TRAUMA TREATMENT MANUAL





BY





EDWARD L. SCHMOOKLER, PHD.

(Click here to contact me)

Berkeley, CA

(510) 486-8903

eds@there.net



Copyright, 1996

First Written 3/93

Last revised 1/96

Introductory Note

This manual was originally written for people working in the field with women survivors of rape in Bosnia, but it can be used more broadly as a guide for helping anyone of either gender who has survived any kind of trauma. Since it is written from afar and based on experiences similar to but not the same as the ones you are dealing with, please use what is useful or helpful and ignore what is irrelevant or wrong for your circumstances, trusting more in your judgment and intuition than in anything contained herein. Also, please be aware that some of the suggestions and conversations suggested here may not fit the cultural context you will be working in. It is best to ask local people about what can be discussed in private or in public with any group you are dealing with. For example, some people in the former Yugoslavia may be unwilling to discuss rape with anyone. It may be necessary to talk "around" such subjects rather than directly. Some groups may not be willing to discuss feelings at all. When in doubt, follow rather than lead.

This manual may be adapted for any purpose the reader feels is appropriate in helping survivors of trauma or those helping them. It is primarily intended for treating adults. The manual may be freely distributed. I'd appreciate it if my name is kept on it. My wish is for this to be a living document, kept alive and changing by the feedback I get from those who use it. Please let me know what works, what doesn't, what you'd like to see changed, removed, or added. I would also be willing to adapt this manual for different purposes, if there are requests and there is time. Please respond to me at:

eds@there.net.





Trauma Treatment Manual













GENERAL GUIDELINES





When people have experienced things they cannot stand, ordinary people can often give them what they need to help them begin to heal. This section gives general guidelines for working with people who have been catastrophically violated.





What they are suffering





The people you will be working with have experienced events that have permanently changed their lives. But they can heal. People who have been raped, who have seen their loved ones killed -- their lives will never be the same again. Yet no matter how great the horror people have experienced, they may recover emotional functioning, so that they are not feeling pain, terror, shame, fear, or horror all the time. Rape and murder may have robbed them of a sense of integrity and wholeness, but in time and with your help, they may be able to resume life with their sense of self restored.





People who have experienced rape or torture or who have witnessed murders of loved ones usually suffer from Post Traumatic Stress Disorder, a psychological disorder that occurs when people have experienced life-threatening, shocking events. It has symptoms that are often the same for different people, regardless of the specific events they suffered.





With Post Traumatic Stress Disorder (PTSD), many normal processes are more intense, while many are deadened. People whose normal lives have been drastically changed by the sudden intrusion of horrifying and destructive events are experiencing more than they can integrate, and their sense of security and safety is shattered. In PTSD, some of people's responses are greatly heightened. The blow of a severe event has told them that the world is not the safe place they imagined. So they become ready for danger at all times: they have hyper-vigilance -- greater readiness to flee or fight. They live in emergency mode, and they have learned not to trust. At the same time as having heightened responses, they also shut down a great deal, so that many of their normal responses to life and to other people are not accessible to them. As a result, these are some of the symptoms you might see:





* Intense emotion and reactivity. People exposed to traumatic events feel intense pain, terror, shame, horror, grief, rage, and shock. They are activated and alert most of the time, ready to react. People may be jumpy, looking constantly for danger, and easily startled. They may have difficulty sleeping or even relaxing.

* Numbness. When hell suddenly breaks into a life, people become overwhelmed. They may experience shock and protect themselves through denial, disbelief, and dissociation (spacing out or splitting away from the terrible events as if they didn't happen to them). They feel numb, feel cut off from other people and from their own feelings, and as if they are no longer really alive.

* Flashbacks. People who have had terrible things happen to them will often re-experience the events over and over again, against their will. They will experience their minds invaded by thoughts of the events and will feel tortured by them.

* Nightmares. Like flashbacks, but these occur in sleep. As a result some people can be afraid to go to sleep and may develop sleep deprivation.

* Triggering. Often people will respond to events that remind them of the trauma with all the feelings that belonged to the trauma itself. Combat soldiers, for example, will respond to loud noises as if it meant incoming mortar; rape victims may respond to the smell of a man as if he were her rapist.





