Ioana Ababei Expat Psychologist

Note to Readers: This article is intended for practitioners and psychology students interested in the theoretical and evidence-based frameworks of trauma therapy. This research highlights the importance of a responsive framework, one that honours established guidelines while remaining open to somatic and creative interventions when a client’s unique needs require a more tailored path, like in the integrative approach. While it contains academic terminology, the core message focuses on how we can better tailor therapy to the individual.

The need for finding effective and accessible treatment for psychological trauma is highly justifiable for alleviating the suffering of the survivors, but also for reducing the personal, societal, and economic costs associated with untreated mental health problems.

Is effective trauma therapy always a combination of stabilisation and trauma exposure? This approach is aligned with a phased approach to trauma therapy, an initial model developed by Pierre Janet (1889/1971) and revised by Herman (1992), which, in fact, includes three phases (Dyer & Corrigan, 2021). The initial phase, stabilization, focuses on recreating a sense of safety and managing symptoms and emotions. The trauma exposure phase, centres around memory reprocessing of the trauma. The third phase, reintegration, emphasises personal growth beyond the trauma, however, is less researched (Dyer & Corrigan, 2021).

This essay argues that while the combination of stabilization and trauma exposure is often critical for effective trauma therapy, this approach is not universally applicable and should be tailored to the individual needs of clients.

Is Stabilization Really Necessary? To understand whether stabilization is essential in trauma therapy, it is important to examine the current clinical guidelines. For post-traumatic stress disorder (PTSD), the NICE guidelines (2018) recommend trauma-focused therapy, individual trauma-focused cognitive behavioural therapy (CBT) or Eye Movement Desensitization and Reprocessing (EMDR), recommendations aligning with several clinical guidelines (Lewis et al., 2020; Willis et al., 2023). The unimodal, exposure therapy, which prioritises addressing the fear-inducing memories, along with engaging with avoided stimuli or situations, is shown to be highly effective in reducing PTSD (McLean et al., 2022), CPTSD (Voorendonk et al., 2020), and mental health comorbidities symptoms (Coventry et al, 2020). Therefore, exposure therapy is the first-line treatment and seems to be sufficient for treating psychological trauma.

While exposure therapy has demonstrated significant effectiveness, its implementation is not without challenges, particularly regarding its tolerability. The provocative and adverse elements of the intervention can cause amplification of current symptomatology (Lewis et al., 2020). One important consequence of low tolerability is the higher rate of treatment dropout, in comparison with therapies that do not use exposure (Lewis et al., 2020). Therefore, a stabilisation phase of the treatment could serve to prepare the patients for the exposure phase (Coventry et al, 2020) and enhance the exposure treatment tolerability (Willis et al., 2023) and adherence, contributing in this manner to treatment effectiveness.

The stabilization phase can have a preparatory role for the patients, being particularly important for supporting those on waiting lists to receive the standard recommended exposure treatment. This initial phase and its importance is especially emphasised in the treatment of CPTSD (Ford & Courtois, 2020). The focus is on fostering a sense of safety, reducing immediate distress, and offering patients the tools to manage their symptoms by using psychoeducation and skills training (Eichfeld et al., 2019). For example, the implementation of Compassion Focused Therapy (CFT) in the stabilisation phase can improve the emotional state of the patient by alleviating the personal sense of guilt associated with the experience of trauma (Ashfield et al., 2021). Therefore, the stabilization phase is effective in managing the impact of trauma symptoms.

The Combined Approach
Building upon the benefits of stabilization and exposure therapy, combined approaches offer an integrative model that incorporates both elements into a cohesive treatment framework. For example, the STAIR Narrative Therapy contains both phases, the initial phase focuses on regulation of emotions and skills training, whereas in the narrative phase, the focus is on processing the traumatic memories (Hassija & Cloitre, 2014). According to Cloitre et al. (2020), the strong therapeutic relationship and enhanced negative mood regulation resulting from the initial phase support the reduction of PTSD symptoms in the second phase. Moreover, the combined approach seems to show improvement in symptoms for comorbid conditions such as anxiety and depression (Cloitre et al., 2020). At the same time, the stabilisation interventions should be implemented as components of more complex trauma treatment, and not as a self-contained treatment (Melegkovits et al., 2023). Therefore, the phased approach of trauma treatment has a therapeutic impact, showing the importance of the stabilisation phase for the outcome of the treatment (Willis et al., 2023) and for the personal experience of the individuals who engage with the therapy (Wells et al., 2023).

Despite the potential benefits of combined approaches, the effectiveness of the stabilization phase can vary depending on personal factors and the perceived difficulty of the process. People who experience trauma can find it difficult to undergo psychological treatment, including stabilization (Willis et al., 2023). Motivation for change and readiness to follow treatment are crucial elements for a successful stabilization phase, helping patients feel prepared for the next phase of the treatment (Willis et al., 2023). Even if positive outcomes are reported, such as a sense of safety, recognition, normalization of the experience (Willis et al., 2023), and skills integrated over time, for the participants, the stabilisation phase can be demanding to engage (Stige & Binder, 2016). At the same time, some authors report that the stabilization phase may be redundant, not having a clear effect alongside the exposure treatments (De Jongh et al., 2016). Therefore, besides the recommended protocols, taking into consideration individual preferences and characteristics when deciding the therapeutic approach can have important benefits.

Should Trauma Therapy Be Always About Stabilisation and Exposure?
Given these challenges, it is crucial to explore alternative treatment approaches that cater to clients who may not respond well to the traditional treatment. First, the effectiveness of exposure therapy can differ based on demographics, clinical characteristics and implementation (McLean et al., 2022). Second, some patients show resistance to the classical treatment (Loerinc et al., 2015). Even more, some patients following an intense treatment can show no results regarding decreasing symptoms, an increase in avoidance mechanism, somatization and anxiety (Haeyen & Wanten, 2024).
Nevertheless, the classical interventions emphasise cognitive processing (Kuhfuß et al., 2021) and patients with PTSD suffer from impaired cognitive functioning (Quinones et al., 2020). Therefore, alternative approaches that show promising results, like trauma-focused art therapy (TFAT) (Haeyen & Wanten, 2024), or somatic experiencing (SE) (Kuhfuß et al., 2021) could be used to increase the clinical impact for people who may need a different approach.

Conclusion
Effective trauma therapy is not always a combination of stabilisation and trauma exposure, as individual needs, preferences, and circumstances may require different approaches. As a practitioner, I recognise the importance of balancing evidence-based practices with tailored interventions to each client’s unique needs. I believe clear guidelines protect the clients from being harmed in the therapeutic process. At the same time, from a philosophical and personal standpoint, I believe therapy must prioritise patients’ autonomy and unique needs, and avoid imposing interventions that may cause too much distress. In my opinion, the focus should be on prioritising collaboration and individualisation to achieve both effectiveness and tolerability.
I believe choosing the best approach requires assessing each client’s trauma history, emotional readiness, and treatment preferences.

Practically, stabilisation can be valuable for clients with complex trauma, helping to prepare them for exposure therapy. However, not all clients require this phase, and its unnecessary use could delay effective treatment. Moreover, for clients who can not engage with the classical treatment because of low tolerability, alternative approaches should be offered, like TFAT or SE, when appropriate. Therefore, I recognise that stabilisation and exposure are effective components, but not universally required, and treatment guidelines should offer a more inclusive path to recovery.

References

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