Famous psychotherapist Dr. Salih Murat Paker gave important information about trauma therapy.
The subject of trauma has become very popular in the last few decades in the world. As a result, the number of people going to therapy for their traumatic experiences has been continuously increasing. Although there are several different approaches to trauma therapy, we can still talk about certain basic principles. What are those?
What kind of therapeutic role should be pursued to lessen the impact of traumatic destruction? What kind of psychological support should be exhibited?
Salih Murat Paker: The first priority, as always, is safety. For example, if there is active war or civil war, or if there is domestic violence, the primary duty of mental health professionals is to make visible the devastating effects of this violence and to raise a strong demand for peace/safety. Because if there is active violence, we can only do superficial/supportive counseling, which might be crucial in itself in that moment, but, in the presence of ongoing violence, no real treatment is possible. Superficial/supportive counseling should not be underestimated either, it can prevent the wound from getting worse after all, but it is not a final solution. Between the macro and micro levels, there may be initiatives that can be made at the broader community or smaller community level to show that the suffering of survivors of violence is recognized and honored. The establishment of human rights museums, monuments, and national education curricula including these issues can be considered under this heading. At the micro level, there are healing activities that mental health professionals do with trauma survivors at the individual, family, and group levels. There are many different approaches in this field according to the therapy school. Ideally, teamwork is required. An ideal team may include a clinical psychologist, social worker, psychiatrist, art/body therapist, lawyer for legal issues, and an interpreter if necessary.
Regardless of the school of therapy, there are basic principles to be followed in trauma therapy
Salih Murat Paker: To summarize them briefly:
1) Every survivor is unique. The post-traumatic life of each survivor is different, even for those who have been exposed to the same trauma in the same way. That’s why extremely manualized and structured approaches are inconvenient. Each therapy process should be specifically tailored to the trauma survivor’s situation and needs.
2) The main premise in therapy is not the technique, but the therapy relationship. This is especially critical for survivors of human-made traumatic events. The traumatic event has turned the survivor’s relational world, that is, their styles of relating to others and to themselves, poisoned, so to speak; now, with a new relationship, a therapy relationship, the effects of this poisoning will be eliminated. Therefore, a high-quality, stable, and well-defined therapeutic relationship with respect and empathy should be at the center of the work.
3) The traumatic situation primarily impaired the victim’s sense of security and predictability. The world and relationships are now perceived as unreliable and unpredictable. One of the most important tasks of trauma therapy is to reestablish these senses. Therefore, the therapist must be sure that the client is safe, and if not, how to be safe should be one of the main topics of therapy. Likewise, the therapy framework itself should be safe and predictable, with rules that are consistently applied.
4) The trauma survivor does not live alone in an aquarium in an isolated manner. He lives in a certain socio-political-cultural context before, during and after the trauma. The coding, interpretation and processing of trauma takes place on this socio-political-cultural level along with biological and psychological processes. Therefore, as in all therapies, this context must be a part of the work in trauma therapy.
5) One of the most basic effects of the traumatic event is the inhibition of the symbolization capacity of the person. There are no words for those traumatic moments, they cannot be articulated properly. If pain cannot be articulated, that is symbolized via a verbal or non-verbal expressive system, it cannot be metabolized, digested, remains inside us like a glue, and continues to poison us. Therefore, in trauma therapy, regardless of the school, it is aimed to rework and process traumatic memories at some point and in some way. However, this situation can vary greatly from survivor to survivor, both in terms of timing and amount. Our basic criterion is how prepared the survivor is for what; there should not be any forceful push.
6) Trauma therapy is a difficult and complex business. While the client can experience intense positive/negative feelings (transference) towards the therapist, the therapist can also experience intense feelings (counter-transference) towards the client. At least basic training is essential for therapists in these situations and how to work with them. Similarly, occupational burnout is very common among trauma therapists. Due to the weight of the material being studied, they may feel emotionally exhausted and depressed after a while. That’s why trauma therapists need to pay close attention to their self-care. Under this heading, going to one’s own therapy, getting supervision, having quality relationships, hobbies, activities that provide physical and mental relaxation can be counted.
What are the treatment options, especially for traumatized children?
