Treatment Planning for

Sexual TraumaSexual Trauma

Helen Hill MA MFT

SAFETY!• Safety is the IMMEDIATE Number One issue:

1. Is Your Client Physically Safe from Further Harm?

• Is Your Client Emotionally Safe from Further Harm?

2. Have Resources on File and Available!

3. Is the Client under 18? Call DCFS!

4. Does Your Client need to go to the Hospital?

5. Does a police report need to be made? If the

client is under 18 � YES!

6. Is Your Client Suicidal? A Danger to Self? To

Others? Possible 5150? Suicide Contract? Call 911?

DCFS: Phone 1-800-540-4000

http://lacdcfs.org/contactus/childabuse.html

More Resources…

More Resources…

Signs of Trauma

Mood Instability Unexplained Outburst of Temper

Depression Nightmares

Sleep Disturbances Flashbacks

Hypervigilance Anxiety and Panic Attacks

Dissociative Experiences Avoidance

Inability to Experience Pleasure Unexplained Grief Reactions

Hopelessness Poor Concentration

Alcohol and Substance Abuse Food Consumption Disturbances

Suicidal Thoughts and Attempts Sexual Problems

Desire to Hurt or Mutilate Oneself Poor Self-Esteem, Shame, Guilt

Chronic Muscle Tension Unexplained Physical Discomfort

Headache, Stomach Ache, Dizziness

Other Features of Trauma• Ambivalence

• Very compliant, always wanting to please others

• Self-destructive and impulsive behaviors

• Sleeping with clothes on

• Incontinence or "bed wetting"

• Constipation

• Poor hygiene, making oneself "ugly" • Poor hygiene, making oneself "ugly"

• Wanting to have things a certain way (obsession or compulsion)

• Need to be in control

• Ritualized behaviors

• Hoarding

• Eating disorders

• Loss of previously sustained beliefs

• Having a hard time dealing with failures

• Hostility

Other Features of Trauma…

• Difficulty making decisions

• Uncontrolled fear

• Feelings of ineffectiveness

• Feeling victimized

• Feeling permanently damaged

• Feeling constantly threatened or unsafe • Feeling constantly threatened or unsafe

• Feeling powerless to create change

• Feeling out of control

• Social withdrawal

• Impaired relationships with others, difficulty trusting others

• Making "false accusations"

Factors Affecting Trauma Recovery

• Person

– Age / development stage

– Relationship to Offender

– Pre-Trauma personality, functioning and coping – Pre-Trauma personality, functioning and coping

mechanisms

– Perceptions of and meaning ascribed to trauma

– Qualities assigned to self and others Post-Trauma

– Cultural, Ethnic, Religious, Racial, Sexual

Orientation variables

Factors Affecting Trauma Recovery

• Event– Severity, Duration, and Frequency

– Degree if Physical Violence / Personal Violation

– Shared with Others or Suffered Alone

– “Power Politics”–

• Environment– Quality and continuity of social supports

– Responses of the “Recovery Environment”

– Community Attitudes and Values

– Quality, Availability, and Diversity of Community Resources

– Measure of the Physical and Emotional Safety Ensured Post-Trauma

Common Reactions to Violence and Trauma

Common Reactions to Violence and Trauma

Common Reactions to Violence and Trauma

Response Stages For Trauma• Acute Crisis

– Immediate management of health and safety issues

– Emotional safe space

– Reduction / elimination of threat

• Outward Adjustment– Reclaiming one’s life and routines– Reclaiming one’s life and routines

– Can begin within 24 hours of trauma

– Can last for years

• Integration– Integrating the experience of trauma within one’s life and

character

– Survivors report a grieving process

– Aspects of physical safety become part of the “normal”

– Creating distance from trauma while considering its impact

Treatment Planning

1. Deal with Immediate Safety Issues

2. Establish the Therapeutic Alliance

3. Assessment:

– Identify Patient Concerns– Identify Patient Concerns

– Ongoing Mental Status Exam (and other

assessment tools)

