Author Archives: Lauren Rich

The Disservice of Trauma Treatment

Dear Veteran, Thank you for taking the time to revisit the notion of trauma treatment and for your continued understanding as the field continues to develop better treatments as well as better providers. I strive each and every day to make the best choices regarding your care, and I will continue to do so learning from each mistake I have made along the way.


My instruction for trauma-focused work was very limited in the beginning of my career, as I suspect it is for most clinicians. I had basic skills of Cognitive Behavioral Therapy and Solution-Focused Therapy, but limited education regarding the impact trauma on our bodies. Initially, my training came from an “Evidence Based Practice” called Prolonged Exposure, an intensive and excruciating treatment that seemed to offer benefits dependent on the type of trauma endured. I was ill-prepared for trauma work, largely having a background working with the chronically/severely mentally ill Veteran population. Our daily tasks focused much more on maintenance and case management services.

My initial training for the treatment of PTSD was called Prolonged Exposure. PE focused mostly on cognitive distortions and the general reduction of diagnostic symptoms. Distortions are better explained as those thoughts, beliefs, opinions, and attitudes of the world that are irrational, illogical or somehow harmful to ourselves. These distortions may be thoughts such as, “I am weak. I am unlovable. I am a failure.” The PE approach toward resolution involves choosing one trauma the client felt was the most bothersome or upsetting. How is a client to choose only one trauma if they’ve experienced three deployments, multiple suicides, and the death of a child? PE advertises treating the most complex event first in hopes the other incidents will resolve themselves. Looking back, I could never choose between the devastating loss of my best friend in combat versus losing my two-year-old to heart failure. If I cannot accomplish this how can my Veterans?  PE requires the Veteran to revisit the event in chronological order, taking note of sights, sounds, tactile and physical sensations for weeks at a time. For most Veterans this is an excruciating process. While desensitizing is a large part of the treatment, I found Veterans were returning to my office within a few months to a year with no long-term resolution. If the PE curriculum was a success, they had no issues with the trauma we targeted but this was only the case for one Veteran I had treated. If there were multiple traumas, the others became problematic and the physical sensations of anxiety, anger, and fear remained constant and unwavering even after we had concluded the PE sessions.

It was not until two years later that I began learning more about trauma and the physiological impact that remains so strong. This concept was discussed in an EMDR (Eye Movement Desensitization Reprocessing) training, and challenged the concepts of dealing with trauma through our cognitions. Instead the EMDR is much more emotion based and sensation oriented. What does this actually mean? It means I had been continually failing my beloved Veterans week after week. Such a disservice I had unknowingly inflicted, as we had not addressed hardly any of the emotions or sensations that accompanied trauma. The sensations I had addressed in PE were shallow at best, only discussing what the “gravel beneath your feet” felt or sounded like. I realized that the present-day sensations were far more ingrained than I previously thought. The anxiety was being experienced through nausea, stomach cramps, panic attacks, passing out or profuse sweating. I had not discussed these issues in Prolonged Exposure. How could I possibly have expected long-term benefit when all I had dealt with was the frontal lobe of rationalizing trauma? The real “trauma” was being aggressively rekindled in each Veteran’s limbic system or emotional brain every single day. As time passed, I began learning more about The Polyvagal Theory proposed by Steven Porges, and realized that my Veterans were having greater success if I focused on the sensations of past trauma coupled with present day life, not cognitions as I had once thought.

As a result of what I consider to be a personal and professional failure, I now approach trauma very differently focusing on present-day sensations and disturbances Veterans experience as a result of the fight/flight/freeze response being initiated. I have had substantially lower drop-out rates, notably improved responses from Veterans, and genuinely happier more secure Veterans leaving my office each week.

My sincerest and most heartfelt apologies to those who agonized through weeks of Prolonged Exposure with no benefit. Undoubtedly, I think of you each day in hopes that you return for a reconciliation of the past, as we work to provide better outcomes for your future.

V/r,

Lauren Rich

ATSA Annual Conference 2018

Re-posted with permission

By Kieran McCartan, PhD, David Prescott,LICSW, & Alissa Ackerman, PhD
The annual ATSA conference took place from the 17
th – 20th October in Vancouver.The conference was a real mix of research, practice and engagement with international colleagues from 16 different countries including the USA, Canada,UK,  Australia, New Zealand, Sweden,Germany, Hong Kong, Netherlands, Belgium and Israel to name a few. In this blog we are going to take you on a whistle stop tour of the event. For Kieran, the highlight of the conference was Ruth Mann’s opening plenary in which she discussed the challenges of developing an evidence base. Ruth’s presentation focused on what the risk, consequences and impact of being evidence based are in the real world, and more specifically in a public arena; especially if the evidence base negates your current working practices. Ruth discussed the recent changes to sex offender treatment in the UK and the government evaluation which initiated these changes (i.e., it indicated that previous programs had no impact or made people slightly worse,rather than better); reflecting upon the personal, political and policy fallouts.Ruth discussed the content of the report, her reflections of the impact of the report on systems as well as institutions, and report’s consequences for the management/treatment of people who have committed sexual abuse.

