 This episode was prerecorded as part of a live continuing education webinar. On-demand CEUs are still available for this presentation through all CEUs. Register at allceus.com slash counselor toolbox. I'd like to welcome everybody to today's presentation on trauma-informed care screening and assessment. This is the first of, I believe, five parts. The other parts are coming in February for the trauma-informed care sort of curriculum, if you will. And it's based on a treatment improvement protocol put out by SAMHSA that is designed to help you create a trauma-informed care work environment. So, in this particular hour, we're going to review the 16 principles for trauma-informed assessment and screening. Explore reasons why providers may not screen for trauma. And explore reasons trauma-related disorders may be misdiagnosed or underdiagnosed. So, we really want to look at some things. And we talked about this a little bit back in November when we were talking about differential diagnosis of certain issues. But we're going to hit on it a little bit again here. So, 16 principles for trauma-informed assessment. We need to promote trauma awareness and understanding. And as you'll see when we get to the adverse childhood experiences or events, there are a lot of things that can happen in childhood that are traumatic, that as adults we look back and we're like, well, you know, we don't really think of that as traumatic because it's not traumatic to us at the time. It may be stressful, but we wouldn't consider it traumatic. But to a child, it could be totally overwhelming. So, we want to help promote trauma awareness and understanding, not only among other clinicians and our clients, but also in the community. So, people in the community can understand, hey, you know, what may be traumatic for one person may not be for another, but it doesn't mean that it's not traumatic. We want to recognize that trauma-related symptoms and behaviors originate from adapting to traumatic experiences. These are the best solutions that somebody had at that particular point in time to deal with something that was extraordinary. We view trauma in the context of individuals' environments. So, you know, if their environment is supportive and healthy and helpful, they may not experience as much trauma impact as someone who is in a chaotic environment. We minimize the risks of retraumatization or replicating prior trauma dynamics, and we can do that a lot of ways, just, and we really don't mean to, but bringing somebody in and like jumping right into the assessment and treating them kind of like a number and where they don't feel like they have a say, where they feel disempowered, that can be part of it. Or asking them detailed questions about a prior trauma can retraumatize them. So, there are a lot of things we're going to talk about. We need to create a safe environment, both emotionally and physically. So, you know, emotionally, we don't want clients to feel like they're being interrogated. We don't want them to feel uncomfortable, but physically, we want them to be able to look around and feel safe. And for each client, for each trauma, there may be something a little bit different. You know, for example, if somebody went through a hurricane, a really bad hurricane, whether it was Andrew or Ivan, or, you know, we've had some bad ones in Florida. You know, when they hear thunder and when we get those hurricane watches that come out and everybody starts packing and preparing, somebody who's been traumatized before may start having a resurgence of trauma symptoms. So, if they're working with you or if they're a client of yours, we want to help them feel safe where they are. So, all right, you know, bad storms coming. We're going to hunker down. This is what we do. This is our protocol. That way, they feel like they're not in harm's way. We want to identify recovery from trauma as a primary goal. It's not just one of those things that'll self-correct when we deal with your depression. It's a primary issue that we may need to focus on. Not everybody is going to want to focus on it, but it's one we want to help clients understand how their trauma may be impacting them. And they can say yes or they can say no, but that's, we educate and then go from there. We want to support control, choice, and autonomy among clients. So, they have control how quickly they delve into trauma details, whether they delve into trauma details. They have choices about the types of treatment, and they have a certain level of autonomy in going through that. We create collaborative relationships and participation opportunities. And familiarize clients with trauma-informed services. What does this mean? And hopefully, by the end of the series, you'll understand how trauma-informed services are different than just regular old services. And hopefully, we're all working towards trauma-informed. That's like culturally responsive. Hopefully, our agencies are embracing these notions already, where we're recognizing that things we do can have an inadvertent negative impact. So, we're being more sensitive. We want to incorporate universal routine screenings for trauma. Anybody that comes in, you know, let's just give them a screening for trauma. We don't have to go super in depth, but to see if something's there. And ideally, encourage primary care physicians. I have one that works right next door. So, that's why I always point over there. Ideally, have primary care physicians also incorporate universal routine screenings for their clients so they can refer to mental health should there be a trauma history. We want to view trauma through a sociocultural lens. You know, what caused the trauma, and are there certain factors that are continuing to perpetuate the trauma in the current environment? Is there intergenerational trauma? We want to look at kind of what's going on. And because of that trauma, even if it happened back then, you know, whenever then is, are there deficits, or are there things that are keeping people from being able to completely recover from that trauma? We want to use a strengths-focused perspective to promote resilience. Foster trauma-resistant skills, demonstrate organizational and administrative commitment to trauma-informed care, or TIC, and develop strategies to address secondary trauma, and promote self-care. Secondary trauma is sort of the burnout or the experiences that we get from hearing about trauma on a pretty consistent basis. I mean, we hear a lot of stuff, even if we're not characterizing it as this is a trauma session. You know, when