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Trauma-Focused, Present-Centered, Emotional Self

Trauma Focused Present Centered Emotional Self Regulation Approach to Integrated Treatment for Posttraumatic Stress and Addiction Trauma Adaptive

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	 Present-Centered
 Self-Regulatio
 Approac
 Treatmen
 fo
 Posttraumati
 an
 Addiction
 Traum
 Adaptiv
 Grou
 Educatio
 an
 Therap
 Ph.D.
 RUSSO
 Ph.D
 describe
 the
 rationale
 and
 procedures
 for
 trauma-focused,
 present-
 emotion
 self-regulation
 model
 for
 concurrent
 treatment
 of
 posttrau-
 stress
 disorder
 (PTSD)
 and
 substance
 use
 disorders:
 Trauma
 Adaptive
 Group
 Education
 and
 Therapy
 Based
 on
 review
 of
 clinical
 and
 research
 relevant
 to
 models
 of
 psychotherapy
 for
 PTSD
 and
 addiction,
 we
 develop
 conceptual
 model
 and
 skill
 that
 has
 been
 operationalized
 in
 Clinical
 with
 challenging
 cases
 are
 provided
 to
 illustrate
 the
 application
 of
 model
 in
 individual
 and
 group
 psychotherapy
 of
 co-occurring
 and
 addiction.
 stres
 disorde
 (PTSD
 prevalen
 amon
 adult
 treatmen
 fo
 substanc
 us
 disorder
 (SUD
 (Triffleman
 Marmar
 Ronfeidt
 1995)
 mos
 adult
 treatmen
 ar
 neithe
 fo
 PTS
 no
 offere
 PTS
 treatmen
 despit
 voicin
 clea
 fo
 concurren
 psychotherap
 fo
 PTS
 an
 SU
 (Brow
 2003)
 Moreover
 ther
 preliminar
 evidenc
 tha
 SU
 treatmen
 an
 retentio
 (Brow
 al.
 2003
 an
 outcome
 (Palacios
 ar
 adversel
 affecte
 undetecte
 an
 untreate
 PTSD
 treatment
 hav
 bee
 develope
 fo
 PTS
 (Eoa
 Kean
 Connecticu
 Schoo
 Medicine
 ^Mailing
 Address:
 Departmen
 Psychiatry
 Universit
 Connecticu
 Healt
 Center
 26
 Farmingto
 Ave.
 Farmingto
 06030
 [email protected]
 JOURNA
 PSYCHOTHERAPY
 Vol
 60
 No
 200
 JOURNA
 PSYCHOTHERAP
 2001
 an
 fo
 addiction
 (Kadden
 1999)
 However
 psycho
 approache
 fo
 co-occurrin
 PTS
 an
 addictio
 ar
 les
 wel
 thi
 article
 wil
 describ
 th
 complicate
 interactio
 PTS
 an
 addiction
 an
 identif
 th
 primar
 objective
 fo
 PTS
 an
 addiction
 treatment
 wil
 discus
 th
 strength
 limitation
 extan
 approache
 PTS
 an
 addictio
 treatmen
 eac
 primar
 objective
 an
 the
 describ
 th
 conceptua
 mode
 skil
 se
 taugh
 ne
 treatmen
 model—Traum
 Adaptiv
 Recov
 Grou
 Educatio
 an
 Therap
 (TARGET)—i
 orde
 illustrat
 complementarit
 wit
 an
 departur
 fro
 th
 alternativ
 treat
 Finally
 wU
 provid
 clinica
 example
 illustrat
 th
 applica
 TARGET
 COMPLE
 INTERACTIO
 PTS
 AN
 SUBSTANC
 IDENTIFYIN
 TARGET
 FO
 TREATMEN
 diagnosi
 PTS
 formall
 involve
 thre
 symptom-base
 criteria
 reexperiencin
 (unwante
 traum
 memories
 reminders
 an
 avoidanc
 reminder
 pas
 traum
 an
 emotiona
 numb
 an
 hyperarousa
 an
 hypervigilanc
 (America
 Psychiatri
 Associa
 1994)
 neurobiolog
 traum
 an
 dissociatio
 (Ford
 2005
 provide
 framewor
 fo
 understandin
 th
 interpla
 thes
 symptom
 wit
 othe
 an
 wit
 addiction
 Th
 alteration
 brai
 chemical
 believe
 underli
 PTS
 ten
 simila
 to
 complementar
 with
 th
 alteration
 associate
 wit
 SUD
 includin
 th
 dysregula
 ke
 neurotransmitter
 (e.g.
 dopaijiine
 serotonin
 norepinephrine
 neuropeptide
 (e.g.
 glucocorticoids
 neuropeptid
 substanc
 body'
 centra
 (brain
 an
 periphera
 (autonomic
 nervou
 systems
 modulat
 stres
 reactivit
 (Jacobsen
 Kosten
 Southwick
 2001)
 cor
 neurobiologica
 alteratio
 PTS
 hyperarousal,
 tendenc
 th
 brai
 an
 th
 body'
 nervou
 syste
 reac
 rapid
 extreme
 prolonge
 manne
 stressors
 attemp
 modulat
 thes
 physiologica
 reactions
 th
 individua
 ofte
 draw
 upo
 adaptiv
 anticipator
 awarenes
 (e.g.
 watchfulnes
 fo
 sign
 externa
 bodil
 distress)
 hyperarousa
 persists
 th
 adaptiv
 attemp
 an
 prepar
 ma
 escalat
 int
 maladaptiv
 preoccupatio
 wit
 mil
 remot
 sign
 threa
 bodil
 distres
 {hypervigilance).
 reduc
 hyperarousa
 an
 sustai
 hypervigilance
 avoidance
 places
 activities
 thoughts
 emotions
 bod
 sensation
 associate
 threa
 distres
 tend
 occur
 Avoidanc
 associate
 wit
 sever
 Adaptiv
 Recover
 Grou
 Educatio
 an
 Therap
 (TARGET
 wit
 th
 recognitio
 an
 expressio
 emotion
 {emotional
 especiall
 emotion
 involvin
 intimacy
 vulnerability
 trus
 {social
 result
 survivor
 becom
 unabl
 proces
 integrat
 traum
 memories
 leadin
 bein
 flooded
 wit
 unwante
 {intrusive
 re-experiencing).
 Whe
 thi
 persist
 th
 bodil
 dys
 ca
 lea
 th
 perso
 fee
 traum
 happenin
 al
 ove
 {flashhacks).
 thes
 feature
 PTS
 ca
 lea
 substanc
 us
 problems
 us
 alcohol
 stree
 drugs
 an
 prescriptio
 medication
 (Ja
 al.
 2001
 Triffleman
 2002)
 Exposur
 traum
 no
 alon
 lea
 SUD
 bu
 PTS
 ma
 lea
 SU
 (o
 ma
 cooccu
 SU
 resul
 othe
 factors
 e.g.
 impulsivity
 socia
 isolation
 2003)
 Hyperarousal
 ca
 lea
 attempt
 reduc
 anxiet
 an
 throug
 self-medication
 th
 othe
 han
 th
 us
 drug
 orde
 maintai
 stat
 hig
 arousal
 Hypervigilance,
 ma
 sustaine
 th
 us
 drug
 tha
 artificiall
 increas
 th
 maintai
 aler
 watchfulness
 Psychoactiv
 substance
 ma
 reduc
 th
 distres
 associate
 wit
 intrusiv
 reexperiencin
 an
 temporar
 form
 avoidanc
 traumati
 memorie
 an
 associ
 distres
 (i.e.
 self-medication)
 Emotiona
 numbin
 an
 socia
 detach
 PTS
 ma
 lea
 th
 us
 substance
 mean
 regainin
 abilit
 fee
 pleasur
 connectio
 othe
 people
 Posttraumati
 disorde
 als
 ofte
 involve
 dysphoria
 impulsivity
 an
 socia
 isola
 eac
 whic
 ca
 lea
 SUD
 SU
 ca
 exacerbat
 complicat
 PTSD
 Substance
 tha
 depres
 th
 body'
 arousa
 leve
 an
 th
 interactiv
 effect
 neurotransmitter
 ten
 directl
 indirectl
 (e.g.
