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The field of trauma treatment is at a crossroads.Evolving research and experience demonstrate thatthere is a strong need to include trauma response andtreatment skills across counselor training. Advances intraumatology further indicate the need to separatetrauma treatment into individual trauma treatment(sexual abuse, physical and emotional abuse, domesticviolence) and mass disaster mental health response(hurricanes, floods, terrorist attacks). While both requiretrauma response, they are in fact different kinds oftrauma events and necessitate specialized skills.

With recent research and study, the field is closerto matching specific types of interventions with the typeof trauma experienced. Over the past 20 years, andespecially since September 11th, public and professionalinterest in the impact and effects of trauma hasincreased. With each disaster, we are moreknowledgeable about the complex relationshipsthat exist among experience, neurophysiology,endocrinology, and behavior related to traumatic stress(Solomon & Heide, 2005). This article briefly reviewsthe history of trauma treatment and advances intreatment approaches, and makes recommendations forfurther research and policy to help counselors gain theskills necessary for contemporary practice.

Advances in Trauma Treatment: A Brief History

Trauma and its effects have been studied andreferred to throughout history as early as 700 BCE inthe Iliad and the Bible. In the 19th century terms likenervous shock began to appear describing posttraumaticdisorders. At that time clinical conditions such as warneuroses and hysteria and their similarities were beingdiscussed by physicians and psychologists. As early as1859 there was recognition of the similarity betweensymptoms of hysteria and childhood trauma. Freud andBreuer in Austria and Janet in France concluded thecause of hysteria was psychological trauma thatsomehow produced altered states of consciousness.Janet referred to these states as dissociation, and Freudused the term double consciousness (Gentry &

Baranowsky, 2002a). Ironically, their approaches totreating these conditions are conceptually related tocontemporary interventions employing exposure andreexperiencing the traumatic events.

During World War I, posttrauma symptoms weremainly attributed to weakness and cowardice, but byWorld War II, popular belief held that symptoms ofcombat neurosis could befall anyone. It was not untilthe period after the Vietnam War that posttraumaticstress received serious attention when returning soldierscomplained of being ill-tempered, of having violentoutbursts, nightmares, problems with alcohol and drugs,and work and relationship problems. The VeteransAdministration eventually recognized the condition andbegan providing treatment throughout the U.S.

In 1980 when posttraumatic stress disorder(PTSD) was validated and included in the third editionof the Diagnostic and Statistical Manual of MentalDisorders (DSM-III; American Psychiatric Association[APA], 1980), symptoms common to victims of rape,domestic violence, and child abuse were recognizedby the medical and psychological communities as beingsimilar to those experienced by returning veterans.These symptoms are also common to residents ofcommunity war zones, mainly children living in violentcities (Gentry & Baranowsky, 2002a, 2002b; Roth,Newman, Pelcovitz, van der Kolk, & Mandel, 1997).

In addition to the trauma experience, the mostrecent edition of the Diagnostic and Statistical Manualof Mental Disorders (DSM-IV-TR; APA, 2000) includesdiscussion of the individual’s response to the traumaticevent. This makes the individual’s response to the eventas important as the event itself, helping make sense ofwhy some individuals become debilitated afterexperiencing an event while others appear to experienceno negative effects.

Although individual reactions may vary, commonpatterns of behavioral, biological, social, andpsychological responses have been identified amongindividuals who have been directly or vicariouslyexposed to life-threatening events. In some casescomplex PTSD, a syndrome in survivors of prolonged

Article 4

Moving Forward: Issues in Trauma Response and Treatment

Jane M. Webber, J. Barry Mascari, Michael Dubi, and J. Eric Gentry

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and repeated trauma, is experienced as well as disordersof extreme stress (DESNOS). Researchers suggestedthat PTSD seems to mimic various personalitydisorders. Prolonged childhood sexual abuse has beendescribed as severe PTSD which includes dissociativestates, ego fragmentation, affective and anxietydisorders, somatization, and suicidality as well asreenactment and revictimization (Gentry &Baranowsky, 2002b).

Advanced Trauma Treatment Approaches

There are a variety of treatment approaches forsurvivors of trauma. One of the more effective is theTriphasic Model (Baranowsky, & Gentry, 2002;Baranowsky, Gentry, & Schultz, 2004; Herman, 1992).The three phases of this model are safety andstabilization, remembrance and mourning, andreconnection. Safety is the actual task of recovery withthe clinician primarily helping the client to regain bothinternal and external control. The goal is to enable theclient to make a gradual shift from unpredictable dangerto reliable safety.

The mourning and remembrance phase allows theclient to reconstruct the story of his or her trauma inminute detail. The clinician bears witness to the client’sexperiences to help him or her find the strength to heal.Within this phase there are many techniques that areeffective such as EMDR (Eye MovementDesensitization and Reprocessing) and TIR (TraumaticIncident Reduction). Reconnection is the final phaseand involves redefining oneself in the context ofmeaningful relationships. Survivors bring closure totheir experiences and learn that these events do notdetermine who they are. They are liberated by theconviction that regardless of what else happens to themthey always have themselves.

