Trauma Informed Care and Clinical Practice: Top Questions Asked by Professionals

Congratulations field of behavioral health and human services! You have again shown how thoughtful, insightful and driven you all are.  I had one of those work days where I was excited and looking forward with high anticipation for a work task. On a Monday no less. Relias conducted our second webinar earlier this week with our partner National Council for Behavior Health on Trauma-Informed Care (TIC).

Just like last time, we had a full webinar, lots of attendees and great content on best practices in TIC.  We have created this post to answer all the questions that came in and provide additional information.  We appreciate how many of you were asking about how to apply what you are learning at work, how to change the way you practice, seeking ways to improve and implement best practices.

We’ve organized the questions into themes to make them easier to review, answered by our panel of experts at National Council:

• Karen Johnson, Director of Trauma-Informed Services, NCBH
• Cheryl Sharp, Exclusive Consultant for Trauma-Informed Services, NCBH
• Linda Henderson-Smith, Consultant for Trauma-Informed Services, NCBH

Peer Related

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Are you aware of peer specialist services for adolescents?

Answer: Yes. There are individual peer specialist services for adolescents in some states.  Others are working on developing them. YouthMOVE National has created a curriculum and is working with some states on proper training and implementation. There are also ways to establish group peer services through group therapy and skills building curriculum, i.e. G-TREM.  In addition, Wellness Recovery Action Planning (WRAP©) offers training and skill building for children and adolescents to develop their own wellness plans as well as opportunities to become facilitators.  The National Council offers Training Trauma-Informed Peers© that can adapted for adolescents.

How do we train our peer workforce to be trauma informed?

Answer:   Your peer workforce can be trained to be trauma-informed the same way in which your clinical staff should be trained, through training, technical assistance, coaching and supervision.  The National Council has a Trauma-Informed Services department that can assist you with that.

How have you integrated peer support specialist into Trauma Informed Care work?

Answer:   Peers are frequently integrated into the Trauma-Informed Care work.  We recently did a trauma-informed care for non-clinical staff webinar.  We also provide training, technical assistance and coaching to peer workforces.  Peers provide a unique opportunity to offer us essential feedback from the perspective of lived experience of services as well as the perspective of what a person’s experience of distress feels like.  Peers will often see solutions that can be simple to implement but can have a profound impact.  It is all about perspective and until we have walked a mile in someone’s shoes, our perspectives cannot be reflective of others’ realities

What resources are available for non-clinical treatment/case management?

Answer:   We recently did a webinar for non-clinical staff regarding Trauma-Informed Care.  Other resources include:

• Bloom, Sandra L., and Brian J. Farragher. Restoring Sanctuary: A New Operating System for Trauma-informed Systems of Care. Oxford: Oxford UP, 2013. Print
• Grotberg, Edith H. A Guide to Promoting Resilience in Children: Strengthening the Human Spirit. The Hague, Netherlands: Bernard Van Leer Foundation, 1995. Print.
• Harris, Maxine, and Roger D. Fallot. Using Trauma Theory to Design Service Systems. San Francisco: Jossey-Bass, 2001. Print.
• Hodas, G. (2006). Responding to childhood trauma: The promise and practice of trauma-informed care. National Association of State Mental Health Program Directors.
• Substance Abuse and Mental Health Services Administration. Trauma-Informed Care in Behavioral Health Services. Treatment Improvement Protocol (TIP) Series 57. HHS Publication No. (SMA) 13-4801. Rockville, MD: Substance Abuse and Mental Health Services Administration, 2014.

Comment by an attendee: Connecticut has a certificate program through Recovery University for Peer Supports.

Recalling a Traumatic Event

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Isn’t the question “What happened to you” counter intuitive to “the client doesn’t have to recall the traumatic event”? I prefer “what do you see as problematic?”

Answer: This is a good question.  When we talk about changing the question to “What happened to you?” we are referencing a change in how we think about and view the people we serve, ourselves and each other.  This is the big paradigm shift at the foundation of trauma-informed care.  This reframe gives us a new lens that all of our interactions, policies, practices and procedures are filtered through.

So, we move from the disease model to the strength model with this different way of thinking.  The actual question is not always asked, and when it is asked, it needs to be asked in a sensitive, safe way by trained a trained clinician, often employing validated tools.  The purpose behind asking the question is not to have the client recall the event necessarily, but often to help them connect the dots between their life events and how they are currently functioning.  This reframe can open up a whole new world for us as service providers and the people we serve, and help them to change internal messages around their perceived weaknesses and deficits.  The message “I am broken and weak” can become “I am a survivor and very strong.”

If recalling a traumatic event is not important in doing trauma-informed work, how is “remembrance” different from recalling?

