The Downward spiral - how a trauma informed approach could change treatment for mental health in the UK.


Most trauma survivors also experience depressive symptoms to the extent that the diagnosis of depression or anxiety may come prior to the realisation of having a trauma disorder or even experiencing trauma itself. It is a common trend in the uk to unsuccessfully treat depression or anxiety in potentially millions of patients primarily suffering unresolved trauma. That initial diagnosis of depression, anxiety, borderline, bipolar, OCD, anorexia and a whole host of separate psychiatric illness may instead be a symptom of trauma, of the progression of maladaptive coping and reliance or of a plethora of other issues stemming from unknown or 'silent' trauma's. Therefore it is not only common for individuals to attend psychiatric treatment for a symptom of trauma, but to feel unsuccessful after treatment as many underlying issues still remain. That being said, the addition of developmental trauma and a developed ACE screen would have the potential to change not only the face of mental illness but the statistics that come as a result of said treatment.

When looking at the depressive symptoms of trauma related illnesses; symptoms do not always follow along a clear cut line of the criteria for diagnosis of depression. Clinically, depression is diagnosed as a feeling of hopelessness and despair on most days - lasting at least 2 years, which leads to avoidance, sell harm or suicidal behaviour, memory issues, Insomnia or oversleeping and the lack of interest or over interest in food. On a scale; depression can range from mild, moderate and severe and as recently researched - "high functioning". High functioning depression is similar to the standard definition of depression however the individual experience a less 'severe' symptom type and can or is a functioning member of society (Ie holding a job, has a support structure, can maintain social life etc). 

The NHS look and treat depression over a 6-week course of CBT as a standard protocol as well as introducing medication to stabilize an individuals depressive/reactive symptoms; making it 'easier' to work through and be successful at therapy provided.  This is not always the case for a variety of reasons; however during this particular article, I intend to focus on how unresolved trauma causes relapses in a trauma survivors recovery journey - or as the NHS have stated; how depression causes a Downward Spiral. 

Therapy provided by the NHS regarding The Downward Spiral of mood (1) looks at how an individuals depression and low mood causes a downward spiral and a potential relapse in treatment. I tend to view the latter differently, I view it as how unresolved trauma causes relapses in a trauma survivors recovery journey. With focus shifting away from an individual's "faulty cognition" and onto the potential that an individual may have developed maladaptive coping a response to (unresolved) trauma. That being said; I would like to dissect the downward spiral model further and apply it to trauma in a more trauma informed way

NHS UK shows the downward spiral to be concurrent with depression however one could easily apply it to many other psychiatric illnesses. The notion being when an individual is depressed they experience low mood which leads to negative thinking and low self-worth. This is said to cause an individual to behave in ways that maintain the depressive mood, causing a downward spiral (1).

This notion is based on the CBT method of treating depression. Even within intensive trauma therapy programs set by NHS; depression is viewed as a sub disorder or comorbidity to individuals with trauma. Having looked at developmental trauma previously, we know that both complex trauma and childhood trauma cause an individual to feel shame, low self-worth and to have a negative mindset imprinted within them. One that is difficult to deconstruct in terms of trauma symptoms. Applying the model explained by the NHS to trauma can be destructive; placing some blame on the individual for experiencing a downward spiral of mood due to their own "faulty cognition" and not as a relapse or awakening of unresolved trauma can serve to retraumatise and compound feelings of low self-worth and shame in survivors.

The downward spiral as applied to unresolved trauma - gives a survivor a greater understanding of why they seem to frequently feel like they are in cycles of coping vs crisis.

The NHS further state that is through responding to a low mood with negative thinking or unhelpful behaviours that can result in an individual being stuck in a downward spiral of negative thoughts and unhelpful behaviours leading to another episode of depression. It is through "not being able to tolerate a mild state of depression and avoid negative thinking and behaviours" which creates this downward spiral and thus having the ability to challenge negative thoughts and behaviours with safer coping will allow an individual to maintain theur mood positively and safely.

With regards to 'pure' depression with no other comorbidity or trauma being involved; this is in many ways correct and a little bit of common sense. However with regards to the fact that 1 in 13 individuals suffer traumatic events in the UK within their life - the standard depression that the NHS diagnose may not be the full picture. For those individuals who had "high functioning depression" or a "depression" diagnosis turn to the realisation that they actually experienced trauma; the standard treatment and explanation may be counterproductive and dangerous.

Trauma survivors are notoriously hardened to being able to withstand others negative tactics and projections. It's not so much the case that a trauma survivor cannot 'tolerate' a mild and negative state than a trauma survivor unknowingly may use negative coping which can eventually manifest to a secondary illness. Many individuals of Childhood trauma or interpersonal relationship trauma may have been taught at one point that these coping mechanisms brought safety. In terms of brain development and function; we already know trauma changes neural pathways and volume in areas of the brain. Therefore it is not through low tolerance that a survivor may enter a downward spiral rather than that is all they are wired to know at that point in time - unresolved trauma thus needs to be explored to understand the reasons why an individual may repeatedly experience cycles of coping vs crisis. 

In many instances, a trauma survivor may not always be aware of everything traumatic that ever happened to them. This could be either due to memory changes in the brain, dissociation or age and developmental stage at the time of traumatic events. In fact, it is very common for a survivor of trauma to be hit by either new nemories or new triggers on a day-to-day basis - even hour to hour in some instances. The triggering of one memory or one small aspect may set off a chain reaction of memories and triggers; flooding the body, making it feel at times that the event has just happened all over again and is just as raw as it once was. 

The fact being in this case the already heightened survival mode becomes activated and an individual initially relies on their 4f or cross type responses. Frequent reliance on these responses is known to have the ability to manifest into secondary psychiatric illnesses, however in terms of the downward spiral, we see a survivors use of these responses as being the cause of.

In cases of Childhood trauma and developmental trauma, it is common to have a variety of unresolved traumatic events manifest suddenly and without warning. Similarly, in cases of adult complex trauma; dissociation and numbing during the event can we lead to effects manifesting years later leading to a downward spiral in TRAUMA symptoms.

It is also common for survivors of trauma to experience subtle emotional or somatic flashbacks or to be inadvertently triggered; unaware of the cause. A survivor of trauma can have hundreds of different triggers, some of which they are unaware until they are faced with suddenly. With regards to the downward spiral, it may not be caused solely by a low mood and negative behaviour but instead caused by the sudden realisation of events once unresolved being triggered and awakened.

With regards to the NHS treatment protocol, focus is placed on overcoming negative thoughts and behaviour through fixing 'faulty cognition' either via behavioural strategies, acceptance or cognitive strategies. If the NHS were however to take a more trauma informed approach to treating all mental illness - we may find a massive change in the current statistics of mental health in the UK.

A trauma informed approach is necessary for screening for the true effects of trauma in individuals. Further normalising what a large proportion of the UK may inadvertently suffer from and removing some of the stigma of 'poor' mental health. Instead of solely treating depression or depressive SYMPTOMS through behavioral and cognitive modification, identifying past unresolved issues when they arise or giving an individual the knowledge and understanding of that possibility could serve to benefit millions of people in the UK. 

Our research group can be found here;

Currently we are conducting research into the causes of trauma. I have included a link to the survey here :

If you would be interested in taking part, please feel free. If you would like to share this study i would also welcome you to use the link, many thanks!


1. Dr. Lisa Reynolds (2012), the downward spiral. NHS UK therapy options for CBT