Lecture 4 phase 1 safety & stabilization


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Lecture 4 of 10 on Complex trauma for Counselling Studies Level 6 module. Based on the book Courtis & Ford (2013) Treatment of complex trauma.

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Lecture 4 phase 1 safety & stabilization

  1. 1. Lecture 4 Phase 1: Assessment of complex trauma; Goal setting; Safety and Stabilization Complex trauma Kevin Standish
  2. 2. Learning outcomes 1. To Assess complex trauma adequately. 2. To set treatment goals for complex trauma. 3. To identify the core tasks of Phase 1: Safety, Stabilization, and Engagement
  3. 3. 1. ASSESSMENT 1.1.The need for support neutrality 1.2. Principles and strategies 1.3. Assessment measures using various instruments 1.4. Formulation: Descriptive diagnosis
  4. 4. 1. Assessment 1. The primary function of psychological assessment is to inform treatment. 2. Where the variety of potential symptoms for any given client may be significantly associated with various disorders, assessment is essential to determine an accurate treatment approach. 3. Clinical intervention is customised for each individual in terms of symptoms and problems that they experience
  5. 5. 1.1.The need for support neutrality 1. A stance of "supportive neutrality" is recommended 2. As the individual may be unable to disclose traumatic events unless supported through direct yet sensitive questioning 3. Trauma victims have experienced intrusion and damage at the hands of others and are highly suspicious of the motives and intentions of anyone wanting to help them.
  6. 6. 1.2.PRINCIPLES AND STRATEGIES 1.2.1. Assessment provides baseline information 1.2.2. Impact of Assessment the client and Therapist 1.2.3. Under- and Overreporting 1.2.4.The crisis presentation 1.2.5. When trauma and abuse victimization are disclosed 1.2.6. When trauma and abuse are not disclosed
  7. 7. 1.2.1. Assessment provides baseline information 1. Assessment begins with an intake interview and a comprehensive psychosocial evaluation 2. The intake assessment provides a baseline of information about the individual status at the time 3. A clinical interview is usually the basis for a broad-based assessment which covers a range of issues from basic demographic information, presenting complaints, review of symptoms, previous treatment, life stresses, personal safety and current medication or abuse of substances. 4. A second major area involves personal and social histories. These include developmental milestones, family history, parental relationships, extended family history, cultural background, religion, sexual identity, culture of origin, ethnicity etc
  8. 8. 1.2.1. Assessment provides baseline information 5. A third major area is assessing the individual's personal strengths and resources as well as their personal support network 6. A general risk assessment is part of the overall assessment and includes questions about past or current trauma, current safety and risk of violence to self or others, domestic violence, substance abuse and history of mental illness 7. Other areas of assessment include the clients current living situation, economic status and job security, current medical treatments including other alternative treatments.
  9. 9. 1.2.2.Impact of Assessment the client and Therapist 1. The assessment process is likely to be stressful. 2. It is crucial to create conditions that are safe, supportive and non-judgemental 3. The client is encouraged to maintain as much control as possible, to communicate dissociative features, to ask for clarification and choose not to answer questions when necessary 4. Adjust the pace of assessment or suspended if it becomes unsettling or causes a decompensation in the client functioning 5. If the client becomes distressed and destabilised the assessment process must be halted and the individual re-stabilised 6. Therapist must be aware of trauma transference and the vicarious traumatisation
  10. 10. 1.2.3.Under- and Over-reporting 1. Traumatised individuals may under or over report their experiences, especially if questions are imprecise or misunderstood 2. Questions need to be phrased precisely but neutrally using behavioural descriptions: "did you, as a child, ever have a sexual experience with an adult?" 3. Disguised presentation will often take the form of parentified clients: those who come across as competent, responsible, confident and mature. They are expert at masking difficulties and concerns, and taking care of others. Described as pseudo-mature. 4. The overly responsible client resembles the apparent normal personality (ANP), with the EP being separated off from the trauma with emotional material not available in pretreatment assessment
  11. 11. 1.2.3.Under- and Over-reporting 5. Various other reasons for disguised presentation or under reporting include: lack of awareness, gender (males less likely to disclose) trauma bonding, dissociation, memory loss, and avoidance due to shame and embarrassment. 6. Over-reporting can occur due to secondary gain, retribution, an explanation for life problems, memory errors, and severe personality disturbances. 7. It is unknown how often trauma is over or under reported due to false memory, false belief or other factors.
