Week 4 Homework Assignment (Trauma-Informed Care)

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    Patricia Burke
    Please Note

    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.

    Homework Exercises

    Exercise 1

    Review these culturally specific responses to stress (reprinted from SAMHSA, TIP 57, 2014, p. 105).

    Exercise 2

    Read the following case illustration of Jacinta.

    Case Illustration: Jacinta

    Jacinta is a 28-year-old woman who is in a TIC intensive outpatient program for substance abuse that also has a track for consumers with co-occurring PTSD and other trauma-related mental health issues which includes a women’s Seeking Safety group. Her parents are from Guatamala, but immigrated to the United States when Jacinta was 3 years old. She was sexually abused by a male babysitter when she was 8 years old and began drinking and smoking marijuana at the age of 13. She had a bad car accident while intoxicated 6 months ago, was in the hospital for several weeks, and was then prosecuted for Operating Under the Influence. The court mandated her to seek substance abuse treatment. She reports symptoms including nervousness, anorexia, insomnia, listlessness, despondency, sadness, lack of motivation, low self-esteem, and diarrhea. She also reports that she is afraid that her soul has left her body. She was previously diagnosed with complex PTSD with delusions. After the initial intake and evaluation at the IOP, she is assigned a counselor who is a licensed clinical social worker. Jacinta is quiet in group, which is mostly male. She is guarded and appears to be off in her own world. Her counselor is concerned about Jacinta’s demeanor in group and her reports of her soul leaving her body. The counselor is also concerned about her previous diagnosis of complex PTSD. During an individual counseling session Jacinta discloses that she believes she is suffering from Susto, which she had heard about from her parents, and thinks this is why she is so anxious and unhappy. She is not able to make the connection between her childhood trauma and her substance use issues at this time.

    Homework Questions

    Question 1

    If you were Jacinta’s individual counselor (as described in the case illustration) which of the General Treatment Issues and Strategies outlined in this lesson would you focus on first with Jacinta. Why? Be specific.

    Question 2

    If you were Jacinta’s individual counselor how would you explore her belief in Susto and possible therapeutic interventions, in a way that is in alignment with the cultural competencies described in this lesson? Be specific.

    Question 3

    If you were Jacinta’s individual counselor would you refer her to a trauma-specific treatment (e.g. Seeking Safety) group or program in your agency or outside your agency? Describe your rationale for referring or not referring. Be specific.

    Question 4

    Take a moment to reflect on the course material over the past four weeks and the new insights you have gained about trauma-informed care. How do you envision bringing this new insight and self-awareness into your work with people who suffer from trauma-related mental and substance use disorders?


    Please Note

    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.

    Click here to go back to the course.

    Ellen LCSW

    Question 1: Working with Jacinta requires the therapist to be culturally competent. Jacinta’s intake resulted in a diagnosis of PTSD and Delusions because of her feeling as if her soul has left her body, when Jacinta’s family culture views this belief as common given her symptoms. Three urgent actions occur to me almost simultaneously: Employing mindfulness techniques such as grounding in our work together to increase Jacinta’s felling of safety and presence in the here-and-now; advocating for her to transfer into the program’s women’s Seeking Safety group because it would be more appropriate and helpful to her; and consulting Jacinta’s family and/or community at large about Susto, specifically inquiring about interventions or treatments that have been known to help people afflicted with Susto.

    Question 2: Because Jacinta is more knowledgeable about Susto than I am, I would ask Jacinta to tell me more about it, including everything she has heard about it, how it resembles what she herself is feeling, if she knows anyone else who has/had it and what might have helped them, and whether she has any ideas about what might help HER with it. I would also take what I know about trauma and its effects and try to weave it into the framework of Susto in order to connect what her cultural experience with the broader context of TIC. As mentioned in #1 I would also incorporate any information I got from her family and/or community about Susto to show that I hear her, take it seriously, and respect her cultural perspective.

    Question 3: I do think the women’s Seeking Safety group that’s part of the agency with which she is already connected sounds like a viable alternative, as it might streamline the referral, acceptance, and paperwork process, provided this arm of the IOP program seems effective and culturally sensitive (hopefully I would be in a position to ascertain this). I would also consider changing her diagnosis to eliminate Delusions from her record if I could.

