Healing and Help

from Jules - Thursday, December 22, 2005
accessed 2480 times

I have wanted for some time to talk about my own experience with therapy and treatment and to ask for others opinions on this issue. I do agree that we all have our own path to healing and it is a deeply individual and personal road. What I am writing about here is my own experience and what I have learned. I invite those with differing views as well as those who have experienced the same to comment on this topic.

This past year I have faced a number of personal crisis’s and began the difficult process of finding appropriate treatment and support. What I write here is my own opinion, based on my own experiences and research. I am not a medical professional and my views are subjectively just my own.

Counselling vs. Treatment

Personally I strongly dislike the term counselling and I never use it for myself when thinking or talking about my own support. Counselling is a trigger word for starters. It was usurped into the group lexicon and for me recalls memories of intrusive “shepherds” in the group who took it upon themselves to pass judgement on every aspect of my life.

Counselling also implies advice giving, which is not, in my experience, what therapy entails. What therapy is, in my experience, is what a participant previously expressed so well: “[it’s] about you placing things properly, it’s not necessarily about you learning, it’s about you understanding.”

The therapeutic practitioners I have seen who have been appropriate and helpful do not tell me what to do, what my “faults” are or what I should or should not think. What they have done and continue to do is to provide assistance, tools and guidance for my own processing of my experiences and thought processes.

Myths and Lies

One of the most insidious myths the Family perpetuated that has haunted me is that: “if you doubt the Family you will go crazy”. After the publication of “The Last State”, in which Merry Berg was portrayed as insane for believing that David Berg was an abusive alcoholic, one of the primary fear tactics used on teenagers and children raised in the Family was that doubting anything the leaders said would make you crazy. The emotional distress caused from the inability to reconcile what was forced on to us as truth and what our minds, bodies and souls screamed to us was consistently and frequently used as evidence of “instability” and “insanity”.

Of course, looking back from the other side of the wall, I can see the insanity in the position that doubting nonsense like “astronomical fakery” and believing that the stars really were millions of light years away meant you were crazy. Yet, even when I became aware of the manipulation and obvious gaslighting, the residue of the stigma and fear of the C word lingered.

This disdain and simplistic dismissal of psychiatric distress can be seen in the slickly manufactured statements from Family spokespersons and leaders regarding Ricky Rodriquez’s “disturbed mental state”. In it’s more raw essence it can be seen in the condescending and sociopathically callous statements from current young Family members such as Lorie Richards on the Dr. Phil message board: “can’t agree more that these folks appearing on your show obviously need help and need to move on with their lives.”

Perhaps the greatest obstacle to overcome for me in seeking professional support has been learning to understand that being in psychiatric distress does not make one “crazy”. I began to educate myself on the effects of trauma and started to understand why I was in so much pain. I began to understand the principles of cause and effect and how the years and years of abuse had built up residue in my body and mind. I began to understand that the pain I was feeling was not my fault nor was it the result of “hanging on to the past” or a conscious choice to relive the trauma. The shame the Family had taught me to associate with my emotional distress was unwarranted and yet another lie. I started to see past my own fear of being “crazy” and to understand that to attempt to ignore the effects of trauma and to ignore my own need for resolution, balance and healing was to silence my inner self all over again.

When I could finally face up to the fact that many things I was doing to relieve my own anguish were in the long term self-destructive, harmful and dangerous, although admittedly providing a measure of immediate and short term relief, I could then begin to look for resolution and treatment.

Trauma and Recovery

The single most useful thing I have experienced this past year since actively seeking treatment has been reading the book Trauma and Recovery (Judith Herman, 1992). While written for health care providers and therapists, it describes, with uncanny accuracy, everything I have experienced. From the self-destructive behaviour I engaged in without knowing why, to the fears, nightmares and unexplained panic, to attempted revictimization by perpetrators, almost each and every passage in this book was something I could immediately relate to.

Most importantly of all, the second half of the book describes recovery for trauma victims, which meant for me that there is a healing process and there is a way out of the darkness and pain.

PTSD and Complex PTSD

From what I understand, when a person undergoes a traumatic event, five neurotransmitters in the nervous system are altered. These are natural and biochemical responses that put the body and mind into hyper-vigilance so as to react for maximum survival in an emergency response situation. However the body’s chemistry becomes radically altered through this process, the after effects of which can be long lasting and is known as post traumatic stress disorder (PTSD).

