The Three-Phase Model
With a diagnosis of complex PTSD, a trauma-informed approach is crucial. Previous treatments that were not trauma-informed proved ineffective for this client. It’s essential to consider what has and has not worked in the past.
The trauma field has been profoundly influenced by Judith Herman’s phase-oriented trauma treatment model. This is a revision of an approach initially proposed by Pierre Janet, and encompasses three phases.
Phase One: Stabilization and Safety
Before addressing the trauma, the initial stage is stabilization. This phase emphasizes:
- Overcoming autonomic dysregulation, self-harm tendencies, and addictive behaviors
- Establishing a safe environment, as recovery cannot happen if the client is still in danger, or feels that they are
- Establishing emotional and autonomic stability, allowing people to handle and regulate emotions, especially when dealing with day-to-day stress
Phase Two: Focus on the Traumatic Memory
The treatment’s second phase concentrates on traumatic memories. As the field has evolved, the definition of a traumatic memory has shifted. The focus used to be on recalling every traumatic memory in detail. However, it’s now understood that recovery isn’t merely about remembering but involves coming to terms with the past and associated implicit memories.
Phase Three: Integration and Meaning
The final phase revolves around integration and meaning-making. It is about understanding oneself after trauma, and helping people to derive meaning from their life choices. For instance, raising children in a nonviolent way, pursuing a social cause, or a career focused on justice or healing.
Popular Treatments for Trauma
Various treatments address trauma, including psychodynamic and psychoanalytic treatments, supportive psychotherapies, eye movement desensitization and reprocessing (EMDR), and internal family systems (IFS). There are also somatic approaches to trauma, influenced significantly by Bessel van der Kolk’s insights, which are detailed in his book The Body Keeps the Score.
While numerous treatments are available, not all have an equally robust evidence base.
- EMDR has well-tested effectiveness.
- Prolonged exposure has an excellent evidence base in simple PTSD cases. It has not been tested on PTSD with specific complications such as addictive behaviors, psychotic symptoms, self-harm, and suicidality.
- IFS has an evidence base, but its primary study focused on patients with rheumatoid arthritis.
- Somatic experiencing has two randomized controlled studies supporting its efficacy.
When determining the best treatment, it’s also vital to consider the client’s needs and whether they’re likely to complete the chosen therapy.
Ruling Out Treatments
Some treatments could be ruled out for this particular client based on effectiveness and appropriateness. Prolonged exposure wasn’t suitable due to its high dropout rate, intensity, and focus on one memory at a time. Clients with complex PTSD may have endured hundreds of traumatic events, making this approach inappropriate.
Supportive psychotherapy, psychodynamic trauma-focused therapy, IFS, and EMDR had been tried and found ineffective. Indeed, EMDR dramatically exacerbated her symptoms. And a purely somatic treatment was inappropriate for this very intellectual client. All of this context explains why Dr. Fisher chose trauma-informed stabilization treatment (TIST) for “D”.