“Trauma-informed care is a strengths based framework that is grounded in an understanding of and responsiveness to the impact of trauma, that emphasizes physical, psychological, and emotional safety for both providers and survivors, and that creates opportunities for survivors to rebuild a sense of control and empowerment.” Hopper et al. (2010).
The principles of trauma informed approaches are client centred and work holistically using 5 principles as its foundation. Safety, trust, choice, collaboration and empowerment. According to Harris and Fallot (Pg. 182). And the core meaning of based dilemma, which is listening to survivors, listening to their experiences and stories. Conversely, while treatment based programmes can be useful in addressing issues of immediate risk the difficulty can be that negative patterns continue to be repeated as they try to cope with work, families, children and their relationships far into their future, restricting the possibilities of positive and successful outcomes within their lives.
Understanding what these woman and young girls have been through horrendous suffering, difficulties and challenges which, have worked to exacerbate stressors in their everyday lives and they are trying their best to get on with their lives. To work and develop practices that recognise individuals experiences and perceptions of them and how this has challenged a client or patient’s current frame of reference causing them problems and issues in the present, rather than labelling people as sick or, ill creates the possibilities of hope. This can be done in the medical model as well, which you put as opposing trauma informed approaches above.
Taking into consideration and honouring cultural experiences and expressions. We cannot impose a westernised perspective when working with other cultures. This diminishes their experiences. Leads to cultural insensitivity, misdiagnosis, misunderstanding and can work towards re-traumatization. What is normal as expression and manifestation of trauma in one culture can well not be seen as normal as expression and manifestation in another. We, as professionals have a responsibility to be informed, to ask questions. Questions such as; ‘what is your story’, and be ready to listen to their stories, ‘what has happened to you’, and later on, ‘what are your wishes, hobbies etc’.
When working with women and young girls, we have a responsibility to sensitively and flexibly gather the information that gives us insight into their identities. It is important to understand where are these women and young girls coming from, their identities and/or identity confusion, explore their status of education, family life, look at the attachment and adversities as a child and young person, what are they survivors of; defeat, entrapment, disconnection or loss. What is their social status, have they been excluded, disowned by parents and family members, explore shame and coercive power. How many threats have they survived and traumas have they experienced. What does it mean to be a female; checking at social, historical, political and cultural context and ideological meaning.
When working with these groups or, individuals it is important to explore the impact that violence and victimisation has on development and coping strategies of the patient or client. Exploring the skills and abilities of the client so they become more aware of their own resilience. Working to identify recovery, coping mechanisms by explores collaboration rather than competency. For me it is important in collaborative process to ask what an individual would like, explore their skills by being flexible in support.
The five principles of informed trauma practice, ensuring physical and emotional safety is paramount to ensure trustworthiness, choice, collaboration and empowerment. To ensure client’s safety in a more effective and in a consistent way, settings can be modified by maintaining appropriate boundaries, creating clear tasks, making control and choice a priority. All this can be helpful to work with in order to create the best outcome for the client’s working towards recovery successful outcomes. For example, a person may feel anxious moving from individual therapy to group therapy, it might be helpful to adjust by checking in after first and third session. Keeping in mind that client is at heart of process, prioritizing client empowerment and help with skills building. Being transparent with the process, collaboration, asking the client how or, what they think might be beneficial.
Trauma informed practice allows us to be sensitive to past issues being present and triggered in the present by exploring what has happened rather than the suggestion or, interpretation that something is wrong. Explores the skills and abilities of the client so they become more aware of their own resilience. Working to identify recovery, coping mechanisms. As well as exploring collaboration rather than competency. Being aware as professionals of the barriers that particular groups such as Asylum seekers, Refugees, Immigrants etc, face.
