American Association of Therapists Treating Abortion Related Trauma
Professionalizing the treatment of abortion related trauma Bridging the gap between research and practice
Evidenced Based Practice
In order to understand what evidenced based practice is, it is best to start with a definition. The American Psychological Association (APA) defines evidenced based practice as,
"Evidence-based practice in psychology (EBPP) is the integration of the best available research with clinical expertise in the context of patient characteristics, culture, and preferences." *
They go on to describe the reason evidenced based practice is needed.
"The purpose of EBPP is to promote effective psychological practice and enhance public health by applying empirically supported principles of psychological assessment, case formulation, therapeutic relationship, and intervention." *
The model below shows the three aspects of what makes up evidenced based practice. To better understand it, it is best to go into a little more detail on each aspect.
Best Available Research
"The research literature on the effect of psychological interventions indicates that these interventions are safe and effective for a large number of children and youths (Kazdin & Weisz, 2003; Weisz, Hawley, & Doss, 2004), adults (Barlow, 2004; Nathan & Gorman, 2002; Roth & Fonagy, 2004; Wampold et al., 1997), and older adults (Duffy, 1999; Zarit & Knight, 1996) across a wide range of psychological, addictive, health, and relational problems." *
"Best research evidence refers to scientific results related to intervention strategies, assessment, clinical problems, and patient populations in laboratory and field settings as well as to clinically relevant results of basic research in psychology and related fields." *
"Clinical expertise is essential for identifying and integrating the best research evidence with clinical data (e.g., information about the patient obtained over the course of treatment) in the context of the patient’s characteristics and preferences to deliver services that have the highest probability of achieving the goals of therapy." *
"Clinical expertise encompasses a number of competencies that promote positive therapeutic outcomes. These include (a) assessment, diagnostic judgment, systematic case formulation, and treatment planning; (b) clinical decision making, treatment implementation, and monitoring of patient progress; (c) interpersonal expertise; (d) continual self-reflection and acquisition of skills; (e) appropriate evaluation and use of research evidence in both basic and applied psychological science; (f) understanding the influence of individual and cultural differences on treatment; (g) seeking available resources (e.g., consultation, adjunctive or alternative services) as needed; and (h) having a cogent rationale for clinical strategies." *
"Normative data on “what works for whom” (Nathan & Gorman, 2002; Roth & Fonagy, 2004) provide essential guides to effective practice. Nevertheless, psychological services are most likely to be effective when they are responsive to the patient’s specific problems, strengths, personality, sociocultural context, and preferences (Norcross, 2002)." *
It would seem appropriate at this point to address two issues of contention briefly and later discuss further. The first issue raises the question as, "Can the Diagnostic Statistical Manual (DSM V) be trusted completely as a neutral, unbiased source of what is deemed to be a mental health disorder without being influenced by politics, agendas etc?"
The second issue raises the question, "Are theoretical approaches that are recommended as (EBP) models for the treatment of PTSD the only effective research based models of treatment?" We can't assume that interventions that have not yet been studied in controlled trials are ineffective. They may be simply untested to date to meet the requirements as an EBP. In addition, "Are the decisions as to what theoretical approach to treating PTSD is deemed an (EBP) and what is not, influenced by outside issues such as government, politics, agendas etc.?" As a result, "Are there models of treatment outside of those recommended, that may be more effective and beneficial for clients?"
Lastly, as a component of Clinical Expertise, interpersonal expertise we know has a great impact on the effectiveness of a treatment.
"This is an excellent review of meta-analyses of studies on psychotherapeutic efficacy. While very rich in information, one item of particular note is the clear finding that "there is only modest evidence to suggest the superiority of one school or technique over another" (p. 161). The authors suggest several alternative explanations for the "general finding of no-difference", including 1) different therapies can achieve similar goals through different processes, 2) different outcomes do occur but are not detected by past research strategies, and 3) different therapies embody common factors that are curative although not emphasized by the theory of change central to a particular school (p. 161). Unfortunately, current evidence does not permit these explanations (or some other) to be distinguished. Of particular interest to the person-centred approach is the observation that "Reviewers are virtually unanimous in their opinion that the therapist-patient relationship is critical; however, they point out that research support for this position is more ambiguous than once thought" (pp. 164-65). Finally, the authors' observations about the importance of individual therapist quality are notable; in several studies and meta-analyses, individual therapist effects accounted for a very large portion of outcome variance -- in other words, the abilities of individual therapists turned out to be more important than most other factors (including their theoretical orientation). While the evidence remains too thin on the ground to draw strong conclusions directly from the data, it is not at all far-fetched to say there is little to suggest that particular therapies are more effective, only that particular therapists are more effective."
