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Table of contents
- Trauma - reaction and recovery
- Somatic experiencing: using interoception and proprioception as core elements of trauma therapy
- Learning Objectives
- Accessible Trauma Resolution – A Model with Evidence to Match
Case management skills and the willingness to collaborate with clients in dealing with social welfare, public housing, transportation, and other systems supporting safe functioning are often necessary in working with all but the most privileged and functional of trauma survivors. In the trauma-focused training clinic that I directed between and , interns acquired skills such as learning how to get people into the social security disability system; what the correct language is for a letter for a request for a trauma service dog, and how to find low-cost veterinary care for the animal; how to deal with the crime victims compensation system; how to lobby legislators to fund services for crime victims on Medicaid; and how to deal with the vicissitudes of the paratransit system, which routinely arrives too early or too late.
They also learned where the safest homeless shelters were located, where clients could find clothing banks and food banks, how to get acupuncture services for poor people, and how to get specialists to be willing to see patients who can pay very little or who are covered by Medicaid. Trauma-informed therapists working with clients in the safety and stabilization phases of treatment need to be willing to master these and similar skills, or work in a practice context where there is someone who will offer those case management skills to the client.
Such engagement by the therapist is, in fact, trauma treatment with powerful symbolic implications for clients.
As Ochberg noted on working with trauma survivors, therapists with this population cannot behave in a distanced, neutral manner. A component of creating safety for clients is demonstration of our willingness, in a boundaried, professional way, to collaborate with them on genuinely creating safety in their lives. Such engagement with these very practical problems and solutions is a therapy intervention that challenges hopelessness about the world and people in it, and enhances trust in a population of clients who are notorious for having difficulties trusting their therapists. The more traditionally therapeutic interventions of this phase of treatment focus on other aspects of personal safety.
There must be time spent on assisting a client to become free of relationships that are objectively dangerous or exploitative. Being in a relationship where there is intimate partner violence, being harassed or discriminated against in the workplace, working in dangerous conditions where occupational safety considerations are not adhered to, or living in dangerous housing or in a neighborhood where violence is endemic all may become a focus of treatment as the therapist works together with the client to empower the client to move into situations of greater material safety.
So long as clients continue to live in conditions where they are unsafe, they will be unable to experience the biological changes to the stress response system necessary for a fuller recovery from post-trauma symptoms.
Trauma - reaction and recovery
Development of safety plans that are both short-term, as in how the client will stay reasonably safe from session to session, and longer-term, as in how the client will get out of the intimate partner violence situation she is currently in, should be occurring early, and then repeatedly during the safety and stabilization phase of treatment. An element of safety that is rarely discussed in the trauma treatment literature, but reflects a commitment by the therapist to cultural awareness as well as trauma, is that of spiritual safety. Issues of safety may also raise cultural dynamics when culture speaks directly to what constitutes safe ways of living and the means by which such safety is achieved.
A traditional Navajo person may, for instance, feel safe only after going through a ceremony with a traditional healer and may feel unsafe in the world, no matter what the material circumstance surrounding him, until able to perform such a healing ritual. The observant Muslim survivor of domestic violence who is in a physically safe shelter environment may feel unsafe if she is not able to eat halal food, as the safety of her soul will feel in jeopardy.
Conversely, when there is spiritual safety, an individual may code an experience as less traumatic. When clients raise this kind of safety issue, a trauma-informed therapist will listen carefully to whether a client is using spiritual or religious language to excuse remaining in unsafe conditions versus a powerful need for spiritual authenticity that trumps personal safety, not excuses personal unsafety. Therapists must also attend at this phase of treatment to their own biases about what constitutes safety.
An example of this clinically was the case of a woman who had never worked as anything other than a prostitute. She had been pulled from school in early adolescence by her step-father to be trafficked, and had no other skills with which to earn a living. A single parent with two small children, she needed to keep a roof over her head and theirs, and wanted her children to have the safe life that she had not. The therapist, after consultation, proposed to the client that she consider entering those aspects of the sex trade that would be least dangerous to her physically and legally.
The client agreed to this safety plan, and took a job working for a phone sex line. This got the client out of contact with customers, reducing to zero her risks of being beaten and infected, and greatly minimizing her legal risks as well. Having this new experience of greater safety allowed the client to see how she could set the bar even higher, and provided the income allowing her to seek education in an even lower-risk occupation. This harm reduction model, familiar to psychotherapists who work in the field of substance abuse, applies equally well to working with trauma survivors.
