Working in ways that are trauma-informed, strengths based, and culturally safe are important when supporting people with FASD. Trauma-informed practice is based on the understanding that experiences of trauma are prominent in people with FASD and therefore it is important to emphasize safety, collaboration, connection, choice, and empowerment1. A strengths-based approach moves away from a deficit focus on disability toward an emphasis on capabilities2,3. In this way, trauma-informed and strengths-based approaches can complement and enhance one another. Cultural safety is another important component of supporting people with FASD. Cultural safety should be embedded in a willingness for mental health professionals to engage in self-reflection, to recognize that Indigenous people carry a disproportionate burden of substance use related harm due to the historical and ongoing impacts of colonization, and to understand that clients from the same cultural backgrounds may present with a wide variety of experiences related to racism, discrimination, connection with culture, and desire to engage with cultural supports2. This section will discuss:
What is Trauma?
A traumatic event involves either a single experience and/or an enduring and/or repeated experience that is overwhelming to the point that an individual has challenges coping, as well as integrating ideas and emotions involved in that experience4,5,6. Examples of trauma may include child abuse, neglect, witnessing violence, accidents, and sudden unexpected loss4. Traumatizing events can happen to anyone and can have a serious impact on people’s mental health and wellbeing5.
“Trauma is when we have encountered an out of control, frightening experience that has disconnected us from all sense of resourcefulness or safety or coping or love.” ~ Tara Brach5
People with FASD may experience significant adverse life experiences and traumatic events in their lives. For example, in a study conducted by Streissguth and colleagues (2004), 61% of children and 72% of adolescents and adults with FASD had experiences of physical or sexual abuse or intimate partner violence. Childhood trauma has been connected to a range of emotional and psychological reactions, such as depression, low self-esteem, anxiety, behavioural problems, substance use, and suicidal ideation7. The challenges associated with FASD may be compounded by the impacts of trauma and it is therefore important to consider all the intersecting factors that may be impacting a client with FASD who is seeking support.
In the context of trauma-informed care it is also important to consider intergenerational trauma, which describes the psychological or emotional effects that can also be experienced by people who live with those who have experienced trauma4. The coping and adaptation strategies and patterns developed in response to trauma may be passed from one generation to the next4. Specifically, it is important to consider the historical and current impacts of colonialism in Canada and how this has impacted Indigenous people and communities historically and currently. Many historical and current events (e.g., the Sixties Scoop, residential schools, the Millennial Scoop) have led to personal and collective trauma in Indigenous communities4.
- The following handout is available from CAMH to accessibly discuss trauma with clients: What is Trauma?
- Strengths-based and Trauma-informed Practice (Looking beneath the surface)
- For Love – FOR LOVE is a film of resilience and resurgence – colonization has led to many adverse impacts on the Indigenous population of Canada – most significantly on familial and societal structures.
People’s reactions to trauma will vary significantly but across the spectrum people may experience anxiety, terror, shock, shame, emotional numbness, disconnection, intrusive thoughts, helplessness, and powerlessness4. People’s physical health can also be impacted, including chronic pain, gastrointestinal problems, asthma, and headaches4. It is also important to note that many people will find positive methods of coping with and responding to trauma, including increased bonds with family/community, redefining sense of purpose/meaning, increased commitment to personal missions, revised priorities, and increased altruism6.
What is Trauma-Informed Practice?
Trauma-informed approaches take into consideration the long-lasting emotional responses that can persist from distressing events in all aspects of service delivery8. This approach recognizes how experiences of trauma can impact the confidence, beliefs, and behaviours of people coming for support9. Trauma-informed approaches are not meant to “treat” trauma, but rather to recognize the prominence of trauma, understanding how it can impact people, and integrating appropriate approaches into all aspects of support4,5. Trauma-informed practice emphasizes safety, trustworthiness, choice, connection, collaboration, strength, and skill-building1,4. The therapeutic alliance/relationship is an important factor in creating a safe space to heal and express emotions related to trauma5,7. As mental health professionals, our focus and responsibility are to develop genuine and authentic relationships with our clients5.
