If you’ve experienced trauma, therapy can be an invaluable tool for healing. But with so many different types of trauma therapy, it can be difficult to know where to start.
What is trauma?
When you hear the term “trauma,” you might think of Post-Traumatic Stress Disorder (PTSD). While that is certainly an appropriate use of the term, the word trauma encompasses a much larger set of experiences, behaviors, and symptoms.
The Diagnostic and Statistical Manual of Mental Disorders, commonly known as the DSM-5, is a standardized set of criteria for mental health disorders, and the most recent edition upholds a fairly narrow definition of trauma in relation to PTSD. It states that for an experience to be defined as trauma it must include “actual or threatened death, serious injury, or sexual violence”.
In practice, clinicians know that trauma goes well beyond this definition.
Emotional abuse, and even witnessing traumatic events happening to someone else can all be categorized as trauma. In truth, trauma has much less to do with what you’ve experienced and much more to do with how your brain and body experience it.
What is a trauma response?
When we experience something traumatic, the brain responds immediately, and generally, this is a good thing! We need our brains to tell our bodies to run away from a natural disaster or convincingly act so we can sneak away from a situation undetected.
But sometimes, the initial response gets “stuck” and we find ourselves returning to it over and over. Essentially, the brain learned that a specific response helped it last time, so it’s going to continue doing it so long as it still feels threatened.
You may be familiar with the concepts of “fight or flight”. More research about how widely trauma responses vary has offered a framework of The 4 F’s.
There are many schools of thought when it comes to trauma responses, but in general, the most commonly identified are:
Fight (self-preservation by means of engaging in conflict)
- Physical fighting
- Aggressively yelling or confronting
- Attempting to control others/situations
Flight (self-preservation by means of escaping)
- Running away
- Avoiding people, places, conflicts, uncomfortable or uncertain situations
- Preemptively removing yourself from a situation at the first sign of potential threat
Freeze (self-preservation by means of dissociating or numbing)
- Physically being unable to move when faced with a threat
- Feeling unable to move forward or leave things behind
- Being passive about what happens in your life even if it is detrimental to you
Fawn (self-preservation by means of placating)
- Focusing on other people’s needs above your own
- Acting unbothered despite internal feelings
Important note:There is nothing inherently wrong with any trauma response, and an important part of trauma work is unpacking any shame you might hold for the trauma responses you engaged in. Trauma treatment helps your brain relearn that there are other ways of responding and that it’s now safe to do so.
Big T and little t trauma
Another way to think about trauma is through the framework of big T and little t traumas. While not a clinical specifier, these designations can be helpful for exploring how trauma occurs on a spectrum, and also for folks who might have trouble identifying what they’ve experienced as trauma.
Big T traumas are the ones that come to mind when you hear the word trauma. Car crashes, physical abuse, attacks, and natural disasters all fall under this category.
Little t traumas are sometimes less obvious, but research has shown that especially with repeated exposures, little t traumas can have similar effects on the brain as Big T traumas. Experiences like divorce or infidelity, loss of a pet, and forms of emotional abuse can be considered little t traumas.
For many people, it’s easy to brush off little t experiences; acknowledging they were difficult or painful but not understanding why they are experiencing lasting symptoms. Understanding that even a little t trauma can have a lasting impact on the brain, can be the difference between someone receiving treatment and feeling relief or spending the rest of their life “sucking it up” while feeling unwell.
This framework can be helpful in certain situations, but it’s important to acknowledge its major limitation: no one can define your trauma as big or little except you!
Signs you may have experienced trauma
As with nearly all things related to our mental health, trauma symptoms are different for every person. Even people who experience the exact same traumatic event can have widely varied trauma symptoms.
In general, people who have experienced trauma may notice symptoms like:
- Intrusive thoughts of the event
- Anxiety or heightened fear
- Sleep disturbances and nightmares
- Feeling numb or dissociating
- Anger or irritability
- Difficulty concentrating
- Muscle tension
- Being easily startled
- Avoidance of triggers
It is normal and common to experience these symptoms after witnessing something traumatic, and for some people these ease on their own in the following weeks or months. If your symptoms don’t seem to be easing over time, reach out to a mental health professional; there are many treatments available!
The American Psychological Association publishes clinical practice guidelines for many mental health conditions, and they have several recommendations for the treatment of PTSD.
They break their recommendations into two categories: strongly recommend and conditionally recommend. The therapies they conditionally recommend are not necessarily less effective, but maybe newer, more specialized to specific groups/situations, or simply have fewer research studies backing them at this time.
- Cognitive Behavioral Therapy (CBT)
- Cognitive Processing Therapy (CPT)
- Cognitive Therapy
- Prolonged Exposure
- Brief Eclectic Psychotherapy
- Eye Movement Desensitization and Reprocessing Therapy (EMDR)
- Narrative Exposure Therapy (NET)
Cognitive Behavioral Therapy (CBT)
One of the most widely studied therapeutic modalities, cognitive behavioral therapy, targets the relationships between your thoughts, feelings, and behaviors.
In this case, the APA recommended several different types of CBT: Cognitive Processing Therapy (focusing on unhelpful beliefs), Cognitive Therapy (focusing on patterns in behaviors and thoughts), and Prolonged Exposure (gradually exposing to memories and emotions of the trauma).
