Dancing Around the Unspeakable at Intake

“Have you ever been emotionally, physically, or sexually abused?”  It’s a standard intake question asked tens of thousands of times a day as part of mental health assessments all across the country.  At the beginning of my career I asked this question within the first 20 minutes of meeting every client for the first time.  That question was on my intake form. I thought it was my job to ask that question and to provide a summary of the client’s response in the space below it.

It wasn’t until a close friend and fellow intern pointed out how triggering that question can be for clients with trauma that I started to find other ways to take a trauma history.  If I am honest, I had abundant evidence of how activating that question can be from my initial clients: some clients burst into tears; some simply went blank; some nodded “yes,” but refused to say more; and some clients nodded “no,” only to come back a session or two later and tell me through tears how guilty they felt for “lying to me.”  Like a nurse ripping off a bandage quickly, I thought it was my job as a “professional” to ask these hard questions and it was the job of the client to endure it.  I did not know that I had options… that the client had options.

Clarify Roles and Options

Now, my intake assessments begin with a clear explanation of who I am (my professional role as a counselor) and what is about to happen over the next hour.  I then ask the client’s permission to continue the assessment.  I’m careful to clarify my role, because a surprising number of people I saw early in my career thought I was a prescriber throughout the assessment, only to get to the end of it and ask some version of: “wait, what just happened here?”

As part of my introduction, I attempt to give the client as much flexibility as possible in responding to my questions:

Some of the questions I might ask can connect with difficult stuff for some clients and I don’t always know which questions might be upsetting.  It’s often better to talk around difficult things in the past the first time I meet someone than it is to open up that stuff before the person has a chance to be comfortable here.  Please feel free to let me know that you would like to skip or wave off [I make a hand motion letting the client know he does not need to speak his intention of moving on] anything that might be difficult to talk about.  I don’t need to know details about anything today.

If a client does disclose something difficult, make sure that you validate and align with the experience of the client and don’t rush to tell the client how she should feel about anything.

The Scope of the Problem in Our Clients and in Our Profession

Complex trauma is much more common than I initially realized. Among the first 300 clients that I saw at the beginning of my career, at least two thirds had unspeakable trauma—meaning that they could not talk about it without causing a catastrophe in the body.   The vast majority of the other third had survived astonishingly horrible things but they were able to allow it (or parts of it) into consciousness and into language without intense incident.  For nearly everyone I saw, life had been profoundly wounding.  In community mental health, extensive trauma is the rule rather than the exception.

A history of extensive past counseling is not necessary an inoculation against the unspeakable.  Effective trauma work in counseling is astonishingly rare.  In my first four full years as a mental health therapist across two agencies serving about 300 people in different populations I did not meet a single client who ever has engaged in structured trauma treatment (I have asked every client about their progress and experience of past therapy).  Not one… even though the vast majority of my clients had been in therapy for many years.  Based on the experience of my clients in past therapy, “professional” trauma care generally hasn’t even evolved to the equivalence of the medicinal bloodletting stage, much less evolved beyond it.  Said differently, a client may have been therapy nearly all her life across a half-dozen agencies and her trauma may still be stuck, lava-like, and unspeakable.

These Things will be Triggering for Many Clients at Intake

For clients who carry containered lava in their limbic brains, be careful how you ask them to interact with that lava before you help them develop lava gloves.  You can expect that these questions or interventions at intake will be triggering for many clients with unspeakable trauma:

• Doing any of the items on this list.
• Asking the client to tell you more details about a traumatic event.
• Asking questions that might open adjacent traumatic content, for example: “When that happened to you, who did you tell?” [Often what comes after a traumatic event is even more wounding than the event itself.]  “What do you think that you felt at that time?”  “Was he ever punished for what he did to you?” “Do you have any insight into why they did that to you?”
• Allowing a client who is already upset and may be already outside of her affective window of tolerance to continue to tell you about additional horrible things that have happened to her.
• Not letting a client who is comfortable communicating about his past wounding communicate about his past wounding. [Yes, you can be too cautious and a client may not feel heard or validated.]

Things You Can Ask Instead of That Question

One of my favorite assessment questions related to developmental trauma is: “When you were young, who knew how to love right?”  This question is incredibly helpful and is rarely triggering.  At least a quarter of my clients respond with “no one.”  My clients do not need to think about this question.  At some point in development, the rational and emotional brain have already computed that sum.  They usually respond quickly and definitively.  If the client reports severe attachment deficits, we quickly move on to avoid trauma seeping connected to people who should have been supportive attachment figures but weren’t.  This question lets me know a lot that is helpful for assessment and for treatment planning.  It will inform the phase two EMDR resources that we will have in place before tackling any attachment connected traumatic memories.

It is much, much, safer to assess for current symptoms than it is to ask the client to tell you a trauma narrative.  In short, do everything you can to avoid having the client to tell you a detailed trauma narrative on first contact.  This is especially true if the client is moderately or highly anxious before discussing traumatic content.  It is better to ask one of these questions (and notice the vague and passive way that past trauma is referenced in the questions):  Do you ever have bad dreams related to anything that may have happened in the past?  Without going into details, do you ever have very visual (or sensory) memories of something that happened in the past?  If the client responds affirmatively to either question, I’m likely to ask the client to help me complete a PCL-5.  For my clients, the PCL-5 is significantly triggering for less than one client in 100.  As with all interventions or assessments, I’m careful to ask permission and I do so in this way:

If it’s okay with you, I’d like to ask you some questions about your current symptoms that may be related to past difficult experiences.  These questions do not ask about what happened to you in the past, it simply asks how much you are bothered by certain symptoms like anxiety now.  Most of my clients can complete this with me without it being too difficult.  If anything difficult comes up just let me know.  It’s fine to just put aside.  Is it okay to try?

I do a PCL-5 with most of my clients.  When client report or therapist intuition indicate we also do a Dissociative Experiences Scale.  I read, record responses, and explain the questions if needed.  I never ask my clients to complete either assessment on their own.  Completing the assessments together provides an opportunity for conversation and psychoeducation that might not be possible otherwise.  The PCL-5 provides a fairly comprehensive snapshot of potential trauma seeping and can help guide both diagnosis and treatment planning.

Other questions that may more gently start a conversation than that standard assessment question is: Without going too much details, how difficult was it for you on a scale of one to ten before the age of seven?  Between seven and 13?  Between 13 and 18?  Between 18 and now?  If the client reports difficulties, you can gently ask (and again give permission to the client to speak generally or to skip responding entirely): “In general, what was going on that made things difficult for you at that time?”

Also, having a discussion with the client about negative cognitions is usually much safer than asking the client to speak about specific traumatic events.  Negative cognitions are often closely tied to traumatic memories but may be stored in different enough mind-space to avoid severe triggering.  Negative cognitions are also very helpful in both assessment and treatment planning.

I Promise, At Intake You Don’t Have to Know Exactly What Happened to the Client

Throughout this short essay, I’ve encouraged you to approach traumatic content carefully.  You don’t want to open any doors that the client can’t easily close.  Otherwise, the first time may be the last time that you see that client.  I also don’t intend to communicate that phase one of EMDR Therapy isn’t necessary.  It’s essential.  But, you do not need to take a comprehensive inventory of awfulness from every client on first contact.  You don’t.  In short, you don’t need to know.  You have options.  The client has options.  You and the client can learn a lot about each other by how you dance together around the lava—especially at first contact.