Marjan G. Holloway, PhD, Beck Institute Faculty

As an educator, I have noticed that two subgroups of clients are highly likely to activate anxiety and other types of emotional distress (e.g., professional burnout) among clinicians. The first subgroup consists of traumatized clients and the second subgroup consists of suicidal clients. When working with clients who are traumatized and suicidal, the potential for therapy-interfering emotions such as excessive worry and therapy-interfering behaviors such as avoidance on the part of the clinician notably increases. These problematic emotional and behavioral reactions often stem from a series of maladaptive clinician cognitions, as described below.

  1. All-or-None Thinking (Example: “After months of therapy, nothing has changed.”)
  2. Catastrophic Thinking (Example: “If I ask too many questions about the traumatic event, the client will deteriorate, fall apart, and may even become suicidal.”)
  3. Labeling (Example: “This client is resistant to change – wants to remain a victim.”)
  4. Personalizing (Example: “As an incompetent therapist, it’s my fault that the client remains symptomatic.” )

We have all been there. I recall my excitement after having received a new client referral in the early years of my practice. This excitement quickly transformed to anxiety, indecisiveness, and self-doubt as I learned about this particular client’s history of multiple lifetime traumas and suicidal behaviors. I was terrified to accept the case as a newly licensed psychologist and I frankly questioned my ability to work effectively with the client (even after years of solid clinical training). Not surprisingly, I avoided taking the case. 

Young woman crying during a counseling session

To address my sense of responsibility and guilt, I started to call colleagues to find a good referral source. Very quickly, I discovered that other clinicians, regardless of their seasonality, were similarly not available to accept a “complex” trauma case who was also considered at high risk for suicide. As I listened to the justifications provided by these clinicians, I had an opportunity to examine my own beliefs about the client. I realized that these beliefs, along with my negative emotions, were dictating my decision to avoid.

Which CBT Approaches Are Most Effective for Trauma?

When I teach CBT for PTSD, I review two evidence-based CBT interventions for trauma: Prolonged Exposure (PE; Foa, Hembree, & Rothbaum, 2007) and Cognitive Processing Therapy (CPT; Resick & Schnicke, 1996).  While each intervention has a different theoretical underpinning and technical approach, both emphasize the following:

  • The importance of having the client understand (i.e., “digest”) the traumatic event
  • The importance of having the client understand that the memory of the traumatic event, by itself, is not dangerous and therefore, not to be avoided

By repeated exposure to the memories associated with the traumatic event and/or repeated examination of the impact of the traumatic event, the traumatized client can gain a sense of control and mastery over the traumatic memories.

Building Competence and Confidence with High-Risk Clients

To date, there is no scientific evidence to suggest that asking about trauma-related and/or suicide-related content exacerbates psychiatric symptoms. CBT clinicians can learn to effectively manage their own anxiety and emotional distress, while working with this highly vulnerable client population, by engaging in the following recommended activities:

  • Gaining continuing education in evidenced-based CBT for PTSD
  • Being mindful of their own therapist maladaptive emotions, cognitions, and/or behaviors
  • Seeking peer consultation and/or supervision, as needed
  • Listening carefully to the trauma/suicide narratives of their clients in order to construct meaningful cognitive behavioral conceptualizations for treatment planning
  • Paying close attention to self-care and early signs of professional burnout

Working with traumatized clients is certainly not easy. However, we as CBT clinicians have the responsibility to intervene, rather than to avoid. Prolonged Exposure and Cognitive Processing Therapy are two CBT-oriented treatment packages that are evidence-based. Gaining familiarity and future competency in delivering these interventions will certainly prove to be beneficial to your clients and to you.

References:

Foa, E. B., Hembree, E. A., & Rothbaum, B. O. (2007). Prolonged exposure therapy for PTSD: Emotional processing of traumatic experiences – Therapist guide. New York, NY: Oxford University Press.

Ghahramanlou-Holloway, M., Neely, L., & Tucker, J. (2014). A cognitive-behavioral strategy for preventing suicide. Current Psychiatry, 13(8), 18-25.

Resick, P. A., & Schnicke, M. K. (1996). Cognitive processing therapy for rape victims. Newbury Park, Sage Publications.

Read more about CBT for trauma and suicidality: