Module 4: - Theoretical Frameworks for Understanding Trauma

Chapter 3

Cognitive-Behavioral Theory

In this module, we will learn about the theoretical frameworks used to understand trauma and in the treatment of traumatized individuals, beginning with cognitive-behavioral theory. The foundation of all cognitive-behavioral therapy (CBT) approaches to treating trauma highlight the important role our cognitive processes play in both our emotional and behavioral responses to our environment and experienced events. CBT collectively refers to a variety of approaches and strategies that have been shown in the literature to be beneficial and effective in treating post-traumatic stress disorder (PTSD; Ringel and Brandell, 2012).

Treatment Approach

The CBT approach to treating trauma is founded in two general theoretical perspectives, learning theory and emotional-processing theory, which explain the development and experience of fear and the associated responses (Ringel and Brandell, 2012). Learning theory encompasses various approaches aimed at modifying behavior by altering environmental stimuli (e.g., reinforcing behavior).

Conceptualizing Traumatic Events

How we cognitively conceptualize a traumatic event greatly affects our ability to process that event and eventually restructure our memory and minimize the effect of the trauma. If our thoughts about the traumatic event are persistent and are experienced with the same intensity that occurred during the initial trauma, the symptoms of PTSD are chronically maintained. Avoiding situations associated with the traumatic event further prevents individuals from modifying thought processes, including inaccurate or distorted belief systems and emotional assessment that perpetuate the disorder.

Cognitive therapy used to treat PTSD is aimed at addressing the inability to reprocess, and more importantly to reframe, the traumatic memory . This trauma-informed approach uses various strategies to better educate an individual about the underlying processes contributing to the experience of traumatic stress as well as exposure therapies to aid in the cognitive and emotional restructuring of the traumatic memory (Ringel and Brandell, 2012). One such strategy is cognitive processing therapy (CPT) that addresses the conflict between new information and established conceptual frameworks, or schemas. For example, if an individual experiences an event (e.g. sexual assault) that is inconsistent with their existing framework (e.g. good people are not sexually assaulted), the resulting conflict between this new experience and existing schema gives rise to the symptoms of PTSD.

Other strategies exercise exposure therapies, such as prolonged exposure (PE) and virtual reality exposure (VRE), to address the counterproductive avoidance component inherent in maintaining anxiety disorders, such as PTSD. PE consists of repeated exercises in which an individual reimagines the traumatic event to confront traumatic associations, whereas VRE utilizes computer simulations to recreate the traumatic event.

Additional Treatment Strategies

Additional strategies that have been successful in treating PTSD are eye movement desensitization and reprocessing (EMDR), stress inoculation training (SIT), and the self-trauma model. EMDT uses a temporal approach that addresses the cause of the trauma (past), the onset of PTSD symptoms (present), and the development of effective strategies to reduce the trauma (future). Although EMDT has gained popularity for its usefulness in treating PTSD, it has also been criticized for a lack of empirical support for the effectiveness of the eye movement component used in this strategy. SIT is aimed at empowering individuals to develop skills which enable them to defuse situational anxiety, while strengthening confidence and appropriate applications of the skill set. The self-trauma model, which incorporates humanistic, psychodynamic, and cognitive-behavioral theories, is an integrated trauma-informed approach to treating PTSD. In the self-trauma model, avoidant tendencies are addressed through relaxation techniques prior to the introduction of exposure therapy that addresses the conditioned fear response. The self-trauma model also highlights the importance of the therapeutic relationship on the healing process.

Effectiveness of Treatment

Overall, there is substantial evidence to support the effectiveness of many of the forementioned CBTs for treating PTSD. However, there is disagreement in the literature on which, or if any of the CBTs is the most beneficial in practice. Some research suggests that the efficacy of various therapies may be dependent on timing, or the length of time necessary to see reductions in PTSD symptomology (Ringel and Brandell, 2012). Current and future research on CBT needs more clarify and justification for the inclusion of comparison groups in research studies, address the high rate of attrition, as well as the diversity of traumatized individuals and how these characteristics might impact the effectiveness of various therapies.

