5.3: Client-Centered, Trauma-Informed Services

Client-Centered and Trauma-Informed Services

Deborah WernerPat Tucker

Advocates for Human Potential, Inc,

This presentation is made possible with support from the Substance Abuse and Mental Health Services Administration

The importance of a home• Place to be• Stability• Security/safety• Control• “Stuff”• Responsibility

When you don’t have these things what happens?

Homelessness is often not the first experience of trauma and

uncertainty in a homeless mother’s life.

Trauma among mothers who are homeless:

• Over their lifetime, 92% experienced severe physical and sexual assault.

• 25% experienced random violence.

• 66% experienced severe physical violence as children.

• 43% were sexually molested as children.

Bassuk EL, Weinreb L, Buckner J, et al. (1996). The characteristics and needs of sheltered homeless and low-income housed

mothers. JAMA, 276(8): 640-646.

• Emotional, sexual or physical abuse• Natural disaster/fire• Physical attack/ abuse/ threats• Life-threatening accident,

catastrophic injuries and illnesses• Witnessing injury/death• Combat• Family separation• Extremely painful and frightening

medical procedures• Rape or assault• Domestic violence

Trauma can come from many things

Photo: h.koppdelaney @ flicker.com

Accompanied by feeling of intense fear, helplessness, or horror.

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

American Psychiatric Association [APA] (2000, p 463)

Definition of Trauma (cont.)

“The person’s response to the event must involve intense fear, helplessness or horror.

…or in children, the response must involve disorganized or agitated behavior.”The

disturbance causes

clinically significant distress or

impairment in social,

occupational, or other

important areas of functioning.

American Psychiatric Association [APA] (2000, p 463)

Common Symptoms• Dissociation/freezing• Flashbacks• Hyper-vigilance• Terror• Anxiety• Self-injury• Eating problems• Sleep disturbances or

nightmares• Fight or flight response

alarm reaction followed by intense fear

• Numbing of responsiveness

• Depression• Substance abuse• Upsetting reminders and

triggers

(DSM IV(DSM IV--TR, TR, 20002000))

Photo: will fisher @ flickr.com

Trauma begins a complex pattern of

actions and reactions that have a continuing

impact over the course of one’s life.

The Impact Continues

Relationships are characterized by victim -victimizer dynamic.

Someone is the controller and someone controls.

A victim’s world view

Francine Feinberg, MetaHouse, Inc

This world view is carried through all relationships

including social services and employment.

• The world is a frightening place– Shouldn’t trust others

– Feels vulnerable

–Misreads cues– Under-reacts to real danger

– Over-reacts to innocent exchanges

The Internal Working Model

Francine Feinberg, MetaHouse, Inc

Photo: aryche @ flicker.com

• No ability to affect the situation. – Actions bring disappointment,

retribution– Hostility – Anger, Attitude– Passivity – May as well not try – Bad things will happen and no

one will protect her– Fear, anxiety– Self-protective hostility

The Internal Working Model

Francine Feinberg, MetaHouse, Inc

Photo: aryche @ flicker.com

Men React Differently to Trauma• This is an emergency!

– “Fight or flight” : men may be aggressive,

antisocial, or “on guard”

– Boys may “act out,” use substances, or be truant

• Better keep this quiet.– Boys and men are less likely to talk it

out or admit fear.

• Being a man means appearing strong.– Males may feel shame that they could

not defend themselves.

Hodas (2006), Responding to Childhood TraumaMejia (2005), Gender Matters: Working with Adult Male Survivors of Trauma

RETREAT

ISOLATIONDISSOCIATIONDEPRESSION

ANXIETY

SELF-DESTRUCTIVE ACTION

SUBSTANCE ABUSEEATING DISORDERDELIBERATE SELF-

HARMSUICIDAL ACTIONS

DESTRUCTIVEACTION

AGGRESSIONVIOLENCE

RAGES

Stephanie Covington: The Progression of Trauma

• Sense of self• Sense of efficacy• World view• Coping skills• Relationships with others• Ability to regulate emotions• How one approaches services• How one approaches the culture of the

treatment agencies, work environments, and life in general

Trauma can be self-defining

Francine Feinberg, Meta House, Inc

3 Stages of Trauma Recovery

• Safety

• Mourning

• Reconnection

Our focus today is on safety

Judith Herman

Photo: Andy and Becky’s bits@flickr.com

• Based on current literature and informed by research and effective practice.

