Trauma Practice E-Book

Anna B Baranowsky

• Herausgeber: Hogrefe Publishing
• Kategorie: Geisteswissenschaft
• Sprache: Englisch
• Veröffentlichungsjahr: 2023

Seitenzahl: 568

Beschreibung

New edition of this effective toolbox for treating trauma survivors is even more comprehensive This popular, practical resource for clinicians caring for trauma survivors has been fully updated and expanded. It remains a key toolkit of cognitive behavioral somatic therapy (CBST) techniques for clinicians who want to enhance their skills in treating trauma. Baranowsky and Gentry help practitioners find the right tools to guide trauma survivors toward growth and healing. Reinforcing this powerful intervention is the addition of a deeper emphasis on the preparatory phase for therapists, including the therapists' own ability to self-regulate their autonomic system during client encounters. Throughout the acclaimed book, an effective tri-phasic model for trauma treatment is constructed (safety and stabilization; working through trauma; reconnection with a meaningful life) as guiding principle, enabling a phased delivery that is fitted to the survivor's relational and processing style. The authors present, clearly and in detail, an array of techniques, protocols, and interventions for treating trauma survivors (cognitive, behavioral, somatic, and emotional/relational). These include popular and effective CBST techniques, approaches inspired by research on neuroplasticity, and interventions informed by polyvagal theory. Many techniques include links to video or audio material demonstrating how to carry-out the intervention. Further sections are devoted to forward-facing trauma therapy, a safe, effective, and accelerated method of treating trauma, and to clinician self-care. Over 40 video and audio demonstrations of many of the techniques are available for download. There are also 36 handouts for clients that can be downloaded and printed for clinical use.

Leseprobe

Trauma Practice

A Cognitive Behavioral Somatic Therapy

4th edition

Anna B. Baranowsky, PhD, CPsych

J. Eric Gentry, PhD, LMHC

About the Authors

Anna B. Baranowsky, PhD, CPsych, is a registered clinical psychologist and the founder and director of Traumatology Institute (Canada). She was instrumental in developing training materials for the Traumatology Institute Training Curriculum (TITC). She is the developer of www.psychink.com, the e-learning site for TITC; the Trauma Recovery Program – self-guided online trauma informed care (http://www.whatisptsd.com/trauma-care-online); the 30-day video stabilization program (http://www.whatisptsd.com/find-calm/); and the WhatIs PTSD YouTube channel, filled with tips and tools for trauma recovery (https://youtube.com/whatisptsd). She is the clinical director of Bear Psychology in Toronto, Ontario Canada (https://annabaranowsky.com) with her talented team of clinicians and a remarkable and dedicated administrative team.

Dr. Baranowsky received her doctorate in clinical psychology from the University of Ottawa, Canada. Her accomplishments include the co-development of the Accelerated Recovery Program (ARP) for Compassion Fatigue, national and international presentations on the ARP, trauma assessment, treatment, and interventions. She has published in the area of posttraumatic stress disorder, secondary traumatization, compassion fatigue, the ARP, and therapeutic relationships (the silencing response). Dr. Baranowsky served on the Board of Directors of the Academy of Traumatology’s Commission on Certification and Accreditation. She has been recognized by the American Academy of Experts in Traumatic Stress with Diplomate status and is a board-certified expert in traumatic stress.

Dr. Baranowsky dedicates a large portion of her clinical practice on the emotional well-being of trauma survivors. She has been trained in many cutting-edge trauma treatments now being recognized as highly effective in resolving the emotional aftermath of exposure to trauma and works with a wide range of trauma survivors, from airplane crash survivors to victims of violence as well as first responders at trauma scenes. Her dedication to the emotional recovery of survivors is demonstrated by her passion for training and supervising professionals working on skills development in the field of trauma informed care. For information contact: [email protected]

The Trauma Practice for Healthy Communities is a charitable organization that she launched in 2017. Since that time TPHC has provided thousands of direct client service hours using a trauma informed care model for those in need. This has been particularly crucial during the COVID-19 Pandemic in 2020–2021 where services have been provided virtually for those isolated, while struggling with post-traumatic stress. For details visit: https://traumapractice.org

J. Eric Gentry, PhD, LMHC, is an internationally recognized leader in the study and treatment of traumatic stress and compassion fatigue. His PhD is from Florida State University where he studied with Professor Charles Figley – a pioneer of these two fields. In 1997, he co-developed the Accelerated Recovery Program (ARP) for Compassion Fatigue – the world’s only evidence-based treatment protocol for compassion fatigue. In 1998, he introduced the Certified Compassion Fatigue Specialist Training and Compassion Fatigue Prevention & Resiliency Training. These two trainings have demonstrated treatment effectiveness for the symptoms of compassion fatigue, and he published these effects in several journals. He has trained over 100,000 health professionals over the past 25 years.

Dr. Gentry was original faculty, curriculum designer, and Associate Director of the Traumatology Institute at Florida State University. In 2001, he became the co-director and moved this institute to the University of South Florida where it became the International Traumatology Institute. In 2010, he began the International Association of Trauma Professionals. He is currently the co-owner and vice president of the Arizona Trauma Institute/Trauma Institute International.

Forward-Facing® Trauma Therapy: Healing the Moral Wound, a landmark text for re-imaging trauma treatment, was published in 2016. Forward-Facing® Professional Resilience detailing the evidence-based practices for developing resilience and professional well-being was published in 2020. Forward-Facing® Freedom: Healing the Past, Transforming the Present and a Future on Purpose is the book that will introduce Forward-Facing® practices to the lay public was published in 2021. In 2005, Hogrefe and Huber published Trauma Practice: Tools for Stabilization and Recovery – a critically acclaimed text on the treatment of traumatic stress for which Dr. Gentry is a co-author. The Second Edition was released in 2010 and the Third Edition in 2015. Professional Resilience: Helping Doesn’t Have to Hurt, a compassion workbook for the Professional Resilience and Optimization Workshop was published in 2017. Transformative Care: A Trauma-Focused Approach to Caregiving was published in 2018. He is the author of numerous chapters, papers, and peer-reviewed journal articles in the areas of traumatic stress and compassion fatigue. In 2021, He co-authored Trauma Competency for the 21st Century: A Salutogenic Approach. In 2022, Dr. Gentry co-authored Forward-Facing for Educators: A Journey to Professional Resilience and Compassion Restoration and published the Second Edition of Forward-Facing Trauma Therapy: Healing the Moral Wound.

Dr. Gentry is owner of Compassion Unlimited, LLC – a private coaching, training, and consulting practice – that he began in Tampa., FL in 2004 and is now in Phoenix, AZ.

In 2020, Dr. Gentry incorporated the Forward-Facing Institute, LLC. This institute provides training, consultation, and credentialing in all things Forward-Facing.

