Trauma-informed psychotherapy puts the body – and love – back in mental healthcare

Photo:"Warengestell mit Gehirnen (Display Stand with Brains)," By Katharina Fritsch.
Photo of “Warengestell mit Gehirnen (Display Stand with Brains),” By Katharina Fritsch

For the past 50 years, psychotherapy has taken a back seat to biomedical psychiatry, largely due to reliance on medications for the treatment of mental disorders. Yet clinical evidence increasingly points to chronic, unresolved traumatic stress as the source of many — if not most — mental disorders. Furthermore, longitudinal analyses show continued use of psychotropic medications is bad for the body, even causing chronic diseases. Granted, medications can stabilize a body wracked by recurrent distress, but such an approach is hardly a long-term cure. According to psychiatrist and trauma specialist Bessel Van der Kolk, “dramatic advances in pharmacotherapy have helped enormously to control some of the neurochemical abnormalities caused by trauma, but they obviously are not capable of correcting the imbalance.” To correct the “imbalance” often requires learning to inhabit one’s body and relationships in new ways.

Fortunately, the psychotherapeutic treatment of psychological trauma has advanced significantly the past several decades. In part, this is due to scientific discoveries of how the body and relationships naturally defend against traumatic stress. In particular, trauma-informed psychotherapies that draw from neuroscience and attachment studies are more holistic and scientifically based than ever before, although they often support the intuitions held by originators of psychotherapy such as Pierre Janet, Sigmund Freud, and C. G. Jung.

The neurobiology of trauma

Pierre Janet was the first to recognize how the body responds to present events as if past traumas were recurring — what today we call flashbacks. He observed patients

“continuing the action, or rather the attempt at action, which began when the [traumatic event] happened, and they exhaust themselves in these everlasting recommencements.”

Today we know the neurobiological reasons for flashbacks. Unlike narrative memories that seamlessly integrate remembrances of the past — e.g., feelings, perceptions, thoughts, body sensations, beliefs — the memories associated with traumatic events largely remain unintegrated. This has to do with how the body has evolved to deal with threat. Thinking about a threat would slow down reaction time. Thus the frontal lobe — the so-called “thinking part” of the brain — effectively shuts down during perceived threats as energy and attention are directed towards survival responses. Consequently, a coherent narrative of the traumatic event is not created, inhibiting the past from becoming, well, the past.

These fragmented, often unconscious memories can be stimulated by even the subtlest reminders of past traumas. When this happens, the amygdala is also stimulated. The amygdala functions like the body’s alarm for the presence of danger, setting off survival responses even if no danger is present. The stock example of this process is the war veteran who hears a car backfire and automatically drops to the ground because his body “thinks” it hears gunfire. Today, sensorimotor psychotherapyEMDR, and somatic experiencing are a few of the psychotherapeutic approaches that help release what Bessel van der Kolk described as “fixed action patterns” of the body that the trauma survivor would otherwise continually replay.

The significance of early life relationships

Sigmund Freud described psychoanalysis as “a cure through love.” Learning to trust love — and seeing oneself as lovable — remains one of the best possible outcomes of psychotherapy. Perhaps this is because even more debilitating than enduring something traumatizing is the pain of facing trauma and its aftereffects alone. Traumatic stress incubates in isolation and feeds on shame. Over time, survivors can lose trust not only in others, but also in their own minds as they defend against intrusive reminders of past traumatic events.

Common goals when starting therapy include gaining control over distressing emotions such as fear and anger, ending depression, creating better relationships, and functioning well at work. Traumatic stress and fragmentation are rarely seen as the root causes of suffering even though these experiences are often the neurobiological underpinnings of feelings of despair, distress, or impaired functioning.  Furthermore, present difficulties are often the long-term outcome of adapting to maladaptive or traumatizing caregiving early in life.

Trauma-informed psychotherapies distinguish between two types of trauma:

  1. Big “T” trauma associated with fear-based events (i.e., overwhelming experiences that cannot be integrated)
  2. Little “t” trauma that results from maladaptive caregiving (i.e., cause emotional distress, but do not overwhelm)

Both can lead to mental disorders in later life as well as problems with intimacy. Connecting current problems to early relationships is difficult. It can be distressing to describe them as traumatic, or even maladaptive, when there are continued feelings of emotional dependency on parents or caregivers. Even so, research and clinical evidence reliably show the extent to which we have evolved for specific emotional experiences with caregivers. When these experiences were lacking, or if there was abuse, developing intimate relationships later in life can be particularly challenging. There can also be difficulties with consistently feeling confident, calm, and hopeful about one’s abilities.

