Trauma therapy

Trauma therapy is a collective term for various approaches to treating the consequences of trauma. A psychotrauma ('trauma' of Latin: 'injury') is the result of a severe emotional stress caused by either a single event (accident, natural disasters, crime, but also major medically necessary interventions or operations) or the persistent impact of difficult life situations, such as persistent sexual abuse, war or imprisonment.

In contrast to other forms of psychotherapy, the cause of the disorder can be clearly described and, in general, the patient is well aware of it. Not all heavy stresses lead to trauma! On the one hand, people can withstand different types of stress; on the other hand, the situation shortly after the end of the traumatic situation is crucial in determining whether or not a trauma remains.

It is also important to distinguish between apersonal trauma (those that affect an entire group of people simultaneously - disasters and accidents) and personal trauma that affect only one victim individually, such as assaults or rape. These traumatizations can cause feelings of shame and guilt as well as self-accusations.

Development of trauma: The central factor for the development of trauma is the lack of relief after the trauma. Peter Levine, one of the leading researchers in the field of traumatology, points out that it is important that people are comforted, experience human proximity and feel permitted to express the normal physical relief that follows highly stressful events, e.g. the body's natural shivering and trembling.

Central to the formation of trauma is the experience of intense fear over a long period of time, usually combined with the experience of complete helplessness. This shakes self-confidence and can break off trust in others (especially in cases of abuse and violence). When this happens, normal "rules of life" no longer seem to apply, and a feeling of enduring alienation and deep anger over the injustice of the world emerges. Victims of violence, especially sexualised violence, are often blamed for what happened, leading the victim to react with a deep sense of enduring shame and self-condemnation. Deeply felt grief and sadness can also be a core part of these feelings.

The most frequent consequences of such traumatisation are a greatly increased anxiety, often combined with a withdrawal from social contacts. Strong self-rejection and a deep sense of shame and grief are equally common.
The victim is (sometimes rightly) of the opinion that other people cannot or do not want to have empathy.

All this regularly leads victims, who often suffer from a chronic post-traumatic disorder (PTSD), to have difficulties feeling comfortable in normal social situations and coping in professional life. Frequent interruptions in school or careers are often the consequence.

Some people affected by PTSD in this way react so extremely that they also run the risk of forced admission to psychiatry. Yet, the common experience of forced immobilisation and social stigmatisation can deepen the traumatisation.

Often, but by no means always, victims will experience flashbacks. This means that the patient repeatedly and uncontrollably is overwhelmed by memories that seem like a hallucination or delusion, during which the person is flooded with feelings and pictorial impressions associated with the traumatising situation. Taste and smell are also often part of traumatic memeories and can trigger such flashbacks, as well as music, noise or special social situations, such as loneliness or confined spaces, etc..

The following criteria indicate the presence of a trauma disorder:

• The person concerned can clearly identify an incriminating event or there are indications of special, unusual circumstances in the biography of the person that are not clearly remembered, but are accompanied by strong emotion.
• The affected person suffers from flash-backs, has nightmares and is repeatedly concerned with the triggering event in his thoughts and memories.
• The person concerned avoids situations, places or even people who are connected with the triggering circumstances.
• The affected person suffers from insomnia and/or concentration disorders. Sometimes eating disorders and/or the consumption of mind-altering drugs (alcohol, illegal drugs) also occur in the sense of self-medication. However, a high level of excitement and consequently also irritability, distrust, excessive vulnerability and unstable, exaggerated emotions are always typical.
• The symptoms last longer than four to six weeks. Symptoms of unresolved traumatisation can also occur (or reoccur) unexpectedly after many years, mostly triggered by feelings or situations experienced analogously, which are connected with the triggering situation. Due to the long time interval between now and the past situation, it is often not easy for the affected person to classify the connection correctly. 
• In most cases, only individual aspects of this list are clearly recognisable for a person affected. The exact diagnosis should be left to an experienced specialist. If someone has reason to believe that he or she suffers the consequences of trauma but is not sure, it is always advisable to have a psychotherapeutic consultation to clarify this question.

The sooner the victim of trauma is treated competently by a specialist, the lower the risk of chronification. But every positive, empathetic, human sympathy is helpful.

There is an approach to the treatment of acute trauma, for example after accidents or major disasters, called 'debriefing'. As a rule, this is only used for the so-called initial care of victims.

There are more comprehensive approaches to the treatment of trauma victims. Most approaches are a compilation of different techniques from different therapeutic traditions. Psychotraumatology (The Science of Traumatology) is a very new field of psychotherapy and therefore the field is constantly moving, new therapy is being researched and applied.

Essentially, trauma therapy is divided into 3 typical phases:

The stabilisation phase is about (re-) creating a feeling of safety and security in the world for the person concerned. A central aspect of this is the development of a sustainable therapeutic bond. Depending on the type of trauma and personality of the affected person, this can be a lengthy and difficult process. Another important part of this phase is to provide information about trauma and the impact trauma has on the experience and behaviour of those affected, so that they can overcome the feeling of alienation and incomprehension for their own feelings and behaviour.

Then the ability to relax and regain control over one's own thoughts and feelings is also an important part of the treatment. Relaxation techniques and imaginative procedures are used for this purpose. Often the person concerned is sought with an inner image, an idea of what a "safe place" is for him or her. The affected person can withdraw into this image (imagination/daydream) if he/she subjectively threatens to destabilize mentally or is flooded by feelings and images (flashback).

A basic therapeutic rule is that in this phase the trauma itself is not specifically addressed, unless the person concerned would like to do so.

In many cases, social problems or conflicts within the family must also be discussed and treated in the case of trauma in connection with sexualised violence, abuse and rape. Then all aspects of family therapy come into play. The treatment of self-mutilation, addictive drug use and eating disorders can also be a central focus of this phase.

In this phase, the emotional connection between the current state and the feelings and images from the trauma experience is treated. A kind of "detoxification", a "deletion" of this connection is sought, so to speak. For illustration, the following example is described: Everyone certainly experiences embarrassing situations in their life through a slip of the tongue or an accident. Everyone knows how painful the memory of this situation can still feel days and weeks later. At some point, however, this feeling fades away. If one is then much later reminded of this "funny" story in a circle of friends, then one can surely remember every detail of this situation, also of one's own feelings, but these feelings are then no longer current in the here and now, in the cheerful circle of friends who enjoy digging up this story and one can laugh along with the friends. This is exactly the process of decoupling, the erasure of current feelings and memories, which is to be achieved in trauma therapy, only with the difference that it is not about a funny story and in the end nobody has to laugh.

The most commonly used techniques to achieve this decoupling or deletion are EMDR (Eye Movement Desensitization and Reprocessing) and EMI (Eye Movement Integration). Other approaches work on imaginative techniques, psychodrama, and also body-oriented approaches based on bioenergetics are used. All these techniques are currently being intensively researched and constantly revised and improved.

The integration phase is about integrating these experiences into the patient's everyday life and consolidating and further stabilising them. Sometimes it is necessary to overcome social problems, often the partnerships and friendships of the affected person have to be rearranged. A very important part is also mourning and building resources, for example through the development of friendships and hobbies. The development of creative skills as part of new self-esteem can also be an important part of this phase. Here too, family and couple therapy is an important component. At this point, trauma therapy is very similar to other classical forms of therapy.

Of course, in a concrete therapy these phases are not neatly separated from each other, but merge into each other. Some phases are repeated and deepened into a flowing process, sometimes even within a single therapy session.

Anywhere between a few sessions up to several years, depending on individual circumstances.