Treating Trauma

Complex Trauma 

 Treating complex trauma is more complicated than treating patients with post-traumatic stress disorder. Survivors of complex trauma have often endured repeated physical, sexual, or emotional abuse in childhood. Often these survivors experience more trauma later in life that triggers all the early pain and vulnerability. Developmental disruptions can be observed, which can include difficulties in regulating emotions, impaired relationships, and negative self-worth (Kimberg 2019).  

Trauma Specific Treatments

National Center for PTSD (2019) explains some of the most current specific treatments for posttraumatic stress disorder. These include cognitive processing therapy for PTSD, prolonged exposure for PTSD,  eye movement desensitization, and reprocessing trauma.

Cognitive processing therapy is based on the theory that individuals consolidate information into learned categories. These classifications of information are used to make sense of the environment, assimilate new information, and allow for a feeling of expectation of following situations. This interpretation of experience provides for feelings of security and safety in the world (National Center for PTSD, 2019).

 Traumatic events rupture beliefs related to security, trust, and control in the world. As a result of people often experience PTSD, which destabilizes a feeling of security with an array of symptoms related to anxiety and panic. Individuals have a difficult time getting back to feeling stable and secure (National Center for PTSD, 2019).

Cognitive processing therapy allows the patient to identify disruptions that impede recovery. Through cognitive restructuring, the clinician can help the patient to work toward gaining balanced interpretations of the events. The therapist teaches the patient about cognitive restructuring and challenges the patients thinking about the trauma — the cognitive restructuring results in the patient modifying beliefs about the environment and the self. The goal is symptom reduction and an increase in the sense of empowerment (National Center for PTSD 2019).

Prolonged exposure therapy allows the patient to process painful memories in a safe and supportive environment.  As soon as this step is mastered, prolonged exposure therapy tries to have the patient interact in activities that they have been avoiding because of the trauma. Symptoms of PTSD can be observed when small symbolic events elicit a response that is out of proportion to the event or experiences a stimulus that most people would consider safe (National Center for PTSD, 2019).

The object of prolonged exposure therapy is to revise the level of fear though exposure to the trauma so that the patient adapts to responses that are relative to stimuli. Prolong exposure therapy usually is completed between 8-15 90-minute sessions. Psychoeducation gives the patient information about the treatment, possible reactions, and breathing training to help with anxiety.  The first part of therapy involves the patient retelling the therapist in the present tense with his/her eyes closed the events that occurred during the trauma. The session is generally recorded.  Homework for the patient is to listen to the recording of the meeting several times before the next session (National Center for PTSD, 2019).

The second part of the treatment involves the therapist and patient to do some in-vivo therapy. The in-vivo part consists of the therapist exposing the patient to situations that the patient has avoided because they have evoked great distress. The therapist then works with the patient to discuss the experience of the exposure and the impact the patient has experienced (National Center for PTSD, 2019

Eye Movement Desensitasation Reprocessing

Eye movement desensitization and reprocessing (EMDR) is a trauma-focused psychotherapy that has been researched sufficiently for PTSD. Many of these studies have reported that this method is effective in treating PTSD. Eye movement desensitization and reprocessing works on the principle that humans assimilate new information and experiences by linking and incorporating them with related emotions and knowledge in the memory networks of the brain. Complex trauma or PTSD occurs when an experience is overwhelming and cannot be processed. The information and experience do not join with other information in the memory networks. The traumatic memories are retained separately, developing feelings of distress. Patients struggle to process through the disturbance resulting in difficulty resolving the experience (National Center for PTSD 2019).

EMDR is presented by the therapist weekly in up to 90-minute individual sessions for about three months. In the initial meetings, the therapists explain the theory and method. A history is taken. The patient is then familiarized with bilateral stimulation by eye movement or taping to assist with trauma processing.

The therapists begin the session by helping the patient identify the most disturbing image of a traumatic situation. Once the vision is clear, the therapist assists the patient in determining negative self-talk as well as rating the level of physical and emotional distress.

Bilateral stimulation continues as the patient describes a wish of how the trauma could have been a better situation.  The therapist continues to assist the patient in noticing and incorporating ‘new perceptions. Connections, affect, and physical sensations are described until, finally, the anguish related to the traumatic memory diminishes (National Center for PTSD, 2019).

