Treating Trauma
Posted by Cynthia Horacek at 1/8/2008 4:13 PM 
Categories: trauma, Hypnosis, Treatment, EMDR, Brainspotting
Categories: trauma, Hypnosis, Treatment, EMDR, Brainspotting
It is very common for individuals with a history of trauma to ask me in our first phone call how I treat trauma and what I will do to help them. These are both good questions. The first is easy to answer - I treat trauma in a variety of ways, depending on the needs of the individual among other issues. The second is harder to answer, because it depends on the needs of the individual among other issues! How can two questions have the same answer, yet one be easy to answer, and the other so hard? Because one question is more general, while the other is more specific. The general question is how do I treat trauma? Generally, I might use talk therapy, EMDR, hypnosis, Brainspotting, talk therapy or somatic therapy,. More specifically, what will I do to help a specific individual? That's harder, because for one thing, until I've actually met the individual and spent a little bit of time with them in person, I can't assess where they are in their process, or how ready they are to deal with their specific traumatic experiences.
Just the other day I had a conversation with someone who was asking me these very questions. I was asked, on the phone, "What will you do to help me?" Not having met the person face to face, I could not commit to a specific treatment modality, but I understood the need to ask and the desire to know before investing the time and money in starting therapy.
What I truly believe is that in any good therapy is that the treatment modality, while important, is less important than the fit between therapist and client, and the relationship that is built between the two. The real healing, in my humble opinion, is in the therapeutic relationship. Finding a therapist who you feel understands you, hears you and with whom you feel there is good "chemistry" is of utmost importance.
The same person I mentioned above asked me also, if there is a higher charge when I use EMDR, hypnosis, or another "treatment." The answer, of course, is no. EMDR, hypnosis, Brainspotting, etc. are all just treatment modalities - therapeutic tools. If you join a gym and pay a monthly fee, you don't pay more if you use certain equipment one time or another, or take one class or another - they are included in the price. In psychotherapy, you are paying the fee for service for the amount of time you are with the therapist. A 45 or 50 minute session will cost less than a 75 or 80 minute session (some therapists keep to 45 minutes; some to 50, and an extended session might be 75 or 80 minutes) but you are paying for the time, not the specific treatment used - at least, that's the way it's done in my practice and in those of my colleagues. But this is a separate issue and not the point of this article.
So how do I treat trauma? Let's look at a few different possibilities (some from actual cases, but the facts are changed to protect privacy):
Case One: Single Incident Trauma
A "single incident trauma" usually involves something that happened only once, such as a motor vehicle accident, a medical trauma, the loss or death of a loved one or perhaps witnessing a death or traumatic incident such as a natural disaster or accident. It might be something like being the victim of a crime, like a robbery, a home invasion or a rape. It might involve a family abuse incident that only happened once, like a one-time child abuse or domestic violence. These are all traumatic for the person who was the victim (more about the "victim" word in another article later...)
Let's take the case of a crime. A man was home alone when robbers broke in, tied him up and locked him in the bathroom. He heard them talking about him and thought they were going to kidnap him, take him to another location and kill him. The robbers left him where he was, however, but he was uncertain until another family member came home - hours later - found him tied up in the bathroom, untied him and called the police. This man also had a medical condition that was complicated by this incident. By the time he came to see me, the robbers had been caught (partly due to his description of them, and partly because they were sloppy) and the trial was approaching. He was experiencing nightmares, anxiety attacks, flashbacks to the crime and his health was being jeopardized. I met with him a few times and we determined between us that the best treatment would be EMDR. (For more on EMDR, please see my other article or see my website and go to the Services page and scroll down to EMDR.) In one session, we set up the protocol, and began to process by using auditory and tactile bilateral processing (again, please see more about EMDR on the website.) His SUDs (Subjective Units of Distress, measured on a scale of 0 -10) came down from a 9 to a 4 in the first session. In the second session, his SUDs had remained a 4 over the intervening week, and we picked up where we left off. We were able to bring his SUDs down to a 0 in the second session, and began to install his "positive cognition" (what he would like to be able to think about himself when he thinks about the incident). This is measured on a scale of 1 - 7, and is called the VOC scale - Validity of Cognition - where 1 is completely untrue, and 7 is completely true. Usually when we start out, the individual's VOC starts at a 1 or a 2, meaning they don't believe what they'd like to believe about them self when they think about the trauma is at all true. For most people, this usually increases to a 5 to a 7 in one session. That happened in this case. Sometimes a single incident trauma is the easiest to treat.
