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Standards of Practice

STANDARDS OF PRACTICE
V 3.2  (revised 12 June 2007)

Table of Contents

I. Purpose of Guidelines

II. Ethical Principles of Practice
    1. Respect for the Dignity of Persons
    2. Responsible Caring
    3. Integrity in Relationships
    4. Responsibility to Society

III. Standards of Humane Practice for Practitioners of Clinical Traumatology
    1. Clients Universal Rights
    2. Procedures for Recruiting Clients
    3. Procedures for Assessment

      Distress of divulging
       Tracking the Event
       Past Memories
       Normalize as part of the Assessment
       Shattered Assumptions
       Secondary Traumatization
       Suicidality and Safety
       Assessing Readiness for Trauma Therapy
       Assessment Methods
                    Interviews
                    Psychophysiological Method
                    Self-Report Inventories

    4. Procedures for Diagnosis and Reporting
   Clinical diagnosis of PTSD and trauma-related disorders

      Misdiagnosis
       Reporting Clinical Findings
       Notes and Record Keeping

    5. Procedures for Establishing Safety

      Roles and Boundaries
       Safety
       Assessing Readiness

    6. Exposure Treatment
    7. Procedures for Assuring Client-Adjusted Progress

      Pacing and timing
       Monitor Symptoms and Progress
       Identifying and Dealing with Flashbacks and Triggers
       Symptom Exacerbation
       Dissociation during therapy
       Destabilization/decompensation

    8. Procedures for Using Risky Treatment Methods with Informed Consent
    9. Reaching Therapy Goals Through Consensus
    10. Termination/Transition from Regularized Sessions
    11. Ongoing Relationships and the Issues of Boundaries

      Dual relationships
       Sexual Contact

    12. The Issue of Recovered Memories of Abuse
IV. Standards of Care for Research with Traumatized Persons
    1.  Research Participants Universal Rights
     2. Guidelines for Diagnosis of PTSD for Research Purposes
     3. Procedures for using Risky Research Methods with  Informed Consent
     4. Procedures for  Recruiting Research Participants Humanely
     5. Procedures for Collecting Data Humanely - General Research Principles
     6. Procedures for Reporting Findings and Impressions Humanely

V. Related Online Codes of General Professional Ethics

VI.  References

I. PURPOSE OF GUIDELINES

These guidelines seek to build a common foundation across disciplines/professions for the humane treatment of persons who have been traumatized. Such individuals may experience a spectrum of responses, including persistent rexperiencing of the traumatic event, avoidance of related stimuli, numbing of general responsiveness, and persistent symptoms of increased arousal.

Because traumatized individuals may feel a deep sense of vulnerability, dehumanization, and betrayal, as well as cognitive and emotional disequilibrium, increased care is called for in providing a healing environment that conveys respect for their experience and their dignity.

These guidelines of the Academy of Traumatology are intended for use not only by treatment providers, but by front-line workers (e.g., police, paramedics, crisis intervention workers, victim assistance workers, nurses, etc.), researchers, lawyers, media, and other professionals who come into contact with traumatized persons. These guidelines focus specifically on the prevention and intervention of complications that may arise when in contact with individuals who have experienced trauma, both single event traumas and chronic traumata of long duration. As such, these Academy guidelines are more generic and broader in scope than the treatment guidelines for simple PTSD of the International Society for Traumatic Stress Studies (ISTSS). The Academy expresses its appreciation to Anne Dietrich and her team for the initial draft of these standards.

II. ETHICAL PRINCIPLES OF PRACTICE
(CTSN, modified)

1. Respect for the Dignity of Persons

Traumatologists recognize and value the personal, social, spiritual and cultural diversity present in our societies, without judgment. As a primary ethical commitment, traumatologists make every effort to provide interventions with respect for the dignity of those served.

Traumatologists assist traumatized persons to come to an understanding of their traumatic experience. Traumatologists are dedicated to helping individuals, groups and communities build on their strengths, and help enhance their coping skills.
 

    * American Association of Marriage and Family Therapy: Responsibility to Clients
    * American Psychiatric Association: Section 1
    * American Psychological Association: Respect for Rights and Dignity of Persons
    * Canadian Psychological Association:  

2. Responsible Caring

Traumatologists take the utmost care to insure their interventions do no harm.

Traumatologists, by providing services, have a commitment to the care of those served until the need for care ends or the responsibility for care is accepted by another qualified service provider.

Traumatologists support colleagues in their work and respond promptly to their requests for help.

Traumatologists recognize that service to survivors of traumatic events can exact a toll in stress on providers.  They maintain vigilance for signs in themselves and colleagues of such stress effects, and accept that dedication to the service of others imposes an obligation to sufficient self-care to prevent impaired functioning (see Figley, 1995; Pearlman & Saakvitne, 1995)
 

    * Compassion Fatigue
    * Compassion Fatigue Certifications

Traumatologists engage in continuing education in all the appropriate areas of trauma response.  Traumatologists remain current in the field and insure that interventions meet current standards of care.
 

    * American Association for Marriage and Family Therapy: Professional Competence
    * American Association of Pastoral Counsellors: Professional Practices
    * American Psychiatric Association: Section 5
    * American Psychological Association: Maintaining Expertise
    * Canadian Psychological Association: Values statement on Responsible Caring
    * Canadian Psychological Association: Competence and Self-Knowledge
    * Canadian Psychological Association: Training, Qualifications & Competence

See also Pope & Brown (1996, Ch. 4)

3. Integrity in Relationships

Traumatologists clearly and accurately represent their training, competence, and credentials. Traumatologists restrict their practice to methods and problems for which they are appropriately trained and qualified. Traumatologists readily refer to or seek consultation from colleagues with appropriate expertise; they support requests for such referral or consultation from their clients.
 