With a single traumatic event, the after effects can last for some time, but usually will eventually wear off and can be helped with treatment and medication. However when the trauma persists for an extended period of time and is repeated again and again, the body and brain’s chemistry may not just become altered but will radically change. The long term consequences of such neurological hijacking can be profound and is known as complex post traumatic stress disorder (CPTSD). In particular when children undergo extensive and prolonged trauma, the effects are much more difficult to overcome.

As an example, one of the neurotransmitters released during a traumatic event are endorphins, which inhibit pain and relax us. This can enable victims of physical trauma to mobilise themselves as needed to escape further harm and to overcome fear and react in a crisis. As the endorphins subside, the victim may go into a period of withdrawal, similar to opiate withdrawal and may experience irritability and anger. If one has experienced frequent and repeated trauma over many years, the brain may become accustomed to a higher level of endorphin release. This can result in an addiction to the higher level and as a result one may be driven to seek out danger, pain or trauma re-enactment to maintain the neurological levels they have become accustomed to. This behaviour is subconsciously and neurologically driven, without the person consciously knowing why they engage in such things as abusive relationships, self-inflicted harm or dangerous activities.

Another example is the effect of the neurotransmitter norepinephrine, a by-product of adrenaline. Norepinephrine increases alertness, muscle readiness and efficient problem-solving. It enables us to cope with a crisis and do what we must to survive. However, extended stimulation of adrenaline can result in hyper-vigilance long after the danger is past. One may experience insomnia, exaggerated startle responses, mood irritability, panic attacks, muscle and joint pain and tension headaches.

In particular both endorphins and norepinephrine are crucial in encoding the memory of a traumatic event. When both neurotransmitters are present, the memory of an event is recorded in a different way than a typical memory. Most memories are integrated into the consciousness in a somewhat linear way. While there is no hard evidence on this as yet, researchers speculate that REM sleep and dreams help us accomplish this. Traumatic memories can become detached and may become intrusive, resurfacing at inappropriate times and places. They may be triggered by smells, sounds, places, feelings or words that remind one of the event (which is what is meant by a “trigger”). An intrusive memory that resurfaces with force is known as a flashback. The person experiencing such a memory may think, react and feel as though they are right back experiencing the traumatic event.

In addition, people who have endured repeated trauma may have depleted their bodies supply of certain neurotransmitters. When this occurs a person may retreat into avoidance. They may find little motivation for anything at all and generally retreat from life. Learned helplessness, which is a common effect of repeated trauma, compacted with biochemical withdrawal may result in depression. Depression in victims of extended trauma is bio-chemically different from depression in non-traumatised persons in that there is no cortisol present. From what I understand, no one yet knows exactly why this is, but it is a measurable and quantifiable neurological difference.

Why Seek Treatment?

Not everyone who has experienced trauma suffers from PTSD. I however do, and for me the symptoms had been slowly pushing my life further and further out of control for a number of years. It reached the point where I was no longer able to maintain the level of functioning I needed to and my life became unmanageable. In retrospect, I realise it would have been better for me to seek treatment before I reached this stage of anxiety, but at least I am getting help now.

Symptoms of PSTD have been listed as follows:

"The symptom profile of adults who were abused as children includes posttraumatic and dissociative disorders combined with depression, anxiety syndromes, and addictions. These symptoms include
(1) recurrent depression;
(2) anxiety, panic, and phobias;
(3) anger and rage;
(4) low self-esteem, and feeling damaged and/or worthless;
(5) shame;
(6) somatic pain syndromes
(7) self-destructive thoughts and/or behavior;
(8) substance abuse;
(9) eating disorders: bulimia, anorexia, and compulsive overeating;
(10) relationship and intimacy difficulties;
(11) sexual dysfunction, including addictions and avoidance;
(12) time loss, memory gaps, and a sense of unreality;
(13) flashbacks, intrusive thoughts and images of trauma;
(14) hypervigilance;
(15) sleep disturbances: nightmares, insomnia, and sleepwalking; and
(16) alternative states of consciousness or personalities."
- Joan A. Turkus, M.D.

