Evidence-Based Interventions Used in Trauma

Applying Recovery Principles to the Treatment of Trauma

Jasset C. Smith and Scott M. Hyman Albizu University–Miami Campus

Raquel C. Andres-Hyman Bruce W. Carter VA Medical Center, Miami, Florida

Jessica J. Ruiz Albizu University–Miami Campus

Larry Davidson Yale University School of Medicine

The recovery movement, a paradigm shift in mental health care, recognizes that individuals diagnosed with even the most debilitating and long-standing disorders may still go on to lead meaningful and fulfilling lives. Symptom reduction is only part of the recovery process. In this article, we discuss principles of recovery and recommendations concerning the application of these principles to the treatment of individuals with trauma-related difficulties to improve hope, meaning, and overall quality of life. We conclude by identifying diagnostic and treatment approaches that are consistent with principles of recovery, and we discuss how practitioners can incorporate recovery principles into their evidence- based care planning.

Keywords: recovery, trauma, flourishing, meaning, posttraumatic stress disorder

Research has demonstrated that traumatic experiences are rela- tively common occurrences among clinical and general popula- tions (Breslau et al., 1998; Gold, 2008) and are associated with a number of persistent psychological difficulties including posttrau- matic stress disorder (PTSD), acute stress disorder, substance use disorder, major depressive disorder, dissociative disorders, anxiety disorders, borderline personality disorder (BPD), attention deficit/ hyperactivity disorder, and even psychosis (American Psychiatric Association, 2013; Cook et al., 2005; Cutajar et al., 2010; Gold, 2008; Heim, Newport, Mletzko, Miller, & Nemeroff, 2008; Mol-

nar, Buka, & Kessler, 2001; Najavits, Hyman, Ruglass, Hien, & Read, in press; Sansone, Gaither, & Songer, 2002; E. J. Wolf, Mitchell, Koenen, & Miller, 2014). In accordance with criteria found in the Diagnostic and Statistical Manual of Mental Disor- ders (5th ed.; American Psychiatric Association, 2013), the term trauma refers to exposure to an event that is in excess of the normal vicissitudes of life, involving actual or threatened death or injury or a threat to the physical integrity of oneself or others (such as sexual violence). Indirect exposure includes learning about the violent or accidental death or perpetration of sexual violence to a

This article was published Online First September 1, 2016. JASSET C. SMITH received her MS in psychology from Florida Interna-

tional University and her PsyD in clinical psychology from Albizu University–Miami Campus. She completed her predoctoral internship at Broughton Hospital, in Morganton, North Carolina, and is currently a psychology postdoctoral fellow at the Watershed Addiction Treatment Programs, in Boynton Beach, Florida. Her areas of professional interest include psychological responses to trauma, recovery from serious mental illness and trauma exposure, and treatment of addictive disorders.

SCOTT M. HYMAN received his PhD in clinical psychology from Nova Southeastern University. He completed his predoctoral internship at the Boston Consortium in Clinical Psychology–Boston VA Healthcare Sys- tem, in Boston, Massachusetts, and his postdoctoral fellowship at the Yale University School of Medicine. He is currently an associate professor and Institutional Review Board chairperson at Albizu University in Miami, Florida. His areas of professional interest include psychological trauma and addictive disorders.

RAQUEL C. ANDRES-HYMAN received her PhD in clinical psychology from Nova Southeastern University. She completed her predoctoral intern- ship and postdoctoral fellowship at the Yale University School of Medi- cine. She is currently clinical program manager for the Psychosocial Residential Rehabilitation Treatment Program at the Bruce W. Carter VA Medical Center in Miami, Florida. Her areas of professional interest include recovery from serious mental illness, trauma, and addictive disor-

ders and the transformation of systems of care to be culturally competent and recovery-oriented.

JESSICA J. RUIZ received her PsyD in clinical psychology from Nova Southeastern University. She completed her predoctoral internship and postdoctoral fellowship at the Yale University School of Medicine in the Division of Substance Abuse. She is an assistant professor in the Doctoral Psychology Program at Albizu University in Miami, Florida. Her areas of professional interest include the use of motivational interventions for the treatment of mental health and co-occurring substance use problems.

