Trauma-Centered Psychotherapy Techniques

Continuing the Trauma History

Introduction

The primary objective during early therapy sessions centered around trauma is to acquire an in-depth narrative of the traumatic event and the client's accompanying traumatic experience. This exploration has several purposes: it supports a trauma-centered framework, aids in the construction and understanding of the client's trauma schemas and triggers, and initiates imaginal exposure, which has inherent therapeutic benefits.

Although therapists may feel compelled to address urgent issues such as family matters, legal complications, medication concerns, and symptomatic increases, an experienced trauma-centered clinician will prioritize uncovering the distressing details of the trauma over these pressing concerns.

Conducting the Detailed Inquiry

The nuanced process involved in conducting a trauma inquiry is outlined here. Importantly, while a coherent chronological narrative may surface over time, early sessions should not strictly aim for chronological order. The therapist's role is to remain attentive, allowing the client's thoughts and images to emerge spontaneously as they converse.

Fragmentation of Traumatic Memories

Traumatic memories often do not appear in chronological order; instead, they manifest as fragmented elements, resembling a jumbled collage prompted by specific words, images, or associations. The client's instinctual drive to avoid the direct expression of trauma leads to various avoidant strategies. These avoidant maneuvers can be classified into five categories: stops, jumps, bumps, labels, and bridges.

Avoidant Maneuvers

1. Stops: Sudden pauses in the narrative indicating distress. Clients may freeze or ask, "Do I have to go on?"

   • Example: “He took me over to the corner of the room. He pushed me down on the floor….” Expanded: “He took me over to the corner of the room. He pushed me down on the floor and raped me.”

2. Jumps: Smooth transitions in the narrative that skip over distressing details. These shifts allow clients to progress in their recounting of events while avoiding triggering specifics.

   • Example: “He took me over to the corner of the room. He pushed me down on the floor and raped me.” Without the jump: “He took me over to the corner of the room. He pushed me down on the floor, rammed his finger into my rectum, and grabbed me around the neck, and raped me.”

3. Bumps: Small disturbances in the narrative's flow revealing underlying, unexpressed thoughts or images. Indicators may include throat clearing, gestures, hesitations, and physiological changes.

   • Example: “He took me over to the corner of the room…” with a slight pause suggesting a hidden thought, expanded narrative: “He took me over to the corner of the room. He pushed me down on the floor, rammed his finger into my rectum, and grabbed me very hard around the neck…”

4. Labels: General terms that describe actions without detailing the specific events, intended to shield the client from distress.

   • Example: “He raped me” minimizes the specifics of the trauma. Expanded description includes: “pulled off my panties, tried to enter my vagina with his penis, which was not erect…”

5. Bridges: Information that diverts attention from the distressing detail while maintaining narrative continuity. These often take the form of commentary on the perpetrator or the event.

   • Example: “He’s a macho kind of guy…” serves as a bridge, diverting focus from the more horrific details.

Techniques to Enhance Inquiry

Experienced trauma therapists utilize specific strategies to deepen the inquiry, which include:

• Looking Around: Asking about the environment to uncover specific details.
  • Example: "What else was in the room?"
• Zooming In: Focusing closely on intricate details.
  • Example: "What was the skin on his face like?"
• Slowing Down: Pacing the conversation to allow reflection.
  • Example: "Let’s see, how fast is that?"
• Repeating: Echoing the client’s words to encourage deeper exploration.
  • Example: "You heard the sound. Smack?"
• Backing Up: Returning to a previous detail to explore it further.
  • Example: "I need to back up here…"
• Pausing: Allowing silence after an emotional revelation to encourage further expression.
  • Example: The therapist maintains eye contact, facilitating emotional release.
• Using Present Tense: Shifting questions to present tense to enhance emotional engagement.
  • Example: "What is the expression on his face?"

Example of Technique Application

When applying these techniques to a trauma narrative, the interaction may unfold as follows:

• CLIENT: “He took me over to the corner…” [Stop]
• THERAPIST: “He pushed you down on the floor.” [Repeating]
• CLIENT: “Yeah, and then he raped me.” [Jump and Label]
• THERAPIST: “Okay, now let’s slow down… What did he do?” [Backing Up]

Engaging Clients in the Narrative

Therapists can facilitate opening up the client's narrative by actively engaging with their expressions and challenging avoidant maneuvers. These interactions help elicit new details, furthering the understanding of the client's trauma schemas.

Understanding Client Distress after Sessions

Clients may feel distressed post-session due to invoking traumatic details that remain unaddressed. Therapists are encouraged to recognize this and assure clients of the ongoing journey to further understanding and expression of their trauma narratives, reinforcing confidence in therapy.

Formulating the Trauma Schema

Trauma schemas are dynamic structures developed after experiencing trauma, designed to stabilize the individual when faced with triggering stimuli in present environments. They help differentiate between past traumatic experiences and present situations, often leading to misperceptions of safety.

Layers of Trauma Schemas

The trauma schema consists of five layers:

1. Fear or Shame: Represents the primary emotional state experienced at the time of trauma. Typical thoughts include feelings of isolation and inability to articulate their suffering.
2. Pain: Reflects both physical and emotional pain experienced during and after the event, leading to chronic physical distress.
3. Sensory Elements: Includes sensory stimuli that trigger recollections of the trauma, e.g., specific sounds, colors, or smells.
4. Anticipated Actions: Involves fears surrounding potential future harm that might have occurred during the traumatic event.
5. Lack of Response: Encompasses feelings of abandonment related to the absence of help or rescue during the traumatic incident.

Tables and Figures

Table 7–1: Layers of a Trauma Schema

Table 7–2: Analysis of Clinical Example in Terms of Layers of Trauma Schemas

Conclusion

In this chapter, we highlight the complexity and sophistication associated with conducting a thorough trauma inquiry. By employing the techniques outlined and understanding trauma schemas, therapists can better assist clients in articulating their experiences and pave the way for effective therapeutic interventions. Through this journey of exploration, effective therapy can lead clients toward integrating their trauma narratives, leading to healing and resolution.