Trauma Informed Care Clinical Issues

Welcome everybody to today's presentation, trauma informed clinical issues. So this is the last in our six session series on trauma informed care and we're really going to focus on wrapping everything up and kind of summarizing and tying it up in a nice little bow. Today we're going to define trauma informed prevention and treatment objectives. So once you do the assessment, once you get somebody in, once you've got an organization that's trauma informed and responsive, then what do you do? We'll highlight some treatment issues, understand when and how to make referrals to trauma specific services, and we'll talk about what those are and explore trauma specific treatment models, integrated models for trauma, and some emerging interventions. Attention therapists all CEUs is grateful to our new sponsor, the Diversion Center. They offer workbooks that are 100% editable and delivered to you in a word document on topics including anger management, substance use disorders, domestic violence, parenting and shoplifting addiction. Each workbook can be used for individual or group sessions and is over 120 pages. You have the option to add or remove content, insert your name as the author and reprint and resell the workbooks to your clients. Go to privatelabelworkbooks.com and take advantage of their buy one, get one free bundle offers. Remember, that's privatelabelworkbooks.com not even realize that trauma is still impacting them or impacting them. And once they start coming to that realization, they may start looking back and going, okay, now I see why I'm making all these unhealthy choices. What is my next best course of action? And it's up to us to create that safe place for them to explore what that course of action might be. Trauma informed care also focuses on prevention strategies to avoid retraumatization in treatment. So obviously we don't want to traumatize anybody, but we don't want to re traumatize anyone. Even those people who don't realize that they may be dealing with some traumatic reactions. You know, we want to make sure we don't inadvertently re traumatize them and trigger trauma symptoms. We want to promote resilience and we want to prevent the development of trauma related disorders. Most people go through a traumatic event and don't develop ptsd. Most people, it happens that sometimes people do, but most of the time they don't. So we can get in there and provide prevention and early intervention services in order to prevent it from becoming a problem. If someone does start developing acute stress disorder or ptsd, we can provide services to keep it from worsening. To keep it from making their depression relapse, to keep it from spiraling out and causing more mental health and physical problems. So prevention isn't just prevention of trauma or re traumatization, it's prevention of further problems when at all possible. The first thing is to establish safety. And we have personal safety, which is what we often think about. We want to make sure that areas are well lit. Clients don't feel unsafe when they're in the lobby or in our office or walking down the halls or going to the bathroom. Bathrooms are big trigger places for a lot of people. So making sure that people do feel safe when they're in your facility, but we also want to make sure that they're safe from trauma symptoms. We want to make sure that they're safe from things that are going to trigger those symptoms and or if they are triggered, we're able to help them de escalate and get grounded again. Because, you know, sometimes during a session they will have a flashback, there will be a trauma symptom. And you know, we don't want to traumatize them in order to bring it out. But when those do happen, they need to feel like they're in a safe environment to handle it. I mean, think about a little kid. When something bad happens, what do they do? They run back to home base. They run back to their caregivers and go, okay, that, that was really pretty awful. And the caregivers say, you're safe now, I'm sorry that happened. I'm sorry you're going through that, but let me help you deal with it. And that's what we want to do. So we can't prevent the trauma symptoms, but we want to make sure that they feel safe and secure and not like they're flapping out there in the wind. We can help clients gain more control over trauma symptoms and even label them when they arise and use grounding techniques when flooded with feelings and memories. So when they start to have, they start to dissociate. For example, you know, you start to see that spaced out look coming on. You can help clients get focused, you know, bring them back to the present, label what's going on, talk about why it happened, and get grounded back in reality, back in the moment. So using mindfulness techniques, having them look around and identifying three things they hear, three things they smell, three things that they feel, you know, that's a good way to get them focused on the present. Or having them look at object and have them tell you five things about this object. It's blue It's a water bottle. Whatever it is, it helps the person get refocused in the here and now and kind of get out of their own head. Establish some specific routines in individual, group or family therapy, such as having an opening ritual or routine. When starting and ending a group session, a structured setting can provide a sense of safety and familiarity. Now this, that is a recommendation that comes out of the treatment. Improve protocol. I will tell you from clinical experience, this can also backfire wickedly on you. If the person that you are working with was a victim of ritualized abuse, sexual abuse especially, often has a ritual component to it. So, you know, each night after the person went to bed, you know, the lights would go out and something would happen and then they would hear dad or whoever it was coming down the hall. So there was a specific routine, so dark lights, a specific time, being told that you have to be quiet. There are certain things that can reactivate or bring back a sensation of being in that situation again. So do use routines and rituals very, very carefully with your clients and only once you know what their history is. Some clients, you know, in substance abuse treatment, a lot of times they will end 12 step meetings, for example, by saying the Serenity Prayer. Well, if the person was victimized by somebody who happened to be a pastor or a priest, that might be triggering as well as is, you know, some people just don't like to be touched. Hand holding and hugging might not be be appropriate. So, you know, being aware of, you know, what usually happens. Like in AA meetings generally, there's a lot of hugging and a lot of hand holding and saying the Serenity Prayer, all of which can trigger people. So if you've got somebody who that might be a trigger, brace them ahead of time, help them figure out how to set boundaries and. Or that might not be the best support place for them right now. Maybe later, but maybe not right now. 