Additional information on the symptoms of PTSD can be found here: http://www.behavenet.com/capsules/disorders/ptsd.htm

For myself, the most intense and distressing symptom of PTSD was dissociation. When my anxiety and level of stress would peak, I would detach and completely shut down. This resulted in memory gaps and “lost time”. I would “wake up” hours later with no memory of how I got where I was or what had occurred in those hours. This was both extremely frightening and dangerous. While this was the most extreme symptom, other symptoms caused a great deal of emotional distress as well.

Friends and Family

Some participants here have said that the role of a therapeutic practitioner can be filled by friends and family. I disagree with this as it relates to trauma recovery and have disagreed with my own health care providers on the level of support these people can and should provide.

Firstly, I think it is unfair for friends to be expected to be in a supportive role for extended periods of time. My own experience has been that turning to friends for support while in the throes of a crisis can overwhelm them and cause them a great deal of stress and worry. While friends can provide short term and immediate support, I do not believe it is appropriate to expect them to carry out this role for any extended time period. In particular if the friend also struggles with similar PTSD symptoms, emotional venting from those they care about can exasperate their own condition. Over the past few years, one of the reasons for my own symptoms worsening has been from the constant expectation of support that I have believed others required of me. This is not anyone’s fault, but as I learn about healthy boundaries I am able to pull away from demands that are unreasonable or unsafe, some of which I had placed on myself.

I believe that writing or interacting on a web site can be different due to the emotional detachment from most of the other participants (emotional flame wars aside). There is also no direct expectation on most participants for support of another.

Secondly, for many of us, including myself, our families are anything but healthy and/or supportive. My parents are still cult members and anything I tell them is duly reported to cult leaders and used as a way to attack myself and others. When not actively participating in my abuse as a child, my parents took on the role of the non-protecting bystander, a position that still generates a great deal of anger for me. My parents still take on this role and their simplistic world-view does not provide any sort of support or care. To even expect support from them does me harm as they again and again choose their own religious zeal over the well being of their children.

With my siblings, as with my friends, I believe it is unfair to expect them to provide extended support. Many of the view-points we grew up with, taught to us by our parents and reinforced by the group, were unhealthy and damaging. When emotions run hot it is easy to fall back into those roles of blame, anger, jealousy and dishonesty. I have had a great deal of anger towards my siblings through much of this year because they have simply not provided the support for me that I have for them for so many years. However, again as I learn more about appropriate boundaries, I realise that the role I previously allowed myself to be cast in was unfair to me and it is equally as unfair to expect them to provide that to me.

Self-Medication

A common by-product of trauma and one that I have experienced first hand for many years is self medication. The first day that I first started coding the first version of MovingOn I was drinking to do so. From that point on almost every time that I have met, talked to or written a co-survivor of TF, I was drinking. I wanted to do what I could to provide support to others and I wanted to keep my promise to myself that no one should ever have to be as alone as I was. But just being around, talking to, or even working on the code for a web site for other people from my past put me into an immediate panic. I couldn’t breathe, my heart would pound, I would shake from head to toe and I had an irrepressible urge to get up and run. The only thing that would keep me there was a drink or two or three or more.

I have been in treatment for my drinking. I have been learning other ways to cope with my obligations and I have also been learning that some obligations I think I have I can actually walk away from. As a trauma survivor, self-medication, whether drinking in the past few years or other substances in the previous ones, is what I have found as an immediate relief from the panic and the pain. I have tried to hide it most of the time, but it is what is and I am now at the point where I can face it. I have not been entirely successful in overcoming this and still find it very difficult to be around a large number of former survivors without alcohol, but it is getting better.

PTSD and CPTSD is a result of neurochemical imbalances in the brain. Medication can help bring the AWOL neurotransmitters under control and help to restore balance in the body. (If you don’t believe that neurochemistry fundamentally alters us, try seeking comfort from a PMSing woman or getting a truthful answer from a sexually aroused man.)

I find myself now looking to my own advice and something I have told many of my friends and family throughout the years who have also gone down this road: “if you self-medicate, why not see a doctor? At least the drugs you get from them are regulated, not cut with anything and can be specifically tailored by a specialist to treat your specific need. They are not illegal and can actually help your neurochemistry in the long run instead of doing who knows what to it.”

Psychopharmacology

I do think that many doctors tend to gravitate towards medications they have a vested interest in, whether or not they are the most appropriate for their patient. I know for a fact that here in Canada, pharmaceutical companies have relationships with hospitals, clinics and researchers and fund grants and research in exchange for recommendations and prescriptions from medical practitioners to their patients.