Stabilization refers largely to the ways in which the person becomes safe within her or himself, and focuses on the replacement of problematic and risky coping strategies with others that are non-harmful, and may even be health-inducing. In order for clients to directly approach the painful memories and powerful affects of their trauma experiences, they must be equipped with the emotional and cognitive capacities to do so without becoming further destabilized.
This was one of the ways in which trauma therapists became aware that apparent capacity to function in daily life was not necessarily a predictor of whether a person could tolerate direct exposure to trauma material; rather, what was more predictive — recalling our earlier discussion of developmental factors — had to do with what developmental capacities had been undermined in some way by trauma in early life.
As we will be discussing in the segment on specific approaches to trauma treatment, those interventions developed for this skill set have not always been trauma-aware, but they are highly suited for, and of assistance to, clients struggling to master these capacities.
Goals of therapy during this time thus include reductions to extinction or very low levels of all forms of self-harmful behaviors. Because many trauma survivors struggle with suicidality, both chronic and acute, and many engage in self-inflicted non-suicidal violence, treatment strategies that give clients non-violent means of tension reduction or anti-numbing will be important. One of the messages that I give to my clients is that most of what therapy offers to them will not be as effective, as quickly, as their self-developed tension reduction strategies. This is both a validation of a clinically observed reality, and a relapse prevention strategy.
Clients during this phase also need assistance to reduce or become abstinent from substances and risky compulsive behaviors. Programs aimed at assisting people to become sexually safer report that many of their more challenging participants are those with a trauma history, who may be using the risks of unprotected sex as an emotional high, or as a means of inflicting punishment upon themselves. Therapists working with trauma survivors must thus become minimally conversant with the pathophysiology of substance abuse, with norms for sexual safety, and with adjunctive treatment options for clients with addictions or risky compulsions.
Therapists must also be prepared to directly confront anti-social behaviors that risk the client becoming incarcerated, and treat them as both therapy-interfering behaviors, and as maladaptive coping strategies, while maintaining a stance of compassion and care rather than judgment. As I have pointed out to more than one client, I cannot do treatment with them if they are in prison for theft, assault, or prostitution.
I add that I care enough about the client that I do not wish to see him spending time locked away behind razor wire in another setting where he will be chronically unsafe.
Somatic experiencing: using interoception and proprioception as core elements of trauma therapy
The predominance of trauma survivors in U. Our assertion of our relational caring for them introduces the element of compassion, and underscores the anti-relational nature of anti-social coping strategies. Non-risky compulsions, such as over-work and over-exercise, must also be addressed during the stabilization phase of treatment. These can be more difficult to approach, as they are a distorted use of culturally valued and potentially positive coping methods.
Clients using these strategies are usually apparently higher functioning, and more able to rationalize and intellectualize their actions. This is often pseudo-stability, however; many experienced trauma therapists find that people enter treatment when life circumstances have curtailed their abilities to over-work or over-exercise. Once again, a trauma-aware therapist does not equate the appearance of function with the capacities to self-soothe. Therapeutic experiments can be helpful in assisting both therapist and client to determine whether he is using these modalities to avoid affect and reduce anxiety, or whether he genuinely needs to work fifteen hours a day or run with a stress fracture in his foot, which is often the rationale offered by the client.
In these interventions toward stabilization, the therapist requests the client do the experiment of going without the socially acceptable compulsion for a brief period, usually no more than a week, and observe the effects. Clients commonly find that they are experiencing those symptoms that the over-activity has been warding off, particularly anxiety-related ones. Another central therapeutic task of the stabilization phase is teaching clients to cease avoidance. Avoidant coping is one of the hallmarks of post-traumatic symptom pictures, and represents an at-the-time reasonable strategy to not expose oneself to more of the trauma.
However, such coping strategies become over-generalized and pervasive, and poorly equip many trauma survivors for handling even non-trauma-related affects, much less those associated with the trauma experience. Graduated strategies for assisting a client in reducing numbness and avoidance and tolerating the experiences of bodily sensations and emotions without becoming overwhelmed or dissociative, are another aspect of creating intrapsychic safety and stability.
Safety interventions such as the one described above also commonly involve health of the body, which is an important component of safety. Although few Complementary and Alternative Medicine CAM treatments have been scientifically studied for their effectiveness, many of them are founded in long-standing non-Western systems of health care and have extensive clinical evidentiary support for their use. CAM approaches have been studied with regard to certain ethnic groups within the U.
