This is a beginning to intermediate course. After completing this course, the mental health professional will be able to:
The materials in this course are based on the most accurate information available to the author at the time of writing. The field of trauma psychology grows daily, and new information may emerge that supersedes these course materials. This course material will equip clinicians to have a basic understanding of trauma and its effects, and how to assess those effects across a broad range of diagnoses. This content may provoke painful feelings for some readers, or bring the reader’s own personal trauma experience to mind.
This is the second of three courses in a series about trauma, which is a biopsychosocial/spiritual-existential phenomenon whose effects can be seen in the forms of distress and dysfunction on almost every variable of human functioning. The first course, Becoming a Trauma-Aware Therapist: Definitions and Assessment, covers questions of what constitutes a trauma, and how to assess for its effects in a range of ways. This second course, Treating Trauma: Basic Skills and Specific Treatments, introduces an overarching framework for trauma treatment, and then reviews the large variety of specific treatments for trauma that are now available. The third course, Emotional and Cultural Competence in the Trauma-Aware Therapist, explores being sensitive to the patient's multilayered cultural identities when being treated for trauma, as well as that of the therapist working with the trauma patient.
Once the clinician has determined that trauma constitutes an important aspect of what is troubling a client, there are a number of considerations to take into account when moving forward with treatment. Clinicians working with trauma survivors should become familiar with the overarching paradigm for trauma treatment, which serves as the foundation and framework for the application of specific interventions. The choice of a specific intervention will, in turn, reflect the nature of the trauma (e.g., complex trauma), as well as considerations regarding effectiveness and client capacity to tolerate a particular approach to treatment.
Best practices in trauma treatment today, no matter what the specific approach, tend to be guided by a meta-model. This “ecological model of trauma treatment” (Harvey, 1996) used by Herman, Harvey, and their colleagues at the Cambridge Victims of Violence Program reflected much earlier recommendations made by Janet regarding working with complex trauma, and Kardiner and Spiegel’s descriptions of effective treatment of soldiers with combat-related PTSD, as well as more recent work by colleagues such as Putnam. This model, because of its broad dissemination in the field of trauma therapy, serves as a paradigm for other transtheoretical treatments for trauma, and has been integrated into the work of many psychotherapists working with trauma survivors. Before going on to specific interventions, trauma-aware psychotherapists must familiarize themselves with this model to ensure that they are guided by its parameters in their work.
While this model posits three phases of treatment, clients rarely proceed in a linear fashion through these phases, as there is no typical trauma survivor client. The individual with a positive developmental experience and solid attachment who suffers an adult-onset trauma may need to spend little to no time in the stabilization and safety phase of treatment, while the person with a complex developmental trauma history may spend almost the entire course of therapy there. Clients go in and out of these stages; they often enter treatment with florid intrusive or dissociative symptoms, which call for the therapist to utilize interventions that directly target those distressing experiences. However, as will be discussed below, it is more clinically prudent to do whatever possible to focus on safety and stability prior to, or simultaneous to, dealing with the overtly distressing trauma materials. I use the metaphor of a slinky-toy for trauma therapy (and keep one on my desk where clients can see it). It involves moving through a continuous spiral of levels, sometimes so tightly packed in that they seem to be a circle rather than a spiral, other times more clearly separate from one another and more obvious evidence of progress. Similar material is addressed therapeutically at each step along the spiral, but addressed differently at each level as the spiral progresses forward.
The initial stage is that of establishing safety and stability. Safety, like trauma, would appear at first glance to be a neutral, easily agreed upon construct. However, there are likely to be specific variables that delineate safety for a given trauma survivor. There are other aspects of this phase of treatment that are foundational and must be established with every client in order for trauma treatment to proceed. For some clients, these boundary conditions are more or less in place when they enter therapy; this is most likely true for individuals with single-episode adult-onset traumas who have good social supports, or children whose single-episode trauma occurred outside of the family system. For other clients, safety and stability are dimensions on which they have always experienced deficit, and a large component of the treatment may consist of ensuring that these elements are in place before proceeding to more directly address the specific material of the trauma.
Some aspects of safety are basic and resemble the bottom layers of Maslow’s famous pyramid of needs: safe food, safe water, safe air to breathe, and safe housing. For many trauma survivors, these basics cannot be taken for granted. Depending on the type of trauma involved, survivors often have both immediate and longer-term, chronic challenges to their basic needs for safety. Disaster survivors may not have a roof over their heads or water to drink – or worse, may be domiciled, but in unsanitary and unsafe conditions, like the Katrina survivors placed in the toxic FEMA trailers. Combat veterans have among the highest rates of unemployment in the U.S., and are at significant risk of being homeless, with the attendant risks to safety.
Survivors of complex trauma are often engaged in trauma reenactments in their adult lives. This means that they are frequently embroiled in relationships that are physically or emotionally dangerous – or both. Many clients who have been trauma-exposed are also not safe with themselves, engaging in a range of self-injurious behaviors. Safety in trauma therapy must, consequently, focus on addressing questions of strategies that people have adopted in order to soothe themselves and manage intolerable affects in the wake of trauma. Many of the symptoms associated with post-traumatic diagnoses represent some component either of those intolerable effects or people’s self-help strategies for trying to deal with them. Some of those strategies are problematic and risky, such as excessive consumption of mind-altering substances, cutting or burning oneself to evoke either heightened or numbed states of awareness, over-exercise, over-work, eating less or more than nourishes the body, being sexual in unsafe ways or with unsafe partners, and so on.
A component of safety rarely addressed in the trauma treatment literature, but one that takes into account the explicit presence of possible insidious trauma in the psychosocial environment, is extending the definition of safety to include considerations of ways in which systemic oppression and bias may be creating inherent and difficult to avoid unsafety for the client. The presence of such systemic challenges to safety for members of target groups must be addressed and identified given that some clients may be chronically responding to these embedded phenomena. A trauma-aware therapist who is also culturally attuned will add to discussion of standard safety issues discussions of the presence of systemic safety-undermining life experiences that may not be avoidable or changeable due to their ubiquity. Therapists working with clients who cannot come to full safety due to such environmental realities can, however, have the goal of assisting the client to make life as safe as possible.
