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PRESENTED BY: BEVERLY ENGEL

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1 PRESENTED BY: BEVERLY ENGEL
TRAUMA INFORMED/TRAUMA SENSITIVE TREATMENT OF VICTIMS OF CHILDHOOD SEXUAL ABUSE PRESENTED BY: BEVERLY ENGEL

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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 harm—to 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 relationships—in particular: 1. Control/domination—feeling powerless 2. Hierarchical boundaries—feeling less than 3. Isolation/confinement—feeling trapped 4. Silence/secrets—questioning reality

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5. Being unheard or invalidated—feeling unimportant or invisible. 6. The reconstruction of reality— questioning her perceptions or her very sanity. 7. Betrayal—feeling 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

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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 doesn’t 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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Trust what the victim tells you—especially 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 saying—we 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 person’s 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 individual’s 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 victim’s 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 present—in 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 client’s 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 survivor’s 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 Isn’t 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 CLIENT’S 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 consumer’s 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 people’s 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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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 individual’s identity rather than a single discrete event. A focus on what happened to the person rather than what is wrong with the person.


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