The Center for Rehabilitation and Recovery provides assistance to the New York City mental health provider community through expert trainings, focused technical assistance, evaluation, information dissemination and special projects.

The new paradigm in trauma healing and recovery is trauma-informed care. In this issue, we  continue to explore trauma, and ways organizations and clinicians can become more trauma-informed.

How to Identify Trauma Histories in Your Clients: Three Tips

Elizabeth Saenger, PhD

People with mental illness or substance abuse issues often have histories of trauma. These backgrounds not only affect how they engage in services, but are associated with the diagnoses they are most likely to get and the kind of treatment that would benefit them most. Consequently, it is not surprising that the Substance Abuse and Mental Health Services Administration (SAMHSA), and other stakeholders, now emphasize the importance of detecting trauma histories in clients.

Nevertheless, clinicians frequently miss trauma as part of assessment. Here are three tips to help you identify this critical element in your work with clients.

1. Keep in mind how common trauma is. Many of us received our formal training in the days when trauma histories were considered the exception rather than the rule. However, one study finds 61% of men and 51% of women report experiencing at least one trauma, most frequently witnessing a traumatic event.

Clients with mental health diagnoses are even more likely to have trauma histories than the general population. For example, a study finds that 47% of those with mental illness, compared with 21% of the general population, experienced physical abuse in childhood. For sexual abuse, these figures are 37% and 23% respectively.

If you expect many of your clients have trauma histories, you will be alert to this possibility.

2. Ask about trauma. You may hesitate to ask about trauma because you fear that your client might find such questions intrusive or harmful. On the contrary, many clients welcome the opportunity to talk to providers about this aspect of their lives, and may not have others in whom they can confide.

That said, not all clients will be responsive – at least initially – to questions about past or current trauma. They may deny an event has occurred, downplay its severity or impact, or say they prefer not to answer.  Don’t press a person to share before he or she is ready, but be alert to signs that a person may be willing to open up. Ask gently, starting with framing statements such as, “Many people have experienced violence in their past, so I always ask…”

3. Differentiate signs of trauma from symptoms of psychiatric disorders. Symptoms of trauma and symptoms of psychiatric disorders may be very similar. For example, the dissociation your client has may be due to trauma, post-traumatic stress disorder (PTSD), schizophrenia, dissociative disorders, or attention deficit hyperactivity disorder (ADHD). To figure out which condition, if any, she may have, look at the total clinical picture, including both her trauma history, and current symptoms.

If you suspect trauma, follow up with specific additional assessments when indicated, because the presence of a trauma history should inform our care.

Screening for Trauma

Elizabeth Saenger, PhD

Trauma screening and assessment measures come in several shapes and sizes. They may focus on reactions to specific events, or multiple events. They may take five minutes, or up to a hundred minutes, to complete. They may be:

• Structured or semi-structured
• Validated with different populations, such as veterans, or battered women
• Self-administered, or administered by others.

Many screening and assessment tools specify the training necessary to administer the instrument.  Some background is often necessary to respond appropriately if a test item triggers dissociation. Test administrators may also require sufficient cultural competence to interpret distress correctly, since culture determines how trauma is experienced, and some stress responses are culture-bound.

Because the answers to questions about trauma may point to other concerns, it is important that people who screen for trauma know mandatory reporting requirements regarding circumstances such as suspected cases of child abuse or neglect, elder abuse, or danger to self or others. It is also critical for these same professionals to know their agency’s policies and procedures, and have access to a supervisor, or consultant, who can help.

When you screen clients for trauma, try to:

• Use a checklist to make sure you do not miss items
• Focus on how trauma symptoms affect living today
• Remember that clients may not associate trauma with current functioning
• Explain to the client how answers to questions will inform treatment
• Make sure the client is grounded when you end the session, that is, is oriented to person, place, and time, safe, and not overwhelmed. Grounding can involve distracting the client from intense emotion, using deep breathing or guided imagery, or other techniques.

As you assess the client, do not:

• Minimize or deny the client’s experiences
• Pathologize the client’s feelings, particularly rage
• Forget to promote client-clinician collaboration, and empowerment. 

Treat clients with care—both at the level of the clinician, and the organization—so you do not re-traumatize them. If you can, go further by using the screening and assessment process to generate trust and confidence in future care.

Post-traumatic Growth

Elizabeth Saenger, PhD

Surprisingly, trauma leads to post-traumatic growth more often than it leads to post-traumatic stress disorder. Post-traumatic growth occurs when resilient people successfully find meaning in adversity, and become stronger in measurable ways. Clinicians may underestimate the frequency of this phenomenon because people tend to seek professional help when they are not doing well, rather than when they are flourishing.

Post-traumatic growth involves dialectical thinking—the ability to see both negative and positive aspects of situations from multiple perspectives. This tends to lead to the development of five characteristics:

• a greater appreciation of life
• deeper relationships
• increased spirituality
• feelings of strength stemming from survival
• the ability to identify new possibilities.

Post-traumatic growth does not enable people to put their world back together as it was, but helps people leverage adversity so they can build a better future for themselves.

New Respite Center Opens

ACMH, Inc., a member of the Coalition of Behavioral Health Agencies, is proud to announce the opening of its Garden House Respite at 165 East 2nd Street in Manhattan. Like the Parachute Crisis Respite Centers RECOVERe-works has covered, the Garden House provides an alternative to hospitalization in a home-like setting staffed by Peer Counselors.  It can also be used as a transitional resource for people leaving the hospital, before they go home.  The purpose is to help guests achieve their personal recovery goals. 

This pilot respite center was funded with a grant from the New York State Office of Mental Health to ACMH (formerly The Association for Rehabilitative Case Management and Housing, Inc.).

To make a referral, contact Kearyann Austin at 212-253-6377 x406, or [email protected].

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The opinions expressed in RECOVERe-works do not necessarily reflect the views of the Coalition of Behavioral Health Agencies.

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