Trauma Informed Care in Private Practice

Q: As a therapist, how do I create a safe environment for my patients?

As private practice clinicians, we are generally aware of the importance of the therapeutic environment we create, with lighting, comfortable seating, and soothing colors being the norm. 

​​What you may not think, however, is how to create a safe environment for clients who have experienced trauma.  Whether or not you specifically work with clients who have encountered trauma, it is important to recognize that certain things in the therapeutic environment can be triggers, even re-traumatizing, if we’re not careful.

When we think of trauma, we often think of an obvious event or catastrophe in a person’s life, that they identify and are coming to therapy to process.  However, trauma can be a set of circumstances, a series of events, or even a long-term process, that ultimately causes a person to view their world as unsafe. Viewing the world as unsafe has lasting effects on the brain and nervous system, often causing a near-constant state of hyper-vigilance and acute awareness of stimuli.  Little things can cause big reactions, and may derail what otherwise were productive and therapeutic sessions.

According to SAMHSA, the five principles of trauma-informed care practice include: safety, choice, collaboration, trustworthiness, and empowerment.  This article will focus primarily on the environmental factors to consider when creating a safe space for our clients.  The following environmental suggestions address both psychological and physical safety.

Seating

• Allow clients to choose their own seat, if possible. Whenever we can give our clients the ability to choose, we help to empower them in their own treatment.
  
  
• Make certain that the client can see the door from their seat, as well as have a clear path to the door.  People who have experienced trauma (including law enforcement and military personnel), feel safest when they have a clear view of, and path to, the exit.
  
  
• If possible, do not place yourself or any other person that might be in the session, in between the client and the door.  If a client feels physically trapped, they are less likely to feel emotionally safe in session.
  
  
• Client chairs should back up to a wall, if possible.  This eliminates the thought and fear that someone could approach them from behind without their knowledge.
  ​
• Consider having throw pillows available for clients to hold or place on their lap; this creates a sense of safety and security.  Agencies that work primarily with trauma survivors often have weighted pillows or soft objects for clients to hold in their laps.  These work as a type of tactile grounding, helping clients to feel securely rooted in their physical space.
  ​

Communication​

• Prior to closing the door, ask the client for permission: “Is it ok with you if I close this door?”  99% of clients will say yes, yet the act of asking permission, and the client feeling empowered to say no, may prevent any feelings of being closed in or trapped against their will.
  
  
• Before beginning the session, during rapport building, make sure to ask the client if they are comfortable.  Any opportunity to check in and empower clients to share their discomfort will aid in their feelings of safety in your office.
  ​
  
• Verbally telegraph when you change positions or stand up. For example, at the end of session: “I’ll stand up and walk you to the door.” If you have to get up to get something during session: “I’m going to stand up to grab my notebook,” etc…  This may prevent a startle response if you suddenly change position from sitting to standing.
  ​

Auditory Considerations

• Use a sound machine outside the office door, to minimize any sounds interrupting the session.
  
  
• Inform the client if there are others in the office, and if they may be hearing other voices outside the door during session.  This prevents a possible startle response if other clients or staff happen to speak loudly enough to be heard.
  
  
• Be extra cognizant about informing clients if there is any construction or possible loud noises happening in or around the office.  This includes any traffic or road sounds that carry into the space.  Making clients aware that they may be hearing loud sounds during session may minimize their startle response if/when they hear them.
  ​
  

Visual Considerations

• Avoid harsh overhead lighting; keep the room well-lit with ambient light using lamps.
  
  
• Keep office decor neutral and simple, yet have enough decor displayed where clients can find something to focus on during session- a place for their eyes to rest while their mind works.
  
  ​

As clinicians, these are small yet effective ways of intentionally creating a safe space for our clients to be able to be vulnerable and engage in healing. 

​The idea is to carry this through for all of our clients, as we may be unaware of trauma they have experienced in the past.  However, despite our best efforts at creating a safe environment, clients may still experience triggers, flashbacks, and panic episodes in session. Because of this, it is important for all clinicians to have basic knowledge of trauma, its impact on the brain, and how to deal with trauma responses in session. Even the most prepared and educated clinician may find themselves in a situation where a client is re-traumatized, and it is critical to understand how to respond in the moment. Psychological First Aid, Grounding Techniques, Breathing Exercises, and a neutral, calming presence, are all skills that clinicians should have in their repertoire, so we may help our clients process what they’re experiencing, and continue to grow and heal in therapy.

---

Written by Jamie Cullen, LCMHC, LMHC, LCPC

Jamie is a Licensed Clinical Mental Health Counselor specializing in adult and childhood trauma, addictions, disordered eating, grief and loss, and co-occurring disorders. She has experience working with both chemical and process addictions, specifically their root in trauma, and is passionate about helping individuals enter and maintain recovery, utilizing therapy, psychoeducation, and community supports.

References:
SAMHSA’s Concept of Trauma and Guidance for a Trauma-Informed Approach. (2014). Substance Abuse and Mental Health Service’s Administration.