Introduction Creating a good atmosphere in which people can work is extremely important for the success of the processes of dealing with traumatic reactions and for education. The physical environment, the tension between people, the tension on the caregiver and the client, the theme of the discussion, and many other factors can contribute positively or negatively. The main point here is that the caregiver is responsible for creating an atmosphere in which the client feels safe and can work through his or her issues in a productive way.
Again, we strongly urge you to carry out the activities suggested. If you post any of your answers, please never give details such that other people can be identified. This is highly unethical.
The Physical Environment The physical environment for the work is important. In our view, in working with traumatized clients, it should be as informal as possible so as to make the client as relaxed as possible. Medical settings may remind the client of torture or of medical procedures. Formal offices with desks may remind the client of interrogation. Light and temperature also are important. It should be the client who determines these. Doors should not be locked and the exit route should be clear, as locked doors may remind the client of imprisonment. Sound levels should be low. We recommend against music, as various clients may like various sorts of music and, again, it can bring up a variety of memories, good and bad. Music also may distract the caregiver and the client.
As we have said before, interruptions should be avoided except in emergencies. In this direction, the mobile telephones of the client and the caregiver should be turned off. There may be circumstances, however, in which the client feels safer with the mobile telephone turned on, this as a means of escape. The caregiver needs to be sensitive to this.
We have held individual and group sessions, that is, therapeutic and educational sessions, in virtually every setting imaginable. We also have had the client suggest where the session should be held. Flexibility is important.
Activity Describe the physical environments under which you have held sessions and the challenges that you have faced.
Formality Opinions differ on the level of formality that should be observed between the client and the caregiver. In general, we maintain a fairly high level of formality. In languages in which there is a formal “you” (German: Sie; French: Vous; Croatian/Bosnian/Serbian: Vi), we use that form. During the first conversation, we use the form Mr./Ms. X, perhaps later switching to the first name and allowing the client to use our first names if the client feels comfortable with that. This also will be dependent on culture. We never talk down to the client. Thus, if the client calls us Mr./Ms./Dr. X, we use the same form of address with the client. Our points here are to maintain a relationship of objectivity and to see the client as a valuable person who is determining the course of the work. Later in this course, we will deal with the question of closeness to the client and the possible loss of objectivity in a number of contexts, including ethical ones. It is important for both the client and the caregiver that the caregiver maintains that objectivity.
What level of formality do you use with clients?
What are the cultural aspects of your use of formality with clients?
Do you have different levels of formality with different clients? Why or why not?
Describe a situation, if you have had one, in which you used an inappropriate level of formality, either too formal or too informal.
The Theme of the Session The theme of the session may be an easy one or may lead to a high level of tension. We don’t believe in avoiding difficult topics, and there are many such topics that are important to work with. The point is to handle them in as relaxed a way as possible and in a way in which the client feels safe in dealing with them. This comes down to a non-judgmental and accepting approach in which the caregiver is attentive and listening. It may be necessary to leave a given topic and come back to it later if the level of tension gets too high. However, sometimes, high levels of tension may stimulate the client to deal with the issues and sometimes are necessary to do so. Experience is key here.
Describe a situation in which the topic of the session created a tense atmosphere.
Describe a situation in which the tension of the topic was useful to the client.
Describe difficulties that you have had with the topics of sessions.
The Presence of Other People in the Session We strongly discourage the presence of people other than those directly involved in the session. Thus, in an individual session, only the client and the caregiver should be present and, in a group session, only the members of the group should be there. This is a matter of the privacy of the client. The presence of a spouse, a parent, or anyone else can inhibit the client and can strongly influence the relationship between the caregiver and the client and what the client is prepared to talk about. This also applies to educational sessions where personal material is dealt with. In our view, this is a matter of ethics. We also must note that, sometimes, donors, students, or others wish to attend sessions. We have a blanket rule that we do not allow the presence of anyone except the client(s). Very occasionally, we will ask a client or a group if someone else could be permitted to sit in. If there is agreement, the client or group or the caregiver may ask the person to leave at any moment. We will discuss this in greater detail in the section on ethics.
Another point here is the recording of sessions. We will get into that extensively later in this course. In brief, we tell the client why we want to make the recording and who will see or hear it. We will not make the recording if the client doesn’t agree. This, again, is a very important ethical point.
Describe a situation in which the presence of another person disturbed the session and the relationship between you and the client or the group.
Are there any circumstances under which it is useful or even required to have another person present in the session or to record the session?
The Pressure on the Caregiver and the Client Both the client and the caregiver can be subject to internal and external pressures. Each of these pressures separately as well as the combination of them can contribute to make the atmosphere more difficult.
One frequent issue is the time available for the session. In general, we allow about an hour for individual sessions and an hour and a half to two hours with a break at about the half-way point for group sessions. Also, we allow time for ourselves to prepare for the session and to depressurize after the session has finished. We find this critical for ourselves. We will discuss this in greater detail in the section of this course on self-care.
There may be personal pressures on both the caregiver and on the client. It is the responsibility of the caregiver to be aware of these on both sides. The caregiver also is responsible to keep the influence of his or her own personal pressures to the absolute minimum during the session. Unfortunately, this doesn’t always happen. If the caregiver feels that the internal pressures on him or her are too great, the session should be canceled. The internal pressures of the client should come out during the session. This frequently will make the atmosphere easier, as the client will find a place to express them. That opportunity may not be available elsewhere. This also will be part of the therapeutic process.
The same is true of external pressures. Again, it is the responsibility of the caregiver to be aware of such pressures and to minimize these for himself or herself to the greatest degree possible and to bring the external pressures of the client into the open. Again, if the pressures are too great, the session should be canceled.
Describe a situation in which the internal pressures on the caregiver influenced the atmosphere.
Describe a situation in which the external pressures on the caregiver influenced the atmosphere.
Describe a situation in which the internal pressures on the client influenced the atmosphere.
Describe a situation in which the external pressures on the client influenced the atmosphere.
Are there situations in which internal and external pressures on the caregiver or the client are not relevant?
Final Remarks The point that we want to make here is that the creation of a safe place is essential if the therapeutic and educational processes are to succeed. It takes thought, time, and experience to get it right. Each individual and each group is specific.