[edostie]

(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.

[edostie]

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.
question 2:

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.

question 3:
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.

[edostie]

Question 3:

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.

[edostie]

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.

[edostie]

Question 1
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.

[edostie]

question 1

Anna’s artwork so clearly delineated her experiences it is shocking no professional talked to her about them. I have to wonder if there were not any art therapists available at the time to help her.
The sad tale of her life seems so unnecessary. Certainly listening to her experience would have been critical to helping her find a better way to live. Symptoms in such cases seem to be coping mechanisms, however dangerous and attention seeking mechanisms to try and get help. What she was trying to say stood out in her art work, in her deterioration and finally in her death. That she was also kept silent while screaming for help with her behavior really should have been noticed.

question 2
The character I am using is from a book I just finished, Liane Moriarity’s Apples Never Fall (c. 2021 Pan MacMillan)

Savannah is a young woman who insinuates herself into the main characters’ lives proceeding to lie constantly, scam them in various ways, systematically attempting to ruin their marriage, harm their 4 children and blackmail them, all the while pretending to be their friend by endearing acts of kindness.
As the story proceeds, more is revealed about who she truly is, she turns out to have legitimate grievances from her childhood against these people. This character’s presentation is a perfect example of using coping mechanisms that derive from childhood incidents of neglect and abuse (her mother starved her so she could be a ballerina, so she developed an eating disorder, for example). Indeed this particular family she is now scamming on one given day in her distant past ignored her, abused her by refusing to give her food, yelled at her and by turning attention only to her brother, the star tennis champion of the story, totally annihilated her sense of self-worth.
A trauma informed person, indeed, any responsible adult, near this child or now, working with this troubled young adult, who would use an understanding and collaborative approach instead of punishing and confronting her, or convicting her, could have truly helped the chain of events that continued to engulf her way of living. Luckily, in the end, one of the main characters does show her compassion and it makes a difference to her so she can honestly feel love and care from a person she formerly wanted to continue harming in revenge scenarios.

Question 3
How my agency utilizes these principles

PEER SUPPORT AND MUTUAL SELF-HELP; EMPOWERMENT;
INCLUSIVENESS AND SHARED PURPOSE
My work takes place in a setting using group therapy with DBT as the major modality employed. Within the group set up, however, each person participates in making an individual treatment plan and follows with an individual therapist at least once a week to assess progress with their individual goals. Time and time again as clients graduate at the end of their time they
mention peers in the group who have helped them, how they have helped them and how meaningful the mutual support has been. It is wonderful to be part of facilitating these exchanges and to be able to be the bones to support rather than didactically lecturing or pretending to be the “experts.”

SAFETY, TRUSTWORTHINESS AND TRANSPARENCY
The program uses a simple, consistent, predictable structure the clients can count on as they come for approximately six weeks with 3 groups a day DBT, Education and Psychotherapy. Various topics are covered during these sessions but a big focus is placed on art therapy and self-care through Yoga, gratitude lists and, in general, Positive Psychology approaches.

B) How my agency could improve

EMPOWERMENT and VOICE AND CHOICE
Our agency could better utilize individual strengths within the group – such as seeking opportunities for talents to be displayed. Once in awhile client’s ability or talent with music has been shown and the group always benefits from this. We have seen this utilized with art directives to great success. Expanding this to include other areas would be a good way to include more of what is good and positive in people.
***
I don’t know what category it would fit under but I know there is still too much repetition of information required from clients – such as when a therapist has to fill in for another person – unavoidable sometimes. Even if you read the chart or evaluations it seems that sometimes you have to cover ground they’ve had to go over before – this is frustrating for clients and definitely does not enhance the therapeutic relationship. At least starting with a disclaimer when talking with the client such as “I promise to only cover the bare minimum of what you’ve already told Ellen” would be affirming.

[edostie]

Hello – I’m Elizabeth Dostie, LCSW – retired and then recalled recently to work at co-occurring IOP at MGMC. Technically I’m per diem but so far it’s been more “diem’s” than I anticipated! I do like the work – I notice since the pandemic that the groups are much quieter and people seem almost shell-shocked from the experience of talking to one another in a group.
I took a class from Patricia in the past and found it very valuable and this topic is really important. I look forward to both a refresher and learning new things.
Sincerely,
Elizabeth

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