April 6, 2017 at 2:51 pm #4595Patricia 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.
Watch this 7-minute video in which Christina describes her experience in non-trauma-informed treatment services and how she has been able to take charge of her own recovery. As you watch the video, jot down some notes about what you see as Christina’s strengths and her resilience. Review the strategies for building resilience in this lesson.
Review the screening instruments in the lesson. Pick 2 screening tools from the list below that you think would be appropriate to use in your private practice or clinical program. Jot down your thoughts about the pros and cons of each of the screening tools you reviewed and how they might be used in your private practice or clinical program.
The Stressful Life Events Screening Tool
Review the section Clinical Issues and Strategies Across Services, and read the following case illustration (reprinted from SAMSHA TIP 57).
Case Illustration: Selena
Selena initially sought treatment for ongoing depression (dysthymia). During treatment, she identified being sexually assaulted while attending a party at college. At times, she blames herself for the incident because she didn’t insist that she and her girlfriends stay together during the party and on the way back to their dorm afterward. Selena reported that she only had two drinks that night: “I could never manage more than two drinks before I wanted to just sleep, so I never drank much socially.” She was assaulted by someone she barely knew but considered a “big brother” in the brother fraternity of her sorority. “I needed a ride home. During that ride, it happened,” she said. For years thereafter, Selena reported mild bouts of depression that began lasting longer and increasing in number. She also reported nightmares and chronic difficulty in falling asleep. In therapy, she noted avoiding her bed until she’s exhausted, saying, “I don’t like going to sleep; I know what’s going to happen.” She describes fear of sleeping due to nightmares. “It’s become a habit at night. I get very involved in playing computer games to lose track of time. I also leave the television on through the night because then I don’t sleep as soundly and have fewer nightmares. But I’m always exhausted.”
Reprinted from SAMHSA, 2014, p. 122
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 of helping people build resilience would you employ with her? Why?
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?
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.
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.October 7, 2021 at 4:09 pm #31228Ellen LCSWParticipant
Question 1. My general impression of Christina’s story is two-fold: First, 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. That no one addressed her sexual assault was not just NOT TIC, it was criminal malpractice in my opinion. Secondly, 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. That Christina took charge of her own recovery at a relatively young age speaks volumes about her capacity for resilience.
If I were counseling Christina, I would definitely have listened to her first and foremost and behaved in a way that showed her I was worthy of her trust. 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.
Question 2. I have used something very similar to the Adverse Childhood Effects Calculator to help certain adults–especially those presenting with complex trauma–gain insight into their present symptoms and difficulties, and to help shift their mindset from deep shame and self-blame to at least an understanding of the factors that may have contributed to their troubles. My purpose was not to give them ready-made excuses for problematic choices and behavior or diagnoses stemming from neurological factors, but rather to provide a realistic context that might give some meaning to an otherwise chaotic and confounding life. I have also used it with parents to help them understand the risk factors their foster or adopted children are contending with and why certain treatment approaches might be more successful than others. 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 really like the Life Events Checklist and can see myself using it with adults and older adolescents, as it’s brief and simple yet fairly comprehensive in terms of types of trauma, but I might worry that the questions themselves might retraumatize some clients, especially younger or very vulnerable teens.
I feel like I would use the PTSD Checklist only with adult clients because it seems wordy and the rating scale might frustrate teens.
Question 3. 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 listen to her story without interruption, and I would give her every opportunity to make her own choices in our work together. I would use an illustration I have to convey that “There is more than one way to look at something,” pointing out that while in the illustration neither way is right nor wrong, in life one way might be more helpful than another. I would help her examine the meaning she made of her story (blaming herself for not insisting her group stay together, and choosing the “convenient” ride home, or perhaps misjudging the boy she “barely knew”) and see those things in a different, more forgiving way. I would help her see herself as a survivor and identify real-life examples of her resiliency. 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. Finally, I would help her find an appropriate support group for survivors of sexual assault.October 12, 2021 at 7:45 pm #31274Jamie WilliamsParticipant
Question 1: It was heartbreaking to watch Christina’s story and see that not only did her family fail her but the health system did as well. Instead of providing treatment for the problem they provided treatment for the symptoms. Christina was not heard but instead was punished for what had happened to her. Christina went to counseling on her own and was able to eventually get sober and complete college. If I was Christina’s counselor I would first encourage her to establish personal and social connections to help her feel a connection to something bigger, loving and healing. Helping her to become spiritually led instead of people reliant in times when people may not be available. Establish a daily routine with her so she had structure and meaning/ purpose of her day/life. And encourage the client to take action towards the life she dreams to have.