In contrast ‘Trauma Specific’, practice and the focus on symptoms and syndromes rather than recovery and resilience, creates a mindset of illness and pathology. Emphasising women’s strengths, focusing on wellbeing by highlighting adaptations over symptoms, syndromes and resilience. Not focusing on illness and pathology which, is a focus of trauma specific approaches. It is possible to explore this in relation to Asylum seekers who can enter or, engage with services with a myriad of traumas and issues. Without sensitivity and awareness, it is highly likely that issues and trauma will be compounded, causing re-traumatization. Further explained, a trauma is an alteration, an injury to the brain, not a moral failure or a lack of willpower.
The possibilities being that they could have experienced or, exposed to physical, sexual abuses, loss on multiples of levels, death, murder, substances etc then compounded with the cultural, social and economic lack of understanding can cause re-traumatization with increased risks of physical and psychological trauma. All of which, without being mindful and sensitive to an individual’s history places this group at High-Risk Mental Health Difficulties. Talking of risk for developing mental health difficulties is adopting a medical model.
Within current research has been recorded statistically that children who have had the benefit of support from agencies who employ ‘trauma Informed Practice, exhibit more spontaneity, freedom, play, autonomy, creativity and uninhibited joy. Where in contrast research has suggested that people who have been supported by Trauma Specific, practices, people who suffer from PTSD are the opposite and develop a chronic vigilance for and sensitivity to threat.
As a therapist working with trauma, I find that a subjective assessment has to be made. This brings to mind an assessment I made recently of a young, Asylum seeking woman that presented as intermittently tearful and agitated. At one point in the assessment her gaze went blank and she appeared briefly unaware of the assessment situation where she was. This indicated a degree of ‘dissociation’- a psychological defence mechanism manifested as a perceived detachment of the mind from the emotional state and body. Such dissociation often occurs in the aftermath of severe trauma. In view of my client’s evident distress, I was mindful throughout the assessment, of the potential for my client to be retraumatised. As the Istanbul Protocol (paragraph 149) states, “Despite all precautions, physical and psychological examinations by their very nature may re-traumatize the patient, provoking or exacerbating symptoms of post-traumatic stress by reviving painful effects and memories”.
It was clear to me that the client was experiencing difficulty in dealing with direct questioning. As I got to know my client and allowed her space and time to bring her experiences without pressing her, the experiences she describes, the trauma had a major sexual component and she often had difficulty in describing the context in which traumatic events took place. All the training and the work I do in daily based with my clients has enabled me to develop my understanding and practice, as well as the importance of professionals such as, immigration officers, being trauma informed in order to minimise the severity of destress during interviewing process. Without training of the sensitivity of issues interviewing vulnerable people suffering from PTSD should put additional measures in place as before to safeguard their wellbeing. Particular consideration should be given to controlling manner of questioning and ensuring adequate breaks as well as monitoring closely for signs of escalating distress and/or dissociation.
In my view people suffering from complex PTSD issues and the marked distress when recounting past experiences, should be treated as a vulnerable witnesses as they are likely to have considerably greater difficulty in giving an account of self in the formal and potentially adversarial setting of a substantive ‘Home Office’ interview or during a Tribunal hearing and is also likely to become markedly distressed. Further, such individuals are likely to have a dissociative episode while attempting to describe own traumatic experiences which would add to difficulties in giving a clear and consistent account.
Therefore, the potential for retraumatising will not meet successful outcomes, more drain on services across services which can impact for decades on a person, community and services. The impact being that trauma works to compromises the brain area that communicates the physical, embodied feeling of being alive. Vulnerable women and young girls, become hypervigilant to threat at the expense of spontaneously engaging in their day to day lives which, diminishes their ability to live life exploring their potentialities.
A Trauma-Informed approach does not necessarily seek disclosure, rather it shifts our frame of reference so that we are mindful of the myriad of experiences that may influence our clients. It also equips us with language to normalize conversations about violence, an important step in shifting the culture from one plagued by silence to one that challenges the misconception that sexual assault (and violence) is normal or acceptable. (Heather L. McCauley, Sc.D., Dept. of Paediatrics and Psychiatry, University of Pittsburgh School of Medicine, Editorial/Journal of Adolescent Health 56 (2015) 584-585).
