5.3: Client-Centered, Trauma-Informed Services Presentation by Deborah Warner and Pat Tucker

1. Client-Centered and
Trauma-Informed Services
Deborah Werner
Pat Tucker
Advocates for Human Potential, Inc,
This presentation is made possible with support from the
Substance Abuse and Mental Health Services Administration

2. The importance of a home
• Place to be
• Stability
• Security/safety
• Control
• “Stuff”
• Responsibility
When you don’t have these
things what happens?

3. Homelessness is often not the
first experience of trauma and
uncertainty in a homeless
mother’s life.

4. Trauma among mothers who are
homeless:
• Over their lifetime, 92% experienced
severe physical and sexual assault.
• 25% experienced random violence.
• 66% experienced severe physical violence
as children.
• 43% were sexually molested as children.
Bassuk EL, Weinreb L, Buckner J, et al. (1996). The characteristics
and needs of sheltered homeless and low-income housed
mothers. JAMA, 276(8): 640-646.

5. Trauma can come from many things
• Emotional, sexual or physical abuse
• Natural disaster/fire
• Physical attack/ abuse/ threats
• Life-threatening accident,
catastrophic injuries and illnesses
• Witnessing injury/death
• Combat
• Family separation
• Extremely painful and frightening
medical procedures
Photo: h.koppdelaney @ flicker.com • Rape or assault
Accompanied by feeling of • Domestic violence
intense fear, helplessness,
or horror.

6. Definition of Trauma
The diagnostic manual used by mental health
providers (DSM IV-TR) defines trauma as,
“involving direct personal experience of an event
that involves actual or threatened death or
serious injury, or other threat to one’s physical
integrity; or a threat to the physical integrity of
another person; or learning about unexpected or
violent death, serious harm, or threat of death or
injury experienced by a family member or other
close associate.
American Psychiatric Association [APA] (2000, p 463)

7. Definition of Trauma
(cont.)
“The person’s response to the event
must involve intense fear,
helplessness or horror.
…or in children, the response must
involve disorganized or agitated
The behavior.”
disturbance
causes
clinically
significant
distress or
impairment in
social,
occupational, American Psychiatric Association [APA]
or other (2000, p 463)
important areas
of functioning.

8. Common Symptoms (DSM IV-TR, 2000)
• Dissociation/freezing • Numbing of
responsiveness
• Flashbacks
• Depression
• Hyper-vigilance
• Substance abuse
• Terror
• Upsetting reminders and
• Anxiety triggers
• Self-injury
• Eating problems
• Sleep disturbances or
nightmares
• Fight or flight response
alarm reaction followed by
intense fear
Photo: will fisher @ flickr.com

9. The Impact Continues
Trauma begins a
complex pattern of
actions and reactions
that have a continuing
impact over the course of
one’s life.

10. A victim’s world view
Relationships are
characterized by victim -
victimizer dynamic.
Someone is the controller
and someone controls.
This world view is carried
through all relationships
Francine Feinberg, MetaHouse, Inc
including social services and
employment.

11. The Internal Working Model
• The world is a frightening
place
– Shouldn’t trust others
– Feels vulnerable
– Misreads cues
– Under-reacts to real danger
– Over-reacts to innocent
exchanges
Photo: aryche @ flicker.com
Francine Feinberg, MetaHouse, Inc

12. The Internal Working Model
• No ability to affect the
situation.
– Actions bring disappointment,
retribution
– Hostility – Anger, Attitude
– Passivity – May as well not try
– Bad things will happen and no
one will protect her
– Fear, anxiety
Photo: aryche @ flicker.com
– Self-protective hostility
Francine Feinberg, MetaHouse, Inc

13. Men React Differently to Trauma
• This is an emergency!
– “Fight or flight” : men may be
aggressive,
antisocial, or “on guard”
– Boys may “act out,” use substances, or
be truant
• Better keep this quiet.
– Boys and men are less likely to talk it
out or admit fear.
• Being a man means appearing strong.
Hodas (2006), Responding to Childhood
Trauma
– Males may feel shame that they could Mejia (2005), Gender Matters: Working
with Adult Male Survivors of Trauma
not defend themselves.

