March 06, 2016 at 11:49 PM
The standard of care in trauma therapy includes a stabilization phase prior to engaging in the trauma resolution work. This preliminary phase gives clients an opportunity to improve their affect regulation and coping skills, in order to be more successful in facing and overcoming their trauma memories during therapy. This standard has just been challenged in a critique co-authored by 21 prominent trauma therapy experts (de Jongh et al, 2016).
The authors note that the various expert guidelines advocating for a stabilization phase in treatment of complex PTSD are based on limited research that does not specifically support the independent value of the stabilization phase. They further note that at least a few studies disconfirm the need for the stabilization phase, by showing that research participants with PTSD responded well to trauma-focused therapy that did not include preliminary stabilization work. Furthermore, as I have also noted in a previous post, trauma resolution is better at stabilizing than so-called stabilization interventions are. This is because the destabilization is the result of traumatization; heal the trauma and the destabilization tends to disappear.
The critique also highlights a problem with the various studies’ means of defining complex PTSD: either by severity of symptoms, or history of child abuse. They note that such criteria may not meaningfully delineate complex PTSD as a distinct subtype of PTSD. They conclude by recommending that stabilization should no longer be considered an essential preliminary phase of PTSD treatment.
Like the guideline they were challenging, their recommendation is also based on limited research (in particular, limited field research), and in my opinion is not sufficiently nuanced. I don’t think they were looking at the whole picture. Practice guidelines are based only in part on the research, especially when the research has not thoroughly examined actual practice contexts. These guidelines tend to be written by teams of expert practitioners whose clinical experience influences their interpretation of the research – as it should. So when practice guidelines call for stabilization prior to trauma work, based on admittedly skimpy research, there might be more to it.
Attachment Status and Dissociation
De Jongh et al noted that, as per the research, neither presence/absence of childhood abuse nor degree of affect dysregulation effectively delineated a discrete type of PTSD, nor made any difference in participants’ ability to respond to trauma treatment that did not include a stabilization phase. This may indeed be the case, because those aren’t quite the right things to be looking at.
Attachment status is a key factor to consider in treatment responsiveness in general, and responsiveness to trauma treatment in particular (Muller & Rosenkranz, 2009). Dissociation is another. In our clinic we routinely screen for attachment status and dissociation, because we have consistently found that both non-secure attachment status and habitual dissociation predict considerable difficulty with trauma resolution work. And that such clients often do require some additional preparation in order to be able to tolerate the trauma work. Note that I don’t consider the dissociative subtype of PTSD to be a significant obstacle to proceeding with trauma work. I am referring here to major dissociative disorders such as Dissociative Identity Disorder.
Avoiding Further Deterioration
The other primary purpose of the stabilization phase of trauma treatment, which de Jongh et al failed to mention, is – of all things – stabilization. Many clients are in treatment because of serious problems associated with their trauma-related symptoms. Working through the trauma memories can take months, and meanwhile the symptoms remain. Without working on stabilization skills, some clients may risk further deterioration while awaiting completion of treatment. We don’t want our clients losing jobs or relationships because we were not careful with them. No responsible clinician is going to skip the stabilization phase if doing so would increase the client’s risk.
When Is Stabilization Necessary?
“Is stabilization necessary?” is the wrong question. Better: When is stabilization necessary?
- When the client has major issues with attachment and/or dissociation, and is unable to successfully undergo the trauma-focused portion of treatment without additional preparation.
- When the client’s symptoms are so disruptive that skipping the stabilization phase risks further deterioration in the client’s status or life situation, while awaiting completion of treatment.
The Intensive Therapy Solution
In our clinic we provide trauma-focused therapy in an intensive format, in which the client works with the therapist for two or more consecutive full days, as needed. Our experience in this treatment format gives us a unique perspective on the stabilization issue.
Even in the intensive format, we find that many clients with major attachment and/or dissociation issues do require additional preparatory interventions to enable them to tolerate the trauma work. Furthermore, even with this extra preparation, the trauma work with such clients tends to go more slowly.
Consistent with de Jongh et al’s recommendations, we have found that many of our intensive therapy clients even with complex PTSD (as well as other serious problems) are in fact able to successfully engage in trauma resolution work, without the preliminary stabilization interventions.
With intensive therapy we can get away with skipping the stabilization phase because when the entire course of treatment is completed in a matter of days, the risk of further deterioration is minimized. But in conventional hour per week therapy, skipping the stabilization phase could be risky for some clients.
De Jongh, A., Resick, P. A., Zoellner, L. A., van Minnen, A., Lee, C. W., Monson, C. M., Foa, E. G., Wheeler, K., ten Broeke, E., Feeny, N., Rauch, S. A. M., Chard, K. M., Mueser, K. T., Sloan, D. M., van der Gaag, M., Rothbaum, B. O., Neuner, F., de Roos, C., Hehenkamp, L. M. J., Rosner, R., & Bicanic, I. A. E. (2016). Critical analysis of the current treatment guidelines for complex PTSD in adults. Depression and Anxiety, 00, 1-11. DOI: 10.1002/da.22469
Muller, R. T., & Rosenkranz, S. E. (2009). Attachment and treatment response among adults in inpatient treatment for posttraumatic stress disorder. Psychotherapy: Theory, Research, Practice, Training, 46, 82-96.
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Odd, but maybe the "online-first" publication accounts for it.
Finally, for those interested (and maybe you want to add this to your citation?) the complete article can be downloaded PDF from: