230 -Trauma Informed Care Clinical Issues | SAMHSA TIP 57
Counselor Toolbox

 
 
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Trauma Informed Care  Clinical Issues
Instructor: Dr. Dawn-Elise Snipes PhD, LPC-MHSP, LMHC
Podcast Host: Counselor Toolbox & Happiness Isn’t Brain Surgery
Objectives
~ Define Trauma Informed Prevention and Treatment Objectives
~ Highlight Treatment Issues
~ Understand When and How to Make Referrals to Trauma Specific Services
~ Explore Trauma Specific Treatment Models, Integrated Models for Trauma, and Emerging Interventions

Prevention and Treatment Objectives
~ Trauma-informed care (TIC) places considerable effort in creating an environment that helps clients recognize the impact of trauma and determine the next course of action in a safe place.
~ TIC also focuses on prevention strategies to avoid retraumatization in treatment, to promote resilience, and to prevent the development of trauma-related disorders
Establish Safety
~ Types of Safety
~ Personal Safety
~ Safety from trauma symptoms
~ Strategies
~ Help the client label and gain more control over trauma symptoms when they arise and use grounding techniques when flooded with feelings/memories.
~ Establish some specific routines in individual, group, or family therapy (e.g., have an opening ritual or routine when starting and ending a group session). A structured setting can provide a sense of safety and familiarity. ***Use carefully
~ Facilitate a discussion on safe and unsafe behaviors. Have clients identify, on paper, behaviors that promote safety and behaviors that feel unsafe for them today.
~ Refer to Seeking Safety: A Treatment Manual for PTSD and Substance Abuse (Najavits, 2002a). This menu-based manual covers an array of treatment topics.
~ Encourage the development of a safety plan.

Establish Safety
~ Creating Safety
~ Help client feel in control and prepared for the unexpected.
~ Encourage thinking about how supports will respond and connect in the event of another crisis.
~ Encourage thinking about future steps that could help make the client safer/prevent a recurrence.
~ People with histories of trauma and substance abuse are more likely to engage in high-risk behaviors
~ Early treatment should focus on helping clients stop using unsafe coping mechanisms, such as substance abuse, self-harm, and replace them with healthy coping strategies
~ Balance preparation and the realization that one cannot prepare for all possible traumatic events.
Establish Safety
~ Scenarios
~ Date rape
~ Home invasion
~ Natural disaster (Fires)
~ House fire
~ Child neglect
~ Car accident
Prevent Retraumitization
~ Examples of unintentional trauma
~ Compassionate inquiry into a client’s history can seem similar to the interest shown by a perpetrator many years before.
~ Direct confrontation about behaviors can be seen by someone who has been abused as a sign of impending assault
~ Strategies
~ Be sensitive to the needs of clients who have experienced trauma
~ Do not ignore clients’ symptoms and demands when clients with trauma are triggered and act out; doing so may replicate the original trauma.
~ Walking out of a tense group
~ Avoiding particular clients or topics
~ Be mindful that efforts to control and contain a client’s behaviors remind them of being trapped as part of the trauma.
~ Listen for specific triggers driving the client’s reaction and help the client identify these cues and thereby understand their reactions and behaviors.

