This chapter:
You may also find excerpts from this chapter in Clinical/ Entry/ Multiple Sources.
Before describing ETM theory for the treatment of multiple sources of trauma and the application of that theory, some definition is required.
Each source of trauma, excepting that being addressed in the near-term, is comprised of a set of 4 psychological trauma patterns. A paradoxical system of control attends each set. The paradoxical personal management system prevents the patterns' dissolutions (and the trauma's resolution). The 4 trauma patterns theory is described in About/ Theory/ Psychology of Trauma Etiology. The paradox is addressed in the same chapter under "Paradoxical System of Control: The Survivor."
The consequences of each source of trauma, to include its set of 4 psychological patterns and two etiologies, is retained (in the psyche) relative to the values, beliefs, images and realities contradicted by the particular trauma-causing event(s). Together, the existential identity and the contradictions to it, are retained as if in a time capsule within memory.
To explain this idea by example, a series of violent attacks by an alcoholic father would be retained in a child's memory in accordance with the aspects of existential identity that related to that child's values and beliefs about fathers and how they are to behave. Even though the child may eventually be separated from the violence and then grow older in one where happenstance should lead for a period to no further trauma, and possibly even love and caring from the people comprising the new environement, the set of patterns establihed during exposure to the childhood violence could and likely would be still retained within the memory, albeit unconsciously. Only the 3rd pattern reflecting aberrant behavior would probably be manifested, and then not always overtly. For purposes of language, let's refer to this retention as the first source of trauma.
Now, years later, when the same child achieves adult status, he or she may be exposed to an extraordinarily impacting event again, such as combat during a war, or a violent crime, or marriage to a violent person. The trauma resulting from that later violence, to include the development of 4 psychological trauma patterns resulting from the later event(s), would be retained in memory again, but this time based upon the make up of the existential identity underpinning the psychology that exist when the second event occurs. Again 4 sets of patterns with attending dual etiologies and defending paradoxical system of control become established capsule like within memory. This latter experience and retention can be referred to as the second source of trauma.
The person in this example would now have been affected by 2 individual and separate sources of trauma.
I have some other ideas about how to describe these formations. At the same time, they function within their stored capacities as both autonomous and interrelated. These functionings are referenced in ETM language as the "clustering effect," implying that although the patterns have distinguished themselves separately in their memory storages, they also connect in a manner that demonstrates interrelatedness. For example, the contradictions to existential identity may be retained in completely different memory storage capsules, but the emotional elements associate with each cluster invariably connect the two retained experiences. Emotional response to the memory of one of the events will initiate emotional experience related to the memory of the other event.
Multiple sources of trauma, that is, more than one set of patterns, defend themselves through collective interaction; the individual paradoxical system of controls attending each set are combined into one defense apparatus. ETM language refers to this collective defensive effort as the overall survival system of diversion.
The name is taken from the defensive system's use of two methods to defend the various sets of patterns. First, the "system" creates the perspective that the address of any one of the groups is too emotionally overwhelming to contemplate. When this defense is used, the person attempts to abandon the therapeutic effort entirely. Second, the "system" shifts the therapeutic focus between the various sources of trauma so that resolution attempts are confounded; the shifting-focus method prevents the resolution of all the sources of trauma.
For example, the system of diversion that defends two sources of trauma resulting from a battered spouse of an alcoholic and an adult child experience of the same, will shift the resolution focus, or allow the focus to be shifted, to the earlier source of trauma. The defense changes the person's focus from the most recently and probably impacting event. Subsequently, if the defense were successful, the case will be made during the resolution effort focused on the earlier trauma that the later experiences were actually only offshoots of that initial trauma. The later trauma's resolution is prevented when the trauma resulting from the spousal battering is minimized as not really being trauma at all, but as an activity that was chosen to meet the skewed needs of the trauma-affected adult child. Thus, the later battering experience is likely to not be addressed as a true source of trauma.
If the patterns from this source of trauma are not addressed, the etiologies underpinning the overall survival system will be maintained. Ironically, such maintenance will eventually strengthen the paradoxical system of control that individually defends the childhood trauma. Neither source of trauma will be fully resolved; neithers' etiology will be reversed.
For a bibliographical review of the issues and often contradicting perspectives of the various approaches to the treatment of trauma comorbity, see About/ Comparison - Contrast/ Multiple Sources.
