● Work with animals can help with affect and energy regulation. Because horses are attenuated to their handlers and can “smell fear,” equine therapists will direct clients to complete frustrating or challenging tasks with the horses so that they learn to calm and regulate themselves in an effort to complete the task successfully. Alternatively, interacting with the horses may be a fearful activity for clients, during which they can practice regulating their fear response. Forgiveness Forgiveness can be a challenging concept for many clients, as holding on to anger or revenge fantasies can provide emotional fuel. The timing and pacing for addressing forgiveness are crucial, as a period of anger at and blame of others (rather than self) is often a necessary step in moving from a victim stance to a more empowered stance as a survivor. Forgiveness can be reframed as a letting go of the distress that keeps a person tied to the offender or the process of blaming and an opportunity to break free from these toxic ties. Forgiveness can be seen as “a gift you give to yourself” (Hallowell, 2004, p. 3) rather than absolving a perpetrator of a crime. Hallowell also asserts that forgiveness “detoxifies hurt and hatred,” “sets you free,” “improves your health,” and “is brave” (Hallowell, 2004, pp. 13, 25, 37, 51). Forgiveness allows a person to become neutral in the face of what were once traumatic memories—one of the goals of deconditioning trauma memory. Pumla Gobodo-Madikizela, a survivor of apartheid, writes: Forgiveness doesn’t forget, forgiveness remembers. It is about reclaiming . . . dignity . . . it transcends bitterness and hatred. Forgiveness is a transcendent moment. It doesn’t give absolution; it neither clears the slate nor condones atrocities. It is instead revenge on a higher level, it says “I will not stoop to the level that you did,” that whenever evil occurs, someone somewhere must stop the cycles of violence and evil. (Gobodo-Madikizela, 2004, p. 115) Service Delivery Trauma-specific care (or direct trauma treatment) refers to interventions and skills offered by the clinician. However, additional considerations in the provision of integrated trauma treatment include the treatment environment as a relevant factor. Trauma-Informed Care It is important to differentiate direct trauma treatment from trauma-informed care (TIC). Trauma is insidious, and it can contribute to various forms of psychological and physical suffering beyond PTSD. (Refer to Chapter 4 on the neurophysiological effects and Chapter 6 on co-occurring disorders.) Thus, TIC is an approach to provide healthcare with a healing orientation that takes into account a patient’s past and present in order to improve patient engagement, treatment adherence, and health outcomes (Center for Health Care Strategies, 2021). TIC shifts from asking “What is wrong with you?” to “What has happened to you?” (Center for Health Care Strategies, 2021). According to the Trauma-Informed Care Implementation Resource Center (Center for Health Care Strategies, 2021), an individual, organization, or system that is trauma- informed: ● Realizes the widespread impact of trauma and understands potential paths for recovery ● Recognizes the signs and symptoms of trauma in clients, families, staff, and others involved with the system ● Responds by fully integrating knowledge about trauma into policies, procedures, and practices ● Seeks to actively resist re-traumatization
connection to a source of healing larger than themselves and a way to feel that they are not alone. Case Example Jackie reported that she regularly spoke with her dead grandmother, and it seemed to her clinician that Jackie’s grandmother usually gave her sound and useful advice. Jackie also would ask herself, “What would Jesus do now?” when confronted with a dilemma in her life. In addition, Jackie had prepared a little altar in her bedroom with some herbs, holy pictures, crystals, and a picture of her daughter, where she would sit and meditate when she needed calming. Play Therapy While trauma-focused CBT has the most research support behind its use in treating trauma in children, many providers express a preference for treatment utilizing play therapy as an alternative approach that may allow a child to explore and express their experiences and emotions without having to directly discuss the trauma itself (Humble et al., 2019). Despite the popularity and prevalence of play therapy, there have unfortunately been limited studies assessing its effectiveness (Humble et al., 2019). In play therapy, children use play to communicate, construct narratives, make meaning, and express the inner workings of their conscious and unconscious structures. Although play therapy can be direct, child-centered play therapy (CCPT) is the most frequently utilized approach (Ray et al., 2015). Child-centered play therapy is based on a person-centered philosophy and believes in the child as a person “who experiences the world in a uniquely conceptualized way and is fully capable of enacting change in one’s self and in relationship to the environment” (Ray et al., 2015, p. 110). Understanding and accepting children in the context of their world creates space for growth and healing (Ray et al., 2015). Therapists employing CCPT typically provide a menu of play options for the child and then follow the child’s lead, searching for metaphor and meaning in the child’s actions. Specific interventions and responses include: r eflecting feelings (you feel angry), reflecting content (your mom was fighting with your dad), tracking behavior (you’re moving to over there), facilitating decision-making (you can decide), facilitating creativity (that can be whatever you want), encouraging (you’re trying hard on that), facilitating relationship (you want to make me feel better), and limit-setting. (Ray et al., 2015, p. 111) Equine-Facilitated Therapy Equine-facilitated therapy is a creative way to infuse therapeutic trauma work into nontraditional therapeutic formats. This type of therapy looks similar to recreational equestrian activities (e.g., riding or caring for the horse), but a practitioner conducts the activity with the goal of therapeutic intervention through metaphor, analogy, and anthropomorphization (i.e., attributing human characteristics to animals; Ferruolo, 2016; Lentini & Knox, 2015). Ferruolo (2016) offers some salient examples. ● As clients are asked to provide their assumptions and beliefs about horses, they learn that some of their initial beliefs did not match reality. The practitioner can then use this opportunity to ask if there are other times the client might engage in faulty thinking patterns and how the client might reframe or re-evaluate those beliefs. ● In more experiential activities, the horse mirrors back to the client their way of being in the world. For instance, a client who is often irritable or aggressive as a result of PTSD symptoms will experience the horse’s negative reaction to this behavior.
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