I was consulting with someone today about a case that really highlighted the difference between standard care and trauma-informed care. My colleague is treating a young adolescent, "Suzie" (fictitious name) with a history of witnessing domestic violence, low IQ and a communication disorder. Suzie has been getting worse again (severe anxiety, regression in behavior, tantrums, loss of bladder and bowel control, etc.) because she and her mother moved into a neighborhood that she feels is very dangerous.
Suzie showed up for one of the first appointments and curled up in the waiting room and refused to come in. My colleague did the standard thing of giving Suzie two choices, something like "to either come in now or come in later" type of thing (which is a common behavioral technique). My colleague then met with her mother alone and left the door ajar to let Suzie know she is welcome to join whenever she can. She eventually joined but rarely engaged and played with her phone instead. To help manage the pressing anxiety, my colleague focused the session on teaching Suzie basic coping and self-soothing skills. These two interventions are based in models of behavioral therapy and developmental skill building, which are important and useful models. But, they can miss the point when they are not trauma-informed.
Here is what I suggested.
First, instead of giving two choices, either try to name the nonverbal communication of curling up and refusing to join the session (e.g., "You are telling me loud and clear that really don't want to be here today!) or if you don't know what's going on, wonder aloud (e.g., "I wonder what you are trying to tell me right now?"). So many traumatized youth become less and less verbal and withdrawn. You have to give them the words for their experience or their intentions.
Second, instead of teaching coping skills, frame Suzie's behavior in general as a heightened alarm reaction to the new threat of the dangerous neighborhood. One might say, "Thank goodness that your body's alarm is going off and trying to keep you and your mother safe! I know it's not comfortable for your alarm to take over your body like that, but I'm glad it's trying so hard to tell us that it doesn't think you're safe. Now, let's pay attention to the alarm and try to figure out how we can make sure you and you're mom are safe! Can you draw me a map of your neighborhood and tell me where the danger spots are? How can you tell when someone is safe or dangerous? How can you prepare for that situation together with your mom?"
Also, in the context of the domestic violence, another major goal of the therapy is to use other clinical sensitivities and techniques with Suzie and her mom, together and sometimes separately, to get to the point in which Suzie's mom gets back to being in control and becomes a powerful source of protection and emotional and physical safety. Ideally and after much clinical work, one wants to see mom tell Suzie, "I will do everything I can to keep you safe. That's my job as your mom."