At such times, it can be particularly important for the therapist not to join with a client’s learned helplessness and hopelessness, the “sense of a foreshortened future” symptom of post-trauma symptom pictures. Rather, the therapist must insist that neither he nor the therapy process will settle for any less than is fully possible for the client – to do otherwise is to collude with the oppressive system in continuing to make it unsafe for the client. While therapists cannot eradicate racism, for instance, they can certainly work with clients to strengthen bonds within their own communities, reduce exposure to overtly and insidiously racist materials, and validate clients’ experiences of those daily exposures so that clients feel allied with, seen, and heard rather than alone in the therapy office with their experiences of feeling unsafe.
The tasks of the therapist during the stabilization and containment phases of treatment may begin by not looking very much like what therapy is generally imagined to be. 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 2006 and 2015, 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 (1988) 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. 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. Spiritual safety can often transcend physical safety in a particular trauma survivor’s personal hierarchy of needs, and its absence can undermine apparently safe settings. 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. While the therapist’s own bias was that prostitution was always a form of victimization, she was aware that her client did not share this perspective, and moreover was unprepared to function in the “straight” world. 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. The therapist’s focus on “as safe as possible” allowed the client herself to set a goal of even more safety – in this case, emotional safety as well. 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. One of the very difficult learning curves of the trauma treatment world in the 1980’s was the discovery that the exposure and abreaction models of trauma treatment that had emerged from work with veterans and adult-onset trauma survivors were badly decompensating those persons whose developmental trajectory had, for reasons of trauma or other causes, not equipped them with skills for soothing themselves and quieting their levels of arousal after directly confronting trauma materials in session. 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.
At this stage of treatment, interventions that improve clients’ capacities to regulate emotion, self-soothe, use relationships appropriately for attunement and positive connectivity, and develop compassion for self are central. 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. Predicting the difficulty of mastering non-trauma-based skills reduces the perfectionism and rigidity with which many trauma survivors approach the task of their own recovery, and models compassion for self via the therapist’s compassion and empathy for their struggle.
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. The predominance of trauma survivors in U.S. prisons, especially those housing women, speaks volumes to the importance of insisting that clients work toward becoming legally safe. 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.S.; for example, studies of collaboration with traditional curandero, as in Hispanic communities (Comas-Diaz, 2006), or with traditional healers in American Indian communities (Robin, Chester & Goldman, 1996) seem to indicate that integration of these CAM approaches into the psychological healing process can be extremely helpful. A trauma-aware therapist working with clients on issues of safety and stability is encouraged to be open to methods of health management that are congruent with clients’ beliefs, even when those beliefs run counter to those held by psychotherapists, many of whom are trained within Western models of medical care and standards of proof. 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. Many do not experience those, and have a damaged self-percept as “weak” or “crazy.” Others have lost their usual resilient strategies in the wake of the trauma and are struggling to identify how they are still capable, seeing themselves as “damaged goods.”
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.
The second stage of this model is what Herman calls “mourning and remembrance.” This is the component of therapy in which a survivor tells the story of what happened, and begins the process of integrating that narrative into the narrative of life, grieving for what was and what could not be as a result of the trauma so as to create the emotional space in which a life and a future can be constructed. 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.
Cultural awareness and sensitivity, and attention to issues of a survivor’s identity, can be centrally important to the successful accomplishment of this component of therapy. As discussed in the segment of this course about cultural competence, trauma frequently insinuates itself into multiple locations in an individual’s identity and self.
Inviting trauma survivors to tell their stories is the process of gradually rewriting their life narratives so that two things occur. First, the reality of the experience of trauma is acknowledged, not in the form of intrusive symptoms representing dissociated affects and sensory stimuli, but rather as part of the individual’s autobiographical narrative. Recall the discussion of trauma’s effects on the brain, and the way in which Broca’s area is deactivated during traumatic memories. Related research has demonstrated that after treatment, at which point the trauma is well-integrated into the personal narrative, Broca’s area is activated; the survivor can now truly speak of her experience.
A component of this process of rewriting the personal narrative is unpacking, interrogating, and disrupting those cultural and contextual master narratives that have informed and distorted the survivor’s experience of herself. Such a process of disentangling oneself from the trauma narratives of a culture can be tricky and fraught with pitfalls. A trauma-informed psychotherapist cannot simply dismiss the official cultural lenses on the trauma experiences as irrelevant to the client’s realities by naively challenging them as irrational thoughts or beliefs that are not relevant within the immediate cultural surround.
At times, cultural survival and safety of the group has led to suppression of individual narratives and experiences of trauma that are not part of the culture’s particular dominant trauma narrative. 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. Such endemic experiences are often referred to dismissively; for example, “It’s no big deal. This happens to all of us. It’s the way of the world.” These cultural numbing strategies may also need to be compassionately challenged as the survivor rewrites the story of what his life means with trauma in it.
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. This master narrative undermines the military’s attempts to screen for and treat combat-related PTSD in personnel returning from deployments, with many anecdotal reports of lying on screening questionnaires because the motives of such documents are transparent, and the veteran does not wish to be labeled as having PTSD.
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. Some of the grieving that occurs at this juncture is for the lost mythologies of trauma survivor’s lives, the mythologies about “how it was supposed to be” woven into the dominant narratives of their cultures.
One of the more contentious aspects of trauma treatment since the early 1990s has been the issue of memories for trauma that emerge after having been unavailable to conscious awareness for periods of time. The focus of the so-called “memory wars” of that decade was delayed recall of childhood sexual abuse. Despite the well-documented phenomenon of delayed recall of all kinds of trauma (Courtois, 1999), 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.
One of the few productive aspects of this debate was that it spurred an outpouring of research examining the question of what cognitive and/or biological mechanisms might underlie a clinical reality that had first been described by the British psychiatrist W. H. R. Rivers in a scholarly publication about combat-related PTSD in 1918. In the second decade of the 21st 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 2010 Nebraska Symposium on Motivation, which took the memory debate as its topic (Belli, 2011). 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. 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.