Asay and Lambert later expand what they learned from studies in the bookThe Heart and Soul of Change: What Works in Therapy edited by Mark A. Hubble, Barry L. Duncan, Scott D. Miller, 1999. Their findings suggest that the therapeutic relationship is a greater determining factor of client change than in a particular type of theory or techniques.
40%: client and extratherapeutic factors (such as ego strength, social support, etc.
30%: therapeutic relationship (such as empathy, warmth, and encouragement of risk-taking)
15%: expectancy and placebo effects
15%: techniques unique to specific therapies
As a result, Scott Miller is a strong proponent of Feedback Informed Treatment. You can read more about this at his website here. www.scottdmiller.com
As therapists treating abortion related trauma, the previous mentioned issues above will need to be taken into account also as evidenced based practice models of treatment are developed.
In order to effectively treat abortion related trauma, or Post Traumatic Stress Disorder (PTSD) as a result of abortion related trauma, it would make sense that a good starting point would be to review what evidenced based practice models are recommended for PTSD in general. It would also make sense then that the treatment of abortion related trauma would need to follow these same evidenced based practice models in order for clients to receive effective treatment. In addition to EBP models of treatment for individual trauma, EBT models of treatment for couples who have experienced trauma will also be considered. The models also need to take into account as an example, how gender or culture differences might impact the most effective theoretical model of treatment.
The International Society for Traumatic Stress Studies (ISTSS) has issued PTSD guidelines based on a grading system from "A" to "E". The guidelines confirm the recommendations of other organizations such as the U.S. Department of Veteran Affairs, the Department of Defense, and the American Psychiatric Association. The type of EBT treatment and theoretical approaches that made the A list for the treatment of PTSD include the following:
Prolonged-exposure therapy, developed for use in PTSD by Keane, University of Pennsylvania psychologist Edna Foa, PhD, and Emory University psychologist Barbara O. Rothbaum, PhD. In this type of treatment, a therapist guides the client to recall traumatic memories in a controlled fashion so that clients eventually regain mastery of their thoughts and feelings around the incident. While exposing people to the very events that caused their trauma may seem counterintuitive, Rothbaum emphasizes that it's done in a gradual, controlled and repeated manner, until the person can evaluate their circumstances realistically and understand they can safely return to the activities in their current lives that they had been avoiding. Drawing from PTSD best practices, the APA-initiated Center for Deployment Psychology includes exposure therapy in the training of psychologists and other health professionals who are or will be treating returning Iraq and Afghanistan service personnel.
Cognitive-processing therapy, a form of cognitive behavioral therapy, or CBT, developed by Boston University psychologist Patricia A. Resick, PhD, director of the women's health sciences division of the National Center for PTSD, to treat rape victims and later applied to PTSD. This treatment includes an exposure component but places greater emphasis on cognitive strategies to help people alter erroneous thinking that has emerged because of the event. Practitioners may work with clients on false beliefs that the world is no longer safe, for example, or that they are incompetent because they have "let" a terrible event happen to them.
Stress-inoculation training, another form of CBT, where practitioners teach clients techniques to manage and reduce anxiety, such as breathing, muscle relaxation and positive self-talk.
Other forms of cognitive therapy, including cognitive restructuring and cognitive therapy.
Eye-movement desensitization and reprocessing, or EMDR, where the therapist guides clients to make eye movements or follow hand taps, for instance, at the same time they are recounting traumatic events. It's not clear how EMDR works, and, for that reason, it's somewhat controversial, though the therapy is supported by research, notes Dartmouth University psychologist Paula P. Schnurr, PhD, deputy executive director of the National Center for PTSD.
Medications, specifically selective serotonin reuptake inhibitors. Two in particular-paroxetine (Paxil) and sertaline (Zoloft)-have been approved by the Food and Drug Administration for use in PTSD. Other medications may be useful in treating PTSD as well, particularly when the person has additional disorders such as depression, anxiety or psychosis, the guidelines note.
It's again important to remember in looking at these theoretical models that are listed in the "A" category, the aforementioned issues. As a result, it doesn't mean that they will be the only ones useful in developing evidenced based treatment models for abortion related trauma.
We are also supportive of the model of Trauma Informed Care and need to have trauma informed approaches. www.traumainformedcareproject.org/resources/SAMHSA%20TIC.pdf As therapists treating clients with abortion related trauma, we understand that clients who present with an abortion in their history may also be dealing with other traumas in their history either as an adult or a child. We need to be sensitive to this with our clients and use clinical expertise to work with the appropriate trauma at the right time. We also understand that many clients will present in counseling for other reasons such as behavioral manifestations of past trauma. We need to respect the client and not impose any therapist agenda, as to when they are willing or ready to address any particular trauma in their history, including abortion related trauma. We also need to be not only mindful of the timing of addressing a particular trauma but also use clinical expertise in what needs to happen first based on a thorough assessment such as working with client stabilization, existing addictions, or co morbid disorders or symptoms, as a few examples.
