Trauma history

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It is important to identify whether the client has experienced any traumatic events in his/her life [276, 281, 282]. As described in Chapter A4, traumatic events do not refer to any event that the person has found upsetting. Rather, they are events where the individual perceived his/her own (or someone else’s) life or physical integrity to be at risk. The trauma may be a one-off event or it may have occurred over a period of time [24].

A history of trauma exposure may be integrally linked with the person’s current AOD use; a number of people with AOD use disorders who have experienced trauma describe their use as an attempt to self- medicate the thoughts and feelings they have had since the trauma. The presence of a trauma history also indicates that further investigation is required to determine whether the person may have symptoms of PTSD (described in Chapter A4).

While identification of past trauma is important, questioning needs to be sensitive and should not be pursued if the client does not wish to discuss it. In some circumstances, it may be better to raise the issue of trauma several weeks after the initial assessment interview, once the client feels safer and has developed a therapeutic relationship with the AOD worker [276]. Before conducting trauma assessments, workers should seek training and supervision in dealing with trauma responses. Some AOD workers may be reluctant to discuss trauma with their clients due to events that have happened in their own lives. These workers should seek assistance from their colleagues and should not be forced to conduct trauma assessments if they are not comfortable doing so.

Before questioning the client, the AOD worker should:

  • Seek the client’s permission to ask him/her about exposure to traumatic events, and advise the client that he/she does not have to talk about these experiences or provide any detail if he/she does not want to. Clearly communicate the reasons for asking about past trauma. It may not be readily apparent to the client that his/her current situation may be related to his/her past [281]. For example, clearly explaining to the client that the questions relating to trauma will help contextualise his/her druguse, which will also help gain a better understanding of the interplay between AOD use and trauma symptoms [276]. Ensure that the client has the opportunity to say if they feel uncomfortable.
  • Advise the client that talking about traumatic events can be distressing; even clients who want to talk about their trauma history may underestimate the level of emotion involved [282]. It should be noted that studies have found that while some people may become upset when talking about these events, talking about the trauma does not overwhelm or re-traumatise the majority of people. On the contrary, most people describe the process as a positive experience [283-286].
  • Advise the client of any restrictions on confidentiality; for example, in relation to the mandatory reporting of children at risk or serious indictable offenses.

When broaching the subject of trauma, ask the client if he/she has ever experienced any traumatic events such as witnessing or experiencing: car accidents or other types of accidents, natural disasters, war, adult/ childhood physical or sexual assault, having been threatened. Reliable reporting of events is best obtained by asking about specific event types. Under-reporting of exposure tends to occur when people are asked only broad questions such as ‘Have you ever experienced a traumatic event?’ [287]. Standardised screening tools such as the Traumatic Life Events Questionnaire (TLEQ) and Trauma History Questionnaire (THQ) described in Appendix H may be used to assess for a history of trauma exposure. Some clients find it easier to complete a self-report screener than to say aloud to the assessor that they have, for example, been raped [282], and research suggests that verbal disclosure of trauma via interview evokes more distress than completing written questionnaires [286]. However, such screeners should always be completed with an AOD worker present and should never be given to the client to complete at home. 

It is important to understand that clients may be uncomfortable answering questions relating to past trauma because of the personal nature of such questions. Client discomfort may also be associated with distrust of others in general (or of service providers in particular), a history of having their boundaries violated, or fear that the information could be used against them [281].

During the trauma assessment it is essential that the AOD worker questioning the client does not ‘dig’ for information that is not forthcoming, as this may result in destabilisation [282]. For those who have experienced interpersonal trauma in particular, such pressure from an authority figure may imitate the interpersonal dynamics that were evident in an abusive relationship and exacerbate trauma symptoms. There is an inherent power imbalance in the helper–helped relationship and AOD workers must do their best to reduce this inequity [281]. Trauma and AOD use are both characterised by the loss of control and it is important that a sense of control be re-established. The following are some additional guidelines on discussing traumatic experiences with clients [288]. Further information regarding the management of trauma symptoms is provided in Chapter B6.

  • Create a safe, welcoming environment. Let clients know what to expect and avoid surprises. Sometimes clients who have experienced trauma may be physically and mentally ‘on guard’, so use slow, calm movements, and a gentle tone of voice, and don’t encroach on their personal space.
  • Adopt a non-judgemental attitude. People who have experienced trauma often feel a great deal of shame and guilt either in relation to the trauma itself or how they reacted to the trauma. Sometimes clients may have experienced stigmatisation from others due to their trauma experiences, mental health, and/or AOD use. The client needs to feel that the AOD worker does not consider them in a negative way (e.g., weak, immoral). It is important not to judge how the person reacted during or after the trauma. It is easy to judge people harshly with the benefit of hindsight, but even if they did make a mistake in judgement, they did not deserve to suffer.
  • Display a comfortable attitude if the client describes their trauma experience. Some clients will have had experiences that people do not want to hear about, especially the gruesome or horrific details. They need to know that they can tell you anything.
  • Praise the client for having the courage to talk about what happened. The client needs to know that you appreciate how difficult it is for him/her to talk about his/her trauma. Make it clear to the client that you respect and admire his/her strength in coming through the traumatic experience and in seeking help, but do not patronise them.

  • Normalise the client’s response to the trauma and validate their experiences. Many people who have experienced trauma (especially those with PTSD) feel that they are ‘going crazy’ because of the feelings they may have had since the trauma (e.g., re-experiencing the event, avoidance, hypervigilance). Just hearing from a professional that the reactions they are experiencing are common helps to normalise their experience, and also alleviate possible shame or guilt about not recovering sooner. Normalisation and validation are discussed in further detail in Chapter B6.