What Trauma-Informed Therapy Is And How It Helps People With Wounds That Aren’t Visible

There are countless people who have lived a lifetime, scarred and consumed by trauma – the consequences of a tragic event in life that has the power to change a person’s pathology and alter their world-view.

There are also individuals who have suffered unimaginable anguish and have emerged stronger from that ordeal.

As Dr Peter A Levine puts it,

A historical case in point is the many victims who survived the Nazi holocaust, overcoming pain - both physical and psychological - and lived to tell the tale.

How The Body Can Act As A Coping Mechanism After Suffering Trauma

In many cases, the victim, in order to overcome trauma, simply chooses to forget what happened. This is a coping mechanism and is called “Motivated forgetting’. To overcome pain, they simply try and forget unwanted memories, either consciously or unconsciously.

There are two ways to suppress individual trauma and to avoid anxiety-arousing memories. One is psychological repression, which is an unconscious act, and thought suppression, which is a conscious way of expunging thoughts and memories.

But such coping mechanisms can be very dangerous, because memories that are buried deep in our consciousness can cause harm.

How Trauma Became A Subject Of Interest For Psychiatrists After First World War

Trauma was first studied and documented by physiatrists during the First World War and the term “shell shock” was used to describe soldiers suffering from trauma. During the Second World War, it was called “battle fatigue”.

But over the years, with studies regularly done by psychiatrists, the view of trauma evolved. In the 1980s, the term “Post Traumatic Stress Disorder” was introduced and it not only covered soldiers, but also victims of sexual assault and domestic violence.

Sadly, many men who fought in the first and second world wars had to silently endure years of agony as many coped using internal coping mechanisms.

In order to obtain a better understanding of trauma and what is “trauma-informed therapy”, Swarajya spoke to two leading experts, Dr Janaki Rajagopalan MD, clinical psychiatrist, and one of the few practitioners of trauma-informed therapy in India, Anindita Kundu.

In the first part, Swarajya spoke to Dr Janaki Rajagopalan and here are excerpts from that conversation:

How are victims of trauma perceived in India and how does society or the family of a trauma victim react in a country like India where any form mental illness is still seen as a taboo?

One of the more grim realities of trauma is the way society reacts to it, often failing to acknowledge or even blaming the victim for the same. I have come across several cases where the victim of child sexual abuse is not supported even by the parents. The child then loses trust in the possibility that anyone will help her and this then leads to several issues in relationships as an adult.

Are all traumas caused by catastrophic events?

As society evolves, we are now obtaining a better understanding of the human emotional condition and how trauma can be a cause for distress for many other reasons, including the death of a close relative or spouse.

For example, a woman who had lost her adult son who was fond of drinking milk, felt traumatized and biologically nauseous by the very smell or sight of milk. This trauma she carried till the very end of her life.

Such trauma, however, does not fall in the catastrophic event category but nonetheless, has the power to leave a profound impression on the human condition.

How trauma impacts a person is something that can’t be explained but it all depends on the individual’s level of distress tolerance. The scars of trauma will never show on the body but it runs deeper and is more hurtful.

Are there any serious studies being done in India to promote awareness on trauma?

There has been an increasing focus on the effect of trauma on individuals over the last decade or so. Fifteen years ago, trauma was hardly addressed adequately, even in mental health settings in India.

But things are changing and more awareness can be seen in our society now. The role of trauma-focussed and trauma-informed care has been analysed in several studies such as The Adverse Childhood Experiences Study (Centers for Disease Control and Prevention, 2013) and The Women, Co-Occurring Disorders and Violence Study (SAMHSA, 2007).

Is it possible for two people to experience the same trauma but have different reactions?

What one individual experiences as a life event may not be perceived as a trauma by another. It is not just the event itself, but individual’s experience of and response to the event which in turn is based on various biopsychosocial and cultural factors.

However, everyone, regardless of their background, responds to trauma with some form of fortitude.

Though, for some, the reactions may be temporary, for others, the symptoms may be more acute, severe and prolonged, often leading to enduring mental health consequences like posttraumatic stress and other anxiety disorders, substance abuse and mood disorders.

That is why it is important to recognise that trauma may still affect life in significant ways.

In the second part, Swarajya spoke to Anindita Kundu, a Bangalore- based psychologist specialising in Trauma- Informed Therapy. Here are excerpts from that conversation:

What is trauma-informed therapy?

Trauma-informed therapy is a specific approach to therapy, directed towards healing from childhood trauma, Complex PTSD, addictions and eating disorders.

What is the first step in healing a patient using trauma-informed therapy?

First, it is necessary to provide a safe therapeutic environment emotionally and psychologically, because trauma makes us feel unsafe. In order to work with trauma, the therapeutic environment must be a safe one.

The patient should feel safe with the therapist. The room itself should be calm, relaxing and free of triggers. This approach recognises and emphasises how a traumatic experience can shape a person.

At the heart of this approach is the belief that we can all work towards achieving a sense of grounding, healing and hope.

