psychotherapeutic strategies for healing trauma

132 Perspectives in Psychiatric Care Vol. 43, No. 3, July, 2007

Blackwell Publishing IncMalden, USAPPCPerspectives in Psychiatric Care0031-5990© Blackwell Publishing 2007XXX

ORIGINAL ARTICLES

Psychotherapeutic Strategies for Healing Trauma


Kathleen Wheeler, PhD, APRN-BC

PURPOSE

.

The Adaptive Information Processing

Model (AIP), originally developed by Shapiro

(2001), provides a model for understanding how

trauma affects the brain and how healing occurs.

CONCLUSIONS

.

The effects of trauma are thought

to be much broader than the diagnosis of PTSD

and overlap with many other diagnostic

categories. Recent physiological research supports

the complexity of neurobiological responses to

childhood stress and trauma.

PRACTICE

IMPLICATIONS

.

The Treatment

Hierarchy, AIP model, and evidence-based

treatment framework presented here provide the

context and a compass for holistic PMH-APRN

practice for working with traumatized patients.

Search terms:

Adaptive information

processing, disorders of extreme stress

(DESNOS), healing trauma, posttraumatic

stress disorder (PTSD)

Kathleen Wheeler, PhD, APRN-BC, is a Professor at Fairfield University School of Nursing in Fairfield, CT.

T

rauma is an inescapable part of the human experienceand affects all dimensions of the person. Psychologicaltrauma has been posited to underlay or contribute toa wide range of psychiatric disorders and medicalproblems (Hennessey, Ford, Mahoney, Ko, & Siegfried,2004; Morrison, Frame, & Larkin, 2003; Scaer, 2005;Teicher, Polcari, Andersen, Anderson, & Navalta, 2003).Trauma disconnects the person physiologically,emotionally, spiritually, cognitively, interpersonally,and socially. The National Comorbidity Study foundthat 60.7% of men and 51.2% of women interviewedreported having experienced at least one majortraumatic event in their lifetime (Kessler et al., 1999),and of those exposed to trauma, the prevalence rate forposttraumatic stress disorder (PTSD) is approximately25% overall in the United States (Foa, Keane, & Fried-man, 2000).

Findings (Amsel & Marshall, 2003) from the WorldTrade Center disaster indicate that many people didhave significant symptomatology afterward, such asinsomnia, irritability, general anxiety, vigilance, andimpaired concentration. However, those problems thatpeople sought help for did not fit into the diagnosticcategories of the

DSM-IV-TR

. Van der Kolk (2003)says that single incident traumas account for thosediagnosed with PTSD but that most adults who seekpsychotherapy have had numerous traumatic eventsand suffer from a variety of psychological problems,most of which do not fall within this diagnosticcategory. Broadly speaking, these fall into problemsin aggression, self-hatred, dissociation, somatization,depression, distrust, shame, relationship problems, andaffect regulation.

The Effects of Trauma Beyond PTSD

The effects of trauma are thought to be muchbroader than the diagnosis of PTSD and overlap with

Perspectives in Psychiatric Care Vol. 43, No. 3, July, 2007 133

many other diagnostic categories. This is true foradults as well as children. One study (Teicher et al.,2003) found that almost two thirds of children withdocumented abuse do not suffer from PTSD but froma variety of other psychiatric disorders, such as dis-sociative disorders, borderline personality, bipolarand unipolar depression, substance abuse, eating dis-orders, oppositional defiant disorder, and attentiondeficit disorder.