    * American Association of Marriage and Family Therapy: Professional Competence and Integrity
    * American Psychiatric Association: Section 2
    * American Psychological Association: Principle of Integrity
    * American Psychological Association: Boundaries of Competence
    * Canadian Psychological Association: Reliance on Discipline
    * Canadian Psychological Association: Accuracy and Honesty

Traumatologists hold fast to the commitment of confidentiality, insuring that rights of confidentiality and privacy are actively maintained for those served.
 

    * American Association of Marriage and Family Therapy: Confidentiality
    * American Association of Pastoral Counsellors: Confidentiality
    * American Psychiatric Association: Section 4
    * American Psychological Association: Confidentiality 1, 2, 3
    * American Psychological Association: Privacy
    * Canadian Psychological Association: Privacy

Traumatologists do not, except for the duration of an emergency in which no other qualified person is available, provide professional services to persons with whom they already have either emotional bonds or extraneous relationships of responsibility. Traumatologists refrain from entering other relationships with present or former clients, especially sexual relationships or relationships that normally entail accountability.
 

    * American Association of Marriage and Family Therapy: Responsibility to Clients, Competence and Integrity, Responsibility to Students
    * American Association of Pastoral Counsellors: Client Relationships, Other Relationships
    * American Psychiatric Association: Section 1,  Section 2
    * American Psychological Association: Multiple Relationships
    * American Psychological Association: Sexual Harrassment
    * American Psychological Association: Exploitive Relationships
    * American Psychological Association: Current Clients
    * American Psychological Association: Former Sexual Partners
    * American Psychological Association: Former Therapy Clients (please note this guideline is undergoing revision)
    * Canadian Psychological Association: Conflict of Interest
    * Canadian Psychological Association: Client Relationships
    * Canadian Psychological Association: Guidelines for the Elimination of Sexual Harassment

Within organizations, traumatologists insure confidentiality to the extent possible and consistentwith organizational policies; they explicitly inform individuals of the extent to which accepting services from within the organization entails risks to confidentiality; and they are prepared to make appropriate external referral for those who desire it.
 

    * Canadian Psychological Association: Values Statement on Relationship Integrity
    * Canadian Psychological Association: Ethics on Relationship Integrity

4. Responsibility to Society

Traumatologists are committed to responding to the needs generated by traumatic events, not only at the individual level, but also at the level of community and community organizations, in ways that are consistent with their qualifications, training, and competence.

Traumatologists recognize that their professions exist by virtue of societal charters in expectation of their functioning as socially valuable resources. They seek to educate government agencies and consumer groups about their expertise, services, and standards, and support efforts by these agencies and groups to ensure social benefit and consumer protection.

Traumatologists who become aware of activities of colleagues that may indicate ethical violations or impairment of functioning seek first to resolve the matter through direct expression of concern and offer of help to those colleagues. Failing a satisfactory resolution in this manner, traumatologists discharge their professional obligation to society by bringing the matter to the attention of the officers of professional societies and of government with jurisdiction over professional misconduct.
 

    * American Association of Marriage and Family Therapy: Responsibility to Society
    * American Psychiatric Association: Section 3, Section 7
    * American Psychological Association: Social Responsibility
    * Canadian Psychological Association: Values Statement on Responsibility to Society

III. STANDARDS OF HUMANE PRACTICE FOR PRACTITIONERS OF CLINICAL TRAUMATOLOGY

1. Clients Universal Rights

All clients have the right:

    * To be treated at all times with respect, dignity, and concern for their well-being
    * To not be judged for any behaviors they had used to cope, either at the time of the trauma or following the trauma
    * To refuse treatment, unless failure to receive treatment places them at risk of harm to self or others
    * To be treated as collaborators in their own treatment plans
    * To informed consent before receiving any treatment
    * To not be discriminated against based on race, culture, sex, religion, sexual orientation, socio-economic status, disability, or age
    * To have all reasonable promises kept

 

    * Trauma Survivor's Recovery Bill of Rights

2. Procedures for Recruiting Clients

Obtain informed consent,  providing clients with information on what they are to expect while receiving professional services.

In addition to general information provided to all new clients, traumatized clients presenting for psychotherapy should also receive information on:

    * the possible short-term and long-term effects of trauma treatment on the client and the client’s relationships with others
    * the amount of distress typically experienced with any particular trauma treatment
    * possible iatrogenic effects of a particular trauma treatment
    * the possibility of lapses and relapses when doing trauma work and clarify that these are a normal part of healing and are to be expected

 

    * American Psychological Association:  Fees
    * American Psychological Association:  Structuring the Relationship
    * American Psychological Association:  Informed Consent to Psychotherapy
    * Canadian Psychological Association:  Informed Consent
    * Canadian Psychological Association: Freedom to Consent
    * Sidran Foundation: Psychotherapy Disclosure Statement

Clients presenting for legal assistance should be informed that involvement in the legal process may be experienced as re-traumatizing. It may be helpful for victimized clients who are involved in legal proceedings against an assailant to be informed that a finding of "not guilty" is a legal finding (i.e., is based on degree of available evidence), and is not a statement as to whether or not the event(s) in question occurred. They should also receive, from an attorney or other qualified individual, information on:

    * the nature of the legal process as it pertains to the client's specific case
    * the estimated length and cost of legal services, if applicable
    * what to expect during police investigations
    * court procedures
    * full information on all possible outcomes
    * what to expect during cross examination

Therapists should be aware of current legislation in their jurisdictions regarding disclosure of client information. Consult with qualified attorneys (Pope & Brown, 1996). Therapists should not provide legal counsel or guidance to clients.

