Why Your Trauma Counseling Hasn't Worked

Recovering from trauma is a bit like surviving a zombie apocalypse. You’re attacked by infected artifacts of your past experience, but the world still looks the same. Previously neutral relationships are polarized into allies and enemies. Skeletons from your past linger behind doors in your consciousness, scratching at you—judgment, addiction, regret, anxiety, resentment, compulsion, numbness. Scratch, scratch, scratch.

But more to the point, and very much like a zombie apocalypse, you have to follow a certain protocol in order to survive and overcome the wound. For example, your therapist would be the last person you should consult in the midst of a zombie crisis. What would they even say?

  • “How do the zombies make you feel?”

  • “I want you to write a letter to your inner ‘Self’ before the zombies.”

  • “When a zombie is banging on your glass window, I want you to practice these mindfulness techniques…”

  • “The point isn’t to hate the zombies, but to accept them for who they are.”

That would be stupid. You wouldn’t go to a therapist. You would get the closest sharp object or gun, then build a cohort with people you trust, get as many guns as you can, get as much food and water as you can, and go from there. In a zombie crisis, you’d instinctively address physical needs first, then social needs. Once all of those realities have been secured, you would make bonds with people, grieve your loved ones who were killed by the zombies, and build a new society with values.

Talk therapy wouldn’t be your first line of defense against a real crisis, so why would it be your first line of defense against post-traumatic stress?

Talk therapy wouldn’t be your first line of defense against a real crisis, so why would it be your first line of defense against post-traumatic stress? Would you consider the notion that other helpers might be more suited to help you recover? In this article, we will examine why cognitive therapy isn’t as effective as it’s made out to be, and what are some better places to begin trauma recovery.  

The Silent Failure of Therapy

For some reason, the most popular response to trauma is: “You should see a therapist.” There is almost evidence to warrant that recommendation. For example, one study demonstrated an 87% rate of full recovery among women diagnosed PTSD who completed cognitive behavioral therapy.[1] However, we should note two things about studies like this. First, patients are pre-selected for these clinical trials who are likely to validate the hypothesis. Second, patients who drop out of therapy are usually not included in these numbers. Therefore, studies which “prove” the effectiveness of therapy for PTSD demonstrate it only for those sorts of patients whose trauma is mild enough to consistently complete 12 hour-long sessions. In other words, studies tend to stack the deck in favor of  "talk therapy" so that people think it's much more effective than it really is.

Studies tend to stack the deck in favor of  “talk therapy” so that people think it’s much more effective than it really is.

Most psychological studies that investigate therapy inflate their success rate by choosing the patients who are most likely not to “drop out.” Psychologists often pre-select clients who have a solid track record of attending therapy, and regard unstable clients as “unsuitable” for inclusion in the numbers. This makes the drop out rate seem much lower, and also fabricates a perception of effectiveness for methods such as Cognitive Behavioral Therapy.

Researchers commonly recognize that the “real world” drop out rate is significantly higher than the rate in clinical studies—this may be due to a failure to build a meaningful therapeutic alliance, cost, efficacy of treatment, disagreement about what needs to be accomplished.[2]

The truth is that the traumatized are twice as likely to drop out of therapy as the non-traumatized. Indulge me with some data:

  • Among one veteran sample, 79% of PTSD cases dropped out of treatment, compared with 50% of anxiety cases and 57% of non-PTSD cases.[3]

  • One meta-analysis showed that PTSD could be nonresponsive to cognitive-behavioral therapy at rates of 50%.[4]

  • Another study found that PTSD cases had a 78% therapy drop out rate.[5]

  • One study of 1,924 veterans diagnosed with PTSD who were referred to a cognitive behavioral therapist, 98% had dropped out of therapy by the fifth session (against the therapist’s recommendation).[6]

The traumatized are twice as likely to drop out of therapy as the non-traumatized

I interviewed a therapist in the Philadelphia suburbs who has an 80% retention rate. I asked him why his retention rate was so high. He answered:

“Two factors. First, my clients have very middle-class traumas. In a sense, there is no natural end to the therapy, because there is no particular symptom to overcome. Second, my clients are fairly wealthy. So, they can afford to treat therapy as an indulgence, rather than a necessity.”  

One study comments that “dropout plagues virtually every treatment trial, leading to average recovery rates in intent-to-treat analyses of only around 40%.”[7]

People pay to see counselors because the counselors sell themselves as “trauma experts” when, in reality, most of the traumatized people they treat never return after the first session.

So, let’s put this in perspective. Would you take a car to a mechanic whose customers, 50-70% of the time, do not return for a second visit? Would you buy a gun for self-defense that jammed on the second bullet 50-70% of the time? If not, why would you go to a talk therapist to recover from trauma?

