Clinician Q&A—Treating Trauma Cases Using Groups
1. If you were talking with therapists who don’t usually treat trauma, especially in a group environment, what guidance would you give them—both in treating clients who were directly impacted and those whose mental states or illnesses were exacerbated by the September 11 tragedy?
First, go slowly. Let the group develop slowly. It is important to provide and ensure safety within the group. Pay attention to basics such as boundaries and boundary violations—role boundaries…time boundaries…confidentiality boundaries. As the therapist, you should be emotionally available. Bear witness and validate the clients’ feelings, while helping them find their own voices. Begin to try and make sense of what has happened but use interpretations very sparingly. In these cases, one should also avoid unnecessary probing and pushing.
Clearly, patients with prior trauma histories will be amongst those who are most vulnerable in the present circumstances, especially as they were proximate to the disaster or were directly impacted either through loss (in whatever form) or injury. Therapists need to assess their capacity to listen to narratives of profound loss and/or tragedy, while tolerating feelings of helplessness. It is most often the case that therapists unfamiliar with the phenomenonology of trauma are propelled to a level of activity that may well surprise them. This is one of those instances where the dictum: “Don’t just do something, sit there," is most apt.
Equally, someone who is not at all familiar with trauma would do well to be sure he/she has a peer group or supervision available within which to air both the content and countertransference material that arises. Particularly given the complexity of the issues arising from the current disaster, it is not a time to go solo.
It is important to contain/control the level of emotional stimulation and anxiety that arises in the group. One needs to monitor the degree to which narratives of survival by traumatized patients may consciously or unconsciously traumatize other group members. The group therapist needs to be especially alert to not let the group become mired in the horrors of whatever the trauma may have been. The amount of trauma stories must be titrated so that members can take in what is being said without being retraumatized—a very tricky task.
Often in a trauma group there are sudden and surprising revivals of intense affects, images and memories. Remember, too, the spreading of intense, overwhelming affect can occur via the process of emotional contagion. Also, there may be revivals and reenactments within the group itself. Such events provide important opportunities to begin the process of “working through” and recovering.
Trust is a core issue for most trauma groups. Members are likely to experience severe and protracted mistrust and suspicion. Establishing an atmosphere of safety is a top priority with any trauma group, immediate or later. The therapist must guarantee every kind of safety within the group because trauma always involves danger and loss of safety. Go slowly and carefully; do not try to rush group development. Supervision is absolutely required for someone who does not normally do trauma groups; they are the hardest of the hard, partly because they pull at the therapist's own feelings so strongly. Patients with preexisting mental illnesses will be vulnerable to an exacerbation of previous psychopathology as well as Post Traumatic Stress Disorder (PTSD).
It is likely, too, that some patients in the current crisis will appear with more than usual difficulties around issues of feeling and expressing anger. It would not be surprising if this anger were targeted to specific groups as in racial hatred, a circumstance that presents a particular challenge for the therapist to be able to respond to sensitively.
A unique aspect of the events surrounding the disaster of September 11 is the fact that therapist and patient may have been equally exposed to the tragedy. As a consequence, the therapist may find it especially difficult to provide and maintain appropriate boundaries in listening to patients.
2. What symptoms of patient trauma should clinicians be aware of?
Therapists should be on the alert for anxiety and depressive symptoms and disorders, especially PTSD. Depending on the patient, the exposure, the prevailing defensive style and the prior history, trauma will appear with a variety of "faces." The patient may appear quite detached from the experiences he/she has endured or may be flooded by the perceptual re-experiencing of the event(s) that surrounded the event. The re-experiencing/reliving is important to discriminate and ought not to be mistaken as "remembering." Often, therapists who are unfamiliar with the phenomenon will assume that the patient is more intact and is reporting a "memory," organized and intact while, in fact, because of the power of the sights, smells, sounds, physical aspects that are attached, the individual is back in the middle of the trauma. Therapists should be alert, too, to an increase in substance use/abuse as patients look to self-medicate.
3. Conversely, what trauma symptoms should clinicians watch for in themselves as a result of treating their clients' trauma?
Therapists are particularly prone to suffering "secondary" or "vicarious" traumatization from the exposure to a host of trauma narratives. Witnessing the recall and reliving of trauma can cause adverse reactions in therapists. As a consequence, therapists are subject to feelings of despair, inadequacy and helplessness; or, conversely, to feeling pressure to jump in too quickly, to rescue, to take action, to fix or to interpret things. Therapist symptoms can include, but are not limited to, irritability, impatience, insomnia, nightmares, overactivity and feeling as if the traumas were happening to them. It can even appear in the form of inattentiveness to patients or colds and flu (trauma as with any severe stress takes its toll on the immune system). The key here is good self-care and supervision.
4. What models of intervention work best?
The answer depends on your orientation to your work in general. Often, patients do need concrete direction to develop competencies at self-soothing or the regulation of overwhelming affect attendant to the reliving of trauma. At the least, patients need to be helped to stay in the "here and now" rather than, in the throes of the trauma, to be led into a focus on historical material except to the extent that history can be used to help patients have access to coping strategies and other strengths from the past. It is crucial that the therapist be experience-near—that is, staying with the patient affectively and being willing to acknowledge indications of feeling that the patient may see in the therapist without burdening the patient about the therapist's reactions or problems.
5. What is different about these types of interventions than what clinicians normally use?
With recent trauma, making historical connections is not helpful. Staying in the here and now is essential. Departures from a more detached, neutral stance may be required for the therapist to effectively witness and validate the trauma experiences. Later, making the connections will be helpful because, in part, that determines the nature and severity of the trauma response. Providing the patient with hope and some reassurance that coping is possible at appropriate times is invaluable.
6. How would you help instill confidence in clinicians who are faced with having to deal with this new level of trauma and grief?
First, the therapist who is good at working with trauma is the good therapist. We all have varying skills at just plain listening. As a result, the ability to communicate a respectful willingness to be with the patient wherever he/she is at the moment is what we are able to do under any circumstances with whatever patients. Creating a safe, non-judgmental, accepting atmosphere in which group members can feel free to speak about and share their experiences with a reliable, caring, stable therapist is essential.
Listening is a powerful healer. Depth interpretations, wizardry and brilliance are not required. But staying with the patient emotionally is crucial. Really listening can be very hard to do when the material is painful and awful. People do heal from trauma and the clinician can see results rather quickly compared to some of the other patient populations we work with.
7. Why is "the group" beneficial in dealing with this type of trauma?
One of the most damaging aspects of trauma is the social isolation that can occur because of people's difficulties with listening, shame, guilt, etc. This is a circumstance in which the shared experiences, mutual support and validation, learning from one another and altruism that group members can provide to one another is especially powerful. A trauma group can provide multiple opportunities for telling and witnessing the trauma, managing and reducing symptoms of PTSD, grieving for the trauma and its consequences, and restoring trust and hope for the future. As with an illness group (breast cancer, for instance), the example of each others' modes of coping and progress become valuable agents for change. Sharing painful feelings in a group while feeling safe, supported and accepted is very healing. Also, it benefits group members’ self-esteem and restores their sense of competence when they are able to help other human beings.