In selecting appropriate therapeutic interventions,expert guidelines are often considered instead ofresearch. This is important because research does notoften generalize well or answer the questions that arisein clinical practice in a comprehensive and effectivemanner. Many systematic studies have failed to addressthe complexities of the clinical cases addressed inpractice. Research can often be tedious and time-consuming, but it is as critically important to advancingthe field of traumatology. However, an expert consensusmust also be considered.

Table 1 and Table 2 reflect the preferences ofexpert clinicians in the field of traumatology and areadapted from Foa, Davidson, and Frances (1999). Thesepreferences reflect a work in progress in treating traumasurvivors.

Table 1. Preferred Psychotherapy Techniquesfor Different (PTSD) Target Symptoms

Most Prominent Recommended Also Consider Symptom Techniques

Intrusive thoughts Exposure therapy Cognitive therapyAnxietymanagementPsychoeducationPlay therapy forchildren

Flashbacks Exposure therapy AnxietymanagementCognitivetherapyPsychoeducation

Trauma-related Exposure therapy Psychoeducationfears, panic, and Cognitive therapy Play therapyavoidance Anxiety for children

management

Numbing/ Cognitive therapy Psychoeducationdetachment from Exposure therapyothers/loss ofinterest

Irritability/angry Cognitive therapy Psychoeducationoutbursts Anxiety Exposure therapy

management

Guilt/shame Cognitive therapy PsychoeducationPlay therapy forchildren

General anxiety Anxiety Cognitive therapy(hyperarousal, management Psychoeducationhypervigilance, Exposure therapy Play therapystartle) for children

Sleep Anxiety Exposure therapydisturbances management Cognitive therapy

Psychoeducation

Difficulty Anxiety Cognitive therapy

concentrating management Psychoeducation

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Table 2. Selecting Psychotherapy TechniquesBased on Effectiveness, Safety, and Acceptability

Recommended Also Consider Techniques

Most effective Exposure therapy Anxiety techniques Cognitive therapy management

Quickest acting Exposure therapy Anxietytechniques management

Cognitive therapyPsychoeducation

Techniques Cognitive therapy Psychoeducationpreferred across Exposure therapyall types of Anxietytrauma management

Safest techniques Anxiety Play therapymanagement for childrenPsychoeducation Exposure therapyCognitive therapy

Most acceptable Psychoeducation Play therapytechniques Cognitive therapy for children

Anxietymanagement

These techniques help provide the clinician with anarray of interventions to address the chaos andunpredictability that often surround traumatic events.Individuals who experience trauma have the sights,sounds, and smells of the event imprinted in their minds.These techniques can be effective in helping the clientresolve these psychological issues ands resume optimalfunctioning.

Moving Trauma Counseling Forward

Although practicing clinicians regularly treattrauma survivors, they tend to be inadequately trainedin the theory and practice of trauma counseling. As thereal world continues to be perceived as a moredangerous place, the need for specialists trained andcertified in trauma counseling becomes more importantin treating a wide range of individual and mass traumavictims. Mascari and Webber (2005) noted that traumatraining is a complex challenge. There are differenttypes of disaster events, and a single event may involvemultiple levels of intervention for victims and mentalhealth responders’ needs. It is likely that counselorsacross a wide range of employment settings will seeclients who have experienced Type I trauma in the formof sexual abuse, physical abuse, rape, witnessing gangviolence, and other unexpected powerful events. Since

counselors often work with children, Baggerly (2005)proposed the employment of trauma techniques that aredevelopmentally appropriate such as play therapy aswell as special disaster response procedures in schools(Baggerly & Rank, 2005). Counselors need the mosteffective techniques at hand to provide a timelyresponse; this can only come through additionalgraduate or postgraduate training.

After September 11th, it became clear thatcounselors need to be trained, certified, and competentto treat posttrauma disorders. Specialized models oftraining built on the ground-breaking work of pioneerslike Gentry and Baranowsky are needed. All counselorsshould be competent in basic trauma knowledge andresponse. According to Smith (2005), an American RedCross Disaster Mental Health Services trainer,

Providing mental health services in adisaster environment requires an additionalset of skills that are noticeably lacking incounselor education programs. That skillset, in brief, includes the ability to applyclinical skills in an environment where chaosand lack of organization prevails, toconcentrate on getting individuals to anacceptable level of functioning quicklyfollowing traumatization, and applying theseskills in a systematic manner for the benefitof all. (p. 37)

At this time the American Counseling Associationdoes not have a division or affiliate dedicated to traumacounseling. The Trauma Interest Network madesignificant progress under the leadership of Dr. KarenJordan. Counseling Today published several featureson individual trauma treatment and disaster response.

