Instructor Responses to Week 1 Homework

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    Patricia Burke
    Keymaster

    Trauma Informed Care in Behavioral Health and Co-Occurring Services

    Week 1 Instructor Responses to the Homework

    I deeply appreciate your responses to the homework, which demonstrate that you are already using the reading and exercises to support your own personal, as well as professional explorations of what trauma-informed care is and how you might align yourselves with its principles and practices. I offer this class as a vehicle for your own explorations to whatever extent you choose to engage in that process.

    1)What are your general reactions and responses to Anna Jennings’ story of re-traumatization in the documentary Important Souls? What are your reactions to the statements “Symptoms are adaptations to distress” and “Truth lies in a person’s story, not in their symptoms?

    Some of your reactions to Anna’s story include feelings of sadness, anger, frustration, awareness Anna’s has been re-traumatized over and over again by staff, shocking, being disheartened or broken-hearted, deep sorrow, it is a tragedy, sadness for the loss of such a gifted woman, the system failed her,

    The general consensus in your responses is an appreciation for the importance of understanding that psychological, emotional and behavioral symptoms that are the basis of a psychiatric perspective on trauma, can be understood as adaptive responses and that, as helpers, we can hold the perspective of placing these adaptations into the larger context of a person’s narrative of lived experience.

    The simplest, but perhaps most powerful way to gain a larger perspective on peoples’ behavioral responses to trauma is to listen and focus on the unique and resourceful ways the person has responded to trauma instead of only focusing on the trauma experience itself or a client’s “symptoms.” For example, E Dostie observed, “What she was trying to say stood out in her art work. . .”

    In Narrative Therapy practices we emphasize the importance of helping people “thicken” their preferred stories of lived experience, so I think it is important when listening to people’s stories of trauma, to not simply focus on the traumatic events, but to gently inquire and open up the conversation to how this person responded to the events, how they evaluate their responses, who would appreciate how they responded, etc. Then we begin to move into conversations that focus on resilience and strengths (from the storyteller’s perspective) instead of simply re-telling the trauma story over and over again.

    In Narrative Therapy we also talk about “critical witnessing” and “acknowledging witnessing.”  Pathologizing people’s behavioral expressions of responding to trauma can be experienced as judging, critical, and objectifying. Pathologizing behavior can be dehumanizing. My preference, which is in alignment with the idea of “symptoms” as adaptations, is to be an acknowledging witness. When we adopt this stance the people we are working with feel listened to and understood, because we are acknowledging their lived experience instead of labeling them.

    I also want to re-emphasize the importance of cultural awareness when listening and acknowledging people’s trauma. Every culture has their own understandings of trauma and what are considered helpful or culturally appropriate responses and adaptations to it. When we allow ourselves to open to others’ narratives of lived experience we can learn a lot about how their culture supports or doesn’t support their healing.

    Anna’s re-traumatization while in the care of the psychiatric system was, in part, related to the belief that people are their psychiatric labels and that their behaviors are symptoms of pathology that need to be eliminated through medication and/or behavioral change therapies. The shift in awareness to the idea that people’s “symptoms” are adaptive responses to traumatic experiences can go a long way toward preventing the kind of re-traumatization Anna and many others have experienced.

    As Danielle remarked, “I like the emphasis on the quote “the truth lies in a person’s story not their symptoms” because it reminds me that all clients are only human. It is easy to get caught up in what the insurance companies/DSM/agencies would like us to see when the reality is putting people inside a criteria drive box can be detrimental to their overall care.” And Katie wrote, “The statements “Symptoms are adaptions to distress” and “Truth lies in a person’s story, not in their symptoms?” reminds me to place the focus on the client (as a whole being) rather than placing the focus on the problem or symptoms.”

    2) What are your thoughts on Harris and Fallot’s paradigm shift in focus from the traditional approach to behavioral health treatment which asks “How do I understand this problem?” to a trauma informed approach to treatment which asks “How do I understand this person?” Then pick a behavior from your list of someone who has experienced trauma that would be considered a pathological symptom in the traditional approach and describe how you might view that behavior as a coping strategy from the trauma-informed care approach. Be specific.

     Russell commented on this paradigm shift, “My thoughts on the paradigm shift, person centered focus, excellent goal with consistency challenges . . .” Danielle remarked,” I agree with the paradigm shift in full. Historically clinicians have been quick to pick apart behaviors to find a dx instead of looking at the behavior as a symptoms of traumatic experience.” Alicia noted, “I love this paradigm shift. Some of the most challenging clients we work with are those suffering from Borderline Personality Disorder. It can be so easy to dismiss them as “oh, she’s a borderline”. Instead, I was told by a supervisor long ago that “when you see borderline, think trauma”. Jamie wrote, “I feel the paradigm shift is so important. When we can view others as what they have been through and not how they are presenting. We can focus on treating all parts of them and not just behavior modification.”

    Here are some examples from you of how “pathological symptoms” might be alternately viewed as “coping strategies.”