  12. 12. 1.2.4.The crisis presentation 1. The crisis presentation is the re-emergence of the trauma and its symptoms often in an unplanned and spontaneous manner 2. The symptoms can bring on acute states of anxiety, depression or dissociation with individual the compensating into more severe mental health states 3. The re-emergence of the trauma is highly distressing, and is often stirred up by events or other stimuli the that has served as a reminder. 4. Various life events whether they are distressing and decremental ( involving illness, death, Anniversary Dates etc) or happy and incremental (marriage, pregnancy, birth of a child) can trigger symptoms.
  13. 13. 1.2.4.The crisis presentation 5. These positive events can cause a crisis when they provide enough security for defences to lessen resulting in the emergence of symptoms and memories. 6. Crisis intervention requires emotional support, stabilisation and safety, normalisation of reactions and a non-judgemental stance 7. In severe cases hospitalisation and medication may be required
  14. 14. 1.2.5.When trauma and abuse victimization are disclosed 1. When trauma is disclosed the therapist should enquire about both objective factors (who, what, when, where), and subjective thoughts beliefs and feelings, and record responses factually. 2. In the disclosure the therapist must remain aware of the split between ANP and EP: often there are delayed emotional responses to the disclosure. 3. It is important clarify underlying childhood messages and beliefs about disclosure of the abuse information: threats of death or injury upon the disclosure 4. Therapist needs to be supportive, understanding and not press for certainty and tolerating unclear answers
  15. 15. 1.2.5.When trauma and abuse victimization are disclosed 5. Therapist must assess and evaluate for possible PTSD, dissociation, substance-abuse and other related emotional somatic disorders 6. It is important to emphasise to the client that disclosure does not mean resolution, but rather signifies the beginning of the treatment process in which resolution is the major goal 7. The process of telling for the first time for many victims is cathartic and therapeutic for them, but does not mean resolution
  16. 16. 1.2.6.When trauma and abuse are not disclosed 1. Trauma and victimisation may not be divulged even when questions direct and unambiguous: trauma events may not be known but only suspected; the event is known but not disclosed; or the event did not occur and there is nothing to disclose. 2. When the occurrence of the event is unclear, expectations and motivations need to be clarified. 3. Do not assume the meaning of the lack of disclosure. Therapist may observe and identify the possibility of traumatisation from the clients presentation and history. The therapist may develop a hypothesis of trauma, but this needs to be kept private in order not to be suggestive of trauma. 4. The development of false memory syndrome needs avoided at all costs. http://www.ted.com/talks/elizabeth_loftus_the_fiction_of_memory 5. When memory is absent, the therapist should not speculate about, fill in, or try to confirm suspicions. It is important to tolerate the uncertainty of not knowing. Ongoing open exploration over time is what is required.
  17. 17. 1.3. Assessment measures using various instruments 1. A number of trauma specific psychological instruments available to supplement the psychosocial interview 2. Accurate assessment of traumatic experiences and trauma related symptoms can be made with psychometricly sound instruments constructed specifically for assessments of trauma.
  18. 18. 1.3. Assessment measures 1.3.1.General psychological inventories and structured interviews 1.3.2. PTSD and Dissociative symptoms questionnaires 1.3.3. Measures of traumatic events and experiences 1.3.4. Assessment of attachment style 1.3.5.Collateral Assessment 1.3.6. Prognostic indicators
  19. 19. 1.3.1. General psychological inventories and structured interviews 1. A variety of self report inventories, symptom checklists and structured interviews are available to guide a generic clinical interview. 2. Many of these instruments are not specifically designed to assess complex trauma. They tend to assess a variety of other broader categories of mental health problems which victims of complex trauma will have. 3. Pervasive symptoms covering a range of disorders are highly correlated with complex trauma.
