Educational Resources and Evidence-Based Treatment for Adults

Julian D. Ford, PhD, and Christine A. Courtois, PhD

A history of ACEs is the norm rather than the exception among adult healthcare patients. Research documents a dose-response relationship between the number of ACEs experienced and the number and severity of both illness risk factors and psychosocial/behavioral problems (e.g., smoking, obesity, physical inactivity, depression, suicide attempts, alcoholism, drug abuse, sexual promiscuity, and sexually transmitted diseases) and serious disease or other physical health problems (e.g., heart disease, cancer, stroke, chronic bronchitis, COPD, chronic pain, diabetes, hepatitis, and skeletal fractures). Screening for ACEs in primary care can identify patients for whom ongoing clinical surveillance of psychosocial/behavioral problems, anticipatory guidance and education, and timely early intervention are indicated.1 Many of these patients have developmental, psychological, and relational impairments that constitute a complex form of posttraumatic stress disorder.2

Therefore, patients with clinically significant behavioral or medical conditions should routinely be screened for ACEs and other potential traumatic stressors. They should be provided with education2 about how these “normal reactions to abnormal circumstances” can lead to persistent hypervigilance and chronic stress reactivity as a result of changes in the brain/body that were necessary to survive exposure to traumatic formative experiences early in life.3 The adult sequelae of ACEs can be summarized as a shift into a perpetual state of alarm that takes the form of one or more of five “As”: anxiety, anger, anhedonia, alienation, and avoidance. Patients tend to find these concise, strengths-based, non-pathologizing explanations affirming and de-stigmatizing.

Educational resources for patients with ACE histories who are at risk for or have mild to moderate severity psychosocial/behavioral problems can be retrieved from public information pages of professional organizations’ web sites, such as the International Society for Traumatic Stress Studies, the International Society for the Study of Trauma and Dissociation, the American Psychological Association Division of Trauma Psychology, the National Center for PTSD, and the National Child Traumatic Stress Network.

When psychosocial/behavioral or medical conditions are severely impairing, the medical practitioner should consider referring the patient for specialized traumatic stress assessment/evaluation and treatment. Evidence-based psychotherapy for adults with a history of ACEs requires careful attention to the therapist’s training and experience in treating trauma of this type and his or her ability to respond to the patient with empathy and respect while maintaining appropriate and defined boundaries and limitations.3 Therapy should also focus on ensuring the patient’s personal and interpersonal safety and on the teaching of emotional regulation and other life skills, which, when warranted, often includes preventive medical checkups and timely medical care.

These foundations establish the treatment setting and relationship as a safe haven from which clients can explore and come to better understand and regain their sense of self, their access to a full range of emotions, and involvement in affirming relationships. There are a number of evidence-based approaches to psychotherapy for adults with ACEs histories, each of which guides the client through a progression of three phases: (1) safety and stabilization, (2) trauma processing, and (3) consolidation of therapeutic gains.4 The first and third phases are standard-of-care best-practice approaches for all psychotherapies, although they must be done with careful attention to the unique impact of ACEs. The second phase, trauma processing, requires specific therapeutic expertise and sensitivity in order to enable the patient to develop a coherent autobiographical understanding of the effect that traumatic experiences have had on his or her life. Table 1 provides a list of current evidence-based psychotherapy models for adults with ACEs-related disorders.3,4

Psychotherapy within this framework can enable adults who have experienced ACEs to achieve five key positive outcomes. First, they can gain a de-stigmatizing awareness and understanding of how expectable adaptations to early life trauma have resulted in what they now experience as troubling post-traumatic symptoms. Second, they can become more attuned to the full range of their emotions and able to recover from periods of emotional distress. Third, they can develop or regain a sense of self—the awareness that they are unique, worthy of respect, and capable of forging a satisfying life. Fourth, they can (re)gain a sense of trust and security in healthy relationships. Finally, as a result of these therapeutic gains, they can “jump-start” and resume their interrupted personal development. In sum, effective psychotherapy can enable adults who have experienced ACEs to achieve a productive, personally meaningful, and satisfying life.

References

1. Ford, JD. Identifying and caring for acutely traumatized children in pediatric practice. Consultant for Pediatricians. 2013;12(4):182-7

2. Ford JD. Neurobiological and developmental research: clinical implications. In: Courtois CA, Ford JD, eds. Treating complex traumatic stress disorders: an evidence-based guide. New York: Guilford Press; 2009:31-58.

3. Courtois CA, Ford JD. Treating complex trauma: A sequenced relationship-based approach. Chapter 3: Preparing for Treatment of Complex Trauma. New York: Guilford Press; 2013.

4. Cloitre M, Courtois CA, Ford JD, et al. The ISTSS Expert Consensus Treatment Guidelines for Complext PTSD in Adults. November 2012.

Table 1. Evidence-Based Psychotherapy Models for Adults with ACEs-Related Disorders3,4

  • Brief Psychodynamic Therapy
  • Cognitive Processing Therapy
  • Emotion-Focused Therapy for Trauma
  • Eye Movement Desensitization and Reprocessing
  • Imagery Rehearsal/Rescripting Therapy
  • Narrative Exposure Therapy
  • Phased Model for Treatment of Dissociation
  • Prolonged Exposure Therapy
  • Present-Centered Therapy
  • Present-Focused Group Therapy
  • Seeking Safety
  • Skills Training in Affect and Interpersonal Regulation
  • Trauma Affect Regulation: Guide for Education and Therapy
  • Trauma-Focused Group Therapy


© 2015 by Academy on Violence and Abuse