Professional Boundaries:

..Trauma Informed Service Delivery

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The Alberta College of Speech-Language Pathologists and Audiologists (ACSLPA) is the regulatory body for the professions of speech-language pathology and audiology in Alberta. ACSLPA carries out its activities in accordance with provincial legislation to protect and serve the public by regulating and ensuring competent, safe, ethical practice of speech-language pathologists and audiologists.

The intent of this guideline is to support regulated members in practicing in compliance with the standards of practice with respect to therapeutic relationships and professional boundaries. The guideline is founded upon the following guiding principles:

• ACSLPA believes that the sexual abuse of and/or sexual misconduct towards patients by regulated members is unethical and an abuse of the therapeutic relationship. ACSLPA holds a zero-tolerance stance towards any abuse or misconduct of this nature by regulated members. Regardless of the patient’s conduct and/or consent, it is always the responsibility of the regulated member to maintain professional boundaries and abstain from engaging in sexual abuse and/or sexual misconduct.
• ACSLPA regulated members are expected to be fully informed of the terms and implications of the Health Professions Act (HPA) and the issues related to the avoidance and prevention of sexual abuse and/or sexual misconduct.
• ACSLPA regulated members are accountable for practicing in accordance with the ACSLPA Standards of Practice and Code of Ethics regardless of their role, practice area or practice setting. Breach of the Standards of Practice or Code of Ethics may constitute unprofessional conduct.

In accordance with the ACSLPA standards of practice on Professional Boundaries and Standard Area 5 – Sexual Abuse and Sexual Misconduct, regulated members must maintain appropriate professional boundaries with clients, professional colleagues, students, and others at all times; and protect patients from sexual abuse and sexual misconduct.  The Health Professions Act (HPA) requires that colleges take measures to for preventing and addressing sexual abuse and sexual misconduct by providing educational requirements and guidelines for the conduct of regulated members. This guideline is meant to provide this educational component to regulated members, along with ACSLPA’s Jurisprudence E-Course. Both educational components include concepts related to trauma informed practice.

Clarification of Terms Used

It should be noted that throughout this guideline, the more narrowly defined terms of health services and patient are used in reference to sexual abuse and sexual misconduct.

• Health services, as defined in the HPA, refer to the specific services provided by regulated members in their professional roles as speech-language pathologists and audiologists.
• Patient, as defined by ACSLPA, is the direct recipient of the health services provided
  by the regulated member and does not include others such as their parent, guardian
  or substitute decision-maker. If service is provided in accordance with the Standards
  of Practice, ‘patient’ does not include the regulated member’s spouse, adult
  interdependent partner or other person with whom the regulated member is in an existing sexual relationship.

ACSLPA foundational documents, including the Standards of Practice, use broader definitions for the following terms, which are used in reference to professional boundaries and trauma informed services in this guideline:

• Client refers to “a recipient of speech-language pathology or audiology services, and may be an individual, family, group, community, or population. An individual client may also be referred to as a patient.”
• Professional services refer to “any service that comes within the practice of a regulated profession; for the professions of speech-language pathology and audiology, these are as outlined in section 3 of Schedule 28 of the HPA.”

The relationship of the four terms can be illustrated as follows:

While ACSLPA regulated members do not provide services to treat trauma directly and specifically, they can incorporate trauma-informed practices into their service delivery. This involves developing an understanding of the lived experiences and ongoing impacts of trauma, developing ways to effectively manage the impacts of trauma on a client, and avoiding or minimizing retraumatization.

Clarification of Terms Used

For the purposes of this guideline, in reference to trauma informed service delivery, the more broadly defined term ‘client’ is used. Regulated members are encouraged to review the section ‘Clarification of Terms Used’ in the Introduction section of this guideline for a more comprehensive explanation of the differentiation between the terms ‘client’ and ‘patient’. Definitions of both terms are also included in the Glossary of this guideline.

The Definition of Trauma

The Substance Abuse and Mental Health Services Administration (2014) defines trauma as an event, series of events, or set of circumstances experienced by an individual as physically or emotionally harmful or life-threatening, with lasting effects on the individual’s functioning and mental, physical, social, emotional, or spiritual well-being.

Some examples of traumatic experiences are:

Trauma is common and often undiagnosed. Members of historically marginalized groups have a disproportionately higher prevalence of trauma than the general population. This includes people from low-income communities, ethnic and racial minorities, LGBTQ individuals, people with disabilities, and women and girls.

Many individual, contextual, and environmental factors impact how a traumatic event affects an individual:

A traumatizing event may not affect two people the same: one person may consider an event traumatic while another person may not. Not all children or adults who are exposed to traumatic events experience long-term health problems. Protective factors, e.g., healthy attachments and social connections, or social or emotional competence, may help shield an individual from lasting effects of trauma.