  20. 20. 1.3.2. PTSD and Dissociative symptoms questionnaires 1.A variety of instruments available for the assessment of PTSD and dissociative disorders. 2.Post-traumatic stress diagnostic scale, dissociative experience scale, dissociative disorders interview schedule are just a number of available instruments for the assessment of these conditions
  21. 21. 1.3.3.Measures of traumatic events and experiences 1.Instruments that explore specific types of traumatic events and experiences have been developed using structured set of questions posed by the interviewer who records responses verbatim. 2.They elicit specific information about the experience and event when a trauma history has been disclosed: e.g. Courtis incest history questionnaire is an example.
  22. 22. 1.3.4.Assessment of attachment style 1.It is imperative to measure attachment status as part of a comprehensive assessment of complex trauma. 2.Early attachment predicts a significant proportion of adult psychopathology in relation to traumatic events 3.The Adult Attachment Inventory (AAI) is the most used instrument for determining attachment style.
  23. 23. 1.3.5.Collateral Assessment 1. Collateral assessment with spouse, family members, friends, teachers etc can be warranted to obtain more objective information, to provide information about events which the client has little or no recollection. (The movie Prince of Tides is an example). 2. It can also help assess the impact the client has on others and the way in which they interact in relationships can provide valuable data 3. Seeking collateral information is best decided and undertaken collaboratively with the client. The suggestion to include information from outside sources must be judicious and have a clear rationale with the client explicit permission. 4. The failure to do so would reinforce the clients sense of victimisation and powerlessness.
  24. 24. 1.3.6.Prognostic indicators The capacity of the client to manage the treatment process has to do with the unique circumstances of each client and their resilience. Kluft (1999) has three descriptions: 1. client in the low trajectory had conditions of chronic trauma, chronic mental illness, chaotic love and unstable families, complicated with addictions, self harm and suicide, limited support and difficulty to engage with the therapeutic agenda. 2. Client in the middle trajectory had more stability in their lives, greater resources at their disposal, yet required years of treatment in order to achieve a stable recovery. Emotional regulation was the major treatment task. High levels of mistrust impeded the therapeutic work. 3. High trajectory clients have the most personal and interpersonal capacities and resources at their disposal. Treatment is the least crisis prone, they are able to engage in the therapeutic relationship, and treatment takes the least amount of time.
  25. 25. 1.3.6.Prognostic indicators “Not all clients heal from the trauma in the same way or to the same degree despite receiving similar treatments”
  26. 26. 1.3.6.Prognostic indicators Prognosis needs to look at the following eight main categories: 1. Lack of motivation 2. Lack of healthy relationships 3. Lack of healthy therapeutic relationship 4. Lack of other internal and external resources 5. Serious axis I comorbidity 6. Serious axis II comorbidity 7. Poor attachment 8. Self-destructive behaviours This checklist can help focus therapeutic attention towards specific treatment goals related to the prognostic categories, or in the case of a low trajectory client be aware that the treatment goals may be limited to the stabilisation phase only.
  27. 27. 1.4. Formulation: Descriptive diagnosis 1. Arriving at a post assessment diagnostic formulation for complex trauma client is a complicated process involving a number of symptoms and developmental consequences that spanned more than one diagnostic category and the co-occurring symptoms that emerged over the course of treatment. 2. The conceptualisation of complex PTSD/DESNOS is a useful way of organising multiple symptoms and associated diagnosis.