Library of Congress of Congress Cataloging in Publication information for the print version of this book is available via the Library of Congress Marc Database under the Library of Congress Control Number 2022949918

Library and Archives Canada Cataloguing in Publication

Title: Trauma practice : a cognitive behavioral somatic therapy / Anna B. Baranowsky, PhD, CPsych,

J. Eric Gentry, PhD, LMHC.

Names: Baranowsky, Anna B., author. | Gentry, J. Eric, author.

Description: 4th edition. | Includes bibliographical references and index.

Identifiers: Canadiana (print) 20220470391 | Canadiana (ebook) 20220470456 | ISBN 9780889375925

(softcover) | ISBN 9781616765927 (PDF) | ISBN 9781613345924 (EPUB)

Subjects: LCSH: Post-traumatic stress disorder—Treatment. | LCSH: Psychic trauma—Treatment.

Classification: LCC RC552.P67 B37 2023 | DDC 616.85/2106—dc23

© 2023 by Hogrefe Publishing

www.hogrefe.com

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Cover image: © Yuliia Khvyshchuk 14jan092017 – iStock.com

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Format: EPUB

ISBN 978-0-88937-592-5 (print) • ISBN 978-1-61676-592-7 (PDF) • ISBN 978-1-61334-592-4 (EPUB)

http://doi.org/10.1027/00592-000

Citability: This EPUB includes page numbering between two vertical lines (Example: |1|) that corresponds to the page numbering of the print and PDF ebook versions of the title.

|v|Foreword

This book, Trauma Practice: A Cognitive Behavioral Somatic Therapy (CBST), represents a new generation of resources for traumatologists – those who study or treat the traumatized. A good indication of this comes in the first few chapters of background and history, because by now the assessment and treatment of the traumatized are far from novel.

Today we know that traumatic stress treatments work. We know that learning how to attend gently to our inner fear response with acceptance and compassion combined with exposure to the conditioned (fear) stimulus are critical elements to resolution of traumatic stress symptoms or active ingredients. We also know that a person’s ability to tolerate exposure to what they fear varies greatly and that it is counterproductive, if not a breach of professional standards of practice, to not offer gentle ways for individuals to reach a therapeutic threshold for such exposure.

We know today that iatrogenic effects of trauma therapy are real and that practitioners must be extraordinarily cautious when interviewing a patient, developing a treatment plan, and ensuring that there is sufficient safety as well as retraumatization containment strategies. Remission is expected and, therefore, relapse prevention training is a requirement.

We also know that the individual presentation and assessment of traumatized persons is not an exact science. Extraordinary events that would traumatize most people have little effect on some. Conversely, exposure to rather noxious stimuli can cause extraordinary traumatic stress reactions for others. Children tend to appear rather hardy springing back with less apparent negative effects. Their parents, on the other hand, have lingering symptoms. Although women present as more symptomatic, a desire to be seen as emotionally and psychologically well may be a more significant motivator in male than female patients. However, war-related PTSD is actually less frequently seen in women than men. This may be a factor related to women harnessing social support within a community setting during times of strain.

Clients with PTSD can pose unique clinical challenges to the practitioner. Most PTSD patients, for example, are dual diagnosed. It is rare to find clients with PTSD who do not have at least one additional diagnosis (i.e., panic disorder, somatic symptom disorder, depression, borderline personality disorder, addiction, etc). It is also important to recognize that a common comorbidity exists with addictions (drug dependency) and PTSD.

This important book both addresses what we know today at a theoretical level and, equally importantly, explains clinical methods in the context of treatment. More than the typical book about why and how the cognitive behavioral treatment approaches work, Baranowsky and Gentry offer a comprehensive guide for clinicians working with the traumatized. This book presents clear instructions to traumatologists – even the most experienced in working with the traumatized – to help the traumatized. The guidance is detailed. The authors direct practitioners to focus on symptoms of the body as well as on behavior and emotions associated with trauma. They also link their guidance to a tri-phasic treatment model that starts with establishing Safety, continues with Working through Trauma, and ends with Reconnection. This book is also an excellent resource for trainers, teachers, and educators of trauma practitioners, providing a how-to manual to address the challenges of clinical traumatology.

These authors represent the current and future generation of clinical traumatologists who are well-equipped to handle the extraordinary challenges of traumatized clients. We have come a long way in nearly thirty years, as illustrated by this useful book.

Charles R. Figley, PhD

Florida State University Traumatology Institute Tallahassee, November 2022

|vi|Acknowledgments

Anna B. Baranowsky – To my beloved parents who taught me love and life exist even after terrible losses. To my dear husband Chris, my compassionate warrior and companion in all life’s joys. For Cassie, Jasper and Sukhi, who have enriched my every waking day. To Gold and the Golds, who are special in my heart; to Zahava, who showed me that love, strength, and intelligence live harmoniously together; to my dear Maj buddies; my incredibly talented team (Tamara, Betty Ann, Usha, Sandy, the BPPC, Ya’ara, and Jaime of the Trauma Practice Team). I am deeply fortunate to have found myself surrounded by incredible people. Without them I would be unable to dedicate my life to this work. In appreciation of Dr. Michael McCarrey, my ally and supervisor (University of Ottawa). To Marlene Mawhinney and B. K. S Iyengar, my yoga teachers of over 30 years, whose work has brought me the harmony and resiliency, which has enabled me to follow the call to trauma work.

I am grateful to Dr. Charles Figley for laying fertile ground at just the perfect time. To my friend and inspiration, Eric, who willingly joins me in challenging dialog and laughter. Mostly, to my clients, students, trainers, and friends over the years who have taught me more than they could imagine and helped me stay humble and continue to learn and grow... I am grateful.

J. Eric Gentry – Thanks go to the mentors in my life in order of their appearance: Charles “Charlie” Yeargan, PhD; Louis Tinnin, MD; Charles Figley, PhD; and Joseph Moore. Gratitude to N. A. and H. P. for keeping me alive long enough to write this work. Thanks to my support, in no particular order: Marjie, Jeffrey “Jim” Dietz, MD, Mike Dubi Mom, Bubbita, Augie, Rick O., Helen MaryJoan, PDR, Mason, Rosalina, TZap, Jennifer, Connor, Frank, Jim “Big Bro” Norman, Carlos & family, Eduardo & Maria, Jim Hussey, Joe Williams, Nacho & Lucy, ITI Site Directors, Sheryl Hakala, MD, Mason Hines & family, and my family. A special mention of gratitude for the creative and supportive relationship that I share with Anna – you are the BEST! I dedicate this text to all my clients and trainees – past, present, and future.

|vii|Dedication

This text is dedicated to unsung heroes, the caregivers who maintain the courage and the stamina to bear witness to the stories and selves of trauma survivors, making healing a reality.

