Therapy for Post-Traumatic Stress and Dissociative Conditions:
What to Look for and How to Choose a Therapist
Esther Giller, MA
One of the primary roles of Sidran Institute's Help Desk is to assist people who have been traumatized in finding various kinds of help. "Treatment" is usually sought when the behavioral adaptations (usually called "symptoms") typical of trauma survivors become disabling, interfering with work, home life, recreation, sleep, parenting, and other aspects of daily function.
Our aim is not only to help people feel better and function better, but also to help them learn to be informed and empowered consumers in general and consumers of mental health services, in particular. We hope trauma survivors find that taking appropriate and well-considered action to improve one's life is made a little easier by the information on this page.
If you are currently in crisis: The process of choosing a helpful therapist takes some time, thought, and focus. If you are currently in a crisis, or are worried that you might hurt or kill yourself or someone else, please contact your community's mental health center, hospital emergency room, or a hotline. Here are some hotline numbers that might be useful:
National Suicide Prevention Lifeline: 1-800-273-TALK
National Domestic Violence/Child Abuse/Sexual Abuse: 1-800-799-SAFE
National Youth Crisis Hotline: 800-442-HOPE
When the crisis has passed, this brochure will help you organize the task of finding a therapist for ongoing treatment.
What Is Good Trauma Therapy? What Is a Good Trauma Therapist?
Historically, mental health treatment has been treated according to the "medical model": the "sick" patient treated by the powerful doctor, who has the responsibility, the expertise, and the tools to cure the illness. The patient's job is to be compliant and to follow orders. With some practitioners, this model continues to this day.
Recently, however, some therapy models have come to recognize that individual distress is often caused or made worse by poor social, political and economic environments as well as by harmful family dynamics. Trauma survivors are generally best served by therapists who work from an environmental framework, or "trauma model," as they are also more likely to see their clients as experts in their own lives and as partners in healing.
Later we will look at some of the different disciplines, approaches, and techniques most appropriate to trauma therapy. Suffice it to say, however, that good trauma therapists come from every discipline, work in all settings, use a variety of approaches and techniques, and have a wide range of credentials and experience.
There are aspects, however, that the best trauma therapists have in common. We will start by discussing what constitutes good trauma therapy, and then explore how to find it. As Dr. Bessel van der Kolk of Boston University explains, most trauma survivors benefit from one-on-one psychodynamic therapy. It "allows disclosure of the trauma, the safe expression of related feelings, and the reestablishment of a trusting relationship with at least one person."
Therapists do rest much of their practice on the basis of their professional training. But perhaps as much as anything else, they rest their practice on their integrity and personal talents-on their perceptions, feelings, insights, intuition, and the degree to which they can hear unspeakable truths. "Pay more attention to the therapist's intellectual and emotional equipment than theoretical system," Dr. van der Kolk advises survivors. "Pay attention to whether the therapist really wants to hear the troubles you have to tell. Ask yourself, 'Do I feel validated? Is the therapist really listening to my story?'"
If validation is one important selection criterion, Dr. Judith Herman, Director of Training at the Victims of Violence Program at Cambridge Hospital in Cambridge, Massachusetts, makes clear a second criterion and one that seems of equal importance: An effective trauma therapist empowers the survivor rather than imposes a cure.
The dual formulation of validation and empowerment seems to be fundamental to post-traumatic therapy. -Excerpt from Unspeakable Truths and Happy Endings: Human Cruelty and the New Trauma Therapy, by Rebecca Coffey (Sidran Institute Press, 1998), pp. 85-86.
The idea of the therapist and client working together as partners, sharing responsibility and expertise, is still radical in many mental health settings. But for trauma survivors, this is in many ways the key to success in therapy.
When treater and client share the trauma perspective they can collaborate. A shared perspective allows collaboration between the individual, who has expertise on him or herself (the client), and the individual who has expertise on the process of healing (the helper). Helper and client collaborate to identify the central concerns of the survivor. They work together to improve the survivor's life. Treatment requires both people's active participation. The trauma model is also an empowerment model. The helper has useful information to impart, but is not "the expert" or "the authority" on all matters concerning the survivor. The client is an important member of his or her own treatment team, and everyone on the team needs to collaborate to help the client move forward. The four most important things a therapist has to offer a survivor are as follows:
With these four components, any relationship can promote healing. -Excerpt from Risking Connection ®personal talents : A Training Curriculum for Working with Survivors of Abuse, by K.W. Saakvitne, L.A. Pearlman, S.J. Gamble, and Beth Tabor Lev (Sidran Institute Press, 2000), p. 13.