As a consequence of the known problematic effects of trauma on the recall process, many trauma survivors during this phase of treatment will struggle with questions of “Did this really happen?” The pull for the therapist to simply say, “I believe you” can be powerful, but not necessarily helpful. As Pope and Brown (1996) and Courtois (1999) note, the therapist at this point must assist the client in holding the ambiguity and unclarity of what is consciously known, and refrain from drawing conclusions about a client’s experiences based on their symptoms. 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.
Psychoeducation can be a very important component of addressing questions of the client’s memory for the trauma. 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 (1996), 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.
Instead, the focus of the remembrance process for the trauma survivor must be on coming to terms with what both is remembered and what cannot be recalled, and integration of those experiences into the client’s life narrative in an empowering manner. Courtois’s description of this is particularly felicitous, “Safe, self-reflective disclosure of traumatic memories and associated reactions in the form of progressively elaborated and coherent autobiographical narrative is the primary task of this phase.” (2009, p. 93).
Trauma is always a loss of some kind. The losses can range from apparently small and transient – a broken arm from a serious car accident that affects the person’s ability to do valued activities – or it can be profound and enduring – the realization that one was raised by adults who were malevolent and predatory, not caring. Grief for what was, and grief for what never was or could be, emerges as the coherent life narrative forms.
As with other kinds of grief and loss, grief emerging from trauma can be destabilizing, and will appear to the naïve therapist as evidence of regression in the therapy. 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. Such grief is also likely to emerge at important developmental points throughout the trauma survivor’s life, as events occur that evoke the losses inherent in the particular trauma. The Hurricane Katrina survivor who cannot visit his mother’s grave on the anniversary of her death because the grave was swept away in the flood re-experiences the grief of her death, the loss of home and safety associated with the hurricane and its attendant systemic betrayals, and the continuing exile to a new home. 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, 2012). 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. When the bereavement is specifically trauma-related, the therapist needs to have a paradigm for grief that integrates both post-traumatic and grief dynamics (Pearlman, Wortman, Feuer, Farber & Rando, 2014).
The third stage of this overarching model of trauma treatment is about reconnection with self, body, social world, and meaning-making. A theme of this stage is of “radical acceptance,” (Linehan, 1993) the end of resistance of the reality of the trauma, and a commitment to move forward in life with this reality integrated into the life narrative. 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. Herman refers to this component of the process as the development of a “survivor mission,” wherein the trauma survivor searches for ways to transform his experience in an empowering manner.
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. Therapy centers around assisting survivors to deepen their own systems of meaning-making, and to make intentional choices about how to craft an identity as a “thriver,” the person who has moved from surviving into a new identity of a person with an understood history of trauma.
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. The end of the tunnel can be full of surprises, and the goal of therapy at this point is to strengthen and deepen client’s capacities to blend with those surprises rather than struggle against them.
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. Inoculating clients at this point against the notion that they are “fixed” will include the invitation for the survivor to return for booster shots as needed. 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 survivor of a terrorist attack may wish to plan for coping with the news of the perpetrator’s trial. 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 (2002) 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.
As is the case for other transtheoretical models of psychotherapy, the three-phase model for trauma treatment can be integrated into a psychotherapist’s own particular paradigm for clinical work. 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 (1992) 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. I follow the lead of Norcross, Beutler & Levant (2005) in defining evidence-based in a very broad manner that includes not only those specific interventions studied through randomized clinical trials, but also evidence on relationship variables and therapist and client characteristics. 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. Ellis, Simiola, Brown, Courtois & Cook (in press) have recently reviewed the extant literature on the application of the ESRs to trauma treatment, finding that neither the psychotherapy research field nor the trauma treatment field have paid very much attention to the overlap of these concerns. 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 findings described below derive in the most part from a series of meta-analytic studies conducted by APA’s Division of Psychotherapy under the leadership of John Norcross; more details can be found in his text Psychotherapy Relationships That Work (2002).
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. Factors of the therapeutic relationship such as empathy, collaboration, genuineness, positive regard and respect, and the nature and quality of the therapeutic alliance all have demonstrated effects, which are estimated to account for 10% of the outcome variance of any approach to psychotherapy (Norcross & Lambert, 2005). As noted by Najavits and Strupp in their study of psychotherapy process variables contributing to good and bad therapy outcomes, “…basic capacities of human relating – warmth, affirmation, and a minimum of attack and blame – may be at the center of effective psychotherapy intervention.” (1994, p. 121)
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. This is particularly the case, according to Farber & Lane (2002), when the client’s viewpoint about whether or not the therapist communicated these emotions to the client successfully is used as the metric for measuring this variable. 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. Farber & Lane suggest that ruptures in the therapeutic alliance are more likely to occur when the therapist is not perceived by the client as offering this care and dignity. Since ruptures in the alliance are quite common with many trauma survivor clients due to dynamics of mistrust and hypervigilance, the value of positive regard’s role in trauma treatment receives even more emphasis.
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. As it happens, Bilbo and Frodo have symptoms of PTSD; thus, the message is not that being brave forecloses wounding. Rather, it is that the wounds are the evidence of courage – and the client’s presence in therapy is further evidence of that. 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.