That being said, medication can be extremely helpful in the treatment of CPTSD. There are drugs that can alleviate the trauma of nightmares and deal with insomnia. Anti-depressants can treat suicidal ideation, anxiety and depression. Other medications can help with disassociation and flashbacks. Medication alone is not seen an effective treatment for PTSD, but studies have found that a combination of medication and psychotherapy is the most effective form of treatment.

There are a number of medications that are used for PTSD treatment. These include:

Sertraline (Zoloft) – A 2000 study concluded that: “Our data suggest[s] that sertraline is a safe, well-tolerated, and effective treatment for PTSD.” As of May, 2000, the U.S. Food and Drug Administration (FDA) approved this medication for treating PTSD.
Paroxetine (Paxil) – A 2001 study stated that: “Paroxetine treatment resulted in statistically significant improvement on all three PTSD symptom clusters (reexperiencing, avoidance/numbing, and hyperarousal), social and occupational impairment, and comorbid [concurrent] depression.” In 2002 the Therapeutic Products Directorate (TPD) of Health Canada approved Paxil for the treatment of PTSD.
Citalopram (Celexa) - Affects the concentration and activity of the neurotransmitter serotonin, a chemical in the brain thought to be linked to anxiety disorders.
Fluoxetine (Prozac) – A 2002 study found that “Fluoxetine is effective and well tolerated in the prevention of PTSD relapse for up to 6 months”.
Fluvoxamine (Luvox) – A 1992 study of Dutch WWII veterans found that “treatment with fluvoxamine may offer alleviation of chronic PTSD symptoms, in particular insomnia, nightmares, anxiety, intrusive recollections, guilt feelings and tiredness.” .

Medications considered second line treatments for PTSD are:

Venlafaxine (Effexor) – Often used to treat panic and anxiety disorders. A 2005 study found “Patients with posttraumatic stress disorder (PTSD) showed significant improvement when treated with sustained-release venlafaxine”.
Nefazodone (Serzone) – A 1999 study concluded “Nefazodone showed a broad spectrum of action on PTSD symptoms. This profile might make nefazodone a useful drug to treat PTSD.”
Mirtazapine (Remeron) – A 2002 report found that “of more than 300 patients treated, approximately 75% have reported improvement due to reduction of the frequency and intensity of nightmares. A substantial minority of these patients have reported a total absence of dreams related to the traumatic events.”

Other medications may include:

Quetiapine (Seroquel) – This is a mild anti-psychotic. While apparently questionably ineffective in treating psychosis, it is effective in the treatment of insomnia, nightmares and disassociation.

Medications to avoid:

Benzodiazepines – they are addictive and the effects are similar to intoxication. Benzos are sometimes effective in providing immediate and short term relief from intense anxiety. However long term use renders them ineffective and after a couple weeks a physical dependency is likely to occur.

Common benzodiazepines include:
Diazepam (Valium)
Alprazolam (Xanax) – The staff of the in-patient PTSD unit at the American Lake VA in Washington State have published a paper reporting extreme violence by combat vets treated for long periods with Xanax and then taken off of it. This was apparently more frequent and more severe than what they found taking their patients off of other benzos, such as Valium.
Lorazepam (Ativan) – Commonly prescribed as an anti-anxiety medication.

Other medications to avoid are:

Yohimbine (Actibine, Aphrodyne, Yocon, Yohimex) Causes flashbacks and panic attacks. This drug is sometimes used to treat impotence.

Hypnotic sleep-aids such as Immovane are used to treat insomnia and can be useful in overcoming sleeplessness. However, these medications may also affect memory and if something happens between the time you take the drug and the time you fall asleep, you may have no memory of it, which can be frightening.

Medications can interact badly with other drugs and substances. It is important to discuss all other medications you may be on with your doctor and to be honest about your substance use. In addition, herbal remedies (such as St. John’s Wort) can also interact with medications and should be discussed with your doctor. In particular Ma Huang (Ephedra) has been marketed as a natural weight loss supplement and sinus decongestant. This herb contains ephedrine and can react very badly with many medications and can also cause panic, nervousness and heart palpitations all on it's own.

Therapeutic Practitioners

There are different types of therapeutic practitioners, with vastly different levels of expertise and focus among each type.