What they need





Most of all people need to feel realtively safe. Anyone who has been extremely hurt by other people, especially when they have been systematically tortured has learned not to trust anyone. This is how they survived. They will not trust you at first, not for a long time, maybe never. Moreover, in areas of the world in which brutality, horror, and extreme danger have become commonplace, talking about safety can seem absurd or even offensive. But you still can help people to feel relatively safer. All of us know how to do that with people; we just need to be reminded how: we may begin simply by performing simple acts of kindness, by letting people alone when they want to be let alone, by treating other people as if you cared about them. Most important for survivors of extreme abuse is that they need to know these things:

* They need to know that you will respect their boundaries. Trauma, almost by definition, breaches people's normal boundaries. It is as if life drives a bulldozer over people's normal sense of protection, sense of safety, and sense of self. So people need to know that their wishes matter, that you will not force them to respond in anyway other than what they choose, and that you will not invade them.

* They need to know they can leave if they want to. People who have experienced prison and torture must know that they are not trapped, that they can get out if they want.

* They will not be touched if they do not want to be. People who have learned to associate touch with violation often cannot bear to be touched, even in kindness. Especially when the violation was sexual, they may not be able to tolerate intimacy, even when you mean well.

* They need to feel accepted and not judged. When people have been violated, they experience a lot of feelings about themselves they cannot stand. They judge themselves very harshly and can often not even stand the fact that they are alive. They need those around to accept and affirm them as having value and not as having been "spoiled" or "ruined" by what they have been through, even if that is how they themselves feel.



* People usually need to talk and be listened to. When people hurt, especially when they hurt more than you can stand to hear, or think about, or feel, it is hard just to listen to people. But it the most important thing you can do.

* Often people need to have their feelings paid attention to. When people hurt in ways they cannot stand, they freeze up their feelings. They just try to survive. That is nature's way of helping them to get through what they have to endure. But afterward they need to get their feelings back, so that they can function again, and so that they don't have to go through their lives closed down inside. If they are still numb, you should not push them. Nature knows when it is time to feel again.



* Sometimes people need to be left alone. We should never force help on people who have already been forced to do things by other people. We should help people only when they want help. Sometimes people are unready to face what has happened to them, or to experience their own feelings, or to talk about what has happened. It is always important to respect people's healing process. Each person needs to heal in her own way in her own time. Some need to feel, some need to remain numb. The best approach, when you are uncertain about what a person wants is to ask. It is always good to ask people's permission to talk about what happened, to talk about their feelings, or to help them in any way. It is almost always damaging to people to insist that you know what they need better than they do.









What you can do to help: Your Characteristics



* Your presence is the most important gift you can give. Many people think that to help severely emotionally wounded people they should have highly specialized medical training, or they should know the right things to say in order to make them feel better. That is not true. What is most important to badly hurt people is that they know that you are there and that you care. It is often remarkably simple what people need. They need you to be able to be present, focusing your attention on them; and they need you to be open, listening to them with your heart and your feelings, feeling with them.





* Detachment. In addition to your compassion, survivors of trauma also need your neutrality. Many of the events that you hear about may elicit very strong feelings in you -- feelings that are very appropriate. You may feel angry, sad, grieving, frightened, horrified, shocked, and deeply disturbed. Sometimes it is helpful to share a little of these feelings, so that people you are working with realize that they are with a human being, and so that you can remind them that it is appropriate to feel. But for the most part, the goal of individual work is to help people find their own feelings again, and for that they often need your calm, grounded presence rather than a lot of your emotional reactions. They have already had their space violated by others, now they need their own space to work in, and you can provide that best by making sure that it is their feelings, not yours, that occupy most of the time and space in the room.





What you can do to help: Procedures and Processes





* Begin simply. Introduce yourself, tell the person you are working with (we shall call her the survivor from now on, because she has survived some terrible events) that you are there to help and there to listen. Do not begin with discussion of the traumatic events unless they initiate that themselves. Begin by helping the survivor to become comfortable, asking her how she is doing in the present, whether she would like your help, how she would like to you to help, whether she wants to talk to you, what she would like to talk about now. . The goal in the beginning is to meet and set up an agreement and a space in which hard work can later occur; it is not necessarily a time to begin that hard work, unless this is the only meeting you will have, or unless you will have very few meetings.