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Trauma Informed Care

Trauma-informed treatments  is empathic and focused on the needs of the trauma survivor. Trauma-informed treatment does not seem time-limited, which is conducive for the therapist and patient to develop a therapeutic alliance leading to feelings of safety and trust for the patient. Trauma-informed care is focused on understanding the neurological, biological, psychological, and social effects of trauma and the impacts these occurrences have led people to receive mental health services. Trauma-informed care considers knowledge about trauma, its effects on interpersonal relationships and impediments to recovery.

According to Kimberg (2019), trauma-informed care is consistent with the philosophies of patient-centered care.  Patient-centered care focuses on the patient's experiences as well as collaborating with the patient. The care concentrations are on the patient’s comfort as well as values, culture, and socio-economic conditions, which psychologically and emotionally create a sense of safety. The patient and family function as part of the care team. Information is shared with the family and patient, so informed decisions could be made to rebuild a perception of control and empowerment (Fix et al., 2017). Trauma-informed treatment can begin with assessments of the patient and family to fully understand unique information about the trauma survivors so that treatment does not retraumatize them (Cutuli et al., 2019).

Trauma-informed care was developed with six core principles: (1) Trauma understanding through awareness so providers can act with compassion, which helps survivors move toward wellness. (2) Safety and security increasing stability and safety reduces stress and anxiety on a primal level and allows for people to concentrate and move toward wellness. (3) cultural understanding allows trauma survivors to feel understood, which augments wellness. (4) Compassion and dependability are imperative for trauma survivors' improvement. Trauma changes a person's world view and often feel nothing in the world is stable. To feel someone is dependable helps bring back a sense of stability. (5) Collaboration and empowerment: people who have experienced complex trauma usually feel they have no control over their lives. In treatment collaborating with the patient about the treatment plan and allowing them to take the lead restores a sense of empowerment and having control over one’s life. (6) Resilience and recovery. When trauma survivors are reminded of their strengths they begin to feel less like a victim and more as a survivor. This empowerment allows them to work on taking steps to resiliency and recovery[WN1] .

Murray, Sullivan, Lent, Chaplo, and Tunno (2019) researched trauma-informed parenting for children in out of home care. Children who have been placed in out of home care most likely have experienced complex trauma. These children are usually removed from the home because the home has not been suitable for them. Often, they have experienced abuse and or neglect to the point that the Department of Family and Children; s Services has had to intervene.

In addition to the trauma the children experienced at home,  they have been removed from their primary care-givers, which can trigger many attachment issues. Some children have been moved to several different homes. Therefore, each time they reach a level of comfort and perhaps attachment, they are uprooted again forced to make new attachments again if possible.

It can be challenging for foster, adoptive, or even kinship caregivers to understand and manage the range of possible acting out behaviors, lack of emotional regulation or difficulty forming attachments that children coming into their home can exhibit. If parents receive training in trauma-informed parenting, they may understand the child’s trauma cand coping skills so they can care for the children in a healing manner rather than retraumatize them.

The object of the study designed by Murray, Sullivan, Lent, Chaplo, and Tunno (2019) was to evaluate  caregivers of out of home place children could gain information about trauma-informed parenting, The researchers’ hypothesized that caregivers would develop increased knowledge and awareness, develop a tolerance of the child’s misbehavior, and acquire a sense of self-efficacy in parenting a child who had faced complex trauma.

            The study involved eight modules, each giving information about one of nine elements of trauma-informed parenting. The parents attended in-person workshops that occurred over multiple weeks. Measures of parental demographics were taken as well as pre and post-workshop evaluations.

           

            The researchers reported several limitations in the study, including not having a control group,  reasons for the attrition rate, and the impact of individual facilitators of the workshops. The most significant limitation was there was no evaluation of how the parenting effects affected the child’s post-traumatic stress, behavior or enhanced parent-child relationship (Murray et al., 2019).The writer was disappointed that there were no measures that evaluated the child’s coping or healing from some of the trauma as a result of trauma-informed parenting.

            Trauma-informed care and trauma-specific services do not have to be mutually exclusive. All treatments have limitations, and it seems that trauma-informed care could be used with trauma-specific treatments. According to DeCandia, Guarino, and Clevil (2014), some patients may not be ready for trauma-specific treatments. Some people cannot tolerate reprocessing the trauma. In these two instances trauma-informed care might be a better modality.

              Others may be ready to experience evidence-based treatment, and those treatments have shown improvement in outcome. However, clinical judgment is always critical when treating trauma survivors. Some people have particular treatment needs. Trauma-informed care before during and after specific evidenced-based treatments seems to make sense to make sure the individual is coping well or needs to stop. It appears that more research needs to be done on clinical judgment, individual clients, ability to cope with specific types of trauma. It seems some clients can only tolerate trauma-informed treatment and it can work very well for them. An example would be the use of trauma-informed parenting with out of home placed children.

