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.
References
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.
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6 Responses
Excellent article on a tricky subject. I find myself in agreement with all its major assertions.
Question: why no link to recommend this in G+? There are a number of thriving therapy-related communities there who would benefit from this (I run one of them). Why not let them in as well? Just a suggestion.
I follow a phase model approach
(fairytale) and as a result I rarely struggle with where to go and when to go there with a client. I tend to be the “jump in and see what happens” clincian because my experience tells me that most of the time going ahead with trauma work is the answer. If I am wrong and we work on a trauma too soon I use options such as saying something like “This is more than we were prepared to work on this today. Is it OK if we put it away for now?” Or, I shorten exposure time (do PC or EMDR for less time) so the client can manage the work more effectively. When using a phase model clients are more comfortable as they can predict what comes next and measure progress and that is a confidence booster in and of itself. I certainly assess a client’s resources and strengths before trauma work and, if needed, will teach resource and relaxation tools to help them get started. A key is to make sure their “fence” (current living situation, supports, etc.) are “good enough” to go forward. There is no perfect fence and most of the time trauma resolution helps strengthen it on it’s own.
Kriss, to clarify, I think you’re saying that you tend to “jump in” when you’ve already done what you can to help the client be ready. I also agree with you that trauma resolution can itself be a stabilization strategy.
Tricky subject indeed. Having been led into intensive trauma work without adequate stabilization I’m much more cautious in working with therapists these days. Being activated for years and not completely stable (i.e. undertaking adequate self care,engaged in risky behavior, lots of dissociation) or even really having a sense of what that looks like in a person, was a big problem. Let alone having the ability to believe things like boundaries would make me feel safe in the world. Problem with therapy is that until you’re stable enough to know about these issues you can’t advocate for your own self care in the treatment. Instead, you just can’t understand why you’re living life on a loop… Heaven help the patient who’s learned to look highly functioning in this case. In my case. Neurofeedback proved to be eye opening, but I’m very interested in following this up with EMDR.
I’m sorry for your struggles, and thank you for posting. This is a good illustration of the value of helping someone to stabilize. It’s also a good illustration of the importance of helping someone to get all the way through their trauma work, rather than leaving them stranded partway through, in an activated state.
6 Responses
Excellent article on a tricky subject. I find myself in agreement with all its major assertions.
Question: why no link to recommend this in G+? There are a number of thriving therapy-related communities there who would benefit from this (I run one of them). Why not let them in as well? Just a suggestion.
Tom, thanks for the suggestion, I’ll look into how to get this set up.
I follow a phase model approach
(fairytale) and as a result I rarely struggle with where to go and when to go there with a client. I tend to be the “jump in and see what happens” clincian because my experience tells me that most of the time going ahead with trauma work is the answer. If I am wrong and we work on a trauma too soon I use options such as saying something like “This is more than we were prepared to work on this today. Is it OK if we put it away for now?” Or, I shorten exposure time (do PC or EMDR for less time) so the client can manage the work more effectively. When using a phase model clients are more comfortable as they can predict what comes next and measure progress and that is a confidence booster in and of itself. I certainly assess a client’s resources and strengths before trauma work and, if needed, will teach resource and relaxation tools to help them get started. A key is to make sure their “fence” (current living situation, supports, etc.) are “good enough” to go forward. There is no perfect fence and most of the time trauma resolution helps strengthen it on it’s own.
Kriss, to clarify, I think you’re saying that you tend to “jump in” when you’ve already done what you can to help the client be ready. I also agree with you that trauma resolution can itself be a stabilization strategy.
Tricky subject indeed. Having been led into intensive trauma work without adequate stabilization I’m much more cautious in working with therapists these days. Being activated for years and not completely stable (i.e. undertaking adequate self care,engaged in risky behavior, lots of dissociation) or even really having a sense of what that looks like in a person, was a big problem. Let alone having the ability to believe things like boundaries would make me feel safe in the world. Problem with therapy is that until you’re stable enough to know about these issues you can’t advocate for your own self care in the treatment. Instead, you just can’t understand why you’re living life on a loop… Heaven help the patient who’s learned to look highly functioning in this case. In my case. Neurofeedback proved to be eye opening, but I’m very interested in following this up with EMDR.
I’m sorry for your struggles, and thank you for posting. This is a good illustration of the value of helping someone to stabilize. It’s also a good illustration of the importance of helping someone to get all the way through their trauma work, rather than leaving them stranded partway through, in an activated state.