II. Ethical
Principles of Practice
1. Respect for the Dignity of Persons
2. Responsible Caring
3. Integrity in Relationships
4. Responsibility to Society
III. Standards
of Humane Practice for Practitioners of Clinical Traumatology
1. Clients Universal Rights
2. Procedures for Recruiting Clients
3. Procedures for Assessment
Distress
of divulging
Tracking
the Event
Past
Memories
Normalize
as part of the Assessment
Shattered
Assumptions
Secondary
Traumatization
Suicidality
and Safety
Assessing
Readiness for Trauma Therapy
Assessment
Methods
Interviews
Psychophysiological Method
Self-Report Inventories
4. Procedures for Diagnosis
and Reporting
Clinical
diagnosis of PTSD and trauma-related disorders
Misdiagnosis
Reporting
Clinical Findings
Notes
and Record Keeping
5. Procedures for Establishing
Safety
Roles
and Boundaries
Safety
Assessing
Readiness
6. Exposure Treatment
7. Procedures for Assuring Client-Adjusted
Progress
Pacing
and timing
Monitor
Symptoms and Progress
Identifying
and Dealing with Flashbacks and Triggers
Symptom
Exacerbation
Dissociation
during therapy
Destabilization/decompensation
8. Procedures for Using Risky Treatment
Methods with Informed Consent
9. Reaching Therapy Goals Through
Consensus
10. Termination/Transition from Regularized
Sessions
11. Ongoing Relationships and the Issues
of Boundaries
Dual
relationships
Sexual
Contact
12. The Issue of Recovered
Memories of Abuse
IV. Standards
of Care for Research with Traumatized Persons
1. Research Participants Universal
Rights
2. Guidelines for Diagnosis of PTSD for
Research Purposes
3. Procedures for using Risky
Research Methods with Informed Consent
4. Procedures for Recruiting
Research Participants Humanely
5. Procedures for Collecting Data Humanely
- General Research Principles
6. Procedures for Reporting Findings and
Impressions Humanely
V. Related Online Codes of General Professional Ethics
VI. References
These guidelines seek to build a common foundation across disciplines/professions for the humane treatment of persons who have been traumatized. Such individuals may experience a spectrum of responses, including persistent rexperiencing of the traumatic event, avoidance of related stimuli, numbing of general responsiveness, and persistent symptoms of increased arousal.
Because traumatized individuals may feel a deep sense of vulnerability, dehumanization, and betrayal, as well as cognitive and emotional disequilibrium, increased care is called for in providing a healing environment that conveys respect for their experience and their dignity.
These guidelines of
the Academy of Traumatology are intended for use not only by treatment
providers, but by front-line workers (e.g., police, paramedics, crisis
intervention workers, victim assistance workers, nurses, etc.), researchers,
lawyers, media, and other professionals who come into contact with traumatized
persons. These guidelines focus specifically on the prevention and intervention
of complications that may arise when in contact with individuals who have
experienced trauma, both single event traumas and chronic traumata of long
duration. As such, these Academy guidelines are more generic and broader
in scope than the treatment guidelines for simple PTSD of the International
Society for Traumatic Stress Studies (ISTSS).
1. Respect for the Dignity of Persons
Traumatologists recognize and value the personal, social, spiritual and cultural diversity present in our societies, without judgment. As a primary ethical commitment, traumatologists make every effort to provide interventions with respect for the dignity of those served.
Traumatologists
assist traumatized persons to come to an understanding of their traumatic
experience. Traumatologists are dedicated to helping individuals, groups
and communities build on their strengths, and help enhance their coping
skills.
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Traumatologists
take the utmost care to insure their interventions do no harm
(American
Psychological Association; Canadian
Psychological Association)
Traumatologists, by providing services, have a commitment to the care of those served until the need for care ends or the responsibility for care is accepted by another qualified service provider.
Traumatologists support colleagues in their work and respond promptly to their requests for help.
Traumatologists
recognize that service to survivors of traumatic events can exact a toll
in stress on providers. They
maintain vigilance for signs in themselves and colleagues of such stress
effects, and accept that dedication to the service of others imposes an
obligation to sufficient self-care to prevent impaired functioning (see
Figley,
1995; Pearlman & Saakvitne,
1995)
Traumatologists
engage in continuing education in all the appropriate areas of trauma response.
