Introduction
The first step in assessing trauma is acknowledging that one cannot have any trauma-related symptoms if one has not experienced trauma. Therefore, it is imperative to first inquire about the client’s difficult, overwhelming or painful experiences in the past. Essentially, gathering the initial information should be in a manner that minimizes intrusiveness but maximizes clarity. A brief questionnaire can be more appropriate for a client in the initial contact than a face-to-face interview since it is less threatening (Bhangu et al., 2021). However, interviews should be part and parcel of any assessment or screening process. There is the possibility of a client denying or minimizing the history of trauma. In such a case, it is advisable to administer the questionnaire later or delay the questions related to trauma. The delay allows the client to develop trust in the clinical environment and feel safe in expressing their emotions and thoughts in discussing their experiences.
The Stressful Life Experiences (SLE) Screen
SLE is a trauma screening tool with a checklist of traumas, and it considers the client’s view on how the life events have impacted their functioning. The SLE has 20 statements describing possible life experience scenarios and two Likert scales of 1 to 10 (Center for Substance Abuse Treatment (US), 2014b). The scales allow the patient to indicate how the statements describe their experience and the stressfulness of their experience. The scale “Describes your experience” has four choices along the scale, with 0 relating to a statement that does not describe what the client experienced and 10 precisely describing the client’s experience. For the scale “Stressfulness of Experience,” 0 relates to an experience that is not at all stressful, while 10 indicates a highly stressful experience. One of the significant advantages of this tool is that it fosters the counselor-client relationship. As the counselor goes over the answers with the client, they gain a deep understanding of the client. Also, the client gets to witness that the counselor is not only sensitive to but is also concerned about their life experiences.
Combat Exposure Scale and Intimate Partner Violence Screening Tool
While SLE is a comprehensive screening tool that captures diverse symptoms and traumatic experiences, some tools focus on helping clients acknowledge specific traumatic events. They include the Combat Exposure Scale and the Intimate Partner Violence Screening Tool (IPVST). For this case, the counselors will use the STaT IPVST that asks specific questions about violence, like whether the client has been in a relationship where their partner slapped them. These tools are essential in getting the precise and intrusive details of clients and are advisable for the second-tier screening after the broad-based screening like SLE.
The PTSD Checklist
Another tool recommended by the Center for Substance Abuse Treatment (US) (2014) used in this facility is the PTSD Checklist which captures both combat and non-combatant traumas. This tool is appropriate since a counselor can choose the type of trauma to screen and give the clients answers concerning that particular trauma. Because of the ease of customization and coverage of different types of traumatic experiences, the tool is versatile and, therefore, appropriate for the center.
Dispositional Resilience Scale
Apart from the above assessments and screening tools, the clients will also be assessed for trauma-related symptoms like depression and suicidality. The reason for doing this is to ensure the counselors address both the internal and external resources like coping styles, strengths, and support systems (Center for Substance Abuse Treatment (US), 2014). When a counselor knows the client’s strength, it helps them in planning the treatment process, allowing them to apply strategies that have been successful in helping the client and harmonizing them with strategies that build resilience.
Screening for suicidality
Wamser-Nanney and Campbell’s (2022) study recommends that all clients assessed and found to have experienced trauma should be assessed for suicidality. They can be asked whether they have ever had suicidal thoughts or intended or attempted to commit suicide. A client with a history of trauma or substance abuse is always at a high risk of suicidal thoughts and behaviors.
Intervention Programs for Trauma
Prolonged Exposure
The first intervention that will be utilized in the facility will be prolonged exposure (PE). This intervention program is strongly recommended by both the Veterans Health Administration and Department of Defense (VA/DoD) and the American Psychological Association’s (APA) treatment for PTSD. It is founded upon the emotional processing theory that states that victims of trauma do not process their experiences emotionally at the time of the event. The theory further suggests that in a victim’s brain, fear appears like a cognitive structure that has the representations of the fear striking stimuli, the responses to fear, and the meaning that the victims associate with stimuli and the responses to the fear. It is perfectly normal when the fear structures represent real threats. However, there are situations when the fear structures do not represent reality, and they become dysfunctional and interfere with a person’s adaptive behavior. The main focus of PE is to alter that fear structures so that they stop being problematic. The PE entails two processes which begin with the activation of the fear structures, then incorporating new information that is not compatible with the wrong information.
