Lecture 4 phase 1 safety & stabilization

Lecture 4
Phase 1: Assessment of
complex trauma; Goal setting;
Safety and Stabilization
Complex trauma
Kevin Standish

Learning outcomes
1. To Assess complex trauma adequately.
2. To set treatment goals for complex
trauma.
3. To identify the core tasks of Phase 1:
Safety, Stabilization, and Engagement

1. ASSESSMENT
1.1.The need for support neutrality
1.2. Principles and strategies
1.3. Assessment measures using various instruments
1.4. Formulation: Descriptive diagnosis

1. Assessment
1. The primary function of psychological
assessment is to inform treatment.
2. Where the variety of potential symptoms for
any given client may be significantly
associated with various disorders,
assessment is essential to determine an
accurate treatment approach.
3. Clinical intervention is customised for each
individual in terms of symptoms and
problems that they experience

1.1.The need for support
neutrality
1. A stance of "supportive neutrality" is
recommended
2. As the individual may be unable to disclose
traumatic events unless supported through
direct yet sensitive questioning
3. Trauma victims have experienced intrusion
and damage at the hands of others and are
highly suspicious of the motives and
intentions of anyone wanting to help them.

1.2.PRINCIPLES AND STRATEGIES
1.2.1. Assessment provides baseline information
1.2.2. Impact of Assessment the client and Therapist
1.2.3. Under- and Overreporting
1.2.4.The crisis presentation
1.2.5. When trauma and abuse victimization are disclosed
1.2.6. When trauma and abuse are not disclosed

1.2.1. Assessment provides
baseline information
1. Assessment begins with an intake interview and a
comprehensive psychosocial evaluation
2. The intake assessment provides a baseline of information
about the individual status at the time
3. A clinical interview is usually the basis for a broad-based
assessment which covers a range of issues from basic
demographic information, presenting complaints, review
of symptoms, previous treatment, life stresses, personal
safety and current medication or abuse of substances.
4. A second major area involves personal and social
histories. These include developmental milestones,
family history, parental relationships, extended family
history, cultural background, religion, sexual identity,
culture of origin, ethnicity etc

1.2.1. Assessment provides
baseline information
5. A third major area is assessing the individual's
personal strengths and resources as well as their
personal support network
6. A general risk assessment is part of the overall
assessment and includes questions about past or
current trauma, current safety and risk of violence to
self or others, domestic violence, substance abuse and
history of mental illness
7. Other areas of assessment include the clients
current living situation, economic status and job
security, current medical treatments including other
alternative treatments.

1.2.2.Impact of Assessment the
client and Therapist
1. The assessment process is likely to be stressful.
2. It is crucial to create conditions that are safe,
supportive and non-judgemental
3. The client is encouraged to maintain as much
control as possible, to communicate dissociative
features, to ask for clarification and choose not to
answer questions when necessary
4. Adjust the pace of assessment or suspended if it
becomes unsettling or causes a decompensation in
the client functioning
5. If the client becomes distressed and destabilised the
assessment process must be halted and the
individual re-stabilised
6. Therapist must be aware of trauma transference and
the vicarious traumatisation

1.2.3.Under- and Over-reporting
1. Traumatised individuals may under or over report their
experiences, especially if questions are imprecise or
misunderstood
2. Questions need to be phrased precisely but neutrally
using behavioural descriptions: "did you, as a child, ever
have a sexual experience with an adult?"
3. Disguised presentation will often take the form of
parentified clients: those who come across as competent,
responsible, confident and mature. They are expert at
masking difficulties and concerns, and taking care of
others. Described as pseudo-mature.
4. The overly responsible client resembles the apparent
normal personality (ANP), with the EP being separated off
from the trauma with emotional material not available in
pretreatment assessment

1.2.3.Under- and Over-reporting
5. Various other reasons for disguised presentation or
under reporting include: lack of awareness, gender
(males less likely to disclose) trauma bonding,
dissociation, memory loss, and avoidance due to
shame and embarrassment.
6. Over-reporting can occur due to secondary gain,
retribution, an explanation for life problems, memory
errors, and severe personality disturbances.
7. It is unknown how often trauma is over or under
reported due to false memory, false belief or other
factors.

