Written by: Danieyella Rodin
Content reviewed for clinical accuracy by a multidisciplinary team at Papillon and external Drama Therapist, Paula Kingwill.
The term “trauma” has increasingly become a modern buzzword. As psychologist Richard McNally warns, “if nearly everything can count as trauma, the term morphs into a trope for misfortune.”[1] In clinical settings, stretching the concept to cover ordinary distress risks diluting its diagnosis and over-pathologising everyday stress.
However, this widened lens has a crucial upside – particularly within the South African context. It has driven the rise of trauma-informed care, which acknowledges the somatic, psychological, and social ways trauma shapes a patient’s presentation (even without a formal PTSD diagnosis) and guards against unwitting re-traumatisation.[2]
At Papillon, our multidisciplinary team (MDT) balances this clinical nuance with a whole-person approach. We devise treatment plans where each discipline adds targeted expertise. As a drama therapist, my focus is somatic, incorporating creative expression and body-based work into our trauma programme.
So, What Is Trauma?
Colloquially, the word trauma has become an umbrella term capturing everything from a traumatic event to PTSD and Complex post-traumatic stress disorder (C-PTSD). Though these terms are related, understanding the broader landscape of trauma, treatment and psychiatric care requires treating them as associated but discrete concepts.
Trauma refers to an experience (perhaps an event or set of circumstances) that overwhelms a person’s capacity to cope at the time. EMDR developer Dr. Francine Shapiro coined the terms “Big T” and “Little T” to describe two distinct types of traumatic events. The former refers to life-threatening, single-shock events such as assault, an accident or an environmental disaster. The latter refers to a cumulative pattern — such as chronic neglect or ongoing relational harm — that individually might not seem catastrophic, but which collectively erodes a person’s sense of psychological safety.[3]
What Is PTSD?
PTSD is a specific, clinical diagnosis that some – not all – people develop after trauma exposure. The diagnostic criteria require exposure to actual or threatened death, serious injury, or sexual violence, whether experienced directly, witnessed, learned about, or encountered repeatedly through professional duties (as with frontline workers).
For a diagnosis of PTSD to be given, these trauma events would have to be followed by experiences across four symptom clusters:
- Intrusions (unwanted memories, flashbacks, nightmares)
- Avoidance (steering clear of places, people, or thoughts tied to the event)
- Negative alterations in cognition and mood (persistent fear, guilt, detachment, or numbing)
- Marked alterations in arousal and reactivity (hypervigilance, exaggerated startle response, or irritability)[4]
Complex PTSD (C-PTSD)
Complex PTSD requires meeting the full diagnostic criteria for PTSD, plus persistent “disturbances in self-organisation” across three further areas:
- Affect dysregulation
- Negative self-concept
- Relational difficulties
C-PTSD is most commonly associated with prolonged, repeated, or inescapable traumatic events – such as long-term childhood abuse or neglect, sustained domestic violence, captivity, or trafficking. It often correlates with chronic trauma exposure and greater functional impairment than PTSD.[5] While this ICD-11 diagnosis is not formally used in South Africa, the clinical presentation is most often captured under a PTSD diagnosis with specifiers and comorbid conditions.
In summary, trauma is what happened; PTSD and C-PTSD are possible, but not inevitable, outcomes of the traumatic event. There are a range of protective factors which may prevent people exposed to severe trauma from developing PTSD. Others develop certain trauma responses – anxiety, avoidance, dissociation, hypervigilance – that never rise to full diagnostic threshold but still warrant trauma-informed, compassionate care.