 throug
 re
 effects
 heighte
 hyperarousa
 an
 hypervigilance
 Substance
 tha
 moo
 alterin
 effect
 ca
 increas
 hypervigilance
 emotiona
 numb
 an
 socia
 detachmen
 inducin
 state
 persisten
 dysphori
 Substance
 tha
 alte
 informatio
 processin
 ca
 interfer
 wit
 workin
 memor
 an
 narrativ
 autobiographica
 memory
 thu
 unwante
 traum
 memorie
 tha
 ar
 fragmentary
 confusing
 involuntary
 Th
 lifestyl
 associate
 wit
 chroni
 SU
 ofte
 include
 activitie
 an
 involvemen
 wit
 pee
 group
 tha
 increas
 th
 exposur
 traumati
 stressor
 (e.g.
 violence
 crime
 abuse
 goal
 psychotherap
 fo
 PTS
 an
 SU
 thus
 whil
 no
 ar
 complementary
 Increasin
 th
 abilit
 replac
 impulsiv
 wit
 reflectiv
 reality-base
 decisions
 critica
 managin
 bot
 JOURNA
 PSYCHOTHERAP
 traum
 memorie
 an
 th
 craving
 fo
 substance
 an
 automati
 pattern
 tha
 sustai
 addiction
 orde
 esche
 avoidanc
 vi
 substanc
 us
 othe
 self-defeatin
 behaviors
 primar
 strategy,
 th
 individua
 mus
 hav
 skill
 tha
 enabl
 he
 modulat
 (e.g.
 hyperarousal
 intrusiv
 re-experiencing
 craving
 fo
 sub
 an
 diminishe
 (e.g.
 emotiona
 numbing
 disregar
 fo
 persona
 an
 well-being
 state
 bodil
 an
 emotiona
 activation
 Planfu
 makin
 an
 effectiv
 emotio
 regulatio
 requir
 th
 abilit
 long-ter
 memor
 dra
 upo
 pas
 learnin
 an
 short-ter
 formulat
 an
 follow-throug
 wit
 timel
 an
 organize
 choices
 APPROACHE
 FO
 PTS
 AN
 ADDICTIO
 ther
 stron
 evidenc
 bas
 suppor
 th
 us
 cognitiv
 therap
 (CBT
 fo
 treatin
 PTSD
 mos
 studie
 CB
 fo
 PTS
 exclude
 individual
 wit
 activ
 SUD
 th
 applicabilit
 thi
 th
 concurren
 treatmen
 SU
 an
 PTS
 remain
 (Fo
 al.
 2000)
 Man
 peopl
 wit
 co-occurrin
 SU
 an
 PTS
 suffere
 victimizatio
 traum
 childhoo
 wel
 adulthoo
 al.
 1995)
 Treatmen
 fo
 PTS
 resultin
 fro
 chil
 abus
 require
 attentio
 basi
 self-regulator
 deficit
 (Herman
 1992)
 Tarrie
 al
 (1999
 exclude
 CS
 survivor
 fro
 thei
 stud
 an
 cognitiv
 restructurin
 becaus
 concer
 tha
 thes
 treat
 woul
 no
 addres
 developmenta
 sequelae
 McDonagh-Coyl
 al
 foun
 hig
 rat
 (43%
 prematur
 dropou
 fro
 exposure
 therap
 fo
 adul
 survivor
 childhoo
 sexua
 abus
 (th
 majorit
 who
 ha
 lifetim
 SU
 histories
 althoug
 non
 wer
 currentl
 usin
 bu
 lo
 drop-ou
 rat
 (5%
 fro
 supportiv
 socia
 solvin
 therapy—an
 comparabl
 efficac
 reducin
 PTSD
 whe
 adul
 survivor
 chil
 abus
 wer
 provide
 wit
 prepa
 trainin
 skill
 fo
 affec
 management
 CB
 fo
 PTS
 wa
 wel
 an
 beneficia
 (Cloitr
 al.
 2002)
 al
 (1996
 cit
 persisten
 dysfunctiona
 belief
 an
 associate
 self-car
 skill
 complicatin
 facto
 fo
 th
 survivor
 CS
 PTSD
 hig
 initia
 level
 ange
 (Foa
 Riggs
 aL
 1995)
 memorie
 "menta
 defeat
 th
 absenc
 menta
 plannin
 (Ehler
 al.
 overal
 sens
 alienatio
 permanen
 chang
 followin
 th
 (e.g.
 feelin
 permanentl
 tainte
 damage
 (Ehler
 aL
 1998)
 inabilit
 develo
 coheren
 narrativ
 recountin
 traum
 (Foa
 Molnar
 Cashman
 1995)
 th
 positiv
 side
 Adaptiv
 Recover
 Grou
 Educatio
 an
 Therap
 (TARGET
 th
 McDonagh-Coyl
 al
 (2005
 stud
 wh
 wer
 abl
 an
 modulat
 stron
 emotion
 therap
 ha
 positiv
 out
 bot
 th
 CBT
 an
 problem-solvin
 treatments
 Thu
 psychother
 mus
 addres
 longstandin
 belief
 an
 dysregulate
 emotion
 whe
 PTS
 wit
 survivor
 childhoo
 abuse
 Intervention
 fo
 th
 treatmen
 PTS
 an
 SU
 hav
 take
 severa
 approache
 thi
 goal
 FO
 CONCURREN
 PTS
 AN
 SU
 TREATMEN
 behaviora
 therap
 onl
 recentl
 ha
 bee
 applie
 PTS
 individual
 recover
 fro
 addiction
 Fo
 example
 16-sessio
 combinin
 prolonge
 exposur
 an
 cognitiv
 restructurin
 cocain
 dependen
 adult
 reporte
 promisin
 result
 fo
 completers
 hig
 (60+%
 dro
 ou
 rat
 (Brady
 Dansky
 Back
 Foa
 Caroll
 12-wee
 partia
 hospita
 grou
 CBT
 interventio
 ("Transcend,
 Padin-River
 Kowaliw
 2001
 reporte
 clinicall
 significan
 PTS
 an
 alcoho
 an
 dru
 us
 tha
 wer
 maintaine
 12-mont
 follo
 ups
 Assiste
 Recover
 Traum
 an
 Substance
 Triffleman
 2002)
 20-week
 one-to-on
 therap
 tha
 first
 pro
 session
 CB
 focuse
 substanc
 abstinenc
 an
 the
 individualize
 an
 pace
 CBT
 fo
 PTSD
 resulte
 simila
 PTS
 symptom
 an
 superio
 attendanc
 an
 abstinenc
 CBT
 focuse
 onl
 SUD
 Safet
 (SS
 Najavits
 2002
 manualize
 grou
 interventio
 wome
 adolescen
 girl
 wit
 co-occurrin
 PTS
 an
 SU
 tha
 mor
 tha
 "saf
 copin
 skills
 organize
 curriculu
 eac
 sessio
 cover
 define
 topi
 wit
 presentatio
 th
 grou
 an
 structure
 exercise
 practic
 skill
 relevan
 th
 topi
 (e.g.
