CBT, Trauma, and Epistemic Bias

Cognitive-Behavioral Therapy (CBT), the dominant therapeutic modality in the United States, systematically inflicts epistemic injury on trauma survivors by invalidating their accurate perceptions of reality as “cognitive distortions.” When trauma survivors say “the world is unsafe,” “relationships often involve abuse,” or “people who hurt children never get punished,” they are stating empirically supported facts: 41% of women and 26% of men experience intimate partner violence; 40-50% of marriages end in divorce; rape and child abuse are among the least prosecuted crimes. Yet therapists, lacking training in epidemiology, logic, or trauma frameworks, label these accurate assessments as “catastrophizing,” “overgeneralization,” or “distorted thinking”—pathologizing trauma-informed survival logic by comparing it to therapists’ relatively safe baseline of experience. This epistemic violence occurs because CBT operates at the wrong level of the nervous system (targeting thoughts when trauma responses are limbic), assumes a “normal” baseline that doesn’t account for extreme experiences, and evaluates reasoning using therapists’ intuitive judgments rather than logical or empirical analysis. The result: trauma survivors who accurately describe their statistically common experiences are told their perception is distorted, compounding rather than healing their trauma. This paper argues that CBT’s distortion framework is fundamentally incompatible with trauma-informed care and that therapy must shift from generic cognitive restructuring to trauma-specific framework application that respects clients as reasoning agents with valid interpretations of reality.

For background on Cognitive-Behavioral Therapy (CBT), including its history, prevalence, and fundamental premises, see Cognitive-Behavioral Therapy (CBT). For definitions of CBT cognitive distortions and skills, see Cognitive Distortions.

For historical context on how trauma has been recognized and misdiagnosed throughout the history of psychiatry and psychology, see The Recent Recognition of Trauma. Briefly, trauma has only recently been taken seriously as a legitimate focus of mental health treatment. For much of the history of psychiatry and psychology, the effects of trauma—particularly chronic, developmental trauma—were misdiagnosed and misunderstood. This historical misdiagnosis created a cascade of epistemic injustice: trauma survivors seeking help were told their suffering stemmed from disordered thinking or personality defects, rather than from the legitimate effects of abuse. CBT, developed in the 1960s and rising to dominance before trauma-informed frameworks existed, inherited and perpetuated this legacy.

The Problem Trauma Creates: Adaptations That Need Adjustment

For a full explanation of trauma adaptations, see Trauma Adaptations. Briefly, trauma survivors develop adaptations—patterns of thinking, feeling, and behaving that served survival during childhood but may or may not serve them in adult life.

The critical distinction is that these adaptations were not “distorted thinking”—they were accurate, adaptive responses to the reality of childhood trauma. A child who had to stay in an abusive home developed the belief that leaving wasn’t an option, because for them, it wasn’t. A child who learned to read subtle threats to avoid punishment developed accurate pattern recognition, even if they now overgeneralize that pattern. A child who learned that expressing needs led to punishment developed emotional suppression, because in their environment, it genuinely was dangerous to show emotion.

The purpose of trauma therapy is to help clients adjust to adult life—identifying which adaptations are still useful and which need to change because adult contexts differ from childhood contexts. This requires using trauma models to understand: What pattern did this serve during childhood? Is this pattern still accurate in adult life? What resources are now available that weren’t available then?

However, CBT’s generic approach doesn’t use trauma models. Instead of identifying specific trauma adaptations and determining which need adjustment, therapists default to comparing the client’s thinking to their own experience. If the thinking doesn’t match the therapist’s relatively safe baseline, it’s labeled as “distortion”—pathologizing accurate trauma-informed logic while missing actual maladaptive patterns that need to be addressed through trauma frameworks.

The Therapist’s Experience Becomes the “Normative” Baseline

In traditional therapy, the therapist’s worldview—shaped by their temperament, privilege, neurotype, and life experiences—is treated as ‘neutral.’ When clients describe experiences outside that frame, therapists often assume these perceptions are distortions rather than differences. For example, if an autistic woman describes being systematically disliked or excluded because of her neurodivergent communication style, a therapist without comparable experiences may dismiss this as unrealistic or paranoid—assuming the client is misreading social cues rather than accurately perceiving ableism. This is a form of epistemic bias—mistaking personal improbability for objective impossibility.