Before You Begin
Although many trauma survivors find it difficult, now would be a good time to get a complete physical (medical) examination, especially if you have not had one in the past two years. This is important for at least three and possibly four reasons:
- Many medical illnesses (such as thyroid, diabetes, and seizure disorders) might mask or contribute to mental health conditions and interfere with appropriate psychological assessment and treatment. It makes sense to see your physician first to rule out any potential medical causes of your distress.
- If you are eventually going to see a psychiatrist for prescribing antidepressant, anti-anxiety, or other symptom-reducing medications, the psychiatrist will require a current medical evaluation and will want to consult with your personal physician.
- Post-traumatic stress disorder has both psychological and physiological symptoms. The best way to proceed toward recovery is to attend to medical and emotional needs in a simultaneous and integrated way. Ideally, your physician and your therapist should consult periodically about your progress.
- If you have a trusting relationship with a family doctor, internist, or general practice physician, he or she might be a good source of referrals to a mental health specialist in your community.
Before you actually begin the process of selecting a therapist, it is important to have a working knowledge of the range of professional options (and there are many). It is important to remember that credentials do not necessarily ensure quality. Still, qualifications are a good starting point in evaluating a therapist, and should you ever have a harmful therapy experience, you may have some recourse through a complaint to a licensing body or professional association.
Types of Mental Health Care Providers: Alphabet Soup!
The words "therapist" and "counselor" are unregulated, generic terms. They can be used to refer to anyone providing treatment and can be used as a title by anyone, with no requirement of special training.
In some states, anyone can hang a shingle on their door and practice "therapy" with nothing more than a high school diploma, so beware of "therapists" with unfamiliar titles. No ethical professional therapist should mind being asked about his or her educational or professional backgrounds. You should likely stay away from individuals who don't have at least a master's degree (e.g., M.S., M.S.W., C.S.W., M.A.).
In the United States, Doctors of Philosophy (Ph.D.), Psychology (Psy.D.), or Education (Ed.D.) must complete at least four years of post-graduate school, however, only those who have been licensed can call themselves psychologists. Clinical psychologists are specifically trained in assessing a client to determine the problem and to respond by providing treatment. In most states, if medication is needed in addition to therapy, a psychologist will refer the client to a psychiatrist for that aspect of treatment.
However, not all psychologists are experienced therapists. Some specialize in areas such as statistical research or industrial psychology and may have little experience treating people. Also, don't assume that Ph.D. always indicates a psychologist. Many people have earned Ph.D. degrees in unrelated academic fields and may decide to practice therapy without being clinically trained or licensed.
Clinical Social Workers (CSW) usually have earned at least a master's degree (two years of graduate school) and some may have doctoral degrees. Clinical social workers credentials may vary by state, but these are the most common:
- B.S.W. (Bachelor's of Social Work)
- M.S.W. (Master's of Social Work)
- A.C.S.W. (Academy of Certified Social Workers)
- D.C.S.W. (Diplomate of Clinical Social Work).
Although there are exceptions, most licensed clinical social workers generally have an "L" in front of their degree (e.g., L.C.S.W.).
Marriage and Family Therapists and Professional Counselors
Marriage and family therapists (LMFT), and professional counselors (LPC) may have two years of graduate school and have earned at least a master's degree such as:
- M.A. (Master of Arts)
- M.S. (Master of Science)
- M.Ed. (Master of Education).
Marriage and family therapists have additional specialized training in the area of family therapy.
Professional counselors, most typically drug or alcohol abuse specialists-C.A.C. I, II, or III (Certified Addiction Counselors)-may have a variety of more generalized training in the area of psychology and counseling. A counselor may or may not have a master's degree. Counselors are trained for supportive therapy. They usually focus on behavioral problems not clearly classified as mental illnesses. Counseling is usually less intensive than psychotherapy.
Other Categories of Professionals
Many other categories of professionals also provide mental health care services in private practices or in agencies.
Pastoral counselors are clergy who have the credentials
- M.Div. (Master of Divinity)
- Th.D. (Doctor of Theology)
and have a degree from a seminary or rabbinical school with additional training in therapy.
Psychiatric nurses and nurse practitioners comprise a growing segment of mental health treatment professionals. They display the credentials
- R.N. (Registered Nurse)
- R.N.P. (Registered Nurse Practitioner)
- M.S.N. (Masters of Science in Nursing).
A Psychiatric Nurse Clinical Specialist is a registered nurse with a master's degree who has been trained in individual, group, and/or family psychotherapy.
