by Monica Forst, Ottawa Canada

M. You created the Therapeutic Spiral Model, is that right?

K. That's right.

M.Can you just say a little bit about yourself?

K.The Therapeutic Spiral has three strands- the energy, experience and meaning, and
that's relevant to who I am. I em a clinical psychologist, that's the emphasis of the model in making meaning and putting cognitive frames on trauma symptoms, bringing up the words. I'm a psychodrama trainer, board certified, and that's why we go into the experiencing. I was trained to go into the experiencing and then you put the words on so that you can access the trauma material in the state that it's stored, and the third strand is energy, and that comes from being a trauma survivor myself, so that's the energy, the passion to create the model, and also the emphasis on safety.

M. How long have you been a psychodramatist and clinical psychologist?

K.I've been a clinical psychologist for 15 years and a psychodramatist for 20.

M.How long ago did you start developing the therapeutic spiral model?

K.I got into writing in about 1990, but certainly before that we were seeing that the
classical psychodrama did not necessarily serve the needs of trauma survivors the best it could be done, so maybe a couple of years before that.

M.What was going on that you felt a new model had to evolve?

K.As a psychodramatist, I saw that when you have a trauma survivor actively working
on trauma issues, even sometimes not actively working on trauma issues, they get triggered. Classical psychodrama has the potential for uncontrolled regression, so that you would have a protagonist, in the here and now, doing an adult scene, and they would be triggered into regression back to their trauma state, and it wasn't a conscious going there, it was like "wow, there I am". I saw that this had the potential for retraumatizing people. As a clinical psychologist I thought it doesn't have to be this way. We can put a balance of words, cognitions in the experiencing, so that there is a container, and people might regress but only if they choose to regress, so that it becomes a regression in the service of the ego. le. If the ego needs to regress to back and access the trauma state, but that's a choice by the adult mind saying yes, lets go back and do that for a good reason, not just slipping back there and not having any control over it. So, it was basically to put in more containment, more control for the protagonist, also more control for the therapist. Therapists don't normally use experiential methods for trauma survivors because they can't go very deep very quickly. The therapists are going "Oh my god, what do I do with this". So this gives both therapist and client more conscious control over what they're doing in the experiential work.

M.What's your philosophical approach to substance abuse?

K.12 Step program. They need to be in a recovery process. I do look at the underlying
issues to the substance abuse, whether that's for people who are new in recovery or people who have been in recovery for 2 years, 5 years. I also see it as a primary disease, and I see that the addictive component can serve a defensive function for the personality structure. So for trauma survivors, they often use addictive processes to push down the trauma material" and so when you get the addiction under control, the trauma material all comes up. They will get triggered back into their addiction if they don't have a containment for the trauma material that is coming up.

M.What is your history of experience with trauma and substance abuse?

K.Well, I first started working in the addictions field in 1981 and I did a lot of work with
ACOA'S, with eating disorders. These were my primary populations that I began to work with, not direct substance abuse, but those who had been effected by it. What I found as I scratched the surface there was trauma material just popping out their ears. Lots of sexual abuse started coming up and they were just waiting for someone to tell this stuff to. They came in the door identifying themselves as ACOA and having an eating disorder, but as we worked in therapy, that was the presenting problem, but the underlying issues were much more severe than that. It was easier for them to present with an eating disorder than it was for them to come in and say well, I've been sexually abused and it's driving me crazy!" Once the trust was built, then they could talk about the real traumas. At that point in the 80's was when all the ACOA stuff was just coming to fruition. Everyone at that time was talking in terms of codependency. So, that was an easy way for people to connect. Once the therapeutic alliance was in tact, they could share more. So, I saw that both needed to be treated. le. The symptom and the underlying trauma material.

M.How do you treat the consequences or the negative effects of the substance abuse itself?

K.I see that as kind of post addiction trauma. They're finally getting their mind back and they're starting to see the impact of their drinking, drugging, compulsive gambling behavior on themselves, but also on other people, so they're really recognizing the traumas they've created, and the traumas they have been through- Many people who have been abusing substances have experienced date rapes, black outs they don't remember, and I see those as traumas.

M.I've also read in the literature that trauma survivors will often re-create the trauma.
Is this an example of re-creating the trauma?

K.It's a defense against the early trauma, so they are trying to push the early
experiences down, away from them. And then what happens when it is not in your
consciousness you do act it out. So, if someone has been sexually abused and they are a substance abuser, in a confused state, they're going to act out promiscuously in ways that represent the original abuse. Substance abuse lets go of the impulse control that would have made it possible for them to not go into the re-enactment, but when the substance abuse is there pushing down the trauma material, then it is going to get acted out unconsciously and so then you do have a re-creation.