The reason is this: People pay to see counselors because the counselors sell themselves as "trauma experts" when, in reality, most people they treat never return. Where else would you go? Here, we propose a different starting point.

Maslow’s Sequence

Traditional therapy models try to help counselees think their way out of post-traumatic stress. And recovery from trauma certainly does require mental effort. But once you know how trauma recovery should work, you’ll see that they’re trying to get people to through the right process, but they’re doing it back asswards. Let me explain.

Once you know how trauma recovery should work, you’ll see how therapists are doing it back asswards.

A psychologist named Abraham Maslow proposed a theory about how human psychology works. He proposed that human beings have certain needs, and that those needs have to be met in a certain sequence—that is, following a certain order.

Just like building a house, if you don’t lay the foundation, the rest of the structure will be compromised. Maslow suggested that the structure of human psychology was made up of five needs, one building on the other, met in this order:

  1. Physical Needs (food, shelter)

  2. Security (financial, personal, basic health)

  3. Social acceptance (friends, family, communal belonging)

  4. Esteem (respect, confidence, recognition)

  5. Self-Actualization (ideals, purpose, peace, equanimity)

For Maslow, you couldn’t meet Security needs without meeting Physical needs. Building your financial portfolio doesn’t make sense if you don’t have access to food or shelter. Working on your Esteem by updating your Instagram account doesn’t make sense if you don’t really have any friends or family. Likewise, it doesn’t make sense to tinker around in Self-Actualization by going to therapy if you don’t have your physical, safety, social, and public needs met.

Again, for Maslow, this hierarchy is the ideal sequence in which one should meet one’s needs. We can use this hierarchy as a model for trauma recovery. This same sequence can translate into the order in which you should address your post-traumatic recovery.

Pursue a Hierarchy of Competence

Maslow’s hierarchy has been seen as a means of self-actualization. But this is a misinterpretation of the model.[8] This hierarchy does not privilege self-actualization, but quite the opposite—it insists upon putting it at the very end. Pursuing the physical, social, and relational first is fundamental to the model, and therefore fundamental to trauma recovery. When a lower level is compromised, the higher levels which it supports become equally compromised.[9]

Putting the physical, social, and relational first—before “talk therapy”—is fundamental to trauma recovery.

If we’re going to translate Maslow’s hierarchy into something actionable for recovery, we need an action-oriented lens. That lens is competence. The question at the heart of trauma recovery is this: What competence would enable me to process and overcome my undesirable post-traumatic experiences? If we use Maslow’s hierarchy as a model, then the answer is fivefold: Trauma recovery means becoming:

  1. Competent at physicality

    1. weight lifting

    2. clean environment

    3. personal hygiene

  2. Competent in personal security

    1. steady pay

    2. self-defense

  3. Competent with intimacy

    1. maintaining healthy relational boundaries

    2. distancing from toxic people

    3. learning to trust trustworthy people

  4. Competent at respect

    1. giving respect where it is due

    2. requiring respect where it is due

    3. not being dependent on other peoples’ opinions

    4. cherishing the respect of others

    5. taking to heart friendly criticism without overreacting

  5. Competent in self-actualization

    1. understanding your emotions

    2. processing past trauma

    3. regulating emotions

    4. making sense of one’s personal story

    5. determining ultimate values

1_MaslowsHierarchy.png

What particular competencies each survivor needs to build will be different. For example, if you’re a trauma survivor who has powerlifted for years, perhaps you need to learn how to be more competent at personal hygiene, or maintaining a clean and orderly environment that inspires peace rather than chaos. If you’re already financially secure, perhaps you need to join a jiu-jitsu class. If you’re already good at cutting toxic people out of your life, perhaps you need to learn the competency of trusting others.

If you don’t exercise or eat healthy, talk therapy will likely not significantly decrease your traumatic symptoms.

One study which treated homeless people contrasted those who received housing first, and those who received therapy first. At 12 months, nearly half of the homeless enrolled in therapy dropped out of the program, whereas those who received housing had an active strategy for improving their lives, such as attending school, reuniting with estranged children, and investing in real estate.[10] Another study shows that therapists who treat anxiety about medical issues as “cognitive behavioral” problems only do more harm than good—they ignore the clear physical need at the heart of the issue.[11]

Incompetence in a fundamental tier of the hierarchy will compromise your performance at higher levels.

The important thing is to follow the sequence in order. The reason it’s important to follow this sequence in order is that incompetence in a fundamental tier of the hierarchy will compromise your performance at higher levels. If you don’t exercise or eat healthy, you shouldn’t think that your depression is caused by a serotonin imbalance.

If you don’t know how to give and receive in a social ecosystem of friendship or family, you shouldn’t be confused why you’re not respected at work. Start from the bottom, and work your way up. Jordan Peterson says something similar in his book 12 Rules For Life. “Rule 1: Stand up straight with your shoulders back.”[12] Recovering from trauma means starting with the physical and moving up to the existential (competency approach), not the other way around (typical therapy).