Question 2: Adverse childhood effects calculator, because it gives a broad understanding of how someone grew up and what type of support they had during childhood. Our childhood experiences condition us in how we behave in the world. The other would be the Brief trauma questionnaire. To get a starting point of understanding the level of trauma a person has experienced.
Question 3: 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. Then develop a plan with her on how to work through her triggers and her nightmares.October 12, 2021 at 10:06 pm #31275Russell KohrsParticipant
Q !, My general reactions to Christina’s story? 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. If I were Christina’s counselor, 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.
Q 2, We have been using the ACE’S calculator, I have experienced positive results, I think it helps to normalize the symptoms that result, I am curious working with men how comfortable they are with answering question 3, at times I am concerned with the consumers I work with calculating the benefits of having a high score. Consumers identifying a shorter life expectancy has concerned me in the retraumatizing potential. increasing relapse motivation.
Q 3, 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.October 13, 2021 at 12:15 pm #31278Janice BlackParticipant
I was consistently mazed by her resiliancy…even from an early age. It was difficult to realize how her sexual assault wasn’t addressed. In trying (!!!) to do the math, I was brought back to my days as a school social worker in the late 80’s and 90’s remembering how schools focussed so much on ADHD…kids unable to sit in their chairs, play with others and talking too much etc. The idea of a child being sexually assaulted was a difficult concept at that time…even though we were definitely starting prevention programs.I was also stuck by how affected by the medical model she was…medication was the answer to everything then. What a strong and sturdy woman she is!
I have used the Adverse Childhood Experience checklist for the past several years.It has been helpful to many in normalizing their childhood experiences…they were not alone! I could not open up any of the listed screening tools on this MacBook but have sent a screen shot of the list to my partner to open on his non-Apple computer.I’m always interested in looking at other instruments. Thanks for the list.
I was initally struck but the a sense of betrayal she must have experienced. She trusted herself to limit her drinking (it don’t work), she was assaulted by a ‘big brother’ and she felt she ‘knew better’ but didn’t listen to herself. Of course she feels guilty and blames herself. 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. A safe environment, an established professional relationship and an understanding of the delayed effects of trauma would also be imperative.October 13, 2021 at 8:40 pm #31294Greta GarveyParticipant
1. 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. Listening to Christina speak about taking her recovery into her own hands was empowering. She shares that she started doing research online to learn about alternative options for treatment. Being medicated was not helping her to get better. She shares that her diagnosis and behaviors were viewed as a weakness and not a strength. She learned about the benefits of cognitive behavioral therapy, and started attending a group. She shares that peer support was helpful. Christina started going to school and got a job as a Medical Assistant. If I were working with Christina, 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.
2. The Brief Trauma Questionnaire is a screening tool that I would use in my practice. In reviewing this tool, a positive would be that client’s, 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. The PTSD Checklist is another screening tool that I would use. This would be a helpful tool in assessing my clients for PTSD symptoms. Many of the client’s that I meet with have previously been diagnosed with PTSD. This would be a tool that would allow my clients to assess the symptoms they are experiencing. 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.
