April 7, 2017 at 4:03 pm #4738Patricia BurkeKeymaster
If you have experienced trauma in your life and the homework exercises activate a stress response or you think they might, please stop what you are doing and engage in whatever self-care activities help you get centered, grounded, and calm your central nervous system.
Review the Suggested Guidelines for Implementation of a Trauma-Informed Approach in this lesson. Pick one of the guidelines that you think your organization is following with regard to implementing a TIC approach and jot down your thoughts about how following this guideline has been helpful in creating a safe, welcoming and trauma-sensitive environment for consumers. Pick another guideline that you think your organization is not following and jot down some ways that not following this guideline has or might negatively impact both clinical staff and consumers.
Review the Trauma-Informed Counselor Competencies Checklist. Make two columns on a piece of paper. On one side jot down 2–3 items from the checklist that you feel you have achieved a level of competence in and on the other side jot down 2–3 items that you feel you need to improve on.
Read the following case illustration, reprinted from SAMSHA TIP 57.
Case Illustration: Larry
Larry is a 28-year-old clinical social worker who just finished his master’s program in social work and is working in a trauma-informed outpatient program for people with substance use disorders. He is recovering from alcohol use disorder and previously worked in a residential rehabilitation program as a recovery support counselor. There, his primary responsibilities were to take residents to Alcoholics Anonymous (AA) meetings, monitor their participation, and confront them about their substance use issues and non-compliance with the program’s requirement of attendance at 12-step meetings.
In Larry’s new position as a counselor, he confronts a client in his group regarding her discomfort with attending AA meetings. The client reports that she feels uncomfortable with the idea that she has to admit that she is powerless over alcohol to be accepted by the group of mostly men. She was sexually abused by her stepfather when she was a child and began drinking heavily and smoking pot when she was 11 years old. The client reacts angrily to Larry’s intervention.
In supervision, Larry discusses his concerns regarding the client’s resistance to AA and the feedback that he provided to her in group. Beyond focusing supervision on Larry’s new role as a counselor in a trauma-informed program, the clinical supervisor recommends that Larry take an interactive, multisession, computer-assisted training on the 12-Step facilitation (TSF) model. The TSF model introduces clients to and assists them with engaging in 12-step recovery support groups. The agency has the computer-based training available in the office, and Larry agrees to use follow-up coaching sessions with his supervisor to work on implementation of the approach. The supervisor recognizes that Larry is falling back on his own recovery experience and the strategies he relied on in his previous counseling role. He will benefit from further training and coaching in an evidence-based practice that provides a nonaggressive, focused, and structured way to facilitate participation in recovery support groups with clients who have trauma histories.
Reprinted from SAMSHA, 2014, p. 178
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.
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.
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?
While answering the homework questions please only share personal information or specific responses to the homework exercises you feel comfortable sharing. It is up to you to decide how much or how little to disclose. Please respect the privacy and confidentiality of consumers/clients and other class participants in your sharing.
To post your assignment, please reply to this topic below.September 30, 2021 at 1:53 pm #31150Ellen LCSWParticipant
Question 1. As a sole practitioner I aim to follow all the guidelines except, of course, those that are irrelevant to a private practice like mine. That’s the way I was trained, and it’s my personal belief system as well. That being said, 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. If siblings, a couple, or a parent-child dyad are there together, the sit right next to each other, which also might be re-traumatizing for some. I don’t believe that has been an issue for my clients, but I really can’t be 100% sure. I always check in with them and ask directly about “physical closeness” issues, but trauma survivors may not always speak up about their discomfort. Thankfully, the majority of my work is with individuals. I try to make the space homey and non-threatening in every way I can, but–well, you never know.
Question 2. Again because of my training, experience, and personal values, I am extremely person-centered and resiliency/recovery-centered as well as skilled at developing therapeutic alliances which involve shared responsibility for decisions. 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.” In fact, many people are surprised when that word comes up because they never thought of their experiences that way, no matter how horrific or abusive they were/are. 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. New evidence-based practices are being developed all the time and I’d like to stay current on these. Another area I’m not sure how well I’m doing with is clinician self-care practices that prevent or lessen the impact of Secondary Trauma Stress. I plan to read the Fact Sheet that I printed out from this week’s material, so we’ll see.
