Working Effectively with Trauma- Guidelines for Clinicians

As stated in the previous blog, a purely talk-based approach is not sufficient for most complex trauma patients, and indeed may further traumatize them(Van Der Kolk, 2015).

So if we cant do “treatment as usual”, what options do we have? To begin, we need to widen our skill base to include other types of therapy(Blue Knot Foundation 2019).

Remember, there is no magic treatment approach that will help everyone. For example there is growing evidence for EMDR for complex trauma and C-PTSD, but Bessel Van Der Kolk suggests this may be best used with people who have single incident trauma- not complex trauma. I have found it useful to include practices such as trauma sensitive yoga, especially where there is significant dissociation, however where clients are body- phobic this may be inadvertently re-traumatising . Nonetheless it is useful for clinicians to have a wide skill set to complement existing skills, for example Sensorimotor psychotherapy or somatic experiencing training, art therapy training, equine therapy training, EMDR, the Conversational Model, Trauma Sensitive yoga training, child and adolescent trauma therapy, family therapy, neuroscience etc. I would suggest adding to your skills gradually so you aren’t putting too much pressure on yourself to be the ” perfect” therapist.

How we “show up” in therapy is also important. The Blue Knot guidelines (2012) suggest following 5 threads from Shapiro, which I compare with similar ideas and practices from Gestalt Therapy and Acceptance and Commitment therapy(ACT) Mindfulness practices.

  1. Presence (defined as `getting into the here-and-now experience of body, affect, and thought’) In Gestalt this is described as the phenomenological attitude, for others this is known as a state of Mindfulness.
  2. Dual awareness (`holding the trauma in mind, while maintaining focus in the current time and place’) In Gestalt this is known as “bracketing”. In ACT this is known as “holding lightly” “being present” and “observing self”
  3. Affect (emotion) while in relationship (`It’s not that the affect is discharged, though it might be. It’s that it’s felt and not avoided [ie within the `window of tolerance’] then witnessed and survived, then transformed into a memory, and no longer a developmental catastrophe’) In Gestalt this is known as “entering the experiential world of the client”, done with patience, reverence and respect. In Mindfulness, this is called “rolling out the welcome mat” for emotions.
  4. Relationship with self and other Patients gain tolerance and acceptance of their own affect and history and the capacity for relating to others through having a relational experience of tolerance and acceptance in the room. In  ACT, this is about acceptance of what is, and commitment to taking action to build a life enriched by values. However, where the patient has disorganised attachment, it is important to seek supervision regarding how to proceed, as attachment also creates terror or anger and may sabotage therapy. Handling disorganized attachment is much more complex, and the Janina Fisher website has many resources on this subject. Also, the principles of Richard Schwartz on Inner Family Systems are useful to bring into relational work with people suffering complex trauma.
  5. Making meaning of the traumatic events (`often accompanied by anger, then grief, then great relief’)227       In Gestalt we make meaning together. We believe that grief and shame need to be witnessed for healing to occur. In ACT Mindfulness we try to profoundly accept that suffering is part of the process of living. Rather than avoid, we make contact with suffering, grief or shame, with support from the therapist We are not trying to get rid of suffering, but rather to change our relationship with it.

Locating these 5 `threads’ helps to orient to what is now a rich, expanding but also contrasting landscape of therapy modalities for working with complex trauma. Again, the strengths, resources and preferences of the patient need to be included, including their age and cultural requirements. Children who have limited words for what they are experiencing can be supported via the generosity of the free resources on the Australian Childhood Foundation website. I have found some of their resources useful when working with adults.

