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1. Trauma Informed Care
Seeking Safety Part 1
Dr. Dawn-Elise Snipes, PhD, LPC-MHSP, LMHC
Executive Director, AllCEUs.com
Podcast Host: Counselor Toolbox
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2. Objectives
 Review five central ideas:
 Safety as the priority of this first-stage treatment;
 Integrated treatment of PTSD and substance abuse
 A focus on ideals
 Content areas: cognitive, behavioral, interpersonal,
and case management
 Attention to therapist processes.
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3. Safety as the Priority of the First Stage
 People with PTSD often also struggle with depression,
addiction and eating disorders
 The most urgent clinical need is to establish safety.
 “Safety” is an umbrella term that signifies various
elements:
 discontinuing addictive behaviors
 reducing suicidality
 minimizing exposure high-risk situations
 letting go of dangerous relationships
 gaining control over extreme symptoms (such as
dissociation)
 stopping self-harm behaviors (such as cutting).
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4. Safety as the Priority of the First Stage
 Even though the trauma may have occurred long
ago, patients have typically been abused and are
now abusing themselves
 treating themselves in ways that repeat it
 ignoring their needs
 perpetuating pain (albeit sometimes in the guise of
trying to satisfy short-term impulses).
 This represents a meaningful connection between
their disorders
 Recovery requires that the patient establish
safety, grieve and reconnect
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5. Safety as the Priority of the First Stage
 Safety is addressed in numerous ways, including
 The safe coping sheet
 The list of safe coping skills
 The safety plan
 The safety contract
 Other methods
 Emotional safety
 Physical safety
 Interpersonal safety
 Environmental Safety
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6. Integrated Treatment
 “Integration” means attention to both disorders at the
same time in the present.
 It is not asking patients to talk in detail about the past
 Helping patients
 Learn what the disorders are and why they cooccur
 Explore their interrelationship in the present (e.g., bingeing and
purging when they felt rejected)
 Understand the course of the disorders in recovery (e.g. with
abstinence, PTSD may feel worse before it feels better)
 Increase compassion by viewing unhelpful behaviors as an attempt
to cope with the pain of trauma
 Learn safe coping skills that apply to both.
 Patients are encouraged to see that healing from each
disorder requires attention to both disorders
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7. Integrated Treatment
 Integration is ultimately an intrapsychic goal for
patients as well as a systems goal:
 to “own” both disorders, to recognize their
interrelationship, and to fall prey less often to each disorder
triggering the other.
 This treatment provides opportunities for patients to
discover
 Connections between the two disorders in their lives
 In what order they arose and why
 How each affects healing from the other
 Their relationship to other life problems
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8. Integrated Treatment
 Integration is created by fluid movement among
the four target areas of the treatment
 Cognitive
 Behavioral
 Interpersonal
 case management
 To help patients recognize the links among their
thoughts, actions, and relationships, and between
their internal experience and their functioning in
the external world.
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9. A Focus an Ideals
 This treatment explicitly seeks to restore ideals that
have been lost.
 The title of each topic is framed as a positive ideal—
one that is the opposite of some pathological
characteristic
 Honesty combats denial, lying, and the “false self.”
 Commitment is the opposite of irresponsibility and
impulsivity.
 Taking Good Care of Yourself is a solution for the bodily self-
neglect of PTSD and other behaviors.
 The language throughout the treatment emphasizes values
such as “respect,” “care,” “integration,” “protection,” and
“healing.”
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10. 4 Content Areas
 CBT is the basis for this treatment
 It is brief, time-limited, and structured, with the goal
of strong treatment gains over a short time frame.
 It is educational, with emphasis on rehearsal of new
skills.
 It is directive and collaborative, guiding patients
(much as a good parent would) while emphasizing
patients’ mature contribution to their own treatment.
 These processes provide, in the very format of the
treatment, an antidote for the powerlessness and
lack of control
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11. 4 Content Areas
 The importance of cognition is addressed through
standard cognitive therapy interventions, such as
 Identification of beliefs
 Restructuring
 Exploration of the meaning of their behaviors in the
context of their PTSD (e.G., Self-medication?
Compensation? Slow suicide? Revenge?).
 Contrasting cognitive distortions with healthier
meaning systems
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12. 4 Content Areas
 In the behavioral topics, patients are encouraged
to commit to action.
 The “behavioral bottom line” is taught: that it is
not sufficient to talk about action, but real
action, however small, is essential
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13. 4 Content Areas
 The interpersonal domain is an area of special
need because most PTSD arises from trauma
inflicted by others that may evoke in the survivor
 Distrust of others
 Confusion over what can be expected in relationships
 Concern over reenactments of abusive power
 Interpersonal topics seek to help patients
maximize the presence of supportive people and
let go of destructive people
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14. 4 Content Areas
 Patients are encouraged to
 Communicate honestly when it is safe to do so
 Recognize that they can only change themselves at this
point
 Explore parallels between their relationship with
themselves and with others (e.g., It is common to have
problems setting boundaries both internally within
oneself and externally with others)
 Notice extreme relationship dynamics that reevoke
trauma (e.g., Overcompliance, enmeshment) and
unhelpful behaviors
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15. 4 Content Areas
 Case management is begun in the first session and
addressed at every session throughout the
treatment
 It is assumed that psychological interventions can
work only if patients have an adequate treatment
base
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16. Other Core Features
 Use of educational research strategies to maximize
learning including
 Contrast-set teaching (comparing extremes such as safe vs. Unsafe
coping, supportive vs. Destructive people)
 Role preparation (e.G., Helping clients determine how to make the
most of the treatment, providing suggestions)
 Teaching for generalization (e.G., Asking patients to teach a new
skill to a partner who can cue them to use it)
 Affectively engagement: “Why do I care”
 Memory enhancement devices: Mnemonics
 A focus on potential rather than pathology. Successes
rather than failures
 Emphasis on practical solutions
 Relating the material to client’s lives
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17. Attention To Therapist Processes
 Therapist processes emphasized in this treatment
include
 Building an alliance
 Having compassion for patients’ experience
 Using the various coping skills in one’s own life
 Giving patients control whenever possible
 Modeling what it means to try hard by meeting the patient
more than halfway (e.G., “Heroically” doing anything
possible within professional bounds to help the patient get
better)
 Obtaining feedback from patients about their genuine
reactions to the treatment.
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18. Attention To Therapist Processes
 The flip side of such positive therapist processes
is negative countertransference, including
 Harsh confrontation
 Sadism
 Inability to hold patients accountable, due to
misguided sympathy
 Becoming victim to patients’ abusiveness
 Power struggles
 Allowing a patient to be scapegoated.
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19. Attention To Therapist Processes
 Attention is also directed to what might be
termed “the paradox of countertransference”
 PTSD and addictive or self-harm behaviors appear to
evoke opposite countertransference reactions, and it is
difficult for therapists to balance these.
 PTSD tends to evoke sympathy and identification with
patients’ vulnerability, which if taken too far may lead
to excessive support and overindulgence rather than
encouraging accountability and growth
 Addictive and self harming behaviors can evoke
frustration and resentment
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20. Summary
 Emotional, mental, physical, environmental and
interpersonal safety is the priority of this first-stage
treatment
 Integrated treatment of PTSD and addictive and self-
harm behaviors is essential to recovery
 A focus on ideals can help patients embrace the
recovery lifestyle
 Content areas: Cognitive, behavioral, interpersonal,
and case management
 Attention to therapist processes is essential since 80%
of therapeutic change is attributed to the
relationship, not particular skills.
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