 an
 managin
 PTS
 symptoms
 anger
 guilt)
 Seekin
 doe
 no
 includ
 discussio
 specifi
 traum
 memories
 bu
 skill
 fo
 managin
 traumati
 stres
 symptom
 the
 impac
 lif
 functionin
 an
 recover
 fro
 comorlbi
 SUD
 stud
 wit
 women
 Seekin
 Safet
 wa
 comparabl
 relaps
 preventio
 an
 addictio
 treatmen
 usua
 reducin
 PTS
 an
 SU
 severit
 an
 wa
 superio
 bot
 othe
 intervention
 improve
 anxiety
 depression
 hostility
 suicidality
 an
 interpersona
 prob
 (Najavits
 2002)
 Recover
 an
 Empowermen
 Mode
 (TREM
 Harri
 Fallot
 educationa
 grou
 interventio
 (lik
 Seekin
 Safety
 fo
 wome
 me
 wit
 co-occurrin
 majo
 menta
 iLlness
 SUD
 an
 PTSD
 focusin
 JOURNA
 PSYCHOTHERAP
 th
 cumulativ
 effect
 livin
 wit
 povert
 an
 stigm
 victimizatio
 trauma
 Traum
 Recover
 an
 Empowermen
 manualized
 wit
 version
 rangin
 fro
 4-sessio
 introductio
 24-3
 sessio
 group
 Initially
 TRE
 focuse
 skill
 an
 knowledg
 persona
 an
 relationa
 awarenes
 addres
 arrest
 psychosexua
 an
 provide
 supportiv
 (gender-separated
 grou
 mi
 whic
 eac
 survivo
 ca
 disclos
 memorie
 traum
 an
 overcom
 grief
 an
 sham
 th
 for
 tellin
 he
 lif
 story
 recen
 multisit
 stud
 multicomponen
 treatmen
 model
 fo
 wit
 co-occurrin
 psychiatri
 an
 addictiv
 disorder
 an
 historie
 exposur
 violenc
 include
 Seekin
 Safet
 an
 TRE
 severa
 sites
 model-specifi
 findings
 supporte
 eithe
 approac
 specificall
 usua
 car
 condition
 "smal
 bu
 statisticall
 significant
 wer
 foun
 PTS
 an
 menta
 healt
 sympto
 reductio
 whe
 result
 wer
 aggregate
 fo
 bot
 thes
 integrate
 PTSD/SU
 approache
 acros
 al
 site
 an
 intervention
 (Morrissey
 Ellis
 Amaro
 Brown
 Najavjts
 2005
 1213)
 Despit
 differ
 thes
 models
 thei
 commo
 focu
 th
 psychotherapeuti
 bot
 PTS
 an
 SU
 women'
 curren
 live
 prove
 DIFFERENCE
 AMON
 TREATMEN
 MODEL
 FO
 CO-OCCURRIN
 PTS
 AN
 conceptua
 an
 technica
 feature
 distinguis
 th
 evolvin
 model
 fo
 co-occurrin
 PTS
 An
 SUD
 Behaviora
 Therap
 approache
 focu
 reducin
 anxiet
 avoidanc
 relate
 traum
 memorie
 (Fo
 Kozak
 1998)
 an
 correctin
 dysfunctiona
 cognition
 reduc
 intrusiv
 symp
 reexperiencing
 emotiona
 numbing
 hyperarousal
 an
 hypervigi
 (Brad
 al.
 2001
 Donova
 aL
 2001
 Muese
 aL
 2002
 2002
 Triffleman
 2002)
 Althoug
 CBT
 theorist
 recogniz
 tha
 information
 processing
 mus
 deal
 wit
 modif
 maladap
 belief
 (Brewi
 Holmes
 2003
 Fo
 Kozak
 1998)
 systemati
 enhancin
 informatio
 processin
 fo
 PTS
 PTSD/SU
 no
 develope
 fo
 CBT
 interventions
 approache
 PTS
 therap
 emphasiz
 helpin
 survivors
 regai
 ove
 th
 rememberin
 process
 (Harvey
 1996
 11
 an
 sens
 trus
 themselve
 an
 health
 relationship
 (Harri
 Fallot
 2001
 Herman
 1992
 tellin
 thei
 persona
 stor
 (o
 narrative
 thereb
 "makin
 meanin
 ou
 trauma
 (Harvey
 1996
 13)
 Th
 Adaptiv
 Recover
 Grou
 Educatio
 an
 Therap
 (TARGET
 no
 reduc
 avoidanc
 extinguis
 maladaptiv
 fea
 (a
 bu
 develo
 regai
 sens
 empowerment
 persona
 identit
 worth
 secur
 involvemen
 health
 relationships
 an
 realisti
 lif
 an
 hop
 fo
 th
 future
 Simila
 som
 CBT
 model
 trainin
 affectiv
 an
 interpersona
 regulatio
 wit
 prolonge
 [STAIR-PE]
 Seekin
 Safety)
 thes
 self/relationa
 approache
 helpin
 client
 lear
 strengthe
 skiLl
 fo
 health
 bodil
 an
 psychologica
 an
 relationa
 safety
 Cognitiv
 Behaviora
 model
 als
 ai
 hel
 client
 creat
 positiv
 persona
 narratives
 relationships
 an
 self-worth
 bu
 vie
 thes
 byproduc
 anxiety
 wherea
 self/relationa
 model
 vie
 narrativ
 an
 self
 wor
 th
 mean
 rathe
 tha
 th
 reducin
 anxiety
 self/relationa
 model
 hav
 no
 develope
 systemati
 thera
 protoco
 grounde
 theor
 an
 researc
 guid
 therapist
 an
 doin
 personal/traum
 narrativ
 work
 CB
 an
 th
 self/relationa
 approache
 PTSD/SU
 treatmen
 intervention
 designe
 enhanc
 socia
 proble
 solvin
 skill
 an
 regulatio
 skill
 (Ford
 Courtois
 va
 de
 Hart
 Nijenhuis
 Steele
 Thi
 particularl
 importan
 wit
 survivor
 earl
 childhoo
 traum
 wh
 ar
 ris
 fo
 extrem
 dysregulatio
 emotio
 rage
 despair
 terror)
 informatio
 processin
 (e.g.
 sever
 dissocia
 bodil
 functionin
 (e.g.
 debilitatin
 somatization)
 an
 relationship
 enmeshe
 explosive
 (Ford
 1999
 va
 de
 Kol
 aL
 1996)
 Behaviora
 Therap
 focuse
 helpin
 client
 identif
 an
 thei
 reaction
 trauma-relate
 trigger
 thei
 curren
 live
 Brief
 Peirce
 Meehan
 Mannix
 1999
 Triffleman
 2002)
 replacin
 maladaptiv
 copin
 style
 wit
 effectiv
 proble
 solvin
 an
 skill
 (Donova
 aL
 2001
 Najavits
 2002
 Triffleman
 Self/relationa
 model
 instea
 rel
 upo
 therapeuti
 activitie
 de
 buil
 self
 awareness
 self-esteem
 persona
 boundaries
 an
 intimac
 (Harri
 Fallot
 2001
 Pearlma
 Saakvitne
 1995)
 PTSD/SU
 mode
 ha
 explicate
 systemati
 se
 step
 client
 ca
 us
 guid
 the
 regulatin
 intens
 emotion
 an
 socia
 problem
 whil
 maintainin
 sobriety
 AdditionaUy
 non
 model
 provide
 practica
 framewor
 fo
 understandin
 an
 fo
 traum
 memorie
 an
 affec
 dysregulatio
 whil
 als
 strength
 sobriety
 Th
 treatmen
 describe
 thi
 pape
 base
 upo
 suc
 organizin
 framework
 whic
 wa
 develope
 buil
 upo
 exten
 th
 stron
 bas
 provide
 othe
 model
 fo
 concurren
 SU
 an
 PTSD
 JOURNA
 PSYCHOTHERAP
 ADAPTIV
 RECOVER
 GROU
 EDUCATIO
 AN
 (TARGET
 adaptiv
 recover
 grou
 educatio
 an
 therap
 (TARGET
 manualize
 grou
 an
 one-to-on
 psychotherap
 tha
 provide
 educatio
 abou
 th
 biologica
 an
 behaviora
 underpinning
 an
 SUD
 guidanc
 applyin
 integrate
 se
 information/emotio
 pro
 an
 self-regulatio
 skill
 curren
 lif
 experiences
 an
 experientia
 componen
 throug
 th
 developmen
 autobio
 narrativ
 tha
 incorporates
 bu
 doe
 no
 primaril
 focu
 trauma
 PTSD
 an
 SUD
 TARGE
 wa
 flrst
 develope
 practic
 an
 communit
 menta
 healt
 setting
 fo
 adult
 wit
 menta
 illnes
 an
 PTSD
 Fo
 thi
 populatio
 wa
 clinicall
 indicate
 an
 feasibl
 delive
 TARGE
 closed
 open-ende
 treatmen
 lastin
 betwee
 si
 month
 an
 severa
 orde
 matc
 th
 logistic
 SU
 treatment
 briefe
 TARGE
 versio
 wa
 develope
 an
 wa
 foun
 wit
 significantl
 bette
 abstinenc
 self-efflcac
 tha
 treatment-as-usua
 conditio
 randomize
 effectivenes
 (Frisman
 Ford
 Lin
 2005)
 ORGANIZIN
 FRAMEWOR
 focuse
 eac
 client'
 attentio
 th
 cor
 value
 an
 hope
 hav
 bee
 th
 basi
 fo
 he
 lifelon
 projec
 evolvin
 persona
 (i.e.
