Lecture 3 Preparing for treatment of

complex trauma

Complex CaseworkKevin Standish

1. Learning outcomes

To explore the best practices based on research evidence, the process of recovery

To identify the therapeutic stages in a phased based relationship approach

Create a safe therapeutic setting To understand the dynamics of the

therapeutic process

2. RANGE OF TREATMENT MODALITIES

2. Range of treatment modalities

• When working with survivors of complex trauma, practitioners will need to be mindful of a range of treatment modalities that they can integrate into their already existing therapeutic approach.

• In this integration a framework in which safety and stabilisation are emphasised to minimise the risk of re-traumatization.

• Many of the skills used come from CBT combined with humanistic principles

• Whichever model is used, need to ensure that core therapeutic goals are addressed

2. Range of treatment modalities

The therapeutic process needs to be sensitively paced to provide more than symptom relief characterised by some limited therapies: eg brief CBT

Clinical evidence indicates that healing from complex trauma requires long-term therapeutic intervention (minimum of two years of support)

Counsellors need to consider if they can offer such a commitment. If not they need to be able to refer clients to a specialist agency is required.

2. Range of treatment modalities

There are a range of alternative, body therapy focused approaches like sensory motor therapy and eye movement desensitisation and reprocessing (EMDR), and relationship based therapies like Emotional Focused Therapy (EFT)

These best combined with therapies that promote reflection, cognitive processing and integration for example dialectical behaviour therapy (DBT) and schema therapy (Young 2003)

2.1.Core therapeutic goals

3. ASSESSMENT

3. Assessment

1. It is essential to assess the degree of post-traumatic stress symptoms, dissociative symptoms and overall level of functioning.

2. It helps to identify primary and secondary symptoms as well as any associated disorders.

3. Primary symptoms consist of trauma reactions elicited by the trauma.

4. Secondary symptoms represent attempts by survivors to manage the primary effects such as self harm, self medication and withdrawal.

5. Over time secondary symptoms lead to associated disorders such as self-destructive behaviour, substance dependency, chronic depression and personality disorders.

3. Assessment

1. Survivors of complex trauma who have been dehumanised tend to benefit more from a warm, genuinely engaged, human relationship than a distant or clinical one which is driven by protocols and assessments.

2. An important element in the treatment of complex trauma survivors is to avoid pathologising the clients. Pathologising survivors taps into their deep rooted fears that they feel inadequate, flawed or crazy.

3. It reactivates abuse dynamics in which reality is distorted by someone more powerful than them. You need to guard against such power dynamics so as not to re-traumatised the client.

3. Assessment

1.How assessment is approached plays an important role in this process. An overly clinical approach can be more destructive than an informal and more discussion based approach in the initial clinical assessment through therapeutic dialogue.

2.You need to use your judgment in terms of what is most coherent with your theoretical approach, therapeutic style and what is most helpful with the individual client.

3. Assessment1. You need to be familiar with the range of trauma

assessment scales and how they used. It is helpful to ascertain the degree of trauma using a traumatic event scale and to check the magnitude and intensity of trauma reactions.

2. Sometimes clients do not initially present with complex trauma or dissociative disorders and these emerged later in the therapeutic process. Use assessment scales when these emerged rather than a global generalised assessment.

3. The importance of using assessment scales is to assess the survivors therapeutic need more accurately, to help empower them to decide to what extent they can provide effective therapeutic interventions with the client, or whether they need to refer the clients to more specialist agency.

3. Assessment

1. Assessment needs to be ongoing throughout the therapeutic process. It is important to keep track of emergence of symptoms or difficulties and respond appropriately to the need. It is also important consolidate and integrate newly acquired knowledge and skills for the client.

2. To engage clients with this and to highlight the importance of collaboration, it helps to invite clients to assess progress every six weeks in terms of symptom reduction and what is helpful in the therapeutic process and what is less helpful.

3. This reduces the power dynamics in the therapeutic relationship and allows the client to feel in control and to take ownership of their recovery and healing

4. THE ROLE OF PSYCHO-EDUCATION

4. The role of Psycho-education

1.An important part of recovery is to make sense of traumatic experiences and reactions to restore a sense of control.

2.This is facilitated through psycho-education.3.This involves sharing information to enhance

awareness and improve cognitive understanding.4. This equips clients with the knowledge about

trauma and the process of recovery so they can develop reflective functioning and metacognition to make sense of the experiences.

4. The role of Psycho-education

1. This allows clients to normalise their reactions and begin to take more control of their emotions.

2. To maximise the effect of Psycho education counsellors need to be mindful of how knowledge is conveyed so as not to patronise or overwhelm the client.

3. It needs to reflect the clients need at a specific time and be accessible to them in order to make use of it. It is important to ask clients if they would find the information helpful rather than assuming they need to know particular information.

4. The sharing of information needs to be carefully paced and collaborative with the client in order to avoid being "the expert".

4. The role of Psycho-education

1. As dissociative clients are often not present, or switch between conscious awareness and dissociation, they have difficulty in receiving, processing and storing information.

2. This is especially the case when they are exploring experiences that are painful and threatening, when they most likely to dissociate, rendering information meaningless.

3. It is important to monitor to what degree information has been understood and integrated at regular intervals, normally through homework exercises.

4.1.Areas of Psycho education

1.Much of psycho-education will take place in the early stages of therapy in order to help survivors feel more in control of trauma reactions, to understand the therapeutic process and understand the nature and impact of trauma.

2.Psycho education needs to include information on specific areas of difficulty that the client is grappling with.

