Treatment Planning for. Helen Hill MA MFT

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1 Treatment Planning for Sexual Trauma Helen Hill MA MFT

2 SAFETY! Safety is the IMMEDIATENumber 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?

3 DCFS: Phone

4 More Resources

5 More Resources

6

7 Signs of Trauma Mood Instability Depression Sleep Disturbances Hypervigilance Dissociative Experiences Inability to Experience Pleasure Hopelessness Alcohol and Substance Abuse Suicidal Thoughts and Attempts Desire to Hurt or Mutilate Oneself Chronic Muscle Tension Headache, Stomach Ache, Dizziness Unexplained Outburst of Temper Nightmares Flashbacks Anxiety and Panic Attacks Avoidance Unexplained Grief Reactions Poor Concentration Food Consumption Disturbances Sexual Problems Poor Self-Esteem, Shame, Guilt Unexplained Physical Discomfort

8 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" 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

9 Other Features of Trauma Difficulty making decisions Uncontrolled fear Feelings of ineffectiveness Feeling victimized Feeling permanently damaged 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"

10 Factors Affecting Trauma Recovery Person Age / development stage Relationship to Offender 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

11 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

12 Common Reactions to Violence and Trauma

13 Common Reactions to Violence and Trauma

14 Common Reactions to Violence and Trauma

15 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 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

16 Treatment Planning 1. Deal with Immediate Safety Issues 2. Establish the Therapeutic Alliance 3. Assessment: Identify Patient Concerns Ongoing Mental Status Exam (and other assessment tools) Any Legal or Criminal Justice Involvement

17 Treatment Planning cont 4. Intervention Strategies Physical and Emotional Safety Ventilation and Validation Education and Information Mobilization of Internal and External Resources Preparation and Planning 5. Closure

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19 Other Considerations Record Keeping Patients with Ongoing Mental Illness Ongoing Danger History of Prior Victimization Secondary Traumatic Stress Vulnerability of the Clinician to Patients with Recent Trauma

20 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

21 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) 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

22 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 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)

23 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 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

24 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 Somatic Trauma Therapy the study of the body, somatic experience, and the embodied self, including therapeutic andholisticapproaches to body. There is increasing use of body-oriented therapeutic techniques within mainstream psychology (likeemdrandmindfulness 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

25 Cognitive Behavioral Therapy Early Stage Goals: Form a collaborative therapeutic relationship Set collaborative goals Symptom reduction Socialize to the cognitive model 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

26 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 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

27 More Cognitive Behavioral Therapy Late Stage Goals: Evaluate therapeutic progress Strategize to prevent symptom reoccurrence Late Stage Interventions: 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

28 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 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

29 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: 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

30 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: 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

31 Somatic Trauma Therapy The study of the body, somatic experience, and the embodied self, including therapeutic andholisticapproaches to body. There is increasing use of body-oriented therapeutic techniques within mainstream psychology (likeemdrandmindfulnesspractice) The idea of exposing embodied trauma

32 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 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

33 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

34 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) 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

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