When addressing multiple sources of trauma, ETM applies two general principles and recommends that six guidelines be followed.
Guideline 1
ETM principles and guidelines are clarified through the following application examples.
This section addresses 4 aspects of the assessment/evaluation process: identification of sources of trauma (as opposed to identifying the trauma's symptoms), the consideration of depression, how to address repressed trauma, and using ETM Forms.
The assessment process for ETM is provided within the context of an overall psych/social evaluation where standard consideration is given to the presentment of problems or symptoms -- application of the nosotropic method. Once the ETM evaluation is initiated, however, the focus changes to the identification of sources of trauma. From there, except where chemical use symptoms are apprised and noted for the purpose of identifying chemical dependency, symptom identification is generally irrelevant to the treatment process.
Determinations of sources of trauma are made through personal interview or questionnaires. Addendum A to this chapter provides a copy of the ETM assessment instrument for making such determinations.
If, while collecting psych/social data, chemical dependency infers itself, chemical dependency evaluation instruments should be applied to the prospective chemically dependent person and to family members (see Clinical/ Family). Because the instruments for assessing chemical dependency have changed over the last 15 years, and likely will continue to change, I will not include one here. However, I can say that the instrument should provide for a documentation of the chemical use's interference with any major life process and documentation of the person's subsequent continued drug use despite the interference.
Moreover, we apply a social/family evaluation that provides for corroboration of these same interferences; the interferences are delineated by the system surrounding the chemically dependent person. Once the chemical dependency is identified, or prospectively identified, it is, respectively, treated as a source or prospective source of psychological trauma.
Trauma victims often suffer depression. When a history of unresolved trauma is documented, we assume that the depression is both physiologically-and psychologically-based. We make this assumption within the context of current information available on the subject; the information on depression is not yet unequivocal -- depression is not fully understood by the mental health professions. Moreover, because we rarely saw a client who was not affected by psychological trauma, we can't comment on the assessment or treatment of depression absent such trauma.
Regardless of its neuropsychological-basis, trauma-induced depression will usually be alleviated by the end of TRT's application. In the mean time, however, the depression affecting trauma victims is considered in the assessment phase, as well as throughout the application of TRT, as prospectively being endogenous -- having its origins in brain functions that are unrelated to trauma. Consequently, special controls are administered starting with the beginnings of the assessment process and continuing through the treatment applications; the controls provide for the safety of severely depressed people (see the next section, "Treatment Planning").
The reader will recall that the pharmacological approach is incompatible with TRT (see the addendum to chapter 1). Thus, if during the assessment phase the treatment provider elects the use of medication as one of the treatment remedies, then that patient exits the ETM program to be treated, in addition to the pharmacological method, probably with a parallel form of psychotherapy, possibly including cognitive-behavioral therapy; this therapy has been shown to be an effective talking remedy for depression. Although trauma victims experiencing depression can almost always be treated successfully with TRT, that is, in lieu of the application of the medication and parallel psychotherapy, should such application be initiated, the probabilities are substantially reduced that a person so treated will ever be a candidate for TRT.
Usually, ETM/TRT application will eventually result in the address of all psychological trauma retained within the reality system. Consequently, it is not necessary during the assessment or entry level stages of the therapeutic process to ferret suspected repressed trauma or sources of such trauma. Additionally, the TRT structure makes obsolete the need to breakthrough the "denial" that results from repression. For that matter, there is no aspect of TRT's administration that requires the use of the "breaking-through-denial" method. If this approach is not compatible with the provider's philosophy, then a model other than TRT should be administered to the patient. The questionnaire provided in the addendum to this chapter emphasizes the ETM policy regarding these subjects.
Three forms assist the assessment/evaluation process. The first instrument is the "ETM Psychtrauma Questionnaire." A copy of this document, which is self-explanatory, is provided in the addendum to chapter 11 in the text. Data collected from this assessment process and all others is recorded in ETM form 1A. Follow the form's directions and the provider will be assisted in identifying and codifying the sources of trauma to be considered in the treatment process. If the patient has only been affected by one source of trauma, then the provider should skip form 1B (a worksheet used for evaluation of multiple sources of trauma) and proceed directly to the treatment planning processes (additional forms described in the section on treatment planning). If the patient has been affected by more than one source of trauma, then the provider should transfer the data recorded on form 1A to form 1B.
