One of the pillars of effective trauma therapy is psychoeducation. Many studies and reports now confirm that survivors benefit from a clear, complete understanding about trauma and how it affects them biologically, emotionally, cognitively and spiritually. One study (Phipps et al., 2007), found that psychoeducation alone assisted survivors to better understand their stress symptoms and contributed to a decrease in their stress symptoms.
What then should be included in the psychoeducation we provide our patients and their families?
In this post, I review things I commonly include in my work with patients. I also summarize new research that shows that the pedagogical medium for psychoeducation is just as critical in regard to impact on patients as the information itself.
The Big Picture
Athough trauma integration is not fully linear, I lay out for trauma survivors a framework of phases as a roadmap for their journey. This helps them make sense of what has happened and helps them return to a sense of control over life.
I use a Trauma Integration Roadmap that emerged from my study and research to help survivors describe their experience in six stages (see image): 1) Routine, 2) Event, 3) Withdrawal, 4) Awareness, 5) Action, 6) Integration.
Survivors can locate themselves in their current status there, find new understanding of what they’ve been through and anticipate what lies ahead. In the safety of a therapeutic setting, they can explore options for further steps towards trauma integration.
Although stages two and three seem to fit virtually all survivors, the whole framework doesn’t apply to every survivor in exactly the order given. The intention is not detailed prediction, but rather to provide a sense of order, control and connection to the experience of the larger human community in a time when disorder, disempowerment and disconnection threaten to overwhelm life.
Frankel (1985) wrote: ”An abnormal reaction to an abnormal situation is normal behavior.” (p. 20) One of the biggest goals of trauma therapy is to help survivors reclaim a sense of order, control and connection i.e. normalcy. By naming their experience and locating it in a framework shared with others, they take a big step in that direction.
How to Manage the Dynamics of Withdrawal
A stage important for survivors to understand is what I call Withdrawal. Following the traumatic event (fight/flight/freeze) response that survivors universally experience in response to a traumatic event or threat, withdrawal represents a next phase.
Prompted by powerful defense mechanisms designed to ensure survival by reducing vulnerability to further injury, survivors now experience a strong instinct to withdraw. Some stay in this stage for a short time, some for a long time. Some who do not get proper help may spend the rest of their lives in it.
In withdrawal, survivors cycle through intense feelings of fear, anger, shame, guilt, moral injury and are gripped by endless rumination (“shoulda’/coulda’/woulda’”).
I think survivors benefit from several understandings about withdrawal:
1) It is a normal response to an abnormal situation. Though a disengagement from life, withdrawal is, in fact, a lifesaving and life-giving stage. When we are hurt, our entire being urges us to step back to avoid more hurt. So the instinct to withdraw is confirmation of a strong survival instinct.
2) Survivors should not rush themselves out of withdrawal. The quickest way through it, in fact, is to take their time and be fully in it. The ticket to further movement towards integration is awareness.
3) Healing is cyclic, not linear, so withdrawal is not a once-and-done event. The instinct to withdraw is likely to reappear from time to time, even after many years. This feels like a return to the same place, but proper psychoeducation about that will help survivors to come to see it is not.
Brain Responses Following Trauma
One of the most valuable learnings for me as a trauma survivor myself was about the psychophysiology of brain response to trauma. At last, I could make sense of inner responses that had puzzled and troubled me for many years.
A good understanding of brain responses to trauma is important for those who are affected by trauma or work with them. Trauma survivors ought to be educated in the psychophysiology of brain responses to trauma (Raider et al., 2008. p. 172).
In working with clients, I focus on how brain responses affect survivors in each of the stages and in particular, the second (Event) and third (Withdrawal) stages of the ETI roadmap.
In the Event stage we are in fight/flight/freeze mode. We function very differently than at other times. Once activated, the instinctual part of the brain (the Reptile in the sketch) takes charge and sends powerful signals to the entire body. Heart rate, breathing and perspiration get turned way up high. Muscles and nervous system are tense and ready for action.
