In Module 5, you will focus on treatment and intervention strategies geared toward recovery. As part of this module, you will explore the stages of therapy.
The first stage involves correctly naming the problems and restoring a sense of control to patients by providing a feeling of safety in the room with you and in the process of therapy. It is only after this point when the clinical recommendation is for you to invite the patients to the second stage, when the patients begin to tell the events, or as it is sometimes called in lay terms “tell their story.” In the third stage, you consider the ways in which the client has incurred a variety of losses as a consequence (such as trust, sense of safety, belief in the world as just, physical loss, and loss of job/friend/family).
Can you look at a calendar and determine the right time to move to the second stage? Unfortunately, there is no magic amount of time required to elapse between stages. Instead, the clinician must determine when the client is ready, for example, when the client has made sufficient progress in the first stage, is feeling more comfortable in the therapeutic situation, has established a sense of hope regarding the future, or has voiced a desire to begin taking action to “feel better.” Having an understanding of “where the client is” in the therapeutic process is where clinical judgment, experience, good supervision, and good assessment skills come into play. In general, however, when the person is relatively stable and appears ready to talk about the underlying trauma (and this can occur in the first session or years into treatment), you can begin the second stage of treatment.
Remembrance and Mourning
The Second Stage of Treatment
During this period, the overall functioning of the client may decline and some of the previously resolved emotional and physiological symptoms may resurface. This is the period commonly referred to as hard work. It is critical to let your adult patients and the parents of your child patients know that they may experience some recurrence of earlier anxiety, sleeplessness, or whatever the presenting symptom might have been. In severe cases of trauma, sometimes, it is advantageous that the second-stage work take place in a more structured setting (such as a residential program) or that the number of sessions be increased from once to twice a week if you are continuing in an outpatient setting. Some therapists suggest that their patients consider reducing their work schedules to half or to work on more serious issues during a long summer break. At first, this may sound dramatic or extreme, but consider this question—wouldn’t you consider it good clinical care if your doctor said you should consider making some temporary adjustments in your life to allow you to properly heal?
Put another way, imagine that you need to undergo a major surgery or a round of chemotherapy. It is likely that you would make such a medical intervention a high priority in your life and allow yourself the time to rest and heal and spend sufficient time on your recovery. Should the intensive treatment of mental health issues be considered to impact your life any less seriously? he reality is that many people underestimate the impact that a struggle with a mental health issue can have on one’s life. But depression, anxiety, substance abuse, grief, addiction, and anger issues have all caused demonstrable economic, vocational, social, and familial losses for people. It’s likely that you know people for whom these mental health challenges have caused measurable harm and that several examples of this come to mind. With regard to a trauma survivor, the hope is that early intervention and direct, individualized therapeutic techniques can assist the survivor in stabilizing quickly enough to ensure that the more severe posttraumatic stress disorder (PTSD) symptoms never develop. Then, once stabilization has occurred, the work of actual recovery can proceed at a more deliberate pace.
· Describe theoretical and empirical knowledge about psychological trauma and the impact of victimization.
· Identify and evaluate commonalities and differences in demographic variables and psychological profiles between subtypes of victims that may present in forensic settings.
Exploring the Trauma
Students and clinicians often express concerns about how to begin the second stage of treatment; they fear digging too deep or fear hurting the patient. When you and the client have adequately named the problem and you have shared your expertise with the client regarding what you think is the treatment necessary to relieve the level of distress, either you will have a contract for treatment or you will not. Your client will agree to move in this direction, or you will get all kinds of evasive messages about how it (the traumatic event) really wasn’t such a big deal. If you get the latter as the case, the client may not be ready to move forward. And that’s OK. As a clinician, it’s important to remind yourself that therapy should move at the client’s pace, not the therapist’s.
It is equally important for you to assure yourself that you and the patient are not likely to accidentally and prematurely end up in this stage. You may find it can feel like this when you are working with a client who starts with a different presenting issue, and then it becomes apparent that there is an unresolved trauma component. This can feel like accidentally stumbling on to an emotional landmine, but accidents of disclosure do not happen in therapy. If you have been in therapy yourself, you know this to be true. Despite what it may look like on the other side, major life traumas cannot be easily forgotten. The client is watching very closely—often without seeming to—to see how you are going to react, and if you let it go, the client is likely to get the message that you are not comfortable addressing it and may not raise it with you again. So if your client brings it up, take the opportunity to explore it.