See first that you yourself deserve to be a giver, and an instrument of giving. For in truth it is life that gives unto life – while you, who deem yourself a giver, are but a witness.

Khalil Gibran

Contents

Foreword

Acknowledgments

Dedication

Introduction to Trauma Practice: A Cognitive Behavioral Somatic Therapy

The surprising act of arriving at 2023

Purpose of This Book

Self-of-the-Therapist

Core Objectives

Book Description

Phase 0: Foundations of the Trauma Practice Model

Phase 0: Foundations of the Traum Practice Model

Preparation for the Therapist

Exposure in a Relaxed State – Reciprocal Inhibition

Meaningful Human Care and Connection

The Evolution of PTSD Treatment and the “Active Ingredients”

The Four Active Ingredients

1.  Therapeutic Relationship and Positive Expectancy

2.  Relaxation and Self-Regulation

3.  Exposure/Narrative and Reciprocal Inhibition

4.  Cognitive Restructuring and Psychoeducation

The Main Therapeutic Approaches, Research, and Guidelines

1.  Behavioral Therapy

2.  Cognitive Therapy

3.  Cognitive-Behavioral Therapy

4.  Cognitive-Behavioral Therapy Research

5.  Psychophysiology of Trauma

The Mind-Body Connection

The Amygdala

The Hippocampus

The Sensory Thalamus

The Sympathetic Nervous System

Cortisol: The Stress Hormone

Traumagenesis: The Creation of Trauma

The Biology of Traumagenesis

Symptoms of Traumagenesis: Where Do Problematic Behaviors Come From?

Traumagenesis and Relationships

Tri-Phasic Model

Phase I: Safety and Stabilization

Phase II: Working Through Trauma

Phase III: Reconnection

Necessary Ingredients: Treatment Codes (R, RE, CR)

Somatic, Cognition, Behavior, and Emotion/Relation

Posttrauma Response

Treatment Resistance or Failure: Addressed with Integrative Approaches

Phase I: Safety and Stabilization

1.  What Is Safety?

Minimum Criterion Required for Transition to Phase II Treatment

30-Day Video Stabilization Program for Adjunctive Online Trauma Therapy

2.  Somatic

Creating a Nonanxious Presence (R – RE – CR)

Titration Part I: Trigger List Using Braking and Acceleration (R – RE – CR)

Progressive Relaxation (R)

Autogenics (R – CR)

Diaphragmatic Breathing (R)

3-6 Breathing (R)

5-4-3-2-1 Sensory Grounding and Containment (R)

Postural Grounding (R)

Anchoring Part I: Collapsing Anchors (R)

Breathe 911 (R – CR)

Body Scan (R)

3.  Cognition

Anchoring Part II: Safety (R)

Safe-Place Visualization (R)

Positive Self-Talk and Thought Replacement/Transformation (CR)

Flashback Journal (R – RE)

Buddha’s Trick (R – CR)

4.  Behavior

Rituals (R – CR)

Contract for Safety and Self-Care (R – CR)

Safety Net Plan (R – CR)

5.  Emotion/Relation

Transitional Objects (R)

Support Systems (R – CR)

Drawing Icon and Envelope (Emotional Containment) (R – RE – CR)

Internal Vault (Emotional Containment) (R – RE – CR)

Positive Hope Box (R – RE – CR)

Make Peace with Your Sleep (R – CR)

Relaxed Breathing Guided Meditation (R)

Phase II: Working Through Trauma

1.  Somatic

Titration Part II: Braking and Acceleration (RE)

Layering (RE – CR)

Comfort in One Part (RE)

Timed Reflection (R – RE – CR)

Timeline Approach (RE – CR)

Biofeedback (R – RE – CR)

Hands Over Heart Space (R – CR)

Paced Breathing (R – RE – CR)

2.  Cognition

Downward Arrow Technique (RE – CR)

Cognitive Continuum (CR)

Calculating True Danger (CR)

Looped Tape Scripting (RE – CR)

Cognitive Processing Therapy (RE – CR)

Story-Book Approach (RE – CR)

Written Narrative Approach (RE – CR)

Corrective Messages from Old Storylines (CR)

Traumagram Exercise (RE – CR)

3.  Behavior

Behavior Change Rehearsal Exercise (RE – CR)

Skills Building Methods (CR)

Imaginal and In Vivo Exposure (RE)

Stress Inoculation Training (RE – CR)

Systematic Desensitization (RE)

IATP Narrative Exposure Therapy (CR)

4.  Emotion/Relation

Learning to Be Sad (CR)

Assertiveness Training (CR)

Thematic Map and Release (CR – RE – R)

Grounding Lightstream (RE)

Phase III: Reconnection

1.  Somatic

Centering (CR)

Tame and Decode Bad Dreams (RE – CR)

Going Slow to Heal After Trauma (RE)

Shake to Release (RE)

2.  Cognition

Exploring Your Cognitive Map (CR)

Victim Mythology (CR)

Self-Compassion Reflection (RE – CR)

Letter to Self (CR)

Wellness Mind Map (RE – CR)

Your Heart’s Desire (CR)

3.  Behavior

Self-Help and Self-Development (CR)

Picture Positive (RE – C – CR)

4.  Emotion/Relation

Memorials (CR)

Connections with Others (RE – CR)

Codependency Revolution (CE – CR)

Integrative and Clinician Self-Care Models

Forward-Facing® Trauma Therapy

Introduction

Phase I: Education

Phase II: Intentionality

Phase III: Practice (Coaching and Desensitization)

Conclusion

References

Appendices

Appendix 1 Self-Regulation

Transformation: Shift From Sympathetic to Parasympathetic Nervous System

What Happens When My Sympathetic Nervous System Is Dominant?

Where Are the Pelvic Muscles? How Do I Find Them?

What Now That My Pelvic Muscles Are Relaxed?

Appendix 2 Training Opportunities

Notes on Supplementary Materials

|1|Introduction to Trauma Practice: A Cognitive Behavioral Somatic Therapy

If you are perfect you don’t need to learn anything and if you don’t need to learn anything, you wouldn’t need to be a teacher.

Stuart Wilde, The Secrets of Life (1990)

The surprising act of arriving at 2023

After living through the unprecidented events of the COVID-19 pandemic, revelations of an encouraged white supremist mob, and the real cruelty to brown and black lives, my sense about the importance of human kindness, courage, and trauma-informed care has been reinforced. I could never imagine all of the complex layers of the last three years unfolding, but what I am aware of is the ongoing need for the use of the right tools, the ones that guide those in need toward their own growth and healing. After all, when you and I heal we are less likely to react from a place of fear and rigidity and more from a place of wisdom and kindness. At least that is what I have witnessed over the past 20 years of helping trauma survivors.