Empathy was defined by Rogers as “the therapist’s sensitive ability and willingness to understand the client’s thoughts, feelings, and struggles from the client’s point of view…It means entering the private perceptual world of the other.” (1980, p. 142.) Three types of empathy have been measured in the research literature: the therapist’s self-perception, the degree of empathy rated by an external observer, and received empathy, what the client experiences. Levels of received empathy rated by the client are another predictor of good outcome in psychotherapy. Greenberg, Watson, Elliot, and Bohart (2001) found that across studies in a meta-analysis empathy accounted consistently for 10% of the variance of outcome, and routinely was found to account for a higher percentage of outcome variance than did any specific intervention (Wampold, 2005). 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. As will be discussed below in the section on countertransference and other therapist emotional responses, therapists often numb and distance themselves from their survivor clients’ stories, in parallel to how the survivors themselves are numbing and distancing. 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. Genuineness is defined as the therapist’s capacity to exhibit congruence, and to be transparent in the present about her feelings and responses to the client. This mode of therapeutic functioning can be seen in a number of different therapy paradigms; for instance, Stark (2000) gives examples of genuineness in a relational psychoanalytic treatment. Self-disclosure can be a component of genuineness; in fact, self-disclosures of the therapist’s here-and-now feelings about the client and the therapy has been found to be the variety of self-disclosure rated as most helpful by clients (Hill & Knox, 2001).
The trauma treatment literature has, from the very first, been replete with the recommendation that to be successful with trauma survivors the therapist must be “real.” Ochberg (1988) and Herman (1992) both speak of the importance of not being morally neutral about what has happened to the client. To say to a trauma survivor, “my heart breaks for you when I hear what you experienced” can, when sensitively timed, create the necessary feedback that what happened was not acceptable, that the client did not over-react, and that the therapist grieves with the client for the losses inherent in the traumatic experience. Many trauma survivors feel as if their lives are a daytime TV drama, and that they are an object of curiosity, a “fascinoma,” as one of my clients dubbed her experience of being non-empathically related to by another treatment provider. The therapist’s capacity and willingness to express concern and interest in the client as a human being makes genuineness and congruence into means by which empathy and positive regard are communicated to the client as well. While meta-analysis did not yield a specific portion of outcome variance for this ESR, the research indicates that when clients rate their therapists as high on this variable, they are more likely to be satisfied with the outcome of therapy (Klein, Kolden, Michels, & Chisholm-Stockard, 2001).
Another ESR that has been found to generally positively affect outcome in psychotherapy is the therapist’s ability to recognize ruptures, initiate their repair, and make amends for errors. Safran, Muran, Samstag & Stevens (2001) found that this capacity was a more potent predictor of outcome in therapy when the client had fearful, angry, or ambivalent attachment styles – in other words, the common relational dynamics present with a trauma survivor. 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. One of them is the therapist’s attunement to the very high likelihood that the client is being compliant and deferential, not letting the therapist know when he has done something that feels painful or betraying. This can be a challenge; one study found that therapists correctly identified only 17% of the ruptures that their clients reported. Therapists tend to be particularly challenged by noticing clients’ negative feelings; when they do notice them, they are likely to be defensive, or become more rigidly adherent to their model, thus becoming less empathic, genuine, and positive. 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.
However, when therapists are attuned to possible ruptures in the therapeutic relationship, actively solicit feedback from their clients, and then take responsibility for the rupture and its repair, the impact on the therapy can be quite salutary. Early encounters with heartfelt, non-defensive therapist responses to relationship rupture have been shown to lead to clients feeling more fully engaged in the therapeutic relationship, and to improve trust. Safran et al. note that for some clients, a “tear-and-repair” dynamic in the therapy relationship can predict improved outcome. For trauma survivors, this pattern may hold special meaning. It teaches, in a very present and embodied fashion, that errors, disconnections, and losses are not forever, and that repair and healing is possible.
Briere & Scott (2012) add to this list of ESRs a relationship variable that has not been formally tested, but which every trauma therapist and survivor of my acquaintance would agree is an essential foundational component of trauma therapy. That variable is hope. Trauma wounds hope. Many trauma survivors enter treatment feeling ground down by their symptoms, and by the belief that they cannot be helped – a belief that has in some instances sprung from therapies that ignored trauma or stigmatized the client’s symptoms as evidence of severe psychopathology. Despair is such a common consequence of trauma, particularly complex trauma, that to not encounter it in a trauma survivor is remarkable.
To genuinely assess with a client his chances for recovery and a good life after trauma is not leading the client on. Therapists should, of course, make no guarantees; we cannot promise anyone what the outcome of treatment will be. However, at this point in the development of trauma treatments, it is reasonable for a therapist to predict that, if the therapist and client work diligently together and use the range of possible treatment strategies wisely, carefully tailoring them to the client’s specific dynamics and difficulties, the client will be able to experience significant symptomatic relief, gain or regain a sense of safety and trust in the world, and find ways to have a life that has meaning and purpose. The research on recovery from PTSD indicates that even without treatment, some percentage of individuals experience remission over time. With complex trauma, although there are many more variables at play, and treatment is likely to be more protracted, the data emerging from studies of longer-term therapies with complex trauma clients (see Brand, 2011; Cloitre, Cohen, & Koenen, 2006; Gold, 2000) indicates that survivors of complex trauma can experience substantial recovery as well. It is impossible to overstate how powerful this variable is, and how difficult it can be for a therapist to maintain hope in the face of what can be lengthy periods of slow forward motion or even apparent absence of progress in work with a trauma survivor. For trauma therapy, hope is the “thing with wings,” to rephrase Emily Dickinson; like the butterfly of chaos theory whose flapping wings on one continent cause a tornado on another thousands of miles away, hope, expressed early and then as needed by the trauma- informed psychotherapist, will add potency to whatever other therapeutic interventions are employed.
Integrating and synthesizing these commentaries on the relationship in therapy, it becomes apparent from these findings that quality of relationship has been empirically demonstrated to be necessary in trauma treatment. Individuals living in the emotional, biological, spiritual, and psychosocial aftermaths of trauma exposure can often challenge their psychotherapists with the complexity of their distress, and with their apparent difficulties in making change. Avoidant strategies have been effective enough to stave off some of the painful images and effects; inviting client to stop avoiding and jump into the abyss with us is difficult at best. It can feel almost unbearable for people to let go of coping strategies, even dangerous and deeply dysfunctional coping strategies that were developed as a response to the need to contain trauma-induced terror, helpless, shame, and disgust. It is difficult for psychotherapists to be co-present with those coping strategies, and a psychotherapist may feel strong pulls, both internal and interpersonal, to overpower the client’s process in order to more quickly produce a particular behavioral outcome, or to abandon the client as a treatment failure. In this difficult emotional exchange, the relationship and its quality become paramount. The ESRs are foundational to the application of any other intervention, no matter how manualized. Additionally, their contribution to outcome of psychotherapy appears to account for a larger percentage of the variance than any of the specific interventions reviewed below.