 self-definition
 self-esteem
 an
 self-efficacy
 an
 meaningfu
 worthwhil
 relationships
 Intrusiv
 traum
 memorie
 an
 hypervigi
 ar
 reframe
 occurrin
 no
 becaus
 th
 perso
 di
 no
 cop
 wit
 trauma
 bu
 becaus
 th
 survivo
 cope
 effectivel
 tha
 sh
 ha
 interna
 biologica
 alar
 syste
 tha
 adjuste
 fo
 traum
 no
 fo
 ordinar
 living
 Therefore
 rathe
 tha
 attemptin
 hav
 th
 becom
 desensitize
 intens
 emotions
 thinkin
 mor
 rationall
 relaxin
 instea
 bein
 hypervigilan
 whe
 experiencin
 intrusiv
 memories
 th
 goa
 fo
 th
 clien
 lear
 way
 prepare
 for,
 and
 process,
 current
 trauma
 reminders
 (interna
 an
 external
 an
 rese
 th
 body'
 surviva
 alar
 appropriatel
 curren
 lif
 focuse
 resilienc
 shiftin
 clients
 attentio
 th
 reactions
 feelings
 thoughts
 goals
 an
 choice
 tha
 ar
 occu
 wit
 SU
 an
 PTS
 symptoms
 Eac
 sympto
 involve
 (eve
 seem
 automatic
 an
 skillfu
 plannin
 an
 actio
 Adaptiv
 Recover
 Grou
 Educatio
 an
 Therap
 (TARGET
 TH
 TARGE
 FREEDO
 STEP
 Focu
 reduc
 anxiet
 an
 increas
 menta
 alertnes
 Recogniz
 specifi
 stres
 trigger
 Emotion
 identif
 primar
 feeling
 Evaluat
 primar
 thoughts/self-statement
 Defin
 primar
 persona
 goal(s
 Optio
 identif
 on
 choic
 tha
 represent
 successfu
 ste
 towar
 primar
 goal(s
 tha
 th
 individua
 actuall
 accomplishe
 durin
 stressfu
 experienc
 Mak
 contributio
 recogniz
 ho
 tha
 optio
 ha
 th
 adde
 benefi
 reflectin
 th
 person'
 cor
 value
 an
 mad
 differenc
 others
 ha
 becom
 impulsiv
 reaction)
 Th
 goa
 treatmen
 th
 persona
 goals
 choices
 an
 abilitie
 tha
 hav
 bee
 ob
 th
 problemati
 aspect
 PTS
 an
 SU
 symptoms—no
 ri
 of
 th
 symptoms
 simpl
 "substitute
 adaptiv
 way
 bu
 fin
 an
 rebuil
 adaptiv
 skill
 tha
 th
 survivo
 possesse
 value
 withi
 her/himself
 Th
 goa
 validat
 strength
 rathe
 tha
 failing
 deficits
 an
 engag
 client
 constructiv
 examinatio
 th
 problemati
 aspect
 symptoms
 Thi
 wit
 blen
 empathi
 validatio
 (i.e.
 identifyin
 problemati
 "alarm
 reaction
 whic
 th
 brain/bod
 attemptin
 th
 perso
 fro
 potentia
 threats
 rea
 perceived
 automati
 tha
 wer
 adaptiv
 survivin
 trauma
 an
 strengths-based
 client
 reframin
 (i.e.
 explorin
 alternativ
 choice
 tha
 alread
 exis
 reflec
 th
 person'
 fundamenta
 cor
 emotions
 beliefs
 goals
 an
 bu
 whic
 ar
 obscure
 automati
 "alarm
 reactions)
 organize
 aroun
 skil
 sequenc
 tha
 describe
 FREEDOM
 mnemoni
 too
 (se
 Tabl
 1)
 Th
 FREEDO
 sequenc
 mirror
 th
 neurobiolog
 adaptiv
 developmen
 (Ford
 an
 th
 thre
 phase
 PTS
 treatmen
 (For
 al.
 2005)
 involve
 stabilizatio
 an
 self-regulatio
 vi
 focusin
 ("E")
 taugh
 three-ste
 proces
 tha
 ca
 don
 inatte
 bu
 require
 repeate
 practic
 well-rehearse
 an
 availabl
 stres
 reaction
 ar
 experienced
 Th
 thre
 step
 ar
 summarize
 familia
 cod
 fo
 call
 fo
 help
 SOS.
 Th
 first
 "5
 stand
 fo
 Slow
 pause
 tak
 breath
 clea
 you
 mind
 an
 inhibi
 impulsiv
 actions
 "O
 stand
 fo
 Orient
 pa
 attentio
 wha
 you
 five
 sense
 ar
 yo
 abou
 you
 bod
 (especiall
 health
 feelings
 an
 you
 environ
 JOURNA
 PSYCHOTHERAP
 (especiall
 things/peopl
 tha
 ar
 interesting)
 Th
 secon
 "S"
 stand
 5elf-check
 client
 lear
 mak
 rapi
 rating
 curren
 stres
 an
 persona
 contro
 tw
 10-poin
 scales
 Th
 purpos
 SO
 provid
 practical
 easil
 recalle
 self-cu
 (o
 cu
 fro
 othe
 people
 friend
 counselor
 wh
 ca
 sugges
 doin
 "SOS"
 tha
 reactive/impulsiv
 thinkin
 an
 actio
 an
 facilitate
 simpl
 processing
 include
 traum
 processin
 vi
 Recognizin
 ("R"
 specifi
 fo
 "alarm
 reaction
 an
 th
 "reactive
 Emotion
 ("E")
 an
 Evaluation
 ("E")
 goa
 Definition
 ("D")
 an
 behaviora
 re
 Option
 ("O")—th
 "REEDO
 FREEDOM—i
 th
 contex
 therapeuti
 examinatio
 current
 lif
 experiences
 wit
 pas
 experi
 (traumatic
 wel
 other
 formativ
 event
 relationships
 fo
 meaning-makin
 (Harvey
 1996
 rathe
 tha
 th
 prin
 focus
 Th
 TARGE
 framewor
 easil
 understood
 remem
 an
 utilize
 sequence
 step
 fo
 informatio
 an
 emotio
 pro
 tha
 incorporate
 th
 trauma-base
 processin
 PTSD
 bu
 shift
 th
 person'
 focu
 mor
 self-reflectiv
 processing
 respect
 TARGE
 complementar
 wit
 othe
 skills-base
 psycho
 model
 fo
 PTS
 (e.g.
 Cloitr
 al.
 2002
 Resic
 al.
 2002)
 (e.g.
 Kadden
 2001)
 co-occurrin
 PTS
 an
 SU
 (e.g.
 Donova
 2002
 Muese
 al.