2_CompetenceVsTherapy.png

 

The problem with most trauma therapy is that it starts with the top of the hierarchy rather than the bottom. It treats trauma recovery as though it were an existential boo-boo, rather than a profound rupture of the self, with a fault line that reaches all the way down to one’s basic physical constitution.

Recovering from trauma means starting with the physical and moving up to the existential, not the other way around.

Again, when applied to trauma, don’t think of Maslow’s model fundamentally as a hierarchy of needs, but a hierarchy of competence.[13] Applied to trauma recovery, one can properly “recover” one’s self that was lost by rebuilding competencies in Maslow’s sequence—beginning with physical and extending only later to the existential.

Don’t buy the cultural myth that you can recover from trauma by tinkering around in talk therapy alone. It's meant to help culminate energy you've already put into the process, not be the entire process. If you need professional help pursuing physical competence, here are some professionals it would be better to hire instead:

The point here isn’t to bash therapy. The point isn’t to say that therapists are never helpful. Therapists are helpful sometimes. But their work, and their competence, must be put in its place. Therapy is garnish that we use to give coherence to work we’ve already done.

One of the reasons the drop out rates for therapy are between 50%-70% (up to 98%)—especially among those diagnosed PTSD—are because most therapists are not addressing the issues that really need to be addressed.

You don’t need to talk for an hour about the traumatic event or your feelings. You need to have particular competencies that you’re working toward, for which you can quantitatively track your progress and consider strategies for improvement. Otherwise, therapy is just an attempt to get an emotional payoff for work you’re not doing.

Talk therapy at its best facilitates the strategic improvement of more fundamental competencies—therapy at its best requires skillsets most therapists don’t have.

Look at the sequence above. Ask yourself honestly: “What incompetencies are sabotaging my life? And how are they sticking points for my post-traumatic stress?” Then address those deficiencies in sequence by establishing habits that enable the construction of those competencies. Don’t put your hope for recovery in a talk therapist. Let talk therapy be one tactic you use to succeed in your broader strategy to cultivate key trauma-related competencies that are unique to your situation.

Books Referenced in This Article

Click to buy on Amazon.

FOOTNOTES

(Click book titles to purchase on Amazon)

[1] Edward S. Kubany, Elizabeth E. Hill, Cindy Iannce-Spencer, Mari A. McCaig, Julie A. Owens, Ken J. Tremayne, Paulette L. Wiliams, “Cognitive Trauma Therapy for Battered Women With PTSD,” Journal of Consulting and Clinical Psychology 72, no. 1 (2004): 3-18. Bessel van der Kolk counters: “The majority of patients treated with [the cognitive] method continue to have serious PTSD symptoms three months after the end of treatment. … [F]inding words to describe what has happened to you can be transformative, but it does not always abolish flashbacks or improve concentration, stimulate vital involvement in your life or reduce hypersensitivity to disappointments and perceived injuries.” Bessel van der Kolk, The Body Keeps Score: Brain, Mind, and Body in the Healing of Trauma (New York: Penguin, 2014), 196. The truth of the matter is certainly complex.

[2] See Zac E. Imel, Kevin Laska, Matthew Jakcupcak, and Tracy L. Simpson, “Meta-Analysis of Dropout in Treatments for Post-Traumatic Stress Disorder,” Journal of Consulting and Clinical Psychology 81, no. 3 (2013): 393-404.

[3] J. C. DeViva, “Treatment Utilization among OEF/OIF Veterans Referred for Psychotherapy for PTSD,” Psychological Services 11, no. 2 (2014): 179-84.

[4] M. A. Schottenbauer, C. R. Glass, C. B. Arnkoff, V. Tendick, S. H. Gray. “Nonresponse and Dropout Rates in Outcome Studies on PTSD: Review and Methodological Considerations,” Psychiatry 71, no. 2 (2008): 134-68. See also R. A. Bryant, K. Flemington, A. Kemp, et al., “Amygdala and Ventral Anterior Cingulate Activation Predicts Treatment Response to Cognitive Behavior Therapy for Post-Traumatic Stress Disorder,” Psychological Medicine 38, no. 4 (2008): 555-561.

[5]  J. M. Mott, S. Mondragon, N. E. Hundt, M. Beason-Smith, R. H. Grady, E. J. Teng, “Characteristics of U.S. Veterans who Begin and Complete Prolonged Exposure and Cognitive Processing Therapy for PTSD.” Journal of Traumatic Stress 27, no. 3 (2014): 265-273.

