Many studies over the years have shown that the best treatments for chronic trauma include outpatient therapy, group therapy, and psychiatric medications. It is not recommended to treat trauma with medication only.
Outpatient based interventions
Cognitive Behavioural Therapy (CBT) or other collaborative and relational approach to therapy. (If someone is diagnosed with, or suspected to have, a dissociative disorder, a therapist with experience in this area is important. These patients need careful stabilization before working on traumatic memories).
Dialectical Behavioural Therapy (DBT): Often done in group format, usually see an individual therapist trained in DBT as well.
Psychiatric medication consult. Medication can be helpful for some people who also experience severe depression, anxiety, flashbacks, insomnia, etc. Meds should always be supplemented with therapy.
Eye Movement Desensitization and Reprocessing (EMDR): This can be helpful for people with PTSD. It is NOT recommended for someone with a dissociative disorder, as it can cause destabilization, unless the therapist is trained in the modified version for dissociative patients. See the International Society for the Study of Trauma and Dissociation website for more information.
Support groups (NAMI peer support, family support groups, recovery groups, eating disorder groups, etc.)
Improving self care. Regular exercise, routine, and sleep. Basic self care can sometimes be difficult for trauma survivors, as many symptoms get in the way. Establishing routines and healthy habits are key.
Partial hospitalization or day treatment to stabilize for 1-3 weeks if patient is experiencing an increase in frequency and/or intensity of symptoms, or may be used as a step down from inpatient care.
Psychiatric hospitalization may be required at times to stabilize patients who are experiencing extreme suicidal ideation or attempts.
Inpatient hospitalization for addiction may also be required for some patients. Trauma and addiction are often comorbid conditions (occuring together). Patients with a mental illness and addiction are often labeled as “dual diagnosis” by clinicians. Inpatient treatment for addiction is helpful for medical detox and then inpatient recovery programs or residential treatment to support the patient in developing healthier lifestyles and support systems.
Sometimes people with chronic trauma experience many difficulties in different areas of functioning. This can include medical, financial, and social issues. A case manager or community support person can be assigned to help them manage life stressors and function more effectively. Local nonprofit behavioral health agencies and community health centers offer these services to people who are seeing a therapist. Most states also have a Department of Mental Health that provides case management to individuals affected by mental illness.
It’s probably not a surprise that I encourage anyone who is struggling to find a therapist. I spent years in grad school learning about counseling theories and interventions, worked as a therapist in office settings, visited families in their homes, and worked on site in urban neighborhoods, daycares, and in shelters. I’ve also spent countless hours reading studies, articles, and treatment books. I went to a very well regarded graduate school that taught us the latest in Cognitive Behavioral Therapy. CBT has been extensively studied and proven to be effective for the majority of clients in a number of conditions such as depression, anxiety, PTSD, addictions, and phobias. The basics of CBT include teaching the client about their condition (psychoeducation), teaching how to identify thoughts and beliefs that contribute to negative moods and behaviors, and then learning to challenge and reframe those thoughts. It is considered a collaborative approach to therapy because the client works with the therapist on shared goals. The client is often asked to do homework assignments to reflect on their actions, behaviors, and consequences. They are encouraged to observe their thoughts and behaviors and try to activate behavioral changes in themselves to feel better. They are taught the powerful connection between their thoughts, emotions, and actions. This can lead to much better functioning in many areas of life.
I absolutely love CBT, and I think it can help a lot of people. However, it definitely falls short when trying to treat clients with a dissociative disorder or complex PTSD. (To learn more about complex PTSD, see my post about conditions caused by trauma). In grad school, I politely pointed out to my professors the inadequacies of CBT in treating chronic trauma. Most of the time they didn’t want to hear it, because often academics get stuck in a rigid belief that their school of thought is the only way. I don’t blame them because as I said, CBT has been proven by science time and time again to help people. But one of the reasons it has more studies to back up its effectiveness over other techniques is because it’s easier to study. CBT is supposed to be a relatively short type of therapy that follows a particular schematic and structure. The usual course of CBT treatment lasts about 8-12 weeks. A patient can definitely make some improvements in functioning in this amount of time, but it’s less likely if their mental illness is chronic or severe. If someone has mild to moderate anxiety, depression, or phobias, 8-12 weeks could be all they need. As I’m sure you can imagine, insurance companies also love CBT because it’s short term. But people who suffered from chronic trauma do not often respond well to CBT alone. When I challenged my favourite professor with this limitation of CBT, his answer saddened and angered me. He was a kind and intelligent man who spent his life counseling children and families. However, he basically wrote off anyone with chronic trauma from their family of origin. He described them as chronically ill and not likely to show much improvement in functioning. He wrote me off without even knowing it. I’ve spent my whole life trying to survive, and this man I respected was telling me I had no hope of getting better. I’m trying my hardest now to prove him wrong.