There are important principles of trauma-informed care4,5,6,8:
- Trauma Awareness: understanding how common trauma is for people with FASD; building an understanding of how it can impact people.
- Emphasis on Safety and Trustworthiness: physical, emotional, and cultural safety for client
- Opportunity for Choice, Collaboration, and Connection: communicate openly, equalize power imbalances, and allow expressions of feelings without judgement.
- Strengths Based and Skill Building: identify strengths and develop resiliency and coping skills.
When supporting a client with FASD who may have experiences of loss, grief, and trauma, the following approach may be beneficial9:
The 4R Concept
|Realize||That everyone may have experiences of trauma|
|Recognize||Signs and triggers of trauma in clients with FASD|
|Respond||To each client using a trauma-informed approach with dignity, respect, and empowerment|
|Resist retraumatizing||Take precautions to ensure safety
It is important to understand that some people will want to share their traumatic experiences, while others may not feel comfortable or may be triggered when speaking about these events. If a client is triggered during a session, focus on the here and now (e.g., use grounding technique; SAMHSA, 2014)
It is also important to recognize and understand that trauma will likely be experienced differently based on people’s own unique identities and experiences (e.g., trauma will be experienced differently by immigrants, people with developmental disabilities, women, men, non-binary or gender non-conforming people, Indigenous people, etc.)4. It is important to be open to learning, asking questions, and meeting clients where they are at in terms of their reactions and levels of trust5.
If a client decides to share their story here are some strategies/approaches that may help to facilitate a safe space (from the CanFASD training):
- Let the client know that you are there for them to listen
- Make sure there are no interruptions or distractions
- Make sure they are comfortable (physically)
- Provide some tissues close by and something to drink if wanted
- Offer something for them to hold if they would like that (e.g., a pillow, stuffed animal)
- Be aware of the time but give sufficient time, try not to rush
- Be familiar with their story, use language common to them and be aware of the feelings and responses invoked
- Be willing to hear the same story as many times as needed
- Identify triggers and physical responses in clients
- Make sure to follow the lead of the client, do not lead/direct them
The following handout from the Centre of Excellence for Women’s Health outlines grounding techniques that can be used with clients when discussing trauma: Grounding Activities and Trauma-Informed Practice
Why a Strengths-Based Approach is Important
Generally speaking, people’s understandings of FASD and resulting research and policy regarding the topic have been largely focused on the challenges, impairments, and deficits2,11. This perspective is likely to increase feelings of shame, victimization and suffering, and can also lead to people with FASD being viewed as burdensome or an object of pity11. It is important that mental health professionals examine their own biases regarding disability, or any negative perspectives that may be present due to the deficit-focused nature of disability research11.
“By neglecting to explore the successes of individuals with FASD, we fail to recognize their immense potential and celebrate the unique contributions that each individual has to offer.”12
A strengths-based approach to practice is collaborative in determining and drawing on the client’s strengths and assets13. It encourages a quality relationship between those providing and receiving support, recognizes the expertise and strengths the person seeking support brings to the process, and emphasizes collaboration in support4,13.
Although it is necessary to acknowledge potential challenges associated with FASD, and knowledge of these challenges is needed to inform services and supports, a balanced perspective considering strengths and capacities is equally important to informing intervention approaches2,3. For mental health professionals, a shift from a deficit-based focus may reduce potential bias and negative outcomes by reframing behaviour and honouring the capabilities of each client, with an optimistic approach to support2. This perspective may also help to avoid unintended feelings of shame and stigma2.
In the following podcast Dr. Katy Flannigan and Dorothy Reid speak to what it means to be strengths-based: Dr Katy Flannigan & Dorothy Reid: What does strengths based even mean?
It is important to engage in an effortful identification of strengths and capabilities to inform the interventions and approaches used2. For example, you may inquire about what your client enjoys, what they are good at, or times they have been successful.
