Preparing for Trauma Work in Clinical Mental Health

A Workbook to Enhance Self-Awareness and Promote Safe, Competent Practice

Lisa Compton, Corie Schoeneberg

• Publisher: Routledge
• Year: 2020
• ISBN:
  9781000173505
• Edition: 1
• Topic: Psychology
• Subtopic: Post-Traumatic Stress Disorder (PTSD)
• Index: Psychology

This workbook is a foundational and unique resource for clinicianspreparing to work with clients affected by trauma. Chapters integrate a holistic understanding of the unique client within trauma-specific case conceptualization, promote trainees' identification of personal values and past experiences that could impact their ability to provide safe and ethical services, and offer ways to reduce the risk of occupational hazards such as vicarious traumatization. The trauma treatment process is presented within the tri-phasic framework, which is applicable across settings, disciplines, and various theoretical orientations. Each chapter also provides experiential activities that link the chapter content with clinician reflection and application of knowledge and skills, which instructors and supervisors can easily utilize for evaluation and gatekeeping regarding a student's mastery of the content. An ideal resource for graduate-level faculty and supervisors, this book offers a versatile application for mental-health related fields including counseling, psychology, social work, school counseling, substance abuse, and marriage and family therapy.

Designed for students and professional clinicians, this groundbreaking text fills an important education and training gap by providing a comprehensive and enlightening presentation of trauma work while also emphasizing the clinician's growth in self-awareness and professional development.

SECTION I

Foundations

Concepts and Principles of Trauma Treatment

Chapter 1

Orientation to Trauma Work: The Triad of Trauma, Client, and Self

I will never forget my first encounter with trauma in a client case. I was in my master’s practicum experience, and my client was a nine-year-old boy who had recently disclosed an extensive history of sexual abuse. As I met with his mother during private parent sessions, I listened to the harrowing details of the tremendous fallout that was occurring for the child and his family, and suddenly, all of my class lectures and textbook readings about trauma crystalized into strikingly vivid focus within the painful reality of an actual person. Much like the mother who sat before me, I felt completely overwhelmed and at a loss as to how to help this young boy through his pain and fear. As I listened to this mother’s lengthy list of problems that they were experiencing, I thought to myself (but, thankfully, did not say out loud to my client): “Wow, you really need talk to a counselor.” This thought was immediately followed by another more alarming thought: “Oh my—I am that counselor!”

Moments like these tell us so much about the depths of trauma and the needs of our clients while simultaneously illuminating and bringing to center stage our own cavernous feelings of self-doubt. If we look at this scene again, we can see that there are three aspects that the clinician must attend to in order to help this young client: the clinician must have knowledge of the nature of trauma, knowledge of the individual client, and knowledge of self. Without all three of these elements, the therapeutic process is incomplete.

This text aims to illustrate the full clinical picture by drawing attention to all three elements of the triad (trauma, client, and self), each of which is critical for safe and effective trauma work in mental health. In order to provide the best treatment for these cases, we must understand our client’s presenting problems and symptomology through a trauma-informed lens, which requires a proficient understanding of the origins and impacts of trauma on the individual. Despite the prevalence of trauma-related problems across client populations, trauma work is considered a specialty area of mental health as it requires a robust set of functional knowledge and specialized clinical skills that are not covered in most graduate curricula.

Additionally, within the trauma treatment context, we must also carefully consider the individual client, who comes with a unique background of development, diversity factors, personal beliefs, and special history. The diversity of our clients tells us that trauma is not always experienced and manifested in the same way, and it is incumbent upon the clinician to understand the client’s uniquely personal interaction with trauma. In many ways, trauma is like a backdrop on a theater stage, and our client is like the main character of the play. In order to fully understand the meaning of the play, we must know the characters as well as the setting and context within which the scenes occur.

However, a client does not engage in his or her trauma work alone. Effective post-traumatic growth and healing occur within the therapeutic relationship, and trauma work, at its core, is a powerful relational interaction that requires the full engagement of both the client and clinician. This relational exchange necessitates that the clinician be safe, self-aware, and fully present as, indeed, the clinician cannot help a client go further than he or she has personally gone on the road towards self-growth.