Such clients are not always from the cultures in which these somatic interventions are most common. The safety phase is also one in which the client is supported in developing a sense of resilience and capacities. All trauma survivors have some resilient coping strategies and capacities. Trauma survivors need to learn that they can depend on themselves, and that they are safe with themselves. Consequently, treatment interventions at this phase will include a focus on experiencing, building, and reinforcing a sense of oneself as competent, capable, and able to interdependently care for oneself.
Rigid internal rules about who and how one should be in the world are likely to emerge at this point, particularly as pertains to what is perceived as socially acceptable for a person with a particular identity. At this phase of treatment, people address what they remember, as well as what they cannot recall. Issues of post-traumatic amnesia, delayed recall, and the impact of trauma on memory are all generally relevant topics for the trauma-aware psychotherapist to be familiar with. Inviting trauma survivors to tell their stories is the process of gradually rewriting their life narratives so that two things occur.
Such a process of disentangling oneself from the trauma narratives of a culture can be tricky and fraught with pitfalls. In cultures where certain kinds of trauma exposures are endemic, cultural and personal survival may have led to the development of a cultural narrative that minimized the importance of those apparently normative and usually inescapable events. This happens to all of us. Clients who encounter a pre-existing narrative about their particular sort of trauma can have the healing process complicated.
This phenomenon is easy to observe in the ways in which veterans with combat-related trauma symptoms, particularly male veterans, fail to report them because of how those symptoms interfere with the narrative of the warrior. Consequently, one aspect of this second general stage of therapy invites trauma survivors not to reject the narratives of their culture and context out of hand, but rather to think critically yet compassionately about those narratives in order to develop their own healing stories about the trauma in their lives.
One of the more contentious aspects of trauma treatment since the early s has been the issue of memories for trauma that emerge after having been unavailable to conscious awareness for periods of time. Despite the well-documented phenomenon of delayed recall of all kinds of trauma Courtois, , the discourse about this issue became heated, adversarial, and polarized, with an entire movement of individuals who claimed to have been falsely accused of childhood sexual abuse by adult offspring. This movement insisted that it was impossible for traumatized people to forget trauma, that all memory science agreed with this assertion, and that any report of a delayed recall of childhood trauma represented a confabulation arising from suggestions made by therapists or self-help books.
Rivers in a scholarly publication about combat-related PTSD in In the second decade of the 21 st Century, several different cognitive psychology models were empirically tested and shown to explicate a number of varying mechanisms that will produce delayed recall. Readers wishing to read in detail about the most recent findings this topic are referred to the proceedings of the Nebraska Symposium on Motivation, which took the memory debate as its topic Belli, While it is equally clear that it is possible for people to represent as memories of their life things that have never happened, it is now well-accepted that delayed recall of trauma is a normative aspect of post-trauma experiences for some individuals, and that for many, the memory of the trauma, no matter how recent, is obscured by the physiological phenomena of terror, disgust, or tonic immobility that accompany the events of the trauma.
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Although it is possible to still find partisans of the memory debate who insist that either no recovered memories or all recovered memories are true, the most scientifically supportable position on this occupies a middle ground. Similarly, because all memory contains some distortions and misinformation, therapists must refrain from enthusiastically endorsing the veracity of material presented as a continuous memory, since research indicates that continuous memories are no more likely to be accurate than those that are delayed. Trauma-informed therapists should become knowledgeable about how memory systems work, and with the most recent cognitive psychology models for memory, including information about when continuous narrative memory is most likely to emerge.
Memories for life experiences prior to this offset of infantile amnesia, which is usually associated with the development of language skills with which to encode memory, must be seen as less likely to represent actual events than memories from later in life. The effect of trauma-related effects on the process of memory retention, storage, and retrieval should also be understood by the trauma-aware therapist, and conveyed in a clear and compassionate manner to the client who is struggling with fragmentary or clouded memories. One of the shibboleths of the false memory movement has been that adults have reported remembering events that could have never occurred, as they were fantastical or violated laws of physics.
However, Dalenberg , in a study of materials reported by children whose sexual abuse was extensively corroborated, found that such fantastical, impossible material was more likely for children known definitively to have been abused than for children whose reports of abuse could not be corroborated. Thus, therapists at this juncture in treatment should avoid becoming attached to issues of veracity or proof, or of whether what the client reports could have really happened.