The Intersectionality Problem: Compounding Epistemic Injustice

The problem intensifies when clients occupy multiple marginalized identities. Testimonial injustice is a form of epistemic injustice where speakers receive less credibility due to prejudice—when a hearer assigns a level of credibility to a speaker’s testimony that is lower than it should be, based on identity prejudice (Fricker, 2007). In therapy, this manifests when a trauma survivor who is also neurodivergent, a person of color, disabled, or occupying multiple marginalized identities has their testimony systematically discounted.

Consider an example: a Black autistic woman who is a trauma survivor describes being dismissed by doctors, teachers, and police. A therapist might label her belief that “authority figures don’t take me seriously” as “paranoid” or “overgeneralization”—failing to recognize that her experience reflects systematic testimonial injustice based on racism, ableism, and sexism. The therapist’s frame of reference (often shaped by privilege) cannot comprehend the reality of intersectional oppression, so they pathologize accurate perception as cognitive distortion.

This intersectional epistemic injustice compounds: each marginalized identity further reduces the credibility assigned to the client’s testimony. A disabled trauma survivor of color may have their experiences invalidated not just because they’re a trauma survivor, but because they’re disabled, because they’re a person of color, and because they’re all of these things simultaneously. The therapist, occupying privileged identities, cannot easily imagine this reality, so they default to assuming distortion—mistaking intersectional oppression for individual pathology.

The “Rationality Fallacy” and CBT’s Structural Asymmetry

CBT’s structure begins with an asymmetry of rationality: the therapist is trained to identify “distorted cognitions,” while the client is assumed to have them. CBT manuals literally classify thoughts as “rational” or “irrational,” with the therapist’s task being to replace irrational ones with “more realistic” ones. That builds a one-way authority channel: clinician = judge of reason; client = subject of correction.

Therapists are trained to identify cognitive distortions, so they reflexively pathologize statements that seem irrational in their worldview. When a client says, ‘People often hate me for no reason,’ the therapist may label it as distorted thinking without context. In reality, there are social and psychological mechanisms—envy, gender competition, trauma signaling, or neurodivergent communication—that make such experiences plausible. The error arises when the therapist uses their subjective experience as the reference point for truth.

Similarly, when a trauma survivor who has been repeatedly abused and experienced systematic failure from protective systems (police, social services, schools) believes that the world is fundamentally unsafe, a therapist may label this as “overly negative” or “catastrophizing.” However, this belief is highly rational given the survivor’s actual experiences. If every system that was supposed to help you failed you, if every authority figure who should have protected you instead harmed or abandoned you, then believing the world is unsafe is not a distortion—it is a data-driven conclusion. The therapist’s error lies in assuming that the survivor’s worldview should match the therapist’s experience of relative safety, rather than recognizing that the survivor’s perception accurately reflects their lived reality. This is epistemic bias in action: mistaking a trauma-informed worldview for irrational negativity.

Cognitive-behavioral therapists are trained to identify and correct thought distortions such as overgeneralization, catastrophizing, and mind-reading. However, trauma survivors—especially those conditioned to hyper-read social danger—often do perceive hostility or malice accurately. When a therapist reflexively replies, ‘You can’t know that; you can’t read minds,’ they imply that the therapist’s interpretation of social reality supersedes the client’s. This reverses the intended healing structure: instead of teaching the client to reality-test, the therapist becomes the arbiter of reality.

For a cognitively capable person, having your reasoning pre-labeled as distorted means you never get a fair evidentiary hearing. You can’t prove a point inside a model that defines disagreement as pathology. So the therapist doesn’t have to persuade; they can “intervene.” The framework suspends mutual rational dialogue in advance—the diagnosis of irrationality becomes the argument itself. Once that asymmetry is granted, argument becomes unnecessary.

The “Normal” Baseline Problem

The fundamental flaw in CBT’s distortion framework is that it assumes a “normal” baseline of experience. What constitutes a “distortion” is determined by what seems reasonable or typical within a therapist’s frame of reference—which is often grounded in relatively safe, predictable life experiences. For example:

Catastrophizing assumes the worst-case scenario is unlikely. But if you’ve experienced repeated worst-case scenarios—systematic abuse, institutional failure, medical emergencies that were ignored—then expecting the worst is not a distortion; it’s accurate pattern recognition.
Overgeneralization assumes one bad experience doesn’t predict others. But if your pattern has been consistent—every authority figure you’ve trusted has betrayed you, every protective system has failed—then generalizing is logical, not distorted.
Emotional reasoning assumes feelings don’t reflect objective reality. But if your emotions consistently signal danger that proves accurate, then trusting your emotional data is rational.

