Trauma Focused Clinical Supervision and Workforce Development

TRAUMA FOCUSED
CLINICAL SUPERVISION
Building Trauma Competence in Our Workforce
Toni Mosley, M.S. and Brenda Wiewel,
LCSW
October 27, 2011

WORKSHOP OBJECTIVES
1. Define trauma informed supervision and goals
2. Review the impact of trauma on the treatment process
as it relates to clients and clinicians
3. Learn how to help clinicians take the trauma into
account, while maintaining their own balance through
self-caretaking
4. Explore how to address vicarious trauma and trauma
triggers for staff to improve staff functioning and prevent
burnout

TRAUMA IMPACT
ON ROLES AND RELATIONSHIPS
Parallel process
Client/Therapist
Therapist/Clinical Supervisor
Importance of relational issues
Awareness and incorporation of trauma impact

TRAUMA: GENERAL DEFINITION
An extreme stress that overwhelms a
person’s ability to cope -- a normal
response to an abnormal event.

HUMAN BIOLOGY
Our body responds automatically to stressful
situations, especially those that are perceived as a
survival threat where we feel fear, horror, and
helplessness
The result is an impact on our body’s nervous system
and brain chemistry
We may then negatively label our reaction, leading to
self-blame/shame

UNDERSTANDING THE BRAIN
1. External stimulus
perceived by
prefrontal cortex
2. Hormones sent to
amygdala for flight,
fight, or freeze
3. Survival memories
imprinted in basil
forebrain
4. Bypasses cerebral
cortex where
logical thinking
occurs- so need to
reprocess through
cerebral cortex to
put all the pieces
together

TWO PART NERVOUS SYSTEM
Part 1: Sympathetic
Prepares for action by ramping us
up, energizes or activates body
Part 2: Parasympathtic
Prepares for rest by relaxing
body
This part gets stuck on if external
risk or threat from stress is high
We need to learn how to reduce this
automatic activation.
This part lies dormant when part
1 is stuck on “ON”. We need to
learn how to turn back on the
rest/relaxation response within
body to rebalance ourselves.

RESILIENT ZONE
Each body has a resilient zone where we are able to function best
in all areas
Stressful events (too much/too fast/too long) can bump us out of
our resilient zone
Stuck on LOW: depression, fatigue, numb
Stuck on HIGH: hyper-vigilant, anxious, rage
Can cycle between low and high out of resilient zone

PRINCIPLES FOR TRAUMA-INFORMED TREATMENT
Take the trauma into account.
Avoid triggering trauma reactions and/or
traumatizing the individual.
Adjust the behavior of clinicians and the
organization to support the individuals’ coping
capacity
Allow survivors to manage their trauma
symptoms successfully so that they are able to
access, retain, and benefit from the services.
(Harris and Fallot)

CORE CONCEPTS FOR TRAUMA-INFORMED
TREATMENT
• Trauma-informed services are based on an
understanding of the impact of violence and
victimization
• All treatment for substance use/co-occurring
disorders should be trauma-informed
Institute for Health and Recovery

CLINICAL SKILLS FOR TRAUMA-INFORMED
TREATMENT
See trauma as a defining and organizing
experience that can shape a survivor’s sense of
self and others
Develop a self-care plan (as a helper) to avoid
compassion fatigue and burnout.
Establish clinical intervention strategies that
respond to the individual’s experience of
trauma

STRATEGIES FOR TRAUMA-INFORMED TREATMENT
Clinician works with client to:
get and stay safe
separate here and now from there and then
stay in control of process
recognize and understand trauma triggers
use safe coping skills to manage reactions
support emotional literacy development
recognize and use internal strengths
build and use external support systems
THESE ARE THE TREATMENT PLAN GOALS!

FAILURE TO UNDERSTAND & ADDRESS TRAUMA
CAN LEAD TO:
1. Failure to engage in treatment services (Farley, 2004)
2. Increase in symptoms (eating disorders, self-harm)
3. Increase in management problems
4. Retraumatization (Harris and Fallot, 2001)
5. Increase in relapse
6. Withdrawal from service relationship
7. Poor treatment outcomes (Easton et al 2000; Ouimette et al 1999)
Institute for Health and Recovery

UNIVERSAL PRECAUTION
A client should not
have to disclose
trauma to receive
trauma-informed
services—treat
everyone as a potential
trauma survivor.
Institute for Health and Recovery

CLINICAL IMPLICATIONS OF
TRAUMA IN TREATMENT
FOCUS ON THE CLIENT

CORE ISSUES THAT IMPACT A CLIENT
WHAT IS THE EMPHASIS AREA FOR THE CLIENT
WHAT ARE THE IMPLICATIONS FOR TREATMENT
Relationships
Cultural Context
Cognitive/Affective Coping
Life Experience/Trauma
Gender Role
Developed by Toni Mosley M.S. (2007)

SAFETY
Safety is an enormous therapeutic task for many clients
Treatment progress can’t occur unless a client feels
safe
How does the client/clinician define safety
What are barriers to client feeling safe
How can the clinician intervene to improve physical
and emotional safety