Clinical psychologist Robert Karen described attachment theory as a “theory of love and its central place in human life.” According to attachment theory, one of the primary roles of the caregiver is to teach the child how to bond with others and regulate emotions. Emotions are the basis for intimacy and are also fundamental for understanding one’s own needs and desires. Furthermore, having the capacity to regulate emotions is vital for forming relationships and self-knowledge.

Studies conducted by Mary Ainsworth revealed mothers who provided secure attachments do the following:

  • reflect sensitivity rather than misattune to emotional needs
  • accept rather than reject the infant’s emotional needs
  • cooperate with the infant rather than attempt to control and dominate
  • appear emotionally available to the infant rather than remote
  • adapt to the infant’s natural rhythms and emotional needs.

Challenges to developing secure attachment include:

  • the caregiver frequently appears frightened, such as when intimate partner violence is occurring
  • the caregiver is emotionally unavailable, such as when the caregiver is depressed
  • the caregiver is frightening, which is how a caregiver is perceived when abusive
  • the household is chaotic, keeping the caregiver from emotionally attending to the infant.

According to the Adverse Childhood Experiences study, two-thirds of US households have conditions that can damage the caregiver-infant bond. Adverse childhood experiences also increase the likelihood of later developing mental disorders. Of note, most people receive or seek mental health services after a period of isolation, which suggests difficulties trusting others or having safe people in their lives who could offer support.

The healing impact of relationships

Just as treatments for the body’s response to trauma have improved other the years, so has the “love cure” originating with Freud and others. Relationships involving the safe exchange of emotions may be the single most healing experience a person with a history of trauma can have. Yet such intimacy is a two-directional process, which challenges the idea that an effective therapist is a distant one. Early in psychotherapy’s history, C. G. Jung realized that psychotherapy heals when both therapist and client are equally invested in the relationship.  He went so far as to claim, “unless both doctor and patient become a problem to each other, no solution is found.”

The idea of the therapist as “blank screen,” which Freud advocated, fails to fit the present-day understanding of the neurobiological effects of trauma or the nature of attachment. Instead, attachment theorists see healing occurring through the repeated experience of finding oneself in the mind of the therapist — and altering that image by genuinely impacting the therapist. Yet to have such an impact on another person means having a real relationship, albeit one in which the focus in psychotherapy is on the client. Clinical psychologist David Wallin wrote,

“psychotherapy ‘works’ by generating a relationship of secure attachment within which the patient’s mentalizing and affect regulating capacities can develop. … such a relationship must be an intersubjective one in which the patient comes to know him- or herself in the process of being known by another.”

I would venture to add the client comes to trust love through being loved.

Of course, therapy isn’t the only way to learn to trust love and trust loving oneself. We can begin to do this for ourselves and each other by prioritizing emotional safety and love in all our interactions. Sometimes this is as simple as asking ourselves, Is this emotionally safe for me/him/her/them? Is this loving?

Photo: "Love," By Robert Indiana (1973).
Photo of “Love,” By Robert Indiana (1973)

 

References

Kolk, Bessel A. van der, Alexander C. McFarlane, and Lars Weisaeth. 1996. Traumatic Stress: The Effects of Overwhelming Experience on Mind, Body, and Society. New York: The Guilford Press.

Ogden, Pat, Kekuni Minton, and Clare Pain. 2006. Trauma and the body: A sensorimotor approach to psychotherapy. New York: W. W. Norton & Co.

Wallin, David J. 2007. Attachment in Psychotherapy. New York: The Guilford Press.

Whitaker, Robert. 2010. Anatomy of an Epidemic. New York: Crown Publishers.

Young-Eisendrath, P. and T. Dawson (Eds.). 2008. The Cambridge Companion to Jung. Cambridge, UK: Cambridge University

© 2013 Laura K Kerr, PhD. All rights reserved (applies to writing and photography).

  • Pamela Spiro Wagner

    “dramatic advances in pharmacotherapy have helped enormously to control some of the neurochemical abnormalities caused by trauma, but they obviously are not capable of correcting the imbalance.”

    I am not so sure of this. Benzodiazapines have been proven to increase anxiety levels beyond the level that was originally present, in every case, that is, every drug studied. Anti-depressants are a misnomer, and it is now known beyond a shadow of a doubt that serotonin levels in those suffering from “depression” are not fundamentally different from anyone else’s. Ditto the levels of dopamine or phenylethylamine in those with psychosis. All the drugs do is act in a psycho-active manner, they do something, change something in the brain that makes a person FEEL differently from before. Which may be good, or bad, depending on your point of view. But NONE of these drugs actually are corrective or curative or even truly “analgesic”. In my view the best of them only dull the pain a bit, and if used more than occasionally end up starting a feedback loop that causes more harm than good. This may seem to be purely in my own opinion, but read Whitaker, Robert, or better yet, Joanna Moncrieff, the British psychiatrist and author of several books recently critical of the pharmaceutical mythology that any psychoactive drug actually does what it is said to do. (THE BITTEREST PILLS, about anti-psychotic drugs is her most recent)

    Lovely article otherwise, I learned a lot. Thank you! Pam W.