Provide Psychoeducation
~ Education can play a pivotal role in enhancing motivation, in normalizing experiences, and in creating a sense of safety.
~ Understand the client’s expectations and reasons for seeking help
~ Educate the client and other family members about the program
~ After obtaining acknowledgment of a trauma history, give information to clients to help normalize presenting symptoms
~ Highlight potential short-term and long-term consequences of trauma
~ Explore various paths to recovery, and underscore that recovery is possible
~ S.E.L.F. is a group curriculum: creating Safety, regulating Emotions, addressing Loss, and redefining the Future
Provide Psychoeducation
~ Develop a resource box/webpage that provides an array of printed or multimedia educational materials that address
~ specific symptoms and tools to combat trauma-related symptoms
~ treatment options and therapy approaches
~ advantages of peer support
~ steps in developing specific coping strategies
Trauma Informed Peer Support
~ Living with a history of trauma can be isolating and consuming and can reinforce beliefs about being different, alone, and defective.
~ Treatment for trauma effects can inadvertently strengthen clients’ beliefs that there is something wrong with them.
~ Peer support can break the cycle of beliefs that one is damaged; nobody understands; or no one could tolerate one’s story
~ Peer support provides opportunities to
~ Form mutual relationships
~ Learn how one’s history shapes perspectives of self, others, the future
~ Move beyond trauma
~ mirror and learn alternate coping strategies.
~ Peer support is an interactive process, not a definitive action where someone fixes the “problem.”
Peer Support
~ Provide education on what peer support is and is not and the value of using this resource.
~ Use an established peer support curriculum to guide the peer support process.
~ Intentional Peer Support: An Alternative Approach (Mead, 2008) is a workbook that highlights four main tasks for peer support:
~ Building connections
~ Understanding one’s worldview
~ Developing mutuality
~ Helping each other move toward set desires and goals.

Normalize Symptoms
~ Normalizing symptoms gives considerable relief to clients who may have thought that their symptoms were untreatable or represent a disorder
~ Have the client list his or her symptoms.
~ After each symptom, ask the client to list the negative and positive consequences of the symptom.
~ Remember that symptoms serve a purpose, and focus on how the symptoms have served the client in a positive way
~ Research the client’s symptoms specific to trauma, and provide individualized education
~ An individual who was conscious and trapped will more likely have strong reactions to interpersonal and environmental situations that are perceived as having no options for avoidance or resolution
~ Feeling stuck in a work environment where the boss is emotionally abusive
~ Being hypervigilant about exits, plan escape routes even in safe environments
Identify and Manage Trauma-Related Triggers
~ Key steps in identifying triggers are to
~ Reflect back on the situation, surroundings, or sensations prior to the strong reaction.
~ Determine connections among these cues, the past trauma, and the client’s reaction.
~ Discuss the ways in which it is connected to past trauma.
~ Use self-monitoring to identify the frequency and intensity of reactions to gain an understanding of the types of triggers, the level of distress that each one produces and see reductions or changes in frequency and intensity.

Identify and Manage Trauma-Related Triggers
~ Identify one trigger at a time, and then discuss the following:
~ When and where did you begin to notice a reaction?
~ How was this current situation different from the past trauma?
~ How are your reactions to the current situation similar to your past reactions to the trauma(s)?
~ How did you react differently to the current situation than to the previous trauma?
~ How are you different today?
~ What choices can you make that can help you address the current situation/trigger?
OBSERVATIONS Coping Strategy
~ Take a moment to just Observe what is happening
~ Focus on your Breathing.
~ Name the Situation that initiated your response. In what way is this situation familiar to your past? How is it different?
~ Label Emotions and remember that they come and go.
~ Recognize that this situation does not define you or your future. It does not dictate how things will be, nor is it a sign of things to come. Even if it is familiar, it is only one event.
~ Validate your experience.
~ Ask for help. You don’t have to do this alone.
~ This too shall pass. There are times that are good and times that aren’t
~ I can handle this. Name your strengths that have helped you survive.
~ Keep an Open mind. Look for and try out new solutions.
~ Name and choose strategies that have worked before.
~ Remember you have survived. You are a Survivor!

Draw Connections
~ Writing about trauma can help clients gain awareness of their thoughts, feelings, and current experiences. Use with caution.
~ Encourage clients to explore the links among traumatic experiences and mental and substance use disorders
~ Identify how substances have helped address symptoms
~ Teach clients how trauma, mental, and substance use disorders commonly co-occur to reduce shame and isolation.
~ Discuss how substance abuse or anxious or depressive behaviors have impeded healing from trauma
~ Help clients recognize trauma symptoms as triggers for relapse to substance use and mental distress.
~ Develop coping skills to recover from trauma and co-occurring issues.
~ Recognize how both trauma, mental illness and substance abuse often occur in families through multiple generations.
~ Cycle of abuse
~ Inability of parents to protect or teach healthy coping