M.As a very rough estimate, no need for accuracy. In all the time that you have been a clinical psychologist, roughly how many trauma survivors have you treated?

K.We've begun compiling some data, so in the last 5 years, since 1995, we've treated about 200 a year, so that would be 1,000 in the last five years using the therapeutic spiral model. Every workshop we've given has at least fifteen trauma survivors in any given group.

M.And that's in many parts of the world?

K Yes, and we would reach many more if we had more therapists trained in the model in order to apply it. The demand is there. We could treat five thousand a year with the contracts that people are asking us to do if we had trained staff.

M.From the time you started working with trauma, not necessarily with the Therapeutic Spiral Model, but from the time you started working with trauma survivors, how many of those would you say suffered some form of addiction.

K.75%. 1 would even say it is higher than that. They just seem to go together.

M.When I review the literature on trauma and addictions, I was surprised to find that
there's one book written that talks about trauma and addictions as related issues. Can you say something about that?

K.I think that for a long time the fields were separated. Addictions were treated with a 12 Step model, in general, and trauma was treated by a psychological model for post traumatic stress disorder. They were seen as very separate, and there was kind of an antipathy, each camp not respecting or liking what the other was doing. So. the psychologists were saying, "oh, those addictions counselors don't really know what they're doing. They're just sending people to 12 Step programs, and that's not really treating the problem", and then the 'addictions counselors were saying, "oh those psychologists aren't addressing the addiction". There was a warring between the two fields. But in the last three years I know of two people who are starting to really recognize the need to come together. Certainly, Tian Dayton and Patrick Cames who are blending the fields and bringing them together.

M.When I was looking at your model and reading more about it, as an addictions counselor, I was surprised to see that there are some parallels between the Therapeutic
Spiral Model and the 12 Step programs, and there are some parallels to treating trauma and treating addictions. Am I totally off the mark here? Can you make some comments about this?

K.It wasn't conscious. I've really only been conscious of bringing the model into addictions in the last couple of years. But one of the clear connections is that we start out by bringing in a transpersonal strength. Spirituality. We make that part of every Spiral psychodrama, that there is some representation of a higher power, a god, nature, something beyond the human, so that the trauma that happened human to human has a bigger component so that you can kind of turn over the trauma to your transpersonal strength to help you deal with it. I also think that the emphasis on containment that we provide is similar to the 12 Step programs providing containment, you know, so they do it in a different way, "go to meetings, but the idea is to create a safe space for people to do this where they won't be triggered into other things. There is also an interpersonal in the sponsor relationship. Yes, the interpersonal strength is important because the trauma survivor is very isolated, and used to being attached to their addiction versus being attached to human, so A.A. gets you attached to other humans at meetings and we bring in that interpersonal strength right away, and we also try to build up people in terms of their personal strength. Personal strength might be powerlessness. It doesn't have to be "I'm courageous. I'm determined'. It can actually be things that the 12 step program fully supports. I'm actually curious as to what other things you've thought of.

M.When I was reading Karen Drucker's paper, she talked about six stages of recovery for trauma survivors, and Terry Gorski's model of relapse prevention in the addictions treatment is also based on six stages, and of course, the first one is stabilization, which for an alcoholic or addict would be detoxification. I'm not sure what that stabilization means for a trauma survivor.

K.I see stabilization for the trauma survivor as building up the prescriptive roles. You need those roles if you're going to stop drinking. You need to have those strengths in place so that you can do it. You need to have the containment there so that you can stop acting out. I see that, even in detox you can start building the strengths. This is not going to touch off the trauma material, it's just going to help stabilize the trauma survivor in their recovery by holding up the personality structure. So, it's like coming at it internally, whereas the 12 Step Program comes at it more externally. Inside the person build up these strengths so they can go to meetings, so they can attach to people at the meetings, so they can psychologically do the piece that is so hard for some trauma survivors to follow through with for their relapse prevention in their early recovery. When early recovery people get detoxed, and they used alcohol as a defense, the trauma material is just going to burst through, and so you've got somebody three days into detox that all of a sudden is having body memories and flash backs that they're feeling really crazy about and that's going to put their recovery at risk, whereas if those things start happening and you build up the strengths and you put in a container, they can focus on detoxing and getting sober better because the trauma material isn't crashing through.
After they get stabilized both in terms of the addictive process and in terms of having their personality structure resourced enough, then you can go to the trauma material. But you don't go into the trauma material until all that has happened first.

M.What is it about your model that is different from other forms of treatment for trauma.

