Trauma-Informed Therapy

Function

Trauma-informed therapy comprises a range of therapeutic modalities designed to address the complex needs of individuals affected by trauma. These therapies, applied within behavioral health contexts, strive to establish a supportive environment conducive to healing and resilience while ensuring that trauma awareness is integrated into every facet of care.

Applications of Trauma-Informed Therapy in Behavioral Health

Trauma-informed therapy is frequently utilized in addressing a spectrum of mental health conditions where trauma significantly influences symptom development or etiology. These conditions encompass PTSD. Therapeutic approaches such as cognitive processing therapy and eye movement desensitization and reprocessing (EMDR) are frequently used to address PTSD symptoms resulting from traumatic experiences.[6]

Trauma-informed therapy has been applied and successful in treating PTSD-related mental health disorders, including the below-mentioned conditions.

• Complex PTSD or C-PTSD: This condition, characterized by prolonged and repeated trauma, often necessitates trauma-informed therapy to address the intricate array of symptoms and experiences.[6][7]

• Dissociative disorders: Trauma-informed therapy is essential in treating dissociative disorders, such as dissociative identity disorder and dissociative amnesia, where trauma plays a central role in symptom development. Trauma-informed therapy helps patients to develop a cohesive sense of self and to integrate fragmented memories.[8][9] 

• Borderline personality disorder: Many individuals with borderline personality disorder have a history of trauma. Trauma-informed approaches such as dialectical behavior therapy or schema therapy and EMDR can address trauma-related distress, for example, flashbacks, nightmares, anxiety, and depressive features. Trauma-informed therapy can also improve borderline personality disorder symptoms by promoting emotional regulation, interpersonal effectiveness, and distress tolerance skills.[8][9] 

• Substance use disorders: Integration of trauma-informed therapy into the treatment of substance use disorders is common due to the frequent connection between trauma and addiction. Approaches such as trauma-focused cognitive-behavioral therapy (TF-CBT) are often used in these cases.[8][9][10] 

• Anxiety and mood disorders: Trauma-informed therapy can benefit individuals with anxiety and mood disorders, particularly when trauma exacerbates symptoms. Techniques such as narrative therapy or mindfulness-based interventions may be used.[9][10] Trauma-informed therapy helps patients develop coping strategies to manage anxiety symptoms effectively and aids in reconstructing cognition and improving emotional regulation in mood disorders.[9][10]

Trauma-Informed Psychotherapies

A variety of psychological therapies have demonstrated efficacy in treating trauma among the general population. These include modalities such as exposure therapy, TF-CBT, and EMDR.[11][12][13] These therapies share components designed to help individuals address and work through their traumatic memories, cognitive patterns, and perceptions of traumatic experiences.[12][13][14] 

Trauma-informed therapy components include the below-mentioned psychotherapies.

• Psychoeducation: Understanding trauma's impact on mind and body, therapy educates individuals on common reactions, reducing isolation and shame. 
• Exposure and processing: Using exposure therapy, individuals safely confront traumatic memories, integrating experiences to lessen emotional intensity. 
• Cognitive restructuring: Therapy challenges negative beliefs and fosters adaptive thinking to help individuals regain control and empowerment.
• Skill building: Coping skills such as relaxation, mindfulness, and communication enhance resilience and aid recovery. [SAMHSA, 2017] [9][15]

Exposure therapy: Exposure therapy involves gradually exposing individuals to the thoughts, feelings, and situations they fear or avoid.[16][17] This therapy is based on the principle of habituation, where repeated exposure to the feared stimuli leads to a decrease in anxiety over time. Exposure therapy often involves guiding an individual to revisit the trauma by using methods such as mental imagery, writing, or recording a comprehensive account of the event.[16][17] The individual is then encouraged to repeatedly interact with the narrative through listening or reading to build comfort and reduce the anxiety evoked by exposure to fearful stimuli. An alternative method of exposure therapy reintroduces cues connected to the traumatic event systematically, using a hierarchy of stimuli associated with the trauma.[15][18] 

A new addition to exposure therapy is virtual reality, which provides multisensory cues in an interactive and emotionally engaging environment.[19][20][21] This approach allows better control over stimuli, unlimited exposure repetitions, and the creation of challenging environments. Studies have shown virtual reality's effectiveness in inducing stress and anxiety comparable to real-life situations. These features make virtual reality a valuable tool for exposure therapy. Previous research demonstrates the effectiveness of virtual reality exposure therapy for various specific phobias and PTSD.[19][20][21]

Prolonged exposure therapy: Prolonged exposure therapy is a specialized form of exposure therapy tailored specifically for treating PTSD. This therapy entails guiding individuals to confront traumatic memories, situations, or objects they have avoided due to trauma. This exposure is prolonged and repeated over time to help individuals process and reduce their fear response to these triggers.[18][22] Prolonged exposure therapy incorporates the below-mentioned key components.