Chapter 4

Psychoanalytic Theory

We continue learning about the theoretical perspectives used to understand trauma and in the treatment of traumatized individuals this week, focusing on Psychoanalytic Theory. The conceptualization of trauma according to the psychoanalytic theory emphasizes the unpleasant and persistent response to a traumatic event, and not the event itself (Ringel and Brandell, 2012). Further, the nature of the traumatic event, whether it is an impersonal trauma (e.g. natural disaster) or an interpersonal trauma (e.g. sexual assault) impacts the severity of traumatic stress associated with the traumatic event, with interpersonal traumas resulting in increased stress responses.

Freud was the first to discuss and apply psychoanalytic theory to treating trauma in his writings on hysteria over a century ago. An emphasis on the relationship between external events and the development of the symptoms of hysteria was a central component in Freud's contributions. Abreaction, a cathartic process allowing the release of built-up stress and negative emotions (later termed libido), was the required process for progress and improvements in the experienced symptomology associated with the traumatic experience.

Freud experimented with using hypnosis to treat patients with hysteria and formulated the initial "seduction hypothesis" to highlight the impact of and traumatic stress associated with childhood sexual abuse (Ringel and Brandell, 2012). These methods were later abandoned or modified significantly, respectively, in favor of clinical approaches like free association, interpretation, and transference. Freud's seduction hypothesis resurfaced in the literature examining the etiology of traumatic stress, the correlation of childhood sexual trauma, and differences in the ability of children and adults to process trauma. Of specific importance is the impact on an individual when a traumatic event is denied, as described in the "confusion of tongues" (Ringel and Brandell, 2012). The denial of the traumatic event compounds the effects of the traumatic stress and can potentially lead to dissociation, a key component in PTSD.

The components of the psyche, the id (the pleasure principle), the ego (the reality principle), and the super ego (the moral principle), were central to Freud's conceptualization of trauma. As psychoanalytic theory evolved, there was an emphasis on the ego's role in identifying signals of trauma, minimizing trauma, and eventually the ability to prevent traumatic stress. Throughout development, the ego gradually adapts and reduces anxiety associated with traumatic events through learned defense mechanisms. For example, a traumatized individual may dissociate from the experience by operating in an altered state of consciousness as a protective measure.

The loss of an object is an early example of an anxiety inducing experience that could also be considered as a traumatic experience for a child. Associated with loss is the act of mourning, which is usually associated with the loss of a living object (e.g. death of a parent). Mourning is a process that involves acceptance of the loss, withdrawing attachments with lost object, and establishing new attachments or relationships. There are developmental differences related to loss and the experience of traumatic loss, with children and adolescents more likely than adults to experience a loss as traumatic due to a greater likelihood of disruptions in overall functioning (e.g. cognitive, social, emotional). Midcentury British theorists expanded theories on object relations, attachment, and object seeking that further expanded the contributions of Freud on the psyche and psychoanalytic theory (Ringel and Brandell, 2012).

The idea that the first traumatic experience for humans involved the trauma of birth was a framework proposed to explain early, or primal anxiety, and its influence on subsequent pathology. In coping with the anxiety associated with birth, an infant may become fixated on returning to the security of the womb resulting in neurosis or adapt to the new environment and develop productive coping skills that could be applied to other potentially traumatic events. Although this theory was not initially universally accepted, it has evolved significantly and gained momentum in more contemporary frameworks.

Contemporary Psychoanalytic Theory

Self-psychology  is an example of a contemporary theory for understanding trauma that is a relatively new addition compared to other psychoanalytic theories. Self psychology is useful for clinical applications and as a framework for understanding normal human development and the etiology of psychopathology. Chapter 3 concludes with a case study to illustrate the theory of self-psychology and its application in a specific clinical example (Ringel and Brandell, 2012).