14. Stephanie Covington: The Progression of Trauma
SELF-DESTRUCTIVE DESTRUCTIVE
RETREAT
ACTION ACTION
SUBSTANCE ABUSE
ISOLATION
EATING DISORDER AGGRESSION
DISSOCIATION
DELIBERATE SELF- VIOLENCE
DEPRESSION
HARM RAGES
ANXIETY
SUICIDAL ACTIONS

15. Trauma can be self-defining
• Sense of self
• Sense of efficacy
• World view
• Coping skills
• Relationships with others
• Ability to regulate emotions
• How one approaches services
• How one approaches the culture of the
treatment agencies, work environments, and life
in general
Francine Feinberg, Meta House, Inc

16. 3 Stages of Trauma Recovery
• Safety
• Mourning
• Reconnection
Judith Herman
Our focus today is on
safety
Photo: Andy and Becky’s bits@flickr.com

17. Trauma-Informed Approaches
• Based on current literature and informed by research and
effective practice.
• Take trauma into account.
• Avoid triggering trauma reactions or retraumatization.
• Recognize the trauma of coercive interventions.
• Support the individual’s coping capability.
• Allow survivors to manage their trauma symptoms
successfully so they can access, retain, and benefit from the
services.
(Fallot & Harris, 2002; Ford, 2003; Najavits, 2003)

18. Trauma-Sensitive vs. Trauma-
Insensitive Approaches
Trauma-sensitive Trauma-insensitive
services/approaches services/approaches
• Recognition of culture and • “Tradition of toughness”
practices that retraumatize valued as best care approach
• Power/Control minimized • Keys, security uniforms, staff
demeanor, tone of voice
• Caregivers/Supporters • Rule Enforcers
• Collaboration-focused • Compliance-focused
• Staff training builds • “Client-blaming” as fallback
awareness, sensitivity position without training
• Understand function of • Behavior seen as
behavior such as rage, intentionally provocative and
repetition-compulsion, self- volitional
injury
(Fallot & Harris, 2002; Cook et al., 2002; Ford, 2003; Cusack et al., 2004; Jennings, 1998; Prescott, 2000)

19. Trauma-Sensitive vs. Trauma-
Insensitive Workers
Trauma-sensitive Trauma-insensitive
workers workers
• Objective, neutral language • Labeling language: manipulative,
needy, gamey, “attention-seeking”
• “Let’s talk and find you something • “If I have to tell you one more time
to do that will help.” ….”
• Focus is on person – eye contact • Focus on task, not person
• Says hello and goodbye • Comes and leaves with little
acknowledgement
(Fallot & Harris, 2002; Cook et al., 2002; Ford, 2003; Cusack et al., 2004; Jennings, 1998; Prescott, 2000)

20. Client-Centered, Trauma-
Informed Approaches
• Understanding Triggers
• Building Trusting
Relationships
• Emphasize Strengths
• Building Coping Skills
• Children and Families

21. What is a Trigger?
• A trigger is a
troubling reminder of
a traumatic event.
• The trigger itself need
not be frightening or
traumatic.
• It can be conscious
or unconscious.
• Triggers are often
Photo: .craig@flikr.com
subtle and difficult to
anticipate.
Adapted from Fagan, Nancy; Kathleen
Freme. 2004

22. Some things that may be
triggering
• Individual people • Animals
• Places • Films or scenes
• Emotions within films
• Noises • Dates of the year
• Images • Tones of voice
• Smells • Body positions
• Tastes • Bodily sensations
• Color • Weather conditions
• Environmental • Time factors
conditions

23. Discussion
• What are some environmental factors
in your agencies or groups that may
trigger someone who has experienced
trauma?
• What may happen when an individual
who has experienced trauma is
triggered?
• What can you do to prevent or
minimize crises?

24. Building Trust
• See the family/believe in them
• Take the time
• Start where they are
• See the possibility
• Demonstrate compassion
• Share hope
• Avoid judging
• Be responsive to immediate needs
• Show respect
• Do what you say you will do

25. Hope
Everything we do and say should be infused with
the hope and belief that people’s lives change,
people get better, and recovery is possible!

26. Tips for Trauma-Sensitive
Relationships
• Be aware, mindful, respectful
• Don’t probe – let the person
raise the issues
• Avoid judging or labeling
behaviors as manipulation
• Maintain strengths-based view
• Work through resistance: What
is the person trying to tell us?
Photo: Aussiegirl@Flikr.com

27. See the Strengths
• As an individual
• As a family
• As a family member
• As a parent
• In the environment

28. Discovering
Strengths
There are many ways to see strengths of an
individual or family, including:
• Patterns • Talents – hobbies
• Attitudes • Stamina
• Coping styles • Common sense
• Values – family, cultural, • Relationships
social • Interests – desires
• Choice • Physical attributes, health
• Personality characteristics • Behavior – skills
• Environmental – home, • Things person does well
community, resources
• Achievements
• Beliefs
• Flexibility
• Feelings – emotions
• Resourcefulness
• Knowledge – intelligence

29. Sometimes we think our
clients should do one
thing and they choose to
do another.
They may have different
priorities.
They may make mistakes.
Either way, they are the
decision-makers.