An individual’s vulnerability to trauma depends onthe developmental stage, genetic vulnerability, gender,past experiences, preexisting neural physiology, cog-nitive deficits, emotional maturity, coping skills, hardi-ness, relationships with others, sociocultural factors,and a host of other factors (Antai-Otong, 2002). Ifthe trauma is particularly prolonged and/or severeand/or the person is vulnerable, pervasive personalityproblems develop. The person may then develop com-plex PTSD or disorders of extreme stress not otherwisespecified (DESNOS) (Herman, 1992). Although not a

DSM-IV

diagnosis yet, six deficit areas for DESNOShave been delineated, which include: dysregulationof affect and impulses, disorders of attention andconsciousness, disorders of self-perception, distortedinterpersonal relationships, distortions of systems ofmeaning, and somatization of external stress mani-festing in the body as disease or physical disorders(Dworkin, 2005). These individuals, referred to as thechronically disempowered by Chu (1998), are oftensurvivors of childhood abuse and require long-termtreatment extending over several years.

Shapiro (2001) expanded the concept of traumafrom what we traditionally consider

Big T

events, suchas natural disasters, terrorist activities, war, incest,physical abuse, car accidents, and other major life-threatening events, to include

small t

traumas.

Small t

traumas are those that occur often and to most people,such as emotional neglect or indifference, humiliation,and family issues and do not rise to the level of a

BigT

trauma, yet may create problems and long-termsequelae, both physically and emotionally. For example,childhood experiences such as caregiver depression,

chronic mother-infant misattunement, being bullied,chronic loneliness, separation from parents, feelingstupid and humiliated in the classroom setting, signifi-cant physical illness, relationship and/or personalityproblems between parents, economic hardships, familyinstability, frequent moving and/or change of school,taking care of an alcoholic parent, and many other lifeevents impact the developing child’s brain.

Recent physiological research supports the com-plexity of neurobiological responses to childhoodstress and trauma (Stien & Kendall, 2006; Teicher et al.,2003). Of course, adults, too, are affected by

small t

events, especially if they have experienced many

smallt

childhood events because the cumulative effects oftrauma on the developing brain are apt to be profoundand long lasting, particularly in those with a geneti-cally encoded vulnerability. Traumas, both big andsmall, can significantly compromise functioning andlead to psychiatric problems and disorders.

Adaptive Information Processing Model

The Adaptive Information Processing Model (AIP),originally developed by Shapiro (2001), provides amodel for understanding how trauma affects thebrain and how healing occurs. AIP hypothesizes thathumans have an inherent information processingsystem that usually processes experiences to a physio-logical adaptive state where information can be takenin and learning will occur. This model posits thatthere is a self-healing quality in all persons and thatnegative experiences can inhibit innate neurophysio-logic functions. Memory is stored in neural networksthat are linked together and organized around earlyevents with associated emotions, thoughts, images,and sensations. Interconnected neuronal and bio-chemical patterns are developed as templates forfuture experiences through interaction with others,and specific profiles emerge that may be adaptive ornonadaptive. Healthy functioning is reflected in theoptimal integration and coordination of these neuralnetworks.



In trauma, the experience is so overwhelming thatthe event is not fully processed and instead is stored asit was at the time of the disturbing event in a state-specific form and does not get linked to other networksin an adaptive way (Shapiro, 2001, 2002). Intenseaffect occurs, and the experience may be isolated withthe thoughts, emotions, and sensations locked intothe memory network. Trauma dysregulates integratedneural processing of information in these networks(Cozolino, 2002). Later, similar experiences may thenactivate this material. The response to trauma that wasadaptive at the time it occurred is now, in the present,compromising functioning.

Psychotherapy facilitates information processingso that painful memories are integrated with othermore adaptive memories. Processing dysregulatedinformation to an adaptive resolution and connectingsubcortical areas with cortically mediated higher brainfunctions changes dysfunctional symptoms (Cozolino,2002; Shapiro, 2001, 2006). Emotional arousal andnovel sensory experiences activate implicit memorythat is necessary in order to access these state-dependentmemories and link these neural networks in the brainto more adaptive, positive, information networks.Accessing traumatic events marked by sadness, anger,or fear activates all areas where the emotional memoryis stored, recreating all dimensions of the experience,and thus provides an opportunity to facilitate restruc-turing neural networks.