This form is also self explanatory and aids in the determination of which source of trauma should be addressed first, second, and so on.
The referenced ETM Assessment - Treatment Strategy forms may be found in Clinical/ Entry.
If the patient has only been affected by one source of trauma, refer that person into a TRT process to address that source of trauma. Similarly, if the person has been affected by multiple sources of trauma, refer the person into a TRT process that provides for the resolution of the most pressing trauma first; make the referral with the intent that the application be followed by TRT's application to other sources via the chronologically descending-order approach. The rest of this section describes the clinical/educational vehicles used in these applications.
TRT is administered in either or both individual and group therapy processes. The groups are open ended and consist of between 4 to 8 participants and one Certified TRT Counselor. Depending on the number of patients making up the entire program, the groups may be comprised of people who are all addressing the same source of trauma, or the groups consist of people addressing different sources of trauma. The former distribution is preferable.
Conduct TRT groups for 1 hour and 25 minutes, but do not break them if in the middle of a critical passage for any person progressing through the trauma resolution process. Dedicate approximately 75% of the time to TRT's application. Use the remaining time for discussion of current experiences or issues related to the homework component of TRT.
In some programs, a standard (non TRT) group may be conducted parallel to TRT. Offer the standard group on another day (from TRT) and apply a combination of unstructured psychodynamic and cognitive-behavioral models. The parallel group provides patients with a forum for addressing current issues related to relationships, job processes, and general life-living experiences. The standard group is normally more valuable in the beginning of the therapy and less valuable (needed) subsequent to normal TRT progression.
Use individual sessions to discuss progress, address issues unrelated to the application of TRT and to address issues that are too difficult to address in group process. If individual sessions are applied in conjunction with TRT groups, conduct the individual sessions only periodically, that is, during high stress periods usually accompanying the entry or Phase One application stages.
Many TRT counselors apply TRT in individual sessions only and speak highly of the experience. However, such applications, except when used for stabilization (described below), place all of the responsibility for providing the structured feedback onto a single person, the therapist. In contrast, the group application disseminates this responsibility -- the shared experience of traumatic events.
Clinical/ Family addresses family psychological trauma treatment via ETM. Generally, in this section I hope that it will suffice to say that although many people have completed TRT successfully without the participation of their families, the family treatment component is an extraordinary experience for all, patient and treatment providers, who avail themselves of it.
Some patients require additional stabilization. They suffer severe depression and suicidal ideation and are unable to function in employment, school, and in other social environments. Cases requiring additional stabilization methods are hallmarked by depression (discussed earlier) and fragility -- it is demonstrated by extreme withdrawal and wide emotional swings that can include hysteria, hyperarousal, and startle response.
The use of stabilization measures is a function and the responsibility of the judgment of the therapist; the judgment comes from pre-ETM professional training. However, we offer some recommendations. They include increasing the number of individual sessions, consultation, education, anti-suicide contracts, direct and frequent phone contact, cognitive-behavioral interpretations of depression to include providing descriptions of its prospective causes and effects, full day care programming, residential care, and any accepted preventive measures. Usually, as such people are facilitated through the first Phase of TRT, the stabilizing measures are needed less frequently. The client's confidence in the structure of TRT, brought about by the person's understanding of what that structure will allow him or her to accomplish over and above what was previously achievable, will inevitably replace those psychological processes that led to the requirements for additional stabilization.
The ETM program does not use the challenge method to stabilization. For example, ETM does not recommend confronting the client with (1) the morbid view (a description of the patient's body following death) as a means of dedramatizing suicidal ideation, (2) the selfish perspective (reminding the suicidal person that he or she is only thinking selfishly -- as opposed to considering the effects of the suicide on loved ones), (3) telling the person that taking his or her life is a function of choice, or (4) any other method that is based on stoicism philosophy.
These are unnecessarily high-risk methods that are intended, in our view, not so much to mitigate the risk of suicide, but to shift the responsibility for its occurrence away from the helping method, and thus the helper. Suicide is correlated to low levels of the brain neurotransmitter and neurophone serotonin, which lack can be a function of neurobiological changes resulting from the client's unresolved experience of the traumatic event. Superficial interchanges based on the helper's projections of philosophy onto the trauma victim requiring stabilization are not only in our view woefully inadequate, but, while engaged in this life or death struggle, also tantamount to spinning the cylinder in a game of Russian roulette.
|
|
|
|