If clients express interest in initiating a civil or criminal suit, encourage them to consider the ways in which they are and are not prepared for this, including their own mental state, capacity for resilience, and the invevitable loss of confidentiality (Pope & Brown, 1996).
 

    * American Professional Society on the Abuse of Children (APSAC): Proposed guidelines for Investigative Interviewing in Child Abuse
    * International Victimology Website (contains the UN Declaration of Basic Principles of Justice for Victims of Crime & Abuse of Power, and related documents)
    * Justice Information Center (U.S.)
    * National Center for Victims of Crime (U.S.)
    * World Society for Victimology

Clients presenting for medical assistance should receive information on:

    * the nature of the medical treatment they will be receiving
    * the cost of treatment
    * any discomforts or distress the client may experience during treatment

3. Procedures for Assessment (see Blank, 1994; Briere, 1997; Carlson, 1997).

Distress of divulging

Trauma assessment can be very stressful for some people (e.g., see Litz, et al, 1992), and the process of talking about trauma may alter the client's state. If a client is highly distressed or unstable, postpone the assessment until the client is sufficiently stabilized such that the assessment data are not contaminated by negative reactions to the assessment or the assessor (Briere, 1997, p. 58).

The assessment environment itself can also prove triggering for traumatized clients (e.g., Vesti & Kastrup, 1995). Provide a safe environment for assessment and develop as much rapport with the client as possible (Armstrong, 1995; Carlson, 1997). Explain testing procedures in advance. Inform the client that testing may be stressful. Post-assessment debriefing can help the client process the experience of recalling traumatic events (Briere, 1997).

Explain in detail the nature of the assessment process to the client before beginning the assessment. Describe any self-report measures to be filled out. Provide clients with choice as to whether to continue with the assessment. After the assessment is over, point out to the clients their successes and strengths in having coped with the trauma.  (Carlson, 1997)

Always pace the assessment based on the client's lead and respectfully follow without probing deeper than the client is willing or able to go at that early stage (Herman, 1992; Krell, 1986; Rosenman & Handelsman, 1990). Use a calm and reassuring voice and demeanor (Briere, 1997)

If clients become increasingly stressed, excited, angry, tangential, withdrawn, flooded with flashbacks or dissociative responses, further assessment may be contraindicated. In such circumstances, stabilize the client (Briere, 1997).

Some clients who have experienced chronic child abuse may fear to disclose their abusive histories due to feelings related to betrayal trauma, including fears of abandonment for disclosing (Freyd, 1994; 1996). Provide clients with clear and concrete assurances that you will not abandon them for disclosing (Pope & Brown, 1996)

Tracking the Event

Take care to avoid any statements that the clients might perceive as indicating that they are to blame for having “failed” to recover.

When clients are reporting their traumatic experiences, follow the client’s own pace. If the client is not aware of a link between current symptoms and a past traumatic event, do not tell the client that his/her symptoms are necessarily due to a past trauma.

Past Memories

Some clients may have concerns about whether or not a certain traumatic event did or did not happen, thereby sidetracking the assessment process. In such circumstances, educate clients about the vagaries of memory, including that memories are not necessarily exact representations of past events, but that subsequent events and emotions can have the effect of altering the original memory. Inform clients that the determination of whether or not an event occurred may not be possible, but that treatment can nonetheless be effective in alleviating distress (Carlson, 1997; Meichenbaum, 1994; Pope & Brown, 1996).

Support the client without creating premature closure or certainty, and model tolerance of doubt, ambiguity, and uncertainty. Assist the client in actively participating in making sense out of that which is being experienced (Pope & Brown, 1996)
 

    * Canadian Psychological Association: Guidelines for Psychologists Addressing Recovered Memories
    * International Society for the Study of Dissociation: Veracity of Memories   (scroll down to section M)
    * Ken Pope's Pages

Normalize as part of the Assessment

Include a psychoeducational component that normalizes the client’s response to the traumatic event (Albeck, 1994). Use care to not minimize the effects of trauma.

Shattered Assumptions

Include assessment of any "Shattered Assumptions" (Janoff-Bulman, 1992), such as “I am not safe, the world is a dangerous place” and so forth. Addressing shattered assumptions is an important focus of treatment.

Secondary Traumatization

If clients have not experienced a traumatic event directly, be alert to the possibility of secondary traumatization, where individuals may evidence posttraumatic symptoms when hearing the trauma stories of others (Figley, 1995; Pearlman & Saakvitne, 1995).

Suicidality and Safety

Conduct a risk assessment whenever basic indicators reveal potential for self-harm, suicide, or harm to others (Boudewyn & Liem, 1995; Everly, 1990; Kilpatrick et al., 1985; Pope & Brown, 1996).

Screen for such risk at the initial assessment and throughout the course of treatment (Pope & Brown, 1996).

If you are not qualified or comfortable working with clients who evidence intense instability, or suicidal or homicidal feelings, screen during the initial telephone contact and provide appropriate referrals (Pope & Brown, 1996).
 

    * Suicide Information and Education Center

Assessing Readiness for Trauma Therapy

Ask clients about their desire to do trauma work before proceeding.  Assess their motivation and their confidence in their ability to change.  If a client has signs or symptoms of Complex PTSD, Dissociative Identity Disorder (DID), or other Dissociative disorders, use extra caution when utilizing interventions for trauma. Stabilization is necessary before traumatic material is processed (Herman, 1992; Briere, 1996).

