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.

 

 

 

Compassion as the Core of Healing

What is Compassion?

A simple definition of compassion: Deep awareness of the suffering of self or others, and the ability to be with that suffering, with profound acceptance, and without pushing it away, labelling it or judging it.

Here’s another:

According to Pema Chodron (a Buddhist nun), “When we practice compassion, we can expect to experience the fear of our pain. Compassion practice is daring. It involves learning to relax and allow ourselves to move gently toward what scares us”. 

Chodron teaches that we must be honest and forgiving about when and how we shut down. In compassion, we draw from the wholeness of our experience- our suffering and empathy, as well as our cruelty and terror. It has to be this way. Compassion is not a relationship between the healer and the wounded. It’s a relationship between equal parts of ourselves. Only when we know our own darkness can we be present with the darkness of others. Compassion becomes real when we recognise our shared humanity. 

Reflection: To know our own darkness, is to allow ourselves to know the truth that we are human, fragile or imperfect. Yet many people with complex past experiences struggle to be compassionate with themselves. There may be a very harsh inner critic or a persecutory part that is quite relentless. Do you have an inner critic? If so, what are the most common beliefs or statements from this part? Would your best friend agree with what this part is saying?

So how do we learn to be more compassionate? It helps if we break compassion down into a behaviour or an action, so that we can get to know it as an experience, rather than just an idea which we might get around to “some day”.  Think of compassion as an action word. What attitudes and behaviours would go with compassion, what does it look like in action? For example, being compassionate to yourself could mean:

  • listening to your body
  • learning to be present
  • accepting or allowing difficult emotions or pain calmly
  • learning to accept life on life’s terms if this is the best or only option
  • being honest and gentle with vulnerabilities
  • healing old patterns that are problematic
  • finding balance
  • allowing yourself to heal
  • slowing down
  • letting go of excessive shame or guilt
  • being humble and soft instead of arrogant or rigid
  • allowing your voice to be heard
  • putting boundaries on those who dishonour you
  • backing yourself instead of undermining yourself
  • communicating frequently with inner parts to soothe and settle the system
  • giving yourself and others kindness instead of harsh judgements/criticism
  • all of the above
  • other things not listed?

Looking at the list above, which aspects of compassion stand out the most and which ones do you long for ? I look forward to hearing your thoughts and ideas on this.