Fundamentals of Trauma Processing

Course #66232 - $48 • 8 Hours/Credits


Study Points

  1. Outline concepts and definitions important to effective trauma work.
  2. Identify various models of trauma and information processing.
  3. Assess for the presence of clinically significant trauma in an individual.
  4. Evaluate aspects of the first stage of trauma treatment with the three-stage consensus model.
  5. Describe stages 2 and 3 of the three-stage consensus model and their use in the treatment of trauma-related disorders.
  6. Determine one's own strengths and weaknesses in clinically addressing trauma and their various clinical manifestations.
  7. Access the best possible referrals for enhanced client care.

    1 . The term trauma comes from the Greek word meaning
    A) scar.
    B) wound.
    C) devastation.
    D) near-death experience.

    FOUNDATIONS: CONCEPTUALIZING TRAUMA

    Trauma is defined in many ways, but it is important to remember that it is a noun; it refers to an actual experience or wounding. Often, clinicians describe trauma based on its effects, not the actual experience. The word trauma is derived from the Greek word that literally means wound. By considering what physical wounds are and how they affect humans, the meaning of emotional trauma may be further understood. Basic principles of physical wounds and wound care include [1]:

    • Wounds come in all shapes and sizes.

    • Open wounds are usually visible to others and include incisions (e.g., from knives), lacerations (tears), abrasions (grazes), punctures, penetration wounds, and gunshot wounds.

    • Closed wounds are usually not obvious to others and include contusions (bruises), hematomas (blood tumors), internal scar tissue, crush injuries, and slowly forming chronic wounds that can develop from conditions such as pressure ulcers.

    • Wounds can form due to a variety of causes.

    • Wounds can affect different people in different ways, depending on specific variables (e.g., medical issues, genetics, environmental factors, psychosocial considerations, economic issues, access to treatment).

    • Wounds heal from the inside out.

    • Wounds are usually obtained quickly but take time to thoroughly heal.

    • Before wounds can begin to heal internally, steps must be taken to stop the initial bleeding (e.g., using bandages, gauze, stitches, sutures).

    • Failure to receive the proper treatment after a wounding can complicate the healing process.

    • Wounds can leave a variety of scars. Some are permanent, others are temporary. Many no longer hurt after the scarring has taken place, but some scarring can cause ongoing irritation.

    • The skin around a healed scar is tougher than the rest of a person's skin.

    • No two people wound in exactly the same way, even if they experience similar injuries.

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    2 . Because the human experience of trauma is fundamentally subjective, comparing traumas is difficult and generally not helpful.
    A) True
    B) False

    FOUNDATIONS: CONCEPTUALIZING TRAUMA

    Helping professionals continue to debate whether certain types of trauma are "worse" than others. For instance, this definition goes on to propose that traumas caused by humans (e.g., rape, assault) often result in greater psychologic impact than those caused by nature (e.g., earthquakes, floods) [2]. Others, however, assert that trauma caused by people may be worse for certain people, but it depends on an individual's situation, constitution, and overall coping system in place to deal with the trauma. Because the human experience of trauma is fundamentally subjective, comparing traumas is difficult and generally not helpful.

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    3 . Large-T trauma is commensurate to what construct in the DSM-5?
    A) PTSD
    B) Criterion A trauma
    C) Dissociative disorder
    D) Criterion D symptoms

    FOUNDATIONS: CONCEPTUALIZING TRAUMA

    In 2001, Shapiro introduced the ideas of classifying trauma into one of two forms: large-T trauma and small-t trauma [3]. Large-T traumas are events that most people would experience as horrific or life-threatening. Examples of large-T traumas include assault, rape, military combat, or natural disasters. Essentially, whenever there is a life-threatening component or one perceives his or her life to be in danger, large-T trauma is involved. Large-T trauma is commensurate to what is called a Criterion A trauma in the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5) description of PTSD.

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    4 . In the DSM-5, witnessing a traumatic experience does not qualify as a Criterion A trauma.
    A) True
    B) False

    FOUNDATIONS: CONCEPTUALIZING TRAUMA

    The PTSD diagnosis first appeared in the DSM-III in 1980, in response to cases stemming from the Vietnam War [4,5]. However, PTSD certainly did not start in 1980. The notion of it has been recognized throughout the ages, being referred to by such names as combat neurosis, shell shock, and hysteria. According to the DSM-5, an individual must have experienced a Criterion A trauma for PTSD to be officially diagnosed [5]. The DSM-5 significantly expanded the definition of Criterion A trauma. In the DSM-IV-TR, Criterion A trauma required there to be some threat to physical integrity or life; many professionals used the colloquialism "threat to life or limb." In the DSM-5, witnessing a traumatic experience (real or threatened) happen to someone else also qualifies, as does violent or accidental death (real or threatened) to a family member or close friend. Sexual assault and certain cases of vicarious traumatization connected to work experiences also now qualify as Criterion A. Although the presence of a Criterion A trauma is a necessary qualification for a diagnosis of PTSD, not all persons who experience Criterion A trauma will develop PTSD.

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    5 . Symptoms related to the re-experiencing of trauma are considered Criterion D symptoms.
    A) True
    B) False

    FOUNDATIONS: CONCEPTUALIZING TRAUMA

    Criterion B encompasses symptoms related to the re-experiencing of the trauma. The classic examples include flashbacks, vivid dreams, and nightmares. Hallucinations of all types can also be a part of Criterion B. When an individual is experiencing hallucinatory symptoms, he or she is typically diagnosed with some type of psychotic disorder and placed on the corresponding medications. However, it is important to assess whether or not these voices or visions are connected to earlier trauma; if so, PTSD may be a more appropriate diagnosis than a psychotic disorder. Auditory hallucinations may represent voices of an abuser or of a cruel parent, and visions may be flashbacks to an abusive episode. It becomes especially important to explore the content of these hallucinations in individuals who have experienced complex PTSD, which will be discussed in greater detail later in this course. Intense physiologic distress, often conceptualized as manifestations of a body memory, can also fall under Criterion B symptoms.

