TRAUMA INFORMED/TRAUMA SENSITIVE TREATMENT OF VICTIMS OF CHILDHOOD SEXUAL ABUSE

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TRAUMA INFORMED/TRAUMA SENSITIVE TREATMENT
OFVICTIMS OF CHILDHOOD SEXUAL ABUSE

• PRESENTED BY BEVERLY ENGEL

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TRAUMA INFORMED/TRAUMA SENSITIVE

• Trauma-Informed Services
•  
• Trauma-informed services involve understanding,
  anticipating, and responding to the issues,
  expectations, and special needs of a person who
  has been victimized.

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• At a minimum, trauma-informed services
• should endeavor to do no harmto avoid re-
• traumatizing survivors or blaming them for
• their efforts to manage their traumatic
• reactions.

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• Trauma Specific 
• Trauma specific treatment is based upon
  empowerment of the survivor and the creation of
  new connections
•  

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• Instead of isolation, there is a focus on
  relationships,
• Instead of coercion, there is a focus on
  persuasion,
• Instead of authoritarian control, there is a
  focus on mutuality. 

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• Trauma-specific services are designed to treat
  the actual consequences of trauma.
• Examples of trauma-sensitive treatment
  approaches include
• Grounding techniques which help trauma survivors
  manage dissociative symptoms.

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• Desensitization therapies which help to render
  painful images more tolerable .
• Behavioral therapies which teach skills for the
  modulation of powerful emotions.

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• Treatment programs designed specifically for
  survivors of childhood trauma are consistent on
  several points
• The need for respect, information, connection and
  hope for clients.

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• The importance of recognizing the adaptive
  function of symptoms.
• The need to work in a collaborative, empowering
  way with survivors of abuse

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• It is important to become aware of the dynamics
  that characterize abusive relationshipsin
  particular
•  
• 1. Control/dominationfeeling powerless
• 2. Hierarchical boundariesfeeling less than
• 3. Isolation/confinementfeeling trapped
• 4. Silence/secretsquestioning reality
•  

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• 5. Being unheard or invalidatedfeeling
  unimportant or invisible.
• 6. The reconstruction of reality questioning her
  perceptions or her very sanity.
• 7. Betrayalfeeling unsafe and unable to trust

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• Make certain that the same dynamics are not
• being unwittingly replicated in the helping
• relationship.
• For example
•  
• In a trauma informed setting both parties
• are acknowledged for bringing valid sources
• of information and expertise to the
• relationship.
•  

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• Providers have information and expertise to
• offer victims, but victims also have
  information to share with providers.
• Avoid talking down to the victim or conveying to
  her in any way that you are more important than
  she is or that what you have to say is more
  important than what she has to say.

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• Putting victims in secluded rooms or being in a
  small room with a victim can re-traumatize
  victims and may trigger a flashback.  

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• It is important to inform the victim about
  exactly what is going to happen.
• For example, if you are going to do an intake or
  take a history on the client, explain to her in
  advance the nature of the intake, the length of
  the process and how she can signal you if she is
  unable to continue the interview.

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• Keeping victims fully informed can help them with
  their trust issues.
• Knowing what is going to happen ahead of time
  helps them to feel safe.
• Making sure that you do what you say you are
  going to do will help prevent a victim from
  feeling betrayed.

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• Make sure that you listen to what the victim is
  saying and that you take what she is saying
  seriously, even if it doesnt seem to make sense.
  

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• The more they feel heard and their experiences
  validated they will calm down.
• Victims are accustomed to having what they say
  minimized, discredited or ignored so active
  listening can be a corrective experience for
  them.

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TRAUMA INFORMED/TRAUMA SENSITIVE TREATMENT
OFVICTIMS OF CHILDHOOD SEXUAL ABUSE

• Trust what the victim tells youespecially when
  she tells you about her abuse experiences. Even
  if it seems unlikely that it happened or that it
  happened in the way she is describing it, it very
  well may be true. 

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• There may be some distortion in what she is
  sayingwe all have different perceptions of
  things that happen--but on the other hand, some
  of the most extreme and outrageous experiences
  described by victims often turn out to be true.

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• Key Elements in Trauma Informed/Trauma Sensitive
  Treatment
•  

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• Collaboration
• Education
• Adaptive
• Safety Focused
• Empowerment focused
• Interpersonal skills development

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• Collaboration
•  

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• Trauma-Informed Systems are based on
  collaboration between the victim and the service
  provider.
• Instead of assuming you know what is best for the
  victim, ask her what she wants and what would
  help her to feel comfortable and safe. This helps
  her to begin to establish trust in you.

