Managing trauma-related symptoms

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The importance of providing trauma-informed care in AOD treatment settings has received increasing recognition in recent years [346, 806, 807]. It is common for the frequency of trauma-related symptoms to increase when a person stops drinking or using drugs [808-810]. This is because clients often use these substances to suppress these feelings and control traumatic thoughts [25, 28]. However, it is important to note that avoidance symptoms, rather than re-experiencing symptoms, have been associated with the perpetuation of trauma-related symptoms [811-814]. It is therefore crucial that if a person does become upset due to these traumatic thoughts, that they are not encouraged to avoid or suppress these thoughts or feelings. Telling a person not to think or talk about what happened may also intensify feelings of guilt and shame. For those who have experienced abuse, it may closely re-enact his/her experience of being told to keep quiet about it [281]. This does not mean that clients should be pushed to revisit events or disclose information if they are not ready to do so. Rather, it means that it is understandable that the person may be upset by these thoughts and feelings that may arise, and he/she should be allowed to engage with these feelings in order to help process the trauma emotionally.

As mentioned in Chapter B2, it is crucial that clients are not forced to discuss any details about past events if they do not wish to. It is preferable that clients develop good self-care and have skills to regulate their emotions before they delve deeply into their traumatic experiences or are exposed to the stories of others; however, choice and control should be left to the client [281]. In-depth discussion of a person’s trauma experiences should only be conducted by someone who is trained in dealing with trauma responses [346]. Notwithstanding, even without knowing the details of a client’s trauma, AOD workers can use the techniques outlined in Table 43 to help clients manage their symptoms (Chapter B2 also provides guidance on how to discuss trauma with clients). Praising clients for their resilience in the face of adversity is important even if past adaptations and ways of coping are now causing problems (e.g., AOD use). Understanding AOD use as an adaptive response reduces the client’s guilt and shame and provides a framework for developing new skills to better cope with symptoms [281].

Table 43: Dos and don’ts of managing a client with trauma-related symptoms

DO:

  • Display a comfortable attitude if the client chooses to describe his/her trauma experience.
  • Give the client your undivided attention, empathy and unconditional positive regard.
  • Normalise the client’s response to the trauma and validate his/her feelings.
  • Praise the client for his/her resilience in the face of adversity.
  • Praise the client for having the courage to talk about what happened.
  • Use relaxation and grounding techniques where necessary.
  • Educate the client on what to expect if they undergo detoxification (e.g., a possible increase in trauma-related symptoms).
  • Maximise opportunities for client choice and control over treatment processes.
  • Monitor depressive and suicidal symptoms.

DON'T:

  • Rush or force the client to reveal information about the trauma.
  • Engage in an in-depth discussion of the client’s trauma unless you are trained in trauma responses.
  • Judge the client in relation to the trauma or how he/she reacted to the trauma.
  • Abruptly end the session.
  • Encourage the client to suppress his/her thoughts or feelings.
  • Engage in aggressive or confrontational therapeutic techniques.
  • Be afraid to seek assistance.
  • Use overly clinical language without clear explanations.

Adapted from Ouimette and Brown [815], Elliot et al. [281], and Marsh et al. [346].

Brief psychoeducation about common reactions to trauma and symptom management has also been found to be of benefit to AOD clients who have experienced trauma [816]. It is important to normalise clients’ feelings and convey that such symptoms are a typical and natural reaction to an adverse traumatic event; they are not ‘going crazy’. Letting them know that their reactions are quite normal may also help to alleviate some of the shame and guilt they have been feeling about not recovering from the trauma sooner. It is also important that trauma sufferers hear that what happened was not their fault, especially for those who have experienced sexual assault. An information sheet for clients on common reactions to trauma is provided in the Worksheets section of these Guidelines. Clients may also find the relaxation techniques described in Appendix U useful for managing trauma symptoms.

Elliot and colleagues [281] also identify a number of measures that can be taken at a service level to help prevent the amplification of trauma symptoms. Staff approaches, programs, procedures, and the physical setting can be modified to create a place perceived as safe and welcoming. Such an environment is one in which there is sufficient space for comfort and privacy, the absence of exposure to violent or sexual material (e.g., staff should screen the magazines in the waiting area) and sufficient staffing to monitor the behaviour of others that may be perceived as intrusive or harassing. Many common procedures and practices may re-trigger trauma reactions. For example, aggressive or confrontational group techniques can trigger memories of past abuse. Such techniques are counterproductive; those who have been exposed to abuse in particular may revert to techniques used to cope during the trauma such as dissociating or shutting down emotionally. This may then lead to the client being labelled as ‘treatment resistant’ and, consequently, feelings of self-blame. The US Substance Abuse and Mental Health Services Administration also provides guidance on how to create and implement an institutional framework for trauma-informed services in program delivery and staff development, policies and procedures, administrative practices, and organisational infrastructure, which services may find useful [698].

As discussed in Chapter B7, it is also essential that workers attend to their own responses to working with traumatised clients through self-care. Hearing the details of other’s trauma can be distressing, and in some cases may lead to vicarious traumatisation or secondary traumatic stress [817]. By attending to one’s own self-care and engaging in clinical supervision, the likelihood of developing secondary traumatic stress may be reduced. Chapter B7 provides more detail on strategies for promoting and enhancing AOD worker self- care and reducing burnout.