Psychiatrists
These are medical doctors who can prescribe medication for different conditions. A psychiatrist undergoes basic medical training and then chooses to specialise in psychiatry, for which further training and study is needed. Psychiatrists may also be skilled in different talk therapy approaches, but will very probably prescribe medication as well. PTSD and complex PTSD are psychiatric disorders and are generally classified under anxiety disorders.

Psychologists
A psychologist is not a medical doctor, but is trained more in the psychological and behavioural aspects of mental health and illness. A psychologist has a Ph.D or Psy.D degree and may specialise in clinical or counselling psychology. Psychologists today often focus on cognitive-behavioral therapies (talk), and do not have as intense a training regime in the biological components of mental health disease as psychiatrists.

Licensed Social Worker (L.S.W.)
Licensed social workers are also considered mental health providers because many deal with the issues surrounding life events, substance abuse, family conflicts, disabilities, and violence. However, unlike psychiatrists and psychologists, social workers may also address problems such as inadequate housing, health and work problems.

Licensed Counsellor/Therapist
There are a variety of additional certifications with focuses on different aspects of mental health. These may include: substance abuse, alcoholism, family and children, school therapy, etc. In the US, a therapist may be licensed to practice only in a particular state, and may not be able to provide support to those outside of the geographical area of their own practice.

The Treatment Process

In the book Trauma and Recovery, Judith Herman outlines the process of recovery from CPTSD. This landmark book has become the most common form of trauma treatment and is utilised by many trauma specialists. The three main stages are: Stabilization, Resolution and Reconnection.

Stabilization
Most specialists will not begin treatment if they feel that you are currently in crisis. An initial level of stability is needed in order to begin trauma work and is often a requirement for admission into many trauma programs.

In addition, if substance use is an issue, many specialists will require you to be clean and sober before beginning work. This can be difficult, as substance use is often used by trauma victims to self-soothe and cope with traumatic memories. The notion of attempting trauma work without this coping mechanism can seem overwhelming. However, treatment for substance use can be found through a number of different self-help groups and specialists who can provide support for this particular issue. In recent years practitioners are also starting to understand the need for concurrent treatment and many programs can now offer addictions treatment along with trauma work.

The first step of many trauma recovery programs is to provide a safe place. Without the establishment of trust and feeling of safety, it is impossible for the other stages to progress. A number of techniques for controlling intrusive memories, panic attacks and nightmares may be taught to the client. This enables the progression into more intense trauma work without the process becoming overwhelming and unmanageable.

Resolution
Techniques such as narrative trauma processing allow the patient to tell their own story in their own words. The creation of a detailed coherent narrative with a beginning, middle, and end brings together the fragmented images of the trauma. The therapist may employ techniques such as the development of both an objective account of events and a subjective account of what the trauma felt like and what it meant for them.

This is an intense period of treatment for both patient and therapist and it is essential that the therapist be sufficiently skilled to effectively facilitate this stage. Alice Miller has described the role of a therapist as an “enlightened witness” to a survivor. Clarity, space and compassion are the three qualities of bearing witness. This is an important skill for the therapist while treating a client with shock and trauma.

“the adult who has grown up without helping witnesses in his childhood needs the support of enlightened witnesses, people who have understood and recognized the consequences of child abuse. In an informed society, adolescents can learn to verbalize their truth and to discover themselves in their own story. They will not need to avenge themselves violently for their wounds, or to poison their systems with drugs, if they have the luck to talk to others about their early experiences, and succeed in grasping the naked truth of their own tragedy. To do this, they need assistance from persons aware of the dynamics of child abuse, who can help them address their feelings seriously, understand them and integrate them, as part of their own story, instead of avenging themselves on the innocent.” (Miller, 1997)

“With the help of an enlightened witness, our early emotions will stand revealed, take on meaning for us, and hence be available for us to work on. But without such empathy, without any understanding of the context of a traumatic childhood, our emotions will remain in a chaotic state and will continue to cause us profound, instinctive alarm.” (Miller, 2001)

The goal of this stage of trauma work is to integrate the fractured traumatic memory into a cohesive whole. Techniques such as cognitive reframing, Video-dialogue and somatic interventions may assist with this process.