we're working with somebody who's depressed or who's anxious and we're getting a life history, we hear a lot. So we need to have adequate resources, because if we're going to start screening for trauma, we're going to start hearing more about it. And if we're hearing more about it, it's going to impact us more, because we care. So because of that, what can we do to protect ourselves, protect our staff members, and make sure that our environment stays healthy? And we want to provide hope that recovery is possible. So the first step in all of this is screening. We want to offer psychoeducation and support from the outset of service-prevent provision. So whenever anybody comes into your office, whether you're a caseworker, whether you're a clinic, mental health clinician, or you're a medical doctor or a physician's assistant, we want to start creating a therapeutic alliance that educates people about what trauma is, what depression is, what anxiety is, and provide support from the outset, so they know that they can talk to us. And they can say, you know, I'm having this experience. We want to explain the screening and assessment and pacing of the initial intake. Some people are like, well, what's the difference between screening and assessment? And some places, we don't really do screening. If somebody comes to our facility, they say, you know, I want to enroll in services, then we just jump straight to the assessment. Screening is often done by your prevention team and your outreach team to, you go into communities, you go to wellness fairs, you know, primary care physicians may do morning, or primary care physicians may do initial screenings when people come in. So it's important to help clients understand what screening is. If they're like, well, I already talked about this with my doctor, and that's why I'm here. Well, that's great. You gave him some information that helped him see that you needed a referral. Let me see if I can help understand a little bit more about what's going on. The assessment process really helps me learn more so we can develop a plan of action and help them understand that the pacing of the initial intake and the evaluation process is partly set by them. We don't want them to feel like they're just a number, a cog in the machine, whatever metaphor you want to use. We want them to feel like they have some control. So if things start getting too, we can back off. When I used to do assessments a lot, we had a assessment trauma screening set of questions that we would ask. And for some reason, it was like the eighth, ninth, and tenth question that you asked somebody from the minute you met them. And I never liked that because I didn't feel we had any rapport going yet. So I always would skip that section and come back to it later. And then when I came to it, I would always broach it by saying, you know, some of this may be really difficult for you to talk about. If you don't feel comfortable answering questions, you don't have to. So let them know that they have the option of non-response, and that's okay because it may be true traumatic to go through. The most important domains to screen among individuals with trauma histories or potential trauma histories are their trauma related symptoms. So if somebody was a victim of sexual assault at some point in the past, you know, we want to talk about what are some current trauma related symptoms you may be experiencing, and they may identify none. And you're like, okay, no problem. Or they may still have occasional flashbacks or whatever the case is. We're just going to talk about it because bringing it up normalizes it. So they don't think, well, that happened 15 years ago. I shouldn't still be experiencing this. So I'm not going to say anything. I just need to suck it up and deal with it. No, let's bring it out in the open. Let's talk about it so we can figure out how to help you eliminate or mitigate that symptom. Depressive or dissociative or intrusive symptoms and sleep disturbances. We know that mental health stuff is probably going to get worse if sleep starts to get disrupted. You know, the less somebody can sleep, especially if they go to sleep and then they wake up like two hours later and they're up all night long kind of pace on the floor, we know that's a higher risk for increasing depression and other symptoms. So we want to see what's triggering that. Is it the trauma or is it something else? And, you know, past and present mental health issues. I don't like the word mental disorders, but that's what the text used. Severity and characteristics of the specific trauma type. So, you know, was it interpersonal violence? Was it a combat experience? If you're working with law enforcement, they have what's considered chronic low grade repetitive trauma because they see people on the worst day of their lives and they see things with regularity, not every day, but they see things with regularity that no person should ever have to see. So, you know, what are we talking about? Are we talking about that? Or are we talking about adverse childhood events or experiences? And if I can get it to come up. And that can include physical abuse, sexual abuse, emotional abuse, physical or emotional neglect, intimate partner violence. If the mother of the child was treated violently, if there was substance misuse, not even addiction, but substance misuse within the household, household mental illness, parental separation or divorce or an incarcerated household member. Those are like, I think the top 10 adverse childhood experiences that they identified. And if you think about the clients that you've worked with and maybe even think about yourself, you know, you probably have one or two of those in your history. So, thinking about, you know, for some people, they have enough other strengths and protective factors that it's not that traumatic. For other people, it's extremely traumatic. So, we want to, you know, talk about those adverse childhood events and screen for them. If the person has substance abuse, you know, let's screen for that. A lot of people with trauma histories try to numb it out, try to deal with some of the anxiety and the flashbacks and stuff with drugs. We want to assess their social support and coping styles. You know, do they have people that they can talk to? Do they have healthy coping mechanisms that they use to deal with the symptoms of trauma? And, you know, that can run the gamut. And we also want to look, if you're dealing with something that's a proximal trauma, like, and even for some people right now, it's