1.
Practice within the established code of ethics and practice standards First
and foremost, the mental health practitioner is advised to abide by the ethical
code and standards of practice for his/her discipline. As of yet, no formal practice
standards have been adopted for posttrauma treatment (in general or for postabuse
and delayed/recovered memory issues). Professional organizations are only currently
devising principles, recommendations, and statements as precursors to the development
of standards of practice; consequently, clinicians must exercise caution and sensitivity
when working with these issues.
2. Develop specialized
knowledge and competence The mental health practitioner who works with
abuse-related cases has responsibility for developing specialized knowledge in
issues of abuse, trauma, memory, and posttrauma treatment as well as developing
competence in this treatment. In all likelihood, these issues were not addressed
during the practitioner's formal clinical training since they have been largely
absent from the medical and mental health curricula; therefore, they must be learned
through supplemental focused training, continuing education, professional reading,
and through ongoing participation in consultation, supervision, and peer study/support
groups. An additional training issue pertains to students or novice therapists
who, due to their apprentice status, may have neither the knowledge nor skills
to work effectively with the complexities and high-risk situations inherent in
many of these cases. Trainer/supervisors must closely monitor the trainee's ability
to understand and manage the dynamics of these cases and, wherever possible, assign
cases that are commensurate with the trainee's knowledge and developmental progression
as a therapist.
3. Maintain an awareness of transference,
countertransference, secondary traumatization, and self-care issues The
therapist should strive to maintain an awareness of transference, countertransference,
secondary (or vicarious) traumatization, and burn-out issues that characterize
these cases. Self-monitoring, self-analysis, and supervision/consultation assist
in therapeutically managing rather than inappropriately reacting to or enacting
patient issues. The practitioner should, whenever possible, maintain a varied
caseload, avoiding one that is overly taxing and/or one comprising only abuse
and trauma cases. Furthermore, the practitioner would be well advised to avoid
becoming isolated in work with these patients and to engage in adequate self-care,
including a variety of social outlets. It is crucial that the therapist also monitor
the status of his/her mental health, seeking additional support and personal therapy
during times of intense stress or crisis. When a therapist has a personal history
similar to the patient's, over- or underidentification may be problematic and
additional consultation may be necessary to maintain a therapeutic role and perspective.
4. Provide information about treatment and establish a
therapeutic contract The practitioner should consider using some sort
of "Rights and Responsibility Statement" at the initial meeting to provide
the prospective patient with information about the practitioner's therapeutic
orientation and practice and the mutual rights and responsibilities of patient
and therapist. Such a document is tailored to the needs and practice preferences
of the individual clinician and discusses numerous issues, including assessment
and diagnosis; consent to treatment, goal-setting, and treatment planning; scheduling;
fees and payment; insurance issues; limits of confidentiality and reporting requirements;
therapist availability and absences; cancellation and therapy termination policies;
adjunctive evaluations and treatment; collateral assessments; the use of contracts
for specific issues; safety issues; the use of hospitalization and medication
and how determined, etc. A signed Informed Consent Statement can be used in conjunction
with this general orientation statement and more specific forms prepared when
any specialized technique (e.g., hypnosis, Eye Movement Desensitization and Reprocessing)
is introduced and given consideration. Preliminary information about how the
practitioner works with abuse and trauma and delayed/recovered memory issues can
also be included and can be supplemented with more specific materials, as needed.
For example, the American Psychiatric Association Statement on Delayed Memory,
a concise but comprehensive overview of these issues, can be attached to the "Rights
and Responsibility Statement." This introductory material provides the basis
of a mutual understanding of the practitioner's approach that is addressed in
more depth and detail during the course of treatment, as discussed below.
5.
Begin with a comprehensive assessment including questions about past abuse/trauma
and use psychological testing and ancillary assessments as warranted The
practitioner begins treatment with a comprehensive psychosocial and personality
assessment. Questions about experiencing or witnessing problematic family and
childhood events (such as family violence of any sort, intra- or extrafamilial
sexual contact, serious childhood medical conditions, significant family crises)
should be included among other questions in the initial history-taking. These
provide a baseline of information and further indicate to the potential patient
the legitimacy and importance of these events and the practitioner's openness
to discussing them. At the outset of treatment, some individuals with a positive
history of abuse and trauma will spontaneously disclose, others will make a direct
disclosure only upon direct inquiry, others will deliberately not disclose even
with direct inquiry, and others will not have such information. Nondisclosure
or a "disguised presentation" of a positive history is not uncommon
and may be part of the individual's posttraumatic (avoidance/ dissociative) response.
For this reason, assessment should be considered as ongoing throughout the course
of treatment and is reinitiated as warranted by the emergence of any new memories,
issues, and symptoms. The therapist must recognize, however, that a significant
number of individuals who seek therapy do not disclose because they have a negative
abuse/ trauma history and thus have nothing to disclose. In this circumstance,
the therapist should make no assumptions regarding the meaning of a lack of disclosure
and, in particular, should not assume that the individual is consciously or unconsciously
concealing an abuse history.