What if you are not able to appropriately and professionally deal with the trauma in that setting or, for some reason, it is not appropriate? Being sensitive to the psychology of the victim can also allow you to determine in what cases and how you should navigate a situation in which you may not be in the position to provide trauma therapy.
For example, should a client recall a memory of an earlier trauma during a short-term treatment currently heading in a specific alternate direction (such as school counseling, substance abuse, and domestic violence), then there is a dilemma. It is not your dilemma; it is a shared dilemma. Your role is to let the client know you have just heard something very significant, something that, in your experience, is often related to many issues and problems in later life if unaddressed. You may then invite the client to consider discussing the issue further to see if it seems worth pursuing in this therapy.
One option is to refer the client for therapy specific to this issue (such as rape treatment, incest groups, and veterans’ treatment of war trauma). Alternately, if you feel confident in your ability to work on the trauma piece, then you can decide if you want to offer the client the option of doing this piece of work with you.
It is worth mentioning that the treatment section may need an addendum for some patients for whom the disclosure may hold promise of some secondary gain. For example, a small but irritatingly provoking percentage of patients have been known to report issues of abuse, which, although they are true, are not unresolved so much as they are disclosed as a means to distract the clinician from a potentially conflicting goal of treatment, such as expecting the client to focus on accepting the responsibility for his or her behavior. When there is room for a benefit to occur from a disclosure (for example, a transfer to a less restrictive unit or receipt of disability monies), the motivation of secondary gain must also be considered.
From Stabilization to Recovery
It is helpful to keep in mind the distinction between the primary and secondary gains in relation to disclosure. The primary gain of disclosure means the client is hoping to receive the simple gain of having a disclosure heard, sympathized, or empathized with—this is what 99% of the patients seek when they share a horrific incident. It is reasonable to expect that the therapist will provide this primary gain. A secondary gain of disclosure is when, as an indirect consequence of disclosure, there is an acquisition of something beneficial. Examples of these potential benefits include time out of the cell, increased privileges, or a less severe sentence, and this has nothing to do with the relationship in the room with the therapist per se. You are less likely to feel comfortable providing a secondary gain unintentionally. In both cases, the client is trying to get needs met through the process of disclosure; however, we tend to see the secondary gains as manipulative and primary gains as normal.
What seems to be helpful in using yourself as a tool to distinguish between the two is being available emotionally but providing no extra benefits. If the goal of the patient is the primary gain, the individual will be responsive to the emotional attention and support, and it will be helpful to the patient. If the goal is secondary, the person will quickly want to know how this will relate to special privileges or rules and seem disinterested in talking about emotional reactions to the event or the actual experiences involved in it. As a therapist, one simple way to set a boundary with regard to secondary gains is to explain your role again. You are there to help the client to cognitively accept a traumatic experience and begin to emotionally and behaviorally stabilize. It is likely that other professionals (case managers, social workers, law enforcement officers, and judges) make decisions about environmental privileges.
The Third Stage of Treatment
At this stage, the client has progressed through a decrease in symptoms, has been able to re-process the trauma in a manner, which allowed a new access to thoughts and feelings that may have been blocking full recovery (for example, shame, guilt, disbelief, rage, or sadness), mourn the changes in the past, and begin to look to the future.
The third stage of therapy, much like the first, is often bypassed. Normally, we hear much emphasis on the idea of telling the story and catharsis (which is the bulk of stage 2). While this is an essential component of trauma treatment, it is not the end. Once working through is done, the person is left with the task of figuring out where to go from there.
This portion of the treatment involves consolidating gains, considering future plans, and working with the client to conceptualize how this event is going to impact the patient’s life in a new way—and suggesting something possibly never even considered: the impact may result in improvements for the better. Research has shown that resilience and recovery from trauma often lead to significant personal growth in individuals. Nietzsche said, “That which does not kill me makes me stronger.” This existential perspective is a core component of what is considered the transition point from a survivor to a thriving person. This is not to say that the survivor asked for the trauma or that anyone is glad that the trauma occurred; however, the client may be able to accept the concept that some good may have come from the trauma and the subsequent treatment.