Question 3. 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, and getting her agreement to integrate it into her recovery plan, if at all possible.October 2, 2021 at 10:32 am #31166Jason AntkiesParticipant
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. This is going to lead to the client being able to accomplish treatment goals and produce greater organizational outcomes. The non-clinical members who are not trauma-informed are more likely to pathologize clients. This greatly hinders the quality of care delivered, impacting relationships and leading to less compassion and empathy for the client. I also see more burnout and compassion fatigue.
I have developed competencies in evidence-based practices, the development of therapeutic alliances, and awareness and commitment to self-care practices. My clinical practice is grounded in Motivational Interviewing. I practice listening with compassion, being empathetic, not having an agenda, not being attached to outcomes, and remaining neutral in conversations with clients. I believe this practice allows me to form strong alliances with the people I work with. I can improve with screening for and assessment of trauma history and trauma-related disorders and becoming more competent in trauma-specific interventions.
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. 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.October 2, 2021 at 1:41 pm #31167Alan AlgeeParticipant
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. The first is to assess how the goals in the last two-year cycle were performed. The second is to develop new goals for the new cycle. Goals are never duplicated from cycle to cycle to assure ongoing development (unless one of the previous goals was not developed which, we hope, is rare). This leads to confidence that we really are making progress in TIC.
Every year we require all employees to have 4 hours of training in trauma per year (more than that is encouraged). We do not require any specific training (Providers may choose their own topics in trauma). Each provider has a Professional Development Plan which is reviewed with their supervisor. This way Providers and their supervisors can visit their PDP and decide on which counselor competencies would be best to work on. This, we hope, reflects the systematic and on-going model of training rather than specific event training.
I would say that Larry really doesn’t need any more training in the 12-step approach. He probably is something of an expert in that model. 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.October 4, 2021 at 1:48 pm #31186
8. Quality assurance
In both of the organizations I have worked for in the past 10 years, Maine Children’s Home in Waterville and the Maine General Medical Center there has been recognition at the urging of the State of Maine to implement some measures of quality assurance with regard to trauma informed care. What I recall from my time as Clinical Director at MCH was all of our clinicians working with children were encouraged to take the Trauma Focused CBT courses offered nationally and become proficient with that method – this was my first exposure to using evidence based trauma specific interventions.
At the IOP where I’ve been for the past 6 or 7 years, the focus on trauma is incorporated into the primary modality used, DIALECTICAL BEHAVIORAL THERAPY, an evidenced based program for helping suicidal people, initially, but now widely recognized as being useful to sufferers of depression, certain personality disorders and other mood disorders.
In the interest of continuous improvement the IOP sought to have all of the clinicians trained in SEEKING SAFETY as mentioned elsewhere in this class as an evidence based program to deal specifically with trauma and substance abuse which often go hand in hand. So as of today, October 2021, this Seeking Safety modality is frequently used as an education class, one of the three daily scheduled sections of the IOP day, and is also offered as a weekly Friday afternoon group for those patients invited to attend after their completion of the 6 week morning classes in the IOP. This particular use of Seeking Safety has the wonderful added benefit of being facilitated by a Clinical Art Therapist who incorporates art directives into every group.
Other topics presented during Education often come directly from requests from the clients for more information on other topics, as well as Trauma.
Finally, about 4 years ago IOP instituted a continual client centered evaluation system called the Outcome Rating Scale which gives an individual picture of how a client is doing and progressing, or not, in the experience of IOP. These evaluations are then tracked, presented to the clinical team in a weekly visual presentation and used to assist in planning phases of the individual’s treatment: ie, is IOP right for them? would they rather simply go to individual therapy, is hospitalization recommended, etc.
