Ethical guidelines for treating trauma survivors

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Ethical guidelines for treating trauma survivors can provide professionals direction to enhance their efforts. Trauma survivors have unique needs and vary in their resilience, post-traumatic growth, and negative and positive outcomes from their experiences. Numerous ethical guidelines can inform a trauma-informed care (TIC) approach. [1]

Contents

Trauma can result from a wide range of experiences which expose humans to one or more physical, emotional, and/or relational dangers. Treatment can be provided by a wide range of practices, ranging from yoga, education, law, mental health, justice, to medical. It can be provided by organizations.

Within the field of psychology, ethics define the standards of professional conduct. The American Psychological Association (APA [2] ) describes their Ethics Code as a “common set of principles and standards upon which psychologists build their professional and scientific work” (p. 8). Ethics help clinicians to think through and critically analyze situations, while also serving as aspirations and virtues that clinicians should strive towards. [3] When working with trauma survivors, oftentimes a client's traumatic experiences can be so overwhelming for both the patient and the clinician that professional and ethical boundaries may become endangered. [3]

Guidelines

The following ethical guidelines should be considered when working with clients who have survived a traumatic experience:

The APA ethics code [4] outlines many professional guidelines for clinicians including the maintenance of confidentiality, minimizing intrusions to privacy, and obtaining informed consent. Informed consent ensures the client has an adequate understanding of the techniques and procedures that will be used during therapy, expected timeline for treatment, and possible consequences for engaging in specific tasks and goals. [4]

When clinicians work with trauma survivors their informed consent should emphasize diagnosis and treatment of trauma and include clear guidelines for maintaining secure and firm boundaries. Some research suggests that clients who have experienced complex trauma may deliberately or unconsciously test clinician's boundaries by missing or arriving late for appointments, bringing the clinician gifts, attempting to photograph the therapist, calling during non-office hours, or trying to extend the session either in person or with a follow-up phone call. [5]

Risk management

Research suggests that trauma survivors are more likely than those without a history of trauma to report suicidal ideation and to engage in self-harming behaviors. [6] Furthermore, research also indicates that suicide attempts are correlated with both childhood maltreatment and PTSD symptom severity. [7] Clinicians who treat trauma survivors should continuously monitor their client's suicidal ideation, means, and plans especially surrounding anniversary dates and triggering experiences. [3] Client safety should be prioritized when working with trauma survivors, and should include immediately assessing client safety following intense sessions and frequent follow-ups with clients between sessions. [5]

Establishing and maintaining a strong therapeutic alliance

The APA outlines General Principles that clinicians should use in order to aspire towards the very highest ethical ideals. [2] Among these General Principles are Principle A: Beneficence and Nonmaleficence and Principle C: Integrity. Beneficence and Nonmaleficence describes that clinicians strive to benefit those with whom they work, and make efforts to do no harm. [2] Fidelity and Responsibility includes establishing relationships of trust and being aware of one's professional responsibilities. [2] Both of these principles should be considered when a clinician attempts to establish and maintain a strong therapeutic alliance with trauma survivors.

For clients with a history of trauma, particularly those who have experienced betrayal trauma, forging close and trusting relationships with others may be difficult. [6] In addition, during the course of therapy clients may discuss terrifying, horrific, or disturbing experiences, which may elicit strong reactions from the therapist. Some of the possible negative reactions could include distancing and emotional detachment, [3] which may reinforce clients’ often negative schemas and self-image. Clinicians may also contribute to the challenges of establishing a strong therapeutic alliance by becoming overly inquisitive about the client's traumatic experience, which, in turn, may lead to a lack of accurate empathy. For these reasons, clinicians treating those with a history of trauma may encounter unique challenges when attempting to develop a strong therapeutic alliance.

Addressing transference and countertransference

Within the course of traditional therapy it is possible for transference and counter transference to interfere with treatment. For clinicians treating those with a history of trauma it is possible to experience “a priori counter-transference”. [8] A priori counter-transference includes the thoughts, feelings, and prejudices that may arise before meeting with a potential client as a result of knowing that the client has gone through a certain traumatic event. [8] These initial reactions may create ethical dilemmas as the clinician's personal attitudes, beliefs, and values may become compromised, thereby increasing the amount of counter-transference the clinician may have towards the client. The APA ethics code 2.06(b) describes a clinician's ethical responsibility should personal situations interfere with a clinician's ability to perform their duties adequately. [2] Clinicians experiencing a priori counter-transference should consider utilizing more frequent consultations, receive increased levels of personal therapy, or consider limiting, suspending, or terminating their work-related duties. [2]