What therapists label as “extreme” thinking is often accurate for people who’ve lived through extreme situations. The distortion framework pathologizes trauma-informed survival logic by comparing it to the relatively safe baseline of therapists who haven’t experienced systematic harm.

The Epidemiology Problem: When “Distortions” Match the Data

Consider the trajectory of a trauma survivor’s life: As a child, they experience abuse. According to CDC data and the Adverse Childhood Experiences (ACE) study, childhood maltreatment is alarmingly common—over 4.4 million child maltreatment referrals were received in 2022 alone. These children often grow up to experience revictimization, creating consistent patterns of harm throughout their lives.

As adults, they continue to be harmed. According to CDC data, 41% of women and 26% of men have experienced contact sexual violence, physical violence, or stalking by an intimate partner during their lifetime (CDC, 2022). More than 2 in 5 adult women and men reported experiencing physical violence victimization by an intimate partner. Approximately 40-50% of marriages end in divorce (CDC, National Center for Health Statistics). Rape and sexual assault are among the least prosecuted crimes, and child abuse cases are significantly less likely to lead to charges being filed and incarceration compared to other felonies.

So when a trauma survivor says “I was abused as a child and continue to be abused as an adult, and the world is unfair,” they are describing their actual life—a life that reflects statistically common patterns of harm and systemic failure.

Yet therapists are not trained in epidemiology—the study of patterns, causes, and effects of conditions in defined populations. They have no basis for evaluating whether client statements about population patterns are factually accurate. When a client says “relationships often involve abuse” or “I don’t trust partners” or “people who hurt children never get punished,” a therapist may label this as “catastrophizing,” “overgeneralization,” or “distorted thinking”—assuming the client is making inaccurate claims about reality. The therapist evaluates these statements using their own anecdotal experience or intuitive sense of what seems “reasonable”—not by checking whether they match available population-level data.

The result: A trauma survivor accurately describes their statistically common experience of abuse in childhood and adulthood, and their therapist labels this accurate perception as “distorted thinking” or “cognitive distortion”—pathologizing the survivor’s correct assessment of reality.

This is epistemic violence disguised as treatment. Therapists substitute their own optimistic assumptions (which may be false) for clients’ accurate assessments based on data and lived experience. Without epidemiological training, therapists cannot distinguish between accurate pattern recognition and genuine overgeneralization—so they default to pathologizing accurate perception as cognitive distortion.

The Logic Problem in Therapy Training

If we want to be truly fair in evaluating whether someone’s thinking is “distorted” or accurate, we need to apply formal logic: examining premises, evidence, and logical inference. However, therapists are not trained in logic. Psychology programs teach therapeutic techniques, empathy, and case management—but rarely require courses in formal logic, critical thinking, or epistemology.

Moreover, the therapy profession does not self-select for logical aptitude. It selects for empathy, emotional intelligence, and interpersonal warmth—qualities that are valuable but not the same as logical rigor. This creates a structural problem: therapists are tasked with evaluating the rationality of clients’ thinking, but they lack training in the tools (logic, critical thinking, formal reasoning) that would allow them to do this fairly.

The result is that therapists default to intuitive judgments about what seems “reasonable”—judgments based on their own limited experience rather than logical analysis of whether a client’s conclusions follow from their premises. When a trauma survivor concludes that the world is unsafe based on consistent evidence of harm, a therapist’s intuitive response (“that’s too negative”) overrides logical analysis (“does this conclusion follow from the available evidence?”).

This is epistemic injustice institutionalized: clients’ reasoning is evaluated not by logical standards, but by therapists’ subjective sense of what seems “normal” or “reasonable”—a sense shaped by their own limited and relatively safe life experiences.

Mechanism of Harm

The process by which epistemic injury occurs in therapy follows a predictable pattern:

Contradiction Induction: The client observes consistent evidence of harm or dislike. The therapist introduces a rule (‘you can’t know what others think’) that invalidates the observation.
Cognitive Split: The client experiences conflict between sensory data and the therapist’s authority, creating what van der Kolk (2014) describes as the “knowing/not knowing” dynamic central to trauma.
Epistemic Erosion: Over time, the client learns that perception cannot be trusted unless validated by an external authority, further fragmenting their already compromised sense of self-trust.
Reenactment of Abuse: This mirrors early environments where abusers denied observable reality (‘I didn’t hit you,’ ‘you’re too sensitive’), deepening dissociation and reinforcing the very survival mechanism that trauma treatment should be addressing.