 2002
 Najavits
 2002)
 relate
 relational
 an
 characterologica
 problems
 suc
 Dialecti
 Behavio
 ([DBT]
 Linehan
 1993)
 Skill
 taugh
 thes
 models
 suc
 an
 distres
 toleranc
 (Linehan
 1993)
 groundin
 (Najavits
 an
 abstinenc
 violatio
 managemen
 (Kadden
 1999)
 ar
 poten
 valuabl
 tactic
 fo
 managin
 urges
 agitation
 dysphoria
 risk
 Th
 EREEDO
 sequenc
 additionall
 provide
 systemati
 mode
 fo
 simultaneousl
 addressin
 addictio
 an
 PTS
 upo
 th
 researc
 literatur
 th
 psychobiolog
 traum
 an
 (Eord
 2005)
 clai
 mad
 tha
 th
 EREEDO
 step
 exactl
 ont
 th
 traum
 survivor'
 neurobiolog
 affect/informatio
 However
 th
 EREEDO
 sequenc
 provide
 organizin
 tha
 therapist
 an
 client
 ca
 us
 proactiv
 sequentia
 deployin
 self-regulation
 informatio
 processing
 an
 rela
 skills
 orde
 simultaneousl
 addres
 PTS
 an
 SU
 by
 (1
 triggere
 stres
 reactions
 an
 (2
 enhancin
 th
 clarit
 feeling
 an
 relatedness
 involve
 extensio
 therap
 incorporatin
 th
 learnin
 Phase
 an
 int
 wor
 th
 client'
 overarchin
 lifestyle
 values
 Adaptiv
 Recover
 Grou
 Educatio
 an
 Therap
 (TARGET
 an
 plans
 Thi
 accomplishe
 revisitin
 th
 thir
 throug
 fifth
 step
 an
 assistin
 th
 clien
 identifyin
 alternative
 th
 goal(s
 tha
 ar
 wha
 th
 clien
 feels
 thinks
 an
 aim
 fo
 lif
 whe
 caugh
 "alarm
 reactions
 Thi
 phas
 involve
 th
 carefu
 action
 th
 clien
 already
 is
 taking
 when
 experiencing
 "alarm"
 reactions
 tha
 th
 clien
 view
 positiv
 step
 (howeve
 partial
 towar
 he
 mai
 goals
 Lastly
 Phas
 include
 discussion
 how
 fro
 th
 client'
 poin
 vie
 (wit
 guidanc
 th
 therapis
 or
 grou
 therapy
 fro
 grou
 members)
 sh
 makin
 contributio
 th
 peopl
 an
 value
 tha
 ar
 mos
 importan
 he
 hi
 takin
 thos
 step
 towar
 mai
 goals
 TARGE
 CLINICA
 INTERVENTIO
 ar
 thre
 cor
 therapeuti
 component
 th
 TARGE
 clinica
 Th
 first
 education
 whic
 provide
 nove
 definitio
 an
 PTS
 biologica
 chang
 th
 body'
 "alarm
 syste
 occur
 th
 resul
 automati
 an
 highl
 adaptiv
 reaction
 th
 individual'
 (o
 significan
 other's
 survival
 Th
 rol
 th
 (e.g.
 autonomic
 an
 centra
 (e.g.
 brai
 stem
 limbic
 anterio
 prefronta
 cortex
 nervou
 system
 (Eord
 2005
 respondin
 dange
 an
 seekin
 pleasur
 an
 avoidin
 distres
 illustrate
 wit
 an
 metaphorica
 example
 (e.g.
 subcortica
 neura
 circuit
 th
 "alarm
 an
 "reward
 systems
 limbi
 an
 prefronta
 circuit
 th
 "i
 box
 an
 "decision-maker"
 tha
 mak
 th
 neurobiolog
 an
 SU
 accessibl
 laypersons
 Th
 concep
 biologica
 alarm
 tha
 become
 sensitized
 an
 therefor
 highl
 reactive
 appea
 mino
 stressor
 substanc
 us
 cues/context
 ("trig
 help
 participant
 mak
 sens
 th
 varie
 symptom
 PTSD
 an
 associate
 socioemotiona
 problem
 (e.g.
 rage
 panic
 dyspho
 denial
 dissociation)
 Thi
 help
 client
 relat
 thei
 ow
 experienc
 reframe
 versio
 tha
 emphasize
 tha
 thes
 norma
 reaction
 circumstance
 ar
 health
 surviva
 adaptation
 tha
 hav
 becom
 reactiv
 du
 trauma
 thi
 introduction
 client
 (wh
 typicall
 hav
 sketch
 superfi
 informatio
 abou
 th
 nature
 origins
 an
 cause
 th
 persistenc
 an
 SU
 symptoms
 ofte
 becom
 ver
 intereste
 learnin
 ho
 ca
 gai
 greate
 contro
 ove
 PTS
 an
 SU
 bette
 recognizin
 managin
 th
 body'
 "alarm
 reactions
 Therefore
 th
 secon
 cor
 TARGE
 th
 teachin
 an
 guide
 practic
 th
 skil
 sequenc
 fo
 managin
 traumati
 stres
 symptoms
 Th
 JOURNA
 PSYCHOTHERAP
 protoco
 incorporate
 basi
 safet
 an
 self-managemen
 skill
 Najavits'
 [2002
 "grounding
 skills
 teachin
 sequenc
 tha
 wit
 thes
 skill
 befor
 focusin
 trauma-relate
 emotio
 pro
 an
 autobiographica
 reconstructio
 (Cloitr
 al.
 2002)
 Th
 mode
 provide
 practica
 templat
 fo
 reflectiv
 examinatio
 curren
 stressfu
 experience
 wit
 self-monitorin
 assis
 client
 ho
 th
 skill
 ca
 "reset
 th
 body'
 alar
 system
 FREEDO
 skil
 sequenc
 use
 primaril
 prototyp
 fo
 recen
 stressfu
 experiences
 bu
 also
 ca
 serv
 guid
 safel
 examinin
 traum
 memories
 Traum
 memor
 wor
 under
 onl
 th
 memor
 troublin
 th
 clien
 currentl
 and
 th
 clien
 clinicia
 judg
 tha
 cleare
 an
 mor
 organize
 understandin
 th
 event(s
 an
 th
 antecedent
 an
 consequence
 wil
 hel
 th
 copin
 wit
 curren
 stressor
 an
 symptoms
 Traum
 memor
 an
 disclosure
 therefore
 no
 automati
 require
 TARGET
 optio
 pursue
 onl
 th
 client'
 behes
 preferabl
 afte
 th
 FREEDO
 skil
 sequenc
 ha
 bee
 wel
 learne
 extensivel
 practice
 examinin
 curren
 sub-traumati
 stressfu
 Th
 on
 exceptio
 thi
 rul
 whe
 clien
 feel
 flooded
 intrusiv
 memorie
 durin
 earl
 TARGE
 session
 Thi
 no
 th
 bu
 occur
 ofte
 enoug
 warran
 clinica
 preparation
 thi
 case
 TARGE
 therapis
 help
 th
 clien
 regai
 sens
 presen
 safet
 an
 usin
 th
 SO
 paradigm
 Thi
 achieve
 eithe
 explorin
 trigger
 tha
 elici
 th
 intrusiv
 memorie
 (i.e.
 shiftin
 wor
 "R
 ste
 recognizin
 specifi
 triggers
 an
 ho
 th
 client'
 reaction
 appropriat
 posttraumati
 alar
 state
 helpin
 th
 clien
 key
 specifi
 element
 th
 memor
 (agai
 parallelin
 th
 FREE
 steps
 includin
 trigger
 an
 primar
 emotions
 thoughts
 goals
 increas
 reflectiv
 distanc
 fro
 th
 memor
 an
 enhanc
 th
 client'
 experienc
 th
 memor
 organize
 an
 manageabl
 rathe
 tha
 an
 overwhelming
 client
 choos
 no
 reexamin
 traum
 memorie
 detail
 selec
 ke
 memorie
 an
 develo
 persona
 pla
 fo
 reexaminin
 disclosin
 thes
 memorie
 wa
 tha
 enhance
 thei
 sens
 thei
 memorie
 (Harvey
 1995
 an
 emotion
 (Gleise
 al.
