Complementary & Alternative Techniques and Interventions

Biofeedback-based Techniques

Biofeedback refers to a wide range of techniques used to help people become aware and gain voluntary control of bodily functions that are normally involuntary or automatic, like breathing and heart rate.

Biofeedback-based therapies have primarily been used to aid relaxation and more effectively manage chronic stress by helping people shift baseline levels of physiological activity. For example, biofeedback can be used to help someone lower their blood pressure or reduce muscle tension.

Biofeedback typically works by attaching non-invasive sensors to a person’s skin or hair that measure various forms of physiological activity such as body temperature, sweat gland activity and even frequency of brain waves. These sensors track changes over time in the type of physiological activity being measured. Clients gain increased awareness and control of these automatic body processes over time through use of computer screens or other devices that enable them to visualize and monitor their internal experience.

Two Forms of Biofeedback

Two specific forms of biofeedback have been applied extensively and evaluated for use with complexly traumatized adult and youth populations:

1. heart rate variability retaining and
2. brain biofeedback, also referred to as clinical neurofeedback.

Heart Rate Variability (HRV) Retraining

Are you interested in taking a bottom up approach to trauma treatment, targeting the biological impact of trauma on your body and its alarm system?

What sets this treatment apart:

HRV Biofeedback is a treatment intervention which increases flexibility and adaptability of the body by changing cardiac functioning through controlled breath.

Heart Rate Variability is the balance between:

• the sympathetic nervous system, which prompts stress hormones to support the body and brain in taking effective action, and
• the parasympathetic nervous system, which regulates basic bodily functions such as sleep and digestion.

Complex trauma negatively impacts the balance between the sympathetic and parasympathetic nervous system, decreasing a person’s baseline HRV. This effect is associated with:

• negative cognitive functioning,
• negative emotional and behavioral responses, and
• an impaired stress response system.

HRV Biofeedback helps retrain the biological system to regulate and balance the nervous system through the creation of a healthier HRV baseline. Surface sensors are placed on the fingertip or earlobe to measure a client’s HRV which is then displayed using visual or auditory cues.

Utilizing breathing techniques, the client learns how to reach the desired cardiac functioning improving their HRV and decreasing symptoms associated with their trauma. Numerous companies have created software and associated devices to aid clients in either therapist-administered or self-directed practice of heart rate variability retraining.

The HeartMath Institute offers perhaps the most extensively researched system of heart rate variability retraining techniques and tools. While no large-scale or controlled research on use of the HeartMath system for traumatic stress has been conducted to date, this system has seen widespread use in private practice, clinics and residential treatment settings with youth and adults impacted by complex trauma. Anecdotal report and case history data has suggested promising use of this methodology with select clients as a component of overall trauma-focused treatment.

Population served:

HRV retraining is an adjunctive technique primarily used in the context of overall individual psychotherapy with children, adolescents, and adults. These techniques frequently include home-based practice. While several packages are designed for self-administration outside the context of therapy, it is always recommended that people consult with a therapist or other trusted medical provider before undertaking a new intervention or technique on their own.

Clinical Neurofeedback (Brain Biofeedback)

Are your long-term efforts to address the effects of complex trauma through medication or traditional talk therapy showing limited results? Are you interested in learning to retrain your brain so you can prevent it from running in constant trauma-mode?

What sets this intervention apart:

Neurofeedback is a treatment intervention which acknowledges the natural capacity of the brain to heal and reshape to support a healthier, calm state.

Neurofeedback understands repeated adverse experiences in a person’s life results in the strengthening or loss of different connections in our brain to support for survival.

These disordered connections often produce hyperarousal within the emotional regions of the brain and lessened activity within the cognitive regions of the brain.

Neurofeedback decreases trauma- based symptoms and improves executive functioning through directly accessing the brain through non-invasive monitoring of the frequency of various brain waves. This is accomplished through use of electroencephalogram (EEG) monitors, which tracks the brain’s signals through use of slightly sticky but non-invasive surface electrodes placed on the scalp.