In his defense, it is often true that people like me spend most of their lives suffering. The amount of pain, sadness, loneliness, grief, shame, self loathing, and anger that chronic trauma creates in someone can be overwhelming. I’ve struggled to function ever since I was a teen, and I’ve been depressed just as long. But in all fairness, most therapists are not trained adequately to assess and treat chronic trauma. The field lacks comprehensive and effective interventions for this population. As I mentioned earlier, I went to a good grad school, and they taught us almost nothing about dissociative disorders or complex PTSD. The DSM 5 (the American Psychiatric Association’s manual for assessment of clinical disorders) is the standard for assessment and overlooks major dissociative disorder symptoms such as psychosomatic pain, paralysis, and seizures. I also think that the field overlooks resiliency in trauma survivors. They focus too much on a patient’s weaknesses, and they need to highlight their strengths.
In 2017, a book was published that changed my life. I’d been waiting 17 years since I was first diagnosed with DID to read something that explained everything I experienced and struggled with. My therapist calls it the ONE book for dissociative disorders, and she’s absolutely right. Treating Trauma Related Dissociation: A Practical, Integretative Approach by Steele, van der Hart, and Boon accurately explains dissociative disorders and how to treat them. It includes the conversion (psychosomatic) symptoms, attachment issues, and covert switching that no other book explained for me. Admittedly, when I first started reading it, I was a little bit scared because it was like someone wrote a book about me. But I was relieved to finally have all my questions answered. It explained that DID is an attachment disorder as well, which made so much sense to me. I believe that complex PTSD is also an attachment disorder caused by childhood trauma. (For those interested in attachment disorders and how they affect adult relationships, I will be posting about this in the future).
Although I don’t recommend the treatment book unless you have some clinical background, Coping with Trauma Related Dissociation by the same authors is an excellent resource for someone with a dissociative disorder. There are also some helpful books for Complex PTSD which are beneficial to individuals with childhood trauma. Complex PTSD: From Surviving to Thriving by Pete Walker and The Complex PTSD Workbook: A Mind-Body Approach to Regaining Emotional Control and Becoming Whole by Arielle Schwartz are two that people find useful. But these books are just resources and cannot take the place of therapy. Unfortunately I’ve seen countless people struggling with trauma try to avoid counseling and use self help books. Anyone with clinically significant symptoms should be seeing a therapist, these books are just supplements to treatment.
So what should you look for in a therapist if you have experienced chronic trauma? The treatment book and I agree that the most important thing is a therapist you can trust, build rapport with, and work as a team. A good therapist will always educate and explain, encourage client collaboration with determining treatment goals, and attempt to repair misunderstandings or misattunements. The most important thing in healing attachment disorders is working with a therapist who can be consistent, compassionate, reliable, and is able to set good boundaries. No therapist is perfect, we are all human. Sometimes we are tired or just not on our game. Sometimes we misunderstand or miss an opportunity to be empathic when the client needs it. The critical piece in attachment is repairing these misattunements. The client needs to learn that human relationships are always going to contain some sort of misunderstanding or misattunement, and that it’s a natural part of the relational process to repair such conflicts. They can learn to repair personal relationships in their life instead of avoiding or being anxious. This is where the real healing is done. Techniques and theory are important, but the absolute most important thing is to have a therapist that you trust. The therapeutic relationship is the most healing factor when working with chronically traumatized people. Patients need a guide who shows compassion and empathy while they try to navigate the painful traumas of their life in order to integrate them. I have personal experience with the fact that psychiatric medications often fall short for people with dissociative disorders and complex PTSD. Antidepressants and mood stabilizers did nothing for my severe depression, and they often made my symptoms worse. Atypical antipsychotic medications only sedated me enough for it to trigger me, and they caused bad side effects. Benzodiazepines helped my anxiety but are addicting, so I chose to wean off them. Therapy is my hope for a better life.