    • Thanks so much for sharing this very important information. While I am personally opposed to the use of psychotropic medications, I have also worked with people for whom a combination of medications with trauma-focused psychotherapy has led to remarkable improvements. That said, I always prefer someone getting extensive psycho-social support to being put on drugs.

  • Pamela Spiro Wagner

    I appreciate your understanding…and all that i point out should be taken also with the knowledge that despite my opposition, i myself take several medications of precisely the sort i so strongly oppose. That said, as Joanna Moncrieff points out, psychosis can become iatrogenic after taking antipsychotics for a long period of time and no one can know what is an innate condition now and what has simply been caused by my having been forced to take such drugs for decades…

    • There is so much unknown about the psychotropic medications, and yet they have been touted as if they were wonder drugs. Especially the novel antipsychotics. So many dangerous side effects, and yet so many people have been led to believe these drugs were their only hope.

      Unfortunately, we all have to be advocates for ourselves when seeking mental healthcare, especially if taking medications. Which sucks, because in the best possible worlds, the mental health field would be the place where defenses get relaxed and trustworthy care is available.

      Sincerely, I appreciate the information you provided both above and below. We all benefit when you share your research and efforts to get the care you need and deserve. In the mental health field, its the consumers who provide a good deal of the critical debate and perspective that are so desperately needed.

      Thank you.

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  • Roberta McDonnell

    Hi, I love this post, it reminds me of the work of Professor Ivor Browne in Ireland on ‘frozen trauma’ – his bodily release type therapy has helped many people and he veers away from medication when at all possible. I agree with Pamela and have cited her references many times especially Dr Moncrieff and Robert Whitaker (see also the blog beyondmeds.com and madinamerica.com as well as Dr Duncan Double in UK). Being an avid Jung adherent as well I find your blog most informative and enjoyable. May I ask if you can direct me to any self-help material along the lines of non-medication approaches? I use meditation, exercise, dietary supplements and creative activity for myself, my family, friends and clients but wonder if there are any other practices out there that people could avail of in their own time and lives? Thanks again and best wishes, Roberta

    • Thanks so much for the wonderful references. I haven’t heard of Professor Browne’s work, but it sounds similar to the work I’ve done with sensorimotor psychotherapy.

      Monica at Beyond Meds has shared some of my work in the past, and I used to be a writer for Mad in America, but the cyberbullying that sometimes happens on that site was too much. Truly a loss for me; other than the bullying, I had great discussions with readers.

      Sounds like you have a really well-rounded approach to your self-care.

      I have been lecturing on burnout lately, and will be posting some stuff on that topic in the new year, which I think applies to both professionals as well as anyone focused their own recovery (I don’t make strong distinctions between these groups, since I belong to both, as do many others.)

      I consume a lot of Pema Chodron’s books on meditation and dealing with difficult emotions. I like to play CDs of her books when I have to do less enjoyable things, like housework and commuting. I also read a lot of depth psychology — like Carl Jung, Marie Louise von Franz, James Hollis, Murray Stein — which helps me see the larger picture, that the ups and downs of life are part of the terrain, and the journey of selfhood is found in how we navigate them.

      I also love writing and believe that art, in any form, is one of the most healing things a person can do. So I often read books on creativity. If you click on the “creativity” category in the right sidebar, I mention some books on creativity there.

      Thank you for visiting my blog.

  • Roberta McDonnell

    Oh and creative journaling as well, very important!

  • Roberta McDonnell

    Hi Laura, great to hear from you – thanks so much for all that rich material which I will be following up. Shame about the cyberbullying, bullying is very not nice and I think you are wise to extract yourself from it. Agree too that creativity is a wonderful resource, I did some qualitative research with mental health day centre clients and every one of them cited the art class and the daily baking and cooking as well as the social contact as ‘lifelines’ for them. I wrote the study up in a book for Palgrave -it’s on Amazon, the other researchers cited had similar findings, many of them service user-led projects, and of course individual lived experience counts more than anything I find, including our own as you mention. My own experiences were that antidepressants helped me for a six month period to move far enough away from a traumatising situation (workplace bullying co-incidentally) to then start to rebuild my self and my confidence but I was glad to get off of them, I did not like the side effects that were developing (akathisia). The journey of remaking yourself is tough at times but I am glad to say that I am generally growing, as you have beautifully described in the Jungian view). Great to meet you Laura and really looking forward to keeping up with your posts. Thanks again, keep well and all the best for now, Roberta 🙂

    • Thanks so much for sharing your research, which sounds really hopeful and useful.

