What is Trauma Informed Practice?
People with histories of trauma, borderline personality disorder and/or PTSD usually, but not always have a history of sexual abuse, physical abuse, psychological abuse, emotional abuse or chronic rejection or neglect. This trauma resides in body, mind, brain and soul. I have completed two Blue Knot Foundation workshops because they promote the reality that we have body muscle memory of traumatic events that activate when we are under heavy stress is something most of us can relate to. When I was nineteen, I was kicked in the face by a horse, and ever since I have nightmares being trapped in a stable of many angry horses all wanting to kick the living daylights out of me. I remember feeling this horrendous body memory triggering me on a light plane ride once when the pilot was having difficulty locating the landing strip. Experiencing the same fear and terror that I was going to die. I don’t ride horses anymore and I have never been in a light plane since.
However, body muscle memory fascinates me. I work in trauma informed care with clients, helping them to understand, process and integrate their cognitive, emotional, visual and muscle memories when something reminds them of their history of trauma and they feel it is happening all over again in the present moment. When dissociation (feeling emotionally separated from your body) occurs, or flashbacks (when you experience a current event that evokes a historical memory – as in my case) happen, clients will have a strong sense of self and strategies and skills to help get them back into the present moment safely.
Babette Rothschild (The Body Remembers, 2000) and Bessel Van Der Kolk (The Body Keeps the Score, 2017) both teach and conduct “Trauma Informed Care and Principles.” These principles include dual awareness, the body as an anchor and gauging and pacing hyperarousal, and applying these when panic attacks, flashbacks or any sort of emotional dysregulation occurs in session or at home.
In my therapy room safety, security, trust and rapport are of paramount importance. This is a client’s “safe haven,” possibly the only one they have, where they can explore at their own pace their personal narrative. The client has to feel, a dual awareness, both safe in their body and safe in my therapy room. This is a safety most people can take for granted.
This is the ability of the client in session to notice equal awareness of what’s happening in their body and in the therapy room. Noticing body sensations from their sensory nervous system, as well as being aware able to correctly interpret the safety or the danger of their environment. This is important for perceiving the therapist’s intention and the safety factor in the therapy room. Unsafe feelings in the body do not mean that the environment is unsafe. Sometimes this is terribly difficult to distinguish between.
The body as an anchor
The pull of past memories evoked in therapy can be triggering and sometimes retraumatise the client. It can then be helpful to guide the client into visualising an anchor, be it working on anchoring their body in safety, or visualising a safe person as an anchor when they feel triggered. Or a safe place, such as the beach or the mountains for some of the more difficult work.
Gauging and pacing hyperarousal
Asking the client “what are you feeling at this moment” and using a “feelings wheel” can help them gauge their more nuanced emotions in the present.
As well, using a scale of 1-100 they can let you know the intensity of the emotion they are feeling. Naming and gauging the emotions helps anchor and ground clients out of the memories and into focus and awareness. Naming the emotion helps to tame the emotion. People have said when they get triggered, they experience a “closing in, shutting down’ sensation, or an “expanding ‘lifting off the chair and get bigger sensation’, or they can dissociate and disappear right out of the therapy room. It’s the therapist’s job to pull the client back into the room. Helping people ground themselves by pushing their feet into the ground to feel the calf muscles, or gently talking them down from the ceiling helps anchor people in the present. It is then useful to discuss what just happened in the room for them.
Trauma Informed Care involves developing a safe trusting relationship. Being consistent, non-judgemental, non-blaming, compassionate, empathic, reliable, honest and predictable are all part of how a trauma-informed-therapist should work with traumatised clients. Emotional control and stability must be established before any processing of trauma memories can occur. This can take months or even years. It is done at the pace of the client not the therapist.
I check in regularly with feelings and moods using statements like,
“Do you feel I’m understanding what you are saying?”,
“Can I check that I have understood you?”,
“Is there something in particular that you need from me right now?”,
“How can I best support you right now?”
Trauma removes a person’s ability to make choices. Dangers to watch for with vulnerable clients in therapy are retraumatisation, fear of not being believed, fear of being blamed or punished for speaking out and invalidation and patronisation. Trauma can feel like a power imbalance in relationships where clients have little or no power. Restoring a sense of personal power to clients is key to healing. Use an optimistic approach. Help empower them to make independent, executive decisions in their own lives and not be afraid of making an error. Making an error can sometimes lead to a new path that hadn’t been thought of before but works much better for them.
Therapists make mistakes and most freely admit this. If it happens with a client in session, using a technique called “rupture and repair” can re-establish the therapeutic alliance. All people have experienced attunement, misattunement and attunement again in their families, at work and in relationships. The therapist/client dyad is no exception. This process can enhance and strengthen existing relationships, because trust and valour have been evoked.
Post therapy care in trauma informed practice also involves how the (triggered in session) client is going to get home safely and feel safe and secure in both their bodies and their environment. I encourage clients to make a safety/sensory/self-care box embracing all five senses – sight, hearing, touch, smell and taste. This helps clients regulate their emotions outside the therapy room. Breathing, grounding and progressive muscle relaxation can help establish present awareness in the body and de-escalate potential melt-downs when clients are triggered.
When (triggered in session) clients go home, I have a list of questions I ask before:
Are you going to feel safe when you leave?
What will you do when you leave here?
What are your plans after that?
How will you get home?
Who will be at home?
Can I contact someone for you?
What are some self-care strategies and skills that have helped you before? Will you be able to carry these out?
What mindfulness exercises can you do at home?
Here is a list of mental health care hotlines
Can I ring you later on to make sure you are ok?
This is how I work with clients with a history of trauma, BPD or PTSD. I also check in the same way sometimes with my more robust clients. We are all vulnerable to the slings and arrows and kicks in the head of life. Pretty much everyone will have some form of unintegrated trauma in their lives. Even therapists. When I go home, I take good care of myself as well. Self-care, good self-esteem and confidence helps us not just survive, but to enjoy the short time we have here.