Clients are taught techniques, such as breathing, which regulates brain activity. Measured brain activity in real-time is compared to the desired goal for change. The client receives instantaneous information about the changes in their brain’s activity.

As the client effectively focuses and regulates, achieving the desired goal for change, they are rewarded with a visual or auditory reward. These rewards let the brain know that the regulated state is the desired outcome. With repetitive exercise brain networks are reshaped for improved functioning.

Neurofeedback is associated with sharpened attention and improved mood, learning, and behaviors without, in most cases, medication.

Population served:

Neurofeedback is an individually administered technique which can be used with adults, adolescents, and children five years or older. It is primarily used as a complementary or adjunctive component of overall trauma-focused therapy with youth or adults.

One randomized controlled study of adults with longstanding trauma-related symptoms associated with histories of early onset trauma demonstrated substantial symptom resolution in the absence of other forms of intervention. While such findings need to be replicated and should be considered preliminary, they suggest that clinical neurofeedback may have the potential to function as a primary or standalone treatment for select adult clients with chronic, treatment-resistant symptoms associated with complex trauma.

Mindfulness-based Therapies and Techniques

The 2000’s have been a renaissance for holistic medicine, with overdue recognition of the contemporary relevance and value of a growing number of ancient healing practices.

The utility of mind-body techniques, from tai chi to acupuncture, has been supported by scientific research. In the mental health realm, mindfulness-based approaches incorporating meditation and yoga, have demonstrated robust benefits for a number of mental health concerns, including anxiety and depression.

Meditation and yoga are the focus of two models that have been extensively practiced and evaluated in the context of trauma-informed treatment: mindfulness-based stress reduction and trauma-sensitive yoga.

Mindfulness Based Stress Reduction (MBSR)

Are you interested in cultivating your natural capacity for learning and healing within a supportive environment of people who share the same desire for growth?

What sets this intervention apart:

MBSR is a meditation-based intervention which integrates meditation and mindfulness promoting a present focused, emotionally supportive environment.

Mindfulness is a meditative technique which brings a person's awareness and engagement to the present experience and is associated with:

• increased peace of mind,
• enhanced ability to cope with stressful situations, and
• improved energy, focus, and resiliency to support recovery from challenging events.

Meditation, as an intervention, refers to a variety of mind-body techniques with a generalized goal of healing symptoms through trained awareness and regulation.

MBSR uses meditation and mindfulness techniques such as:

• body scanning,
• mindful yoga, and
• sitting meditation,

to emphasize the inner resources, effort, and motivation of the client.

MBSR provides the challenge and adventure of a changed lifestyle rather than feeling as though healing is a chore.

MBSR provides an opportunity where people of all diagnosis and experiences engage in MBSR together sharing commonalities such as life, body, breath, and thoughts.

Population served:

MBSR was originally created for adults though mindfulness and meditation as a practice is adapted for all ages. MBSR is delivered in three different formats: An eight-week in person program, an eight-week online program, or an intensive five-day residential program.

Trauma Center-Trauma Sensitive Yoga (TC-TSY)

Tired of endless talk therapy that doesn’t change how you feel? Would you instead like to shift the focus to creating or reestablishing a positive sense of connection to your body?

What sets this intervention apart:

TC-TSY recognizes trauma’s impact on the whole person, guiding individuals on a journey of healing--mind, body, and spirit. Yoga is well known for its ability to:

• reduce symptoms,
• improve physical health, and
• decrease emotional distress.

Yoga is a meditative practice guiding individuals through rest, breath, and movement.

Unlike traditional yoga, TC-TSY is sensitive to people with complex needs. Rather than being form focused, TC-TSY empowers each person to choose movements which feel safe to the individual, increase tolerance at their own pace, and participate in a setting without touch or peer communication to guide.

TC-TSY promotes present awareness and internal reflection of individual somatic and affective experiences to:

• support regulation,
• establish a renewed connection to self and community, and
• support a healthy relationship between body and mind.