TRIGGERS
In AOD, trigger refers to people, objects, feelings,
times that cause cravings
In trauma, trigger refers to people, objects, feelings,
times that cause trauma memories/PTSD symptoms
Cycle of trigger-trauma reaction can be emotional,
behavioral, or attitudinal and feels overwhelming
Clients may need help to manage the symptoms and
triggers

KEY TRAUMA SYMPTOMS
Dysregulation of emotions
High level of anxiety
Dissociation
Lack of support to label and identify experience

CLINICAL IMPLICATIONS OF
TRAUMA IN TREATMENT
FOCUS ON THE CLINICIAN

KEYS TO DEVELOPING THERAPEUTIC
RELATIONSHIPS WITH COD CLIENTS
1. Use therapeutic alliance to engage client in treatment
2. Maintain a recovery perspective
3. Manage counter transference
4. Monitor psychiatric symptoms
5. Use appropriate and empathic counseling
6. Employ culturally appropriate methods
7. Increase structure and support

10 STRATEGIES TO SUPPORT
CLIENTS
1. Listen more than talk
2. Give permission to speak
3. Respond to the pain you hear the client convey
4. Support emotional literacy
5. Help client understand role and use of grounding tools

10 KEY STRATEGIES TO SUPPORT CLIENTS
6. Help client identify individualized coping tools
7. Check for client’s readiness for change
8. Support safety plan development and use
9. Look for link to trauma experience in survival, protective,
or defensive behaviors that interfere with relationships
10. Never underestimate the power of caring

RELATIONAL BARRIERS
Inability to connect with self
Problems with parental bond
Difficulty connecting with others

OVERCOMING RELATIONAL BARRIERS DURING
TREATMENT PROCESS
Clinician is the tool of his/her trade
Create a holding environment with safety
Focus on relationship difficulties
Tolerate client’s level of anxiety and emotion
Build capacity for emotional processing an insight

BASIC CONCEPTS FOR CLINICIANS TO LEARN
Client choice and self-control: client must be a full partner in
deciding on goals, feel validated regarding experiences, and be
given info/options to help improve decisions and self-care
Need to recognize trauma triggers/reactions and help client
feel supported
Importance of responding to immediate practical needs,
especially safety
Clients have ability to develop a healthy compassionate
resource within themselves
Clients can learn to listen to their bodies, understand their
feelings or symptoms, and express themselves

CLINICAL IMPLICATIONS OF
TRAUMA IN TREATMENT
FOCUS ON THE CLINICAL SUPERVISOR

BOUNDARIES
Maintain strong boundary expectations for clinicians
Train and educate about expressing their own
feelings and reactions outside of the client- clinician
relationship safely and appropriately
Help clinicians learn and practice safe and
professional options for how to respond to
aggressive, agitated, overly clingy/dependent, or
isolative behaviors in clients
Clarify how boundary violations harm clients

TRAUMA TRIGGERS FOR CLINICIANS
Create a safe supervisory environment for clinicians to
identify and communicate as needed/desired about their own
trigger reactions
Help clinicians understand their own reactions in relation to
their personal history
Teach clinicians to take responsibility to protect clients
from their own overreactions or to re-engage clients
afterwards

PRACTICAL STRATEGIES TO HELP CLINICIANS
ACCOMPLISH TRAUMA-INFORMED TREATMENT GOALS
Evaluate clinician strengths, capacity for self-awareness,
tolerance for strong emotions, and listening skills
Be patient
Use broken record technique to teach key concepts
Carefully match clinicians to clients, considering trauma
issues and vulnerabilities on both sides
Maintain positive curious attitude that there is always a
reason behind behavior to discover and learn from

KEY AREAS FOR CLINICAL SUPERVISION
Client/Clinician emotional regulation or
disregulation (overloaded=stuck on “on” or
shut down=stuck on “off”
Immediate practical needs (danger in
environment)

ATTENTION TO CLINICIAN PROCESSES
Attend to Negative Countertransference:
1. Harsh confrontation
2. Inability to address accountability
3. Becoming a victim
4. Power struggles
5. Allowing clients to be scape-goated in group settings

ATTENTION TO CLINICIAN PROCESSES
Building an alliance
Compassion for client’s experience
Using various and assigned coping skills
Providing an environment of control
Modeling and meeting clients halfway
Open to obtain feedback

CLINICAL SUPERVISION QUESTIONS
Identify 1 concern you have about your client and how this
relates to a strength they bring.
What is hardest for you personally when you interact with
your client Is there a parallel process here
How is the client’s behavior related to their trauma triggers
and reactions
How is the client’s behavior triggering something for you
(the clinician) personally
How am I (as the supervisor) reacting to this clinician Is
there a parallel process here and is it trauma related
At what points might you have wandered away from your
clinician role

SKILL PRACTICE
Please join into groups of three, pick one person to play the client, clinical, and clinical supervisor
1.Client will choose an issue (significant grief/loss, rape,
domestic violence) and discuss what they need to do to take
care of themselves
2.Clinician will then share how this might affect them and
what they need to do to take care of themselves with the
clinical supervisor
3.Clinical supervisor will then discuss what they might do
with what they heard.