Psychological testing should be considered
as part of the assessment. Generic screening and assessment instruments (e.g.,
the MMPI, MCMI, Beck Depression Scale, SCL-90) can be used to provide general
assessment and diagnostic information (including comorbid conditions). In the
case of known or strongly suspected abuse/trauma in the patient's background,
trauma specific instruments (e.g., Dissociative Experiences Scale, Impact of Events
Scale, Structured Clinical Interview for Dissociation, Traumatic Antecedents Questionnaire,
Clinician-Administered PTSD Scale, the Structured Interview for Disorders of Extreme
Stress, The Trauma Symptom Inventory) can provide information on trauma-related
symptoms not covered systematically in the more generic instruments.
As
part of the comprehensive assessment, records should be requested for any previous
psychological (and, at times, medical) treatment so that issues of assessment,
diagnosis, and course of treatment can be reviewed. Additionally, the practitioner
should consider the utility of a second opinion, formal consultation, and ancillary
assessments (e.g., psychiatric and/or medical examinations and treatment) as needed.
This applies to a variety of issues but may be especially important in cases of
variable/spotty or delayed/recovered memory to rule out other explanations for
memory loss (e.g., organic conditions, alcoholism, or other disorders that affect
memory). It is helpful for the practitioner to develop a network of professionals
who are comfortable working with and consulting on the wide array of conditions
and complications that typically arise in these types of cases.
6.
Develop a diagnostic formulation over time and after considering a range of information
A preliminary diagnosis is made after careful consideration of the individual
and his/her presenting information, symptoms, and level of functioning. Individuals
who have been abused often have a variety of comorbid conditions and thus meet
criteria for a number of diagnoses, including possibly Posttraumatic Stress Disorder
(PTSD). Optimally, multiple diagnoses should be listed hierarchically according
to their urgency and their order in the treatment process (with the understanding
that treatment of one issue often--but not always---has a simultaneous effect
on others and/or allows for the emergence of previously unavailable material once
the original concern is successfully treated. Obviously, treatment strategies
will vary according to the patient's individual diagnostic picture and general
psychological condition.
When past abuse/trauma is in question, a diagnosis
of PTSD is generally not made because Criterion A (i.e., witnessing, experiencing
or being confronted with a traumatic event) necessary for making the diagnosis
is not definitively met; however, when the symptom picture is posttraumatic without
the patient's conscious knowledge of a specific trauma history, the diagnosis
might be held in abeyance or given provisionally. A posttrauma and postabuse treatment
model (see item 7 for a description) is adopted when PTSD is formally or provisionally
diagnosed. For patients who suspect abuse yet do not have posttraumatic symptoms,
a more generic treatment strategy is recommended.
7. Follow
the consensus model of sequenced treatment for trauma The practitioner
is advised to establish a treatment plan that conforms with the consensus model
of posttrauma treatment that is sequenced and organized initially around patient
stabilization/functioning and that addresses traumatic content as necessary. The
treatment is individualized and titrated according to the patient's status, needs,
and available resources, is systematic rather than laissez-faire, and organized
in progressive stages and tasks. The trauma is addressed according to a careful
plan rather than haphazardly after the patient has developed the skills and defenses
necessary to address both traumatic content and affect. Following pretherapy assessment,
three stages of treatment are generally outlined in this model: (1) directed towards
personal safety, stabilization, and functioning, the resolution of immediate problems
and crises, the improvement of current personal and interpersonal functioning,
the teaching of coping and selfsoothing skills, and the development of the therapeutic
alliance; (2) addressed to the traumatic content and emotions, titrated to the
individual's capacities; and (3) directed towards issues remaining after the trauma
resolution stage. As noted in item 6, when no trauma history is known or determined
from available information, a more generic model of treatment is advisable. This
three-stage model with its initial emphasis on present-day issues and functioning
resembles more generic treatment. Thus, its adoption provides for an adequate
course of treatment for a patient with questions about a trauma history, whether
or not such a history is later determined. - Courtois PhD, Christine A, "Guidelines
for the treatment of adults abused or possibly abused as children"; American
Journal of Psychotherapy; Fall 1997, Vol. 51 Issue 4, p497
Personal
Reflection Exercise #6 The preceding section contained information
about treatment guideline for treating adults who may have been abused as children.
Write three case study examples regarding how you might use the content of this
section in your practice.
Reviewed 2023
Update A phenomenological exploration of work-related post-traumatic
growth among high-functioning adults maltreated as children
Kaye-Tzadok, A., & Icekson, T. (2022). A phenomenological exploration of work-related post-traumatic growth among high-functioning adults maltreated as children. Frontiers in psychology, 13, 1048295. https://doi.org/10.3389/fpsyg.2022.1048295
Peer-Reviewed Journal Article References:
Conlin, W. E., & Boness, C. L. (2019). Ethical considerations for addressing distorted beliefs in psychotherapy. Psychotherapy, 56(4), 449–458.
Franeta, D. (2019). Taking ethics seriously: Toward comprehensive education in ethics and human rights for psychologists. European Psychologist, 24(2), 125–135.
Levy, N., Harmon-Jones, C., & Harmon-Jones, E. (2018). Dissonance and discomfort: Does a simple cognitive inconsistency evoke a negative affective state? Motivation Science, 4(2), 95–108.
QUESTION
14 What are the three stages of treatment outlined in the consensus model
of posttrauma treatment? To select and enter your answer go to Test.