With these three elements—knowledge of trauma, knowledge of client, and knowledge of self—the triad of trauma work is set, with each tip of the triangle relying on the others for support and structure. These three elements must be understood as distinctive forces, yet also considered in relationship to their adjacent parts to form one overall framework. This chapter provides a brief introduction to each of these triadic elements and offers the reader an overview of how these topics will be discussed throughout the text. A summary of the structure of this unique book is provided, and recommendations for how to best utilize this workbook are also outlined.

Trauma: Understanding the First Corner of the Triad

Trauma can be understood as “an experience or event that overwhelms your capacity to depend on or protect yourself. The hallmarks of trauma are feelings of terror, horror, and helplessness” (Schmelzer, 2018, p. 11). While these emotions often define the affective reactions in a traumatic experience, physiologically, trauma is “a stress response … outside of a person’s normative life experience, and a sufficient condition that the response includes a breakdown of self-regulatory functions” (Krupnik, 2019, p. 259). Trauma ignites emotional and physiological responses from those who are impacted by it, and the lingering effects can be expressed in a variety of ways. Individuals reeling in the wake of trauma often represent some of the most hurting and vulnerable client populations, and as such, clinicians who provide care for these clients are held to a high standard of knowledge and expertise regarding this specialty area in the mental health field.

Competency in Trauma Work

Trauma is ubiquitous in mental health, and according to the National Association of State Mental Health Program Directors (NASMHPD, 2012), more than 90% of clients who access therapeutic services are estimated have been exposed to trauma. Consequently, all mental health professionals will, at some point, work with at least one client who has experienced trauma, regardless of the clinical setting in which they practice. The high percentage of trauma-impacted clients is not surprising to clinicians who have practiced for a significant length of time, as vast numbers of clients present with experiences of abuse, violence, loss, war, betrayal, natural disasters, and many other terrifying events. Very often, important trauma-related history is missing or overlooked in the client’s initial discussion of his or her presenting problem, but in cases of unprocessed trauma, trauma-related problems and symptoms are, more often than not, impacting the client’s current distress, thoughts, behaviors, and feelings.

Whether your professional identity is in psychology, social work, counseling, psychiatry, marriage and family therapy, school counseling, or any another mental health–related discipline, caring for individuals, couples, and families often means addressing trauma wounds. Two-thirds of adults have been exposed to at least one traumatic event, and many of these individuals experience significant complications, including addictions and problems at work and in relationships (Goodman, 2015). While most individuals who have been exposed to a traumatic event do not meet full criteria for posttraumatic stress disorder (PTSD), lack of an official diagnosis does not mean there is a total absence of trauma symptoms (Kilpatrick et al., 2013; Schubert, Schmidt, & Rosner, 2016). Given the pervasiveness of trauma, clinicians should be thoroughly competent in their abilities to conceptualize cases through a trauma-informed lens.

Unfortunately, without comprehensive trauma-specific training, misdiagnosis occurs frequently for clients who are experiencing trauma symptoms disguised as other mental health disorders. For example, a child experiencing difficulty concentrating in school and fidgeting with her hands in class may be diagnosed with attention-deficit/hyperactivity disorder, or ADHD (American Psychiatric Association, 2013). However, if this same child is experiencing physical abuse at home, these symptoms might better be understood within the context of trauma as her problematic behaviors may be more consistent with the hyperarousal caused by the survival reactions to trauma rather than simply understood as inattention and/or hyperactivity. In another example, an adult male presenting with symptoms of pronounced and desperate efforts to avoid abandonment and who experiences significant and persistent relationship problems may be diagnosed with borderline personality disorder (BPD). However, this man’s history of sexual abuse and incest requires an understanding of trauma and attachment ruptures, not a narrow focus on his interpersonal difficulties perceived to stem from an inherently “impaired” personality. If clinicians are not knowledgeable about the many faces and presentations of trauma, inappropriate diagnoses are often assigned and, subsequently, insufficient treatment is provided. A degree in a mental health–related field alone does not qualify someone to be an effective trauma therapist (Langberg, 2003), and a lack of proper trauma training is not only unethical, it is also a preventable healthcare hazard.