The therapy requires 8-15 sessions, including psycho-education about PTSD and the reactions common to breathing retraining, common reactions to exposure and trauma, targeting both imaginal exposure and in vivo exposure. Even though the counselors will train the client, imparting essential skills to help them deal with stressful circumstances, it should never be used during exposure. In in vivo exposure, the patients learn appropriate ways of approaching circumstances, people, and places a client has been avoiding due to repeatedly fear stemming from the patients after a traumatic event until the condition reduces. The imaginal exposure entails helping the clients to approach the emotions, thoughts, and memories surrounding their traumatic events, which they have tried to avoid. Through these two types of exposures, the patients will activate their fear structure and then incorporate new information. This intervention method has been chosen because studies have proven its helpfulness across victims in diverse cultures and countries, regardless of the number of previous traumatic events of the period since traumatization.
Studies have shown the superiority of PE effectiveness in comparison to other intervention methods. For example, in one study, researchers found that individuals randomly assigned to PE therapy experienced more remarkable and more significant pre-post therapy PTSD symptoms reductions than those assigned to supportive counseling, relaxation training, and pharmacology (Watkins et al., 2018). According to Watkins et al. (2018), one meta-analysis revealed that, on average, patients taken through PE fared better than 86% of their counterparts in the control group on symptoms of PTSD when they were through with their treatment. Also, studies show that 41% to 95% of PE participants lost their traumatic diagnosis after completing their treatment, and 66% attained a loss of trauma diagnosis than those who were in the waitlist control groups (Watkins et al., 2018). These pieces of evidence demonstrate that PE is a tested and proven method of intervention that will be effective in attending to the PTSD patients at the center.
Cognitive Processing Therapy
The other intervention that is strongly recommended by VA/DoD and APA guidelines for treating PTSD is Cognitive Processing Therapy (CPT), which shall be used at the center, along with PE. CPT is based on the informed emotional processing theory and social cognitive theory and posits that the survivor will try to make sense of what happened to them after a traumatic event. Most of the time, such attempts lead to distorted cognition about the survivor’s understanding of themselves, other people, and the world. As the victim attempts to assimilate traumatic events with prior beliefs, they often accommodate, assimilate, or over-accommodate.
In assimilation, the incoming information is altered to confirm pre-conceived ideas, leading to self-blame for a traumatic encounter. For instance, victims may reason that they were assaulted since they did not fight harder. Accommodation, on the other hand, entails a person altering their beliefs to accommodate new learning. For example, when a client says, “I could not have prevented them from raping her.” Over-accommodation, on the other hand, entails a victim changing their belief to prevent a traumatic event from occurring in the future. For example, the victim can start believing that the world is dangerous, and that people cannot be trusted. So, they will say, “Because I was sexually assaulted in boarding school, I cannot trust anyone.” During CPT, the memory is cognitively activated, and maladaptive cognitions, including assimilation and over-accommodation that have emerged from the trauma, are identified to shift the beliefs towards accommodation.
The center will adopt Resick et al. (2017)’s updated treatment manual for CPT, which consists of 12 weekly sessions delivered in group or individual formats. CPT is an effective tool that has been studied widely. Initially, it was developed to treat rape survivors. Over time it has been modified scientifically and implemented in treating all trauma types in different populations. Studies show that it is effective in treating PTSD in survivors of sexual assault, veterans who served in wars in countries like Afghanistan, Iraq, and Vietnam, and adult men with comorbid PTSD and TBI. It exhibits a clinically significant reduction of depression, anxiety, and PTSD in the Veteran and sexual assault sample. According to Watkins et al. (2018)’s appraisal, 30% to 97% of participants treated through CPT no longer met the diagnosis criteria for CPT, while 51% more participants taken through CPT attained a PTSD diagnosis when compared to usual care, waitlist, and self-help booklet control groups.