Let us begin by reviewing therapies that are known to be helpful for the treatment of classic PTSD. Some of these interventions will also be helpful with Complex Trauma, although may require tailoring to the needs of clients with low levels of self-soothing capacities.
Eye Movement Desensitization Reprocessing (EMDR)
EMDR was first proposed by Shapiro (2001) as a trauma-specific treatment whose goal was the reduction of intrusive symptoms. The model of PTSD on which EMDR is based, Adaptive Information Processing (AIP), posits that much of the symptom picture of PTSD is due to the maladaptive encoding of and/or incomplete processing of traumatic or disturbing adverse life experiences, impairing capacities to effectively process the information. It instead becomes an emotion-driven introject that is experienced in the present tense as if the trauma were continuing to occur. EMDR targets how memories for trauma are encoded to transform them from intrusive to a coherent verbal component of that narrative. While initially controversial because of the form that treatment takes, sufficient empirical research on its effectiveness in the past decade has led to it being designated as a Level A treatment (evidence for the treatment is based on randomized, well-controlled clinical trials) in the Guidelines of the International Society for Traumatic Stress Studies. Use of EMDR generally requires completion of a sequence of training classes. Recent research comparing EMDR to Prolonged Exposure (PE) found no significant difference in effectivesness between the two treatments.
EMDR has eight components. In the initial stage, a careful clinical history is taken, including screening for the presence of a dissociative disorder. Basic (Level I) EMDR is considered potentially destabilizing to individuals with dissociative disorders, who should only be treated by clinicians trained at EMDR Level II. The therapist next works with the client to ensure adequate capacity for self-soothing during and between EMDR sessions. A component of this phase of treatment is the establishment of an effective working relationship between therapist and client; a therapist may take considerable time with some clients, particularly those with complex trauma, in establishing this secure base before proceeding to trauma processing.
Therapist and client next move into an assessment phase. Reviewing the client’s history, they collaborate on the development of a target image or images with which to begin reprocessing. The client is also asked to develop a self-statement, called the Negative Cognition (NC) that is based in the target trauma image. She is then requested to come up with a new statement, the Positive Cognition (PC), that would be true when treatment has been effective, the goal of which is to stimulate a connection between the experience as it is currently held with the adaptive memory network(s) and the validity of the positive belief. The client is asked to rate the subjective truth of the PC on a scale from 0 (feels not at all true) to 7 (feels completely true); this rating is known as the Validity of Cognition (VOC).
Clients are next asked to scan their bodies and rate the Subjective Units of Distress (SUDS) that they experience emerging from the target image on a scale of 0 (no distress) to 10 (worst distress). This completes the assessment phase of treatment.
Clients are then asked to hold the target image, NC, and current bodily state of distress together, and are exposed by the therapist to bilateral sensory stimulation. This is the reprocessing stage of treatment. EMDR initially used side-to-side eye movements, and has now expanded to include bilateral physical touches or taps, and bilateral tones. In the standard EMDR protocol, clients are exposed to 24 sets of bilateral movements, then asked to stop, reflect on what has emerged, and develop the next target for the reprocessing activity. A variety of strategies are available to the clinician for use if clients become stuck in trauma material, including changes to the direction, speed, or intensity of the bilateral stimulation, and the use of Socratic questioning, called “cognitive interweave” between reprocessing sets. During the reprocessing, clients are instructed to allow whatever material that emerges to do so, and to be treated as objects passing by the windows of a moving vehicle, rather than focused on.
When a target image has been processed to as low as possible a SUDS (preferably 0 or 1), the therapist then begins the installation phase of treatment. In this component of EMDR, the PC is paired with the target image and processed up to as high a VOC as possible, with attention to ecological validity (e.g., is it reasonable for the client to have no negative emotions about their trauma). Next, the client is directed to scan the body, and treatment sets are utilized so that eventually neutral or positive emotionality is associated with the image. Clients generally move freely between the reprocessing, installation, and body scan phases of treatment. The last two components of EMDR focus on reorienting the client to the here and now, and the target image revisited for possible unprocessed trauma material.
EMDR has been found effective in sharply reducing intrusive trauma symptoms in persons with PTSD. For individuals with complex trauma, EMDR can be modified in order to focus almost exclusively on the safety and stability aspects of the treatment, using protocols that have been specifically developed to strengthen inner resources and resilience. It can also be effectively utilized to target and reduce problematic self-statements and beliefs that have been resistant to more direct cognitive challenges. Because it can be destabilizing, it must be employed with attention to the client’s specific functional capacities. Clinicians wishing to use EMDR are advised to complete formal training in its applications. For use with complex trauma, clinicians should have completed the second level of EMDR training, which addresses specific protocols for work with these clients.
A wide range of cognitive and cognitive-behavioral therapies have been adopted to and studied with trauma survivors. Almost all of these interventions have been taken from those used with anxiety disorders and depression, and reflect a number of different paradigms for how PTSD symptoms develop and ameliorate. An in-depth description of each of these techniques can be found in the Guidelines for Treatment of PTSD promulgated by the International Society for Traumatic Stress Studies, summarized in the volume Effective Treatments for PTSD (Foa, Keane, Friedman & Cohen, 2009).
The exposure therapies for PTSD posit that the avoidant symptoms of the disorder lead to a failure to recondition cues related to the trauma to new, non-traumatic experiences in the present. A variety of strategies are utilized to reduce avoidant behaviors and increase the survivor’s exposure to trauma-related material.
