Psychotherapy

Your Guide to Trauma-Informed Intakes

A therapist hands a box of tissues to a young woman who looks upset.
Farid Alsabeh, TLLP

Farid Alsabeh, TLLP

Farid is a Temporary Limited Licensed Psychologist in Michigan

Research has shown that trauma is a prevalent occurrence, with 90% of mental health clients having experienced some form of trauma such as sexual violence, childhood neglect, race-based stress, or many other possible forms. Trauma events can play a central role in a client’s symptomatology, making it crucial for any competent clinician to assess for them early on in the therapeutic process.

Oftentimes, therapists will learn about a history of trauma during the intake session, and in these cases they must be able to respond effectively. After all, the whole therapeutic process is founded on a successful intake: one that is equal parts sensitive, comprehensive, and informative.

In their book Principles of Trauma Therapy, psychologists John Briere and Catherine Scott provide guidelines for dealing with reported trauma during the intake session. In this article, we’ll outline their steps for conducting trauma-informed intakes.

Assessing immediate risks

The first priority during a trauma-informed intake is to determine whether the client presents with any immediate risks. These fall under two categories: dangers to self or others, and psychological instability.

Dangers to self or others

The client may present with signs of threats to life, either to their own or to others’. These should quickly be identified.

The therapist should look for:

  • Danger of imminent death, either due to the environment (for example, the presence of pollutants or natural disasters) or other people (for example, a threatening person)
  • Incapacitation that has a risk for harm (for example, drug use or psychosis)
  • Acute suicidality
  • Homicidality
  • Vulnerability to maltreatment (for example, clients who are young children or immigrants)

In the case that threats to life are present, the therapist should intervene or provide the appropriate resources to ensure the immediate safety of the client.

Psychological instability

The client may also present with signs of psychological instability, which would indicate that they may need stabilization before further assessment.

Signs of psychological instability include:

  • Inability to comprehend the current situation
  • Inability to coherently respond to the therapist
  • High affective reactivity which interferes greatly with their level of functioning

In the case that psychological instability is present, the therapist should provide stabilization interventions like mindfulness and relaxation techniques to increase the client’s insight and stress tolerance before continuing with the assessment.

Assessing trauma exposure

Once the presence of immediate risks has been assessed and mitigated, the next task of a trauma-informed intake is to assess the client’s trauma history.

Discussing experiences of trauma is a delicate task. Although some clients may be forthcoming, others may be more withdrawn, finding it difficult or even re-triggering to discuss past events. For that reason, the therapist should establish a minimal level of trust and rapport before discussing trauma experiences.

When the time comes to discuss traumatic material, it helps to give a short introduction to properly orient the client. For example, the therapist might say:

“I’m now going to ask you some questions about what has happened to you. This information will help me to better understand your situation, and develop strategies for helping you. However, I know that it may be difficult for you to talk about this. I encourage you to try your best, but if at any point you don’t want to answer, just let me know and we’ll move on. You can set the pace for our session today.”

This short preface has two major benefits. First, it provides the client with an explanation for the questions, which makes them more likely to disclose information and collaborate. Second, it gives the client a sense of empowerment and agency.

When discussing the trauma, the following recommendations are advised:

  • Communicate non-judgemental support, to counteract the client’s possible feelings of shame and stigmatization.
  • Listen to the traumatic material without registering too much pain, which may make the client feel that they’re burdening the therapist.
  • Use specific behavioral definitions of trauma, such as ‘unwanted sexual contact’ as opposed to ‘sexual assault’.
  • Validate the client’s feelings about their trauma, which may be complex and paradoxical.

These aspects of a therapist’s engagement with a client can facilitate the sharing of all necessary information while ensuring the client feels safe and empowered in the process

Assessing effects of trauma

Trauma can leave lasting marks in an individual’s mind and body, some of which will develop into the symptoms of a trauma-related disorder. Besides manifesting as symptoms, they will also influence the way that a client presents to the session and interacts with the therapist. These are known as process responses.

In order to conduct an effective trauma-based intake, the therapist should be aware of the four major kinds of process responses the client may be exhibiting: activation, avoidance, affect dysregulation, and relational disturbances.

Activation responses

Trauma results in cognitive and affective changes which make the client vulnerable to re-experiencing aspects of the trauma. This usually happens after exposure to a triggering stimulus. This re-experiencing is known as an activation response, and it can come in the form of panicking, crying, and anger.

A moderate amount of activation is expected, and even beneficial. It shows that the client is actively reprocessing the experience, as opposed to numbing or dissociating from it. However, the therapist should ensure that these responses aren’t so overwhelming as to harm the client or interrupt the therapy process. They should navigate what has been called a ‘therapeutic window’: an ideal amount of activation which allows the client to perform reprocessing, without overwhelming their ability to cope.

Avoidance responses

Trauma also results in cognitive, affective, and behavioral changes which may function to limit the client’s exposure to potentially re-triggering stimuli. These are known as avoidance responses, and they can come in the form of emotional numbing, disengagement, thought suppression, denial and intoxication.

Avoidance responses can come in two forms: inferred underactivation, and avoidance activities. Inferred underactivation is the lack of a response which would be considered normal after a given traumatic experience, such as describing details in a matter-of-fact and detached way. Avoidance activities are more direct, and may include effortful avoidance of discussing the material or being intoxicated during the session to cope with the event.

It is important to understand that avoidance responses can play a crucial role in the client’s psychological stability, especially early in the recovery process. The clinician should refrain from the simplistic view that they are obstacles to be removed, and recognize them instead as transitory steps in the gradual road to recovery.

Affect dysregulation

Trauma can disrupt a client’s ability to regulate and express their emotions. This involves both an inability to tolerate painful feelings (affect tolerance) and the ability to face and control feelings (affect modulation).

Signs of affect dysregulation in a client may include:

  • Mood swings
  • Short depressive episodes
  • Acute states of emotional distress
  • Acting out or externalizing behaviors
  • Prolonged substance abuse
  • Sudden dissociations

The therapist should be careful to distinguish these instances of affect dysregulation from mood disorders such as bipolar or depressive disorders, or personality disorders which involve disordered mood. Trauma-induced affect dysregulation can be present alongside, or instead of, these disorders.

Relational disturbances

Because many traumas occur in the context of an interpersonal relationship, or more generally at the hands of a person, the client can be left with lasting changes in the way they relate to others. These include heightened alertness to interpersonal danger, abandonment concerns, the need for security through interpersonal control, and issues with the intimacy of a sustained therapeutic relationship.

Conclusion

Conducting a sensitive and effective intake for clients with trauma histories is the first step on their path to healing and post-traumatic growth. The guidelines outlined here won’t apply equally to every client: each one will require a greater or lesser focus, depending on the client’s mental state and the circumstances of their referral. The trauma-informed clinician is encouraged to keep these guidelines in mind, and use them flexibly in response to each particular client’s needs.

Farid Alsabeh, TLLP

Therapy is an opportunity to fulfill our potentials and create a more meaningful life. Whether that means relief from persistent anxieties, clarity on a current relationship, or improvement in a worthwhile skill, the process will be the same.

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