  1. I would add 8 further dimensions to those above when working with people with complex trauma, starting with awareness of the role of culture, gender and other forms of diversity, presence or absence of external supports, and inclusion or exclusion of family in the work, including acknowledgement of intergenerational trauma.
  2.  The work should be phased- with stability and safety as phase one, as per the International Society for the Study of Trauma and Dissociation (ISSTD) guidelines. However, if sessions are limited in number by funding or other issues, focus on safety and stabilization, and liaise with other experts eg community psych support services. Don’t try and do too much or do the work on your own.
  3. Management of risk should be done carefully, sensitively and thoroughly, and decisions about how to reduce risk be made with the patient where possible. I will write more on this later this year, as it is a painful truth that many patients presenting to health services with risk have reported they are shamed or treated badly by those services (Benjamin 2019).  As much as possible, patients need to be empowered to make choices that best support them when they feel unsafe or have high risk behaviours.
  4. It is important that the power base of the work is not “one-up one-down”. Clinician should never consider that they are “expert”, instead a collaborative, respective and co-equal approach is best (Benjamin, 2019). Therapists should be committed to lifelong learning including from consumer forums online as the field is rapidly and significantly changing in multiple fields eg the neuroscience of attachment.
  5.  Unlike other types of psychotherapy, clinicians in this field should be careful not to foster attachment to them too soon by the patient (Fisher 2017). Work is enhanced by adopting a curious, respectful and collaborative stance with the patient about their parts, and by teaching the patient to distinguish between triggers which reprise past trauma or trauma happening now. This is best done gradually and by working with all parts of the fragmented self of the patient with equal care and consideration. Psychoeducation and Mindfulness training should be foundational, and teaching the patient how to manage strong or uncomfortable emotions is essential.
  6. Clinician should learn to be grounded, centred, and calm, no matter what is happening with the patient in the room (Schore, 2012). Our state helps to model, anchor, settle and soothe patients, to give them a beginning experience of secure attachment (if or as much as they can tolerate.) Eventually the work will lead patients to secure attachment with themselves, built on a foundation of awareness, compassion and trust. This in turn will change the way they relate to others and the world.
  7. This implies that all therapists who work with traumatized patients have undertaken their own psychotherapy previously, so that they can be the solid ground from which to do the work. Personal therapy offers many advantages to the clinician including awareness of their own character strategies and defences, and how this affects their way of working, e.g. what things are avoided in the room.
  8. Clinicians should be reliable and consistent, and with good written terms and conditions including boundaries, and explaining the limitations of therapy. Annual leave and the like should be advised beforehand, and time allocated to process the effects of the clinician’s absence on all parts of the patient’s inner family system.
  9. Clinicians who work with complex trauma must have regular supervision, by someone with recent experience and additional training in this field. This is to help prevent burnout or vicarious traumatization, and also to ensure that practices are up to date.

I am hoping these guidelines are helpful and welcome your feedback and comments on this series of blogs offering guidelines for clinicians working with complex trauma.

 

 

 

Working Gently with Embodied Awareness

 Most modern trauma psychotherapy treatments aim to include the body in some way in the work of healing trauma.

Yet many patients with complex trauma conditions have an understandable phobia about noticing  their body, or are numb or dissociated from their body. Body awareness often triggers a danger response or feels unsafe in some way.

For example, health professionals may start by inviting patients to practice mindfulness, eg with the breath, only to find that simply focusing on the breath has inadvertently triggered a fight/ flight/ freeze/ dissociation or hypervigilance response. So it is essential to approach any body work with great caution, respect, gentleness and preparation!

Preferably, the health professional will  undertake additional training in somatic modality  such as sensorimotor psychotherapy or somatic experiencing before attempting any such work, and will also be aware of their own transference and countertransference through their own in depth personal psychotherapy experience. I add this caution as untold harm is possible via unaware or unskilled interventions when working with the body. Please do not attempt this unless you are professionally prepared!

How do we work safely with the body? There is a four step process that can help to set this up. This week we will discuss step one, which is setting the stage properly, to create the optimal setting before beginning any body work.

According to Dr. Andy Harkin, a Sensorimotor Psychotherapist from the UK now living in Australia, we need to be clear with the patient HOW we are working with the body as well as WHY. He talks about this on youtube

So, ideally, we could start with Psychoeducation, right? Hmm, not so fast! What if the patient is not ready for this? Patients at the more complex end of the trauma spectrum will probably need preparation, prior to the apparently simple step of psychoeducation.

