November 01, 2016 at 1:16 PM
We’re in the golden age of trauma therapy. We have research-supported treatments that are effective, efficient, and well-tolerated by clients. A lot of traumatized people are getting a lot more better than they ever dreamed was possible.
Yet many people who contact me for help are leery, because they’ve already tried trauma therapy and had a bad experience.
So you get into a room with a therapist and start opening up about the worst things that ever happened to you. What could possibly go wrong?
Well... a lot of things. The problem is that many therapists who are trained in a particular trauma resolution method (such as EMDR, PE, TF-CBT, etc.) are not very well trained as trauma therapists. Here are the treatment mishaps I hear about the most.
This isn’t specific to trauma-focused therapy. Now and then I hear a story about some therapist who did something bone-headed, or (less egregious) just didn’t click with the client. It happens. And when the client doesn’t feel comfortable or safe with the therapist, it’s hard to get much done.
For example, someone told me that she brought up an important issue and her therapist responded by saying, “If it upsets you, you shouldn’t talk about it.” (Yes, this is a true story.) She didn’t go back to that therapist.
It’s important that a client be adequately prepared for trauma work:
- They should understand how their trauma history is impacting their current situation, and how trauma healing can help them to get to their goals.
- They should be stable enough and strong enough to be able to face the trauma work.
- They should be prepared for some emotional pain during the therapy session.
Without adequate preparation, some clients report having felt blind-sided by the trauma therapy experience. If you don’t understand why the therapist is having you do it, or if you’re not expecting the (sometimes) intense emotional pain, you’re probably not going to hang around for much more.
Some people report having worked with a therapist but never gotten around to working through the trauma memories. One way this can happen is by meeting so infrequently – every couple of weeks, or even once per month – that therapy can't ever move beyond checking in, catching up, and perhaps a little pep talk or work on coping skills.
More commonly, the client has so much instability that it’s hard for therapy to get past a focus on stabilization and self-management skills. Unfortunately, that may only lead to more of the same. And sometimes the therapist is overly cautious and does not encourage the client to move past this, into the trauma work that could lead to lasting improvement.
Risky Target Order Strategy
This one will be more controversial, because we haven’t yet published our research, and because anyway our research is only preliminary. So take this as my personal clinical judgment, based on years of experience (and providing supervision) as well as preliminary research findings. People report that their previous therapists used what I consider risky “target order” strategies – that is, which memories to treat (target) in which order. I consider the following strategies risky.
- Going right for “the big one” or the memory that precipitated the symptoms the client is coming to therapy about.
- Treating whichever memory the client feels like working on at the moment.
- Within a cluster of similar memories (for example, a cluster of memories regarding exposure to domestic violence), using strategies 1 or 2.
Why do I say these are risky? Because of what I call the sore spot reaction. Let’s say that something bad happens at age 5 that creates a psychological wound, or sore spot. Something else bad happens at age 10, and because it hits that sore spot (from the earlier memory), it feels even worse than it would have. If you work first on the age 10 memory, it may go poorly because of the sore spot reaction from the earlier unresolved memory. If you work first on the age 5 memory, it will likely go well because there’s nothing underneath. And then when you get to the age 10 memory, having already worked on the earlier one, the later memory will go smoother as well.
Not that you can’t get away with these “risky” strategies sometimes. Many therapists routinely use these strategies and enjoy a fair bit of success. Which perhaps convinces them that they are doing therapy properly.
And we get some of their failures.
We Can Do Better
Many people who come to us have already tried therapy elsewhere. People may report that they were working with a trauma-trained therapist who did not do trauma work with them. And I often hear some variation of, “I tried EMDR, but it didn’t work.” Or worse, “It messed me up.” In those cases, when I inquire about what happened in the treatment, it almost always turns out that the client was not adequately prepared, and/or the therapist used a risky target order strategy.
We don’t take every case, because I don’t think everyone’s suitable for intensive trauma-focused therapy. We do take many cases in which the previous therapist either did not initiate the trauma work, or did but with poor outcome. Yet in nearly every case, the client is successful in their treatment with us. This tells me that it’s not that the client couldn’t do it.
There are plenty of excellent trauma therapists out there. But too many trauma trainings do not include sufficient focus on how to adequately prepare clients for the trauma work, and/or how to determine an effective target order strategy. The result is that well-intentioned therapists, who believe they have been properly trained, end up providing substandard treatment to some clients. Then the clients have to suffer for longer, and some may never be willing to try trauma therapy again.
We can do better, and we must. Now that we have the ability to help clients to heal from their psychological wounds, we have to get better at enabling them to get through the treatment. This is why some of our current research is focusing not only on treatment effectiveness and efficiency, but on how to help clients better tolerate trauma therapy so that they are able to hang in there and get the job done. This is why, when we teach trauma therapy, we do not offer brief training on EMDR or PC; we only offer full-length training programs that teach the entire trauma therapy approach. And this is why, when we provide therapy, we thoroughly prepare clients, and then work through the trauma memories in chronological order.
Please add a comment
Or maybe I should have added a category: Incompetent Therapist. For those therapists who claim to know what to do with trauma, but simply don't.
Probably most trauma experts are seeing the same things.