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    6 . Criterion E symptoms in the PTSD diagnosis (DSM-5) are
    A) depression.
    B) avoidance symptoms.
    C) heightened arousal symptoms.
    D) re-experiencing of the trauma.

    FOUNDATIONS: CONCEPTUALIZING TRAUMA

    Criterion E contains heightened arousal symptoms, which are also associated with psychologic pain. The two major symptoms associated with Criterion E are hypervigilance (e.g., always being on guard for something bad to happen) and an exaggerated startle response (i.e., a person is more "jumpy" than what would be considered normal). However, there are other major avoidance symptoms that are often attributed to other diagnostic categories without the trauma ever being examined. These other symptoms are [5]:

    • Problems focusing or paying attention

    • Sleep disturbance

    • Increased irritability or outbursts of anger

    • Reckless or self-destructive behavior

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    7 . Small-t trauma refers to adverse life events not qualifying for PTSD.
    A) True
    B) False

    FOUNDATIONS: CONCEPTUALIZING TRAUMA

    Trauma does not necessarily need to be Criterion A for it to be clinically significant. This notion is the basis of Shapiro's concept of small-t trauma, now referred to as adverse life events not qualifying for PTSD [3]. This type of trauma includes all of the upsetting life events that may prove difficult to handle. Many clients may minimize small-t traumas, believing that if they did not survive a major disaster their trauma is somehow less legitimate or significant. Sadly, professionals and family members may further reinforce this devastating belief by comparing levels of trauma among clients or family.

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    8 . Trauma does not need to meet PTSD criteria in order to be clinically significant.
    A) True
    B) False

    FOUNDATIONS: CONCEPTUALIZING TRAUMA

    There is a wide variety of diagnoses that are either caused by or exacerbated by adverse life events. Depression is one diagnosis that may be the manifestation of or exacerbated by adverse life event(s). Other anxiety disorders, mood disorders, adjustments disorders, and even a variety of paraphilias and other problematic behaviors catalogued in the DSM-5 can fall into this spectrum of trauma-related disorders. For example, many personality disorders are being conceptualized as complicated manifestations of unhealed trauma that occurred at a developmentally vulnerable period. Because these disorders cover a wide range of the population, clinicians may be clinically interacting with traumatized individuals without being aware of it. For full practical purposes, clinicians should always diagnose according to symptoms. However, using the logic of adverse life events and the broader conceptualization of trauma, one may be able to honor the significant nature of all traumas and treat disorders using trauma-competent strategies, even if the diagnosis is not PTSD. The general principle to keep in mind is that trauma does not have to meet PTSD criteria to be clinically significant; it may manifest as something else entirely. The principles of trauma competency discussed in this course, however, may be used to enhance the treatment of other diagnoses.

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    9 . Dissociation and severe trauma do not usually co-occur.
    A) True
    B) False

    FOUNDATIONS: CONCEPTUALIZING TRAUMA

    It is irresponsible to present a course on trauma without covering dissociation. Although the dissociative disorders receive their own diagnostic attention in the DSM-5, it is important to consider that dissociation and severe trauma often co-occur. Dissociation is a numbing, detaching defense on which the mind may rely to cope with the intense disturbance of trauma. The most extreme forms of dissociation, such as dissociative identity disorder (formerly known as multiple personality disorder), dissociative amnesia, and depersonalization/derealization disorder, can be particularly baffling to even the most experienced clinicians.

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    10 . Processing is defined as the act of
    A) talking through an issue in a group.
    B) talking through a problem one-on-one.
    C) doing a morning "check in" with oneself.
    D) making sense of an experience or learning.

    THEORETICAL MODELS

    The three stages originally proposed by Janet were [60]:

    • Stabilization, symptom-oriented treatment, and preparation for liquidation of traumatic memories

    • Identification, exploration, and modification of traumatic memories

    • Relapse prevention, relief of residual symptomatology, personality reintegration, and rehabilitation

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    11 . What are the three stages in the consensus model of trauma treatment?
    A) Reintegration, stabilization, and cognitive restructuring
    B) Stabilization, working through of the trauma, and reintegration
    C) Working through the trauma, reintegration, and survival mode
    D) Leave survival mode, stabilization, and working through of the trauma

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    12 . One of the greatest misconceptions about trauma counseling is that it is all about catharsis.
    A) True
    B) False

    THEORETICAL MODELS

    One of the greatest misconceptions about trauma counseling is that it is all about catharsis, or the second stage (i.e., identification, exploration, and modification of traumatic memories). However, if a patient or clinician jumps into catharsis without having a foundation of stabilization, including a therapeutic alliance and a set of coping or affect regulation skills, further damage can result [13].

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    13 . What are the three "brains" in MacLean's triune brain model?
    A) Right, left, and integrated
    B) Neocortex, limbic, and R-complex
    C) Pre-frontal lobe, midbrain, and R-complex
    D) Amygdala, hippocampus, and hypothalamus

    THEORETICAL MODELS

    To further the role of processing, it is vital to review some basic biology. MacLean's triune brain model suggests that the human brain actually operates as three separate minds, each with its own special role and its own respective senses of time, space, and memory [10]. While this model's use in terms of neuroanatomic evolution is considered by some to be outdated or oversimplified, it is useful as a purely explanatory tool. It describes the brain structure in a manner that is easy to understand and use as a conceptualization for treatment planning.

    • The R-complex brain (reptilian brain): Includes the brainstem and cerebellum. It controls reflex behaviors, muscle control, balance, breathing, and heartbeat, and is very reactive to direct stimulation.

    • The limbic brain: Contains the amygdala, hypothalamus, and hippocampus. It is the source of emotions and instincts within the brain, including attachment and survival. When this part of the brain is activated, emotion is activated. According to MacLean, everything in the limbic system is either agreeable (pleasure) or disagreeable (pain/distress), and survival is based on the avoidance of pain and the recurrence of pleasure.

    • The neocortex (or cerebral cortex): Contains the frontal lobe and is unique to primates. The more evolved brain, it regulates executive functioning, which can include higher-order thinking skills, reason, speech, meaning, and sapience (e.g., wisdom, calling on experience).

