Editor’s note: The following has been adapted from Inside This Moment: A Clinician’s Guide to Promoting Radical Change Using Acceptance and Commitment Therapy (Link), by Kirk Strosahl, PhD, Patricia Robinson, PhD, and Thomas Gustavsson, MSc.
When severe violations of safety, trust, or vulnerability occur, including outright threats to survival, humans are wired to shut down higher-order neural functions and fight, flee, or freeze in order to survive the threat. Clients suffering from post-traumatic stress are faced with the dilemma of figuring out how to carry negative personal history in the present moment without letting it dictate or control their behavior. But when you have a nervous system that has evolved with self-protection as its number one mandate, this is hard to do. Although post-traumatic stress is typically regarded as an anxiety state, the truth is that there are very few traumatized clients who don’t manifest high levels of both depression and anxiety, as well as addictive and self-harming behaviors designed to numb or banish distressing and unwanted reminders of traumatic experiences.
From a neuroscience perspective, something that is unique to trauma is that the attention resources of clients suffering from post-traumatic stress are exclusively focused on detecting and avoiding situations, interactions, or events that might subject them to further trauma. For example, they may find it difficult to go into grocery stores for more than a few minutes without experiencing intense urges to escape. Similarly, they may avoid the movie theater because the darkness interferes with their ability to detect threats.
Present-moment-awareness interventions can help clients suffering with post-traumatic stress learn to approach rather than suppress or avoid trauma symptoms. These may also help clients integrate symptoms into a coherent narrative consistent with valued directions of living,
Guiding Clinical Principles
We think of healing from post-traumatic stress as consisting of two distinct, interrelated processes. One is coming to grips with the original traumatic event and making sense of it within the context of a coherent life narrative. This is the pain part of trauma. The second, and more demanding, process is learning to carry the memory of the trauma, and the symptoms it triggers, in a way that doesn’t create oppressive life outcomes. This is the trauma part of trauma, and whereas the clock cannot be reversed and the trauma undone, there is much that can be done to change how clients relate to their trauma-based experiences in the present. At one end of the continuum, clients are capable of reconstructing past events with such precision that it can almost seem as if the trauma is happening again in the present. If they relate to these experiences in a fused state, they’ll be compelled to seek safety, so emotional and behavioral avoidance will be inevitable. At the other end of the continuum, they can relate to these experiences simply as unpleasant products of human memory, in which case their behavior won’t be regulated by the appearance of these experiences.
The two themes (accepting the trauma and living a valued life in the presence of trauma-related experiences) are intimately related and often indistinguishable within a present-moment-awareness intervention. Even decades after a trauma has occurred, many clients can’t accept the reality of the trauma itself; it just seems like a bad dream that never ends. This leads to emotional (and often behavioral) avoidance of any action that will reignite the raw reality of being traumatized. If people can’t accept what has happened to them, they’ll avoid doing anything that might require acceptance of what happened. Therefore, they tend to studiously avoid making contact with distressing, unwanted private experiences associated with the original event. Figuratively speaking, clients with trauma histories carry their history in a heavy bag held at arm’s length, in an effort to keep at a distance. The problem is that carrying a heavy bag with arms extended makes it heavier and more difficult to carry and precludes more workable ways of making contact with it. Speaking figuratively once again, as clinicians we want to help clients learn to cradle this heavy bag filled with unwanted memories and feelings closer to their heart, much like they would carry a crying baby they were trying to comfort. Even if what’s in the bag is despicable, they can carry it this way for a very long time without consuming a lot of physical and mental resources and while pursuing a better life.
Thus, the main goal of present-moment-awareness interventions with traumatized clients is to help them accept the reality of their trauma and all of the associated private reactions stored in their memory. Moreover, they need to accept that these experiences will be triggered randomly by events that naturally arise in the course of daily living. The only control they have is over what they do when these private experiences show up.
One alternative is to build a life based on avoiding triggers or preventing them from happening, which requires them to give up on almost every life goal that matters to them. This is the strategy most traumatized clients are following when they come to therapy, and it’s the cause of enormous suffering, given that there is no end to the things that could conceivably evoke the trauma or be dangerous to them. Busy mind absolutely feasts on situations like this. The other path involves learning to let go of attachment to the products of memory and soften in response to the trauma narrative, which typically includes shame, blame, guilt, and mistrust. Clients can then focus on what matters in life and move in that direction, accepting the fact that doing so will trigger previously suppressed and avoided trauma-related experiences.
A very important caveat is that clinicians need to bend over backward to avoid appearing to minimize the seriousness of the trauma itself. Most clients suffering from trauma have been advised to just move on from it, suggesting that the way to cope is to just forget about it. They then feel broken and defective because they weren’t able to put the trauma behind them. So it’s exceedingly important to bore in on the traumatic event itself, to get clients to tell their story, and then to validate every last bit of emotional pain that resulted. Particularly in the case of sexual trauma, part of the client’s story may include the reactions of important others in response to the event. If a young sexual abuse victim finally discloses the abuse to a parent and is told she’s making it up and will ruin the family if she tells anybody else, that becomes another trauma the child has to contend with. If you don’t first validate clients’ emotional pain, you’ll probably find it quite difficult to get them to follow you into the heart of the hornet’s nest.