Cognitive Reappraisal and Safety/Basic Needs
In this section we will delve into the lower two tiers of the hierarchy of needs, which share similarities with the challenges often associated with trauma. We'll explore the essential cognitive therapy steps required to address and heal these foundational aspects of well-being.
There are many exciting therapies emerging in the field of trauma. In this course, we won't extensively cover the field of trauma-informed therapies, given the wide range of approaches and ongoing developments. Instead, our focus will be on providing essential insights into our goals and methods when providing treatment to this client group, so that we can have a foundational understanding of our objectives and strategies.
When addressing trauma, we encounter a distinctive set of challenges that set it apart from other forms of psychological distress. Trauma often engages our primal fight or flight mechanisms and can have profound physiological and neurological effects. Therefore, navigating trauma therapy necessitates a comprehensive approach that considers the intricate interplay between mind and body. So before we delve into the cognitive reappraisal steps for these lower-tier needs, we'll need to touch upon several other elements of trauma therapy that must be holistically considered.
Some Thoughts on the Stabilisation Phase of Trauma Therapy
Stabilisation in the context of trauma therapy refers to the initial phase of treatment which focuses on enhancing the client's sense of safety, emotional regulation, and coping skills. It aims to prepare clients for the challenging work of processing traumatic memories and experiences. While the components of stabilisation can vary widely among different approaches or therapists, some typical elements of stabilization include:
Safety Planning: Collaboratively developing a safety plan to help the client feel safe about any overwhelming emotions that may arise during trauma processing. For example, you and your client could write down emotion processing strategies, emergency or support contacts, and other coping strategies to use if needed.
Grounding Techniques: Introducing grounding exercises that anchor clients in the present moment and prevent them from becoming overwhelmed by traumatic memories. Examples of grounding techniques include simple mindfulness strategies like focusing on the five senses, such as noticing or describing what they see, hear, touch, taste, or smell in their immediate environment. Additionally, clients can engage in rhythmic activities like deep breathing or tapping specific parts of their body to foster a sense of safety and connection to the here and now.
Relaxation techniques: Introducing deep breathing and relaxation exercises to help clients manage physiological arousal related to trauma triggers. For example, progressive muscle relaxation can be taught, where clients systematically tense and then release different muscle groups to promote physical relaxation. Additionally, diaphragmatic breathing techniques can be employed, encouraging slow, deep breaths to calm the nervous system and reduce anxiety associated with traumatic memories.
A common misconception is that effective treatment needs to follow an exact, step-by-step process, involving a stabilisation phase, followed by a trauma processing phase, and finally reintegration into daily living. The necessity of a stabilisation phase before trauma work has been a topic of debate within the field of trauma therapy. The concept of stabilisation often stems from models like Herman's phased approach for complex PTSD, suggesting that a stabilisation phase should happen before trauma processing. It's important to note that Herman herself emphasised the oscillating and dialectical nature of these phases (Herman, 1992b). In practice, the stages of healing from trauma don't always happen in a strictly sequential manner. They can overlap or be repeated at different points during treatment. Also, there isn't strong evidence to suggest that a phased approach, where stablisation has to take place before trauma processing, always works better than just focusing directly on dealing with the trauma itself. Critics argue that stabilisation can be an unnecessary use of clinical time without significantly improving outcomes or reducing dropout rates (Baekkalund et al., 2021; de Jongh et al., 2016; Oprel et al., 2021).
An additional concern raised is that overly emphasising a stabilisation phase in trauma therapy can inadvertently encourage avoidance behavior in clients. The idea behind this concern is that if therapy overly prioritises or prolongs the period dedicated to helping clients feel safe and stable, without addressing traumatic memories and their associated distress, it can reinforce the idea that avoiding those memories is the safest option. Clients may interpret this focus as confirmation that their fear of confronting the trauma is justified and that avoidance is an acceptable strategy.
Over emphasising or prolonging the stablisation phase can stem from several factors, including therapists' empathetic and compassionate tendencies leading to the concern that they may upset the client, therapists’ feeling under-confident, or a misconception that addressing trauma memories may cause harm or retraumatisation (Murray et al., 2022). However, it's crucial to stress that substantial evidence supports the idea that actively engaging with trauma memories, rather than avoiding them, is the most effective approach to treating trauma patients.
