15 minute read
IN PRACTICE
Embracing diverse approaches to trauma treatment
Social workers provide high-quality counselling and therapy in communities across Nova Scotia, working to support individuals, families, and groups within the context of their environment. Here are just a few of the strategies and modalities they use.
Using etuaptmunk in counselling
BY CRAIG BESAW, RSW
Trauma within Indigenous people can have various origins and can include intergenerational aspects. Assisting individuals through their journey exploring, managing, and working through trauma, especially within the populations I have and still work with, the approach I use most often is termed etuaptmumk, or two-eyed seeing.
Etuaptmumk, as termed by Mi’kmaw Elder Albert Marshall, originates from a pathway other than social work, and involves the practice of finding the balance through use of multiple perspectives.
In application to social work and/or counseling, it involves finding strengths from traditional Indigenous processes and aspects of more Western or Eurocentric processes that fit well together, and that will allow for the best solutions that fit and benefit the individual one works with.
Such practices must be respectfully entered into and done in cooperation with an Indigenous colleague or an Indigenous community member that is able to provide guidance, especially to anyone who is not Indigenous.
Ongoing research and assessment of Western practices by therapists have shown that when purely Western approaches are applied to Indigenous peoples, it does not necessarily provide the best outcomes or experiences. However, there can be much more success overall when Western methods are modified to complement the use of Indigenous holistic approaches.
Certain Western approaches such as dialectical or cognitive behavioural therapies have been and can continue to be adapted through culturally appropriate use of Indigenous knowledge, ways of seeing, and healing.
At the initial stage of any work, one should by assessing where the client is at this time, general supports, and ensuring a safety net as trauma work is started. Building the safety net can include exploring the ability or willingness for the individual(s) to engage with traditional spiritual practices such as sweats or smudging, and allowing them to connect with a trusted Elder; this can be done over time depending on their engagement level.
In a world that is constantly shifting and prone to changes, assisting the individuals toward support and balance is a given.
Culturally responsive CBT & psychoeducation
BY LANA MACLEAN, MSW, RSW
Over the past 12 years of private practice I have had the privilege of supporting individuals, families and various African Nova Scotian communities on the effects of trauma on our individual and collective lives.
The question posed required me to be intentional andreflective of my practice. In doing so here are my initialthoughts on how I work from a race and trauma informedlens in my practice. I hope this sharing provides us with anopportunity to continue our clinical dialogue as a discipline.
What I have learned and continue to learn doing this work is the art of humility and the joy of laughter and growth as a shared journey with clients and community. I lean towards using multi-modalities using race and trauma informed CBT skills such as the externalizing of voices or double standard techniques to support clients in accessing self-compassion and empathy in a world where anti-Black racism resides. This process takes at least three sessions to build towards but has been successful; clients have reported back on how they were able to challenge their negative thoughts and beliefs.
Using role play with ANS is a shared and active and engagingprocess for the client and myself to actively participate in.
Using a race and trauma informed CBT approach layers within it three of the principles of Kwanzaa: Kujichagulia (self -determination), Imani (faith) and Ujmia (collective work and responsibility).
I also find it important to provide mental health literacy with my clients. Using psychoeducational sessions with individuals and in community-based sessions provides the opportunity for capacity building and self-advocacy. The ANS community historically does not access the conventional mental health and addictions programs, due in part of not having the language to express what harms and emotional challenges they are presenting with (how ‘we’ as Black folks show up and culturally present, name and describe our psychological distress is often outside of the conventional learning of many mental health practitioners-who may lack understanding of cultural formulation) and working through stigma. Providing psycho-education on trauma and the brain 101, mapping the effects of intergenerational trauma using eco-grams and genograms, and re-framing and giving cultural and racial context to trauma provides clients and communities a greater situational awareness and pathways to creating safety in their own understanding of the world.
Community social work & art-based perspectives
BY DR. IFEYINWA MBAKOGU
Social work interactions with populations dealing with trauma is not limited to clinical practice. When working with populations dealing with trauma, as survivors of forced displacement/migration and human trafficking, I favoured creative expressions that offered new perceptions of the problem and the development of new coping skills and alternative platforms to healing and wellbeing. Art-based interventions enliven the social work encounter by allowing individuals to create art that explores and acknowledges their inner world and emotions, and develop critical skills of self-awareness for understanding the nature of their trauma, while building the confidence required to overcome challenges.
The benefit of art-based interventions lies in its flexibility and ease of application.
It can be applied to individual, family and group settings existing in community encounters. Participants in these encounters do not require prior artistic skills. I do not present participants with templates to gauge if their artistic creations are right or wrong. It is a non-judgemental process, where individuals follow the best artistic paths to tell their story, analyse their art, the themes that are generated and the way the creations make them feel, manage their circumstances, and identify the best support(s) needed.
My research reinforces that children dealing with trauma are likely to speak and interact when they explore art forms that include drawing, music, poetry, dance, writing, and drama in individual and group settings. Further, art-based interventions when used with children could reduce anxiety, improve their self-esteem, socialisation, and memories of difficult encounters.
Art-based interventions are effective when coordinated by professionals with skills, training, and personal qualities that allow them to be sensitive to client’s needs, understand clients’ interpretations of the art-based media, and avoid causing further harm by reawakening the trauma they set out to address.
EMDR
BY ADAM MATTHEWS, MSW, RSW
When I first began clinical social work in the Nova Scotia health authority, I was met with the idea that CBT-based models were the gold standard for mental health treatment. I was taught to look at behaviours and cognitions, and by targeting behaviours and cognitions people’s lives would change after enough repetition.
I always felt there was something missing.
Many of the people I supported could not get their nervous system on board with the changes they were fightingso hard to make. Due to my familiarity with auricular acupuncture, I had a sense that that the body has a role in carrying our emotional scar tissue. I had witnessed myself and others heal emotionally from physically-based modalities.
When I first experienced eye movement desensitizing and reprocessing (EMDR) therapy on day 2 of my 5-day EMDR training, I was floored by the insights regarding my own emotional inner workings. When it was my training partner’s turn to practice, I was asked to focus on some of my emotional wounds from childhood. During the sets of bilateral stimulations (tapping, in this case), I was able to see the emotional threads that ran through seemingly unrelated mental content. My first thought was a lighthearted and self-deprecatory, “I’m nowhere near insightful enough to make this quality of insight into the lives of my clients without this modality.” I realized through EMDR I could facilitate the minds/bodies of my clients to transform themselves.
Now, I get to witness my clients express the same amazement I experienced repeatedly with EMDR. It is such an honour to be present with people when they learn to utilize their body’s own capacity to heal from trauma, and to witness them begin to see their nervous system as an ally in creating the changes the world needs.mental content. My first thought was a lighthearted and self-deprecatory, “I’m nowhere near insightful enough to make this quality of insight into the lives of my clients without this modality.” I realized through EMDR I could facilitate the minds/bodies of my clients to transform themselves.
Now, I get to witness my clients express the same amazement I experienced repeatedly with EMDR. It is such an honour to be present with people when they learn to utilize their body’s own capacity to heal from trauma, and to witness them begin to see their nervous system as an ally increating the changes the world needs.
Bowen family systems theory
Bowen family systems theory shapes my thinking about trauma.
Finding Bowen theory was predicable but circuitous. I grew up in a closely connected extended family and joined a relationship-focused profession. I stumbled on family systems ideas during my MSW education.
For a decade, my understanding of the troubles bringing clients to the clinic, the hospital and my practice was influenced by structural, strategic, solution-focused, and narrative approaches.
I routinely saw family members together and used reflecting teams, video and one-way mirrors to study process. Then, when I began teaching, I read the work of Murray Bowen, a family systems pioneer, to gather historical material and discovered a theory of human behaviour. It transformed my practice.
“Bowen theory holds that if anxiety-driven symptoms exist in the present, an important relationship disturbance exists in the present,” (Kerr, 2019). Cause is not the issue. Bonanno found that many people exposed to trauma experience “only minor or transient disruptions in their ability to function.” “It is our complex interactions with multiple systems,” adds Michael Ungar, “that account for our success or failure later in life.” Trauma may be experienced in combat, as child abuse, in an accident or sexual assault, but its aftermath is influenced, shaped and lived in the contexts of our families.
Bowen family systems theory brings decades of research and close contact with the biological sciences to clinical treatment, replacing cause-and-effect, linear constructions with systems ideas that guide interventions “at the points where people interact with their environment.” It offers a set of concepts that describe individual, family and societal relationships and shows how human health and symptoms unfold. Bowen theory provides a helpful framework for clients and the social workers who serve them.
Social groupwork & ACES
BY JOANNE SULMAN, MSW, RSW & DR. NANCY ROSS, RSW
Trauma research demonstrates that adverse childhood experiences (ACES) are pervasive and associated with negative physical and mental health outcomes (Felitti et al. 1998; Ross et al. 2020). ACES include childhood experience of physical, sexual or emotional abuse, witnessing violence, suicide, or living in a home with mental health or substance abuse challenges. The impact on negative health and behavioural outcomes throughout the lifespan is cumulative.
Social groupwork, once essential to social work practice, has been lost to much of the profession. However, we advocate that it is a powerful method of working with people who are dealing with ACES.
Since the time of the settlement houses, social groupwork has been social work’s own method of working with groups. It is a democratic, non-hierarchical, strengths-based practice that incorporates social justice in every group (IASWG, 2015). Today’s social workers may work in the field of groups but are usually not practising social work with groups. In contrast, we suggest that the following essential, ethicsbased skills can transform any group in the helping field into a social work group:
1. Generating a non-hierarchical, democratic and social justice framework in all groups.
2. Mobilizing mutual aid to foster peer support, therapeutic helping relationships, skill development and the accomplishment of individual and group goals (Steinberg, 2014).
3. Nondeliberative practice that uses active engagement such as play, art, drama, film-making and music to unlock the range of ways that people can communicate with others and find solutions that are not exclusively talking or deliberating (Lang, 2016).