Answer: In any good model of trauma treatment, the first goal should be to do no harm.  The telling of events is something that a person needs to be ready to remember.  In a trauma-informed environment, this requires that the person feels the safety, security and trust.  It is also important that the person has the ability to be grounded and to learn to ground themselves.  If you recall from the webinar, we discussed Judith Herman’s Stages of Trauma Healing and Recovery.

• Safety
• Mourning and Remembrance
• Reconnection

Herman, J., 1992

In a trauma-informed organization, we are looking at the full experience of the person and working to create an environment that wraps its arms around the survivor to begin to provide the corrective experience that the person so desperately needs.  The retelling of the story, not just recalling the factual events as in a clinical assessment, can be such a healing experience.  When recalling the facts, many of us are able to separate ourselves from those facts without too much dysregulation.

Still, in the retelling, as in the assessment phase, we have an opportunity to establish the early stages of safety and trust using solid clinical skills that convey that we are here to listen, not judge and allow the person to let the retelling unfold.

In remembrance, we support the container for the person’s story and allow this to be a gentle process and are mindful of the power of our presence as a witness to a person’s deepest pain.  We do not push or prod, we invite the unfolding.  This can take time, but the power of the process is one of the greatest gifts a person ever receives.

Allow for the mourning.  Perhaps it is all of the losses a person experiences, the recognition of the innocence that can never be fully restored.  Remember that a person has a right to express their anger or grief and that this is healthy.  Once again, having worked on building those skills in order to manage intense emotions is part of regaining one’s power as a human being, having the confidence that this person is aware that they are now the one in charge of emotions and not the trauma.

Is it accurate to say that having clients construct a trauma narrative is no longer a necessity? This gives me hope for a couple of survivors I know who avoid processing their trauma simply in order to avoid speaking of it. Is this now the new norm?

Answer:  The general message is that constructing the trauma narrative is not necessary for everyone.  The following article summarizes the stages referenced in the webinar and notes that for some, the first stage of recovery may provide a foundation that is enough for moving forward and achieving goals. Herman’s Stages of Recovery

Are you familiar with Dr. Siegel’s work concerning moving traumatic memories from one section of the brain to another in order to avoid flashbacks?

Answer:  Yes.  Excellent body of work relevant for clinicians embracing clinical practice addressing trauma.  Thank you for sharing.  We have referenced Dr. Siegel’s work in other answers in this blog.

Questions regarding working with children and families

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How do we maintain a daily plan when the child is young and does not have the skill to keep track of daily. Also, what behaviors would be on the daily plan?

Answer:   Consistency is how to teach any child on a behavioral pattern.  Children learn by repetition.  As for what behaviors would be on the daily plan, that will depend on age and cognitive ability for the each child.

The following booklet by Dr. Bruce Perry from the Child Trauma Academy offers very helpful information about working with children who have experienced trauma. Helping Traumatized Children:  A Brief Overview for Caregivers

Are there any helpful trauma informed strategies to utilize in the school setting?

Answer:   There is significant body of knowledge related to advancing trauma-informed approaches and strategies in the school setting.  Below are excellent resources:

• Wisconsin DPI website
• Calmer Classrooms: A Guide to Working with Traumatized Children
• ACEs Too High – Lincoln High School Principal on Compassion and Punishment
• The Heart of Teaching and Learning
• Creating Emotionally Safe Schools: A Guide for Educators and Parents. Jane Bluestein Ph.D. 2001
• Restorative Justice

What do you recommend to those responsible for parenting classes with parents involved with child welfare forced to take classes?

Answer:  Approach them as clients with trauma histories, be trauma-informed in your approach, and train them to be trauma-informed parents.

The following curriculum from The National Child Traumatic Stress Network is an effective resource for training with parents involved in child welfare. Caring for Children Who Have Experienced Trauma:  A Workshop for Resource Parents

Special Populations

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We are working with clients who are also living in poverty and have to deal with a human service system that is very punitive.  How can we minimize the impact of the system we have to work within to better serve our clients?

Answer:  Poverty is a trauma in and of itself and recognizing this will help.  There are several things that come to mind here.  Understanding that there is a culture of poverty for many and that poverty is usually intergenerational and often coupled with other historically significant trauma is important.

Having a culturally sensitive and humble workforce is the first line of caring in a trauma-informed system.  Staff will often look at those they serve and think things such as; this person is malingering or just lazy, she shouldn’t have had this fourth baby, he is able-bodied, he should be doing better, etc.  The only way to make a punitive system less punitive is to bring your common humanity to the table.  All of us are more alike than we are different.

It is going to take time for the system to change but it is changing.  We have to be on the cutting edge to create environments where people can begin to heal and where they are not broken or bad because they are using services.