1. The crisis presentation is the re-emergence of the
trauma and its symptoms often in an unplanned and
spontaneous manner
2. The symptoms can bring on acute states of anxiety,
depression or dissociation with individual the
compensating into more severe mental health states
3. The re-emergence of the trauma is highly
distressing, and is often stirred up by events or
other stimuli the that has served as a reminder.
4. Various life events whether they are distressing and
decremental ( involving illness, death, Anniversary
Dates etc) or happy and incremental (marriage,
pregnancy, birth of a child) can trigger symptoms.

5. These positive events can cause a crisis
when they provide enough security for
defences to lessen resulting in the emergence
of symptoms and memories.
6. Crisis intervention requires emotional
support, stabilisation and safety, normalisation
of reactions and a non-judgemental stance
7. In severe cases hospitalisation and
medication may be required

1.2.5.When trauma and abuse
victimization are disclosed
1. When trauma is disclosed the therapist should
enquire about both objective factors (who, what,
when, where), and subjective thoughts beliefs and
feelings, and record responses factually.
2. In the disclosure the therapist must remain aware of
the split between ANP and EP: often there are
delayed emotional responses to the disclosure.
3. It is important clarify underlying childhood
messages and beliefs about disclosure of the abuse
information: threats of death or injury upon the
disclosure
4. Therapist needs to be supportive, understanding and
not press for certainty and tolerating unclear
answers

victimization are disclosed
5. Therapist must assess and evaluate for
possible PTSD, dissociation, substance-abuse
and other related emotional somatic disorders
6. It is important to emphasise to the client that
disclosure does not mean resolution, but
rather signifies the beginning of the treatment
process in which resolution is the major goal
7. The process of telling for the first time for
many victims is cathartic and therapeutic for
them, but does not mean resolution

are not disclosed
1. Trauma and victimisation may not be divulged even when questions
direct and unambiguous: trauma events may not be known but only
suspected; the event is known but not disclosed; or the event did not
occur and there is nothing to disclose.
2. When the occurrence of the event is unclear, expectations and
motivations need to be clarified.
3. Do not assume the meaning of the lack of disclosure. Therapist may
observe and identify the possibility of traumatisation from the clients
presentation and history. The therapist may develop a hypothesis of
trauma, but this needs to be kept private in order not to be suggestive
of trauma.
4. The development of false memory syndrome needs avoided at all
costs.
http://www.ted.com/talks/elizabeth_loftus_the_fiction_of_memory
5. When memory is absent, the therapist should not speculate about, fill
in, or try to confirm suspicions. It is important to tolerate the
uncertainty of not knowing. Ongoing open exploration over time is
what is required.

1.3. Assessment measures using
various instruments
1. A number of trauma specific
psychological instruments available to
supplement the psychosocial
interview
2. Accurate assessment of traumatic
experiences and trauma related
symptoms can be made with
psychometricly sound instruments
constructed specifically for
assessments of trauma.

1.3. Assessment measures
1.3.1.General psychological inventories
and structured interviews
1.3.2. PTSD and Dissociative symptoms
questionnaires
1.3.3. Measures of traumatic events and
experiences
1.3.4. Assessment of attachment style
1.3.5.Collateral Assessment
1.3.6. Prognostic indicators

1.3.1. General psychological
inventories and structured interviews
1. A variety of self report inventories, symptom
checklists and structured interviews are available to
guide a generic clinical interview.
2. Many of these instruments are not specifically
designed to assess complex trauma. They tend to
assess a variety of other broader categories of
mental health problems which victims of complex
trauma will have.
3. Pervasive symptoms covering a range of disorders
are highly correlated with complex trauma.

