20 Ways Trauma Therapy is Really Different Nowadays
Trauma therapy has changed in recent years. Some of the traditional approaches to treating trauma are now recognised as ineffective, and in some cases even harmful. In this blog post I’ll outline some of the key differences between how trauma was sometimes treated in the past, compared to more up-to-date approaches. (Wondering what trauma is? Read my article What is PTSD).
Why has trauma therapy changed? Well, it’s partly to do with modern-day brain imaging techniques. Trauma therapists, who were already noticing which approaches seemed to work well and which were less effective, began to collaborate with neuroscientists, discovering that neuroscience actually backs up particular clinical methods. Let’s look at 20 examples.
(This article is based on many trauma trainings and literature, with a special thanks to Janina Fisher’s book, Healing the Fragmented Selves of Trauma Survivors.)
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1. Old Approach to Trauma Therapy: What Happened to You?
In the past, a therapist might have wanted to know, above all, ‘What happened to you?’ They wanted to help you talk through the ‘facts’ of your trauma — who, when, where, what — almost like piecing together a puzzle with you.
How Trauma Therapy Has Changed: How Does it Affect You?
A trauma-informed approach has your therapist equally interested in ‘How are you affected now by what happened to you?’ They want to help you make sense of how the effects of the trauma live on in you.
2. Old Approach to Trauma Therapy: Symptoms Are Random
In some schools of therapy, such as CBT, it used to be thought that your symptoms are pathology – just random stuff that’s wrong with you – and make no sense.
How Trauma Therapy Has Changed: Symptoms Have Meaning
Trauma therapists recognise that symptoms are creative attempts to keep the person safe, which made sense at the time they were created (although they may not be helpful now). This has always been the view of psychodynamic psychotherapy, and some humanistic approaches too. And now, thanks to trauma research, even cognitive and behavioural therapists have started recognising the value of understanding the underlying ‘logic’ of even the most tricky symptoms.
3. Old Approach to Trauma Therapy: Telling is Healing
It used to be believed that the best way for a client to desensitise their memories of the traumatic event(s) was by telling their story repeatedly. However, this approach is hit-and-miss: it works for some clients, but doesn’t for many. In fact, it can be re-traumatising and harmful for a person to tell about their trauma in the wrong context, and at the wrong moment.
How Trauma Therapy Has Changed: Cultivating New Experiences
Trauma therapists nowadays prioritise the repair and transformation of trauma-related states through cultivating new experiences of connection and safety. This creates a stronger, safer basis for the client’s healing.
4. Old Approach to Trauma Therapy: Focus on ‘Back Then’
In the past, there was a focus on the traumatic events. Therapists wanted to know what had happened to you, in as much detail as possible. They thought that relief would be provided by bringing your trauma as much as possible into conscious awareness. (And to be fair, sometimes this was part of what helped; but in many cases this simply had the effect of re-traumatising the client, and sadly, even making them flee therapy).
How Trauma Therapy Has Changed: Focus on Now
These days, your therapist is going to focus much more on how the implicit memory of trauma lives NOW in your body, brain, and nervous system. After all, what you’re wanting relief from is in the present, so that you can feel freer and lighter going forward.
5. Old Approach to Trauma Therapy: Goal is Remembering
Therapists used to view the goal of trauma treatment as remembering the trauma. They believed that helping you access memories of the trauma was the key to healing.
How Trauma Therapy Has Changed: Goal is Repair
Your trauma-informed therapist will have repair as the treatment goal, rather than remembering. Many traumas can never be remembered. Often this may be because they occurred very young, before the brain’s explicit memory systems were fully developed.
6. Old Approach to Trauma Therapy: I Survived; So What?
The fact that the person had survived the trauma was ‘taken as read’ and somewhat overlooked; the main focus was on the damage done.
How Trauma Therapy Has Changed: Wow – I Survived and may Thrive
There’s an emphasis on not just how the person was harmed, but also on how the person survived what happened, and that they did survive (and perhaps thrived, or potentially could now go on to thrive).
