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Trauma Treatment Planning for Clinicians

"I can't go on like this!" A client recently spoke these words to me when referring to symptoms of posttraumatic stress disorder (PTSD). The impact of PTSD on quality of life cannot be underestimated.
My former supervisor, Victor Carrion, MD, Director of the Stanford Early Life Stress Research Program, says PTSD is a disorder of fear extinction and it feeds on avoidance. I was his intern for two years, and later was hired to be one of two therapists in a 3 year clinical research trial of a cutting edge, short-term treatment for youth suffering posttraumatic symptoms.

We tested Stanford Cue Centered Treatment, a 15-18 session intervention with youth, ages 8-17, meeting with them in their schools. We had outstanding results, with participants having a 65% drop in posttraumatic symptoms very quickly, along with a 50+% decrease in depression and anxiety.

Categories of PTSD Symptoms
  • Hyper-Arousal: An unpleasant sensation where the person feels hyper-aware of every stimuli. Aware of every tiny sound, the person is hyper-vigilant, startles easily, and often feels irritable and angry. It is difficult to concentrate. Hyper-arousal symptoms are a crescendo from mild anxiety all the way up to a full-fledged fight or flight reaction, or a panic attack that sends someone to the emergency room.
  • Intrusive Recollection: Unpleasant thoughts related to the trauma. Sometimes there are nightmares or recurring bad dreams. Flashbacks are a serious form of intrusive thoughts that make a person feel as if they are right back in the middle of the trauma once again.
  • Avoidance / Numbing: The person avoids situations, thoughts, and feelings that remind them of the trauma. This can make a person's world much smaller as they work to avoid all traumatic cues. A great deal of energy is used trying not to think about it. Emotional affect is flattened. There may be a sense that the future is fore-shortened.

All of these symptoms sap a person's energy. It is bad enough that they either witnessed or experienced trauma, and now they are having a host of unpleasant symptoms.

As clinicians it is our job to bring immediate relief. As a Stanford-trained trauma therapist, we began immediately by doing a thorough intake and assessment. Dr. Carrion says that the greatest mistake clinicians make is not asking about trauma, or if they do, they do not ask in enough detail.

When we ask a client to tell us about the trauma in great detail, (i.e., "What did you see? Was there blood? How much and where was it? Could you see inside the bullet hole? What could you hear/smell?") we do two things. First, we demonstrate our faith in the client; s/he is strong enough to survive telling us about this trauma. Sometimes this may be the first time the trauma is being discussed. Second, by discussing the trauma, we begin to reactivate the body's fear extinction mechanism. Retelling the details of a trauma acts as a form of exposure.

As the client survives the memory of the trauma in a safe environment with a caring clinician, they begin the process of desensitization. By asking for all the details, we show the client we can handle it, even the really, terrible stuff they have never told anybody.

The bad news about PTSD is it does not go away over time if left untreated, and instead gets worse. The good news is it responds very well to treatment.

In my own private practice, when clients seek me out for trauma treatment, I focus first on educating the client about PTSD symptoms, and giving them tools for body mastery. In the first two sessions after the intake, we solely focus on tools that give them relief from posttraumatic symptoms.

Using Aureen Wagner's "Feelings Thermometer" with both adults and children, I coach clients to rate their feelings on a scale of 1-10 (1 = Life is a piece of cake, 10 = Out of control! Ballistic!). I explain the anatomy of the flight or flight reaction, and why long, slow deep breathing in which the exhale is twice as long as the inhale is essential to stop the reaction in its tracks. This type of breathing calms many people, in addition to stopping the ratcheting up of the body's fear reaction. However, some people still continue to feel anxious. Next, I teach progressive muscle relaxation, which helps almost everyone.

Finally, we do guided imagery. Usually, by the time all three are done, the person's "temperature" is back to a 1 or 2. This demonstration is powerful as they realize they can achieve body mastery over their anxiety and fight or flight reactions. I instruct them to practice all three every day in the coming week, and that we will discuss their progress, particularly how they handle traumatic cues. I remind them that anytime they notice their temperature is a 5, they should do something to bring it down.

During the nest session, I ask how they did with managing their symptoms throughout the week. Were they able to remember the tools? How high did their temperature get? Often both of us are delighted at the progress they have made towards achieving body mastery. We continue practicing, and add some cognitive tools such as thought insertion and reality testing for catastrophizing.

Once a person with PTSD learns body mastery so that they can calm their body on command, we are ready to explore the trauma narrative. Body mastery is essential to help them tolerate the anxiety of telling their story in full detail. The person I mentioned at the beginning of the article had a steep decline in post-traumatic symptoms within three sessions thanks to the techniques I have outlined.

After the intake, education and body mastery are the first big keys to curing PTSD. When we use the strategy outlined above, clients receive immediate relief from symptoms and they begin to develop hope--the greatest gift I can give.

Easy-to-use examples of these tools and more information on trauma treatment are on my website. To learn more about Stanford Cue Centered Treatment, and to sign up for online training, please visit the Stanford Early Life Stress Research Program website.

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