Reconnection
At this stage of the process, group therapy is often used. Reconnection is described as a time of "I know I have myself". At this stage one can explore the positive changes wrought by the traumas, celebrate the survivor self, and discover intimacy with others in ways that were not possible before.

In the previous two stages, isolation is a common feeling. In the reconnection stage, one can begin to feel a part of the larger society again. Studies show rape survivors and demilitarized soldiers that go on to recount their experience, help others cope, testify, etc. eventually loose PTSD symptoms. Specialists say at this stage is it truly safe for a person to confront perpetrators, to participate in media truth telling or other people's healing.

There are a number of additional and alternative treatment processes for PTSD sufferers. These include:
Autogenic Therapy - http://www.autogenic-therapy.org.uk/
Eye Movement Desensitization and Reprocessing (EMDR) - http://www.emdr.com/
Somatic Experiencing - http://www.traumahealing.com/intro.html
Cognitive Behavioural Therapy – http://www.cognitivetherapy.com/
Group Therapy – http://www.group-psychotherapy.com/
Psychosocial Rehabilitation – http://www.psychosocial.com/
Addictions and Trauma Recovery Integration Model (ATRIUM) - http://www.dustymiller.org/

An in-depth look at a number of different treatments for PTSD can be found in the book Effective Treatments for PTSD: Practice Guidelines from the International Society for Traumatic Stress Studies

Finding Support

In my own quest for treatment and support, there have been some principles I have learned that have greatly helped with finding appropriate care.

Educate Yourself on Your Own Condition
Understanding what you are experiencing is very helpful in both being able to gain control over one’s condition and in expressing and describing your symptoms to a health care professional. Simply understanding that you are not weak, bad or wrong to feel the way that you do is very helpful in maintaining hope, looking for solutions and progressing towards recovery. For me, learning that there is a natural and biological response to trauma relieved much of the guilt and shame I felt in not being able to “just get over it”.

Be as Clear and Accurate as Possible when Initially Speaking With Practitioners
PTSD is very frequently misdiagnosed. The symptoms and effects of trauma can look much like other illnesses and are often wrongly labelled. When you first meet with a health care professional, they will most likely complete an initial assessment of your condition and then make a diagnosis. It is important for this to be accurate as, like most of us, after making a decision practitioners tend to stick to it. The diagnosis may also become part of your permanent health record and it is very important that it is accurate.

Something that can greatly help this process is to, if at all possible, describe rather than act out feelings and emotions. For example, if something makes you angry, rather than reacting in anger, verbalising the feeling can be more useful in helping them understand what you are experiencing and why. “I am feeling very angry right now about X. I understand that my reaction may seem disproportionate, but my anger is due to experience Y, which X is reminding me of.” This is very difficult to do, and health care professionals should be trained to explore reasons for behaviour and reactions, but they do not always do this, nor do they always interpret behaviour successfully. If you can verbalise as much as possible, it can be very useful in reaching an accurate understanding and deciding on an appropriate form of treatment. This level of emotional detachment is only needed in the initial assessment phase. Once the practitioner has accurately diagnosed your condition and you have a mutually agreed on plan of treatment, you can then more safely begin to access and explore your feelings and emotions.

Find a Suitable Practitioner
It is very important to find someone who you can work with appropriately. I have sought treatment in previous years from a number of different therapists and doctors. Some of these were profoundly unhelpful, and I now understand the fault was not usually with them personally, but that they were not trained in the areas of specialty that I needed treatment for. For example, I once went to see an art therapist who specialised in women’s issues. It was very weird and uncomfortable for me and her proposed treatment seemed rather flaky and odd. After that experience I wrote off therapy for a number of years. It was not that the process was wrong, but she was not qualified to treat me. If you know and understand what you need treatment for, it can greatly help in finding a suitable specialist. Some specialists may provide a referral service and will complete an assessment with you and then refer you to an appropriate practitioner.

If possible, I strongly believe it is best to find a practitioner who has access to a team of specialists. Someone who works with a clinic or has hospital privileges will have access to support themselves from colleagues. The treatment of Complex PTSD can in itself create trauma for the practitioner, and while this is not your responsibility, if your provider has access to support from colleagues, this risk can be lessened. In addition you will also have the added benefit of the expertise of the entire team through your own health care provider if needed. A team based environment also provides a level of accountability for the practitioner that may not be available if they are solely in a lone private practice. A health care provider should not take you on if they are not qualified to do so. If they must present your case to the rest of the team before admission into a program, the risk of your investing resources and energy into something that is not suitable for you is considerably lessened.