7. Old Approach to Trauma Therapy: ‘Hm. Tell Me More’
Traditionally, the therapist would listen to client’s story in silence, or with a few ‘encouragers’ (nods or minimal comments like ‘mm’). Sometimes this approach can be exactly what’s needed; however, what often happens in trauma is that a person telling their story will either start to feel overwhelmed with feelings, or go numb. These are signs of hyperarousal or hypoarousal of the nervous system. A person who’s stuck in hyperarousal or hypoarousal is not going to benefit from telling their trauma story; they need help to regulate their nervous system first.
How Trauma Therapy Has Changed: ‘Let’s Just Pause Here’
The trauma informed therapist carefully helps the person track their nervous system activation, and may frequently interrupt with questions like ‘what’s happening inside right now?’ or ‘would it be okay for us to slow down and take a pause here?’ This helps the person slow down and keep their nervous system within its window of tolerance.
8. Old Approach to Trauma Therapy: No Attachment Lens
Although science has known about attachment since the 1950’s, most therapists tended not to view trauma through an attachment lens.
How Trauma Therapy Has Changed: Attachment Lens
Now, trauma-informed therapists view trauma through an attachment lens. It’s recognised that insecure attachment makes a person far more vulnerable to trauma (as well as being a traumatic experience in itself). An attachment-oriented approach is generally seen as important for trauma healing (perhaps with the exception of some EMDR treatment; although attachment-focused EMDR tends to be very effective).
9. Old Approach to Trauma Therapy: The Old World
There used to be a focus on discussion of the “old world” of painful, humiliating experiences and overwhelming feelings. Therapy like this could feel dispiriting, depressing, and bleak, as the person was encouraged to delve back into their darkest moments, sometimes without much help for getting out.
How Trauma Therapy Has Changed: Me, Now and Then
Nowadays, there’s more focus on increasing client’s curiosity and interest in their own feeling-states, parts, thoughts, body responses. The past, and the trauma, may still be processed and felt, but with ‘one foot in the present’ as the client and therapist together explore things.
10. Old Approach to Trauma Therapy: Aim is a Clearer Story
In older approaches to trauma therapy, the aim was for the client to develop a detailed narrative memory of their traumatic experience. The trouble was, this focus on cognition (story and thoughts) did not always address the deeper parts of the brain and body where the trauma effects lived.
How Trauma Therapy Has Changed: Aim is Compassion for Past Self
Nowadays, trauma therapists help their client to develop a compassionate felt-sense of what they’ve been through. There’s a focus on collaboratively undoing shame, and building the capacity to internalise a sense of healing kindness. This can be difficult for many trauma survivors, and usually takes time, but without feelings of self-compassion, many traumas cannot heal.
11. Old Approach to Trauma Therapy: Aloneness isn’t Relevant
Some of the old approaches to trauma treatment didn’t view things through a relational lens. But trauma is always relational: it’s not just the event that happened, but also the fact that in trauma the person feels themselves to be profoundly emotionally alone.
How Trauma Therapy Has Changed: Aloneness Made it Traumatic
Now, there’s an acknowledgement that (most often) the aspect that made the trauma so very traumatic was the fact that the person felt unbearably alone at the time(s). Diana Fosha, founder of AEDP, talks about ‘the individual’s unwilled and unwanted aloneness in the face of overwhelming emotional experiences’ and encourages therapists to be intentional in ‘undoing aloneness’ with their clients. Relational trauma requires relational healing.
12. Old Approach to Trauma Therapy: You’re Self-Sabotaging
Most trauma survivors engage in some unsafe/ self-destructive behaviours at times. In the past, this was often seen as self-sabotage, attention-seeking, manipulation, or avoidance. Self-destructive behaviours were sometimes viewed as signs that the person just didn’t really want to get well.
