Relational Issues and Risk
Management in the Treatment of
Complex Trauma
ESTD, Belfast, April 2010
Christine A. Courtois, PhD
Psychologist, Independent Practice
Christine A. Courtois, PhD & Associates, PLC
Washington, DC
CACourtoisPhD@aol.com
www.drchriscourtois.com
Treating the traumatized:
A vulnerable and high risk population
n
n
n
Complex PTSD/DESNOS: not in DSM
u “PTSD plus”
Most resembles BPD
Challenges of treating complex trauma patients:
u
u
u
u
u
Relational deficits and attachment disturbances
Life skill deficits/chaotic lifestyle
Somatic/medical problems
Risk: depression, anxiety, dissociation, self-injury,
suicidality, revictimization, memory disturbances
Intense transferences that trigger equally intense
countertransference reactions/errors
Current Atmosphere and Issues
n
n
n
n
n
n
n
Era of increasing liability
Era of managed care
Changes in professional ethical codes
More stringent licensing and professional standards
The delayed/false memory controversy
Discoveries in the field of neuroscience, memory,
attachment, psychotherapy practice
Evolving science (evidence-based treatment) and
standards of care for trauma treatment
Science: The Evidence Base of
Trauma Treatment
n
Ever growing for “simple”/classic PTSD sx
u
specific treatments:
F
F
F
F
u
CBT (prolonged exposure)
CPT & other cognitive protocols
EMDR
others?
applicable to complex trauma?
F
F
F
research generally excludes these patients
research easier to conduct on CBT approaches and
specific posttraumatic symptoms
difficulty assessing multiple modalities
Science: The Evidence Base of
Trauma Treatment
n Will some techniques hurt more
than help?
u A major ethical concern
u
u
u
u
Potential for retraumatization?
Treatment tailored to the individual
Therapist must monitor response
Apply most effective but safe strategy
F
informed consent/refusal
The Evolving Standard of Care
for Trauma Treatment
n
n
n
n
Foa et al. (2000)
Journal of Clinical Psychiatry Expert
Consensus Guidelines (2000)
ApA Treatment Guidelines for PTSD/ASD
(2004)
ISSD Treatment Guidelines for DD’s
u
u
n
Adults (1994; 1997; 2005)
Children (2000)
Delayed memory issues
u
Courtois (1999); Mollon (2004): overviews
The Evolving Standard of Care
for Trauma Treatment
n
n
Psychotherapy and psychopharmacology in majority
of cases
Stage-oriented for the entire PTSD-DD spectrum;
three stages:
u
u
u
n
Early: safety, stabilization and functioning, skill-building:
decrease symptoms, increase coping; therapeutic alliance
Middle: trauma information and emotional processing
Late: self and relational development
Different trajectories
u
according to patient’s psychological make-up, tolerance
and capacity, and resources
Science: The Evidence Base of
Trauma Treatment
n
Growing for complex trauma
u
critical role of the therapeutic relationship (the
original evidence-based strategy)
F
F
u
relational healing for relational injury
interpersonal neurobiology
hybrid models of treatment
F
F
F
F
F
CPT (Resick)
STAIR model (Cloitre)
Seeking Safety (Najavits) and ATRIUM (Miller)-substance abuse
DBT (Linehan)--BPD, affect dysregulation and
skills
TARGET (Ford)
Definition of Risk Management
in Therapy
“Responsible clinical practice within
the standard of care, which minimizes
risk to patient and his/her significant
others and to self as therapist”
Responsible and Ethical
Practice Framework
“First, do no harm”
Responsible and Ethical
Practice Framework
n
For psychotherapy in general:
Professional code of ethics, professional
standards, and applicable state law
u Professional business practices in keeping
with the law (now HIPAA) and
ethics/standards
u
Billing, record-keeping, confidentiality, staff
F Emergencies and coverage
F
Framework (cont.)
u
Collaborative relationships
Supervision and consultation
F W/ prescribing psychiatrist
F W/ all other treaters
F
u
Ongoing training and continuing
education
F
Have specialized training with specialized
techniques and use tailored informed consent
forms
Framework (cont.)
n
Structure of psychotherapy:
u
u
u
u
u
Assessment before treatment
Full, informed consent/refusal
F treatment frame
F treatment plan
Comprehensive treatment and plan
F ongoing monitoring of plan
F with adjunctive work if needed
Documentation
Planned, thoughtful termination
Framework (cont.)
n
For trauma treatment: all this and more
“First, do no more harm”
Framework (cont.)
n
For trauma treatment
u
Specialized knowledge/willingness to treat
F Therapist must be open to trauma
• does not dismiss or stigmatize
• therapist has training
– if not, refer or get training
• is not over-invested/over-fascinated
u
Comprehensive assessment
F
F
F
F
general and specialized
non-suggestive, non-suppressive
supportive neutrality
may extend over time as issues unfold
Framework (cont.)
u
Comprehensive treatment
F
with attention to available evolving standards
and science
F stage-oriented, progressive, carefully
paced
F not oriented to memory retrieval
and/or only to trauma processing
F
u
with ongoing attention to skill-building, selfmanagement, functioning, attunement
Initial and ongoing attention to safety
safety planning
F changing from a life of chaos/victimization
F therapist stance
F
Framework (cont.)
u
Ongoing attention to treatment alliance
F
F
F
F
u
active vs. passive stance
reliability and consistency; attunement
collaboration, relational approach
awareness of relational instability, mistrust
Boundary management with particular attention
to transference and countertransference
F
F
F
F
F
boundaries, boundaries, boundaries … with a
certain degree of flexibility
“treatment traps”
transference enactments
CT and VT
beware abandonment
Framework (cont.)