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    14 . Journaling and exercise are not healthy modalities of processing trauma.
    A) True
    B) False

    THEORETICAL MODELS

    One reason trauma may remain unprocessed is due to a misunderstanding of what processing involves. In many Western cultures, clinicians tend to assume that talking is the best way to process trauma; however, in other cultures, the approaches can vary from spiritual interventions to physical treatments. In many mental health and addiction treatment settings, talking is synonymous with processing. Although talking can help a person process, it is primarily a function of the frontal lobe. A person can talk about the trauma extensively, but until it is addressed at the limbic level, the trauma will likely remain a problem [13]. Other healthy modalities of processing can include exercise, breath work, imagery, journaling, drawing, prayer, or dreaming. These experiential modalities are more likely to address limbic-level activity when compared to the classic "talking it out" strategies [13].

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    15 . Which of the following is defined as a condition of prolonged trauma or trauma that occurs at developmentally vulnerable times, resulting in effects more significant than are believed possible with standard PTSD?
    A) Complex PTSD
    B) Dissociative disorder
    C) Developmental trauma
    D) Borderline personality disorder

    PROPOSALS FOR THE FUTURE OF TRAUMA DIAGNOSIS AND TREATMENT

    In response to these criticisms, the concept of complex PTSD has been introduced [18]. Essentially, complex PTSD refers to conditions of prolonged trauma or trauma that occurs at developmentally vulnerable times, resulting in effects more significant than is believed possible with standard PTSD. In its most updated definition, complex PTSD manifests from conditions that [15]:

    • Are repetitive or prolonged

    • Involve direct harm and/or neglect or abandonment by caregivers or ostensibly responsible adults

    • Occur at developmentally vulnerable times in the victim's life, such as early childhood

    • Have great potential to severely compromise a child's development

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    16 . Complex trauma manifests from conditions that
    A) occur in a single event.
    B) involve natural disasters.
    C) have potential to compromise a child's development.
    D) occur at relatively stable points in a person's life, such as middle age.

    PROPOSALS FOR THE FUTURE OF TRAUMA DIAGNOSIS AND TREATMENT

    In response to these criticisms, the concept of complex PTSD has been introduced [18]. Essentially, complex PTSD refers to conditions of prolonged trauma or trauma that occurs at developmentally vulnerable times, resulting in effects more significant than is believed possible with standard PTSD. In its most updated definition, complex PTSD manifests from conditions that [15]:

    • Are repetitive or prolonged

    • Involve direct harm and/or neglect or abandonment by caregivers or ostensibly responsible adults

    • Occur at developmentally vulnerable times in the victim's life, such as early childhood

    • Have great potential to severely compromise a child's development

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    17 . Personality disorders do not typically occur in individuals who have experienced profound trauma in childhood.
    A) True
    B) False

    PROPOSALS FOR THE FUTURE OF TRAUMA DIAGNOSIS AND TREATMENT

    Santoro suggests that borderline personality disorder is a manifestation of complex PTSD, and upon closer examination, many of the Cluster B personality disorders (e.g., borderline personality disorder, antisocial personality disorder) occur in individuals who have experienced profound trauma in childhood [20]. If a clinician is treating personality disorders, it is likely that his or her clients may be displaying complex PTSD in some form. Therefore, knowledge about trauma and PTSD can help to enhance understanding of these complicated and relatively common personality conditions.

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    18 . If no red flags for trauma are apparent in the initial session, trauma should be ruled out as a factor in the client's treatment plan.
    A) True
    B) False

    ASSESSING FOR TRAUMA-RELATED DISORDERS

    Clinicians often view assessment as the first session in which a clinician gets to know a client and gathers enough data to make a diagnosis. However, it is important to think of assessment as an ongoing process, starting before diagnosis and continuing throughout treatment, whereby data are gathered to inform the course of treatment based on the client's goals. A good initial assessment is important to ensure that an appropriate clinical snapshot is obtained and treatment is begun on the most appropriate footing. However, especially with traumatized clients who may be hesitant to disclose too much too soon, it is vital to remember that more may be revealed throughout the treatment process. Just because there were no obvious red flags for trauma in the initial session does not necessarily mean that trauma is not a factor. The client may be testing boundaries or a clinician's trustworthiness before revealing his or her most painful, private material.

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    19 . Which of the following is an example of an open-ended question as it relates to asking about family history?
    A) Was your family dysfunctional?
    B) Were you abused in your home of origin?
    C) What were things like for you growing up?
    D) Were you the victim of any kind of abuse growing up?

    ASSESSING FOR TRAUMA-RELATED DISORDERS

    Just as some mandatory forms are very vague, other facilities' assessment forms may be extensively detailed. For instance, forms may require very specific questions to be asked about the nature of clients' sexual experiences, but clinicians may find that there is not sufficient rapport established for the client to feel comfortable answering such questions. Regardless of the scenario, following guidelines can be very effective for conducting the best possible assessments, especially with clients who may be struggling about whether or not to disclose their trauma histories [1]:

    • Do not re-traumatize. Well-intentioned clinicians can re-traumatize clients if they ask questions in an interrogatory manner, minimize clients' experiences, or ask clients to talk about some aspect of their life or trauma before they are ready to talk about it. Be careful how you ask the questions. If you simply read down the list in a cold manner, the client may feel interrogated. On the other hand, you also want to avoid coming across as too saccharine and sweet in your questioning, or the client may perceive this as being disingenuous, placating, or pitying. Be the best version of yourself, and think of how you would feel if you were being asked such difficult questions about your life.

    • Consider the role of shame in complex presentations. Shame is defined as the belief that who one is, at the core, bad or defective. Shame is pervasive in many survivors of abuse or other traumatic experiences and in people who feel they are defective because they have not been able to "get better" from the disorder that brought them into treatment. From the initial history-taking session, you have the power to reinforce this shame (through re-traumatizing behaviors) or to begin dispelling it by edifying the client during the initial assessment.

