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Working with Trauma: Disclosures

Clinical, Legal, and Ethical • Risk Management Consultant for The Trust
Considerations
Amanda D. Zelechoski, JD, PhD, ABPP
Valparaiso University
The Trust
www.psychlawtrauma.com
@azelechoski

Agenda Learning Objectives


I. Self-Assessment 1. Describe the added impact of trauma on several common
clinical and ethical situations.
II. Overview of Trauma 2. List three ways that history of trauma exposure could
impact clinical work with children and adolescents.
III. Working with Traumatized Children, Adolescents, 3. List three ways that history of trauma exposure could
and Families impact clinical work with adults.
IV. Working with Traumatized Adults 4. Identify common factors that increase risk of legal or
disciplinary involvement when working with traumatized
V. Working with Trauma in Integrated Care Settings patients/clients.
5. Explain strategies for addressing and minimizing risk when
VI. Self-Care working in integrated care settings.
6. Recognize the impact of vicarious traumatization and the
importance of self-care.

Professional Ethics
• Clinical & Counseling Psychologists (APA Ethical Principles of
Psychologists and Code of Conduct)
• School Psychologists (NASP Principles for Professional Ethics)
• Counselors (ACA Code of Ethics) The ProQOL
• Clinical Social Workers (CSWA Code of Ethics; NASW Code of
Ethics)
• Marriage & Family Therapists (AAMFT Code of Ethics) Professional Quality of Life Scale
• Substance Abuse Counselors (NAADAC/NCC AP Code of Ethics) https://proqol.org/
• Physicians (AMA Code of Medical Ethics)
• Nurses (ANA Code of Ethics for Nurses)

(c) Amanda D. Zelechoski 1


Why Trauma? Why Now?

If 20 million people were infected by a virus that


caused anxiety, impulsivity, aggression, sleep
problems, depression, respiratory and heart
problems, vulnerability to substance abuse,
antisocial and criminal behavior, retardation and
school failure, we would consider it an urgent
public health crisis.

Yet, in the United States alone, there are more


than 20 million abused, neglected, and
traumatized children vulnerable to these
problems. Our society has yet to recognize this
epidemic, let alone develop an immunization
strategy.
-Dr. Bruce Perry

https://www.npr.org/sections/health-shots/2018/11/09/666143092/should-childhood-
trauma-be-treated-as-a-public-health-crisis

(c) Amanda D. Zelechoski 2


What is trauma?
• Exposure to one or more event(s) that involved death or
threatened death, actual or threatened serious injury, or
threatened sexual violation.

• In addition, these events were experienced in one or


“Events are never ‘traumatic’ just
more of the following ways: because they meet a threshold
• You experienced the event
• You witnessed the event as it occurred to someone else criterion.”
• You learned about an event where a close relative or friend
experienced an actual or threatened violent or accidental death ~Arieh Shalev, M.D.
• You experienced repeated exposure to distressing details of an
event, such as a police officer repeatedly hearing details about
child sexual abuse
DSM-5 (2013) M. Blaustein Curriculum (used with permission): www.traumacenter.org

Classifying Trauma Understanding Trauma


Acute
Single traumatic event
that is limited in time
Acute
Trauma
Chronic
Multiple traumatic events
Chronic of longstanding trauma
exposure Exposure Response

Complex Complex
Exposure to chronic trauma,
Traumatic MH
usually within the caregiving Acute Chronic Complex Stress Symptoms Diagnosis
system, which can interfered
with the child’s ability to form a
secure attachment and sense of
safety and stability.

Trauma Work and Risk Trauma Work and Risk


• Client Factors
• Re-traumatization
• Ability to truly provide informed
consent
• “Trauma work requires additional care in the areas of • Revisiting and processing of
navigating the minefield of client experience, maintaining self- traumatic memories
awareness as the practitioner, and attending to ethical
guidelines.
• Clinician Factors
• Some of the risks inherent in trauma treatment include the risk
of re-traumatization of the client and vicarious traumatization • Competence
of the therapist. • Complacency
• It is therefore imperative that the trauma therapist consciously • Vicarious traumatization and
adheres to ethical standards to protect client and practitioner burnout
from such psychological harms.”
Mailloux, 2014, p. 50 Mailloux, 2014

(c) Amanda D. Zelechoski 3


Working with Traumatized
The Scope of
Children, Adolescents, and Childhood
Trauma
Families

https://www.samhsa.gov/sites/default/files/programs_campaigns/nctsi/nctsi-infographic-full.pdf

Situations that can be traumatic for kids: Other Sources of Ongoing Stress
• Witnessing or experiencing • Life-threatening illness of a • Children frequently face other sources of ongoing
community violence caregiver stress that can challenge child welfare and mental
• e.g., drive-by shooting, robbery,
school fighting
health professionals’ ability to intervene.
• Witnessing domestic violence
• Witnessing police activity or • Some of these sources of stress include:
seeing a loved one arrested or • Car accidents or other serious
incarcerated accidents • Poverty

• Physical or sexual abuse • Discrimination


• Life-threatening health
situations or painful medical • Separations from parent/siblings
• Abandonment or neglect by procedures
caregiver • Frequent moves
• Natural disasters • School problems
• Death or loss of a loved one
• Traumatic grief and loss
• Being bullied • Acts or threats of terrorism
• Refugee or immigrant experiences
NCTSN, 2012 NCTSN, 2012

What is child traumatic stress?


What is child traumatic stress?
• Child traumatic stress refers to the physical and
emotional responses of a child to events that threaten
the life or physical integrity of the child or of someone
critically important to the child (such as a parent or
sibling).