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. You know what feels unsafe for you and it can be sleeping with your back towards the door or, you know, sleeping with in complete darkness. Some people, you know, when they've been traumatized, don't like to sleep in complete darkness, going certain places, driving at night, whatever it is that feels unsafe for them and have them start making a list. That way they can start seeing ways that this trauma is impacting their life and they can start taking control back. When you facilitate the discussion of safe behaviors, you know, we're going to talk about you know, maybe one unsafe behavior is being out after dark or wearing your headphones when you're out jogging after dark, which is unsafe. So you want to talk about, okay, if you want to go running after dark, what's a safe way to do it? You know, maybe go to the gym and run on a treadmill or, you know, figure out something. But talk about ways to help people be safe and not have trauma negatively impact their lives to where they're feeling like they're, you know, locked in. You can refer to Seeking Safety, a treatment manual for PTSD and substance abuse. This menu based manual covers an array of treatment topics. One of the therapists that I worked with in Gainesville used this exclusively with her groups and it was phenomenally effective. She was a phenomenal therapist, but it was phenomenally effective. So I would highly recommend, if you're working with a population that has a lot of trauma issues, I would highly recommend, at least looking at this resource to consider adopting it. You know, is good. And encourage the development of a safety plan. So when you're at home, what can you do to feel safe? When you're here, what can you do? So I can help you feel safe? And what can we do as an agency to help you feel safer when you are traveling? You know, identify the common places people are work, traveling home, and treatment. What can you do to feel safe in all those places and what may make you feel unsafe? And let's talk about that. Encourage them to develop a plan so, you know, they don't have unnecessary triggers of their trauma symptoms. Help the client feel in control and prepared for the unexpected. So talk about, you know, what happens if you are triggered. Something happens. You see somebody that reminds you of your attacker, or you're driving down the road and you see a car that's on fire and it reminds you of a car accident you were in or something, whatever it is, how do you deal with that? And again, mindfulness works really, really well for a lot of these things. When somebody starts to notice a cop I worked with that was involved in a particularly bad, he was responding to a particularly bad motor vehicle accident, lots of trauma afterwards. And when he went back out on the road, not even in patrol, but even in his personal vehicle, if he would get stuck in traffic and he would start smelling exhaust fumes, it would trigger him. So he started learning how to stay in the present and stay focused on what was going on. Sometimes he would sing to a song on the radio. You know, he had a certain CDs that he would put in that he could focus on. Sometimes he would use mindfulness techniques and look around and see how many red cars were surrounding him. He had a variety of different tools that he would use, but it helped him stay focused in the present. And he also at that same time was reminding himself that I am safe. This is not that same thing happening again. Encourage thinking about how supports will respond and connect in the event of another crisis. So should something bad happen again, and not to say that whatever the trauma was is going to happen again, but there could be another crisis. You know, somebody who's been traumatized by a car wreck or something may be traumatized again when there's a tornado that comes through and rips the roof off their house. You know, there are a lot of things that can happen, unfortunately. So what supports do you have in the event of another traumatic event and how can they best respond to help? You let them know that ahead of time. What do you need from them? Encourage thinking about future steps that could make the client safer and prevent a recurrence of traumas that have happened. You know, how can you just generally stay safe? You know, how can you protect yourself if you're going out dancing, if you're walking home from work, if you're going through the parking garage at night, how can you be more safe? You know, walking around glued to your tablet and not paying attention to your surroundings, that's not a way to stay safe. So encouraging people to do that. When I used to have to walk out to my car in the dark, if there was nobody that could walk me out for whatever reason, I would always call either my husband or a friend and talk to them on the phone while I was walking until I got in the car and had the doors locked. And, you know, that was just a safety behavior in order to protect myself. In the environment where the clinic was that I worked, people with histories of trauma and substance abuse are more likely to engage in high risk behaviors. So if they do have a substance abuse history, you know, be aware that some substances may encourage disinhibition like alcohol. You know, they're not really thinking straight and they're. They get themselves potentially in positions where people could take advantage of them and it's not their fault. We're not blaming the victim, but we're saying there are bad people out there that are going to do bad things. There are many, many, many more good people. But being aware that you could be vulnerable and paying attention to the fact that if they're using illicit drugs, just getting those can put Them in some pretty risky situations. So encouraging them to keep their wits about them, you know, stay sober and you know, ideally not use illicit drugs. 