  28. 28. 1.4. Formulation: Descriptive diagnosis 3. Complex traumatic sequelae are changes in the mind, emotions, body and relationships experienced following complex psychological trauma, including severe problems with dissociation, emotional dysregulation, somatic distress, relational or spiritual alienation, referred to as complex traumatic stress disorders. 4. It is important to arrive at a comprehensive and descriptive diagnosis of complex trauma. Utilising the DSM axis system will help formulate important descriptive elements needed to understand the client in a comprehensive manner. 5. Multiple diagnoses and descriptions within each axis should be given where necessary to describe the current condition.
  29. 29. 2. GOAL SETTING 2.1. Goals for ptsd 2.2. Additional goals for complex trauma 2.3. Metagoals for therapy with complex trauma
  30. 30. Goal setting 1. As survivors of complex trauma will experience symptoms of both PTSD and complex traumatic stress disorders, along with the associated features and co- occurring disorders, the therapist must assess and identify the specific symptoms that are most troubling and cause the greatest degree of personal and interpersonal impairment. 2. These collaboratively established goals are required to be treated, together with the phase based approach to treatment.
  31. 31. 2.1.Goals for ptsd Numerous treatment models for PTSD available. The core goals for the treatment of PTSD include the following: 1. To increase the capacity to respond to the threat with realistic appraisal rather than exaggerated responses. 2. To maintain normal levels of arousal rather than hypervigilance or numbing. 3. To facilitate the return to normal development, adaptive coping and improved functioning in work and relationships. 4. To restore personal integrity and normalise traumatic stress response by validating the symptoms and establishing a frame of meaning. 5. Conduct treatment in the atmosphere of safety and security and ensure re-traumatisation is minimised.
  32. 32. 2.1.Goals for ptsd 6. To regulate the level of intensity of traumatic aspects through cognitive reappraisal. 7. To increase capacity to differentiate remembering from reliving past traumas. 8. To place trauma in perspective and regain control of a life experiences. 9. To attend to biological and social learning risk factors that shape the trauma response. 10. To actively intervene to address secondary responses and comorbidities. 11.To improve the sense of self from victim to an individual engaged in life. 12. To enhance personal courage in approaching the memories of trauma.
  33. 33. 2.2.Additional goals for complex trauma Clients with complex trauma histories tend to have additional problems: self, relational, developmental and life skill deficits beyond those of PTSD. 8 Additional goals build on the 12 listed to address these developmental deficits: 1. To face the trauma memory and its associated feelings, cognitions, beliefs and schema about self and others. 2. The experience relational safety and attunement in the treatment relationship as a secure base. 3. To develop and restore emotional regulation, to identify emotions and increase the capacity for tolerance of emotional expression through self development. 4. To shift the self-concept from permanently damage to resilient and recovered from injury.
  34. 34. 2.2.Additional goals for complex trauma 5. To shift the self-concept from helplessness to autonomous self determination. 6. To acquire capacities for bodily self awareness and arousal regulation that have been split off through somatoform dissociation. 7. To develop a self regulatory capacity to recognise and reduce the severity and frequency of dissociation, addiction, self harm, impulsivity and aggression towards self and others. 8. To identify re-enactments of traumatic events and develop self protection and self enhancement skills to prevent re-victimisation and re-traumatisation.
  35. 35. 2.3.Metagoals for therapy with complex trauma 1. Challenge avoidance through attachment security and skill development 2. Enhance self determination and autonomy 3. Enhance ability to manage extreme arousal states 4. Enhance sense of self and personal identity 5. Enhance Sense of Personal Control and Self- efficacy 6. Maintain functioning and over-come co- occurring difficulties and disorders 7. Recognise and prevent traumatic re-enactments 8. Repair the Mind - body split The following list of metagoals help simplify the complete list of 20 points. The following eight metagoals acts as a reference point for the therapist to ensure that they remain on track overall
  36. 36. 2.3.1.Challenge avoidance through attachment security and skill development 1. Avoidance in order to self protect from the trauma of painful memories is a common process for victims. However it results in of an over-generalisation and prevents the processing of the traumatic memories. 2. There are a myriad of avoidance strategies used by victims. The strategies involve avoiding experiencing intolerable and unmanageable internal and affective emotional distress. 3. Driven by healthy motivation to survive overwhelming experiences, avoidance results in the loss of emotional, cognitive, behavioural and interpersonal functioning. 4. Trauma clients require assistance with the attachment insecurity and emotional dysregulation in order to learn to recognise and modify the ways in which the use avoidance to cope with distress.
