Instructor Response to Week 3 Homework

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    Patricia Burke
    Keymaster

    Trauma Informed Care in Behavioral Health and Co-Occurring Services

    Week 3 Instructor Responses to the Homework

    Once again, I appreciate your thoughtful and extensive responses to the homework questions. You are all contributing a great deal to the learning experience for everyone.

    1) After watching Christina’s story and reviewing the strategies for helping people build resilience answer these questions: What are your general reactions to Christina’s story? What are the actions she took in her life that you would describe as expressions of her resilience? Be specific. If you were Christina’s counselor which of the strategies for helping people build resilience would you employ with her? Why?

    I was particularly taken with the way Christina took her recovery into her own hands, instead of succumbing to the re-traumatization she experienced at the hands of the mental health system she was forced into as a child and young person. Her narrative of lived experience is quite compelling and demonstrates how important it is for those who are working with people who have experienced trauma to listen to and trust the clients’ own expertise and knowledge about what is going to support them to move forward in their lives, toward their own goals. Christina also emphasized the importance of peer support to help people sustain their recovery.

    Here are some of your responses to her story of resilience and recovery and some strategies you might employ to help her build upon her own resilience:

    Responses to Christina’s Story and Expressions of Resilience

    * I was horrified that a 6-year-old in her situation was subjected to the kind of “treatment” she described, which seems like the psychiatric hospitals during the bad old days.

    * It saddens me to hear of Christina’s experience of hospitalization as a child. She was sexually abused by her babysitter, confided in her parents, and then was punished at the hospital by being put in isolation, and by being medicated. No one took the time to listen to Christina’s experience. She wasn’t given the opportunity to have a voice.

    * Christina’s story was a bit disturbing in the way she was treated at such a young age. It was also disturbing that the doctors wanted to medicate her and put her in a facility.

    *  I was thoroughly impressed by Christina’s insight around her response to being violated, believing that “any kid would have done what I did,” knowing that she didn’t need to be drugged, she needed to be HEARD, and realizing that she is not her diagnosis, she is a person with strengths and challenges who needs resources not judgment.

    * Christina went to counseling on her own and was able to eventually get sober and complete college.

    * Admiration for her resiliency, the actions she has already taken, she recognizes her early childhood strengths, she sounds authentic with her acceptance, taking her recovery into her own hands, very powerful action, continuing her education, not using alcohol, self advocacy, finding her voice, encouraging others to find their voice.

    * I was consistently amazed by her resiliency…even from an early age. . .What a strong and sturdy woman she is!

    * Christina had the inner resilience (not sure where this came from) that propelled her to seek out answers and change. She some how knew that she needed help and sought help. She continued to strive to be better than her diagnosis, going to school and getting her degree.

    *  I am amazed by her strength and insightfulness.

     Strategies to Build Resilience

    *  I would have validated her insights, affirmed her resilience, and co-created a plan to connect her with the resources she needed, because that’s what helps people recover from trauma.

    * I would first encourage her to establish personal and social connections to help her feel a connection to something bigger, loving and healing.

    * I would continue to reaffirm her self advocacy and help her to continue to remember how far she has come, remind her to continue to explore avenues to help others, as helping others is the best reward, discuss spirituality in the post traumatic growth category, the spiritual journey.

    * I would help her find an appropriate support group for survivors of sexual assault.

    *  I would utilize Strategy #7 encouraging participation in 12 step, peer support, and other mutual-help programs. (SAMHSA, 2014, p.121) I would also focus on person centered approach, and encourage Christina’s self-advocacy.

    * I would listen to her story and build on her strengths. I would want to develop a trusting relationship at her pace.

    I am moved by your recognition of Christina’s strengths and resilience in meeting the adversity she has encountered in her life and your strategies to support her in her own recovery plan (which, by-the-way, seems to be working just fine!). This emphasis is the opposite of what she experienced in her earliest encounters with the mental health system.

    2) Tell us which 2 screening tools you picked and say a bit about why you think they would be appropriate in your private practice or clinical program. What might be the pros and cons of using these screening tools with the population you work with in your setting?