– Any Legal or Criminal Justice Involvement

Treatment Planning cont…

4. Intervention Strategies

– Physical and Emotional Safety

– Ventilation and Validation

– Education and Information– Education and Information

– Mobilization of Internal and External

Resources

– Preparation and Planning

5. Closure

Other Considerations

• Record Keeping

• Patients with Ongoing Mental Illness

• Ongoing Danger

• History of Prior Victimization• History of Prior Victimization

• Secondary Traumatic Stress

– Vulnerability of the Clinician to Patients with

Recent Trauma

Treatment Planning – Early Stage

• Early Stage Goals: – Provide a safe holding environment

– Establish therapeutic relationship

– Explore presenting problems and establish goals

– Symptom reduction and reframe role of identified patient–

• Early Stage Interventions:– Establish and model boundaries

– Use Empathic Listening

– Ask questions that clarify and amplify issues / begin to put language to feelings

– Psychoeducate and normalize to promote symptom reduction

Treatment Planning – Middle Stage

• Middle Stage Goals:– Identify and interrupt dysfunctional patterns (e.g. projective

identification)

– Make unconscious dynamics conscious

– Explore and reframe defense mechanisms (e.g. splits, repression, etc)repression, etc)

– Promote insight

– Promote and emotionally corrective experience

– Help clients recognize and integrate split-off aspects of the personality

– Develop ability to distinguish between the past and present

– Increase the level of individuation and promote the development of a cohesive self

Treatment Planning – Middle Stage

• Middle Stage Interventions:

– Continued use of clarification and amplification

– Interpretation and linking the past to the present

– Reframe the adaptive purpose of defense mechanisms

– Identify and educate about defenses– Identify and educate about defenses

– Explore and interrupt the projective identification process

– Interpret and explore transferences and projections

– Identify and increase tolerance of split-off parts

– Continue psychoeducation when relevant

– Use of objective countertransference (therapist aware of own feelings to aid in therapy)

Treatment Planning – Late Stage

• Late Stage Goals:– Symptoms have been connected with a cause

– Client has become conscious of defense mechanism

– Transference of past issues to present relationships has been brought to awareness

– Restructuring of object relations for each family member– Restructuring of object relations for each family member

– Family members act in an authentic and adaptive manner

– Work through termination issues – loss of the therapeutic relationship

• Late Stage Interventions:– Interpret and explore recapitulated issues / loss of

therapeutic relationship

– Review and consolidate self-soothing and other coping mechanisms

Approaches to Treating Trauma• Same-Gender Group Therapy

• Art Therapy

• Eye Movement Desensitization And Reprocessing (EMDR)

• Psychophysiological Trauma-work

• Dialectical Behavioral Treatment

• Narrative Therapy

• Feminist Therapy• Feminist Therapy

• Somatic Trauma Therapy– the study of the body, somatic experience, and the embodied

self, including therapeutic and holistic approaches to body. There is increasing use of body-oriented therapeutic techniques within mainstream psychology (like EMDR and Mindfulness practice) and psychoanalysis has recognized the use of somatic resonance, embodied trauma, and similar concepts, for many years

• Gestalt Therapy

• Psychodynamic Therapy / Attachment Theory

• Psychopharmacology

Cognitive Behavioral Therapy

• Early Stage Goals:– Form a collaborative therapeutic relationship

– Set collaborative goals

– Symptom reduction

– Socialize to the cognitive model

• Early Stage Interventions:• Early Stage Interventions:– Conduct a structured interview to clarify problem

– Create a problem list

– Develop a therapeutic contract of goals and responsibilities

– Ask clients to chart and track problem behavior

– Teach relaxation; develop action plan, e.g. activity schedule

– Activate collateral resources

– Explain theoretical model, teach automatic thought record

More Cognitive Behavioral Therapy

• Middle Stage Goals:– Establish more balanced ways of thinking

– Correct faulty cognitions

– Improve communication skills

– Evaluate underlying assumptions and schemas

• Middle Stage Interventions:– Use automatic thought record and downward arrow technique to facilitate the – Use automatic thought record and downward arrow technique to facilitate the

guided discovery of underlying assumptions and schema

– Teach thought stopping and other diversion techniques

– Teach communication skills (“I” statements, role playing)

