Deconstructing Trauma Schemas
Journal of Psychiatry Reform vol. 10 #3, March 2023
Caroline Giroux, MD, FRCPC
Professor of Psychiatry, Psychiatrist, University of California, Davis Medical Center,
Department of Psychiatry and Behavioral Sciences, Sacramento, California, USA. [email protected]
A traumatic event shakes people’s core beliefs about the world, other people or themselves. Because of the intense sense of threat to the person’s safety, waves of fear and shame (especially if there is a humiliating aspect of an attack) overwhelm the victim. This cognitive after effect of autonomic reactivity might lead to even more distressing emotions and behaviors, hence interfering with healing and integration of the trauma. Fortunately, a cognitive intervention can be easily applied to address every index trauma that still has an impact on the victim even many years later and offers promise of recovery and reorganization of a person’s life and identity for the better. Cognitive processing therapy (CPT) is a specific type of cognitive behavioral therapy that is evidence-based for PTSD and has been effective in reducing trauma-related manifestations that have developed after experiencing a variety of traumatic events.
CPT is generally delivered over 12 sessions and helps patients challenge and modify unhelpful beliefs related to the trauma. This article aims to explain how by showing a 4-column grid used in a group therapy fostering empowerment of survivors of trauma. The important concept in that dimension of trauma recovery using CPT is called trauma schema. A trauma schema refers to the set of ideas, feelings and patterns of behavior that arise after a traumatic event and that forms the person’s adaptation and integration of the traumatic experience . It can be a belief, an automatic thought, a cognition or assumption that emerged after trauma to cope with it and that is maintained to buffer resulting helplessness and powerlessness. Trauma schemas arise in order to reduce the primary emotions of fear and shame they are reinforced to cope with the secondary emotions (like despair). Trauma schemas are relational; the empathic bridge between self and other is broken. Their central themes often revolve around safety, security, trust, power, control, esteem and intimacy: “the world is unsafe”, “I am worthless”, “everyone wearing a uniform is out to get me”. They are also called “stuck points.” The schemas will have some elements that mirror the traumatic experience and some elements that ward of or deny the traumatic experience .
If we want to look at the phenomenon in a linear fashion, the traumatic event generates a primary emotion (fear, shame), which in turn leads to thoughts, interpretations, new beliefs. In response to the schemas and primary emotions, secondary emotions (such as anger, depression, guilt) will emerge. As a result, anything triggering the fear and shame might have a trauma schema attached to them, further reinforcing the unpleasant emotions. Deconstructing the sequence and understanding how each step leads to another can be very enlightening and this is usually one of the most engaging and dynamic sessions for the group I have been offering since 2018. And why does this take place in this way on a cognitive level? In order to cope, it is easier at first for the survivor to try to assimilate the outside reality to fit their world views or preconceived ideas (such as “bad things only happen to bad people”), rather than accommodate to the outer reality by expanding core beliefs so that they are more nuanced. Assimilation means attempting to force our representations of reality into our belief system. This leads to rigidity (“this happens to me, therefore it means I am bad, or unworthy”). The opposite is accommodation, which means appraising a new experience as objectively as possible and adapting the core belief so that it reflects reality more are totally outside of our control and therefore can happen to anyone. Maybe I can find ways to use this experience and become a more authentic, compassionate person. I am worthy of pausing, healing and finding out.”).
In a group setting for survivors of trauma at UC Davis, I guide the participants in identifying their schemas by looking at their triggers, and using a grid or table (see below), I encourage them to ultimately challenge the trauma schema and replace it with a more adaptive cognition, or healing mantra. For instance, column A lists triggers (“something happens”, like seeing a man looking like the perpetrator of a sexual assault). In column B, we display the corresponding thought, block, stuck point or schema (“I tell myself something”, like “I cannot trust men”). In column C, we include sensations, emotional responses or behaviors (“I feel/do something”, like nausea, fear and shame, and an urge to run away from a situation orperceived intimacy as a result).
B: thought, block, stuck point (trauma schema)
C: consequence or reaction (emotion, autonomic response, behavior)
D or B’: new, more adapted belief
I think or hear a narrative
I feel/do something
I tell myself/I believe…
|Seeing a man who has a resemblance to the rapist.
“I cannot trust men”
Urge to run away
|“This person is different, this is now and not the past. I can ensure my safety and bring myself back in the moment. I take deep breaths.”
Sometimes C precedes B, or B is unnoticed or not that explicit at first, so we often start filling up the table at the column C, then we identify the associated trigger in A, and finally we decode the reaction by finding the silent script or trauma schema. The next step consists of challenging the latter. Is the thought in B realistic? How accurate does the patient think it is? The final and most rewarding, empowering step in this exercise is to choose a positive affirmation (column D). It is about bringing in the evidence that contradicts the schema (for instance, by naming all the men that are worthy of trust in the victim’s life). What can you tell yourself in the future if a similar situation or encounter with a trigger occurs? We introduce discrepancy and point out the different aspects of the current situation compared to the traumatic experience.
We can also add self-validation and statements about self-efficacy (“I have control over how safe I can feel, moment by moment”, “If I sense danger, I trust that I will be able to try to seek help”, “I am resilient and how I approach or view a situation is under my control”, or “I can do deep breathing whenever I feel triggered, breathing gives me a sense of safety and it is my anchor, it brings me in the moment” etc.).
In conclusion, the exploration of trauma schemas can be easily incorporated in any therapeutic encounter. Once survivors go through the deconstruction exercise under a therapist’s guidance, they may find the active role they took in selecting a situation to discuss rewarding. They may later feel comfortable using the table or grid as an assignment during cognitive-behavioral therapy and beyond to tackle the maladaptive responses to trauma and develop a sense of empowerment.
- Johnson DR, Lubin H. Principles and techniques of trauma-centered psychotherapy. American Psychiatric Pub; 2015 Apr 8