Complexity and Hope in Treating Trauma

As a mental health clinician and expressive arts therapist, I work with many clients with high trauma loads. I work with individuals, couples, and groups where trauma is a significant component of the dysfunction they experience and often have not yet identified as such. It is both an area of professional interest and expertise for me, as well as the work that emerges from decades of personal healing work. I have learned from my training, ongoing study, and the strengths and weaknesses of my own therapists over 35 years of my healing journey, a lot that works and some that definitely does not. At this point, I feel a great deal of hope when clients start work with me. I don't always project that hope out into the shared space explicitly because it's not always the right time for the client, but I hold that hope explicitly in my own awareness.

That hope is based on my direct observation and personal experience that people do heal from trauma, and there is a path to healing that can be replicated.

The path to healing is not a singular formula, but there are some components of it that I have found get quick relief to my clients initially, which is often what they need in order to catch the spark of hope for themselves and to gain traction through personal experience, without me needing to push the concept of hope on them.

1. Begin from a position of deep respect for the individual's strengths. Find the strengths in the client and name them, even if they appear to be maladaptive. Are they angry? Validate the energy of anger and name it as the impulse to stop things from harming them or others. Are they self-sabotaging? Validate the legitimate role those behaviors have had (by working with them to identify how those behaviors have served them) while naming that other options are now possible, and we can work together to identify them.
2. Honor the client's limits. When I do an intake, I have to ask stock questions from a form that includes questions about trauma, family history, and addictions. I preface all of it by saying something like this: "We're just getting to know one another, and part of my job is to ask some very sensitive questions. I'd like to encourage you to listen to your own limits and only answer to the extent that you want to right now. You can name things you've experienced from a high level, decline to answer, or go into great detail, as you like. Over time, as we get to know one another, if you want to say more, you're always welcome to add to the story of your life and experiences." By acknowleding that they have no reason to trust me yet with their most sensitive information, I'm paradoxically beginning to establish that they can trust me to be respectful of their needs.
3. Offer psycho-education about trauma as a way to orient the client. This also involves a lot of validation. Clients frequently wonder what's wrong with them that they can't function or can't find happiness. They often find themselves engaging in damaging compulsive behaviors or destructive relationships and wondering what's wrong with them. The psycho-education often involves validating the normalcy of their reactions under profoundly toxic conditions and understanding that this is what humans do under those conditions. They are not alone.
4. Psycho-education also involves information about how trauma affectts the nervous system, not just the psychology, of the traumatized person. Some trauma happens prior to client memory or language development. I draw from Gabor Maté's work and child development principles to name the role that pre-verbal perception of threat has in programming the nervous system, even before we can remember what happened. I'll add information about childhood perception: it's the perception of threat that contributes to traumatization, not the actual facts of what happened. In other words, the trauma is real, even if it "only" happened in a particular way or wasn't "that big of a deal" from the adult perspective. I also name that while this programming is deep and often unseen, it can be healed. New neurological grooves can be established.
5. Distinguish between the energy behind the maladaptive behaviors and the behaviors themselves. Use a "both/and" approach. For example, "Your anger makes sense. Your emotions are non-negotiable. They simply are, and they give information about your inner truth. And the behaviors are 100% your reponsibility. What we can work on together is finding ways to honor your emotions and find alternative, constructive ways to express them and to get your needs met." This same principle applies to addictions, poor quality of interpersonal communications and relationships, lack of boundaries or rigid boundaries, and to other self-sabotaging behaviors.
6. Follow the client's priorities, interests, and strengths. I take some time during intake to identify the client's goals, and those become my goals. Are they interested in any of the arts, either as a consumer or a creator? Do they enjoy exercise, reading, social groups, their children? Build on the strengths of those interests and use them to build a platform for their success. If they like a particular art form and find it relatively easy to engage with, incorporate that into their sessions or after-session care. If they can't find words for how they feel, is there a song they like to listen to that expresses it for them? Pull it up and listen to it together. If they like to draw, invite them to use mediums and methods of self-expression to share what they feel. If they are highly kinetic, invite physically expressive movement or a plan to engage with their movement practices after session as a way to discharge emotion intentionally. I don't ask clients to engage in interpretive dance if it's not already an area of strength.
