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This post by Laura Kerr, PhD, is being reprinted from her blog with permission.
There seems to be two main views of the nature of traumatic stress guiding the treatment of trauma. One view, which informs treatments such as prolonged exposure therapy, focuses on regulating emotions and sensations. People are seen as needing help with controlling overwhelming feelings and the reactions they cause, such as Morris running out of the movie theatre when engulfed by fear. This is a reasonable view, and partly correct. Most people who deal with ongoing traumatic stress are often overwhelmed by their emotions and body sensations. However, when controlling emotional reactions becomes the sole focus of treatment, the whole person is not considered or addressed. Van der Kolk observed:
“Desensitization may make you less reactive, but if you cannot feel satisfaction in ordinary everyday things like taking a walk, cooking a meal, or playing with your kids, life will pass you by.”
The other main view of traumatic stress focuses on the loss of the integrative capacity of both mind and body that trauma causes. High arousal and shutdown at the time of a traumatic event results in fragmented memories and dissociative splitting. Furthermore, as Pat Ogden and colleagues pointed out in their book, Trauma and the Body, “under conditions of arousal that are either too high or too low, traumatic experiences cannot be integrated.” Consequently, trauma often leads to compartmentalization of experience and a fragmented sense of self.
When integration is the goal of treatment, the split off memories, emotions, and sensations are mindfully brought back into awareness, contributing to a sense of self as whole again. Increasing emotional regulation is central to regaining integrative capacity, although not the primary goal. Rather, treatment begins with modulating arousal, which helps reduce the need to avoid internal and external reactions to traumatic reminders.
The shift in focus from desensitizing emotional reactions to increasing integrative capacity may seem new. Van der Kolk wrote:
“Over the past two decades the prevailing treatment taught to psychology students has been some form of systematic desensitization: helping patients become less reactive to certain emotions and sensations. But is this the correct goal? Maybe the issue is not desensitization but integration: putting the traumatic event into its proper place in the overall arc of one’s life.”
The pioneer of trauma treatment, French psychologist Pierre Janet, identified integration as the focal point of trauma treatment back in the nineteenth century. Janet advocated phase-oriented treatment, which is directed towards integrating traumatic memories in ways that contribute to an integrated sense of self.
Janet identified three stages of phase-oriented treatment, which are still used today:
Similar to exposure therapy, Phase 1 of phase-oriented treatment addresses emotional regulation. Yet when integration is the treatment goal, emotional regulation is gained by increasing the felt-sense of safety rather than desensitizing a person to feelings and body sensations.
Exposure to memories of past traumas is still a significant part of treatment (Phase 2). However, the goal is to experience these memories within a window of tolerance that increases the likelihood of their integration with non-traumatic memories and non-traumatic self-states.
Phase-oriented treatment decreases the likelihood of dysregulation by helping clients to:
Central to the integrative approach is the development of mindful awareness of the conditions that contribute to high arousal or shut down, along with identifying resources that can help reduce arousal when hyperaroused, or increase arousal when hypoaroused. Resources include skills, practices (e.g, yoga, mindfulness), objects, relationships, services, etc., that support a sense of stability and safety, regardless of what might be going on. With this approach, a person can direct his energy towards full living and greater self-awareness. This is a fundamentally different outcome than exposure therapy, which as van der Kolk observed, “desensitization to our own or to other people’s pain tends to lead to an overall blunting of emotional sensitivity.”
At times, there are benefits to desensitization. When trauma has been chronic, acute, and under treated (if treated at all), survivors will sometimes try to deal with feelings of overwhelm by avoiding the situations that might trigger them, which depending on the person and the conditions of her or his life, can lead to a very circumscribed existence. Thus, sometimes in the beginning stages of treatment people need to desensitize themselves to overwhelming emotions and sensations as a first step towards a more active life. This level of desensitization is sometimes accomplished with medications — an approach many others and myself generally don’t support. However, I know from experience that people who lack resources and support for an extended period often do well in the beginning stages of treatment with some medications in combination with Phase 1 work. Of course, a better approach than medications is to adapt services to fit the needs of the most vulnerable people, such as providing support in their homes, or through technologies such as Skype that allow for contact without forcing the client to endure conditions that might trigger high arousal or shut down.
Desensitization can also be beneficial when a person is aware her intense reactions are out of proportion to the situation, and she has already identified ways to resource herself when overwhelmed. For instance, in Dialectical Behavior Therapy one exercise, called “Opposite to Emotion Action,” encourages a person to take an action when she can tell her anticipated emotional reaction to a situation is unjustified, otherwise causing her to avoid that circumstance and unnecessarily limit her life. For example, if a person anticipates feeling frightened at the dentist, but knows she will be safe, she is encouraged to override her emotional response and keep the appointment. The goal is not to suppress the emotion, but rather to mindfully be open to the possibility of having a new experience. Nevertheless, the process can potentially activate overwhelming feelings and memories that a person must learn how to tolerate.
Sometimes we have to be less sensitive that we would like, or endure conditions we would rather avoid, to live full, meaningful lives. But the operative word here is sometimes. Most of the time, we should aspire to live a life that is open to a variety of experiences and relationships, and have confidence in our ability to tolerate, adapt, learn, and grow, which is the opposite of fear-based, defensive living. And in the best of worlds, we all feel responsible for developing our capacities for both resilience and compassion. Society should also be held responsible for creating conditions that promote thriving as much as simply surviving. Similarly, we deserve trauma treatments that help us not only tolerate suffering, but also allow us to regain the capacity to live the full measure of our humanity.
Ogden, Pat, Kekuni Minton, and Clare Pain. 2006. Trauma and the body: A sensorimotor approach to psychotherapy. New York: W. W. Norton & Co.
Kolk, Bessel van der. 2014. The Body Keeps The Score: Brain, Mind, and Body in the Healing of Trauma. New York: Viking.
© 2015 Laura K Kerr, PhD. All rights reserved.
Laura K. Kerr, PhD is a mental health scholar, former trauma-focused psychotherapist, and soon-to-be “trauma coach.” Read more of her reflections on trauma, healing, and society at her blog, Trauma’s Labyrinth.
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