Prolonged Exposure is a unique form of CBT for trauma. When you are experiencing trauma symptoms, your brain is likely working very hard to avoid specific triggers of that trauma. You might take another route home, avoid certain places or people, or stop listening to specific music.
In Prolonged Exposure work, a trained therapist will first educate you about the process and answer any questions you have (no exposure will come as a surprise!). Gradually, you will address memories, triggers, and emotions related to the trauma in order to help your brain relearn that those things no longer need to be avoided and that the trauma has not reoccurred because you exposed yourself to them.
Brief Eclectic Psychotherapy
Though you may be less likely to see this therapy modality listed when searching for a provider, Brief Eclectic Psychotherapy is used quite frequently in trauma work. It refers to a combination of treatment types highlighting Cognitive Behavioral Therapy (CBT) and a psychodynamic perspective.
Mental health professionals using elements of Brief Eclectic Psychotherapy will help you manage and challenge feelings of guilt and shame related to trauma. This treatment is typically conducted in 16 structured sessions.
Eye Movement Desensitization and Reprocessing (EMDR)
EMDR has gained popularity as a front-line treatment for trauma symptoms, and some recent studies indicate it can even be more effective than other trauma treatments.
In EMDR, a therapist will provide a thorough education about the process and ensure you have a solid toolbox of coping skills at the ready should any reprocessing become too intense.
This treatment uses an exercise known as bilateral stimulation. While placing your focus on a trauma memory or experience, you will alternate stimulation on both sides of the body (through eye tracking of a light bar or the therapist’s fingers, tapping movements the client does on themselves, and sometimes through sound). Your brain naturally engages in bilateral stimulation while you are engaged in REM sleep, so the theory with EMDR is that by mimicking the brain’s natural processing methods, we can help it reprocess memories to be less distressing.
Like Prolonged Exposure, if you are reading about EMDR and thinking “why would I want to purposefully focus my brain on these traumatic memories?”, you aren’t alone. Starting EMDR can be uncomfortable, but a skilled therapist can guide you through the process and help you find relief.
Narrative Exposure Therapy (NET)
Narrative therapy involves creating a chronological story of what has happened in a person’s life. It focuses on traumatic experiences in an effort to contextualize and understand them within the greater picture of their experiences and identity, but it can also explore positive experiences.
As the name implies, Narrative Exposure Therapy has some similarities to Prolonged Exposure Therapy, in that both treatments guide the person through reliving/reexperiencing the traumatic experiences. However, Narrative Exposure Therapy seeks to understand and provide context for the traumatic experience, rather than achieve desensitization to it.
In Narrative Exposure Therapy, a client and a therapist will work together to document the client’s life story, and when a traumatic experience is encountered in that storytelling, the therapist helps the client relive that moment while staying firmly attached to the present. Many clinicians practicing PE document the client’s story, review it with them, and present it to the client at the end of treatment.
Other treatment types often used for treating trauma
Dialectical Behavior Therapy (DBT)
Technically an offshoot of cognitive behavioral therapy, DBT combines CBT practices with mindfulness skills.
In the treatment of trauma, DBT is especially helpful for people who have experienced repeated traumas impacting their sense of hope, emotion regulation, and attachment. In this treatment, therapists educate, offer specific skills, and work from a collaborative approach; therapists are often available for in-the-moment coaching as well as individual sessions.
Somatic Experiencing (SE)
Researchers are working to better understand trauma every day. Much of that research has uncovered a greater emphasis on the brain-body connection and how the body holds traumatic experiences.
One treatment gaining popularity and is known as Somatic Experiencing (SE), which is a body-focused treatment modality. SE practitioners focus on the body’s trauma response and the lasting overactivation of the body’s stress response. With the support of a SE practitioner, clients slowly increase their tolerance of physical sensations and accept them as they are.
An important difference to note is that in Somatic Experiencing (in contrast to Prolonged Exposure) it’s not necessary to relive the trauma memory itself, which may be beneficial in situations in which a person doesn’t have specific memories or does not wish to revisit them.
Somatic experiencing is still often considered an alternative therapy, and is typically conducted alongside a more traditional type of therapy.
An important factor for many people who have experienced trauma is the connection, community, and understanding that can come from group therapy. Finding validation and support from a group of people who have similar experiences can be incredibly important.
For some people, group treatment is best when conducted in addition to individual treatment. Others benefit from a primarily group approach. In fact, many of the therapy modalities listed above can be conducted in a group format, or at least with some component of group work. Cognitive Behavioral Therapy, Dialectical Behavior Therapy, and Narrative Exposure Therapy all routinely implement a group format.
Support groups can also be a useful tool in trauma treatment. They are often less structured than group therapy, but can offer an important safe space for healing and feeling understood.
Trauma treatment is never one size fits all
Trauma treatments will look different based on the clinician, the client, and on the trauma they are treating. Each provider will bring a different set of skills, experiences, and preferences, so if you notice that this description of a type of treatment doesn’t match your experience, that’s ok!
We’ve described the more classic presentation of each modality, but it is not uncommon for mental health professionals to use several different treatment modalities, or borrow elements from multiple treatments. A skilled provider will help you tailor your treatment plan to include what will work best for your specific set of symptoms and experiences. Whatever modality you choose, effective treatment is available!