Psychiatrists are medical doctors (M.D.s), who after completing a medical degree like any other physician, follow up with a four-year psychiatry specialty. Psychiatrists' fees are likely to be the highest of all mental health providers. In this day of managed care, psychiatrists rarely provide "talk therapy." It is generally not necessary for a person with a trauma disorder to use a psychiatrist as a primary therapist. However, for those who have complex or co-occurring medical and mental health conditions, a psychiatrist has the advantage of being a trained M.D. Psychiatrists often work together with other nonmedical psychotherapists to provide prescription and medication management services when needed.
The term psychoanalyst refers to any therapist trained in or practicing in the Freudian or analytic styled psychodynamic approach.
Hypnotherapist refers to anyone trained in or practicing hypnosis.
A twelve-step sponsor or a mentor can provide support for those seeking help, but they cannot take the place of a psychotherapist.
A 1997 Consumer Reports readers' survey showed people in therapy generally rated psychologists, clinical social workers, and psychiatrists about as equally effective. Marriage counselors were rated significantly worse, according to patients' rating of their own improvement.
In general, the most helpful therapists are:
- willing to share information about themselves as helpful and appropriate,
- have respect and a high positive regard for their clients,
- are warm and empathic,
- are responsive and hopeful,
- have firm boundaries but are not domineering.
Helpful therapists also have
- a variety of clinical skills to address the specific needs of the client;
- an understanding of the power imbalance that exists in therapy and a willingness to work toward empowerment of the client;
- a view of the client as the expert on his or her own life and as an active partner in therapy.
- awareness of their own biases and the limits of their skill, and willingness to refer you to other professionals if necessary.
Consumers of mental health services have contributed to the following list of things to look for in a therapist:
- Find a therapist you feel comfortable with. Therapy is not an easy process and your therapist is not there to be your friend.
- Find a therapist who respects your individuality, opinions, and self.
- Find a therapist who will not get upset if you disagree with what he or she has said, but instead encourages you to express yourself when you do not agree.
- Find a therapist who never minimizes your experiences and always respects your feelings.
- Find a therapist who will not try to force you to talk about things that you might not be ready for.
- Find a therapist who does not spend time talking about his or her own problems. Those sessions are for you, not your therapist.
- Find a therapist who wants neither a friendship nor a sexual relationship with you outside of your counseling sessions.
- Find a therapist who is more than willing to discuss problems that might arise between the two of you within the therapist/client relationship.
- Find a therapist who will help teach you new and healthier ways to cope.
- Find a therapist who will never make you feel like a failure or cause you to believe they are disappointed in you if you have a slip or a relapse.
Objectives of Therapy to Address Trauma Issues
Effective psychotherapy for trauma survivors usually involves helping the survivor maintain safety, manage symptoms, and work through the traumatic experience(s). While the techniques employed vary, the primary goals of psychotherapy for trauma survivors are:
- to examine the role of the traumatic experience in the context of the person's life, currently and historically
- to make meaning of the experience
- to learn skills to manage symptoms and to develop alternative ways of coping
- to build or rebuild the ability to trust within a relationship in order to view the world as an increasingly tolerable place to function
There has been a lot of controversy about therapy that focuses on memories of past trauma. Because the nature of traumatic stress is to distort memory in a variety of ways (remembering too much about traumatic experiences or too little, and in some cases both), therapeutic discussions of the meaning of past events are important. It is not necessary to use special techniques to discover hidden memories of violence or abuse. In the course of addressing problems in current daily function, the opportunity to discuss past events and the ability to recall them will evolve naturally as part of therapy.
Types of Therapy
There are many approaches to therapy, and most good therapists are trained in several and use them in combination. Approaches may be long or short-term and may be focused primarily on the past or on the present, but all should aim to alleviate distress and help clients learn how to acquire more effective coping strategies.
Psychodynamic approaches attempt to help the client discover the origins of the problem in the past as well as how it affects life today. A behavioral approach tends to focus on changing current behavior with little emphasis on past events. The cognitive approach focuses on changing the client's way of thinking, and a family systems approach aims to change unhelpful patterns in families.
Formats for therapy include individual (or one-on-one) therapy, couples' therapy, family therapy, and group therapy. Some therapists use a combination of these formats. Today, many therapists describe their work as eclectic, meaning that they draw from a wide variety of approaches in order to best meet the needs of each individual client. Research indicates that the quality of the therapeutic relationship is often more important than the particular methods employed. In therapy for traumatic stress, the relationship is particularly important, as rebuilding interpersonal trust is often a key objective of treatment. The most important thing to remember is that your needs are paramount; choose a therapist whose approach seems most appropriate for you.
You can begin the process by getting referrals. REMEMBER: when choosing a therapist, you are a consumer of service, and it is your right to shop around. Your family doctor may be able to make a referral for you, although doctors may not know therapists who have particular experience with trauma survivors. Sidran Institute has a list of therapists around the world who have made a commitment to addressing the needs of trauma survivors. We would be happy to provide names of therapists in your area from which you can choose. Referral agencies or a women's resource center in your area may also be able to assist you in your search. Some insurance companies require that you choose from a list of preapproved therapists in your area.
