Trauma is a normal part of the human experience, but it varies widely in terms of severity and impact. Patients who come to therapy with a history of trauma that has caused significant havoc and dysfunction in their lives may struggle to reach their treatment goals without a treatment plan that emphasizes the resolution of the trauma itself. For this reason, all psychotherapists should be aware of the conditions needed for trauma treatment to be successful.
In 2006, Wolfgang Toller outlined eight prerequisites for trauma treatment, which are outlined in Dagmar Härle’s book, “Trauma Sensitive Yoga.” The following have been adapted from Härle’s book and represent the basic requirements for the treatment of trauma in therapy.
Trauma involves an inherent lack of security—an experience in which a person’s needs for safety are ignored or somehow violated. Therefore, it is critical to establish safety in the therapeutic space in order for the work to be effective.
Part of establishing security involves identifying what the patient needs to feel safe and validating that these needs are understandable, legitimate and worth honoring.
Certainly, mistakes are an inevitable part of any therapeutic process, but a clinician’s willingness to take accountability for mistakes that compromise the patient’s sense of security serves an important therapeutic function. Owning up to mistakes is an opportunity to model the healthy ways in which relationships can return to a state of safety, even when trust has been temporarily broken.
Trauma expert Peter Levine describes trauma as something that “overwhelms us and makes us feel helpless.” So it makes sense that the loss of control in traumatic situations is a part of what makes these events so frightening and destructive.
For this reason, it is important to create opportunities for clients to experience a sense of control around the therapeutic process and their healing.
Härle recommends encouraging clients to consider clinician recommendations as suggestions as opposed to strict orders, as well as to evaluate any techniques or intervention tactics being used in sessions based on whether or not the client feels they are helpful or effective. Härle cautions, though, that clinicians should be sure to have alternative options available for people who dislike certain interventions or practices.
3. The Ability to Create Distance from Affects
Patients with trauma may struggle to regulate intense, difficult emotions that may make it seemingly impossible for them to make contact with the emotions associated with their trauma. Even if a patient does not respond to an inquiry or other stimulation of trauma-related emotions, they are likely to be flooded by these emotions soon after.
Härle recommends that clinicians spend time with patients exploring tactics that have helped them cope with emotional intensity in the past and to offer exercises and practices to add to their toolkit. Clients may wish to make a list of their coping strategies, so that they know the tools that are available to them and can continue to seek out additional tools if necessary.
4. The Ability to Differentiate Between Emotions
Clients with trauma often have trouble differentiating between emotions from the past and emotions in the present, which can make it difficult for them to experience relief.
Härle suggests that clinicians help clients establish boundaries between “the origin of the current feeling and this feeling in the past,” because these are often merged with one another post-trauma. The ability to separate the two can provide relief from the overwhelm that often occurs when present feelings intermingle with past ones.
“It is also important to be able to distinguish between internal and external threats between the acute danger that demand action and overwhelming, paralyzing fear. Various affects are often located in different parts of the body and also do not feel the same. This is where we can start with the initial possibilities for differentiation,” Härle writes.
Clients with trauma often struggle to access their own inner resources or may even believe that such resources are lacking or absent. One way to help clients recall their inner resources is to ask them to remember a time when they felt powerful or were able to handle something that felt overwhelming.
“The nature of adequate self-care is being able to stand up for our own needs, setting boundaries against other people’s demands, trusting in close relationships, protecting ourselves against violent assaults and regulating closeness and distance,” Härle writes.
Because of the helplessness that often accompanies the experience of trauma, clients can become so out of touch with their capacity for self-care that they may need help remembering that it is even an option.
It is important to remember that as clinicians, we have the potential to model self-care through gentleness, boundaries and taking good care of ourselves with things like getting enough sleep, eating nutritious food, exercise and creativity.
Trauma often results in the patient’s loss of ability to understand his or her own mental states and those of others and the reflective ability to place them in categories such as needs, desires, expectations and so forth.
While these abilities are crucial for healthy relationships, their development is also dependent on secure relationships. It’s one reason why a secure, stable therapeutic relationship is so crucial in the treatment of trauma.
8. Self-Observation and Reflection
The ability to observe and reflect on one’s inner experiences is another way for clients to learn to create distance from their thoughts and feelings, which is helpful for a range of reasons. One way that clients can learn to build self-observation skills is through the observation of physical sensations. Härle also suggests intellectual games that help people become more detached—without dissociating—from their experiences.
For more about trauma treatment and particularly the work of Dagmar Härle, check out her book “Trauma Sensitive Yoga.”