When I was a resident at NYU in 2009, I worked extensively at Bellevue Hospital's Survivors of Torture Center. I was training to be a psychiatrist, seeing patients who'd endured unspeakable terrors in war-torn regions of Bosnia, Côte d'Ivoire, and Sri Lanka.
Even though they shared similar experiences, their trauma presented itself differently. For some, there were little to no traumatic symptoms, while others could not escape their painful memories for more than a few hours a day.
At the time, there was little consensus on whether you'd want to encourage patients to speak about their trauma, which could desensitize them to the negative emotions of the memory (an arguably positive result), or else risk retraumatizing them (an obviously negative result).
As our knowledge of mental health expands, we are beginning to see that trauma isn't relegated only to survivors of war or serious abuse, but that the experience is more universal, with a variety of different forms and severities.
The DSM-V currently recognizes three types of trauma: Acute, Chronic, and Complex.
Acute trauma — or what I often call Trauma with a capital T — involves a single incident, usually surrounding the threat of loss of life or limb, such as a sexual or physical assault or a serious car accident. Chronic trauma is on-going, such as persistent bullying, abuse, neglect or domestic violence. Complex trauma entails repeated or multiple traumas from which there is no escape (feeling trapped).
After having treated trauma as a psychiatrist for over 15 years, I befriended the founding director of the International Trauma Studies Program, Dr. Jack Saul. He introduced me to the term "moral injury trauma," which is where people have done, by no choice of their own, unspeakable things like killing mothers and children in war, and then come home and must carry this moral burden (it can also include simply witnessing moral atrocities).
Dr. Saul explained to me that the way to treat moral injury is through group therapy, treating the so-called perpetrators (the people who went to war) alongside other members of the community who did not go to war. Those individuals who did not themselves endure the trauma are able to be present and hold space for those who did, and breaking their silence about these crippling memories can help patients break free of the shame and social isolation that comes with having to endure moral injuries.
One-on-one therapy is a privilege not afforded to all people of the world, making group therapy a more accessible form of treatment for developing nations or the working poor.
Another cost-effective form of therapy, controlled breathing, which can be done individually or in a group setting, has been shown to have remarkable effects on calming the sympathetic nervous system, reducing the amount of the stress hormone, cortisol, which causes sensations of alarm and danger when PTSD victims are triggered.
This is different from Somatic Experiencing Therapy, which aims to reduce or eliminate the stress response to memories through an encouraged focus on internal sensations.
Created by neurobiologist Peter A Levine, author of Waking the Tiger: Healing Trauma, Somatic Experiencing pulls from both mainstream science as well as various shamanistic practices from around the world.
Spirituality has been making a resurgence in mental health treatment in recent years, particularly in the treatment of trauma. Doctor of Divinity Erin Fall Haskel has been taking a more metaphysical approach to the treatment of trauma. Her approach is supported by scientific literature that holds that it's not as important what happened to you, but what happened within you, that determines how your trauma materializes and how to treat it.
During my psychiatry residency at Bellevue, I spent a month in Rwanda, helping survivors of the brutal genocide process their trauma. Perhaps most horrendous was the use of rape as a tool of war, which created a whole generation of babies produced by the atrocity.
While in Rwanda, I met Jean-Baptiste Ntakirutimana, whose mother was killed by his best friend and neighbor during the bloody rampage of "kill or be killed." When the genocide was over and his neighbor was in jail, Jean-Baptiste was filled with rage and a desire for revenge for the man, which he soon realized was draining him of his life force. After a period of fasting and praying, Jean-Baptiste visited his old friend in jail, and ultimately forgave him. Afterward he felt an enormous burden of hatred and pain lifted from him in what he describes as "the most liberating moment of my life." Based on his life-changing experience, he began The Forgiveness Project.
In addition to social and spiritual therapies, psychedelic interventions have proved successful where other trauma treatments have failed. Pharmaceutical treatments like SSRIs have proved helpful for many sufferers of trauma, but often these medications treat only the symptoms of illness. In contrast, a medication like MDMA (i.e., Ecstasy) can act as a kind of surgery of the mind, targeting the specific memories, perceptions, and narratives created by the trauma and removing or transforming them.
MDMA has been found to be effective across all forms of trauma, but that doesn't mean it's effective for all minds, bodies, and spirits. I have seen time and again how two people can endure the same traumatic experience and wind up with different presentations of trauma (or none at all). It comes down to an individual's worldview, genetics, spiritual perspective, community, access to treatment, and a host of other factors that determine how they will respond to horrifying experiences.
The future of trauma therapy is likely to involve an increasing emphasis on integrating different trauma modalities. While traditional evidence-based therapies, such as psychotherapy, Eye Movement Desensitization and Reprocessing (EMDR), and Somatic Experiencing are likely to continue being prominent, there will likely be a greater recognition of the value of integrating spiritually-based approaches and mind-body practices like breathing techniques. With ongoing research and clinical trials, psychedelic-assisted therapies will likely also become more accessible to clients in mental health settings. As these developments unfold, the ultimate goal will be to provide more effective, holistic, and compassionate care for individuals experiencing trauma.
The trends in therapy are why our expanding knowledge of what trauma is, and how to treat each individual case, is one of the most exciting developments in mental healthcare today.