      So sorry you went through workplace bullying. Can you imagine how better this world would be without bullying?! That’s what I wish for in 2015.

      I wrote an article on antidepressants and social anxiety (you can download it from my Writing page), and although I didn’t mention bullying, I think it explains why the antidepressants initially might have been helpful. So much better to be off them, though.

      Thanks again for sharing.

  • Judy Hall

    We have a son who struggles with paranoid schizophrenia. He and us as his parents would love him not to be on anti-psychotics. We all agree that it damages his body with little real benefits to observe. However his ability to engage in therapy such as you describe seems impossible. His mind is so disorganized and the cognitive impacts of the illness and the treatments so profound that they are huge barriers to therapy.
    And it certainly feels like a step backwards to say that lack of loving relationship have led to this illness. We feel and have always felt close with him as parents. He was a responsive easy to love type of kids, well liked. He had typical relationships growing up with friends. Other parents have described their children the same. Our son did experience an adverse childhood experience in that his birth mother had schizophrenia (as well as other family members). He was placed in an orphanage at birth in Hong Kong until he was placed with us at 4 1/2 months. However lots of children experience that experience and don’t develop schizophrenia due to lack of loving relationships. It seems like biology is the more important factor and we have nothing proven to work with that.
    That said, how do you engage a person with schizophrenia in meaningful therapy?

    • Hi Judy,

      Thank you for taking the time to share your experiences. The love and commitment you have to your son are admirable, and what we hope all children have, especially those with early adverse childhood experiences.

      When I read your comment, I got the sense that you thought this blog post implied that the lack of love is what contributed to your son’s psychological and behavioral issues. The research on the significance of early life attachment for emotional development is very robust. And I think the focus on early life attachment is a step forward for the field, and is well supported by neurobiological research. Attachment research also underscores that we can make changes in the environment, including relationships, to improve mental well being and development across the lifespan. You wrote that I implied a “lack of loving relationships” led to your son’s illness, yet that isn’t really an accurate reflection of what is implied by attachment research or what I shared above.

      Furthermore, the research on schizophrenia as a purely genetically inherited disease is far from conclusive. There is also a high association of schizophrenia with adverse childhood experiences and exposure in utero to toxic substances. Here is a wonderful article on these correlations:

      “Time to Abandon the Bio-bio-bio Model of Psychosis: Exploring the Epigenetic and Psychological Mechanisms by Which Adverse Live Events Lead to Psychotic Symptoms,” by John Read, Richard P. Bentall and Roar Fosse. In De-Medicalizing Misery II, edited by Ewn Speed, Joanna Moncrieff and Mark Rapley. Palgrave Press, 2014.

      The research supporting the neurobiology of trauma is robust, and there are increasingly sound methodologies to address early life attachment problems, such as sensorimotor psychotherapy. That said, the path towards greater functioning and increased stability is invariably arduous and takes time. It’s also often very difficult — and sometimes impossible, depending where you live — to find someone trained in the modalities that could provide the foundation for a new trajectory. This, I believe, is a fault of the mental health field and its over reliance on medications and diagnoses to explain and treat problems that are caused by a combination of biological, social, and psychological factors (and not just biology).

      I think often when people think of psychotherapy, the image that comes to mind is two people talking in a reflective way about life experiences. And while this is one model of psychotherapy, there are many others too. Trauma-informed care is often more somatically-based and focuses on emotional regulation and developing the mindfulness that are necessary prerequisites to meaningful and lasting change.

      Thank you again for sharing from your experience. I hope I answered your question, and I wish you and your family all the best.

  • Zibo Anto

    Hi, Laura, thanks so much for your work. I appreciate the way you integrate, understand and pass on Trauma-based theories and experiences. May I use your work, citing you, during one of the training I am delivering on Trauma? How would you like to be cited?

    • Hi Zibo,
      Thanks so much for the feedback! With regards to citing, all I can do is tell you how I cite others. With slides, I make a smaller font text box at the bottom, and put in the relevant information. If in a handout, I’ll put an inline reference (Name, date), and then references at the end of the handout. If verbally mentioning, I just share the source. In the actual citation for a website like mine, I would put the name of the author, title of the post, URL, and date I accessed the material. Hope this helps. Good luck with your training!

      • Zibo Anto

        Thank you, Laura! I mentioned your name and work and now that the students want the slide show copy, I will be putting your website link. The Training was excellent (from the students feedback), we have been told!!! I am very grateful for you and all those who have paved the way in understanding trauma ( its physiology and impact to body/psyche) and for having the honour to continue the work.

        • Congratulations on your training! I so enjoy hearing your success.

          Given that the trauma model encourages accepting the body’s natural reactions and cultivating nonjudgmental self-awareness, sharing it is a bit like sharing peace and hope. So thanks for YOUR efforts!