However, that isn't always true...
Case Two: Unconscious Memories of Trauma:
Let's look at the case of a teenager who suffered from anxiety attacks, had chronic insomnia and couldn't spend the night away from home. As in most cases of anxiety, there are several goals, the first being to help the individual manage their anxiety so that it doesn't interfere with their daily functioning. This might include teaching them breathing techniques to slow their breath and lower their heart rate (especially if they are having panic attacks), thought stopping (identifying negative through processes and stopping those thoughts before they can have a negative impact, and replacing them with positive ones), identifying what triggers the anxiety - for example, if someone is afraid of having a car accident on the freeway, maybe it is best to avoid the freeway until the more bothersome symptoms can be addressed. There are too many symptoms and interventions to be addressed here (I list some books on my Resources page on my website if the reader is interested). I began to see this young lady at a time there were some disruptions in her home between her parents that were also intensifying her anxiety. We talked about what was bothering her most, and I made her some relaxation CDs to help with her sleep. We continued to work together for some time, and she appeared to be resistant to letting go of her anxiety. This sometimes happens; sometimes the client has a need to hold on to their symptoms. Until and unless they acknowledge this, the truth is that there is little that I or anyone else can do. We might eliminate one symptom only to have another one take its place. One day I asked her how she felt about doing some hypnosis to find the root cause of her anxiety and she agreed, saying that she wanted to know why she always felt this way; she had felt this way ever since she could remember. The young lady turned out to be a very good subject for hypnosis, and recalled waking up one morning when she was quite young, maybe as young as 5, and finding herself home alone. She was frightened and thought her family had been kidnapped! Her parents had taken her sister to the emergency room, and asked a neighbor to look in on my client, not wanting to wake her up or take her with them. She told me that ever since she had a fear that her family would be kidnapped and she wouldn't be there to save them. This incident caused her to be fearful of sleeping at someone else's home, because when she returned to her own home in the morning, she had an unconscious thought that her family might be gone. She was afraid if she fell asleep at night then in the morning when she woke up, her family would again be gone. In this case, it was important for the client to find the source of her anxiety, not just treat the symptoms. Once we had the source, we did some EMDR sessions specific to it and she experienced a great deal of relief. She even went on a vacation with a friend and the friend's family, leaving her own family at home and experienced no anxiety at all.
Case Three: But I Don't Want to Let it Go....
As I mentioned above, sometimes people just don't want to let go of their traumas, or the resulting symptoms. Take the case of a client who had a fear of flying and who's family was getting ready to take a vacation that involved a transoceanic flight. When you have a fear of flying, even a brief flight that is under an hour can be paralyzing. But when you have to sit on a plane flying over water for hours upon hours, well, you can just imagine the stress and terror that induced! As we worked together on her flying phobia, more and more phobias surfaced (what most people call a "fear of flying" is a phobia - a fear for which there is no basis; that is, the person has not been involved in a plane crash, has not witnessed a plane crash - in fact, there are far fewer plane crashes than there are car crashes, but very few people have car phobias. Plane crashes are so rare in fact, that when they do happen, they make international news!). We continued to work together, trying EMDR, hypnosis, talk therapy, somatic therapy, cognitive behavioral therapy, exposure therapy... truthfully, I ran out of tools! I finally asked her if she was willing to let go of some of her fears, and she admitted that maybe not. We parted company, but she knows my door is always open should she desire to return, or call me for a referral to another therapist. We did make some progress, and she was able to make that transoceanic flight with her family without as much anxiety as she expected. In fact she reported back to me that she was fairly relaxed on the plane, both ways.
