Trauma is defined in many ways, but it is important to remember that it is a noun; it refers to an actual experience or wounding. Often, clinicians describe trauma based on its effects, not the actual experience. The word trauma is derived from the Greek word that literally means wound. By considering what physical wounds are and how they affect humans, the meaning of emotional trauma may be further understood. Basic principles of physical wounds and wound care include [1]:

Helping professionals continue to debate whether certain types of trauma are "worse" than others. For instance, this definition goes on to propose that traumas caused by humans (e.g., rape, assault) often result in greater psychologic impact than those caused by nature (e.g., earthquakes, floods) [2]. Others, however, assert that trauma caused by people may be worse for certain people, but it depends on an individual's situation, constitution, and overall coping system in place to deal with the trauma. Because the human experience of trauma is fundamentally subjective, comparing traumas is difficult and generally not helpful.

In 2001, Shapiro introduced the ideas of classifying trauma into one of two forms: large-T trauma and small-t trauma [3]. Large-T traumas are events that most people would experience as horrific or life-threatening. Examples of large-T traumas include assault, rape, military combat, or natural disasters. Essentially, whenever there is a life-threatening component or one perceives his or her life to be in danger, large-T trauma is involved. Large-T trauma is commensurate to what is called a Criterion A trauma in the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5) description of PTSD.

The PTSD diagnosis first appeared in the DSM-III in 1980, in response to cases stemming from the Vietnam War [4,5]. However, PTSD certainly did not start in 1980. The notion of it has been recognized throughout the ages, being referred to by such names as combat neurosis, shell shock, and hysteria. According to the DSM-5, an individual must have experienced a Criterion A trauma for PTSD to be officially diagnosed [5]. The DSM-5 significantly expanded the definition of Criterion A trauma. In the DSM-IV-TR, Criterion A trauma required there to be some threat to physical integrity or life; many professionals used the colloquialism "threat to life or limb." In the DSM-5, witnessing a traumatic experience (real or threatened) happen to someone else also qualifies, as does violent or accidental death (real or threatened) to a family member or close friend. Sexual assault and certain cases of vicarious traumatization connected to work experiences also now qualify as Criterion A. Although the presence of a Criterion A trauma is a necessary qualification for a diagnosis of PTSD, not all persons who experience Criterion A trauma will develop PTSD.

Criterion B encompasses symptoms related to the re-experiencing of the trauma. The classic examples include flashbacks, vivid dreams, and nightmares. Hallucinations of all types can also be a part of Criterion B. When an individual is experiencing hallucinatory symptoms, he or she is typically diagnosed with some type of psychotic disorder and placed on the corresponding medications. However, it is important to assess whether or not these voices or visions are connected to earlier trauma; if so, PTSD may be a more appropriate diagnosis than a psychotic disorder. Auditory hallucinations may represent voices of an abuser or of a cruel parent, and visions may be flashbacks to an abusive episode. It becomes especially important to explore the content of these hallucinations in individuals who have experienced complex PTSD, which will be discussed in greater detail later in this course. Intense physiologic distress, often conceptualized as manifestations of a body memory, can also fall under Criterion B symptoms.

Criterion E contains heightened arousal symptoms, which are also associated with psychologic pain. The two major symptoms associated with Criterion E are hypervigilance (e.g., always being on guard for something bad to happen) and an exaggerated startle response (i.e., a person is more "jumpy" than what would be considered normal). However, there are other major avoidance symptoms that are often attributed to other diagnostic categories without the trauma ever being examined. These other symptoms are [5]:

Trauma does not necessarily need to be Criterion A for it to be clinically significant. This notion is the basis of Shapiro's concept of small-t trauma, now referred to as adverse life events not qualifying for PTSD [3]. This type of trauma includes all of the upsetting life events that may prove difficult to handle. Many clients may minimize small-t traumas, believing that if they did not survive a major disaster their trauma is somehow less legitimate or significant. Sadly, professionals and family members may further reinforce this devastating belief by comparing levels of trauma among clients or family.