Since the last edition of Trauma Practice there has been awareness of post-trauma care. The public has become more educated on the need for specialized trauma-informed care and that clinicians need precise training in order to attend to trauma impact. It has been more than seven years since the authors collaborated together on Trauma Practice, yet independently we seem to have arrived at a similar place in terms of the meaning of our work, the new refinements in our field, and our sense of how to move the trauma practice approach forward. Although there are some differences in the use of language, the overall approach appreciates the need to face the ever-present moment and use it as the gift for growth while down-regulating the body to stay present and extinguish the past.

This is no regular revised edition but rather our 20-year anniversary edition! We are excited, grateful and humbled to announce our 21st year of offering Trauma Practice to you, our readers. We published the first edition of Trauma Practice: Tools for Stabilization and Recovery in 2001. Over twenty years later, this is our fourth publication of this book. We have heard from hundreds of you, kind folks, providing feedback about how much this book has assisted you in helping trauma survivors to recover from their painful history and begin to live lives of choice instead of continuing to live in fear and self-defense. It has been joyful for us to contribute to your growth as clinicians and to our field’s growth in treating trauma survivors using gentler, more effective and accelerated methods of healing. We have matured along with you and we are excited to share our combined 60 years of experience with you in this, our 4th edition.

Since the publication of the previous edition of Trauma Practice, much has changed in the field of trauma treatment. The organic emergence of complex posttraumatic stress disorder (C-PTSD) as something distinctly different from PTSD, and the demand for more sophisticated clinicians and treatment strategies for these clients has been a powerful catalyst for the evolution of our field. The discovery that traditional evidence-based treatments, driven by narrative exposure and cognitive processing, were not sufficiently effective for clients with C-PTSD (and in some cases exacerbated symptoms) has led to an awakening among clinicians working with this population. Teaching somatic (in previous texts simply referred to as body) self-regulatory skills – which we have advocated in each previous edition of this book – has become a primary focus of early treatment when working with C–PTSD. As |2|our clients develop competency with these skills of self-regulation and threat response interruption, we can then coach them to take these skills into their personal and professional lives to confront the plethora of perceived and real threats they encounter each day.

We have re-discovered the use of in vivo and imaginal exposure (Wolpe knew this in the 1950s) as a powerful mechanism for activating reciprocal inhibition that desensitizes and, ultimately, extinguishes intrusion and arousal caused by the trauma exposure (Criterion A in the DSM-5), including childhood attachment trauma. For us, the power and utility of in vivo and imaginal exposure paired with intentional self-regulation has become an essential triage for the treatment of all traumatic stress. We have discovered that teaching self-regulation skills early in treatment and then coaching our survivor clients to begin the process of confronting situations of perceived threat (instead of engaging the instinctual self-defense of avoidance in these contexts) provide a rapid relief of symptoms while simultaneously significantly augmenting well-being, a sense of accomplishment, and improved quality of life.

Thankfully, there has been an increased emphasis on addressing the somatic effects of trauma. For many, this somatic posttrauma impact metastasizes into instinctual procedural or “muscle” memory patterns of self-defense employed in situations where there is little or no danger (only perceived threat). In order to properly update this version of Trauma Practice we have begun to reference our approach as Trauma Practice: A Cognitive Behavioral Somatic Therapy (or CBST). In previous editions, where we have labeled the somatic response and related interventions as “body” interventions, in this edition we are now identifying them as “somatic-based” interventions. So, for this edition, interventions will include: cognitive, behavioral, somatic, and emotion-relational categories.

In addition to the emergence of C-PTSD as a catalyst for trauma treatment maturation over the past several years, there are many other phenomenon that have emerged that have also spurred us forward. The research by the Centers for Disease Control and Prevention (CDC) and Kaiser Permanente captured the original Adverse Childhood Experiences (ACE) data from 1995 to 1997. The reverberations and understandings of the ACE studies are now taking a more central role on reflections of lifetime trauma impact and posttrauma treatment. We have now witnessed that most of our clients have ACE scores above 5. This has led us to consider how much trauma contributes to the etiology of adult PTSD and other mental diseases and disorders. There are many clinicians that are discovering much of the distress experienced by our clients can be traced to an over-activation of their sympathetic nervous systems (SNS). We are also discovering that treating this over-active threat response with self-regulation is diminishing distress and enhancing quality of life with clients who have a trauma history but had actually been diagnosed with mood disorders or another psychiatric condition.

In 2017, we (along with Robert Rhoton, PsyD), published the article “Trauma Competency: An Active Ingredients Approach to Treating Posttraumatic Stress Disorder” in the Journal of Counseling and Development. In this article, we explored the integration of the “active ingredients/common factors” among all effective trauma treatment into a phased delivery that is fitted to the survivor’s relational and processing style. This has been a focus of many researchers in the field of trauma treatment – looking for generic treatments that do not require adherence to treatment manuals and that are, instead, tailored to fit the individual needs of each client struggling with posttraumatic stress. In our article, we review several of the meta-analyses that have been conducted with evidence-based treatments for PTSD and have found four primary ingredients/factors embedded in each of these effective treatments. These are: (1) a good therapeutic relationship (using Miller’s feedback informed treatment; Black et al., 2017; Duncan et al., 2010; Miller et al., 2015, 2020), (2) relaxation/self-regulation, (3) exposure (in vivo and imaginal), and (4) cognitive restructuring/psychoeducation. The intentional engagement and integration of these factors into a phased delivery with our clients, represents the nascent offering of a generic equivalent to evidence-based, manual-driven treatment. For sure, more research will be required before we can pronounce this delivery of the active ingredients/common factors as an evidence-based treatment, but we have found much success in our own application of these skills and principles with our clients.

The 2021 publication of Trauma Competency for the 21st Century: A Salutogenic Active Ingredients Approach to Treatment (Rhoton & Gentry, 2021) provides a deeper contemporary dive into these issues. In the first half of the book, the history and utilization of each of the four active ingredients/common factors is explored within current treatment models. In the second half, the salutogenic trauma treatment structure is presented as a semi-structured phased delivery for these factors. The four stages for delivery of treatment in the salutogenic trauma treatment structure are: (1) preparation and relationship-building, (2) psychoeducation and self-regulation (skills-building), (3) integration and desensitization, and (4) posttraumatic growth and resilience. Trauma Compentency, also |3|addresses clinician preparation as the first and primary intervention for trauma treatment.

Inspired by the work on Trauma Competency, this edition of Trauma Practice, has been updated and augmented to include the discussion of the active ingredients/common factors from these recent developments.