1.3.2. PTSD and Dissociative
symptoms questionnaires
1.A variety of instruments available for the
assessment of PTSD and dissociative
disorders.
2.Post-traumatic stress diagnostic scale,
dissociative experience scale, dissociative
disorders interview schedule are just a
number of available instruments for the
assessment of these conditions

1.3.3.Measures of traumatic
events and experiences
1.Instruments that explore specific types of
traumatic events and experiences have been
developed using structured set of questions
posed by the interviewer who records
responses verbatim.
2.They elicit specific information about the
experience and event when a trauma history
has been disclosed: e.g. Courtis incest
history questionnaire is an example.

1.3.4.Assessment of attachment
style
1.It is imperative to measure
attachment status as part of a
comprehensive assessment of
complex trauma.
2.Early attachment predicts a
significant proportion of adult
psychopathology in relation to
traumatic events
3.The Adult Attachment
Inventory (AAI) is the most
used instrument for
determining attachment style.

1.3.5.Collateral Assessment
1. Collateral assessment with spouse, family members, friends,
teachers etc can be warranted to obtain more objective
information, to provide information about events which the
client has little or no recollection. (The movie Prince of Tides is
an example).
2. It can also help assess the impact the client has on others and
the way in which they interact in relationships can provide
valuable data
3. Seeking collateral information is best decided and undertaken
collaboratively with the client. The suggestion to include
information from outside sources must be judicious and have a
clear rationale with the client explicit permission.
4. The failure to do so would reinforce the clients sense of
victimisation and powerlessness.

1.3.6.Prognostic indicators
The capacity of the client to manage the treatment process has to do with
the unique circumstances of each client and their resilience.
Kluft (1999) has three descriptions:
1. client in the low trajectory had conditions of chronic trauma, chronic
mental illness, chaotic love and unstable families, complicated with
addictions, self harm and suicide, limited support and difficulty to engage
with the therapeutic agenda.
2. Client in the middle trajectory had more stability in their lives, greater
resources at their disposal, yet required years of treatment in order to
achieve a stable recovery. Emotional regulation was the major treatment
task. High levels of mistrust impeded the therapeutic work.
3. High trajectory clients have the most personal and interpersonal
capacities and resources at their disposal. Treatment is the least crisis
prone, they are able to engage in the therapeutic relationship, and
treatment takes the least amount of time.

“Not all clients heal from the trauma in
the same way or to the same degree
despite receiving similar treatments”

Prognosis needs to look at the following eight main
categories:
1. Lack of motivation
2. Lack of healthy relationships
3. Lack of healthy therapeutic relationship
4. Lack of other internal and external resources
5. Serious axis I comorbidity
6. Serious axis II comorbidity
7. Poor attachment
8. Self-destructive behaviours
This checklist can help focus therapeutic attention towards specific
treatment goals related to the prognostic categories, or in the case of a
low trajectory client be aware that the treatment goals may be limited to
the stabilisation phase only.

1.4. Formulation: Descriptive
diagnosis
1. Arriving at a post assessment diagnostic formulation
for complex trauma client is a complicated process
involving a number of symptoms and developmental
consequences that spanned more than one
diagnostic category and the co-occurring symptoms
that emerged over the course of treatment.
2. The conceptualisation of complex PTSD/DESNOS is
a useful way of organising multiple symptoms and
associated diagnosis.

1.4. Formulation: Descriptive
diagnosis
3. Complex traumatic sequelae are changes in the mind,
emotions, body and relationships experienced following
complex psychological trauma, including severe
problems with dissociation, emotional dysregulation,
somatic distress, relational or spiritual alienation,
referred to as complex traumatic stress disorders.
4. It is important to arrive at a comprehensive and
descriptive diagnosis of complex trauma. Utilising the
DSM axis system will help formulate important
descriptive elements needed to understand the client in a
comprehensive manner.
5. Multiple diagnoses and descriptions within each axis
should be given where necessary to describe the current
condition.