u
Ongoing supportive neutrality with regard to
suspected trauma history
F
F
u
encourage tolerance for “living with uncertainty”
therapy is not a hunt for missing memories and
recovery of memories does not mean recovery
Caution with regard to
F
F
F
F
F
disclosures/confrontations/breaking off relationships
with major attachment figures
legal action
major life decisions
transference, countertransference, vicarious trauma,
self-care
practicing in isolation
Framework (cont.)
u
Continuing education
F
F
F
Training
• assessment and treatment of posttraumatic and
dissociative disorders
• nature of traumatic memory
• clinical hypnosis, EMDR, other
• general training (non-trauma-oriented)
Literature on posttraumatic and dissociative
disorders, existing practice guidelines, memory
research, suggestibility (see bibliography)
Supervision and consultation
• peer support: do not practice in isolation
The Importance of Relationship
n
Relational healing for interpersonal trauma
u
n
A sacred obligation
Interpersonal neurobiology
u
Right brain to right brain attunement
F
u
Development of new neuronal pathways
F
u
implicit memory and knowledge
“neurons that fire together wire together”
“Earned secure” attachment
The Importance of Relationship
n
Therapist must maintain empathy and
attunement
u
When ruptures occur (as they always will), the
therapist uses the opportunity for communication and problem-solving leading to repair
F
F
F
u
therapist owns mistakes
therapist shares feelings in the moment (with
discretion)
therapist is not blaming
Therapist must not make self the “all-knowing
authority on high”
Boundary Issues
n
Potential for boundary violations (vs.
crossings) common with this population
(indiscretions, transgressions, and abuse)
u Playing out of attachment style and issues
u Playing out the roles of the Karpman triangle,
plus
F
F
u
victim, victimizer, rescuer, passive bystander
potential for sado-masochistic relationship to
develop
Roles shift rapidly, especially with dissociative
patients
Boundary Issues
u
u
Therapist must be aware of transf, countertransf
issues and carefully monitor the relationship
Therapeutic errors and lapses will occur and
how they are handled can either be disastrous or
can be restorative to the patient and the
relationship
F
knowing about them can help the therapist get out of
them more rapidly and manage them with less
anxiety (Chu, 1988)
Boundary Issues
n
Responsibility of therapist to
u
u
Maintain frame
Be thoughtful about boundaries/limits
F
u
u
u
u
u
re: availability, personal disclosure, touch, fees, gifts,
tolerance for acting out behavior, social contact, etc.
On average, start with tighter boundaries
Avoid dual roles wherever possible
Be prepared to hold to boundaries/limits but also to
have some flexibility
Complete personal therapy as necessary
Engage in ongoing consultation/supervision, peer
support
Boundary Issues
n
Rescuing-revictimization “syndrome”
u
u
u
u
n
“vicarious indulgence” as a treatment trap, especially
for novice therapists and those who have a strong need
to caretake or are enticed by the patient
may give patient permission to overstep boundaries, ask
for and expect too much
may then lead to resentment/rage on the part of the
therapist and abrupt, hostile termination for which the
patient is blamed
may relate to malpractice suits, in some cases (see BPD
literature)
Progression of boundary violations: the “slippery
slope” e.g., from excessive disclosure to patient as
confidante, excessive touch to sexual comforting and
contact
Boundary Issues
n
Responsibility of supervisors
u
u
n
To protect patient and the supervisee
To document supervision
Response to a patient’s report of past or ongoing
sexual relationship with previous therapist [The
“Sitting Duck Syndrome” (Kluft)/”Professional Incest” (Courtois)]
u
u
u
Know the law--varies by jurisdiction
Consult state board, professional organizations,
attorneys, insurance trust
Patient welfare issues
F
F
F
u
be aware of ambivalent attachment
work slowly and carefully
mistrust and boundary issues
Therapist welfare issues
F
Impairment, CT, VT, & self-care
Safety and The Spectrum of
Dangerousness
n
A portion of this population is at high risk for:
u Self-injurious behaviors
u Harm from others
F
u
u
u
Suicidality (approximately 10% successful in BPD population)
Homicidality
Other risk to third parties
F
F
n
domestic violence and other revictimization
Minor children --abuse, neglect, inability to parent, suicide
Family -- disclosures/confrontations, cutoffs, legal action
Emphasis on safety is necessary
Extension of Duty to Protect to
Third Parties (Not Yet Formal)
n
n
n
n
“Hot spot” in the field
Therapists are being sued by families of alleged
victims for damages to the family
u Cases in litigation now
Emphasizes the need for neutrality, careful
documentation, not recommending “cut offs”
from family unless there is clear evidence of
contemporary danger
Therapists are not private investigators or law
enforcement officers
u
criminal prosecution or civil suits against alleged
abusers will not succeed without independent
corroborative evidence; patient recollections are not
evidence of sufficient weight to carry a case
Resources
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http://kspope.com/ethcodes/index.php
http://kspope.com/taboo.php
Bennett, B. E., Bricklin, P. M., Harris, E., Knapp, S., VandeCreek, L.,
& Younggren, J. N. (2006) Assessing and managing risk in
psychological practice: An individualized approach. Rockville, MD:
The Trust.
Pope, K. S., & Vasquez, M. J. T. (2005). How to survive and thrive as
a therapist: Information, ideas, and resources for psychologists in
practice. Washington, DC: American Psychological Association.
Pope, K. S., Sonne, J. L., & Greene, B. (2006) What therapists don’t
talk about and why: Understanding taboos that hurt us and our clients.
Washington, DC: American Psychological Association.