There is a wide variety of diagnoses that are either caused by or exacerbated by adverse life events. Depression is one diagnosis that may be the manifestation of or exacerbated by adverse life event(s). Other anxiety disorders, mood disorders, adjustments disorders, and even a variety of paraphilias and other problematic behaviors catalogued in the DSM-5 can fall into this spectrum of trauma-related disorders. For example, many personality disorders are being conceptualized as complicated manifestations of unhealed trauma that occurred at a developmentally vulnerable period. Because these disorders cover a wide range of the population, clinicians may be clinically interacting with traumatized individuals without being aware of it. For full practical purposes, clinicians should always diagnose according to symptoms. However, using the logic of adverse life events and the broader conceptualization of trauma, one may be able to honor the significant nature of all traumas and treat disorders using trauma-competent strategies, even if the diagnosis is not PTSD. The general principle to keep in mind is that trauma does not have to meet PTSD criteria to be clinically significant; it may manifest as something else entirely. The principles of trauma competency discussed in this course, however, may be used to enhance the treatment of other diagnoses.

It is irresponsible to present a course on trauma without covering dissociation. Although the dissociative disorders receive their own diagnostic attention in the DSM-5, it is important to consider that dissociation and severe trauma often co-occur. Dissociation is a numbing, detaching defense on which the mind may rely to cope with the intense disturbance of trauma. The most extreme forms of dissociation, such as dissociative identity disorder (formerly known as multiple personality disorder), dissociative amnesia, and depersonalization/derealization disorder, can be particularly baffling to even the most experienced clinicians.

Processing is the act of making sense of an experience or learning and can include achieving the resolution needed to move on from a traumatic experience or series of experiences. Processing can be equated to digesting an unsettling event. Thus, if some aspect of trauma is not processed (or digested) properly, it will continue to cause problems until it can be dealt with and released, a process referred to as reprocessing. Reprocessing refers to consciously accessing the affected memory or experience (trauma) that has not been properly processed and striving to bring about a more adaptive experience. This term came into wider use with the advent of eye movement desensitization and reprocessing (EMDR) therapy. However, the term may be used with appreciation of the underlying logic even if EMDR therapy is not applied.

The three stages originally proposed by Janet were [60]:

One of the greatest misconceptions about trauma counseling is that it is all about catharsis, or the second stage (i.e., identification, exploration, and modification of traumatic memories). However, if a patient or clinician jumps into catharsis without having a foundation of stabilization, including a therapeutic alliance and a set of coping or affect regulation skills, further damage can result [13].

To further the role of processing, it is vital to review some basic biology. MacLean's triune brain model suggests that the human brain actually operates as three separate minds, each with its own special role and its own respective senses of time, space, and memory [10]. While this model's use in terms of neuroanatomic evolution is considered by some to be outdated or oversimplified, it is useful as a purely explanatory tool. It describes the brain structure in a manner that is easy to understand and use as a conceptualization for treatment planning.

One reason trauma may remain unprocessed is due to a misunderstanding of what processing involves. In many Western cultures, clinicians tend to assume that talking is the best way to process trauma; however, in other cultures, the approaches can vary from spiritual interventions to physical treatments. In many mental health and addiction treatment settings, talking is synonymous with processing. Although talking can help a person process, it is primarily a function of the frontal lobe. A person can talk about the trauma extensively, but until it is addressed at the limbic level, the trauma will likely remain a problem [13]. Other healthy modalities of processing can include exercise, breath work, imagery, journaling, drawing, prayer, or dreaming. These experiential modalities are more likely to address limbic-level activity when compared to the classic "talking it out" strategies [13].

In response to these criticisms, the concept of complex PTSD has been introduced [18]. Essentially, complex PTSD refers to conditions of prolonged trauma or trauma that occurs at developmentally vulnerable times, resulting in effects more significant than is believed possible with standard PTSD. In its most updated definition, complex PTSD manifests from conditions that [15]:

In response to these criticisms, the concept of complex PTSD has been introduced [18]. Essentially, complex PTSD refers to conditions of prolonged trauma or trauma that occurs at developmentally vulnerable times, resulting in effects more significant than is believed possible with standard PTSD. In its most updated definition, complex PTSD manifests from conditions that [15]:

Santoro suggests that borderline personality disorder is a manifestation of complex PTSD, and upon closer examination, many of the Cluster B personality disorders (e.g., borderline personality disorder, antisocial personality disorder) occur in individuals who have experienced profound trauma in childhood [20]. If a clinician is treating personality disorders, it is likely that his or her clients may be displaying complex PTSD in some form. Therefore, knowledge about trauma and PTSD can help to enhance understanding of these complicated and relatively common personality conditions.