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• A victim knows her own responses, needs and
  history better than anyone else. By respecting
  her knowledge and insights about what she needs
  in order to bring order and healing to her life,
  the provider allows for a truly collaborative
  partnership.
• As much as possible, consumers need to be offered
  options and choices rather than be directed or
  told what to do.

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• Service providers need to work on adopting a
  collaborative tone versus an authoritarian one.
  It is important to stress that you and the client
  are working together. You are not the expert, you
  are not the one in control. 

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• EDUCATION

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• The impact of trauma narrows the persons life,
  constricting choices, undermining self-esteem,
  taking away control, and creating a sense of
  hopelessness and helplessness.
• Trauma-Informed Systems stress the importance of
  service providers being educated about the
  effects of trauma on an individuals emotional
  development and behavior.

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• This education enables service providers to
  re-frame their basic assumptions about the
  behavior of consumers who were trauma victims and
  helps them to begin to treat victims with more
  dignity, respect and compassion.

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• Making the important connection between a trauma
  victims behavior and their trauma experience
  will help service providers become more
  compassionate and less impatient, judgmental and
  angry at their behavior.

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• For example, understanding that often behaviors
  initially perceived as combative and/or
  reflecting a lack of motivation can actually be
  reactions to fear can help advocates to respond
  differently, which in turn allows the traumatic
  reactions to subside.

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• AN ADAPTIVE MODEL
•  

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• In trauma-informed settings, symptoms are seen as
  adaptations rather than pathology.
• Every symptom helped a survivor in the past and
  continues to help in the presentin some way.

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• An adaptation model emphasizes resiliency in
  human responses to stress. It helps survivors
  recognize their own strengths and inner
  resources, rather than defining themselves by
  weakness and failure.
•  

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• TRAUMA-INFORMED SERVICES ASSUME THAT PEOPLE ARE
  DOING THE BEST THEY CAN AT ANY GIVEN TIME TO COPE
  WITH THE LIFE-ALTERING AND FREQUENTLY SHATTERING
  EFFECTS OF TRAUMA.

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SAFETY
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• Safety is of the utmost importance in
  trauma-informed, trauma sensitive programs. It is
  the basis from which all rules should be
  created.
• Creating safety includes such things as allowing
  participants to set their own pace in groups and
  to determine when and how they share their trauma
  stories.

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• Safety also includes anticipating crises. For
  example, many victims of child sexual abuse are
  frequently flooded with painful memories and many
  are self-destructive in some way.

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• EMPOWERMENT

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• Empowering victims is one of the major goals of
  trauma sensitive treatment. This occurs by
  counselors focusing on clients strengths versus
  problems.
• It also occurs by working collaboratively with
  clients, encouraging them to create their own
  goals, treating them with respect and the
  understanding that the client knows what she
  needs.

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• Empowerment is also accomplished by providing
  clients with psycho-educational material that
  will help them to learn to regulate their
  emotions, self-soothe, and create healthier
  relationships

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• INTERPERSONAL SKILLS

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• Focusing on interpersonal skills can help clients
  increase their self-knowledge, self esteem, self
  trust, expression of needs and desires, clear
  communication, limit setting, accurate
  perceptions of others and honest labeling,
  establishment of safe boundaries and mutuality
  and reciprocity.

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• AN INTEGRATIVE APPROACH

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• It is assumed that trauma, substance abuse, and
  mental health interact within a single
  individual.
• Therefore approaches to recovery must be holistic
  approaches.

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• Integrative explanations include
• Primary trauma is a stressor that may trigger
  substance use and the development of psychiatric
  symptoms.
• Trauma symptoms such as flashbacks or nightmares
  are stressors that may trigger substance use or
  result in a psychiatric diagnosis.

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• Substance use and certain psychiatric symptoms
  may have evolved as coping strategies at a time
  when options were limited.

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• STRENGTH BASED APPROACH

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• The trauma-informed system values a
  strengths-based approach to assessment and
  intervention that highlights the assets of the
  survivor.
• Instead of being defined by her problems, the
  consumer is described as having capacities and
  abilities.

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• Understanding that strengths can be invisible or
  even undermined if they are not acknowledged and
  supported, counselors and advocates point out the
  strengths they see in the survivor, thus helping
  her to gain more of a sense of well-being,
  competence, and self-esteem.

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• The experience of having a sense of competence
  sets in motion a further change, helping
  survivors to appreciate their own abilities.
• For example, it can be enormously beneficial to
  have a survivor develop an inventory of her
  positive qualities. 
•  

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• PSYCHO-EDUCATIONAL PROGRAMS

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• Instead of presenting yourself as the expert,
  it can be empowering to share information in a
  psycho-educational program that is both
  interactive and flexible enough to accommodate
  what the survivor thinks is important.