    • Be genuine and build rapport from the first greeting. Edifying a client does not mean being fake and phony with goodness. Be yourself, but be attuned to how you present yourself. Always show the client dignity and respect.

    • Ask open-ended questions. One of the basics of counseling is using open-ended questions (e.g., typically those starting with what or how). These tend to be less interrogatory. For example, questions like "What were things like for you growing up?" or "How did that experience affect you?" allow clients to steer the interview in a direction commensurate with their comfort level. There are exceptions to this rule, but it is best to generally avoid using leading or closed-ended questions, like "Was that experience traumatic for you?" or others that can be answered with a simple yes or no. Be mindful of where the client is steering the interview. Using open-ended questions is a good way to accomplish this task.

    • Make use of the "stop sign technique." In this technique, the client may be instructed to give a "stop" signal (e.g., a hands up, or simply saying stop) if the assessment begins to enter into an area the client is not yet ready to discuss. At the beginning of sessions, let clients know that if they are not comfortable answering any questions they can indicate their unwillingness to continue by saying so or giving a stop sign.

    • Do not be judgmental. This should be a given for clinicians who are embarking on doing any type of trauma work. However, it is an area that requires constant self-assessment. Interpretations and diagnostic proclamations, for instance, may come across as judgmental. Remember that you may be dealing with a person with a high degree of shame-based baggage; how he or she interprets things may be different from how you would.

    • Assure clients that they may not be alone in their experiences, if appropriate. This is a strategy to use with caution, but it can be effective if used appropriately. Many clients present for treatment bogged down with shame, feeling they are uniquely bad or crazy for feeling a certain way or engaging in a certain behavior. In some cases, the simple assurance that they are not alone can make a world of difference. Only attempt this practice if you can be genuine about it. Be careful not to make it sound like you are minimizing their experience.

    • Send the client away with a quick affect regulation technique or assignment, if appropriate. If, during the first session, the client has addressed a significant amount of trauma-related issues or engaged in an unexpected catharsis, it is important to ensure that her or she is comfortable leaving. Consider teaching clients a quick breathing exercise or other body-based coping technique (e.g., pressure points, muscular clench and release, mindfulness) to effectively "shut down" the session. It is vital not to arouse client emotions with questioning unless you have a way to guide him or her back to calmness before leaving.

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    20 . The Primary Care PTSD Screen should only be used for veterans.
    A) True
    B) False

    ASSESSING FOR TRAUMA-RELATED DISORDERS

    The Primary Care PTSD Screen was developed not as a diagnostic tool, but as an effective screening tool [21,61]. This screening tool was initially validated with Veterans Affairs primary care patients, but its use has been demonstrated for nonveteran clients as well [22,23]. If a client answers yes to any three of the following questions, the results of the screening should be considered positive:

    In the past month, have you had an experience in your life that was so frightening, horrible, or upsetting that you:

    • Had nightmares about it or thought about it when you didn't want to?

    • Tried hard not to think about it or went out of your way to avoid situations that remind you of it?

    • Were constantly on guard, watchful, or easily startled?

    • Felt numb or detached from others, activities, or your surroundings?

    • Felt guilty or unable to stop blaming yourself or others for the event(s) or any problems the event(s) may have caused?

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    21 . The negative cognition "I should have known better" falls under the domain of
    A) value.
    B) safety.
    C) power.
    D) responsibility.

    ASSESSING FOR TRAUMA-RELATED DISORDERS

    NEGATIVE COGNITIONS LIST

    DomainStatements
    Responsibility
    I should have known better.
    I should have done something.
    I did something wrong.
    I am to blame.
    I cannot be trusted.
    Value
    I am not good enough.
    I am a bad person.
    I am permanently damaged.
    I am defective.
    I am terrible.
    I am worthless/inadequate.
    I am insignificant.
    I am not important.
    I deserve to die.
    I deserve only bad things.
    I am stupid.
    I do not belong.
    I am different.
    I am a failure
    I am ugly.
    My body is ugly.
    I am alone.
    I have to be perfect.
    I have to please everyone.
    Safety
    I cannot trust myself.
    I cannot trust anyone.
    I am in danger.
    I am not safe.
    I cannot show my emotions.
    Power
    I am not in control.
    I am powerless/helpless.
    I am weak.
    I am trapped.
    I have no options.
    I cannot get what I want.
    I cannot succeed.
    I cannot stand up for myself.
    I cannot let it out.
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    22 . A well-devised treatment plan documents specific, measurable goals that reflect what the client wants to get out of treatment and how the clinician will be able to therapeutically assist the client in reaching those goals.
    A) True
    B) False

    TRAUMA TREATMENT IN THE THREE-STAGE CONSENSUS MODEL

    Following the initial assessment session(s), the next step is typically the formulation of a treatment plan. A well-devised treatment plan documents specific, measurable goals that reflect what the client wants to get out of treatment and how the clinician will be able to therapeutically assist the client in reaching those goals. There are two main best practices at this stage of treatment planning: determine what the client really wants to get out of treatment and assess the client's willingness to change.

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    23 . When laying the groundwork for trauma work, the two main best practices are: determine what the client really wants to get out of treatment and assess the client's willingness to change.
    A) True
    B) False

    TRAUMA TREATMENT IN THE THREE-STAGE CONSENSUS MODEL

    Following the initial assessment session(s), the next step is typically the formulation of a treatment plan. A well-devised treatment plan documents specific, measurable goals that reflect what the client wants to get out of treatment and how the clinician will be able to therapeutically assist the client in reaching those goals. There are two main best practices at this stage of treatment planning: determine what the client really wants to get out of treatment and assess the client's willingness to change.

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    24 . A person intending to change soon is in what stage of change?
    A) Denial
    B) Action
    C) Contemplation
    D) Precontemplation

    TRAUMA TREATMENT IN THE THREE-STAGE CONSENSUS MODEL

    Part of treatment planning involves determining how a client feels about change and how much work/commitment he or she is ready to put into the process. Prochaska and DiClemente's stages of change model, very popular in the medical and addiction fields, applies to trauma treatment [25]. The stages are as follows:

    • Precontemplation: The person is not prepared to take any action at this time or in the foreseeable future.