This section reviews a non-exhaustive list of the various forms and types of trauma. Please note that lack of relevance is not implied if a given trauma is not listed or addressed in the following content. In addition, the order of listing of the types of traumas does not denote a specific trauma’s importance or prevalence. Some forms of trauma discussed below may fit in multiple categories. The intent of this section is to give a broad perspective of the various categories and types of trauma.

Natural or Human-Caused Trauma

• Natural Trauma: natural events, which are typically unavoidable, which may impact a small number of people, or whole communities.
• Human-Caused Trauma: caused by human failure (e.g., infrastructure catastrophes, accidents), intentional acts (e.g., home invasion, stabbing or shooting), or by human design (e.g., war).

How survivors of natural and human-caused traumas respond to the experience often depends on the degree of devastation, the extent of individual and community losses, the amount of time it takes to reestablish daily routines and services, and the amount, duration, and accessibility of relief services. Traumas perceived as intentionally harmful often make the event more traumatic for people
and communities.

Individual, Group, Community, and Mass Trauma

• Individual trauma: an event that only occurs to one person – a single event (e.g., mugging, physical injury, assault), or multiple or prolonged events (e.g., a life-threatening illness, multiple assaults).

Although the trauma directly affects one individual, others who know the person will likely experience emotional repercussions from the event(s) as well. Survivors of individual trauma may not receive the environmental support that members of collectively traumatized groups and communities receive. They are less likely to reveal their trauma or to receive validation of their experiences. Often, shame distorts their perception of responsibility for the
traumatic event(s).

• Group trauma: traumatic experiences that affect a particular group of people, whereby the experience of trauma and the characteristics of trauma-related reactions are unique to a small group of people. Groups may share identity, history, activities, or concerns e.g., first responders responding to a crisis, and military servicepeople.
• Trauma affecting communities and cultures: this can cover a broad range of violence and atrocities that erode the sense of safety within a given community (e.g., schools, neighborhoods, reserves). It may involve:
  • Assaults, hate crimes, violence;
  • Actions that attempt to dismantle systemic cultural practices, resources, and identities (e.g., the residential schooling system);
  • Indifference or limited responsiveness to specific communities or cultures that are facing potential danger; and/or
  • Events that erode the heritage of a culture (e.g., prejudice, disenfranchisement,
    heath inequities).

This type of trauma includes:

• Historical or generational trauma – widespread events that affect an entire culture and influence generations of the culture beyond those who experienced them directly. Historical trauma can increase the vulnerability of multiple generations to the effects of traumas that occur in their lifetimes.
• Mass trauma – events that affect large numbers of people directly or indirectly. In mass traumas, the initial event often causes additional traumas and other stressful events that lead to more difficulties.

Interpersonal Traumas

Events that occur (and typically tend to reoccur) between two people who often know each other, such as spouses, or caregivers and their children. Examples include physical and sexual abuse, intimate partner violence, or elder abuse.

Developmental Traumas

Specific events or experiences that occur within a given developmental stage and influence later development, adjustment, and physical and mental health. Often, these traumas are related to adverse childhood experiences, but can occur from any event in the life cycle that create significant loss or have life-altering consequences. Exposure to adverse childhood experiences have impacts on development which are different to trauma experienced later in life. For example, exposure to adverse childhood experiences increases the likelihood of delays in language, emotional, or cognitive development.

Political Terror and War

Anything that threatens the existence, beliefs, well-being, or livelihood of a community. Political terror and war are likely to have lasting consequences for survivors. Examples include the trauma experienced by political asylum seekers and refugees.

Retraumatization

Retraumatization occurs when clients experience something that makes them feel as though they are undergoing another trauma. Re-traumatization is any situation or event that resembles an individual’s trauma (literally or symbolically) which then triggers difficult feelings and reactions associated with the original trauma.

Treatment settings can create retraumatizing experiences, often unintentionally, and sometimes clients themselves are not consciously aware that the clinical situation has triggered a traumatic stress reaction. Staff and agency issues that can cause retraumatizing include:

• Clients being asked to continually retell their story.
• Challenging or discounting reports of abuse or other traumatic events.
• Using isolation or physical restraints.
• Allowing the abusive behaviour of another staff member or client towards the client.
• Failing to provide adequate security and safety within the clinical environment.
• Limiting the participation of the client in treatment decisions and planning.
• Minimizing, discrediting, or ignoring client responses.
• Clients feeling like they are treated ‘as a number’ rather than as a person.
• Disrobing being required for healthcare procedures.
• Clients feeling like they are seen as their diagnosis or label (e.g., addict, schizophrenic).
• No choice being offered in services or treatment provided, or when services are non-collaborative.
• Clients feeling like they are not being seen or heard by their healthcare provider.