  37. 37. 2.3.2.Enhance self determination and autonomy 1. Attachment security and emotional regulation also help achieve self-determination and autonomy. 2. The therapist needs to treat each client as the "authority" in determining the meaning and interpretation of their traumatic experiences 3. It is important for the client to take ownership of their memories and life story by determining their personal meaning associated with this. 4. To survive many clients gave up self-determination and choice: through a process of "other – directedness", developing an external locus of control, and being hypervigilant to the needs of the dominant other. 5. It is important to help the client develop autonomy and choice but balanced against appropriate dependency needs through the course of treatment.
  38. 38. 2.3.2.Enhance self determination and autonomy 6. Preoccupied attachment style are more dependent and require more closeness 7. Dismissive/detached attachment style require more distance initially 8. Disorganised/disorientated style involve a blend of closeness and detachment. 9. It is important to notice the pattern and encourage reflection by the client as to its meaning and purpose 10.The therapist engagement, predictability and consistency are essential in helping them develop healthy and secure attachment
  39. 39. 2.3.3.Enhance ability to manage extreme arousal states 1. Trauma survivors suffer from extreme states of arousal, or insufficient arousal of numbing and dissociation. Both states, hyper arousal and hypo arousal create distress for the client 2. These emotional states of arousal and nothingness are maladaptive self soothing attempts 3. The therapist assists the client to monitor these states through specific instruction in emotional identification, bodily awareness and processing of these states cognitively. 4. Clients learned to identify their emotions and self regulate their states that there are no longer at the mercy of them.
  40. 40. 2.3.4.Enhance sense of self and personal identity 1. The self concept of most abuse children is highly negative as they incorporate the blame for their mistreatment and neglect. 2. Primary goal is to provide conditions that allow and encourage self exploration to allow a more positive sense of self to develop. Rogers therapeutic conditions help develop a sense of worth. 3. Achieving connection at relational depth allows for greater attunement between therapist and client. The significance of this is reflected in the healthy development of the mind of the child and later the adults.
  41. 41. 2.3.5.Enhance Sense of Personal Control and Self-efficacy 1. Particular attention is be paid to assisting clients to develop personal and interpersonal pride and confidence without being overwhelmed by negative emotions such as fear, alienation self-hatred and shame. 2. Trauma memory and symptom processing must be timed and structured to support the client ability to process memories and gain a sense of self efficacy.
  42. 42. 2.3.6.Maintain functioning and over-come co-occurring difficulties and disorders 1.It needs to be recognised that some clients functioning is permanently compromised and will never return to their original potential. 2.Clients often steeped in helplessness due to repeated disempowerment, and comorbid disorders such as anxiety, depression and dissociation 3.These are best addressed by teaching specific skills such as assertiveness, goal setting, decision-making, problem solving, and boundary management.
  43. 43. 2.3.7.Recognise and prevent traumatic reenactments 1.The ways in which trauma histories are re- enacted in relationships with others and generally in life need to be addressed in the therapeutic process. 2.The interventions may include developing strategies for coping, developing a safety plan to prevent reenactments, to develop a strategy for safety in interactions with abusive others, workplace plans to prevent abuse and bullying.
  44. 44. 2.3.8.Repair the Mind - body split 1. Trauma results in major physiological based coping responses (fight flight freeze or collapse). 2. This results in a state known as allostatis: a chronic stress response of unremitting arousal that occurs in the absence of danger even when the individual is in a relaxed state. 3. Somatoform dissociation is the body's attempt to split off the trauma and its reactions 4. Therapy is directed towards mind-body integrationon the level of arousal management and emotional responses. 5. Progressive relaxation is often taught in early treatment.
