Treating Trauma – The Individual and Need for Personalized Therapy

I suspect I will be writing about trauma from time to time in this newsletter, given it is my main area of clinical work and research. Having been in the field of trauma work for more than 30 years now, I am keen to share what I have learned, but also what I would like to unlearn. To unlearn, of course, is tongue in cheek, as I know that is not truly possible—but I can add, expand, and refine. I want to keep learning as I recognize the variability, nuances, and deeply individual nature of trauma experience. That recognition leads me to what I’d like to focus on here.

I recently worked with a client who shared their experience of seeking a higher level of care for a family member who had experienced a traumatic event. They described a treatment center offering a protocolized approach. The wishes of the client were essentially dismissed, as the program “really knew” what was best based on its science-based interventions. The client went unseen and entered the process already certain it would not work. Many of you, as I did, will recognize a problem in this approach—it isn’t client-centered, and it isn’t humanizing.

I am hearing this more and more as I engage with clinicians from different parts of the world: “Use this protocol for that diagnosis” is the dictate, often insurance-driven (or therapist are advised to use a particular technique--again and again). Health care systems are heavily burdened with this approach: “What’s the diagnosis, and what is the evidence-based practice for it?” I have worked inside a system that mandated these methods. This is not without merit, and I am always mindful that mental health providers “stand on the shoulders of giants.” We are indebted to invaluable research that led to the creation of protocols for disorders. However, asking “What’s the recipe for working with that diagnosis?” misses something essential—the living, breathing human being, with their own unique learning history and context, sitting in front of us.

I want to be fair. I, too, have played this game and have written a number of protocols myself, adding to the heaps of therapy manuals in the mental health world. There is a place for such items—group therapies, psychoeducation courses, skills training, and more. And yet, a part of me wants to take those protocols back, redo them, and reorient them toward a process-based, client-centered approach. I would write in the manuals, right up front, about the necessity of expanding our ways of understanding therapy to consider client, treatment, and therapist, who also has their own learning history--which inevitably shows up in the therapy room.

Let me now return to trauma. In my more than 30 years of work, I have met and worked with survivors of childhood sexual abuse, natural disasters, refugee trauma, rape, violence, war, moral injury, and many other forms of suffering. None of these survivors’ experiences has been precisely the same, nor have the traumas had identical impacts on the individuals I’ve served. Avoidance is often present, yet the nuances and paths diverge widely. Trauma treatment is not one-size-fits-all. The pathways that lead survivors to suffer, the symptoms they experience, the ways they are expressed, and the processes maintaining their distress are often profoundly different. No bag of tools or quick techniques will suffice.

Perhaps I am preaching to the choir. Many of you are already tailoring to the individual or beginning to read and learn about idiographic approaches to mental health care. Still, let me share more about the problem. Just as with other disorders, much of trauma treatment has historically leaned on nomothetic, protocolized interventions developed from group-level data. While these treatments are effective on average, and I have been trained in them, value them, and use them. Still, they may miss or even suppress individual variability, especially in clients with complex or layered trauma histories, co-occurring conditions (such as dissociation, moral injury, or substance use), cultural or systemic factors shaping trauma expression, or functional avoidance that may be adaptive in context (such as emotional numbing in a violent environment).

I would argue there has been a degree of technique and protocol overreach. Nomothetic models—the “on average” approaches—often assume that if a treatment works for most, it should work for anyone. This ignores critical realities: timing (is the client ready for exposure?), context (is safety or trust a greater priority than symptom reduction?), function (is avoidance maintaining suffering, or preserving stability in an unsafe situation?), and individual variability (what is the impact for this person with their specific learning history at this point in time?). In trauma work, these are not side issues; they are central issues.

I also want to acknowledge that many clinicians, perhaps most, have been individualizing care from the very beginning. That’s not to suggest that protocols and techniques are without value. I have seen, firsthand, the relief they can bring. But trauma is not a single story, and no protocol can fully account for the history, meaning, or context a person carries into the room. For some, what looks like avoidance is actually wisdom in motion—a way of staying safe in a world that has not always been kind. As we deepen our understanding of trauma and its expressions, our task is not to discard what works, but to meet complexity with flexibility, hold structure lightly, and follow the process wherever it leads. That is where individualized, process-based work becomes not just a technical choice, but an ethical one.

Here I want to pause and clarify something important. Process-Based Therapy (PBT), a meta-model (not a therapy model) as a scientific and organizing framework for integrating processes of change across therapies, has recently been advanced in the literature. My use of “process-based” in this newsletter is aligned in its focus on individualizing therapy for sure, but I also mean something slightly more immediate and clinical. For me, it is about tracking the living movement of processes as they show up in this client, in this moment, in this context, while also staying attuned to how those same processes evolve in session and over time. That ongoing awareness—the way processes shift, recur, and interact across the arc of therapy (see The Heart of ACT)—is essential in trauma work. Each trauma survivor carries their unique measure of suffering. 

Just as importantly, it includes the therapist’s process: our moment-to-moment noticing, our histories and reactions as they arise in session, and our flexibility in responding. I know my reactions to hearing a trauma story vary. Some being more activating than others and reminding me to soften into compassion and presence.