Avoiding Overactivation:
Although we do not wish to encourage avoidance of trauma memories, we should simultaneously be vigilant to only activate trauma memories at a pace that is tolerable to the client and can be processed effectively within the time limits of the session. We must avoid overwhelming clients by uncovering too many facets of the trauma memory at once. Instead, we should focus on one aspect or part of the memory during a session before considering addressing other aspects, preventing potential retraumatisation.
There are moments when we, as therapists, need to act as a brake during the session. Sometimes, clients struggle with regulating their emotions, and they might start recounting multiple layers of trauma. This can lead to unresolved issues when they leave the session, as there isn't enough time to address them comprehensively. In other cases, clients may share more about their trauma than they're emotionally prepared to handle at once, often because they believe it's what we expect from them.
Unfortunately, I've seen instances where such situations caused clients with PTSD to disconnect from treatment. They return home to flashbacks, distress, nightmares, and develop the belief that therapy is too intimidating or unhelpful. In some instances, this has occurred despite my best efforts to prevent it, as I may have underestimated the painfulness of certain memories for the client. Therefore, while our goal is to bring these memories to the surface and facilitate a reframing process, it must be done carefully and thoughtfully, ensuring that we only delve into the amount that the client can update and heal during a specific session.
Here are a few strategies that may prove helpful in this regard:
1. Notice Client Discomfort: If a client expresses that recalling certain memories is uncomfortable, emotional, triggers nightmares, or causes other psychological distress, or if they mention that they tend to avoid talking about or remembering a particular memory, take these remarks as cues to exercise extra caution with these memories. It's important to emphasise that this cautious approach isn't about avoidance but rather a means to assist the client in confronting their trauma memories in a supportive and considerate environment.
2. Attentive History Taking: During the client's history-taking phase, be attentive to any memories that appear trauma-related or trigger distress or discomfort. Ask the client questions such as, "How do you typically feel after revisiting or discussing this memory?" If a client indicates that recalling or discussing a memory induces significant distress or mentions avoidance, treat these memories with care.
3. Act as a Gentle Gatekeeper: In such cases, inform your client that while you're eager to hear their story, you are also aware that this memory may be overwhelming to them, and you would like to make sure that at this stage of assessment or treatment, you don’t uncover memories that they are not ready to process. An effective strategy is to ask clients to flag with you the existence of trauma memories but not delve into too many details during that stage. Encourage them to communicate the existence of these memories but to provide only the level of detail that feels comfortable at this stage. Explain that you do need to know if they've experienced certain traumas for a more accurate assessment, but that you don't require all the details immediately. This proactive approach can be crucial, as many clients mistakenly believe they must divulge all the details of their trauma to the therapist at once, which can put them at risk of retraumatisation or disconnection from treatment.
Keeping these considerations in mind, here are some guidelines regarding when and how to employ stabilisation techniques:
Assessing Current Needs: At the start of each trauma-focused session, begin by assessing your client's current emotional state and their readiness to engage with traumatic memories. Ask about their anxiety levels, emotional regulation, and any immediate distress.
External Circumstances: Some clients may be experiencing external life circumstances that contribute to instability, such as house moves, financial difficulties, or ongoing medical or legal issues. It is important to adopt a client-centered approach here, maintaining open communication with the client about their priorities and their capacity to engage in trauma work. An initial goal in therapy could be to focus on supporting them through handling the external circumstances. While some clients prefer to arrive at greater stability around their external circumstances before commencing trauma work, others are happy to get to trauma work straight away. External difficulties shouldn't always be a reason to delay trauma-focused treatment, especially if the client is willing and able to engage in therapy. Additionally, therapists should remain vigilant in cases where clients use a prolonged focus on external circumstances as a way to avoid addressing their trauma.
Gradual Exposure: When the time comes to address traumatic memories, therapists often use a gradual and systematic approach. This involves breaking down the traumatic material into manageable pieces and addressing it step by step, ensuring that the client is well-prepared and has effective coping strategies in place.
Monitoring Emotional Threshold: Continuously monitor your client's emotional threshold during the trauma processing phase. Be vigilant for signs of distress or overwhelm, and be ready to pause or shift back to stabilisation techniques if needed.
Post-Processing Stabilisation: After a trauma-focused segment, reintroduce stabilisation techniques to help your client re-center and manage any emotions that may have been stirred up by the processing.