Traumatic bonding

Dutton and Painter [9] originally coined the term “traumatic bonding” to describe the relationship bond that occurs between the perpetrator and victim of abusive relationships. As a result of ongoing cycles of positive and traumatic experiences powerful emotional bonds are created that are resistant to change. [9] The term can also be borrowed to describe the relationship between a trauma clinician and the client. As the client describes their traumatic memories and re-experiences the accompanying powerful emotions and sensations they are prone to form a remarkably intense bond with their clinician. These emotionally driven experiences present ethical challenges and pitfalls for the clinician including behaving in extremes such as acting in an overprotective manner or distancing themselves from the client. The clinician may also feel triggered by their own similar trauma history, causing unnecessary discloses or the need to share the client's story in order to seek revenge or justice. The APA ethics code 2.06(a) describes that clinicians should refrain from practicing if they know there is a substantial likelihood that their personal problems will prevent them from being objective or competent. [2] Clinicians who recognize that traumatic bonding might be occurring should increase consultations or consider limiting, suspending, or terminating their work-related duties. [2]

Related Research Articles

<span class="mw-page-title-main">American Psychological Association</span> Scientific and professional organization headquartered in the Washington, D.C.

The American Psychological Association (APA) is the largest scientific and professional organization of psychologists in the United States, with over 146,000 members, including scientists, educators, clinicians, consultants, and students. It has 54 divisions—interest groups for different subspecialties of psychology or topical areas. The APA has an annual budget of around $125 million.

Clinical psychology is an integration of human science, behavioral science, theory, and clinical knowledge for the purpose of understanding, preventing, and relieving psychologically-based distress or dysfunction and to promote subjective well-being and personal development. Central to its practice are psychological assessment, clinical formulation, and psychotherapy, although clinical psychologists also engage in research, teaching, consultation, forensic testimony, and program development and administration. In many countries, clinical psychology is a regulated mental health profession.

Counseling psychology is a psychological specialty that began with a focus on vocational counseling, but later moved its emphasis to adjustment counseling, and then expanded to cover all normal psychology psychotherapy. There are many subcategories for counseling psychology, such as marriage and family counseling, rehabilitation counseling, clinical mental health counseling, educational counseling, etc. In each setting, they are all required to follow the same guidelines.

Psychological trauma is an emotional response caused by severe distressing events that are outside the normal range of human experiences, such as experiencing violence, rape, or a terrorist attack. The event must be understood by the affected person as directly threatening the affected person or their loved ones with death, severe bodily injury, or sexual violence; indirect exposure, such as from watching television news, may be extremely distressing and can produce an involuntary and possibly overwhelming physiological stress response, but does not produce trauma per se.

Psychodynamic psychotherapy and psychoanalytic psychotherapy are two categories of psychological therapies. Their main purpose is revealing the unconscious content of a client's psyche in an effort to alleviate psychic tension, which is inner conflict within the mind that was created in a situation of extreme stress or emotional hardship, often in the state of distress. The terms "psychoanalytic psychotherapy" and "psychodynamic psychotherapy" are often used interchangeably, but a distinction can be made in practice: though psychodynamic psychotherapy largely relies on psychoanalytical theory, it employs substantially shorter treatment periods than traditional psychoanalytical therapies. Psychodynamic psychotherapy is evidence-based; the effectiveness of psychoanalysis and its relationship to facts is disputed.

Complex post-traumatic stress disorder (CPTSD) is a stress-related mental disorder generally occurring in response to complex traumas, i.e. commonly prolonged or repetitive exposures to a series of traumatic events, within which individuals perceive little or no chance to escape.

Recovered-memory therapy (RMT) is a catch-all term for a controversial and scientifically discredited form of psychotherapy that critics say utilizes one or more unproven therapeutic techniques to purportedly help patients recall previously forgotten memories. Proponents of recovered memory therapy claim, contrary to evidence, that traumatic memories can be buried in the subconscious and thereby affect current behavior, and that these memories can be recovered through the use of RMT techniques. RMT is not recommended by professional mental health associations.

Exposure therapy is a technique in behavior therapy to treat anxiety disorders. Exposure therapy involves exposing the target patient to the anxiety source or its context without the intention to cause any danger (desensitization). Doing so is thought to help them overcome their anxiety or distress. Procedurally, it is similar to the fear extinction paradigm developed for studying laboratory rodents. Numerous studies have demonstrated its effectiveness in the treatment of disorders such as generalized anxiety disorder, social anxiety disorder, obsessive-compulsive disorder, post-traumatic stress disorder (PTSD), and specific phobias.

Gay affirmative psychotherapy is a form of psychotherapy for non-heterosexual people, specifically gay and lesbian clients, which focuses on client comfort in working towards authenticity and self-acceptance regarding sexual orientation, and does not attempt to "change" them to heterosexual, or to "eliminate or diminish" same-sex "desires and behaviors". The American Psychological Association (APA) offers guidelines and materials for gay affirmative psychotherapy. Affirmative psychotherapy affirms that homosexuality or bisexuality is not a mental disorder, in accordance with global scientific consensus. In fact, embracing and affirming gay identity can be a key component to recovery from other mental illnesses or substance abuse. Clients whose religious beliefs are interpreted as teaching against homosexual behavior may require some other method of integration of their possibly conflicting religious and sexual selves.

