GoodTherapy.org Reviews ‘Principles of Trauma Therapy’

“…Not all psychological impacts can be encompassed by a list of symptoms or disorders.” —From Principles of Trauma Therapy

Make no mistake about it, Principles of Trauma Therapy: A Guide to Symptoms, Evaluation and Treatment is a psychiatric textbook. However, it is a rare breed of psychiatric textbook. It has a soul. To borrow from the dialectic wisdom of Marsha Linehan, the question in mental health treatment is often “What is being left out?” This book fills the void in terms of a comprehensive examination of the causes of trauma. It is not solely focused on the lists of symptoms. There are some areas where the book has “left out” important information, but emphasis on cultivating compassion for trauma survivors makes up for it.

John N. Briere and Catherine Scott describe how challenging behaviors exhibited by people who have gone through traumatic events are normal and within the context of psychological resilience: “Although therapists may interpret these behaviors as ‘resistance,’ such avoidance often represents appropriate protective responses to therapist process errors.” (p. 170). The adaptive functioning—or attempts to “metabolize” the trauma—is often interpreted as sabotaging or therapy interfering, but in reality, it suggests the clinician is in error (e.g., moving too fast in therapy). Unfortunately for the person in therapy, these attempts to lessen the pain can inadvertently prolong their trauma (this is what’s called the “pain paradox”). The unskillful attempts used to extinguish the pain often produces an increase in pain for the individual.

The pervasive message in Principles of Trauma Therapy is that a person’s symptoms due to a trauma can resolve via therapeutic engagement within a safe, therapeutic environment. The treatment approach is eclectic, and it weaves together strategies from various models (e.g., cognitive behavioral therapy, psychodynamic approaches, and mindfulness). People in therapy are given the opportunity to develop a coherent narrative of their past experiences, while learning stress reduction skills and psychoeducation through validation, respect, and supportive encouragement.

At the heart, Principles of Trauma Therapy comes from the theoretical perspective of exposure therapy and much of the content centers around this orientation for treatment. The clinician invites the person in therapy to develop alternative perceptions to their negative beliefs about themselves (oral and written) and the environment where the trauma manifested, while reducing “conditioned emotional responses” (CER).

To simplify, the recollection of the traumatic memory (i.e., exposure) occurs by activating the emotional states and schemas. The “disparity” that occurs is based on the idea that the therapy space is safe, so the person in therapy is counter-conditioned to realize they will not be harmed by experiencing the intense emotions that surround the memories. The integration of memories and emotions through exposure—along with the inability to avoid (i.e., CER) in the moment—creates resolution. The emotions are no longer as powerful. The positive results occur if the clinician is able to finesse the client’s capacity to “regulate and tolerate the associated painful affect” (p. 267). Briere and Scott advocate a titrated exposure to avoid both undershooting the level of exposure and not overwhelming the person in therapy. This person should be emotionally activated to allow processing to take place, but not to the point that their coping resources are overwhelmed, which leads to avoidant behaviors (i.e., to seek safety from the distress).

Exposure therapy techniques are undoubtedly effective and reliably decrease posttraumatic stress. However, the dysregulated elephant in the room during my review of this book was a question of ethics: is exposure therapy humane?

There are a couple of areas that should have been addressed more thoroughly in the text. Exposure therapy techniques are undoubtedly effective and reliably decrease posttraumatic stress. However, the dysregulated elephant in the room during my review of this book was a question of ethics: is exposure therapy humane? This form of therapy elicits pain for the person in therapy, often expressed in the form of panic attacks, dissociation, and intense anxiety through a re-experiencing of the trauma. Is it morally right for clinicians to prescribe this approach? Does the end justify the means? Or, are there other treatment approaches that can be used to relieve the immense amount of suffering experienced by trauma victims?

Principles of Trauma Therapy provides only a brief conceptualization of eye movement desensitization and reprocessing therapy (EMDR). In 2004, the APA acknowledged EMDR as a recommended effective treatment of trauma. According to Shapiro (2001), EMDR is the most empirically studied treatment for posttraumatic stress (PTSD). The philosophy of EMDR treatment does not differ drastically from exposure therapy: deconditioning disturbing input, redefining the event, finding meaning in it, and eliminating self-blame, while integrating new skills (Shapiro, 2001). The stark difference between EMDR and exposure therapy is the method of delivery, as well as the path a person in therapy takes toward healing. Exposure therapy is analytical with a narrative-driven process that involves a significant amount of “homework” assignments for the person in therapy. It also runs a risk of vicarious traumatization (for both the therapist and person in treatment) due to repeatedly describing the often horrific events.