3. In my approach with Selena, I would focus on building trust, addressing sleep disturbances, and providing psychoeducation. Building trust will be vital for treatment with Selena. Her trust was violated when she was sexually assaulted by someone that she knew, and thought of as a big brother. Providing a safe and trusting environment will assist in building a strong therapeutic alliance. Selena’s sleep disturbance is severe. She has developed a fear of sleeping, and avoids sleeping until she is exhausted. Assisting Selena in increasing her sleep hygiene and creating a routine before bed, will assist in increasing restful sleep. Providing psychoeducation about PTSD symptoms would be beneficial. Selena appears to be experiencing severe sleep disturbances related to trauma. As she has predominantly been treated for depression, she may be confused about the emotions and symptoms that she is experiencing. Discussing treatment options, coping strategies, and types of therapy will be helpful in assisting Selena choose the right treatment option for her needs.October 13, 2021 at 9:54 pm #31295Tanya HaleyParticipant
Question #1: 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. That part of the story, I just do not understand. But one thing that stood out to me was her resilience at a young age and the fact that the mother (while not believing her) was still present enough to know that what was being done was not sufficient or aiding in her daughter’s care. 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.
Connecting her to resources-finding therapist. Taking action-which she did when she began searching the internet for answers. She was taking an active role in her recovery. Peer support-attending groups of those who have had similar experiences
Question #2: Two tools that could be helpful in my practice would be the ACE inventory and PTSD inventory. Pros to using these tools would be to enlighten the practitioner on some potential trauma that might be impacting the client current physiological or psychological symptoms. Some cons to using these tools is the potential to uncover some past traumas that the client may not be ready to process. So it is a balance on learning when the appropriate time and situation to use would be.
Question #3: First and foremost, one must establish safety. Establishing that you are safe with you and in the environment. Work to avoid re-traumatization and normalize her feelings. Then work on establishing some healthy sleep habits through empowering her.October 14, 2021 at 6:44 am #31296katie VarneyParticipant
My reaction to Christina’s story is I am amazed by her strength and insightfulness. This is an individual who was traumatized at the age of 6, then retraumatized by the system and her parents did not believe her. So the distrust this person had experienced for so many years is heartbreaking. However, her resiliency and determination throughout this story is incredibly inspiring. She took it upon herself to seek out alternatives for treatments and continue to move forward. If I was her counselor, I would listen to her story and build on her strengths. I would want to develop a trusting relationship at her pace.
I am not a clinician so I have not used these screening tools. I did take a look at them and I am familiar with the ACEs tool. I am not aware if we use this in primary care but I plan to ask around and speak about this at our next meeting. I know that providers are familiar with the screenings, I am just not sure how readily they are used.
Since I work in primary care, I took a look at the PC-PTSD-5 screening tool. I can see where this can be useful. We have a population of patients who are refugees and are aware that many have past trauma. I think this tool would be beneficial in identifying trauma. We have the resources in place to assist patients who may need counseling and follow up.
I am not a clinician, but if I were, 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.
Normalizing symptoms with the client is also a strategy that is important. It can be reassuring for the client who went through a traumatic event to understand these symptoms as a reaction vs an untreatable MI.
Focusing on building resilience would be the third strategy I would use. Assisting a client in identifying their own strengths can benefit the client and build on resiliency.October 14, 2021 at 9:08 am #31301Alan AlgeeParticipant
Able to talk about it with apparent ease and objectively. Good command of language. Researches her options for recovery and then engages after she choses a recovery option. Strong philosophical values. Able to develop a vision for herself. Puts accomplishments on the record which is positive and self-inspiring. Realizes that an internal locus of control is very powerful when in recovery.
Pros: thorough, fidelity to DSM 5, could foster talk for follow through
Cons: of the 17 questions, it might take only one event to cause the PTSD but the client may feel that 1/17 might not mean very much, it’s hard to gauge the severity of an event, just because it “happened” or was “witnessed” does not mean much diagnostically
Adverse Childhood Effects Calculator
Pros: I like the fact that this narrows down to a phase of life; ACEs are very serious and this assessment is important to understanding who we might be
Cons: like most instruments, this might feel invasive; should be used judicially and skillfully—not routinely
Establish Safety: ask her to try to recognize “in the moment” safety (assuming that, in fact, she is in a safe place).
Address Sleep Disturbances; this would be critical. We would explore all available resources to try to get good sleep (there’s lots out there; sleep study?)