 In closing, she reminded us that if we are to be truly evidenced based we have to be open to all forms and outcomes of evidence, even the evidence that indicates that what we are doing may not be best practice or achieving what we want it to achieve. To Kieran, this set the tone of the conference as ATSA has always been about sharing good practice and reflecting upon problematic practice.   The engagement event at the 2018 ATSA conference was based around bystander intervention and had colleagues from Simon Frasier University (Ashley Bentley) and community action groups (Katheren Szabo) talking about the work that they were doing to prevent sexual abuse. The fact that the speakers were coming from different parts of the community, used different approaches and engaged in different activities (from campus sit in’s, to poetry readings and gardening clubs) really indicated the range of activities and novel ways that we can engage different “communities”around sexual abuse prevention in ways that are meaningful to them. The engagement event this year was targeted at people involved in professions at the front line of safeguarding and community participant (i.e., teachers, volunteers,community workers, etc) and this resulted in some interesting and practical debates.  

The international round table this year had a series of 8 minute talks from 9different speakers, each from a different country, on public/media attitudes to sexual abuse in their country and how professionals are engaging in the debate.This was interesting as there were a lot of common themes across countries(i.e., “not in my backyard”, negative media stories and good/bad examples of professional and policy maker engagement) as well as some distinctive good practices in certain countries that we could all learn from internationally.The round table really cements ATSA as an international conference! The entire conference was a high point of the year for David. Although pinpointing specific moments is next to impossible,three come immediately to mind: First, I had the privilege of moderating a symposium with Tony Ward, Gwen Willis, and Jeffersonian. Tony and Roxie discussed many of their recent projects which involve looking at the processes underlying risk and protective factors. A down side to having so much research available to us regarding these factors is the temptation to reify them as discrete factors rather than viewing them as proxies for underlying processes which will be different for each person.Although on its own this is not a new idea, Ward and Fernandina have explored this in very great detail in their risk-causality method. For Tony and Roxie,this method provides a new level of explanatory depth to our knowledge of risk and protective factors. For Gwen and David, it provides rich areas of clinical understanding.  Second, Laurie Rose Kepros delivered a fascinating workshop describing the effects of experiences within the legal system on people convicted of sex crimes. Titled the process is the punishment, she explored how elements of these experiences can actually have a detrimental effect on engagement in rehabilitation efforts (e.g., engagement in treatment and with supervising agents). This is clearly a situation involving multiple perspectives. On one hand, the US Supreme Court has been clear that law enforcement officials can use deception as a part of the investigative process.On the other hand, this same deception can be devastating to others’ attempts to engage meaningfully with these people after their conviction, particularly when they view professionals as agents of the police power of the state. As one might imagine, the subsequent discussion was lively, with advocates of each perspective describing points for consideration. 

Finally, Michaelmas delivered a moving speech as he accepted this year’s Lifetime Significant Achievement award. With his father and brother on stage, he described the important contributions of immigrants to the cultures who receive them.Originally from Hong Kong, Seto is a clear example of why this is so.  For Alissa, the Vancouver ATSA conference was among the best she has ever attended. Along with Pantechnicon and Cordelia Anderson, Alissa co-led a pre-conference seminar titled Accountability and Responsibility in the Era of #MeToo. We quickly learned that this is an important issue that many clinicians are currently grappling with. The presenters lead participants in pseudo-restorative justice circles, which provided opportunities to experience the power of authentic human connection. By embracing and honoring a common humanity, clinicians and restorative justice practitioners can create safe spaces for those who have sexually violated others and those who have experienced sexual abuse to find common ground and healing.  Perhaps the best example of this was articulated by our Friday morning plenary speaker, Gerry Oleman, a First Nations man who has been involved in creating change for First Nations communities since the 1970s. Gerry spoke about the importance of connecting to language, to nature, and to each other. He spoke about the atrocities committed by colonizers, including the rape of First Nations people,the forced enrollment of indigenous children in residential schools, and the violent removal of indigenous people from their land onto reservations. Gerry spoke about the importance of healing, not allowing the pain, anger, and violence, stay on his heart. It was a lesson that everyone in attendance was privileged to hear.  One of the primary benefits of being an ATSA member and attending the annual conference is the opportunity to connect with friends, colleagues, and collaborators from around the world. This was true for Kieran, David, and Alissa who had the chance to present on a panel with Danielle Harris, Jill Levenson, and Gwenda Willis.On Friday afternoon, we presented a panel titled Are We Listening: Valuing All Individuals Impacted by Sexual Victimization. We were each given ten minutes to present on one of the specific voices impacted by sexual victimization. None of us knew what to expect with this unique format, but the feedback we received from audience members reminded each of us about the passion inherent in our individual work that we then bring to the table when we work as a team. After all, we are all better together.  The primary take-away from these conference experiences for all three of us was the importance of working together towards common goals… “Better Together”, the conference theme, appropriately described it. In the end, we are all at our best when we can discuss the issues of the day, acknowledge differences, come together to establish new ideas and goals,and make them happen; next year it’s Atlanta, Georgia!!

