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2020 – 02 – Basics

Trauma.

First, let’s start off with some basics about trauma.

Psychological trauma results when a person experiences a negative, stressful event such as being physically beaten, verbally abused or exposed to a terrorist attack or other horrifying event. Psychological trauma can therefore be thought of as an experience that overwhelms a person’s capacity to protect his or her psychological integrity. An example of this would be soldiers when they return from war or someone who witnessed a gruesome car accident.

The interesting thing about trauma is that not all of these events lead to severe, lasting, psychological trauma effects in all people. In other words, traumatic events impact people in various ways with some individuals severely impacted while others are not. For example, let’s say a school bus full of elementary school aged children is involved in an accident. All of the children on the bus are physically unharmed. Some children might experience symptoms of psychological trauma immediately after the event and then see these symptoms fade within a few days. Others might have a more difficult time with the incident and may experience lingering symptoms due to severe psychological trauma. And other children might not experience any symptoms at all.  

So, what is the difference between these children? Why do some experience severe symptoms while others don’t? The difference is resiliency. According to the American Psychological Association (2018) resiliency is defined as the “process of adapting well in the face of adversity, trauma, tragedy, threats or significant source of stress.” Those individuals that are able to successfully adapt to and overcome a traumatic event are considered resilient.

Healthy adults have the capacity to manage most stressful events when they occur. Previous studies have found that most individuals experience some stressful reaction symptoms after they experience a traumatic event (U.S. Department of Veterans Affairs, 2018). These symptoms could be flashbacks, insomnia, anxiety, etc. However, these symptoms tend to lessen with time as the physiology returns to its normal resting stance after the trauma has diminished.

A few years ago, I was in a car wreck. I was driving a Toyota Camry and I was stopped at a red light with a coworker. All of a sudden, a big truck hit my car from behind and the force was so intense that it literally pushed my car to hit the truck in front of me and that truck hit the vehicle in front of them. My car was sandwiched between two huge trucks and my car was totaled. The backseat was completely crushed in as was the front of my vehicle. Although me and my coworker were completely physically unharmed, I suffered from a mild form of trauma symptoms for a few weeks following the accident. Every time I was stopped at a red light I would have to look in my rear view mirror because I kept feeling like another truck was about to hit my car. I could recall that physical feeling of the impact and it made me paranoid that it was going to happen again.  

In my example, I experienced some symptoms after the initial traumatic event but it did not take long before those symptoms disappeared. Still, others who experience traumatic events might not react in the same way. In fact, other individuals may not have the internal capacity to manage their stress levels (e.g. resiliency) and experience recovery on their own.

While some individuals may seek out treatment for the traumatic event that they experienced, many do not. And while some are able to return to their normal level of functioning, others may experience a reduction in their overall quality of life. Individuals who have experienced trauma may or may not even be aware of the reason why they are experiencing symptoms. Let’s discuss some of those symptoms.

Symptoms of Trauma (Trappler, 2009)

Dissociation – This is the most extreme response from a person in which they cannot engage psychologically in the present. In these instances, these individuals might be so threatened by the traumatic experience that their consciousness of awareness literally escapes them.

The most common indicator of dissociation is amnesia. This occurs when the person has a hard time recalling the details of what happened during the trauma. A more extreme version of dissociation occurs when an individual temporarily cannot identify themselves or the situation around them due the event being so traumatic. From an outsider’s perspective, individuals who manifest dissociation shut down as they lose touch with their sense of being in the present.

Dissociation is an automatic response to an overwhelming feeling. Dissociation is an experience where a person becomes unconsciously removed from the present environment. Dissociation is usually triggered by fear and allows the person to escape unbearable emotional pain.

Fear – another common symptom of psychological trauma. People who have been chronically traumatized experience a blurring of their traditional boundaries between danger and safety. Their world becomes dominated by a fear paradigm. The world is constantly unpredictable and uncontrollable.

While living in a state of apprehension and perceived threat may be adaptive for most trauma sufferers, this is not the case for victims of PTSD. They continue to function in a survival mode even when the threat has been removed.