LARRY DAVIDSON received his MA and PhD in clinical psychology from Duquesne University and completed pre- and postdoctoral fellowships at the Yale School of Medicine, Department of Psychiatry. He is currently a professor of psychology at Yale, where he directs the Program for Recov- ery and Community Health. His research interests have been processes of recovery from serious mental illnesses and substance use disorders and the transformation of behavioral health policy and practice to better promote the recovery and community inclusion of persons with these disorders.

WE THANK Steven N. Gold for his helpful comments on an earlier version of this article. We are also grateful to Danielle Lewis for assisting with the preparation of the manuscript.

CORRESPONDENCE CONCERNING THIS ARTICLE should be addressed to Jasset C. Smith, Albizu University–Miami Campus, 2173 Northwest 99th Avenue, Doral, FL 33172. E-mail: [email protected]

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Professional Psychology: Research and Practice © 2016 American Psychological Association 2016, Vol. 47, No. 5, 347–355 0735-7028/16/$12.00 http://dx.doi.org/10.1037/pro0000105

347

loved one or repeated, indirect exposure to the ghastly and dreadful consequences of a traumatic event (e.g., police personnel and first responders to the 9/11 attacks; American Psychiatric Association, 2013).

Despite trauma’s documented association with the development of numerous psychiatric disorders (most notably PTSD, which requires trauma exposure as a diagnostic criterion), a large per- centage of individuals exposed to it demonstrate exceptional re- silience; they either experience a transient symptomatic period or may not develop symptoms at all (Alim et al., 2008; Ozer, Best, Lipsey, & Weiss, 2003; Southwick & Charney, 2012). Although continued research is still needed to improve understanding of factors that contribute to resiliency, Southwick, Vythilingam, and Charney (2005) highlighted optimism, positive emotionality, hu- mor, acceptance of adversity, spirituality, altruism, supportive relationships, having positive role models or mentors, being cog- nitively flexible, and having an action-oriented coping style as psychosocial factors that may lead to more positive outcomes.

Perhaps as a result of a growing understanding of the perva- siveness of trauma and the manner in which its impact can be mitigated, the last two decades has seen the development of trauma-informed approaches to health care (U.S. Department of Health & Human Services, 2014). The Substance Abuse and Mental Health Service Administration’s (SAMHSA) conceptual- ization of a trauma-informed approach is one in which a program, organization, or system realizes the widespread impact of trauma and potential approaches to recovery; recognizes the signs and symptoms of trauma among stakeholders in the system (i.e., pa- tients and families); and responds by fully integrating knowledge about trauma into policies, procedures, and practices while ac- tively seeking to avoid retraumatization.

In this article, we offer a number of recommendations concerning the application of basic recovery principles to a trauma-informed approach to mental health care. Some of these principles overlap with the six key principles promoted by SAMHSA (safety; trustworthiness or transparency; peer support; collaboration and mutuality; empow- erment; and cultural, historical and gender-specific factors). Building on these recommendations, we seek to expand these principles in accordance with recovery-oriented practice and offer recommenda- tions to the field by proposing sets of practices that are consistent with recovery-oriented, trauma-informed care (TIC). Whereas these prin- ciples may be generalizable across multiple types of settings and populations, for the purposes of this article, our recommendations are specific to clinical work with adult survivors of trauma (those exposed to single or multiple traumas, interpersonal in nature or otherwise).

According to Davidson, Sells, Sangster, and O’Connell (2005), there are nine core components that constitute recovery from mental illness: (1) being supported by others, including the impor- tant role of community and social support; (2) renewing hope and commitment through spirituality or other means; (3) engaging in meaningful activities through reclaiming social roles held prior to illness onset and/or identifying new ones; (4) redefining oneself by shifting the view of mental illness to include an understanding that it is only one aspect of the self, rather than all encompassing; (5) incorporating illness by accepting any limits that may persist due to mental illness; (6) overcoming stigma related to having a mental illness; (7) assuming control over treatment and choices; (8) man- aging symptoms; and (9) becoming empowered and exercising citizenship. In the sections that follow, we discuss each of these

recovery principles and how they can be applied to individuals with trauma-related difficulties to improve hope, meaning, and overall quality of life. We conclude by identifying diagnostic and treatment approaches that are consistent with principles of recov- ery and discuss how practitioners can incorporate trauma-informed recovery principles into their evidence-based care planning.