* Let the survivor lead. Perhaps the simplest and best rule in healing is to trust the other person's process. Nature heals, not you, and the person will bring things up in their own way and own time, as they are ready. It is therefore often best simply to sit in comfortable silence, once initial greetings have taken place and you have let the other person know that they can talk about whatever they want, and wait for them to decide what they want to talk about.



* Ask questions. Even though it is good to wait, you need not be passive. Once the other person has begun to talk about events it is good to engage with them, to let them know you are interested and also to help guide the process. What questions to ask is a matter of judgment and experience. Basically, it is good to trust your own intuition, instinct, and interest to provide the questions, but below are some further guidelines suggesting how to direct the process.

* Always work with permission. Never force or pressure a survivor to remember or to feel. Always ask if they would like to discuss something before leading further.

* As long as the survivor is not overwhelmed and is willing, create space for her to move into discussing more emotionally difficult material. One goal is to help the survivor to integrate what has happened to her. You are following nature. If the person is already having flashbacks and nightmares, part of her mind wants to bring the experience into consciousness and master it, making sense of it, integrating it into her life, so she can go on. Therefore you will want to help her do that. Here is an example of how one may work with a survivor by asking questions that permit movement into discussing more emotionally intense material.

Therapist: What would you like to talk about today? Survivor: I've been having some disturbing thoughts lately. T: Disturbing thoughts? S: Yes. T: Would you like to talk about those thoughts? S: I guess so. It's just that the feelings are so disturbing, that I'm not sure that I want to go into it. T: I understand that. The feelings are so strong that it is hard to be willing to talk about these things. S: Yes. But I guess I need to talk about it. It won't just go away. Right? If you want to talk about it, I'm interested in hearing. You should talk about it only if you are ready.

Let people tell their story. Generally, people who are healing from horror need to tell their story. They don't need you to push them, but they need to know that you are there who cares and want to know and are willing to listen. Generally, you can convey this through quiet openness and some encouragement to go into the story.

Survivor: I am haunted by nightmares of what happened to me. Therapist: Do you want to tell me about the nightmares? S: In each dream, I am alone in my house, and I hear noises outside. I feel absolute terror, just waiting for them to come in. They come in and I scream. Sometimes I wake myself up then. T: It sounds like a lot of terror. Do these dreams remind you of what happened? S: Yes. T: Do you want to talk about it? S: (Long pause.) I can't believe what happened. These people were my neighbors. My children went to school with their children....How can people....They were drunk. They made so much noise. I thought the door would break....There were three of them. I didn't know what to do. I wanted to run out of the house, but -- I don't know what was wrong with me. I just froze. One of them said bad things to me. I knew what was going to happen. Their eyes. They looked like dogs, when they attack. I couldn't breathe.



* Allow the experience and expression of feeling. In general, within the guidelines above it is helpful for people to experience and express the feelings they have about what they have endured.

The feelings that may emerge are fear, terror, shock, horror, anger, rage, grief, sadness, disgust, and shame. Each of these feelings is a legitimate and understandable response to the experiences survivors have had. Being able to re-experience and express these feelings in the context of a trusting relationship with you can help them to overcome the mistrust, isolation, and damaged relationships that experiencing rape and torture, and witnessing murder inevitably bring.

Many times you may find yourself very uncomfortable with the intensity of feelings that a survivor has. You may wish to make the person wrong for having those feelings by denying the reality of their experience or by telling them they should not feel as they do. Or you may want to try to make them feel better, to spare both them and yourself the rawness of their feelings. It is almost always wrong to tell someone they should not feel as they do. It is often not helpful to try to make someone feel better before fully registering, accepting, and mirroring the feeling as it is. It is generally best just to accept the feelings as they emerge, realizing that is probably the best you can do for their healing.