• Traumatic events overwhelm a child’s capacity to cope


and elicit feelings of terror, powerlessness, and out-of-
control physiological arousal.

NCTSN, 2008

(c) Amanda D. Zelechoski 4


The Impact
of Childhood
Trauma

Trauma can derail development.


NCTSN, 2012

Relational Development

“The way we
The Impact talk to our
of Childhood
Trauma children
becomes their
inner voice.“
–Peggy O’Mara

(c) Amanda D. Zelechoski 5


Relational Poverty
Typical Child

Foster Child
The Impact
of Childhood
Trauma

Ludy-Dobson & Perry (2010)

The Adverse Childhood


Experiences Study
(Felitti et al., 1998)

The Adverse Childhood


Experiences Study
(Felitti et al., 1998)

https://www.echotraining.org/

(c) Amanda D. Zelechoski 6


Common Diagnoses for Traumatized Youth
• Posttraumatic Stress Disorder • Attention-Deficit/ Hyperactivity
• Acute Stress Disorder Disorder (ADHD)
• Oppositional Defiant Disorder
• Adjustment Disorder
• Bipolar Disorder
• Reactive Attachment Disorder • Conduct Disorder
• Dissociative Disorders

Many children with these diagnoses have a complex


trauma history.

These diagnoses generally do not capture the full extent


of the developmental impact of trauma.

Trauma’s Varying Impact

“If child abuse and neglect were to


disappear, the Diagnostic and
Statistical Manual would shrink to the
size of a pamphlet and the prisons
would be empty in two generations.”
-Dr. John Briere

Variability in Responses to Trauma


“It is an ultimate irony that at the time
when the human is most vulnerable to • The impact of a potentially traumatic event depends on
the effects of trauma – during infancy several factors, including:
and childhood – adults generally • The child’s age and developmental stage
presume the most resilience.” • The child’s perception of the danger faced
• Whether the child was the victim or a witness
-Perry et al., 1995
• The child’s relationship to the victim or perpetrator
• The child’s past experience with trauma
• Public versus private nature of the trauma
• The adversities the child faces following the trauma
• The presence/availability of adults who can offer help and
protection
• Individual differences (e.g., child’s coping style, temperament,
cognitive functioning, etc.)
NCTSN, 2012

(c) Amanda D. Zelechoski 7


“Children’s behavior almost Functions of Behavior
always makes sense given an
understanding of the context in • Two primary functions of behavior:
which they develop…“ • To fulfill a need
• To avoid danger or seek safety
-Dr. Margaret Blaustein

• People who have experienced ongoing trauma in


their families have generally had to cope with
either or both:
• Not enough attention/failure to meet basic needs
(neglect)
• To much danger (lack of safety) M. Blaustein Curriculum
(used with permission):
www.traumacenter.org

What helps the traumatized individual Key Triggers for Traumatized Individuals
survive?
• Lack of power or control
• Assumption of danger
• Unexpected change
• Rapid mobilization in the face of perceived threat

• Feeling threatened or attacked


• Self-protective stance

• Development of alternative strategies to meet • Feeling vulnerable or frightened


developmental needs
• e.g., self-injury, substance use, re-enactment)
M. Blaustein Curriculum • Feeling shame M. Blaustein Curriculum
(used with permission): (used with permission):
www.traumacenter.org www.traumacenter.org

Traumatic Assumptions Case 1:


• I am not safe. Jessica
• People want to hurt me.
You are contacted by Ms.
• The world is dangerous. Jones, who was referred to
you by her child’s
• If I am in danger, no one will help. pediatrician. During the
intake appointment, you
• I am not good enough/smart enough/worthy learn that Ms. Jones is
enough for people to care about me. concerned about her 14-
year-old daughter, Jessica,
• It will never get better. and her recent behavior at
M. Blaustein Curriculum
(used with permission): school and at home.
www.traumacenter.org

(c) Amanda D. Zelechoski 8


How old is Jessica?

Before we go Before we go
any further, any further, Who has custody of Jessica?
what what
What types of behavior is
potential potential Jessica engaging in?
issues and issues and
questions questions How long has this been going
on?
might you should you
What might have changed in her
have in have in life recently to trigger these
mind? mind? issues?

What other systems/providers


are involved?

How old is Jessica?


Minor’s Consent to Treatment
Before we go • Age of consent in WI?
any further, • < 14: Parent must consent to
what outpatient MH treatment
potential • ≥ 14: Parent AND minor must
consent to outpatient MH treatment
issues and • Depends on:
questions • Type of treatment
should you • Type of treatment setting
• Parent-Child (Dis)Agreement
have in • Why does this matter?
mind? • Informed consent
• HIPAA
• Confidentiality
• Records requests

Who has custody of Jessica? What types of behavior is


Jessica engaging in?
Before we go Before we go How long has this been going
any further, Sole Joint any further, on?
what what
• Current level of risk?
potential Physical Legal Physical Legal potential • Suicidal or homicidal ideation?
issues and • Require copies of:
issues and • History of suicide attempts and/or self-
questions • Current custody orders questions injurious behavior?
• Symptoms escalating?
should you • Notification of any changes to should you • Intensity?
custody orders
have in • Any protective/restraining orders
have in • Frequency?
mind? • If joint legal custody, seek consent mind?
from both parents.
• Legally required? Not necessarily…
• But, good risk management

(c) Amanda D. Zelechoski 9


What might have changed in her What other systems/providers
life recently to trigger these are involved?
issues?
Before we go Before we go • Education
• Teachers
any further, • Why now? any further, • School administrators
what • Why might symptoms be manifesting in
this way?
what • Medical
• Pediatrician
potential • Recent crises? potential • Other Specialists
issues and • Transitions? issues and • Mental/Behavioral Health
• Psychiatrist
• Displacements?
questions • Relationship ruptures? questions • Previous therapists/counselors
should you Perceived failures? should you •
• Case Managers
Child Welfare System
have in have in • Legal/Juvenile Justice System
mind? mind? •

Housing
Church
• Mentoring/Coaching
• Childcare
• Others?