Increase Community and Social Support

The experience of trauma often disrupts an individual’s ability to form and maintain important interpersonal relationships (Brown, 2008; Tsai, Harpaz-Rotem, Pietrzak, & Southwick, 2012). For example, childhood trauma that occurs in the context of an invalidating or abusive home environment may impair the devel- opment of the social learning, coping, and executive functioning skills necessary to develop and maintain supportive interpersonal relationships in adulthood (Gold, 2000; Kostolitz, Hyman, & Gold, 2014). Adults raised in these contexts are more likely to form insecure attachments to others, and to develop beliefs that inhibit seeking out assistance in times of need (Cloitre, Stovall- McClough, Zorbas, & Charuvastra, 2008), to withdraw from car- ing relationships as a way to cope with uncertainty (Sandberg, Suess, & Heaton, 2010), and to lack the executive functioning (planning, organizing, decision-making, critical-thinking) skills necessary to develop supportive relationships and to avoid rejec- tion (Gold, 2000; Gould et al., 2012; Kostolitz et al., 2014).

Adult trauma survivors may also overuse behavioral and cog- nitive avoidance as a coping strategy, which can lead to impaired family cohesion and relationship intimacy (Tsai et al., 2012). In addition, the self-hatred and shame associated with many forms of trauma may cause a rift between people affected by trauma and those close to them (Brown, 2008; Marshall, Robinson, & Azar, 2011). For example, studies focusing on the relationship between shame and intimate partner violence (IPV) have found that indi- viduals experiencing shame associated with trauma were more likely to perpetrate aggression toward their partners (Harper, Aus- tin, Cercone, & Arias, 2005; Lawrence & Taft, 2013; Marshall et al., 2011). LaMotte, Taft, Weatherill, Scott, and Eckhardt (2014) found that, in addition to higher levels of perpetration of IPV among trauma survivors, male Operation Iraqi Freedom and Op- eration Enduring Freedom combat veterans also tended to be on the receiving end of physical aggression from their partners. This is an important finding and highlights relational instability and the bidirectionality of aggression and violence in the relationships of persons affected by trauma.

Peer support may be helpful in increasing resilience among trauma survivors. Peer support refers to integrating individuals with lived experiences of mental illness and recovery into mental health services. Self-help groups are one of the best examples of peer support and are often referred to as “mutual help” groups to highlight “the notion that help is both given and received” in these settings (Salzer, 2002, p. 357). In some mental health systems, such as that of the U.S. Department of Veteran’s Affairs, peer support extends beyond the grassroots level of mutual aid to including certified peer support specialists as an integral part of mental health rehabilitation and recovery interdisciplinary teams. The U.S. Department of Health and Human Services (1999), in its mental health report of the surgeon general, and the President’s New Freedom Commission on Mental Health (2003), in its final

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348 SMITH, HYMAN, ANDRES-HYMAN, RUIZ, AND DAVIDSON

report on transforming mental health care in America, cited peer support as an important practice in the transformation of mental health systems to be recovery-oriented. Moreover, as noted earlier, SAMHSA includes peer support among its recommended practices in line with trauma-informed care.

Researchers have examined outcomes related to the effective- ness of peer support and have uncovered preliminary evidence of its effectiveness in several domains: engagement into care; reduc- ing the use of emergency rooms and hospitals; reducing substance use among individuals with co-occurring disorders; reducing de- pression and psychosis; and increasing hope, self-efficacy, self- care, sense of community belonging, and life satisfaction (David- son, Bellamy, Guy, & Miller, 2012; Landers & Zhou, 2011; Rowe et al., 2007; Tondora et al., 2010). As the data continues to accumulate as to its effectiveness, peer support emerges as a recovery-oriented practice that may be particularly beneficial to trauma survivors.

Renew Hope and Commitment

People with higher levels of hope have been shown to possess certain positive attributes that lead them to demonstrate a higher frequency of attaining goals and a tendency to attain more difficult goals than do individuals with lower levels of hope (Snyder et al., 1991). Conversely, persons with lower levels of hope tend to perceive themselves as having a “relatively low probability of goal attainment, a focus on failure rather than success, a sense of ambi- valence, and a relatively negative emotional state during goal- related activities” (Snyder et al., 1991, p. 571). This negative disposition may result in a self-fulfilling prophecy, because those with low hope do, in fact, have lower frequency of goal attainment (Snyder et al., 1991). Not only does hope play a large role in goal attainment and feelings of agency, but it is also positively related to work performance, overall feelings of well-being, and reduced levels of stress (Reichard, Avey, Lopez, & Dollwet, 2013).