On the other hand, the use of trauma-informed treatment might help a trauma survivor to become ready to try a specific evidenced-based treatment          

 

References

Alemeda County Behavioral Health Care Services 2013 Trauma Informed Care vs. Trauma Specific TreatmentAlameda County Behavioral Health Care Services. (2013). Trauma-Informed Care vs. Trauma Specific Treatment. Retrieved from https://alamedacountytraumainformedcare.org/trauma-informed-care/trauma-informed-care-vs-trauma-specific-treatment-2/ 201910201024241751845599

Cutuli J J Alder M A Marsac M 2019 Trauma Informed Care for Children and Families.Cutuli, J. J., Alder, M. A., & Marsac, M. (2019). Trauma-Informed Care for Children and Families. Psychological Services Special Issue, 16(1), 1-6.  20191017093045716353655

DeCandia C J Guarino K Clevil R  Trauma Informed Care and Trauma-Specific Services:A Comprensive Approach to Trauma InterventionDeCandia, C. J., Guarino, K., & Clevil, R. (2014, October). Trauma-Informed Care and Trauma-Specific Services: A Comprehensive Approach to Trauma Intervention. Washington: American Institutes for Research.  20191016102509498070240

Fix G M Lucus C V Bolton R E Hill J N Mueller N Le Vela S L Bokhour B G 2017 Patient Centred Care os a Way of Doing Things: How Healthcare Employees conceptualize Patient-Centered Care.Fix, G. M., Lucus, C. V., Bolton, R. E., Hill, J. N., Mueller, N., Le Vela, S. L., & Bokhour, B. G. (2017). Patient-Centered Care as a Way of Doing Things: How Healthcare Employees conceptualize Patient-Centered Care. Health Expectations, 21(1),.  201910170834051950127006

Kimberg L 2019 Trauma Informed Healthcare ApprochesKimberg, L. (2019). Trauma and Trauma-Informed Care. In R. Gerber (Ed.), Trauma-Informed Healthcare Approaches (pp. 25-56). , Switzerland: Springer International Publishing.  201910160913441073317766

Kimberg L S Wheeler M 2019 Trauma Informed Heathcare ApprochesKimberg, L. S., & Wheeler, M. (2019). Trauma-Informed Healthcare Approaches.  201910160833441760856986

Murray K J Sullivan K M Lent M C Chapio S D Tunno A M  Promoting Trauma-Informed Parenting in Out-of-Home-Care:.20191020120441388285279Murray K J Sullivan K M Lent M C Chaplo S D Tunno A M 2019 Promoting Trauma-Informed Parenting of Children in Out-of-Home Care: An Effectiveness Study of the Resource Parent Curriculum.Murray, K. J., Sullivan, K. M., Lent, M. C., Chaplo, S. D., & Tunno, A. M. (2019). Promoting Trauma-Informed Parenting of Children in Out-of-Home Care: An Effectiveness Study of the Resource Parent Curriculum. Psychological Services, 16(1), 162-169.  20191020121033602074146

National Center for PTSD 2019 Treatment EssentialsNational Center for PTSD. (2019, October). Treatment Essentials. Retrieved from https://www.ptsd.va.gov/professional/treat/txessentials/index.asp 20191019091442107558488

Sweeny A Filson B Kennedy A Collinson L Gilard S 2018 Paradim Shift: Relationships in Trauma Informed Mental Health Services.Sweeny, A., Filson, B., Kennedy, A., Collinson, L., & Gillard, S. (2018). A Paradigm Shift: Relationships in Trauma-Informed Mental Health Services. BjPsych Advances, 24(5), 319-333.  201910200214381058128715

VWan Woudenberg C Voorendonk E M Bongaerts H Zoet H A Verhagen M Lee C W 2018 Effectiveness of an intensive treatment programe combining prolonged exposure and eye movement desensitization and reprocessing for severe post tramatic stress disorder.vVVvvvVvvan Woudenberg, C., Voorendonk, E. M., Bongaerts, H., Zoet, H. A., Verhagen, M., & Lee, C. W. (2018). Effectiveness of An Intensive Treatment Programe Combining Prolonged Exposure And Eye Movement Desensitization And Reprocessing For Severe Post Traumatic Stress Disorder. European Journal of Psychotraumatology, 9(1).  201910190901081434044242