11. Physical environment of the organization:
Located in downtown Augusta in a large brick building formerly used by Central Maine Power, Maine General IOP occupies one-half of the 2nd floor, shared by the needle-exchange program and other social service offices. Other floors are also occupied by Maine General divisions, including outpatient counseling, the ACT team, and medication assisted treatment. Although this can have its advantages in that clients can easily locate the next phase of their treatment with the help of clinical personnel, 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.
Next, the front lawn of the building because of its proximity to downtown attracts smokers – specifically not welcomed by the hospital but tolerated as a reality of having working offices near a population of sometimes homeless people. I believe our staff deals with this situation as well as they can – certainly there is plenty of help offered to quit smoking, recognized as another addiction. Information about finding nearby shelters is also available- although often those shelters are not open during the day. I do not offer a solution to this situation – I am merely describing it for purpose of a less than ideal environmental condition, both for clients, employees and those individuals smoking on the lawn.October 4, 2021 at 2:19 pm #31189
Question 2: 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. Noticing when expressing a traumatic situation isn’t necessary, for example during an intake or a group session, is also a skill I have – sometimes it’s important to recognize that one client’s presentation of their trauma will be too hard for the group to hear and they can be asked to discuss it individually when they are ready, and not necessarily with me. Working with a team is an ideal way to do clinical work and I rely on other clinicians and our psychologist/psychiatric providers to be there to assist with content when necessary.
I have put off getting trained in specific trauma treatments such as EMDR which I am now regretting as I get older. I would like to be able to offer direct help in the manner that modality does, often. I know it doesn’t work for everyone but I’ve seen it be really helpful for several clients when done at the optimum time.
My self-are has always included taking additional courses I am interested in – I would like to pursue for creative modalities such as drama therapy and art therapy as time, money and distance allow – these are particularly helpful with trauma.October 4, 2021 at 2:48 pm #31190
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.
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 supervisor needs to get in the group and observe Larry and, especially to model appropriate, less confrontational methods of working with these clients. Larry needs experience and education about wrap -around support this particular client could use to help her begin to feel safe about not using. Basic social work training for Larry would be good – how to access community resources; how to seek mentors that can be supportive for clients – all of these areas to expand his view of “recovery” which he has practiced in an oversimplified manner which may have worked for him in his previous position and, indeed, in his own recovery.October 5, 2021 at 11:03 am #31203Jamie WilliamsParticipant
Question 1: Following these guidelines promotes a safe and welcoming environment for healing to occur. Staff training at all levels is important for TIC to occur. When members of a clients care team are not in alignment with each other, it can cause clients to not feel safe or have trust in their treatment. It also leads to staff splitting and burn out. Clients need/deserve consistency with treatment that promotes healing and growth and not shame.
Question 2: Areas in which I feel competent in are Person-centered planning, development of therapeutic alliances and recovery-oriented care. I feel strongly about consumer/ client advocacy and self-care practices for both myself, my staff and clients. I would like to work more on being competent in delivering trauma-informed and trauma-specific evidenced based interventions.
Question 3: I do not feel Larry’s approach with this client aligned with TIC. Larry’s approach feels shaming and does not seem client centered. He lacks insight into this clients trauma and probably retraumatizes her in front of the group. It seems that Larry believes his way of recovering is the only way to recover. I believe Larry’s supervisor acknowledges the need for Larry to gain further training and insight outside of his own 12 step experience, however, does not address training for Larry to become trauma informed .October 6, 2021 at 10:55 am #31210Janice BlackParticipant
In reviewing TIC competencies and returning to this homework post, I see that my response to question 1 isn nor here…hopefully it was received!!! Technology in spite of the newest and best is not my strong suite!! Regarding question 2…I feel that a strong believe in resiliency and a strengths perspective is an asset and strength. I started my private practice in a medical model…fortunately that has has changed!!! I am slowly becoming a better advocate for my clients. In the past, our work was conducted in the confines of the office during the 50 minutes allowed. Today I have started to do more advocacy in the community. I’ve helped an elderly client secure safer housing. I have another older client who recently had her car taken away due to diminished judgement and reaction. This has significantly reduced her social connections…ie regular trips to Shaw’s, church nail salon etc. I have the number for two transportation agencies I really need to call for her. This is a great reminder!!
