By Tammy Rasmussen and Julia Bloomfeld
Spring 2009 Volume 12 No 2
Kim is a 38-year old woman with two children, ages 7 and 8.
As a child, she experienced physical and sexual abuse and now
struggles with flashbacks, nightmares, hypervigilence, depression
and anxiety. At 14, Kim began drinking and cutting herself. By
her late teens, she was binge drinking most weekends. At 25, she
moved in with her partner and stopped drinking when she became
pregnant. When they separated three years ago, Kim began to drink
occasionally. After being sexually assaulted by a stranger a year ago,
she began drinking daily. Child welfare became involved and Kim’s
children were placed in the father’s custody. For the first time, Kim
reached out for help.
Kim’s experience with traditional care
Kim enters a co-ed treatment program and is triggered into flashbacks
after a male client flirts with her. The program is unaccustomed
to working with trauma issues, so Kim is sent to the local hospital for
mental health support. There, she becomes increasingly agitated and
is restrained, which causes her to spiral into painful memories. She is
told that she must first deal with her substance abuse, so she is sent
back to the residential program. When flashbacks and intrusive memories
continue and trigger Kim to drink, she is discharged. Without
supports in the community, Kim’s trauma responses and other problems
Kim’s experience with trauma-informed care
Kim’s child welfare worker refers her to a substance use treatment
agency for assessment. The receptionist shows her into the pleasant
waiting room. A female counsellor invites Kim into a private office
and explains the assessment process. Kim says she is nervous and the
counsellor comments on Kim’s courage. She is informed of her
privacy rights and exceptions to confidentiality. The counsellor
explains that the assessment includes questions about trauma and
that Kim needs only to share what is comfortable for her.
During assessment, Kim begins to dissociate. The counsellor, like
all clinical staff at the agency, is trained in first-stage trauma work and
helps Kim re-orient to the present and become safe and grounded.
She reassures Kim that in treatment she can work on her greatest concerns
– her flashbacks and substance use – at the same time. The
counsellor asks Kim about her strengths, which she identifies as her
motivation to change.
After a few sessions, the counsellor recommends that Kim attend
an out-of-town women’s residential substance use program that is
trauma informed. Plans for withdrawal management are made.
During orientation, staff invite Kim to discuss any concerns and she
mentions having nightmares of the sexual assault. A plan is made for
Kim to use her MP3 player at night, as she finds listening to music
soothing. On particularly difficult nights, she can sleep on a couch in
the living room.
During the first week, physical and emotional safety are defined
in group therapy, where Kim learns a grounding exercise to help her
deal with cravings and post-traumatic stress responses. When Kim’s
trauma issues emerge, she is encouraged to speak about the impact in
the present – its connection to her alcohol use – and to identify and
practice positive coping strategies.
With her primary counsellor, Kim explores how to cope with
intrusive memories and gets information on dealing with flashbacks.
She is informed about an upcoming fire drill, as unexpected loud
noises trigger her. Kim also works on a commitment to herself to avoid
self-cutting, and coping strategies are identified to enhance her safety.
During the second week, Kim tells her counsellor that she has
been experiencing overwhelming memories and panic during the
women and relationships sessions. She worries that she will be discharged
from the program if she needs to leave the room. They speak
about the importance of pacing and identify parts of the program
that while triggering are still manageable for her. They agree that if
Kim is feeling overwhelmed in a session she will leave and practice
Over time, Kim is able to use these strategies to remain in the
sessions longer. She makes connections between her substance use,
mental health issues, and trauma and begins to feel validated regarding
her traumatic responses.
During her final week, Kim develops a continuing care plan that
incorporates strategies for emotional and physical safety and relapse
prevention. When she expresses concern about her antidepressant,
the counsellor organizes an assessment with the agency’s consulting
psychiatrist, who has expertise in substance abuse, to review Kim’s
medication options with consideration for her trauma responses. A
telephone conference is also held with Kim and her service providers,
including her child welfare worker, to discuss aftercare. Kim decides
to attend a relapse prevention group and a parenting program for
women with substance use issues.
Kim returns to her community and works on rebuilding her
relationship with her children and strengthening her coping skills.
After several months in the relapse prevention group, Kim arrives distraught.
She explains that last week her daughter turned 8, which
triggered flashbacks she has never had before. Kim drank in response
but does not want to return to old patterns. The counsellor validates
her courage to share this and reinforces her determination to heal.
Kim and her counsellor connect with her child welfare worker to
discuss the nature of the healing process and identify further supports.
Kim accepts a referral to a trauma therapist who can work with
her through the stages of trauma recovery. Kim continues to
strengthen herself and work with her ex-partner and child welfare to
one day have her children home again.
Tammy Rasmussen is a trauma counsellor at the Jean Tweed Centre. Julia Bloomenfeld is
the centre’s director of Clinical Services.