This mechanism is particularly dangerous because it occurs at the level of implicit memory—the procedural, emotional, and sensory memories that operate below conscious awareness. As Pat Ogden and colleagues (2006) explain in Trauma and the Body, trauma is “stored in implicit memory, encoded in sensations, movement impulses, and emotional responses” (p. 27), making it resistant to purely cognitive interventions.

Why It’s Especially Dangerous for Trauma Survivors

Trauma is fundamentally a disorder of self-trust. As Bessel van der Kolk (2014) articulates in The Body Keeps the Score, “Traumatized people chronically feel unsafe inside their bodies: The past is alive in the form of gnawing interior discomfort. Their bodies are constantly bombarded by visceral warning signs” (p. 97). Survivors spend years doubting their own memories, emotions, and instincts—not because these faculties are faulty, but because trauma operates through implicit memory systems that bypass verbal narrative.

When a therapist challenges legitimate perceptions under the banner of cognitive restructuring, the survivor internalizes yet another layer of confusion: ‘Not only did I experience abuse, but now I’m irrational for noticing it.’ This results in secondary traumatization, turning therapy into a form of epistemic colonization—where the client’s mind must be remade in the therapist’s image.

The danger is compounded for survivors of pre-verbal trauma—trauma that occurred before the development of language, typically in infancy or early childhood. These experiences are encoded entirely in implicit memory: somatic sensations, emotional states, and procedural patterns that have no verbal narrative (Schore, 2003). As Allan Schore explains, “Early attachment trauma is imprinted into the developing right brain, which processes emotional and bodily information outside of conscious awareness” (2003, p. 11). For these survivors, there are no “distorted thoughts” to restructure—only bodily experiences and emotional patterns that existed before words.

Over time, epistemic invalidation erodes the client’s confidence in their own perception. Clients begin to doubt what they observe in the world, not because they were mistaken, but because a professional repeatedly invalidated their cognition. This epistemic injury represents a gradual loss of trust in one’s interpretive authority—a loss that trauma survivors can least afford to sustain.

The Memory and Credibility Problem

Trauma inherently affects memory—dissociation, fragmentation, and the storage of trauma in implicit rather than explicit memory systems all impact how trauma survivors recall and narrate their experiences. However, this memory impact is then used to further discredit their testimony. A survivor who cannot provide a linear, detailed narrative of their abuse may be seen as “inconsistent” or “unreliable”—their fragmented memory becomes evidence against their credibility, rather than evidence of the trauma itself.

This creates a vicious cycle: trauma fragments memory, which reduces credibility, which compounds the epistemic injustice, which deepens the trauma. As Fricker (2007) explains, testimonial injustice can cause “a significant epistemic injustice to the hearer as well as an injustice to the speaker” (p. 44)—but in therapy, when a therapist systematically discounts a trauma survivor’s testimony due to memory fragmentation or emotional expression, they compound the original trauma while also receiving flawed information about what actually happened.

The therapist who says “you’re remembering this wrong” or “that doesn’t make sense” to a trauma survivor with fragmented memory is not correcting a cognitive distortion—they are participating in testimonial injustice by using the effects of trauma (memory fragmentation) as grounds to discredit the survivor’s testimony about the trauma itself.

What Good Practice Would Look Like

What’s needed is an autonomy-respecting alternative that restores the rational contract between equals. This requires several fundamental shifts:

Treat Cognition as Contextual Rather Than Distorted

Ethical cognitive restructuring should include:

Epistemic humility: ‘You might be right—let’s check the evidence together.’
Transparency of rationale: ‘I’m asking this not to dismiss your conclusion but to see what data you’re relying on.’ ‘I’m proposing this reframing because in CBT it usually reduces anxiety. Do you want to test it?’
Contextual awareness: Recognizing when ‘distortion’ is actually survival learning.
Reaffirmation of self-trust: Teaching clients to weigh external feedback against their own data, not in place of it.

Replace “Thought Correction” with Epistemic Collaboration

A competent trauma-informed clinician does not assume falsehood in difference. They might respond, ‘I don’t personally experience that, but I know those dynamics exist. Let’s examine the evidence together.’ Rather than correcting thoughts, therapy should compare models of reality: “Let’s compare models of reality and see which predicts better outcomes.”