• Imaginal exposure: In this exposure therapy, individuals repeatedly revisit and recount distressing, traumatic memories, followed by a 15- to 20-minute processing session to discuss the experience and associated emotions.
• In vivo exposure: In this exposure therapy, individuals gradually face avoided but safe trauma-related situations.

Typically, prolonged exposure therapy sessions for trauma span approximately 8 to 15 sessions, occurring once or twice per week, with each session lasting approximately 60 to 90 minutes.[18][22]

Trauma-focused cognitive behavioral therapy: TF-CBT primarily helps individuals identify, explore, and modify negative beliefs about themselves, others, and the world. This intervention addresses issues such as mistrust, self-blame, feelings of inadequacy, and perceptions of danger. Additionally, TF-CBT addresses maladaptive behaviors that may worsen trauma symptoms or impair functioning, such as avoiding certain activities or excessive substance use, either individually or in combination.[23][24] 

Providing information on typical responses to trauma is a fundamental aspect of all TF-CBT treatments to validate the individual's symptoms and offer a rationale for subsequent interventions.[12][13][14] The standard duration of TF-CBT typically ranges from 12 to 20 sessions, although this may vary based on individual needs and the severity of the trauma. The number and duration of sessions are adjusted based on the client's progress, treatment goals, and clinical judgment.[25][26]

TF-CBT utilizes exposure techniques to assist individuals in confronting their traumatic memories and gradually engaging with real-life situations they have been avoiding since the event. This therapy also integrates cognitive restructuring to challenge overly negative views of trauma and its consequences. Cognitive therapy aims to identify and modify individuals' interpretations of the trauma and problematic evaluations they make about its effects, such as initial PTSD symptoms and reactions from others. TF-CBT also targets behaviors and thought patterns that perpetuate the condition, such as rumination on the trauma and engagement in safety behaviors that disrupt daily functioning.[11][23][25]

Behavioral experiments are incorporated into TF-CBT to illustrate how different maintaining mechanisms operate, such as thought suppression, hypervigilance to danger, and avoidance of triggers. These experiments aid individuals in adopting more effective coping strategies.[23][24][26] The initial TF-CBT sessions prioritize psychoeducation and breathing retraining, while subsequent sessions are divided into segments dedicated to cognitive restructuring. The remaining sessions, typically between 9 and 13, focus on cognitive restructuring.[6][27]

Eye movement desensitization and reprocessing: EMDR is a psychological therapy aimed at assisting individuals in reprocessing traumatic memories. During the therapy, distressing trauma-related images, beliefs, and bodily sensations are recalled while the therapist guides side-to-side eye movements.[28] The goal is to identify more positive perspectives of the traumatic memories, aiming to replace problematic ones. EMDR was discovered by Shapiro, who observed that swift eye movements reduced distress in her own experience.[28][29][30] Following this discovery, she refined EMDR into a systematic, protocol-driven therapy specifically targeting trauma-related distress. EMDR therapy consists of 8 phases, during which the individual recalls aspects of the traumatic event, such as images, thoughts, emotions, and bodily sensations, while receiving bilateral stimulation, often through eye movements.[28][29][30]

During the initial session, a case conceptualization is crafted, involving the identification of a hierarchy of relevant traumatic experiences tailored to each patient. Subsequent sessions involve using bilateral eye movements as dual-attention stimuli in processing traumatic memories. The number of EMDR sessions can vary depending on factors such as the severity of the trauma, the individual's response to treatment, and the therapist's clinical judgment.[28][29][30] However, EMDR therapy typically ranges from 6 to 12 sessions, with each session lasting approximately 60 to 90 minutes. In some cases, additional sessions may be necessary to process the traumatic memories and to fully achieve therapeutic goals.