still pretty proximal. And I think it was Harvey. I can never remember the names of the hurricanes, but the hurricane that hit Texas this year. You know, that was pretty daggone traumatic for a lot of people and they're still dealing with it. So, what sort of resources and social support do you have right now? And then as FEMA and everybody else starts to disappear, what social support and resources are still available in the community and to you among your friends and family, because maybe half your family had to be displaced to some other state. OK, so we want to look at what's going on for that person. At that point in time with regard to the trauma. What are the risks for self-harm, suicide and violence? And we want to do a health screening to see if there are any other health factors either related to the trauma, maybe they if they were sexually assaulted, they could have contracted an STD or HIV or hepatitis. Or, you know, we want to look and see if there's anything else that may be going on that might be related. Discussing the occurrences or consequences of traumatic events can feel unsafe and dangerous to the client as if the event were reoccurring. Now, if you've been a survivor of any sort of crime, especially, but, you know, it's true even with other types of traumas, like hurricanes, where people are like, well, tell me what happened. So you're retelling the event and every time you retell the event, it's kind of like ripping the scab off the open wound. So we don't want to have people feel like they're being violated over again. We don't want to encourage avoidance of the topic or reinforce the belief that discussing the trauma related material is dangerous to them. But we also want to be cognizant and we want to be careful. And, you know, how would we want to be treated? And how would we want somebody to approach us if we had been raped or robbed or seen somebody murdered or been in the middle of a hurricane and lost our house and all of our belongings? Initial questions about trauma should be general and gradual. Have you ever experienced trauma, for example? If so, you know, maybe what kind of trauma were you were you the victim or did in personally, or did you experience the trauma and then gradually get into it? And if they start getting too upset, you know, you can pause or you can encourage them and empower them to take a time out. You know, let them know that all they have to do is say the word and you guys can take a time out by going over the answers of the questions with the client. You can gain a deep understanding of what's going on and how the trauma may be impacting that person. Now, you probably still at best have met the person three times by this point when you're finishing up this part of the assessment. Most places the whole whole assessment is done in one sitting. So we're still kind of guessing about whether they're symptoms or the direct result of trauma or whether their symptoms are caused by something else, but you can start seeing how trauma might be influencing things. And also you can start seeing how you might need to alter or things you might need to be cognizant of when working with this particular client. Ask all clients about any history of trauma and use a checklist to increase the proper identification of such a history. The ACE study is one that you can give them if so they can identify adverse childhood events. And we're going to talk pretty soon in here about the fact that one way of doing a less intrusive trauma screening is by letting people do a paper pencil inventory. Obviously, they need to be able to read and write to complete that. And if not, you're going to have to read it to them and mark it for them. But if they do a paper pencil, it can be it can feel less humiliating and less violating than having to sit there and tell somebody you've known for 45 minutes about the worst day of your life. Use only validated instruments for screening and assessment. So if you're going to use instruments, the stressful life experiences screen is a checklist of traumas that also considers the client's view of the impact of those traumas on life functioning. So you can see if your agency can start using that one. And then the National Center for PTSD website offers similar instruments and they're not all directed just at veterans. So that's another resource that you might be able to find free validated instruments because I know cost is a big issue for a lot of agencies. Integration with the EMR is also a big issue, but that's a different podcast. In early treatment screen all clients who have histories of exposure to traumatic events for psychological symptoms and mental disorders related to trauma. When the client screens positive also screen for suicidal ideation and behaviors because sometimes when people are struggling with trauma, it gets so bad that they feel like it needs to stop. Treatment and protocol improvement protocol 50 addressing suicidal thoughts and behaviors in substance abuse treatment from SAMHSA. Free publication, you can get talks about things that you can do there. Be aware that some clients won't make the connection between trauma in their history and their current patterns of behavior, such as substance use or avoidant behavior and domestic violence that among their parents when they were growing up or whatever the case may be. And that's okay. You know, remember the stages of readiness for change, pre-contemplation. I don't have a problem. Contemplation, there might be an issue, same sort of thing here. People may say, that has nothing to do with this, pre-contemplation. Contemplation, okay, maybe you got a point, maybe there is some connection. But again, we are going to probably morph in our understanding of what's causing their symptoms as we go through the first few sessions of treatment. Don't require clients to describe emotionally overwhelming traumatic events in detail and focus the assessment on how the trauma symptoms in fact impact the client's current functioning. You know, if it happened 10 years ago, spending a whole bunch of time talking about the next six months isn't going to do a whole lot of good right now. And especially in this early assessment, you may have a reason to go back there later, but we do want to look at how might that be still impacting you today. For example, survivors of certain crimes may have difficulty sleeping because they're afraid that they can't let their guard down. Consider using paper pencil instruments for screening because it can be less threatening. Talk about how you're going to