2. GOAL SETTING
2.1. Goals for ptsd
2.2. Additional goals for complex trauma
2.3. Metagoals for therapy with complex trauma

Goal setting
1. As survivors of complex trauma will experience
symptoms of both PTSD and complex traumatic stress
disorders, along with the associated features and co-
occurring disorders, the therapist must assess and
identify the specific symptoms that are most troubling
and cause the greatest degree of personal and
interpersonal impairment.
2. These collaboratively established goals are required to
be treated, together with the phase based approach to
treatment.

2.1.Goals for ptsd
Numerous treatment models for PTSD available.
The core goals for the treatment of PTSD include the
following:
1. To increase the capacity to respond to the threat with
realistic appraisal rather than exaggerated responses.
2. To maintain normal levels of arousal rather than
hypervigilance or numbing.
3. To facilitate the return to normal development, adaptive
coping and improved functioning in work and relationships.
4. To restore personal integrity and normalise traumatic
stress response by validating the symptoms and
establishing a frame of meaning.
5. Conduct treatment in the atmosphere of safety and
security and ensure re-traumatisation is minimised.

2.1.Goals for ptsd
6. To regulate the level of intensity of traumatic aspects
through cognitive reappraisal.
7. To increase capacity to differentiate remembering
from reliving past traumas.
8. To place trauma in perspective and regain control of a
life experiences.
9. To attend to biological and social learning risk factors
that shape the trauma response.
10. To actively intervene to address secondary
responses and comorbidities.
11.To improve the sense of self from victim to an
individual engaged in life.
12. To enhance personal courage in approaching the
memories of trauma.

2.2.Additional goals for complex
trauma
Clients with complex trauma histories tend to have
additional problems: self, relational, developmental and
life skill deficits beyond those of PTSD.
8 Additional goals build on the 12 listed to address these
developmental deficits:
1. To face the trauma memory and its associated feelings,
cognitions, beliefs and schema about self and others.
2. The experience relational safety and attunement in the
treatment relationship as a secure base.
3. To develop and restore emotional regulation, to identify
emotions and increase the capacity for tolerance of
emotional expression through self development.
4. To shift the self-concept from permanently damage to
resilient and recovered from injury.

2.2.Additional goals for complex
trauma
5. To shift the self-concept from helplessness to
autonomous self determination.
6. To acquire capacities for bodily self awareness and
arousal regulation that have been split off through
somatoform dissociation.
7. To develop a self regulatory capacity to recognise
and reduce the severity and frequency of dissociation,
addiction, self harm, impulsivity and aggression
towards self and others.
8. To identify re-enactments of traumatic events and
develop self protection and self enhancement skills to
prevent re-victimisation and re-traumatisation.

2.3.Metagoals for therapy with
complex trauma
1. Challenge avoidance through attachment
security and skill development
2. Enhance self determination and autonomy
3. Enhance ability to manage extreme arousal
states
4. Enhance sense of self and personal identity
5. Enhance Sense of Personal Control and Self-
efficacy
6. Maintain functioning and over-come co-
occurring difficulties and disorders
7. Recognise and prevent traumatic re-enactments
8. Repair the Mind - body split
The following list of metagoals help simplify the complete list of 20 points.
The following eight metagoals acts as a reference point for the therapist to
ensure that they remain on track overall

2.3.1.Challenge avoidance through
attachment security and skill development
1. Avoidance in order to self protect from the trauma of
painful memories is a common process for victims.
However it results in of an over-generalisation and
prevents the processing of the traumatic memories.
2. There are a myriad of avoidance strategies used by
victims. The strategies involve avoiding experiencing
intolerable and unmanageable internal and affective
emotional distress.
3. Driven by healthy motivation to survive overwhelming
experiences, avoidance results in the loss of emotional,
cognitive, behavioural and interpersonal functioning.
4. Trauma clients require assistance with the attachment
insecurity and emotional dysregulation in order to learn
to recognise and modify the ways in which the use
avoidance to cope with distress.