How Trauma Therapy Has Changed: You’re Trying to Cope
Trauma informed therapists now see unsafe/ self-destructive behaviours as a person’s desperate attempt to tolerate unbearable feelings and regulate their traumatised nervous system.
13. Old Approach to Trauma Therapy: Insight Heals
It used to be thought that the mechanism for healing is the gaining of insight and understanding about what happened.
How Trauma Therapy Has Changed: Relationally Processing Emotion Heals
Insight is useful, but trauma informed therapists now know that insight follows emotion processing and relational connection. People heal through experientially processing their emotions in the presence of the actively attuned and empathic therapist, whilst feeling compassion for their traumatised parts. This emotional work then leads to insight, and feeling better.
14. Old Approach to Trauma Therapy: Tell it Properly
Therapists used to assume that the person could put their traumatic experiences into words and chronological sequence if given the opportunity.
How Trauma Therapy Has Changed: Words Aren’t Enough
Neuroscience has shown that biology simply doesn’t allow a traumatised brain to recall traumatic events in words and chronological sequence. Unprocessed trauma is held in the body as odd sensations and physical patterns of tension; it’s also held in the brain as a jumble of unintegrated thoughts, images, and responses. Before it’s processed, trauma can’t really be put into words, because it’s simply not accessible to the word-finding parts of the brain. Trauma therapy works to gradually process the muddle of trauma so that eventually the person will be able to feel more integrated and put things into words for themselves.
15. Old Approach to Trauma Therapy: You’re Safe Here
In the past, many therapists (particularly CBT therapists) thought that their client should realise that therapy is a safe place. Clients who were slow to settle and who felt anxious of the therapy situation were sometimes seen as resistant.
How Trauma Therapy Has Changed: I Understand Why You Don’t Feel Safe Yet
The trauma-informed therapist understands that the therapy situation itself can trigger trauma-related responses. For example, for a trauma survivor the following can all be triggering: trusting the therapist, being the centre of attention, revealing avoided emotions or secrets, feeling too close or not close enough, etc. This is particularly likely to be so when the perpetrator of trauma was an attachment figure for client.
16. Old Approach to Trauma Therapy: PTSD is a Problem of Memories
It used to be believed that the active ingredient in PTSD is unprocessed memories of traumatic events.
How Trauma Therapy Has Changed: PTSD Has to do with Parts and Fragments
Research suggests that the active ingredients underlying PTSD are ‘chronic autonomic dysregulation, situationally activated implicit memories without words, and fragmented parts that experience themselves as still in danger of abandonment or annihilation or both’ (Fisher, 2017: 220) The memories in themselves aren’t the problem; it’s the unprocessed residue in the body and mind that are the problem. When someone heals from trauma, they still have a memory of the trauma; but it no longer has the same effect on how they feel.
17. Old Approach to Trauma Therapy: ‘There’s Something Wrong with Me’
In the past, a person’s view of themselves might have been formulated as something like “I am sick and there is something wrong with me”.
How Trauma Therapy Has Changed: ‘I Care for the Traumatised Part of Me’
Nowadays, a person might be helped in therapy to gradually develop a different attitude, more along these lines: “I’ve been injured, and it has impacted me. I feel deeply sad for my younger self that I had to go through that. And I know that I’m strong and brave for getting through it, and I’m loveable. I’m proud that I’m on a healing journey.”
18. Old Approach to Trauma Therapy: Events are at the Heart of Trauma
It used to be thought that at the heart of trauma is the event(s) that happened. The focus was on revisiting the traumatic events, putting them in order, and moving on from what happened.
How Trauma Therapy Has Changed: Shame is at the Heart of Trauma
Nowadays, there’s more a focus on the emotional component. Negative core beliefs about the self (shame that the self is somehow defective, unloveable, etc) are recognised to lie at the heart of trauma. Those core beliefs need to be transformed into compassion, respect and love for the traumatised self, through an engaged, attuned, emotionally present attachment relationship with another person.