Trauma in the South African Context
This approach is even more important in our South African context, where we still live with the wounds of our violent history, ongoing structural inequality, high crime rate, and high rates of GBV.[6]
It is possible that large numbers of South Africans carry unaddressed trauma, compounded by limited access to care and persistent mental health stigma – making a trauma-informed multidisciplinary team, where every member of the therapeutic team can recognise and respond to trauma responses, vital in our social context.[7]
Your Trauma-Informed Team at Papillon
Our team is multidisciplinary, which means that each resident here gets access to a diverse group of mental health professionals who approach trauma-informed care and trauma treatment from within their scope of practice. Residents have the benefit of a team who meets regularly to review and adjust their treatment plan collaboratively, ensuring that all therapeutic interventions work towards integrated rehabilitation goals.
Papillon’s therapeutic team consists of:
Psychiatrists: We work with your psychiatrist or our partner psychiatrists to ensure continuity of care. Psychiatrists confirm diagnosis, manage comorbid conditions, and oversee any indicated medication.
Nursing staff: Administer medication and provide ongoing monitoring of trauma-related or PTSD symptoms. Nursing provides a safe daily touch-point for all residents, establishing an empathic morning routine which helps to optimise well-being.
Psychologists: Work with patients to understand how trauma may be impacting daily living, relationships and function, as well as providing evidence-based individual therapy to process and work through traumatic material.
Social workers: Address the practical, family, and community context of a person’s life, helping patients think of rehabilitation not only as an individual endeavour, but as one in which support structures are engaged towards recovery. Where trauma-related symptoms are interfering with function, this looks like honestly evaluating triggers and putting practical plans in place to support the individual.
Occupational therapists: Support the rebuilding of routine and restoring of daily functioning after traumatic events.
Arts therapists (Art and Drama): Offer alternative therapeutic languages through creative techniques, for navigating past traumatic events, as well as generative and meaningful routes back into relationship with self and others.
Drama Therapy and the Body in Treatment: Physiological Symptoms and Implicit Memory
From a drama therapy perspective, effectively treating trauma requires turning directly toward the body and the mechanics of implicit memory.
The Physiological Symptoms: The Smoke Detector
The core symptoms of PTSD have a well-documented neurobiological basis. Under threat, the amygdala (the smoke detector) activates the body’s fight-flight-freeze response via the hypothalamic-pituitary-adrenal (HPA) axis, flooding the system with cortisol and adrenaline. The smoke detector sounds the alarm to help you act in a way to avoid harm as far as possible.
In PTSD, neuroimaging has repeatedly found the amygdala to be hyperresponsive, with this heightened reactivity correlating with symptom severity, while the medial prefrontal cortex – which normally helps regulate and “put the brakes on” fear responses – shows reduced volume and activity.[8] In other words, after unresolved trauma the smoke detector may become increasingly sensitive, while part of the control panel which helps to regulate the system and override false alarms becomes duller: instead of going off only when there is a large and dangerous fire, now it sounds the alarm when you light a fire in the hearth.
What this means in practice is that, in the case of PTSD and other trauma-related disorders, someone’s sensory perceptions may be disrupted. These sensory systems include interoception (a person’s capacity to read and interpret their internal, embodied sensations),[9] proprioception (a person’s ability to know where their body is in space), and neuroception (the continuous, subconscious evaluation of moment-by-moment risk).[10] While the healthy functioning of all these systems is vital for daily living, it is easy to see how neuroception in particular could be continuously disrupted – first by the trauma itself, and then by the PTSD symptoms that follow.[11]
In other words, in PTSD there is a cumulative risk in the perception of danger: as neuroception is distorted through a hyper-sensitive amygdala, while the regulatory parts of the brain become correspondingly less responsive, benign stimuli can trigger the body’s threat responses more frequently. This can create a nervous system that becomes increasingly over-sensitive, resulting in increasingly muddied sense-perception.[12] So, using our analogy, this cumulative risk looks like the smoke detector becoming hypersensitive while the override feature in the control panel recognizes fewer situations as false alarms. The system’s alarm rings loudly in response to more and more stimuli: from the fire in the fire-place, to the flame of a candle, burned toast or steam from the shower.