3.The most common of these include dissociation, shame, self harm, self medication, substance abuse and sexuality.

5. THE THERAPEUTIC PROCESS

5. The therapeutic process

1. Given the betrayal of trust and disruption of attachment bonds, it is critical that a safe and secure base (Bowlby) is created in which the survivor can work through traumatic experiences into which the therapist can bear witness.

2. This function is similar to what Winnicott describes as "holding" and Bion as "containing". In this sense secure base is also similar to therapeutic alliance.

3. It is only within a human relationship that the dehumanising effects of complex trauma can be reversed

5. The therapeutic process

1. As traumatic experiences are associated with abandonment and aloneness, counsellors must guard against being too distant and clinical. The need to listen with both head and heart to provide an engaged therapeutic stance.

2. In other words Rogers core conditions need to be met.

6.CREATING A SAFE THERAPEUTIC SETTING

6.Creating a safe therapeutic setting

1. As trauma survivors sense of safety is compromised, it is essential that you create a safe therapeutic setting that will act as a "secure base" for clients.

2. You need to provide a predictable and consistent therapeutic space to reverse the unpredictability and inconsistency associated with complex trauma.

3. You need to ensure that therapeutic space is safe from intrusions, loud and unexplained noises to minimise trauma reactions.

4. They need to feel safe in contained and reduce the need for hyper-vigilance to focus on establishing internal safety.

6.Creating a safe therapeutic setting

1. Re-experiencing trauma can revive terror states in which survivors will be overcome by nausea or the need to evacuate the bowels.

2. They need to know that they have access to a toilet during the session and that it is permitted as fear of vomiting in the session may prevent the therapeutic process.

3. Clients will not express their needs and will endure discomfort rather than ask for help.

4. It is important to be proactive in offering the support needed, and have a glass of water and tissues etc available in the therapeutic space.

6.Creating a safe therapeutic setting

Consistent use of the same room is important

Changes to room best avoided

7.ATTACHMENT DYNAMICS IN THE THERAPEUTIC PROCESS

7.Attachment dynamics in the therapeutic process

1. As a relationships are experienced as dangerous rather than a source of pleasure, you will need to monitor attachment dynamics that emerged in the therapeutic process.

2. As clients have had insecure attachment in childhood, the ability to connect will be hindered by an approach/avoidant behaviours

3. You will need to monitor your own attachment style in response to the survivor and how this influences the therapeutic process.

4. This will help enhance the therapeutic dance between client and counsellor and manage dynamics such as idealisation and vilification of the counsellor

7.Attachment dynamics in the therapeutic process

8. POWER AND CONTROL

8. Power and control

1. It is vital to pay attention to power and control dynamics and ensure these are minimised.

2. Survivors know all too well what it feels like to be controlled by someone else, and to feel they have no control over their body, feelings thoughts or actions.

3. Counsellors need to provide opportunities for survivors to gain control by providing a genuinely collaborative therapeutic alliance, it would enable survivors to take ownership of the healing.

4. This is best achieved by encouraging clients to set personally meaningful goals and to pace therapeutic work

8. Power and control

1. Counsellors will need to be client led rather than imposing a rigidly held theoretical orientation or prescribed therapeutic techniques. This requires flexibility in how they work with their clients.

2. An emphasis must be placed on establishing a mutually respectful relationship in which the client feels valued and validated as an individual, not just as a survivor of complex trauma in which the central organising principle is the trauma and victimisation.

8. Power and control

9. BOUNDARIES

9. Boundaries

1.Boundaries play an essential part in the development of a safe space in which trust is developed.

2.There is a balancing act between establishing safety needs whilst leaving control to the client.

3.Counsellors must make sure they set appropriate boundaries to keep both client and counsellor safe, in which they feel contained but flexible.

9. Boundaries

1. Core boundaries in trauma therapy involve being:

Explicit Boundaries of safety Confidentiality Duration of therapy Length of session After hours session contact Touch Support in an emergency

2. Counsellors need to be explicit in stating agreed boundaries to provide these in a written form.

10. PHASES OF TREATMENT

10. Phases of treatment

1. In the therapeutic process it is essential to promote client safety and to minimise re-traumatisation.

2. It is crucial that you do not explore the trauma narrative until the survivor has acquired sufficient skills to feel in control of trauma symptoms, and there is an improvement in daily functioning.

3.This enables survivors to manage primary symptoms of trauma and to learn vital skills to reduce secondary symptoms such as self harm and substance abuse.

10. Phases of treatment

Phase 1: safety, stabilisation and engagement measured in skills, not time

Phase 2 trauma memory, emotion processing, an application to the present

Phase 3:future considerations reconnection to self and post-traumatic growth

Seminar: Challenges of treatment

What do you think are the major challenges in the treatment of complex trauma?

Professional Challenges? Challenges in the Therapy process? Challenges in session? Challenges due to dissociation? Core challenges to the counsellor? Read chapter 6 Sanderson (2013)

Reading list

Core readings1. Sanderson (2013) Chapter 5 Safe Trauma Therapy chapter 8 the process of recovery.2.Courtois & Ford (2009) chapter 4. Best Practices in Psychotherapy for Adults, Christine A. Courtois, Julian D.

Ford, and Marylene Cloitre 3. Courtis & Ford (2013): Chap 3 Preparing for treatment of complex trauma Chap 4 Treatment Goals and AssessmentAdvanced reading 4. Courtois & Ford (2009) Chap 2. Neurobiological and Developmental Research: Clinical Implications, Julian D. Ford