Counseling That Works - The Integrity Model Standard of Care For Trauma Treatment
Judy's journey to healing had been stormy.
Numbness, depression, and anxiety led her to seek counseling periodically.
Sleep was at best restless and brief, at worst nightmarish and unending.
Sights, sounds, and smells during the day triggered horrific flashes of Images at unexpected times.
Her relationships never felt solid.
She was not sure of direction in life.
Judy presented these concerns in each of her many attempts at counseling.
Each therapist gave a different diagnosis and used a different approach.
Judy experienced brief episodes of relief.
She learned about her dysfunctional thoughts.
She knew the principles of assertiveness but had difficulty implementing them.
Others saw her smile as a sign of her functioning well in her job.
While active in church, Judy quietly battled feelings of guilt, doubts about God, and desires to end her internal anguish at her own hand.
When the pain or flashes got too intense, she would turn to drastic measures drinking to numb out or cutting her body to help her feel real.
This vignette is generally descriptive of many of over 500 trauma survivors that I have seen.
These individuals vary in trauma experiences from war to natural disaster, from criminal assault to child abuse, from medical procedures to accidents.
The client often had been through numerous diagnoses, therapies, medications, and hospitalizations, as well as criticisms that he or she was not trying to get better.
As my caseload and the realization of the complexity grew, I for trauma treatment sought to develop a process that was a road map for both counselor and client to follow in handling the extensive healing needed.
In 1991, I began training and consulting others in the use of The Integrity Model as a standard of care.
This model has provided both a plan for treatment and a safeguard for clients in crises.
Whatever the modality of therapy of the counselor or the presenting concern of the client, this model is an effective way of thinking about the counseling process.
The Integrity Model consists of five stages to help both counselor and client to navigate the healing process while moderating the symptoms: safety to reduce the hyper arousal symptoms; stability to reduce the compulsive numbing and acting-out and to maintain a better stream of consciousness; strength to establish a support network and to reinforce self-care; synthesis to identify and resolve the distorted beliefs and self perceptions caused by the trauma; and solidarity to develop a sense of self that can thrive in life.
Judy learned in the first stage (Safety) to identify the issues that aggravated her hyper arousal symptoms.
She examined several are as events in her daily life which produced a startle response, certain interactions and types of people, and certain settings where she felt unsafe.
All were examined for choices to reinforce a sense of safety.
Healthy choices protection were supported.
When Judy identified not feeling safe within herself, a very specific Imagery for a Safe Place was constructed with the counselors help.
This purposefully addressed the lack of a future focus for healing, countering the sense of foreshortened future that is symptomatic of trauma survivors.
Further safety was fostered in this stage by providing Imagery for containment in the Safe Place, a means for containing flashbacks.
When Judy heard a click from a closing door, it sounded like the cocking of the gun prior to her assailant shooting her.
That sound brought up an image of a trauma event that had happened 10 years earlier.
With that flashback came all the feelings of helplessness and pain she felt then.
To stop the related anxiety, she placed that scene in the Cleft of the Rock in her Safe Place, erased the tape which held the trigger sound, and reminded herself that what was currently happening was only the sound of a door opening.
The second stage (Stability) helped Judy face numbing behaviors which kept healing at a standstill.
She replaced impulsive and compulsive behavior drinking, gambling, eating disorders, and self-harm to name a few with healthy boundaries and accountability.
She sought medical intervention for depression to help lift her mood and clarify her thinking, allowing quicker progress and awareness.
The counselor contracted for safety in relation to potential acting- out, utilizing the contracting as a means to foster commitment to therapy.
For example, Judy frequently would make tiny razor cuts of her thigh to stop the feelings of unreality.
Judy and her therapist contracted to use an ice pack on her thigh so the cutting cold would help her feel real, call one of her supporters, or call the therapist for 10 minute calls between session.
This contract helped to stabilize the feelings of being alone, out of control, and helpless.
If Judy were to break a contract, there would be an understanding that there would be one more session when the therapeutic relationship would be evaluated by both Judy and the counselor.