    • Contemplation: The person is intending to change soon.

    • Preparation: The person is intending to make a change in the immediate future.

    • Action: The person is making significant changes in his or her lifestyle.

    • Maintenance: The person is working to prevent relapse.

    • Termination: The person has achieved 100% self-efficacy, and the relapse potential is near zero. (There are those in the drug and alcohol field who will, of course, argue that a recovering addict is always in maintenance.)

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    25 . Clients who present at lower stages of change should be firmly persuaded to address trauma through therapy.
    A) True
    B) False

    TRAUMA TREATMENT IN THE THREE-STAGE CONSENSUS MODEL

    Clients at lower stages of change (e.g., precontemplative) should not be bombarded with the possibility of trauma resolution all at once. Start with the basics (e.g., rapport building; discussions about problems, solutions, and treatment options; motivational enhancement) and work up from there. The basics of counseling and rapport building become even more vital with traumatized populations because of the trust factor; these relational imperative strategies are discussed in greater detail later in this course.

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    26 . In the three-stage consensus model, stage 1 is primarily a time for
    A) reintegrating into society.
    B) reprocessing of traumatic memories.
    C) development of motivation for treatment.
    D) development of coping skills and affect regulation strategies.

    TRAUMA TREATMENT IN THE THREE-STAGE CONSENSUS MODEL

    Some clinicians feel an urge to get clients talking about the trauma so the treatment process can begin as soon as possible. Although this approach can sound like common sense, the neurologic concepts covered in the first section of this course suggest otherwise. First, an individual might not be able to easily talk about a traumatic experience because of the way that it is stored in the brain. Secondly, in some cases, talking about the trauma can do more harm than good, such as if the client does not have skills in place to cope with the intense, body-level disturbance that recalling the trauma can stir up. There are two primary tasks that must be accomplished during the stabilization phase of treatment: facilitate coping skills training and affect regulation strategies, and assess/help build recovery capital, or the "good" material that a client has to draw upon, before major trauma processing work can commence.

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    27 . Basic grounding strategies consist of clients practicing their awareness in space and connecting to the present in the space they occupy.
    A) True
    B) False

    TRAUMA TREATMENT IN THE THREE-STAGE CONSENSUS MODEL

    Basic grounding strategies consist of clients practicing their awareness in space and connecting to the present in the space they occupy. One of the most basic grounding skills involves asking the client to name and describe five things he or she sees. A more multi-sensory approach may include describing sounds, smells, tastes, and sensations. This technique allows clients to return back to the room if they have left their affective window of tolerance during therapy, and it is an especially effective regrounding tool at the end of a session.

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    28 . Clients who are able to regulate their breath will likely derive more benefit from a guided imagery exercise than persons whose breathing is uncontrolled.
    A) True
    B) False

    TRAUMA TREATMENT IN THE THREE-STAGE CONSENSUS MODEL

    Although it may be easy to dismiss breathwork as too simplistic, it is a good place to start. Teaching clients a series of breathing exercises may offer them a new, radical approach to stabilization because they may have never thought about breathing before. Moreover, once a client has a strong sense of how to regulate his or her breath, other sensory skills can be practiced more effectively. For instance, those who are able to regulate their breath will likely derive more benefit from a guided imagery exercise than persons whose breathing is uncontrolled [13].

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    29 . The official name for "belly breathing" is
    A) ujjayi breathing.
    B) stomach breathing.
    C) three-part breathing.
    D) diaphragmatic breathing.

    TRAUMA TREATMENT IN THE THREE-STAGE CONSENSUS MODEL

    Three basic breath exercises that may be incorporated into a treatment plan are diaphragmatic breathing, complete breathing, and ujjayi breathing:

    • Diaphragmatic breathing (or belly breathing): Instruct the client to breathe in through the nose and out through the mouth, focusing only on the rise and fall of the belly (not the whole rib cage). Challenge the client to expand the belly as far as possible as he or she inhales. It may help for the client to put his or her hand on the belly to concentrate on this motion.

    • Complete breathing: For this exercise, the client should begin with the belly breath. When the stomach expands as far as it will go, teach the client to inhale through the nose again and concentrate on the air coming into and fully expanding the rib cage. There are two variations on the release: either a slow, steady release, which helps promote tranquility and mindfulness, or a sudden, rapid release, which can help the client experience how good "letting go" can feel.

    • Ujjayi breathing ("ocean breathing" or "Darth Vader breathing"): This breath, which is effective as an affect regulator during moments of high stress or intensity, is a noisy in-through-the-nose, out-through-the-nose technique. The mouth should stay closed, although it should also feel as if one is sucking through a straw. This allows for a greater flow of oxygen into the lungs, which can stimulate a relaxation response. For clients who are not used to mindful breathing, it is especially important to start slow with this exercise, doing no more than 5 breaths at a time. Let the client know that the louder this breath sounds (even if he or she feels self-conscious at first), the better it is likely to work.

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    30 . Pressure points that may be helpful to trauma clients are the "sea of tranquility point" (on the breastbone) and the "letting go points" (on the collarbones).
    A) True
    B) False

    TRAUMA TREATMENT IN THE THREE-STAGE CONSENSUS MODEL

    Many clinicians also use pressure points from the acupuncture/acupressure tradition and energy psychology tapping points to help enhance relaxation responses. The two points that may be useful for trauma clients are the "sea of tranquility point" (on the breastbone), and the "letting go points" (on the collarbones). While clients hold these pressure points, it is important that they maintain steady, concentrated breathing to achieve optimal impact in relaxation and regulation.

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    31 . Before doing a guided imagery exercise with a client, it is important, for the sake of safety, to
    A) have the client read the script ahead of time.
    B) choose a script using the simplest possible language.
    C) screen the image with the client first to ensure there is not any loaded meaning.
    D) use the guided imageries that you are most familiar with so you will not be led astray.