Trauma informed approach is aware of history and the importance of the information gathering while, being mindful that we do not push for the information. We work to be sensitive to the patient/client’s needs. Cultural responses which, may differ to the expected responses of the home culture. As professionals it is our responsibility to remain alert, we do not push. The history gathering process is mindful of triggers that could emerge for multiples of reasons within the present environment. For example, security of premises, location, time, day access could interfere with precarious work situation. Who might see the person in the local environment and how this might affect the victim, restraints, male or, female support workers; male female groups, interpreters, driving, transport etc.
Concentrating on what is relevant, such as the past, culture, language, kinship, loss of community, in relation to the present. Such as, alienation and isolation, culturally, socially, economically; shame, stigma of discussing or, even recognising issues such a relocation in an environment that client experiences as safe. When all this is considered then the prospects of eventual recovery becomes more archivable.
Though antidepressants are effective in the treatment of PTSD and associated depressive symptoms, psychological treatments (particularly eye movement desensitization and reprocessing [EMDR] and trauma-focused cognitive behaviour therapy, are crucial components of a comprehensive individual treatment package (National Institute of Health and Care-Excellence [NICE] 2018). NICE emphasizes that psychological treatments should be regarded as ‘first-line’ treatment and medication as second- line treatment.
It is a well-known fact that NHS offers to asylum seeking women an initial brief course of trauma focused Cognitive Behaviour Therapy (CBT) which consist of 8-12 one to one sessions with a therapist. Keeping in mind that the majority of these women do not speak English and the therapy is done via an interpreter. This brings up huge issues in relation to cultural sensitivity and the impact of the traumas an individual has experienced. CBT works to address symptoms and syndromes and while it can create coping mechanisms it does not work to allow a person to explore their traumas so that they can potentially work towards exploring the impact that this has had on their self-perception, helplessness, fear, disempowerment the capacity to do so, being that more successful ways of being can be worked towards.
People whose PTSD is a result of multiply and repeated trauma and who may be regarded as having ‘complex PTSD’, require more individual tailored psychotherapy which requires the slow building up of trust and needs to continue for considerably longer. This is in keeping with the recommendations of the International Society for Traumatic Stress Studies (ISTSS) whose guidelines for ‘complex PTSD’ recommended a three-phase approach, focusing initially on stabilisations through the understanding and control of symptoms, followed by work on processing of traumatic memories and a final phase of social and psychological integration (Cloitre et al2012). The use of the term complex PTSD may not be in line with trauma informed approaches which try to shift focus from deficit and disorders to strengths and coping strategies.
Through my experience as a therapist and in discussion with trauma therapists, it has become clear to me that clients seeking Asylum, in particular those with complex PTSD, experience a novel sense of validation and self-worth if granted protection. Clearly the granting of protection and sanctuary is not in itself a cure and in any particular case those responsible for determining the asylum claim may judge that protection is unnecessary. However, the sense of being deemed worthy of protection by the authorities can be a key component in enabling the symptoms stabilizations for that in turn allows trauma-focused therapy to start and to be effective. A large body of research estimates that between 55-90% of the population has experienced one or more forms of trauma in their lives (CDC & Kaiser Permanente, 1995-2011; Harris & Fallot, 2009; Farro et al., 2011). Therefore, in relation to recovery and more positive outcome we need to take into consideration that not only the patients/clients we work with and serve but, us as the professionals that work with these vulnerable people may be dealing or, may have a history of traumatic stress and experience.