• Take trauma into account.

• Avoid triggering trauma reactions or retraumatization.

• Recognize the trauma of coercive interventions.

• Support the individual’s coping capability.

• Allow survivors to manage their trauma symptoms successfully so they can access, retain, and benefit from the services.

Trauma-Informed Approaches

(Fallot & Harris, 2002; Ford, 2003; Najavits, 2003)

Trauma-sensitiveservices/approaches

Trauma-insensitiveservices/approaches

• Recognition of culture and practices that retraumatize

• “Tradition of toughness”valued as best care approach

• Power/Control minimized • Keys, security uniforms, staff demeanor, tone of voice

• Caregivers/Supporters • Rule Enforcers

• Collaboration-focused • Compliance-focused

• Staff training builds awareness, sensitivity

• “Client-blaming” as fallback position without training

• Understand function of behavior such as rage, repetition-compulsion, self-injury

• Behavior seen as intentionally provocative and volitional

Trauma-Sensitive vs. Trauma-Insensitive Approaches

(Fallot & Harris, 2002; Cook et al., 2002; Ford, 2003; Cusack et al., 2004; Jennings, 1998; Prescott, 2000)

Trauma-sensitiveworkers

Trauma-insensitiveworkers

• Objective, neutral language • Labeling language: manipulative, needy, gamey, “attention-seeking”

• “Let’s talk and find you something to do that will help.”

• “If I have to tell you one more time ….”

• Focus is on person – eye contact • Focus on task, not person• Says hello and goodbye • Comes and leaves with little

acknowledgement

Trauma-Sensitive vs. Trauma-Insensitive Workers

(Fallot & Harris, 2002; Cook et al., 2002; Ford, 2003; Cusack et al., 2004; Jennings, 1998; Prescott, 2000)

• Understanding Triggers

• Building Trusting Relationships

• Emphasize Strengths

• Building Coping Skills

• Children and Families

Client-Centered, Trauma-Informed Approaches

What is a Trigger?• A trigger is a

troubling reminder of a traumatic event.

• The trigger itself need not be frightening or traumatic.

• It can be conscious or unconscious.

• Triggers are often subtle and difficult to anticipate.

Adapted from Fagan, Nancy; Kathleen Freme. 2004

Photo: .craig@flikr.com

Some things that may be triggering

• Individual people

• Places

• Emotions

• Noises

• Images

• Smells

• Tastes

• Color

• Environmental conditions

• Animals

• Films or scenes within films

• Dates of the year

• Tones of voice

• Body positions

• Bodily sensations

• Weather conditions

• Time factors

Discussion• What are some environmental factors

in your agencies or groups that may trigger someone who has experienced trauma?

• What may happen when an individual who has experienced trauma is triggered?

• What can you do to prevent or minimize crises?

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

Building Trust

Hope

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

Tips for Trauma-Sensitive Relationships

• Be aware, mindful, respectful

• Don’t probe – let the person raise the issues

• Avoid judging or labeling behaviors as manipulation

• Maintain strengths-based view• Work through resistance: What

is the person trying to tell us?

Photo: Aussiegirl@Flikr.com

See the Strengths• As an individual

• As a family

• As a family member

• As a parent

• In the environment

Discovering Strengths

• Patterns• Attitudes• Coping styles• Values – family, cultural,

social• Choice• Personality characteristics• Environmental – home,

community, resources• Beliefs• Feelings – emotions• Knowledge – intelligence

• Talents – hobbies• Stamina• Common sense• Relationships• Interests – desires• Physical attributes, health• Behavior – skills• Things person does well• Achievements• Flexibility• Resourcefulness

There are many ways to see strengths of an individual or family, including:

Sometimes we think our clients should do one thing and they choose to do another.

