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Trauma: Little t or Big T?

By: Bridgette W. Gottwald, LPC, NCC

When it comes to psychotherapy, trauma is a popular word. Within treatment, I often refer to trauma and the event experienced as a trauma with a little t or a capital t, depending on the gravity of the event. Little t traumas are highly distressing events that affect the individual on a personal level. Some examples are non-threatening injuries, emotional abuse, the death of a pet, bullying, or harassment. Big T traumas are most commonly associated with post-traumatic stress disorder (PTSD). Some examples of big T traumas may be sexual abuse or violence, serious injury, or life-threatening experiences. 

If you are still impacted by something months and years later, it’s not the events themselves that are the issue, it’s the injuries of the event that occurred that are keeping you stuck. Traumas are experiences that are stuck in processing: memories, images, sounds, smells, taste, emotions, body sensations, thoughts, the meaning of events, and beliefs about the self. Trauma hinders brain development and bad experiences before the age of 25 can impact development. 

Bottom-up vs. Top-Down Approaches to Therapy 

With psychotherapy, there is never a one size fits all approach. For this reason, it’s useful to integrate many different approaches and to pay special attention to what best suits the client and their unique situation. Often in trauma-informed care, bottom-up approaches might be the best route. So you might be thinking to yourself what does all of this mean? A bottom-up approach refers to starting therapy with the parts of the brain that are located towards the base. These are the areas that are responsible for reflexes, memories, and automatic survival responses, as well as playing an important role in learning. 

For top-down approaches, we begin therapy with the parts of the brain that are associated with thinking, speaking, and emotional awareness. These areas of the brain are located towards the top and include the neocortex, frontal, and prefrontal lobes. 

EMDR, Trauma Treatment, and Stages

You’ve likely heard of Eye Movement Desensitization Reprocessing (EMDR) which involves gentle sensory input that actives both parts of the brain. During this process, the brain becomes desensitized to the experience and it allows the individual to learn from it in positive ways. EMDR is facilitated in stages, which are described as follows:

  1. Client history and treatment planning: this one is a bit self-explanatory, but this involves history taking to evaluate the entire clinical picture to ensure that treatment is facilitated properly.
  2. Preparation: This includes establishing the appropriate therapeutic relationship, breaking down the theories it involves, and encouraging successful processing. 
  3. Assessment: In this phase, you identify the component of the target. Once the memory is identified, the client then selects an image that best represents the memory. Then, the client chooses a negative cognition that is dysfunctional, maladaptive self-assessment that is related to their participation in the event. 
  4. Desensitization: This phase of treatment encompasses all responses regardless of the client’s distress increasing, decreasing, or being “stuck.” 
  5. Installation: Within this phase, the client is focused on installing the increasing the strength of the positive cognition that the client has identified to replace the negative cognition. 
  6. Body scan: After positive cognition is fully installed, the client is asked to hold the target within their minds, identify residual tension, and form body sensations. 
  7. Closure: At the end of each session, the client must be returned to a place of equilibrium, regardless of the processing being completed or not. Self-control techniques can be used to close the session. Often, journaling is used to report on sessions. 
  8. Reevaluation: The eighth and final phase of treatment includes additional targeting, re-assessing, and review to ensure optimal treatment effects.  

Hopefully, this blog gave you more intel on trauma treatment amidst psychotherapy, which hopefully makes the idea of it less intimidating and confusing. Good luck everyone! 


Brickel & Associates, LLC. EMDR Therapy. Retrieved from:

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