Chicken and egg. Someone is unstable due to traumatization. So do you focus on stabilization interventions, which means the client continues to struggle with the trauma? Or do you take the leap, risking further destabilization, to treat the trauma and solve the problem?
For example, many substance abusers have been told by therapists, “You can’t work on your trauma until you’ve been sober/clean for a year.” And they often respond, “But how can I get sober/clean while the trauma is still bothering me?”
I believe in the phase model approach, in which stabilization and coping skills come before trauma resolution – in fact, I developed such a model. So I understand the therapist’s rationale in deferring the trauma work until the client is stable. But that doesn’t work for those clients who can’t achieve stability. So I think it’s important to be creative and courageous in finding ways to get the trauma work done, even in less than ideal conditions.
This is not as risky as it may sound. A research team in the Netherlands (ter Heide et al, 2011) treated severely traumatized refugees with EMDR and found that
• EMDR treatment did not increase the dropout rate, compared to the stabilization approach.
• Those who did drop out in the EMDR condition did not do so because of unmanageable stress.
• Those receiving EMDR had better outcomes than those receiving stabilization.
This does not mean that we should be recklessly jumping into trauma work. If a given client is at risk of becoming destabilized from the work, we would typically utilize the phase model approach to build stability and coping skills first.
On the other hand, we should not wait indefinitely for perfect stability before getting the trauma work done. Unfortunately, even many who self-identify as trauma therapists may incessantly postpone the actual trauma work, waiting until the client is “ready.”
So how is it balanced? When to stabilize, and when to go forward with trauma work?
I’m often asked by potential clients whether they should go to an inpatient program or to one of our private intensive therapy retreats. I advise them that if they are so unstable as to be in danger (of physical harm or deterioration in daily functioning), then they need the safety and support of the inpatient setting. Otherwise I encourage them to do the intensive therapy, which features extensive trauma work.
If stability is an issue but the client is capable of doing the trauma work, one solution is to build in temporary external supports while the trauma work is being done. In that case we would get the trauma work done quickly via intensive treatment, so the external supports are not needed for very long. In practical terms this may simply involve being accompanied by a supportive and responsible family member while participating in a multi-day intensive therapy retreat.
Someone recently told me that in her inpatient setting, she was advised that she would benefit most from something like EMDR – but it was only available to her for two hours per week! The rest of the time was devoted to group meetings, yoga, and the like. Since most of therapy’s deep and lasting change happens via memory reconsolidation, I think the preference has to be for the trauma work when that is feasible.
And I think it’s our job to make every effort to make it feasible. Trauma resolution is often the best stabilization strategy.
ter Heide, F. J. J.; Mooren, T. M.; Kleijn, W.; de Jongh, A.; & Kleber, R. J. (2011). EMDR versus stabilisation in traumatised asylum seekers and refugees: results of a pilot study. European Journal of Psychotraumatology, 2, 1-11.