In 1997, during our early collaborative efforts, we began to develop products and protocols for compassion fatigue treatment and professional resilience (i.e., accelerated recovery program for compassion fatigue) and are consensual with the a priori importance of clinician preparation as the bedrock of effective trauma treatment. Add to this the recent development of a body of research around “deliberate practice” as a primary means for augmenting treatment outcomes (Chow et al., 2015; Rousmaniere, 2016). Our instincts were later affirmed by the current researchers, (i.e., Miller et al., 2013, 2016, 2020) who, for the past decade, have identified the potency of individual therapist’s preparation and on-going development as an important predictor of positive change in clients.

Individual therapist effects account for between 5–9 times more of the outcome variable than the difference between theory and techniques (Baldwin & Imel, 2013; Firth et al., 2019; Wampold & Imel, 2015). Embracing this contemporary research, we have addressed this important factor by adding a Phase 0 (or pre-phase) to the tri-phasic presentation of interventions in this book. In Phase 0, we focus upon the importance of trauma-specific training – beyond that of only developing expertise in any particular evidence-based model for treatment. We advocate that trauma clinicians develop expertise in also delivering the four active ingredients inside the models which they use. We also argue that a crucial clinician capacity is the ability to self-regulate the sympathetic nervous system so that they are able to remain ventral vagal dominant throughout their encounter with clients. This capacity is both catalytic for positive change with our clients (i.e., produces co-regulation and secure attachment) while, simultaneously, affording us de facto professional resilience – you cannot get (secondarily) traumatized while remaining in a relaxed-muscle body. In addition to these benefits, self-regulation also maximizes our cognitive and motor functioning, helping to optimize our performance with each client. In Phase 0 we also discuss the importance of on-going personal and professional development, consultation, connection/support, and self-care/revitalization.

We are also excited to add to this edition an exploration of the important work of Lawrence Calhoun and Richard Tedeschi (1996) who have been quietly working away for the past 25 years on one of the most important discoveries in the field of trauma treatment – posttraumatic growth. In their 2013 book Posttraumatic Growth in Clinical Practice, the researchers invite the move away from treating the “disease” of PTSD or even the symptoms and, instead, advocate a coaching process of helping trauma survivors suffering from either acute stress or posttraumatic stress to acquire resilience and growth-catalyzing skills, practices, and perceptions. This evidence-based protocol has helped thousands of survivors to lessen the effects of trauma in their lives and begin to find effective living here in the present. Posttraumatic growth and Forward-Facing® trauma therapy (introduced in the previous edition of this book) are both salutogenic approaches to the treatment of trauma.

The allopathic – or medical model – of treatment focuses upon the diagnosis of disease and then using prescribed treatments that have demonstrated effectiveness for a particular diagnosis. In contrast, Salutogenic approaches eschew (at least initially) the medical model treatment focus on disease and instead attempt to immediately catalyze and address the impediments to health. With trauma survivors the primary impediment to health seems to be their chronically activated threat response – it is difficult to heal and repair while we are busy surviving our lives. By helping trauma survivors to develop skills and practices that interrupt and then minimize the activation of their threat responses throughout the day, we have found their symptoms begin to ameliorate and their sense of comfort and well-being flourish in a relatively short amount of time. In this volume, we suggest that these salutogenic approaches may prove themselves to become increasingly useful in the treatment of trauma, especially in early treatment, as mentioned before, and as part of a generic triage process for everyone.

For many, it will be sufficient to aid individuals to acquire self-regulation skills along with the capacity to face in vivo and imaginal exposure to life stressors. This alone, can be the main step toward a personal and deep shift in self-care and the beginning a life-long process of independent healing. There will be, of course, trauma survivors whose symptoms remain recalcitrant to this self-engaged solution and will need more traditional phased trauma treatment with ongoing imaginal exposure approaches. However, even these clients with high acuity symptoms will benefit moving into this more intensive therapy with the capacity to self-regulate their own autonomic nervous systems (ANS).

This edition also brings to the forefront probably the most important emergence in the treatment of trauma over the past decade and that is the polyvagal theory. Although Stephen Porges has been busy developing this |4|work since the late 1980s, it has become increasingly central to working with traumatic stress over the past several years. The polyvagal theory provides a framework to understand the neurophysiology of traumatic stress both for the clinician and the survivor. While the research and depth of understanding is quite complex, it can be tooled into a simple understanding. Specifically, how traumatic stress and the subsequent self-defense behaviors manifest in those suffering with posttraumatic stress. This edition incorporates the use of the polyvagal theory to understand the dual-polar and biphasic nature of traumatic stress, contrasting arousal vs. shut-down. It also provides a platform for understanding the neurobiology of relationships, or as Porges states: “All relationships are a neural exercise” (Porges, 2018, April 23) Teaching clinicians both self-regulation and then co-regulation immediately augments their effectiveness and resilience.

Finally, for this edition we have updated and overhauled our references and citations to provide you with the latest and relevant clinical research for use in your practice. We are extremely grateful to our dedicated readers whose continued interest in our work have allowed us to continue to bring these materials to each of you. As such we are able to continue to carry out our mission of the past 20 years: to help those who help trauma survivors. It is a privilege for us to provide this text. In great appreciation, thank you for joining us in this work.

Anna B. Baranowsky, PhD, CPsych.

J. Eric Gentry, PhD, LMHC, DAAETS, FAAETS

Purpose of This Book

This book has been written for the trained clinician and the novice-in-training as a means of enhancing skilled application of cognitive behavioral somatic trauma therapy (CBST). The term trauma practice was conceptualized after many years of reflection on the trauma work and training experiences that the authors have encountered. It became clear to us that a practical approach was needed for practitioners who apply themselves in the field of trauma treatment. Recent books and current research on CBT or CBST for trauma stabilization and recovery are focused more on outcome than application and we have made it our mission to produce a practical “how-to” text. In addition, this text draws upon the development and implementation of many trauma training programs that have been ongoing since the fall of 1997 through the Traumatology Institute. We have been training students in trauma recovery within this CBST trauma therapy framework and have found both a great need for and a warm response to this very practical approach.

This book will provide both the novice and advanced trauma therapist with much of the knowledge and skills necessary to begin utilizing CBST in their treatment of trauma survivors. In addition to presenting a foundational understanding of the theoretical tenets of CBST, this book will also provide step-by-step explanations of many popular and effective techniques of CBST. Some of these techniques include: trigger list development, breath training, layering, systematic desensitization, exposure therapy, storytelling-approaches, assertiveness training, thematic map, and relaxation training. The book is packed with practical approaches that we have used with our clients for many years. In this updated edition, we have replaced some less useful approaches with interventions that have proven more effective with clients and students of the Traumatology Institute. We also include approaches inspired by current research on neuroplasticity (i.e., picture positive, corrective messages from old storylines, and hands over heart space).