A Framework for Treatment

Given the complexity of responses to trauma, aframework for using psychotherapeutic interventionsneeds to address the bewildering symptoms anddeficits that result, particularly when there has beensevere and prolonged trauma. The Treatment Hierarchyoutlined in Figure 1 is based on research and theorydeveloped by numerous clinicians (Briere & Scott,2006; Chu, 1998; Davis & Weiss, 2004; Najavits, 2002;Shapiro, 2001). This is a phase-oriented treatmentmodel: Phase 1, safety and symptom stabilization,

involves increasing external and internal resources,and Phase 2 is aimed toward processing the painfulmemories so the person can move toward enhancingfuture visioning and self-actualization. This frame-work is based on neuroscience underlying the AIPmodel. Cognitive-behavioral therapy (CBT) and eyemovement desensitization and reprocessing (EMDR)interventions can be used for both Phase 1 Stabilizationto enhance internal resources and Phase 2 Processing.

Phase 1: Stabilization

To begin the healing process, decisions are maderegarding where to target interventions based on acomprehensive assessment of the strengths andresources the person already has. What coping skillshave worked for the person in the past? A thoroughhistory of the patient and an accurate assessmentincludes selected appropriate assessment tools thathelp the Psychiatric-Mental Health Advanced Practice

Figure 1. Practice Treatment Hierarchy

Adapted from Davis & Weiss (2004).


Registered Nurse (PMH-APRN) formulate a plan. Ingeneral, the lower the patient falls on Maslow’shierarchy of needs, the more active the therapist mustbe. For example, the patient who abuses substances, ishungry, and is homeless must first have physiologicalneeds of safety met. Safety is always a priority in thestabilization phase, and crisis intervention may beneeded. Many clinicians recommend treating co-morbid disorders simultaneously, that is, bothPTSD and alcohol abuse together, because of theinterdependent relationship between the person’sproblems (Briere & Scott, 2006; Expert ConsensusGuideline Series, 1999).

Since dissociative disorders frequently co-occurwith PTSD, every patient should be screened with theDissociative Experiences Scale (DES) (Bernstein &Putnam, 1986) (see Table 1). Patients who score highlyon this scale should be further evaluated by theStructured Clinical Interview Schedule for

DSM-IV

Dissociative Disorders (SCID-D) (Steinberg, 1994). If adissociative disorder is present, the patient should betreated by a clinician who is skilled in the treatment ofthese disorders, as the patient may rapidly destabilize.These patients may need a prolonged period of

stabilization and may never be able to tolerate Phase 2,Processing, but will still improve functioning signifi-cantly. Some indicators that the person is ready tomove to Phase 2 include: the patient is able to establisha useful distance from the traumatic event, there is nocurrent life crisis, there is a support system in place,patient’s mood is stable even if depressed, the personcan self-soothe and manage emotions, there is nomajor dissociation, and living conditions are stable.

Goals of Treatment

Patients with significant trauma histories come totreatment with a range of disturbing symptomsand present significant diagnostic and treatmentchallenges. The complexity of symptoms and multiplediagnoses confuse and challenge clinicians who carefor this population. In general, the goals of treatmentfor PTSD can be applied to those who suffer fromother trauma-related diagnoses. These are delineatedin The American Psychiatric Association PracticeGuidelines for PTSD (2004) and include reducing theseverity of symptoms, preventing or treating trauma-related comorbid conditions that may be present oremerge, improving adaptive functioning and restoringa psychological sense of safety and trust, protectingagainst relapse, and integrating the danger experiencedinto a constructive schema of risk, safety, prevention,and protection. Clinical signs of recovery includebeing able to talk about the trauma without feelingupset or numb, functioning in daily life, havingfeelings of being safe and confident, participatingin healthy relationships without feeling vulnerable,taking pleasure in life, having the ability to rely on selfand others, experiencing minimal dissociation, havingthe ability to manage emotions, feeling deserving, andbeing able to plan for the future and expand one’sfocus beyond the self.