 review
 an
 contro
 thei
 bod
 an
 thei
 relationship
 (Harri
 2001)
 Typically
 thes
 client
 us
 FREEDO
 skill
 addres
 reexperiencin
 symptom
 focusin
 greate
 awarenes
 an
 bodil
 reactions
 emotions
 an
 thought
 triggere
 curren
 Adaptiv
 Recover
 Grou
 Educatio
 an
 Therap
 (TARGET
 an
 refocusin
 cor
 goal
 an
 effectiv
 choice
 durin
 afte
 unwante
 memor
 pas
 traumas
 traum
 memorie
 ten
 reexamine
 individua
 therap
 th
 clien
 wit
 privac
 an
 th
 counselor'
 uninterrupte
 atten
 wel
 preven
 th
 contagio
 distres
 tha
 ca
 occu
 whe
 disclos
 detaile
 traum
 memorie
 grou
 therapy
 note
 clien
 experience
 unwante
 memor
 othe
 intrusiv
 symptom
 grou
 sessions
 sh
 choose
 disclos
 grou
 session
 th
 grou
 leader
 us
 th
 FREEDO
 protoco
 hel
 th
 clien
 (an
 al
 othe
 grou
 members
 refocu
 thei
 imme
 reactions
 emotions
 an
 thought
 an
 identifyin
 curren
 trigger
 tha
 ma
 hav
 elicite
 th
 unwante
 memor
 symptoms
 examinin
 specifi
 traum
 memor
 individua
 counseling
 FREEDO
 skil
 sequenc
 use
 assis
 th
 clien
 developin
 complet
 reconstructio
 no
 onl
 wha
 happene
 bu
 als
 (a
 event(s
 tha
 precede
 le
 th
 traumati
 experience
 (b
 event(s
 an
 th
 client'
 reaction
 an
 copin
 strategie
 th
 minutes
 an
 day
 afte
 th
 foca
 trauma
 an
 (c
 persona
 goals
 choices
 an
 before
 during
 an
 afte
 th
 traum
 tha
 th
 clien
 ha
 overlooke
 discounted
 Th
 goa
 th
 FREEDO
 no
 chang
 th
 valenc
 traum
 memorie
 stressfu
 experience
 fro
 negativ
 positive
 bu
 instea
 increas
 th
 complexity
 an
 contextualizatio
 th
 client'
 memor
 th
 pas
 event
 tha
 ther
 greate
 balanc
 coexistin
 (rathe
 fragmente
 compartmentalized
 negativ
 an
 positiv
 element
 recollection
 thir
 cor
 componen
 TARGE
 experientia
 exercis
 enabl
 client
 reengag
 autobiographica
 narrativ
 processin
 an
 memor
 safel
 accessing
 containing
 an
 emotionall
 charge
 persona
 memories
 Thi
 don
 usin
 nonverba
 creativ
 art
 modalit
 (Johnson
 2000
 tha
 enable
 clien
 construc
 pictur
 he
 lif
 (i.e.
 th
 "Persona
 Lifeline"
 Stewart
 1999)
 Th
 Lifelin
 exercis
 intersperse
 throughou
 session
 tha
 eac
 client'
 emergen
 persona
 stor
 recon
 withi
 growin
 contex
 persona
 efficacy
 autonomy
 related
 an
 safet
 tha
 enable
 th
 survivo
 organiz
 cognitivel
 an
 proces
 th
 previousl
 fragmente
 an
 overwhelmin
 memorie
 traum
 an
 othe
 importan
 positiv
 an
 negativ
 lif
 experiences
 JOURNA
 PSYCHOTHERAP
 ALLIANC
 TARGET
 REPAIRIN
 DISORGANIZE
 FORM
 designe
 provid
 vehicl
 fo
 th
 developmen
 therapeuti
 allianc
 betwee
 provider
 th
 treatmen
 tea
 an
 client
 Th
 structure
 education
 skill
 sequence
 an
 autobiograph
 reconstructio
 component
 TARGE
 provid
 th
 tool
 fo
 clini
 an
 cas
 manager
 wh
 wor
 wit
 traum
 survivor
 tha
 enabl
 the
 serv
 rol
 model
 fo
 adaptiv
 emotio
 self-regulatio
 th
 contex
 emotionall
 charge
 bu
 secur
 an
 reliabl
 therapeuti
 relationship
 thes
 tool
 th
 provider
 ca
 teac
 subtl
 skill
 fo
 self-regulatio
 throug
 nonverba
 proces
 coregulatio
 (Schore
 2001
 wel
 th
 over
 educational
 skil
 building
 an
 creativ
 art
 modalitie
 provid
 th
 obviou
 structur
 fo
 TARGET
 LINGUISTIC
 AN
 GENDE
 ADAPTATION
 wa
 develope
 pilo
 wor
 wit
 divers
 clien
 population
 includ
 wome
 an
 men
 hearin
 an
 non-hearin
 individuals
 rang
 ag
 fro
 year
 mor
 tha
 year
 old
 Ethnocuitura
 include
 individual
 wh
 self-identifie
 Blac
 (African
 Caribbean-American)
 Latino/Latin
 (Puert
 Rican
 Centra
 Ameri
 an
 Mexican/Chicano)
 Nativ
 American
 an
 Caucasia
 (American
 an
 Middl
 Eastern)
 Clinician
 an
 cas
 manager
 teachin
 carryin
 ou
 therap
 wit
 TARGE
 hav
 develope
 numbe
 th
 wording
 example
 an
 metaphors
 an
 eve
 th
 material
 (e.g.
 laminatin
 eac
 lette
 fro
 EREEDO
 card
 fo
 displa
 househol
 cabinets
 appliances
 bulleti
 boards
 educationa
 handout
 wit
 enhance
 graphic
 fo
 dea
 clients
 mak
 th
 curriculu
 accessibl
 client
 fro
 thi
 wid
 an
 heritages
 TARGE
 als
 ha
 bee
 formall
 translate
 field
 teste
 psychotherapist
 Spanish
 Dutch
 an
 Hebrew
 Th
 an
 exercise
 TARGE
 ar
 designe
 accommodat
 th
 interests
 preferences
 an
 activitie
 wome
 an
 men—^wit
 ther
 bein
 an
 priori
 (stereotyped
 activitie
 tha
 ar
 gende
 specific
 SU
 TREATMEN
 designe
 complemen
 an
 no
 compet
 wit
 replac
 othe
 SU
 treatmen
 modalitie
 (e.g.