Some specific techniques are helpful in working with feelings:

* Ask the survivor what she feels. Sometimes hearing the story is enough. Other times, it is helpful to elicit the feeling. For example,

S: Every day they came in and did the same thing. (Speaks in monotone, without apparent feeling.) T: What are you feeling? Survivor: I feel terrible about myself now. I don't see any point in living. Therapist: Why? Why is it that you don't see any point in living? S: I'm ruined. They spoiled me. I can never be the same again. T: You feel ruined. [Notice that the therapist is not agreeing with the client's self-assessment, but is re-framing (changing the meaning) of the client's statement by pointing out that it is a feeling, not necessarily a reality.] S: Yes. I feel dirty. T: What they did to you made you feel terrible about yourself. S: (Starts to cry.) I feel so ashamed. (Cries freely.) T: When people have been violated as you have, it makes them feel a lot of shame. [This tells the client that it is natural to feel as she does, and it is not her fault that she feels this way.]





* Reflect what you hear and see. Telling the survivor how she comes across to you can sometimes help her focus on how she feels. Example,

Survivor: I've .been thinking about going back to my village. Therapist: I notice you look a little frightened. S: I am. I don't know if there is any chance I ever can go back. What is to keep the same thing from happening again. If I couldn't trust my neighbors before, how can I now?



* Do not push for catharsis. People in shock do not always benefit from strong expression of emotion. Shock is a state in which functions get frozen and knotted. Sometimes, a spontaneous expression of feeling helps to thaw the freeze. Other times it is better to let the system unfreeze gradually and gently, letting the "knots" in the nervous system unwind slowly. While cathartic experience can help, repeated experiences of powerful emotion, especially when pushed by someone else, can sometimes be retraumatizing and reinforce the traumatic state.





* Focusing on body sensations helps the nervous system to unwind from trauma. In trauma, people get stuck in the past. They need to move carefully out of being stuck. You can assist this by helping people follow their own inner sensations.

Survivor: I don't think I can stand how I feel. Therapist: What are you feeling? S: I don't know. I just know I can't stand it. T: What do you notice going on in your body? S: I don't notice anything. T: Nothing. S: I feel like I'm not even in my body. T: Yes. Where are you? S: Up there (points to ceiling). (Survivor is indicating she is dissociated.) T: Good. What do you notice about your body from up there? (Begins to reintroduce the body back into consciousness.) S: It's tense. T: Where do you notice the tension? S: In the shoulders. And the chest. T: OK, good. (Saying "good" or "fine" lets the client know implicitly that she is on the right track, no matter what she reports; that she only needs to say what is there, and that whatever is there is fine.) So you're tense in the shoulders and chest. Anywhere else? S: Yes, my stomach is tight. T: Good. So let's see what happens if you pay attention to your shoulders and chest and arms being tight. Just notice that for awhile. S: (Long silence. This kind of work is a very slow process. Don't worry if it takes a long time for anything to seem as if it is happening.) (Takes a deep breath) My stomach is starting to loosen a little bit. (Survivor is starting to unwind a little. This is good; in this kind of work, we don't need drama to be effective.)





* If the person seems overwhelmed, lead away from emotionally painful material. It is important to monitor the survivor, to make sure that the feelings and experiences that are arising are not overwhelming to the survivor in the present. "Overwhelming" is not the same as intense. Overwhelming means that the person simply cannot take in the experience now. Signs that the person is feeling overwhelmed are the following:

* The person experiences herself leaving her body. This is a symptom of dissociation and a sign that the person's nervous system cannot deal with the overload of sensation. * The person loses the ability to communicate. Sometimes people will become quiet when absorbed in the memory of an experience. That is often a sign of healing. Other times, however, they may find themselves unable to talk, speaking very haltingly, etc. This may be a sign that the person is feeling overwhelmed. If you are unsure about whether the client is handling the silence productively or is feeling overwhelmed, ask her what is happening. * The survivor seems "spacey," that is, the eyes become glazed, they seem "not there," or somehow seem to be far away. This is another sign of dissociation. * The person experiences perceptual distortions. Her body might feel like cotton, her visual field may narrow severely, she may feel cold and numb or unable to move parts of her body, or she may feel cut off from her surroundings.





If these signs and symptoms are present, or if you have other reasons to believe that the survivor is feeling more sensation and feeling than she can handle (not more than you can handle, more than she can handle), then lead the discussion back into the present. Here are examples of leading back to the present. Notice how in this example, body sensation is used to "ground" the person, that is bring her back into present time and in this place, away from the past trauma.