– Assign homework, e.g. journaling, automatic thought records, Bibliotherapy, etc

– Shape desired behavior by identifying positive and negative behavioral reinforcers in the family

– Systematic desensitization

– Negotiate quid pro quo and contingency contracts

– Specific discernable acts

– Downward arrow – auto thoughts to schema

More Cognitive Behavioral Therapy

• Late Stage Goals:– Evaluate therapeutic progress

– Strategize to prevent symptom reoccurrence

• Late Stage Interventions:– Review the problem list– Review the problem list

– Highlight therapeutic gains

– Cognitive rehearsal: anticipate future obstacles and rehearse ways to cope with them

– Identify behavioral reinforcers likely to maintain changes

– Establish booster session schedule

Narrative Therapy

• Early Stage Goals:– Establish collaborative relationship and goals

– Create openings for the client’s story to be told

– Map the effects and history of the problem

– Map family members’ influence on the problem

– Identify factors that support the problem– Identify factors that support the problem

– Begin separating the client from the problem

• Early Stage Interventions:– Ask permission to pursue sensitive lines of questioning

– Ask questions that personify the problem

– Ask questions to learn about client apart from the problem

– Ask how the problem invites the client’s participation

– Utilize externalizing language

More Narrative Therapy

• Middle Stage Goals:– Deconstruct context in which problem occurs

– Help clients develop a new relationship to the problem

– Locate and thicken alternative story or narrative

– Help client to uncover competencies and self-knowledge

• Middle Stage Interventions:• Middle Stage Interventions:– Note unique outcomes and exceptions to the problem

– Explore the client’s internal resources and strengths

– Ask questions to elicit preferred selves and stories

– Ask externalizing questions

– Ask deconstruction questions

– Facilitate re-authoring of the client’s new narrative

– Assess client’s week to week progress

More Narrative Therapy

• Late Stage Goals:– Reinforce the client’s new story

– Circulate client’s new, alternate, or preferred story

– Extend the new story into the future

– Process the end of therapy

• Late Stage Interventions:• Late Stage Interventions:– Recruit problem fighters and a community of concern

– Encourage letter writing to circulate the new story

– Ask questions to extend the story into the future

– Identify rituals and traditions that support the new story

– Celebrations and certificates to thicken the alternative story

Somatic Trauma Therapy

• The study of the body, somatic experience,

and the embodied self, including therapeutic

and holistic approaches to body.

• There is increasing use of body-oriented • There is increasing use of body-oriented

therapeutic techniques within mainstream

psychology

(like EMDR and Mindfulness practice)

• The idea of exposing embodied trauma

Gestalt Therapy

• Early / Middle / Late Stage Goals:– Develop therapeutic relationship as microcosm of other healthy

relationships

– Facilitate awareness of:• One’s parts that are out of awareness

• One’s unique, subjective experience

– Facilitate client’s search for personal meaning and life goals– Facilitate client’s search for personal meaning and life goals

– No stages

– Therapist’s role as Facilitator

– Affirm personal choices and responsibilities

– Acceptance of anxiety as a basic human characteristic

– Acceptance of responsibility

– Increase personal choice

– Assume responsibility for and ownership of one’s life• From “Victim” to “Chooser”

More Gestalt Therapy

• Treatment Interventions:

– Therapist’s Use of Self as person in response to the client

– Clarifying

– Identifying

– Guiding

– Exploration of client’s internal world

– Noting metacommunication (body language)

– Experimenting

Elements of Your Treatment Plan

1. Intake

2. Patient History

3. Mental Status Examination

4. Developmental History (if applicable)

5. Clinician Assessment and Recommendations

6. Diagnosis (DSM)6. Diagnosis (DSM)– Axis I, II, III, IV, and V

7. Theoretical Approach**

8. Treatment Goals– Extent of Client’s Trauma

– Early, Middle, Late Stage Goals

** APA format with references