The most basic of these exposure strategies is imaginal systematic desensitization. In this intervention, clients are taught deep muscle relaxation, and then directed to construct a hierarchy of imagined feared materials, which are then paired with relaxation under the theory of reciprocal inhibition. These procedures can also be done in vivo. Given the difficulty in reproducing the situations in which some traumas occur, recent developments in computer-assisted technologies have led to the grown of virtual reality exposure therapies, in which the client is not quite in vivo, but has the closest thing given the possibilities of a VR environment.
Exposure therapies are also employed without the use of relaxation techniques. Prolonged Exposure (PE), developed by Foa and her colleagues from interventions used with other anxiety disorders, stems from the emotional processing theory of PTSD, which emphasizes the importance of changing emotional reactions to the trauma cues, and interrupting the avoidant behaviors that maintain the association between the original trauma exposure and cues associated with it. It is the most-researched specific intervention for trauma. In PE, the client is first educated as to the nature of the trauma response, and to how and why PE works. Clients are taught to attend to their breath as a strategy for self-regulation although, unlike in systemic desensitization, clients do not use this self-soothing strategy during the exposure components of the treatment itself. Clients are then introduced to in-vivo exercises in which they expose themselves to something in the present that they have been avoiding due to its potential to stimulate PTSD symptoms, but which is not directly related to the trauma itself. So, for example, a person who was traumatized by a hurricane might be asked to spend time outside in bad but not dangerous weather, instead of going into the house and closing off all evidence of wind and rain.
Finally, clients are requested to write a detailed script of their trauma experience, which is then utilized for imaginal exposure. With both in vivo and imaginal exposures, clients are led repeatedly through the exposure experience or script, telling and retelling the story of the trauma, and classically reconditioning their response to it in the context of the safety of the therapy office. Therapy sessions for PE are generally 90 minutes in length so as to accommodate the need to go completely through the trauma experience and have clients remain exposed for an extended period to the trauma-related material. Extensive research on the use of PE has found it to be highly effective in the treatment of combat and sexual assault trauma. Concerns have been raised about the use of PE with complex trauma clients, given that many of them do not have sufficient self-soothing skills available to cope with exposure to painful post-trauma affects. Teaching of emotion regulation and affect tolerance skills are a necessary precursor to doing PE with the complex trauma population. Simply teaching relaxation has been found to be less effective than adding the exposure component; thus therapists using PE must be sure to include all components of the treatment protocol.
Cognitive Processing Therapy (CPT), also a very frequently-researched intervention for trauma, was developed by Resick and her colleagues (1993, 2008) for the treatment of rape survivors, and has since been applied to work with other adult trauma populations. Although CPT incorporates some exposure elements, it is largely a cognitive treatment that focuses on problematic belief systems and self-schema developed by the trauma survivor in the wake of the experience. Two kinds of beliefs are targeted for challenge; what the theory refers to as “assimilated beliefs” having to do with how the trauma changes self and other schemata, and what are called “overgeneralized beliefs” about a variety of factors symbolically associated with the trauma. The client is asked to write a detailed account of the trauma and read it back to the clinician, as well as practice reading it between sessions. The goal of this is not simply exposure, but to identify the points in the trauma experience where the survivor made decisions about herself due to violations of pre-existing belief systems. Such beliefs and schemata are then targeted during the cognitive therapy component of treatment. Resick urges clinicians to combine the challenges to the cognitive schema with exposure to the affects of the trauma, so as to maximize the likelihood that the client will have access to the trauma-related thoughts and emotions that occurred while the traumatic event was in progress. CPT has been found to be equivalent in its effectiveness to both PE and EMDR.
Cognitive therapy for PTSD very much mirrors treatments for anxiety and depression as described by Beck and his colleagues, and is one of the treatments for which evidence for efficacy in trauma treatment is strong. The special emphasis of CT with trauma survivors is on dysfunctional cognitions and schemata related to the trauma itself such as beliefs about one’s own judgment, the trustworthiness of other people or institutions, and the fundamental safety of the world. Several authors (Briere & Fox, 2006; Courtois & Pearlman, 2005; Gold, 2000) have observed the manner in which survivors will have complex schemata about being betrayed, abandoned, or harmed, and about other people being rejecting, critical, contemptuous, and shaming.
What distinguishes CT with trauma survivors from CT in general is the very real presence of the very real trauma. It is not a distortion or irrational for the trauma survivor to have beliefs that the world, certain situations, or people in it are likely to be unsafe. In fact, the trauma survivor, unlike people outside of the invisible world of trauma, has no illusions about the justness or safety of the world. Thus, it is usually more productive to bring CT to bear on the ways in which such founded beliefs have become over-generalized and function in the service of avoidance, or have led to unfounded and distorted perceptions of self.
Mindfulness based approaches to therapy take the approach that they are not attempting to change a client’s beliefs or symptoms. Rather, they attempt to change the client’s relationships to their beliefs or symptoms through the use of mindfulness strategies. Many of these strategies, which derive from Buddhist meditation methodologies, teach their practitioners to compassionately observe their experiences without judgment or reactivity.
ACT was developed by Hayes and his colleagues initially as a non-drug intervention for individuals with psychotic symptoms such as hallucinations and delusional thoughts. The slogan of ACT is “get out of your mind and into your life.” A mindfulness-based approach to treatment, ACT teaches that the productions of the mind, including thoughts, obsessions, feelings, intrusive images, and so on, are not real things, and need not be reacted to or serve as sources of guidance for the individual experiencing them. The mind itself is identified as a construct that is a metaphor for language, where language has been used to make schemata about self, others, and world. ACT has as its goal changing how people relate to the productions of their minds, freeing themselves from being reactive to and controlled by those productions.
ACT assists clients in identifying their values, and what their goals are for life, and through the development of skills of mindful observation of self and others, in developing behaviors that are congruent with those goals and values. Clients are taught skills in mindful observation, with an emphasis on compassionate, non-judging, non-reactive awareness of self. The therapy has six “core therapeutic processes” (Harris, 2009). They are:
An overarching principle of ACT is the development of psychological flexibility. Clients are offered strategies to be fully present, be open to their realities, and act in ways that make valued differences in their lives, rather than rigidly avoiding or protecting against experience.