    TRAUMA TREATMENT IN THE THREE-STAGE CONSENSUS MODEL

    The biggest concern when doing guided imagery as part of trauma stabilization is to screen for the image or place the client would view as calm, happy, or safe (or any other positive emotion) prior to starting. If the client says that he or she feels safe locked in the closet, that is probably not the most adaptive place to use for an exercise, although it may be a starting point. Some traumatized clients may have no conception of what the word safety means or have a safe place. An alternative construct, such as a calm or happy place, could work. With a few exceptions, it is also advisable to give clients a general orientation to imagery and to let them know that it is typically best not to have other people involved in their image, especially at first, because this can complicate the image.

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    32 . Visual images should not be used as part of stabilization unless they are accompanied by formal guided imagery scripts.
    A) True
    B) False

    TRAUMA TREATMENT IN THE THREE-STAGE CONSENSUS MODEL

    Visual images can be used as part of stabilization, even without formal guided imagery scripts. One option is to ask the client if he or she has any pictures that he or she finds especially calming or edifying. Sometimes, a client has a picture of himself or herself as a small child that represents a state of freedom that he or she would like to access, or a recovering addict may carry pictures of family and children for motivation. Any picture that represents something positive to the client can be used as a resource, and such pictures are easy to carry around for the purposes of affective regulation.

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    33 . Which of the following stabilization exercises taps into a blend of the senses?
    A) Journaling
    B) Focusing on positive memories
    C) Imagining hopeful future scenarios
    D) All of the above

    TRAUMA TREATMENT IN THE THREE-STAGE CONSENSUS MODEL

    Three useful stabilization exercises tap into a blend of the senses: focusing on positive memories, imagining hopeful future scenarios, and journaling. Installing positive memories, when carefully done, can be a tremendously healing resource, especially as a frontloading strategy. With this technique, the clinician helps the client take a positive memory or experience and use it as a safe place image. Elicit the memory in detail and have the client give that experience a cue name. If appropriate, the cue name can be a positive self-belief that the client associates with the memory.

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    34 . Secondary gains are
    A) explanations of stage 2 trauma processing work.
    B) benefits a person obtains from staying sick/unwell.
    C) traumas counselors experience by addressing clients' trauma.
    D) improvements to physical health resulting from treatment of mental illness.

    TRAUMA TREATMENT IN THE THREE-STAGE CONSENSUS MODEL

    The following questions should be asked before moving to stage 2 trauma processing work [1]:

    • Have I assessed for secondary gains? Secondary gains are benefits a person obtains or maintains from staying sick. These gains can be as tangible as procuring a government disability check due to a diagnosis or as subtle as maintaining an excuse for irresponsible behavior. Be direct with clients about exploring secondary gains, and if they are holding on to reasons for staying stuck in maladaptive behavior(s), discuss these reasons in the context of the therapeutic alliance. Doing trauma processing work with clients who have not fully considered their secondary gains can result in more surprises or give them more excuses for poor behavioral choices. If the past is not examined at in the context of larger recovery, it can do more harm than good.

    • What is the client's motivation for wanting to do trauma processing work? Trauma processing work with a client, especially a complex one prone to destructive behaviors, can be difficult when a client's motivation for seeking treatment is unclear, especially if no effort has been made to embrace lifestyle change (e.g., if the client is in a precontemplative or contemplative stage of change) and he or she feels that a simple explanation for his or her problems lies in the past.

    • Does the client understand what may happen if change results and the effects of the trauma on his or her life start to shift? If trauma processing works for the client, there is a good chance he or she will change and adopt healthier lifestyle patterns. It is important that this possibility is discussed with clients ahead of time to ensure they are aware of what is to come, especially if people in their life are used to the client being sick or unhealthy.

    • Does the client have emotional support resources, including but not limited to, a 12-step program sponsor, a support network, a church group, or access to healthy friends and family? It is essential that if the client has an emotionally draining trauma processing session and has some disturbance after leaving, he or she has someone healthy and supportive (beside the clinician) on whom he or she can call. Encourage clients to let at least one person in their life know they are going through intense therapy. The absence of a support system does not necessarily rule out doing trauma processing with a client, but it does mean more time should be spent on stabilization. If a client is genuinely without any positive social support, explore whether there are 24-hour on-call services in the community or on-call mental health professionals available during a client's trauma processing.

    • Is the client able to reasonably calm and/or relax himself or herself when distressed? Of course, it is not necessary for a client to be able to perfectly calm himself or herself when distressed. But, it is important for clients to be able to use one or more coping skills to self-soothe. Skills can include imagery exercises, music, somatic techniques, or talking to someone. Practicing these exercises and building an arsenal of options for self-soothing is critical. Moreover, it becomes vital for clients to do these exercises on their own if disturbance from processing emotional material emerges between sessions.

    • Is there a sufficient amount of adaptive, healthy material in the client's life? Positive material can include everything from acquisition of the basic needs (e.g., food, water, shelter) to work, hobbies, a supportive family, life goals, and healthy friends. The absence of such positive material does not rule out trauma processing, but does necessitate more advanced preparation in the realm of resource development.

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    35 . Reprocessing refers to
    A) therapeutic exploration.
    B) the replacement of a healthy belief with a negative, less adaptive belief.
    C) filtering the world and experiences through the perspective of a negative cognition.
    D) consciously accessing the affected memory or experience that was not properly resolved and striving to bring about a more adaptive experience.

    TRAUMA TREATMENT IN THE THREE-STAGE CONSENSUS MODEL

    If the stabilization stage is completed successfully, the next stage, trauma processing, will be less daunting. As a quick review, processing is making sense of an experience or learning; it can be equated to digesting an unsettling event. Reprocessing refers to consciously accessing the affected memory or experience that was not processed properly and striving to bring about a more adaptive experience. The two terms will be used interchangeably in this section.