Despite the recent proliferation of yoga-based interventions claiming to be trauma-informed, TC-TSY intentionally designed for this purpose over a five-year period of model development, piloting and refinement, is the most extensively evaluated and widely disseminated of yoga-based trauma treatment model, and was the first yoga-based therapy to be recognized as an evidence-based practice in the United States.

Population served:

TC-TSY was initially developed for adult civilian and veteran trauma clients, but has been adapted for use with adolescents.

TC-TSY is offered individually, as an open group, or as a closed group. Groups are also often organized by gender preference. TC-TSY groups are primarily facilitated in select:

• studios,
• social service organizations,
• outpatient or community treatment centers,
• VA’s or residential treatment facilities.

Individual TC-TSY has been adapted to be readily incorporated by mental health clinicians into ongoing psychotherapy in clinic or private practice settings.

Somatic Regulation-based Therapies

Neuroscientific research has shown the pervasive imprint of complex trauma on the body. Problematic manifestations of physiological and somatic dysregulation are prevalent in individuals who have endured complex trauma. Nevertheless, there has been longstanding skepticism of somatic regulation-focused therapies within the traditional posttraumatic stress field. Professional resistance toward use of somatic approaches in trauma treatment has been especially pronounced in academia, and may be due to the historical lack of research evaluating this type of intervention.

Two somatic regulation-focused interventions have been widely disseminated and implemented by outpatient therapists over the past three decades, amassing extensive practice-based support of their benefit to the overall course of complex trauma treatment: somatic experiencing and sensorimotor psychotherapy.

Somatic Experiencing (SE)

Are you ready to address the overwhelming physical sensations and stop feeling as though your body is stuck reliving a stressful past event?

What sets this intervention apart:

SE addresses the cause of a person’s physiological symptoms by turning off a person’s danger response system which is believed to underlie present dysregulation.

When a person experiences trauma their stress response prepares the individual for a fight or flight response. When these responses are ineffective or unavailable, an individual is immobilized into freeze mode. The energy prepared for a fight or flight response is then stored within the individual's body and replayed through problematic somatic symptoms. SE introduces the concept of healing through the slow release of energy using techniques such as titration. The therapist gently guides the client to increase tolerance for difficult bodily sensations by altering between the sensations associated with trauma and those which are a source of comfort. The therapist consistently assesses for somatic sensations and promotes self-regulation through maintaining a safe space within the client’s window of tolerance and exploring safe spaces in the client’s mind. In the first major outcome study of this model, SE was associated with significant reductions in symptoms of posttraumatic stress and depression in a randomized control trial.

Population served: SE primarily serves adults, but elements of the model have been adapted and utilized within the context of other modalities for children and adolescents. SE is primarily administered individually, typically adjunctively, integrated within or in consultation to ongoing trauma-focused psychotherapy.

Sensorimotor Psychotherapy (SP)

Have you felt like your body, mind, and thoughts continue to be controlled by memories of a painful past event?

What sets this intervention apart:

SP is an integrative treatment model that combines body-based intervention with elements of mindfulness-focused talk therapy. SP was founded on the belief that for healing to occur trauma needs to be processed on three levels:

• sensorimotor,
• emotional and
• cognitive.

SP guides clients to build awareness of how their body communicates emotions and assists clients in exploring the imprint of trauma left within their physical selves and in learning methods of managing the related emotional and somatic expressions.

Within the context of the safe therapeutic relationship, the client is asked to slowly recall parts of an adverse experience, and is supported in mindfully tracking physical movements and sensations. The therapist helps the client better articulate and differentiate their present somatic experiences associated with trauma-related thoughts, feelings and memories. The therapist supports the client to reintegrate their physiological sensations into a recollection of the adverse event without the same overwhelm, and to decrease limiting beliefs and related emotions.

Population served:

SE is primarily implemented individually with adults, but elements of the model have been adapted and utilized within the context of other modalities for children and adolescents.