The materials in this book are organized and presented from the perspective of the tri-phasic model (Herman, 1992) for the treatment of trauma. In 2000, the International Society for Traumatic Stress Studies (ISTSS) adopted Herman’s tri-phasic Model as the standard of care for clinicians working with clients diagnosed with posttraumatic stress disorder (ISTSS, 2000). The expert clinician survey findings of Cloitre et al. (2011, 2012) strongly endorsed a phase-oriented approach for complex PTSD that remains patient centered with attention to prominent symptoms. This is consistent with the trauma practice approach outlined in this book.

These three phases of treatment: Phase I: Safety and Stabilization, Phase II: Working Through Trauma, and Phase III Reconnection are thoroughly explored in this edition. The three phases are the organizing structure and foundation for the trauma practice approach. Specific treatment goals and techniques are offered for each of these three phases of trauma care, making this text a “hands-on” reference and guidebook for clinicians as they navigate through the potentially difficult treatment trajectory with clients who have survived trauma.

With our contemporary look at trauma-informed care, we have already discussed the need to add a Phase 0 as a fundamental element in training trauma focused clinicians. The required prescription for training would include competence, excellence, and mastery. There is a recognition of the crucial element of capacity to self-regulate and then to co-regulate with clients and this demands that the |5|clinicians have inner resources for down-regulating in times of personal strain. It asks that you dedicate yourself as diligently to caring for yourself as you would for your clients.

This edition of Trauma Practice also includes the section introducing Forward-Facing® trauma therapy. This form of therapy is an exciting treatment process for rapidly and effectively addressing traumatic stress and all anxiety disorders that do not require accessing and processing survivor’s painful trauma memories. Instead, this method teaches and coaches clients to master the regulation of their own autonomic nervous systems (ANS) as the primary focus of treatment. As clients learn and practice these skills, they find their symptoms diminishing and their quality of life maximizing. In addition to mastering self-regulation capacities, the method also assists clients in developing intentional living. The survivor defines for themselves their integrity and then the therapist, through coaching them to confront the perceived threats in their daily lives with regulated bodies, helps them to live principle-based lives with an internal locus of control. This method allows the client to experience immediate and profound treatment effects that quickly lead to an enhanced quality of life. Forward-Facing® trauma therapy also focuses upon helping the client to become more and more purposeful and intentional as they practice self-regulation. The combination of these two factors rapidly accelerates trauma treatment for many survivors.

The authors wish to make a clear statement that this book is only a guidebook and does not act as a substitute for the training and supervised practice necessary to integrate these principles and techniques into practice. The authors have presented the materials found in this book in an e-learning program available or as a two-day intensive training program through the Traumatology Institute (Canada; http://www.psychink.com) and Forward-Facing Institute, LLC (USA; www.forward-facing.com). Please see Appendix 2 for more information on these training courses. Additional trauma training is now available online at psychink.com for those individuals who do not have direct access to face-to-face training programs or the opportunity to bring institute trainers to their locations. We believe that proper training and supervision is required to safely and successfully integrate these powerful techniques into practice with trauma survivors. We offer these principles and techniques based upon the belief that the primary responsibility of the clinician is to “above all else, do no harm.” While persons suffering with posttraumatic stress have demonstrated their strength and resiliency by having survived some of the most painful and heinous experiences known to mankind, it is possible for the well-intended but untrained therapist to engage in treatment with survivors that can actually retraumatize their clients, thus resulting in failed treatment and rendering future treatment even more difficult and painful for the survivor.

For those interested in adjunctive therapy with clients using a tri-phasic approach, visit: http://www.whatisptsd.com. Details of the Trauma Treatment Online Program and the use of adjunctive trauma care programs, systems, and online applications are available for your use with clients.

A further complication within trauma care are personality changes that establish themselves rigidly over time, which form interpersonal skills from a reactive position in the attempt to keep one out of harm’s way (Cloitre et al., 2011, 2012). Trauma survivors may have developed concurrent personality disorders and resulting behaviors that may have been useful at the time of the trauma but no longer serve the individual well. Although as clinicians we may aid our clients to resolve the traumatic memories, harness improved self-care skills, and establish systems for reconnecting with meaningful community and activities, our clients may then have to tackle the personality structures or themes that no longer work for them once trauma is extinguished.

Self-of-the-Therapist

In Friedman’s (1996) landmark article entitled “PTSD Diagnosis and Treatment for Mental Health Clinicians,” he argues strongly that the development and maintenance of the “self-of-the-therapist” may be one of the most important aspects of treatment with traumatized individuals. We have found, in our own practices and in our training programs, that the ability to develop and maintain a nonanxious presence while working with trauma survivors is a key ingredient to successful treatment outcomes and in maximizing the resiliency of the therapist.

The article of Baldwin (2013) certainly does an excellent job of explaining the underpinnings of nervous system ignition and the brain among trauma survivors and this reinforces our belief that the clinician must be well suited or suitably prepared for exposure to those experiencing PTSD. This will prove helpful not only for the clinician but also for those working with the therapist. Trauma ignition can work both ways and if the clinician is unprepared to bear witness to the trauma content without extreme reactivity neither the client nor the therapist will benefit.

|6|Confronting traumatic material is painful and can be debilitating for the therapist. Many of the techniques presented in this text involve, in one way or another, the confrontation and narration of traumatic experiences by the trauma survivor with support and guidance from the therapist. It is theorized that the ability of the trauma survivor to access, confront, and self-regulate while narrating traumatic experiences may be one of the active ingredients leading to the resolution of traumatic stress. Developing trauma competency is of critical importance in the emerging maturity of any trauma therapist (Gentry, Baranowsky, & Rhoton, 2017). The ability of the therapist to elicit, assist, and self-regulate while the survivor struggles through these narrations is, in our opinion, an a priori requirement for effective treatment. Indeed, we have all worked with posttraumatic clients who have “failed” in previous therapy attempts because they were unable to complete these narratives with their therapists. We believe that a courageous, optimistic, and nonanxious approach, tempered with safety and pacing, to be the key to rapid amelioration of traumatic stress symptoms.

In our training programs, we work diligently toward helping therapists develop the capacity for self-regulation and the maintenance of a nonanxious presence. Research demonstrates that high levels of anxiety can diminish cognitive and motor functioning (Baldwin, 2013; Scaer, 2001, 2014) and this diminished capacity may account for some of the symptoms associated with traumatic stress. It may also point toward some of the difficulties encountered by therapists who work with clients who suffer from traumatic stress. Compassion fatigue resiliency is the focus of the article that you can review at https://psychink.com/blog/2019/06/25/compassion-fatigue-resiliency-a-new-attitude/. Clinician stress when working with trauma survivors is a reality that we all need to reflect on and work through. We hope that you will make a commitment to your own well-being as a trauma care provider.