Clinicians often view assessment as the first session in which a clinician gets to know a client and gathers enough data to make a diagnosis. However, it is important to think of assessment as an ongoing process, starting before diagnosis and continuing throughout treatment, whereby data are gathered to inform the course of treatment based on the client's goals. A good initial assessment is important to ensure that an appropriate clinical snapshot is obtained and treatment is begun on the most appropriate footing. However, especially with traumatized clients who may be hesitant to disclose too much too soon, it is vital to remember that more may be revealed throughout the treatment process. Just because there were no obvious red flags for trauma in the initial session does not necessarily mean that trauma is not a factor. The client may be testing boundaries or a clinician's trustworthiness before revealing his or her most painful, private material.

Just as some mandatory forms are very vague, other facilities' assessment forms may be extensively detailed. For instance, forms may require very specific questions to be asked about the nature of clients' sexual experiences, but clinicians may find that there is not sufficient rapport established for the client to feel comfortable answering such questions. Regardless of the scenario, following guidelines can be very effective for conducting the best possible assessments, especially with clients who may be struggling about whether or not to disclose their trauma histories [1]:

The Primary Care PTSD Screen was developed not as a diagnostic tool, but as an effective screening tool [21,61]. This screening tool was initially validated with Veterans Affairs primary care patients, but its use has been demonstrated for nonveteran clients as well [22,23]. If a client answers yes to any three of the following questions, the results of the screening should be considered positive:

In the past month, have you had an experience in your life that was so frightening, horrible, or upsetting that you:

Following the initial assessment session(s), the next step is typically the formulation of a treatment plan. A well-devised treatment plan documents specific, measurable goals that reflect what the client wants to get out of treatment and how the clinician will be able to therapeutically assist the client in reaching those goals. There are two main best practices at this stage of treatment planning: determine what the client really wants to get out of treatment and assess the client's willingness to change.

Following the initial assessment session(s), the next step is typically the formulation of a treatment plan. A well-devised treatment plan documents specific, measurable goals that reflect what the client wants to get out of treatment and how the clinician will be able to therapeutically assist the client in reaching those goals. There are two main best practices at this stage of treatment planning: determine what the client really wants to get out of treatment and assess the client's willingness to change.

Part of treatment planning involves determining how a client feels about change and how much work/commitment he or she is ready to put into the process. Prochaska and DiClemente's stages of change model, very popular in the medical and addiction fields, applies to trauma treatment [25]. The stages are as follows:

Clients at lower stages of change (e.g., precontemplative) should not be bombarded with the possibility of trauma resolution all at once. Start with the basics (e.g., rapport building; discussions about problems, solutions, and treatment options; motivational enhancement) and work up from there. The basics of counseling and rapport building become even more vital with traumatized populations because of the trust factor; these relational imperative strategies are discussed in greater detail later in this course.

Some clinicians feel an urge to get clients talking about the trauma so the treatment process can begin as soon as possible. Although this approach can sound like common sense, the neurologic concepts covered in the first section of this course suggest otherwise. First, an individual might not be able to easily talk about a traumatic experience because of the way that it is stored in the brain. Secondly, in some cases, talking about the trauma can do more harm than good, such as if the client does not have skills in place to cope with the intense, body-level disturbance that recalling the trauma can stir up. There are two primary tasks that must be accomplished during the stabilization phase of treatment: facilitate coping skills training and affect regulation strategies, and assess/help build recovery capital, or the "good" material that a client has to draw upon, before major trauma processing work can commence.

Basic grounding strategies consist of clients practicing their awareness in space and connecting to the present in the space they occupy. One of the most basic grounding skills involves asking the client to name and describe five things he or she sees. A more multi-sensory approach may include describing sounds, smells, tastes, and sensations. This technique allows clients to return back to the room if they have left their affective window of tolerance during therapy, and it is an especially effective regrounding tool at the end of a session.

