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Spring 2009 | Vol 12 No 3

Focus

Helping to heal the scars

What does trauma-informed care look like?

By Tammy Rasmussen and Julia Bloomenfeld

Kim is a 38-year-old woman with two children, ages 7 and 8. As a child, she experienced physical and sexual abuse and now struggles with flashbacks, nightmares, hypervigilence, depression and anxiety. At 14, Kim began drinking and cutting herself. By her late teens, she was binge drinking most weekends. At 25, she moved in with her partner and stopped drinking when she became pregnant. When they separated three years ago, Kim began to drink occasionally. After being sexually assaulted by a stranger a year ago, she began drinking daily. Child welfare became involved and Kim’s children were placed in the father’s custody. For the first time, Kim reached out for help.

Kim’s experience with traditional care

Kim enters a co-ed treatment program and is triggered into flashbacks after a male client flirts with her. The program is unaccustomed to working with trauma issues, so Kim is sent to the local hospital for mental health support. There, she becomes increasingly agitated and is restrained, which causes her to spiral into painful memories. She is told that she must first deal with her substance abuse, so she is sent back to the residential program. When flashbacks and intrusive memories continue and trigger Kim to drink, she is discharged. Without supports in the community, Kim’s trauma responses and other problems intensify.

Kim’s experience with trauma-informed care

Kim’s child welfare worker refers her to a substance use treatment agency for assessment. The receptionist shows her into the pleasant waiting room. A female counsellor invites Kim into a private office and explains the assessment process. Kim says she is nervous and the counsellor comments on Kim’s courage. She is informed of her privacy rights and exceptions to confidentiality. The counsellor explains that the assessment includes questions about trauma and that Kim needs only to share what is comfortable for her.

During assessment, Kim begins to dissociate. The counsellor, like all clinical staff at the agency, is trained in first-stage trauma work and helps Kim re-orient to the present and become safe and grounded. She reassures Kim that in treatment she can work on her greatest concerns – her flashbacks and substance use – at the same time. The counsellor asks Kim about her strengths, which she identifies as her motivation to change.

After a few sessions, the counsellor recommends that Kim attend an out-of-town women’s residential substance use program that is trauma informed. Plans for withdrawal management are made. During orientation, staff invite Kim to discuss any concerns and she mentions having nightmares of the sexual assault. A plan is made for Kim to use her MP3 player at night, as she finds listening to music soothing. On particularly difficult nights, she can sleep on a couch in the living room.

During the first week, physical and emotional safety are defined in group therapy, where Kim learns a grounding exercise to help her deal with cravings and post-traumatic stress responses. When Kim’s trauma issues emerge, she is encouraged to speak about the impact in the present – its connection to her alcohol use – and to identify and practice positive coping strategies.

With her primary counsellor, Kim explores how to cope with intrusive memories and gets information on dealing with flashbacks. She is informed about an upcoming fire drill, as unexpected loud noises trigger her. Kim also works on a commitment to herself to avoid self-cutting, and coping strategies are identified to enhance her safety.

During the second week, Kim tells her counsellor that she has been experiencing overwhelming memories and panic during the women and relationships sessions. She worries that she will be discharged from the program if she needs to leave the room. They speak about the importance of pacing and identify parts of the program that while triggering are still manageable for her. They agree that if Kim is feeling overwhelmed in a session she will leave and practice self-care strategies.

Over time, Kim is able to use these strategies to remain in the sessions longer. She makes connections between her substance use, mental health issues, and trauma and begins to feel validated regarding her traumatic responses.

During her final week, Kim develops a continuing care plan that incorporates strategies for emotional and physical safety and relapse prevention. When she expresses concern about her antidepressant, the counsellor organizes an assessment with the agency’s consulting psychiatrist, who has expertise in substance abuse, to review Kim’s medication options with consideration for her trauma responses. A telephone conference is also held with Kim and her service providers, including her child welfare worker, to discuss aftercare. Kim decides to attend a relapse prevention group and a parenting program for women with substance use issues.

Kim returns to her community and works on rebuilding her relationship with her children and strengthening her coping skills. After several months in the relapse prevention group, Kim arrives distraught. She explains that last week her daughter turned 8, which triggered flashbacks she has never had before. Kim drank in response but does not want to return to old patterns. The counsellor validates her courage to share this and reinforces her determination to heal.

Kim and her counsellor connect with her child welfare worker to discuss the nature of the healing process and identify further supports. Kim accepts a referral to a trauma therapist who can work with her through the stages of trauma recovery. Kim continues to strengthen herself and work with her ex-partner and child welfare to one day have her children home again.

Tammy Rasmussen is a trauma counsellor at the Jean Tweed Centre. Julia Bloomenfeld is the centre’s director of Clinical Services.