Methods of clinical trauma management


Along with the unconfirmed notion that bodies are born with inherited trauma, MGH’s author emphasizes the practices of somatic therapy for traumatic stress, “body work,” approaches that are not yet among those that enjoy the greatest level of evidential support.
A cursory survey in Google Scholar reveals that even the most widely used treatments for trauma, such as cognitive behavior therapy, do not reliably provide positive and lasting outcomes. NEJM, 2017: available at this link.

As in the challenging fields of nutrition and dietary research and recommendations, such absence of good therapies, plus the extreme, if not impossible, ability to conduct robust non-pharmaceutical clinical trials with convincingly appropriate controls and sufficient numbers of patients, invite many practitioners to admirably explore new approaches in their clinics, including recently trials with MDMA.
It is widely admitted by physicians that positive treatment outcomes often involve placebo effects, and that a trusted rapport between patient and practitioner can be essential. This is clearly even more important for psychological interventions. It is not surprising that various strategies to treat PTSD will have some success for many patients, as it is likely that a key factor is that a patient continues to work with a therapist when a good rapport is in place, and, if nothing else, the boost of hope that arrives when a patient is bumped up from a waiting list to appointments with a therapist. Optimistic expectations can go a long way toward perceptions of relief from suffering.

Numerous trauma therapists, who have become key opinion leaders, often with heavy doses of self promotion, have developed “brands” of treatments, with an accent on some central feature such as various types of body work. They praise each other’s books, and in the guise of scientific conferences, assemble to promote their work, in the absence of any critical voices.

In practice, many types of interactions occur in therapeutic sessions, so it is not clear if the promoted core of the brand is the primary feature responsible for any successful outcomes.

Despite the title of the bestseller The Body Knows the Score by B v d Kolk, hinting at a focus on body work as central to therapy, the book highlights numerous other approaches. Many of these address cognitive aspects, such as via role-playing, self-descriptions, cooperative community interactions, some exposure type work, etc. The “somatic” work includes touch, massage, dance and exercise, elements that have documented beneficial effects, whether embedded in a branded practice or not.

A relevant paper:  “Psychotherapies for PTSD: What Do They Have in Common?”
Co-authors are from several clinics in different countries.  “…..a number of evidence-based treatments are available. They differ in various ways; however, …. The currently available empirically supported psychotherapies for trauma survivors have a lot in common.” Commonalities identified by these clinicians include: psychoeducation, focus on emotion regulation and coping skills, memory processes, and cognitive processing, restructuring, or meaning making. The authors accent the importance of the cultures of the therapists and patients and thus “….recommend developing treatments that are tailored to the needs of different patient groups with regard to factors such as age, sex, culture, comorbidities, and type of trauma experience.”
            Even if covert racism were rampant in our communities, it remains uncertain if the healing strategies of this IBT program were suitably tailored to succeed for our group.

A general impression from this brief view of the literature: Patients with the most severe cases of PTSD suffered traumatic physical injuries. Somatic approaches that explicitly address these wounds would seem to make sense, at least intuitively. In contrast, in our particular communities, it is likely highly uncommon to have experienced a physically violent event that contributed to feelings of racism. As well described in MGH and in B v d Kolk’s book, psychological trauma does produce discomfort in our bodies via the autonomic nervous system, with signals conveyed by the vagus nerve. To justify the centrality of body work, the guide promoted the importance of another unsupported claim, “polyvagal theory,” (PVT) which attributes various unfounded roles to vagus nerve circuitry.

            In the wikipedia article for PVT, see references that challenge the bases of PVT.
            In addition to the problems with the science behind PVT, literature descriptions are loaded with incomprehensible language.

The tone of this essay is echoed by Kevin Mitchell, an Associate Professor of Genetics and Neuroscience at Trinity College Dublin, in an essay on ways to detect unreliable science publications.

Elements in this commentary address the ways that some branded therapies are presented. Mitchell refers to specific examples, including the problems with the credibility of transgenerational transmission of psychological trauma. These problems are also elaborated in Annex 4.

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