I don’t dare go back and review the case illustration for fear of losing what I’ve already written. What stood out for me in memory 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.
A review of the 12 step program in concert with trauma is necessary.October 6, 2021 at 9:17 pm #31215Greta GarveyParticipant
Services and Interventions are the guideline the agency that I work for is following in using a TIC approach. The assessments we use have a specific section to evaluate for current and past trauma. 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. We have specific counselors at the agency who have additional training in trauma. As part of our CEU requirement for the agency each year we need to receive 4 hours of training specifically related to trauma. Individual supervision is readily available to all staff members, and group supervision takes place twice a month. The staff members are caring and work as a team to support one another. As the agency offers SUD and Mental Health counseling the ability to collaborate with one another is helpful to our clients, especially when addressing issues related to trauma.
In regards to Training and Workforce development our agency would benefit in offering additional support for providers who are experiencing secondary traumatic stress and who have trauma histories. 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.
In reviewing the trauma-informed counselor competencies checklist the following areas are where I feel competent; understanding my client’s need for personal and physical safety, maintaining clear boundaries within the client/counselor relationship, and using a strengths-based approach. 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. Being able to have additional training and competency in substance use assessments will help me to incorporate integrated treatment for my client’s. In addition to recognizing signs of burnout, it would be helpful to have a better understanding of secondary traumatic stress reactions, and what to do when experiencing this in the moment with a client. 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.
As a young male clinical social worker Larry may not be taking into account the past trauma the female member of his group has experienced. “In addition, since addiction treatment services have traditionally been designed to address the needs of men, in order for a program to be truly trauma-informed, it must not only adopt an integrated treatment approach but also be re-designed to meet the needs of women survivors of trauma (Harris & Fallot, 2001, p. 57). In this situation the female group member had a negative reaction when she was confronted by a male facilitator. Larry’s approach does not align with a TIC approach which is person centered. Larry’s supervisor has addressed the needs regarding the approach to the group, but has not addressed the need for further training specifically regarding trauma, and a TIC. 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. It may also be helpful to have a co-facilitator for the group until Larry has more of an understanding of TIC approach.October 6, 2021 at 10:00 pm #31217Tanya HaleyParticipant
Trauma informed approaches are a more recent approach to the organization that I work for. Efforts are being made to train and educate staff because of current employee’s efforts to bring awareness to mental health and trauma informed care. Currently there are no procedures and policies in place that support TIC within the organization, but we are making strides to get there.
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.
Larry’s approach was confrontational and not in line with TIC. Given the clients past exposure to trauma and the fact that she was uncomfortable sharing in a group which was mainly dominated by men. Larry should have engaged her in a supportive conversation to give her the opportunity to express her concerns or engage in further discussion on how she can remain in the program that might include an environment that is more supportive of her past trauma. Larry also could have taken a step back and consulted with a coworker or supervisor prior to engaging in a confrontation with the client to elicit other ways to engage this client.October 7, 2021 at 6:52 am #31218katie VarneyParticipant
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. There is nothing in my job description that says I need this training. I chose to pay for this training out of my own pocket because its important to me to understand the people I work with daily. My plan is to discuss this with my team and with these guidelines start implementing some organizational changes.
In reviewing the competency checklist, I feel most comfortable with the patient centered planning. I believe in meeting clients where they are at. I believe in order to encourage change, the client needs to be fully engaged and the social worker is there to support and provide the resources necessary.
Some of the competencies that I would like to know more about is the self care practices ( to avoid burn out) and culturally competent care.
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. Larry had little insight and came across closed minded to other approaches. It appears that the clinical supervisor working with Larry is aware that his approach does not line up with TIC approach. This supervisor works with Larry on additional training and coaching in a non- confrontational approach which Larry appears to be open too.October 8, 2021 at 11:40 am #31239Danielle CiminoParticipant
The agency I work with make an active effort to continue interviewing consumers, their families, additional providers and referents in order gain insight into what we could change to make treatment better for clients. In addition we have consumers fill out anonymous treatment effectiveness surveys in to provide them with space to be honest about how their clinicians can improve.