Because ACT was originally developed with individuals who had psychotic symptoms, it is easily transferable to the intrusive and avoidant symptoms of PTSD. Walser & Westrup (2007) have developed a specific variant of ACT for PTSD that addresses some of the more challenging aspects of ACT for trauma survivors, particularly the notion that clients must give up their attempts to change or get rid of their post-trauma symptoms, and instead focus on learning to have a new relationship with those symptoms. Assisting clients to be in the here and now, and to observe their intrusive and avoidant thoughts and feelings without reacting to them, changes the survivor’s relationship to her own insides. Rather than, “I am having a flashback, this is really scary,” an ACT intervention might assist a client to mindfully observe the flashback and note, “I am having a flashback. It’s information about the past; it’s not information about the present.” ACT forcefully does not attend to symptom reduction, which distinguishes it from almost every other treatment modality developed by cognitive-behavioral psychotherapists. ACT relies on research showing that such a focus can increase experiential avoidance, and may increase distress as the client develops secondary distress over the failure of a symptom to remit. Rather, its emphasis is on simply accepting, mindfully, that the symptom is there.
ACT’s emphasis on the development of values and having a life that is informed by values also has special usefulness in work with trauma survivors. Trauma is often an existential/spiritual crisis, and some persons respond to trauma exposure with nihilism, alienation, and the expression of foreshortened future that says that nothing matters any more. Therapy that explicitly attends to questions of values, and of building a life that reflects a client’s value rather than one that is reactive to the experience of trauma contains a powerful message about the worth of the client’s life.
Dialectical behavior therapy (DBT) was developed by Linehan (1993a) as a treatment package for individuals who engaged in non-lethal self-inflicted violence, and was eventually marketed as a treatment for Borderline personality disorder (BDP). Because persons with a complex trauma picture are frequently diagnosed with BPD, and because many trauma survivors struggle with affect management, relationships with others, self-care and self-soothing, many components of the DBT treatment model are extremely helpful in work with trauma survivors, particularly those with Complex Trauma histories. Linehan’s model focuses on clients’ experiences of validation, positing that the behaviors that are diagnosed as BPD arose from the context of highly invalidating environments. Consistent with the goals of a trauma-informed therapy, DBT therapists are encouraged to see themselves as the client’s ally and a source of validation for their personhood, while simultaneously working with the client to change ways of behaving that create difficulties in life. The dialectical tension between compassionate acceptance and validation of client’s realities and their humanity, and the emphasis on the necessity for making specific behavior change in order to have a life that is more powerful, effective, and enjoyable lies at the foundation of this approach. The balance of acceptance and change is at the heart of the DBT paradigm.
DBT as a complete package has two components. The first is individual psychotherapy; the second is a skills training curriculum, generally taught in groups. Both group and individual treatment focus on ameliorating specific categories of behavior, with distinct stages for treatment and targets for intervention that standard DBT therapists use in the order specified by Linehan. The rationale for this very structured approach is to avoid a focus on client crises, and to ensure that the client is alive and coming to therapy in order to develop new skills for having “the life worth living.” PTSD is directly addressed by DBT, with its treatment described as one of the specific goals of the second stage of DBT treatment, in which a focus is on non-avoidant emotional expression.
The specific targets of DBT are, in the order of priority, self-inflicted violence and other risk-to-life behaviors; behaviors that undermine therapy, referred to as “therapy-interfering behaviors,” which can include avoidance, persistent non-participation in homework, missing sessions, or actions that undercut the therapeutic alliance; and behaviors that reduce quality of life. The treatment is grounded in a mixture of behavioral principles, including the use of self-monitoring through diary cards, relapse prevention strategies such as behavioral chain analysis, exposure exercises, and mindfulness skill building. Linehan’s model closely mirrors the general principles of trauma treatment, in that there is an initial emphasis on stabilization, the processing of material, and then on exploration of existential concerns, although she sees the last as optional, rather than core, to DBT.
DBT skills training groups focus on the same set of problem behaviors, with curriculum divided into four modules: core mindfulness skills, which are practiced at the start of every DBT group; interpersonal effectiveness skills; emotion regulation skills; and distress tolerance skills. DBT uses a variety of helpful mnemonics to assist people in acquiring and utilizing the various skills (e.g., the interpersonal effectiveness skill set DEARMAN, used to negotiate for what one wants, stands for Describe your situation, Express why this is an issue and how you feel about it, Assert yourself by asking clearly for what you want, Reinforce your position by offering a positive consequence if you were to get what you want, Mindful of the situation by focusing on what you want and ignore distractions, Appear Confident even if you don’t feel confident, and Negotiate with a hesitant person and come to a comfortable compromise on your request (Linehan, 1993a).
Although mindfulness is a core component of DBT, it is, unlike ACT, very focused on behavioral change. What differentiates DBT from other CBT-based approaches to therapy, and makes it particularly useful in work with trauma survivors, is that it combines the notion of mindful radical acceptance of what is (i.e. that the trauma has happened) and mindful skills at observing and relating compassionately to one’s own distress with specific skills focused on empowering clients to change their intra- and interpersonal behaviors. Most of the focuses of DBT are those that are germane to trauma survivors, who struggle with emotion regulation and self-soothing in the face of trauma’s powerful affects and intrusive images.
Some clinicians have found the standard DBT protocols problematic because they require that clients must have a DBT therapist to participate in a skills group. DBT therapists are required to participate in DBT consultation teams, with the goal of supporting therapists and improving their own self-care, in part because of the high demands of DBT on both therapist and client. While there has not been research on the adaptation of components of the DBT model, and Linehan and her research teams are careful to indicate that only the complete package of individual DBT and DBT skills group has been empirically supported, many of the strategies in DBT map onto the treatment needs of traumatized individuals, particularly those with complex trauma and any of those with serious challenges of emotion regulation and interpersonal relatedness.