Exposure to catastrophic life events (trauma) can predispose an individual toward loss of hope and to beliefs that their efforts to attain valued life ends will be in vain. Increasing hope, connection, and positive emotions is a central focus of positive psychology (Seligman, 2011; Seligman, Rashid, & Parks, 2006). According to Seligman (2011), sense of well-being is a construct that includes positive emotion, engagement, relationships, meaning, and achievement. An explicit therapeutic focus on these aspects of well-being may be particularly helpful to individuals who have experienced a loss of hope as a consequence of painful life events and who may remain symptomatic for an extended period of time.

Trauma survivors might also begin to regain a sense of purpose, hope, and meaning through gainful employment. Recovery-oriented models of vocational rehabilitation in the U.S. Department of Veter- ans Affairs include assistance with job training, employment accom- modations, resume development, and skills coaching for job seeking. Those who are severely disabled and unable to work in traditional employment may receive assistance in starting a business or securing independent living.

Individual placement and support (IPS) supported employment programs are also available in many communities to help individ- uals with mental illness find and keep competitive employment. IPS teams are a partnership between the individual with mental illness, employment specialists, mental health care providers, and

family or friends, as desired by the prospective employee. IPS has proven to increase the incidence of competitive employment in individuals diagnosed with serious mental illness and in veterans with substance use disorders (Marino & Dixon, 2014; Rosenheck & Mares, 2007). These findings underscore the benefit of increas- ing the use of vocational rehabilitation programs with individuals experiencing trauma-related difficulties.

Foster Engagement in Meaningful Activities

For trauma survivors, a loss of meaning may occur as a result of an existential crisis related to trauma exposure and may inhibit participation or engagement in pleasurable activities (Southwick, Gilmartin, McDonough, & Morrissey, 2006). This loss of mean- ing—in addition to other factors, such as having a “severely skewed” external locus of control; a foreshortened sense of the future; and feelings of guilt, including survivors’ guilt—will likely make it difficult for these individuals to function at a level that they previously enjoyed (Southwick et al., 2006, p. 171). Through a review of empirical research focusing on meaning, Park (2010) found that stressful events, such as trauma, tended to violate an individual’s sense of meaning. Thus, the meaning that trauma survivors may have created about the world and themselves (i.e., global meaning; Koltko-Rivera, 2004) may become disrupted fol- lowing a traumatic experience, leaving survivors of trauma with a sense that the world does not hold a purpose. For persons who hold a belief in a “just world” (i.e., people tend to get what they deserve; Lerner & Miller, 1978), trauma exposure or being confronted with heinous events occurring to “good” people can cause a disruption in their belief that the world is orderly (Lerner & Miller, 1978). When a loss of meaning occurs, individuals may be left with a void and feelings of hopelessness (Southwick et al., 2006). Victor Frankl (1969) referred to this void as an “existential vacuum” (p. 83) of meaninglessness, lack of contentment, and apathy.

Several well-known evidence-based approaches to the treatment of trauma and mental illness more generally address this loss of meaning in some fashion. For example, seeking safety therapy (Najavits, 2002) includes several treatment topics concerned with restoring ideals that have been lost, including creating meaning. Acceptance and commitment therapy (ACT; Luoma, Hayes, & Walser, 2007) discusses the restoration of values and behaviors consistent with important life ends. However, the manuals of evidence-based treatments (EBTs) endorsed by the Department of Defense and the U.S. Department of Veteran’s Affairs for treating PTSD (i.e., cognitive processing therapy and prolonged exposure) do not explicitly address the transgression of deeply held moral or religious beliefs, commonly referred to as “moral injuries” (Maguen & Burkman, 2013; Steenkamp, Nash, Lebowitz, & Litz, 2013). Logotherapy may serve as an adjunctive intervention to these EBTs to increase the explicit focus of therapy on rediscov- ering meaning (Frankl, 1969; Southwick et al., 2006). Logo- therapy, which has a literal meaning of “healing through meaning” (Southwick et al., 2006, p. 162), is a meaning-focused philosophy with origins in existentialism (Frankl, 1969; Southwick et al., 2006).

