Trauma Sensitive Guidelines for Clinical Services
1. Center the Client’s Experience and Humanity
a. If possible, use the client’s primary language, if you speak it or if an interpretation service is available. If interpretation or a second language is in use, budget extra time (at least 1.5x) for each session. If the client speaks more than one language, ask them which one they prefer.
b. Ask for and use the client’s chosen name and pronouns. Make a concerted effort to clarify pronunciation from the outset so that you don’t get this wrong, which can be felt to be careless or overtly disrespectful.
c. Use the client’s own language to label the client’s experience. I.e., if the client says they do “sex work,” don’t use the word “prostitution” when referring to their experience.
d. Explain your rationale if you need to use external language where absolutely necessary, i.e. where needed in paperwork for diagnosis for insurance reasons, for legal reasons, etc.
e. Do not refer to clients by their diagnosis as a shorthand. Just as you would never call someone with lymphoma “a cancer”, you should never refer to clients or clients as “a borderline”. This is reductive and disrespectful
2. Clarify your role and explicitly lay out the parameters of care.
a. This is preliminary psychoeducation which reduces ambiguity about what you can offer, and lowers clients’ anxiety.
b. Emphasize the voluntary nature of care. Clients respond better when they feel that they are active members of their own treatment team. Avoidance of painful, traumatic memories is a natural and adaptive response to trauma, and these subjects should be broached carefully and gently, with the client’s permission.
i. Ask permission when turning to sensitive material.
ii. Allow the client to lead in discussing sensitive or triggering material when possible.
iii. Do not unnecessarily punish the client for missing or cancelling sessions.
Clients may struggle to gather the psychic energy to leave the house or engage with therapy, or the financial resources to travel to or pay for therapy. Client-centered, trauma-informed care will acknowledge these realities.
c. Continue to offer psychoeducation and explain your rationale as you proceed with treatment, i.e. “It sounds like you’ve had a lot of difficulty sleeping, so I’d like to discuss medication options that will address that,” or “it sounds like there are times when you’re very upset by things and have trouble calming yourself down. Let’s talk about what kinds of things you can do for yourself when you feel that way.” Don’t take actions or make interpretations in ways that assert an unearned authority, as traumatized people are often sensitive to being overpowered or controlled and may shut down or get activated.
d. In the case that the client needs involuntary care, such as hospitalization for safety reasons, explain this in terms of your medical and ethical concern for the client’s wellbeing: “When you tell me that you are seriously planning to kill yourself, that is as serious for me as hearing that you are having a heart attack. I believe you that you are in a great deal of pain, and just like if you were having a heart attack, I am legally obligated to make sure that you get the care you need to save your life.” Do your best to explain to the patient what they can expect to happen next, stay with the patient if possible, follow up, and check in.
3. Validate affect first.
a. First, join with and empathize with the client’s emotions and feelings. Traumatized people may have reactions that appear disproportionate to you, but their feelings are real, and belittling them will not foster a healthy clinical exchange. This doesn’t mean you have to validate everything that they’re doing! But just make sure that you don’t forget to begin by validating affect.
b. If you need to set limits or contain the client’s affect, do so gently and with validation. Traumatized people are especially sensitive to invalidation, and may feel ungentle limit-setting as personal rejection. I.e., end the session by saying “That sounds so important, and maybe we can talk about that more next week, but that’s our time for today,” and contain by saying things like “That sounds like something really important to discuss further, but it also seems like it’s making you really upset right now. Can we take a moment to check in about that?”
c. Respond as compassionately as possible even when the client is mistrustful, inappropriate, provocative, manipulative, or violent. Traumatized people may believe in a “broken world hypothesis”, that the world is an inherently malevolent place, and that they therefore need to be constantly vigilant, or that they are inevitably going to have negative experiences anyways, and can “skip all the BS” by eliciting these experiences directly. Over time, you can build trust with these individuals, but you need to earn it by showing them no malice consistently. Validate these feelings by saying “that’s right, we just met, so it’s natural that you wouldn’t trust me”, or “Sometimes when we’ve felt really hurt, it can be hard to calm down”. Modeling gentle, sensitive boundary-setting can be instructive.
4. Believe the client’s inherent goodness and believe their narrative.
a. Affirm that the client was not responsible for any abuse or adversity that they incurred. People who have encountered early adversity often internalize a sense of self-blame, but no one deserves to be abused, oppressed, or neglected. It’s natural to want to control these types of experiences by claiming control over them—and self-blame allows for control, because it allows clients to believe that they can prevent this from happening again. However, this is not an adaptive response: it often results in negative cognitions and mood symptoms, and does not protect clients from future harm.
b. Demonstrate genuine curiosity about the particulars of the client’s experience, but never overtly doubt them. Truth is occasionally stranger than fiction, but even if the client isn’t telling you the truth or the whole truth, challenging the client’s reality is gaslighting (ie a type of emotional abuse many traumatized individuals have already encountered and internalized), and invalidating and will foster defensiveness and resistance in the client. Genuine listening and empathy are great healers.
5. Elicit and support the client’s agency.
a. Ask questions like “What questions do you have?” and “How can I be most helpful to you?” to elicit curiosity and remind the client they can take an active role in their treatment.
Adapted with permission from:
Weiss, M.R. (In Press) Appendix A: Trauma-Informed Guidelines for Clinical Practice in Okuda Benavides, M., Berry, O.J.O., Regincos, R., Weiss, M.R., Fitelson, E.M., Monk, C. Online Toolkit: Best Practices for Working with Survivors of Intimate Partner Violence & Sex Trafficking. American Psychiatric Association.