  46. 46. 3. Phase 1: Safety and Stabilization 1. Phase 1 is usually the longest stage of treatment, and the most important to its success. 2. It includes pre-treatment issues such as development of motivation for treatment, informed consent, and psycho-education 3. It begins with the development of the collaborative alliance. 4. Some clients do well in this phase and have no need to complete the other two phases of treatment or choose not to do so. 5. Others never move beyond this phase and use it as a life maintenance process, often under the term of supportive therapy.
  47. 47. 3. Phase 1: Safety and Stabilization 1. Personal and interpersonal safety is an essential condition for successful treatment and takes time to develop 2. Treatment must enhance the client's ability to manage extreme arousal states 3. Treatment must enhance the clients ability to cope with bodily/affective states. To manage dissociative states. 4. Psycho-education is a core and essential element in this phase 5. Develop self awareness and enhance relational capacities 6. Trauma antecedents are described directly or indirectly, but trauma memory processing and resolution are not the focus. 7. Building the therapeutic alliance
  48. 48. 3.1.Personal and interpersonal safety is an essential condition for successful treatment and takes time to develop 1. Complex trauma survivors often are living in conditions of relational and laugh chaos, back basic forms of safety in relation to others (e.g. Domestic violence) and insults (self harm, addictions, suicide). 2. It is essential to establish conditions of safety to the fullest extent possible 3. The client cannot progress if the relative degree of safety is not attainable 4. Lack of safety means the client remains engaged in defensive and protective strategies in order to avoid being emotionally overwhelmed 5. When the client continues to be an unsafe situation, the therapist should focus on providing education and support and not move beyond the initial stage of treatment
  49. 49. 3.2.Treatment must enhance the client's ability to manage extreme arousal states 1. Treatment assists the client in identifying arousal states, labelling emotions, and carrying through decisions to prevent hyper or hypo-arousal. 2. Clients learn to self modulate their states of arousal through specific skills training interventions rather than remaining reactive or dissociated.
  50. 50. 3.3.Treatment must enhance the clients ability to cope with bodily/affective states. 1. Avoidance is a hallmark of traumatic stress disorders and resolving avoidance a benchmark for successful treatment 2. Developing ways of actively engaging with both positive and negative experiences requires a conscious approach and self regulation to shift away from automatic responses. 3. The main challenge in phase 1 is to enhance awareness of subtle and obvious forms of avoidance in times of distress and develop more effective active coping strategies
  51. 51. 3.4.Psycho-education is a core and essential element in this phase Education about trauma and impact is important and may help clients understand their reactions and develop increased self compassion. It also provides a foundation for the teaching of specific skills
  52. 52. 3.5.Develop self awareness and enhance relational capacities 1. Interpersonal trauma interferes with the acquisition of a positive identity, personal control and self efficacy. 2. Particular attention needs to be paid to identity development. 3. The process of collaborative analysis by client and therapist of the clients self-perceptions, values, emotions and personal resources help determine how early life experiences and subsequent psychological trauma shaped the individuals working model of attachment. 4. Clients are assisted in recognising and understanding the origins of the insecure and dis-organised attachment patterns while experiencing a secure relational base through interaction with the therapist and the role modelling of interpersonal skills by the therapist.
  53. 53. 3.6.Trauma antecedents are described directly or indirectly, but trauma memory processing and resolution are not the focus. 1. The major difference between phase 1 and phase 2 is is not the working through, or processing of the traumatic experience itself in phase 1. 2. In Phase 1 it is the impact of traumatic experiences is addressed by teaching the client what are post-traumatic stressors and that developmental problems are adaptive reactions to traumatic experiences in childhood. 3. The clients ongoing symptoms becomes the basis for determining whether more directed work is required. If the client continues to have PTSD, as well as other symptoms, and is willing to work more directly on trauma memories treatment proceeds to phase 2. 4. Clients may move back and forth between phases, especially in times of crisis.