Traumatologists remain current in the field and insure that interventions
meet current standards of care.
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See also Pope & Brown (1996, Ch. 4)
Traumatologists
clearly and accurately represent their training, competence, and credentials.
Traumatologists restrict their practice to methods and problems for which
they are appropriately trained and qualified. Traumatologists readily refer
to or seek consultation from colleagues with appropriate expertise; they
support requests for such referral or consultation from their clients.
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Traumatologists
hold fast to the commitment of confidentiality, insuring that rights of
confidentiality and privacy are actively maintained for those served.
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Traumatologists
do not, except for the duration of an emergency in which no other qualified
person is available, provide professional services to persons with whom
they already have either emotional bonds or extraneous relationships of
responsibility. Traumatologists refrain from entering other relationships
with present or former clients, especially sexual relationships or relationships
that normally entail accountability.
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Within organizations,
traumatologists insure confidentiality to the extent possible and consistentwith
organizational policies; they explicitly inform individuals of the extent
to which accepting services from within the organization entails risks
to confidentiality; and they are prepared to make appropriate external
referral for those who desire it.
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Traumatologists are committed to responding to the needs generated by traumatic events, not only at the individual level, but also at the level of community and community organizations, in ways that are consistent with their qualifications, training, and competence.
Traumatologists recognize that their professions exist by virtue of societal charters in expectation of their functioning as socially valuable resources. They seek to educate government agencies and consumer groups about their expertise, services, and standards, and support efforts by these agencies and groups to ensure social benefit and consumer protection.
Traumatologists
who become aware of activities of colleagues that may indicate ethical
violations or impairment of functioning seek first to resolve the matter
through direct expression of concern and offer of help to those colleagues.
Failing a satisfactory resolution in this manner, traumatologists discharge
their professional obligation to society by bringing the matter to the
attention of the officers of professional societies and of government with
jurisdiction over professional misconduct.
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III. STANDARDS OF HUMANE PRACTICE FOR PRACTITIONERS OF CLINICAL TRAUMATOLOGY
All clients have the right:
2. Procedures for Recruiting Clients
Obtain informed consent, providing clients with information on what they are to expect while receiving professional services.
In addition to general information provided to all new clients, traumatized clients presenting for psychotherapy should also receive information on:
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Clients presenting for legal assistance should be informed that involvement in the legal process may be experienced as re-traumatizing. It may be helpful for victimized clients who are involved in legal proceedings against an assailant to be informed that a finding of "not guilty" is a legal finding (i.e., is based on degree of available evidence), and is not a statement as to whether or not the event(s) in question occurred. They should also receive, from an attorney or other qualified individual, information on:
If clients express
interest in initiating a civil or criminal suit, encourage them to consider
the ways in which they are and are not prepared for this, including their
own mental state, capacity for resilience, and the invevitable loss of
confidentiality (Pope & Brown,
1996).
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Clients presenting for medical assistance should receive information on:
Trauma assessment can be very stressful for some people (e.g., see Litz, et al, 1992), and the process of talking about trauma may alter the client's state. If a client is highly distressed or unstable, postpone the assessment until the client is sufficiently stabilized such that the assessment data are not contaminated by negative reactions to the assessment or the assessor (Briere, 1997, p. 58).
The assessment environment itself can also prove triggering for traumatized clients (e.g., Vesti & Kastrup, 1995). Provide a safe environment for assessment and develop as much rapport with the client as possible (Armstrong, 1995; Carlson, 1997). Explain testing procedures in advance. Inform the client that testing may be stressful. Post-assessment debriefing can help the client process the experience of recalling traumatic events (Briere, 1997).
Explain in detail the nature of the assessment process to the client before beginning the assessment. Describe any self-report measures to be filled out. Provide clients with choice as to whether to continue with the assessment. After the assessment is over, point out to the clients their successes and strengths in having coped with the trauma. (Carlson, 1997)
Always pace the assessment based on the client's lead and respectfully follow without probing deeper than the client is willing or able to go at that early stage (Herman, 1992; Krell, 1986; Rosenman & Handelsman, 1990). Use a calm and reassuring voice and demeanor (Briere, 1997)
If clients become increasingly stressed, excited, angry, tangential, withdrawn, flooded with flashbacks or dissociative responses, further assessment may be contraindicated. In such circumstances, stabilize the client (Briere, 1997).
