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 The first concept suggests that professionals be aware of the prevalence of trauma and its role in affecting multiple domains of functioning (e.g., emotional, behavioral, cognitive, and physical) and contributing to co-occurring disorders. The second concept refers to the way professionals recognize and respond to trauma symptoms. Viewing trauma symptoms as adaptive responses— normal reactions to abnormal situations—can shift both the client’s and professional’s classification of the systems from pathological to resilient or from victim to survivor (Substance Abuse and Mental Health Services Administration [SAMHSA], 2014). The third concept extends the TIC approach to the entire agency system, including all types of staff (e.g., frontline and administrative), agency policies (e.g., no restraint holds for children, assessing for current trauma or histories in all intakes) and procedures (e.g., asking clients about gender preferences for examiners, separating or not separating accompanying parties, asking if the client prefers the door open or closed during evaluations), and sensitivity to environmental triggers (e.g., waiting area spaces, sensory stimulants such as lighting or scents). The fourth concept highlights the need to be familiar with potentially retraumatizing actions. Some examples include “using seclusion, restraint, or ‘time-out’ practices that isolate individuals; mislabeling client symptoms as personality or other
mental disorders, rather than as traumatic stress reactions; and challenging or discounting reports of abuse or other traumatic events” (SAMHSA, 2014, p. 2). Telehealth Many clients suffering from PTSD and trauma are unable to obtain quality services due to multiple treatment barriers. Fears of stigmatization or judgment exist related to both sharing trauma with another person and seeking therapy in general (Kuester et al., 2016; Valentine et al., 2019). For others, negative beliefs about the mental health system or institutions as a whole may push clients away from seeking services (Kuester et al., 2016; Valentine et al., 2019). According to Kuester and colleagues (2016, p. 3), “Trauma survivors often experience difficulty in interpersonal relationships,” including the ability to trust others, which may deter treatment seeking. Even when clients are eager and willing to engage in services, logistical challenges can create roadblocks. Because there is a shortage of quality psychotherapy available for PTSD, clients often face long waiting lists and less accessibility to professionals offering evidence-based treatments (Kuester et al., 2016; Miner et al., 2016). Additional barriers include lack of transportation; lack of childcare; and distance from providers, particularly when living in rural areas (Valentine et al., 2019). Telehealth and other Internet-based distance interventions offer a potential solution to existing PTSD treatment impediments. Telehealth for PTSD encompasses a broad range of complementary approaches. While tele-videoconferencing offers an experience most similar to an in-person session, there are additional ways in which technology can facilitate treatment. Internet-based interventions offer the delivery of existing approaches (e.g., CBT) through interactive modules that can be completed online (Kuester et al., 2016). Clients may complete skill-building or psychoeducational tasks that hone therapeutic skills (Kuester et al., 2016). Various models of Internet-delivered CBT (i-CBT) have been developed that involve differing levels of therapist engagement/feedback and may involve aspects such as writing activities for imaginal exposure and cognitive restructuring tasks. Similarly, mobile apps offer easily accessible complementary therapies. PTSD-Coach, developed by the NCPTSD, is an app that offers high-quality trauma psychoeducation, self-regulation tools, and symptom monitoring (Miner et al., 2016). These programs may be trauma-focused or non-trauma-focused, have been shown to have improved outcomes when compared to waitlist, and can be a useful option for individuals who may be unable to commit to standard treatment and because there is growing demand for treatment (Simon et al., 2019). For many years, research has revealed that no evidence exists showing that telehealth is less effective than in-person counseling, even in cases of suicide risk assessment in crisis situations. Studies have consistently found that telehealth interventions show a significant reduction in PTSD symptoms, noninferior outcomes, and similar dropout rates compared to in- person treatment (Bongaerts et al., 2021; Morland et al., 2020). Although prior to the COVID-19 pandemic telehealth had been used more frequently than it had been in the past, many providers and clients had remained reluctant. From 2014 to 2020, it was estimated that there was a 15% increase in telehealth services (Gustin et al., 2019). The pandemic led to a significant shift, with telehealth becoming more strongly relied upon because options for in-person sessions were limited at a time when mental health needs were increasing. The Centers for Disease Control and Prevention (CDC; 2020) safety and accessibility guidelines recommended the use of telehealth as a means of providing essential care despite COVID-19 limitations, including social distancing and mask wearing. Beyond these factors alone, the reliance on telemedicine throughout the pandemic has increased digital literacy and comfort with these platforms in many areas of life. From January 2020 to April 2020, Zoom saw an increase from 10 million to 300 million meetings daily (Iqbal, 2020).
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