[6] B. C. Watts, B. Shiner, L. Zubkoff, E. Carpenter-Song, J. M. Ronconi, C. M. Coldwell, “Implementation of Evidence-Based Psychotherapies for Posttraumatic Stress Disorder in VA Specialty Clinics,” Psychiatric Services 2014 65, no. 5 (2014): 648-653.

[7] C. W. Hoge, S. H. Grossman, J. L. Auchterlonie, L. A. Riviere, C. S. Milliken, J. W. Wilk, “PTSD treatment for Soldiers after Combat Deployment: Low Utilization of Mental Health Care and Reasons for Dropout,” Psychiatric Services 65, no. 8 (2014): 997-1004. See also D. S. Riggs, M. Rukstalis, J. R. Volpicelli, D. Kalmanson, and E. B. Foa, “Demographic and Social Adjustment Characteristics of Patients with Comorbid Posttraumatic Stress Disorder and Alcohol Dependence: Potential Pitfalls to PTSD Treatment,” Addictive Behaviors 28 (2003): 1717-1730 and S. Taylor, “Outcome Predictors for Three PTSD Treatments: Exposure Therapy, EMDR, and Relaxation Training,” in S. Taylor (ed.), Advances in the Treatment of Posttraumatic Stress Disorder: Cognitive Behavioral Perspectives (New York: Springer, 2004), 13-37. Riggs et al found that drop out is not related to demographics, depression, general anxiety, personality, trauma characteristics, anger, guilt, shame, nonspecific therapy factors, while Taylor found no relation between drop out and the severity of the PTSD or PTSD-related symptoms, duration of PTSD, or the nature or number of the traumas.

[8] One article in particular, which tries to relate Maslow’s model to PTSD recovery, really misses the point of the hierarchy. This article mistakes the height of the hierarchy for the sum of the hierarchy, when it is not. Therefore, the study measures PTSD recovery in terms of existential fulfillment, corresponding generically to the concept of self-actualization. The study ought to have incorporated studies which measured all elements of the hierarchy, such as physical wellbeing and social connection. I would not recommend reading the study because, again, it misapplies the model, but here is the reference: Hugh Middleton, “Flourishing and Posttraumatic Growth: An Empirical Take on Ancient Wisdoms,” Health Care Analysis 24 (2016): 133-147.  Andrew Trigg’s article likewise misconstrues Maslow’s hierarchy as overly self-involved, while “questions of social interaction and culture are seriously downgraded.” I’m not sure how Triggs doesn’t perceive that the hierarchy clearly finds social and cultural realities important at the third tier of the hierarchy—and, of course, how each tier is met and shaped can transmute how other tiers are met and shaped. Andrew B. Trigg, “Deriving the Engel Curve: Pierre Bourdieu and the Social Critique of Maslow’s Hierarchy of Needs,” Review of Social Economy 62, no. 3 (2004): 393-406.  

[9] Maslow himself explains: “Practically everything looks less important than safety, even sometimes the psychological needs which being satisfied, are now underestimated. A man may be characterized as living almost for safety alone.” Abraham H. Maslow, “A Theory of Human Motivation,” Psychological Review, 50, no. 4 (1943): 370–396.

[10] Benjamin F. Henwood, Katie-Sue Derejko, Kulie Coulture, and Deborah K. Padgett, “Maslow and Mental Health Recovery: A Comparative Study of Homeless Programs for Adults with Serious Mental Illness,” Administration and Policy in Mental Health and Mental Health Services Research 42, no. 2 (2015): 220-228. This gels well with Maslow’s later hypothesis that it is the failure to meet physical needs which tempts people to focus on higher self-actualization needs, while the fulfillment of physical needs tended to satisfy people enough not to pursue self-actualization.

[11] P. J. Haybach, “Maslow’s Hierarchy of Needs and the Individual with Chronic Vestibular Dysfunction,”ORL-head and Neck Nursing 12, no. 2 (1994): 14-17.

[12] Jordan B. Peterson, 12 Rules for Life: An Antidote to Chaos (New York: Penguin Random House, 2018), 1-30. Jackson et al. rightly explain: “One does not move into upper tiers of human needs until the levels of needs are met at each consecutive lower level.” James C. Jackson, Michael J. Santoro, Taylor M. Ely, Leanne Boehm, Amy L. Kiehl, Lindsay S. Anderson, and E. Wesley Ely, “Improving Patient Care Through the Prism of Psychology: Application of Maslow’s Hierarchy to Sedation, Delirium and Early Mobility in the ICU,” Journal of Critical Care 29, no. 3 (2014): 438-444.

[13] Francis Heyleighen suggests that the need is not so much for external supply, but for internal competence. Francis Heylighen, “A Cognitive-Systemic Reconstruction of Maslow’s Theory of Self-Actualization,” Behavioral Science 37 (1992): 39-57

 
 
Name *
Name