SE can be administered adjunctively, integrated within or in consultation to ongoing trauma-focused psychotherapy, or as a primary, standalone treatment for complex trauma.

Other Innovative Interventions for Complex Trauma

Many other cutting-edge approaches have been applied toward the treatment of complex trauma. Some of these interventions— including creative arts approaches and animal-facilitated therapies— draw on longstanding approaches to other mental health issues.

Others feature novel therapeutic applications of non-clinical practices such as ballroom dancing or Shakespearean theater. Still others are highly technical interventions focused on:

• integration,
• stimulation or
• manipulation of sensory inputs, especially the visual, auditory or vestibular systems.

While promising, the majority of these interventions either have limited implementation histories or have yet to be evaluated for use in trauma treatment.

Two leading-edge interventions draw on broader evidence-base paradigms and were specifically designed to ameliorate the effects of complex trauma in youth:

• equine facilitated therapy for complex trauma and
• trauma drama.

Equine Facilitated Therapy for Complex Trauma (EFT-CT)

Is a child you know struggling in the typical treatment environment? Would they benefit from a unique way of approaching symptoms associated with trauma?

What sets this intervention apart:

EFT-CT is an ARC-based treatment model which uses horses in a therapeutic context to target areas impacted by exposure to trauma.

Consistent with the ARC model, EFT-CT engages youth through three core components:

• safety,
• attachment and
• regulation.

At the core of EFT-CT is the incorporation of safety throughout all interactions. The client’s sense of safety is enhanced through introductions to the facility and instructions on how to safely and correctly interact with the horse and equipment. Routines and rituals are implemented around greeting, leading, and grooming the horse to create an environment of predictability and consistency.

Generalizable to their outside lives, clients learn how to act with clear, appropriate boundaries and respect. The client is coached and guided to effectively understand and respond to the horse’s nonverbal cues in a non-threatening manner to promote a healthy relationship.

As body movements are the sole tool of communication between client and horse, treatment highlights the importance of body awareness, regulation, and effective communication. The client and horse begin to form a trusting, well attached bond.

The client is further guided by the horse’s natural rhythm of movement which provides opportunities for co-regulation and transformed internal affective state.

In addition to EFT-CT, there are several emerging treatment models which utilize horses and other animals, most notably dogs, in trauma-informed treatment.

Population served:

EFT-CT was developed for youth five to 17 years old in an individual or group format. EFT-CT is held in select barns or horse facilities with trained therapists.

Trauma Drama

Are you ready to rise above trauma and build community with others who share similar experiences through artistic self-expression, teamwork, and creativity?

What sets this intervention apart:

Trauma Drama is an immersive group intervention which engages youth and young adults in cooperative:

• play activities,
• improv techniques and
• theatrical skits creating opportunities for:
  • self-expression,
  • cognitive flexibility,
  • creative problem solving,
  • conflict resolution, and
  • enhanced sense of personal agency.

Trauma Drama was adapted from the evidence-based Urban Improv youth violence prevention curriculum and was designed to integrate the core components of complex trauma intervention with youth.

A troupe of trained actors, clinicians, and educators lead the group through three phases of intervention.

1. The first phase sets the foundation for a safe therapeutic environment through improv games emphasizing teamwork and competency building with the goal of establishing trust, social rhythm, interpersonal attunement, and self-regulation.
2. The second phase of this curriculum examines challenging themes around violence and trauma through vivid scene work. Without the presence of actual danger, the group is better able to explore different perspectives, recognize their past and present reactions, and respond to the presented scenario in new and different ways.
3. The final phase focuses on themes of personal mastery, community connection, and future vision.

Population served:

Trauma Drama is delivered in group format consisting of 18 to 24 sessions for youth and young adults ages 12 to 22. Groups size can range from 12 to 25 youth. Trauma Drama is often facilitated within school or after care settings, but can also be held within outpatient, community based, or residential settings. An abbreviated six to eight-session version of the model targets self-regulation, teamwork and competency building.