2.3.2.Enhance self determination
and autonomy
1. Attachment security and emotional regulation also help achieve
self-determination and autonomy.
2. The therapist needs to treat each client as the "authority" in
determining the meaning and interpretation of their traumatic
experiences
3. It is important for the client to take ownership of their memories
and life story by determining their personal meaning
associated with this.
4. To survive many clients gave up self-determination and choice:
through a process of "other – directedness", developing an
external locus of control, and being hypervigilant to the needs
of the dominant other.
5. It is important to help the client develop autonomy and choice
but balanced against appropriate dependency needs through
the course of treatment.

2.3.2.Enhance self determination
and autonomy
6. Preoccupied attachment style are more dependent
and require more closeness
7. Dismissive/detached attachment style require more
distance initially
8. Disorganised/disorientated style involve a blend of
closeness and detachment.
9. It is important to notice the pattern and encourage
reflection by the client as to its meaning and
purpose
10.The therapist engagement, predictability and
consistency are essential in helping them develop
healthy and secure attachment

2.3.3.Enhance ability to manage
extreme arousal states
1. Trauma survivors suffer from extreme states of
arousal, or insufficient arousal of numbing and
dissociation. Both states, hyper arousal and hypo
arousal create distress for the client
2. These emotional states of arousal and nothingness
are maladaptive self soothing attempts
3. The therapist assists the client to monitor these
states through specific instruction in emotional
identification, bodily awareness and processing of
these states cognitively.
4. Clients learned to identify their emotions and self
regulate their states that there are no longer at the
mercy of them.

2.3.4.Enhance sense of self and
personal identity
1. The self concept of most abuse children is highly
negative as they incorporate the blame for their
mistreatment and neglect.
2. Primary goal is to provide conditions that allow and
encourage self exploration to allow a more positive
sense of self to develop. Rogers therapeutic
conditions help develop a sense of worth.
3. Achieving connection at relational depth allows for
greater attunement between therapist and client.
The significance of this is reflected in the healthy
development of the mind of the child and later the
adults.

2.3.5.Enhance Sense of Personal
Control and Self-efficacy
1. Particular attention is be paid to assisting clients to
develop personal and interpersonal pride and
confidence without being overwhelmed by negative
emotions such as fear, alienation self-hatred and
shame.
2. Trauma memory and symptom processing must be
timed and structured to support the client ability to
process memories and gain a sense of self efficacy.

2.3.6.Maintain functioning and over-come
co-occurring difficulties and disorders
1.It needs to be recognised that some clients
functioning is permanently compromised
and will never return to their original
potential.
2.Clients often steeped in helplessness due to
repeated disempowerment, and comorbid
disorders such as anxiety, depression and
dissociation
3.These are best addressed by teaching
specific skills such as assertiveness, goal
setting, decision-making, problem solving,
and boundary management.

2.3.7.Recognise and prevent
traumatic reenactments
1.The ways in which trauma histories are re-
enacted in relationships with others and
generally in life need to be addressed in the
therapeutic process.
2.The interventions may include developing
strategies for coping, developing a safety
plan to prevent reenactments, to develop a
strategy for safety in interactions with
abusive others, workplace plans to prevent
abuse and bullying.

2.3.8.Repair the Mind - body
split
1. Trauma results in major physiological based coping
responses (fight flight freeze or collapse).
2. This results in a state known as allostatis: a chronic
stress response of unremitting arousal that occurs
in the absence of danger even when the individual is
in a relaxed state.
3. Somatoform dissociation is the body's attempt to
split off the trauma and its reactions
4. Therapy is directed towards mind-body
integrationon the level of arousal management and
emotional responses.
5. Progressive relaxation is often taught in early
treatment.