Most importantly, the relationship between yourself and your health care provider must be based on trust. If you are not comfortable with a particular individual for reasons that go beyond discomfort in talking about traumatic events or worry about the recovery process, then change practitioners.

Keep Copies of All Documentation
What I have found to be useful is to maintain a full record of all practitioners seen, referrals made, diagnosis’s and medical and therapeutic treatment. As an overview, I made a chart with the facility, name and contact information of the specialist, medications dispensed, treatment received, dates seen, and referred by whom, which I update as needed. This has been very useful when seeing someone new or when needing to refer back to a specific time or date. The process of finding treatment can seem overwhelming and confusing and having this organized and at hand has helped me to navigate through the procedure more comfortably.

You also have the right to access your own medical records and only in rare cases where the doctor believes it could cause you or someone else direct harm can they deny you access to these records. It can be stressful to read a diagnosis and comments made about you in a dispassionate manner, but if you wish to do so, you can then ensure the accuracy of these records. Sometimes requesting your records from the treating specialist and having them go through them with you can be helpful. You can then point out and explain anything they may have misunderstood and can also have them explain anything to you that is not clear.

Learn About Insurance Obligations and Payment Options
The world of medical insurance is a nightmare to navigate through when you are in the throes of a crisis or in the process of undergoing trauma treatment. Find out all you can as soon as possible about your options and obligations from your insurance company. A group health policy can be confusing to understand, but in larger companies a member of the human resources or occupational health department is often available to help explain it to you and guide you through the process.

For example, does your insurance cover therapy from a licensed therapist or is it restricted to medical specialists such as psychiatrists? In Canada and other countries with a national health care plan, you cannot see a medical specialist without a referral from your family doctor. What sort of documentation does the insurance company require from your health care provider? Is PTSD considered an existing condition by your insurance provider and will they cover treatment for it?

In addition a number of therapists will provide services on a sliding fee scale. If you can demonstrate financial need, they may be able to offer you support for a reduced rate. Find out if this is available and what documentation they require.

Know Your Rights
Your medical and therapeutic history is strictly confidential. People such as your employer or family may want to know details of what your condition and treatment is. You are under no obligation to disclose any of this information.

Therapeutic practitioners are also bound by a strict code of conduct and medical ethics. Find out from them what these are and what your rights in sessions are.

If you believe that your rights have been violated, you have the right to seek recourse. Find out what the complaint process is for a therapeutic practitioner, insurance company, employer or any other party that has caused you harm. It can be extremely difficult to stand up to an authority figure, especially if you are in a vulnerable state, but regaining a level of control over something that directly affects you can be very helpful in ensuring that you are the primary person who guides your own recovery.

You are under no obligation to blindly accept what you are told if you disagree, and you have the right to mutually respectful care. I have found that a crucial aspect to rebuilding my capacity for trust is to research what I am told for myself. As I find objective outside substantiation, I find I am able to begin to safely open up, knowing that I can also disagree if I need to.

Understand the Responsibilities of Therapeutic Practitioners
There are two situations in which the confidentiality of your treatment may be broken. These are if the practitioner believes that there is a definite risk of harm to yourself or to another person. If a physician believes that there is an immediate risk of harm to yourself or another, they may involuntarily hospitalise you. I can think of few things more traumatic for our demographic than being involuntarily hospitalised and this in itself can compound the effects of trauma that you are seeking treatment for.

To avoid this situation discuss with your provider as soon as possible what feelings of self-harm and anger towards others are actually like for you. If you have lived with daily suicidal ideation for many years, explain this to them and explain the difference for you between thoughts of self-harm and acting on it. If revenge fantasies are common for you, but you have no history of violence or harming others, make sure they are fully aware of this. Explain to your practitioner why hospitalization would be so traumatic for you and make sure they fully understand this. Ask the practitioner up front what specific circumstances would cause them to take action to protect you and/or others from harm. You can then work with them to prevent this from arising.

Additional Information and Resources:

http://ptsd.factsforhealth.org/PTSDGuide.pdf
http://www.ptsdalliance.org/home2.html
http://www.healthyminds.org/multimedia/ptsd.pdf