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In the conventional approach to trauma, exposure therapy is often used as the primary means for overcoming symptoms of post-traumatic stress and anxiety. Exposure therapy involves deliberately exposing trauma sufferers to the sources and triggers of their anxiety to facilitate desensitization and foster habituation.
The past several years has brought me a string of patients who share that exposure therapy has been unhelpful, unsuccessful, and, quite frequently, emotionally retraumatizing for them.
As a psychologist with training in multiple best-practice models of care, I've developed an alternative approach for trauma patients, one that integrates what is valuable about exposure-based methods while prioritizing a trauma-informed process.
Here’s a key insight: A "trauma focused” therapist is not the same thing as a “trauma informed” therapist. A “trauma focused” therapist sees trauma as a root cause of suffering and aims to resolve the impact of trauma symptoms. A “trauma informed” therapist doesn't just understand trauma but is committed to relieving suffering in a way that does not create further trauma.
Here are six ways that the new approach I’ve developed is meaningfully different from the conventional approach.
Biological interventions come first.
In 2020, along with a team of mental health pioneers, I helped establish an organization called Stella, based on the premise that biological intervention is an overlooked yet critical component of an effective, compassionate treatment plan. Biological interventions address the biological injuries that are caused by exposure to traumas.
When calm and control are restored to the body, subsequent therapy is both more effective and more humane. As my colleague Kevin Santos puts it, it doesn’t make sense to have a patient relearn how to walk without first fixing his or her broken leg. Similarly, it doesn’t make sense to attempt to heal the mind if the brain is not functioning properly or if the nervous system is continually dysregulated.
No exposure for exposure's sake.
Trauma creates a shrunken existence, characterized by limited social interactions and restricted engagement in new environments. In other words, people with unaddressed trauma often withdraw and limit themselves to cautious forays into the world, avoiding people and places that trigger anxiety.
My driving goal is to help patients reclaim the life that trauma has taken from them. When I discuss anxiety challenges, these are embedded in the lives my patients want to live, which are based on their personal values. Instead of setting the challenge of going to a grocery store because it makes a patient anxious, I would start with the meaning of a challenge. Perhaps the deeper meaning could be to bake a family recipe for someone they want to reconnect with. The trip to the grocery store becomes a link in a greater behavioral chain, part of how they reclaim the life that trauma has taken from them.
Restoring incompatible emotions.
Anxiety and fear are mitigated by incompatible emotions like joy, love, connection, and a state of flow. In helping patients reclaim their lives, we can intentionally elicit incompatible emotions to help people heal in an accelerated, more compassionate way.
Take the example of someone who is fearful of crowds who decides to attend their child’s school play. This might restore the incompatible emotion of connection with their child, as their child is smiling, grateful to have this focused attention from their parent.
Not a solo mission.
Conventional exposure protocols urge patients to go through anxiety-provoking challenges on their own. The rationale is this: You ultimately need to work through your own anxiety yourself.
I flatly reject this kind of rugged-individualistic approach. The strongest and bravest people in our society, our warfighters and first responders, are capable of superhuman feats because of the strength of their tribe, not because of their individual resilience. Relying on the strength of loved ones can accelerate their healing and provide a powerful form of social facilitation for expanding their range of activities.
Adrenal fatigue is not the goal.
In conventional exposure therapy, a patient remains anxious without release or relief until reaching a state of habituation, which often translates to adrenal fatigue. My patients often tell me that they have been retraumatized by this kind of process.
Consider this alternative: A patient tells us that their anxiety dropped because of the presence of meaningful engagement and incompatible emotions that are helping them heal and reclaim a life worth living. Therapy is not only work but can and should also bring joy.
Mindfulness during exposure.
Rather than asking patients to white knuckle through their anxiety, we can introduce mindfulness as patients reclaim the lives they want. The mindful state is incompatible with being trapped in trauma’s loop of helplessness and horror. When patients are in a mindful state, they are engaging the executive functioning center of their brain, and the possibility of retraumatization decreases.
One of the things I ask my patients to do is to predict how anxious they will feel, and then record what they noticed about their actual experience of engaging in anxiety challenges. I ask them to take note of the meaning they derive from these experiences as well as the emergence of any incompatible positive emotions, like joy, deeper connection with loved ones, or a state of flow.
Conclusion.
I have described several meaningful differences between conventional trauma-focused exposure therapy and the new approach I’ve developed as a trauma-conscious alternative. As healers, our first goal should be to do no harm. Increasing our patients’ sense of helplessness or physiological dysregulation can be harmful, leading patients to avoid starting therapy, to drop out of active therapy, and sometimes, to feel that they will never heal. Our best outcomes arise when our patients are empowered to regain personally meaningful, connected lives. It’s time for healers to move away from approaches that retraumatize patients and align with a trauma-informed, compassionate way of supporting those who suffer.