Symptom measures used for assessment can trackprogress during treatment as well as help deter-mine whether the goals of treatment have been met.See Table 1 for a selected list of some of the most

Table 1. Assessment/Outcome Measures for Trauma Symptoms

• Impact of Event Scale-revised (IES-R) (Weiss& Marmar, 1997)

• Modified PTSD Symptom: Self Report Version (MPSS-SR) (Falsetti, Resnick, Resnick, & Kilpatrick, 1993)

• The Clinician Administered PTSD Scale (CAPS) (Blake et al., 1995)

• Dissociation Experiences Scale (DES) (Bernstein & Putnam, 1986)

• Structured Clinical Interview Schedule for DSM-IV Dissociative Disorders (SCID-D) (Steinberg, 1994)

Reprinted from Psychotherapy for the Advanced Practice Psychiatric Nurse, Wheeler, K. (in press; 2007, September), with permission from Elsevier.



commonly used instruments. The Impact of Event Scale(IES-R) is a screening tool for a specific trauma (Weiss& Marmar, 1997), while the Modified PTSD Symptom:Self Report Version (MPSS-SR) measures severity oftrauma symptoms (Falsetti, Resnick, Resnick, & Kil-patrick, 1993), and the Clinician Administered PTSDScale (CAPS) is a structured interview tool (Blakeet al., 1995). Although these measures target specificsymptoms, the effects of trauma are wide rangingand affect all dimensions of the person: emotional,intellectual, physical, relational, spiritual, vocational,environmental, and psychological. Holistic outcomemeasurements rather than symptom-specific instru-ments may more accurately reflect healing. Example ofmeasures reflecting holistic outcomes might includequality of life, self efficacy, overall health status, con-nection to others (e.g., a sense of belonging or socialsupport), spiritual well-being, and resilience.

The Therapeutic Alliance

The importance of safety in the therapeutic relation-ship cannot be overemphasized. The therapeutic alliancecultivates a healing environment for emotional safetyand allows the patient to continue and benefit fromtreatment. Traumatized patients may have particulardifficulty forming a therapeutic alliance, and trustissues are often fraught with anxiety. The term

trau-matic transference

was coined to refer to the particulartransference constellations that form for those whohave suffered childhood abuse (International Societyfor the Study of Dissociation [ISSD], 2005). Accordingto the Guidelines for Treating Dissociative IdentityDisorder in Adults, therapy itself:

may begin to erode dissociative barriers anddefenses leading to greater intrusion of traumaticmemories. This may engender additional fears ofloss of control due to increased awareness of ex-treme affects and disturbing cognitions. Feelingvulnerable, patients may manifest more difficultywith trust, fearing that they will be abused or

manipulated as they were in childhood. (ISSD,p. 23)

The therapeutic relationship can offer a correctiveemotional experience through collaborative supportand connection. Meta-analytic reviews of researchstudies have found that the therapeutic alliance is itselftherapeutic and crucial for the successful outcome ofpsychotherapy no matter what model of treatment isused (Martin, Garske, & Davis, 2000). Maintainingfirm boundaries, setting limits, and explaining to thepatient the inherent difficulties the person may en-counter in trust are essential in order to promote a safeenvironment, especially for severely traumatized pati-ents. General strategies for initiating and maintainingthe therapeutic alliance are important and include:(a) asking detailed questions about the patient’s mainconcern, (b) validating affect, (c) explaining the therapyprocess as it unfolds, (d) listening empathicallywithout minimizing or offering “fix it” statements, (e)reminding the person that we are working togethertoward “our” common goal, and (f) pointing out theperson’s strengths (Bender & Messner, 2003).