Case 1: Case 1:
Jessica Jessica
More info:
• Parents are separated and
You are contacted by Ms. currently have joint legal
Jones, who was referred to custody.
you by her child’s • Ms. Jones is seeking a TRO
pediatrician. During the against Mr. Jones, based on
intake appointment, you domestic violence allegations.
learn that Ms. Jones is • Jessica was recently
concerned about her 14- suspended from school for
year-old daughter, Jessica, smoking in the bathroom.
and her recent behavior at • Jessica does NOT want to be in
school and at home. therapy, but has been
compliant thus far.

What issues and questions What issues and questions


come to mind now? come to mind now?
• Clinical? • Clinical?
• Trauma exposure
• Legal? • Risky behavior

• Ethical? • Legal?
• Confidentiality
• Mandated reporting
• Access to records
• Parents
• School
• Medical providers
• Courts

• Ethical?
• Confidentiality
• Clinician’s personal risk threshold

(c) Amanda D. Zelechoski 10


Areas of Potential Ethical & Legal Additional Resources
Challenges
• Informed Consent
• Age of consent
• Assent requirement
• Mandated reporting
• Child maltreatment
• Harm to self
• Harm to others
• Legal Involvement
• Child custody
• School matters
• Malpractice suits
• Confidentiality
• How much to share with parents/guardians?
• Who has access to records?
• Risky decision-making
• Self-harm/suicidality

Working with
Traumatized Adults

Godbold, 2018

Scope of the Problem Scope of the Problem

• More than 70% of people in


the general population have
had at least one lifetime
exposure to a traumatic
event.

• Only around 20% of these


people are likely to develop
PTSD (Briere & Scott, 2006).

Benjet C, et al. The epidemiology of traumatic event exposure worldwide: Results from the World Mental Health
Brown, 2013 Survey Consortium. Psychological Medicine. 2016; 46(2): 327—343.

(c) Amanda D. Zelechoski 11


Trauma Impact: Adulthood
• Trauma reactions may lead to:
• “Despite [this prevalence], most • Low self-esteem
psychologists are poorly prepared to think • High self-blame
about or address trauma in their clients’ • Expectations of rejection and loss
lives, frequently misinterpreting • Mood disturbances
presentations of distress or behavioral – e.g., depression, anxiety, anger, and aggression
dysfunction as evidence of other variables.” • Dissociation
• Drug and alcohol use as a coping mechanism to deal with stress
-Dr. Laura S. Brown, 2013
• Other compulsive behaviors as coping mechanisms
– e.g., binging and purging, self-mutilation, risky sexual behavior
• Increased risk of serious health problems
– e.g., heart disease, obesity, alcoholism, liver disease, etc.

Collins et al., 2010

High-Risk Patients Case 2:


Manny
• Serious personality disorders
• e.g., borderline or narcissistic personality disorder • Manny is 23 years old and has
• Complex PTSD contacted you because he needs
help with his “anger problems,”
• Dissociative Identity Disorders according to his probation officer.
• Recovered memories of abuse • During initial screening, he reports a
history of substance abuse, suicidal
• History of abuse as a child ideation, and past diagnoses of
• Present serious risk of harm to self or others conduct disorder and bipolar
disorder.
• Involved with lawsuits or legal disputes • He currently lives with his girlfriend
and their infant son. She is
threatening to throw him out if he
Knapp et al., 2013
doesn’t deal with his issues.

Would you take this case?


What
potential
issues and
questions
might you
have in
mind?

(c) Amanda D. Zelechoski 12


Is this court-ordered
treatment? Areas of Potential Ethical Challenges
What is the nature of his
What are • Confidentiality
involvement with the criminal
• Who is client?
some justice system?
• Who owns privilege?
potential What is his current level of • With whom do you have authorization to communicate?
issues and risk?
• Mandated reporting
questions Does he have a history of
• Child maltreatment
• Harm to self
you should violence?
• Harm to others
have in What might have happened in his • Legal Involvement
mind? life recently to trigger these
issues? • Relationships
• Boundaries
What other systems/providers
are involved?
• Multiple roles

Confidentiality Clarifications
• Privacy
• Who is client? • Legal right
• Mandated vs. voluntary treatment • Applies to the person
• Clients vs collaterals
• Case example • Confidentiality
• Ethical obligation
• Applies to the data/information
• Communicating with others Manny asks you if his • An extension of privacy
• Family girlfriend can attend
• Providers some of the sessions so • Privilege
• Employers that you can help them • Privileged communication is information that is disclosed in
• Others? work through some of the context of a specific relationship (e.g., psychotherapist-
their conflict. client) and cannot simply be demanded by a third party for
legal purposes
What should you do? © The Trust 2018

Mandated Reporting of Child Fears/Barriers to Reporting


Maltreatment
• Violating confidentiality
• How might this come up in your work with Manny? • Report will cause more harm
• Manny as victim
• Manny as perpetrator • Agency may not investigate
• Manny as witness/reporter • Accuracy of the allegation
• Client may discontinue seeking support
• Often feels like a no-win situation:
• If reporting Manny as potential abuser… • Directly instructed not to file a report
• If don’t report à legal sanction • Reputation
• If do report à rupture, breach of confidentiality
• If reporting Manny as victim or witness, against his • Cultural norms
wishes…
• If don’t report à legal sanction
• If do report à rupture, re-traumatization, breach of
confidentiality
Golomb, 2018 (used with permission)

(c) Amanda D. Zelechoski 13


How to Prepare Decision-Making Considerations
• Review federal and state law • Setting/Context
• Review your applicable ethical codes • e.g., clinic, school, private practice, hospital
• Develop policies & procedures, checklists, decision trees, etc. • Clinical situation
• Informed consent • e.g., assessment, therapy, consultation
• Seek consultation • Your Role
• Build a support network • Clinician, caregiver, teacher, student/supervisee,
supervisor, administrator
• Careful and thorough documentation
• Relationship Factors
• e.g., How long have you been working with client? What
is the nature of your professional relationship?

Minimizing Risk After a Report is Made


Mandated Reporting in Wisconsin
• Preserving the therapeutic alliance
• Mandated Reporters: Sec. 48.981
• Establishing safety • A mandated reporter, in the course of his or her professional duties, has
reasonable cause to suspect that a child has been abused or neglected.
• Monitoring/balancing judgments about cultural • A mandated reporter, in the course of his or her professional duties, has
practices/implications reason to believe that a child has been threatened with abuse or neglect or
that abuse or neglect will occur.
• Educating clients about the role of DCS, supports and services • Definitions: Wis. Stats. Ch. 48
they can provide, de-mystifying the process • Definitions of abuse, neglect, sexual abuse, emotional abuse, abandonment,
etc.
• Involving clients in the reporting process, when possible and • Search by state at www.childwelfare.gov
appropriate
• Sec. 48.981(4): Immunity
• Obtain report about final case disposition, document report • Any person or institution participating in good faith in making a report,
conducting an investigation, ordering or taking photographs, or ordering or
number performing medical examinations of a child or an expectant mother pursuant
to this section shall have immunity from any liability, civil or criminal, that
• Distribute the liability/risk across providers results by reason of the action. For the purpose of any civil or criminal
proceeding, the good faith of any person reporting under this section shall be
• Ongoing monitoring of safety (for client and self) presumed.

• Practice self-care • Reporting in other states…(likely no immunity)

Mandated Reporting of Child “Abuse”


Maltreatment (WI Stat. Sec. 48.02; 48.981)
• 'Abuse' means any of the following:
• Physical injury inflicted on a child by other than accidental means
• When used in referring to an unborn child, serious physical harm
inflicted on the unborn child and the risk of serious physical harm to
the child when born caused by a habitual lack of self-control of the
expectant mother of the unborn child in the use of alcoholic
beverages, controlled substances, or controlled substance analogs,
exhibited to a severe degree
Manny disclosed that he Manny reported that he • Manufacturing methamphetamine in violation of § 961.41(1)(e) under
became so angry at his any of the following circumstances:
was abused as a child by • With a child physically present during the manufacture
girlfriend last week, when • In a child's home, on the premises of a child's home, or in a motor vehicle
his stepfather, who still located on the premises of a child's home
she wouldn’t let him hold
lives with his mother and • Under any circumstances in which a reasonable person should have known
his son, that he yanked that the manufacture would be seen, smelled, or heard by a child
his younger siblings in
the baby out of her arms • 'Physical injury' includes, but is not limited to, lacerations,
Chicago. and stormed out of the fractured bones, burns, internal injuries, severe or frequent
house. bruising, or great bodily harm.
What should you do? What should you do?

(c) Amanda D. Zelechoski 14


Tarasoff /Duty to Warn/Duty to Protect Tarasoff /Duty to Warn/Duty to Protect
• Wisconsin courts have upheld Tarasoff and affirmed • Questions to consider before breaching confidentiality:
that clinicians have a duty: • Sincerity, capability, imminence, gravity of the threat
• To warn others of threats of harm by the patient • Does this person have a genuine intent to inflict harm?
• This extends to whatever other steps are reasonably necessary • Does the person have the ability and opportunity to carry out
under the circumstances (e.g., contacting police, recommending or
requiring hospitalization, notifying a friend/family member who can
the threat?
help ensure safety). • Is there some sense of immediacy to the threat?
• Is there a serious risk of harm?
• The victim does NOT have to be foreseeable.
• You have a duty to warn even if the actual victim(s) was not specified
and was a more general statement • What would a reasonable practitioner do under similar
circumstances?
• Act in a manner that is consistent with the seriousness of the
threat in deciding how, and to whom, to report the threat.
https://dsps.wi.gov/Pages/BoardsCouncils/Psychology/PositionStatements.aspx https://dsps.wi.gov/Pages/BoardsCouncils/Psychology/PositionStatements.aspx

Duty to Protect? Suicide Risk Factors


1. Direct verbal warning 13. Religion
2. Plan
14. Living alone
3. Past attempts
15. Bereavement
4. Indirect statements and
behavioral signs 16. Unemployment
5. Depression 17. Health status
6. Hopelessness
18. Impulsivity
7. Intoxication
8. Marital separation 19. Rigid thinking
9. Clinical syndromes 20. Stressful events
10. Sex 21. Release from hospitalization
“We want to be loved so bad, we’re willing to die for it.” 11. Age 22. Lack of a sense of belonging
12. Race Pope & Vasquez, 2013

Suicide Risk Assessment Suicide Risk Assessment


1. Do not avoid the discussion 3. Protective factors
• Explore the issue sensitively, directly, and frankly. • What factors or resources does the patient have that may be sources
of resilience or serve as buffers against suicide?
• It is a myth that raising the topic of suicide with a patient may • What does the patient care about or feel connected to?
increase the likelihood that the patient will act on the idea. • Is there a person or pet whom the patient loves and for whom the
2. Get specifics patient has important responsibilities?
• Are there causes or projects to which the patient is devoted?
• Replace whatever is vague, abstract, or general with • Is the patient a member of a group or organization in which he/she
information that is as precise and specific as possible. can become more active and make a more meaningful contribution?
• Is there a specific setting, date, time of day? • Is the patient willing to commit to treatment?
• Does the intent include a plan? 4. Ethical and legal responsibilities
• Is there a specific method? Is that method likely to be lethal?
• Does patient have access to the means or already have the means? 5. Cultural, religious, and other personal values
• Does the plan include physically injuring or killing another person? 6. Documentation
• Could the chosen method potentially endanger others? 7. Continuing competence
Pope & Vasquez, 2013 Pope & Vasquez, 2013

(c) Amanda D. Zelechoski 15


Suicide Risk Management Assessing Nonsuicidal Self-Injury (NSSI)
1. Evaluation and assessment
• Most common among Assessment and Treatment:
2. Documentation adolescents • Understand the motivations
3. Information on previous treatment • Affect regulation
• avg. age of onset is 12-
• Self-punishment
4. Consultation on present clinical circumstances 14 years • Ending episodes of dissociation
5. Sensitivity to medical issues • Most common forms: Ensure good rapport

6. Knowledge of community resources • Skin cutting Assess thoroughly

• Burning Consider the level of care

7. Consideration of the effect on self and others
• Banging/hitting body Treat carefully

8. Awareness of diversity and multicultural parts Distinguish between NSSI and

considerations
• Most self-injurers have suicide attempt
9. Special populations (e.g., veterans, older adults, used more than one • Attend to heightened risk for
children) method
suicidal behaviors
10. Preventative preparation • Avoid misconceptions
Bongar & Sullivan, 2013 Klonsky, 2013

Legal Involvement Ethical Issues in Legal Involvement

Potential Situations: Potential Roles: Potential Situations: Potential Roles:


• Child custody • Letter of tip le
• Child custody Com of
• Letter
Support/Advocacy M ul es pete
nce
Support/Advocacy
• Employment-related Rol
• Employment-related
issues • Written request for issues • Written request for
• e.g., worker’s comp, records • e.g., worker’s comp, records
wrongful termination, • What about treatment wrongful termination, • What about treatment
harassment summaries? harassment summaries?
• Disability • Subpoena for records n s ic
• Disability • Subpoena forCrecords
F o re . o n fli
ct
• Malpractice suits • Deposition testimony vs
• Malpractice suits • Deposition testimony
of
i ca l Objectivity
• Criminal adjudication • Court testimony Clin e adjudication
• Criminal I n te r
• Court testimony
u e st
I s s

Legal Involvement
Managing Relationships
Potential Situations: Potential Roles: • Informed Consent
• Child custody • Letter of • Boundaries
• Employment-related Support/Advocacy • Be clear about the rules and expectations
issues • Written request for • Immediately address boundary crossings and
• e.g.,has
worker’s records unacceptable conduct
Manny asked comp,
you to
wrongful
write termination,
a letter to his
Manny
• Whatand his girlfriend
about treatment • Avoid multiple relationships
harassment havesummaries?
spit up and are now
• Repair ruptures
probation officer and
• Disability • in a bitter custody
Subpoena battle.
for records
judge advocating for him • Termination
You receive a subpoena
• Malpractice
and confirmingsuits
that he is • Deposition testimony
for his records from his
“cured” of his anger • Consultation
• Criminal adjudication • Court testimony
ex-girlfriend’s attorney.
• Documentation
issues.
What should you do?
What should you do?
Younggren, 2013

(c) Amanda D. Zelechoski 16


Let’s get to know Manny a little
Would you take this case?
better…

http://www.rememberingtrauma.org/

What do trauma survivors need?


Would you take this case?
• To feel safe

• To feel in control

• To express their emotions

• To know what comes next

OVC, 2001

How can these needs manifest in Complex Trauma Treatment


ways that are challenging?
• Common treatment sequence:
• To feel safe • To express their emotions • Pre-treatment assessment
• Unrealistic demands • Transference • Early stage of safety, education, stabilization, skill-building,
• Mistrust/suspicion • Re-enactment and development of the treatment alliance
• Unrecognized triggers • Displaced rage • Middle stage of trauma processing
• Often destabilizing and requires the skills learned in the previous
• Fear of opening up stage
• Various forms of trauma processing are used in this stage (e.g.,
• To know what comes next exposure, cognitive restructuring, EMDR, etc.)
• To feel in control • Feelings of betrayal • Late stage of self and relational development and life
• Boundary crossing • Ruptures choice
• Sabotage • May experience a bit of existential crisis associated with new
• Increasing demands sense of self
• Interpersonal intrusion
into personal life/privacy • How might there be increased risk in this approach?
Courtois, n.d.