Avoidance – People tend to avoid not only when they perceive external threats, but also when they experience painful affects and memories, which are internal. Mental health research now supports the idea of helping individuals with PTSD to recount their trauma story and to communicate this narrative to a therapist. While avoiding traumatic memories helps the person to not have to experience the pain associated with these memories, it also plays a role in denying people access to all aspects of their trauma story, which also contributes to the symptoms of PTSD.

Flashbacks – sudden, vivid recollection of any past trauma experience. These recollections can be visual, audible, or even experienced as physical sensations, such as physical pain. Flashbacks can be triggered by something specific that they see or hear or they can occur spontaneously as well. Nightmares are also a form of flashbacks. My father is a Vietnam veteran and suffers from PTSD. In fact, his PTSD is so severe that he is actually considered disabled for the condition. While he has been stable and doing well for a few years now, when he was at his worst, it was his flashbacks in the form of dreams that were the most disturbing. At one point, he explained to me that he could not tell the difference between his dreams and reality. They were that real to him. It was one of the most difficult things to see. My dad was suffering from his own thoughts; a living nightmare that he could not escape.

For victims of intimate partner violence, psychological trauma begins and continues within the traditionally safe environment of the home. The kinds of abuse they might experience and suffer from range from constant verbal criticism to restrictions on friendships to outright physical and seual assaults.

 

Adverse Childhood Experiences (ACEs)

For children, traumatic events such as physical, emotional/psychological, sexual abuse and neglect have all been well documented to have lifelong consequences. Particularly for these children, there are adverse effects on their physical and mental health, social development, and overall success in school and work when compared to the general population. In the late 1990’s, the Centers for Disease Control and Prevention along with Kaiser Permanente conducted a study around Adverse Childhood Experiences or commonly referred to as ACEs.

This research was particularly groundbreaking as it offered sufficient support for the idea that the traumatic experiences of children can have long-lasting effects on their lives that continue even into adulthood (Felitti et al., 1998). The more ACEs that a child experiences, the greater the likelihood that they would have more physical and mental health issues as adults compared to the general population and even engage in high risk behaviors, such as substance use and sexual promiscuity (Chartier, Walker, & Naimark, 2010; Corso, Edwards, Fang, & Mercy, 2008; Felitti & Anda, 2010; Chapman, Dube, & Anda, 2007; Edwards, Anda, Gu, Dube, & Felitti, 2007).

Watch this video from child trauma expert, Dr. Robert Anda, about the Adverse Childhood Experiences (ACEs):

https://www.youtube.com/watch?v=QLfUi4ssHmY

 

Recovery from Trauma

In order for a person to recover from psychological trauma, it is almost essential that he or she first remove themselves from the traumatic situation if possible. For example, if someone is a victim of intimate partner violence, it is necessary that they first remove themselves from the situation before therapy or another possible solution can effectively resolve the trauma. In some instances, however, it is not possible for trauma victims to remove themselves from their situation. In these instances, it is possible that some trauma victims may have a natural trauma recovery, but for others recovery will be difficult if not impossible. Once survivors have been rescued from any immediate threat, they need to feel safe enough to understand what happened to them.

Mental health professionals involved in trauma healing have to, before anything else, begin the process of allowing the victim to believe that the world is safe again. The empathic bond established early in therapy may constitute the first building block in replacing your sense of chaos and danger with that or order and predictability. The microcosm of safety in the therapeutic relationships, however, can only be effective if it is supported on the outside by a safe, social infrastructure. The interesting thing when considered trauma-informed care is that it is not just what we say or do with our clients. Instead, it is also about the overall environment of how they experience our treatment. For example, I once had a client who suffered from trauma and had a difficult time in keeping her appointments for our sessions. It wasn’t until I was able to ask her about this barrier to her engagement that she confided in me that my office was located next to a big construction site and at times, there would be loud noises that she would hear while in my waiting room that triggered past traumas for her. I immediately was able to keep to get more sound machines for the waiting room to mask the sounds and my client was able to start to consistently engage in therapy. It’s small things like this that we may miss if we are not actively aware of the potential impact it can have on one’s trauma history.