    Ellen LCSW

    Question 4: OOPS! Forgot this one! One of the most striking insights I gained in taking this course is how many Trauma Specific treatment options there are, and how few of them I was already aware of. I also learned that my own approach is something of a hybrid, in that it is strongest on CBT and Mindfulness Interventions and is not one of the “manualized” treatment programs but rather an eclectic mix of some of these and other approaches. Although I am always aware of substance use as a possible aspect of a client’s treatment needs, literally none of my clients are coming to me for co-occurring disorders at this time. Or rather, their co-occurring disorders are trauma and mental health issues without substance substance abuse.
    As I mentioned in an earlier Homework Exercise, I wanted to improve my Cultural Competency, and this last segment gave me a couple of new ideas to implement with clients (such as consulting the family/community to improve awareness and educate myself, and most importantly to ask questions right up front out of genuine interest and acknowledging that the client herself is the expert on her own life).


    (wow i just deleted all my answers! here I go again)

    question 1) Establishing safety will be the first thing to do with her, using grounding techniques and teaching some simple mindfulness exercises – especially breathing. Establishing boundaries from the beginning so that she feels like an equal partner, not patronized and in control of the pace of the treatment. Disclosure of material only when she decides if that’s the route she wants to take. In general, being respectful and compassionate of her process and honoring of her culture.

    question 2) SUSTO from the description sounds devastating and almost hopeless. It will be important for Jacinta to help me to understand how she sees it for herself – would she be willing to explain to me what the depth of the condition or process is for her- it will be important to not discount what she is feeling and of course be aware of deep depressive symptoms which may need to be assessed by a psychiatric provider to make certain she is not suicidal and to collaborate my approach with her. I think i would take her out of the general population coed group for the time being – after consulting with her, because it might be too
    hard to be herself in such an atmosphere.

    Question 3) I think the women’s Seeking Safety group would be good. Our Seeking Safety group which is almost always all women, has a 50% art therapy component – these directives the therapist gives are remarkably healing and soothing for the patients and reinforce the lessons being covered. Today, for example, we were working on compassion and did a mindful exercise of line drawing similar to a stain glass piece. All of the patients were involved in the exercise and appreciated the time for self-compassion. I also would recommend she consider looking into a RAPE CRISIS response group, if available or a Family Violence support group. I would use the recommended approach to a women’s AA meeting as described here – where she can gradually attend and see if it will feel safe enough for her. It occurs to me that the workbook from the 90’s, the COURAGE TO HEAL series, would also be something to use with Jacinta. The approach to safety in that book would complement the Seeking Safety material and would have ideas.
    Question 4) I have really appreciated and been pleasantly surprised by all the tools I did not know about for measuring trauma and presenting a way to use evidence based information which is so important to take away some of the subjectivity inherent to our profession. I appreciated the lists of methods and referrals to other manual programs. Thank you.

    Jason Antkies

    Question 1
    My first order of business would be to work on creating a safe space so that Jacinta could begin to assimilate and acclimate to the program. I would use Motivational Interviewing so she can feel heard and validated in a non-judgmental way. I would focus on grounding techniques so she can develop skills to feel present in her current situation. I think she would benefit from joining the women seeking safety group. Since her trauma is primarily with males, being in a majority male group could be triggering her PTSD. I would also educate myself about Susto, talk to her about this and collaborate with her family to appropriately support her with Susto.

    Question 2
    I would look to educate myself about Susto. I would discuss this with Jacinta in a caring, supportive, non-judgmental way so that she felt safe and comfortable to explore this. Utilizing a MI approach I would listen compassionately that this is her truth. I would look for what her dream is and identify this with her duality of Susto. I would hold this space for her so she can decide what she would want to do.

    Question 3
    I would refer her to the in-agency seeking safety group. Because we offer a trauma-specific treatment that is female-oriented it would seem like the most appropriate referral for her specific needs.

    Question 4
    This training was very helpful. It is gratifying to know that I am already practicing a lot of components of TIC. I plan to continue to look at people through a lens of what has happened to them instead of why are they doing this. I will continue to be a kind, compassionate, empathetic listener, and holding space for people by remaining neutral. I hope to be able to role model this to clients and other staff members.

    Kellie Westberry

    Answer to Question 1
    Since Jacinta’s trauma is primarily with males, my first course of action would be to find away to transfer her out of the male dominated group and into a female group to minimize and/or eliminate any re-traumatization. I would create a safe, non judgemental space that would allow Jacinta to adjust to the program and address her specific needs. I would educate myself on Susto and Jacinta’s culture. I would listen to Jacinta’s story, validate her thoughts, feelings and experience. I would help her develop a safety plan and teach her basic coping skills that she can build upon while in therapy, such as grounding and mindfulness. I would also talk to her and her family about natural supports in and around Jacinta’s community to incorporate into her aftercare plan.