K.In many ways it's similar in that you do go for stabilization first, before going to the
trauma material. The difference is that it is an experiential model. It's not a "talk" therapy model. It's a model where, rather than saying what strength do you need to have, you choose someone from the group to be that strength, role reverse with that strength. So, it's not just a cognitive attachment to that behavior. You're actually role playing and learning and experiencing new behaviors so that it reaches deeper into the developmental level of the person. When we're talking about child and adolescent stuff, it allows people to have the experience of those earlier ages, and put the change in there. Cognitive is important, but many people doing trauma work can't get the words first because the trauma material is stored in an unprocessed state. It's stored in experiential components ie. body memory, flash backs, where you don't really know what they are yet, but you just have the experience of intrusive memories coming in and all the PTSD symptoms, so we directly go to where the trauma survivor lives. So, the trauma survivor lives internally in a fairly chaotic, unprocessed state, and we go directly there to help them stabilize that rather than just putting the words on it.

M.Are there any problems to working with this model, and are there any wrinkles to
workout.

K.It is a growing and evolving model. One on one there aren't a lot of things to work
out. Working in groups, with teams, there's always more things to work out. So, we think we've got a group where we can handle all the dissociation that's there and then find there's one person who didn't get contained enough, and so it's how to provide that containment and make it bigger and bigger and bigger for people. It's learning the careful finesse at this point. The model was developed to work with multiple personality disorder. It was developed to work with people who were severely traumatized and symptomatic that way, and now as we work with more neurotic populations there is a different set of problems you have to contain. So, not only are you containing uncontrolled regression, but with a more neurotic population you also have to get through the verbal defenses. You know, they want to talk about stuff. They want to go up into their heads rather than going into the experience. With untrained people mind you, with people who think they know about the model, and then go out and do it, they're putting their clients at risk as much as if you were doing untrained classical psychodrama or Gestalt therapy or any other experiential methods. What makes this good is the training program that we have, that really trains people into full competency.

M.In the literature review it stated over and over again that group is the way to go in terms of treating trauma survivors, I would like to hear from you with respect to group versus individual treatment, particularly with respect to this model.

K.TSM is a group therapy model. An ideal treatment, I think, for the trauma\addictions survivor is to have individual therapy in conjunction with group. Group therapy doesn't always provide enough time to cognitively process things, especially when it is an experiential group. TSM has the two components of cognitive and experiential. The more words you put on things, the better. So, I prefer to that people have an individual therapist even if they're only seeing them once a month. Also, we take referrals for people who aren't in individual therapy, but are in 12 Step Programs because that

provides a place for them to continue processing through how this stuff comes into words.

M.What is the cost of setting up this kind of treatment model?

K.To get a team running, the cost runs anywhere from one to two years, and people
learning to train are going to spend anywhere from $1,000 to $3,000 dollars per person. We have a model of contracting for long term training for a program that is already in place, where we go in to train their staff, which can decrease some of those costs. We charge $1200.00 a day for a whole team, minimum of four. So, you can see that we don't get paid a great deal, and the reality is that there is not the money to support more than that. Treatment programs and or trauma survivors in private practice really can't pay $5,000.00 for a team to come.

M.But, on the other hand, when I think of how much it costs for a community to recovery from acting out behavior ie. substance abuse, suicides, the e.r. contact,

K.We have created a charity to be able to fund this work because we do need to pay our practitioners adequately. Right now we pay our practitioners two hundred dollars a day and so they're kind of doing pro bono work there, but we are looking for grants, foundation money and donations from people so that we can adequately pay team members say $500.00 a day. That's our goal, to pay our teams $500.00 to $1,000.00 a day each. We're not there yet.

M.We decided as a community that it was costing way too much money for hospitalization and residential treatment, that the amount of money it cost for Canadian tax payers was enormous. So, when I think of paying a team $1200.00 day for a weekend, which is $3600.00 total, and you're treating 15 to 18 individuals, that's far less than what it costs one individual to spend a weekend in a hospital or a residential treatment setting.

K.Because our work is on containment, we are very successful in treating outpatient. If a person is just being treated for the addiction in a residential setting they are more likely to relapse as well, whereas we do the psychological resourcing while treating the addictions, and this means that they have an easier time in recovery, lowering the relapse rate, and they don't need the sixty day or 28 day treatment.

M.I know that one of the people who has come through your training deals specifically with adolescents. How successful is the model in treating adolescents.

K.Mario Cossa is a drama therapist and psychodramatist. He has embraced the model fully because it really prevents the acting out by building up the personality structure, it also, for kids, they're ready to jump into the trauma because that is what they're living with all the time, but that's not safe. So, teaching them how to build up their personality structure first, you know, maturity. So, if they're stuck at age 4 or 6 and they're acting it out as adolescents because that's when they get into acting out the most, then this helps them grow up and mature sooner, and have better conscious choices about what they're going to do. Mario says the kids just really enjoy it. They like to be able to build up their strengths. He thinks it's "the model" for working with kids experientially.