[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).

[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 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.

[Ellen LCSW]

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.

[Ellen LCSW]

Question 1: My first reaction to the video was: “My god, how could no one ask her about her story in such a LONG time?” It strikes me as collective incompetence of immense proportions. My heart breaks for Anna… I view hearing a client’s story as one of the most important things I do, and–as I tell virtually all of them when I invite them to share their stories–What’s shareable is more bearable.

Question 2: I work with an 18-year-old woman with autism as well as a challenging medical condition. Her first significant statement to me a couple of years ago when we first met was, “I’m terrified of EVERYTHING!” I could have focused only on her SYMPTOMS of anxiety, but instead I listened to her with a different ear that helped me really get to know her as a person. Turns out, her reality is completely denied at home, and every aspect of her life is tightly controlled by her mother. She is really bright, articulate, funny, loves animals, and is NOT who her mother thinks she is (or wants her to be). Therapy is the only place she can speak her truth, be who she is, and work toward the future she wants when she graduates this June. By the way, the only thing that really terrifies her now is the prospect of her mother gaining control of her legally and financially because of her diagnosis.

Question 3: I can honestly say that most of the Principles of Trauma-Informed Care were part of my training and have been integrated into my personal philosophy and practice with clients. I work really hard to provide emotional safety and convey my own trustworthiness, acceptance without judgment, and desire to collaborate, empower, and promote choice in my work with clients. Actually, that’s wrong. I don’t work that hard at it because it comes fairly naturally to me. After finishing this first lesson, however, I did catch myself rushing a client through their story very recently. They told the story of being traumatized by Child Protective Services with great vehemence five weeks in a row and I responded to the statement: “They destroyed my life–it’s over!” by saying: “Your life is over only if you let it be.” I wanted them to see possibilities for a better future, but now I realize they weren’t done with their story yet (although I did validate it every step of the way), which is something I will rectify next session.

[Ellen LCSW]

Ellen Kornetsky LCSW, here. I’m currently practicing outpatient therapy privately in Brunswick, Maine, after 26 years in the fields of foster care, and adoption, and mental health. The vast majority of my clients have suffered trauma at some time in their lives and are still trying to understand and resolve it. Although I’ve had considerable training in the causes and treatment of trauma, I’m hoping this course will refresh what I have learned and add new insights, strategies, and tools for care.

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