S: Then this man came and got....I'm feeling strange now. I don't think I can go on with this. T: You're feeling strange. [Focusing on present feeling is sometimes a beginning point of getting someone back to the present, without being too abrupt.] S: Yes. My head feels kind of funny T: Pay attention to that now. Notice the sensations in your head. [ Focusing on present bodily sensations is the best way of bringing someone into present reality and away from overwhelm. It brings her "back into her body."] S: I feel kind of dizzy. T: What else do you notice going on in your body? [Moving away from the overwhelm in the head, moving to lower parts of the body can be "grounding," that is helping the person "root" in present time with both feet on the ground.] S: I feel kind of sick to my stomach. T: Pay attention to that feeling. Notice the sensations. [Here you are showing the person she does not have to be afraid of sensations that may have seemed overwhelming a few minutes ago.] S: I feel nauseous. T: Stay with that for awhile and see what happens. S: My jaw feels tight. T: What happens if you stay with that sensation? S: I feel a softening happening in my arms. T: Go with that: stay with that sensation for awhile. (Survivor is encouraged to experience the "letting go" into healing. Softening, melting, lightening sensations can be signs that the survivor is letting go and experiencing relief and healing.)





* Enhancing the feeling of safety is another way to reduce overwhelm and allow integration of difficult material. If the person remains persistently overwhelmed but still wishes to go through her story, there is a way to help people to integrate difficult material more easily and safely. In the first part of the technique, the therapist asks the survivor to imagine in her mind a safe place. It can be a real or imaginary scene. It can be a place in nature or indoors. In war zones, nature may not be appropriate to imagine as a safe place, due to the high density of landminds and other dangers. Sometimes people who have suffered severe trauma will say they cannot think of anyplace safe. Then it is best to ask them to think of the safest place they can. Then the therapist asks the survivor to imagine being in the safe place, perhaps with someone whom they trust with them there too. After the person imagines herself there and is feeling somewhat secure, the therapist asks the survivor to leave the safe place and go back to the traumatic incident in her imagination. She is to remain with the traumatic memory, describing it to the therapist until she feels overwhelmed by feeling; at that point, she is to return to the safe place and discuss the incident with the trusted friend in the safe place.

By alternating back and forth between the safe place and the trauma, people can more easily integrate the memories of trauma and also the powerful feelings the trauma has generated.

Here is an example of the use of this "safe place" technique.

Therapist: Would you like to try something that might make this process easier? Survivor: What is it? T: It involves imagining a safe place. S: All right. T: We will be going back and forth between a safe place and the camp where all the terrible things happened to you. Are you willing to do that? S: All right. T: I would like you to close your eyes and imagine a safe place. It might be a real place or an imaginary place. It could be in a house you know, or it could be in the mountains or in a field or wherever you feel safest. Would you do that now? S: (After a minute of trying, cries.) There isn't any place safe any more. T: I understand that. Could you imagine the safest place that you can think of. S: All right. I am in my aunt's house. In her front room. I always felt safe there. T: Is your aunt there? S: Yes. I always trusted her. She was very nice to me. My mother used to leave me there on weekends, when she went to the city. T: Good. So now I would like you to go to the safe place for awhile and spend a little time there. S: (Is silent for a minute or two.) T: How are you doing? S: Fine. T: Good. Now I am going to ask you in a minute to leave the safe place and go to the camp. When you do that, I'll ask you to tell me what you are experiencing. And then as soon as you feel overwhelmed, like the feelings are too much, or that you start feeling like you are leaving your body or loosing touch with yourself, I will ask you to run back to the safe place. OK? S: Yes. T: All right. I want you to leave your aunt's house now and go to the camp. ....What do you see there? S: I see my room. T: What is it like? What do you notice? S: It seems all grey to me. I see my clothes hanging on the door. And I notice the door knob.... I am starting to feel frozen in my body. ... I ...I... (Stops talking.) T: I'd like you to run back to the safe place now. Will you do that please? S: (Pauses, then breathes deeply.) I am with my aunt now. T: Tell your aunt what you just experienced. S: (Silent for half a minute, then begins to cry.) I am telling her about what the men did to me... (Sometimes it is easier for the survivor to "tell" someone in her mind than someone outside herself.)