Salih Murat Paker: The same principles apply to children, as well. But additionally, since the means of verbal expression are much more limited for children, there is a greater need for non-verbal means of expression and symbolization, such as art and movement. Also, because children are so much more dependent on their families, trauma therapy for children also involves much more work with the family.
Dos and don’ts in trauma therapy
Salih Murat Paker: The most urgent thing is to ensure safety. Next is the introduction of a stable environment. It is very important that the treatment process is reliable, consistent, stable,
and predictable. Therefore, in the first sessions of therapy, a psycho-education should be given on both the psychological effects of trauma and the therapy processes, and a kind of roadmap should be presented to the client, albeit roughly. In general, the basic principles that I just mentioned should be followed.
The list of don’ts is probably longer. The situation, speed and needs of the client should be respected, and in no way should they be forced to do or tell something. This kind of coercion in therapy means the risk of re-traumatization.
If the client tries to describe the traumatic events as if he is vomiting in an unbridled way before he is ready, it is necessary to slow down the client a little in order to avoid the risk of re-traumatization.
One of the most common problems experienced by therapists in trauma therapy is the difficulty of standing in an empathetic position. The basic empathetic stance in trauma therapy is one of the prerequisites for any healing to happen, but it is hard work. Empathy is feeling how the other person might be feeling and being able to convey this feeling to the other person. Since we are not him, we may not understand how he feels fully, but we can come very close. In trauma therapy, because the material that the therapist listens to is very heavy and very painful, the therapist may find it difficult to stay in an empathetic position and make two types of deviations. They may either slip into an aloof position to protect himself, or he may exaggerate empathy and slip into a position of over-identification with the survivor, feeling as if he had experienced the traumatic event himself. However, the therapist did not experience the traumatic event described by the survivor. To be able to help the survivor, they must not be as affected as the survivor, they must maintain a certain distance, so the position of over-identification is a hindrance to therapy, it must be overcome. The aloof position has no therapeutic quality anyway.
We see that therapists dealing with trauma therapy generally have a very high awareness of social-political responsibility. This sense of responsibility also comes with a tremendous energy of sacrifice. These are very positive traits, but provided you have a solid self-care. If the therapist does not pay attention to the self-care issue I mentioned earlier, too much responsibility and sacrifice will eventually lead to burnout in the therapist and the therapist will be unable to help anyone because of too much self-sacrifice. Therefore, therapists should know their own limits, vulnerebilities, and self-care methods well, and should not rely on an unfounded sacrifice.
Another problematic area is related to medication use. In cases where daily functioning is severely affected, temporary drug support may be considered in addition to therapy. When working with trauma survivors, medication should never be the sole or primary treatment. It should be used as a supplement to therapy when necessary. The approach of “do not give medication under any circumstances” is wrong, in some cases drug support may be necessary. On the other hand, we hear that in many places, only drugs are given for the psychological complaints of trauma victims, and these drugs are given to suppress all psychological complaints and make them invisible. This is also completely wrong. In trauma therapy, it is not desirable to suppress the symptoms completely with medication, because those symptoms have a meaning, a language, and have guiding functions in therapy. The drug should only be used to reduce the severity of some very severe symptoms, not to eliminate the symptoms altogether.
What should be the role of families in the approach to traumatized children, how should they be supported?
Salih Murat Paker: First of all, it is very important that families are informed about this issue. Speaking at the level of general principles, of course, children should be protected from traumatic events as much as possible. But we also know that in many cases this is not always possible. It is very important for the family to follow the child’s behavior closely, to notice the changes in behavior quickly, and to provide the child with safe and supportive environments where they can express themselves without forcing. The family should be able to listen to the child, spend time with him, play games. Children express their inner world with games that allow creativity. Therefore, it is very important for children to be able to play together in order to understand, process and solve traumatic situations. Children should be allowed to lead in these games, and there should be no coercion. In some cases, children ask adults directly or indirectly about the subjects they have difficulty with. In such cases, explanations should be made in accordance with the age of the child, their feelings should be understood, and the child should not be dismissed in any way. The most critical issue for children to cope with their trauma is that the family environment and their parents are reassuring and empathetic. If traumatic difficulties continue unabated, professional help should be sought if possible.
