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No single path to addressing trauma

November 1, 2010
by Nicholas A. Roes, PhD
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Research confirms a statistical relationship between substance abuse and trauma, and in many cases the relationship is relatively uncomplicated. In the simplest of terms, people sometimes turn to alcohol and drugs to deal with the consequences of trauma. This substance abuse has unpleasant consequences of its own, which makes the situation worse rather than better.

From here it gets more complicated, as professional disagreements exist about how and when to address trauma-and even about what constitutes trauma. The definitions range from covering only life-or-death situations to covering any experience that is emotionally painful.

The exact same approach to treatment for trauma might be described by different schools of thought as liberating or counter-therapeutic. While some advocate a focus on the future without dwelling on past pain, others consider working through the trauma issues to be a prerequisite to any progress.

Diagnostic considerations

Post-traumatic stress disorder (PTSD) was recognized in the DSM-III in 1980. The currently used DSM-IV explains that the diagnosis involves a personal experience of actual or threatened death or serious injury, in which the response is intense fear, helplessness or horror. For children, the DSM-IV includes developmentally inappropriate sexual experiences without threatened or actual violence or injury.

There are disagreements as to whether victims of childhood sexual abuse should have the same diagnosis as combat veterans. Proponents of a “complex PTSD” diagnosis believe that the “simple PTSD” that might result from being in combat or witnessing a natural disaster is much different from the result of long-term childhood victimization.1 Those who argue for a separate diagnosis point out that without a separate listing in the DSM, it is almost impossible to raise the funds needed to study the issue.

Others believe that many victims of child abuse are too young to grasp fully what is happening to them. They may have a vague feeling that something is wrong with what the adult is doing, but they don't feel as if their life is being threatened. Some form of trauma may result later on, when as adults they re-conceptualize these past events.

One of the most comprehensive treatments of that issue can be found in the work of Susan A. Clancy. The results of her research were published in The Trauma Myth (Basic Books; 2009). She reports that it is a minority of victims of childhood sexual abuse who are threatened with death or who physically fear for their lives at the time of the abuse. The great majority of victims are taken advantage of by people they know and trust, so the PTSD model might be less helpful for them.

Treatment options

No matter the cause of the trauma, and as with many other issues, recommended approaches to address the trauma are often made on the basis of a favored theoretical framework, rather than a discussion with the client. Professionals should avoid this. Different approaches will work with different clients at different times, even if they present under nearly identical circumstances. Though any number of clients might have experienced an almost identical trauma, they each might require a different approach. Strategies that are helpful to some might be harmful to others.

At one end of the spectrum is the client whose trauma is attached to her like an anchor. She can't fathom detaching from the trauma until she has shared her story and feels heard. At the other end, a client's trauma may surround him like a foul odor. It doesn't make sense to him to try to analyze it, explain it or understand it until he is in a different place. Sometimes from that new and better place, he no longer has the need or desire to revisit the trauma. Many clients will be situated somewhere between these two extremes.

As for possible treatments, solution-focused therapy may be very helpful to clients who are ready to look past their trauma and focus on identifying and achieving goals. But attempts to develop a focus on the future with other clients might leave them feeling unheard. They might even connect this to times during their victimization when they were not heard or believed.

Nicholas a. roes, phd
Nicholas A. Roes, PhD

Cognitive therapy can be helpful when abuse has resulted in a distorted world view and a distorted view of self. But it also can keep our clients in a dark place longer than is necessary.

Behavioral approaches may ameliorate symptoms, which may lead to better experiences and higher self-esteem. But at other times, not dealing directly with the client's view of self will leave the client feeling empty and alone-even when the visible symptoms are gone. Behavioral interventions used by some addiction treatment programs, relying on artificial consequences to discourage undesired behaviors, can make a deeply hurt and angry victim even angrier.

When upsetting thoughts and urges are too much to handle and are pushed to the unconscious mind, psychodynamic therapy may help. In other cases there may be little change after long and costly efforts, and this confirms the clients’ suspicions that they are basically flawed.

The 12 Steps have helped many traumatized people recover from various addictions. But well-meaning advice from sponsors and peers also can do serious damage, when professional consultations might help.