Core Objectives

Upon completion of this book readers will be:

Aware of the underlying principles of cognitive behavioral and somatic trauma therapy (CBST) that are reported to lead to the resolution of posttraumatic stress symptoms

Aware of the psychophysiology of posttraumatic stress

Aware of how to apply CBST in accordance with the specific criteria in each of the phases in the tri-phasic model of treatment with trauma survivors

Able to apply effective trauma stabilization and resolution interventions that best fit the unique requirements of any survivor

Able to utilize many different CBST techniques to help trauma survivors resolve the effects of their trauma memories and posttraumatic stress symptoms

Able to utilize CBST techniques to assist trauma survivors in developing more satisfying lifestyles in the present

Book Description

CBT is one of the most researched and most effective treatments for PTSD and we believe that all skilled traumatologists should have at least rudimentary understanding and skills in this important area of treatment. This book will focus upon the utilization of the principle of reciprocal inhibition (exposure + relaxation) as a core knowledge and skill that readers will acquire following a thorough reading and integration of the materials covered in this book. Nearly all of CBST is organized around this principle and we believe it can be found in most effective treatments of posttraumatic stress.

This book will begin with a brief outline of the history and the theoretical underpinnings of CBT. A brief discussion of possible physiological pathways to account for the identified behavioral phenomena will be included. This will be followed by an introduction to Herman’s (1992) tri-phasic model for the treatment of posttraumatic stress conditions. The tri-phasic approach is recognized as the highly effective approach we have used in the trauma practice approach since we first developed it in 1999 (Cloitre et al., 2011, 2012). This is followed by a thorough exploration of Phase I: Safety and Stabilization in the treatment, with an opportunity to practice and learn several skills for use at this stage.

After the reader has learned the skills necessary for the essential development of safety and stabilization with their clients, the book will focus on techniques useful for the successful resolution of traumatic memories in Phase II: Working Through Trauma. Readers will learn several specific CBST techniques for assisting their clients with accessing, confronting, and resolving their traumatic memories. These techniques will be presented in a step-by-step process with the goal of skills development. We hope this text will provide readers with a comfort level that will allow them to begin using these interventions in their service to trauma survivors.

|7|In Phase III: Reconnection, we will focus on developing skills to assist trauma survivors in further re-integration of skills developed and the resolution of the residual sequelae from their trauma history. Often, even after a survivor has successfully resolved a trauma memory, symptoms such as survivor guilt, distorted and self-critical thinking styles, relational dysfunction, addiction, or painful affect remain unresolved. This last phase of treatment is focused on helping the trauma survivor reconnect with themselves, their families, and loved ones in the present and to connect to their goals for the future. Several approaches will be presented to the reader for their use in helping their clients navigate successfully through this important phase of treatment (Baranowsky, 2000; Baranowsky & Lauer, 2013).

New in this edition, we provide, where possible, audio and video material demonstrating how the different techniques are carried out. These are available via the YouTube links in the text or practitioners can also download them from the publisher’s webpage (see Notes on Supplementary Materials, p. 225).

With the completion of this book, the reader will have gained sufficient knowledge and skills to integrate the principles and techniques of CBST into their practice with survivors of trauma.

|9|Phase 0: Foundations of the Trauma Practice Model

For fast-acting relief from stress, try slowing down.

Lily Tomlin

Summary

Section 1 provides some of the current theories explaining both the cognitive and physiological underpinnings of the symptoms and successful interventions for the treatment of trauma. The symptoms that manifest from trauma are natural and normal sequelae to exposure to extraordinary events. Understanding the mechanism by which these occur will provide a much better ability to understand the variety of symptoms seen in practice. Understanding how the interventions are logically linked to the mechanism by which symptoms occur should provide a better ability to utilize the techniques presented and increase confidence in their effectiveness with clients. This understanding will help in the creation of on-the-spot interventions to also address the immediate needs of clients.

|10|Phase 0: Foundations of the Traum Practice Model

We have added a Phase 0 to Herman’s (1992) Tri-phasic Model in this edition of Trauma Practice. This addition reflects an attempt to identify and promulgate the knowledge and skills necessary for a trauma clinician to meet their clients with competence from the first session throughout the course of treatment and all the way to discharge. We hope this information supports clinicians working with trauma survivors to become increasingly intentional with the ways in which they manage themselves and engage their clients. Recent research is replete with data that suggests the value of what the therapist brings to the process of treatment is much greater than the technical elements of the treatments themselves.

Benish, Imel, and Wampold (2007, p. 746) state:

Given the evidence that treatments are about equally effective, that treatments delivered in a clinical setting are effective (and as effective as those in clinical trials), that the manner in which treatments are provided are much more important than which treatment is provided…

Recent outcome research (Miller et al., 2013, 2020; Llewelyn et al., 2016) has begun to discover what makes psychotherapy optimally effective. It is much less about the treatment method utilized and much more about the relational and technical expertise of the therapist. This process of developing expertise and maximizing outcomes by psychotherapists with all their clients has given birth to a burgeoning field of clinical training and research called deliberate practice. Deliberate practice was first discussed by Ericsson (2006) after conducting a study with musicians who were enrolled in an elite training academy in Germany. Through surveys and interviews, Ericsson was able to distill what was common among these students that produced excellence in their playing. These activities were:

Observing their own work

Getting expert feedback

Setting small incremental learning goals just beyond the performer’s ability

Engaging in repetitive behavioral rehearsal of specific skills

Continuously assessing performance

These activities have been utilized in training and supervision programs with psychotherapists and yielded significantly improved outcomes among their clients. Evidence-based psychotherapeutic treatments are effective less because of the technical aspects of the treatment (0–1% of variance) and much more a result of clinician expertise with both the treatment model and maintaining a positive therapeutic experience for the client (5–9% of variance) (Chadwell et al., 2018; Duncan et al., 2010; Lutz et al., 2007; Wampold, 2005). The more deliberate the clinician is in refining technical and relational skills the more effective implementation of evidence-based treatments will become. In addition to relational and technical competence is the requirement for the consistent attuning to our clients, the actual experts of their own struggles. This constant attunement allows us to continually bolster our relationships with them as well as repair any unintentional relational damage done in previous sessions. We strongly advocate integrating feedback-informed practice (Miller et al., 2013, 2015) with all clients in each session.

In addition to developing technical expertise with the clinician’s treatment(s) of choice, continual augmentation of relational skills, and the utilization of feedback-informed treatment is highly recommended. This capacity enhances effectiveness with clients across the diagnostic continuum. With this as a starting point, we also wish to add some skills and preparatory activities to evolve a clinician’s expertise specifically with trauma survivor clients.