(c) Amanda D. Zelechoski 17


Other Trauma Treatments General Strategies to Manage
Your Risk
• CBT • Set clear rules at the beginning of treatment
• Trauma-Focused CBT
• Exposure therapies • Maintain control of therapy
• Cognitive Processing Therapy • Immediately address patient boundary
• EMDR
crossings and unacceptable conduct
• Parts Work for Dissociation
• Stress inoculation training • Do not fear termination
• Medication • Do not accept patient misbehavior and threats
• Document all patient misconduct and your
• How might there be increased risk with these termination plans
approaches?
• Consult, consult, consult
Younggren, 2013

Additional Resources

Working with Trauma in


Integrated Care Settings

General Integrated Care Challenges Case 3: Leah


• The need for mental and behavioral health professionals
(BHPs) integrated into primary care clinics and medical
settings is growing at unprecedented rates
• The demand is far outweighing the supply
• The training of mental health clinicians has been slow to
adapt to a changing market and systems
• As a result, new clinicians are often unaware and unprepared for Leah is 27 years old and recently gave birth to her first child.
the differences in culture, modes of operation, and policies that Her pregnancy had been unremarkable, but she experienced
seem to conflict with their training. some unexpected complications during childbirth due to what
• Changing nature and pace of behavioral health care appears to have been a dissociative episode during labor.
delivery formats Much to the shock of her husband and the medical team, she
became extremely hostile and thrashed around such that she
• Evolving or inadvertent multiple roles and conflicts
had to be sedated and an emergency C-section was ordered.
Beacham & Van Sickle, 2018

(c) Amanda D. Zelechoski 18


Case 3: Leah
What
• Leah is 27 years old and just gave birth to her first potential
child. issues and
• Her pregnancy had been unremarkable, but she
experienced some unexpected complications questions
during childbirth due to what appears to have been
a dissociative episode during labor.
might you
• Much to the shock of her husband and the medical have in
team, she became extremely hostile, kicking the mind?
doctor and nurses such that she had to be sedated
and an emergency C-section was ordered.
• Her medical team is worried about her risk for
postpartum psychopathology and want you to
evaluate her before a decision is made regarding
whether she can be discharged.

What is the specific referral


question? Scope of the evaluation?
Areas of Potential Ethical Challenges
What will informed consent need
What are to look like? • Informed consent in a fast-paced environment
some • Maintaining confidentiality with multidisciplinary teams and
potential What risk factors are present and EHRs
what is her current level of risk? • Providing specialty supervision to high-risk patients
issues and • Beneficence versus harm from multidisciplinary
questions Does she have a history of perspectives
dissociation? Trauma? • Feeling pulled in many directions
you should • Loyalty to the treatment team
have in What might have happened during • Maintaining good professional relationships
• Pressure to disclose more than necessary
mind? labor to trigger these issues? • Protecting patient’s privacy
• Sharing difficult news with the patient
• Multiple roles (e.g., therapist and evaluator)
How much information needs to
be shared with the medical team?
Ashton & Sullivan, 2018

Case 3: Leah Informed Consent


• Passive vs. Active consent
• Necessary clarifications (both verbally and in writing):
• During her meeting with you, Leah discloses that she was sexually abused
by an older male relative as a child and that all of the intimate medical • Nature of the referral
exams throughout her pregnancy were difficult, but she was able to • Your role
mentally prepare and get through them alright. • Purpose of the visit
• What types of recommendations may be made
• However, she indicated that something happened in the delivery room and
• Who will have access to the information and how that
she had a flashback while the doctor was examining her and does not information will be communicated (e.g., in a report)
remember anything after that, until she woke up after the C-section.
• How records will be kept and who has access to these records
• Leah reported that she has never told her husband or her family about the • Limits of confidentiality
abuse, as her abuser has since passed away and, given her cultural context,
she can’t bear the shame that would be inflicted by her family were she to • Important to not gloss over these issues in the interest
now dishonor him. of being efficient in a fast-paced medical environment
• She begs you not to include this information in her medical records and to
convince her doctors that she is fine to go home. Ashton & Sullivan, 2018

(c) Amanda D. Zelechoski 19


Working with Multidisciplinary Teams
Confidentiality & Documentation
• BHPs have a responsibility to keep discussion about the patient
• It’s important to be clear about how records will be kept and relevant to the primary question.
who will have access to them.

• The rise of EHRs have made records more accessible and • Consider what level of detail is needed in both written
searchable documentation and when consulting with other professionals.
• Pros: eases care coordination and communication across disciplines
Cons: frequent misunderstandings about who will be accessing records
• Information that is not pertinent to decision-making is not
• Some ways to deal with these concerns: necessary to share with the entire team
• Audit system that records who access records and when • despite the potential for psychological voyeurism, which is not
• Firewall that keeps MH notes separate from rest of chart. uncommon in medical settings
• Warnings that are triggered when someone tries to access a MH note
without authorization (Note: HIPAA prohibits this).
• Always assume the patient will be reading your notes and write them • Balance ethical obligations to cooperate with other
accordingly
• Use behavioral terms and quotes
professionals and protect the client’s confidential information
• Avoid subjective or judgmental comments • Be mindful of multidisciplinary power dynamics that may unduly
• Minimize the inclusion of unnecessary or irrelevant sensitive information influence judgment and compromise the patient’s dignity
Ashton & Sullivan, 2018 Ashton & Sullivan, 2018

Working with Multidisciplinary Teams


• Resist the temptation to go beyond the scope of one’s
competence or role
• e.g., don’t provide opinions for which you do not have sufficient
basis

Toward a
• Become familiar with the similarities and differences between
the various disciplines’ ethics codes to help guide Trauma-Competent
conversations and policy-making Integrated System
• Consult interprofessional competence literature

• Consult with hospital’s legal team or ethics committee when


ethical conflicts arise

Ashton & Sullivan, 2018

We can do better…
Trauma-Informed Care Integration and Trauma-Competence
1. Realize the widespread prevalence of trauma • Build meaningful partnerships that create mutuality
2. Recognize the signs and symptoms of trauma in among children, families, caregivers, and
clients, families, staff, and others professionals at an individual and organizational
level
3. Respond by integrating knowledge into policies,
procedures, and practices
• Address the intersections of trauma with culture,
4. Actively resist retraumatization of clients, history, race, gender, location, and language,
families, staff, and others acknowledge the compounding impact of structural
inequity, and be responsive to the unique needs of
diverse communities.