Assess client's ability for self-containment between sessions, and develop strategies with the client for enhancing self-containment in the therapist's absence (Pope & Brown, 1996)

Assessment Methods
(see Briere, 1997;  Carlson , 1997; Wilson & Keane, 1996).

a) Interviews
When interviewing clients for trauma-related sequelae, monitor the client’s reactions for excessive distress throughout the interview. Excessive coverage of traumatic material may be overwhelming to some clients. Establish rapport and use sensitivity throughout the interviews, using care to normalize or destigmatize the reporting of interpersonal violence  (Briere, 1997)

Use specific behavioral anchors when assessing for PTSD criterion A events (i.e., whether specific traumas occurred) to avoid underreporting, especially for interpersonal victimization (e.g., see Briere, 1992; Hanson, Kilpatrick, Falsetti, & Resnick, 1995). For example, rather than asking "were you ever raped?" it is important to provide specific behaviors that describe rape (Briere, 1997)

Unstructured or semi-structured Interviews allow for client-centered pacing when reviewing traumatic material (Pearlman & McCann, 1994). During an unstructured or semi-structured interview, in addition to assessing for specific posttraumatic sequelae, assess for issues of comorbidity, therapeutic motivation and readiness, rigidity of cognitive distortions, current suicidality/safety issues, and personal goals.

As the interview proceeds, monitor the client's reaction to the questions. If the client becomes overly distressed, the interview can be terminated, if necessary. The process may become overwhelming or retraumatizing, and this may also affect the quality of the interview via avoidance or confusion (Briere, 1997, p. 81).

Structured Clinical Interviews. The benefit of using Structured Interviews is the ability to acquire in-depth evidence for PTSD and the opportunity to explore DSM-IV symptoms or event details at any stage of the interview process. The following instruments are recommended:

    * The Clinician Administered PTSD Scales (CAPS; Blake et al., 1995)
    * The PTSD Symptom Scale-Interview (PSS-I; Foa et al., 1993)
    * The Structured Interview for PTSD (SI-PTSD; Davidson, Kudler &Smith, 1990)

b) Psychophysiological Method

When using trauma-related stimuli (e.g., pictures, audiotapes, narratives, imaginal, etc.) to assess for posttraumatic physiological symptoms, stay with your client at all times, and monitor for signs of excessive distress. If clients become overly distressed or overwhelmed, discontinue the stimulus presentation.

Always explain the psychophysiological assessment procedure in full and obtain consent before starting the assessment. Show clients the equipment that will be used and explain what it is used for.

Always tell the client what you are about to do and ask for the client’s permission before applying recording devices, such as electrodes, respiratory transducers, and so forth.

Give clients permission to stop the procedure at any time, and arrange for a non-verbal means for the clients to communicate this to you (e.g., raising a hand, etc.) in case they have difficulty verbalizing during the procedure.

c) Self-Report Measures

See Briere (1997); Carlson (1997); Wilson & Keane (1996) for information on various trauma-specific and generic self-report measures.
 

    * American Academy of Child and Adolescent Psychiatry: Practice Parameters for the Assessment and Treatment of Children & Adolescents with PTSD and Complete Summary
    * American Psychological Association: Evaluation, Assessment, or Intervention
    * APSAC Guidelines for Practice with Abused Children
    * Canadian Psychological AssociationGuidelines for Educational and Psychological Testing
    * Horizon Healthcare: Assessing  Domestic Violence
    * John Briere's Assessment Webpage
    * United States Preventive Service: Assessing Family Abuse

4. Procedures for Diagnosis and Reporting

Clinical diagnosis of PTSD and trauma-related disorders

When assessing post-traumatic sequelae, assessors should be familiar with the myriad of possible post-traumatic sequelae and disorders, including variations in cultural expression of posttraumatic distress.

Posttraumatic disorders, as per the Diagnostic and Statistical Manual of Mental Disorders, fourth edition (American Psychological Association, 1994; Briere, 1997), include:
 

    * Acute Stress Disorder (ASD)
    * Post Traumatic Stress Disorder (PTSD)
    * Brief Psychotic Disorder with Marked Stressor(s)
    * Major Depression
    * Complex PTSD (as per PTSD Associated Features section)
    * Dissociative Amnesia
    * Dissociative Fugue
    * Dissociative Idenitity Disorder
    * Depersonalization Disorder
    * Dissociative Disorder Not Otherwise Specified

Pre-screen for dissociation using the Dissociative Experiences Scale (DES; Carlson & Putnam, 1993). If a comorbid dissociative disorder is expected through a preliminary screen using the DES, conduct a more thorough structured interview for exploring these symptoms. The Dissociative Disorder Interview Schedule (DDIS; Ross et al., 1989) or the Structured Clinical Interview for DSM-IV Dissociative Disorders-Revised (SCID-D-R; Steinberg, 1994) are recommended. If the client meets criteria for DID or has highly elevated scores on measures of dissociative symptoms, be aware of potential complications when using trauma interventions.
 