In logotherapy, the therapist facilitates the discovery of meaning by assisting individuals in first separating themselves from their emotions and symptoms (paradoxical intention). In this phase, clients are made aware that they have the ability to stand in the

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349APPLYING RECOVERY PRINCIPLES

face of great adversities, instead of succumbing to victimhood or learned helplessness (Tomy, 2014). Next, logotherapists focus on perspective taking and changing attitudes (attitude modulation). Once a shift in attitude has occurred, clients are willing to find new meaning in their situations (creating openness to new beginnings). Last, logotherapists focus on promoting future mental health by discussing all meaning potentials of the individual’s life and/or situation (prophylaxis). For individuals exposed to trauma, includ- ing collective adversities (e.g., terrorist attacks), the ability to find meaning in the experience has been shown to facilitate adjustment to negative life events, allowing for the opportunity to decrease feelings of vulnerability (Updegraff, Silver, & Holman, 2008). Through case studies, Southwick and colleagues (2006) demon- strated that logotherapy assisted veterans diagnosed with PTSD in rediscovering meaning in their lives. Through volunteerism, and other “action-oriented” activities (p. 173), veterans were able to realize that they had the power to effect change and make a lasting impression on the lives of others.

Redefine Self and Incorporate Illness

One of the overarching tenets of recovery, and one of the most difficult to achieve, is the redefinition of one’s self as an individual whose mental illness is merely one aspect of who he or she is (Davidson et al., 2006; Kidd et al., 2011). This is often difficult for consumers of mental health services because they are constantly barraged with messages that lead them to adopt an identity that is defined by their illness and symptomatology. Moreover, the role of “mental patient” is often reinforced by a system that has histori- cally “valued and rewarded compliance and passivity over signs of autonomy and independence” (Davidson et al., 2005, p. 152). There are a number of ways that trauma survivors might begin to redefine themselves, including adopting a view of self-compassion and applying ideologies to their lives that are consistent with their values.

Self-compassion, defined by Neff (2003) as giving oneself the same care and concern that one would provide a loved one expe- riencing difficulties, is comprised of three facets: self-kindness (rather than self-judgment), common humanity (i.e., experiencing difficulties is a normal part of life), and mindfulness (rather than overidentification). Self-compassion can be viewed as accepting oneself including all of one’s imperfections. Possessing self- compassion increases the likelihood of redefining oneself because it increases the likelihood that individuals will engage in goal setting (including health-promoting goals) and the self-regulation needed to attain those goals (Terry & Leary, 2011). If individuals possess self-compassion and, thus, are able to value themselves and engage in behaviors that promote overall well-being, then they might be less likely to rely on others to make health decisions for them. Possessing self-compassion has been shown to lead to an increase in quality of life and an alteration in the perception of stress (Gard et al., 2012). It can be viewed as one way to increase autonomy and independence from mental health systems in which one’s individuality and voice might be lost.

Changing the way they view mental health and symptomatology is another way in which trauma survivors can begin to redefine themselves and incorporate the symptoms of illness into their lives, rather than waiting for symptoms to abate. According to Baer (2005), certain mindfulness-based interventions with an evidence

base, such as acceptance and commitment therapy and dialectical behavior therapy assist individuals to live fulfilling lives as they “place less emphasis on changing the form or content of psycho- logical experiences (thoughts, sensations, emotions, urges) and more emphasis on changing their functions” (para. 4). Baer further stated that the “goal of many of these treatments is to change people’s relationships to their internal experiences, rather than necessarily changing the experiences per se” (para. 4). This phi- losophy is especially pertinent in the case of trauma, in that the life experiences of trauma survivors and/or specific events lead to intrusions, reexperiencing, and avoidance, among other symptoms. Because the trauma cannot be “undone” and the experiences cannot be changed, another way to approach these tragic events and memories would be to accept their occurrence and exercise mindfulness (Baer, 2005). The use of mindfulness to treat trauma has increased in recent years and has been proven effective in treating women with posttraumatic stress as well as with border- line personality disorder (Harned & Linehan, 2008). Recent stud- ies have also shown mindfulness-based techniques to be effective in reducing symptomatology and improving overall functioning of firefighters and other first responders who often meet criteria for trauma exposure due to the nature of their occupations (Smith et al., 2011). These finding suggest that early introduction of and training in mindfulness may attenuate symptoms of trauma expo- sure in vulnerable populations.