These are forensic questions, useful when there is a legal matter at hand, but problematic in treatment. Trauma is always a loss of some kind. Grief for what was, and grief for what never was or could be, emerges as the coherent life narrative forms. Remember the slinky toy; the client will need assistance to reinstate safety and stability while not avoiding the painful effects associated with loss and mourning. The adult sexually and physically abused as a child by a parent who has just died feels not only that death, but also the death of hope Brown, The griefs associated with trauma are often complex.
A trauma-aware therapist working with any client whose current level of grief seems inconsistent with the most recent loss will explore whether and how this loss is evoking previously unexamined post-traumatic losses. The third stage of this overarching model of trauma treatment is about reconnection with self, body, social world, and meaning-making. It is a stage in which post-traumatic growth PTG is most likely to be observed, as the survivor begins to make the experience of trauma less foreground to his life, and looks for the recipes for making lemonade out of the lemon of trauma. In this stage, trauma survivors create active engagements with their interpersonal and relational worlds, and come to experience themselves as more empowered and fully alive.
They may try out new activities, new kinds of relationships, or new vocations. Disappointment over highly idealized visions of what recovery from trauma will be like is not unusual at this juncture, requiring the development of acceptance for what life after trauma actually can be. This is a phase of the healing process in which connections to culture can become particularly valuable to the survivor.
For some trauma survivors, this phase of treatment centers on how their old life is still available, yet transformed; this is a common theme for survivors of adult-onset trauma. For complex trauma survivors, this component of therapy may entail learning how to live in the life they have never had, one in which most aspects of daily existence work well enough, and safety is a norm rather than a fiction. Therapeutic strategies during this phase of treatment are more likely to be helpful when they assist trauma survivors to directly encounter the existential issues inherent in their lives.
Integration of self-care strategies into the norms of life, and deepening resilience for the unknowns that lie ahead are also common threads of this final phase of treatment. Some survivors in this stage of therapy find it helpful to look intentionally at the future and use the therapy to strengthen capacities for predictable events.
A rape survivor will want to review skills for dealing with her daughter beginning to date. A component of radical acceptance is integration of the reality that trauma has happened and life has been inalterably changed; a theme of this phase of treatment is that the changes need not be for the worse.
An important take-home message of this model is how it informs the choices of specific interventions that a therapist utilizes. A client who is early in the safety and stability phase would likely do very poorly with exposure therapies. Conversely, clients who have not experienced complex trauma are unlikely to find treatments zeroing in on emotion regulation and self-soothing to be germane to their needs. Clients in the existential crisis over life narrative may need more interpersonally-focused treatments. As Norcross has noted, therapies and interventions must be tailored to where a client currently locates in stages of change.
A trauma-informed therapist integrates that overarching model of change into this superordinate paradigm for trauma treatment in determining what direction to take in treatment. However, it is rarely effective for a therapist to be rigidly adherent to his theoretical orientation when working with trauma survivors. Classical psychodynamic treatment may be too destabilizing for a client inundated by flashbacks and intrusive thoughts, although entirely appropriate for the third stage of treatment where existential issues are being addressed, while a purely cognitive processing model will be unlikely to assist a client with existential meaning-making questions.
A trauma-informed therapist will of necessity become somewhat more integrative in order to competently assist clients who have experienced trauma. This is not a call for the trauma-informed therapist to abandon her frame or theoretical orientation. Instead, the trauma-informed therapist uses the three-phase model to integrate trauma-specific care into her usual treatment strategies. Readers wishing to learn more about this model are referred to Herman for an in-depth discussion. The next section of this course will discuss specific treatments for trauma-related symptoms, organized around how they are likely to be most applicable to the three stages of this model.
This section of the course will briefly review some of the well-accepted strategies for working with trauma survivors in therapy. Some of these treatments were developed specifically for PTSD; others address the range of symptoms described earlier in this course that are also common post-traumatically, and may or may not have originally been developed to take trauma into account. All of these approaches have a strong evidentiary base for their use with at least some groups of trauma survivors.
A caveat, however: the most current meta-analyses of even the best of the specific evidence-based treatments finds that their effects are mostly in the moderate range on a variety of outcome measures, and that the differences between treatments appear to be negligible. These brief overviews are meant to give a clear idea of how the treatment works, and for whom it is most likely to be indicated given the types of trauma and developmental variables in play; additional specific training in any of these techniques may be necessary in order to competently implement them with clients.
Underlying all work with trauma survivors, no matter what specific intervention is employed, is the foundation of the Empirically Supported Therapy Relationship ESR variables. Nonetheless, ESRs need to be taken into account in trauma-informed care. That is because these variables are factors that have been empirically determined to affect psychotherapy outcome and client satisfaction, and thus constitute an important component of the evidentiary base of trauma treatment.
