Ways to Work with Trauma

Traumatic events are one of the primary contributors to mental health issues. As research on trauma has increased over the years, a growing number of therapeutic approaches specifically targeting trauma have been developed. That does not mean that earlier and foundational therapy modalities are not addressing the trauma. But as our understanding of how trauma is processed in the brain and body deepened, more specialized contemporary approaches such as Trauma Focused Cognitive Behavioral Therapy (TF-CBT), Exposure Therapy, Eye Movement Desensitization and Reprocessing (EMDR), and Attachment, Regulation and Competency Model (ARC) have been developed to address trauma more directly. 

Some of these approaches build on traditional methods, while others were created specifically to work with trauma. For example, TF-CBT introduces a strong trauma-informed lens to the traditional CBT framework. In contrast, ARC aims to address the specific needs that arise when working with the traumatic effects experienced by children and young adults. Alternatively, some modalities are based on specific assumptions about why the effects of trauma persist and offer specialized interventions accordingly. For instance, exposure therapy emphasizes the role of avoidance in maintaining symptoms, while EMDR is based on the assumption that traumatic events disrupt normal memory processing. 

But with so many different approaches, choosing what will work best might be really confusing, especially if you are already experiencing the overwhelming effects of trauma. A long list of therapies and new terms can be hard to make sense of. For this reason, we aim to introduce new concepts in trauma work briefly and explain them through simple examples. In this therapy sketch, we will take a closer look at how TF-CBT, exposure therapy, EMDR, and ARC work with the effects of trauma.

Briefly About Trauma

Before looking more closely at trauma approaches, it may be helpful to revisit what we mean by trauma and how it is affecting us. According to APA (DSM 5; 2022), trauma refers to adverse experiences that elicit intense fear, helplessness, confusion, and dissociation. The effects of trauma can have long-lasting effects and impact a person’s behaviors, emotions, cognitions, and functioning because it directly alters the sense of a safe, fair, and predictable world. The psychology literature provides more insight into trauma, such as how traumatic experiences vary, how they are passed down through generations, and how they manifest at different life stages.

Because trauma can affect people in many different ways, different therapeutic approaches have been developed to address these experiences based on findings from evidence-based studies. 

TF-CBT

Trauma Focused-Cognitive Behavioral Therapy (TF-CBT; Cohen, Mannarino, & Deblinger, 2006) considers trauma as an experience that affects our thoughts, emotions, physical responses, and behaviors all at once. In the therapy process, TF-CBT methods address the body, physical responses, thoughts, emotions, and behaviors. Let’s elaborate further. For example, think of a car accident. Someone who has been in an accident may have physically recovered, their car may have been repaired, and life may appear to have returned to normal from the outside. But the memory of the accident might not feel like something that simply happened in the past. Instead, it may return in pieces, like a sound, an image, or a sudden rush in the body. At times, it can feel as if the accident is happening again. In addition, when they get behind the wheel again, they may notice their heart racing, their hands sweating, and the image of the accident replaying in their minds. So eventually, they may begin to avoid driving altogether.

TF-CBT begins by working with the body. Because the initial response to a triggering situation is a sense of alarm. The body feels like it is in survival mode even though there is no danger around. TF-CBT teaches breathing exercises and relaxation techniques so that the body has new ways to calm down. 

Next, thoughts are addressed. After traumatic events, the mind often produces rigid and simplistic explanations, such as “this was entirely my fault” or “the roads are not safe”. A strong therapeutic relationship, combined with the TF-CBT techniques, can help you understand how these thoughts form and develop a more balanced perspective.

This change in the aftermath of trauma is also reflected in emotions. Fear, guilt, or helplessness might be really intense at first. But as the therapy process unfolds, these emotions gradually become more manageable. The person learns to stay present with their emotions without suppressing them or getting lost in them.

Finally, behaviors are addressed. Many people who have experienced trauma try to protect themselves by restricting their lives (in our case, completely avoiding driving). In TF-CBT, these avoidance behaviors are addressed through small and safe steps. For example, the first step might be just sitting in the car; the next step would be driving a short distance. However, please keep in mind that these steps do not form a fixed list that progresses in the same way for everyone. Each person’s trauma experience, readiness, and needs are different. Progress means taking a small step sometimes, but at other times it means pausing to reinforce the skills gained. For example, in some cases, progress would be driving the car, in other cases, it would be relearning how to stay calm inside the car.

In short, TF-CBT is not about erasing traumatic events; it is about transforming the fragmented traumatic experience into a full story that can be managed effectively. So, the person begins to realize that the moment from the past no longer controls their life.

Exposure-based therapy

TF-CBT offers a comprehensive approach because it focuses on multiple domains that help us understand how trauma affects us. However, in trauma work, sometimes the priority would be to work on avoidance behaviors, especially if they started to take up a lot of space in a person’s life. This is precisely where exposure-based therapies (Zandberg et al., 2017) come into play.

