Instructor Response to Week 2 Homework

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    Patricia Burke
    Keymaster

    Trauma Informed Care in Behavioral Health and Co-Occurring Services

    Week 2 Instructor Responses to the Homework

    Once again, I deeply appreciate your thoughtful responses to the homework and your willingness to be open about your strengths and where you need to work to become more trauma-informed and trauma-competent.

    1) After reviewing the Suggested Guidelines for Implementation of a Trauma-informed Approach describe how following and/or not following these guidelines impacts the level of trauma-awareness and the delivery of trauma-informed and/or trauma-specific services in your organization. Be specific.

    Here are some of your reflections on the impact of following and not following the Guidelines for the implementation of a TIC approach at your organization or private practice:

    Following Guidelines:

    *Following these guidelines creates a safe, supportive, and trusted environment. When a client can feel safe and develops trust they can begin to practice honesty, openness, and vulnerability.

    * Every two years, the leadership uses the “Guide to Trauma-Informed Organizational Development” which is a very well developed grid in which new TIC goals for the agency are developed and detailed accountability is established. This is done in two parts. . .  This leads to confidence that we really are making progress in TIC.

    *  Following these guidelines promotes a safe and welcoming environment for healing to occur.

    *Providers are encouraged to ask clients to share only what they are comfortable sharing, especially during the assessment period. Clients are referred to Provider’s based on their needs, this includes the preference to work with a male or female provider.

    Not Following Guidelines/Needs Improvement:

    *One area I wish I could offer better is providing a physical environment that’s more consistent with trauma-informed care. My office is EXTREMELY small (my walk-in closet at home is just about the same size), and that could be a trigger for some clients affected by trauma.

    * the physical location of the building across from the fire station with its frequent alarms, sirens and speeding vehicles can be very disruptive to group presentations. Imagine for example, leading a meditation exercise with the interruption of a fire alarm followed by 3 firetrucks leaving the station.

    * Self-care is encouraged and suggestions are made during individual and group supervision, but specific trainings and resources would be helpful. Provider’s may not be aware of the negative effects of secondary trauma until they experience it.

    *After reviewing these guidelines for implementing TIC in an organization, I feel the organization that I work for may be lagging behind. For example, I chose this course because I want to learn more about TIC , the impact this has and to provide the best support for my clients . This was not recommended or required by my organization. . . .  My plan is to discuss this with my team and with these guidelines start implementing some organizational changes.

    I am thrilled to see that many of your organizations are already following some of the guidelines outlined in this lesson with such positive effects. It is clear that not following the guidelines has negative impacts for both clients and staff. I hope that you can all bring back what you are learning from this course to your agencies to so you can advocate for implementing as many as possible and enhancing the ones already in place.

    2) After reviewing the Trauma-Informed Counselor Competencies Checklist tell us a bit about the areas in which you feel competent and the competencies you would like to work on. Also, tell us why you feel it is important for you and/or any behavioral health professional, to develop these competencies.

    Here are some of your reflections on the TIP counselor competencies that you feel you have some proficiency in and where you need some development and why developing these competencies are important.

    Trauma Informed Awareness

    * I also automatically screen and assess for trauma history and trauma-related disorders with every client, despite what they identify as their “presenting problem” and even if they never use the word “trauma.”

    *I feel competent; understanding my client’s need for personal and physical safety, maintaining clear boundaries within the client/counselor relationship

    * I can improve with screening for and assessment of trauma history and trauma-related disorders and becoming more competent in trauma-specific interventions.

    *Learning more about the different experiences of cultural reactions to trauma, and beliefs about treatment, will be helpful in increasing my ability to provide my clients with person centered, individualized treatment.

    * I feel I Understand the difference among various kinds of abuse and trauma, including physical, emotional, and sexual abuse; domestic violence; experiences of war for both combat veterans and survivors of war; natural disasters; and community violence, but also feel that continuing education will be essential in maintaining my understanding.

    Counseling Skills

    * I am extremely person-centered and resiliency/recovery-centered as well as skilled at developing therapeutic alliances which involve shared responsibility for decisions.

    * One area I’d like to work on more is my experience (and competence) in delivering trauma-informed and trauma-specific evidence-based interventions that reduce symptoms.

    * I have developed competencies in evidence-based practices, the development of therapeutic alliances, and awareness and commitment to self-care practices.

    * Developing a therapeutic alliance and person centered counseling are strengths I have – which includes the recognition of the fact that I’m not the right person for all clients. I strive to be genuine with clients and create a safe atmosphere for them to talk about what they need to, which can certainly include trauma.

    * I feel that a strong believe in resiliency and a strengths perspective is an asset and strength.

    * In reviewing the competency checklist, I feel most comfortable with the patient centered planning. I believe in meeting clients where they are at.

    * I would like to work more on being competent in delivering trauma-informed and trauma-specific evidenced based interventions.

    *Some areas I would like to focus on learning more about is increasing competence in screening and assessment of substance use disorders, identifying training on Secondary Traumatic Stress reactions, and the impact trauma has on diverse cultures.

