PRINCIPLES OF TREATMENT: PHASE-ORIENTED TRAUMA TREATMENT FOR INDIVIDUALS AND GROUPS
Experts in the field of trauma agree that the healing process for trauma treatment needs to proceed in phases. Phase-oriented treatment approaches are considered the gold standard of care, particularly when treating complex PTSD (Chu, 2011; Ford & Courtois, 2021; Ogden & Fisher, 2015), and recent meta-analyses continue to support the effectiveness of this approach (Corrigan et al., 2020). Each phase builds on the work of the previous one; therefore, inattention to a careful and systematic building of resources, before subsequent arenas of work are opened up, can leave the client at risk for retraumatization. A carefully modulated approach that respects the client’s timing and pacing while providing information, resources, and encouragement for moving forward in the healing process is a combination that appears to be optimal. Respecting the client’s window of affect tolerance is a paramount treatment principle that assists in avoiding excess abreaction (the expression of emotional tension) or the need to withdraw and shut down. Clients often appreciate learning the distinction between the concepts of uncomfortable and unsafe (Schiller, 2008). Feeling uncomfortable at times during the treatment process is probably inevitable; a person who never feels uncomfortable has little reason to effect change. Feeling unsafe, however, should not be a part of the therapeutic Phase-Oriented Healing Judith Herman, in her classic book Trauma and Recovery (1997, first published in 1992), breaks down the central tasks of the healing process into the three stages of: ● Establishing safety ● Remembering and mourning ● Reconnecting Bessel van der Kolk and his colleagues McFarlane and van der Hart (1996) presented more detail in their typology of healing from trauma. They added concepts of stabilization, including “education and identification of feelings through verbalization of somatic states” to Herman’s safety phase. They expanded Herman’s remembrance and mourning phase to include “deconditioning of traumatic memories and responses” and “restructuring of traumatic personal schemas.” Finally, “reestablishment of secure social connections and interpersonal efficacy” and the “accumulation of restitutive emotional experiences” were added to Herman’s reconnection phase (van Components of the safety phase include the establishment of safety, first in the environment and second from self-harming behaviors. The clinician must never assume that a client is safe until the realities of the client’s daily life and extended contacts have been carefully explored. In addition to the obvious need of determining that a client is living in a safe home, clinicians must also assess the reality of the neighborhood and local environment and ascertain whether named perpetrators have access to the client, even if the ostensibly abusive behaviors have ceased (Briere, 2019; Courtois & Ford, 2012). Case Example 1 Marissa, age 42, was sexually abused by her father during childhood and reported that she still saw him on holidays and took her children to visit him. Although the overt sexual fondling and undressing no longer continued, she disclosed that he still kissed her on the lips with his tongue in her mouth and pressed his pelvis against hers at every greeting. Some of the first work in Marissa’s treatment was to empower her to refuse this type of greeting and to ensure that her children were never alone with him, as she discussed her concern over whether they, too, were at risk. Safety from self includes the cessation of any self-harming behaviors, including substance abuse, suicidality, self-mutilation, eating disorders, and unsafe sexual encounters. Some of these der Kolk et al., 1996, p. 426). Stage 1: Establishing Safety
encounter that is encouraged or prolonged. Teaching clients to recognize, differentiate, and control the level of their arousal becomes a form of self-empowerment and self-attunement that, in and of itself, is reparative. Many clients have become so hyperaroused and oversensitized to environmental triggers that they have lost the capacity to differentiate between the feeling states of “uncomfortable” and “unsafe.” This differentiation between safety and comfort becomes the guide on which to base the phase-oriented treatment approach. Although the principle of phase-oriented treatment holds fast, the reality of the therapeutic encounter is actually more of a spiral than a straight line. Real life is never as orderly and neat as a simple, progressive, linear flow. Rather, the work continues to spiral back and forth as more and more material is uncovered and addressed (Ford & Courtois, 2013). With each new traumatic episode or additional aspect of a single episode, a basic phased progression should be followed that, first, ensures safety, then addresses the traumatic material in a resourced and titrated fashion and, finally, reconnects to a more resourced and stable state of being. behaviors can be understood as symbolic or re-enacting of the original traumatic events (Courtois & Ford, 2012). Case Example 2 Louise made the connection between her self-described “promiscuous” behaviors in her 20s and a rape she experienced as a teenager. She said, “It didn’t seem to matter anymore if someone had access to me sexually after the rape; it just mattered that I decided who it was and when I chose to give access. At some level it felt as if I was redoing the original rape— but my way this time.” The goal of establishing even basic self-care may be fraught with difficulty and contention for survivors of chronic childhood abuse because the belief systems that they may have developed do not include a sense of worthiness or self-respect. Some of these self-harming behaviors may provide relief from pain; therefore, more adaptive behaviors need to be learned before the client may be willing to surrender these behaviors. This stage of the treatment can take weeks, months, or years, depending on the degree to which the behaviors and the underlying belief systems are entrenched. Based on the client’s level of maturity, age, or ability to maintain self-care, other family members or community resources may need to be engaged to support this basic level of safety (Briere, 2019). In addition to basic stabilization and safety, other work during this first stage includes naming the problem—meaning that the client identifies and puts into words the nature of the trauma and the effects it has had on their life (Herman, 1997). Information sharing on the part of the clinician is extremely helpful at this juncture to bind the anxiety that is associated with beginning to come to terms with traumatic life events. Naming a problem in words gives an individual some initial power and mastery over it that leaving it unnamed and formless does not allow. Another task of this first stage includes helping the client to regain some control over the areas of their life that feel out of control, both externally and internally (Courtois & Ford, 2012). The basic life tasks of eating and sleeping should not be overlooked. Everything is harder for a person who is fatigued or poorly nourished. A sense of control and mastery needs to be regained over all four areas of self: The emotional self, the cognitive or mental self, the physical body, and the spiritual self. (Specifics of how to address healing in these four arenas will be covered more fully in the next chapter.) Respecting the client’s autonomy and choices is crucial; the clinician should take care not to engage in a power struggle around issues of self-care.
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