30. Self Determination
People make choices all the time about treatment programs,
but it may look to us like non-compliance! Using self-
determination as a principle of case management means
to recognize this fact and use it to create “buy-in” for a
treatment plan.

31. Exercise
• In pairs – one person is the staff
member and one a homeless woman.
The homeless woman wants the candy
and the staff member wants her to have
the carrot.
• What happened. What did the case
manager do? How did the woman feel?
What is the long-term impacts?

32. Key Questions
• Where are you now?
• Where do you want to be?
• What resources do you have available to help you get
there?
• What can we do together to help you get where you want
to be?

33. Planning Tips
• Remember, it’s not your decision.
Help others set goals and prioritize.
• Focus on concrete steps
• Find and offer practical tools
• Don’t be afraid to change horses
• Focus on positive action
• Coordinate and collaborate

34. Building Skills
• Coping Skills
• Responding instead of Reacting
• Life Skills
• Communication
• Parenting (trauma-informed)
Always ask – is it practical? Does if fit with the family
goals? Make it real!
celebrate successes!

35. Life on Life’s Terms
Take it easy!
People who are surviving on
the streets and in shelters
are just that – survivors!
You don’t have to meet
every need immediately, and
they can’t or won’t work on
recovery full time.

36. Worker Reactions
Workers may unwittingly repeat client
trauma roles: victim, perpetrator,
bystander.
• Client problems evoke
sympathy and vulnerability,
which may lead to excessive
support and overindulgence
rather than encouraging client
accountability and growth.
• Client struggles can trigger
staff frustration, harsh
judgments, and punitive
confrontations.

37. The Life Balance Wheel
Is your life in
balance?
Add spokes to the
wheel to represent
your self‐care
activities in each
area.

38. Examples of Trauma Programs
• Amaro, H., & Nieves, R. L. (2009). Boston Consortium Model:
Trauma-Informed Substance Abuse Treatment for Women.
Contact: Hortensia Amaro at h.amaro@neu.edu or Rita Nieves
Rita_Nieves@bphc.org.
• Clark, C., Fearday, F. (eds) (2003) Triad Women’s Project: Group
facilitators manual. Tampa, FL: Louis de la Parte Florida Mental
Health Institute, University of South Florida. (contact Colleen Clark
at cclark@fmhi.usf.edu)
• Covington , S. S. (2003) Beyond Trauma: A Healing Journey for
Women. Center City, MN: Hazelton Press. (Contact Stephanie
Covington at sscird@aol.com)

39. Examples of Trauma Programs
(continued)
• Ford, J.D., Mahoney, K., Russo, E., Kasimer, N., & MacDonald, M. (2003).
Trauma Adaptive Recovery Group Education and Therapy (TARGET):
Revised Composite 9-Session Leader and Participant Guide. Farmington,
CT: University of Connecticut Health Center. (Contact Julian Ford at
ford@psychiatry.uchc.org )
• Harris, M. (1998). Trauma, Recovery and Empowerment: A Clinician’s
Guide for Working with Women in Groups. New York, NY: Free Press.
(Contact Rebecca Wolfon Berley at rwolfson@ccdc1.org)
• Miller, D., & Guidry, L. ( 2001). Addictions and Trauma Recovery: Healing
the Mind, Body, and Spirit. New York: W.W. Norton. (Contact Dusty Miller
at dustymi@valinet.com)
• Najavits, L. (2001). Seeking Safety: Cognitive-Behavioral Therapy for
PTSD and Substance Abuse. New York: Guilford. (Go to
www.seekingsafety.org)
• Saakvitne, K. W., Gamble, S.J., Pearlman, L.A., Lev, B.T. (2000). Risking
Connection: A Training Curriculum for Working with Survivors of Childhood
Abuse. Maryland: Sidran. (Go to www.sidran.org)

40. Transformation in the world
happens when people are healed
and start investing in other
people.
Michael W. Smith

41. Thank You
This presentation has been developed and presented
by Advocates for Human Potential, Inc. with support
by the Substance Abuse and Mental Health Services
Administration
Deborah Werner, MA – dwerner@ahpnet.com
Pat Tucker, MA, MBA – ptucker@ahpnet.com