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. My goal usually when I'm working with people, unless substance abuse cessation is a primary goal or if they meet the criteria for a substance use disorder, then it obviously will become a primary goal potentially. But if they're drinking a little bit more than you know, I would like to see, you know, a little bit more than healthy or if they're engaging in some self harm behaviors, I want to see them be safer. So instead of cutting, you know, that's obviously not something that is safe. Using an ink pen to write, you know, a red ink pen to write on their arm, Is that a super healthy coping skill? No, but it's a step down. It's not self injurious at that point. Ideally, you know, you wouldn't have to have that intermediary step. But if the person has these ingrained coping skills that they have been using, what else can they do that's in an intermediary that is less destructive, less harmful? Balance preparation for recurrences and all that kind of stuff and the realization that you just can't prepare for everything. So yes, you can have some backup plans, but you can't prepare for all possible traumatic events. So what is your plan, if you will have a plan for when you can't plan? You know, take a breath. You know, generally that's the first thing I have people do is take a breath and think, okay, what is the first thing I need to do to get myself and or my family to safety scenarios? When we're talking about establishing safety, someone who has been date raped before, when they go out again, when they start dating again, what's going to trigger them? What's going to feel unsafe and how can they make sure that they are in a safe situation? People are unpredictable. I wish I could say that psychology was an exact science, but it's not. Helping people figure out how they are more empowered and more in control is, you know, going to help them. Someone who is a survivor of a home invasion, how can you feel safer? You know, they may have idiosyncrasies with alarm systems, you know, because alarm systems can be disabled or turned off or cut. BTK did that. So, you know, that kind of freaks me out. I like dogs. Dogs are good. Dogs will bite people. If there was a natural Disaster. For example, the fires in California. How can people prepare and protect themselves to establish safety? Maybe they have a housewide fire suppression system and sprinklers on the outside in order to keep, you know, the area right outside their house from getting, getting burned in the event that it's possible to even prevent it. Sometimes those wildfires are so massive and so powerful, you just can't. So in that instance, when you find out there's a fire, how do you get out? What do you pack? Where do you go? You know, have an exit plan? If there's a house fire, how do you protect yourself? You know, encouraging people to get the local fire marshal to come in and audit their house, make sure there's no fire hazards, Educate them or have them educate themselves about fire hazards. You don't want to use extension cords that are connected. You don't want to have paper near outlets or extension cords. You know, all those things. You know, have them do some research. You don't have to spoon feed that to them because that's more education and psychoed than it is counseling. But encourage them to go online and find out how to be fire safe. If they were the victim of child neglect, you know, how can they feel safe again? When they were little, the people who were supposed to take care of them didn't. So how can they help themselves feel safe again? Because they probably don't trust their caregivers. They probably don't trust their family if they were in a situation where nobody helped them when they were knee high to a grasshopper. So how can they build trust with any other person and start having meaningful relationships? And car accidents, you know, if somebody's in a car accident, they may not want to drive again. They may be triggered by the smell of exhaust fumes. There are a lot of different things that may trigger them. How can they be safe? You know, some people will say, well, I'm not going to travel during rush hour or I'm going to take back roads or I'm not going to go on the interstate. Some of that is more or less practical, but you know, baby steps, you know, right now, what can, what do you need to do to stay safe? How can you feel safe when you're in your car? You know, maybe not tailgating and getting out of the way of people who are tailgating, you know, being an excessively defensive driver. Those are all things people can do to increase their chances of being safe and not having a recurrence, prevent retraumatization. Examples where we may unintentionally re traumatize someone. A compassionate inquiry into the client's history can seem similar to the interest shown by a perpetrator many years before. So sometimes in that grooming phase, if the person was a victim of child sexual abuse or pornography, especially the child was groomed by somebody. And it can feel weird, it can feel invasive. Direct confrontation about behavior can be seen by someone who's been abused as a sign of impending assault. So if you come on really strong, why did you do that? And you have an angry tone or you're using big gestures when you're talking to somebody, it can feel very intimidating to someone who's been abused in the past. So we just want to be cognizant of how we might come off to others and how it might replicate their past. We can't. I mean, I'm not going to say that we're going to be 100% on par, 100% of the time and never do anything to trigger anybody. That's just not practical. But we can be as cognizant as possible. You know, be compassionate with clients instead of aggressive, because that's just gonna get you so much more anyway. Flies and honey, something like that. And be wary about boundaries and appropriate self disclosure. You know that eventually you're gonna go there and you want to get to know the person and you really want to help them, but they may not know that. So try to be, allow them to have their boundaries and not be invasive or intrusive. Be sensitive to the client's needs. Don't ignore their symptoms and demands when clients with traumas are triggered and act out because doing so may replicate the original trauma. So if they walk out of a tense group, you know, don't ignore them and just let them walk out. But likewise, don't make them come back and sit down and force them to tolerate the distress because they may not be able to do that at that point in time with the skills that they have. Or if they avoid particular clients or topics, it could be that that's too scary for them or those particular clients they're having transference reactions with. And it's just too much in terms of trying to deal with learning about their trauma and basically addressing somebody that reminds them of their of the perpetrator. Be mindful that efforts to control and contain a client's behaviors remind them of being trapped as part of the trauma. So if they were trapped physically, or if they were told that they're not allowed to, you know, this is a secret. You can't Tell anybody. Or if they were trapped in a neglectful or abusive family environment and they just couldn't get out and parents were constantly disciplining them, sending them to their room, or ignoring them. We could inadvertently replicate those if we're not careful. So we need to make sure that clients feel like they have a voice, they feel like they're heard, and they don't feel