When we experience trauma, we may learn to perceive many things that remind us of the event (not just the event itself) as a threat. Over time, we begin to avoid certain places, times, or situations. As mentioned above, avoidance may seem functional because it makes us feel safer. However, it also prevents our brain from learning that these situations can now be safe. The core mechanism of exposure-based therapies is to gradually update this learning. The person safely and carefully re-encounters the experiences they have been avoiding, and each new experience weakens the brain’s old alarm a little more.

For example, let’s consider someone who was attacked on the street at night. After the incident, the person might start avoiding going out in the evenings. However, over time, the entire evening or even walking alone might begin to feel like a threat. In an exposure-based intervention, the person can begin to address this avoidance with several steps. For example, after a therapeutic relationship is formed, the person might revisit the traumatic memory in therapy (imaginal exposure), which is a safe environment to process the event that leads to a danger response. Gradually, therapy unfolds into the process of re-engaging with certain avoided situations in real life (in vivo exposure). In our case, that might include taking a short walk in the evening, or strolling for a few minutes on a familiar street. Over time, the walk gets a little longer, and they might venture onto a busier street. These experiences help the brain learn that not every evening, not every street, poses the same danger.

Eye Movement Desensitization and Reprocessing (EMDR)

Another effective way to alleviate the effects of trauma is EMDR therapy (Wilson et al., 2018; Scelles & Bulnes, 2021). According to the EMDR approach (Shapiro, 2001), when we experience traumatic events, such as bullying, the memories may not be fully processed. As a result, emotions, bodily sensations, and beliefs related to the event remain disconnected, which may be associated with the negative effects of trauma, such as intrusive re-experiencing, avoidance, hypervigilance, emotional numbness, or low mood.

EMDR uses bilateral stimulation, such as alternating eye movements or tapping, to activate our brain’s processing system. Once activated, the system becomes “modifiable,” allowing corrective processing so the memory can connect with more adaptive thoughts and become integrated. This integration helps relieve emotional and physical symptoms.

EMDR uses an 8-phase approach (Shapiro & Solomon, 2017). Let’s take a look at what EMDR sessions may look like for someone who experienced bullying and became socially affected by these events:

• 1) History Taking: The first appointment starts with talking about your experiences and current challenges. This helps decide whether EMDR is appropriate and identify target memories and their triggers in the present.
• 2) Preparation: The therapist also explains how EMDR works and introduces bilateral stimulation (e.g., eye movements or tapping). They may teach you grounding techniques to make you help you feel safe, such as visualizing a safe place.
• 3) Assessment: The therapist then helps you focus on the target memory as well as a negative belief (“I am worthless”), a positive belief you want (“I am worthy of friendship”), and the emotions and bodily sensations tied to it.
• 4) Desensitization: While focusing on the memory, you may follow bilateral stimulation. Distressing thoughts, feelings, and physical sensations may surface during this reconstruction, which can help them to be processed and released.
• 5) Installation: The therapist helps you engage with positive beliefs identified earlier so they can become associated with the target memory.
• 6) Body Scan: During this phase, the therapist asks you to mentally scan your body while thinking about the memory and the new belief. Additional bilateral stimulation can be used for any remaining tension or discomfort.
• 7) Closure: The therapist also ensures you feel stable at the end of the session and reminds you to note any new thoughts or feelings between sessions because memory processing likely continues.
• 8) Reevaluation: The therapist would also check whether the memory still causes distress, whether positive beliefs are held, and whether your approach to related situations has improved.

Through this process, EMDR can help you gradually process painful memories and reduce the symptoms they are associated with. It may feel challenging at first, but each step can help you develop your sense of safety.

ARC, for children and developmental trauma

In trauma work with children, one common approach is the ARC Model (Attachment, Regulation, Competency; Blaustein & Kinniburgh, 2010). The core idea behind ARC is that healing often begins by rebuilding attachment, regulation, and competency. This is based on the fact that, unlike adults, children do not have a fully developed nervous system that regulates their emotions and processes difficult events. So, rather than directly starting from trauma work, ARC focuses on building safe relationships and developmental capacities that help children process the trauma first. Think of the ARC model as a construction process. The foundation is attachment; the upper floors are regulation and competency; and the roof is trauma work.  

Let’s consider a child who has been experiencing prolonged tension and unpredictability at home. When this child faces a minor disappointment at school, they may suddenly become angry. Eventhough this seems like an overreaction, from the ARC perspective, it is a reaction of high alert danger alert from the child’s nervous system.

In therapy, the ARC model begins with the relationship where the child begins to experience a secure relationship with an adult (in the therapy case, the therapist and caregiver) who understands them and can remain calm. Within this relationship, they learn to recognize their emotions and gradually regulate them. For example, developing skills like saying I’m really angry instead of pushing the table when they lose a game, or taking a moment to pause and return to the game.