Internal Resources

Along with shoring up external resources, internalresources often need to be increased prior to process-ing. Internal resources are less tangible than externalresources and include the person’s ability to manageboth positive and negative emotions (i.e., affectmanagement), symptom control, spiritual beliefs, asense of inner strength (i.e., ego strength), and a beliefin oneself. Indicators that the person has sufficientinternal resources include the person’s ability to self-soothe, control impulses adequately, identify stressfultriggers, stabilize mood, reach out to supportive people,and communicate and be honest in reporting. Strategiesfor stabilization include strengthening and/or creatinginternal resources. These strategies assist the person inmanaging the state changes required prior to processing(Shapiro, 2006).


Evidence-Based Interventions

Empirical research supports the efficacy of CBTand EMDR as sole treatment interventions for PTSD(Davidson & Parker, 2001; Rauch & Cahill, 2003). Amultidimensional meta-analysis revealed that themajority of patients treated with either CBT or EMDRimproved significantly (Bradley, Greene, Russ, Dutra,& Westen, 2005). Practice guidelines for both PTSDand Dissociative Identity Disorder include CBT andEMDR as effective treatment modalities (AmericanPsychiatric Association, 2004; Department of VeteransAffairs & Department of Defense, 2004; ISSD, 2005).CBT and EMDR are both widely used for other trauma-related disorders as well, such as anxiety, mood,eating, somatic, and dissociative disorders (Wheeler, inpress). Psychoeducation is a key component throughoutall phases and involves education about trauma;how the fear response develops; and informationabout sympathetic nervous system arousal, depressivesymptoms, panic, and education about the psycho-therapeutic process itself. For a more in depth discus-sion about psychoeducation, please refer to Phoenix’s(2007) article in this issue. Medication to decreasehyperarousal may be indicated and help the person tomanage emotions and control symptoms. Please referto Dowben and Keltner’s (2007) discussion of psycho-pharmacological management for PTSD in this issue.

Cognitive Behavior Therapy

CBT is based on the premise that the individual’sview of self and the world are central to the deter-mination of emotions and behaviors, and thus bychanging one’s thoughts, emotions and behaviors canbe changed (Freeman & Freeman, 2004). Dysfunctional(or maladaptive) thoughts relating to self, world,and/or others are based on irrational or illogicalassumptions. Clinical strategies are utilized to helpthe individual recognize the dysfunctional nature oftheir thinking patterns and to assist the individual tochange their interpretations of situations. Behavioral

interventions have been integrated with cognitivestrategies in CBT, and these combined techniquescontribute to better outcomes. CBT enhances copingskills by teaching strategies such as diaphragmaticbreathing, thought stopping, covert rehearsal, guidedself-dialogue, and role playing (Falsetti, 2003).

SeekingSafety: A Treatment Manual for PTSD and SubstanceAbuse

by Najavits (2002),

The Anxiety and Phobia Workbook

by Bourne (2005), and

The Posttraumatic Stress DisorderSourcebook

by Schiraldi (2000) are excellent resourcesfor the PMH-APRN to use in order to assist the personin developing these skills.

Eye Movement Desensitization and Reprocessing

EMDR training began in the 1990s as a behavioraltreatment for PTSD. In EMDR processing, all dimen-sions of the memory, the image, the thoughts, theemotions, and the body sensations are accessed whilethe patient focuses on a dual attention bilateral stimu-lation, with either eye movements, auditory tones, ortapping, while at the same time paying attention tothe disturbing event (Kuiken, Bears, Miall, & Smith,2001–2002; Shapiro, 2001). In between bilateral sets ofstimulation, the patient free-associates, according toprotocols, in order to elicit information and associa-tional memories. Patients process painful memoriesand integrate new information. The exact mechanismof action is unclear, but it is thought that the dualattention that is required during EMDR facilitatesinterhemispheric connection, thus disrupting thetraumatic memory network. The accessing of adaptiveinformation and the integration of memory networkshas been linked to the processes of REM sleep. There issome empirical support for this explanation for EMDR(Christman, Garvey, Propper, & Phaneuf, 2003; Stick-gold, 2002).