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    36 . Which of the following is NOT an example of a strategy for stage 2 trauma processing work?
    A) Trauma-focused CBT
    B) Rational emotive behavior therapy
    C) The Developmental Needs Meeting Strategy
    D) Eye movement desensitization and reprocessing

    TRAUMA TREATMENT IN THE THREE-STAGE CONSENSUS MODEL

    At present, there are many popular therapies being used for the treatment of PTSD and trauma-related disorders, all of which have some level of research to support their efficacy. Of course, the legitimacy of each therapy is weighted differently by respective clinical organizations based on how much research exists to support it. These therapies include:

    • Accelerated experiential dynamic psychotherapy

    • Acceptance and commitment therapy

    • Cognitive-behavioral therapy

    • Cognitive processing therapy

    • Dialectical behavioral therapy

    • The Developmental Needs Meeting Strategy (DNMS)

    • Emotional Freedom Technique (EFT)

    • EMDR therapy

    • Energy psychology

    • Experiential therapy

    • Exposure therapy

    • Expressive arts (e.g., music, dance, drama)

    • Focusing

    • Gestalt therapy

    • Graduated exposure therapy

    • Hakomi therapy

    • Hypnosis and hypnotherapy

    • Internal family systems therapy

    • Interpersonal neurobiology

    • Logotherapy

    • Mindfulness-based cognitive therapy

    • Narrative therapy

    • Neurofeedback

    • Neurolinguistic programming

    • Play therapy

    • Progressive counting

    • Psychoanalysis

    • Psychodrama

    • Psychomotor psychotherapy

    • Sensorimotor psychotherapy

    • Somatic experiencing

    • Stress inoculation

    • Trauma-focused cognitive-behavioral therapy

    • Traumatic incidence reduction

    • Yoga therapy

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    37 . The purpose of stage 3 reintegration is to
    A) help the client obtain meaningful employment.
    B) facilitate the reaching of goals on the client's treatment plan.
    C) help clients transition out of hospital settings into outpatient settings.
    D) help clients transition into living their lives without the sequelae of trauma.

    TRAUMA TREATMENT IN THE THREE-STAGE CONSENSUS MODEL

    Reintegration is perhaps the most logical stage of the entire consensus model, yet it is one that is often missed. The purpose of reintegration is to help clients transition into living their lives without the sequelae of trauma. When clients manage to eliminate the emotional burden of a traumatic experience during stage 2 treatment, they may feel lighter and freer. Because this catharsis is so positive, it can be tempting to stop treatment at this point, with the client feeling "cured." However, it is important to remember that, after carrying a weight for such a long time, it may feel strange or even uncomfortable to maneuver through life without it [1]. For example, if a client has released the burden of guilt over his father's death, he can begin to live his life with the new knowledge that he is a good person. But if the people in his life had grown so used to his negative self-image that they took advantage of his low self-esteem, his new outlook on life could change the whole family dynamic. These changes will require adjustments in the client's way of living. These adjustments and adaptations are not necessarily bad, but they may feel strange and new. The care and concern of a therapist who helped a client release the burden can be an invaluable asset to help him or her reintegrate into ordinary life. Essentially, reintegration work is similar to providing physical therapy or other rehabilitation following a major surgery.

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    38 . Very few clients with lifetime PTSD meet the criteria for substance use disorder.
    A) True
    B) False

    TRAUMA AND ADDICTION

    An estimated 46.4% of clients with lifetime PTSD meet the criteria for substance use disorder [34]. Various studies have found a disproportionately higher number of abuse, neglect, or trauma histories in substance abusers than in the general population [35,36,37,38,39]. Of patients in substance disorder treatment, 12% to 34% have a diagnosis of PTSD; these numbers can be as high as 33% to 59% in certain subgroups, including women [37,40,41]. Brown and Gilman reported that nearly 65% of persons found eligible for county drug court were affected by trauma in some way [42]. Further categorized, 26% met the criteria for PTSD, 35% reported some PTSD symptoms connected to a trauma but did not meet full criteria for PTSD as defined by the DSM-IV-TR, and 3.9% had experienced a Criterion A trauma at some point in their life but had no PTSD symptoms.

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    39 . Substance abuse increases the likelihood of victimization.
    A) True
    B) False

    TRAUMA AND ADDICTION

    Individuals with a history of PTSD are more likely to have a history of other psychiatric disorders, alcohol dependence, and other significant psychosocial impairments [43]. Furthermore, substance abuse increases the likelihood of victimization, which can further promulgate the cycle of coping with trauma-related stress and self-medicating with addictive substances [14,44,45,46,47].

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    40 . An integrated, more holistic approach to the treatment of co-occurring trauma and addiction would extend beyond the cognitive interventions that have traditionally been used in relapse prevention counseling or in 12-step-related interventions.
    A) True
    B) False

    TRAUMA AND ADDICTION

    The authors of the Addiction and Trauma Recovery Integration Model (ATRIUM) assert that traditional models of addiction recovery and relapse prevention do not consider the significant role that unresolved trauma can play in an addicted individual's attempt at recovery [48]. They further contend that these traditional approaches tend to marginalize addicted, traumatized women more than their male counterparts. Though the authors do not discredit the merit of traditional models, such as 12-step facilitation or cognitive-behavioral therapy, they suggest that these approaches do not sufficiently address the role that trauma has played. Ultimately, these approaches can set individuals up to fail. Though these ideas are compatible with common themes on relapse risk factors in the literature (e.g., poor self-efficacy, high volume of negative emotion coupled with poor coping skills), an integrated, more holistic approach is needed to promote long-term recovery and prevent relapse. This type of an approach would extend beyond the cognitive interventions that have traditionally been used in relapse prevention counseling or in 12-step-related interventions [13].

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    41 . The disease model of addiction and conventional 12-step approaches to treatment are productive in treating the addicted survivor of trauma.
    A) True
    B) False

    TRAUMA AND ADDICTION

    Evans and Sullivan proposed a five-tenet model that can be a useful guide [49]. The five essential components of this model are [49]:

    • A large portion of clients presenting for treatment in any setting have a history of childhood trauma. Respecting this history enhances treatment.

    • Successful treatment of the trauma must include working through memories of the trauma in an experiential way, after the clinician and client have established a foundation of safety and coping skills.