like they're. They're ignored. Listen for specific triggers driving clients reactions and help the client identify these cues and understand their reactions to behaviors. So if each time a client hears a fire engine go by, they tense up. You know, you can identify that. And so each time a fire engine goes by, it seems like you tense up. Tell me what that's about. Help them identify what that means, because they probably don't even realize that they're clenching their fists and tensing up or changing their demeanor in any way. So help them notice some of those things so they can start being more aware and cognizant of their environment and addressing those triggers, realizing that it's just a fire truck going down the road. No big deal. It'll be fine. Provide psycho education. Education can play a pivotal role in enhancing motivation, normalizing experiences, and creating a sense of safety. Let's tell clients what these symptoms are that they may experience, how those symptoms actually make a whole lot of sense, and what alternatives are out there. Normalize it for them so they don't feel broken. Understand the client's expectations and reasons for seeking help. Are they seeking help for their trauma? What do they expect is going to happen? And if they're not seeking help for their trauma, maybe they want their depression to remit. Okay, well that's still our goal is remission of depression. Now, if part of their depression may be caused by disempowerment during their trauma, it'll all kind of weave together. But we need to make sure that the treatment plans are strengths based and client guided, individualized, because they're the ones that are going to, you know, participate in treatment and they're going to stay more motivated to achieve the goals they want to achieve as opposed to what you think they need to achieve. Educate the client and other family members about the program. If you've got a trauma informed program, you might want to provide a little video on your website about what is trauma informed counseling? How is it different than other counseling? How can people expect to be treated differently? Or what can they expect is going to be different in this program? And why might it be helpful? After obtaining acknowledgment of a client's trauma history. Give information to the client to help them normalize their presenting symptoms. Handouts. You know, I can't say it enough. I don't like killing trees. I don't. However, if you give handouts or if you have something on your website, if you have the ability. Not everybody has access to their public website in order to post stuff, but if you do, you know, that's great. You can have a little section on your website that people can go to instead of handing out paper all the time. Highlight potential short term and long term consequences of trauma. We talked about that the other day. Explore various paths to recovery and underscore that recovery is possible. So various paths. You can hit this trauma head on. You know, we can talk about it and go there. You can, we can work on your depression and as you start getting more energy and feeling better, we might start talking about how the trauma might be contributing to it. There are multiple different ways to address trauma. You know, we can do it through talk therapy. I can give you a referral to EMDR and providing them different options so they don't feel trapped. Self is a group curriculum. Safety, regulating emotions, addressing loss and redefining the future. So you can google that, find it online. It is not free. It's another manualized curriculum, but I believe you can buy it on Amazon. So that's another curriculum you can look at for psychoeducation for trauma. Develop a resource box or webpage that provides an array of printed or multimedia educational materials that address specific symptoms and tools to combat trauma related symptoms. So little three minute snippets of this is what a flashback is. This is why it exists or why it might happen. And these are some tips you can use when you start feeling a flashback coming on or in the middle of a flashback. Bada bing. You can provide information about treatment options and therapy approaches, advantages of peer support and steps in developing specific coping strategies like mindfulness, distress tolerance, vulnerability prevention, cognitive behavioral stuff, cognitive processing therapy, and any of those tools that you're going to use out of out of those things, you know, small little chunked bits of information, preferably in video with a worksheet that people can either print out or look at online. But time is limited. I understand trauma informed peer support is important because living with a history of trauma can be isolating and consuming and can reinforce people's beliefs about being different, alone and defective. So even though we're saying, you know, this happens to a lot of people, well, who are those people? If you can't actually see those people, then you're kind of wondering where they are. And as people are dealing with trauma, it's exhausting. So dealing with that can feel all encompassing and all consuming. And you know, their mood may not be great for even a couple of weeks because they're dealing with it and they're exhausted and you know, depressed, anxious, angry, a whole mess of emotions. So they may not want to socialize with other people or may not feel like other people can handle their emotional intensity. So they kind of withdraw. And this withdrawal can lead them to feeling isolated and different and alone. Trauma for treatment Treatment for trauma effects can be inadvertently strengthened clients beliefs that there's something wrong with them. So having them come to a trauma specific program inadvertently communicates you need to go to this specialized program in order to deal with your stuff. Well, no, you know, which is why we really want everybody to employ a trauma informed care approach because trauma is not unique. You know, more than 60% of people have been exposed to trauma. So it is not unique and they don't need, you know, it's not specialty services in that sort of way. So we want to help people understand that treatment and needing to come to treatment is a perfectly natural reaction because you were confronted with something you didn't have the tools to deal with. You know, if your car broke down and you didn't know how to fix it, you would go to a mechanic and say, help me fix my car. Or maybe you would go to night school and learn how to fix your car, but you wouldn't be able to do anything about it. So helping them understand that it's just, it's something that happens and sometimes you don't have the skills and tools to deal with it. Treatment helps you get those. That's all it is. Peer support can break the cycle of beliefs that one is damaged. Nobody understands and