The internal process of EMDR utilizes an approach of holding a negative cognition (e.g., “I am unlovable”) paired with what is often an image of the traumatic event (a pre-established target). The person is instructed to focus on the image, negative thoughts, and body sensations while simultaneously engaging in EMDR processing using sets of bilateral stimulation (e.g., eye movements, auditory stimuli, or tactile sensors). They are witnessing in their mind’s eye what surfaces. The clinician does not hear all of the details of the trauma, nor does he or she provide analysis of the experience. Dialogue is at a minimum. It is provided through repeated, brief check-ins between sets of bilateral stimulation; “What comes up now?” or “What did you notice that time?”

Principles of Trauma Therapy has an agenda in terms of promoting exposure therapy, but it also offers a holistic array of coping strategies—for both the therapist and the person in therapy—to increase one’s awareness of bodily reactions and ways to create a vocabulary for the feelings that arise. This mindful mentality is more than a subtle emphasis. Empirically validated mindfulness interventions are presented (e.g., acceptance & commitment therapy, dialectical behavior therapy, mindfulness-based stress reduction, and mindfulness-based cognitive therapy) as to disillusion the reader from the spiritual, Buddhist connotation. Clinicians are encouraged to maintain an open awareness to their own mental states (e.g., reduction of reactivity) without judgement, in order to mirror this process for people (e.g., attending to the breath, a here-and-now focus). There are also scripts for new clinicians and comprehensive assessment material that is applicable to anyone in therapy.

Principles of Trauma Therapy has a final, comprehensive directory of trauma-centered psychopharmacological interventions with content relative to psychobiology. This is extremely informative, but one has to question some of the research that was referenced. One concluding statement regarding the efficacy of selective serotonin re-uptake inhibitors (SSRIs) as antidepressant medication gave me pause. It was noted that SSRIs “have been found to be equally effective in reducing symptoms and improving quality of life across most clinical trials” for many diagnoses. The example reference was to a 2000 study comparing monoamine oxidase inhibitors (MAOIs), tricyclic antidepressants and some selective serotonin re-uptake inhibitors (SNRIs) for depression. ^[1] The citation did not match the broad sweeping claim as the study itself notes “clinically insignificant” differences in efficacy as well as tolerability between SSRIs. ^[1] Read this section with a grain of salt and consider newer research when determining the efficacy of medication for victims of trauma.

Despite the focus on the individual in this book, the reader is walked through the “victim variables”, “characteristics of the stressor”, and “social response and supports” that affect the outcome for the trauma victim, which forces a cultural vista. Briere and Scott implicitly connect to the fact that our society’s disenfranchised groups of individuals (e.g., people of color and in poverty) are much more susceptible to posttraumatic symptoms.

Trauma is no longer just a micro level problem, but an issue of social justice and equality. The book maps out the generational influences and cyclical effects of trauma. There is an “additive effect” of multiple traumatic events throughout one’s life. For example, a survivor of childhood abuse who has residual effects into adulthood will react with “especially severe, regressed, dissociated, or self-destructive responses to the adult trauma” (p. 22). Earlier treatment interventions are essential to desensitize these reactions to stress.

Briere and Scott provide a stylish blend of the metaphysical and tangible aspects of trauma. They do this with learned experience, academic research, and hope as a means to expose the wide-ranging consequences of trauma. If you are a clinician searching for an in-depth examination of the components, conceptualization, causal mechanisms and treatment of trauma, then Principles of Trauma Therapy is here to the rescue.

References:

1. Mace, S. and Tayler, D. (2000). Selective serotonin reuptake inhibitors: a review of efficacy and tolerability in depression. Expert Opinion on Pharmacotherapy: 1(5). 917-933.
2. Briere, John & Scott, Catherine. Principles of Trauma Therapy: A Guide to Symptoms, Evaluation, and Treatment (2^nd Edition). SAGE Publications, Inc; Second Edition – DSM-5 Update edition (March 26, 2014).

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