Clients with a Higher Need for Stabilisation: Finally, there are clients who would benefit from a greater focus on stablisation prior to trauma work. Clients who have engaged in long-term avoidance of their traumatic memories may have a heightened fear or anxiety related to these memories. This fear can be so intense that attempting to address the trauma directly and immediately without adequate preparation can lead to retraumatisation and a breakdown of trust in the therapeutic process. Establishing a sense of safety and trust in the therapeutic relationship is a foundational step in trauma therapy. Clients need to feel confident that the therapy space is a safe and supportive environment in which they can gradually approach their traumatic material. So for clients with a high degree of trauma-related avoidance and fear, a period of psychoeducation and stabilisation work can help the client to become open to the idea of facing their traumas, knowing that they have the necessary tools to manage any symptoms that may arise post-trauma work.
Psychoeducation
One important element of cognitive reappraisal is psychoeducation. Psychoeducation is a powerful tool that can assist clients to understand and depersonalise the changes that they have experienced following their traumatic experiences, as well as instilling hope in the possibility of healing and recovery. Psychoeducation is helpful in the beginning stages of trauma work, although it is helpful to circle back to psychoeducation at subsequent points of treatment work, as the need arises.
Trauma can significantly alter the brain's structure and functioning, leading to a range of emotional and physiological responses. Below are several factors that clients may benefit from learning about during psychoeducation stages of treatment:
a) Neurological Impacts of Trauma:
Trauma significantly alters brain structure and functioning. The amygdala becomes hypersensitive, triggering intense emotional reactions, while the prefrontal cortex, responsible for decision-making and emotional regulation, is affected. These changes lead to heightened stress responses and emotional reactions, making traumatic memories vivid and emotionally charged.
Clients can understand these neurological impacts through psychoeducation. Knowing that these changes are adaptive responses to a traumatic environment, not personal failings, helps alleviate self-blame. Therapists can explain that the brain is capable of change (neuroplasticity), offering hope for healing.
b) Memory Processes:
Trauma often leads to fragmented and emotionally charged memories. During trauma, the brain prioritizes survival over orderly memory encoding. This results in isolated sensory fragments and emotional reactions rather than a coherent narrative. The hyperactivity of the amygdala reinforces emotional intensity.
Clients can grasp these memory processes through psychoeducation. This knowledge helps them understand why traumatic memories resurface with great intensity when triggered, leading to flashbacks, nightmares, or overwhelming emotions.
c) Neuroplasticity and Hope:
Neuroplasticity, the brain's ability to reorganize and form new neural connections, offers hope for healing the neurological and memory aspects of trauma. Through specific therapeutic approaches, clients can experience significant improvements.
d) Healthy and Unhealthy Processing:
Experiential avoidance, the avoidance of distressing thoughts, emotions, or memories related to trauma, can provide temporary relief but hinder long-term healing. Clients need to understand that facing and processing traumatic experiences with therapeutic techniques like cognitive reappraisal is essential for recovery.
Bodily Sensations
Understanding the strong connection between the mind and body is paramount in trauma treatment. Traumatic experiences often manifest as bodily sensations, such as tension, pain, or numbness, which can serve as triggers for distressing memories. Recognising and addressing these sensations are essential for trauma survivors. Emerging research highlights the effectiveness of interoceptive exposure techniques in trauma therapy, emphasising the importance of integrating interoception into trauma treatment strategies. In upcoming sections of this eCourse, we will delve into the practice of these techniques and their application in the therapeutic setting.
Cognitive Reappraisal
Cognitive reappraisal for individuals recovering from trauma involves identifying and challenging negative beliefs and thought patterns associated with the sense of threat stemming from the traumatic event or its aftermath. This perceived threat can manifest as external danger (i.e., the belief that the world is more dangerous than previously realized) or internal vulnerability (i.e. the belief that one is vulnerable, weak or at risk). Furthermore, trauma frequently generates feelings of guilt (commonly known as survivor guilt), remorse, self-blame, and hopelessness.
It’s worth mentioning that trauma does not necessarily only create issues in two bottom tiers of the triangle (sense of safety and deprivation from basic physiological needs). Often perpetrators of trauma also target the individuals’ sense of self worth and their connection to other people. For example, an abusive partner may be physically abusive, creating a sense of fear and threat, but could also be emotionally abusive, making their partner feel worthless, incapable, alone and abandoned. They may even instill in their partner the idea that their family, friends or public look down upon them or ridicule them. Similarly, trauma sustained from persecution, torture or many other forms of abuse and bullying can be multilayered and multifaceted. The purpose of understanding these experiences in light of the hierarchy of needs is not to simplify trauma or deny its many facets. Rather, the purpose is to be able to categorise the different types of harm which our clients can be suffering from at any one moment, and understanding what treatments are most effective for each type of harm. In this section, our focus will be on the aspects of trauma that impact the individual on the level of safety, security and basic needs.