 suppor
 groups
 addictio
 edu
 classes
 relaps
 prevention
 self-hel
 an
 socia
 suppor
 meetings)
 ha
 bee
 use
 th
 primar
 therap
 modalit
 fo
 bot
 SU
 PTS
 treatmen
 som
 instances
 althoug
 thi
 no
 necessary
 Th
 Adaptiv
 Recover
 Grou
 Educatio
 an
 Therap
 (TARGET
 metapho
 an
 FREEDO
 skil
 sequenc
 hav
 bee
 adopte
 SU
 treatmen
 group
 wa
 understan
 addictiv
 urges
 an
 wor
 mindfull
 towar
 sobriety
 EXAMPLE
 TARGE
 CLINICA
 PRACTIC
 WOMA
 RECOVER
 FRO
 ADDICTION
 CHIL
 ABUSE
 AN
 DOMESTI
 year-ol
 Europea
 America
 woman
 wa
 referre
 grou
 he
 clinicia
 severa
 week
 afte
 sh
 entere
 treatmen
 he
 polysubstanc
 abus
 (alcohol
 crac
 cocaine
 heroin)
 Cath
 wa
 an
 friendly
 an
 rappor
 wa
 easil
 establishe
 th
 African
 TARGE
 assessor
 Durin
 th
 cours
 th
 traum
 assessment
 share
 he
 comple
 traum
 histor
 encompassin
 childhoo
 sexua
 physica
 abus
 an
 childhoo
 neglect
 sh
 reporte
 histor
 severa
 bot
 acquaintanc
 an
 stranger
 domesti
 violence
 an
 incident
 assaul
 (robbery)
 Cath
 reporte
 tha
 sh
 wa
 currentl
 livin
 he
 boyfrien
 severa
 months
 Sh
 als
 reporte
 bein
 unhapp
 relationship
 feelin
 thoug
 th
 verba
 abus
 sh
 suffere
 hom
 extremel
 simila
 th
 physica
 abus
 sh
 remembere
 th
 hand
 others
 Sh
 me
 diagnosti
 criteri
 fo
 majo
 depression
 PTSD
 an
 PTS
 (Ford
 1999)
 activel
 participate
 grou
 session
 fro
 th
 beginnin
 he
 Sh
 immediatel
 foun
 th
 psychoeducationa
 concept
 resonan
 he
 persona
 experience
 an
 spontaneousl
 sai
 th
 first
 sessio
 sh
 fel
 thi
 grou
 offere
 he
 wa
 understan
 an
 dea
 wit
 tha
 sh
 fel
 sh
 ha
 neve
 reall
 understood
 Sh
 compare
 bein
 abl
 se
 throug
 ca
 windshiel
 whil
 drivin
 rathe
 tha
 blind
 an
 tryin
 "ru
 fas
 can"
 withou
 sens
 direction
 Sh
 appeare
 comfortabl
 sharin
 persona
 experi
 abou
 he
 journe
 recover
 wit
 th
 group
 bu
 di
 no
 dwel
 pas
 traumas
 Sh
 attende
 th
 group'
 first five
 sessions
 an
 sh
 succes
 usin
 man
 th
 skill
 introduce
 identif
 curren
 us
 trigger
 an
 traum
 reminders
 Whe
 Cath
 misse
 th
 sixt
 th
 grou
 leader
 followe
 wit
 he
 primar
 clinician
 Cath
 faile
 sho
 fo
 he
 day-treatmen
 progra
 fo
 severa
 weeks
 he
 therapis
 wa
 sur
 tha
 sh
 ha
 relapsed
 Whe
 Cath
 returne
 fo
 severa
 week
 later
 sh
 entere
 inpatien
 an
 reporte
 ha
 severa
 wee
 relaps
 an
 feelin
 suicidal
 However
 upo
 he
 sh
 immediatel
 contacte
 on
 th
 grou
 leader
 an
 aske
 sh
 retur
 th
 TARGE
 grou
 sessions
 JOURNA
 PSYCHOTHERAP
 subsequentl
 enrolle
 secon
 TARGE
 group
 an
 al
 sh
 wa
 muc
 quiete
 durin
 sessions
 sh
 wa
 attentive
 Sh
 suggestion
 hel
 explai
 th
 FREEDO
 mode
 an
 experien
 exercises
 bu
 reporte
 tha
 thi
 tim
 sh
 wante
 concentrat
 understandin
 he
 histor
 an
 it
 relationshi
 he
 addiction
 Sh
 questions
 complete
 he
 homework
 an
 receive
 suppor
 fro
 he
 clinicia
 outsid
 group
 Durin
 he
 inpatien
 sta
 th
 center
 Cath
 separate
 fro
 he
 long-ter
 boyfriend
 Sh
 thi
 informatio
 wit
 th
 group
 explainin
 sh
 ha
 begu
 he
 SO
 (Focusing
 self-check
 whe
 sh
 wa
 wit
 he
 boyfrien
 whe
 sh
 wa
 separate
 fro
 him
 Sh
 foun
 tha
 he
 leve
 distres
 alway
 wa
 highe
 whe
 wit
 him
 an
 thi
 evidenc
 he
 separat
 fro
 he
 boyfrien
 concentrat
 treatmen
 trul
 gai
 "FREEDOM
 fro
 he
 pas
 history
 Cath
 di
 ver
 wel
 an
 complete
 th
 TARGE
 grou
 abstinen
 fro
 substanc
 Sh
 becam
 involve
 sobriet
 suppor
 activitie
 (fo
 th
 first
 tim
 lif
 sh
 ha
 sponsor)
 reduce
 reactivity
 an
 increase
 persona
 whe
 sh
 encountere
 trigger
 (e.g.
 message
 fro
 he
 ex-boy
 pleadin
 wit
 threatenin
 her)
 Sh
 wa
 invite
 retur
 pee
 afte
 sh
 complete
 th
 groups
 bu
 wa
 unabl
 becaus
 sh
 jo
 an
 ne
 apartment
 He
 ne
 hom
 wa
 considerabl
 fro
 th
 treatmen
 cente
 an
 becaus
 sh
 wa
 unabl
 driv
 du
 pas
 DU
 convictions
 attendanc
 th
 group
 woul
 hav
 stresso
 rathe
 tha
 suppor
 he
 continue
 recovery
 th
 sessio
 sh
 reporte
 tha
 sh
 wa
 usin
 th
 EREEDO
 skill
 teachin
 the
 he
 friends
 family
 he
 sponsor
 an
 Narcotic
 grou
 members
 Sh
 note
 tha
 thi
 wa
 he
 wa
 continu
 he
 ow
 recover
 an
 makin
 contributio
 (th
 "M
 FREEDOM
 th
 peopl
 he
 life
 MA
 RECOVER
 FRO
 ADDICTIO
 AN
 COMMUNIT
 VIOLENC
 whil
 livin
 supporte
 housin
 apartmen
 fo
 low-incom
 wit
 sever
 menta
 illnes
 an
 addictions
 wa
 enrolle
 grou
 diversio
 progra
 fo
 crimina
 offender
 wit
 abus
 problems
 gav
 sketch
 history
 describin
 physica
 sexua
 abus
 hi
 mothe
 whe
 wa
 youn
 boy
 witnessin
 he
 sex
 an
 bein
 assaulte
 whil
 sh
 wa
 prostituting
 neve
 kne
 father
 an
 gre
 playin
 th
 alternat
 role
 hi
 mother'
 an
 confidant
 "blac
 sheep"
 wh
 wa
 beate
 hi
 mothe
 bein
 "unruly"
 gaine
 reputatio
 "toug
 guy
 schoo
 Adaptiv
 Recover
 Grou
 Educatio
 an
 Therap
 (TARGET
 droppin
 ou
 nint
 grade
 an
 th
 cit
 streets
 no
 showe
 cognitiv
 impairmen
 consisten
 wit
 mil
 retardation
 possibl
 multipl
 concussion
 suffere
 fights
 an
 fro
 mor
 tha
 year
 heav
 polysubstanc
 use
 Robert
 wa
 skeptica
 abou
 TARGET
 an
 fo
 tha
 matter
 reportin
 tha
 didn'
 lik
 "le
 othe
 peopl
 business
 an
 tha
 didn'
 thin
 anything
 excep
 hi
 ow
 coul
 hel
 hi
 wit
 fits
 rag
 an
 depression
 Robert
 foun
 th
 psychoeducatio
 difficul
 understand
 wa
 overwhelme
 th
 ne
 idea
 an
 th
 inpu
 th
 othe
 grou
 the
 gav
 persona
 example
 thei
 "alarm
 reaction
 an
 triggers
 Th
 grou
 leader
 carefull
 slowe
 dow
 th
 pac
 an
 aske
 ever
 grou
 membe
 tak
 tur
 talkin
 abou
 eac
 concept
 Wit