The instinctual part of the brain takes charge of the entire brain structure. The emotional and thinking parts of the brain, which normally play a lead role and bring analysis, reasoning, and moral guidance into our response, is shoved aside. The instinctual part of the brain attends only to our primal survival.
Withdrawal keeps us in survival mode. This makes ordinary life hard. But it also has benefits of which survivors are often only barely conscious, if at all.
The Value of Recognizing Unacknowledged Resources
As soon as we experience trauma, resources begin to emerge, often without our awareness. Recognizing these resources and our emotional responses to them helps us move from Withdrawal, even if only for brief periods, into the next stage of Awareness.
What are these resources? The moment that you experience trauma your survival system calls upon unused personal resources to help you survive and it continues to do so. If you are like most trauma survivors, it is hard to see the strengths you have already displayed in surviving the trauma. But these are innate survival instincts that have helped you to hold on to life even at its most challenging. They are an important source of energy in trauma integration process.
Becoming aware of these personal resources can be a key step to break the cyclic effect of Withdrawal and begin moving to the next stage of Awareness.
Psychoeducation should be experiential
For some time after I had first learned the basics of psychoeducation about trauma, I felt stuck. The ideas spoke powerfully to me yet I was not able to absorb them in a way that changed how I felt in an enduring way or help others to the extent I wanted.
I am an experiential learner. I realized I need to find experiential ways to apply what I was learning about trauma and the brain. In particular I wanted to find experiential ways to educate trauma survivors about how to break the cyclic effects of withdrawal and move beyond the constant shadow it cast over life.
After many years of training, teaching and research, it finally came to me that the psychoeducation information captured my attention because it is cognitive and rational. It spoke to the rational part of my brain that loses out to the reptilian brain and shuts down when the reptilian brain takes charge in an attempt to survive.
Action methods and tools of experiential learning make it possible to regain access with the rational part of the brain. Whole body learning is for me, and pedagogical experts say for most people, grounding and calming. It puts the reptilian brain at ease, allowing the rationale brain to engage and retain concepts for which the reptilian brain has little aptitude or retention.
One of the things that I examined in my doctoral research was how much psychoeducation information participants were able to retain two months after an intervention. One group received a talk based oratory intervention. A second group received fully experiential psychoeducation intervention.
I could hardly believe the findings when we followed up two months later to assess retention of knowledge. Ninety-two percent of the participants in the experiential group remembered specific psychoeducational information about how the brain is impacted by trauma and stress. In the oratory talk-based group, none of the participants remembered any specific content from the entire three day intervention, aside from one experiential (“body map”) activity.
Understanding the implications of this fully would require additional research. But for now, at a minimum, we can say that research suggests that traumatized people retain little of what they hear from frontal presentations and far more of what is presented in experiential methodologies. Among others, this is one of the reasons I build not only psychoeducation but most of my work around experiential methodologies.
The ETI trauma intervention framework is based on bottom-up interventions and I use experiential methods in helping clients apply it to their particular situation. Top-down modalities come in when it is time to merge traumatic events into the integrated narrative.
Learn more about the ideas above in an upcoming Expressive Trauma Integration first workshop of Series I: Experiential Psychoeducation here December 3, 2017 in Silver Spring MD. Use Coupon code ACTION20 for a 20% discount valid until November 20.
Frankl, V. E. (1985). Man’s search for meaning. Simon and Schuster.
Gertel Kraybill, O. (2015). Experiential Training to Address Secondary Traumatic Stress in Aid Personnel. (Doctoral Dissertation). Lesley University, Cambridge, MA.
Phipps, A. B., Byrne, M. K., & Deane, F. P. (2007). Can volunteer counsellors help prevent psychological trauma? A preliminary communication on volunteers skill using the ‘orienting approach’ to trauma. Stress and Health: Journal of the International Society for the Investigation of Stress, 23(1), 15-21.
Raider, M. C., Steele, W., Delillo-Storey, M., Jacobs, J., & Kuban, C. (2008). Structured sensory therapy (SITCAP-ART) for traumatized adjudicated adolescents in residential treatment. Residential Treatment for Children & Youth, 25(2), 167-185. doi:10.1080/08865710802310178