Some clients who have experienced chronic child abuse may fear to disclose their abusive histories due to feelings related to betrayal trauma, including fears of abandonment for disclosing (Freyd, 1994; 1996). Provide clients with clear and concrete assurances that you will not abandon them for disclosing (Pope & Brown, 1996)
Take care to avoid any statements that the clients might perceive as indicating that they are to blame for having “failed” to recover.
When clients are reporting their traumatic experiences, follow the client’s own pace. If the client is not aware of a link between current symptoms and a past traumatic event, do not tell the client that his/her symptoms are necessarily due to a past trauma.
Some clients may have concerns about whether or not a certain traumatic event did or did not happen, thereby sidetracking the assessment process. In such circumstances, educate clients about the vagaries of memory, including that memories are not necessarily exact representations of past events, but that subsequent events and emotions can have the effect of altering the original memory. Inform clients that the determination of whether or not an event occurred may not be possible, but that treatment can nonetheless be effective in alleviating distress (Carlson, 1997; Meichenbaum, 1994; Pope & Brown, 1996).
Support the client
without creating premature closure or certainty, and model tolerance of
doubt, ambiguity, and uncertainty. Assist the client in actively participating
in making sense out of that which is being experienced (Pope
& Brown, 1996)
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Normalize as part of the Assessment
Include a psychoeducational component that normalizes the client’s response to the traumatic event (Albeck, 1994). Use care to not minimize the effects of trauma.
Include assessment of any "Shattered Assumptions" (Janoff-Bulman, 1992), such as “I am not safe, the world is a dangerous place” and so forth. Addressing shattered assumptions is an important focus of treatment.
If clients have not experienced a traumatic event directly, be alert to the possibility of secondary traumatization, where individuals may evidence posttraumatic symptoms when hearing the trauma stories of others (Figley, 1995; Pearlman & Saakvitne, 1995).
Conduct a risk assessment whenever basic indicators reveal potential for self-harm, suicide, or harm to others (Boudewyn & Liem, 1995; Everly, 1990; Kilpatrick et al., 1985; Pope & Brown, 1996).
Screen for such risk at the initial assessment and throughout the course of treatment (Pope & Brown, 1996).
If you are not
qualified or comfortable working with clients who evidence intense instability,
or suicidal or homicidal feelings, screen during the initial telephone
contact and provide appropriate referrals (Pope
& Brown, 1996).
Assessing Readiness for Trauma Therapy
Ask clients about their desire to do trauma work before proceeding. Assess their motivation and their confidence in their ability to change. If a client has signs or symptoms of Complex PTSD, Dissociative Identity Disorder (DID), or other Dissociative disorders, use extra caution when utilizing interventions for trauma. Stabilization is necessary before traumatic material is processed (Herman, 1992; Briere, 1996).
Assess client's ability for self-containment between sessions, and develop strategies with the client for enhancing self-containment in the therapist's absence (Pope & Brown, 1996)
Assessment
Methods
(see Briere,
1997; Carlson , 1997; Wilson
& Keane, 1996).
a) Interviews
When interviewing
clients for trauma-related sequelae, monitor the client’s reactions for
excessive distress throughout the interview. Excessive coverage of traumatic
material may be overwhelming to some clients. Establish rapport and use
sensitivity throughout the interviews, using care to normalize or destigmatize
the reporting of interpersonal violence (Briere,
1997)
Use specific behavioral anchors when assessing for PTSD criterion A events (i.e., whether specific traumas occurred) to avoid underreporting, especially for interpersonal victimization (e.g., see Briere, 1992; Hanson, Kilpatrick, Falsetti, & Resnick, 1995). For example, rather than asking "were you ever raped?" it is important to provide specific behaviors that describe rape (Briere, 1997)
Unstructured or semi-structured Interviews allow for client-centered pacing when reviewing traumatic material (Pearlman & McCann, 1994). During an unstructured or semi-structured interview, in addition to assessing for specific posttraumatic sequelae, assess for issues of comorbidity, therapeutic motivation and readiness, rigidity of cognitive distortions, current suicidality/safety issues, and personal goals.