7. Invite the client to "look away from the trainwreck" periodically. Therapy can become too focused on what's wrong or what wounded the client. In fact, healing within the session and after the session takes place most quickly when the engagement with the wounds happens in a titrated fashion. I educate clients on "bracketing" their engagement with their suffering. It involves both looking away from what they are working so hard to heal and seeing the rest of their lives in order to foster perspective: what is going well, what their strengths are, where they are succeeding. This can be followed by making time to return to the arenas of hard work on a regular basis, at a pace and depth that allows for processing and subsequent metabolism of the processing.
8. While clients will eventually need to address what is most difficult for them, that's not where they need to start, usually. Exceptions to this can be in the realm of active domestic violence, active suicidality, or active addiction in mood-altering substances. Even so, harnessing the client's strengths and what they find easy to engage with along the way is a way to make quicker progress. There is a foundation to be created through learning self-awareness, self-regulation, connection with people, activities, and meaning that makes the direct gaze at trauma and its causes not to be destructive.
9. Actively processing trauma comes much further down the line, and it must be entered into with psycho-education about things such as intentionality, respecting their limits, and establishing and practicing in-session and between sessions emotional and neurological self-regulation. Some folks with try to dive into their deepest wounds too soon, and some folks will avoid those wounds at all costs. In either case, I emphasize to them that the neurological healing of trauma can be indirect: somatic, art-based, mindfully approached therapies can be used for a long time before a person gets into their narratives in a way that they can metabolize.
10. Encourage the client's self-awareness of their needs and limits from early on, and do it explicitly. For example, before a client gets into trauma processing in a session - even to the extent of just telling a story that is highly activating for them - I'll ask them what they have to do after the session. Are they going back to work right after the session? Walking into a house where their children will need their attention? Driving? Or do they have a couple of hours in which they can write, take a walk, take a nap, sit in a tub? By making this explicit, they begin to have control over how deeply they enter their story, and we work together on how to "exit" the processing so that they can function as they need to do. Trauma processing and therapy sessions don't happen in a vacuum; they occur within a context of that person's life, and that context must be integrated into the work of therapy.
11. We don't heal trauma by retraumazing ourselves. Gentleness, compassion, self-care, nonjudgment, friendliness toward self are profoundly healing balms, and they need to be applied liberally. If, as a therapist, I find that the client cannot engage with a therapeutic modality I have suggested (e.g., journaling, creating art to express themselves, doing worksheets, reading a book, going to a support group in the community), then I take a step back from that suggestion, acknowledge their inner wisdom that is telling them it's not time, and actively praise their self-awareness. That self-awareness of their limitations and resistence is a good thing, and it is something we both need to listen to. The clinician needs to adjust their approach; the client needs to take on only what they can, both during and between sessions.
12. Help the client develop a map that orients them to their process. The map (or the path) is not a well-established highway. It's a path they create through the tangle of their experience. But it is based on well-established principles (see all of the above). Everyone who walks into my office with trauma is going to be in a different place of understanding. My job as a therapist is to work with them to understand where they are in their healing journey, and to help them to find a sense of orientation and mastery of the skills they will need to continue the journey. Like any journey, the one through healing trauma can be fraught, but there are also some amazing places along the way, some glorious vistas, some companionship that is even more meaningful because of the shared experiences, and a great deal of enjoyment possible.
13. The relationship with the therapist is more important than the modalities. Research tells us this very clearly. Our presence with our clients that is respectful, validating, compassionate, mindful, and subtly hopeful will do far more than any modality we fee we need to get to with the client.
14. Conversely, a varied toolbox of modalities is going to be helpful. I engage with somatic psychotherapy, expressive arts therapies, parts work/IFS, mindfulness/guided meditation, motivational interviewing, psycho-education, risk assessment/safety planning, CBT, DBT, ACT, and many other modalities with clients, depending on what they need. I'm constantly expanding my own toolbox while also working from my own areas of strength as a therapist.
15. I might be confrontational or directive, but I use those tools very sparingly. As a clinician, part of our expertise lies in knowing when to apply those methods in a way that serves the client's needs. Directive/confrontational methos are the equivalent of a hammer, and we have project-planning, WD-40, screwdrivers, files, levels, stud-finders, saw-horses, and a myriad of other tools to draw upon before we go there. If my client can't get sober enough to engage with therapy, is actively suicidal, or if they are being beaten by their spouse, for example, some directive guidance is an essential, ethical part of the therapy. But in less severe contexts, other tools are more effective in the long-run.

This isn't everything, but it's a start. It's why I have hope. I see clients gain self-mastery and their own organic hopefulness quickly with this approach. This approach builds a foundation from which their healing is accelerated. Healing trauma isn't easy, but it is possible.