Although it may be easy to dismiss breathwork as too simplistic, it is a good place to start. Teaching clients a series of breathing exercises may offer them a new, radical approach to stabilization because they may have never thought about breathing before. Moreover, once a client has a strong sense of how to regulate his or her breath, other sensory skills can be practiced more effectively. For instance, those who are able to regulate their breath will likely derive more benefit from a guided imagery exercise than persons whose breathing is uncontrolled [13].

Three basic breath exercises that may be incorporated into a treatment plan are diaphragmatic breathing, complete breathing, and ujjayi breathing:

Many clinicians also use pressure points from the acupuncture/acupressure tradition and energy psychology tapping points to help enhance relaxation responses. The two points that may be useful for trauma clients are the "sea of tranquility point" (on the breastbone), and the "letting go points" (on the collarbones). While clients hold these pressure points, it is important that they maintain steady, concentrated breathing to achieve optimal impact in relaxation and regulation.

The biggest concern when doing guided imagery as part of trauma stabilization is to screen for the image or place the client would view as calm, happy, or safe (or any other positive emotion) prior to starting. If the client says that he or she feels safe locked in the closet, that is probably not the most adaptive place to use for an exercise, although it may be a starting point. Some traumatized clients may have no conception of what the word safety means or have a safe place. An alternative construct, such as a calm or happy place, could work. With a few exceptions, it is also advisable to give clients a general orientation to imagery and to let them know that it is typically best not to have other people involved in their image, especially at first, because this can complicate the image.

Visual images can be used as part of stabilization, even without formal guided imagery scripts. One option is to ask the client if he or she has any pictures that he or she finds especially calming or edifying. Sometimes, a client has a picture of himself or herself as a small child that represents a state of freedom that he or she would like to access, or a recovering addict may carry pictures of family and children for motivation. Any picture that represents something positive to the client can be used as a resource, and such pictures are easy to carry around for the purposes of affective regulation.

Three useful stabilization exercises tap into a blend of the senses: focusing on positive memories, imagining hopeful future scenarios, and journaling. Installing positive memories, when carefully done, can be a tremendously healing resource, especially as a frontloading strategy. With this technique, the clinician helps the client take a positive memory or experience and use it as a safe place image. Elicit the memory in detail and have the client give that experience a cue name. If appropriate, the cue name can be a positive self-belief that the client associates with the memory.

The following questions should be asked before moving to stage 2 trauma processing work [1]:

If the stabilization stage is completed successfully, the next stage, trauma processing, will be less daunting. As a quick review, processing is making sense of an experience or learning; it can be equated to digesting an unsettling event. Reprocessing refers to consciously accessing the affected memory or experience that was not processed properly and striving to bring about a more adaptive experience. The two terms will be used interchangeably in this section.

At present, there are many popular therapies being used for the treatment of PTSD and trauma-related disorders, all of which have some level of research to support their efficacy. Of course, the legitimacy of each therapy is weighted differently by respective clinical organizations based on how much research exists to support it. These therapies include:

Reintegration is perhaps the most logical stage of the entire consensus model, yet it is one that is often missed. The purpose of reintegration is to help clients transition into living their lives without the sequelae of trauma. When clients manage to eliminate the emotional burden of a traumatic experience during stage 2 treatment, they may feel lighter and freer. Because this catharsis is so positive, it can be tempting to stop treatment at this point, with the client feeling "cured." However, it is important to remember that, after carrying a weight for such a long time, it may feel strange or even uncomfortable to maneuver through life without it [1]. For example, if a client has released the burden of guilt over his father's death, he can begin to live his life with the new knowledge that he is a good person. But if the people in his life had grown so used to his negative self-image that they took advantage of his low self-esteem, his new outlook on life could change the whole family dynamic. These changes will require adjustments in the client's way of living. These adjustments and adaptations are not necessarily bad, but they may feel strange and new. The care and concern of a therapist who helped a client release the burden can be an invaluable asset to help him or her reintegrate into ordinary life. Essentially, reintegration work is similar to providing physical therapy or other rehabilitation following a major surgery.