no one could tolerate my story. People, you know, talk. People get to share their stories a little bit and it has to be done carefully. Peer support programs need to be very, very well monitored so you don't traumatize the peers and so it doesn't end up self perpetuating. Peer support provides opportunities to form mutual relationships. Learn how one's history shapes perspective of self others in the future. So somebody may say, you know, the entire time I was growing up, I felt like nobody understood me and nobody could, you know, get how I felt about things because they didn't know about all these secrets. And then they can start sharing how that affected them during their formative years. In middle school, high school, college. But you know, obviously if the peer is in leading or a participant in the peer support program, they're saying, but I overcame it, you know, this is how I'm dealing with my trauma. Peer support provides opportunities to move beyond trauma and see people who have moved beyond trauma. Not only are other people traumatized, but other people have moved beyond trauma and there is life afterwards, which provides people the opportunity to mirror and learn alternate coping strategies so they can talk about, you know, what do you do when you have a flashback? Or what do you do when you start to space out and share with each other? Peer support is an interactive process, not a definitive action where someone fixes the problem. So the peer is not going to go, okay, you're having a flashback. This is what you need to do. It's an interactive process where the peer is going to say, been there. It really sucks. This is what works for me. I'm wondering when this has happened to you, what's helped you? I mean, it's just going to be a talking process and support. And the peer support programs that they talked about in the book in the treatment improvement protocol were not groups. They were actually individual, peer and peer in person that were paired and they would meet at the facility. So it wasn't a group sort of situation. Provide education on what peer support is and is not and the value of using the resource because peers are not therapists, so it's not the time to go delving into past issues. Use an established peer support curriculum to guide the peer support process which Intentional Peer Support and Alternative Approach is a workbook that highlights four main tasks for peer support. Helping people build connections, Helping people understand their own and others worldview. Developing mutuality and helping each other move towards set and desired goals. So this is another one that you can look up and use as a resource which was recommended in the treatment improvement program protocol. Normalizing symptoms gives considerable relief to clients who may not have thought that their symptoms were treatable. So you know, if you normalize them and say, you know what flashbacks, they are really rough and I can empathize with what you're going through here or even sympathize, you know, if you've had flashbacks yourself and help them understand, you know, what the symptoms do and how they go away, you know, how you can make them become less frequent and less intense. And it's not an overnight process, it's something that takes a while because your brain wants to protect you. So every once in a while you still may have a flashback. Here and there. But they're generally a lot less intense and frequent. Once you start understanding the function of them and dealing with them. Have the client list his or her symptoms. I always just give a checklist. Instead of having people go, well, I think this is a symptom because it's easier to recognize than to recall. After each symptom, ask the client to list the negative and positive consequences of the symptom. So, you know, looking at again, how does this benefit me and what are the drawbacks? So they're motivated to address the symptom, but they also understand the function it serves. Remember, symptoms serve a purpose. And focus on how the symptoms have served the client in a positive way. Instead of going, yeah, that really not helpful. Look at it as, you know, even self injurious behavior. I can see how it helped you feel like you had some control. Let's look at other ways that you might be able to get some control that aren't as destructive. 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. And again, remember, trapped doesn't necessarily mean physically trapped. It may mean stuck in a situation they can't get out of. Emotionally trapped, such as feeling stuck in a work environment where the boss is emotionally abusive, or being hyper vigilant about exits, planning escape routes, even in safe environments. Whatever the situation was for the person, help them figure out how they can, why they feel that way and how they can feel safer. Key steps in identifying triggers for clients are to encourage them to reflect back on the situation, surroundings or sensations prior to a strong reaction. We're not going back to the whole trauma, we're going back to a particular situation that triggered them. Determine connection among the cues, the past trauma and the client's reaction. So, you know, we'll use the police officer, for example, when he started smelling the exhaust fumes. You know, my question is how did that remind you? Or what about that reminded you of that past trauma? And then we talked about it from there and he made the connection and discuss the ways in which it is connected to the 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 one trigger at a time and then discuss the when and where did you begin to notice a reaction. So you know, maybe somebody Just recently started having flashbacks. You know, when and where did this first one happen? How is this current situation different from the past trauma? Not the same, but different. So we're encouraging them to get in the present moment and experience their safety. How are your reactions to the current situation similar to your past reactions? How did you react differently to the current situation than to previous trauma? So, you know, what are you doing positively now that's protecting yourself, that's helping you feel safe. How are you different today? And this can be positive and negative, but how are you different today than you were when you were triggered the first time and then you were when you were the victim? You know, maybe you're older, maybe you're wiser, maybe you're stronger. What is it? How are you different? What choices can you make that help you address the current situation or trigger? So this thing is going on. Maybe it's a smell. You know, you go over to your in laws house and it's the smell that you smell reminds you of the place that you were abused when you were little. You know, they use the same cleaning products or whatever. Well, you