A journal of creative thought and feeling published by LIOS ...

It rapidly became clear to me that she did not think of what had
happened to her within her family as abusive, and yet she had recited
a list of traumatic episodes, which by any of our current Washington
laws would have clearly been considered sexual, physical and verbal
abuse of a child. The perpetrators in her story were her mother and her
older brother, with whom she had detailed a conflicted relationship.
What followed over the next several months was a comprehensive
exploration of her childhood traumas. Most of our goals were small
and achievable within the context of a one-hour session. With each
story, she began drawing pictures of her internal experience, creating
a collection of artwork that was both stunning and revelational
to her as her understanding evolved. We set small goals for her to
accomplish between sessions as well, in order to address her depression:
get outside for 20 minutes each day; call your daughter and
tell her you’re sorry about what happened to her; write a letter to
the depression; and other small actions she could take in support of
her own healing. But the real breakthrough came about six months
into our work together. She had been telling me about another
incident that occurred with her brother as a child, when she
suddenly stopped speaking and looked up at me in dismay. “He
abused me.” In that moment, she understood beyond any doubt
that the word “abuse” was not just a word that had happened to
her daughter, it was her own experience. I waited. She whispered it
again, “He abused me. Lots of times.” Tears began to run silently
down her face, “That’s why I’m so messed up.”
From that point forward, her symptoms began to recede dramatically
as she reclaimed her life, and gave herself permission to be
angry at her brother and the other family members who took no
action to intervene on her behalf, and in some instances told her
to “Suck it up. It’s not that big a deal.” At one point, she said, “I’ve
been going to therapy for years. This is the first time I can see
myself getting better. I can really see it.” I observed, “Maybe you
were ready to do the work now. Maybe it just got safe enough.”
What I often tell clients is that traumatic stress is a chameleon.
It masquerades as other diagnoses—depression, anxiety, ADD/
ADHD, sleep disorders, sexual dysfunction, to name a few.
Treatment modalities that focus on symptom reduction, as
required by most insurance plans, can be very effective for many
people. But, if there’s a trauma history, it’s worth taking a look at
the underlying causes for the symptoms, especially if conventional
treatments do not appear to be working over time. For therapists,
this creates some specific treatment issues.
At the first session, we can be so focused on getting that diagnosis,
and developing a clear treatment plan, that we neglect to ask the
questions that will evoke the information needed to assess trauma
as a possible precursor to the current symptoms. Our insurance
company contracts require us to file claims with a clear diagnosis
attached. Without the diagnosis, we do not get paid. And yet, if
there is a trauma history and we don’t know it exists, we set up
treatment modalities that are less than effective for the client.
Consider the following ideas to build an assessment process that
uncovers potential trauma in a client’s history.
Consider allowing more time for assessments than a typical session.
Taking a comprehensive family history is very difficult to complete
in a 50-minute session. It can be helpful to assess a client over two
sessions, or to do extended intake sessions, if your schedule allows.
Avoid using the word “abuse” in your questions. If you ask many
clients over the age of 40 whether or not they were abused as a
child, they may tell you they were not, because their childhood
family culture may not have recognized family dynamics as abusive.
Thus, they do not label their experience as abuse. Instead, consider
asking questions like: “How did your parents discipline the children
in your home as a child?” “Was there anyone you were afraid of as a
child?” “Were there things no one was allowed to talk about when
you were a child?” “How did your family handle secrets?”
Ask about current safety issues. For instance, you might ask: “Is
there any reason I should be concerned about your safety in your
current living situation?” “Are there any dynamics going on between
you and someone else in your home that you think might be
contributing to your feelings of depression/anxiety/inability to
concentrate?” Many victims of childhood abuse are involved
in abusive relationships as adults. The shame of these relationships
keeps ongoing victims from being willing to admit they are in
abusive dynamics at home. However, if you tie your questions to
concern about their well-being and possible causes of symptoms,
they are frequently more willing to speak about their situations.
Even if they don’t answer the questions during the assessment,
they are more likely to realize you are open to hearing about these
experiences, and to think of you as a resource when they are ready
to talk about it. If safety issues are current problems, then it will be
imperative to develop a safety plan prior to doing any other work. A
client whose home life is inherently unstable and volatile is unlikely
to be able to tolerate in-depth exploration of her trauma history.
Consider your diagnosis a working diagnosis, and be ready to
change it if new information emerges. New clinicians, in particular,
can get very focused on getting the “right” diagnosis, rather than
seeing a diagnosis as a fluid concept that can evolve over time. It
is easy to get stuck thinking of a client as “depressed, 52-year-old,
Caucasian woman,” instead of remaining open to what you do not
yet know about her. In spite of the rigor with which the DSM was
Photo by John McConnell, M.A., LIOS, 1996; Images of Leadership Project
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