    “Pathological Symptom/behavior” “Coping Strategy”
    triggered in a group setting, get up and leave the group practicing resiliency by protecting themselves from more harm
    Yelling and screaming when locked out of MAT for being late doing whatever it takes, including, threatening others to get their dose.
    Anger, verbal and physical aggression Survival skill and way to express her feelings of repression, abuse, and loss
    Weight gain, sleeping with a bat Way to self-protect
    Constant lying A way of coping with childhood incidents of neglect and abuse
    Diabetes, obesity Protective and adaptive strategies
    Yelling A way to be noticed
    Defensive A way to protect herself.

    Thanks for your terrific examples of how “symptomatic behaviors” can be viewed in a different light as coping strategies from a TIC perspective. This shift in thinking helps me remember that people are people, not their problems and that I can work toward staying focused on the whole person and not get stuck in treating symptoms. This shift is also consistent with a strengths focus in our work with others.

    It is also important to remember, however, that we need to explore with clients/consumers what their understanding of “symptoms” is.

    3) Review the 10 Key Principles of a Trauma-Informed Approach from this lesson. Describe how the organization, agency, or setting you work in (including private practice) applies some of these principles to its work with people with histories of trauma. Which of these principles actively inform policies and procedures, treatment approaches, and the general atmosphere? How could your organization improve in order to become more fully trauma-informed?

     A number of you mentioned that at your agency or private practice you follow many of the principles of trauma-informed care.

    For example, Danielle commented “The environment that I work in stresses empowerment and collaboration for providers, consumers, and their families in addition to peer support and mutual self help. It is my intention that empowerment of the consumer will allow them to feel open and that they have more control of their situation to make changes than they have in the past.”

    EDostie mentioned, SAFETY, TRUSTWORTHINESS AND TRANSPARENCY The program uses a simple, consistent, predictable structure the clients can count on as they come for approximately six weeks with 3 groups a day DBT, Education and Psychotherapy.” Greta commented, “In regards to trustworthiness and transparency we ensure that we have releases in place before talking to anyone regarding the client, respect confidentiality within the limitations, and make reports with our clients to child services when needed (as long as there is not a safety risk to the Provider, then it may be done without the client present).

    Jason wrote, Collaboration and mutuality – “We strive to have an environment where everyone is equal. Clinicians do their best to avoid power struggles. We take client’s feedback and opinions into consideration often and we want them to be a part of their process.”

    Ellen commented, “I work really hard to provide emotional safety and convey my own trustworthiness, acceptance without judgment, and desire to collaborate, empower, and promote choice in my work with clients.”

    Alicia mentioned, “Resilience and Strengths-Based—I think this is another area where we do well. Especially in the field of substance use disorders, where there is so much stigma and judgment, it is so important to approach things from a strengths-based perspective. We hold hope for the clients and empower them to believe in their own ability to get better.”

    Tanya wrote: “Collaboration and Mutuality, Empowerment, Voice and Choice. Our practice uses motivational interviewing skills to help elicit the clients engagement in the process. Using these skills to work with a client where they are at and encourage them to have a sense of autonomy. Putting them in the driver’s seat so to speak. Letting them have a sense of control in the situation.”

    A key principle of TIC is Safety. When the physical environment can be changed to evoke a warm, safe, calming and culturally sensitive space then people with histories of trauma will feel a greater sense of safety and trust right from the start.

    As Rose noted, “One of the key policies of our agency is to assume that everyone has a trauma history. We are careful to provide safe spaces and do our best not to re-traumatize with our settings, our actions or our words.”

    Another issue of Safety for clients with trauma is the use of restraints in behavioral health settings. Historically physical and chemical restraints have been used in many settings to control behavioral expressions of trauma aftereffects. This has largely had the effect of re-traumatizing people. So an organizational policy of no physical restraints would certainly be in alignment with the principles of TIC.

    Ultimately, I think safety creates a foundation upon which all of the other principles can be built.

    Another keep principle of a TIC approach is Peer Support. Peer support and advocacy can help raise the consciousness of the organization on all levels, give voice to the needs of consumers, and deconstruct the inherent power differential in the relationship between the organization and the consumer. Danielle remarked, “Peer support is also stressed in order to allow clients to feel a sense of universality in what they are going through.” Jason commented, “Our community relies upon senior peers role-modeling for newer residents. Our goal is for the clients to build healthy support systems within the treatment community where they can practice vulnerability, compassion, and empathy. Our belief is that connection is the solution to addiction.”

    Some of the ways you thought your organization could improve include moving away from a confrontational approach, better utilize individual strengths within the group, addressing a punitive worker’s reactivity with the goal of enhancing psychological safety,

    Unfortunately, there are certain settings that are inherently traumatizing, such a jail and prison, where people are called “inmates” and the goal of the institution is to control behavior and to punish people for their criminal behavior. In these kinds of settings it can be difficult to institute practices based on TIC principles. Yet, there is a movement to bring more TIC principles and practices into the field of corrections that is consistent with some correctional goals. Here is a link to an article that might be of particular interest with regard to efforts that are being made to make correctional facilities more trauma-informed: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3402099/

    Thank you all for your thoughtful reflections on the homework exercises and questions. I encourage you to use these principles to inform your own practice and encourage your organization to improve TIC at all levels of the organization.

    In Class 2 we will explore how to implement the TIC principles we discussed in the first class in behavioral health practice settings.

    ~Patricia

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