use the findings. When you start going into this trauma stuff, and I usually do it at the beginning, talk about how you use the findings to plan the client's treatment and discuss any immediate action necessary, such as arranging for interpersonal support, referrals to community agencies, or whether you need to move directly into the active phase of treatment because it is really bothering them right now. But this helps them understand you're not just collecting this data for giggles. You know, there's a reason for it and you're going to, you know, hopefully you're going to help them improve their quality of life. It's helpful to explore the strategies clients have used in the past that have worked to relieve strong emotions. Now notice I didn't say anything about trauma here. When we start talking about the trauma, it'll probably bring up strong emotions. Okay. Well, we need to know before we start, you know, opening that wound, opening that box that the client can deal with the strong emotions, can kind of put the lid back on the box and recompose themselves. Make sure the client is grounded and safe before leaving your office. After you do an assessment, too often it's easy to say, okay, well, it was nice meeting you, you know, we can start counseling next Tuesday at nine o'clock. Yada, yada, have a good day. Bye-bye. But we want to make sure that the client is really grounded before they leave. Readiness to leave can be assessed by checking on the degree to which the client is conscious of the current environment. So obviously if they were like terribly upset and crying and yada, yada, you're not going to, you know, kick them out the door. You know, you want them to regain their composure a little bit and be able to tell you kind of where they are, how they're feeling, what they're getting ready to go do, you know, get sort of that orientation to time and place. What the client's plan is for maintaining personal safety, if it got to the point where you think they might become suicidal, they're in a really raw crisis point and what the client's plans are for the rest of the day. So using some mindfulness activities, safety planning and, you know, future planning, so you can again kind of be screening a little bit for what are you going to do and are you going to be safe. Ongoing assessment should still be completed to help track changes in the presence, frequency and intensity of symptoms. You want to learn the relationships among the client's trauma, presenting issues and if any, their substance abuse or substance use. And you may not even know that right away. You know, that substance use piece may not come out until later. I was working with a client once and she told me, you know, we've been working together for, I don't know, a few weeks. And at one point she called to cancel her session and she sounded intoxicated and we started talking a little bit and she said, yeah, I need to put back a fifth every night before I go to bed. That way my husband can have sex with me and I'm too unconscious to realize it. And I'm like, whoa, whoa, whoa, whoa, whoa, wait a minute, wait a minute. So that became a treatment issue there. But the substance use and, you know, that particular coping behavior hadn't come up in our, in our sessions until that particular point. And I think partly because she was disinhibited because she was still inebriated. She may not have normally said that if she was in my office. So understanding that some of this stuff may come out a little bit later and, you know, as the trauma symptoms get worse, do the presenting psychological symptoms get worse? If they have an eating disorder, does that get worse? Sometimes it does. Adjust diagnosis and treatment plans is needed. You know, sometimes trauma is a three steps forward, one step back. I don't like two in one because that just doesn't seem as productive. A lot of times clients can do three steps forward, but then they may need to hold for a while, or they may regress a little bit in their mental health symptoms because the trauma has become so overpowering. That's okay. Let's stop. Maybe we need to practice some dialectical behavior therapy skills, something to help you manage your strong emotions, whatever it is. So be willing to modify that treatment plan. And ideally review on a weekly basis. Is there anything that needs to change? Do you feel like we're going too fast, too slow? And select prevention strategies to avoid more pervasive traumatic stress syndrome symptoms. So what does that mean? That means, well, number one, let's not retraumatize the person, but number two, we need to help them build up their reserves. So what sorts of things help people not be traumatized? What sorts of things can people do that help prevent trauma, even if they're exposed to traumatic events? Good social support, strong health behaviors, if they're getting enough sleep, eating a good diet, if they're not using alcohol or other drugs that could potentially mess up their neurotransmitters, infusing happiness into their life. You know, those are all things that can help people prevent trauma. One of the screening things after a traumatic event to identify people who are at higher risk, not necessarily is not indicative, but it's a screening tool for people who may be at higher risk for developing PTSD, is this event for this person, has this person had mental health symptoms or substance abuse issues in the past six months? Have they had multiple stressors in the last six months? Did this event occur in one of their safe places? You know, when I was at the University of Florida, unfortunately, we had the rash of student murders. And, you know, I used to go jogging at 10 o'clock at night on campus with my headphones on. I couldn't hear squad because I felt safe, you know, erroneously, but I felt safe. And after that happened, nobody felt safe. Whereas if you hear about a serial killer in an entirely different state, you're like, oh, well, it sucks to be them. So if it happens closer to one of your safe zones, your home, especially in your home or in your neighborhood, it can be more traumatic. And how similar are you? If you weren't the victim, how similar are you to the victim? So a lot of cops will go out on, you know, especially drownings, drownings tend to be really difficult. If they go out and the toddler is drowned in a pool and they happen to have a toddler at home. It hits them a lot harder in many cases than people who either have grown children or especially people who've never had children because it just does. And there's a certain