Support Empowerment; she already is working on her recovery so we would build on her current strengths and coping strategies while on the hunt for others that she may find helpfulOctober 14, 2021 at 9:25 am #31302edostieParticipant
question 1: the treatment of Christina as a 6 year old child was appalling. Isolating her in a scary room is hard to fathom – this was not that many years ago – she is only 35 now. Who recommended such harsh treatment for her and was there a racist element?
C took charge of her life – the most important thing she did was strategy 2, take action on her own behalf. She also has used strategy 1, 3, to establish a predictable life for herself. She is really amazing.
At this point in her life as her counselor working on a spiritual outlook but truly the simple act of getting rediagnosed would be the first step after establishing a working relationship with her.
I picked the brief trauma questionnaire (BTQ) and the ACES questionnaire. in fact an overview question on our intake evaluation incorporates a general trauma question – the BTQ would be good to go more into depth if they answer yes to the general question. This would be useful to recommend ongoing trauma treatment such as EMDR which can be arranged with our in-house psychologist who is available to us two days a week.
The ACES questionnaire could be used in groups as an enlightenment tool for patients – this would also help them in thinking about preventive medical care – to make sure they get their screenings for diabetes and cancer, etc. Currently we have mostly young patients but there are a couple of middle aged people who would definitely benefit from the knowledge of their trauma score.
Using the strategies I think Selena would benefit from the 6 week IOP program where she could get peer support to know she is not alone. Additionally, the DBT skills we teach including distress tolerance and emotion regulation would give her a segue into focusing specifically on the trauma narrative with an individual therapist – this would be recommended following the initial 6 weeks, or in conjunction if she was able to find the time to do both. Establishing safety – using the SEEKING SAFETY model – the first lesson – would be also good for her – and we regularly use this modality. Probably some help with sleep and nightmare protocols would also be helpful. There is a specific DBT lesson that covers that which could be taught to the group while she was a patient.October 14, 2021 at 7:46 pm #31314Ruth LockhartParticipant
I was astonished with Christina’s resiliency and determination. Christina took control of her treatment by researching a therapy that could help her, built a relationship with a therapist, set goals for herself, and has decided to try and make a difference for others who come into “ “the system”. Christina has kept a steady job, been promoted, and continues her education. She knows that supports are important and continues to be a part of a support group.
If I were working with Christina I would help assist her with maintaining a positive outlook, support her in her future goals, and inquire about her spirituality.
I have used the ACE to learn the types of trauma clients have experienced in childhood to help understand their behaviors and how this effects school performance and the high risk behaviors the adolescents I work with engage in. This tool needs to be used with care because it could bring up past events clients are not prepared to discuss. PCE is the other tool that I use to understand the positive experience in order to understand their sense of belonging and connection.
PTSD checklist is the other tool I have used to screen clients for PTSD. This is helpful to discuss client’s symptoms and ways to cope. This tool is not a diagnostic tool simply for screening and provisional diagnosis.
With Selena I would start by building trust, normalizing symptoms, and ask her to journal about her thoughts and feelings related to the trauma. Teach mindfulness of emotions to help with the emotions she might be avoiding around bedtime. Ask her to check in with PCP to inquire about medication to help with nightmares for a period of time. Education around sleep hygiene and ways to self soothe.
Encourage and explore peer support groups.October 15, 2021 at 1:04 pm #31317Danielle CiminoParticipant
1: Generally this story was frustrating and saddening to watch. She was retraumatized over and over again by a system who traumatized and stigmatized her in the first place. She needed someone to point out her strengths and utilize them in moving her forward instead of labeling them as “wrong” or bad”. Christina showed resilience by enrolling herself in therapy and continuing to maintain social connections that encouraged her to move towards her goals. In addition she discussed that she took control of her own recovery which is an example of her taking action and maintaining a hopeful outlook. If I was her counselor, I would continue playing on the strengths that she has, in addition to exploring new ones. I would encourage her to continue maintaining a daily routine, attending her support groups, in addition to work with her on perspective taking. Lastly, I would encourage her to continue working with a medication manager that she trusts, so to empower her confidence in saying no if she does not want to take something.
