address distorted beliefs and attributions related to the trauma and provide a supportive environment in which clients are exposed to and encouraged to talk about their traumatic experience, reducing negative emotional and behavioral responses following the event. However, as we have come to recognize the physiologic underpinnings of traumatic syndromes, greater emphasis is starting to be placed on treatment modalities and therapeutic models that address the physical side of a trauma. Eye Movement Desensitization and Reprocessing, a technique that relies on physical stimulation, is showing promise in alleviating the distress associated with traumatic memories and building resiliency to explore these memories.

In this same vein, newer treatment models have surfaced involving alternative and integrative intervention strategies such as Sensorimotor Psychotherapy and Trauma Sensitive Yoga that move beyond traditional talk therapy. Starting in 2009, studies have demonstrated that yoga, breathing, and mindfulness can activate the parasympathetic nervous system and counteract the physiologic trauma response. Research at the Trauma Center in Massachusetts has shown that yoga has lead to a reduction in frequency of PTSD and hyper-arousal symptoms, greater gains in vitality and body attunement, and activation of the thalamus and pre-frontal cortex to better filter incoming sensory input from the environment and make better decisions. This research was adapted to clinical practice as Trauma Sensitive Yoga, a technique which uses yoga-based movement to help clients address the physical qualities of trauma memories, gain greater awareness of physical sensations in their bodies, and gain feelings of empowerment. Other research has revealed that purposeful breathing can impact anger, depression, and anxiety and that yoga can positively affect wide ranging medical problems such as high blood pressure, elevated stress hormone secretion, asthma, and low back pain. Similarly, researchers at Harvard University have shown that meditation can have a positive effect on the areas of the brain that are critical for self-regulation.

As our understanding continues to evolve, it is becoming increasingly clear that mindfulness and movement are critical to the process of healing from trauma. Adding these elements while continuing to address feelings, thoughts and behaviors can lead to better outcomes in some survivors of trauma. But how can clinicians best incorporate the evolving research and new treatment modalities into their practice with clients? Drawing on tools many clinicians already have and use, an easy place to start might be to introduce focused breathing, mindfulness or progressive muscle relaxation to survivors as a coping skill to be used during a session and on their own. On the other hand, yoga and many other interventions that address trauma physiology require specific training to be performed correctly and some clients may benefit from a referral to a qualified provider.

While traditional therapeutic modalities work for some trauma survivors, many others benefit from a broader and physiologically grounded approach to treatment. As stronger and more reliable evidence continues to support alternative approaches to trauma care, we must be vigilant to identify those clients who might benefit from these interventions. Survivors who show symptoms of complex trauma, clients who feel stuck in current therapeutic modalities, and clients who struggle with an unresolved stress response with a hyperactive sympathetic nervous system can especially benefit from these approaches. Clinicians should provide clients with psycho-education on the available options, and if a good fit, introduce the appropriate modality into their current therapy program or refer the client to a different, qualified provider.

Macarena Corral, Psy.D., LP, is the co-founder and CEO of the Center for Collaborative Health (CCH), a multidisciplinary group practice that provides innovative and integrated options for the diagnosis and treatment of mental health. As a provider with CCH, she offers individual and couples therapy, yoga therapy, and psychological assessments in both English and Spanish. 

Questions or comments? Please contact Dr. Corral at [email protected] or visit our website at www.centerforcollaborativehealth.com for an option for alternative trauma treatments and training opportunities in the Twin Cities area. 

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Comments on "Our Evolving Understanding of Trauma (and its Treatment)"

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Stephen Parker - Tuesday, October 04, 2016
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The use of yoga in trauma can be extremely helpful. Much of the same stimulation of contralateral cerebral hemispheres that is theorized to be the mechanism behind the success of EMDR also happen in doing yoga postures on one side of the body and then the other, as well as in alternating breathing practices. The advantage is that the person is not focusing on traumatic material and so they are less likely to experience the "chaining" into other trauma history that can sometimes leave people overwhelmed. As a yoga teacher trainer for many years now, the method advocated by the Trauma Center of Massachusetts (Overcoming Trauma Through Yoga) is how yoga should be taught across the board: mindfully and without pushing at every step.

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