  54. 54. 3.7.Building the therapeutic alliance
  55. 55. 3.7.Building the therapeutic alliance 1. Developing the therapeutic alliance is crucial because it addresses the fear associated with relationships in complex trauma clients. 2. Therapy offers a compensatory relationship within a professional framework, bound by an ethical code and therapeutic competence. 3. A core strategy is to explicitly acknowledged and reframe the threatening aspects of the relationship. 4. Due to the mistrust of others, therapists need to acknowledge and validate the client fear of being deceived and betrayed yet again, whilst simultaneously longing for a trustworthy relationship. 5. Trust is not expected but is earned over time through consistency, reliability, and honesty in the therapist words and actions.
  56. 56. 3.7.Threats to the therapeutic alliance 1. The first threat is mis-attunement: It is important to acknowledge that therapist will make mistakes, and be mis-attuned to the client at times, but will strive to rectify them in consultation and collaboration with the client. 2. The second major threat to the therapeutic alliance is the fear of abandonment. Therapist will not always be fully available present for the client for various reasons including holidays, family commitments, after hour calls which cannot be returned right away. The overall message is to be that the therapist is striving in the clients trust despite being imperfect. Therapists can at best be "good enough" not perfect in their responsiveness and availability.
  57. 57. 3.7.Threats to the therapeutic alliance 3. Third threat to the therapeutic alliance is the fear that the therapist will use their authority and expertise to intimidate coerce or control the client. Clients who have experienced exploitation by those in positions of authority expect similar behaviour from others. This is heightened if the therapist presents as a detached observer and in the "expert position". The challenge for the therapist is to maintain a stance of supportive openness, and empathic attunement with limits and boundaries.
  58. 58. 3.7.Threats to the therapeutic alliance 4. A fourth threat occurs when the client has become resigned to their sick role. The client has become comfortable in their discomfort and therapy threatens to destabilise an apparently manageable equilibrium. The client may maintain "the sick role" in order to keep the therapist attention and nurturance. Getting better runs the risk of losing the therapist! The client's legitimate neediness and dependency are issues that are acknowledged and provided for over the course of treatment. The therapist has a responsibility not to overindulge or over deny the client, walking a fine line between being available with reasonable and appropriate limits and boundaries. Understanding the client attachment needs from an empathic and validating perspective does not pathologise or blame the client.
  59. 59. 3.7.Threats to the therapeutic alliance 5. Fifth threat to the therapeutic alliance is a client staying in "survival mode". The therapist needs to see beyond the clinical presentation of the clients symptoms, and develop a truly individualised connection to assist the client in gaining self knowledge through collaborative process. The challenge in phase 1 is to be able to recognise and helped the client become aware of the adaptive and maladaptive characteristics as a result of complex trauma in order to create a solid foundation for challenge Read Courtis & Ford (2009) chapter 9: therapeutic alliance and risk management
  60. 60. Seminar Homework Write up the assessment of the case study using the principles and assessment measures to create a formulation: A comprehensive description of the various facets involved in the case that will affect the outcome.
  61. 61. Readings Core Readings 1. Courtis & Ford (2009) chapter 5. Assessment of the Sequelae of Complex Trauma: Evidence- Based Measures, John Briere and Joseph Spinazzola 2. Sanderson (2013) chapter 5 safe trauma therapy Advanced Reading 3. Courtois & Ford (2013) chapter 5 phase 1: safety, stabilisation and engagement – measured in skills, not time
  62. 62. Helpful Websites 1. National Institute of Mental Health. www.nimh.nih.gov/health/publications 2. Psychology Self-Help Resources on the Internet. www.psyww.com/resource/selfhelp.htm 3. Sidran Institute: Traumatic Stress Education and Advocacy. www.sidran.org 4. Male Survivors: Overcoming Sexual Victimization of Boys and Men. www.malesurvivor.org 5. Recovery from Sexual Abuse: Blog Carnival. www.recoveryfromsexualabuse.blogspot.com 6. Adult Survivors of Child Abuse. www.ascasupport.org