Trauma-Informed Care

Over the past decade, trauma-informed care (TIC) has received increased attention and discussion. In general, the distinction of being a “trauma-informed” individual or organization indicates that there is an acquired understanding how trauma impacts individuals, families, communities, and societies. In addition to possessing this functional knowledge of trauma, the trauma-informed individual or organization must also demonstrate educated responses towards persons struggling with trauma reactions, which involves responses characterized by care, sensitivity, and trauma-informed accommodations. Trauma-informed care, therefore, implies active efforts to gain knowledge about trauma and mindful efforts to avoid situations that may retraumatize others. A trauma-informed approach provides a framework for various services found in settings such as schools, hospitals, police stations, and counseling offices.

The Substance Abuse and Mental Health Services Administration (SAMHSA, 2014) identified six key principles of trauma-informed care, including (1) safety, (2) trustworthiness and transparency, (3) peer support and mutual self-help, (4) collaboration and mutuality, (5) empowerment, voice, and choice, and (6) cultural, historical, and gender issues. Consideration of these principles within the clinical setting emphasizes a climate of safety for the client through tools such as informed consent, skill-building exercises, and, most importantly, through the development of the therapeutic relationship. Proficient trauma specialists advocate for the integration of trauma-informed care across settings, disciplines, and services in order to provide the safest and most fertile environments for growth and healing for individuals overcoming trauma wounds.

Naturally, trauma is discussed in every chapter of this text. However, many of the chapters explore trauma from different angles and through different lenses. Readers can expect a comprehensive presentation of trauma across the arc of this workbook that begins with primary principles of trauma work and concludes with guidelines for treating trauma all the way to termination. Over the course of this book, the identification and conceptualization process of trauma is discussed, and cultural aspects and diagnostic considerations of trauma are explored. Building on these conceptual foundations, trauma-specific treatment and principles of trauma-informed therapeutic care are also comprehensively presented and illustrated.

The Client: Attending to the Second Corner of the Triad

Individuals who survive traumatic events are often affected by the trauma in numerous ways long after the actual danger ceases. Trauma may cause significant distress and impairment in functioning and can potentially result in a wide range of problems, including psychological, affective, and physiological symptoms (Keck, Compton, Schoeneberg, & Compton, 2017). Emotionally, trauma survivors may experience anxiety, depression, fear, guilt, irritability, and grief, while physical symptoms may include shortness of breath, increased blood pressure, gastrointestinal complications, and nausea. Behavioral changes, such as an increase or decrease in eating or changes in sleeping and sexual activity, may occur in addition to other behaviors, such as difficulty concentrating, isolation, and relationship conflict.

Persons reeling from traumatic experiences often experience existential crises and struggle to understand why the painful event occurred. Spiritually, trauma may impact convictions about faith, meaning, forgiveness, and one’s sense of control, regardless of an individual’s specific religion (Sherman, Harris, & Erbes, 2015). Although not all outcomes of trauma are negative (a positive resolution in trauma recovery may result in enhanced resiliency and posttraumatic growth), trauma has the potential to shatter previously held beliefs about ourselves, other people, and the safety of the world around us (Janoff-Bulman, 1992).

With these multifaceted dimensions of the individual, the impacts of trauma are not uniform but, instead, are personally unique and often complex. A person’s developmental stage, previous life experiences, cultural background and worldview, protective and risk factors, and tendencies towards internalizing or externalizing psychological stress all serve to inform the manner in which trauma symptoms are manifested and expressed. Clinicians must develop a strong, working case conceptualization of the unique client in order to accurately identify trauma reactions and tailor appropriate treatment approaches.

The Therapeutic Experience and the Trauma Survivor

Entering into a therapeutic relationship presents many potential challenges for trauma survivors. An incredible amount of vulnerability and trust is required to let down one’s defenses and participate in a therapeutic relationship, and this may be the first time the client discloses long-held secrets to another person. The inherent power imbalance in the therapeutic alliance may pose additional challenges, especially when clients have experienced abuse or betrayal by authority figures in the past. Clients may enter the therapeutic process with powerful fears about confronting trauma memories, especially when avoidance has been an active defense against such painful thoughts and feelings. Clients often worry that the horrific details of the trauma will ensue a psychological tidal wave that will engulf his or her own capacity to cope while simultaneously overwhelming the clinician. They may fear that trauma recovery will not be successful and that confronting the traumatic memories is not worth the risk, which can deepen feelings of hopelessness and helplessness. The clinician has the crucial role of recognizing these struggles and providing a safe pla...