TIP 57: Trauma Informed Care

Ten Guidelines in Screening and Assessing Clients With Trauma

1. Ask all clients about any possible history of trauma. 2. Use only validated instruments for screening and assessment. 3. Early in treatment, screen all clients who have histories of exposure to traumatic events for psychological symptoms and mental disorders related to trauma. 4. When clients screen positive for trauma, also screen for suicidal thoughts and behaviors. 5. Do not delay screening for trauma. 6. Be aware that some clients will not make the connection between trauma in their histories and their current patterns of behavior (e.g., alcohol and drug use and/or avoidant behavior). 7. Do not require clients to describe emotionally overwhelming traumatic events in detail. 8. Focus assessment on how trauma symptoms affect clients' current functioning. 9. Consider using paper-and-pencil instruments for screening and assessment as well as self-report measures when appropriate, as they can be less threatening for some clients than a clinical interview. 10. Talk with each client about how you will use findings to plan the client's treatment, and at the end of the session, make sure the client is grounded and safe before leaving the interview room.

Trauma-Informed Treatment Principles 1-4

1. Promote Trauma Awareness and Understanding 2. Recognize That Trauma-Related Symptoms and Behaviors Originate From Adapting to Traumatic Experiences 3. View Trauma in the Context of Individuals' Environments 4. Minimize the Risk of Retraumatization or Replicating Prior Trauma Dynamics

Trauma-Informed Treatment Principles 11-16

11. View Trauma Through a Sociocultural Lens 12. Use a Strengths-Focused Perspective To Promote Resilience 13. Foster Trauma-Resistant Skills and Use Strengths-Oriented Questions 14. Show Organizational and Administrative Commitment to TIC 15. Develop Strategies To Address Secondary Trauma and Promote Self-Care 16. Provide Hope—Recovery Is Possible

Trauma-Informed Treatment Principles 5-10

5. Create a Safe Environment 6. Identify Recovery From Trauma as a Primary Goal 7. Support Control, Choice, and Autonomy 8. Create Collaborative Relationships and Participation Opportunities 9. Familiarize Clients With Trauma-Informed Services 10. Conduct Universal Routine Trauma Screening

Flashbacks

A flashback occurs when one reexperiences a previous traumatic experience as if it were actually happening in that moment. It includes reactions that often resemble one's reactions during the trauma.

Trauma-informed care (TIC) — definition

A trauma-informed approach includes an understanding of trauma and an awareness of the impact it can have across settings, services, and populations. It involves viewing trauma through an ecological and cultural lens and recognizing that context plays a significant role in how individuals perceive and process traumatic events. TIC involves vigilance in anticipating and avoiding institutional processes and individual practices that are likely to retraumatize individuals who already have histories of trauma.

Triggers or cues

A trigger is a stimulus that sets off a memory of a trauma or a specific portion of a traumatic experience.

Cultural Meaning of Trauma

Culture strongly influences perceptions of trauma. You must recognize that your perceptions of a specific trauma could be very different from your clients' perceptions. Be careful not to judge a client's beliefs in light of your own value system.

Common Experiences of and Responses to Trauma

Emotional dysregulation Numbing Physical Somatization Hyperarousal (hypervigilance) Sleep disturbances

Making Referrals From Trauma-Informed to Trauma-Specific Services

Factors that warrant consideration for referral include: • Excessively negative cognitions regarding the aftermath of the trauma, including consequences, changes after the event(s), responses of other people to the trauma, and symptoms. • Presence of intrusive memories. • Behaviors that reinforce or prevent resolution of trauma, including avoidance, dissociation, and substance use. • Physical consequences of trauma (e.g., chronic pain, disfigurement, health problems). • Additional traumas or stressful life events in the aftermath of the prior trauma. • Co-morbid mood disorder(s) or serious mental illness.

Responses to Trauma — Cognitive

Foreshortened future — Some clients may experience loss of hope about the future, limited expectations about life, suspicion that life will end abruptly or early, or anticipation that normal life events will not occur. Disruption of core beliefs — Trauma challenges the concept of a just world and the core life assumptions that help individuals navigate daily life.

Types of Trauma: Natural / Human-Caused

Natural events are typically unavoidable. Human-caused traumas are either intentional, such as a convenience store robbery at gunpoint, or unintentional, such as a bridge collapse due to structural deterioration.

