It is important to identify whether the client has experienced any traumatic events in their life [389], as many clients presenting for AOD treatment report a history of trauma [137, 138, 378, 434]. As described in Chapter A4, the word trauma is widely used and can mean different things to different people. In these Guidelines, we use the word trauma to refer to an extremely threatening or horrific event, or a series of events, in which a person is exposed to, witnesses, or is confronted with a situation in which they perceive that their own, or someone else’s, life or safety is at risk [10, 11]. Examples of potentially traumatic events include, but are by no means limited to, being involved in a road traffic accident; experiencing or being threatened with physical or sexual assault; being in a life-threatening car or other form of accident; combat exposure or being in a place of war or conflict; or witnessing any of these events. The most important factor in understanding a person’s experience of an event is whether or not they perceived it to be a traumatic event; events that may be traumatic to some people may be perceived as relatively minor to others, and vice versa.
As described in Chapter B2, 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 ‘block out’ or reduce the thoughts and feelings they have had since the trauma [30]. 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).
Recognition and identification of past trauma is an important component of providing trauma-informed care (see Chapter B2). 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. Each AOD worker must use their judgement and expertise in determining when it is clinically appropriate to ask trauma-related questions based on a client’s presentation. 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 [389].
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 them about exposure to traumatic events, and advise the client that they do not have to talk about these experiences or provide any detail if they do not want to. Clearly communicate the reasons for asking about past trauma, and begin with general questions that become more specific as client comfort increases [156]. It may not be readily apparent to the client that their current situation may be related to their past [435, 436]. For example, clearly explaining to the client that the questions relating to trauma will help contextualise their substance use, and will also help gain a better understanding of the interplay between AOD use and trauma symptoms [389]. 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 [437]. 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, even in the context of distress, most people describe the process as a positive, validating experience [402, 438, 439].
- 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 they have 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, or 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?’ [400, 440]. Standardised screening tools such as the Life Events Checklist (described later in this chapter) may be used to assess for a history of trauma exposure. Some clients find it easier to complete a self-report screening tool than to say aloud to the assessor that they have, for example, been raped [437], and research suggests that verbal disclosure of trauma via interview evokes more distress than completing a written questionnaire [402]. However, such screening tools 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 [390, 391]. Clients may also fail to disclose their trauma due to an inability to recall it, feelings of loyalty towards their perpetrators, and dissociative responses in reaction to any inquiry about trauma [436].
During the trauma assessment it is essential that the AOD worker questioning the client does not ‘dig’ for information that is not forthcoming, as doing so may result in destabilisation [395, 437, 441]. 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. As described in Chapter B2, there is an inherent power imbalance in the helper–helped relationship and AOD workers must do their best to reduce this inequity [390, 394, 395]. Trauma and AOD use are both characterised by the loss of control, and it is important that the client feels able to regain a sense of control. In line with this, it can be useful to periodically check in with the client and make sure they are comfortable to continue the discussion [390].
The following are some additional guidelines on discussing traumatic experiences with clients during assessment and at other times during their treatment [442]:
- Display a comfortable attitude if the client describes their trauma experience. Some clients will have had experiences when people did not want to hear their account, especially when details of the experience are gruesome or horrific. The client should know that they can tell you anything.
- Recognise the client’s courage in having talked about what happened. The client needs to know that you appreciate how difficult it is for them to talk about their trauma. Make it clear to the client that you respect and admire their 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 may help to normalise their experience, and also alleviate possible shame or guilt about not recovering sooner [443].
- Utilise grounding and other techniques as necessary. If a client is having a very strong emotional reaction to talking about their trauma, consider the use of techniques outlined for the management of trauma symptoms provided in Chapter B7 and Appendix CC.