Case Four: Trauma from Chronic Stress:
When someone suffers from chronic stress to the extent that it is traumatizing, we call it traumatic stress. When a child grows up in a home with parents who are mentally ill, that can cause traumatic stress. One such young woman came to me complaining of panic attacks. She had no reason for them that she could identify. They had started in college, she told me, and then had subsided, and now she was in her mid 30's, married with a toddler and a newborn, and the panic attacks had started again suddenly out of the blue. She was most disturbed by the negative thoughts she was having about her husband and her children whom she loved "more than anything in this world." The first thing I did was to make a referral to a physician to rule out anything physical, such as a thyroid or hormonal imbalance. I never want to try to treat a physical issue with psychotherapy until it's been checked and treated by a medical doctor. Then I referred her to a psychiatrist for a medication evaluation. There was nothing wrong physically; she was in great health. The psychiatrist started her on an antidepressant that also worked well on anxiety. The medication helped, but did not eliminate her panic attacks. So we continued to work in therapy. As we worked together and I learned this young woman's history, I learned that her childhood had been anything but stable, and she lived in a state of constant chaos because her parents were not themselves stable. In other words, she suffered a series of emotionally traumatic events that caused her to always feel hypervigilant and chronically stressed, or what we call chronic traumatic stress. When we made a chronological time line of the events in her life, and applied EMDR to these events, again, chronologically and one by one, her panic attacks began to subside.
Case Five: Brainspotting
Brainspotting is something that is relatively new to my practice "toolbox" and has been around for just a few years. (Please click on the link for more information.) Brainspotting is an outgrowth of EMDR, and goes deeper, faster. It is ideal for almost any kind of trauma, and also works well for chronic pain, illnesses, headaches... in fact, I'd be hard pressed to find an issue that it isn't useful for, unless the client just isn't ready to "go there."
A young woman who had experienced a medical trauma was referred to me for anxiety and panic attacks, and was getting so panic-stricken she was having trouble leaving her home because she was fearful of becoming ill while out. In three sessions of using Brainspotting, we were able to reverse this fear and she was able to return to work and leave her home without problems. In processing the issue using this technique, other past traumas that she had "forgotten" (or rather pushed out of her consciousness) came up and she talked about them, processed them and released them. This process of bringing them into awareness, talking about them (and feeling them in the body as well) and releasing them is of utmost importance to processing trauma.
I feel compelled to say that it is my clients who actually treat their traumas in therapy. I am, as I have said before, merely a guide who is there to help people on their journey. I am a facilitator. Do I "treat" trauma? If you'd like to look at it that way, it's okay with me. But please be aware that when you enter therapy, you are starting something that is work, and it isn't necessarily easy work. There will be times that you will want to stop, and many people do stop before they make much progress. Sometimes you'll feel worse before you feel better. But you will, at some point, if you hang in there, feel better. Someone once said, "What doesn't kill you makes you stronger." I can't remember who said it, but I'm sure it was someone famous. And for what it's worth, I believe it. Everything is a lesson, and we keep learning. Some lessons some of us don't need, and some of them we could certainly have survived without, and for some people, it's amazing they survived those "lessons" they were given.
One more thing...