Teach Balance
~ It is a myth that every traumatic experience needs to be expressed and every story told.
~ Working with trauma is a delicate balancing act between the development and/or use of coping strategies and the need to process the traumatic experiences.
~ Too much trauma can trigger dissociation, shutting down, or becoming emotionally overwhelmed.
~ Too little focus can reinforce avoidance and confirm the client’s internal belief that it is too dangerous to deal with the aftermath of the trauma.
~ Traditional desensitization processes start at a very low level of distress, gradually working up through a hierarchy of trauma memories and experiences until those experiences produce minimal reactions when paired with some coping strategy, such as relaxation training.
Subjective Units of Distress Scale (SUDS)
Build Resilience
~ Encourage mindfulness and thought awareness
~ Help clients reestablish personal and social connections by accessing friends, family and community and cultural resources
~ Encourage the client to actively taking care of his/her own needs early in treatment
~ Encourage stability and predictability in the daily routine.
~ Nurture a positive view of personal, social, and cultural resources. Help clients recall ways in which they successfully handled hardships in the past.
~ Help clients gain perspective and foster a long-term outlook
~ Help maintain an optimistic outlook. Visions of good things in life and can keep people going even in the hardest times.
~ Encourage participation in peer support
~ Set SMART Goals

Build Resilience
~ Essential Elements of Resilience
~ Challenge–Look at failures and mistakes as opportunities for growth not as a negative reflection on their abilities or self-worth.
~ Commitment – Enhance commitment to their lives and goals.
~ Personal Control –Focusing on situations and events that they have control over.
~ Explain Setbacks and Successes
~ Permanence – Stable or Changeable attribution
~ Pervasiveness – Global or Specific attribution
~ Personalization – Internal vs. External attribution
Address Sleep Disturbances
~ Educate clients about the importance of sleep in setting the HPA-Axis
~ Identify habits that interfere with sleep
~ Develop a sleep routine
Support Empowerment and Build Trust
~ Provide effective informed consent
~ Empower clients to make choices and assume an active role in treatment
~ Establish a sense of self-efficacy

Acknowledge Grief and Bereavement
~ Traumas cause a variety of losses
~ Emotional (Happiness, hope)
~ Cognitive (How you think about the world and prior schemas)
~ Interpersonal (Faith in others, friends)
~ Environmental (Safety, job, housing )
~ Physical (Abilities, control of one’s own body)
~ Risk factors for chronic bereavement
~ Perceived lack of social support
~ Concurrent stressors in past 6 months
~ Ambivalence about the lost
~ History of mental health or substance abuse issues

Signs of Destabilization
~ Increased substance use or other unsafe behavior (e.g., self-harm).
~ Increased psychiatric symptoms (e.g., depression, agitation, anxiety, withdrawal, anger).
~ Increased symptoms of trauma (e.g., severe dissociation).
~ Helplessness or hopelessness expressed verbally or behaviorally.
~ Difficulty following through on commitments (e.g., commitment to attend treatment sessions).
~ Isolation.
~ Notable decline in daily activities (e.g., self-care, hygiene, care of children or pets, going to work).
Other Treatment Issues
~ Engagement
~ Clarify the situation through discussion, reinterpreting from “can’t” to “won’t” to “willing”
~ Use motivational interviewing
~ Pacing and timing
~ Frequently discuss and request feedback from clients about pacing and timing.
~ Signs it is going too fast include no-shows, dissociation, excessive silence, confusion or inability to comprehend simple concepts, redirecting the conversation, increase in symptoms

Other Treatment Issues
~ Memories
~ Some people are not able to completely remember past events, particularly events that occurred during high-stress and destabilizing moments.
~ Explore how a memory of an event helps the client understand his or her feeling, thinking, and behaving in the present.
~ Persistently trying to recall all the details of a traumatic event can impair focus on the present.

Summary
~ Establish safety
~ Prevent retraumitization
~ Provide psychoeducation
~ Use trauma informed peer support
~ Normalize symptoms
~ Identify and manage triggers
~ Help clients draw connections
~ Teach balance
~ Develop resilience
~ Address sleep disturbances
~ Support empowerment and build trust
~ Acknowledge grief and bereavement