 

    * International Society for Study of Dissociation (ISSD): Diagnostic Procedures

In addition, there are specific culture-bound stress responses the clinician should be aware of when working with multicultural clients (see Briere, 1997, pp. 47-49; DSM-IV Appendix I), including:

    * Attaques de Nervios
    * Nervios
    * Susto

Other DSM-IV disorders sometimes associated with trauma include

    * Conversion Disorder
    * Somatization Disorder
    * Borderline Personality Disorder

All diagnostic possibilities are to be considered given the overlap of posttraumatic symptoms with other disorders (Breslau & Davis, 1992; Burnham et al., 1988; Davidson & Foa, 1991; Green, et al., 1989; Kessler, et al, 1995), so as to avoid misidentifying other disorders as posttraumatic disturbance and vice versa (Briere, 1997)

Some clients will not meet full criteria for any particular disorder, yet may nonetheless experience significant distress or impairment as a result of trauma.

Avoid pressuring clients to accept a diagnosis at any stage of assessment or treatment, and respect their timing, pacing, and readiness to integrate information (Pope & Brown, 1996).

Misdiagnosis

Assess for PTSD and associated features and disorders even if not recognized by the referring professional, using care to not underestimate the prevalence of misdiagnosis from referral sources (Beck & van der Kolk, 1987; Bende & Philpott, 1994; Domash & Sparr, 1982; Friedman, 1997; Froehlich, 1992; Gayton, Burchstead & Matthews, 1986).

Use care in the choice of assessment measures and in the interpretation of more generic measures. Utilize trauma-specific measures to augment more generic measures. Many generic instruments have insufficient sensitivity to pick up on posttrauma symptoms, and may misclassify trauma symptoms as other disorders, including personality disorders or psychosis. Intrusive posttraumatic symptoms may show up on generic measures as indicative of hallucinations, obsessions, primary process, or faking bad. Dissociative avoidance may show up as indicative of fragmented thinking, chaotic internal states, or negative signs of schizophrenia. Trauma-based cognitive phenomena may show up as evidence for paranoia or other delusional processes (Briere, 1997, p. 71). Similarly, Rorschach responses in persons severely traumatized may erroneously suggest personality disorder or psychosis (Briere, 1997; Levin & Reis, 1996; Saunders, 1991; van der Kolk & Ducey, 1984,1989).

Maintain awareness of possible symptom underreporting. Clients who are exhibiting avoidance symptoms (including dissociation) may deny or mask trauma-related symptoms (Elliott & Briere, 1994; Epstein, 1993). Give careful attention to posttraumatic clinical presentations, facilitate an assessment environment that will keep client avoidance to a minimum, and use trauma-sensitive measures (Briere, 1997).

When clients present with dramatic, sexualizing, or seemingly manipulative behaviors, it is important to recognize these as possible symptoms of early trauma, rather than assuming that they serve a secondary gain or reflect “primary process thinking” (Briere, 1996).
 

    * Canadian Psychological Association: Guidelines for Therapy and Counseling with Women

5. Reporting Clinical Findings

Clinical Note taking

When writing clinical notes, write them as though your client is sitting next to you and is reading every word.

In general, notes should include the problems addressed in session and the interventions used. Utilize behavioral descriptors (e.g., what your client said and did) and direct quotations whenever possible. Be brief, but utilize sufficient detail such that an independent reader would have a basic understanding of what occurred in session (Pope & Brown, 1996).

Pay attention to language.  For example, "sexually reactive" vs. "promiscuous" (McEvoy, 1995)

Avoid careless interpretation, speculation and assumptions. Content of notes should be based in standards of care and empirical science on treatment effectiveness (Pope & Brown, 1996).

Be brief about details of flashbacks.  At intake, record the range of your client’s memory, e.g., that s/he has always remembered, etc.  Record the timing of flashbacks. For example, “flash of wiping up white substance off “bathroom” floor."  Leave room on page for further understanding, corrections.  If inconclusive, say so (McEvoy, 1995).

Keep current with legal provisions regarding notes (McEvoy, 1995; Pope & Brown, 1996).

The following information has been subpoenaed by courts:  audio/video tapes; client’s drawing during session; client’s drawings brought to/talked about in session; client’s writings done in session; client’s diary/journal; diagrams, charts; assessment reports; consultation requests/reports; reports to funding agencies; recordings by office staff (e.g., intake worker); business recordings (billings, appointment book, etc.); materials stored in computers; photographs; ledgers; and notes scribbled on scraps of paper (McEvoy, 1995; Pope & Brown, 1996).

Do not replace original notes with "substitute" notes written after the fact. Consult with attorneys or other qualified individuals regarding how to make corrections to notes, however, original notes should always be preserved as is (Pope & Brown, 1996).

       

          o American Psychological Association: 1, 2, 3, 4, 5,6, 7, 8
          o Canadian Psychological Association: Records and Confidentiality
          o American Psychological Association (1993)
          o Eberlein (1990)
          o McEvoy, 1995/1996
        

6. Procedures for Establishing Safety

Roles and Boundaries

Roles and boundaries/structure should be clarified from the start and gently reiterated whenever required (Briere, 1992; 1996; Matsakis, 1994; Pope & Brown, 1996)

Safety and Stabilization

It is crucial for clients to feel relatively safe prior to the processing of the trauma. Specific means of facilitating a sense of safety for clients can be found in Briere, 1996; Herman, 1992; Matsakis, 1994; Meichenbaum, 1994; van der Kolk, McFarlane, & van der Hart, 1996.

Always give clients choice, including choice over when/how much traumatic material to self-disclose, respecting their boundaries and defenses so as to avoid re-traumatizing them (Briere, 1996; Herman, 1992; Matsakis, 1994; Meichenbaum, 1994).