Concretely, this may look like inviting the client to consider how to now approach choices differently regarding interpersonal relationships, professional goals, or self-care. It does not have to be a complicated phase of treatment, because clients know if the ultimate goal is to return to life as it was, it may not be to have a good life. When life has been marred by trauma, the best may be what lies ahead, and the client may need help in imagining the possibilities and making it happen.
One important issue to keep in mind is that people are individuals who see the world through the lens of their own backgrounds and experiences and we cannot impose our own values and experiences on the experiences of others. During your training, you will be asked to find out more about trauma in different cultures, its meaning, and different ways of dealing with it.
Crisis Management
The focus of crisis management is to overcome the initial shock of the victimization and find a level of stabilization. In the immediate wake of the trauma, a victim may experience suicidal ideations or try to achieve a numbing effect through drug or alcohol use. The goal of crisis management is to help the individual to stabilize and return to a baseline level of functioning. This is not the time to have the victim relive or work through the trauma; rather, the counselor may need to be more directive in an effort to focus on safety and stabilization. This may be a good time to help the client activate his or her primary support system. Ideally, the client will have family members or a partner who can volunteer to be with the survivor, help with daily tasks, provide companionship, listen, and provide comfort. If such individuals are not nearby, the survivor may be willing to reach out and ask for a visit from support system members living elsewhere.
If initial efforts toward crisis management prove ineffective and if the victim is unable to contract for safety during this or any other stage of treatment, the counselor or therapist is obligated to facilitate the survivor’s psychiatric hospitalization either willingly or involuntarily, if necessary.
Healing Relationship
The counselor or therapist working with a trauma victim must be flexible and nonjudgmental. He or she must be able to hear the intimate painful details of the victimization without becoming overwhelmed or overemotional themselves. If the treatment provider reacts emotionally to the victim’s disclosure, the victim may assume that the counselor has never heard anything so horrible before or the victim might shut down in an effort to protect the counselor from his or her pain.
The counselor should help the victim properly place blame for the victimization on the perpetrator, not on self. The guilt accompanying victimization can lead to a major depressive episode, self-harm, or suicide attempts. The therapist should provide perspective for the victim that the experienced trauma can be overcome and survived and that the therapist has witnessed the successful recovery process of survivors. The therapist should emphasize that it is a process and warn the client that there will be good days and bad days. There will be thoughts, feelings, tastes, smells, and situations that may trigger memories of the assault; but, the therapist should remind the victim that he or she is safe now and needs to remain anchored in the present.
Reference:
Fisher, J. (1999). The work of stabilization in trauma treatment. Paper presented at the Trauma Center Lecture Series 1999, Boston, MA. Retrieved from http://smchealth.org/sites/default/files/docs/tic_stabilize.pdf
Revictimization Causes and Prevention
A review of ninety studies of sexual revictimization indicates that two out of three sexual assault victims will experience another sexual victimization during their lifetime (Classen, Palesh, & Aggarwal, 2005).
Treatment may be a crucial factor in preventing revictimization. Building awareness of risk factors and focusing on safety can work to reduce the risk of future victimization. This is certainly an area where future research is important.
Reference:
Classen, C. C., Palesh, O. G., & Aggarwal, R. (2005). Sexual revictimization. A review of the empirical literature. Trauma Violence Abuse, 6(2),103–129.
Conclusion
In this module, you focused on understanding the treatment process for victims. Some of the important topics covered during this module included:
· Therapeutic reenactment
· Roles of family, friends, and community
· Victim-to-survivor trajectory
· Revictimization causes and prevention
Throughout this course, you focused on understanding the victimization process, from assessment to treatment. It is hoped that you will take what you learned in this course and apply it to future learning opportunities with a varied client population. Many clients have experienced trauma, and individuals have a wide range of reactions when faced with the aftermath of trauma. Taking your time to explore your client’s individual experience will guide you in your choices of assessment and treatment and help you facilitate your client’s recovery.