Feminist psychology is a form of psychology centered on social structures and gender. Feminist psychology critiques historical psychological research as done from a male perspective with the view that males are the norm. Feminist psychology is oriented on the values and principles of feminism.

PTSD or post-traumatic stress disorder, is a psychiatric disorder characterised by intrusive thoughts and memories, dreams or flashbacks of the event; avoidance of people, places and activities that remind the individual of the event; ongoing negative beliefs about oneself or the world, mood changes and persistent feelings of anger, guilt or fear; alterations in arousal such as increased irritability, angry outbursts, being hypervigilant, or having difficulty with concentration and sleep.

<span class="mw-page-title-main">Transgenerational trauma</span> Psychological trauma

Transgenerational trauma is the psychological and physiological effects that the trauma experienced by people has on subsequent generations in that group. The primary modes of transmission are the uterine environment during pregnancy causing epigenetic changes in the developing embryo, and the shared family environment of the infant causing psychological, behavioral and social changes in the individual. The term intergenerational transmission refers to instances whereby the traumatic effects are passed down from the directly traumatized generation [F0] to their offspring [F1], and transgenerational transmission is when the offspring [F1] then pass the effects down to descendants who have not been exposed to the initial traumatic event - at least the grandchildren [F2] of the original sufferer for males, and their great-grandchildren [F3] for females.

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<span class="mw-page-title-main">Lillian Comas-Díaz</span> Psychologist and Professor

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Trauma-informed care (TIC) or Trauma-and violence-informed care (TVIC), is a framework for relating to and helping people who have experienced negative consequences after exposure to dangerous experiences. There is no one single TIC framework, or model, and some go by slightly different names, including Trauma- and violence-Informed Care (TVIC). They incorporate a number of perspectives, principles and skills. TIC frameworks can be applied in many contexts including medicine, mental health, law, education, architecture, addiction, gender, culture, and interpersonal relationships. They can be applied by individuals and organizations.

References

  1. ↑ Rudolph, Kaila (2021-12-01). "Ethical Considerations in Trauma-Informed Care". Psychiatric Clinics of North America. Ethics in Psychiatry. 44 (4): 521–535. doi:10.1016/j.psc.2021.07.001. ISSN   0193-953X.
  2. 1 2 3 4 5 6 7 8 "Ethical Principles of Psychologists and Code of Conduct". American Psychologist. 57 (12): 1060–1073. 2002. doi:10.1037/0003-066x.57.12.1060. ISSN   1935-990X.
  3. 1 2 3 4 Frankel, A. Steven (2017), "Legal and ethical considerations in working with trauma survivors: Risk management principles for clinicians.", APA handbook of trauma psychology: Foundations in knowledge (Vol. 1), American Psychological Association, pp. 547–558, doi:10.1037/0000019-027, ISBN   978-1433826559
  4. 1 2 "Ethical Principles of Psychologists and Code of Conduct". apa.org. Retrieved 2018-10-14.
  5. 1 2 Ducharme, Elaine L. (2017-09-01). "Best practices in working with complex trauma and dissociative identity disorder". Practice Innovations. 2 (3): 150–161. doi:10.1037/pri0000050. ISSN   2377-8903. S2CID   149049584.
  6. 1 2 Ellis, Amy E.; Simiola, Vanessa; Brown, Laura; Courtois, Christine; Cook, Joan M. (2017-06-29). "The role of evidence-based therapy relationships on treatment outcome for adults with trauma: A systematic review". Journal of Trauma & Dissociation. 19 (2): 185–213. doi:10.1080/15299732.2017.1329771. ISSN   1529-9732. PMID   28509624. S2CID   3417960.
  7. ↑ Guina, Jeffrey; Nahhas, Ramzi W.; Mata, Nicholas; Farnsworth, Seth (2017-10-26). "Which Posttraumatic Stress Disorder Symptoms, Trauma Types, and Substances Correlate With Suicide Attempts in Trauma Survivors?". The Primary Care Companion for CNS Disorders. 19 (5). doi:10.4088/pcc.17m02177. ISSN   2155-7780. PMID   29099549.
  8. 1 2 Dalenberg, Constance; Tauber, Yvonne; Palesh, Oxana (2001). "Recovered memory and a priori countertransference in the context of ongoing risk". doi:10.1037/e609242012-147.{{cite journal}}: Cite journal requires |journal= (help)
  9. 1 2 Dutton, Donald G.; Painter, Susan (January 1993). "Emotional Attachments in Abusive Relationships: A Test of Traumatic Bonding Theory". Violence and Victims. 8 (2): 105–120. doi:10.1891/0886-6708.8.2.105. ISSN   0886-6708. PMID   8193053. S2CID   1724577.
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