    I appreciate your candid sharing about these competencies. I think it can sometimes be a bit daunting to look at such a comprehensive list of competencies and identify areas where we need some work. For example, I was in private practice and when someone contacted me seeking therapy, my first impulse was to answer the call to service and say yes. So it was challenging for me, sometimes, to remember to work within my scope of practice. Even though I have many years of experience and training in working with people with trauma histories, it is not within the scope of my practice to work with children or to work with folks who are currently in a suicidal crisis or need multiple linkages to other services. I am a solo practitioner and don’t have the crises or case management backup that a TIC agency would have. One of the ways that I make sure I am working within my scope of practices is to consult regularly with my peers in a peer supervision group that I have been a part of for many years. Developing TIC competencies is a developmental process.

    So, I encourage you all to think about becoming trauma-informed both individually and organizationally as a long-term project. . . and as we say in recovery support groups “Progress not perfection”!

    3) After reading Case Illustration: Larry from TIP 57 what are your reactions to Larry’s confrontation of the client in his group? Is his approach consistent or not consistent with the principles of TIC? How would you evaluate Larry’s supervisor’s competency-based clinical supervision approach to coaching Larry on this particular supervision issue? If you were Larry’s clinical supervisor what would you have done differently, if anything, and why?

    Your responses to this question indicated that there was a general consensus that it was not in accordance with TIC principles. For example, Ellen commented, I felt that Larry’s approach with his client was NOT consistent with TIC because it completely ignored that aspect of her experience. Larry’s clinical supervisor’s feedback and recommendation also ignored the issue of trauma, which is problematic for the client’s recovery so I would have brought that up and tried to provide coaching on recognizing and respecting the client’s trauma experience and how it relates to her SUD. . .” Jason remarked that “Larry’s approach was not in line with TIC. He ignored the client’s trauma history, instead of focusing on what worked for his personal recovery and believing that is what the client needs to do. He lacked empathy and compassion for her situation.” And Katie wrote, “My reaction to Larry’s confrontation to the client in the group is that he came across shaming as a way to get her to do what he wanted. This is not the approach to motivate change. Shaming is never acceptable.”

    EDostie commented on the impact of Larry’s confrontational approach: “Larry’s confrontation of this female client in the group is retraumatizing her – he has not at all acted collaboratively with her – rather he has taken an authoritarian stance which echoes and reenacts her inability to stand up for herself when she was initially traumatized.” And Janice noted, “What stood out for me was the lack of adherence to trauma informed practices….looking at history not symptoms!! His shaming of the client was evident as well as the fact the client was a woman could be felt as re-traumaizing as well.”

    Some of you felt that the supervisor’s approach with Larry was helpful. For example; Jason noted that “I think Larry’s supervisor recognizes that Larry needs more training on evidence-based practices and non-aggressive confrontational styles. He realizes that Larry is relying on his own experience which is not helpful to the client. He wants to help Larry develop the skills to assist the client in engaging in recovery support groups.”

    While Larry’s supervisor acted appropriately to help Larry develop some competency in an evidence-based method (i.e. Twelve Step facilitation) that is also trauma-informed, many of you thought that was not the best focus for the supervisor or wasn’t enough. For example, EDosti wrote: “It is important for the supervisor to recognize Larry’s need to be reeducated about how to use 12 step meetings and theory in the TSF model but he also needs an introduction to basic trim, the risks of retraumatizing and the connection between substance abuse and mental health. Therefore, the TSF course the supervisor recommends is really just the beginning for Larry’s training.”

    The key question to continue to ask ourselves is: “Am I helping or hurting?” I think Larry, missed the mark because he did not ask this question, but simply approached it from a stance of his own “expertise” and not the client’s. If I were Larry’s supervisor, I would explore his relational stance with his clients, particularly the women he works with and address the issue of being focused more on the client’s expertise (i.e. strengths, wisdom, and experiential knowledge) instead of his own.

    As you all might remember from the lesson, Motivational Interviewing (MI) is a non-confrontational, evidence-based practice that helps people resolve ambivalence about behavior change and is consistent with TIC. It is a person-centered, respectful and collaborative approach to helping people change health risk behaviors including substance use problems. So in addition to having Larry take the course in 12-step facilitation, if I were his supervisor, I would also make sure he (and all of the counseling staff) are trained in Motivational Interviewing. With both there will also need to be further coaching and clinical supervision to follow up on the initial training. The research is clear on MI that counselors lose the skills they learn in training if there is no follow up with ongoing coaching and clinical supervision.

    Here are some additional strategies consistent with TIC that you offered for working with Larry as his clinical supervisor on the concern about his use of confrontation.

    * I would have Larry re-visit Carl Roger’s “Six Core Conditions” which would hopefully give Larry some specific skill sets to really work on. I would emphasize these skill over all of the counselor competencies (which can be over-whelming) and really hone in on developing skills to set those conditions which are essential if there is going to be any movement for his clients.

    * Larry may be experiencing a secondary traumatic stress reaction as he is comparing his recovery experience to the member in his group. If I were Larry’s supervisor I would focus more on TIC approach to treatment, and offer Larry further education and resources regarding the possibility for STS reactions in treatment.

    Again, thank you all for your thoughtful reflections on the homework questions. I am taken with everyone’s interest in and commitment to the principles and practices of trauma-informed care.

    In Class 3 we will explore screening, assessment, and clinical issues and strategies across services.

    ~Patricia

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