Explicitly Disclose Therapeutic Logic at Every Step

Therapist reasoning must be transparent and subject to client evaluation. Clients have the right to understand the rationale behind interventions and to consent—or decline—based on that understanding. This approach preserves the client’s epistemic agency and builds a collaborative, rather than paternalistic, therapeutic environment.

Clinical Reforms and Training Implications

Therapy must shift from generic cognitive restructuring to trauma-specific framework application. Rather than attempting to change how someone thinks in general, treatment should identify how specific childhood patterns created specific adult cognitive distortions—and then apply known trauma adaptation frameworks to address them systematically.

Mapping Childhood Patterns to Adult Distortions

Specific childhood experiences create corresponding adult belief systems. For example:

Toxic relationship patterns: A child who had no choice but to remain in an abusive family environment develops the belief that they must stay in toxic relationships as an adult. This isn’t a general cognitive distortion—it’s a survival adaptation that was true during childhood but no longer applies.
Unavailable solutions: Children who grew up without access to protective systems (legal intervention, safe adults, financial resources) may not recognize or utilize these solutions as adults. A client might endure workplace harassment without seeking legal recourse, not because they’re “catastrophizing,” but because their formative experiences taught them that such protections don’t exist or don’t work.
Hypervigilance to rejection: A child who experienced unpredictable abandonment learns to read subtle social cues as threats. This isn’t “mind-reading distortion”—it’s an adaptation that was necessary for survival but may now be overgeneralized.
Fawning and people-pleasing: Children who learned that compliance was the only way to avoid punishment develop hyper-vigilance to others’ needs and emotions. As adults, they struggle with boundaries, saying no, or prioritizing their own needs—not because they’re “codependent,” but because their survival depended on reading and placating dangerous adults.
Emotional suppression: Children who learned that showing emotion was dangerous (led to punishment, ridicule, or further abuse) develop the ability to disconnect from their feelings. As adults, they may struggle to identify, express, or process emotions safely—not because they’re “emotionally avoidant,” but because emotional expression was genuinely dangerous in their formative environment.
Self-blame and internalized guilt: Children who were told they caused the abuse or were responsible for their abuser’s behavior develop automatic self-blame. As adults, they take responsibility for everything that goes wrong—not because they have “irrational guilt,” but because they were systematically taught that they were the source of all problems.
Perfectionism and excessive control: Children who had no control over their environment learn to control everything they can. As adults, they may be rigid, perfectionistic, and unable to delegate—not because they’re “controlling personalities,” but because unpredictability was life-threatening during childhood.
Freeze response and shutdown: Children who couldn’t fight or flee learned to freeze and dissociate. As adults, they may shut down during conflict or become unable to respond—not because they’re “conflict-avoidant,” but because freezing was their only viable survival response.
Minimizing needs and suffering: Children whose pain was ignored or punished learn that their needs don’t matter. As adults, they may minimize their suffering, not seek help, or feel guilty for having needs—not because they’re “stoic,” but because expressing needs was met with punishment or abandonment.

The Limbic System Problem: Why CBT Misses Trauma Adaptations

A critical limitation of cognitive-behavioral therapy is that it operates at the wrong level of the nervous system. Neuroscience research demonstrates that trauma responses are mediated primarily through subcortical structures—the amygdala, hippocampus, and brainstem—which operate independently of and often faster than the prefrontal cortex (LeDoux, 1996; van der Kolk, 2014). For many trauma survivors, particularly those with pre-verbal or developmental trauma, maladaptive behaviors originate in these lower brain structures—they are emotional responses and survival instincts encoded in implicit memory, not conscious thoughts accessible to cognitive restructuring.

As Joseph LeDoux (1996) explains, “The emotional brain responds to an event more quickly than the thinking brain” (p. 19). The trauma survivor might not think “I can never leave relationships”—they simply feel it as an embodied emotional reality, often without conscious awareness of the source. This is especially true for pre-verbal trauma, which exists entirely outside narrative memory. As van der Kolk (2014) states, “We have discovered that trauma is not just an event that took place sometime in the past; it is also the imprint left by that experience on mind, brain, and body” (p. 21)—an imprint that operates through implicit rather than explicit memory systems.