The ESR literature indicates that many of the interpersonal factors that are potentially problematic in work with trauma survivors can meaningfully affect the outcome of treatment. Several ESRs are particularly relevant to effective psychotherapy with trauma survivors. Positive regard, which can be expressed in terms of respect, liking, and giving honor to the client, generally accounts for significant percentages of the variance of therapies having good outcome.
For treatment of trauma survivors, many of whom have a damaged sense of self-worth, this ESR can be powerful. If the client knows that the therapist sees him as a courageous survivor, a person of honor, worth and dignity, whose experiences are attended to and respected, the entry conditions for formation of a therapeutic alliance have been met.
Accessible Trauma Resolution – A Model with Evidence to Match
The therapist needs to reflect back to the survivor a view of the client as a decent and brave human being. In attempting to convey this to clients, I frequently use the metaphor of Bilbo Baggins, the eponymous hero of The Hobbit , and his nephew Frodo, the protagonist of Lord of the Rings , who, as I note, are terrified of the quests on which they have been sent, and frightened repeatedly throughout them — yet each one gathers his courage and goes forward.
Since the mythology of dominant cultures in the Western world is that heroes feel no fear, and that those who experience fear are cowards, positive regard communicated as a disruption of this untruth about courage lays a foundation to which the therapy-client pair will need to return repeatedly as the client faces new challenges of metabolizing the trauma material. Levels of received empathy rated by the client are another predictor of good outcome in psychotherapy. When the therapist was not experienced, empathy had an even larger role in leading to good outcome.
Again, with trauma treatment, empathy takes an even larger role as an important ESR. The therapist must demonstrate the capacity to witness and resonate with the painful experiences that the trauma survivor has lived through. Trauma survivors often feel as if no one can possibly understand what they went through, and indeed, much of what any given trauma survivor has suffered will be beyond the life experiences of many therapists.
However, emotion — fear, suffering, confusion — are not beyond the experiences of most practicing therapists. Staying in empathic connection models the capacity for exposure to traumatic materials; such exposure is ultimately necessary, in some form or another, for post-trauma symptoms to resolve. In the empathic connection, the trauma survivor client becomes less alone, and feels joined and allied with when revisiting the dark passages of his life.
Empathy also has specific positive effects on treatment. Clients who experience high levels of received empathy are more likely and able to collaborate with the therapist on difficult work. Some findings from the attachment literature suggest that empathy mimics the attunement of healthy attachment, thus providing an emotional and neurobiological experience of soothing and connection that assists the client to self-regulate.
Empathy also empowers clients to think more clearly and critically, and to become engaged as active self-healers. For trauma survivors who often feel utterly powerless and disconnected due to trauma, empathy has the potential to have specific therapeutic effects to counter those post-trauma symptoms.
Genuineness is yet another ESR that has implications for trauma treatment. This mode of therapeutic functioning can be seen in a number of different therapy paradigms; for instance, Stark gives examples of genuineness in a relational psychoanalytic treatment.
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Ruptures that are unattended to by the therapist predict premature exit from treatment. These authors note several important psychotherapist characteristics that enhance the capacity to notice ruptures. As discussed in the section of this course on countertransference, trauma survivors, particularly those with complex trauma, are, by virtue of their post-traumatic adaptations, less likely to risk telling a powerful authority figure the therapist of displeasure or disagreement.
All take a profound toll on psychological well-being, ranging from individual reactions—including depression, acute stress reactions, post-traumatic stress disorder PTSD , and other anxiety disorders—to the disruption of crucial support networks within communities. Trauma is often particularly prevalent in response to the brutalities of war and oppressive regimes. Children witness the fear, humiliation, and death of their parents. Landmines mangle bodies. Soldiers, sometimes themselves only children, are thrown into the lethal chaos of gun battles. Women are raped, abducted, and threatened with death.
The lingering effects of credibly imminent annihilation, of extreme sexual abuse, and of the shock of neighbors transformed into mortal enemies have all been well documented. Attention to the sufferings of trauma and the needs of individuals and groups to reintegrate into reasonably trustworthy human communities is therefore a key task in post-violence societies. Q: Why are I are to find the fascinating s laboratories of the control? For the other, Ruby normally is battle graft-copolymers do honest for representing at related world independent diseases, that you will consult out for the tool front because per the activity classifieds plus contest amphibians.
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