In community mental health, most of your client’s mood issues are directly related to everything they have survived (to be fair, this is probably true for the rest of us too). Yet, most of them have survived some particularly horrible things. Many therapists aren’t comfortable with trauma. Many therapists have early horror stories of trying to do trauma work with someone who melted down in session, scaring both client and therapist. So therapists often spend a lot of time talking and focusing on symptoms, the way one might focus on bleeding without exploring the underlying wound or injury. Whole sessions may be spent on “check in” with things that have happened since last session.
If you work in community mental health, you’re already a trauma therapist. You don’t have the luxury of not being comfortable with trauma–the same way an ER doctor doesn’t have the luxury of not treating people for accidents. Because trauma is often the core of client distress and is the most common “problem” you will see, it is essential that you continually work to become a better trauma therapist. As you do this, you are likely to find the process of therapy more rewarding. Your clients are likely to start getting better as their core issues are more directly addressed in the process of therapy.
The following are things that you can do, right now, with clients. These interventions seem to work well with clients from assorted backgrounds and are helpful for clients with severe and complex trauma. At least, they are not likely to cause harm (which is the scenario to most avoid).
First, Do No Harm
Whatever you do, please be careful not to retraumatize your clients. Review the post “Baker’s Dozen of Things Not to Do with Traumatized Clients.” Avoid these “interventions” unless you have a very good reason to do otherwise.
Work Actively Toward Trauma Competence
Read. Essential books are Bessel van der Kolk’s The Body Keeps the Score (2014) and Judith Herman’s classic Trauma and Recovery (1997). Both are available on CD audio/Audible.com and the narrators for both are excellent. Listen to trauma therapist podcasts by gifted clinicians. There are hundreds of them and they are free. You can listen on the way to work. Attend intensive trainings that are trauma-focused. I have found that my weekend trainings and consultation in EMDR have been essential in working with clients to resolve trauma. Intensive trauma training can be expensive, but you may be able to meet nearly all of your continuing education requirements for your biannual licensing. Intensive trauma trainings have been a complete game changer. For the first time in the three years I have been a therapist, most of my clients are getting “better.” The vast majority of my most traumatized clients have improved so that they either no longer meet criteria for PTSD or are progressing rapidly in that direction. I had a front row seat to suffering for a long time. Now, I spend my days being the second witness to deep and astonishing healing.
Expand Beyond Language and into Creativity
Spoken language is just one form of communication. For clients who are talented in other forms, see if they are interested in exploring and sharing with you using poetry, journaling, artwork, music, movement, or other forms. While this can potentially cause trauma to seep and cause distress, it may promote expression of things that have been stuck. You can be the client’s supportive audience for this expression. Listening to and discussing a particularly meaningful song that is implicated in the client’s recovery, assertion of agency, or aspirational/inspirational can be a great way to talk about difficult things without opening too much up.
Mindful Coping Skills
It’s really difficult to “sell” the virtues of mindful coping skills when the therapist does not use them to manage her own stress. Therapists who work with traumatized clients have to find deep, meaningful, and helpful ways to manage the intensity of sessions (and life). Before I could convince clients to take deep breathing seriously, I had to incorporate it into my own daily life. I now deep breathe with clients in many sessions and it’s one of the most helpful and natural interventions that we do. Deep breathing has become a kind of Swiss army knife intervention that I do with virtually every client. If clients are having trouble implementing mindful practices between sessions, demonstrate them in session. You may need to do this repeatedly. Feeling relaxed will not feel safe for many traumatized clients. It is helpful to acknowledge this reality beforehand. The initial “distress” of relaxation is better tolerated if is anticipated. Encourage the client to keep “dipping his foot in” briefly into relaxation techniques until it feels safer.
Acknowledge the Horror
Many people who have been severely traumatized have never had the reality of the horror validated. When a client tells you something horrible, find a kind and empathetic way to acknowledge that horror. To do otherwise may reinforce the negative messages that have been communicated to the client by abusers and implicated family members, related to the trauma being “no big deal,” “something that didn’t happen,” or “happed a long time ago.”
Metaphor development is an underused intervention. It is particularly useful with trauma. My clients like and intuitively understand my Seeping Box Metaphor that explains trauma as a container that holds lava-hot stuff. That container has a lid that seeps to varying degrees depending on how life “shakes” it. In a small fraction of a session, a single working metaphor explains the cause of the problem, normalizes the problem as an expected human response to horror, explains why coping skills are essential and work well (to manage “leaks), and suggests multiple paths and mechanisms of recovery.
Internal Family Systems
Internal Family Systems is an approach to psychotherapy that many trauma therapists find useful (although I just use a tiny slice of it). I have found that explaining the basic premise of Internal Family Systems is incredibly helpful and liberating to many of my clients. They understand it instantly and intuitively. It’s one of the few interventions that they reference in sessions months after it has been introduced. Most of us have internal conflicts between our various “parts.” Clients with trauma often have intense internal conflicts between the parts of themselves–full-blown wars, in fact. Internal Family Systems divides these internal parts into three main categories: manager parts, firefighter parts, and exiled parts. Talking with clients about these internal conflicts and promoting better/kinder communication between disagreeing parts has been incredibly helpful to many clients. Richard Schwartz’s Internal Family Systems Therapy (1997) is quick and accessible to read.
Develop Your Presence
Regardless of interventions used, the client-therapist relationship is the base of the container that permits everything else. My clients struggle mightily with trust and for good reasons. They struggle with trust with me. Likewise, I sometimes struggle to maintain the level of presence that they need. I have to show up. More than anything, my clients usually need me to be present, attentive, and attuned for good work to occur. These things have helped me to better cultivate my presence: talking openly with clients about the quality of the relationship and what the client needs from me; being very aware of when misconnections are occurring and addressing them; staying well within my boundaries and roles as a therapist on one hand, yet striving to be completely and authentically myself on the other (I realize that this is sort of a contradiction… for me, it is partly resolved by thinking deeply about the word “genuine” from the perspective of each hand).
Find Your People
It should be no surprise that some of the best things that you can do for your clients as a trauma therapist involve taking care of yourself. This is a high-risk profession. When you lose your empathy, you are unlikely to realize that you have lost it. It’s easier than not to become a zombie therapist. The priest just hears about guilt and he hears the headline. We hear about all of it and a lot of it is absolutely horrible. We sit three feet from people in incredible pain for an hour at a time all day long. Without good self-care, maintaining empathy in the long-term can come at the cost of maintaining sanity. This impossibly difficult job is made easier when you surround yourself with trauma therapist friends whose empathy, skill, and insight you admire. Trauma therapists who operate in a vacuum are likely to have everything good sucked out of them. Find your people. They will be busy. You are busy. Make it happen.
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