Kotler and his co-authors capture this succinctly in their recent paper when they say that “trauma is a disorder of prediction.” They describe that this hypersensitive smoke detector, alongside “weakened top-down regulatory connections,” reduces the brain’s predictive repertoire. The system’s “connectivity patterns shift toward [more] defensive configurations, and the system’s capacity for flexible reconfiguration is diminished.”[13]
Sensory, Implicit Memory
Dr. Cathy Malchiodi, a leading trauma researcher, advocates for arts-based, embodied and experiential treatment interventions for PTSD and other trauma-related disorders:
“Neurobiology research has taught us that we need to ‘come to our senses’ in developing… trauma interventions. Traumatic reactions are not just a series of distressing thoughts and feelings; they are experienced on a sensory level by mind and body… individuals’ memories of trauma are more sensory, implicit, and perceptional than explicit and declarative.”[14]
What Malchiodi is suggesting is that, in addition to the muddied perceptions and narrowed predictive system described earlier, creative and embodied work should ideally be included as a therapeutic intervention because traumatic memories are often stored as implicit rather than explicit memories. An implicit memory encodes emotions, sensations and perceptions, as well as sensorimotor skills such as learning to walk, run or drive. Explicit memories, on the other hand, require integrating contextual and autobiographical data.[15]
Explicit memory requires capacities such as attention, which develop in early childhood. As Dr. Dan Siegel notes (a point of particular interest in relation to early childhood trauma), before two years of age the bulk of our memories are implicit, as our capacity to encode explicit memory is still developing.[16] Once our capacity to encode explicit memory has developed, however, it becomes a vital part of our brain’s predictive processes and ability to evaluate danger.
Sometimes, however, traumatic events overwhelm a person’s nervous system to such an extent that the combination of disrupted hippocampal function (which processes and stores explicit memory) and “heightened amygdala activation” results in vivid sense-memory imprinted without the temporal, narrative elements.[17] The hippocampus is unable to store vital predictive information because the alarm is sounding so loudly that it interrupts this process.
In PTSD, these neurobiological responses continue to be maladaptive over time. For example, the hippocampus, responsible for placing memories in the context of time and place, shows reduced volume and functional changes. This may help explain why traumatic memories often feel fragmented, present-tense, and disconnected from their actual context – the hallmark of a flashback rather than an ordinary memory.[18]
Furthermore, flashbacks, physiological arousal, shutdown and hypervigilance may increasingly result from implicit memories triggered by ordinary, benign stimuli. In effect, the alarm system becomes overactive, leaving a person’s body responding to reminders of danger (even when none are present), as though the threat were still happening and long after the event itself has ended. As Dr. Dan Siegel puts it, “Implicit-only memory is experienced in consciousness but is not ‘tagged’ or felt as something emerging from the past… A reactivated implicit memory is fully conscious; it just lacks the sensation of recall.”[19]
It is here that drama therapy’s embodied techniques hold specific clinical relevance. Embodied and enactment-based therapeutic interventions employ the same implicit, sensorimotor memory systems in which traumatic material is often stored. Clinical health psychologist Dr. Louis Damis argues that trauma-related disorders require interventions which work within this sensory-emotional layer of experience, going so far as to suggest that creating “imaginal scenes” to engage this layer is necessary for trauma recovery.[20] In a drama therapy session, this could look like exploring notions of safety or danger (for example) by creating frozen body sculpts which capture either the feeling-experience or the dynamic of victim-perpetrator relationships, making this sensory-emotional layer manifest and accessible.
Neuroplasticity: The Path to Change
This is the good news: through experience and learning, our neuroplastic brains make change possible.[21] Drama therapy’s deliberate use of dramatic distance (which I’ll explain more below) and embodied enactment engage the brain’s predictive processing systems in real time, allowing the nervous system new sensory and relational experiences from which to generate safer, updated expectations.[22]
For example, drama therapeutic interventions create opportunities to relearn what safety feels like in experiential terms: in relation to intrapersonal, as well as interpersonal stimuli. This could be through play within a group or identifying and mapping resources using objects and creating a physical/psychological safe anchor to return back to when overwhelm begins to creep in.