Psychoanalytic theory has evolved significantly from its initial conception with the development of relational and intersubjective perspectives, which were heavily influenced by research on attachment and early development. The relational view of trauma highlights the increasingly involved role of the therapist and the inability to maintain a neutral and objective viewpoint during treatment, which deviates from initial frameworks. Research on adult survivors of sexual abuse illustrates aspects of the relational view, such as dissociations of the self, regression and disorganization, and hyperactivity and trauma responses to neutral stimuli. Relational psychoanalysis has expanded to account for fluidity and the possibility of multiple versions of the self and an attempt to understand these multiple representations rather than realizing a single, cohesive self. The application of this perspective in clinical practice focuses on improved communication between patient and therapist, a better understanding of the treatment process, and the establishment of a positive therapeutic relationship. Clinical Example 1 in Chapter 4 provides an illustration of the application of relational psychoanalysis in a specific case (Ringel and Brandell, 2012).

Freud's early views of dominance and submission, or sadomasochism, which he believed was inherent in the relationships between children and caregivers and subsequently affected attachment, have also changed significantly in contemporary psychoanalysis. The initial rigid and inflexible dichotomy created by this uneven power dynamic (e.g. the doer and the done to) contributes to barriers in treatment, such as the inability to conceptualize relationships outside of the dichotomy. The concept of "the third" was established to provide an alternative and additional perspective that allows complete surrendering of the self from being controlled by the traumatic stress and eliminates the power dynamic. Clinical Example 2 in Chapter 4 offers another application of contemporary psychoanalysis in a specific case (Ringel and Brandell, 2012).

Intersubjective perspectives draw significantly on the attachment literature, specifically the importance of establishing a secure attachment style, as well as the framework of self-psychology. The intersubjective approach establishes an integral relationship between attachment to a caregiver and trauma, suggesting that insecure attachment styles lay the groundwork for the development of a fragmented self, a disconnection from reality, and the experience of traumatic stress. This is especially pronounced in victims of early sexual abuse. As a therapist, it is important to be aware of patients' inability to regulate emotions and how that might impact treatment effectiveness. Therapists need to provide these patients with assistance in emotion regulation, empathic attention, and provide a secure environment to prevent re-traumatization.

Contemporary psychoanalytic theory accentuates the importance of the patient and therapist relationship, the necessity of the therapist to use his/hers own personal experiences to relate to the patient, and the ability to engage with the patient in a genuine and supportive environment. Specific approaches include enactments of the trauma, essentially role-playing between the therapist and patient, establishing 'the third' viewpoint, dissociation and the fluidity of the self, and the integration of the patient and therapist's personal experiences.

Chapter 5

In this module we will conclude our examination of conceptual frameworks with a review of Attachment Theory, infant research, and neurobiological perspectives and their applications to trauma. The general focus of this chapter is on the pervasive effects attachment and early experiences have on our development. Specifically, how insecure attachments and early adverse experiences can cause trauma and potentially impact our ability to cope with traumatic stress into adulthood.

Neurobiological research is included to highlight the biological basis of our behavioral responses to trauma, especially in the developing brain, and the resulting impact on cognitive, emotional, and behavioral functioning throughout our lives.

Attachment Theory

We conclude our review of the theoretical perspectives as applied to trauma theory with an introduction into attachment theory and the respective research on infants and neurobiology.

From the beginning, attachment theory has focused on traumatic events and their impact on developing children. Much of the initial research in this area emphasized the necessity for attachment through observations of children living in orphanages due to the loss or separation from their parents. Contemporary researchers have expanded their scope to include neglected and abused children (Ringel & Brandell, 2012).

Bowlby's Theory Bowlby developed the first theory of attachment, drawing on several other disciplines and respective contributors, suggesting that human children required attention and a nurturing environment for optimal development. Preceding the viewpoints by advocates of psychoanalytic theory on the association of separation and loss and traumatic stress, Bowlby recognized the importance of an emotional relationship between children and caregivers and the potential for a significant, negative developmental impact in its absence. In his observations of children in hospitals separated from their caregivers, Bowlby recognized that children responded in different ways. **

Further, he made the connection between these various response tendencies and the relationship between the caregiver and child. At the time, this was a novel concept as the relationship or attachment of a child to a caregiver was not considered important in treating traumatic stress in children. Attachment has since then become an integral part of trauma treatment, overall development, and wellbeing into adulthood.