    Answer to Question 2
    I would first educate myself about Susto and discuss with Jacinta her understanding and belief around Susto. I would approach this in a supportive, non-judgemental manner to promote a safe space for Jacinta to share her thoughts, feelings and beliefs.

    Answer to Question 3
    I would refer Jacinta to the Seeking Safety (For Women’s) group within the agency to prevent any further delay in her treatment and limit the stressors associated with finding and obtaining another provider.

    Answer to Question 4
    I have learned a great deal from this course and appreciate the information and tools offered. It has allowed me to identify some areas I wish to explore and improve on as a clinician. Thank you.

    Russell Kohrs

    Q. 1, My first area of concern would be her physical health, try to determine if the symptoms anorexia, insomnia, diarrhea, have been addressed by her Dr. Her symptoms listlessness, despondency, sadness, lack of motivation, present concern of SI, SIB. Was this assessment incomplete? Establishing a level of safety for her comfort and the safety of offering her treatment, Motivational interviewing so that Jacinta feels heard, Mindfulness intervention to determine her understanding and ability to move forward, grounding techniques and breathing techniques to help her self regulate if possible. moving her to a Women’s seeking safety.to bring her into direct contact with her peers.

    Q, 2, Susto appears to be an accurate description of Jacinta’s symptoms, the counselors comment, ” appears to be off in her own world,” is another description of Susto. With her Parents awareness of Susto, do they have an possible cultural therapeutic interventions? Does Susto presume a disconnect from the soul permanently? Learning about this Guatemala Dx could be very useful in overall understanding and trying to help her understand her Tx plan options.

    Q.3. I would ask Jacinta directly if she was comfortable with a Seeking Safety group or program in this agency? Is she comfortable with coming out of one group and placed in another or would that cause her to feel further traumatized? My rationale would be patient centered care. does she feel safe and comfortable with the change?

    Q.4, I appreciate the challenges this course present, further understanding of the scope pf TIC in treatment How much there is to learn. The deep dive into the language of the course material, the overall raising awareness into the many aspects of trauma, re-traumatized and treatment. The insights I carry forward is how prevalent this topic is, how to bring consistency into trauma-informed care. Practicing present moment with this challenge, continuing to increase self-awareness within the work, trying to bring the best results possible with people who suffer from trauma-related mental and substance use disorders. I remain a work in progress in this regard. Thank you.

    Ruth Lockhart

    Question 1
    I would recommend individual treatment to start due to Jacinta’s symptoms of anxiety, listlessness, despondency, and low self esteem.
    I would focus on client engagement to explore ambivalence about treatment and introduce grounding techniques and inquire about the ways she copes. I would explore Jacinta’s willingness to be seen by a psychiatrist to help with insomnia, anxiety, and explore possible delusions. Medication can be helpful for a period of time to help reduce some of her symptoms so she can engage in treatment.

    Question 2
    I would inquire what Jacinta’s beliefs are regarding Susto and what events in her life have led to her being unhappy and anxious. I would inquire if she has knowledge about interventions or healing techniques that have been helpful for others who have suffered from Susto.

    Question 3
    I would ask Jacinta’s if she is comfortable joining a Seeking Safety group for women. If not I would continue to work with her individually until she is feeling safe and comfortable to join the group.

    Question 4
    I appreciate learning about the various tools for assessing trauma and the different modalities of treatment. The exercises were helpful with reflecting on my practice and how my work place applies many components of TIC.

    Jamie Williams

    Question 1: I would first advocate to move Jacinta out of the male dominated group and into the women’s seeking safety group, given the circumstances of her trauma. Finding ways to help Jacinta feel safe while also educating myself on her culture and beliefs. Utilizing motivational interviewing to help understand what Jacinta wants to get out of treatment will help to determine what area is the primary focus initially (substance use or PTSD).

    Question 2: I would first explore Susto with Jacinta. Gather an understanding of her perception and how it impacts her life. Also find out more about if other family member’s in Jacinta’s life have experienced this and what their outcomes were. I would then doing my own research and possibly reach out to community members or other professionals with experience working with this population. Understanding my limited knowledge is part of helping Jacinta.

    Question 3: I would refer Jacinta to seeking safety within the agency. Keeping her with the same professionals allows for less barriers and better communication between providers.

    Question 4: This course has been eye opening. It has driven home the fact that clients know themselves best and their story is true to them. It helps me to remember that it’s a collaborative approach and their treatment is what they want not what I feel is best for them.