Drama Therapy at Papillon
In both individual and group sessions, drama therapy offers a somatic approach which centres the body in trauma treatment.
Weekly Trauma-Informed Open Groups
A weekly group open to all residents at Papillon. This is often the place where some of the foundations of embodied and relational safety are established, as well as where residents are introduced to the tools and techniques of drama therapy.
Individual Somatic Drama Therapy and Trauma Group (by Referral)
Whether in individual or group therapy, fundamental principles of embodied trauma treatment include pendulation and titration (explained below). These principles – moving toward and away from activation in manageable, therapeutic doses – are inherently built into drama therapy’s core processes: distancing, projection, role-play and embodiment, which offer a controlled way to approach material and step back from it.
Pendulation, Titration and Therapeutic Distance
Pendulation is the process of moving between an expanded, safer-feeling state and a contracted fear-response state in order to develop greater tolerance for distress. Titration is working with traumatic memory gradually, “one piece at a time” – in bite-sized, digestible chunks rather than trying to do too much too quickly.[23] Drama therapeutic distance is determined by the deliberate use of role, symbol, and fiction to hold material at a workable remove: close enough to engage with, far enough not to overwhelm.[24]
Together, these processes give the client and therapist continuous, in-session control over dosage and distance – titrating exposure and pendulating between coming closer to and moving away from the traumatic responses and material, and developing greater tolerance for, as well as ability to process, the embodied experience. In practice, more distance from specific traumatic material could look like exploring the sensory, emotional and motor impulses related to playing roles from within the frame of a story, say that of the victim, perpetrator or bystander, while less distance might involve working with objects to map out a scene/story drawn from client material.
The distance from patients’ personal material may close even further, through embodied exploration and enactments of specific relationships or scenarios which are of therapeutic relevance to the trauma treatment. Even within these embodiments or scenes, the client will be continually invited to bring the sensory, emotional and sensorimotor layer of the present-tense experience into the therapeutic picture. Processing therapeutic material through these “imaginal scenes” creates an experiential way to work with our inherent neuroplasticity.
Some patients with more complex presentations may take a long time, or may perhaps never engage directly with specific traumatic material. However, even at a greater distance, the experiential nature of engaging with the more subtle layer of trauma’s impact can help develop greater neuroplastic capacity to manage what were once overwhelming and confusing neurobiological symptoms.
Drama therapy’s somatic approach works alongside the other important psychological, social, biological and functional approaches of the multidisciplinary team at Papillon. Here, we offer a whole-person rehabilitation approach to working with trauma presentations: biopsychosocial therapy in action.
References
[1] McNally, R.J. 2010. Can we salvage the concept of trauma in DSM-V? The Psychologist. 23: 386–389. In: Kelly, M. 2018. A Critical Phenomenology of Trauma. MA dissertation. George Washington University.
[2] Haslam, N. and McGrath, M.J. 2020. The Creeping Concept of Trauma. Social Research: An International Quarterly. 87(3): 509–531.
[3] Shapiro, F. 2001. Eye Movement Desensitization and Reprocessing (EMDR): Basic Principles, Protocols, and Procedures. 2nd ed. New York: Guilford Press, pg 43.
[4] American Psychiatric Association. 2013. Diagnostic and Statistical Manual of Mental Disorders. 5th ed. Arlington, VA: American Psychiatric Publishing.
[5] Hyland, P., Shevlin, M., Fyvie, C. and Karatzias, T. 2018. Posttraumatic Stress Disorder and Complex Posttraumatic Stress Disorder in DSM-5 and ICD-11: Clinical and Behavioral Correlates. Journal of Traumatic Stress. 31: 174–180. https://doi.org/10.1002/jts.22272
[6] Kaminer, D. and Eagle, G. 2010. Traumatic Stress in South Africa. Johannesburg: Wits University Press.
