Jump in, the waters not too deep.
When individuals present in treatment with significant trauma it understandably may give pause to a treating professional. Whether a single devastating event or a constellation of experiences, which lead to a designation of complex trauma, how best to initially treat the individual is often questioned. Recently, I pulled out an article from the journal of Depression and Anxiety a colleague sent me some time ago. The article by de Jongh and colleagues, Critical Analysis of the Current Treatment Guidelines for Complex PTSD in Adults (de Jongh, et.al., 2016, holds the potential to generate an interesting conversation. The following is not an exhaustive discussion of the topic, but rather a brief description of two perspectives which may influence the direction of treatment.
One encourages creating a safe environment by first stabilizing clients. This typically includes resourcing clients by teaching them self-regulation skills in order to build emotional, relational, and psychological competency prior to directly working on the trauma. Once the client has developed a level of competency in self-regulating and the clinician believes they can tolerate working on their trauma, the trauma work begins. The other position believes clients enter therapy ready to work on their trauma and directly addresses it using a variety of evidence-based techniques. These positions are not necessarily at odds and yet are often treated as such.
In 2012 the Complex Trauma Task Force of the International Society of Traumatic Stress Studies (ISTSS) released The Expert Consensus Treatment Guidelines for Complex PTSD in Adults which identified support for a phased-based or sequential approach to complex PTSD (cPTSD) beginning with initial stabilization and skills building period prior to engaging in treating trauma. De Jongh and colleagues (2016), on the other hand, reviewed studies which “suggest trauma focused treatment without a prior stabilization phase is feasible and clinically beneficial for cPTSD, contrary to the recommendations of the guidelines” (p. 364). They went on to state the studies they reviewed did not support worsening of symptoms for those receiving trauma treatment and did not increase treatment drop out. They stated, “In our view, the evidence arguing for special stabilization procedures prior to trauma-focused treatment for patients referred to as having cPTSD is weak” (p. 366).
Most interesting de Jongh et.al. (2016) stated “For patients with more cPTSD presentations, the recommendation for an initial stabilization phase has the potential to result in a delay or restriction of access to effective trauma-focused treatments” (p. 367). They continued by sharing “Delaying trauma-focused treatment could also be demoralizing to patients by inadvertently communicating to them they are not capable of dealing with their traumatic memories, thereby reducing self-confidence and motivation for more active trauma processing. Labeling a patient as ‘complicated’ or ‘complex’ has a potential iatrogenic effect of giving the patient the impression that ‘traditional’ treatments will not be effective or that special or longer treatments are necessary” (p. 367).
Perhaps these two perspectives support clinicians considering which approach best fits their client. Certainly, there are instances when helping a client to feel more resourced and confident supports them engaging more productively with their trauma. On the other hand, many clients are ready to dive into sorting through their traumatic past. I have found it most productive for me to assess the client’s belief about self and how they have managed life while carrying a tremendous pool of pain. I believe de Jongh and colleagues encourage us as clinicians to strengthen our belief in the capabilities of our clients. This supports a process of directly addressing trauma while concurrently resourcing individuals. Imagining the strength, resolve, and resourcefulness of a child to continue moving forward in the face of what are often horrifying experiences. Coping through addiction, withdrawal, perfectionism, people pleasing, etc. do not define the individual rather reflect their creativity and desperate desire to somehow make it through life. Helping clients honor these efforts while simultaneously supporting an experiential process, one which affirms they are currently the most capable adult in their life to nurture themselves through their painful past. There may be moments where the work slows in order to manage a crisis, but even this process can become another resource for moving forward.
I know my bias for diving is reflected in this writing and I am clear for some of my clients this confidence in them has left them feeling I lack empathy for the depth of their struggle. This always reflects a miss on my part in slowing and connecting with the client. I share this in recognition of the risks, whichever approach a therapist takes, and with an increased understanding there is not “a right way” to approach trauma. We can only possess the willingness to jump in and recognize the water is rarely too deep.
De Jongh, A., Resick, P.A., Zoellner, L.A., van Minnen, A., Lee, C.W., Monson, C.M., Foa, E.B., Wheeler, K., Broeke, E.t., Feeny, N., Rauch, S.A., Chard, K.M., Mueser, K.T., Sloan, D.M., van der Gaag, M., Rothbaum, B.O., Neuner, F., de Roos, C., Hehenkamp, L.M., Rosner, R. and Bicanic, I.A. (2016), CRITICAL ANALYSIS OF THE CURRENT TREATMENT GUIDELINES FOR COMPLEX PTSD IN ADULTS. Depress Anxiety, 33: 359-369.
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