The American Counselor Association Foundation(ACAF) advanced trauma knowledge and practicethrough two initiatives. The Winter CounselingSymposium: Responding to Tragedy, Trauma, andCrisis, at Argosy University Sarasota, encouraged theexchange of current research and techniques by bothpractitioners and counselor educators. The ACAFvolume, Terrorism, Trauma, and Tragedies: ACounselor’s Guide to Preparing and Responding(Webber, Bass, & Yep, 2005) focused on practicalstrategies for counselors across several settingsincluding schools, the military, the community, privatepractice, the workplace, agencies, and government.

With the impact of terrorism on American soil,Webber and Mascari (2005) emphasized the “criticalneed to research effective ways to assess clients’immediate needs and match trauma symptoms totreatment strategies for those who experienced trauma

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directly” (p. 23). Data collection and research responseare essential during disaster response to study the effectsof both victims and responders.

The Trauma Network will continue efforts todevelop an organizational affiliate and ultimately adivision for trauma counselors and to build bridgesbetween trauma counselors here and internationally. Wealso plan to

• actively encourage and mentor traumacounselors to document their practice andresearch;

• advocate for the inclusion of crisis andtrauma training in counselor educationprograms;

• promote timely publications and Webresources helpful to the profession (seeDavid Baldwin’s http://www.trauma-pages.com );

• develop continuing education andprofessional development programs forcounselors at all levels of skills and acrossdivisions and regions;

• dialog with public and private sector groupsdedicated to trauma and disaster response;

• collaborate with trauma experts, universities,ACA, and ACES to develop training modelsand curricula for graduate programs;

• develop research designs and training forvolunteers to be ready to conduct researchshould a disaster occur in the future;

• encourage research to determine efficacy ofapproaches and treatment matching; and

• promote public awareness of communitymodels of disaster response to dispel mythsand to prepare the public.

References

American Psychiatric Association. (1994). Diagnosticand statistical manual of mental disorders (3rd ed.).Washington, DC: Author.

American Psychiatric Association. (2000). Diagnosticand statistical manual of mental disorders (4th ed.,text revision). Washington, DC: Author.

Baggerly, J. N. (2005). Ring around the rosie: Playtherapy for traumatized children. In J. Webber, D.D. Bass, & R. Yep (Eds.), Terrorism, trauma, andtragedies: A counselor’s guide for preparing andresponding (pp. 93–96). Alexandria, VA: AmericanCounseling Association Foundation.

Baggerly, J. N., & Rank, M. G. (2005). Bioterrorismpreparedness: What school counselors need to know.Professional School Counseling, 8, 458–463.

Baranowsky, A. B., & Gentry, J. E. (2002). Resiliencyand recovery: Trauma survivor group (2nd ed.).Toronto, Canada: Traumatology Institute.

Baranowsky, A. B., Gentry, J. E., & Schultz, F. F. (2004).Trauma practice: Tools for stabilization and recovery(2nd ed.). Toronto, Canada: Traumatology Institute.

Foa, E. B., Davidson, J .R. T., & Frances, A. (1999).The expert consensus guideline series: Treatment ofposttraumatic stress disorder. Journal of ClinicalPsychiatry, 60, 6–79.

Gentry, J. E., & Baranowsky, A. B. (2002a). Earlyintervention field traumatology—Full program (8th

ed.). Toronto, Canada: Traumatology Institute.

Gentry J. E., & Baranowsky, A. B. (2002b). Overviewof assessment and interventions (2nd ed.). Toronto,Canada: Traumatology Institute.

Herman, J. L. (1992). Trauma and recovery. New York:Basic Books.

Mascari, J. B., & Webber, J. (2005). September 11th:Lessons learned. In J. Webber, D.D. Bass, & R. Yep(Eds.), Terrorism, trauma, and tragedies: Acounselor’s guide for preparing and responding (pp.21–26). Alexandria, VA: American CounselingAssociation Foundation.

Roth, S., Newman, E., Pelcovitz, D., van der Kolk, B.,& Mandel, F. S. (1997). Complex PTSD in victimsexposed to sexual and physical abuse: Results fromthe DSM-IV field research trial for posttraumaticstress disorder. Journal of Traumatic Stress, 10, 539–555.

Smith, H. (2005). The American Red Cross: How to bepart of the solution, rather than part of the problem.In J. Webber, D. D. Bass, & R. Yep (Eds.), Terrorism,trauma, and tragedies: A counselor’s guide forpreparing and responding (pp. 37–38). Alexandria,VA: American Counseling Association Foundation.

Solomon, E. P., & Heide, K. M. (2005). The biology oftrauma: Implications for treatment. Journal ofInterpersonal Violence, 20, 51–66.

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Webber, J., & Mascari, J. B. (2005). September 11th:Lessons learned. In J. Webber, D. D. Bass, & R.Yep (Eds.), Terrorism, trauma, and tragedies: Acounselor’s guide for preparing and responding (pp.21–26). Alexandria, VA: American CounselingAssociation Foundation.

Webber, J., Bass, D.D., & Yep, R. (Eds.). (2005).Terrorism, trauma, and tragedies: A counselor’sguide for preparing and responding. Alexandria, VA:American Counseling Association Foundation.