can't tell your in laws, you got to change the cleaning products. So how can you help yourself address the current situation when you have to go over to your in laws? What can you do? And you know, maybe some people can say, can tell their in laws that, you know, you need to change your cleaners. But a lot of people won't feel comfortable. So we want to encourage them to figure out how they can address that. I know when I go into hospitals, I smell. It's like hospitals all use the same cleaner, I think. And whenever I go into the hospital, which is where my doctor's office is, I smell that smell. And it's the same smell that they had at the hospital when my son was in the neonatal intensive care unit. And you know, that was a very stressful time, but it was also a very positive time. It was my firstborn and you know, thankfully he did really well once. He, you know, cooked a little longer, so to speak. But that smell, every time I walk into the bathroom and it kind of brings a smile to my face, I'm like, oh, I remember when he was little. The same thing can be true for, you know, exceedingly traumatic experiences. And it can, you know, seem to be in weird places. So help them recognize what's reminiscent. Encourage observations, coping strategy. Take a moment to observe what's happening, Focus on your breathing. Name the situation that initiated your response. In what way is this similar? Or familiar to your past. And how is it different? So you can say, you know, both times, you know, it was on the interstate, I smelled the smell. How is it different? Well, there is not a semi on fire in front of me now, and I'm safe. That's how it's different. Label emotions and remember that they come and go. And this is one of those radical acceptance, mindfulness techniques. Thinking of emotions like clouds in the sky, they just come and they go. And, you know, you don't want to try to struggle with them and hold on to them. They will pass if you don't feed them. 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's only one event. So somebody who was abused in their past as a child, they get into a relationship with somebody and it becomes domestically violent. Well, that's very similar to their past. So it's going to trigger them. But this situation right here does not define your future. It is one event of domestic violence. You can choose what to do with it henceforth in your life. Encourage people to validate their experience. You know, if it was terrifying, it was terrifying. It doesn't matter whether other people think it should be or shouldn't be. If you felt terrified, that's how you felt, and that's okay. Ask for help, because you don't have to do this alone. You know, have people that you can call on when you're having a bad night, when you're feeling uneasy. Remember that this too shall pass. There are times that are good and times that aren't. You're going to have some times where you're more triggered than others. And encouraging people to breathe and get themselves through it and remembering that, you know that they've gotten through crappy times before. Encourage them to remind themselves. I can handle this by naming their strengths that have helped them survive. Have them keep a list of it on their mobile device so they can look at their strengths. List if they need to. Keep an open mind and try and look for new solutions. I feel trapped in this particular situation. What's a new solution I could use in order to get out of it? Name and choose strategies that have worked before. Again, encourage them to keep a list of strategies that have worked. That way they don't have to think of them on the fly when they're stressed. And remember, you have survived and you're a survivor. Draw connections. Writing about trauma can help clients gain Awareness of their thoughts, feelings, and current experiences. But obviously use it with caution. This is something that's potentially going to get pretty intense for people, so make sure that they're able to handle it. I encourage clients, if they're doing a writing exercise, they set a timer, and I usually say 30 minutes. 30 minutes is enough, and after 30 minutes, you quit writing. Otherwise they can get stuck in it for hours on end. Have them have an emergency support person. If they start to feel triggered and they need to call somebody while they're working on it, they can call. If you don't feel like they're ready to do that as a home assignment, especially if they live by themselves, encourage them to do it. You know, maybe you have a break room or somewhere that they can do it at the clinic so they're in a safe place where they already know that they're safe and they can more safely explore. Encourage clients to explore the links among traumatic experiences and mental and substance use disorders. Identify how substances may have helped address symptoms or addictive behaviors of any sort. Gambling, sex, food, shopping, you know, anything that produced that dopamine rush and helped them escape. Teach clients how trauma, mental and substance use disorders commonly co occur in order to reduce shame and isolation. So help them understand that, you know, maybe this addictive behavior or this behavior over here was the self injury, for example, were the only ways that you could figure out how to survive at that point in time. And it helped you survive, but it also monkeyed with your neurochemicals, your brain chemicals that help you feel happy. So all this kind of feeds in on itself, but as one starts to improve, the other ones will too. Discuss how substance abuse or anxious or depressive behaviors have impeded healing from trauma, have kept people from actually feeling their feelings or having the energy to do the work they needed to do. Help clients recognize trauma symptoms as triggers for relapse to substance use and mental distress. So trauma can trigger an anxiety, generalized anxiety disorder relapse, a depressive relapse. You know, if there are enough triggers and the person's under stress, it can trigger, you know, a bipolar episode. There's a lot of things that can happen because of a trauma situation. When trauma happens, that HPA access, that fight or flight thing goes off and the body feels like it's under stress. So however that person reacts under stress, and if they already have low levels of cortisol, we know that they're probably going to react more extremely than other people. So it's going to intensify their sense of anxiety. And or helplessness. Develop coping skills to recover from trauma and co occurring issues and recognize how both trauma, mental illness and substance abuse often occur in families through multiple generations, such as the cycle of abuse. You know, if there's verbal or physical abuse, we see that a lot of times it does carry through families. So this behavior traumatizes successive