And, process-based, as I refer to it, includes the process between therapist and client—the therapeutic relationship itself—as a living context in which change unfolds. In this sense, therapy is not only about observing the client’s processes unfolding, but also about recognizing and skillfully engaging with both the therapist’s evolving process and the shared relational process in the room. Methods that do not capture what is most essential in the therapy room: the functional analysis of behavior as it occurs in context, and the moment-to-moment dynamics that shape client experience and therapist response, will not suffice. For trauma work especially, it is this ongoing awareness—the way processes shift, recur, and interact in lived context—that matters most.

A personalized model offers a different lens. A process-based, client-centered approach allows us to ask: What is actually driving this person’s suffering in this moment and across therapy? What is changing—or not—over time, and in what contexts? How do we align interventions with the client’s unique history, culture, values, and nervous system? How is the therapist’s presence, history, and approach influencing process and change over time? How does the relational nature of therapy impact process? This shift is more than academic. It is a clinical necessity in trauma therapy, where small misattunements can replicate harm, and where what works often hinges on timing, context, relationship, and meaning. To treat trauma effectively, we must move beyond average outcomes and begin to track, analyze, and respond to the individual patterns of change that matter most for the clients sitting in front of us, tucked inside an attuned, flexible, and compassionate relationship.

Personal Reflection: Your Unique Map

In trauma work, and really in all therapy, it is great to have useful guides such as protocols or manuals. However, they will never capture the full complexity of the person in front of you. That’s true for you, too. No single story about you can truly capture the complexity of you. 

Take a moment to reflect:

• What professional and personal experiences have most shaped the way you practice?
  (e.g., a mentor who influenced your style, working in a crisis setting, a cultural lens you bring, lived experience of loss)

• How might your perspective be different if even one of those events or influences had gone another way?
  (e.g., if you hadn’t trained in a specific model, if you had worked in a different population or country)

• In what ways might your “map” of the world differ from the maps of your colleagues, or your clients?
  (e.g., beliefs about safety, assumptions about family, comfort with certain emotions)

Finally, ask yourself, if my professional journey is unique, how likely is it that any client’s path and the processes that maintain their suffering will mirror that of others? How might this awareness shape my flexibility in meeting each person where they are?

ACT Micro Practice: Stepping Into Their Shoes

Pause for a moment and picture one client you’re currently working with.

Notice the immediate stories or assumptions your mind offers about who they are or what they need.

Now, step back and imagine you are seeing them for the first time, with no file, no diagnosis, just a human being in front of you.

Ask yourself:

• What might I be missing if I only see them through my existing lens?

• What would it look like if I could come behind their eyes and look back at me? What would they want me to know or understand?

In your next session, see if you can hold that this person in front of you is no “average” being.

Research Spotlight: Continuing With the Theme

Much of psychological and medical research relies on group averages—combining data from many people to find “what works.” The problem is, those averages often don’t match what’s actually happening for any given individual. Studies show that the way variables relate within a single person over time can be very different from how they relate across a group, and individual variation can be up to four times greater than group-level variation. In other words, what’s true “on average” may not be true for the person sitting in front of you. Recent work highlights that this change from group level analysis to idiographic understanding of behavior, is not just a statistical refinement; it’s a fundamental shift toward evaluating and responding to multi-level, biopsychosocial processes of change that are tailored to each person’s unique history, context, and goals (Fisher et al., 2018; Hayes et al., 2022; Molenaar, 2004; Wright & Woods, 2020).

That said, both the scientific and clinical uses of “process-based” matter. From a research standpoint, Steve Hayes and colleagues argue for an idionomic science—tracking processes of change idiographically and then scaling up to group-level knowledge when it genuinely improves the individual fit. From a clinical standpoint, process-based work means staying attuned to the movement of processes as they unfold in real time—moment by moment, session by session, across the arc of therapy inside of a relational experience.

For trauma treatment, especially, this dual lens is critical. Research can help us identify which processes matter, but in the therapy room, what matters most is how those processes are showing up inside of a relational field (Walser & O’Connell, 2022; Walser & O’Connell, 2021). This requires awareness not only of what processes are present, but of their shifting function over time—whether avoidance today is destructive or protective, whether exposure is grounding or overwhelming, whether numbing is shutting down life or keeping someone safe. That ongoing movement demands continuous awareness, flexibility, and responsiveness from us as therapists.

• Fisher, A. J., Medaglia, J. D., & Jeronimus, B. F. (2018). Lack of group-to-individual generalizability is a threat to human subjects research. Proceedings of the National Academy of Sciences, 115(27), E6106–E6115. https://doi.org/10.1073/pnas.1711978115

• Hayes, S. C., Ciarrochi, J., Hofmann, S. G., Chin, F., & Sahdra, B. (2022). Evolving an idionomic approach to processes of change: Towards a unified personalized science of human improvement. Behaviour Research and Therapy, 156, 104155.

• Molenaar, P. C. M. (2004). A manifesto on psychology as idiographic science: Bringing the person back into scientific psychology, this time forever. Measurement: Interdisciplinary Research and Perspectives, 2(4), 201–218. https://doi.org/10.1207/s15366359mea0204_1

• Walser, R. D., & O’Connell, M. (2022). The therapeutic alliance in acceptance and commitment therapy. Revista de psicoterapia, 33(122), 5-20.

• Walser, R. D., & O’Connell, M. (2021). Acceptance and commitment therapy and the therapeutic relationship: Rupture and repair. Journal of clinical psychology, 77(2), 429-440.

• Wright, A. G. C., & Woods, W. C. (2020). Personalized models of psychopathology. Annual Review of Clinical Psychology, 16, 49–74. https://doi.org/10.1146/annurev-clinpsy-102419-125032