Based on TIP 57: Trauma-Informed Care in Behavioral Health Services|SAMHSA A single counseling CEU course is available at https://www.allceus.com/member/cart/index/product/id/395/c/ or the complete Trauma Informed Care Training Certificate are available at https://www.allceus.com/member/cart/index/product/id/399/c/
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Trauma Informed Care: Treatment Issues
1. Trauma Informed Care
Clinical Issues
Instructor: Dr. Dawn-Elise Snipes PhD, LPC-MHSP, LMHC
Podcast Host: Counselor Toolbox & Happiness Isn’t Brain Surgery
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2. 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
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3. 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
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4. 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.
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5. 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.
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6. Establish Safety
Scenarios
Date rape
Home invasion
Natural disaster (Fires)
House fire
Child neglect
Car accident
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7. 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.
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8. 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
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9. 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
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10. 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.”
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11. 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.
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12. 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
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13. 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.
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14. 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?
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15. 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!
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16. 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
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17. 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.
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19. 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
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20. 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
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21. 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
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22. 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
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23. 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
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24. 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).
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25. 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
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26. 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.
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27. 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
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