Characteristics of Trauma: Objective / Subjective

Objective characteristics are the tangible or factual elements of a traumatic event; subjective characteristics include internal processes, such as determining the personal meaning of the trauma.

Reenactments

Reexperiencing can occur through reenactments, by which traumatized individuals repetitively relive and recreate a past trauma in their present lives. Examples of reenactments include a variety of behaviors: walking alone in unsafe areas, driving recklessly, or involving oneself repeatedly in destructive relationships.

Behavioral Changes in Response to Trauma

Some people reduce tension or stress through avoidant, self-medicating (e.g., alcohol abuse), compulsive (e.g., overeating), impulsive (e.g., high-risk behaviors), and/or self- injurious behaviors. Others may attempt to gain control over their experiences by being aggressive or subconsciously reenacting an aspect of the trauma.

Strategies To Prevent Retraumatization

Strategy #1: Be sensitive to the needs of clients who have experienced trauma; consider behaviors in the treatment setting that might trigger memories of the trauma. Strategy #2: When clients with trauma histories act out in response to triggered trauma memories, ignoring their symptoms and demands is likely to replicate the original traumatic experience. Strategy #3: Be mindful that efforts to control and contain a client's behaviors in treatment can produce an abnormal reaction, particularly in trauma survivors for whom being trapped was part of the trauma experience. Strategy #4: Listen for specific triggers that seem to be driving the client's reaction. An important step in recovery is helping the client identify these cues and thereby reach a better understanding of reactions/ behavior.

Strategies To Build Trust

Strategy #1: Clients can benefit from a support or counseling group composed of other trauma survivors. Strategy #2: Use conflicts that arise in the program as opportunities. Helping clients understand that conflicts are healthy and inevitable in relationships—and that they can be resolved while retaining the dignity and respect of all involved—is a major lesson for those whose relationship conflicts have been beset by violence, bitterness, and humiliation. Strategy #3: Prepare clients for staff changes, vacations, or other separations. Some clients may feel rejected or abandoned if a counselor goes on vacation or is absent due to illness, especially during a period of vulnerability or intense work. Strategy #4: Support the development of trust by establishing clear boundaries, being dependable, working with clients to define explicit treatment goals and methods, and demonstrating respect for clients who have difficulty trusting you and the therapeutic setting.

Strategies for Sleep Intervention

Strategy #1: Conduct a sleep history assessment focused first on the client's perception of his or her sleep patterns. Also determine total sleep time, pattern of nightmares, and use of medications, alcohol, and/or caffeine. Strategy #2: Use a sleep hygiene measure to determine the presence of habits that typically interfere with sleep (e.g., falling asleep while watching television). Strategy #3: Provide education on sleep hygiene practices. Strategy #4: Reassess sleep patterns and history during treatment. Sleep patterns often reflect clients' current status, and sleep disturbances can significantly influence clients' mental health.

Strategies To Enhance Culturally and Gender Responsive Services

Strategy #1: Determine if the client is a survivor of cultural trauma (e.g., genocide, war, government oppression, torture, terrorism). Strategy #2: Use cultural brokers (i.e., authorities within the culture who can help interpret cultural patterns and serve as liaisons to people outside the culture). Strategy #3: Determine how an individual's sociocultural support network views trauma. Strategy #4: Understand how the culture manifests PTSD, trauma-related symptoms, and other mental disorders.

Strategies To Build Resilience

Strategy #1: Help clients reestablish personal and social connections. Strategy #2: Encourage clients to take action. Recovery requires activity. Strategy #3: Encourage stability and predictability in the daily routine. Keeping a daily routine of sleep, eating, work, errands, household chores, and hobbies can help clients see that life continues. Like exercise, daily living skills take time to take hold as the client learns to live through symptoms. Strategy #4: Help clients recall how they successfully handled hardships in the past, such as the loss of a loved one, a divorce, or a major illness. Strategy #5: Help keep things in perspective. Even when facing painful events, all things pass. Strategy #6: Help maintain hope. An optimistic outlook enables visions of good things in life and can keep people going even in the hardest times. There are positive aspects to everyone's life. Strategy #7: Encourage participation in peer support, 12-Step, and other mutual-help programs.