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• In such an educational program, past abuses are
  linked to current coping strategies, and current
  symptoms are reframed as attempts to cope with
  past abuses.
• Psychoeducational programs are most effective in
  group settings where consumers can learn from
  each other as well as staff, and staff can learn
  from the survivors perspective.
•  

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• A group-based psycho-educational program also
  helps survivors trust their own perceptions of
  reality and receive validation for correct
  perceptions.
•  

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• Why Isnt Trauma Reported?

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• In spite of the fact that a majority of
  individuals receiving mental health, substance
  abuse and abuse recovery services have a history
  of trauma, many do not report their trauma
  experiences to counselors or intake workers.

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• Reasons for this omission can include
• Fear of being disbelieved or blamed.
• Shame at being victimized and attendant
  vulnerability.
• Childhood experiences of abuse may not be readily
  remembered.

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• UNIVERSAL SCREENING

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• Because of both under-reporting and
  under-recognition, trauma-informed service
  systems have adopted universal screening, asking
  all consumers about trauma as part of the initial
  intake or assessment process.

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• Trauma screening refers to a brief, focused
  inquiry to determine whether an individual has
  experienced specific traumatic events. 
•  

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• WHY PROVIDERS DO NOT ASK ABOUT TRAUMA

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• Lack of training or uncertainty about how to
  respond to the information
• Belief that it will be too upsetting for trauma
  survivors
• Feeling ill equipped to respond helpfully

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• PRIMARY PURPOSES OF SCREENING

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• To determine appropriate follow-up and referral,
  including urgent responses to imminent danger and
  trauma-specific services.
• It communicates to all consumers that the program
  believes that abuse and violence are significant
  events and that staff are willing to discuss
  trauma with survivors.

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• Even if a trauma survivor decides not to talk
  about such experiences at this early stage, staff
  have increased the possibility of later
  disclosure by communicating their recognition of
  and openness to hearing about painful events.

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• And perhaps most important, by recognizing that a
  consumer has a history of trauma, staff can
  better understand the behavior of a survivor

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• YOU CAN CONTRIBUTE TO CLIENTS SENSE OF CONTROL
  BY

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• Maximizing consumer choice and control in the
  screening process (trauma sensitive). This is
  especially crucial for individuals whose
  experiences of powerlessness and lack of choice
  have been pervasive.  You can contribute to the
  consumers sense of control by doing the
  following

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• Being clear about the steps, the process and the
  reasons for the screening (I would like to ask
  you some questions about) (We have found that
  many people who come here for services have been
  physically or sexually abused at some time in
  their lives).

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• Because this can have such important effects on
  peoples lives, we ask everyone about whether
  they have ever been a victim of violence or
  abuse.
• Give permission to not answer the questions or to
  delay the interview.

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• SAMPLE TRAUMA SCREENING

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TRAUMA INFORMED/TRAUMA SENSITIVE TREATMENT
OFVICTIMS OF CHILDHOOD SEXUAL ABUSE

1. At any time in your life have you witnessed
   someone being injured or killed due to an
   unnatural event such as a shooting, stabbing, or
   hit-and-run accident?

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• 2. At any time in your life have you witnessed a
  physical or sexual assault against a family
  member, friend, or other significant person?
• 3. At any time in your life has someone touched
  you sexually when you did not want to be touched?
  
• 4. At any time in your life has anyone forced you
  to have sex when you did not want to?

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• 5. At any time in your life has anyone slapped,
  pushed, grabbed, or shoved you? 
•  6. At any time in your life has anyone choked,
  kicked, bit or punched you?
• 7. At any time in your life has anyone threatened
  you with, or actually used, a knife, gun or other
  weapon to scare or hurt you?

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• 8. At any time in your life, have you been afraid
  that a specific person (whether it was someone
  you knew well or not) would hurt you physically?

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• SUMMARY

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• A TRAUMA SENSITIVE/INFORMED APPROAH IS
• CHARACTERIZED BY
• 1. Safety from physical harm and
  re-traumatization.
• 2. An understanding of clients and their symptoms
  in the context of their life experiences and
  history and culture.

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• 3. Open and genuine collaboration between
  provider and consumer at all phases   
•    of the service delivery.
• 4. An emphasis on skill building and acquisition
  rather than symptom management.

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• An understanding of symptoms as attempts to cope.
  
• A view of trauma as a defining and organizing
  experience that forms the core of an individuals
  identity rather than a single discrete event.
• A focus on what happened to the person rather
  than what is wrong with the person.