    In reviewing your posts, there was a diversity of different screening tools that you thought might be appropriate for your particular program. In choosing screening tools it is important to take into consideration the nature of the tool, the age of your client group, the ease of use, and the capability of your program to follow-up on positive results for trauma and/or PTSD. Here are some of the pros and cons you pointed out to using these screening tools in your clinical setting:

     

    Screening Tools Pros Cons
    The Life Events Checklist LEC Standard

     

    *it’s brief and simple yet fairly comprehensive in terms of types of trauma. * the questions themselves might retraumatize some clients, especially younger or very vulnerable teens.

     

    Adverse Childhood Effects Calculator (ACE) calculator *helps certain adults–especially those presenting with complex trauma–gain insight into their present symptoms and difficulties.

    * it gives a broad understanding of how someone grew up and what type of support they had during childhood.

    * it helps to normalize the symptoms

    * It has been helpful to many in normalizing their childhood experiences…they were not alone!

    * I have not used it directly with children, nor would I feel comfortable do so. I prefer getting to children’s trauma history through a more narrative approach that starts out fairly general then more specifically targets any red flags.

    * I am concerned with the consumers I work with calculating the benefits of having a high score

         
    Primary Care PC-PTSD Screen

     

    * Useful in primary care settings to identify past trauma. * Not having resources in place to help patients who need follow-up.
    PTSD Checklist PCL5 Standard

     

    * This would be a helpful tool in assessing my clients for PTSD symptoms.

    * enlighten the practitioner on some potential trauma that might be impacting the client current physiological or psychological symptoms.

    * I would use the PTSD Checklist only with adult clients because it seems wordy and the rating scale might frustrate teens.

    * The limitation with this tool is it applies to the last month of the client’s life. This would be a limiting factor in diagnosing, and with past trauma.

    * uncover some past traumas that the client may not be ready to process.

    Brief Trauma Questionnaire * Provides a starting point of understanding the level of trauma a person has experienced.

    * clients, especially new clients would be able to share if they had experienced a traumatic event without verbalizing their experience.

    *A negative may be that questionnaires can be triggering. It would be helpful to discuss the possibility for a reaction to the questions being asked.

     

    Screening tools have their place, with some caveats which can include the need for staff to be well-trained in their administration and how to follow-up appropriately when there are indications of trauma and PTSD. You should be aware of your scope of practice, as well.

    Self-administered screening tools are easy to use, but they are also easier for clients to not answer the questions accurately. It is also important to modify the administration of screening checklists with those who have cognitive impairments or difficulties with reading and/or writing.

    In addition, doing any kind of screening or assessment of trauma can activate intense reactions from clients. So you need introduce the tool carefully, let them know that they can stop any time, and be prepared to help them manage any stress reactions that might happen as a result of answering questions about trauma. It is also important to be aware of cultural sensitivity and if possible modify the administration of the tool to fit the client you are working with.

    Therefore, whatever tools you or your organization decides to use, clinical staff should be fully trained in the administration of such tools, how to modify the administration of the tool (e.g. do not self-administer but select a few questions to ask as part of an interview), and how to respond to any trauma reactions that arise as a result of using the checklist. The key is to focus on safety and stabilization.

    3) After reviewing the case illustration of Selena, if you were Selena’s clinician which of the clinical strategies from the lesson would you employ with her? Why? Be specific.

     Here are some of the diversity of clinical strategies from the class 3 lesson that you would employ with Selena to help her manage the trauma-related depression and sleep disturbance:

    * In working with Selena, I would first establish safety (providing a “No-Judgment Zone)” and trust through my words and affect in our sessions.

    * I would help her identify resources that might help her overcome her fear of falling asleep by practicing good sleep hygiene, changing the narrative in her nightmares, and being sure she had some relaxation techniques in her toolbox.

    * I would help her find an appropriate support group for survivors of sexual assault.

    * I would establish safety and trust. Then start to normalizing Selena’s symptoms. Helping her to understand that the ways she copes daily ( ie. Playing games as late she she can to lose track of time , leaving the tv on at night so she does not fall too soundly asleep) are the ways in which she has learned how to survive while minimizing reliving her experience through nightmares.