    Janice Black

    Question 1
    So many needs come to mind immediately. Clearly, one needs to be culturally competent…learning about and respecting the notion of Susto is imperative. I would also want to make sure she is willing and ready to start treatment…how fearful, ambivilant or distrustful is she of the therapeutic process? Teaching her some basic skills like grounding would be at the top of my list..as a way of initially leaning some control over her thoughts and breathing. Looking for a more appropriate group (when she is ready) where she isn’t presented with men who she my view as oppressors or perpetrators. I would also be curious about her physical health and well being as well.

    Question 2
    Clearly it is critical to have an understanding of Susto…from both a personal, familial and/or community perspective as well as a larger more anthropological perspective. I would immediately view her as the expert asking her to help me understand the custom and belief from her perspective. I’d be curious about her understanding of how it is perceived here in this dominant culture.

    Question 3
    Assuming she is ready for group work, a referral to an in agency trauma informed treatment program for women should be explored. This would remove the potential for re-traumatizing her dealing with men, eliminate (hopefully) having to change therapists and a relocation/change and provide her with evidence based treatment.

    Question 4
    I have surprisingly!!!! enjoyed both the content of this course and the process!! I believe I have most of the salient qualities and beliefs necessary in establishing a TIC practice. However, it was nice to have this affirmed. I do believe I have a sharper ‘trauma’ lens in which I now view the folks I work with. I have found myself viewing trauma treatment videos on You Tube a few times during those middle of the night awakenings!! The material was beautifully arranged…I really liked to links to further information. I was surprised to learn of so many other programs and treatment protocols. I struggled with the technology..a couple of times completely losing everything I had written. I really thought online learning wasn’t for me but…surprise!!! Thanks so much, Pat. Well done…would really like to have printed this out but couldn’t figure out how to.

    Alan Algee

    Question 1:

    Is Jacinta in “treatment” or is she in “trauma milieu”? Reading her case, it just didn’t sound like that she was in actual treatment. She is forced into a program syllabus and is highly symptomatic. I cannot hear Jacinta at all. She is being judged a lot. There is no mention of any of her strengths. Is she ready for IOP group? Did she complete a “group readiness” intervention. Anyway . . . I would probably start out with the grounding strategies.

    Question 2:

    Is it believed that Susto can be reversed in the course of healing? I might take one or two symptoms and ask her to monitor it to see if she can notice improvement. Maybe have her use a fitbit to monitor her sleeping patterns—assuming that she is interested in tracking sleep. Of course there’s a risk that her symptom could become worse before better. So I would want to make really sure that she chooses what she would like to track.

    Question 3:

    I probably would not actually “refer” her only because that verb seems a little bit “directive”. I would help her to self-refer to a program that she chooses. I would make sure that we reviewed all of the options available and support whatever direction she takes. I also think that Jacinta really needs a skillful individual counselor with whom she forges a strong and lasting therapeutic alliance. I would also coach her on how to find a support group. It would be hard for me to refer her to a manualized treatment group (e.g. DBT) because she already has little control over herself. I would want her to be in treatment that allows her to be whoever she needs to be for that session—as far from judgement as possible.

    Question 4:

    My big take-away is remembering that humans are very complex and no two people are alike. We must use the trauma informed strategies to learn how to really get to know our clients as best as we can. The theories and content of this course gave me some new tools that I hope will let me better describe the very wide bandwidth of my clients experiences.

    Greta Garvey

    Question 1.
    In working with Jacinta, I would focus on engagement and exploring her mental health symptoms. Moving Jacinta to a female only group would be beneficial, due to her past sexual abuse with a male. She shares that she doesn’t relate her childhood experiences to her current substance use. At the agency where I work, we provide substance use counseling and mental health counseling. It would be helpful to meet Jacinta where she is and focus on her mental health symptoms. If this could not be done due to the court mandated substance use treatment, mental health counseling should be offered additionally. Individual counseling may be more appropriate, especially initially in treatment. Creating a safe environment would be imperative in creating a therapeutic alliance with Jacinta.

    Question 2.
    Practicing cultural competencies in trauma informed care will be vital in working with Jacinta. Creating an understanding and safe environment for Jacinta to explore her feelings regarding Susto will assist in meeting the client’s individual needs, and differentiating between cultural beliefs/norms, and mental health symptoms. In working with Jacinta, I would explore her statement that she thinks that Susto which she heard about from her parents, may be causing her feelings of unhappiness and anxiety. The following was listed in our lesson this week and would be helpful regarding this client’s needs; “Has knowledge of how to differentiate PTSD, trauma-related symptoms, substance-use related symptoms and other mental disorders in that particular culture and the culturally-specific meanings of those symptoms and behaviors.” (SAMHSA, 2014, pp.131–135)

