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Choosing Safe and Appropriate Treatment Interventions

In an empowerment model, the client is a well informed partner in choosing treatment practices. However, the clinician first has to do the homework.

For the conscientious clinician, evaluating treatment approaches and practices to offer clients is often a bit of a juggling act—looking at the grounding of the practice in empirical evidence, cultural factors, the cost of the intervention, available training in the intervention, the time the intervention takes vs. the time available for treatment, the client’s individual preferences, etc. The one consolation might be the evidence that the quality of the therapeutic relationship is far more important to treatment success than the choice of treatment practices (Hubble, Duncan, and Miller, 1999).

Even if all you have time to do is help veterans establish some sense of empowerment and a few safety skills and resources, that is a significant step in the healing process. If you do it in a way that leaves them feeling good about coming back to you or seeking help elsewhere in the future, you have just improved their chances of recovery significantly.

Criteria for Choosing Approaches: In looking at evidence-based and promising practices to offer people with post-trauma effects, the clinician is often caught between:

  • A traditional approach that advises only to use evidence-based practices that have been tested and used extensively with the specific population served and found to be safe and effective
  • The growing use and acceptance of a number of promising approaches for which the body of evidence is still under development, including many somatic and somatosensory approaches designed to make it easier to integrate the body’s procedural memories with narrative memory

Even a well documented technique like Eye Movement Desensitization and Reprocessing (EMDR, a model that combines cognitive and somatic techniques) is sometimes still the subject of debate, with many clinicians, clients, and studies reporting highly positive results, and detractors still casting doubt on the relevance of the somatic component (bi-lateral eye movement, tapping, or sound). It is necessary for clinicians to learn about the practices they are considering from multiple sources, including (and perhaps most important) a number of people who have been treated with those techniques.

Safety Considerations in Choosing Treatment Practices: Trauma is an area of great danger for the patient, and so an area in which safety is the first and most important consideration.

A few safety considerations in choosing treatment practices:

  • As mentioned earlier in these pages, it is important not to mix veterans in with general population (civilian) therapy groups.
  • SUD treatment providers need to work closely with trauma specialists to ensure that all steps are taken to stabilize both the trauma symptoms and recovery from substance use. Withdrawal from addictive substances can often trigger trauma symptoms, and trauma symptoms often lead to self-medication with alcohol and drugs.

Do NOT use techniques that involve the recalling or re-experiencing of traumatic memories unless you are:

  • Well trained, supervised, and experienced in these technique
  • Ready to monitor and lower arousal levels when they start to escalate
  • Working with clients who have strong skills in managing their emotional responses
  • Certain that you will be able to bring to stability and containment before the session ends

Once again, the emphasis is on building veterans’ own skills in creating safety. If you use techniques that involve the recollection of traumatic memories:

  • Establish a firm foundation of safety and resources before you begin
  • Include ample training for the veteran in stopping or shutting down the process
  • Always progress slowly, giving the veteran practice in “toggling” back and forth between arousal and calming (Ferentz, 2008)

For any work with trauma survivors, spend ample time, both on the establishment of safety before working on traumatic material, and on stabilization and containment of the traumatic material before ending the session.

Monitor reactions to and effectiveness of any medications prescribed for the veteran, and take these medications’ side effects into account in planning and carrying out interventions.

To gauge the level of arousal, an old mainstay in the field of trauma is the SUDS (Subjective Units of Disturbance Scale), designed by Joseph Wolpe, the developer of systematic desensitization. On a scale of zero to 10, (in which zero is neutral, no disturbance, and 10 is the worst level of disturbance the client can imagine), the client “rates” his or her disturbance at any given time.

It is essential that clinicians be trained in all the practices they use, and refer clients out for any other technologies they might need. Courtois (2006) strongly recommends the use of informed consent forms for any practice offered to and chosen by the client. These forms would describe the practice, its purposes, its characteristics, and the extent of the evidence base behind it.

Evaluating the Evidence Base: Even within the realm of practices with a solid evidence base, there are several cautions. If you are relying on the evidence, it is important to look at the studies in question and note:

  • The sample size upon which the evidence is based
  • The fidelity to treatment protocols that took place in that study
  • The nature of the control group used (wait list vs. other treatments)
  • The appropriateness of the population studied to your proposed use with veterans
  • Whether or not these results can be generalized to this population—and to this individual veteran

Next: Using Symptoms and Neurobiology in
Considering Treatment Practices


The material on all of the Clinical Pages is taken directly from the draft version of Finding Balance After the War Zone:  Considerations in the Treatment of Post-Deployment Stress Effects, a manual under development for the Great Lakes Addiction Technology Transfer Center and Human Priorities.  This draft is copyright © 2008, Pamela Woll.  Reprint permission is universally granted, but attribution is requested.
Click here for References and Other Resources.
Click here to link to a PDF file of the current version of the clinician’s manual draft.
Click here to link to a PDF file of the accompanying booklet for veterans.

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