Overcome Stigma

The stigma of mental illness is an unfortunate reality that has the potential to disrupt efforts to strive toward recovery. Not only does stigma affect how society responds to individuals diagnosed with mental health conditions (public stigma), but it also negatively impacts how individuals working toward overcoming mental ill- ness perceive themselves (self-stigma; Corrigan, Powell, & Rüsch, 2012). Both public and self-stigma have the potential to thwart efforts to improve quality of life and restore social roles held prior to a mental health diagnosis. The belief that individuals with mental illness are “dangerous,” a belief held for many decades, leads to fear (Corrigan et al., 2002) and can create barriers to recovery. For example, the negative stigma attached to mental illness can create barriers to finding appropriate housing and gainful employment—two major cornerstones of recovery from mental illness.

Though studies show that both public stigma and self-stigma negatively affect employment (Corrigan et al., 2012; Corrigan, Kosyluk, & Rüsch, 2013), further analysis of the effects of stigma have found that self-stigma was related to short-term unemploy- ment (unemployment within the past 3 months up to 1 year), whereas public stigma was related to an individual “ever” having worked (Corrigan et al., 2012). Self-stigma was likely to have an impact on employment due to individuals’ internalized societal beliefs that they were unable or incapable of sustaining employ- ment. The “why try” effect, a term used to describe the internalized feelings of unworthiness and inability to possess work-related skills and independence, is thought to be one of the main under- lying reasons related to short-term unemployment (Corrigan et al., 2012, 2013). Though employment is only one domain in which stigmatization occurs, it is a major factor in recovery from illness because it gives people the opportunity to regain a sense of control

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350 SMITH, HYMAN, ANDRES-HYMAN, RUIZ, AND DAVIDSON

and normalcy in their lives. Through education and realization of strengths, consumers may be able to debunk the commonly held beliefs that they are incapable of maintaining employment, and employers can mitigate the culture of stigma toward mental illness.

Stigma related to difficulties arising from trauma exposure, much like other forms of mental health difficulties, is likely to decrease the chances that mental health services will be sought (U.S. Department of Health & Human Services, 1999). To avoid being labeled and experiencing the inherent stigmatization and discrimination that often accompanies the label of “mentally ill,” many people decide to forgo pursuing mental health services altogether (Kessler et al., 2001). More often than not, soldiers and veterans who are trauma survivors experience a heightened con- cern regarding being labeled as mentally ill due to the hypermas- culine nature of military culture (Bastien, 2013). According to Bastien (2013), military culture values traditional constructs of masculinity, often including endurance and fearlessness. Thus, the idealization of these constructs may make acknowledging a need for services as a “weakness,” and stigma within the military culture (or other hypermasculine professions such as police work) may increase the chances of stigmatization and discrimination.

The medical, or “disease,” model of understanding mental ill- ness might have unintentionally led to increased stigmatization and discrimination of individuals diagnosed with mental health condi- tions due to the inherent segregation of individuals into various categories. Corrigan, Watson, Byrne, and Davis (2005) suggested that although a strength of the medical model is the decreased blame attached to persons with mental health difficulties, a weak- ness is that stigma might be exacerbated by “reinforcing notions of individual difference and defect” (p. 363). In fact, some research- ers have identified borderline personality disorder (BPD) as an example of a diagnosis that is often given erroneously to survivors of childhood sexual abuse (particularly women), which results in increased stigmatization (Miller, 1994; Trippany, Helm, & Simp- son, 2006). The danger of sexual trauma survivors being given a formal diagnosis of BPD is the increased stigma associated with this diagnosis (Miller, 1994: Trippany et al., 2006). In addition to insurance companies’ hesitancy to reimburse for treatment, many mental health professionals are also hesitant to work with clients with a BPD diagnosis, because many hold the belief that prognosis is poor and view the coping strategies employed by these individ- uals as “manipulative” and thereby off-putting. Hodges (2003) suggested that in order to decrease stigma related to BPD, the BPD diagnosis should be subsumed under the PTSD diagnosis as a subcategory. According to Hodges (2003) and Miller (1994), do- ing so may increase the chances that practitioners will shift focus away from characterological concerns and focus more on the feelings or experiences that are maintaining the destructive behav- iors.