amount of you can almost see your own child in the water sometimes. So it's important to recognize that. And the final thing we look at is did the person get social support, adequate social support within four hours? Four hours, not 24, not 48. The window before somebody starts, you know, boxing it up and putting it somewhere is about four hours. Now, the first 24 hours is also a crucial period for getting social support. So if you don't get it in the first four hours, all is not lost. First 24 hours, you know, is also really important. After that, it's helpful, but it's not as helpful. So those are things that we look at. Similarity to the victim, availability of social support within four hours, mental health problems, substance abuse problems and stressors within prior six months and whether it was close to a safe zone or a home zone. Creating, we want to clarify for the client what to expect in the screening and assessment process and approach the client in a matter of fact, yet supportive nature. This is what happened. And, you know, sometimes if you have been a survivor of some sort of trauma, it may, and I use the term may, very strongly, be appropriate to share and it may not. A lot of times it's not. It's too much self-disclosure at that point. But you also may share that, you know, you've worked with hundreds of rape victims or you've worked with hundreds of, you know, people who've survived a loved one's suicide or whatever the case is. Respect the client's personal space. Not everybody wants to be touched. Actually, a lot of people don't. So we want to be respectful. And even if it's not touching somebody, even moving over and sitting on the couch next to them because you want to comfort them may not be what they want. Provide culturally appropriate symbols of safety in the physical environment. So, you know, find things that represent your particular populations. And you can, you know the populations you work with. Be aware of your own emotional responses to hearing clients trauma histories. You know, sometimes it can be devastating to hear and to empathize and to imagine what it must have been like being that person. But we need to be able to be the ones that can, as I've said before, kind of put on the repelling gear and rappel down there, you know, into the depths, into the abyss with them. But we need to keep that repelling gear on. We need to be able to pull ourselves out of it so we can help them come back up. And we need to overcome linguistic barriers via an interpreter and trauma informed care is really difficult if you're having to work via an interpreter because you have a third person in the room and all that kind of stuff. But it's better than nothing. We want to elicit only information necessary for determining a history of trauma and the possible existence and extent of traumatic stress syndromes and related disorders. This is not the time to have them write a narrative of their trauma. Even if a client wants to tell his or her trauma story, it's your job to serve as a gatekeeper and preserve that client's safety. So you may say something like, you know, I hear you're really eager to work on this and I would love to hear more about it. But right now, you know, I think it may be overwhelming to go into this at this juncture. So, you know, let's table that so we can talk about it, maybe next session or whatever the case may be, because you don't want them, you know, 45 minutes into an hour assessment to start telling you the trauma narrative and then, you know, be in crisis. Your tone of voice when suggesting postponement of discussion of trauma is also very important. Avoid conveying the message, you know, I really don't want to hear about this right now. I don't have time. We got to get you out of here in 15 minutes. No, explore with them and explain to them that you don't want them to get overwhelmed and you want to be able to give that issue the attention that it that it deserves. Give the client as much personal control as possible during the assessment by presenting a rationale for the interview and making it clear that the client has the right to refuse to answer any questions, you know, and I also tell clients, because I still do paper pencil, you have the right to see anything I write down. You know, this is your file. So, you know, they don't feel like there's something being said, like I'm writing down something that they're crazy or whatever it is that they may be concerned about. They have the right if they can decipher my chicken scratch, they can read anything they want that I write down. And that a lot of times makes clients feel a little bit more comfortable. About divulging stuff, giving the client the option of being interviewed by someone of the gender with which he or she is most comfortable. So just because I'm a woman doesn't necessarily mean that a woman who has been traumatized wants to talk to me. She may feel more comfortable talking to a male therapist and postponing the interview if necessary. Use self-administered checklists rather than interviews when possible and allow time for the client to become calm and oriented to the present. If he or she has a very intent emotional response when recalling or acknowledging the trauma. So even if you're not doing the full trauma assessment or even if you're in the middle of the trauma assessment, they start to get upset. You can call the time out and say, all right, let me let you take a couple of breaths for a few minutes or however you, whatever you want to say. And then we'll carry on. We don't need to push through this right now. Let's, I can see you're really struggling. Avoid phrases that imply judgment about the trauma. For example, don't say to a client who survived Hurricane Katrina and lost family members. It was God's will. I know that was tough or it must have just been her time to pass or some things happen and they're just meant to be. None of those make people feel better most of the time. You know, they're a select few, but you don't want to minimize their feelings of grief and loss and their frustration of lack of control over the situation. Provide feedback about the results of the screening and keep in mind the client's vulnerability, ability to access resources, their strengths and their coping strategies. So as we're going through, as I'm providing information about the screening or the assessment to them, you know, I'm going to provide what they can handle based on the resources that they have. I'm going to make treatment recommendations based on the resources they have access