Unfortunately, there are also people who have had ongoing trauma in childhood that was unrelenting and from which they could not escape. Sometimes children learn to dissociate from the trauma in these cases. (Again, you can learn more about dissociation on my website on the "Services" page by scrolling to Dissociative Disorders, and I also encourage you to visit the International Society for the Study for Trauma and Dissociation.) When a young child, usually under the age of 5, is subjected to ongoing abuse, be it physical, sexual or emotional over and over he or she begins to want to be somewhere else, or they wish very hard that this wasn't happening to them, and they learn to literally go away in their mind. They create someone else to take their place. We call these "someone elses" alter personalities. These cases are usually very complex, and these individuals have often been in therapy for a number of years and have had a variety of diagnoses before anyone - including themselves - realize the extent of their trauma and that they have alters. The diagnosis for this "condition" used to be called Multiple Personality Disorder; now it's called Dissociative Identity Disorder, or DID. Again, please visit either my website or the ISST-D for more information on this disorder and it's treatment.
Just the other day I had a conversation with someone who was asking me these very questions. I was asked, on the phone, "What will you do to help me?" Not having met the person face to face, I could not commit to a specific treatment modality, but I understood the need to ask and the desire to know before investing the time and money in starting therapy.
What I truly believe is that in any good therapy is that the treatment modality, while important, is less important than the fit between therapist and client, and the relationship that is built between the two. The real healing, in my humble opinion, is in the therapeutic relationship. Finding a therapist who you feel understands you, hears you and with whom you feel there is good "chemistry" is of utmost importance.
The same person I mentioned above asked me also, if there is a higher charge when I use EMDR, hypnosis, or another "treatment." The answer, of course, is no. EMDR, hypnosis, Brainspotting, etc. are all just treatment modalities - therapeutic tools. If you join a gym and pay a monthly fee, you don't pay more if you use certain equipment one time or another, or take one class or another - they are included in the price. In psychotherapy, you are paying the fee for service for the amount of time you are with the therapist. A 45 or 50 minute session will cost less than a 75 or 80 minute session (some therapists keep to 45 minutes; some to 50, and an extended session might be 75 or 80 minutes) but you are paying for the time, not the specific treatment used - at least, that's the way it's done in my practice and in those of my colleagues. But this is a separate issue and not the point of this article.
So how do I treat trauma? Let's look at a few different possibilities (some from actual cases, but the facts are changed to protect privacy):
Case One: Single Incident Trauma
A "single incident trauma" usually involves something that happened only once, such as a motor vehicle accident, a medical trauma, the loss or death of a loved one or perhaps witnessing a death or traumatic incident such as a natural disaster or accident. It might be something like being the victim of a crime, like a robbery, a home invasion or a rape. It might involve a family abuse incident that only happened once, like a one-time child abuse or domestic violence. These are all traumatic for the person who was the victim (more about the "victim" word in another article later...)
Let's take the case of a crime. A man was home alone when robbers broke in, tied him up and locked him in the bathroom. He heard them talking about him and thought they were going to kidnap him, take him to another location and kill him. The robbers left him where he was, however, but he was uncertain until another family member came home - hours later - found him tied up in the bathroom, untied him and called the police. This man also had a medical condition that was complicated by this incident. By the time he came to see me, the robbers had been caught (partly due to his description of them, and partly because they were sloppy) and the trial was approaching. He was experiencing nightmares, anxiety attacks, flashbacks to the crime and his health was being jeopardized. I met with him a few times and we determined between us that the best treatment would be EMDR. (For more on EMDR, please see my other article or see my website and go to the Services page and scroll down to EMDR.) In one session, we set up the protocol, and began to process by using auditory and tactile bilateral processing (again, please see more about EMDR on the website.) His SUDs (Subjective Units of Distress, measured on a scale of 0 -10) came down from a 9 to a 4 in the first session. In the second session, his SUDs had remained a 4 over the intervening week, and we picked up where we left off. We were able to bring his SUDs down to a 0 in the second session, and began to install his "positive cognition" (what he would like to be able to think about himself when he thinks about the incident). This is measured on a scale of 1 - 7, and is called the VOC scale - Validity of Cognition - where 1 is completely untrue, and 7 is completely true. Usually when we start out, the individual's VOC starts at a 1 or a 2, meaning they don't believe what they'd like to believe about them self when they think about the trauma is at all true. For most people, this usually increases to a 5 to a 7 in one session. That happened in this case. Sometimes a single incident trauma is the easiest to treat.
