Academic journal article Journal of Mental Health Counseling

Current, Continuous, and Cumulative Trauma-Focused Cognitive Behavior Therapy: A New Model for Trauma Counseling

Academic journal article Journal of Mental Health Counseling

Current, Continuous, and Cumulative Trauma-Focused Cognitive Behavior Therapy: A New Model for Trauma Counseling

Article excerpt

Most counselors working with trauma today have been trained in treatment models inspired by a single-past-trauma framework (e.g., Cohen, Mannarino, Kliethermes, & Murray 2012). While these models have important evidence-based strengths (e.g., Lenz & Hollenbaugh, 2015), they do not adequately address more complex or chronic traumas or the cumulative and proliferation dynamics usually present in highly traumatized clients. As an example, torture is not a single trauma. It is a complex series of different trauma types that may include severe physical and sexual abuse and exclusion, such as electrocution and water-boarding, that have been inflicted over prolonged periods to target the individual's personal and collective identity for self-surrender to a captor (e.g., Kira, Ashby, Odenat, & Lewandowski, 2013). It has been shown that, compared to others, refugees and their children are highly traumatized, have more psychotic disorders, and have higher rates of comorbid depression, anxiety, and posttraumatic stress disorder (PTSD; e.g., Bhugra, 2004; Fazel, Wheeler, & Danesh, 2005). Studies suggest that present- and past-focused interventions that address PTSD and comorbid conditions simultaneously are likely to be more effective, cost-effective, and sensitive to client needs than a single-past-trauma-focused approach (e.g., Najavits, 2006; Torchalla, Nosen, Rostam, & Allen, 2012).

Further, current treatment models rarely address the cumulative and proliferation dynamics of traumatization, which are important for multiply traumatized clients. Proliferation suggests that an independent trauma can generate several dependent traumas, such as loss of a job due to discrimination (e.g., Pearlin, Aneshensel, & Leblanc, 1997). Cumulative dynamics refers to the cumulative effects of different traumas and stressors across situations and the life course. When enough stress and trauma factors accumulate to outweigh the protective factors, thereby crossing the threshold of the individual's distress tolerance, posttrauma spectrum comorbid disorders develop. Even for people with higher distress tolerance, chronic and continuous stress and the cumulative dynamics of traumatic and nontraumatic events can cause the victim to decompensate, attempt suicide, or develop complex profiles of comorbidities (Kira, 2010; Kira, Ashby, Lewandowski, et al., 2013; Kira & Wroble, in press).

Additionally, one of the limitations of current cognitive approaches to trauma is their exclusive focus on appraisal as the core of the etiology of traumatization and the key to change (e.g., Scherer, 2001). This focus may be problematic because cognitive appraisal (personal evaluation of the event) is developmentally dependent and not formally articulated in children. Appraisal is also biased by such precognitive processes as motivations, self-concept, mood, societal pressures, and identity dynamics. These dynamics bias perception, attention, memory, and emotion processing, as well as action tendencies and a variety of coping behaviors. Addressing the precognitive processes in counseling, in addition to appraisal, would address important mechanisms of therapeutic change.

Models designed to address chronic, continuing, and emerging traumatic stressors that effectively address the potential flux of changing and emerging life stressors and adversities should be dynamic and open, applied within a flexible structured approach that addresses issues as they arise and evolve. Further, trauma counseling models should integrate the common therapeutic factors--the therapeutic alliance, counselor expertise, and flexible emergent case conceptualization--that address changing client needs and unanticipated events (e.g., Laska, Gurman, & Wampold, 2014). As noted in a white paper published by the American Mental Health Counselors Association, establishing trusting relationships is critical to counseling trauma survivors (Otis, 2013). …

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