to. And beware of the possible legal implications of assessment. And this is a big one. Information gathered can necessitate mandatory reporting to authorities, even when the client doesn't want the information disclosed. So you need to know what the rules are if you have an adult client disclosing prior sexual abuse when he or she was a minor, are you mandated in your state to report? You know, any of that trauma stuff that may come up, just be really aware of your mandatory reporting laws. Ask the client to state what he or she observes if you need to help them get grounded. You can guide the client through the exercise by saying things like you seem to feel very angry right now. This may be related to what happened in the past. You're safe. So let's try to stay in the present. Can you take a slow, deep breath, relax your shoulders, put your feet on the floor and let's talk about what day and time it is. What's on the wall or, you know, mindfulness exercised. Tell me three things that you're hearing right now. Or what else can you do to feel okay in your body right now? Some people need to get up and walk around. They feel very vulnerable if they're having to sit still. So that's important. Help the client decrease the intensity of affect by using something called the emotion dial. So imagine that your emotions are controlled by a little dial or a remote control. You know, we don't usually have dials anymore. But imagine turning down the volume of your emotions. So 10, 9, 8 and kind of count them through it. Encourage them. This is not something we generally do. You know, we just finished anger management, but you can encourage people to clench their fists because it can help move the energy into their hands and then they can let it go and shake it out. I think a lot of us do this sort of involuntarily, if you will, or unconsciously when we start getting stressed out or we start getting ready to do something we're kind of worried about. I know I do. Like, all right, all right, I can do this. All right, let's go. I'm ready. Guided imagery can be used to help them visualize a safe place. Now, if they are emotionally charged, if you've been talking about trauma, forcing them to close their eyes is well, don't force them to do anything. But even suggesting that they close their eyes may be a little bit threatening. So you might, if you want them to consider that, you can say something like, I know it might be scary to close your eyes right now. So you don't have to, you can just look at a space on the wall. That's totally cool. Or, but if you want to close your eyes, you know, I'm here and to make sure that it stays a safe place for you. Use strengths-based questions. So if you're talking to them and they're really upset, talk about how challenging it must have been. And, you know, how did you survive that? How did you get through three weeks living in a shelter? How did you survive after that event happened? What strengths did you have that helped you survive that trauma? Distract the client from unbearable emotional states and, you know, sometimes it's hard to help them calm down because they are so emotionally dysregulated at this point. So have them identify five things they see, hear, smell, feel in order to get more grounded. Sometimes, and if it's safe and if there's an appropriate place to do it, you can go out and walk around to help the client get moving again and kind of get reoriented. You can ask the client to focus on recent and future events. Like, tell me when you got up this morning, tell me everything you did until you got here. Or what's your to-do list? What do you need to get done this week? So tell me a few things that you need to get done today or this week. So it's putting them somewhere else mentally instead of right smack dab in that trauma. Help the clients use self talk to remind himself or herself of current safety issues. So where they may start feeling anxious again, using positive self talk to tell themself I'm safe, that's not happening right now, is important. Encourage them to use distractions such as counting to return the focus to current reality. I use that, you all know I've got an irrational fear of bridges and I use that when I go over bridges. I either say Hail Marys or I say my ABCs and you know, it's whatever works for you, but it gets me over the bridge and I'm not thinking about it the whole time. Some out of sensory techniques such as toe wiggling or touching a chair or even shaking their leg can also help get them refocus because they're focusing on a body part, what they're doing right then. Sometimes having them stand up and do 10 squats can help to if they just really need to move. Progressive muscular relaxation is another good one that can be used to help clients ground because when they start to get upset, they start getting tension everywhere, just like we do when we get upset. So encouraging them to notice the difference between tense and relax and as they relax, notice the energy and the stress moving out of those muscles and down and out. So yeah, that can be great. I don't have a lot of experience with EMDR, but one of you shares that EMDR is also excellent for teaching grounding. So that's another avenue to explore. Finally, ask the client to use breathing techniques if they breathe in through their nose and exhale through their mouth in for three, hold for three, out for three. It triggers the relaxation response in the body. So it starts secreting relaxation hormones. You can also have the client place his or her hand on our abdomen and then watch his or her hand go up and down while the belly expands and contracts. Some people are more willing to do this than others. But you know, there are different activities. You can provide them a list of things they can do and encourage them to practice them at home and put a checkmark by the ones that work because they may feel stupid trying multiple things while they're in your office. And that I've had clients tell me that before and I'm like, cool, well, here's a checklist, do it for homework and come back and tell me which three on here worked best for you. Barriers and challenges, it's not necessarily easy or obvious to identify an individual who has survived trauma, even with screening, but definitely without screening. You can't just look at somebody and go trauma survivor, trauma survivor. Some clients may deny that they've encountered trauma and its effects even after being screened. And for some clients, it may not be denial. It may be that they've already they got enough support and they