Focusing attention toward identifying and leveraging strengths will help to instill a stronger sense of hope, optimism, confidence, self-advocacy, and positive identity for individuals with FASD2. It can also be important to collaborate with the individual and their support team to identify existing strengths to build on in mental health support2.
The following list of strengths has been created anecdotally regarding people with FASD (from CanFASD: FASD for Community and Social Services Professionals Level II):
- Caring, with a strong sense of justice
- Friendly and outgoing
- Affectionate and likeable
- Hardworking, determined, and persistent
- Hands-on, concrete learners
- Lateral thinkers with points of insight in certain areas
- Strong, long-term, visual memories
- Chatty, verbal, and good storytellers
- Helpful and keen to please
- Athletic and sporty
- Creative, musical, and artistic
What is Cultural Safety?
Cultural safety is a concept that was developed by a Māori nurse, Irihapeti Ramsden, in Aotearoa/New Zealand, in a response to the healthcare system’s failure to meet the needs of the Māori community14.
When it comes to considerations of cultural safety, there are many terms that are often used interchangeably, such as cultural awareness, sensitivity, competency, and humility. However, these terms refer to different aspects of a related idea. Ward and colleagues (2016) outline how cultural safety differs from the other terms:
- Cultural Awareness: An attitude that includes awareness about differences between cultures.
- Cultural Sensitivity: An attitude that recognizes the differences between culture and that these differences are important to acknowledge.
- Cultural Competency: An approach that focuses on practitioners’ attaining skills, knowledge, and attitudes to work in more effective and respectful ways with Indigenous patients and people of different cultures.
- Cultural Humility: An approach to care based on humble acknowledgement of oneself as a learner when it comes to understanding a person’s experience.
- Cultural Safety is an approach that considers how social and historical contexts, as well as structural and interpersonal power imbalances, shape care/support experiences. Practitioners from this perspective should be engaging in self-reflection regarding their position of power and the impact of this power.
The key defining feature of cultural safety is that it turns the focus away from understanding and knowledge about other people’s cultures/experiences, toward the professional engaging in reflection surrounding issues of power14.
In the following video Dr. Allison Reeves discusses culturally safe practices as foundational in counselling: Culturally safe practice by Allison Reeves
It is also important to understand and recognize that what culture and safety mean to each of your clients will be different. Cultural safety goes beyond implementing cultural practices, it is about embedding a philosophy of care and respect2. As such, in this section we will not be outlining culturally specific practices or ceremonies as this will look different for each client; instead, we will highlight important tenets and how to enact the philosophy of cultural safety2.
The goal of cultural safety is for people to feel respected, to minimize power imbalances between clients and care providers, to ensure that there is an understanding of the cultural history of those accessing your services, and that people are supported to integrate their identity, culture, and community into the services they are accessing1,2. In addition, cultural safety is about acknowledging the cultural influences on each client you are interacting with, respecting the influence of culture on clients’ realities, and reflecting on your own skills, attitudes, assumptions and beliefs that may impact support2.
Philosophy of Cultural Safety
To promote a philosophy of cultural safety, mental health providers can enact the following (adapted from Moving Towards FASD-Informed Care in Substance Use Treatment):
|(1) Maintain awareness that access to culture, ceremony, and community connections can facilitate the healing process, offer hope, and enhance positive changes for clients. When possible, helping to facilitate these opportunities and access to cultural and/or spiritual support is important.|
|(2) When working with Indigenous clients, it is important to be aware that reconnecting to culture may develop mixed feelings (e.g., joy, satisfaction, loss, pain). In addition, it is important to understand the current and historical complexities that may contribute to your clients’ current life situation to foster a deeper empathy and understanding.|
|(3) Some people may want to reconnect with cultural components of their identity but may be unsure how to do so. They may need support in being connected with communities and resources or knowing cultural protocols.|
|(4) Recognize that clients present with multiple components of their identity (e.g., race, ethnicity, sex, gender) and people may vary with respect to their desire to claim or connect with components of their identity. Cultural connectedness is an individualized choice.|
|(5) Be conscious of past experiences of racism and discrimination that people from various cultural backgrounds may bring to treatment and that can impact the therapeutic relationship (e.g., trust).|
|(6) Reflect on how your own culture/ethnicity impacts your worldview and engagement with clients.|
It is important to consider how you can incorporate aspects of trauma-informed, strengths-based and culturally safe approaches into your practice. Engaging in reflection on how you interact with clients and ways in which you can embed these approaches into your interactions will likely enhance your ability to connect, support, and meet clients where they are at.