Strategies To Acknowledge and Address Grief

Strategy #1: Initially, you can help clients grieve by being present, by normalizing the grief, and by assessing social supports and resources. Strategy #2: When clients begin to talk about or express grief, focus on having them voice the losses that they experienced because of the trauma. Remember to clarify that losses include internal experiences, not just physical losses. Strategy #3: For individuals who have difficulty connecting their feelings to experiences, assign a feelings journal in which they log and name each feeling they experience, assign a number to rate the intensity of the feeling, and describe the situation during which the feeling occurred. Strategy #4: Some individuals benefit from developing a ritual or ceremony to honor their losses. Others prefer contributing time or resources to an association that represents the loss.

Strategies To Support Empowerment

Strategy #1: Offer clients information about treatment, and help them make informed choices. Strategy #2: Collaborate with clients to develop their initial treatment plan, to evaluate treatment progress, to update treatment plans, and to gather program feedback. Strategy #3: Clients should assume an active role in how the delivery of treatment services occurs. Some of the most effective initiatives to reinforce client empowerment are the development of peer support services and the involvement of prior clients in parts of the organizational structure, such as the advisory board or other board roles. Strategy #4: Establishing a sense of self-efficacy—clients' belief in their ability to carry out specific coping strategies successfully—is key.

Strategies To Enhance Peer Support

Strategy #1: Provide education on what peer support is and is not. It is important to provide initial education about peer support and the value of using this resource. Strategy #2: Use an established peer support curriculum to guide the peer support process.

Strategies To Normalize Symptoms

Strategy #1: Provide psychoeducation on the common symptoms of traumatic stress. Strategy #2: Provide education to the client that addresses his or her most prevalent symptoms. Strategy #3: First, have the client list his or her symptoms. After each symptom, ask the client to list the negative and positive consequences of the symptom.

Strategies for Implementing Psychoeducation

Strategy #1: Psychoeducation begins with understanding the client's expectations and reasons for seeking help, followed by educating the client and his or her family members about the program. Strategy #2: After obtaining acknowledgment of a trauma history, it is good practice to provide an overview of common symptoms and consequences of traumatic stress, regardless of whether the person affirms having trauma-related symptoms. Strategy #3: Develop a resource box that provides an array of printed or multimedia educational materials that address the program, specific trauma-related symptoms and tools to combat them, treatment options and therapy approaches, advantages of peer support, and steps in developing specific coping strategies. Strategy #4: Develop a rotating educational group that matches services and client schedules to complement treatment.

Strategy To Teach Balance

Strategy #1: Teach and use the Subjective Units of Distress Scale (SUDS) in counseling. It provides a common language for the client and counselor, and it can also be used to guide the intensity of sessions. SUDS uses a 0-10 rating scale, with 0 representing content that causes no or minimal distress and 10 representing content that is exceptionally distressing and overwhelming.

Strategies To Promote Safety

Strategy #1: Teach clients how and when to use grounding exercises when they feel unsafe or overwhelmed. Strategy #2: Establish some specific routines in individual, group, or family therapy. A structured setting can provide a sense of safety and familiarity for clients with histories of trauma. Strategy #3: 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.

Strategies To Identify and Manage Trauma-Related Triggers

Strategy #1: Use the "Cognitive Realignment" technique to help separate the current situation from the past trauma. Identify one trigger at a time. Strategy #2: After the client identifies the trigger and connects the trigger to past trauma, work with him or her to establish responses and coping strategies to deal with triggers as they occur. Strategy #3: Use self-monitoring by asking the client to record each time a trigger occurs, along with describing the trigger and its intensity level (using a scale from 1-10).

Strategies To Help Clients Draw Connections

Strategy #1: Writing about trauma can help clients gain awareness of their thoughts, feelings, and current experiences and can even improve physical health. outcomes. However, use writing with caution, as some may find that it brings up too much intense trauma material too soon. Strategy #2: Encourage clients to explore the links among traumatic experiences and mental and substance use disorders.

Historical Trauma

The effects of traumas like genocide, slavery, and internment in concentration camps can stretch across generations. Stories, coping behaviors, and stress reactions can cross generational lines far removed from the actual event(s) or firsthand accounts.

Subjective Characteristics of Trauma

The following questions can help you address assumptions, beliefs, interpretations, and meanings related to trauma: • In what ways has your life been different since the trauma? • What does the trauma mean to you? • How do you understand your survival? • Do you believe that there are reasons that this event happened to you? • How did this experience change you as a person? Do you view others and your future differently since the trauma?

Screening Process

The most important areas to screen among individuals with trauma histories include: • Trauma-related symptoms. • Depressive symptoms. • Sleep disturbances. • Past and present mental disorders, including trauma-related disorders. • Type and characteristics of trauma. • Substance abuse. • Social support, coping styles, and availability of resources. • Risks for self-harm, suicide, and violence. • Health screenings.