When these limbic responses are present, the conscious thoughts that clients verbalize are often rationalizations that justify the underlying emotional response. A client might say, “I have to stay in this relationship because I can’t afford to leave,” or “They’re not really that bad, I’m just being too sensitive.” CBT targets these rationalizations—the verbalized thoughts—while completely missing the underlying trauma-based emotional experience driving the behavior. As Peter Levine (2010) argues in In an Unspoken Voice, “Trauma is a fact of life. It does not, however, have to be a life sentence. Not only can trauma be healed, but with appropriate guidance and support, it can be transformative” (p. 19)—but this healing requires addressing the nervous system, not just thoughts.

If instead a therapist were to say, “It’s very common for trauma survivors to stay in unhealthy relationships, and this comes from early experiences where leaving wasn’t possible or was dangerous,” they can begin addressing the actual source: the limbic-level trauma response. By explaining the trauma pattern and its neurobiological origins, therapy can treat the underlying emotional experience rather than looping endlessly through surface-level thoughts that are mere symptoms of the deeper wound.

This distinction is essential—trauma adaptations are often felt, not thought. They exist as emotional realities encoded in procedural and emotional memory that require trauma-informed frameworks to address, not cognitive restructuring of verbalized thoughts that may be post-hoc justifications for limbic responses. As Stephen Porges (2011) explains through polyvagal theory, trauma responses are mediated through the autonomic nervous system, which operates largely outside conscious control. Therapeutic interventions must address these subcortical systems directly, rather than attempting to “think” one’s way out of limbic responses.

Trauma as Classical Conditioning

Many trauma behaviors can be understood as Pavlovian—or classical conditioning responses. For a full explanation of how trauma creates conditioned responses and why CBT fails to address them, see Classical Conditioning (Pavlovian Conditioning) in Trauma.

CBT fundamentally misunderstands this mechanism. By attempting to “correct” conscious thoughts, it fails to recognize that the problem isn’t the thought—it’s the conditioned response that occurs before and beneath conscious thought. A trauma survivor might rationally know “I am safe now” while their body responds as if they’re in imminent danger. You cannot “think” your way out of a Pavlovian conditioned response—these responses require extinction or counterconditioning at the neural level where they were encoded.

The Framework-Based Approach

Instead of generic cognitive restructuring, therapists should:

Identify the specific childhood pattern: What survival strategy did this belief serve during childhood?
Validate the historical accuracy: This perception was accurate and necessary in the original context.
Map to adult context: Where does this belief no longer apply? What resources are now available that weren’t available then?
Apply trauma frameworks: Use established frameworks (complex PTSD adaptations, attachment patterns, developmental trauma responses) rather than generic “thinking errors.”

Therapists must receive explicit training in trauma adaptation patterns and learn to distinguish between maladaptive survival strategies and general cognitive distortions. Without this framework-based approach, therapy risks pathologizing necessary childhood adaptations while failing to address the specific patterns that maintain adult suffering.

Conclusion

A therapeutic framework that routinely undermines client perception is not neutral—it is epistemically violent. Just as medicine evolved to recognize the rights of patients to understand and consent to their treatment, therapy must evolve to respect the cognitive autonomy of those it serves. The goal of trauma recovery should be to restore the client’s trust in their own interpretive faculties, not to replace their worldview with the therapist’s.

As Herman (2015) observes, “The core experiences of psychological trauma are disempowerment and disconnection from others. Recovery, therefore, is based upon the empowerment of the survivor and the creation of new connections” (p. 197). This empowerment requires epistemic respect—recognizing that trauma survivors’ perceptions are adaptations that served survival, not distortions to be corrected.

This critique points to the core philosophical fault line between paternalistic and autonomy-based mental-health care. CBT assumes bounded rationality to justify direction. An ethical framework insists on rational sovereignty—that people remain reasoning agents even when suffering. The challenge isn’t to make therapy more efficient or scalable, but to make it epistemically just: treating clients as cognitive equals with the right to understand, evaluate, and consent to their own treatment.

Furthermore, given what neuroscience reveals about trauma’s storage in implicit memory systems and subcortical structures, therapeutic interventions must address the nervous system directly. As van der Kolk (2014) concludes, “The greatest sources of our suffering are the lies we tell ourselves” (p. 350), but for trauma survivors, these are not the lies of distorted thought—they are the embodied truths of survival adaptations that operated in contexts where leaving truly wasn’t possible. Healing requires recognizing these truths, validating their historical accuracy, and mapping them to current contexts where new options are available—not denying their validity through cognitive correction.

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