Organizations that anticipate the risk of retraumatization and that are sensitive to the histories and needs of individuals who have undergone trauma are likely to have more success in providing care, retaining clients, and achieving positive outcomes.

Trauma informed care involves a broad understanding of traumatic stress reactions and common responses to trauma. The table below highlights some common short- and long- term responses to traumatic experiences. These reactions are often normal responses to trauma but can still be distressing to experience. Such responses are not signs of mental illness, nor do they indicate a mental disorder. This information is presented so that regulated members can increase their awareness of, and sensitivity to, how trauma can affect presentation, engagement, and outcomes in the clinical relationship. However, making clinical inferences or diagnoses related to trauma, or treating trauma responses are outside the scope of practice for ACSLPA regulated members.

Experiencing traumatic events increases an individual’s risk of long-term physical, mental, and behavioral health issues and affects health throughout the lifespan. The more an individual is exposed to a variety of stressful and potentially traumatic experiences (especially as a child), the greater the risk for chronic health conditions and health-risk behaviors. Because of these long-term physical and mental health impacts of trauma, individuals with early experiences of trauma are over-represented in healthcare systems, which increases the likelihood that SLPs and audiologists will encounter clients who have experienced trauma.

Trauma is thought to overwhelm a person’s coping capacity, resulting in adaptive yet unhealthy coping mechanisms. Over time, these coping mechanisms can evolve into health risk behaviors and conditions e.g.,

The effects of trauma may show themselves in therapeutic relationships with clients, e.g.:

• Impaired memory, concentration, new learning, and focus.
• Impaired ability to trust, cope, and form healthy relationships.
• Disrupted emotional regulation and the ability to distinguish between what is safe and unsafe.
• Impacted beliefs about self and others, and outlook on life.
• Experiencing defensive responses (fight, flight, or freeze), even in situations that are not life-threatening.
• Rejection of care.
• Other emotional, behavioural, physical, or cognitive trauma reactions, e.g., flashbacks, dissociation, self-harm.

ACSLPA regulated members are not expected to directly treat any of the above trauma related reactions as part of service provision. However, regulated members should be sensitive and responsive to any trauma related reactions and seek appropriate referrals and/or resources for clients as needed.

Trauma informed care understands and considers the pervasive nature of trauma and promotes environments of healing and recovery rather than practices and services that may inadvertently re-traumatize. Trauma informed care acknowledges that understanding a client’s life experiences is key to improving engagement and outcomes. Providers who understand the connection behind trauma and health are able to create clinical environments that are less triggering, identify appropriate referrals, and develop more effective therapeutic alliances with clients.

Trauma informed approaches are a crucial aspect of high-quality healthcare. They can improve client engagement, treatment adherence, and health outcomes, as well as mitigate risks to physical and mental health. Trauma informed care shifts the focus of care from ‘what’s wrong with you?’ to ‘what happened to you?’ by:

• Developing and maintaining awareness of:
  • The commonness of trauma experiences,
  • The impact of trauma on development,
  • The wide range of adaptations used to cope with trauma, and
  • The relationship between trauma, substance use, and physical and mental health.
• Realizing the widespread impact of trauma and understanding potential paths to recovery.
• Being sensitive and responsive to signs and symptoms of trauma in clients and families.
• Integrating knowledge about trauma into policies, procedures, and practices.
• Seeking to actively resist re-traumatization (i.e., avoid creating an environment that
  reminds clients of traumatic experiences and causing them to experience emotional, physical, cognitive, behavioural, and/or existential distress).

Trauma informed care is grounded in principles of dignity, respect, and justice. It takes the client’s experience of trauma into account when providing services and is attuned to a range of experiences, relevant to the people and communities served. While SLPs and Audiologists should not directly target healing from trauma in their clinical goals, engaging in trauma-informed practice within the therapeutic relationship may support a more effective therapeutic relationship.

Core Principles of Trauma Informed Care

There are five guiding principles that serve as a framework for trauma informed care. The figure below outlines these principles, with examples of trauma informed care practices that can be put into place.

Safety

Oftentimes, people who have experienced trauma have experienced abuses of power in relationships, in the past and/or present. Safety involves implementing strategies to help clients feel physically and psychologically safe. Some examples of safety in practice include:

• Providing safe physical environments (e.g., well-lit areas, clear access to doors, reduced
  noise levels).
• Providing safe, calm, predictable, and transparent socio-emotional environments (e.g., welcoming/greeting clients warmly, having consistency in scheduling and procedures).
• Responding to trauma disclosures in an empathetic and supportive manner that validates the client’s experience and reaffirms their autonomy.
• Clearly explaining to the client what they can expect in the session, or asking the client or their caregiver what might make them most comfortable.
• Creating space for emotions and giving clients the opportunity to regulate or manage their emotions. For example, by providing time, materials to write and/or draw, and/or physical space for a support person.

Choice

Giving the client the experience of choice helps to foster a sense of self-efficacy, self-determination, dignity, and personal control. Choice in the provision of trauma informed professional services may look like:

• Informing clients about their treatment options, so that they can choose the option they prefer.
• Giving choice and control to the client wherever possible.
• Using a robust process for obtaining informed consent for services.

Collaboration

Collaboration can provide the opportunity for (re)building safe relational connections for those who have experienced or are experiencing trauma. Collaboration involves:

• Making decisions with the client.
• Sharing power with the client to support shared decision making.
• Maximizing collaboration among healthcare staff, clients, and families.
• Engaging referral sources and partner organizations as needed.
• Giving clients the opportunity to plan and evaluate the services that were provided to them.

Trustworthiness

People who have experienced trauma often scrutinize authority figures (e.g., healthcare providers) for evidence that they are trustworthy, in order to protect themselves from further harm. It is important to recognize that this scrutiny is not personal or about the practitioner’s skills but is instead influenced by the past or an anticipation of what is to come. Trustworthiness in practice involves:

• Transparency in decision making, with the goal of building and maintaining trust.
• Creating clear expectations with clients about what proposed treatments entail, who will provide services, and how care will be provided.
• Following through on commitments made to clients (i.e., doing what you say you’re going to do, when you say you’re going to do it).
• Creating spaces that allow for privacy, confidentiality, and community.
• Maintaining respectful and professional boundaries.

Empowerment

Empowering clients involves recognizing, building on, and validating client strengths. Empowerment honors what safety means for the client and can further develop resiliency and coping skills. Empowerment in practice may look like:

• Allowing clients to co-create treatment plans with their providers.
• Giving clients opportunities to identify what they are and are not comfortable with and honoring their choices.
• Not starting treatment until the client approves the approach that will be taken.

Responding to Client Disclosures or Trauma Responses

In the case of client disclosure of trauma or client demonstrating a trauma response, practitioners should be mindful of the following practices:

Maintain Confidentiality

Regulated members should review confidentiality requirements, which may differ for adult and pediatric clients. Regulated members should familiarize themselves with the circumstances in which they are obliged to break confidentiality and report concerns, and clients should be informed in advance of providing services what these circumstances are.

In situations where documentation of the disclosure is legally or ethically required, the practitioner could ask “I’m wondering how you would like me to note what you have told me on your health record?” Clients must also be informed of any reporting requirements for the practitioner.

In situations where documentation is not required, the practitioner could ask what the client would like recorded in their health record, e.g., “This is an important conversation, I’m wondering what, if anything, you’d like me to write in your file?”

Acknowledge and Check in

SLPs and Audiologists who are not trained in trauma screening should not directly ask clients if they have a history of trauma. However, regulated members should be mindful of and pay attention to verbal and non-verbal cues that something feels ‘off’ for the client. If anything unusual is detected, regulated members can acknowledge their observation and check in with the client. For example, “You seem a bit uncomfortable, so I want to check in with you. Is there anything about the appointment or something that I’m saying or doing that is making you uncomfortable? How can we make that better?”

Regulated members may be able to provide the client with some options to regulate or exercise choice in the moment. For example, a regulated member can ask if the client is ok to continue with the session, if they would like a few minutes to regroup, or if they would like to reschedule for a different day.

Listen and Validate

In the event of a trauma disclosure, regulated members should listen to the client’s story, without asking for details. The information that is shared should be acknowledged with empathy. Practitioners should validate what is shared; it is important that clients see and hear from their provider that their experience is believed and that there is appreciation for the courage it took to share their story.

Maintain Scope of Practice and Refer

Treating trauma is outside of the scope of practice for ACSLPA regulated members. As such, giving advice or counselling the client is a professional overstep. However, regulated members can initiate referrals as needed to appropriate healthcare professionals (with the client’s consent) who can provide clinical treatment for trauma and its impacts. Regulated members must also respond to immediate safety concerns (i.e., threats of violence in the home, self-harm, child safety, etc.) with appropriate referrals.

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College of Audiologists and Speech-Language Pathologists of Ontario. (2023). Professional relationships and boundaries position statement. http://www.caslpo.com/sites/default/uploads/files/PS_EN_Professional_Relationships_
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