Trauma and PTSD: the 3 levels of psychotherapy treatment

In graduate school, I often thought to myself “I’m not interested in working with people who have trauma, addictions, eating disorders, or anything else along those lines.” At the time, I found those particular issues interesting, but it was not my main area of passion.

You see, passion is big for me. Growing up, I was always told “you can do something well if you’re interested in it.” And that is 100% true of me even to this day. It’s not that I couldn’t work with these issues, I just didn’t have an interest in it at the time. Then, everything changed. And I do mean everything.

In November of 2019, I was sitting in a session on complex PTSD at a conference I was attending. This conference had sessions on every topic you can think of. At this particular time of this day, I thought this session sounded the most interesting out of all the topics. At most, I thought I would walk away with extra understanding for client presenting issues. Little did I know I was about to walk into the session that opened my eyes on my own mental health struggles and would change the trajectory of my entire career.

As the speaker was going over criteria for Complex PTSD, it hit me. I thought to myself “holy crap…that’s ME!” You see, most mental health professionals go into the mental health field as a result of their own experiences in mental health or the experiences of a loved one. I’m no exception. I went into this field wanting to figure out my own issues and help others in the process. But, I thought I was one of those people who just deal with mild depression and severe anxiety. Brain chemicals that are off. Nothing special.

So, here I am, a year and a half into learning about Trauma and PTSD and utilizing my knowledge in the clients I see. What follows in the rest of this blog post is the information I have learned thus far. Disclaimer: I am by no means finished learning everything I need to know to treat trauma. I may be missing some key information in this blog post.

One of the most valuable pieces of information I learned about trauma and PTSD is that it often involves a “nervous system dysregulation.” Our nervous systems consist of 3 states–sympathetic, parasympathetic, and ventral vagal. Those are some big words, so let me break it down further. Ventral vagal is when we are inside our “window of tolerance.” This means we might feel joy, grounded, happy, content, passionate, mindful, curious, open, etc. A “home base” if you will. The other two states, when we are outside our window of tolerance, is sympathetic and parasympathetic. Some more well known terms are fight, flight, freeze. Fight–rage, anger, irritation, and frustration. Flight–panic, fear, anxiety, worry, and concern. Freeze–helplessness, depression, numbness, dissociation, shame, hopelessness, trapped. Situations throughout our life trigger these responses. If we are able to process these emotions in a healthy way, we will file them in our brains as experiences in the past, make some sort of meaning of it, and move forward. *Refer to the above image*

The bad news? Majority of people are unable to process experiences in a healthy way. Majority of us are not raised in family’s who teach emotional health. So, we end up physically becoming an adult, without the skills we need to process our experiences in a healthy way. The result? a lot of us end up with common mental health diagnosis’–depression, anxiety, OCD, panic disorder, personality disorder’s, bipolar 1 and 2, PTSD, and so many others. I would argue that if we looked at mental disorders through a trauma lens–our diagnostic manual would be a heck of a lot smaller.

So, what does this mean? Well, it means that most of us are walking around this earth just attempting to be happy without having problematic, overwhelming experiences. I call these experiences flashbacks. These experiences can be mental (e.g. inner critic), emotional (e.g. depression and anxiety), behavioral (e.g. self-harming and OCD compulsions), visual (e.g. intrusive images), and spiritual (e.g. questioning one’s faith/religion). Symptoms are not the problem, symptoms are messengers of the root problem. Symptoms are trying to tell us that an experience is stuck in the part of our brains that does not allow for healing and resolution of symptoms.

Triggers might be what we are noticing, but they are not the root problem. Traumatic experiences are the root problem. Whenever a client presents in my office, I always screen for trauma. My definition of trauma is: anything that felt greater than your ability to cope. Some practitioners may disagree with me, but I believe anything in this world can be traumatic. Trauma is not reserved for war veterans and rape victims, though these are certainly traumatic as well. 9 times out of 10, I believe emotional and mental symptoms are related to trauma.

Now that we have the basics behind trauma mentioned, I want to talk about trauma treatment. In my experience, there is not only a serious lack of trauma trained professionals, but also a lack of guidance within trauma treatment. You can find books and trainings on specific topics within the realm of Trauma, but no guidance on what level of treatment these models are getting at and which models are best for which type of therapists and clients. The information that follows is by no means comprehensive or for every practitioner out there, it is based on my experience only.

In my experience, there are three levels of trauma treatment:

  • Level 1 includes the basics: assessment, diagnosis, history taking, psychoeducation, and working on coping skills to deal with dysregulation. This phase can include, but is not limited to, psychotherapy models such as DBT, mindfulness, somatic experiencing, sensorimotor, meditation, yoga, etc. The goal of this phase of treatment is to educate the client on what trauma is, help them get an understanding of their symptoms, and practice coping with dysregulation.
  • Level 2 is where you attempt to reform the brain by processing through traumatic experiences cognitively. In other words, a “top-down” approach. These treatment models include, but are not limited to, CBT, REBT, Narrative, CPT, etc.
  • Level 3 is where you attempt to open up the part of the brain where these experiences are stuck in and reprocess them, in other words a “bottom-up” approach. These treatment models include EMDR, Brainspotting, IFS, among others.

In my opinion, the best way to go about trauma is with a combination of all levels. With majority of clients presenting with trauma, a “top-down” approach is not going to be much help. It may be of some help, but most trauma clients need help with opening up the part of the brain that stores their traumatic memories (level 3.) Until you access this part of the brain, the memory will not be fully reprocessed. For many clients, it will feel like they are battling with the trauma part of the brain. Attempting to work through triggers cognitively does not always work.

If you have read through this and find yourself saying “I’m so confused!” Don’t worry, it’s a lot of information to take in all at once. For further reading, I HIGHLY suggest Bessel Van Der Kolk, Pat Ogden, Francine Shapiro, and Stephen Porges. These are well known names within the trauma world that will further fill in the gaps of all the above information!

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