Building a trauma model in the real world

I'm not an academic. I'm a clinician who owns and operates a large specialty DBT practice.

For more than two decades at Mental Health Systems (MHS) www.mhs-dbt.com, I've had the opportunity to develop treatments, train clinicians, build programs around them, and see what actually works in practice.

That's shaped how I think about treatment models. I appreciate theory and research, but I'm especially interested in whether a model helps us understand complex clients and make better clinical decisions.

What is happening with this person, and what should we do next?

That's the practical question behind the Dialectical Trauma Recovery Model (DTRM).

The earliest roots of DTRM go back to trauma-focused DBT work I developed under a federal contract with the Department of Justice for the Federal Bureau of Prisons. The ideas continued to develop through clinical work, training, writing, and building programs for people with complex needs.

Eventually, we built a program around the model at MHS: the RISE Program for Trauma Stabilization and Recovery.

Putting DTRM to work in an actual clinical program has taught us a lot.

Complex trauma is, well, complex

People rarely show up with trauma affecting one convenient part of their lives.

Someone might have intense emotions, dissociation, chronic physiological activation, difficulty understanding body signals, relationship problems, avoidance, shame, and pretty entrenched beliefs about themselves. Maybe all at once.

So where do you start?

DTRM organizes trauma across five systems and eleven domains. That gives us a map of where someone is struggling and how those areas may be interacting.

We've found that map very useful in RISE.

Rather than treating "trauma" as one giant thing, we can get more specific. Is the primary problem emotional? Cognitive? Nervous system activation? Dissociation? Interoception? Behavior? Relationships? Usually there's more than one thing going on, but that doesn't mean we need to work on everything at once.

The map helps us decide where to start.

More skills aren't necessarily better

I've worked with DBT for a long time. It has an extraordinary collection of skills, and obviously I'm a fan as DBT has literally been my career.

But giving someone more skills isn't necessarily better treatment.

The more useful question is: Which skill, for which problem, at which time?

Someone whose nervous system is highly activated may need something different from someone who is dissociating. Someone struggling with rigid thinking may need something different from someone who has difficulty tolerating body sensations.

These problems can certainly interact, but they aren't the same thing.

That's where the RISE method comes in:

Recognize → Identify → Skills-Based Response → Evaluate and Adapt

In practical terms, we figure out what's happening, identify what seems to be driving it, choose a targeted response, and see what happens.

Then we adjust. It's pretty straightforward. That's intentional.

Stabilization is more than preparation

This is one area where running RISE has reinforced something I already believed.

Trauma treatment is sometimes conceptualized as stabilization followed by the "real" work of trauma processing.  I don't think that's quite right.

If someone becomes better able to regulate emotions, stay present, understand what's happening in their body, respond differently to triggers, improve relationships, and have more control over their life, that's meaningful recovery.

For some people, those changes prepare them to do trauma processing later.

For others, they may get where they want to go without needing a separate trauma-processing treatment.

Both are fine.

The point isn't to move everyone through the same sequence. It's to help the person in front of us get better.

It helps clinicians too

One thing we've learned from RISE is that DTRM doesn't just give clients a map. It gives clinicians a shared way to think about complicated cases.

Anyone who has done enough clinical consultation knows how easy it is for five therapists to have six different ideas about what's going on with someone.

That's not necessarily bad. Different perspectives are useful, and at some point we still have to decide what we're treating.

DTRM gives us a common language for doing that.

Where is the dysregulation? Which systems and domains are involved? What seems to be driving the current problem? What capacities does the client already have? What might need to be strengthened? Are we targeting the right thing?

Those conversations tend to be more useful than simply concluding that someone is "stuck" or "not progressing."

For organizations, I think this may be one of the most useful parts of the model.

Clinical practice has changed the model

DTRM wasn't developed, written down, and then handed to clinicians as a finished product.

It's been shaped by practice.

My Department of Justice work influenced it. Years of DBT practice influenced it. Training clinicians influenced it. And building and running RISE at MHS has continued to influence it.

We've changed language. We've refined tools. We've gotten clearer about how we map someone's overall pattern versus how we make a decision about what to do in a particular moment.

And occasionally an idea that seemed really clever turned out to be less useful once we actually tried it.

That's clinical practice.

I'd much rather find that out and change it than become overly attached to my own model.

That's how I approach training

The same thinking carries over to the Lane Pederson DBT and Trauma Training Institute.

I want clinicians to understand the theory, but I also want them to know what they're going to do with it.

Most experienced clinicians already know a lot of techniques. The harder part is often figuring out what to use, when to use it, and why.

Organizations have another challenge. They need clinicians with different backgrounds and approaches to have enough shared language that they can conceptualize cases, consult with each other, and make coherent treatment decisions.

That's where I think DTRM can be especially useful.

Through the Institute, I provide DTRM training and consultation for behavioral health organizations, treatment programs, hospitals, agencies, and clinical teams.

We've learned a lot by putting DTRM to work at MHS, and we'll keep learning.

That's how it's supposed to work.

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