Clinicians and treatment providers are in a unique position to reduce stigma through training, outreach, and education. Although education has been found to be less effective in reducing stigma when compared to having contact with individuals with mental illness (Corrigan et al., 2001, 2002), it has shown some benefits and can be viewed as a starting point. In addition, the employment of individuals with mental illness as peer support specialists may serve to reduce stigma by showcasing the invaluable contributions made to an interdisciplinary care team by a living example of recovery. Illness management and recovery is an evidenced-based

psychoeducational intervention recognized by SAMHSA that ad- dresses the topic of stigma directly and can be implemented in an individual or group format by peer support specialists to assist individuals in recovery.

Assuming Control, Becoming Empowered, and Exercising Citizenship

Assuming control signifies that a person has the right to be “psychologically independent and to maintain psychological integ- rity” (Rogers, 1942, p. 127). Assuming control over one’s identity and life includes having control over treatment decisions and treatment goals. Nondirective approaches allow patients to express their needs and discuss what they would find helpful while inviting discussions of individual differences (e.g., culture, motivation) that could influence treatment goals and preferences (Norcross & Wampold, 2011). In working with individuals affected by child- hood trauma, for example, Gold (2000) found that taking a more nondirective approach with clients led to a treatment focus that moved past a discussion of trauma. According to Gold (2000),

When we entrusted our clients to direct the course of therapy and to educate us about their needs and concerns, specific instances of abuse became an increasingly peripheral focus of attention. Instead, the scope of treatment, while it subsumed overt incidents of maltreatment, became much broader. (p. 215)

Trauma-informed care (TIC) initiatives presume that all indi- viduals have been exposed to trauma, either directly or indirectly, and structure treatment environments around this assumption (Fallot & Harris, 2006; M. Wolf, Green, Nochajski, Mendel, & Kusmaul, 2014). Consistent with nondirective psychotherapies and trauma-informed care, incorporating an awareness of the loss of control inherent to experiences of trauma into evidenced-based approaches to the treatment of trauma may assist providers in empowering the individuals they work with.

Managing Symptoms

Managing symptoms entails an individual’s taking an active role in the utilization of services, medications, and/or coping skills (Deegan, 1996). Complete remission of symptoms is not a prereq- uisite to recovery; however, getting symptoms to a level that is manageable may enhance daily functioning and overall feelings of hope and autonomy. There is a stark difference between managing symptoms in the context of recovery and traditional medical mod- els of treatment. Whereas recovery focuses on individuals’ iden- tification of a level of symptom reduction that is ideal and will allow them to function and take an active role in their recovery, traditional models of care give power to the professionals in determining a level of symptom reduction that is ideal (Deegan, 1996; Slade, 2010). It is important to give credence to factors separate from symptomology when working toward recovery, be- cause research has shown that decreases in symptomatology do not translate into improvement in functioning or feelings of well-being (Becker, Chorpita, & Daleiden, 2011).

Person-centered integrative diagnosis (PID) may be an effective way for clinicians to gain a clear diagnostic picture that includes both illness and positive aspects of health, such as levels of functioning and quality of life (Mezzich et al., 2010; Salloum &

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Mezzich, 2011). PID can be considered recovery-oriented in that the relationship between the clinician and patient is seen as a collaborative one that entails ongoing interactions and shared decision-making that take into consideration the values and aspi- rations held by individuals presenting for treatment (Salloum & Mezzich, 2011). This approach differs from traditional diagnostic systems that focus heavily on deficits, functional impairment, and symptomatology. Similar to recovery-oriented care, PID takes into account the impact that one’s community, significant relationships, and culture have on the expression of illness or wellness and also the role that they play in recovery (Mezzich et al., 2010). The use of the PID pillars in diagnostic formulation provide for a rich informational base that will allow the clinician and patient the opportunity to cocreate strength-based care plans that can guide recovery. The Wellness Recovery Action Plan (WRAP; National Registry of Evidence-Based Programs and Practices, 2013) is another tool that may be helpful in assisting individuals in recov- ery from trauma to experience empowerment and to exercise shared responsibility in recovery planning. WRAP is a manualized group intervention for adults with mental illness, and it is included on SAMHSA’s National Registry of Evidence-Based Programs and Practices. WRAP guides individuals through the process of identifying and understanding their personal wellness resources (“wellness tools”) and then helps them develop an individualized plan to use these resources on a daily basis to manage their mental illness.

Discussion

According to Gehart (2012), providers working in the context of recovery engage patients as partners in treatment, regularly assess social and meaning systems (i.e., assess for sense of purpose, meaning, belonging, hope, well-being, and current resources), engage in recovery planning and therapeutic interventions that allow for advancement toward recovery goals, and provide assis- tance in accessing needed resources. Whereas practitioners may agree to these principles in theory, translating recovery principles into a fully integrated system of knowledge and practices consis- tent with trauma-informed care represents a challenge to the men- tal health field. As but one example, working to infuse hope for recovery while simultaneously encouraging acceptance of limita- tions caused by psychiatric illness may be a particularly challeng- ing prospect.

This article offers specific practice recommendations consis- tent with recovery-oriented, trauma-informed care to assist cli- nicians in transforming theory to practice in treating individuals impacted by trauma. Key practices include (a) increasing com- munity and social support through peer support; (b) renewing hope and commitment through vocational rehabilitation; (c) fostering engagement in meaningful activities through an ex- plicit focus on the discovery of meaning in life through thera- pies that focus on amplifying meaning and engagement; (d) redefining the self and incorporating illness by offering guid- ance on self-compassion, as well as changing the function of psychological experiences through mindfulness-based thera- pies; (e) overcoming stigma through a focus on the psycholog- ical experience and sequelae of trauma and training, outreach, and education concerning trauma and stigma; (f) assuming control, empowerment, and citizenship through the use of non-

directive therapies; and (g) managing symptoms through person-centered integrative diagnosis and the Wellness Recov- ery Action Plan.

Behavioral health system reform is concerned with a growing awareness that the elimination of disease is not equivalent to psychological health and well-being. Similarly, the matter of treat- ing trauma effectively requires a complex understanding of the phenomenology of trauma and factors that both promote and inhibit recovery and resilience. For example, cognitive processing therapy (CPT) and prolonged exposure (PE) have been dissemi- nated throughout the Department of Defense and Veterans Affairs as leading interventions for the treatment of trauma. These inter- ventions were designed to assist individuals exposed to fear-based, life-threatening experiences to reappraise fear-based cognitions about incompetence and/or the dangerousness of the world (as in CPT) or through repeated exposure to the feared stimulus to habituate and extinguish the conditioned fear response (as in PE). However, outside the research lab, the contexts of trauma are more complex and arouse more complex responses than fear—for ex- ample, shame, guilt, resentment, grief, agony. As outlined by Steenkamp et al. (2013), because the mechanisms and techniques to treat trauma flow from a fear-based conceptualization, CPT and PE are less effective for individuals experiencing difficulties as- sociated with complex trauma and complex reactions to trauma. For example, Steenkamp et al. have developed a protocol to treat deployment-related moral injury and traumatic loss that involves confession of the perceived transgression to a compassionate moral authority and then assuming the role of the moral authority to increase self-compassion. Whereas the effectiveness of the intervention is as of yet undetermined, preliminary evidence has been promising (see Gray et al., 2012), and the paradigm shift is noteworthy. Conceptualizations of trauma, recovery from trauma, and resilience are growing from a more mechanical focus on symptom reduction to more careful consideration of the manner in which growing hope, meaning, compassion, and connection can serve to bolster resilience and wellness. Although this article does not focus on resiliency per se, it is important to note that trauma- exposed individuals who do not experience clinically significant impairment may still receive great benefit from receiving treat- ment that incorporates recovery-oriented principles. These individ- uals may be in a unique position to strengthen psychosocial factors that contribute to their resiliency, especially because some of the recovery principles may be directly related to resiliency (e.g., meaning and social support; Alim et al., 2008; Southwick et al., 2005).

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Accepted July 6, 2016 �

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d by

th e

A m

er ic

an P

sy ch

ol og

ic al

A ss

oc ia

ti on

or on

e of

it s

al li

ed pu

bl is

he rs

. T

hi s

ar ti

cl e

is in

te nd

ed so

le ly

fo r

th e

pe rs

on al

us e

of th

e in

di vi

du al

us er

an d

is no

t to

be di

ss em

in at

ed br

oa dl

y.

355APPLYING RECOVERY PRINCIPLES