You might also ask people you know who've been in therapy to make recommendations. A therapist who's right for someone else may not be right for you, but someone you trust who has actually worked with a particular therapist can share very helpful information. Once you have made inquiries, make a list of names of two or three therapists from whom to choose.
When interviewing a potential therapist, keep in mind your needs and goals for therapy, as well as the particular qualities you feel are important in a therapist. We often hear about the need for a "match" when selecting a therapist and there is a lot to be said for feeling comfortable with the person you choose. Although your objective is not to build a friendship with the therapist, you will be spending a lot of time together, and you will need to feel comfortable enough to discuss sensitive, confidential thoughts and feelings. Below you will find a list of questions that may help you interview helpers to determine who suits your needs the best. You may find it helpful to take this list with you on interviews along with a pad of paper to record your information. Click here for a printable PDF version of the list that you can print out and carry along with you.
- What are your credentials?
- What are your specialties?
- What professional organizations to you belong to?
- How long have you been conducting therapy?
- What experience have you had in treating traumatic stress conditions?
- How do you approach treatment of traumatic stress conditions?
- What do you charge?
- Do you accept insurance? If so, what kinds?
- Do you have a sliding fee scale? If so, how is payment determined?
- Do you bill people, or is payment expected at the time of the session?
- How do you protect client confidentiality? Who (besides you) will have access to my files?
- How long is each session? Are there exceptions to this?
- Has anyone ever lodged a formal complaint against you?
- Have you ever been censured by a professional organization?
- If I were in crisis, would I be able to reach you? How do you handle crises?
- What is your policy about missed sessions?
- What is your policy about physical contact with clients?
- What is your policy about contact outside of the session?
- Do you arrange vacation coverage?
- What happens if one of us decides to terminate without the other's agreement?
- Do you think you can help me?
- Is there anything I should know about your services that I didn't think to ask about?
My impressions: check all that apply
- I felt safe and reasonably comfortable
- I felt understood and taken seriously
- I was treated respectfully
- We agreed about the nature of the problem
- This feels like it could be a good "match"
- My questions were answered adequately
- My treatment goals were addressed
- This individual is clinically qualified
- I can afford it
- I can get there with reasonable ease
Don't forget (or avoid) talking about money. You need to know before you start how you are going to pay for treatment. Therapists may take a variety of insurance payments: private insurance, Medicare, or state medical assistance; others will offer a payment plan or work on a sliding scale, based on what a client can afford. Rarely, a therapist may offer to do "pro bono" work (treat one or a few clients at no charge). As appealing as this may seem, it is not really a good idea, and may under some circumstances be unethical. This dynamic reinforces the power imbalance that is inherent in the therapy relationship, and the client may come to feel the "debt owed" interferes with therapy.
After the first meeting with the potential therapist, you will need to ask yourself some questions:
- Did you feel comfortable and able to begin discussing your problems?
- Did the therapist seem to understand what you were talking about?
- Did you feel your concerns were taken seriously and that you were treated with respect?
- Were the two of you in general agreement about the problem and your expectations for therapy?
- Were you satisfied with the therapist's answers to your questions?
- Did you feel that you could grow to trust and work with this person?
Pay attention to your intuition; choosing a helpful therapist will require trusting your own thoughts and feelings. Remember that you are a consumer of a service and that it is your right to choose a therapist who best meets your needs.
Throughout the course of therapy, you will need to be mindful that your work is productive and continues to be helpful. In helpful therapy relationships, the client feels understood and supported, and while therapy is not always a comfortable experience, there should be a sense of trust and warmth.
If you don't feel respected, valued, or understood, or if your experience is being minimized or distorted, it may be a sign that your therapy is not working. If you feel there is something wrong in your therapy, or if you get upset or angry with your therapist, discuss it in your session. If your therapist discounts your feelings or responds in a defensive manner, you can choose to switch to a different, more respectful therapist.
If you are working with a helpful therapist, you will begin to be able to better recognize and understand your feelings, thoughts, and behaviors. You will also begin to develop new, more effective coping strategies, and you should have a sense of change and increased satisfaction in your life. Over time, you should begin to feel more and more independent and able to use the skill and insights you are learning in therapy to solve your own problems.
Reprinted with the permission of the Sidran Institute www.sidran.org
For information on Sidran workshops and trainings go to: http://www.riskingconnection.com and or visit Risking Connection Events: http://www.riskingconnection.com/RC_calendar.html