generations. Inability of parents to protect or teach healthy coping. So if you've got great grandma and she didn't have the skills to deal with life on life's terms and she struggled, she was depressed and anxious and traumatized and then she had kids, she didn't, she can't, she didn't have anything to teach, you know, unless she knew that she had deficient coping skills and picked some up along the way, she didn't have anything to give. So then those people grow up, they don't have any coping skills because we're not born with them. We kind of muddle through and figure some out. But you know, they don't have the benefit of having spoon fed, having been spoon fed coping skills. So intergenerationally you just don't see an improvement. Which means increased anger, increased anxiety, potentially increased abuse. If people are feeling emotionally overwhelmed, a lot of times, not always, but a lot of times they can become aggressive and defensive. Teach balance. It's a myth that every traumatic experience needs to be expressed in every story told. You know, sometimes you don't need to go through every single nitty gritty. That's up to the person. Working with trauma is a delicate balancing act between the development and our use of coping strategies and the need to process traumatic experiences. Too much trauma can trigger dissociation, shutting down, or becoming just emotionally overwhelmed and feeling like you're drowning. But too little focus on trauma can reinforce avoidance and confirm the client's internal belief that it's too dangerous to deal with the aftermath of the trauma. One of my clients likened it to Pandora's box. You know, he was afraid that if he went there he'd never be able to get the lid shut back on Pandora's box. So it was too dangerous to even go there. He was just going to leave it locked up in his little mental attic. 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 the same coping strategies, such as relaxation. So think desensitization and then fear of spiders. You know, that's, you know, basically what we're dealing with. First you want the person to imagine being in a particular situation which may be triggering for them and learn how to deescalate themselves so they can imagine being in that situation and it doesn't cause a stress reaction. Then encourage them, you know, maybe to get some more senses involved. What does it smell like? What is it? You know, and gradually walk them through that process. Subjective units of distress scale is something that you can hand out to clients so they can tell you, you know, particular situations that they encountered in the last week. You know, what situations did you encounter that were a 60 or above? And let's talk about those. And what situations did you encounter that were below 60, that used to be above 60 and why are those different now? So you want to see the symptoms and the distress going down. You know, it's not necessarily going to get down to a zero. And I tell clients that some things are just always going to, you know, give you a little bit of pause, but, you know, you're going to get down to the fact that you feel. You feel good most of the time. Build resilience. Encourage mindfulness and thought awareness. If clients are aware, you know, they wake up in the morning and we know that, you know, sleep deprivation tends to put people on edge anyway because the HPA axis stays a little bit more activated. People are tired, not thinking as clearly. So encourage them to be aware of their vulnerabilities. Be mindful about what they need in the day, but in each situation, you know, when they go into a meeting, you know, where do they need to sit? You know, what is it that they can do to help themselves be as happy, healthy, and calm as possible? Encourage thought awareness. You know, if they have their mind drifts and goes to that place sometimes, encourage them to be aware of what they're thinking and what they're telling themselves about their goodness as a person and their ability to control their situation and stay safe. Help clients re establish personal and social connections by accessing friends, family, and community and cultural resources. Encourage the client to actively take care of his or her own needs early in treatment. We're not going to do it for you. Other people probably aren't going to be able to do it for you forever. So, you know, I want you to identify what your needs are and let me help you figure out how to take care of those needs. Encourage stability and predictability in the daily routine. Now, not necessarily rituals, but it's good to make sure that they're keeping their circadian rhythms pretty stable, getting a good solid 8 hours of sleep every night, if at all possible. Etc. Nurture a positive view of personal, social and cultural resources and help clients recall ways in which they successfully handled hardships in the past. This is that strengths list that you want them to keep. Help them gain perspective and foster a long term outlook. You're at a 2 right now and you want to be to a 10. You know what's going to help? What does a 10 look like? And then what's going to get you to a 3 to a 4? Help maintain an optimistic outlook. Visions of good things in life can keep people going even in the hardest of times. So encourage them to, you know, this thing right here not going so well. What are three things in your life that are going well? And then as treatment progresses, maybe they have a particularly bad week and have more flashbacks than usual or something. All right, you know, it's a particularly bad week that happens. Let's talk about the intensity of those flashbacks. Were they as intense? You want to see them or help them see that they're making incremental progress? You know, maybe two steps forward and one step back. But it was only one step back, so you're still ahead of the game. Baseline, charting, graphing, that's all really helpful journaling in helping people identify those incremental changes and recognize that, oh, you know what I just realized I haven't had a flashback in a week. How awesome is that? Encourage participation in peer support and have them set smart goals. Specific, measurable, achievable, realistic and time limited. So those goals for recovery, you know, have these symptoms gone in a month, ain't gonna happen. That's not realistic. It's time limited, but it's not achievable or realistic. So encourage them to set goals that they can accomplish. Encourage them to look at failures and mistakes as opportunities for growth, not as a negative reflection on their abilities or self worth. This is the challenge part of resilience and hardiness. If you go back to the hardiness work from the 70s commitment. Encourage them to enhance their commitment to their lives and their goals. And yes, it was unfortunate I had to go through whatever that