Orientation to trauma informed practice with men who have been sexually abused in childhood: Introduction to Three Phase Trauma Framework

Distinction between trauma informed practice and trauma specific services

In providing an overview of developing principles and elements that support trauma informed practice with men who have been sexually abused, a distinction is made between general trauma informed practice and trauma specific service that provides specialist therapeutic counselling and support to address impacts and enhance personal and relational well-being.

Quaderia and Hunter (2016, p. 5) differentiate between the application of general 'trauma informed care principles' within community, mental health recovery and social services (drug and alcohol, homelessness, mental health services etc.) and the work of 'trauma-specific services', where practitioners are engaged with clients in directly addressing trauma and its impacts.
The Blue Knot Foundation Practice Guidelines for Treatment of Complex Trauma and Trauma Informed Care and Service Delivery (2012) articulate a distinction between the broader "Practice Guidelines for Trauma-Informed Care and Service Delivery (Organisational)" and more specific "Practice Guidelines for Treatment of Complex Trauma (Clinical)".
Phoenix Australia ‘Guidelines for the Treatment of Acute Stress Disorder and Posttraumatic Stress Disorder’, are oriented to trauma specific service provision, utilising a ‘treatment’ model and state “In cases of complex PTSD, expert opinion suggests a sequential treatment approach, with the use of multiple interventions targeting the most prominent symptoms. Following an initial period of stabilisation and ensuring patient safety, providing education about trauma, narration of the trauma memory, cognitive restructuring, and emotion regulation interventions are viewed as effective first-line interventions for complex PTSD.” (Phoenix 2013:161)

As outlined in the introduction to this module, Trauma Informed Practice is seen as complimenting and providing a foundational base for Trauma Specific Service, utilising the Three Phase Trauma Framework. The collection of practice principles, considerations and orienting frameworks that make up Trauma Informed Practice provide the foundations for Phase I: Engagement, Safety and Stability of the Three Phase Trauma Framework. Practitioners working in community, drug and alcohol, homelessness, mental health, correctional services, etc. are encouraged to familiarise themselves with the Three Phase Trauma Framework in order to best support men who have been sexually abused in childhood.

To support knowledge development in working to address complex trauma, practitioners are encouraged to familiarise themselves with the Blue Knot Foundation Practice Guidelines for Treatment of Complex Trauma (Practice Guidelines) and accompanying online training resources/video.

Three Phase Trauma Framework

Phase I: Safety, Stabilisation and Engagement.
Phase II Processing of Traumatic Memories and Meaning Making for Self.
Phase III: Developing sense of personal and relational integrity and well-being. Integration – reintegration.

Presented below is an outline of the Three Phase Trauma Framework (Herman 2001; Courtois & Ford, 2008; Courtois & Ford, 2013). Blue Knot identify the Three Phase Trauma Framework as the "gold standard" of therapeutic practice to address complex trauma (Blue Knot, 2012). Whilst the framework suggests a hierarchical, lineal structure, the non-linear nature of trauma and recovery is recognised, with the understanding that individuals and therapeutic practice will constantly move through and between phases.

Phase I: Safety, Stabilisation and Engagement

Emphasis on engaging and developing a working alliance with the person.
Enhancing sense of self and relational capacities.
Psycho education in relation to the tactics, dynamics, common impacts and difficulties relating to being sexually abused as children.
Developing knowledge and understanding of the impacts of trauma.
Expanding repertoire of strategies for managing overwhelming thoughts and emotions, memories. Plus ensuring access to basic material resources, secure accommodation, food).
Developing tools and strategies for approaching and mastering internal bodily/affective states and external events that trigger intrusive re-experiencing, emotional numbing or disassociation (Courtois & Ford, 2009).

The aim of this phase is to engage and empower the client, and to build their internal and external resources and supports. It involves establishing a therapeutic alliance, taking time to get to know the person and develop an understanding of their current life context and relationships. The emphasis is on developing a 'safe enough' environment, physically and psychologically, for the man to name and address trauma-reactions (whilst recognising how difficult 'trust' and 'being vulnerable' can be). It is about supporting the person to develop the knowledge and skills to better manage heightened arousal, and master rather than avoid internal bodily/affective states. This will involve a degree of 'psycho-education' regarding the impacts of trauma, as well as common and effective coping mechanisms.