19. Old Approach to Trauma Therapy: The Story was Just Bad
Trauma clients were encouraged to develop a narrative/story of the trauma: ‘This happened, and then that happened, and then I was traumatised’.
How Trauma Therapy Has Changed: The Story Has Meaning
A modern approach to trauma recovery helps the client to create a healing story that allows them to make meaning of what happened. This is not to gloss over or sanitise the awfulness of what happened; but there may be ways of helping the person to internalise a sense of meaning and connectedness that can run alongside the pain and suffering.
20. Old Approach to Trauma Therapy: Transform the Thoughts
Some of the older approaches to trauma took the view that we need to get the person to change the way they think. However scientific advances have shown that changes in thinking aren’t effective in treating trauma, because trauma is held in deeper parts of the brain and body. Traumatised parts can’t be touched by logic and persuasion, so no amount of cognitive reframing will help in trauma recovery.
How Trauma Therapy Has Changed: Transform the Feelings
Trauma treatment nowadays works to help the person to safely access their feelings. These feelings have been held in the body and deeper brain structures, and they need to be accessed in a titrated way that isn’t overwhelming. The relationship with the therapist is a vitally important part of the process: we normally need someone else to help us heal from trauma. (It’s also possible, in many cases, to heal from trauma with the help of loved ones, friends or community).
Not All Therapists!
Not all therapists work in the same way, of course. Some of what I’ve called ‘new’ approaches to treating trauma listed above have actually been standard practice for decades in certain types of psychotherapy (for example, psychodynamic psychotherapy has always valued a meaning-making way of looking at trauma symptoms and trauma experience).
It’s fine to ask your therapist how they work with trauma, and what a trauma-informed approach means to them. Sadly, there still appear to be a few counselling and psychotherapy trainings that disregard some of the more recent findings about working with trauma.
If you’re considering finding a therapist to work with you on your trauma, you might find the following articles useful:
Beginner’s Guide to Finding a Good Therapist
Your First Counselling Session: 12 Things You Need to Know
Secure Attachment – What Is It and How Do You Get It?
Coaching or Therapy – What Do I Need?
Why Now Could Be the Perfect Time to Go to Therapy
Recommended Books for Trauma Survivors
I personally rate each of these books highly:
Complex PTSD: From Surviving to Thriving, by Pete Walker
Getting Through the Day: Strategies for Adults Who Were Hurt as Children, by Nancy Napier
Journey Through Trauma: A Guide to the 5-Phase Cycle of Healing Repeated Trauma, by Gretchen Schmelzer
Letting Go of Self-Destructive Behaviours: A Workbook of Hope and Healing, by Lisa Ferentz
Trauma is Really Strange, by Steve Haines
What Kind of Therapy Helps?
Many types of therapy are very good for healing trauma – IF there is a good connection and ‘fit’ between therapist and client; and of course provided the therapist or counsellor uses a trauma-sensitive, trauma-informed approach.
Experiential therapies, where there’s a focus on helping the client have a contained emotional and somatic experience in the session, can be particularly helpful. Examples of experiential therapy include AEDP, Arts Therapies, Somatic Experiencing, Sensorimotor, EMDR, Body Psychotherapy, Internal Family Systems, Psychosynthesis, Hakomi, Equine-Assisted Therapy, Gestalt, and many more. Integrative psychotherapy and integrative counselling is also very often trauma-informed these days; relational psychodynamic psychotherapy likewise. Person-centred counselling could be helpful too, depending on the practitioner and how they work with trauma. The best thing is to ask any prospective therapist or counsellor if they use a trauma-informed approach; if they seem evasive, or confused by your question, that could be a sign that they might not have taken new approaches to trauma treatment on board.
What Have You Noticed?
What has worked for you in trauma treatment? What stands out for you personally as particularly important? What would you want other trauma survivors to know? Tell us in the comments below!