There is no point trying to educate if a person is in sympathetic nervous system hyperarousal. Their frontal lobes are effectively “offline” for survival reasons, so the capacity to absorb information is greatly reduced, and if they are distressed enough they will quite probably misperceive what is being said as their system is primed to detect danger to help them survive. Ideally, education is not offered until the patient is as calm and settled as possible.

So first step, ensure that you the therapist are calm and grounded, quiet and still, and let your nervous system, body and voice help the patient settle into a calmer state. Explain what you are doing simply. Your limbic system and mirror cells really can help, as calmness is contagious!

At this stage, you are not aiming for the person to be totally relaxed, nor are you beginning to talk about any trauma. Instead, you are just aiming to practice being present with the patient in a way that offers a small amount of relief from SNS symptoms if they are in hyperarousal. A calm gentle presence, some quiet reassuring words, and just sitting.

For some patients, you can invite and co-create small experiments to foster collaboration in helping the room to feel calmer, for example adjusting blinds or reducing lighting a little, adjusting the position or distance of the chairs, adjusting how you are both facing in relation to each other.

It is important to focus on CALMNESS instead of SAFETY. Saying the word “safety” can often trigger hypervigilance and hyperarousal in complex trauma patients.

Some patients feel calmer if they have something to squeeze or hold, a cushion or soft fabric. Some people need to stand up to feel calmer, this seems to be true especially where the spine is collapsed or the posture is slumped. Also, orienting to the room and then naming the date and time can help. Ask the patient to simply notice “calmer” or “less calm” inside the room. Use hand signals not words to communicate regarding this.

Avoid the impulse to DO something such as talking incessantly or writing out a prescription and instead practice just BEING with the patient in a calm and respectful manner.

Sometimes, depending on the patient and situation, being light and playful can also help. Depending on the patient, sometimes I scrunch up and toss paper balls, do side by side colouring in, roll or push large gym balls, play peekaboo, squeeze playdough, ask them to pass something in a funny voice etc.

You may spend hours, weeks or months like this with the patient, helping them to develop a felt sense of calmness and tranquillity in the room, helping them learn to soothe and settle, and gently explaining why this is the foundation for the work of healing. This is body work, as you are helping the patients body, brain and nervous system get used to the unfamiliar state of being in the window of tolerance.

As they begin to settle, you will be able to offer more in the way of psychoeducation. Although you may have very intelligent and sophisticated patients, it is important that the learning material is simplified initially. In my experience, even the word Amygdala can cause panic!

Choose your learning materials- visual, tactile, olfactory, toys and other objects- carefully and allow time and opportunity to absorb the information before you give more. Visual aids or videos are useful for this, for example the 3D Brain App. You can make your own aids or purchase from Janina Fisher and many other international sources.  For the patient with hyperarousal, slow is always better, and you must be able to hold that space and repeatedly explain to the patient why you cannot rush, especially healing!

Now you are ready to explain in detail how trauma affects the body systems and processes, in a way that is appropriate for your patient.  You can also begin to educate about the importance of learning mindfulness at this stage and perhaps now begin to notice mindfully together the experience of being calmer.

To strengthen the patient’s commitment to the work of healing, it makes sense that you practice what you are teaching including developing capacity for interoception, awareness of subtle changes in your own body, and being able to develop a wide vocabulary for describing what you notice. The therapist’s capacity to be embodied greatly enhances the possibility that the patient will eventually learn something more about embodiment.

Next, and before approaching any work with the body, it is important to negotiate conscious permission giving from the person to do the work of healing. This will require negotiation with all the parts if structural dissociation or DID are present. Respect for the patient and their parts is critical at this point. Do not start any body work without permission being established. Do not ignore parts who are undecided. Do not rush this step! We will discuss the art and science embedded in the process of permission giving as part of the forthcoming trainings to be offered next year for health professionals.

The above approach is based on the work of prominent trauma leaders as described elsewhere on this site, and my own experiences as a practitioner working with complex trauma, dissociation and DID. Your views and comments about this post are welcome.