Paying the Price of Self-Neglect

It’s not news to anyone in the field of law that being a practicing attorney comes with a cost. The end of the year means closing out files, invoicing, beginning taxes, and celebrating holidays with loved ones. Ironically, the holidays are one of the busiest times in mental health, which is surprising considering the amount of travel, shopping, and family gatherings. With the snow storm of demands many well-educated professionals look to alcohol or prescription medications for answers.

The ABA Midyear Review revealed its survey numbers at their bi-annual conference in February, an astounding twenty-one percent of attorneys endorsed habits consistent with problem drinkers, more than double the rate of other working professionals. At times alcohol can be part of the job when closing a deal with a client, happy hour after a brutal day of litigation, or even the office Christmas Party. The survey went on to identify twenty-eight percent of attorneys suffering from depression and nineteen percent from anxiety. In comparison, the percentage of Americans with an alcohol problem averages six to seven percent. The holidays can be especially stressful regardless of relationship status. The obligatory visits to five different houses on Christmas Eve would exhaust a normal human being. Humorously, the Clark Griswold in each of us thinks it’s a good idea to host the Christmas dinner, resulting in three days of seclusion in the garage sipping peppermint Schnapps.

During a recent holiday business lunch, the hiring attorney passively disclosed he drank before going to bed. For a few moments I listened and waited for the rest of what I knew would be coming. The young, overworked, highly stressed, heavy set attorney stated, “I only drink to fall asleep.” I sat astounded at what I just heard. How could such an educated man not know that alcohol disrupts the sleep cycle? I took the time to gently provide psychoeducation regarding alcohol and the negative effects it has on a person’s REM sleep. To wit he responded, “So you’re telling me I should drink in the mornings?” I smiled and raised my sweet tea to what he considered his weekly dose of therapy and sarcastically responded, “I’ll drink to that.”

Attorneys face varying amounts of stress in their professional lives that seem to manifest in different forms. If it’s not anxiety from trials or mergers, it may be the nervousness you face coming home to a family that expects you to provide and be emotionally present in spite of your eighty-hour work week. Attorneys work tirelessly to advocate for clients whom they represent, and the gratitude and appreciation motivate most to continue their work despite the doggedness of long days and exhausted lives. But at what cost?

An alcohol or drug addiction presents differently for each person. Many will suffer natural consequences such as car accidents, DUIs, loss of relationships, or poor work performance. Others may come to rely on alcohol or medications to calm their nerves, cope with upsetting cases, or suppress emotions that illicit discomfort. Some may climb their way out of the bottle only to be lost in the dark web of violent pornography and sexual addiction. Many clients report somatic symptoms such as headaches, stomach problems, bowel issues, and stress induced vomiting. Most clients notice a lack of desire to do things they once enjoyed, a need to isolate themselves from others, and anxiety attacks that appear at the worst possible moments.

Professionals report their time is the company’s most precious asset, so how could we give up such an asset to seek help or address these problems? The real question is: what will the company lose and what will the individual sacrifice by not seeking help? Simply put, the cost of treatment should outweigh the financial loss of losing a license. The ninety minutes per week spent in therapy will preserve the limited emotional resources each attorney possess and can be utilized for more pressing issues such as caring for sick or elderly parents. Seeking guidance isn’t complicated. The best way to find a quality mental health provider is by asking those trusted friends and family about who they know. Calling a provider’s office for a five-minute interview of what they specialize in, what type of licensure they possess, and the fees associated with services is also a good start. If individual therapy is not an option support groups such as Alcoholics Anonymous or Sex Addicts Anonymous can be offered in face to face, online, or teleconference settings. Do not seek help from individuals who are unlicensed or do not specialize in the area of treatment you are seeking. Ask for references or consult search engines for client testimonials and any licensure complaints, keeping in mind that some reviewers may be clients who were not ready to seek treatment or hear the truth about their situation.