was, but I have a really good life and I am committed to making the best out of it, despite my past focus on situations and events that they do have control over. You may not be able to control what your boss does tomorrow, but you can control how much longer you work for him. Explain setbacks and successes. Permanence. When people are looking at how things happen, permanence means it's stable. It is always going to suck. It sucks. Now and it's always going to suck. Changeable means this is unpleasant right now. You know, when I used to work in the clinic, we would regularly have auditors coming in. And when auditors, we knew an auditor was coming in, you know, that particular couple of weeks was really pretty unpleasant usually. But the in between times were fine and it wasn't necessarily stable. You know, if you got your treatment team to make sure their documentation was, you know, beautiful, then when auditors came in it was like, you know, no biggie. What file do you want? I don't have a problem with it. So it isn't. That isn't stable. It is changeable. You can make it better. Pervasiveness is global or specific. So when something happens, does the person say, I am bad, I am faulty, I am flawed, or do they say that was an unfortunate event or I am not perfect or whatever? An internal versus external attribution. Do they look at things as being all their fault or do they look at things as being everybody else's fault and nothing to do with them or somewhere in between? Address sleep disturbances. Educate clients about the importance of sleep in setting and settling the HPA axis or you know, what I call their threat response system. Identify habits that interfere with sleep and develop a sleep routine. Some people who've been traumatized are not going to be willing to sleep in 100% darkness. If you can get them to agree to sleep with a sleep mask, then they can pull the sleep mask up if they need to see something that will help. So talk about different things that they can do and encourage them to develop a sleep routine of the same three things they do every night before bed to cue their body in that it's time to start winding down. Support empowerment and build trust by providing effective informed consent so clients know exactly what they're walking into. Empower clients to make choices and assume an active role in treatment and establish a sense of self efficacy. They have a say in what's going to happen. And you know what they're experts on Themselves. Go figure. Acknowledge grief and bereavement Traumas cause a variety of losses. Emotional, cognitive, interpersonal, environmental and physical. So we want to encourage people over time to look at those. And I want to acknowledge, yeah, that happened and you had that loss because of the trauma. So let's talk about it. And they need to work through the grief process for each one of those things. And sometimes it'll be a one session deal, sometimes it'll be a one month deal, but they can work through those and come To a level of acceptance of why things are the way they are now. Risk factors for chronic bereavement, perceived lack of social support. So if they don't feel like anybody was there for them. Concurrent stressors in the past six months. So they were already worn down. Ambivalence about the loss. They're not going to start really dealing with it if they're ambivalent about it. They're just going to be like whatever back in the back of their mind. They may have, you know, stronger feelings about that and a history of mental health or substance abuse issues which could be triggered because of the losses. Signs of destabilization include increased substance use or other unsafe behaviors such as self harm, driving too fast, increased psychiatric symptoms, increased symptoms of trauma, helplessness or hopelessness, either expressed verbally or behaviorally. So obviously if they go, I don't feel like any of this makes a difference. That's verbally. If they quit coming to treatment, you know, they start, you know, just not showing up for their sessions. That may be a sense of helplessness and hopelessness. You know, why should I even bother? Why should I try? Difficulty following through on commitments, isolation, A notable decline in daily activities including self care, hygiene, care of children or pets, and going to work. So, you know, kind of look for all of any and all of these. Other treatment issues include engagement, clarify the situation through discussion. Reinterpreting clients saying I can't to I won't. I have the ability to choose what I'm going to do. I can do it, but I'm choosing not to and I won't to. I'm willing, you know, so helping them see, yes, you have a choice about it. Let's see if I can convince you why it might be helpful. Use motivational interviewing when possible. Frequently discuss and request feedback from clients about pacing and timing. Is it too slow, too fast? You know, do we need to take a little break for a couple weeks on this particular issue? Signs it's going too fast include no shows, dissociation, excessive silence, confusion or inability to comprehend simple concepts. So you can tell they're kind of not with you. They're in this emotional haze, redirecting the conversation or an increase in symptoms. Some people are not able to completely remember past events, particularly events that occur during high stress and destabilizing moments. Explore with the client how the memory of an event helps them understand their feelings, thinking and behaving in the present. And persistently trying to recall all details of a traumatic event can impair a client's focus. On the present. You know, so when they think back, they're like, you know, I can't remember where my dog was during this whole thing. Okay, is that important to your recovery right now? And is. Is that detracting from your ability to focus on the present? So what we want to do, establish safety, prevent retraumatization, provide psychoeducation, use trauma informed peer support. Normalize symptoms, identify and manage triggers. Help clients draw connections. Teach balance between recovery and trauma. You can't plan for everything, and with recovery, your whole life cannot revolve around this trauma recovery. You know, you need to have this over here, but then you need to have a life and you need to have some fun and you need to have some relaxation. It's too intense to work on 247 for any period of time. Develop resilience in your clients. Help them change their sense of powerlessness to one of empowerment, their sense of being stuck to one that believes that things can change. Address sleep disturbances. Support empowerment and build trust with the client. And encourage the client to build trust with others. Start trusting themselves and start trusting safe other people in their life. And acknowledge grief and bereavement.