Phase I involves working with the man to undertake a 'stock take' (assessment) of current difficulties, and to provide him with practical support in addressing trauma-related reactions such as nightmares, flashbacks, triggers, overwhelming emotions, relationship difficulties. It also can involve practitioner's becoming proactive in providing case management support and advocacy to assist victim/survivors to access accommodation, financial welfare and health services. This is where trauma informed practitioners (including those in drug and alcohol, mental health, homelessness services) have a key role to play in helping to develop a solid base.

Possibly because initial work on establishing a safe and 'secure base' involves limited discussion of traumatic events, some practitioners and clients can believe this work is peripheral to the 'real work'. Some people may want to 'fast forward' to 'telling' and processing, working under the belief that this telling will in and of itself provide relief. As will be discussed, the trauma-informed counsellor must be prepared to step in to slow things down and ensure conversations are safe and supportive in the long term. Sometimes an early and rushed disclosure can be triggering, increase distress, amplify a person's sense of shame and produce regret.

The knowledge, understanding, skill and relationship development of Phase I is a necessary prerequisite before moving towards Phase II.

Phase II Processing of Traumatic Memories and Meaning Making for Self

Focus on cognitively and emotionally processing the experience of sexual abuse.
Meaning making for self in the present.
Examining questions of responsibility, shame, guilt, grief and loss and addressing self blame.
Support in developing a coherent autobiographical narrative.
Maintenance of established life style and relationships (Courtois & Ford, 2009).

Where therapeutic focus in Phase I is focused on engaging and resourcing the client with skills to provide safety and stability, Phase II aims to assist the individual to gain increased awareness and mastery over the traumatic impacts, and to review the meaning made of the sexual abuse. The focus of this phase is to purposefully draw attention toward traumatic memories and the associated states of physiological arousal and emotional distress to increase a sense of control over the trauma and to move towards a shift, whereby the trauma memories operate within a 'past tense' rather than an ongoing intrusive present tense. Meaning making is significant in that it offers an opportunity 'to reappraise cognitive and emotional reactions to abuse that undermine wellbeing in order to construct more adaptive meanings' (Simon, Feiring & Kobielski McElroy, 2010).

It is useful to note that Phase II, when working with survivors of childhood sexual abuse, is slightly different from Phase II 'Remembrance and Mourning' of the framework as articulated by Herman (2004). For many people sexually abused in childhood, the processing and meaning making goes beyond remembrance and mourning, as the abuse occurred at a time when the sense of self was becoming established and for many there is no established sense of self separate from or life 'before' the sexual abuse.

Phase III: Developing sense of personal and relational integrity and well-being. Integration – reintegration.

Enhancing emotional literacy and emotionally engaged living.
Building connection with self and others.
Addressing injustice and relational impacts of abuse.
Developing range of trusting, respectful, caring relationships (partner, parent, friend).
Nurturing. Closeness and intimacy and satisfying sexual life.
Possessing a clearly articulated sense of self, with purpose (Courtois and Ford, 2009).

The focus on Phase III is on integrating and consolidating the skills, knowledge, increased self-awareness and meaning made and to enhance personal and relational well-being. The trauma informed framework, as it applies to childhood sexual abuse, does not seek to 'return to' a state and sense of self prior to the trauma. It recognises the profound impact that sexual abuse can have on sense of self and places an emphasis on building personal and relational integrity in the present and future. This may be a person's first opportunity to pause, consider and establish a sense of self, of who he is and what he stands for that is not overshadowed by the legacy of sexual abuse.

It is within Phase III that post traumatic growth can be explored, taking time to acknowledge that whilst trauma is unwelcome, those who survive report (a) a new level of resilience, (b) additional survival skills, (c) greater self-knowledge and self-appreciation, (d) increased empathy, and (e) a broader and more complex view of life in general (Briere & Scott, 2006). It is in Phase III that the focus of work with men who have been sexually abused reaches beyond one of symptom management, towards enhancing overall quality of life.

Recovery and resilience do not reflect simply the absence of problematic symptoms, but rather a zest for life; a positive conceptualisation of one’s self; the ability to form positive, supportive, and safe relationships; and the ability to achieve a fulfilling quality of life.’ (McMackin, Newman, Fogler & Keane, 2012).

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