As the interview proceeds, monitor the client's reaction to the questions. If the client becomes overly distressed, the interview can be terminated, if necessary. The process may become overwhelming or retraumatizing, and this may also affect the quality of the interview via avoidance or confusion (Briere, 1997, p. 81).
Structured Clinical Interviews. The benefit of using Structured Interviews is the ability to acquire in-depth evidence for PTSD and the opportunity to explore DSM-IV symptoms or event details at any stage of the interview process. The following instruments are recommended:
When using trauma-related stimuli (e.g., pictures, audiotapes, narratives, imaginal, etc.) to assess for posttraumatic physiological symptoms, stay with your client at all times, and monitor for signs of excessive distress. If clients become overly distressed or overwhelmed, discontinue the stimulus presentation.
Always explain the psychophysiological assessment procedure in full and obtain consent before starting the assessment. Show clients the equipment that will be used and explain what it is used for.
Always tell the client what you are about to do and ask for the client’s permission before applying recording devices, such as electrodes, respiratory transducers, and so forth.
Give clients permission to stop the procedure at any time, and arrange for a non-verbal means for the clients to communicate this to you (e.g., raising a hand, etc.) in case they have difficulty verbalizing during the procedure.
c) Self-Report Measures
See Briere
(1997); Carlson (1997); Wilson
& Keane (1996) for information on various trauma-specific and generic
self-report measures.
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4. Procedures for Diagnosis and Reporting
Clinical diagnosis of PTSD and trauma-related disorders
When assessing post-traumatic sequelae, assessors should be familiar with the myriad of possible post-traumatic sequelae and disorders, including variations in cultural expression of posttraumatic distress.
Posttraumatic disorders,
as per the Diagnostic and Statistical Manual of Mental Disorders, fourth
edition (American Psychological Association,
1994; Briere, 1997), include:
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In addition, there are specific culture-bound stress responses the clinician should be aware of when working with multicultural clients (see Briere, 1997, pp. 47-49; DSM-IV Appendix I), including:
Some clients will not meet full criteria for any particular disorder, yet may nonetheless experience significant distress or impairment as a result of trauma.
Avoid pressuring clients to accept a diagnosis at any stage of assessment or treatment, and respect their timing, pacing, and readiness to integrate information (Pope & Brown, 1996).
Assess for PTSD and associated features and disorders even if not recognized by the referring professional, using care to not underestimate the prevalence of misdiagnosis from referral sources (Beck & van der Kolk, 1987; Bende & Philpott, 1994; Domash & Sparr, 1982; Friedman, 1997; Froehlich, 1992; Gayton, Burchstead & Matthews, 1986).
Use care in the choice of assessment measures and in the interpretation of more generic measures. Utilize trauma-specific measures to augment more generic measures. Many generic instruments have insufficient sensitivity to pick up on posttrauma symptoms, and may misclassify trauma symptoms as other disorders, including personality disorders or psychosis. Intrusive posttraumatic symptoms may show up on generic measures as indicative of hallucinations, obsessions, primary process, or faking bad. Dissociative avoidance may show up as indicative of fragmented thinking, chaotic internal states, or negative signs of schizophrenia. Trauma-based cognitive phenomena may show up as evidence for paranoia or other delusional processes (Briere, 1997, p. 71). Similarly, Rorschach responses in persons severely traumatized may erroneously suggest personality disorder or psychosis (Briere, 1997; Levin & Reis, 1996; Saunders, 1991; van der Kolk & Ducey, 1984,1989).
Maintain awareness of possible symptom underreporting. Clients who are exhibiting avoidance symptoms (including dissociation) may deny or mask trauma-related symptoms (Elliott & Briere, 1994; Epstein, 1993). Give careful attention to posttraumatic clinical presentations, facilitate an assessment environment that will keep client avoidance to a minimum, and use trauma-sensitive measures (Briere, 1997).
When clients present
with dramatic, sexualizing, or seemingly manipulative behaviors, it is
important to recognize these as possible symptoms of early trauma, rather
than assuming that they serve a secondary gain or reflect “primary process
thinking” (Briere, 1996).