The EMDR treatment process involves sequential steps as follows:

1. Introducing the EMDR protocol and developing coping strategies.
2. Evaluating treatment targets.
3. Desensitization and reprocessing.
4. Integrating positive cognitions.
5. Conducting a body scan to address any lingering negative bodily sensations.
6. Using relaxation techniques to restore emotional stability if distress arises
7. Conducting re-evaluation sessions.[28][29][30]

Clinical Significance

Studies indicate that individuals exposed to human-induced traumatic incidents, such as combat veterans, are at a heightened risk of developing PTSD compared to those experiencing other types of trauma.[31] Childhood experiences, particularly those related to emotional closeness to caregivers, are pivotal in shaping coping mechanisms and establishing a sense of security post-trauma. However, expressing trauma can be challenging for patients, particularly during initial consultations, influencing the onset and progression of various physical conditions. After accounting for sociodemographic characteristics and comorbid conditions such as mood disorders, anxiety, substance use, attention-deficit/hyperactivity, and personality disorders, individuals with lifetime PTSD are more likely to receive diagnoses for conditions such as hypertension, angina pectoris, tachycardia, other heart diseases, gastritis, and arthritis from healthcare professionals.[32]

Trauma-informed therapies, such as exposure therapy, have emerged as an effective intervention for adult PTSD. A meta-analysis by McLean et al demonstrated significant effectiveness of exposure therapy compared to the waitlist and treatment-as-usual groups. Larger effect sizes were observed in studies with fewer sessions and younger participants. Furthermore, effect sizes were also more significant in studies of refugees and civilians compared to military samples, individual therapy versus group therapy, and certain trauma types like natural disasters and motor vehicle accidents.[33] 

Additionally, Ross et al offer valuable guidance for clinicians in addressing the complex interplay between trauma experiences and mental health outcomes in young individuals.[34] TF-CBT has been observed to have a significant improvement in most measures of PTSD, including C-PTSD domains. The quantitative improvement varies based on presentation at baseline and enhances overall functioning.[8][34] By addressing the complex needs of individuals affected by trauma, TF-CBT therapy offers a pathway to healing and recovery, promoting long-term well-being and quality of life.

Enhancing Healthcare Team Outcomes

Nurses, as frontline caregivers operating holistically, are uniquely positioned to play a crucial role in advancing trauma-informed care within healthcare services. In trauma-informed psychotherapy, nurses are critical in creating a supportive and healing environment that enhances the effectiveness of treatment. They begin by assessing patients to identify trauma-related symptoms and collaborate closely with psychotherapists to develop detailed care plans. Throughout therapy, nurses provide ongoing emotional support, help patients manage anxiety and distress during sessions, and teach coping strategies for use in daily life.[35]

Nurses ensure the environment is safe and stable, which is essential for patients to engage fully in therapy. Nurses equipped with training in psychiatric and behavioral sciences can assume the role of therapy facilitators within trauma-informed therapy settings. Supervision is unnecessary when a nurse with appropriate training leads group or individual therapy sessions. Additionally, nurses facilitate clear communication between patients and other healthcare providers, ensuring a comprehensive approach to the patient's well-being. By blending their medical and psychological expertise, nurses are critical in the holistic care of patients undergoing trauma therapy.[35][36]

Enhancing healthcare outcomes through trauma-informed therapy necessitates a collaborative approach among multidisciplinary healthcare teams. This approach involves integrating healthcare professionals such as psychiatrists, primary care physicians, advanced care practitioners, pharmacists, psychologists, behavioral specialists, social workers, and nurses, each contributing unique perspectives and interventions tailored to address different facets of an individual's needs. Through collaborative decision-making, treatment plans are developed holistically, addressing both mental health and physical well-being. The process begins with a comprehensive assessment conducted by a multidisciplinary team of healthcare professionals to identify trauma-related symptoms, physical health concerns, and social support networks.

Cultural factors in trauma-informed therapy are crucial for providing effective and inclusive care, as they significantly influence trauma experiences, coping methods, and therapy engagement. Understanding a patient's cultural background helps therapists recognize how cultural beliefs and practices influence their experience of trauma and their coping strategies. Integrating cultural considerations into assessments ensures that treatment plans are culturally sensitive and appropriate, thereby enhancing therapeutic outcomes. This approach fosters a more respectful and supportive therapeutic environment, which can improve patient trust and engagement in the therapy process.

A comprehensive assessment provides insights into practical treatment approaches based on an individual's history, coping mechanisms, and current challenges. [SAMHSA, 2017] [35][37] Subsequently, coordinated care planning ensures personalized interventions that are aligned and delivered promptly. These interventions may include evidence-based approaches such as CBT, exposure therapy, mindfulness techniques, and medication management delivered by specialized team members. Continuous and effective communication among healthcare team members facilitate care coordination and prompt treatment plan adjustments as needed.

The interprofessional team of healthcare providers advocates for individuals affected by trauma, empowering them to participate actively in their recovery journey. Through education, support, and empowerment, patients acquire resilience, coping skills, and access to resources that promote healing and wellness. This collaborative and integrated approach to trauma-informed care ultimately leads to improved outcomes and enhanced quality of life for individuals affected by trauma.[35][37]