The Adverse Childhood Experiences (ACE) study conducted by the Centers for Disease Control and Prevention and Kaiser Permanente is one of the largest investigations ever conducted to assess associations between childhood maltreatment and later-life health and well-being. Almost two-thirds of the study participants reported at least one adverse childhood experience of physical or sexual abuse, neglect, or family dysfunction, and more than one of five reported three or more such experiences.
“Trauma-informed approaches suggests clinicians, organizations and whole systems of care are in an active and reflective process of engaging consumers with histories of trauma. Trauma-informed transcends the isolated, “in session,” application of specific clinical interventions that are designed to “treat” the symptoms and sequelae of trauma.
Rather, trauma–informed care implies individual and collective systems recognize that trauma can have broad and penetrating effects on a client’s personhood. These effects can range from sensory sensitivities, (to harsh noise, light for example) stemming from a sensitized nervous system, to more existential challenges, like distrust of others, despair, a damaged sense self or powerlessness.
In the active acknowledgment of these broad and varied effects, clinicians, organizations and systems of care actively work to cultivate physical environments that are healing and soothing. Also, we are working to create a “behavioral environment,” where staff (clinical and non-clinical) convey dignity, respect, hopefulness, the opportunity for choices and empowerment among consumers. This seems to be a never ending, ongoing process, involving exchange and dialogue with those we serve.”
-Bharati Acharya, MA, LPCC, Diplomat Narrative Therapy, Trauma Informed Therapist/Mental Health Professional
As therapists treating abortion related trauma, we are very supportive of a systemic approach to both assessment and treatment. Sprenkle, Davis & Lebow, (2009) identify common factors in working with couples. They include: 1. Conceptualizing difficulties in relational terms 2. Disrupting dysfunctional relational patterns 3. Expanding the direct treatment system 4. Expanding the therapeutic alliance.http://www.aamft.org/handouts/202.pdf
It would be important to discuss here evidenced based practice models that have been developed in the treatment of couples, especially where there has been trauma in either the individuals or the couple history. It would make sense that abortion related trauma happened in a system of interaction, then as a result, healing would happen in a system of interaction or there would be a risk of retraumatization of various kinds within that couple system.
Note: There has not been as many studies and research with couples because of the factor that it is not listed in the DSM, thus not a priority.
Emotionally Focused Therapy (EFT)
"Emotionally Focused Therapy for Couples is the fastest growing evidenced-based approach to treating relational distress in couples in the world. Developed by Dr. Sue Johnson, EFT provides a well researched road map for helping couples grow closer and resolve relational problems. The model is based on the science of emotions, attachment theory, humanistic psychology and family systems theory. EFT helps couples move from distress in their relationship to a safer, more fulfilling relationship."
Emotionally Focused Therapy with it's roots in attachment theory appears to be one of the most effective theoretical approaches in working with couples where trauma is present in either of the individual's history or in their relationship history. One of the first keys of working with couples who present in counseling with abortion related trauma is to make sure that they are not currently in a cycle of trauma in their patterns of interaction and communication. It would make no sense to begin working with any trauma issue prior to stabilizing the couple's interactive relationship or the risk would be to create more trauma. Susan Johnson provides a wonderful framework for working with couples who have trauma in their history in the book Emotionally Focused Couple Therapy with Trauma Survivors: Strengthening Attachment Bonds.
Integrative Behavioral Couple's Therapy
"Integrative behavioral couple therapy (IBCT) is an empirically validated approach that integrates the twin goals of acceptance and change as positive outcomes for couples in therapy. Using a variety of treatment strategies in a consistent behavioral theoretical framework, IBCT's key features include emphases on case formulation, emotional acceptance as a basis for concrete change, and evocative rather than prescriptive interventions.
IBCT is keenly focused on the emotional underpinnings of a couple's problems as the therapist offers a conceptualization of the problem from an IBCT perspective and engages in a variety of strategies to promote greater emotional acceptance as well as concrete change."
"Based on over 30 years of basic science and outcome research in the field of marital health and success, including many studies conducted at the University of Denver and funded by the National Institute of Mental Health or the Eunice Kennedy Shriver National Institute of Child Health and Human Development (in the form of various grants awarded to Dr. Howard Markman, Dr. Scott Stanley, Dr. Galena Rhoades, and their colleagues –funding does not imply endorsement)."
