Interventions

Bridging responses: A front-line worker’s guide to supporting women who have post-traumatic stress

On this page:

• What can you offer as a front-line worker?
• Recognizing the signs of post-traumatic stress responses
• How to screen for post-traumatic stress responses
• Actively facilitating abuse disclosures: finding the balance
• Helpful questions for post-traumatic stress response screening
• Be prepared for and be sensitive to clients’ responses

What can yo u offer as a front-line worker?

For effective intervention and support, it is critical to identify post-traumatic stress in women’s lives. Front-line trauma interventions are not restricted to identifying and referring clients to therapy. They also include psycho-educational supportive counselling and help gaining access to basic resources. Appropriate intervention is important in treating PTSR. You can facilitate recovery by integrating the following guidelines into your routine practice:

• Learn to recognize and identify post-traumatic stress reactions.
• Screen for indicators of past trauma or PTSR through routine history-taking.
• Explore the possibility of PTSR as an underlying problem when appropriate.
• Reframe “symptoms” as “adaptations” or “coping strategies” to trauma. This helps to de-stigmatize these responses.
• Understand and explain that reacting to and coping with trauma is a normal response to an abnormal event. Help women understand that dissociation, emotional numbing and self-harm are their ways of adapting and coping with the overwhelming effects of trauma. It helps normalize the responses.
• Offer support by providing information on post-traumatic stress and the effects of violence.
• Be familiar with local referral options for therapy or support, and direct trauma survivors to referrals when needed. Referrals need to include resources for women’s basic needs, such as food, shelter, clothing, physical health and income supports.

Recognizi ng the signs of post-traumatic stress responses

Women with PTSR often seek medical care for a range of health-care problems for which past trauma may be the real underlying or a contributing cause. PTSR is not always recognized, because other problems can mask or intensify PTSR. These problems might include, for example, insomnia, depression, eating disorders, pelvic pain, chronic fatigue and/or fibromyalgia, migraine headaches, irritable bowel syndrome and substance use problems. In many cases, health-care professionals misdiagnose the PTSR because the traumatic cause of the “problems” has not been recognized. To be more effective in the services and support we offer women, we need to adopt the practice of systematic screening for trauma and PTSR as part of the regular history-taking process.

Post-traumatic stress often appears with physiological as well as psychological responses. Some of the most common of these may include:

Mental health problems

• depression
• chronic difficulties sleeping
• dissociation (losing conscious awareness of the “here and now;” a feeling of “spacing out”)
• depersonalization (feeling like an outside observer of one’s own body or mental processes)
• derealization (the external world seems unfamiliar or unreal)
• anxiety disorders, such as panic attacks

Impaired sense of self

• shame, guilt and self-blame
• self-hate and self-loathing
• damaged, defiled or stigmatized
• helpless or paralyzed in terms of taking initiative
• completely different from others (may include a sense of being special, being utterly alone, or a belief that no other person can understand them)

Relationship difficulties

• unable to trust others
• frequent conflicts
• not feeling entitled to set boundaries
• repeated search for rescuer (may alternate with isolation and withdrawal)
• sexual difficulties
• unable to develop and maintain close attachments
• experiences of revictimization (adult sexual assault, involvement with physically or emotionally abusive partners)
• issues with sexual identity

Problems with memory

• gaps in memories of childhood
• difficulty remembering discussions from the previous week
• amnesia or intense recollection of traumatic events

Behavioural expressions of distress

• problems with alcohol or drug use
• suicidal impulses
• self-inflicted harm
• eating disorders
• shoplifting
• high-risk sexual behaviours that may result in unintended pregnancy or sexually transmitted diseases

Physical problems

• chronic pain with no medical basis (often gynecological problems in women)
• stress-related conditions, such as chronic fatigue syndrome or fibromyalgia
• headaches
• sleep disorders
• breathing problems or asthma

How to screen for post-traumatic stress responses

The following are suggestions on how to ask about possible traumatic experiences and responses when conducting a history-gathering interview. The focus of the questions can be modified, depending on the situation.

To establish a rapport and offer comfort to clients, keep in mind a few basic principles.

Practice active facilitation.
When a front-line worker, or anyone in a helping role, sits with a survivor and hears her despair and pain, and remains silent, many survivors will feel even more fear and shame.

In listening to a survivor describe her experiences, active facilitation is the appropriate response. Active facilitation is the process of offering active and respectful engagement, and providing sensitive and nuanced responses to what is being said.

• React so clients understand how you are thinking and feeling about what they are disclosing. Make a direct statement, such as: “I now understand why you feel (specify feeling).” Or say: “What a horrible experience to have lived through.” This kind of statement reflects your empathic reactions, whereas simply asking the client, “How did this experience make you feel?” asks her to disclose more information to you without receiving any reassuring feedback.
• Be familiar with reframing statements and normalizing comments.

For example, if a woman tells you she never tells anyone about her past experiences of abuse, you could say:

“That is a way you try to keep yourself protected from being hurt by the other people’s lack of knowledge about these difficult experiences.”

• Highlight interpersonal strengths and supports. For example, help a woman see her accomplishments in the face of the abuse: “You were able to not accept (the perpetrator’s) definition of you (use the client’s own example; e.g., that you were “useless”) and in fact you provided good care and support to your children.”