SAMHSA, 2014 SAMHSA

(c) Amanda D. Zelechoski 20


We can do better…
Integration and Trauma-Competence
• How are we making it harder on individuals and
families when we, as systems or disciplines, don’t
talk to each other?

• What would an integrated, trauma-competent


system of care look like in your community?

• How can we build on each system’s strengths to


build a more comprehensive, coordinated
approach?
• e.g., Risk-Need-Responsivity (RNR) Model

Essential Elements of a Trauma-Informed… When providers “get” it…


Healthcare System
1. Creating a trauma-informed office.
2. Involving and engaging family in program
development, implementation, and evaluation.
3. Promoting child and family resilience, enhancing
protective factors, and addressing parent/caregiver
trauma.
4. Enhancing staff resilience and addressing secondary
traumatic stress.
5. Assessing trauma-related somatic and mental health
issues.
6. Providing coordinated, integrated care across child-
and family-service systems.

National Child Traumatic Stress Network (NCTSN)

How we ask about trauma matters… How we ask about


• What gets missed in medical and behavioral health
trauma matters…
settings?
• “I suggest we replace the word "screening" with the
word "listening." Screening is something you
give to someone while listening is something you
do with someone.” -Dr. Claudia M. Gold
• Narrative medicine – Dr. Rita Charon
• ”If somebody is in my office talking about chest pain, I think,
Does this sound like heart trouble, stomach trouble, or muscle
trouble?, while also using my narratological brain. What is she
telling me? Why is she telling me this now? What is the
beginning of this story? Where is it going? Even the metaphors
she’s using. And then alongside that is the affective or
emotional stream. What is she really worried about? If she lets
on, in a little dependent clause, that her father died of a heart
attack when he was her age, well then, I have to hear that.”
• -(Dr. Charon, as quoted in an article by Alexander C. Kafka)

(c) Amanda D. Zelechoski 21


How we ask about trauma matters… That we ask about trauma matters…
• “Sure, we can ask our clients for feedback about what’s
• “To not ask about the elephant in the room (trauma)
helping and what isn’t; most therapists do. However, asking leaves the client at great risk of being trampled by it.”
only helps if clients are forthcoming with their answers. And
many clients withhold critical feedback, especially when
therapy is unhelpful.
• In a recent survey, Columbia University’s Matt Blanchard and
Barry Farber asked 547 clients about their honesty in therapy.
Seventy percent reported whitewashing feedback to their
therapists, commonly by “pretending to find therapy
effective” and “not admitting to wanting to end therapy.” And
if patients aren’t telling us the truth, how can we know
whether they are likely to deteriorate?
• Many clients are more willing to report worsening symptoms
to a computer—even if they know that their therapist will see
the results—than disappoint their therapist face-to-face.
• We therapists need to always remain aware that there is
much we can’t see in the fog"—and be open to tools that
might compensate for our limited vision.”
- Tony Rousmaniere, 2017 Mailloux, 2014

When we ask about trauma More Resources for Trauma-


matters… Informed Integrated Care
• It has been estimated that each • https://www.nctsn.org/trauma-informed-care/trauma-
year, over one million children in informed-systems/healthcare/nctsn-resources
the U.S. are misdiagnosed with a
mental illness that could be better
explained by trauma. • https://www.nctsn.org/audiences/healthcare-providers

• https://www.integration.samhsa.gov/clinical-
practice/trauma-informed

• https://www.chcs.org/project/advancing-trauma-
informed-care/
Leahy (2018); Siegfried et al. (2016); Meltzer et al. (2013)

Self-Care

(c) Amanda D. Zelechoski 22


“While all types of therapeutic work are difficult as per
the quest to help people help themselves, perhaps none
Why It Matters
is more challenging than trauma work.”
-Sharon Mailloux Like everyone else, you may
have to contend with trauma
or crises in your personal life.

But, your job guarantees that


you will have to deal with
trauma in other people’s lives.

Williams & Sommer, 2002

Why It Matters Indicators of Distress

• Neglecting self-care significantly increases certain • Emotional Indicators • Personal Indicators


risks: • Sadness • Self-isolation
• Burnout • Prolonged grief • Cynicism
• Vicarious trauma • Anxiety • Mood swings
• Errors in judgment (e.g., blurred boundaries) • Depression • Irritability with
family/partner
• Physical Indicators
• Professional Quality of Life Scale (ProQOL) • Headaches • Workplace Indicators
• https://proqol.org/ • Avoidance of certain
• Stomachaches
• How did you do? individuals
• Are you surprised by your score? • Lethargy
• Constipation • Missed meetings
• Tardiness
• Lack of motivation