3. PHASE 1: SAFETY AND
STABILIZATION

3. Phase 1: Safety and
Stabilization
1. Phase 1 is usually the longest stage of treatment,
and the most important to its success.
2. It includes pre-treatment issues such as
development of motivation for treatment, informed
consent, and psycho-education
3. It begins with the development of the collaborative
alliance.
4. Some clients do well in this phase and have no need
to complete the other two phases of treatment or
choose not to do so.
5. Others never move beyond this phase and use it
as a life maintenance process, often under the term
of supportive therapy.

3. Phase 1: Safety and
Stabilization
1. Personal and interpersonal safety is an essential
condition for successful treatment and takes time to
develop
2. Treatment must enhance the client's ability to manage
extreme arousal states
3. Treatment must enhance the clients ability to cope with
bodily/affective states. To manage dissociative states.
4. Psycho-education is a core and essential element in this
phase
5. Develop self awareness and enhance relational
capacities
6. Trauma antecedents are described directly or indirectly,
but trauma memory processing and resolution are not
the focus.
7. Building the therapeutic alliance

3.1.Personal and interpersonal safety is an
essential condition for successful treatment and
takes time to develop
1. Complex trauma survivors often are living in conditions of
relational and laugh chaos, back basic forms of safety in
relation to others (e.g. Domestic violence) and insults (self
harm, addictions, suicide).
2. It is essential to establish conditions of safety to the fullest
extent possible
3. The client cannot progress if the relative degree of safety is not
attainable
4. Lack of safety means the client remains engaged in defensive
and protective strategies in order to avoid being emotionally
overwhelmed
5. When the client continues to be an unsafe situation, the
therapist should focus on providing education and support and
not move beyond the initial stage of treatment

3.2.Treatment must enhance the client's
ability to manage extreme arousal states
1. Treatment assists the client in identifying arousal
states, labelling emotions, and carrying through
decisions to prevent hyper or hypo-arousal.
2. Clients learn to self modulate their states of arousal
through specific skills training interventions rather
than remaining reactive or dissociated.

3.3.Treatment must enhance the clients ability to
cope with bodily/affective states.
1. Avoidance is a hallmark of traumatic stress
disorders and resolving avoidance a benchmark for
successful treatment
2. Developing ways of actively engaging with both
positive and negative experiences requires a
conscious approach and self regulation to shift
away from automatic responses.
3. The main challenge in phase 1 is to enhance
awareness of subtle and obvious forms of
avoidance in times of distress and develop more
effective active coping strategies

3.4.Psycho-education is a core and
essential element in this phase
Education about trauma and impact is
important and may help clients understand
their reactions and develop increased self
compassion.
It also provides a foundation for the teaching
of specific skills

3.5.Develop self awareness and
enhance relational capacities
1. Interpersonal trauma interferes with the acquisition of a
positive identity, personal control and self efficacy.
2. Particular attention needs to be paid to identity development.
3. The process of collaborative analysis by client and therapist of
the clients self-perceptions, values, emotions and personal
resources help determine how early life experiences and
subsequent psychological trauma shaped the individuals
working model of attachment.
4. Clients are assisted in recognising and understanding the
origins of the insecure and dis-organised attachment patterns
while experiencing a secure relational base through
interaction with the therapist and the role modelling
of interpersonal skills by the therapist.

3.6.Trauma antecedents are described directly or
indirectly, but trauma memory processing and
resolution are not the focus.
1. The major difference between phase 1 and phase 2 is is not the
working through, or processing of the traumatic experience
itself in phase 1.
2. In Phase 1 it is the impact of traumatic experiences is
addressed by teaching the client what are post-traumatic
stressors and that developmental problems are adaptive
reactions to traumatic experiences in childhood.
3. The clients ongoing symptoms becomes the basis for
determining whether more directed work is required. If the
client continues to have PTSD, as well as other symptoms, and
is willing to work more directly on trauma memories treatment
proceeds to phase 2.
4. Clients may move back and forth between phases, especially in
times of crisis.