As therapists working with clients who present with abortion related trauma, it will be important to consider these treatment modalities as an adjunct to evidenced based treatments used in providing the best care for our clients. Yoga Meditation Mindfulness Acupuncture Chiropractor and Spinal Manipulation Massage Aerobic Exercise Energy Therapies such as Emotional Freedom Technique Spirituality Music Pulsed Electric Magnetic Therapy Hyperbaric Chamber Amino Acid Supplementation, Neurotransmitter Testing, vs Standard Prescription Medicine Naturopathy, Diet, Herbal and Vitamin Supplementation Dance, Movement and Expressive Therapies Such as Art Somatic Therapy and the Body Spec Scan and the Technology to Study and Assess the Brain Bio and Neurofeedback Brain Wave Optimization Cranial Electro Therapy Stimulation Device such as the Fisher Wallace Simu
"Broadly conceptualized, the term “complementary and alternative medicine” (CAM) refers to treatments not considered to be standard to the current practice of Western medicine. “Complementary” refers to the use of these techniques in combination with conventional approaches, whereas “alternative” refers to their use in lieu of conventional practices."
"The National Center for Complementary and Alternative Medicine (NCCAM) has proposed a five-category classification system for CAM therapies: 1) natural products (e.g., herbal dietary supplements); 2) mind-body medicine (e.g., meditation, acupuncture, yoga); 3) manipulative and body-based practices (e.g., massage, spinal manipulation); 4) other alternative practices (e.g., movement therapies, energy therapies); and 5) whole medicine systems (e.g., traditional Chinese medicine, Ayurvedic medicine)."
Some recent research compared the rates of PTSD in those that survived both 911 and Katrina, What they found was very surprising. The survivors of 911 only reported a 5% rate of PTSD and those that survived Katrina later suffered PTSD at a rate of 33%. Dr. Bessel van der Kolk, an expert on trauma, reports that the difference was that those that survived 911 were allowed to act on their "fight or flight" response and many who survived Katrina were taken from their homes and trapped inside transport planes etc. They were not able to allow their body to act on that same response. What this research points out is that PTSD rates tend to be higher when the body is not allowed to discharge and act on it's natural response to "fight or flight". Dr. Kolk also points out that the victims of 911 ran toward their homes and to be with their loved ones at home for support and many of those that experienced Katrina were not able to do so. This speaks the the beneficial factor of family support directly after trauma.
What does this research mean for men and women who have just returned from an abortion clinic? It could mean that PTSD rates may be lower if they are able to both act on their fight or flight response and also receive family support versus staying alone in secrecy.
This lines up with the work of Somatic Experiencing that was developed by which is a body based approach to healing trauma developed by Dr. Peter Levine.
"Mindsight is a kind of focused attention that allows us to see the internal workings of our own minds. It helps us get ourselves off of the autopilot of ingrained behaviors and habitual responses. It lets us “name and tame” the emotions we are experiencing, rather than being overwhelmed by them."
He also pioneered the term "Interpersonal Neurobiology". This field of study looks at how the brain has neuroplasticity and can heal itself through integration. The exciting part is in working with relationships where one or both people may have attachment trauma in their past. Through the work of Interpersonal Neurobiology, couples can heal and integrate their brains on an attachment level by replicating what they each should have received from their parents at a young age. This may include mirroring, validating etc.
As therapists working with abortion related trauma, the concepts of Mindsight can help clients heal their brains from being in a reactive state of anxiety to a state of awareness and reflection.
Interpersonal Neurobiology is one of the most exciting theoretical approaches to use as therapists treating abortion related trauma. Prior to an abortion decison, many clients will have had attachment trauma in their past, and struggle with the lack of integration of their brain. As a result, they may lack the ability to regulate emotions, express empathy, may be impulsive etc. Additional attachment trauma happens after an abortion decision. The attachment trauma between the two people can lead to a confirmation of early attachment wounds and belief systems such as "Am I lovable?" and "Can I trust you to be there for me?" The last attachment trauma happens with the loss of the child they could have had.
In working with couples who have had an abortion in their history either with their partner or someone else, the concepts of Interpersonal Neurobiology can be very powerful in treating those couples in counseling. Abortion related trauma happens in the context of a relationship and has a great impact at the attachment level, which is often rooted in the unconscious from childhood. As therapists we can help these couples break the cycle of trauma through techniques such as those from Emotionally Focused Therapy but also through the use of techniques from Interpersonal Neurobiology. We can help couples heal and integrate their brains together, not only from the attachment trauma that happen between them after the abortion decision, but also from earlier attachment trauma they may have experienced in their life. In doing this, there is a great hope that the relationship can survive despite the trauma.
As therapists working with clients who present with abortion related trauma, it would be wise for us to consider as an adjunct to talk based therapies, these complimentary and alternative approaches.