They may have different priorities.

They may make mistakes.

Either way, they are the decision-makers.

Self Determination

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

Exercise• In pairs – one person is the staff

member and one a homeless woman. The homeless woman wants the candy and the staff member wants her to have the carrot.

• What happened. What did the case manager do? How did the woman feel? What is the long-term impacts?

Key Questions• Where are you now?

• Where do you want to be?

• What resources do you have available to help you get there?

• What can we do together to help you get where you want to be?

Planning Tips

• Remember, it’s not your decision. Help others set goals and prioritize.

• Focus on concrete steps

• Find and offer practical tools

• Don’t be afraid to change horses

• Focus on positive action

• Coordinate and collaborate

Building Skills• Coping Skills

• Responding instead of Reacting

• Life Skills

• Communication

• Parenting (trauma-informed)

Always ask – is it practical? Does if fit with the family goals? Make it real!

celebrate successes!

Life on Life’s Terms

Take it easy!

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

• Client problems evoke sympathy and vulnerability, which may lead to excessive support and overindulgence rather than encouraging client accountability and growth.

• Client struggles can trigger staff frustration, harsh judgments, and punitive confrontations.

Worker ReactionsWorkers may unwittingly repeat client

trauma roles: victim, perpetrator, bystander.

The Life Balance Wheel

Is your life in balance?  

Add spokes to the wheel to represent 

your self‐care activities in each 

area.  

Examples of Trauma Programs• Amaro, H., & Nieves, R. L. (2009). Boston Consortium Model:

Trauma-Informed Substance Abuse Treatment for Women. Contact: Hortensia Amaro at h.amaro@neu.edu or Rita Nieves Rita_Nieves@bphc.org.

• Clark, C., Fearday, F. (eds) (2003) Triad Women’s Project: Group facilitators manual. Tampa, FL: Louis de la Parte Florida Mental Health Institute, University of South Florida. (contact Colleen Clark at cclark@fmhi.usf.edu)

• Covington , S. S. (2003) Beyond Trauma: A Healing Journey for Women. Center City, MN: Hazelton Press. (Contact Stephanie Covington at sscird@aol.com)

Examples of Trauma Programs (continued)

• Ford, J.D., Mahoney, K., Russo, E., Kasimer, N., & MacDonald, M. (2003). Trauma Adaptive Recovery Group Education and Therapy (TARGET): Revised Composite 9-Session Leader and Participant Guide. Farmington, CT: University of Connecticut Health Center. (Contact Julian Ford at ford@psychiatry.uchc.org )

• Harris, M. (1998). Trauma, Recovery and Empowerment: A Clinician’s Guide for Working with Women in Groups. New York, NY: Free Press. (Contact Rebecca Wolfon Berley at rwolfson@ccdc1.org)

• Miller, D., & Guidry, L. ( 2001). Addictions and Trauma Recovery: Healing the Mind, Body, and Spirit. New York: W.W. Norton. (Contact Dusty Miller at dustymi@valinet.com)

• Najavits, L. (2001). Seeking Safety: Cognitive-Behavioral Therapy for PTSD and Substance Abuse. New York: Guilford. (Go to www.seekingsafety.org)

• Saakvitne, K. W., Gamble, S.J., Pearlman, L.A., Lev, B.T. (2000). Risking Connection: A Training Curriculum for Working with Survivors of Childhood Abuse. Maryland: Sidran. (Go to www.sidran.org)

Michael W. Smith

Transformation in the world 

happens when people are healed 

and start investing in other 

people. 

Thank YouThis presentation has been developed and presented

by Advocates for Human Potential, Inc. with support

by the Substance Abuse and Mental Health Services

Administration

Deborah Werner, MA – dwerner@ahpnet.comPat Tucker, MA, MBA – ptucker@ahpnet.com