[7] Rink, J. and Lipinska, G. 2020. Evidence of distinct profiles of ICD-11 post-traumatic stress disorder (PTSD) and complex PTSD in a South African sample. European Journal of Psychotraumatology. 11(1): 1818965. doi: 10.1080/20008198.2020.1818965.
[8] Shin, L.M., Rauch, S.L. and Pitman, R.K. 2006. Amygdala, medial prefrontal cortex, and hippocampal function in PTSD. Annals of the New York Academy of Sciences. 1071: 67–79. doi: 10.1196/annals.1364.007.
[9] Critchley, H.D. and Garfinkel, S.N. 2017. Interoception and emotion. Current Opinion in Psychology. 17(7): 7–14. http://dx.doi.org/10.1016/j.copsyc.2017.04.020
[10] Porges, S.W. 2018. Polyvagal Theory: A Primer. In: Porges, S.W. and Dana, D. eds. 2018. Clinical Applications of Polyvagal Theory: The Emergence of Polyvagal-Informed Therapies. New York: WW Norton, Chapter 4: 50–69.
[11] Rodin, D. 2023. The Voice As Felt Sense: An integrative review exploring the potential of embodied voice work in trauma-informed dramatherapy. MA dissertation. University of Witwatersrand, pg 26. [Accessed 18 September 2026].
[12] Gerge, A. 2020. What neuroscience and neurofeedback can teach psychotherapists in the field of complex trauma: Interoception, neuroception and the embodiment of unspeakable events in treatment of complex PTSD, dissociative disorders and childhood traumatization. European Journal of Trauma & Dissociation. 2020(4): 100164. doi: https://doi.org/10.1016/j.ejtd.2020.100164 [Accessed 14 December 2022].
[13] Kotler, S., Mannino, M., Fox, G. and Friston, K. 2026. The body does not keep the score: trauma, predictive coding, and the restoration of metastability. Frontiers in Systems Neuroscience. 20: 1812957. doi: 10.3389/fnsys.2026.1812957. [Accessed 19 September 2026].
[14] Malchiodi, C.A. ed. 2020. Trauma and the Expressive Arts Therapies: Clinical Applications. New York: Guilford Press, pg 25.
[15] Siegel, D.J. 2010. Mindsight. New York: Bantam Books. (ePub version). eISBN: 978-0-553-90710-0, Chapter 8: pg 199–200.
[16] Ibid.
[17] Ibid., Chapter 8: pg 197–198.
[18] Panagopoulou, M.A. 2026. The Effects of Post-Traumatic Stress Disorder on Memory Function. European Psychiatry. 69(Suppl 1): S840. doi: 10.1192/j.eurpsy.2026.11874.
[19] Siegel, D.J. 2010. Mindsight. New York: Bantam Books. (ePub version). eISBN: 978-0-553-90710-0, Chapter 8: pg 197–198.
[20] Damis, L.F. 2022. The Role of Implicit Memory in the Development and Recovery from Trauma-Related Disorders. NeuroSci. 3(1): 62–77. doi: 10.3390/neurosci3010005.
[21] Su, Q. 2024. The role of neuroplasticity in post-traumatic stress disorder recovery. In: Proceedings of the 4th International Conference on Biological Engineering and Medical Science. doi: 10.54254/2753-8818/61/20241527.
[22] Vaisvaser, S., King, J.L., Orkibi, H. and Aleem, H. 2024. Neurodynamics of Relational Aesthetic Engagement in Creative Arts Therapies. Art Therapy (SAGE), online first.
[23] Levine, P. 2015. Trauma and Memory. Berkeley, California: North Atlantic Books.
[24] Jones, P. 2007. Drama as Therapy: Theory, Practice and Research. 2nd ed. London: Routledge, Chapter 5.