I feel my team and I are very person centered when it comes to competencies. We try to individualize reach treatment continuum for clients in an attempt to reach their best possibly outcome. We work with clients to create their own plans in order to give them a sense of control over their own future and well being.
Larry’s interaction with the client in group seemed misplaced. He was utilizing his personal experience as a form of clinical intervention instead of offering a shared experience. By not holding space for the client and her discomfort towards the idea of an AA meeting with all men, he not only could have damaged the therapeutic relationship between them, and created group fracture, but he could have also re-traumatized her. This is not in line with TIC, which Larry’s clinical supervisor realized. If I was his clinical supervisor, I may have also suggested that Larry do his own individual work in order to keep his mental and emotional well being in check, so it will not spill into his clinical work with clients.October 9, 2021 at 10:59 am #31247Ruth LockhartParticipant
Leadership in my work place have made it mandatory for all staff to receive training on how trauma effects behavior and learn prevention strategies to intervene so situations do not escalate to a crisis. The organization keeps track of the crisis situations that occur within the organization and this information is shared with staff and discussions are had on ways to improve the use of prevention strategies.
There is a council that meets monthly that is open to consumers who utilize services provided by the organization. Ways to improve services and unsatisfactory experiences are discussed. This information helps the organization improve delivery of services.
Clinicians collaborate with community service providers when specialized services are needed for consumers that are out of the organizations scope of practice. These often include trauma from domestic violence, human trafficking, and sexual abuse.
My strengths from the competencies are understanding the need for people with trauma histories to have emotional connections with safe people that can help people flourish and move forward. At the foundation of the work that I do is ensuring emotional and physical safety of clients in order to help stabilize them from a crisis and assist with maintaining stability at home and in the community.
I understand and have yearly training on the importance of not confronting unhealthy behaviors that might activate acute stress reactions or trauma symptoms and that the use of empathic listening creates understanding and this helps to guide resolution.
Being clear about rules and boundaries helps with keeping the environment safe and when people are unclear about the rules and boundaries this most often leads to behavioral and psychological acting out in unhealthy ways.
Having a strengths based lens has helped clients focus on their strengths, their accomplishments, and the healthy ways they have learned to cope and build resilience to recover from difficulties in their lives.
People of diverse cultures rarely access the services provided by the organization I work for. So I’m deficient in how trauma affects them and how they understand behavioral health treatment. I would like more knowledge on specific screening tools to screen and assess trauma histories with clients.
Lastly I could benefit from learning additional self care activities and ways to recognize STS in myself.
These competencies are important to know and practice because majority of people seeking services have a trauma history and if one is not competent then consumers struggle to get the help they need and as providers we may become frustrated with clients and this can lead to emotional distress.
Larry appears to be in the habit of confronting based on his skill set and could benefit from supervision and education. I wonder if a Larry is aware of the details of the client’s trauma history.
As a clinical supervisor the 12 step training would not have been my first recommendation. I would have focused on client centered approaches and trauma informed skills.October 10, 2021 at 3:22 pm #31252James SkeltonParticipant
The program I work at allows the clients to inform and guide their treatment goals and plans. We help them feel empowered to make their own decisions which increases their self-efficacy and resiliency. We practice MI so that the clinicians aren’t pathologizing or shaming clients for their behaviors, but using TIC helps the clients become more open and vulnerable about their struggles, therefore leading to a better outcome of change and healing.
Again, my program practices self-determination within the treatment planning and goal setting. Even though we are 12 step based, we encourage the clients to find a community-based resource that they most identify with and feel comfortable in. Even if that isn’t a recovery specific community, it could also be a yoga, meditation, or activity group.
Larry was not aligned with TIC because he used his own experience as an intervention. He did not share as a means of relating. Larry also ignored the client’s history of trauma. Larry ignored the client’s expressions of what his needs were and was making decisions not aligned with the client’s wishes. Larry’s supervisor was right to encourage him to seek more training in TIC and to not project his own life experience onto his clients.
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