had enough protective factors that it didn't have a lasting impact because we know that not everybody develops PTSD or even acute stress disorder. So we know there are some mitigating factors in there. Does it change? I mean, it's something that's imprinted in people's brains. It's a learning experience, whatever kind of learning you want to label it. So it is having an impact in some way, but it may not be what's precipitating their psychological symptoms. The two main barriers to the evaluation of trauma and related issues are clients not reporting the trauma because they didn't consider it traumatic or a history of trauma that encompasses the experience of a traumatic event. Clients not reporting trauma because they don't perceive it as traumatic. The other barrier is providers overlooking trauma and its effects. We just assume if somebody has a trauma, they'll tell us about it and then we'll deal with the PTSD. Well, trauma does a whole lot more than just PTSD. Trauma can cause generalized anxiety, phobias, depression. It may not rise to PTSD. Clients fail to report because of concern for safety. They may fear more abuse for revealing the trauma or they may fear repercussions of some other sort. Fear of being judged shame about being victimized. Reticence about talking with others in response to the trauma. So they may not, you know, they may not just want to discuss it. They may not want to go to a support group. Not recalling past trauma through dissociation, denial or repression. Although the research shows that blockage of all trauma memory is very rare. So a lot of times it's one of these other things. But some people may have completely blocked it out. A lack of a trust in others if they were victimized by someone who was a trusted authority figure, a physician, a pastor, a somebody, you know, that may carry over to you being an authority figure and them not trusting you. Not seeing the event is traumatic, feeling reluctant to discuss something that might bring up uncomfortable feelings. They may know it's still an issue, but they just don't want to go there because when they've tried to go there before, and a lot of times they've tried to do self-help work. It's been so overwhelming that they're just like, I can't. So one thing that we can do is, you know, if we think this may be the case, present, you know, the first couple of sessions you talk on, talk about emotion management and emotional regulation and preventing vulnerabilities and really build that person's self-efficacy and their resources up before you start going into that issue. And they may just be tired of being interviewed. Or being asked to fill out forms and don't believe it matters anyway. You know, sometimes, again, we make them feel like they're just, this is something we got to do. And next week when you come, then I'll actually pay attention to what your needs are. Don't do that. Trauma-informed care starts at the very beginning. Providers also may not screen for trauma because we don't want to inquire about traumatic events and symptoms because these questions are not part of our normal program or standard intake practices. Trauma-informed care would say, make it a part. We may underestimate the impact of trauma on clients' physical and mental health. And yes, it impacts their physical health, too, because it impacts, it causes stress, which can cause GI stuff and lots of cascade effects from that wonderful HPA axis. We may not screen because we believe that treatment should focus solely on presenting symptoms rather than exploring the potential origins or aggravators of symptoms. I tend to be more psychodynamic and I look at how is the past impacting you in the present in my practice, but that's my perspective. A lack of training or feelings of incompetence and effectively treating trauma-related problems. So if you don't feel like you know what to do with a rape survivor or, you know, whatever the trauma is, get education, get consultation, or not knowing how to respond therapeutically to a client's report of trauma. We may also fear that probing trauma will be too disturbing for clients. They're not that breakable. They probably think about it a lot, but they have the ability if we empower them to say, whoa, not going to work for me. We may not use a common language with clients that elicit a report of trauma. So if we say, were you abused as a child, what their definition of abuse is and what the adverse childhood experience's definition of abuse and neglect is may be very, very different. So they may think of abuse as being beaten to a bloody pulp, whereas we're looking for something a lot less dramatic than that. Concerned that if disorders are identified, clients will require treatment that the counselor or program doesn't feel capable of providing. Make sure you have trauma resources, if not within your own agency that you can refer to. Insufficient time for assessment to explore trauma histories or symptoms. Well, that's an agency level thing that we need to do. Yeah, you don't want to rip off a scab and then go, OK, well, your five minutes is up. Toodles, that's not compassionate, it's not safe, it's not OK. And untreated trauma-related symptoms of the counselor, other staff members and administrators. So there may be a culture within your organization because of staff members who've experienced trauma that says, you know, we really don't want to go here right now. And hopefully that's not the case, but it was one of the reasons identified. One of the reasons we made misdiagnosed or underdiagnosed trauma-related stuff because you're sitting there scratching your head going, you know, I see clients all the time and don't see that much trauma-related stuff. Well, maybe you do and you just don't notice it. A lot of the general instruments that we use to evaluate mental issues are not sufficiently sensitive to differentiate PTSD symptoms and can misclassify them as other disorders. For example, intrusive post-traumatic symptoms that show up on general measures can indicate or the general measure can say this person's having hallucinations or obsessions, not flashbacks. Dissociative symptoms may come up as indicative of schizophrenia instead of PTSD. Trauma-based cognitive symptoms can be scored as evidence for paranoia or other delusional issues if they start withdrawing, they see negativity, they see the world as not being safe. It sounds paranoid or delusional, but if you look at it from their perspective, from what they've gone through, it makes perfect sense. Mood and anxiety disorders have symptoms that