Trauma Informed practice works towards encouraging people to experience the feeling of being fully alive, to live in the present and move forward with their lives. The things that are universally difficult for people with PTSD are: to trust others, themselves and to confront their shame around how they behaved during the event. As I have developed my therapeutic practice, I have learnt that working towards empowerment is key in rebuilding lives. More recently, I started a programme with Albanian ladies, for five weeks and taught them new tools and skills that they can implement in their daily lives. Throughout the five-week program, I discussed and engaged women with activities that taught them how to protect themselves from gender-based violence. These skills were taught through interactive games, role playing and physical self-defence training. Some of the topics that we worked on were; learning how and when to avoid risky situations, defining and asserting boundaries, vocalize needs and identifying dangerous behaviour. In addition to these violence prevention strategies, I tough how to fight back, for when de-escalation and avoidance are not an option. For clients to fully embrace the power of their words, they need to feel they have the power and courage to physically back up their words, if the need arises. There’s no ONE-SIZE-FITS-ALL solution to violence, so I taught a variety of skills that women can choose to respond with. Verbal responses, leaving a space, physical defence. There are no judgements on how women have responded to previous situations in their lives. There are no could’s, would’s or should’s used in self-defence sessions.
I used peer-support methodology, in that participants discovered that they are not alone in their concerns of fear, or “not doing it right.” The support system created with a group enabled women to try new things and step out of their comfort zone. In a safer space, supported by their peers, women got to discover power through making difficult choices, facing their fears and taking charge of their life. The supportive energy that was created within a group was infectious and carried on into each woman’s life after the group concludes.
In my experience, evaluating, prevention programming, outcomes should go beyond knowledge acquisition, skill building, and attitude change to include outcomes that focus on behaviour change as a way to challenge the concept of victimisation. This in itself creates a ‘can do’ attitude and state of mind. In my experience this setting and concept allows an individual to see beyond their trauma towards a space where they can be empowered and autonomous and eventually recover or continue to work towards it due, to the possibility of hope. Creating an evaluative plan, including questions, taking into consideration different methods of data collection, ensuring that staff are responsible and well trained. Making sure that professionals working with this group of vulnerable people do communicate with each other.
In conclusion, considering and exploring the difference between Trauma Specific approaches which look only at syndromes, symptoms, treatment in the present which, could lead to unnecessary reliance on medication and, work to retraumatise those being worked with. It is clear in my opinion, that this approach has not recognised the links between substance misuse, past trauma and the development of PTSD, rather than being informed of past histories of women and girls that are survivors of violence. In relation to the more recent beneficial approach of ‘Trauma Informed’ which is sensitive to the impact of past histories and creates a safer space for patients/clients, I find that ‘Trauma Informed’ perspective offers a humane and effective way addressing mental health problems that women and girls. Recognizing that Asylum seeking women and girls are very likely to have experienced a great deal of stressful and traumatic events to come to a safe country and very often does not end there. The process of resettlement can be extremely lengthy at time so a trauma informed approach for me, is clearly relevant to this client group.
Instead of giving the woman and girls that have been through and ordeal of terrible experiences medication, how about we give them safety, an none-judgmental space where they can work with developing their self-autonomy as they work towards empowerment.
References:
Cloitre M. Courtois CA. Ford JD et al (2012). The ISTSS Expert Consensus Treatment Guidelines for Complex PTSD in Adults. Retrieved from https://www.istss.org/ISTSS_Main/media/Documents/ISTSS-Expert-Concesnsus-Guidelines-for-Complex-PTSD-Updated-060315.pdf
Cloitre M. Stolbach BC. Herman JL et al (2009). A developmental approach to complex PTSD: childhood and adult cumulative trauma as predictors of symptom complexity. J Trauma Stress.
CDC & Kaiser Permanente, (1995-2011); Harris & Fallot, (2009); (Farro et al., 2011)
Harris, M. & Fallot, R.D. (2001). Envisioning a trauma-informed service system: A vital paradigm shift. New Directions for Mental Health Services.
Heather L. McCauley, Sc.D., Dept. of Paediatrics and Psychiatry, University of Pittsburgh School of Medicine, Editorial/Journal of Adolescent Health 56 (2015) 584-585).
Hopper, E.K., Bassuk, E.L. & Oliver, J. (2010). Shelter from the storm: Trauma-informed care in homelessness services settings. The Open Health Services and Policy Journal 3, 80-100.
Ungar. (2008) and Ungar. (2011) Raising today’s teens National Clearinghouse on Family Violence