Inform clients from the start regarding any limitations to your availability (Pope & Brown, 1996)

Clients should have stability within their lives before processing traumatic material, including stability in areas of potential danger/revictimization/basic need; use of alcohol and drugs; affect regulation; skills for dealing with flashbacks between sessions; and so forth (see Herman, 1992; Meichenbaum, 1994; Pope & Brown, 1996). Document your discussions with clients regarding need for basic care. Provide referrals to community resources (e.g., transition houses; legal aid; etc.)  when indicated.

In general, stabilization within sessions may be facilitated through reducing stimulation, reassurance, and grounding (Briere, 1997).

Clients who have coped through substance abuse and who attain sobriety may find they become flooded with flashbacks and other intrusive imagery.

Assessing Readiness

Proceed to explore trauma material only when there is evidence of client stability regarding self capacities, safety, self-care, trigger management and symptom management (Briere, 1996; Herman, 1992; Meichenbaum, 1994).

Pay particular attention to

    * extreme anger, anxiety, dependency, or fragmentation when traumatic material is addressed
    * flashbacks, nightmares, or excessive intrusions in response to therapeutic interventions

Exposure-based Treatment

Although recent reviews of the literature suggest that exposure-based trauma therapies appear to be effective and well-tolerated in the treatment of uncomplicated or simple PTSD (e.g., Rothbaum & Foa, 1999), adverse reactions to exposure therapy in some persons with PTSD have been noted both in empirical studies (e.g., Pitman, Altman et al., 1991) and anecdotally (e.g., Scott & Stradling, 1997).

Some traumatized individuals evidence an exacerbation of symptoms following exposure treatments (e.g., Foy et al., 1997; Johnson et al., 1994; Kilpatrick & Best, 1984; Mueser & Butler, 1992; Pitman, et al., 1991, 1996; Shalev et al., 1996; Watson et al., 1995). Moreover, some studies suggest that exposure may be effective with intrusive symptomology, but have little effect on avoidance and numbing symptoms (e.g., Foy et al., 1997; Keane et al, 1989; cf Pitman et al., 1996). Empirical studies have suggested that titrated exposure to trauma-related stimuli and narrative integration is effective in the treatment of intrusive (Carbonell & Figley, 1995; Foa, Rothbaum, Riggs, & Murdock, 1991; Shapiro, 1995). As of August 1999, a database search shows there are no published empirical studies on the effects of exposure therapies with persons who have more complex forms of PTSD or Dissociative Disorders.

Use caution with exposure-based treatments with clients who exhibit the following, as there is some evidence to suggest they are at increased risk of retraumatization, increased anxiety and panic, alcohol abuse, increased shame and guilt, and obsessional thinking following exposure (Litz, et al, 1990):

    * current substance abuse
    * history of impulsivity
    * ongoing life crises, such as suicidality
    * prior failed treatment with exposure-based therapy
    * a history of noncompliance
    * a recent claim for compensation
    * difficulty using imagery
    * absence of reexperiencing symptoms
    * inability to tolerate intense arousal
    * history or presence of a co-existing psychiatric disorder

It is important to take steps to insure that the pacing and timing of exposure-based interventions are carefully monitored

Place emphasis on integrating cognition and affect and give clients sufficient time to process their memories (Pope & Brown, 1996).

    * International Society for the Study of Dissociation: Abreactions (scroll down to section N)

7. Procedures for Assuring Client-Adjusted Progress (Depth, Breadth, Intensity)

Pacing and timing

Frequently review decisions regarding pacing and timing in collaboration with the client (van der Kolk, McFarlane, & van der Hart, 1996).

Avoid moving too quickly into the trauma as it can increase the risk of self-destructive, aggressive, or psychotic behaviors and substance abuse (Briere, 1992; Matsakis, 1994)

Avoid moving too quickly in treatment or terminating therapy prematurely with clients who have a known history of trauma yet appear asymptomatic (Briere, 1992). Such clients may have an underlying fragility masked by an appearance of high functioning.

Allow for mutually agreed-upon, time-limited breaks away from therapy if required.

Slow down the speed of interventions and/or adjust the intensity of the interventions when clients attempt to adjust or titrate, the emotional intensity that comes from confronting very frightening memories, images and feelings (Briere, 1996).

Be aware of signs of dissociation. In milder forms, these include (Briere, 1996):

    * periods of silence
    * dissociation
    * misunderstanding what are usually understandable concepts
    * sudden changes in the direction of the discussion.

At more extreme levels, dissociation may involve (Briere, 1996):

    * acting out behaviors
    * verbal attacks
    * distraction with sexualized material
    * an increase in adversariality
    * termination of therapy

Continually Monitor Symptoms and Progress

Monitor the client very carefully to ensure that addressing traumatic material does not overwhelm the client’s internal capacities, retraumatize the client, or result in excessive avoidance on the part of the client (i.e., make sure therapy occurs within the “therapeutic window;” Briere, 1996).

Inquire as to the client’s emotional state frequently; observe nonverbals and verbals carefully  (Matsakis, 1994).

If any of the following occur, slow down:

    * resistance
    * repetitive flashbacks
    * dissociative withdrawal
    * regression
    * fragmentation of self-functioning
    * substance abuse
    * self-mutilation
    * excessive sexual behaviors

Use much caution and avoid the following (Briere, 1996, p. 115):

    * pushing for rapid processing of traumatic material
    * encouraging the clients to describe material in detail and using exposure techniques before safety and stabilization are in place
    * using overly stressful interventions (e.g., intensive role-plays, group work, guided imagery)
    * giving confrontations or interpretations that are too challenging
    * demanding that the client work harder and stop resisting

Flashbacks and Triggers

Help clients identifying and manage flashbacks and triggers between sessions. Normalize and educate (see Meichenbaum, 1994)

If a client is triggered in session, help focus the client on the facts of what is happening in the here-and-now. Specific techniques can be found in Briere, (1992; 1996); Meichenbaum, (1994).