However, that isn't always true...
Case Two: Unconscious Memories of Trauma:
Let's look at the case of a teenager who suffered from anxiety attacks, had chronic insomnia and couldn't spend the night away from home. As in most cases of anxiety, there are several goals, the first being to help the individual manage their anxiety so that it doesn't interfere with their daily functioning. This might include teaching them breathing techniques to slow their breath and lower their heart rate (especially if they are having panic attacks), thought stopping (identifying negative through processes and stopping those thoughts before they can have a negative impact, and replacing them with positive ones), identifying what triggers the anxiety - for example, if someone is afraid of having a car accident on the freeway, maybe it is best to avoid the freeway until the more bothersome symptoms can be addressed. There are too many symptoms and interventions to be addressed here (I list some books on my Resources page on my website if the reader is interested). I began to see this young lady at a time there were some disruptions in her home between her parents that were also intensifying her anxiety. We talked about what was bothering her most, and I made her some relaxation CDs to help with her sleep. We continued to work together for some time, and she appeared to be resistant to letting go of her anxiety. This sometimes happens; sometimes the client has a need to hold on to their symptoms. Until and unless they acknowledge this, the truth is that there is little that I or anyone else can do. We might eliminate one symptom only to have another one take its place. One day I asked her how she felt about doing some hypnosis to find the root cause of her anxiety and she agreed, saying that she wanted to know why she always felt this way; she had felt this way ever since she could remember. The young lady turned out to be a very good subject for hypnosis, and recalled waking up one morning when she was quite young, maybe as young as 5, and finding herself home alone. She was frightened and thought her family had been kidnapped! Her parents had taken her sister to the emergency room, and asked a neighbor to look in on my client, not wanting to wake her up or take her with them. She told me that ever since she had a fear that her family would be kidnapped and she wouldn't be there to save them. This incident caused her to be fearful of sleeping at someone else's home, because when she returned to her own home in the morning, she had an unconscious thought that her family might be gone. She was afraid if she fell asleep at night then in the morning when she woke up, her family would again be gone. In this case, it was important for the client to find the source of her anxiety, not just treat the symptoms. Once we had the source, we did some EMDR sessions specific to it and she experienced a great deal of relief. She even went on a vacation with a friend and the friend's family, leaving her own family at home and experienced no anxiety at all.
Case Three: But I Don't Want to Let it Go....
As I mentioned above, sometimes people just don't want to let go of their traumas, or the resulting symptoms. Take the case of a client who had a fear of flying and who's family was getting ready to take a vacation that involved a transoceanic flight. When you have a fear of flying, even a brief flight that is under an hour can be paralyzing. But when you have to sit on a plane flying over water for hours upon hours, well, you can just imagine the stress and terror that induced! As we worked together on her flying phobia, more and more phobias surfaced (what most people call a "fear of flying" is a phobia - a fear for which there is no basis; that is, the person has not been involved in a plane crash, has not witnessed a plane crash - in fact, there are far fewer plane crashes than there are car crashes, but very few people have car phobias. Plane crashes are so rare in fact, that when they do happen, they make international news!). We continued to work together, trying EMDR, hypnosis, talk therapy, somatic therapy, cognitive behavioral therapy, exposure therapy... truthfully, I ran out of tools! I finally asked her if she was willing to let go of some of her fears, and she admitted that maybe not. We parted company, but she knows my door is always open should she desire to return, or call me for a referral to another therapist. We did make some progress, and she was able to make that transoceanic flight with her family without as much anxiety as she expected. In fact she reported back to me that she was fairly relaxed on the plane, both ways.