    • Substance use disorders are a significant part of the clinical picture for many survivors of trauma. Thus, treatment of the abuse issues that does not address the substance use issues will be ineffective, and treating only the addiction in those with survivor issues will likely be ineffective.

    • The disease model of addiction and conventional 12-step approaches to treatment are productive in treating the addicted survivor of trauma.

    • Treatment models for addicted survivors of trauma must be integrated and must address the synergism of trauma and addiction. A two-track approach is generally ineffective.

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    42 . Which of the following is NOT one of the qualities of a good trauma therapist?
    A) Spaciousness
    B) Good clinical skills
    C) Comfort with trauma
    D) Rigid adherence to therapeutic protocols

    EVALUATING PERSONAL ROADBLOCKS TO ADDRESSING TRAUMA

    There are several qualities that have been identified as lending themselves to ensuring that an EMDR therapist is effective and accepted by clients [55]. However, these qualities are also positive traits of good trauma therapists in general. The following list and questions can be applied to clinical practice, regardless of approach. These questions should serve as a form of self-evaluation, allowing for the identification of strengths and weaknesses:

    Good Clinical Skills

    • What abilities or special skills do I have as a clinician?

    • How comfortable am I with implementing the most basic clinical strategies for safety (e.g., risk assessment, contracting for safety, seeking outside help when necessary)?

    • If trauma processing sessions do not go as planned, what other clinical skills may I utilize to ensure that the client is not harmed?

    Ability to Develop Rapport with Clients

    • What effective strategies do I have to establish rapport at the first meeting with a client?

    • What are my struggles with forging a solid therapeutic relationship?

    • Are there certain populations with whom I find it especially difficult to connect?

    • If it becomes clear that the client and I are not connecting after several sessions, am I willing to explore the potential problems and solutions? Would I be willing to make a referral?

    Comfort with Trauma and Intense Affect

    • How do I feel when a client enters a state of extreme emotional catharsis in my office (e.g., intense crying, screaming, or lashing out at a figure from the past who is not in the office, such as a past abuser)?

    • What personal issues do clients seem to provoke the most in me?

    • What aspects of trauma and its sequelae might I still find hard to grasp clinically or personally?

    Spacious

    • Have I ever forced a client to work on an area that he or she might not be ready to handle?

    • What might my motives be for pushing a client to work on traumatic material that he or she is not yet ready to address?

    Well-Grounded

    • Have I worked on my own issues when it comes to trauma, addiction, and mental health?

    • What are my motives for helping people deal with their traumas?

    • Do I let the client lead the session, or am I usually the leader?

    Attuned to Clients

    • What issues may keep me from staying present with my client during sessions?

    • At what times might I find myself drifting off or distracted during sessions?

    • Am I able to read my clients nonverbal and paraverbal cues?

    Client perception and comfort can also affect treatment outcomes. One small study with clients who had attained a period of extended addiction sobriety (one to six years) and had been treated with EMDR found that client-identified clinician qualities that resulted in greater satisfaction with care included [13]:

    • Caring

    • Trustworthy

    • Intuitive

    • Natural

    • Connected

    • Comfortable with trauma work

    • Skilled

    • Accommodating

    • Commonsensical

    • Validating

    • Gentle

    • Nurturing

    • Facilitating

    • Smart

    • Consoling

    Likewise, traits associated with ineffective therapists were [13]:

    • Rigid

    • Scripted

    • Detached

    • Not comfortable with trauma work

    • Anxious

    • Unclear

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    43 . In order for self-care to be effective, it must be
    A) recorded.
    B) pre-emptive.
    C) triggered by a stressful event.
    D) extensive and time consuming.

    EVALUATING PERSONAL ROADBLOCKS TO ADDRESSING TRAUMA

    Mastering the arts of self-care and self-improvement are vital for any clinician, but for a clinician doing quality trauma work, they are absolutely essential. Self-care must be pre-emptive to be effective; it is not enough to initiate interventions after the weight of trauma work is taking its toll [56]. Clinicians doing any trauma work must constantly evaluate and care for themselves first. This can be difficult, as clinicians are trained to care for others and clients' needs may seem more urgent. But it is important to recognize that self-care is not selfish—it is essential to ensuring that the client continues to receive the best possible care from a healthy clinician.

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    44 . The therapeutic process of bringing forgotten or inhibited material from the unconscious into consciousness, with concurrent emotional release and discharge of tension and anxiety, is referred to as
    A) trauma.
    B) abreaction.
    C) transference.
    D) intense affect.

    EVALUATING PERSONAL ROADBLOCKS TO ADDRESSING TRAUMA

    Before initiating stage 2 trauma processing work with clients, it is important to assess one's comfort with handling abreaction and intense affect. Abreaction is defined as "the therapeutic process of bringing forgotten or inhibited material (e.g., experiences, memories) from the unconscious into consciousness, with concurrent emotional release and discharge of tension and anxiety" [2]. In simpler terms, an abreaction is a massive emotional reaction to accessing long-repressed experiences and emotions and may be evidenced by crying, screaming, foaming at the mouth, vomiting, or catatonia in extreme circumstances. Although it can be upsetting, these reactions can be part of a healthy resolution if they are addressed effectively in relation to the goals stage 2 trauma processing work is designed to achieve [1].

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    45 . Which of the following is NOT a best practice for collaboration in treating trauma-related disorders?
    A) Know your limits.
    B) Network in your community.
    C) Use the Internet and online resources.
    D) Avoid referrals to physicians who utilize pharmacotherapy.

    COLLABORATION AND REFERRAL OPTIONS

    As the saying goes, it takes a village to help clients affected by trauma. Often, this comes in the form of needed social support, but in many cases, it also involves collaboration among several providers to ensure clients meet their treatment goals. Best practices for collaboration in treating trauma-related disorders include:

    • Know your limits. If a client is triggering you or treatment has moved outside your scope of practice, refer to another clinician.

    • The Internet can be a valuable resource. Many websites focusing on specific therapies publish national databases of clinicians specializing in trauma.

    • Network in your local community. Get to know clinicians in the area who offer treatment for trauma survivors.

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