So, to address those aspects of trauma that threaten the individual’s sense of physical safety, security and access to basic needs, I would like to bring our focus to two exciting methods of reappraisal that are used in cognitive therapy for PTSD (CT-PTSD). These are:
1- Updating Trauma Memories:
This three-step procedure involves:
(i) Accessing memories of the most distressing moments during the traumatic events, often referred to as 'hotspots,' and exploring their associated meanings.
(ii) Identifying information that updates these meanings, drawing from the course of events during the trauma or cognitive restructuring and testing of predictions.
(iii) Linking the new meanings to the worst moments in the memory, essentially 'updating' the memory.
Scenario: Imagine a combat veteran who experiences vivid and distressing flashbacks related to an ambush they survived during their deployment. These flashbacks lead to intense anxiety and hyperarousal.
Therapeutic Process: In therapy, the veteran recalls the traumatic event in detail, openly expressing their emotions, thoughts, and beliefs connected to the memory. As therapy progresses, the therapist guides the veteran in adding new information to the memory. This could involve focusing on moments of resilience, camaraderie with fellow soldiers, or the realization of their survival skills.
Purpose: Revisiting and updating the traumatic memory helps the veteran gradually reduce the emotional intensity associated with it. Over time, the memory becomes less distressing, resulting in decreased flashbacks and anxiety.
2- Stimulus Discrimination Training with Triggers of Reexperiencing:
This technique involves systematically identifying idiosyncratic triggers, often subtle sensory cues, and learning to differentiate between THEN (cue in the traumatic event) and NOW (similar cue in a new safe context).
Scenario: Picture a survivor of a serious car accident who experiences strong emotional reactions whenever they hear the sound of screeching tires, triggering vivid memories of the crash.
Therapeutic Process: The therapist collaborates with the survivor to identify various triggers associated with the accident, creating a comprehensive list that includes triggers like the sound of screeching tires, specific road signs, and images of the accident scene. These triggers are categorized based on their intensity, with the screeching tires sound identified as one of the most distressing.
Purpose: Recognizing and categorizing triggers provides clarity on what specifically prompts distressing reactions. This clarity empowers the survivor to develop strategies for managing these triggers effectively. For instance, they might use relaxation techniques when exposed to the sound of screeching tires.
This comprehensive approach to cognitive reappraisal and the described treatment procedures are valuable tools in helping individuals recover from trauma by challenging and updating the negative thought patterns and beliefs that often arise from these experiences.
Mindfulness and Reappraisal
As we will learn in future sections, an important principle of mindfulness is that staying rooted in the present moment holds the key to peace and wellbeing. This principle also plays a crucial role in successful trauma treatment. Trauma survivors often struggle to distinguish the past from the present. Despite the traumatic event being in the past and no longer occurring in the present moment, they frequently find themselves re-experiencing the trauma through flashbacks, regrets, and distressing emotions.
Assisting clients in reaching a deep realisation that the past trauma is over and no longer happening in the present moment is a vital therapeutic goal. This can be achieved through mindfulness strategies, grounding techniques, and cognitive reappraisal. Let's imagine a conversation between a therapist and a trauma client as an example of using mindfulness principles during cognitive reappraisal:
Therapist: "I understand that reminders of the accident, like the sound of car engines or certain weather conditions, can trigger distressing flashbacks. It's as if the accident is happening all over again. But I want you to consider something. As you hear those sounds, as you experience those moments, can you recognize that, in this current moment, you are safe? The accident is not happening now. You've survived."
Client: "Survived? I don't feel like I've survived. I'm physically and emotionally scarred by what happened. It's not over for me."
Therapist: "I understand. It's true that you've been deeply affected by the accident, both physically and emotionally. But here's a different perspective to consider. If you stay grounded in the present moment and stop comparing it to how things were before the accident, you might find a path to reduced suffering. Yes, your body and emotions have changed, but by accepting your current reality without constantly measuring it against the past, you can find a way to better cope with your current condition. For example, when you experience physical pain, instead of dwelling on how your body used to be comfortable, you can focus on what your body feels like now. It's about being present with your sensations and feelings as they are in this moment, without resistance, and without comparison."