Also, how we instill hope and possibility for individuals who are in dire circumstances is so important.  Helping a person to learn that there are simple things that they can do to begin to move away from the desperation of poverty is empowering for the person.  How we support and encourage people to take the small steps will help lead to the bigger steps.

You might find some helpful tools and resources in The Homelessness Toolkit.

How does trauma-informed care looks on an inpatient psych unit?

Answer:   Trauma-informed care on an inpatient psych unit looks like fewer restraints and seclusions and negative incidences.  Worker’s injuries are reduced and staff retention is greater as well as staff satisfaction.

Trauma-informed care on an inpatient psych unit leads to a place of calm rather than chaos, consistency rather than sporadic treatment and a sense that all of us are in this together; staff and patient alike to provide the most nurturing and healing environment possible.

Staff are educated about their own triggers and trauma responses and work diligently to identify potential triggers for themselves and for the patients on the unit.  Patients understand that there are ways to address their triggers and are comfortable asking for staff to support them in doing something different to self soothe.

Consideration of the physical environment is imperative.  It should feel more like home than a sterile hospital.  Signage and overt direction should be avoided, especially separation between staff and patients.  Replace those seclusion and restraint rooms with comfort rooms as so many hospitals are doing these days.  Seclusion and restraint is an absolute last resort as is chemical restraint.  When an inpatient setting goes through this transition, it can feel like a very rocky course, but it is possible and amazing when it happens.

Provide people with choices and options in types of groups and activities, making sure they are relevant for the population.  Offer gender specific groups, storytelling groups, music, movement, meditation, mindfulness, not only cognitive approaches.

Think about simple things to solve problems.  The best way to solve problems on units is to ask the people who are residing there.  Work with staff to do the same with each other.

Would you have any suggestions on resources for a dual service agency (domestic violence/sexual assault) that may be helpful for both our clients and staff?

Answer: The practices and principles of trauma-informed approaches are pretty universal.  Any type of culture change requires an intentional implementation process. National Council Trauma-Informed Care site can provide you with recommendations for technical assistance as well as past archived webinars that might be helpful.

The Principles of a Trauma-informed Approach are universal:

• Safety
• Trustworthiness and transparency
• Collaboration and mutuality
• Empowerment
• Voice and choice

(Fallot 2008, SAMHSA, 2012)

Recognizing that the vast majority of the people you serve have trauma histories that were prevalent long before they were involved in DV/SA has to be taken into consideration.  Also, recognizing that most of those who batter and abuse are also trauma survivors.

In situations where there is great system involvement (court, etc.) how trust and safety are developed is key.  Making certain that members of the justice system are trauma-informed will also go a long way to ease this very difficult current trauma that is happening.

Is this information available for or currently being used for military personnel and veterans especially combat veterans?

Answer:  Yes, in many places.  We have to remember that the military is a culture within itself and that when a military family member or the veteran themselves is seeking help and support there are still attitudes within the military that struggle is a sign of weakness.  Thankfully, this is lessening and people are reaching out.

Some of the most successful programs around the country are doing great work with practices such as EMDR by Francine Shapiro and the wonderful Somatic Experiencing work of Dr. Dan Siegel are very effective working with veterans.  There is a wonderful online video of his work with one young veteran recovering from PTSD.

Additional resources include:

• http://www.samhsa.gov/veterans-military-families
• http://www.mentalhealth.va.gov/

What differences have you noticed in the treatment of men with trauma histories versus treatment for women?

Answer:  With the exception of treatment of combat PTSD, men have commonly been treated from a poorly informed gender construct.  Men and women process information differently and respond to treatment differently.  There are very good modalities out there that are designed for gender specific groups.  Most specifically Men’s Trauma Recovery and Empowerment Model, M-TREM works very well for men.  You might also look at the work of Dan Griffin, author of The Man Rules and Helping Men Recover.

Questions about Techniques and Treatments

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Any research studies that show the effectiveness of mindfulness in treating trauma?

Answer: Yes.  Here are a few links to some of the information on mindfulness:

• http://www.ptsd.va.gov/professional/treatment/overview/mindful-PTSD.asp
• http://www.intechopen.com/books/a-fresh-look-at-anxiety-disorders/mindfulness-new-research-and-treatment-directions-in-post-traumatic-stress-disorder
• https://www.relias.com/wp-content/uploads/2018/08/4_MindfulnessInTrauma_Briere_Chapter.pdf

You mentioned that Incentives, short and long term may disengage a person.  Please explain further.

Answer: This reference is about being careful in our trauma-informed treatment to avoid conditional extrinsic rewards that are based on how well someone performs.  We need to avoid making treatment conditional, and/or based on earning incentives in order to continue in treatment and/or move forward to the next identified level.  Many of our programs in residential, day treatment and other group settings have level systems designed to increase motivation for advancing in the treatment program.  As a general statement, these types of incentive programs are not trauma-informed.