Cognitive Behavioral Therapy for PTSD
The other intervention utilized at the center is CBT for PTSD, which VA/DoD and APA strongly recommend. This therapy will be complimentary since it will include the trauma-focused behavioral and cognitive techniques not found in PE and CPT. This trauma-focused therapy is founded on behavioral and cognitive models drawn from theories like PE and CPT. It is based on the postulate that a person with PTSD has excessive negative appraisals of their traumatic experience and that they have autobiographical memory of trauma that leads to strong associative memory, poor contextualization, and strong perceptual priming leading to involuntary traumatic re-experiences. Clients with such memories are not able to change their trauma memories and negative appraisals. Therefore, this therapy aims to modify the negative appraisal, remove the problematic cognitive and behavioral strategies and correct the autobiographical memory. In this therapy, traumatic thoughts and images are paired with guilt-associated appraisals, which evoke adverse effects.
Research supports the effectiveness of CBT for PTSD, with one study showing that it is more effective than a waitlist, supportive therapy, and self-help booklet. From the research reviewed by Watkins et al. (2018), participants treated with CBT lost 61% to 82.4% of their PTSD diagnosis, while 26% percent more attained PTSD diagnosis loss than supportive counseling and waitlist counterparts. Treatment programs that embraced the exposure components and cognitive restructuring yielded the most apparent effect size, resulting in fewer PTSD patients at a follow-up six months later.
Cultural Competency Related to Trauma and Client Interventions
Cultural competency entails a myriad of the correct personal traits like awareness, knowledge, and skills that each therapist or a counselor should have. Under the cultural and beliefs segment of cultural competency, healthcare providers will be expected to be sensitive to their personal biases and values and how such matters can influence a client’s perspective, client problem, and the relationship between the counselor and client. Sue et al. (2009) advise that about cultural knowledge, the counselors are required to know the client’s worldview, culture, and expectations for their counseling relationship. Lastly, regarding cultural skills, the counselor should have the ability to intervene in a way that is culturally relevant and sensitive. These three significant competencies are recognized by and form the basis of the multicultural guidelines embraced by the APA.
Method of Delivery
One of the critical skills that a counselor must learn is the method of delivery which makes intervention culturally consistent, increases the provider’s and treatment’s credibility, and makes the therapy comprehensible to clients from the ethnic minority. Some of the methods of delivery include intervention tactics responsive to a client’s ethnic language. For instance, it is essential to translate materials into the ethnic minority’s language or have bilingual counselors who can help with translation. It also entails being responsive to the changing interpersonal intervention styles like showing a Hispanic respeto (which is culturally appropriate) or providing a cultural context for the intervention applied. Such changes are similar because they entail generic applications; counselors can implement them across different treatment types.
It is expected that the counselors will be able to communicate with the clients appropriately and acceptably culturally. A study showed that if a client is limited in English proficiency, they face many difficulties entering, continuing, and benefiting from the therapy (Sue et al., 2009). Such clients may require more culturally adapted interventions compared to clients with more excellent proficiency in English.
Apart from language, cultural competency adaptations should also be reflected in the counselor’s communication patterns. According to a review by Sue et al. (2009), it was revealed that people who are less acculturated were more inclined towards the use of the formal address. The participants not only used the personal pronoun “you” in their conversations with the facilitator but also addressed their group facilitator using their professional title (doctor). Such communication practices are consistent with the client’s cultural values of respect and reverence toward authority figures. Such patterns have been used in CBT and interpersonal psychotherapy. It is important to note that a counselor should understand the culture to effectively show and deliver respect in a given cultural context. In other intervention approaches, counselors have employed adapted practices like a drum call, a unity circle, a blessing, and the use of ethnic delicacies during an intervention and pouring of libation of forefathers.
Content
Another vital element of cultural competency is content which entails dealing with or discussing immigration, cultural patterns, racism, minority status, and cultural background experiences during an intervention. It is crucial to introduce content since it can increase credibility and understanding of the chosen intervention and also demonstrate how appropriate the intervention is to the client’s real-life problems. It is always important to include cultural content in the various interventions by addressing issues like acculturation, beliefs, and attitudes about health care and disability, migratory experience, and support networks. In this way, it is important to give room for storytelling because some ethnic groups, like the Latinos, answer their questions through narratives. In other contexts, a counselor can weave a folktale into a story meant to convey a given moral, helping the clients to quickly adapt to the intervention process. In all the interventions, the primary question in the therapist’s mind is where the content is appropriate to the client, considering their ethnic origins.