 thi
 structure
 Robert
 becam
 mor
 relaxe
 an
 listene
 othe
 grou
 members
 insightfull
 describin
 hi
 stres
 triggers
 emotions
 thoughts
 an
 goals
 wa
 especiall
 abou
 gettin
 mor
 focuse
 hi
 persona
 goal
 an
 hi
 choice
 ("O
 Option
 th
 FREEDO
 model)
 an
 le
 th
 developin
 lis
 goal
 an
 option
 tha
 becam
 ne
 handou
 thi
 an
 subsequen
 TARGE
 groups
 fel
 honore
 receiv
 th
 th
 grou
 member
 an
 leaders
 an
 sai
 tha
 thi
 strength
 hi
 sens
 persona
 contro
 supportin
 hi
 tru
 machismo
 hi
 havin
 th
 "ba
 guy"
 Robert
 complete
 al
 nin
 includin
 developin
 Lifelin
 tha
 poignantl
 showe
 hi
 drea
 havin
 famil
 an
 bein
 bot
 so
 an
 father
 wa
 abl
 us
 FREEDO
 skill
 catc
 hi
 self-critica
 thought
 relatio
 hi
 an
 mor
 assertiv
 wit
 he
 whe
 sh
 wa
 angr
 irritable
 viewin
 he
 reaction
 "jus
 he
 stres
 alarm
 no
 bein
 ba
 als
 decide
 mak
 contac
 wit
 hi
 19-year-ol
 son
 wh
 ha
 no
 see
 sinc
 th
 chil
 wa
 thre
 year
 old
 an
 who
 adult
 wa
 priso
 fo
 violen
 crime
 simila
 Roberto'
 own
 Th
 provide
 Robert
 wit
 venu
 fo
 suppor
 an
 plac
 pla
 fo
 debrie
 afte
 tw
 phon
 call
 hi
 son
 whic
 Robert
 considere
 turnin
 poin
 hi
 lif
 an
 contributio
 tha
 ha
 alway
 wante
 make
 TH
 LIFELIN
 EXERCIS
 WOMEN'
 TARGE
 GROU
 Lifelin
 Exercis
 wa
 introduce
 TARGE
 grou
 th
 en
 th
 fifth
 sessio
 activit
 tha
 th
 grou
 member
 woul
 begi
 th
 week
 Th
 five
 wome
 participant
 (tw
 Latinas
 on
 Caribbean
 an
 tw
 Caucasians
 ha
 immediate
 stron
 reaction
 th
 JOURNA
 PSYCHOTHERAP
 completin
 Lifeline
 appearin
 distrustfu
 becaus
 on
 involve
 explicitl
 disclosin
 an
 chartin
 thei
 pas
 experience
 wa
 tha
 reminde
 severa
 member
 extremel
 stressfti
 pas
 lega
 Grou
 member
 wer
 abl
 sa
 tha
 the
 wer
 fearfu
 tha
 experienc
 woul
 distressin
 fo
 them
 Thei
 concern
 wer
 supportivel
 an
 th
 exercis
 wa
 explaine
 again
 wit
 emphasi
 th
 inclusio
 th
 presen
 an
 futur
 tha
 thi
 pictur
 thei
 lives
 no
 repor
 pas
 trauma
 mistakes
 to
 painfu
 disclos
 ha
 aired
 Th
 participant
 coul
 whe
 an
 ho
 focu
 positiv
 negativ
 memorie
 an
 wa
 gainin
 mor
 contro
 thei
 live
 an
 no
 pas
 experience
 feelin
 judged
 punished
 victimized
 member
 decide
 tr
 th
 exercis
 wit
 th
 understandin
 tha
 wa
 unpleasan
 the
 coul
 sto
 an
 chang
 discus
 th
 exercise
 followin
 week
 fou
 wome
 returne
 fo
 group
 Material
 wer
 ou
 an
 th
 exercis
 reexplained
 Participant
 wer
 reminde
 tha
 the
 us
 poetry
 photographs
 swatche
 colo
 represen
 anythin
 thei
 Lifeline
 Grou
 leader
 informe
 participant
 tha
 th
 Lifelin
 di
 nee
 linea
 (a
 timelines)
 bu
 coul
 tak
 an
 shape
 Th
 bega
 tentatively
 talkin
 softl
 wit
 eac
 othe
 se
 wha
 th
 woul
 do
 The
 worke
 thei
 lifeline
 fo
 minutes
 Periodicall
 grou
 leader
 checked-i
 wit
 th
 participant
 an
 aske
 fo
 feedbac
 th
 process
 Ther
 wa
 littl
 comment
 an
 th
 wome
 seeme
 absorbe
 thei
 creations
 Afte
 minutes
 th
 wome
 wer
 sto
 an
 hel
 pu
 awa
 th
 materials
 Surprisingly,
 give
 th
 reluctance
 eac
 di
 ver
 slowly
 Th
 grou
 circl
 wa
 reforme
 member
 wer
 aske
 abou
 thei
 experienc
 wit
 th
 lifeline
 Th
 wa
 overwhelmingl
 positiv
 an
 differen
 fo
 eac
 woman
 woma
 enjoye
 art
 an
 craft
 an
 paintin
 for
 relax
 sh
 enjoye
 usin
 differen
 material
 expres
 herself
 Sh
 chos
 focu
 th
 presen
 an
 th
 part
 he
 lif
 tha
 wer
 bot
 goo
 an
 Anothe
 clien
 reporte
 tha
 sh
 focuse
 th
 past
 findin
 memorie
 fro
 he
 childhood
 Befor
 beginnin
 th
 project
 sh
 tha
 th
 memorie
 woul
 consis
 mostl
 spendin
 tim
 bu
 sh
 wa
 surprise
 tha
 man
 th
 memorie
 sh
 repre
 clos
 frien
 wh
 wa
 refug
 durin
 he
 traumati
 childhood
 clien
 als
 reporte
 enjoyin
 th
 exercis
 mor
 tha
 sh
 ha
 antici
 Sh
 als
 focuse
 th
 present
 bu
 onl
 positiv
 aspects
 Th
 clien
 chos
 focu
 th
 futur
 wit
 he
 daughter
 Eac
 receive
 prais
 an
 statement
 sincer
 appreciatio
 fro
 Adaptiv
 Recover
 Grou
 Educatio
 an
 Therap
 (TARGET
 grou
 members
 Th
 grou
 leader
 thanke
 th
 entir
 grou
 fo
 honest
 an
 willingnes
 sta
 saf
 the
 riske
 lookin
 carefull
 lives
 despit
 thei
 ver
 understandabl
 anticipator
 anxiety
 eac
 th
 remainin
 grou
 sessions
 grou
 member
 aske
 tha
 se
 asid
 fo
 the
 ad
 thei
 Lifelines
 The
 explaine
 tha
 th
 reduce
 thei
 alar
 reaction
 helpin
 the
 kno
 themselve
 understan
 ho
 the
 becam
 wh
 the
 were
 Severa
 member
 tha
 thi
 wa
 th
 first
 chanc
 the
 ha
 ha
 safel
 loo
 wh
 were—othe
 tha
 jus
 traum
 survivors—whil
 no
 denyin
 th
 traum
 ha
 ha
 them
 on
 severa
 promisin
 ne
 model
 integrate
 psychotherap
 co-occurrin
 PTS
 an
 SUD
 TARGE
 provide
 psychotherapist
 educational
 behavioral
 an
 experientia
 tool
 tha
 engag
 client
 complicated
 comorbi
 PTSD/SU
 proces
 therapeuti
 an
 chang
 tha
 addresse
 PTS
 an
 SU
 simultaneously
 flexible
 templat
 tha
 ca
 utilize
 grou
 psychother
 illustrate
 th
 cas
 examples
 wel
 individua
 conjoin
 therapy
 reframin
 PTS
 an
 SU
 sharin
 com
 dilemm
 biologicall
 based
 bu
 modifiable
 "alarm
 reactions
 make
 bot
 th
 disorder
 an
 therap
 transparen
 an
 manage
 fo
 therapist
 wel
 fo
 clients
 Thi
 researc
 wa
 supporte
 gran
 fro
 th
 Suhstanc
 Ahus
 an
 Menta
 Service
 Administratio
 (L
 Frisman
 PI
 an
 caree
 developmen
 K2
 gran
 fro
 th
 Institut
 Menta
 Healt
 MH01889-01A1
 (J
 Ford
 PI)
 Th
 author
 than
 Drs
 Sharo
 an
 Amhe
 Dougla
 fo
 thei
 revie
 an
 feedhac
 earlie
 draft
 thi
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