    * Addressing sleep with Selena appears to be the first concern after establishing safety and preventing re- traumatization. Discussing her sleep routine, suggesting a less interactive night time activity. determine if she has consulted her PCP, Teaching balance, asking her to consider finding a peer support group. Model mindfulness and breathing techniques.

    * I would work with her to first understand the biology of trauma and the truth that the ‘body keeps score’. I would also address the importance of sleep hygiene and what happens when he body is deprived of sleep.

    * I would focus on building trust, addressing sleep disturbances, and providing psychoeducation.

    * Discussing treatment options, coping strategies, and types of therapy will be helpful in assisting Selena choose the right treatment option for her needs.

    * Work to avoid re-traumatization and normalize her feelings. Then work on establishing some healthy sleep habits through empowering her.

    * I would first want Selena to feel safe so I would establish safety. I would start by encouraging structure and routine. Next, I would work with the client on developing a safety plan. A person who feels in control and prepared is empowering which can lead to that overall secure feeling.

    I think a stepped care approach—create safety first and stabilize before exploring the meaning of past trauma– would be a good way to approach the work with Selena.

    In addition to creating safety and normalizing her current reactions as understandable given her trauma, that a crucial strategy in working with Selena would be to address her sleep disturbance right up front. As a number of you commented, her sleep disturbance is contributing to the physical, emotional, and psychological challenges of coping with her past trauma experiences. I would begin with some psychoeducation regarding the interplay between stress reactions, depression and sleep disturbances would be helpful and then I would work collaboratively with Selena on developing non-pharmacological coping strategies to help her get a more restful and beneficial night’s sleep.

    By-the-way below are some helpful tips on Sleep Hygiene from NIH:

     

    Healthy Sleep

     

    Here are some non-pharmacological strategies from the National Institutes of Health on developing healthy sleep patterns.

     

    Set a schedule:

    Go to bed at a set time each night and get up at the same time each morning. Disrupting this schedule may lead to insomnia. “Sleeping in” on weekends also makes it harder to wake up early on Monday morning because it re-sets your sleep cycles for a later awakening.

     

    Exercise:

    Try to exercise 20 to 30 minutes a day. Daily exercise often helps people sleep, although a workout soon before bedtime may interfere with sleep. For maximum benefit, try to get your exercise about 5 to 6 hours before going to bed.

     

    Avoid caffeine, nicotine, and alcohol:

    Avoid drinks that contain caffeine, which acts as a stimulant and keeps people awake. Sources of caffeine include coffee, chocolate, soft drinks, non-herbal teas, diet drugs, and some pain relievers. Smokers tend to sleep very lightly and often wake up in the early morning due to nicotine withdrawal. Alcohol robs people of deep sleep and REM sleep and keeps them in the lighter stages of sleep.

     

    Relax before bed:

    A warm bath, reading, or another relaxing routine can make it easier to fall sleep. You can train yourself to associate certain restful activities with sleep and make them part of your bedtime ritual.

     

    Sleep until sunlight:

    If possible, wake up with the sun, or use very bright lights in the morning. Sunlight helps the body’s internal biological clock reset itself each day. Sleep experts recommend exposure to an hour of morning sunlight for people having problems falling asleep.

     

    Don’t lie in bed awake:

    If you can’t get to sleep, don’t just lie in bed. Do something else, like reading, watching television, or listening to music, until you feel tired. The anxiety of being unable to fall asleep can actually contribute to insomnia.

     

    Control your room temperature:

    Maintain a comfortable temperature in the bedroom. Extreme temperatures may disrupt sleep or prevent you from falling asleep.

     

    See a doctor if your sleeping problem continues:

    If you have trouble falling asleep night after night, or if you always feel tired the next day.

    http://www.ninds.nih.gov/disorders/brain_basics/understanding_sleep.htm

     Again, thank you all for your thoughtful reflections on the homework questions.

    In our 4th and final class we will explore trauma specific interventions which can be used in a diversity of clinical settings.

    ~Patricia

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About Patricia Burke

I am a Board Certified Diplomat in Clinical Social Work, a Certified Clinical Alcohol, Tobacco, and Other Drugs Social Worker, and a Certified Clinical Supervisor with over 30 of clinical and teaching experience.