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5. Reporting Clinical Findings
When writing clinical notes, write them as though your client is sitting next to you and is reading every word.
In general, notes should include the problems addressed in session and the interventions used. Utilize behavioral descriptors (e.g., what your client said and did) and direct quotations whenever possible. Be brief, but utilize sufficient detail such that an independent reader would have a basic understanding of what occurred in session (Pope & Brown, 1996).
Pay attention to language. For example, "sexually reactive" vs. "promiscuous" (McEvoy, 1995)
Avoid careless interpretation, speculation and assumptions. Content of notes should be based in standards of care and empirical science on treatment effectiveness (Pope & Brown, 1996).
Be brief about details of flashbacks. At intake, record the range of your client’s memory, e.g., that s/he has always remembered, etc. Record the timing of flashbacks. For example, “flash of wiping up white substance off “bathroom” floor." Leave room on page for further understanding, corrections. If inconclusive, say so (McEvoy, 1995).
Keep current with legal provisions regarding notes (McEvoy, 1995; Pope & Brown, 1996).
The following information has been subpoenaed by courts: audio/video tapes; client’s drawing during session; client’s drawings brought to/talked about in session; client’s writings done in session; client’s diary/journal; diagrams, charts; assessment reports; consultation requests/reports; reports to funding agencies; recordings by office staff (e.g., intake worker); business recordings (billings, appointment book, etc.); materials stored in computers; photographs; ledgers; and notes scribbled on scraps of paper (McEvoy, 1995; Pope & Brown, 1996).
Do not replace original notes with "substitute" notes written after the fact. Consult with attorneys or other qualified individuals regarding how to make corrections to notes, however, original notes should always be preserved as is (Pope & Brown, 1996).
Roles and boundaries/structure should be clarified from the start and gently reiterated whenever required (Briere, 1992; 1996; Matsakis, 1994; Pope & Brown, 1996)
It is crucial for clients to feel relatively safe prior to the processing of the trauma. Specific means of facilitating a sense of safety for clients can be found in Briere, 1996; Herman, 1992; Matsakis, 1994; Meichenbaum, 1994; van der Kolk, McFarlane, & van der Hart, 1996.
Always give clients choice, including choice over when/how much traumatic material to self-disclose, respecting their boundaries and defenses so as to avoid re-traumatizing them (Briere, 1996; Herman, 1992; Matsakis, 1994; Meichenbaum, 1994).
Inform clients from the start regarding any limitations to your availability (Pope & Brown, 1996)
Clients should have stability within their lives before processing traumatic material, including stability in areas of potential danger/revictimization/basic need; use of alcohol and drugs; affect regulation; skills for dealing with flashbacks between sessions; and so forth (see Herman, 1992; Meichenbaum, 1994; Pope & Brown, 1996). Document your discussions with clients regarding need for basic care. Provide referrals to community resources (e.g., transition houses; legal aid; etc.) when indicated.
In general, stabilization within sessions may be facilitated through reducing stimulation, reassurance, and grounding (Briere, 1997).
Clients who have coped through substance abuse and who attain sobriety may find they become flooded with flashbacks and other intrusive imagery.
Proceed to explore trauma material only when there is evidence of client stability regarding self capacities, safety, self-care, trigger management and symptom management (Briere, 1996; Herman, 1992; Meichenbaum, 1994).
Pay particular attention to
Although recent reviews of the literature suggest that exposure-based trauma therapies appear to be effective and well-tolerated in the treatment of uncomplicated or simple PTSD (e.g., Rothbaum & Foa, 1999), adverse reactions to exposure therapy in some persons with PTSD have been noted both in empirical studies (e.g., Pitman, Altman et al., 1991) and anecdotally (e.g., Scott & Stradling, 1997).
Some traumatized individuals evidence an exacerbation of symptoms following exposure treatments (e.g., Foy et al., 1997; Johnson et al., 1994; Kilpatrick & Best, 1984; Mueser & Butler, 1992; Pitman, et al., 1991, 1996; Shalev et al., 1996; Watson et al., 1995). Moreover, some studies suggest that exposure may be effective with intrusive symptomology, but have little effect on avoidance and numbing symptoms (e.g., Foy et al., 1997; Keane et al, 1989; cf Pitman et al., 1996). Empirical studies have suggested that titrated exposure to trauma-related stimuli and narrative integration is effective in the treatment of intrusive (Carbonell & Figley, 1995; Foa, Rothbaum, Riggs, & Murdock, 1991; Shapiro, 1995). As of August 1999, a database search shows there are no published empirical studies on the effects of exposure therapies with persons who have more complex forms of PTSD or Dissociative Disorders.