In the following video Myles Himmelreich speaks to the strengths of FASD: FASD = Faith, Ability, Strength, Determination
1Schmidt, R., Wolfson, L., Stinson, J., Poole, N., & Greaves, L. (2019). Mothering and Opioids: Addressing Stigma and Acting Collaboratively. Vancouver, BC: Centre of Excellence for Women’s Health.
2Kapasi, A., Tremblay, M., Pei, J., Rorem, D., Makowecki, E., Wuest, V., Regier, M., McLachlan, K., Dunleavy, B., Mela, M., Benjamin, M., & DesRoches, A. (2022). Moving Towards FASD-Informed Care in Substance Use Treatment. Canada FASD Research Network.
3Pei, J., Kapasi, A., Kennedy, K.E., & Joly, V. (2019). Towards Healthy Outcomes for Individuals with Fetal Alcohol Spectrum Disorder. Canada FASD Research Network in collaboration with the University of Alberta.
4Arthur, E., Seymour, A., Dartnall, M., Beltgens, P., Poole, N., Smylie, D., North, N. & Schmidt, R. (2013). Trauma-informed practice guide. BC Provincial Mental Health and Substance Use Planning Council.
5Klinic Community Health Centre (KCHC). (2013). Trauma-Informed: The Trauma Toolkit. Manitoba, AB: Klinic Community Health Centre.
6Substance Abuse and Mental Health Services Administration (SAMHSA). (2014). Trauma-Informed Care in Behavioral Health Services. Treatment Improvement Protocol (TIP) Series 57. HHS Publication No. (SMA) 13-4801. Rockville, MD: Substance Abuse and Mental Health Services Administration.
7Knight, C. (2015). Trauma-Informed Social Work Practice: Practice Considerations and Challenges. Clin Soc Work J 43, 25–37 (2015). https://doi.org/10.1007/s10615-014-0481-6
8Ninomiya, M. E., Almomani, Y., Dunbar Winsor, K., Burns, N., Harding, K. D., Ropson, M., … & Wolfson, L. (2023). Supporting pregnant and parenting women who use alcohol during pregnancy: A scoping review of trauma-informed approaches. Women’s Health, 19, 17455057221148304. https://doi.org/10.1177/17455057221148304
9Centre for Addiction and Mental Health (CAMH). (2017). Becoming Trauma Informed. (N. Pool, L. Greaves, Ed.). Centre for Addiction and Mental Health (CAMH).
10Kropp, H. (2015). Trauma-Informed Care: Development of a web-based multimedia e-learning course. University of California, Davis.
11Flannigan, K., Wrath, A., Ritter, C., McLachlan, K., Harding, K. D., Campbell, A., … & Pei, J. (2021). Balancing the story of fetal alcohol spectrum disorder: A narrative review of the literature on strengths. Alcoholism: Clinical and experimental research, 45(12), 2448-2464. https://doi.org/10.1111/acer.14733
12Flannigan, K., Harding, K., Reid, D. (2018). Strengths Among Individuals with FASD. Vancouver, BC. CanFASD.
13Pattoni, L. (2012, May). Strengths-based approaches for working with individuals. Glasgow: Iriss.
14Churchill, M., Parent-Bergeron, M., Smylie, J., Ward, C., Fridkin, A., Smylie, D., Firestone, M. (2017). Evidence Brief: Wise Practices for Indigenous-specific cultural safety training programs. Well Living House Action Research Centre for Indigenous Infant, Child and Family Health and Wellbeing, Centre for Research on Inner City Health, St. Michael’s Hospital.