overlap with trauma. So we want to make sure that if there's PTSD or acute stress in there, we're identifying that in addition to the anxiety and the depression. And impulsive behaviors and concentration problems, which are present in trauma, can also show up as ADHD. So again, what is causing the symptoms and what is the function of the behaviors? Many of the symptoms of borderline personality disorder also overlap, including patterns of intense interpersonal relationships, impulsivity, mood swings, going through the PTSD criteria. You know, think about it. I would encourage you to open your DSM-5 and review those criteria and think about it in terms of is this PTSD or is this borderline personality disorder? What might trigger this? What kind of trauma might trigger this kind of reaction? Now, you can have both. You can have borderline personality and PTSD, but we want to make sure that we don't miss addressing the trauma issues that may be the undercurrent that's maintaining the mental health problems. Cultural factors such as norms for expressing psychological distress, defining trauma and seeking help can affect how traumas are experienced, the meaning assigned to the events, how trauma-related symptoms are expressed. Some cultures somaticize. Some cultures have a very high level of emotionality. Other cultures have a very reserved level of emotionality and some have avoidant behavior. So, you know, you want to be aware of the culture and of the individual. When you get stressed, how do you generally handle it? Culture can also affect willingness to express distress or identify trauma with a behavioral health service provider. It may affect whether a specific pattern of behavior, emotional expression or cognitive process is considered abnormal and there are certain culture-bound symptoms that are related to trauma that are considered very normal responses. Willingness to seek treatment inside and outside of one's own culture can affect how people deal with trauma. Their response to treatment and the treatment outcome. The attack de nervios is a Latino culture-bound symptom that includes intense emotional upset in response to a traumatic or stressful event in the family. Nervios has a wide range of emotional distress symptoms including headaches, nervousness, tearfulness, stomach discomfort, difficulty sleeping and dizziness. So, you know, you're really seeing panic, stress, anxiety, stuff right here. Susto is the term meaning fright and is attributed to a traumatic or frightening event that causes the soul to leave the body, resulting in illness and unhappiness, and extreme cases may result in death. Symptoms include appetite or sleep disturbances, sadness, lack of motivation, low self-esteem and somatic symptoms. So, DSM sort of translation would look at major depressive disorder. So, is this major depressive disorder or is this susto? It's important to create a safe space for assessment. And that means not only being kind and warm and all that stuff, but making sure it feels safe to the person. Don't have them sit with their back to the door. That can feel very threatening. Maybe they don't want to be sitting in a room where the windows are open, where people can see them in your office. You know, a lot of therapists who have offices and they have the benefit of windows like to have the curtains open so people can look outside and see nature or whatever. But some clients are very put off by that. So, ask clients what would help you feel safe in this environment. Clinicians need to be aware of the reasons they may not want to screen for trauma as well as the reasons people may choose not to disclose. So, it's their right not to disclose. And it's up to us, it's incumbent upon us to know our own stuff and deal with it so we can screen for it. It doesn't mean we necessarily have to treat it. But ideally, we can work through our own stuff so we can provide adequate treatment to people with trauma issues because there's a significant percentage of people have experienced trauma. The most important domains to screen are their trauma related symptoms, depressive symptoms, past and present mental disorders, severity or characteristics of the specific trauma. Now, we're not going into the whole narrative here. I just want to know how frequent was it? How bad was it? You know, did your father beat you to a pulp or did he use a belt and smack you on the rump once? You know, what are we talking about here? Substance abuse. Does it is it going on with this person because that might contribute not only to impulsive behaviors but also it might contribute to mood symptoms. Social support and coping styles. Do they have adequate social support and do they have effective coping mechanisms? What are their available resources and what are the resources in the community? You know, can you refer to an EMDR clinician? Can you refer to, you know, some other resource that can provide additional services? Are there support groups if the person wants to go there? What is their risk for self-harm, suicide or violence and have they had a health screening recently to make sure there's no underlying physical issues that need to be addressed? OK, so we went through a lot of stuff and one other question came up as far as ongoing assessments to use throughout therapy. I don't know of any instruments that are really useful for ongoing assessments. What I typically do in my practice is make some sort of a protocol for doing an assessment at each at each contact, you know, so I can identify if the person had future plans, if they had any signs of suicidal or homicidal ideation, what their life skills were like if they were oriented times four, yada, yada. That goes at the beginning of every single one of my progress notes. If they identify specific trauma related symptoms, you may add that to their progress notes so you can assess it each week to identify, you know, are the flashbacks reducing in frequency and intensity and stuff like that. Any other questions? All right, everybody, have an amazing weekend and I will see you next week on Tuesday. If you enjoy this podcast, please like and subscribe either in your podcast player or on YouTube. You can attend and participate in our live webinars with Dr. Snipes by subscribing at allceuse.com slash counselor toolbox. This episode has been brought to you in part by allceuse.com providing 24-7 multimedia continuing education and pre-certification training to counselors, therapists and nurses since 2006. Use coupon code counselor toolbox to get a 20% discount off your order this month.