Preparation for the Therapist

In the 21st Century, therapists who treat trauma and have interest in pursuing excellence in this endeavor must dedicate a significant amount of time and resources toward their preparation. This preparation includes two components: preparation in their professional development and preparation for each and every individual client. Many of these professional preparatory capacities may already be a part of the professional’s knowledge and skill set, but if they are not, then some preliminary work will be required to set the work on the right foot before even having contact with their first client. Below is a list of knowledge and capacities that serve as a foundation for the practice of trauma-informed care and the pathway to excellence as a trauma therapist:

Becoming proficient in the principles and practices of trauma-informed care. Trauma-informed care is:

Understanding the prevalence of trauma and adversity and their impacts on health and behavior

Recognizing the effects of trauma and adversity on health and behavior

|11|Training leadership, providers, and staff on responding to patients with best practices in trauma-informed care

Integrating knowledge about trauma and adversity into policies, procedures, practices, and treatment planning

Resisting re-traumatization by approaching patients who have experienced adverse childhood experiences and/or other adversities with nonjudgmental support

The principles of trauma informed care are:

Establish the physical and emotional safety of patients and staff

Build trust between providers and patients

Recognize the signs and symptoms of trauma exposure on physical and mental health

Promote patient-centered, evidence-based care

Ensure provider and patient collaboration by bringing patients into the treatment process and discussing mutually agreed upon goals for treatment

Provide care that is sensitive to the patient’s racial, ethnic, and cultural background, and gender identity

In addition to making the principles and practices of trauma-informed care a central and organizing ethos for trauma clinicians, we outline a few additional principles and practices that we believe help articulate competency in the treatment of traumatic stress in the 21st Century. The concepts and factors presented below are offered as an index checklist only (more thorough discussions can be found in Gentry, 2021; Gentry & Dietz, 2020; Gentry et al., 2017; and Rhoton & Gentry, 2021).

Learn in detail the explanation that trauma is not a psychological pathology but, instead, is the result of an over-adaptative threat detection and threat response system. This includes the ability of the clinician to explain rudimentary components and functioning of the ANS, the human threat response, stress as a threat response with an internal locus of control, and the ways in which this dysregulated ANS (i.e., dysautonomia) can negatively affect a trauma survivor’s physical, cognitive, emotional, and spiritual health.

Possess a thorough understanding of the polyvagal theory (Porges, 2009; Porges & Dana, 2018) that includes the ability to function clinically in the ventral vagal system and to utilize co-regulation as a primary intervention with dysregulated clients.

Clinicians treating trauma survivors should develop the ability to interrupt our own threat response by integrating both neuroceptive (i.e., top down) and interoceptive (i.e., bottom-up) self-regulation strategies.

Develop the ability to teachthe above elements to our clients (e.g., threat response, ANS functioning, polyvagal theory, and self-regulation) using simple and straightforward (jargon-less) language.

Develop a repertoire of common experiences for daily life that illustrate the negative effects of ANS dysregulation and how self-regulation can lessen/eradicate clients’ distress in these contexts and restore optimal functioning.

Be able to use rudimentary motivational interviewing (Rollnick & Miller, 1995) skills to catalyze positive expectancy and engagement; especially in early treatment.

Evolve away from a flat, dry, disconnected, and objective stance with our clients to one that is warm, engaging, dynamic (broad range and low-intensity affect), uses prosodic voice, while remaining in a regulated ANS (i.e., ventral vagal).

Be willing to elicit and attune to negative feedback from our clients. We strongly recommend that feedback informed treatment (FIT) (Miller et al., 2013, 2015) should become a central component of treatment with every client in every session.

Develop an understanding of and an ability to integrate intentionally the active ingredients/common elements of all effective trauma therapies. These minimally include: developing, maintaining, and enhancing a good therapeutic relationship; relaxation and self-regulation skills; exposure protocols (both in vivo and imaginal); and psychoeducational/cognitive restructuring interventions.

Become well-versed and experienced using multiple methods of trauma resolution, especially for memory processing. We suggest at least one bilateral stimulation approach (e.g., thematic map & release, eye-movement desensitization and reprocessing accelerated resolution therapy, or brainspotting), one narrative/CBST approach (e.g., written narrative, story-book, traumagram, cognitive processing therapy), and one somatic approach (hands over heart space, layering, somatic experiencing, or sensorimotor psychotherapy). Competency in one of these treatment approaches in each of the three categories will provide you with trauma expertise and the ability to address many trauma survivor clients who seeks out treatment. Further complexities may require that you augment your skills to address the treatment of personality disorders (i.e., borderline personality disorder), dissociation, chronic pain, and addictions, which may include internal family systems, |12|dialectical behavioral therapy, hypnosis training; structural or strategic treatment for dissociative disorders and an understanding of contemporary approaches for addiction treatment (i.e., smart recovery, etc).

Finally, clinicians should develop a library of short (60–90 s) narratives that outline past successful clients’ navigation through treatment that outlines both their incremental successes and the challenges during which they struggled in their process toward completing therapy. Judicious sharing of some of these narratives throughout the course of treatment can catalyze positive expectancy, normalize clients’ experiences, and point out potential skills they have not yet utilized.

These skills, capacities, and knowledge represent the authors’ suggestion not only for developing essential preparatory practices but also for evolving their practice from competence to expertise to mastery in working with trauma survivor clients.

Exposure in a Relaxed State – Reciprocal Inhibition

Reviewing the work of Patricia Resick (Resick & Schnicke, 1992), Charles Marmar (1990), James Pennebaker (1997), Onno van der Hart (van der Hart & Brown, 1992), Bessel van der Kolk (van der Kolk, 1986; van der Kolk et al., 1996), and the experiences gained from early clinical training, it became apparent that the type of exposure used in therapy is very important to effectiveness. If clients are aided in constructing complete narratives of their traumatic experiences while in a relaxed state, their traumatic stress symptoms (specifically those in Criterion B) could heal at an accelerated rate (van der Kolk, 1986; van der Kolk et al., 1996). By facilitating this important narrative process, not only would the trauma survivor be aided in confronting the traumatic material, but they were being reinforced to structure the intrusive sensory traumata into language. The research supported that effective narrative construction had a powerful ameliorative effect upon the intrusive symptoms of trauma (i.e., flashbacks and nightmares), while virtually every treatment that demonstrated effectiveness with traumatic stress utilized some form of narrative (exposure) paired with some form of relaxation or the use of reciprocal inhibition.

The resolution of intrusive symptoms of PTSD did not mean that PTSD itself was resolved. Early on, that was the primary focus of treatment: to resolve the flashbacks and nightmares. There was an implicit belief in the field that, if you were able to desensitize and reprocess the memories, present-day discomfort, anxiety, and distress would spontaneously ameliorate. By 1997, just before publishing the first edition of Trauma Practice