* Help people recognize and develop their resources. In the midst of trauma, it is sometimes hard to remember that people's lives are about more than their trauma and that their spirit is often greater than what has befallen them. In even the worst of circumstances, there are opportunities to grow beyond the obstacles that beset people. It is helpful to survivors to have their resources recognized. Some resources are inner ones.

Survivor: I spent time with a friend this morning. She was grieving over the loss of her baby. Therapist: What did you do with her? S: I just spent time with her and I held her while she cried. T: It amazes me that after all you've been through you can still be there for someone else.

Or:

Survivor: I am feeling a lot of despair today. I just don't know how I can go on with my life. Therapist: Yes, I can understand your despair. You've lost so much, and life looks like it is not presenting any hopeful possibilities for the future. How is it that you have been able to go on this far? How have you been able to do it? S: I don't know how I've done it. I guess I was always that way. I always went on no matter what. My mother was like that too. She grew up in a family where a lot of her brothers and sisters died. Somehow, she had the strength to keep going. T: It seems that maybe you have a lot of that kind of strength too. S: Yes. But I'm not sure it is going to be enough to deal with all this. T: Right. This seems too much to deal with sometimes isn't it? S: It feels that way.....I don't know. I hope I'll have the strength. My children need me.





Sometimes the resources to be recognized and developed are external ones. Trauma disrupts life, and re-building life usually requires support. Help the survivor recognize and develop support of all kinds in her life: friendship, medical help, housing, whatever is needed.





* Avoid pushing for recovery too soon. In most cultures, there is a conventional tendency to respond to other people's traumas and sometimes one's own by saying clichés like, "You just have to keep on going," "That was in the past, there's no sense in dwelling on it," "I just try not to think about it, you should too," etc. But trauma freezes people into the past, and it robs them of a sense of future. Such clichés, though useful for some, are often hurtful for those who are not yet ready or able to move on. It is important to remain patient with the healing process, reassuring people that healing takes time. And healing from trauma usually takes more time than anyone likes.





* Take care of yourself. Last but definitely not least, make sure you have support and that you do not overextend yourself. Secondary PTSD is a real phenomenon. You can be traumatized by exposure to other people's traumatic stories, energy, and emotions. Don't let your life be overwhelmed by others' traumas, and be sure to get plenty of support and help for the feelings that come up for you in working with other peoples' traumas. If you have had traumas in your own life that you are not finished dealing with -- and most of us do -- then you can expect that the memories and issues and feelings associated with them will be retriggered by working with other peoples' traumas. Get help sooner rather than later in dealing with whatever comes up for you. It can be a great opportunity and lead to greater health and healing for you as well as the people you are helping!





Summary





Survivors need a chance to express themselves and work with their experience in the context of a relationship they can come to trust. This will help them to restore their trust in others and in themselves and also to begin coming to terms with their experience.

In this process, it is helpful to give them lots of room to talk or not to talk, to remember or not to remember, to feel or not to feel, to express or not to express.

It helps to let the survivor lead the way, to ask questions, to reflect feelings, to mirror what you see and hear.

In general, it is helpful to encourage expression of their experience, feeling, and sensation, as long as they are not overwhelmed in doing so. It is best for them to absorb their experience a bit at a time rather than all at once.

It also helps to get people to understand that how they feel is normal and a result of what have happened to them. It helps to give them confidence that they can live with their feelings and experiences and patiently deal with the intensity of feelings they have to absorb.

Most important, it helps for you just to be present, without judgment, trusting in their healing process and your own instinct and intuition.

When people are wounded in war, they heal. The same can be true of emotional wounds. With our help and with time, people may heal from the worst of experiences.









Final Word

Your feedback will help this page grow. Please let me know what works for you and what doesn't. If you have questions, please feel free to ask, and I'll do what I can to answer. If you wish consultation on any of your work with trauma, please ask me, and I'll try to help. E-mail me at:





eds@there.net









Ed Schmookler





Reproduced with Permission