An estimated 46.4% of clients with lifetime PTSD meet the criteria for substance use disorder [34]. Various studies have found a disproportionately higher number of abuse, neglect, or trauma histories in substance abusers than in the general population [35,36,37,38,39]. Of patients in substance disorder treatment, 12% to 34% have a diagnosis of PTSD; these numbers can be as high as 33% to 59% in certain subgroups, including women [37,40,41]. Brown and Gilman reported that nearly 65% of persons found eligible for county drug court were affected by trauma in some way [42]. Further categorized, 26% met the criteria for PTSD, 35% reported some PTSD symptoms connected to a trauma but did not meet full criteria for PTSD as defined by the DSM-IV-TR, and 3.9% had experienced a Criterion A trauma at some point in their life but had no PTSD symptoms.

Individuals with a history of PTSD are more likely to have a history of other psychiatric disorders, alcohol dependence, and other significant psychosocial impairments [43]. Furthermore, substance abuse increases the likelihood of victimization, which can further promulgate the cycle of coping with trauma-related stress and self-medicating with addictive substances [14,44,45,46,47].

The authors of the Addiction and Trauma Recovery Integration Model (ATRIUM) assert that traditional models of addiction recovery and relapse prevention do not consider the significant role that unresolved trauma can play in an addicted individual's attempt at recovery [48]. They further contend that these traditional approaches tend to marginalize addicted, traumatized women more than their male counterparts. Though the authors do not discredit the merit of traditional models, such as 12-step facilitation or cognitive-behavioral therapy, they suggest that these approaches do not sufficiently address the role that trauma has played. Ultimately, these approaches can set individuals up to fail. Though these ideas are compatible with common themes on relapse risk factors in the literature (e.g., poor self-efficacy, high volume of negative emotion coupled with poor coping skills), an integrated, more holistic approach is needed to promote long-term recovery and prevent relapse. This type of an approach would extend beyond the cognitive interventions that have traditionally been used in relapse prevention counseling or in 12-step-related interventions [13].

Evans and Sullivan proposed a five-tenet model that can be a useful guide [49]. The five essential components of this model are [49]:

There are several qualities that have been identified as lending themselves to ensuring that an EMDR therapist is effective and accepted by clients [55]. However, these qualities are also positive traits of good trauma therapists in general. The following list and questions can be applied to clinical practice, regardless of approach. These questions should serve as a form of self-evaluation, allowing for the identification of strengths and weaknesses:

Good Clinical Skills

Ability to Develop Rapport with Clients

Comfort with Trauma and Intense Affect

Spacious

Well-Grounded

Attuned to Clients

Client perception and comfort can also affect treatment outcomes. One small study with clients who had attained a period of extended addiction sobriety (one to six years) and had been treated with EMDR found that client-identified clinician qualities that resulted in greater satisfaction with care included [13]:

Likewise, traits associated with ineffective therapists were [13]:

Mastering the arts of self-care and self-improvement are vital for any clinician, but for a clinician doing quality trauma work, they are essential. Self-care must be pre-emptive to be effective; it is not enough to initiate interventions after the weight of trauma work is taking its toll [56]. Clinicians doing any trauma work must constantly evaluate and care for themselves first. This can be difficult, as clinicians are trained to care for others and clients' needs may seem more urgent. But it is important to recognize that self-care is not selfish—it is essential to ensuring that the client continues to receive the best possible care from a healthy clinician.

Before initiating stage 2 trauma processing work with clients, it is important to assess one's comfort with handling abreaction and intense affect. Abreaction is defined as "the therapeutic process of bringing forgotten or inhibited material (e.g., experiences, memories) from the unconscious into consciousness, with concurrent emotional release and discharge of tension and anxiety" [2]. In simpler terms, an abreaction is a massive emotional reaction to accessing long-repressed experiences and emotions and may be evidenced by crying, screaming, foaming at the mouth, vomiting, or catatonia in extreme circumstances. Although it can be upsetting, these reactions can be part of a healthy resolution if they are addressed effectively in relation to the goals stage 2 trauma processing work is designed to achieve [1].

As the saying goes, it takes a village to help clients affected by trauma. Often, this comes in the form of needed social support, but in many cases, it also involves collaboration among several providers to ensure clients meet their treatment goals. Best practices for collaboration in treating trauma-related disorders include: