How to Maintain Progress After Trauma

Why a self-sustainability plan has to be included in trauma treatment.

Posted Apr 18, 2018

ETI
Source: ETI

A long quest to make the pain of trauma go away is part of the story for many trauma survivors.  I know this story well because it’s also my story. 

Part of why I’m a trauma therapist is that I am myself a survivor of  trauma (both personal and collective). In early adulthood I sought professional help to deal with the trauma symptoms that often held me in a grip I couldn’t escape. 

Many years of therapy didn’t help in the ways I was expecting.  I tried various approaches and modalities without being able to maintain a sense of sustainability.

I was looking for a Big Fix.  It took years, aided by university studies, exploration of many different modalities, not to mention research and travel in different parts of the world, to realize that my quest for one fix had itself become an obstacle.   Trauma is generally complex and it therefore requires complex responses.  A blend of strategies and practices is necessary to achieve and maintain what I have come to call trauma integration.

From personal experience as a survivor and now as a therapist, I’ve learned several things that are important for responses to trauma to be sustainable.

Support from a professional trained in recent learnings about trauma response
Trauma in most cases is caused in relation to someone else and in all cases its consequences have big impacts on relationships.  So working in a safe and contained relationship, in the presence of a seasoned therapist, is key for moving on from the wounds of trauma, what I call “Integrating” (stage 6 in the ETI roadmap).

It is true, of course, that many survivors make some progress in managingement their own pain.  Indeed, many have no choice but to do it on their own because they don’t have access to resources for support.   That said, the far-reaching ways in which trauma effects victims makes it challenging to achieve full integration alone.  Access to expert help is a huge benefit to clients, both in terms of speed and sustainability of their progress.

However, it’s essential that professionals doing indepth work with survivors be up-to-date in their approaches.  The study and practice of trauma response have made tremendous advances in the last two decades.  Responses that were once assumed to be helpful, for example, encouraging survivors to do detailed retelling of their experience, are now recognized to be potentially retraumatizing if used too soon after the traumatic event. 

Define support broadly and keep an open mind as to its sources
The effects of stress and trauma are emotional, physical, cognitive, spiritual, and social.  In my own journey of trauma integration, I’ve benefited from support from professionals in each of those areas. 

In working with clients,  I make a point of regularly reviewing resources for support from a variety of disciplines and backgrounds. Together we figure out a mix of activities suited to the client’s needs, time availability and financial realities.

Design and maintain a routine of daily practices
Healing is not a straight line of continuous progress.   Just when we feel that things are finally better, we get triggered or a new crisis comes along (withdrawal stage #3 on ETI roadmap).  Life brings pain to everyone, of course, and on top of that trauma survivors carry special vulnerabilities that will always be with them.   It’s not realistic to expect to sustain progress made without the stabilizing benefits of a set of routine practices.
So a key task of a therapist is to help clients establish what I call an Individual Sustainability Plan (ISP).  This  is a set of daily activities a survivor engages in over an extended period for purposes of self-sustenance. 

In the context of professional treatment, the design of an ISP comes after we’ve done essential preliminary work on connecting to inner resources and establishing a sense of safety. It typically includes practices that address multiple aspects of life, emotional, mental, physical, spiritual, and social, all of which play an important role in well-being. 

Self-indulgence vs. self-care vs. self-sustainability
The use of the term “self-care” is so common these days that people sometimes understand it as self-indulgence.

To avoid this confusion, see the diagram below that break self-care into three components: enjoyment, self-care, and self-sustainability.

Odelya Gertel Kraybill
Source: Odelya Gertel Kraybill

Enjoyment refers to things that provide immediate gratification, even if the purpose is no larger than feeling good in the moment, such as watching a movie, getting a massage, getting mani-padi, meeting friends, etc.
Self-care activities are also enjoyable, but there is an important additional element present: keeping routines. Self-care activities contribute in direct ways to important basics of daily maintenance and includes exercise, sleep, diet, interacting with loved ones, etc.

Self-sustainability activities support  enjoyment and intentional self-care, by adding a third dimension:  reflection.  The concern here is how to maintain the activities on the higher levels on an ongoing basis.

In therapy, it turns out that the main focus of this third stage usually becomes self-regulation, since difficulties with self-regulation are for most clients the biggest threat to engaging in joy-inducing activities and maintaining self-care.    A therapist therefore works with the client in reflecting on what is working and not working, and why,  observing intentions, stimuli, and sensations, both internal and external, and learning from these observation .

ISP compliments any therapeutic modality    
An ISP does not replace therapy, it supplements it, by providing basic maintenance for people overwhelmed by stress and or trauma. No matter what therapeutic approach you are using to work on trauma, an ISP is necessary to provide a foundation for stability.

In my experience, clients may still benefit from therapy in areas of the counselor’s expertise even in the absence of an ISP. But progress remains limited to these because there is no strategy for dealing with the client as a whole.  Working with trauma survivors requires therapists to expand our skills beyond those of traditional counseling practices.  To truly serve our clients we have to think “outside the box”.   If we do not, we will be unable to assist the many who remain stuck in Withdrawal (stage 3 in the ETI roadmap) even after many years.

Key Elements of an ISP
In designing an ISP with my clients, we focus on the following:

  1. Identifying difficulties faced by a survivor in maintaining self-care practices (recognizing that these provide clues about some of the trauma work ahead), and seeking life enhancing alternatives.
  2. Detecting personal external stressors and internal secondary alerts, and creating practices that facilitate self-regulation, and learning tools and techniques to minimize these.  The goal is to recognize the most common situations, relationships, and embodied cues that cause difficulty and then to work out strategies to reduce their impact. 
  3. Identifying and redirecting triggering thought patterns.  For example, converting self-judging thoughts into self-compassion.
  4. Connecting to inner and external resources that support resiliency, and identifying activities to enhance access to resources.  If the survivor can identify none, create some, using imaginal space.
  5. Journaling. Ideally this should be shared with someone else. My clients share a journal with me on a weekly basis. Some write entries daily, some less often. The journal maintains a connection between my clients and me (providing an added sense of containment), not only for our sessions, but also in giving clients an immediate sense of connection during the week when they write.  
  6. Brain-gut axisStress affect our gut balance, our gut balance affect how we feel. Although research about the impact of diet and nutrition on emotional functioning remains in its infancy, the link is now too obvious to ignore.   After several years of study of it, I am convinced it is impossible to achieve sustainability of trauma integration without paying attention to it. I consider it essential to help clients learn about diet and nutrition, with a goal of identifying foods that impact the client with a triggering or calming effect, and helping the client devise  diet changes and choose supplements accordingly, in order to restore balance to the gut microbiome.
  7. Joy. Weekly exploration of what activities and routines bring the survivor joy.   This can be activities, hobbies, interactions, and relationships. 
  8. Self-compassion.  The goal here is to expand a client’s capacity to deal with post-trauma injury and pain (shame, guilt etc.) by incorporating practices of self-compassion and learning how to use mindfulness, kindness and other physical and mindful activities (meditation, yoga, art expression, dancing and movement exercises) to experience self-compassion.