2. I would use both the life events and ACE’s screening tool with my clients. They are both comprehensive, direct, and non bias. These surveys would give a clinician a picture of what things may be helpful to discuss, and what an appropriate manner to discuss those topics would be. The down side to these screeners, or any other screener is that it leaves space for the clients to be dishonest out of fear, discomfort, anger etc. This can leave the door open for clinicians to misinterpret, or lose sight of providing trauma informed care when speaking with clients.
3. If I was working with Selena, I would first focus on establishing safety, normalizing symptoms, and addressing sleep disturbances. Safety and sleeping are two of our most basic needs as humans, if those are not in check it will be really difficult for Selene to dig into any real work as she will not be physically and mentally healthy enough. With normalizing symptoms, there is also psychoeducation. Providing Selena with factual information about his trauma responses it will allow her to have a clearer picture of why she reacts the way she does. Once she accepts that, it is more likely that she will be able to work to find ways to combat some of those symptoms.October 15, 2021 at 2:10 pm #31336Joseph HaywardParticipant
1)Christina wasn’t believed by her own parents when she reported the sexual abuse. As she moved through all the misdiagnoses looking back she was able to normalize doing what any normal six year old would do. She was a hyper kid and easily bored which she saw as a strength, yet everybody else attached a label to her ADHD, ADD, she never felt heard. She was able to empower herself, tired of numbing out, realized that more CBT was best for her, researched the internet, was proactive in her own recovery, enrolled in therapy (continuity in care with same therapist for years, gave her a lot of credit)hadn’t been in jail in over four years…this is a woman who turned the “system” on its head, she was quietly determined with a steely reserve not to be bamboozled by medication, remained abstinent from alcohol, sought out peer support groups where people listened to her , people she could trust and be vulnerable with and realized she’s not alone. I would encourage Christina to learn more about psychoeducation, continue to collaborate mutual relationships with outside sources where she can rise above , manage and cope with her trauma. I thought the video was inspiring and remain hopeful that others who have experienced similar traumas are moved to take that first step in healing, that they too can recover, be empowered and live useful and productive lives.
@) I favor the Adverse Childhood Effects calculator because like it was mentioned in the module, its easier ( not for all and by no means the rule) for one to fill out a questionnaire and less imposing, the other is Brief Trauma questionnaire. This would again allow a client to acknowledge if there has been something in their past that they may feel warrants further work, it opens the door for a deeper conversation should they choose to be honest on the questionnaire.
3) Working with Selena I would try to create a safe space for her, fostering trust, all the while collaborating on coping strategies and awareness of trauma symptoms that may appear in ways in which she had no idea. Further education in this area would also help to alleviate regression and allow her to add meaning to her already amazing life with all that she’s over come. Build on her strengths, continue to enhance her belief that she is no longer a victim, she is in control of her life.October 16, 2021 at 1:06 pm #31355Jason AntkiesParticipant
This was tough to watch. To see Christina continuously get re-traumatized was heartbreaking. Despite this, Christina continued to push forward and take action to get to a point of peace and joy. This perseverance demonstrated significant resiliency. She did not beat herself down or give up, she continued fighting for the life she wanted to live. If I were Christina’s counselor I would work on providing a safe, non-judgemental space so she can feel comfortable to explore her thoughts and feelings. I would focus on her dreams and have her identify steps she needs to take to achieve those dreams while looking for the duality that is preventing her from taking those steps. Holding that duality with her so can feel empowered to decide what she wants to do with her dilemma.
I like the ACE questionnaire. I think it is a great place to start understanding someone’s childhood and development. From this, there are a lot of directions you can go in to gain more understanding of what has happened to someone. I also like the life events survey. They help maintain a neutral space for clinicians to stay open-minded and present by listening to someone’s story.
If I were Selena’s therapist I would work on creating a safe, trusting environment so she can be vulnerable and open in session. I would listen to what Selena’s dreams are and reflect back to her those dreams. Once I become aware of her duality I would pose it to her so that she can feel empowered to decide what she wants to do with her duality. We would discuss the pros and cons of what she decides to do. Having her in the driver’s seat will help her feel in control of her situation and that she has the power to decide what happens next in her life.
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