Trauma Informed Care
Seeking Safety Part 1
Dr. Dawn-Elise Snipes, PhD, LPC-MHSP, LMHC
Executive Director, AllCEUs.com
Podcast Host: Counselor Toolbox
Objectives
~ Review five central ideas:
~ Safety as the priority of this first-stage treatment;
~ Integrated treatment of PTSD and substance abuse
~ A focus on ideals
~ Content areas: cognitive, behavioral, interpersonal, and case management
~ Attention to therapist processes.
Safety as the Priority of the First Stage
~ People with PTSD often also struggle with depression, addiction and eating disorders
~ The most urgent clinical need is to establish safety.
~ âSafetyâ is an umbrella term that signifies various elements:
~ discontinuing addictive behaviors
~ reducing suicidality
~ minimizing exposure high-risk situations
~ letting go of dangerous relationships
~ gaining control over extreme symptoms (such as dissociation)
~ stopping self-harm behaviors (such as cutting).
Safety as the Priority of the First Stage
~ Even though the trauma may have occurred long ago, patients have typically been abused and are now abusing themselves
~ treating themselves in ways that repeat it
~ ignoring their needs
~ perpetuating pain (albeit sometimes in the guise of trying to satisfy short-term impulses).
~ This represents a meaningful connection between their disorders
~ Recovery requires that the patient establish safety, grieve and reconnect
Safety as the Priority of the First Stage
~ Safety is addressed in numerous ways, including
~ The safe coping sheet
~ The list of safe coping skills
~ The safety plan
~ The safety contract
~ Other methods
~ Emotional safety
~ Physical safety
~ Interpersonal safety
~ Environmental Safety
Integrated Treatment
~ âIntegrationâ means attention to both disorders at the same time in the present.
~ It is not asking patients to talk in detail about the past
~ Helping patients
~ Learn what the disorders are and why they cooccur
~ Explore their interrelationship in the present (e.g., bingeing and purging when they felt rejected)
~ Understand the course of the disorders in recovery (e.g. with abstinence, PTSD may feel worse before it feels better)
~ Increase compassion by viewing unhelpful behaviors as an attempt to cope with the pain of trauma
~ Learn safe coping skills that apply to both.
~ Patients are encouraged to see that healing from each disorder requires attention to both disorders
Integrated Treatment
~ Integration is ultimately an intrapsychic goal for patients as well as a systems goal:
~ to âownâ both disorders, to recognize their interrelationship, and to fall prey less often to each disorder triggering the other.
~ This treatment provides opportunities for patients to discover
~ Connections between the two disorders in their lives
~ In what order they arose and why
~ How each affects healing from the other
~ Their relationship to other life problems
Integrated Treatment
~ Integration is created by fluid movement among the four target areas of the treatment
~ Cognitive
~ Behavioral
~ Interpersonal
~ case management
~ To help patients recognize the links among their thoughts, actions, and relationships, and between their internal experience and their functioning in the external world.
A Focus an Ideals
~ This treatment explicitly seeks to restore ideals that have been lost.
~ The title of each topic is framed as a positive idealâone that is the opposite of some pathological characteristic
~ Honesty combats denial, lying, and the âfalse self.â
~ Commitment is the opposite of irresponsibility and impulsivity.
~ Taking Good Care of Yourself is a solution for the bodily self-neglect of PTSD and other behaviors.
~ The language throughout the treatment emphasizes values such as ârespect,â âcare,â âintegration,â âprotection,â and âhealing.â
4 Content Areas
~ CBT is the basis for this treatment
~ It is brief, time-limited, and structured, with the goal of strong treatment gains over a short time frame.
~ It is educational, with emphasis on rehearsal of new skills.
~ It is directive and collaborative, guiding patients (much as a good parent would) while emphasizing patientsâ mature contribution to their own treatment.
~ These processes provide, in the very format of the treatment, an antidote for the powerlessness and lack of control
4 Content Areas
~ The importance of cognition is addressed through standard cognitive therapy interventions, such as
~ Identification of beliefs
~ Restructuring
~ Exploration of the meaning of their behaviors in the context of their PTSD (e.G., Self-medication? Compensation? Slow suicide? Revenge?).
~ Contrasting cognitive distortions with healthier meaning systems
4 Content Areas
~ In the behavioral topics, patients are encouraged to commit to action.
~ The âbehavioral bottom lineâ is taught: that it is not sufficient to talk about action, but real action, however small, is essential
4 Content Areas
~ The interpersonal domain is an area of special need because most PTSD arises from trauma inflicted by others that may evoke in the survivor
~ Distrust of others
~ Confusion over what can be expected in relationships
~ Concern over reenactments of abusive power
~ Interpersonal topics seek to help patients maximize the presence of supportive people and let go of destructive people
4 Content Areas
~ Patients are encouraged to
~ Communicate honestly when it is safe to do so
~ Recognize that they can only change themselves at this point
~ Explore parallels between their relationship with themselves and with others (e.g., It is common to have problems setting boundaries both internally within oneself and externally with others)
~ Notice extreme relationship dynamics that reevoke trauma (e.g., Overcompliance, enmeshment) and unhelpful behaviors
4 Content Areas
~ Case management is begun in the first session and addressed at every session throughout the treatment
~ It is assumed that psychological interventions can work only if patients have an adequate treatment base
Other Core Features
~ Use of educational research strategies to maximize learning including
~ Contrast-set teaching (comparing extremes such as safe vs. Unsafe coping, supportive vs. Destructive people)
~ Role preparation (e.G., Helping clients determine how to make the most of the treatment, providing suggestions)
~ Teaching for generalization (e.G., Asking patients to teach a new skill to a partner who can cue them to use it)
~ Affectively engagement: âWhy do I careâ
~ Memory enhancement devices: Mnemonics
~ A focus on potential rather than pathology. Successes rather than failures
~ Emphasis on practical solutions
~ Relating the material to clientâs lives
Attention To Therapist Processes
~ Therapist processes emphasized in this treatment include
~ Building an alliance
~ Having compassion for patientsâ experience
~ Using the various coping skills in oneâs own life
~ Giving patients control whenever possible
~ Modeling what it means to try hard by meeting the patient more than halfway (e.G., âHeroicallyâ doing anything possible within professional bounds to help the patient get better)
~ Obtaining feedback from patients about their genuine reactions to the treatment.
Attention To Therapist Processes
~ The flip side of such positive therapist processes is negative countertransference, including
~ Harsh confrontation
~ Sadism
~ Inability to hold patients accountable, due to misguided sympathy
~ Becoming victim to patientsâ abusiveness
~ Power struggles
~ Allowing a patient to be scapegoated.
Attention To Therapist Processes
~ Attention is also directed to what might be termed âthe paradox of countertransferenceâ
~ PTSD and addictive or self-harm behaviors appear to evoke opposite countertransference reactions, and it is difficult for therapists to balance these.
~ PTSD tends to evoke sympathy and identification with patientsâ vulnerability, which if taken too far may lead to excessive support and overindulgence rather than encouraging accountability and growth
~ Addictive and self harming behaviors can evoke frustration and resentment
Summary
~ Emotional, mental, physical, environmental and interpersonal safety is the priority of this first-stage treatment
~ Integrated treatment of PTSD and addictive and self-harm behaviors is essential to recovery
~ A focus on ideals can help patients embrace the recovery lifestyle
~ Content areas: Cognitive, behavioral, interpersonal, and case management
~ Attention to therapist processes is essential since 80% of therapeutic change is attributed to the relationship, not particular skills.