Use caution with meditation and related techniques for clients who are flooded by flashbacks and other intrusive symptoms, as such techniques can induce dissociative states and subsequent panic (Pope & Brown, 1996).

Symptom Exacerbation

Slow down and reconsider the course of therapy if symptoms worsen dramatically during active exploration of the trauma (Herman, 1992). Such symptoms include dissociation, striking out, or screaming repetitively and stereotypically (Briere, 1996).

When clients become agitated and distressed, explore with the client what it is that is causing this state. When clients are feeling agitated or distressed because of current danger in their lives or environments, it is dangerous to stop or soothe away responses that act as warning signals (Pope & Brown, 1996).

Dissociation during therapy (Briere, 1996).

Although some degree of dissociative defensiveness is appropriate, particularly early on in treatment, continued dissociation can interfere with the healing process. Watch for signs of dissociation, including

    * fixed or “glazed” eyes
    * sudden flattening of affect
    * long periods of silence
    * monotonous voice
    * stereotyped movements
    * “unreal” responses
    * excessive intellectualization

Have clients attend to their dissociative behavior and ask them to reduce the dissociative behavior to its minimal level, if possible.

If the dissociation continues, decrease the client’s immediate distress or increase the client’s level of self-support.

Destabilization/decompensation

Destabilization refers to a chronic lessening of functioning over time in the outside world due to uncontrollable intrapsychic events (Briere, 1996).

Signs of destabilization include:

    * increased client dependency on the therapist
    * florid symptoms
    * helplessness
    * hopelessness

If destabilization or decompensation occurs during therapy, immediately consolidate, support, soothe and avoid further exploration of traumatic material, in an attempt to re-instill a sense of control and stability.

Distinguish between (i) a normative increase in symptoms and (ii) destabilization. Avoid unnecessary interventions such as violating confidentiality, medications, and hospitalizations if a client’s symptoms are increasing but they are not destablized. Such interventions, when unnecessary, can retraumatize the client.

However, be responsive to your client’s escalating distress. If clients view a low-key response to their distress as evidence of therapist abandonment or incompetence, it could result in further dysphoria or decompensation (Briere, 1996).

8. Procedures for Using Risky Treatment Methods with Informed Consent

Define to the client what the intended treatment consists of and all possible risks of engaging in said treatment. Provide the client a written summary of the procedure and the risks involved. Obtain written consent.

9. Reaching Therapy Goals Through Consensus

Collaborate with your client in the design of a clearly defined contract that specifies a specific goal in a specific period of time, or a contract for a more open-ended process with periodic evaluations of progress and goals.

Inform Clients about the Healing Process (Matsakis, 1994):

    * Clearly delineate to the client the nature of the healing process, making sure that the client understands.
    * Encourage clients to ask questions about any and all aspects of treatment and the therapeutic relationship. Provide your clients with answers in a manner they can understand.
    * Encourage clients to inform you if the material discussed becomes overwhelming or intolerable.
    * Inform clients of the necessity of contacting you or emergency services if they feel suicidal, homicidal, or out of touch with reality.
    * Inform clients what constitutes growth/recovery and that some trauma symptoms may not be fully treatable.
    * Address any unrealistic beliefs about therapy (e.g., magic cures)

Level of Functioning (Matsakis, 1994)

Inform clients that they may not be able to function at the highest level of their ability, or even at their usual level, when working with traumatic material.

Prepare clients of the possible symptoms they may experience, explaining that these symptoms do not mean the clients are “crazy”. These include

    * reexperiencing of the trauma
    * avoidance
    * vigilance
    * emotional reactivity

10. Termination/Transition from Regularized Sessions

Some clients may experience the termination of therapy or transition from regularized sessions as an abandonment. Clients may present with increased levels of dependency and other symptoms during such times. Inform clients that such symptoms do not necessarily indicate a relapse or a treatment failure, but are understandable and offer a new opportunity for further growth. If clients decide they do not want to terminate treatment, discuss this openly with them. Inform them that they are free to return later if they feel the need for further treatment. Provide them with plenty of advance notice.

11. Ongoing Relationships and the Issues of Boundaries

Dual relationships

Dual relationships are to be avoided as much as possible.  “Dual” includes concurrent and sequential relationships.  Inform clients from the start that sexual or romantic relationships are forbidden in professional ethical codes.

Sexual Contact (Briere, 1996; King, 1987; Pope, Keith-Spiegel & Tabachnick, 1986;  Thoreson, Shaughnessy, Heppner & Cook, 1993)

Never engage in any form of sexual contact with clients.

Do not reward sexualized behaviors with attention or reactivity

Directly clarify the boundaries of the therapeutic relationship and address the underlying motivations of persisting sexualized behavior.

Set limits on client’s inappropriate behaviors while maintaining an ethos of care. Maintain respect for the dignity and worth of the client at all times.

Re-address the absolute inappropriateness of sexual and/or romantic behavior in a non-lecturing, non-punitive, manner.

If you have sexual contact with clients, remove yourself from practice, refer the clients, and notify legal and professional authorities.
 