Strategies to Address Vicarious


Self-Care Strategies
Trauma
• Awareness and acceptance • Professional Self-Care • Personal Self-Care
• Continuing education
• Limit exposure where possible • Seek client feedback • Healthy personal habits
• Attend and expand areas of empathy • Consultation and • Attention to relationships
supervision • Recreational activities
• Attend to and explore reenactments • Networking
• Limit availability • Stress management • Personal therapy
strategies • Foster creativity and
• Maintain professional connection • Refocus on the rewards growth
• Seek support from others • Set (and follow) boundaries
• Limiting the amount of • Relaxation and
• Create balance in your life exposure to traumatic centeredness
material (temporarily or
• Address and prevent VT on an organizational and permanently) • Self-exploration and
personal level awareness

Blaustein, 2010; Saakvitne, Gamble, Pearlman, & Lev: Risking Connection Norcross & Guy, 2013

(c) Amanda D. Zelechoski 23


Why Self-Care is a Legal and
Ethical Obligation

• Competence
• Impairment
• Vulnerability
• Judgment
nts
See clie
ork
Paperw g
ff m eetin
Sta ision
Superv
E
-CAR
SELF

Reporting Impaired Colleagues in


Wisconsin
• Physician’s Duty to Report Act (2009)
• Physicians must report colleagues who engage in a pattern of
unprofessional conduct; engage in acts creating an immediate
or continuing danger to patients or the public; may be
medically incompetent; or may be mentally or physically
unable to safely practice medicine. Failure to report such
physicians may lead to discipline by the MEB.
• Psychologists: no law yet
• Social Workers, Counselors, and Marriage & Family
Therapists:
• Required to report any adverse action taken against a
licensed colleague within 30 days (Wisc. Admin. Code Sec.
MPSW 20)

https://dsps.wi.gov/Pages/SelfService/ProfessionalAssistanceProcedure.aspx

What happens when we make assumptions? Trauma-Informed Interactions


• Without judgment, what was my reaction (physical,
emotional, mental) and how did I then respond?
• Did the behavior offend against my personal values?
• Did it offend against my learned social values?
• Was it triggering my trauma?
• Was I witnessing a trauma response in the other
person?
• Am I able to find compassion for myself and the other
person?
• Did I respond by punishing, shaming, shunning or
badgering?

Godbold, 2018

(c) Amanda D. Zelechoski 24


Traumatized Systems

Prevention at the Organizational Trauma-Informed Supervision


Level
• Primary
• Sources of stress in work setting should be identified and
minimized
• e.g., being isolated, inexperienced, overworked, lacking support
or supervision, unclear role definition
• Secondary
• Early detection of individuals at high risk of developing stress-
related problems and those with early signs of problems
• Tertiary
• For individuals who have already developed stress-related
conditions, strategies are needed that:
• Minimize the effects of the problem
• Prevent further deterioration or complications
• Strive to restore the individual to the highest possible level of
functioning

Phelps et al. (2009) https://www.nctsn.org/resources/using-secondary-traumatic-stress-core-competencies-trauma-informed-supervision

Thank
Aman
da D.
Z ele c
h o ski
you!!
aman
da.ze
le cho
ski@ v
www alp o.e
.psyc du
hlawt
rau m
a .co m
@ aze
le cho
sk i

(c) Amanda D. Zelechoski 25


WORKING WITH TRAUMA: CLINICAL, LEGAL, AND ETHICAL CONSIDERATIONS
AMANDA D. ZELECHOSKI, JD, PHD, ABPP

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Remembering Trauma (film): http://www.rememberingtrauma.org/

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Additional Resources

Blaustein, M. E. & Kinniburgh, K. (2018). Treating traumatic stress in children and adolescents (2nd ed.). New
York, NY: Guilford.

Burke Harris, N. (2018). The deepest well: Healing the long-term effects of childhood adversity. Boston, MA:
Houghton Mifflin Harcourt.

Center for Healthcare Strategies (CHCS)


• https://www.chcs.org/project/advancing-trauma-informed-care/

Courtois, C. A. & Ford, J. D. (2013). Treatment of complex trauma: A sequenced, relationship-based approach.
New York, NY: Guilford.

Greenberg, S. A., & Shuman, D. W. (2007). When worlds collide: Therapeutic and forensic roles. Professional
Psychology: Research and Practice, 38(2), 129-132.

Gutheil, T.G. (2005). Boundaries, blackmail, and double binds: A pattern observed in malpractice consultation.
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Gutheil, T. G., & Gabbard, G. O. (1993). The concept of boundaries in clinical practice: Theoretical and risk-
management dimensions. American Journal of Psychiatry, 150, 188-196.

Koocher, G. P. & Keith-Spiegel, P. (2016). Ethics in psychology and the mental health professions: Standards
and cases (4th ed.). New York, NY: Oxford University Press.

National Child Traumatic Stress Network (NCTSN)


• www.nctsn.org
• https://www.nctsn.org/trauma-informed-care/trauma-informed-systems/healthcare/nctsn-resources
• https://www.nctsn.org/audiences/healthcare-providers
• https://www.nctsn.org/resources/using-secondary-traumatic-stress-core-competencies-trauma-informed-
supervision

Perry, B. & Szalavitz, M. (2017). The boy who was raised as a dog: And other stories from a child
psychiatrist’s notebook—What traumatized children can teach us about loss, love, and healing. New
York, NY: Basic Books

SAMHSA-HRSA Center for Integrated Health Solutions


• https://www.integration.samhsa.gov/
• https://www.integration.samhsa.gov/clinical-practice/trauma-informed

van der Kolk, B. A. (2014). The body keeps the score: Brain, mind, and body in the healing of trauma. New
York, NY, US: Viking.

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