Ainsworth's Theory

Another influential contributor to attachment theory was Ainsworth who developed the Strange Situation paradigm used to classify children into attachment styles, expanding on Bowlby's work (Ringel & Brandell, 2012).

1. Secure

Children who were independent and explored the environment while their caregiver was present, showed distress during separation, but who were quickly soothed by the caregiver upon return were classified as secure.

2. Avoidant

 Children who were independent and explored the environment while their caregiver was present but cared little about the caregiver’s movements (minimal attachment behaviors) and ignored the caregiver upon return were classified as avoidant.

3. Anxious-ambivalent

Children who showed little exploration, focusing on their caregiver’s every move (exaggerated attachment behaviors), displayed great distress during separation, and were not easily soothed upon return were classified as anxious-ambivalent.

4. Disorganized Attachment

This additional attachment style was later included to classify children who failed to respond in a consistent manner, alternating between avoidance, unresponsiveness, and interrupted behaviors.   

Disorganized attachment was entrenched in fear, either the child being afraid of the caregiver or the child’s perception that the caregiver is fearful of the child (possibly related to early trauma experienced by the caregiver).

Further, children classified with disorganized attachment style commonly experienced neglect or abuse by their caregiver supporting the notion of a cycle of abuse and the learned aspect of self-regulation.  Not surprisingly, a common behavioral response in the disorganized attachment style is aggressive behavior toward others.

These attachment styles further emphasized the important relationship between child and caregiver, established the caregiver as a secure base for a child, and recognized this initial relationship as the foundation for establishing future relationships.

Research suggests that children develop the ability to self-regulate early in development through interactions with their caregivers (Ringel & Brandell, 2012). Through these interactions children can either learn to self soothe and regulate their affect or heighten their distress and affective state. Therefore, the successful development of these skills in the child is dependent on the caregiver's abilities since children tend to mirror and adopt the observed behaviors. Potential changes or modifications to self-regulation abilities can be greatly influenced by a caregiver's ability to recognize their own behaviors and subsequent impact on their child's behaviors.

Similar to the learned nature of self-regulation, mentalization is also a capacity that is developed through interactions between child and caregiver. Mentalization is the ability of a child to learn by observing behaviors modeled by a caregiver as well as the ability to interpret other's emotional states and to act accordingly. This ability appears to be negatively impacted by the experience of early trauma (Ringel & Brandell, 2012). Mentalization is a process that begins with psychic equivalence or the inability to separate fantasy from reality, moves to pretend play or a state of dismissing external reality, and finally to a mature state of accepting the external reality. A secure attachment between child and caregiver is an important component of progressing through this process and achieving mentalization.

The Adult Attachment Interview (AAI) is a questionnaire developed to assess attachment style, separation, loss, and traumatic stress in adults (Ringel & Brandell, 2012). AAI was designed as a research tool to identify the ability to be self-reflective, empathetic, and flexible rather than a clinical application. The AAI includes a series of questions about early caregiver relationships, the associated attachments, and an individual's understanding of those interactions. The adult attachment styles derived from the AAI correlate with the child attachment styles identified by Ainsworth using the Strange Situation, although the former relies on self-reported reflections whereas the latter is based on observed behavior.

***Our understanding of the importance of attachment, and more importantly the detrimental effects of attachment disruptions, has been expanded by neuroscience research and established a biological basis for the forementioned observed behaviors. Studies on the impact of trauma show significant effects on several brain structures, including the hypothalamus, limbic system, and neocortex (Ringel & Brandell, 2012). Moreover, individuals diagnosed with PTSD show significant changes to key structures in their brain, supporting the prolonged effects of trauma and the ability to cope with trauma. One region that is adversely affected is the hippocampus, the area of the brain involved in long-term memory formation, which is decreased in individuals with PTSD. The reduced capacity to process information and emotions associated with a traumatic experience prevent the memory from being integrated and may lead to dissociation and further misinterpretation of information.

Neuroscience research provides confirmation of the impact of trauma on the brain as well as the relationship between our behaviors and brain functioning. Along with attachment theory, neuroscience research further contributes to our understanding of developmental differences in traumatic stress and appropriate applications to minimize its impact on the individual, from infant to adulthood.