Trauma survivor — definition

This phrase can refer to anyone who has experienced trauma or had a traumatic stress reaction. Given that the use of language and words can set the tone for recovery or contribute to further retraumatization, it is advisable to avoid the term "victim" and instead using the term "survivor" when appropriate.

Secondary trauma— definition

This term describes trauma-related stress reactions and symptoms resulting from exposure to another individual's traumatic experiences, rather than from exposure directly to a traumatic event.

Retraumatization— definition

This term not only refers to the effect of being exposed to multiple traumatic events, but also implies the process of re-experiencing traumatic stress as a result of a current situation that mirrors or replicates in some way the prior traumatic experiences.

Trauma-induced hallucinations or delusions

Trauma-induced hallucinations and delusions contain cognitions that are congruent with trauma content (e.g., a woman believes that a person stepping onto her bus is her father, who had sexually abused her repeatedly as a child, because he wears shoes similar to those her father once wore).

Objective Characteristics of Trauma

Was it a single, repeated, or sustained trauma? Was there enough time to process the experience? Was the trauma expected or unexpected? Were the effects of the trauma on the person's life isolated or pervasive? Who was responsible for the trauma and was the act intentional? Was the trauma experienced directly or indirectly? What has happened since the trauma?

Creating an Effective Screening and Assessment Environment

• Clarify for the client what to expect in the screening and assessment process. • Approach the client in a matter-of-fact, yet supportive, manner. • Respect the client's personal space. • Adjust tone and volume of speech to suit the client's level of engagement and degree of comfort in the interview process. • Provide culturally appropriate symbols of safety in the physical environment. • Overcome linguistic barriers by using an interpreter. • Only elicit information necessary to determine a history of trauma and the possible existence/extent of traumatic stress symptoms and related disorders. • When possible, use self-administered, written instruments to assess trauma. • An interview is best if a client has trouble reading or writing or is otherwise unable to complete a written instrument. If a client has intense emotional responses when recalling or acknowledging a trauma, give the client time to become calm and oriented to the present. • Provide feedback about the results of the screening. • Be aware of the possible legal implications of assessment.

Types of Cognitive Changes that Can Occur in Response to Traumatic Stress

• Cognitive errors • Excessive or inappropriate guilt Intrusive thoughts and memories Changing perceptions of self and others Dissociation

Resilient Responses to Trauma

• Increased bonding with family and community. Redefined or increased sense of purpose. Revised priorities. Increased charitable giving and volunteerism. Increased commitment to a personal mission.

Trends Regarding Trauma and Mental Disorders

• Individuals in treatment for severe mental disorders are more likely to have histories of trauma. • Many clients with severe mental disorders also meet criteria for PTSD. • Individuals with serious mental illness who have histories of trauma often present with other psychological symptoms or disorders commonly associated with trauma, including anxiety, mood disorders, and substance use disorders. • Traumatic stress increases the risk for mental illness. Research suggests that trauma often precedes the development of mental disorders. • Mental illness increases the risk of experiencing trauma, and trauma increases the risk of developing psychological symptoms and mental disorders.

Trends Regarding Trauma and Substance Use Disorders

• Many people who have substance use disorders have experienced trauma as children or adults. • Substance abuse predisposes people to higher rates of traumas. • People who abuse substances and have experienced trauma have worse treatment outcomes than those without histories of trauma. • More than half of individuals who seek substance abuse treatment report one or more lifetime traumas.

What Decreases the Risk of Secondary Trauma and Promotes Self-Care Among Counselors?

• Peer support. • Supervision and consultation. • Training. • Personal therapy. • Maintaining balance. • Setting clear limits and boundaries with clients.

Potential Treatment Issues That Can Cause Retraumatization

• Using seclusion, restraint, or "time-out" practices that isolate individuals • Mislabeling client symptoms as personality or other mental disorders, rather than as traumatic stress reactions • Being overly authoritative when interacting with clients • Giving treatment assignments that could humiliate clients • Using a confrontational approach • Presenting treatment as conditional on conformity to the counselor's beliefs and definitions of issues • Challenging or discounting reports of abuse or other traumatic events • Allowing the abusive behavior of one client toward another to continue without intervention • Labeling client behavior/feelings as pathological • Being unaware that the client's traumatic history significantly affects his or her life