3.7.Building the therapeutic
alliance

3.7.Building the therapeutic
alliance
1. Developing the therapeutic alliance is crucial because it
addresses the fear associated with relationships in complex
trauma clients.
2. Therapy offers a compensatory relationship within a
professional framework, bound by an ethical code and
therapeutic competence.
3. A core strategy is to explicitly acknowledged and reframe the
threatening aspects of the relationship.
4. Due to the mistrust of others, therapists need to acknowledge
and validate the client fear of being deceived and betrayed yet
again, whilst simultaneously longing for a trustworthy
relationship.
5. Trust is not expected but is earned over time through
consistency, reliability, and honesty in the therapist words and
actions.

3.7.Threats to the therapeutic
alliance
1. The first threat is mis-attunement: It is important to
acknowledge that therapist will make mistakes, and be
mis-attuned to the client at times, but will strive to rectify
them in consultation and collaboration with the client.
2. The second major threat to the therapeutic alliance is the
fear of abandonment.
Therapist will not always be fully available present for the
client for various reasons including holidays, family
commitments, after hour calls which cannot be returned
right away. The overall message is to be that the therapist is
striving in the clients trust despite being imperfect.
Therapists can at best be "good enough" not perfect in their
responsiveness and availability.

alliance
3. Third threat to the therapeutic alliance is the fear that
the therapist will use their authority and expertise to
intimidate coerce or control the client.
Clients who have experienced exploitation by those in
positions of authority expect similar behaviour from
others. This is heightened if the therapist presents as a
detached observer and in the "expert position".
The challenge for the therapist is to maintain a stance
of supportive openness, and empathic attunement with
limits and boundaries.

alliance
4. A fourth threat occurs when the client has become resigned to
their sick role. The client has become comfortable in their
discomfort and therapy threatens to destabilise an apparently
manageable equilibrium.
The client may maintain "the sick role" in order to keep the
therapist attention and nurturance. Getting better runs the risk of
losing the therapist!
The client's legitimate neediness and dependency are issues that
are acknowledged and provided for over the course of treatment.
The therapist has a responsibility not to overindulge or over deny
the client, walking a fine line between being available with
reasonable and appropriate limits and boundaries.
Understanding the client attachment needs from an empathic and
validating perspective does not pathologise or blame the client.

alliance
5. Fifth threat to the therapeutic alliance is a client staying in
"survival mode".
The therapist needs to see beyond the clinical presentation of the
clients symptoms, and develop a truly individualised connection
to assist the client in gaining self knowledge through collaborative
process.
The challenge in phase 1 is to be able to recognise and helped the
client become aware of the adaptive and maladaptive
characteristics as a result of complex trauma in order to create a
solid foundation for challenge
Read Courtis & Ford (2009) chapter 9: therapeutic alliance and risk
management

Seminar Homework
Write up the assessment of the case
study using the principles and
assessment measures to create a
formulation: A comprehensive
description of the various facets involved
in the case that will affect the outcome.

Readings
Core Readings
1. Courtis & Ford (2009) chapter 5. Assessment of
the Sequelae of Complex Trauma: Evidence-
Based
Measures, John Briere and Joseph Spinazzola
2. Sanderson (2013) chapter 5 safe trauma therapy
Advanced Reading
3. Courtois & Ford (2013) chapter 5 phase 1:
safety, stabilisation and engagement – measured
in skills, not time

Helpful Websites
1. National Institute of Mental Health.
www.nimh.nih.gov/health/publications
2. Psychology Self-Help Resources on the Internet.
www.psyww.com/resource/selfhelp.htm
3. Sidran Institute: Traumatic Stress Education and
Advocacy. www.sidran.org
4. Male Survivors: Overcoming Sexual Victimization of Boys
and Men. www.malesurvivor.org
5. Recovery from Sexual Abuse: Blog Carnival.
www.recoveryfromsexualabuse.blogspot.com
6. Adult Survivors of Child Abuse. www.ascasupport.org

Lecture 4 phase 1 safety & stabilization

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