As these skills strengthen, the child begins to develop in other areas, such as problem-solving, forming friendships, and feeling more empowered. After developmental capacities build over time, the child may begin to express their traumatic experiences in a secure environment through drawing, play, or storytelling, and integrate these experiences into a tolerable part of their life story.

Which modality is better for me?

Here, we aimed to introduce some modalities that take a unique approach to alleviating the effects of trauma. This list, of course, is not exhaustive. Most evidence-based modalities that we haven’t listed here, such as psychodynamic therapy, DBT, and ACT, have also proven to be quite effective in helping people cope with the effects of trauma.

Although the existence of so many efforts focused on the effects of trauma can feel hopeful, the variety of modalities may actually make choosing a therapy more confusing. If you feel this way, it can be helpful to remember that there is no single right modality or technique for everyone. 

One of the most important factors in supporting our healing is the quality of the therapeutic relationship we build with our therapists. Similarly, regarding techniques and methods, working with a therapist who makes us feel seen, heard, and understood may be one of the most effective approaches. That is why it can be valuable to give ourselves the space to discover what works best for us and to explore our options openly.

Takeaways

• Evidence-based modalities such as TF-CBT, exposure therapy, EMDR, and ARC incorporate therapeutic components specifically designed to address the effects of trauma.
• TF-CBT is a structured, short-term therapy that assumes trauma leads to maladaptive thoughts and feelings, targeting them through cognitive restructuring, coping skills, and gradual exposure to trauma memories. 
• Exposure therapy assumes that trauma-related fear is maintained by avoidance and involves systematically and safely confronting feared memories, situations, or cues to reduce distress and avoidance over time.
• EMDR assumes that unprocessed memories of traumatic events underlie associated symptoms. In an eight-phase protocol, it uses bilateral stimulation (e.g., eye movements) to activate memory processing, enabling traumatic memories to be integrated and associated symptoms to be alleviated.
• The ARC (Attachment, Regulation, and Competency), a framework especially used with children and adolescents, assumes that trauma disrupts attachment, emotional regulation, and developmental competencies and aims to strengthen these areas by focusing on caregiver relationships, self-regulation skills, and supporting developmental growth.
• The existence of many therapeutic approaches can make starting therapy confusing and overwhelming. In those moments, it could be useful to remember that the quality of the therapeutic relationship we build with our therapist and the permission we give ourselves to explore what works best for us can be just as important, if not more so, than the specific techniques used in a given modality.

References

American Psychiatric Association. (2022). Diagnostic and statistical manual of mental disorders (5th ed., text rev.). https://doi.org/10.1176/appi.books.9780890425787

Blaustein, M. E., & Kinniburgh, K. M. (2010). Treating traumatic stress in children and adolescents: How to foster resilience through attachment, self-regulation, and competency. Guilford Press.

Cohen, J. A., Mannarino, A. P., & Deblinger, E. (2006). Treating trauma and traumatic grief in children. New York, NY: Guilford Press.

Scelles, C., & Bulnes, L. C. (2021). EMDR as a treatment option for conditions other than PTSD: A Systematic review. Frontiers in Psychology, 12, 644369. https://doi.org/10.3389/fpsyg.2021.644369

Shapiro, F. (2001). Eye movement desensitization and reprocessing: Basic principles, protocols, and procedures (2nd ed.). New York, NY: Guilford Press.

Shapiro, F., & Solomon, R. (2017). Eye movement desensitization and reprocessing therapy. In S. N. Gold (Ed.), APA handbook of trauma psychology: Trauma practice (pp. 193–212). American Psychological Association. https://doi.org/10.1037/0000020-009

Zandberg, L. J., Porter, E., & Foa, E. B. (2017). Exposure therapy. In S. N. Gold (Ed.), APA handbook of trauma psychology: Trauma practice (pp. 169–192). American Psychological Association. https://doi.org/10.1037/0000020-008

Wilson, G., Farrell, D., Barron, I., Hutchins, J., Whybrow, D., & Kiernan, M. D. (2018). The Use of Eye-Movement Desensitization Reprocessing (EMDR) therapy in Treating Post-Traumatic Stress Disorder: A Systematic Narrative Review. Frontiers in Psychology, 9, 923. https://doi.org/10.3389/fpsyg.2018.00923

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At Roamers Therapy, our psychotherapists are here to support you through anxiety, depression, trauma and relationship issues, race-ethnicity issues, LGBTQIA+ issues, ADHD, Autism, or any challenges you encounter. Our psychotherapists are trained in Cognitive Behavioral Therapy, Dialectical Behavioral Therapy, Psychodynamic Therapy, Acceptance, and Commitment Therapy, Person-Centered Therapy, and Gottman Therapy. 

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This page is also part of the Roamers Therapy Glossary; a collection of mental-health related definitions that are written by our therapists.

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