4. Strengths-based practice. Steinberg says that “People bring all manner of wisdom and experience to the group, and one way of harnessing their strengths is by calling on that fund.” (2014). Breton (2006) says that every time social workers evoke what she calls “the strength in us” mutual aid dynamic they help the group members experience power. This builds community in every group and is quintessential strengths-based practice. As a bonus, social work groups can become resources for the wider community!
An example of a highly effective 10-year social work group with an ACES population is a women’s recovery group facilitated by Ross that met weekly for 10 years in a town in rural Nova Scotia under the auspices of Addiction Services. The group format was designed to be low barrier and open-ended group so that members could feel welcome to attend, either regularly or often as they chose. A core group of members anchored this 10 year collectivity that became a community resource for its duration. Group members determined the content of the group discussion, hosted picnics and other gatherings off-site, participated in creating a short film about their experiences (Women of Substance) and created a column called “Coming Home: Stories of Women in Recovery” that was included periodically in a local newspaper.
Why do we promote social groupwork for ACES? Health data demonstrate that ACES are prevalent throughout society – prominently among service users accessing social work care. This combined intervention vastly expands the possibilities for effective trauma work. In our experience, awareness of adverse childhood experiences and social groupwork practice skills can enhance the effectiveness of social work practice with many populations and can instantly expand resources for them.
CRAIG BESAW, RSW, lives and practices in Cape Breton.
LANA MACLEAN, MSW, RSW, is a Halifax-based social work clinician who works with individuals, youths and families, and within/for African Nova Scotian communities.
ADAM MATTHEWS, MSW, RSW, practices clinical social work in Cape Breton.
DR. IFEYINWA MBAKOGU is an assistant professor at the Dalhousie School of Social Work, and chairs their Diversity and Equity Committee.
JIM MORTON, RSW, lives in Kentville, Nova Scotia. He has interests in mental health, family systems theory, politics and social change.
DR. NANCY ROSS, RSW, is an assistant professor at the Dalhousie School of Social Work. Among her many other publication credits, Dr. Ross is one of the co-authors of Repositioning Social Work Practice in Mental Health in Nova Scotia, a research report published by NSCSW in 2021.
JOANNE SULMAN, MSW, RSW, is an adjunct lecturer with the University of Toronto and the research and group work consultant for Mount Sinai Hospital’s Department of Social Work in Toronto.
REFERENCES:
Breton, M. (2006). Path Dependence and the Place of Social Action in Social Work Practice. Social Work with Groups, 29(4), 25-44.
Bonanno, G.A. (2004) Loss, trauma, and human resilience: Have we underestimated the human capacity to thrive after extremely aversive events? American Psychologist, 59: 20-28
Felitti VJ, Anda RF, Nordenberg D, Williamson DF, Spitz AM, Edwards V, et al. (1998) Relationship of childhood abuse and household dysfunction to many of the leading causes of death in adults. The Adverse Childhood Experiences (ACE) Study. American Journal of Preventive Medicine, 14(4):245– 58. https://doi.org/10.1016/S0749-3797(98)00017- 8PMID:9635069.
Fuller-Thomson, E., West, K.J., Sulman, J., Baird, S.L. (2015). Childhood maltreatment is associated with ulcerative colitis but not Crohn’s Disease: Findings from a populationbased study. Inflammatory Bowel Diseases. DOI 10.1097/ MIB.0000000000000551 Published online: www.ibdjournal.org
IASWG. (2015). Standards for Social Work Practice with Groups https://www.iaswg.org/assets/2015_IASWG_ STANDARDS_FOR_SOCIAL_WORK_PRACTICE_WITH_ GROUPS.pdf
IFSW. Global definition of social work. International Federation of Social Workers.. Retrieved from https://www.ifsw.org/whatis-social-work/global-definition-of-social-work
Kerr, Michael E. (2019) Bowen Theory’s Secrets: Revealing the Hidden Life of Families. New York: Norton, p.174
Lang, N. C. (2016). Nondeliberative forms of practice in social work: Artful, actional, analogic [Taught by Lang for decades at the University of Toronto’s Faculty of Social Work but published posthumously]. Special Double Issue on Nondeliberative Forms of Practice: Activities and Creative Arts in Social Work with Groups, Eds., Sullivan, N.E., Sulman, J, & Nosko, A.. (2016), 39 (2–3), 97-117.
Ross, N., Gilbert, R., Torres, S., Dugas, K., Jefferies, P., McDonald, S., Savage, S. & Ungar, M. (2020) Adverse Childhood Experiences: Assessing the Impact on Physical and Psychosocial Health in Adulthood and the Mitigating Role of Resilience. Child Abuse and Neglect Journal, 103(2020) 104440.
Smithsonian. (2021, December 22). The seven principles of Kwanzaa. National Museum of African American History and Culture. Retrieved from https://nmaahc.si.edu/explore/ stories/seven-principles-kwanzaa
Steinberg, D.M. (2014) A Mutual-Aid Model for Social Work with Groups, 3rd ed. New York: Routledge. (See pp. 25-39 for Nine Dynamics of Mutual Aid).
Ungar, Michael. (2018) Change Your World: The Science of Resilience and the True Path to Success. Toronto: Sutherland House, p. 85