Case Four: Trauma from Chronic Stress:
When someone suffers from chronic stress to the extent that it is traumatizing, we call it traumatic stress. When a child grows up in a home with parents who are mentally ill, that can cause traumatic stress. One such young woman came to me complaining of panic attacks. She had no reason for them that she could identify. They had started in college, she told me, and then had subsided, and now she was in her mid 30's, married with a toddler and a newborn, and the panic attacks had started again suddenly out of the blue. She was most disturbed by the negative thoughts she was having about her husband and her children whom she loved "more than anything in this world." The first thing I did was to make a referral to a physician to rule out anything physical, such as a thyroid or hormonal imbalance. I never want to try to treat a physical issue with psychotherapy until it's been checked and treated by a medical doctor. Then I referred her to a psychiatrist for a medication evaluation. There was nothing wrong physically; she was in great health. The psychiatrist started her on an antidepressant that also worked well on anxiety. The medication helped, but did not eliminate her panic attacks. So we continued to work in therapy. As we worked together and I learned this young woman's history, I learned that her childhood had been anything but stable, and she lived in a state of constant chaos because her parents were not themselves stable. In other words, she suffered a series of emotionally traumatic events that caused her to always feel hypervigilant and chronically stressed, or what we call chronic traumatic stress. When we made a chronological time line of the events in her life, and applied EMDR to these events, again, chronologically and one by one, her panic attacks began to subside.
Case Five: Brainspotting
Brainspotting is something that is relatively new to my practice "toolbox" and has been around for just a few years. (Please click on the link for more information.) Brainspotting is an outgrowth of EMDR, and goes deeper, faster. It is ideal for almost any kind of trauma, and also works well for chronic pain, illnesses, headaches... in fact, I'd be hard pressed to find an issue that it isn't useful for, unless the client just isn't ready to "go there."
A young woman who had experienced a medical trauma was referred to me for anxiety and panic attacks, and was getting so panic-stricken she was having trouble leaving her home because she was fearful of becoming ill while out. In three sessions of using Brainspotting, we were able to reverse this fear and she was able to return to work and leave her home without problems. In processing the issue using this technique, other past traumas that she had "forgotten" (or rather pushed out of her consciousness) came up and she talked about them, processed them and released them. This process of bringing them into awareness, talking about them (and feeling them in the body as well) and releasing them is of utmost importance to processing trauma.
I feel compelled to say that it is my clients who actually treat their traumas in therapy. I am, as I have said before, merely a guide who is there to help people on their journey. I am a facilitator. Do I "treat" trauma? If you'd like to look at it that way, it's okay with me. But please be aware that when you enter therapy, you are starting something that is work, and it isn't necessarily easy work. There will be times that you will want to stop, and many people do stop before they make much progress. Sometimes you'll feel worse before you feel better. But you will, at some point, if you hang in there, feel better. Someone once said, "What doesn't kill you makes you stronger." I can't remember who said it, but I'm sure it was someone famous. And for what it's worth, I believe it. Everything is a lesson, and we keep learning. Some lessons some of us don't need, and some of them we could certainly have survived without, and for some people, it's amazing they survived those "lessons" they were given.
One more thing...
Unfortunately, there are also people who have had ongoing trauma in childhood that was unrelenting and from which they could not escape. Sometimes children learn to dissociate from the trauma in these cases. (Again, you can learn more about dissociation on my website on the "Services" page by scrolling to Dissociative Disorders, and I also encourage you to visit the International Society for the Study for Trauma and Dissociation.) When a young child, usually under the age of 5, is subjected to ongoing abuse, be it physical, sexual or emotional over and over he or she begins to want to be somewhere else, or they wish very hard that this wasn't happening to them, and they learn to literally go away in their mind. They create someone else to take their place. We call these "someone elses" alter personalities. These cases are usually very complex, and these individuals have often been in therapy for a number of years and have had a variety of diagnoses before anyone - including themselves - realize the extent of their trauma and that they have alters. The diagnosis for this "condition" used to be called Multiple Personality Disorder; now it's called Dissociative Identity Disorder, or DID. Again, please visit either my website or the ISST-D for more information on this disorder and it's treatment.
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