Use caution with exposure-based treatments with clients who exhibit the following, as there is some evidence to suggest they are at increased risk of retraumatization, increased anxiety and panic, alcohol abuse, increased shame and guilt, and obsessional thinking following exposure (Litz, et al, 1990):
Place emphasis
on integrating cognition and affect and give clients sufficient time to
process their memories (Pope & Brown,
1996).
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7. Procedures for Assuring Client-Adjusted Progress (Depth, Breadth, Intensity)
Frequently review decisions regarding pacing and timing in collaboration with the client (van der Kolk, McFarlane, & van der Hart, 1996).
Avoid moving too quickly into the trauma as it can increase the risk of self-destructive, aggressive, or psychotic behaviors and substance abuse (Briere, 1992; Matsakis, 1994)
Avoid moving too quickly in treatment or terminating therapy prematurely with clients who have a known history of trauma yet appear asymptomatic (Briere, 1992). Such clients may have an underlying fragility masked by an appearance of high functioning.
Allow for mutually agreed-upon, time-limited breaks away from therapy if required.
Slow down the speed of interventions and/or adjust the intensity of the interventions when clients attempt to adjust or titrate, the emotional intensity that comes from confronting very frightening memories, images and feelings (Briere, 1996).
Be aware of signs of titration. In milder forms, these include (Briere, 1996):
Monitor the client very carefully to ensure that addressing traumatic material does not overwhelm the client’s internal capacities, retraumatize the client, or result in excessive avoidance on the part of the client (i.e., make sure therapy occurs within the “therapeutic window;” Briere, 1996).
Inquire as to the client’s emotional state frequently; observe nonverbals and verbals carefully (Matsakis, 1994).
If any of the following occur, slow down:
Help clients identifying and manage flashbacks and triggers between sessions. Normalize and educate (see Meichenbaum, 1994)
If a client is triggered in session, help focus the client on the facts of what is happening in the here-and-now. Specific techniques can be found in Briere, (1992; 1996); Meichenbaum, (1994).
Use caution with meditation and related techniques for clients who are flooded by flashbacks and other intrusive symptoms, as such techniques can induce dissociative states and subsequent panic (Pope & Brown, 1996).
Slow down and reconsider the course of therapy if symptoms worsen dramatically during active exploration of the trauma (Herman, 1992). Such symptoms include dissociation, striking out, or screaming repetitively and stereotypically (Briere, 1996).
When clients become agitated and distressed, explore with the client what it is that is causing this state. When clients are feeling agitated or distressed because of current danger in their lives or environments, it is dangerous to stop or soothe away responses that act as warning signals (Pope & Brown, 1996).
Dissociation during therapy (Briere, 1996).
Although some degree of dissociative defensiveness is appropriate, particularly early on in treatment, continued dissociation can interfere with the healing process. Watch for signs of dissociation, including
If the dissociation continues, decrease the client’s immediate distress or increase the client’s level of self-support.
Destabilization/decompensation
Destabilization refers to a chronic lessening of functioning over time in the outside world due to uncontrollable intrapsychic events (Briere, 1996).
Signs of destabilization include:
Distinguish between (i) a normative increase in symptoms and (ii) destabilization. Avoid unnecessary interventions such as violating confidentiality, medications, and hospitalizations if a client’s symptoms are increasing but they are not destablized. Such interventions, when unnecessary, can retraumatize the client.
However, be responsive to your client’s escalating distress. If clients view a low-key response to their distress as evidence of therapist abandonment or incompetence, it could result in further dysphoria or decompensation (Briere, 1996).
8. Procedures for Using Risky Treatment Methods with Informed Consent
Define to the client what the intended treatment consists of and all possible risks of engaging in said treatment. Provide the client a written summary of the procedure and the risks involved. Obtain written consent.