From this brief discussion, it is essential to note that evidence demonstrates that interventions adapted to cultural nuances benefit the intervention outcomes. This added value is more apparent when dealing with clients who are adults than when attending to youths or children (Sue et al., 2009). The effects of cultural adaptation of interventions are consistent with studies investigating how a counselor can implement an intervention concerning its original design. Overall, adaptations where some features of the intervention were added proved to be more effective than those adaptations where the counselors replaced one or several components of the intervention. Counselors should be mindful of this vital fact to ensure the outcome of their interventions is optimized. It is also essential to consider individual, ethnic, and cultural differences when considering the nature, content, and delivery style of intervention.
Three situations should warrant cultural adaptation during an intervention. Firstly, a cultural adaption of an intervention should be implemented if there is evidence that a given problem that a client has encountered comes from a specific set of resilience and risk factors in a particular ethnic group. Secondly, a cultural adaptation should be implemented if there is a poor response from clients from a particular ethnic group to given EBT approaches (Sue et al., 2009). What that means is that a counselor should apply cultural adaptations to EBT if the problems that a client encounters are because he or she belongs to a particular community or if the members of that ethnic group demonstrate a pattern of poorly performing to a standard EBT therapy.
Health Statutes and Regulations for Clinical Staff dealing with Trauma
Treating patients ethically is expected of all healthcare providers and is of particular significance to clients with trauma-related disorders since their trust in other people is severely broken by traumatic experiences. Therefore, the counselors attending to trauma victims regularly have special responsibilities to their patients due to the nature of their work. The Wellness Center and Renewal Place have specific regulations in dealing with clients that every counselor must adhere to. The following guidelines are adopted from the Green Cross Academy of Traumatology Ethical Guidelines for the Treatment of Clients Who Have Been Traumatized.
Firstly, the counselors shall protect the client’s confidentiality, especially concerning their history of trauma. They shall comply with all state and federal laws to protect clients’ confidentiality when being treated for trauma. Secondly, the counselors shall provide the clients with an easy-to-read statement of rights, including their right to confidentiality. Thirdly, the Wellness Center and Renewal Place shall comply with state licensing regulations in providing quality clinical supervision to all the counselors. Fourth, at all times, the counselor shall maintain customer-counselor relationships ensuring healthy boundaries are kept between the two. The center shall create and maintain a trauma-informed environment that respects clients’ self-determination, promoting their dignity and respect. Lastly, the center shall maintain a work environment that fosters counselor self-care.
In attending to clients, there is the issue of boundary crossing and boundary violation, and it is essential to understand the difference to ensure one offers professional services without violating their clients. Even though the above guidelines help counselors stay on course, the concept of boundaries can be interpreted contextually. According to the Center for Substance Abuse Treatment (US) (2014a), boundary crossing entails departing from the customary norms of counseling practice about the trauma and engaging in an activity that is non-exploitative, harmless, and can advance a client’s therapy. For instance, a counselor can take phone calls from clients between sessions if they are in a crisis. On the other hand, boundary violations entail crossings that are dangerous, unwanted, and exploitative, not meant to serve the well-being and growth of the client but for their self-gratification. An example of such crossing is when a counselor invites a client to the same AA session they are attending or when they share drinking stories for the gratification of the counselor.
References
Bhangu, A., Stevenson, C., Szulewski, A., MacDonald, A., & Nolan, B. (2021). A scoping review of nontechnical skill assessment tools to evaluate trauma team performance.Journal of Trauma and Acute Care Surgery, 92(5), e81-e91. Web.
Center for Substance Abuse Treatment (US). (2014). Building a Trauma-Informed Workforce. In Center for Substance Abuse Treatment (US), Trauma-Informed Care in Behavioral Health Services: TIP 57. SAMHSA. Web.
Resick, P., Monson, C., & Chard, K. (2017). Cognitive processing therapy for PTSD. Guilford Press.
Sue, S., Zane, N., Nagayama Hall, G., & Berger, L. (2009). The case for cultural competency in psychotherapeutic interventions.Annual Review of Psychology, 60(1), 525-548. Web.
Wamser-Nanney, R., & Campbell, C. (2022). Suicidality among youth exposed to complex trauma.Journal Of Aggression, Maltreatment &Amp; Trauma, 1-19. Web.
Watkins, L., Sprang, K., & Rothbaum, B. (2018). Treating PTSD: A review of evidence-based psychotherapy interventions.Frontiers In Behavioral Neuroscience, 12. Web.