Gold (2000) has proposed a similar model for working with survivors of trauma within the family context, the Trauma Resolution Integration Program (TRIP) model. This model applies largely to work with complex trauma. He argues that trauma is not a sufficient conceptual framework for understanding the difficulties faced by these individuals, who also fall under the general rubric of complex trauma, and whose trauma exposures were usually the fabric of their early lives, and thus central to their sense of self and coping strategies. Although he divides his model into more specific component parts, the directions taken by treatment in his paradigm are quite similar to those proposed by Herman. Gold focuses on the task of assisting the survivor of intrafamilial abuse to identify the effects of the chaotic family context, and to understand how those are both interactive with and distinct from specific abuse that may have occurred as a first step in developing a collaborative relationship with shared, clear treatment goals and priorities. He then identifies the importance of working with survivors to learn how to manage and modulate distress, reduce dissociative coping, engage in critical thinking, changing problematic behaviors, and titrating exposure to the trauma narrative. Gold de-emphasizes the importance of thorough scrutiny of and exposure to the process of remembering trauma but emphasizes the value of creating a post-abuse narrative with clients that emphasizes the shift from post-abuse functioning to liberation from the power of the abuse and abusers.
Gold argues that if a client wishes to delve into their personal narrative of abuse then the psychotherapist should support them in so doing, but notes that many of the clients treated by him and his co-psychotherapists in their clinic found that once they had behaviorally and emotionally freed themselves from the problematic coping strategies used for dealing with the sequelae of trauma they were no longer very interested in engaging in a narrative exploration of those experiences. He suggests that when a necessary component of solving the problems of life is understanding the roots of difficulties in the trauma experience, then specific exploration of that experience can be useful, as it is in the service of empowering a client into improved functioning. He further emphasizes that this process needs to be client-driven and initiated, a stance consistent with a culturally-sensitive approach to trauma treatment. In Gold’s model, the mourning and remembrance phase of therapy is set further in the background, with the greater emphasis being placed on disruption of the family culture of chaos and neglect that enabled abuse to occur. This model has its primary focus on the first component of the overarching trauma treatment framework.
Cloitre, Cohen, and Koenen (2006) have proposed the STAIR/NST (Skills Training for Affective and Interpersonal Regulation/Narrative Story Telling) model aimed specifically at working with survivors of childhood trauma. This model, which is a technically integrative one, utilizes interventions from exposure therapies, attachment therapies, and narrative therapies, each configured to address specific components of the distress experienced by survivors of childhood sexual trauma. STAIR/NST exists as two modules. STAIR focuses on the reduction of specific post-traumatic symptoms and the development of healthy relationship patterns, while NST targets the narratives developed by trauma survivors and aims at their transformation into narratives of recovery. Similar to the TRIP model, STAIR/NST prioritizes assisting clients in developing skills of affect regulation and life management before attempting exposure to the memories and narratives of the trauma itself.
STAIR/NST is a semi-manualized treatment; although the authors give a specific framework for how it is to be employed and steps that are to be followed, they also emphasize early in their work that flexibility and clinical responsiveness are important, as the therapeutic alliance is core to work with survivors of trauma. A theme and curriculum for each session of a 12-16 session treatment are described, with examples of how clients might respond to each theme and how psychotherapists can utilize the themes and curriculum in manners responsive to the particular clients with whom they are working.
While the goal of debriefing strategies – to prevent PTSD by giving large natural groups of trauma survivors an opportunity to process their response as quickly as possible after the event – has always been a laudatory one, the findings from two decades of research indicate that individual debriefing is clearly not helpful and may be harmful, and that group debriefing can be helpful if it is chosen, rather than required. In consequence, this segment of the course will not discuss the use of debriefing strategies. Meta-analyses of various debriefing protocols have not found them to be effective in reducing PTSD symptoms.
The core model for trauma treatment, discussed earlier in this course, can be and has been integrated into a very wide range of theoretical orientations and modalities. These include psychodynamic treatments, somatically focused treatments, group psychotherapies, couples and family therapies, and expressive and art therapies, among others. Readers interested in learning more about any of these specific approaches to treatment, or in receiving training in one of the approaches discussed above, are referred to the websites of the International Society for Traumatic Stress Studies (www.istss.org) or the International Society for the Study of Trauma and Dissociation (www.isst-d.org).
Additionally, there are a number of emerging trauma treatments that have yielded good reports from practitioners, but have not yet been well-researched. These include Energy Psychology, Brainspotting, Somatic Experiencing, and Somatic Integration. Readers interested in pursuing one of these emerging trauma treatments should keep in mind that anecdotal evidence of effectiveness is not the absence of evidence; rather, it is evidence that there have not yet been sufficient studies of a particular technique in academic or institutional settings, in which gold-standard random clinical trials can be conducted.
This course will not discuss treatment of post-traumatic dissociative symptoms. However, readers interested in this topic are directed to the ISSTD website cited above for further information, or to Steele, Boon, and van der Hart’s (2016) text
Because trauma exposure can lead to such a wide range of symptoms, and because the symptoms affect almost all realms of functioning, therapists working with trauma survivors must become conversant in a wide range of treatment strategies. Following the lead of Norcross & Wampold (2011), who have discussed the importance of tailoring the therapy to the client in terms of the client’s stage of change and her symptoms and capacities, trauma-informed therapists will carefully assess and develop a treatment plan, in collaboration with the client, that reflects the client’s particular needs and difficulties. Each of the specific trauma treatments described above offers some interventions that may be helpful to some trauma survivors, and less so to others. Careful consideration of the overarching model of trauma treatment in the choice of interventions will always remain foundational to competent work with this population.
Readers should also consult with their professional organizations for practice guidelines as they emerge. ISTSS (istss.org), ISSTD (isst-d.org), and the American Psychological Association (apa.org), all either have completed, or are in the process of preparing, clinical treatment guidelines for PTSD, complex trauma, and dissociation.
The next course in this series addresses the person of the trauma-informed therapist. Issues of cultural competence and awareness, countertransference, and vicarious traumatization are necessary components of competent practice, particularly given the emotional effects of trauma work on clinicians.
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