9. Reaching Therapy Goals Through Consensus
Collaborate with your client in the design of a clearly defined contract that specifies a specific goal in a specific period of time, or a contract for a more open-ended process with periodic evaluations of progress and goals.
Inform Clients about the Healing Process (Matsakis, 1994):
Inform clients that they may not be able to function at the highest level of their ability, or even at their usual level, when working with traumatic material.
Prepare clients of the possible symptoms they may experience, explaining that these symptoms do not mean the clients are “crazy”. These include
Some clients may experience the termination of therapy or transition from regularized sessions as an abandonment. Clients may present with increased levels of dependency and other symptoms during such times. Inform clients that such symptoms do not necessarily indicate a relapse or a treatment failure, but are understandable and offer a new opportunity for further growth. If clients decide they do not want to terminate treatment, discuss this openly with them. Inform them that they are free to return later if they feel the need for further treatment. Provide them with plenty of advance notice.
11. Ongoing Relationships and the Issues of Boundaries
Dual relationships are to be avoided as much as possible. “Dual” includes concurrent and sequential relationships. Inform clients from the start that sexual or romantic relationships are forbidden in professional ethical codes.
Sexual Contact (Briere, 1996; King, 1987; Pope, Keith-Spiegel & Tabachnick, 1986; Thoreson, Shaughnessy, Heppner & Cook, 1993)
Never engage in any form of sexual contact with clients.
Do not reward sexualized behaviors with attention or reactivity
Directly clarify the boundaries of the therapeutic relationship and address the underlying motivations of persisting sexualized behavior.
Set limits on client’s inappropriate behaviors while maintaining an ethos of care. Maintain respect for the dignity and worth of the client at all times.
Re-address the absolute inappropriateness of sexual and/or romantic behavior in a non-lecturing, non-punitive, manner.
If you have sexual
contact with clients, remove yourself from practice, refer the clients,
and notify legal and professional authorities.
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Use care with self-disclosure or any behaviors that may be experienced as intrusive by the client, including (Briere, 1996, p. 103):
12. The Issue of Recovered Memories of Abuse
There is some evidence that suggestibility can be enhanced and pseudomemories can develop in some individuals when hypnotic techniques are used as a memory enhancement or retrieval strategy (Pope & Brown, 1996, p. 59). Hypnosis and guided imagery techniques can be used to ehance relaxation and teach soothing strategies with some clients, however, it is recommended that they not be used in the active exploration of memories of abuse.
Traumatologists should maintain a critical stance in relation to their assumptions, theories, research, and assessment procedures/instruments (Pope & Brown, 1996).
Recognize and minimize as much as possible imbalances in power within the therapeutic dyad. Recognize and respect the adult autonomy of clients. Strengthen the client's critical thinking skills through the use of open-ended questions, and strengthen their abilities to resist suggestion. The risk of creating pseudomemories or of avoiding real traumatic memories will be reduced (Pope & Brown, 1996).
When clients are highly distressed by intrusive flashbacks of delayed memories, assist them in regaining their power to move beyond their confusion, however do not provide premature certainty (Pope & Brown, 1996). Encourage and model a tolerance of distress and ambiguity
Inform clients they are free to make their own decisions regarding their intrusive symptoms, without being pushed in any particular direction. Support them in coping with their anxiety from not having immediate or certain answers.
1. Research Participants Universal Rights
When conducting research with traumatized persons, provide as much choice and control as possible over their degree of participation. Guarantee anonymity in every phase of research to honor the privacy of the participants. Avoid all forms of deception, whether direct or indirect, and take all steps to guard against coercion when obtaining informed consent
2. Guidelines for Diagnosis of PTSD for Research Purposes
(a) Rule-out medical
problems
(b) Rule-out substance
use/abuse/toxicity
(c) Rule-out malingering/feigning
(d) Distinguish
from normal or developmental issues
(e) Differentiate
from Adjustment Disorder NOS
(f) Differentiate
from Acute Stress Disorder
(g) Differentiate
from Secondary Traumatization
(h) Identify/diagnose
comorbidity issues
(i) Diagnose PTSD.