 

    * Ken Pope's Pages

Boundaries

Use care with self-disclosure or any behaviors that may be experienced as intrusive by the client, including (Briere, 1996, p. 103):

    * inappropriate personal disclosures
    * sexual behavior with a client
    * excessively intrusive questions or statements
    * habitual interruptions
    * personal space violations
    * conscious or nonconscious use of the client to gratify the therapist’s needs

Use caution with interpersonal touch.  Physical touch may induce flashbacks in some clients
and/or be experienced as a boundary violation.

12. The Issue of Recovered Memories of Abuse

There is some evidence that suggestibility can be enhanced and pseudomemories can develop in some individuals when hypnotic techniques are used as a memory enhancement or retrieval strategy (Pope & Brown, 1996, p. 59). Hypnosis and guided imagery techniques can be used to ehance relaxation and teach soothing strategies with some clients, however, it is recommended that they not be used in the active exploration of memories of abuse.

Traumatologists should maintain a critical stance in relation to their assumptions, theories, research, and assessment procedures/instruments (Pope & Brown, 1996).

Recognize and minimize as much as possible imbalances in power within the therapeutic dyad. Recognize and respect the adult autonomy of clients. Strengthen the client's critical thinking skills through the use of open-ended questions, and strengthen their abilities to resist suggestion. The risk of creating pseudomemories or of avoiding real traumatic memories will be reduced (Pope & Brown, 1996).

When clients are highly distressed by intrusive flashbacks of delayed memories, assist them in regaining their power to move beyond their confusion, however do not provide premature certainty (Pope & Brown, 1996). Encourage and model a tolerance of distress and ambiguity

Inform clients they are free to make their own decisions regarding their intrusive symptoms, without being pushed in any particular direction. Support them in coping with their anxiety from not having immediate or certain answers.
IV. STANDARDS OF CARE FOR RESEARCH WITH TRAUMATIZED PERSONS
(See French & Harris, in press; Harris, 1995 )

1. Research Participants Universal Rights

When conducting research with traumatized persons, provide as much choice and control as possible over their degree of participation. Guarantee anonymity in every phase of research to honor the privacy of the participants.  Avoid all forms of deception, whether direct or indirect, and take all steps to guard against coercion when obtaining informed consent

2. Guidelines for Diagnosis of PTSD for Research Purposes

(a) Rule-out medical problems
(b) Rule-out substance use/abuse/toxicity
(c) Rule-out malingering/feigning
(d) Distinguish from normal or developmental issues
(e) Differentiate from Adjustment Disorder NOS
(f) Differentiate from Acute Stress Disorder
(g) Differentiate from Secondary Traumatization
(h) Identify/diagnose comorbidity issues
(i) Diagnose PTSD.

3. Procedures for using Risky Research Methods with Informed Consent

a) Participants are to be informed of:

    * the purpose of the research in clear, comprehensive terms
    * the reason(s) they have been chosen as a participant in the research
    * their role in the research
    * the procedures that are required
    * the time factors involved
    * who will do the interviews and testing
    * any alternative procedures that may be expected
    * all risks or discomforts
    * the benefits in the research
    * the best time when participants may ask questions
    * contact persons who can provide advice about becoming a research participant
    * their freedom to withdraw from research once they have started
    * that they probably will have unanswered questions

b) Inform participants if you provide counseling/therapy services for them and/or provide referrals. It is recommended that therapy be made available to research subjects who require further assistance.

4. Procedures for Recruiting Research Participants Humanely

a) Include the overall purpose of the research or treatment
b) Describe the role of the research participant and why s/he was chosen
c) Explain any procedures or techniques to be used, without compromising the results or process
d) Discuss any risks and discomforts that could be incurred-both short and long term
e) List the benefits of participation without generating guilt for non-participation
questions regarding the research and provide sources for help with a participant's decision to participate or not
g) Acknowledge the right to withdraw and terminate participation at any time
h) Identify sponsorship of the research
i) Identify likely gains in knowledge or the purpose of the research
j) Discuss how the data will be used and disseminated
k) Offer to debrief at the end of the research
l) Offer to send results to participants if they wish
m) Keep all promises made to participants
n) Clarify and honor all obligations and responsibilities
o) Involve the participants where possible
p) Provide detailed informed consent with understandable language
q) Identify the time, effort and resource requirements for each participant
r) Avoid undue pressure to participate
s) Provide follow-up (after research termination) therapeutic services

5. Procedures for Collecting Data Humanely - General Research Principles

a) Maintain awareness that ethical decisions have value implications
b) Maintain concern for the well-being of participants
c) Take into account the possible future uses of knowledge that will be attained from the research
d) Protect participants from harm

6. Procedures for Reporting Findings and Impressions Humanely

a) Report the findings and impressions only when the following conditions have been met:

    * Universal rights have been observed
    * Participants were recruited appropriately
    * Data was collected appropriately and in accord with relevant professional codes of ethics
    * Participant anonymity is guaranteed

b) Use care to avoid overpathologizing traumatized individuals when reporting findings from research
c) Refer to research participants as "participants" rather than "subjects"
 
 

    * American Association of Marriage and Family Therapy: Research
    * American Psychological Association Research
    * Canadian Psychological Association Guidelines for Nonsexist Research
    * Canadian Psychological Association Checklist for Nonsexist Research


V. Related Online Codes of General Professional Ethics

American Association of Marriage and Family Therapy
 American Association of Pastoral Counsellors
American Psychiatric Association
American Psychological Association
British Psychological Society Code of Conduct
Canadian Psychological Association Code of Ethics
Canadian Traumatic Stress Network Ethical Code
National Association of Social Workers

See also International Society for the Study of Dissociation Treatment Guidelines for DID
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