The following article explores this question for children settings.  The same concepts can apply to adult settings. Beyond Point and Level Systems:  Moving Toward Child-Centered Programming

What are your thoughts on utilizing Trauma Screens / Assessments that are not evidence based?

Answer:  Though evidence-based screens and assessments are preferred, utilizing a screen or assessment to begin the discussion is most important.

During the screening and assessment process the most important factor to consider is creating the environment for safety and trust.  The practitioner is far more important that the tool used.  Regardless of the tool being used, please make certain that the intake person has been trained to sensitively approach these questions.

There are so many screening and assessment tools available that have been validated but we also need to remember that the field is moving very rapidly and that perspectives are changing regarding brain research.

How detailed trauma history should be taken at the beginning of treatment?  I have an intern who refuses to ask any specifics about trauma (when, who, how) in the assessment phase because he is afraid of triggering clients.

Answer:  The first thing to be addressed with the intern is why is this so uncomfortable to him?  It sounds as if he needs education around the importance of asking these questions as the answers will guide appropriate treatment from a trauma-informed perspective.  Supervising this person in a way that will help him understand that this is best treatment.  Also, understanding the difference between screening for trauma which is much shorter and briefer and is not asking so much about the details, but simply if there were difficult things that have happened in a person’s life that might be impacting their current challenges.  In assessment, we still do not go into “the who, when and how” questions, but we do explore the “what” happened and help the client understand that we are asking these questions to make certain we guide them appropriately as treatment options are considered.  Also, offering the client the option of answering or not, and only if they are comfortable is important.

Staff need to understand that a person might not feel safe enough to tell us too much, but we have to start somewhere.

For many clients, this might be the first time that they have ever been asked the question and will feel relieved that someone is finally getting to the heart of the matter.  Simple responses when someone does disclose might be, “I am very sorry this happened to you or this should never happen to a child”, go a long way to calming the triggers that might arise.  Please remember, trauma survivors are not fragile, they have been living and surviving for years with the events that have occurred in their lives.

What are the most successful techniques to deal with adult trauma survivors?

Answer: There are many wonderful ways of working with adult trauma survivors that have great efficacy.  One of the most doable and accessible practices is Seeking Safety.  It is easy to operationalize and adapts to a variety of settings.  One of the nice things is it addresses the various levels of safety, safety within oneself, one’s environment, social safety, etc.  There are also very simple grounding techniques that can be used anywhere.  It doesn’t require extensive training and can also be peer delivered with training.  Any technique you use must have elements of mindfulness and skill building/practice at self-regulation.

Do you have to be certified or can learning on your own be enough?

Answer: Everyone can practice listening nonjudgmentally, treating people with kindness, dignity, respect and compassion.  Trauma-informed approaches bring us back to our basic humanity.  It does require an understanding of the neurobiology of the brain without having to be an expert.  Being able to recognize, support and empathize with a person in extreme distress can have clinical implications, however, your humanity and kindness is far more important than techniques.

I work in a residential treatment center for substance use.  I may meet with a client 3-5 times one on one before discharge.  Is this enough time to enter the remembrance and mourning stage with my clients or should this be left for long term therapy?

Answer: It depends on where the person is in their recovery process and what type of aftercare/follow up they are going to have.  It also depends on how long they have been in treatment.  One of the things we know is that untreated trauma is very often one of the causes of relapse.  What would make the most sense is that trauma treatment and trauma-informed approaches would be integrated into the program from the moment the person makes the first phone call.  Addressing sooner than later will lead to better long term outcomes.  Again, remember, the person has been living with what happened to them most of their lives.

Other topics

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How do you get staff members who do not “buy in” to the “what has happened to you” mantra to practice trauma-informed strategies (ie. reception, food service, etc)

Answer: Many times if you show them how trauma may have affected their own lives or those around them, they are more willing to buy in.  Involving the voice of lived experience in training, through videos and/or consumers sharing their story, can also help people to see the need for this change.  When a trauma survivor shares how the interactions outside of the therapy room, with others in the organization such as the receptionist or security officer, were stigmatizing and disrespectful, or trauma-informed, that can be very powerful for staff.  Also, the CEO and leaders in the organization need to consistently share the message that this is how we operate as an organization and everyone in the organization needs to be involved in order for our organization to be trauma-informed.

Thank you all for the work you all do, we are blessed and are lucky to be a part of helping you achieve a higher quality of care.  See you all at our next webinar on Trauma Informed Care June 14th “Trauma-Informed Care and Its Focus on Staff: Moving from Compassion Fatigue to Compassion Satisfaction”