Client: "I hear what you're saying about being in the present, but honestly, I don't want to accept that the accident happened. I wish it never did. I guess I'm still in denial in some ways."
Therapist: "This is very insightful. Let's talk about acceptance a bit. Acceptance doesn't mean you're okay with what happened or that you're giving up. It's about acknowledging that this event is a part of your life story, whether you like it or not. If we resist what's here to stay and is unchangeable, we don't change the reality. We suffer. The past is something that has happened and can't be changed. It's like a page in a book; you can't erase it, but you can decide how you want to write the next chapters. So, let's try something. Take a moment to imagine what it would feel like if you allowed yourself to accept that the accident did happen. Picture this acceptance as a small, safe step. What thoughts and feelings come up? If you feel an emotional resistence in your body, feel it until it passes."
Client: (After a pause) "I guess it feels like a weight off my shoulders. Maybe I could stop fighting against it so hard. It's been exhausting fighting against it."
Therapist: "So, coming back to our previous point, can you see that you have indeed survived the accident? The accident is in the past, and all that exists right now is what you're feeling and experiencing in this moment. It's about being present with your reality and finding a way to heal from here. How does this perspective feel to you?"
Client: "I can see that perhaps life goes on. I can enjoy things without letting the accident define every moment."
Self-Compassion and Reappraisal
Self-compassion is a vital aspect of trauma recovery, often underestimated in its significance. When individuals have experienced trauma, they often carry profound feelings of shame, guilt, and self-blame. These emotions can impede the healing process. Self-compassion involves treating oneself with the same kindness, understanding, and forgiveness that one would offer to a close friend facing similar challenges. It enables trauma survivors to reframe their internal narrative, fostering a sense of self-worth and acceptance. Integrating self-compassion into cognitive reappraisal for trauma encourages individuals to navigate their trauma with greater resilience and self-care. It helps them let go of self-criticism and embrace a path to healing that acknowledges their inherent worthiness.
Exposure
Exposure therapy is a well-established and effective approach in trauma treatment. It involves gradually and systematically confronting distressing memories, situations, or thoughts related to the traumatic event in a safe and controlled environment. This process allows individuals to process and eventually reduce the emotional charge associated with their trauma. Imagery work plays a significant role in exposure therapy for trauma. Through guided imagery exercises, clients can vividly explore their traumatic memories or triggers while in a secure therapeutic setting. This controlled exposure not only desensitizes them to the distressing content but also provides a valuable opportunity for cognitive reappraisal. Clients can reevaluate their traumatic experiences from a more empowered perspective, leading to a shift in their emotional response and beliefs about the trauma. This dual functionality of imagery work, both as a tool for exposure and cognitive reappraisal, makes it a valuable component of trauma therapy, aiding clients in their journey toward recovery and resilience.
Trauma and The Domino Effect of Memories
Although we have previously discussed the principle that ..., it's important to consider the principle of cascading effect or the domino effect of memories. Meaning that if a person whom had a healthy attachment or healthy self image growing up, but encountered a traumatic event during adulthood, is likely to maintain their healthy self image or attachment patterns, despite developing symptoms of posttraumatic stress disorder or other acute anxiety or mood conditions as an adult. This person is likely to have increased resilience better prognosis as a result of their healthier upbringing as compared to someone who may have experienced a trauma of similar severity but also suffered a background of poor attachment, poor self image or other childhood traumas. Therefore, when treating trauma related conditions, it's important to assess both the implications of the recent trauma and the type and severity of childhood traumas or deficits. Treatment then needs to balance addressing core beliefs from earlier in life, and the way that these core beliefs may have impacted clients' processing of their more recent trauma experiences. To do so, we need to remember the principle of the cascading effect or the domino effect of memories. A good approach is to first address any burning or pressing matters on the client's mind that may prevent them from wishing to address deeper emotional matters, as well as establishing a foundation of relaxation, grounding and psychoeducation. Once these foundational steps are taken, client can be educated about the principle of cascading effect or the domino effect of memories and guided to travel to potential earlier points in their life where foundational core beliefs formed, as well as exploring how these foundational core beliefs impact their understanding of their most recent trauma.