The degree to which an individual will recover from psychological trauma depends on several factors, including the victim’s age, the severity of the trauma, and the speed and effectiveness of their rescue. Trauma survivors immediately placed in a safe environment, especially those united with a familiar or empathic person are more likely to recover using their own health cognitive and emotional resilience. These survivors might also be more effective in mobilizing external resources, such as friends, pastors, or therapists.

 

Client Experience

Next, let’s discuss some of the basics around how our clients’ trauma influences the way that they experience our services.

First, when we talk about the client experience, we are not just referring to what happens during a treatment or therapy session, but well before and after that. The continuum of care for the clients that you serve is an all-encompassing challenge. Clients have beliefs and expectations before ever meeting you or receiving services. And these expectations are often times influenced by their own experiences with trauma and perhaps even past therapeutic experiences. So for better or worse, all parts of the experience need to be considered and understood as you manage the experience.

For example, I once had a front desk manager who was great at scheduling clients and managing the day to day tasks of the front office. However, when clients would call and request an appointment change, he would become annoyed with them and would let it be known through his voice and overall tone. This resulted in some clients just cancelling their appointments altogether or making formal complaints. Ultimately, I was able to provide feedback to the staff member and provide them with trauma training about our population. One the staff person was able to understand the experience from the client’s perspective plus what kinds of past trauma they might be carrying, he completely changed his approach. When clients called or came by the office he treated them with the utmost dignity, sensitivity, and respect. In turn, the clients had a much better overall experience with our agency, starting from the moment that they called for an appointment.

I’d like for you to take a few seconds to think about a time when you were a client in a clinic. Or maybe you had a close friend or family member in the hospital. How does your perspective change when you are on the other side? Think about what parts of your experience met your expectations, what parts of your experience went surprisingly well – such as the therapist or doctor who went out of her way to make sure you had what you needed – and what parts of your experience were frustrating.

Most likely if you had a positive experience, it was because the providers and staff worked hard to meet your needs in multiple ways. These needs were probably not just your functional needs either but most likely they were a combination of functional and emotional needs. And that’s an important distinction for providing trauma informed care. It’s not just about what you do. It’s also how you do what you do. It’s about how you make the client feel about their experience that influences how a client ultimately makes sense of the experience and labels it positively or negatively.

I once had a psychiatrist who was working for our clinic and one of his patients complained to me that he did not listen to her during their session. When I asked the psychiatrist about the situation, he pointed to all of the assessments he did with the patient and and how he had explained her diagnosis to her in great detail, and spent a lot of time going over the medication that he was prescribing to her. In his mind, he went above and beyond with this patient and there was no reason for her complaint. However, the patient did not care about his assessments. She did not care about the diagnosis he gave her and she didn’t even care about the medication that he was prescribing her. In her mind, she could not get past the fact that when she tried to tell him about her dog’s recent death, he brushed it off and kept on talking about her diagnosis. Ultimately, the doctor was focused on the content of what he was providing to the patient while the patient was focused on the experience of the session and how she felt leaving the session.

This is an important example as we can run the risk of only focusing on meeting client’s functional needs – conducting assessments, prescribing medication, reviewing clinical outcomes. All of these aspects are critical to good clinical care but if we are going to take on a trauma informed care approach to treatment, it is not good enough to only focus on these aspects. In fact, these aspects are not usually what drive clients to be particularly satisfied with their experience with our services. Instead, its the way that we make clients feel during their experience with us that ultimately influences how they view the overall service.

Incorporating the needs and feedback of clients also helps mental health professionals be reminded of WHY we are in this field and how our work makes an impact on clients everyday. If you are in a position of leadership at your organization, you know that client experience is also a business objective. It is incorporated into healthcare reform and can even be tied to incentives or funding compliance initiatives. As previously mentioned, client experience is also at the core of trauma informed care. Although there are a lot of descriptions about what it means to be a trauma informed care organization, the basis of it is the ability to meet the clients where they are at and to understand how we can best meet their needs rather than simply follow our usual, cookie-cutter process for everyone. Most of your clients have no idea what trauma informed care means – but they do know what is important to them, and what they need from their experience to meet their unique needs. That’s why this course is focused specifically on tools to understand these needs. Because we can assume what our clients need all day long – but in the end, assumptions are often wrong and we end up missing some very important pieces.