Normalize the process.
Incorporate questions about past or present trauma as a part of all personal history assessments. Make it clear that all clients are asked these questions routinely. Ask questions about possible traumatic experiences in a relaxed and matter-of-fact manner. This will decrease the likelihood that the client will feel singled out and stigmatized.

Reframe negative symptoms.
Describe them instead as understandable adaptations, coping strategies and self-protective behaviours.

Actively facilita ting abuse disclosures: finding the balance

Active facilitation enables you to be present and self-aware in the interview, and to be engaged and empathic without being intrusive. Clients experience questions as intrusive if they are asked in a demanding way or with a tone of judgment or disbelief.

Asking someone about her experiences of abuse or neglect is a finely balanced process. The front-line worker asks questions in a relaxed manner - not in a hushed or indifferent tone. It’s also important to get permission to ask more questions (e.g., “Is it okay if we talk about this a bit more?”).

Some people avoid asking questions about abuse because they believe it’s a violation of the client’s privacy. They may also be afraid of causing the client emotional pain or discomfort. This approach, however, leaves trauma survivors alone, isolated and silenced. Most people are relieved when asked about their experiences in a relaxed and straightforward way.

It’s critically important, however, that you don’t make the following mistakes when asking about trauma and abuse:

• When validating the client’s experience of violation, don’t make sweeping statements about abuse. For example, many clients blame themselves, and believe they actively participated or were complicit in the abuse. As a result, they may interpret statements, such as “abuse is wrong,” to mean they have done something bad. Offer more nuanced responses to explain the harm of abuse, such as:

“What was done to you was wrong.”

“Children can never consent to sex with an adult.”

“Children often accommodate unwanted sexual acts as a way to survive what was done to them.”

• Don’t burden the client with your own revelations or with your own strong or extreme responses. Again, the balance is important to find. At times, it’s appropriate and helpful to tell the trauma survivor that you’ve talked with many women who have similar experiences of abuse, but don’t share examples of other women’s experiences. It’s also inappropriate to express anger at the person who perpetrated the abuse. Many survivors haven’t comes to terms with their own anger, and may feel alienated by your response or feel a need to protect the perpetrator.

Remember: this may be the first time anyone has asked the client about these experiences. A positive and respectful experience may encourage clients to consider further professional help. It’s important to ask these questions, but be respectful if the woman isn’t able to discuss these issues. Let her know you are open to talking about this again in the future.

Helpful questi ons for post-traumatic stress response screening

Here are some questions about past or present trauma that you can ask clients. These are suggestions and can be modified to suit your service or personal style.

Introduce questions with a statement.

“I ask the following questions of all of the people I work with, because the things we experience in life can very often have an impact on our health.”

Ask respectful questions.

“How are things going with your family?”

“How is your relationship going?”

“Have you ever had a traumatic experience in your life? For example, have you ever been hurt or injured? Have you ever felt that your life was in danger?”

“Have you ever been mistreated or harmed by someone you care about?” (like a family member or a partner)

“Has anything very upsetting happened to you recently? What about the more distant past?”

“Did you find it difficult to cope with this experience?”

“Are there things in your life now that worry you?”

“Have you ever been forced into a sexual experience that you didn’t want?”

Give your sense of the situation based on the answers to these questions. Also include your observations about any responses they may be experiencing.

“I’ve noticed that (specify your observation), and I wonder if this is what’s going on?”

“I’m not sure about your situation, but from what you've said to me, it may be that some of the ways in which you cope may have been learned from an experience in your past that was traumatic.”

Ask questions that may help determine the presence of PTSR.

“Are there things from your past that still bother you in an ongoing way?”

“Do you sometimes have the same upsetting dreams?”

“Are there details about your past that you find difficult to remember?”

“Do you feel connected and close to your family and friends?” Or: “Do you feel isolated?”

“Do you still take pleasure in the activities you've always enjoyed?”

“Do you have trouble sleeping? Either getting to sleep, or sleeping through the night?”

“Do you feel on edge?”

“Do you feel upset in your everyday life (for example, at work or in your family)?”

Be prepared fo r and be sensitive to clients’ responses

Remember that a client may become upset or agitated talking about these painful issues.

If a client becomes upset discussing these issues, it doesn’t mean you have traumatized her. Many people avoid asking about trauma and abuse. They think it’s too upsetting for clients. In reality, it’s often the person in the helping role who is uncomfortable or inexperienced in dealing with normal reactions to talking about trauma.

It’s important to acknowledge that you are sorry she is upset, but don’t apologize for asking the questions. These questions are important - suggesting it’s wrong to ask them undermines your effort. The client may also think your apology means it’s bad or shameful to discuss trauma and abuse.

Offer a referral for professional help or services, and/or a follow-up appointment after you discuss such issues with the client.

It's important to explain to clients that relief is possible and that there are many available therapies.

Note:

Avoid asking these screening questions unless you are prepared to offer referrals for appropriate services.

Do not probe women’s trauma memories or explore them any further than is required to screen for a history of trauma. Many survivors of severe childhood abuse require an initial and often lengthy period of therapy to develop fundamental skills before they begin exploring their childhood trauma.

However, in the event that a woman discloses details of her abuse experience, don’t cut her off. This may shame and silence her, and she may not discuss her experiences in the future. Listen and respond with validating statements. Acknowledge what a painful experience it must have been. Give her a referral to a professionally trained therapist who can provide ongoing therapy. If that makes her uncomfortable, tell her she can meet with you again; however, explain that you are unable to offer therapy but can provide support and assistance.

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