    Question 3
    In working with Jacinta, I would discuss the benefits and risks of the seeking safety group. At this point in treatment, it may be overwhelming for her to be involved with two groups and individual counseling. Before I make any referrals I discuss what the group will entail, and what expectations there will be in attending the group. If I were to make a referral, I would make the referral within the agency, so that she would not have to start the process again with another provider. Seeking safety may be helpful in addressing Jacinta’s needs if she is ready to attend a group. It would be imperative to ensure the group was female only.
    Question 4
    Truthfully, this has been one of the most informative, relevant, and inspiring trainings I have taken. I can see myself using the information that I learned within these lessons on a daily basis with my client’s. Screening and assessing for trauma, trauma-informed addiction services, and learning more about cultural competencies in trauma informed care are areas that I learned more about in taking this course. Really meeting my clients “where they are” is what has stood out to me over this course. Everyone has different experiences and will experience trauma in an individual manner.
    Thank you so much for this wonderful training. I look forward to using the knowledge I learned here in my daily practice.

    Tanya Haley

    Question #1: Jacinta may benefit from focusing on engagement strategies. She is ambivalent treatment and exploring avenues to help her become more empowered in her own health care may help her move through the process and take ownership. She also would benefit from strategies that focus on traumatic memories and their tie into her current substance use disorder and behaviors.

    Question #2: As her counselor, I would elicit a sense of collaboration by allowing her to explain what she means by Susto and what that means to her. Ask her if she knows of any family members or friends who have experiences Susto and what might they have done to help them.

    Question #3: Since she is a of Seeking Safety. She might benefit from the ATRIUM model. This 12-week program may help her to address and learn new coping strategies to deal with stress. We would refer Jacinta to this program as we are not equipped to handle this level of trauma and would want to make sure she is in the best care.

    Question #4: This course brought forward many concepts that I had already had knowledge on. The information that may be most useful in our practice relates to making your practice TIC. Establishing procedures and provide tools and resources to staff. This course was also a reminder that trauma effect people in many ways a treating trauma is a very individualized approach. What is good for one client, may not be good for another.

    katie Varney

    Questions 1
    The first strategy I would concentrate on to start is client engagement. I would want Jacinta to feel comfortable and safe. I would use MI to help understand where she is at in terms of her own treatment. I would want to build trust and collaboration.

    Question 2
    Because this term is new to me, I would ask Jacinta to educate me on this term and what it means to her. I would do some of my own research, reach out for clinical supervision and explore with Jacinta if she would be ok with reaching out to her family. By asking questions in a nonjudgmental way, and inquiring interest shows respect and builds trust.

    Question 3
    I would first explain the benefits and risks of each option and explore with her what she feels most comfortable doing. I am familiar with Seeking Safety program and it does sound like a good fit for Jacinta.

    Question 4
    This course has been extremely helpful in understanding the impact of trauma on clients I work with. My awareness to place the focus on the client (as a whole being) rather than placing the focus on the problem or symptoms is a big take away and nice reminder moving forward.

    Danielle Cimino

    1: I would first look into boundary issues and client engagement. Boundaries, in the sense that the program will need to look at what her boundaries are and then ensure they are respected. Given her traumatic hx with males, a male dominated group may not be the best setting for her and alternative options should be explored so that she feels safe and able to engage. Her engagement would be concerning as well, it would be important for her clinician to review triggers that could dysregulate her during sessions (group and individual) in order to minimize traumatization as much as possible.

    2: To start I would seek out consultation with someone who was more aligned with the culture and would be able to teach me pertinent information about Susto. From there, I would want to collaborate with both the consultant and the client in order to ensure that I am not doing any harm to the culture/ideologies/beliefs during treatment. From there using treatment modalities that align with Susto and its symptoms as the relate to PTSD would likely be the most respectful option.

    3: I believe that the seeking safety group would be an appropriate referral for her. Should information come up once she is involved that she needs something different at that time a new referral could be made. Given that this would be a women’s group it would likely be a good place to start in order to observe her engagement.

    4: Two of my biggest takeaways from this course are the impacts that trauma can have from a cultural aspect, in addition to the weight of the role staff can play in re-traumatization/screening. The cultural piece reminded me that if there is something unfamiliar to myself or my team we need to seek consultation not only to educate ourselves but also to ensure that we are no retraumatizing the client, or being disrespectful to their ideologies and beliefs. When it comes to screening, early screening is important and that is something that can get lost in translation during an admission. Continuing to remain consistent with all clients screening will be helpful for both clients and the program as a whole.

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