This gives the counselor a structure to phase out a client who because of a personality disorder is using self-harm threats as a means to manipulate or to remain dependent.
In the third stage (strength), the client learns self-care and social networking which allows the client to reestablish responsibility for self by utilizing soothing techniques, and to broaden relationships for grounding support and healing.
A great sense of reality is the outcome.
The client develops a better awareness (grounding) of the here and now, rather than being lost when the past blends with the present.
The outcome is soothing for the emotional pain, support to counter the depersonalization, and connectedness to change the estrangement.
Cognitive Therapy for Borderline Personality Disorder, A Skills Workbook, by Marsha Linehan, M.
D.
, published by the American Psychiatric Press, has a wealth of material for this phase of treatment.
These first three stages are foundational for healing.
They do not consist of memory work, so are well suited to the trauma survivor who has managed care health benefits.
These can be brief and solution-focused, establishing a sense of mastery in life and/or restoring functioning at work.
The cognitive distortions about safety, self, and relationships will help many to reach functioning.
They may quite naturally finish the final stages on their own.
However, there are those clients who desire to make sense of extensive trauma to reconstruct a shattered life.
They move on to the last stages in the counseling setting.
Extensive trauma, especially that of child abuse, leaves many distorted beliefs and perceptions which often are trapped in a stimulus-dependent state.
Hence the many flashbacks which are memories triggered by an associated event in the now.
Identifying these experiences to understand the distortions that trauma taught them (Synthesis, the fourth stage) is the means to resolve these beliefs.
Note, the focus is on beliefs not on memory.
This focus helps to ward off the False Memory Controversy because any memories are treated as a metaphoric scene in which such a belief can be formed and the person is reclaimed from that scene of the past, brought to now, and helped to resolve the distortions.
This is followed up by mastery steps in which the person can strengthen the new learning in day-to-day life.
The final step of healing (Solidarity) focuses on integrity of self in the light of what one has learned.
This approach de-emphasizes integration which terrifies many abuse survivors and focuses on the person living a full life respecting all the parts of self.
Integration is the coming together of all the dissociated parts of the person fragmented by the trauma experience.
Numbness, depression, and anxiety led her to seek counseling periodically.
Sleep was at best restless and brief, at worst nightmarish and unending.
Sights, sounds, and smells during the day triggered horrific flashes of Images at unexpected times.
Her relationships never felt solid.
She was not sure of direction in life.
Judy presented these concerns in each of her many attempts at counseling.
Each therapist gave a different diagnosis and used a different approach.
Judy experienced brief episodes of relief.
She learned about her dysfunctional thoughts.
She knew the principles of assertiveness but had difficulty implementing them.
Others saw her smile as a sign of her functioning well in her job.
While active in church, Judy quietly battled feelings of guilt, doubts about God, and desires to end her internal anguish at her own hand.
When the pain or flashes got too intense, she would turn to drastic measures drinking to numb out or cutting her body to help her feel real.
This vignette is generally descriptive of many of over 500 trauma survivors that I have seen.
These individuals vary in trauma experiences from war to natural disaster, from criminal assault to child abuse, from medical procedures to accidents.
The client often had been through numerous diagnoses, therapies, medications, and hospitalizations, as well as criticisms that he or she was not trying to get better.
As my caseload and the realization of the complexity grew, I for trauma treatment sought to develop a process that was a road map for both counselor and client to follow in handling the extensive healing needed.
In 1991, I began training and consulting others in the use of The Integrity Model as a standard of care.
This model has provided both a plan for treatment and a safeguard for clients in crises.
Whatever the modality of therapy of the counselor or the presenting concern of the client, this model is an effective way of thinking about the counseling process.
The Integrity Model consists of five stages to help both counselor and client to navigate the healing process while moderating the symptoms: safety to reduce the hyper arousal symptoms; stability to reduce the compulsive numbing and acting-out and to maintain a better stream of consciousness; strength to establish a support network and to reinforce self-care; synthesis to identify and resolve the distorted beliefs and self perceptions caused by the trauma; and solidarity to develop a sense of self that can thrive in life.
Judy learned in the first stage (Safety) to identify the issues that aggravated her hyper arousal symptoms.
She examined several are as events in her daily life which produced a startle response, certain interactions and types of people, and certain settings where she felt unsafe.
All were examined for choices to reinforce a sense of safety.
Healthy choices protection were supported.
When Judy identified not feeling safe within herself, a very specific Imagery for a Safe Place was constructed with the counselors help.
This purposefully addressed the lack of a future focus for healing, countering the sense of foreshortened future that is symptomatic of trauma survivors.
Further safety was fostered in this stage by providing Imagery for containment in the Safe Place, a means for containing flashbacks.
When Judy heard a click from a closing door, it sounded like the cocking of the gun prior to her assailant shooting her.
That sound brought up an image of a trauma event that had happened 10 years earlier.
With that flashback came all the feelings of helplessness and pain she felt then.
To stop the related anxiety, she placed that scene in the Cleft of the Rock in her Safe Place, erased the tape which held the trigger sound, and reminded herself that what was currently happening was only the sound of a door opening.
The second stage (Stability) helped Judy face numbing behaviors which kept healing at a standstill.
She replaced impulsive and compulsive behavior drinking, gambling, eating disorders, and self-harm to name a few with healthy boundaries and accountability.
She sought medical intervention for depression to help lift her mood and clarify her thinking, allowing quicker progress and awareness.
The counselor contracted for safety in relation to potential acting- out, utilizing the contracting as a means to foster commitment to therapy.
For example, Judy frequently would make tiny razor cuts of her thigh to stop the feelings of unreality.
Judy and her therapist contracted to use an ice pack on her thigh so the cutting cold would help her feel real, call one of her supporters, or call the therapist for 10 minute calls between session.
This contract helped to stabilize the feelings of being alone, out of control, and helpless.
If Judy were to break a contract, there would be an understanding that there would be one more session when the therapeutic relationship would be evaluated by both Judy and the counselor.
This gives the counselor a structure to phase out a client who because of a personality disorder is using self-harm threats as a means to manipulate or to remain dependent.
In the third stage (strength), the client learns self-care and social networking which allows the client to reestablish responsibility for self by utilizing soothing techniques, and to broaden relationships for grounding support and healing.
A great sense of reality is the outcome.
The client develops a better awareness (grounding) of the here and now, rather than being lost when the past blends with the present.
The outcome is soothing for the emotional pain, support to counter the depersonalization, and connectedness to change the estrangement.
Cognitive Therapy for Borderline Personality Disorder, A Skills Workbook, by Marsha Linehan, M.
D.
, published by the American Psychiatric Press, has a wealth of material for this phase of treatment.
These first three stages are foundational for healing.
They do not consist of memory work, so are well suited to the trauma survivor who has managed care health benefits.
These can be brief and solution-focused, establishing a sense of mastery in life and/or restoring functioning at work.
The cognitive distortions about safety, self, and relationships will help many to reach functioning.
They may quite naturally finish the final stages on their own.
However, there are those clients who desire to make sense of extensive trauma to reconstruct a shattered life.
They move on to the last stages in the counseling setting.
Extensive trauma, especially that of child abuse, leaves many distorted beliefs and perceptions which often are trapped in a stimulus-dependent state.
Hence the many flashbacks which are memories triggered by an associated event in the now.
Identifying these experiences to understand the distortions that trauma taught them (Synthesis, the fourth stage) is the means to resolve these beliefs.
Note, the focus is on beliefs not on memory.
This focus helps to ward off the False Memory Controversy because any memories are treated as a metaphoric scene in which such a belief can be formed and the person is reclaimed from that scene of the past, brought to now, and helped to resolve the distortions.
This is followed up by mastery steps in which the person can strengthen the new learning in day-to-day life.
The final step of healing (Solidarity) focuses on integrity of self in the light of what one has learned.
This approach de-emphasizes integration which terrifies many abuse survivors and focuses on the person living a full life respecting all the parts of self.
Integration is the coming together of all the dissociated parts of the person fragmented by the trauma experience.
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