Internal resources can also be developed andinstalled with specific protocols using EMDR thatcombine imagery, safe place, therapeutic interweaves,and/or containment exercises with bilateral stimula-tion (Leeds, 2001). Three general types of resources



identified by Shapiro (2001) include: mastery resourcessuch as patient’s memories of past coping, relationalresources such as memories of positive role models orsupportive others, or symbolic resources from dreams,nature, religion, music, future positive image, etc.Often skilled clinicians use both CBT strategies andEMDR to enhance internal resources. An importantpoint about these strategies is that nothing works foreveryone all the time and that some things work betterthan others for certain patients. Accurate assessmentof the person’s coping skills coupled with collaboration,trial and error, and patience guide the PMH-APRNin identifying what will work best for this person atthis time so that the patient can have a repertoire ofresources readily available when needed.

Stages of Change

When working with the patient, considerationshould be given to where the person is in the changeprocess in order to aim interventions toward behav-ioral change. Prochaska and Norcross (2002) provide amodel upon which to match therapist intervention tothe patient’s stage of readiness to change (see Table 2for the Stages of Change). The therapist assesses theperson’s motivation through open-ended questioningand techniques that are specific for each stage of readi-ness. For example, techniques used to assess precon-templation would be exploratory about the person’slifestyle, such as “Where does alcohol fit into yourdaily schedule?” Requesting the person to measure the

amount of alcohol and keep a log of what they drinkfor a week raises consciousness about the reality of theproblem behavior. Observation and confrontation areuseful communication techniques for consciousnessraising and increases information about the self andthe problem. Bibliotherapy also helps the person toprogress to contemplation. Another technique usefulfor both precontemplators and contemplators is todraw a line vertically down the middle of a paper andask the person to list the

good things

about the behavioron one side and the

not so good things

on the otherside. Allowing time for the person to think about thisand then verbally summarizing without judgmentare important so the person can explore their ownambivalence.

Imagery can also be useful in moving towardcontemplation and assist in self-reevaluation by askingthe person to imagine themselves doing the positivebehavior or change. Along with this process, the personmay experience dramatic relief through experiencingand expressing feelings about the loss of changing.However, the PMH-APRN should help the personmodulate the intensity of the experience by namingthe experience and rating the level of disturbance (0–10 scale) but not encourage detailed rememberingof the trauma. Once the patient has moved into thecontemplation stage, the therapist helps the person tofocus on the discrepancy between now and the waythe person would like things to be. This can be accom-plished through exploring questions, such as “Howwould you like things to be different in the future?”

Table 2. Stages of Change

Precontemplation Contemplation Preparation Action Maintenance TerminationNo intention to change in the foreseeable future

Aware that there is a problem and thinking about doing something about it

Ready to work on change

Person modifies behavior, experiences and/or environment

Free of the problem for >6 months

Confident and free of problem

Reprinted from Psychotherapy for the Advanced Practice Psychiatric Nurse, Wheeler, K. (in press; 2007, September), with permission from Elsevier.


“What’s keeping you from doing things you want todo?” and “How does your current behavior fit intoyour future goals?” These strategies gently lead theperson to their own change.

Phase 2: Processing

Once stabilization has been achieved, the person isready to move to the next phase, that of Processing.Processing reflects access of all dimensions of memory;behaviors, affect, sensations, cognitions, and beliefsassociated with the trauma. Processing involves assist-ing the person in constructing a narrative through theexploration of the meaning of significant small andlarge traumas that impair functioning, and through thisprocess, new learning can occur so that trait changesare possible (Shapiro, 2006). Changes in physical andemotional responses that occur as components of thedysfunctional memory are integrated with other moreadaptive networks. Once processed, the event nolonger increases emotional arousal. Implicit memoriesare accessed and this must occur in the context of asafe therapeutic relationship with adequate resourcesin place. Ensuring safety and stabilization are prioritiesduring emotional arousal so the person is not retrau-matized and the information is integrated and notfurther dissociated (Shapiro, 2001).

Evidence-based CBT interventions in the processingphase are those that involve exposure components,such as writing about the cognitive event, imaginalexposure, in vivo exposure to trauma and/or panic-related cues, and interoceptive exposure to physicalsymptoms (Rauch & Cahill, 2003). Deciding whichexposure component to use depends on the person’spresenting problem. If the person suffers from panicanxiety, interoceptive exposure should be considered.This involves exercises such as stair stepping and headshaking that bring on panic-like symptoms. If theperson does not suffer from panic, imaginal exposurethrough writing or talking about the trauma is appro-priate. In vivo exposure and constructing a hierarchyof associated fears from the least to the most anxiety

provoking and then pairing with relaxation techniquescounters sympathetic arousal with the parasympa-thetic relaxation response.

Processing with EMDR involves targeting thetrauma with an eight-phase protocol that guides theperson through a description of the disturbing eventrelating to his or her presenting problem (Shapiro,2001). The PMH-APRN asks the patient to identifyand focus on the image (picture), negative belief aboutoneself at the time of the trauma, emotions, and phys-ical sensations associated with the traumatic memory.While the person is engaged in some form of bilateralstimulation, he or she is experiencing various aspectsof the initial memory or related memories. The pra-ctitioner pauses between sets of bilateral stimulation toensure that the person is processing adequately on hisor her own and to get the patient’s associations.

During processing,

abreaction

, which is the intensivedischarge of emotions related to the trauma, mayoccur (Chu, 1998; Shapiro, 2001). During abreaction,the person experiences the same sensations, thoughts,and emotions that occurred during the time of thetrauma and becomes immersed in the event. Hyper-arousal occurs sometimes with rapid eye movements,increased respirations, and increasing anxiety. Helpfulstrategies during abreactions include a calm voice,grounding techniques, distraction, asking for clarifica-tion, changing the subject, calling the person by name,and orienting them (i.e., “It’s ok, Jeanne, this is Kate.You are at my office and can hear my voice. You areupset now but you will be able to calm yourself.Notice the rug, the fabric on the chair, and your feet onthe ground. You are right here with me and you aresafe.”) Don’t touch the person or make any suddenmoves, and allow for personal space.

Clinically, processing has been achieved oncerelationships are adaptive, work is productive, self-references are positive, there are no significant affectchanges, affect is proportionate to events, and there iscongruence between behavior, thoughts, and affect(Davis & Weiss, 2004). It is important to keep in mindthat periods of processing are sometimes followed by



periods of destabilization. The PMH-APRN paces andstructures treatment so work on traumatic materialalternates with resources, such as grounding andcontainment. Returning to Phase 1 interventions, suchas somatic awareness, safe place, anchors, dual aware-ness, progressive muscle relaxation, and establishingboundaries is important (Rothschild, 2000). The treat-ment process often looks more like a spiral, alternatingwith interventions aimed toward stabilization andthen processing leading toward self-actualization andfuture visioning.

Implications for Nursing Practice

Healing trauma brings together all parts of one’sself at deeper levels of inner knowing. Empowermentand autonomy is fostered as the person moves towardself-actualization and into envisioning and planningfor the future. The Adaptive Information ProcessingModel provides the framework for understandinghow neuroscience is embedded in holism. Informationprocessing through psychotherapy restores harmony,balance, connection, and integration of neural net-works, which are key to healing and reflected in deeperconnections with one self and others. The TreatmentHierarchy presented here provides the context and acompass for holistic PMH-APRN practice for workingwith traumatized patients.

Acknowledgment.

The author wishes to acknow-ledge and thank Katherine Davis, M.S.W., for herconsultation and discussion of this article. Thisarticle is revised from sections of

Psychotherapy forthe Advanced Practice Psychiatric Nurse

by KathleenWheeler that will be published in September 2007by Elsevier.

Author contact: [email protected], with a copy tothe Editor: [email protected]

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