Addressing Survivor's Interpersonal Problems. Trauma survivors' problems often show themselves in the survivors' interpersonal interactions. Cognitive-
behavioral psychology has, of course, a rich history of attention to the interpersonal context of behavior problems, a focus that is seeing increasing development related to PTSD. In this book, interventions that focus on couples concerns are described in Chapter Fourteen by Leonard, Follette, and Compton. Deblinger, Thakkar-Kolar, and Ryan in Chapter Sixteen describe interventions that work conjointly with both children and parents in addressing child traumatic experiences. Group psychotherapy, an important component of treatment for many trauma survivors, is reviewed in Chapter Fifteen by Foy and Larsen. The latter authors point to the advantages for trauma survivors, whose experiences so commonly involve social isolation, social alienation, perceptions of being ostracized from the larger society, shame, and diminished feelings for others, of working toward recovery with other survivors.
Working with Challenging Clinical Behaviors. Mental health providers must navigate many difficult situations in their interactions with survivors. For example, clients with a history of trauma in the family of origin may have developed a number of maladaptive coping mechanisms to deal not only with the trauma but also with other invalidating aspects of their environment. In fact, much of what is particularly helpful in cognitive-behavioral interventions goes beyond the core treatment components outlined in the sections above, and includes procedures that help the therapist both to motivate the client and to avoid or manage difficult clinical situations such as suicidal behavior. These procedures include encouraging the client to take an active role in setting the goals of treatment, presenting persuasive rationales for treatment, assigning and ensuring completion of homework tasks, instructing clients in techniques of self-monitoring, and so on. For example, Najavits emphasizes in her Seeking Safety treatment ways of giving clients control whenever possible, "listening" to client behavior more than words, giving positive and negative feedback to clients, and asking clients about their reactions to treatment. In the same spirit, Wagner and Linehan utilize a number of techniques from DBT to address noncompliance, suicidal ideation, and other self-injurious behavior.
Using the Therapeutic Relationship. In their historical perspective on cognitive-behavioral therapies for trauma, Monson and Friedman in Chapter One observe that cognitive-behavioral therapy is often stereotyped as a mechanical form of therapy lacking in a certain type of human contact. But the attention to interpersonal processes that is included in many cognitive-behavioral therapies also extends to the client-therapist relationship. Generally, most of the approaches described in this text emphasize the importance of the therapeutic relationship. In particular, Functional Analytic Psychotherapy (FAP) as described in Chapter Eight by Kohlenberg, Tsai, and Kohlenberg provides an extensive introduction to how providers of cognitive-behavioral treatments can use the therapeutic relationship as a primary component of treat ment. This conceptualization, in contrast to the stereotypes of cognitive-behavioral treatments, places the client-therapist relationship at the core of the change process. FAP theory indicates that the therapeutic process is facilitated by a caring, genuine, sensitive, and emotional client-therapist relationship. The therapeutic relationship itself is used to help identify interpersonal stimuli that lead to problems and to provide in vivo opportunities to change interpersonal repertoires. Therapists are taught to recognize and address clinically relevant behaviors that occur in session, and to strengthen client improvements within the therapy session itself. DBT similarly posits that a strong relationship characterized by mutual trust, respect, and positive regard will increase the likelihood that the client will engage in efforts to change that are difficult and uncomfortable, and that a strong relationship can be therapy in itself.
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