Trauma can result from an event or a series of events and circumstances experienced by an individual as physically or emotionally harmful with lasting effects on the individual’s mental, physical, social, emotional, or spiritual well-being.

Can you describe the kind of trauma patients who come to you for therapy?

Trauma can range from experiencing loss of a loved one, discrimination, childhood neglect, emotional physical or psychological abuse, to experiencing war. There’s no right or wrong in trauma - if it was traumatic to you, even if you can’t name it, it is trauma.

Each person experiences trauma differently and has a different response to trauma. e.g Two children growing up in the same household might not experience the same event as traumatic.

Let’s say both of them have been hit by their parents, one starts of act retaliating and the other tries to avoid any sign of conflict-manifesting flight response.

There are four different responses to trauma: Fight, Flight, Freeze and Fawn. People pick either one or a combination of them.

Trauma-informed therapy is when a therapist recognises the complicated and complex ways that trauma influences various parts of someone’s life, body, and brain, and makes treatment decisions based on that framework.

A trauma-informed therapist recognises that most people have lived through some type of trauma because of the commonality of trauma, understand its manifestations and determines treatment through that lens.

Why it is important for a therapist being trauma-informed?

A trauma-informed therapist realises the ways in which trauma triggers thoughts, desires, behaviours and emotions that are impossible to understand without a full grasp of the role that trauma plays.

It is important for a therapist to at least be trauma-informed, if not specialised. It makes therapy less pathologising and more accepting.

Trauma-informed therapy makes therapy more effective for people who are living with effects of trauma and can provide a container in which it can feel possible to heal (whatever healing means to each person).

Trauma impacts many aspects of life, so understanding how trauma works plays a critical role in helping someone work through it.

When a therapist is trauma-informed and trained in the same, they are willing and are able to recognise the depths of the traumatic event beyond the surface of the diagnosis.

While working with patients, I have observed that there are is always a traumatic experience which gives rise to various coping mechanisms, like anxiety, anger, avoidance et cetera. Most of the times, these are attachment trauma or ACE (Adverse childhood experiences).

So, what happens is, as humans, we tend to get stuck with our narrative of the traumatic experience. A very big part of trauma therapy is to provide a safe space for the patient to be able to recognise the trauma endured.

How do trauma-related symptoms and behaviours originate?

Without braking patient confidentiality, I will give an example where patient “A” would sometimes withdraw and “shut down” when she felt overwhelming pain.

She would also sometimes have intense rage every time she felt emotional pain. In the therapy set-up, it was accepted that this was a coping skill developed over a period of time. While these behaviours were not ideal coping strategies, they did serve a purpose.

Some people develop coping mechanisms that are detrimental to their wellbeing.

A trauma-informed therapist gives individuals an opportunity to see how resourceful they were in managing a very difficult experience.

The role is to help patients recognise that our coping mechanisms have kept us alive and safe so far, and that is nothing to be ashamed of.

In order to help trauma patients, why it is necessary to help them confront suppressed emotions?

I will again use the example of patient “A” who had initially come to therapy because of depression. She hadn’t connected the dots between her past trauma history and her current difficulties.

As a trauma-informed therapist, providing hope that the trauma and the pain they have been undergoing can be recovered from, is vital.

Trauma therapy not only looks at the surface level behaviours but aims to heal the underlying issue that causes them: the original trauma.

Healing the trauma can lead to reducing or eliminating the coping behaviours that are causing distress.

How do trauma-informed therapists help patients cultivate resilience and coping skills?

Healing from trauma often includes learning about the original trauma and the impact of that trauma.

After that, a trauma-informed therapist works with the patient to develop new coping skills and new ways of relating to and soothing your nervous system’s response to being activated.

One of the things I use is to work on activating the vagus nerve-which activates the rest-and-restore response in our body.

Why does trauma-informed care include a focus on strengths rather than pathology?

As A’s therapist, I noted that she had survived the trauma and asked questions such as: “What would she say are her strengths? What characteristics have helped her manage her experiences? How has she coped with her feelings? What are some of her accomplishments that made her feel good about herself?”

As a trauma-informed therapist, it is important to help the patient recognise that even though the coping skills haven’t been the best, they still have been a sign of resilience on the patient’s part. It still exhibits strength.

Why is trauma therapy called a ‘collaborative approach’?

A trauma therapist works with you to provide your care. I always ask my patients what their goals are for treatment, and what recovery would look like for them. It is important for the patient to recognise that they are an active participant in the treatment process.

In Conclusion

In India, we have a long way to go in dealing with mental health crises, and according to The National Institute of Mental Health and Neuro-Sciences (NIMHANS ), a premier medical institution located in Bengaluru, the Government of India has not allocated enough funds in the 2018-19 Budget for mental health.

The government allocated only Rs. 50 crore with a small increase of a mere Rs 15 crore over 2017-18.

According to mental health professionals, a lot more study and funding/support is needed to help the cause of mental health and patients of trauma.