3. Procedures for using Risky Research Methods with Informed Consent
a) Participants are to be informed of:
4. Procedures for Recruiting Research Participants Humanely
a) Include the
overall purpose of the research or treatment
b) Describe the
role of the research participant and why s/he was chosen
c) Explain any
procedures or techniques to be used, without compromising the results or
process
d) Discuss any
risks and discomforts that could be incurred-both short and long term
e) List the benefits
of participation without generating guilt for non-participation
questions regarding
the research and provide sources for help with a participant's decision
to participate or not
g) Acknowledge
the right to withdraw and terminate participation at any time
h) Identify sponsorship
of the research
i) Identify likely
gains in knowledge or the purpose of the research
j) Discuss how
the data will be used and disseminated
k) Offer to debrief
at the end of the research
l) Offer to send
results to participants if they wish
m) Keep all promises
made to participants
n) Clarify and
honor all obligations and responsibilities
o) Involve the
participants where possible
p) Provide detailed
informed consent with understandable language
q) Identify the
time, effort and resource requirements for each participant
r) Avoid undue
pressure to participate
s) Provide follow-up
(after research termination) therapeutic services
5. Procedures for Collecting Data Humanely - General Research Principles
a) Maintain awareness
that ethical decisions have value implications
b) Maintain concern
for the well-being of participants
c) Take into account
the possible future uses of knowledge that will be attained from the research
d) Protect participants
from harm
6. Procedures for Reporting Findings and Impressions Humanely
a) Report the findings and impressions only when the following conditions have been met:
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American
Association of Marriage and Family Therapy
American
Association of Pastoral Counsellors
American
Psychiatric Association
American
Psychological Association
British
Psychological Society Code of Conduct
Canadian
Psychological Association Code of Ethics
Canadian
Traumatic Stress Network Ethical Code
See also International Society for the Study of Dissociation Treatment Guidelines for DID
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Foa, E. B., Riggs, D. S., Dancu, C. V., & Rothbaum, B. O. (1993). Reliability and validity of a brief instrument for assessing post-traumatic stress disorder. Journal of Traumatic Stress, 6, 459-474.
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Friedman, M. J. (1997, April). PTSD Diagnosis and Treatment for Mental Health Clinicians. National Center for Post-Traumatic Stress Disorder [On-Line]. Available: http://www.dartmouth.edu/dms/ptsd/clinicians.html
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Herman, J. L. (1992). Trauma and Recovery. New York: BasicBooks.
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Krell, R. (1986). Therapeutic value of documenting child survivors. Annual Progress in Child Psychiatry and Child Development, 281-288.
Levin, P. & Reis, B (1996). The use of the Rorschach in assessing trauma. In J.Wilson & T. Keane (Eds.), Assessing psychological trauma and PTSD (pp. 529-543). New York: Guilford Press.
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Malloy, P. F., Fairbank, J. A., & Keane, T. M. (1983). Validation of a Multimethod Assessment of Postraumatic Stress Disorders in Vietnam veterans. Journal of Consulting and Clinical Psychology, 51, 488-494.
Matsakis, A. (1994). Post-Traumatic Stress Disorder. A complete treatment guide. Oakland CA: New Harbinger Publications.
Meichenbaum, D. (1994). A clinical handbook/practical therapist manual for assessing and treating adults with Post-Traumatic Stress Disorder (PTSD). Waterloo, Ontario: Institute Press
McEvoy, M (1995). Some guidelines for keeping clinical notes. Unpublished manuscript. Available 104-825 West 7th Ave., Vancouver, BC., V5Z 1C2. Fax 604-873-3278.
McEvoy, M. (1995/1996). Controversies and courts: The Canadian response to the disputed memory debate. Treating Abuse Today, 5-6, 13-22.
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Pitman, R.K., Altman, B., Greenwald, E., Longpre, R.E., Macklin, M.L., Poire, R.E., & Steketee, G.S. (1991). Psychiatric complications during flooding therapy for posttraumatic stress disorder. Journal of Clinical Psychiatry, 52, 17-20.
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Rosenman, S., & Handelsman, I. (1990). The collective past, group psychology and personal narrative: Sharing Jewish identity by memoirs of the Holocaust. The American Journal of Psychoanalysis, 50, 151-170.
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van der Kolk, B.A. & Ducey, C. (1989). The psychological processing of traumatic experience: Rorschach patterns in PTSD. Journal of Traumatic Stress, 2, 259-263.
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