The main thing I want people to get from this post is that asking for help shows a lot of strength. It’s not easy, but it’s critical to feeling better. If your trauma effects your functioning in any areas (socially, vocationally, economically, health, emotionally, etc.), then you are doing yourself and your loved ones an extreme disservice by not seeking treatment. I know people who struggle with severe PTSD symptoms and yet refuse to go to counseling. I think that’s for two reasons: 1) The unfair stigma society puts on therapy. People often feel weak or that something is wrong with them if they seek help. Nothing could be further from the truth. It takes a lot of strength to ask for help and work on trauma. 2) It’s scary. Obviously people avoid working on trauma because it’s difficult. Sometimes people are afraid that trauma work will temporarily affect their functioning. This fear is understandable. And avoidance is a major symptom of PTSD. That’s why it’s imperative that if you suspect that you have experienced chronic trauma, please find a therapist with extensive trauma experience. A therapist with experience will know that a dissociative patient needs stabilization, to establish safety, and learn skills for emotional regulation before diving into the challenging area of processing memories. And if you suspect that you have a dissociative disorder, it’s best to work with a therapist with experience specifically with dissociative disorders. Sometimes therapists claim they understand dissociation, but they are confusing this with the type of dissociation seen in PTSD and Borderline Personality Disorder. Patients with dissociative disorders experience an extreme form of dissociation that needs to be fully understood. If you want to find a therapist with dissociative disorder experience, try the International Society for the Study of Trauma and Dissociation. They have a find a therapist search. https://www.isst-d.org/
The ISSTD also recommends the Coping and Treating books by Steele, Van der Hart, and Boon. If you’re already seeing a therapist and have built good rapport, it might be best to keep this therapist if they’re willing to get consultation from someone with dissociative disorder experience, or at the very least, they should read the treatment book. Another important thing to mention is that EMDR and DBT can be helpful to trauma patients, but with an exception. If you have a dissociative disorder, EMDR and DBT must be modified to include working with parts who experience different thoughts, emotions, and behaviors. I had a severe seizure after a therapist tried one session of EMDR with me, so I know firsthand the dangers of not modifying these treatment approaches for dissociative disorders.
When I was 15, I met a therapist who I worked with until I was 22. She is the one who diagnosed me with DID at age 18. I know she cared, but she did a lot of harm because she crossed my boundaries. She had a dual relationship with me. She saw me sometimes outside of the office, invited me to her kid’s soccer and hockey games, had me watch her pets, gave me her credit card number so I could buy her tickets to a concert, and often made comments to me about my appearance. She was possessive and angry when I found a new therapist. The new therapist I found claimed she had experience with DID. I saw this next therapist for 8 years, and unfortunately she also crossed my boundaries. She tried to be my mom in a sense, telling me she loved me, invinting me to her house, calling me with her own troubles, etc. She ended up losing her license to practice and was forced to retire early. I’m telling you these stories not to worry you, but to tell you that if I’m in therapy right now despite all these obstacles, then you have no excuse not to get help. That may sound harsh, but I believe that to feel better you have to put the work in. And you have to be brave. I was abused by therapists, and yet I never miss my appointment every week. It obviously helps that I finally found a therapist I could trust, but I give myself a ton of credit for not giving up. I’m extremely resilient. Despite being abused by countless people, I never stop trying to find meaningful connections, especially when I know it’s my only chance at a better life. So I urge you to take the steps to find a therapist online, ask your doctor for help, or look up therapists on your health insurance’s website. If you Google “find a therapist,” there are sites like Psychology Today that have search engines. You can put in your location, and you can search for specifics like “dissociative disorder therapist.”
And finally, as a former therapist, I encourage you to ask your new counselor as many questions as you need to ask. And if you don’t feel like your therapist is a good match, shop around. It’s your treatment and your life. Being vulnerable isn’t easy, but it’s the only way.