Trigger Warnings : Balancing challenging material with overwhelming students

Students with trauma histories are requesting explicit alerts called trigger warnings that required course material may be upsetting to them. This workshop provides a conceptual discussion of what constitutes student trauma history; a summary of a qualitative research project with faculty who teach student trauma survivors; and practical suggestions for balancing healthy classroom culture with the demands of content. Relevant for all chairpersons

New Pharmacological Agents to Aid Smoking Cessation and Tobacco Harm Reduction: What has been Investigated and What is in the Pipeline?

A wide range of support is available to help smokers to quit and aid attempts at harm reduction, including three first-line smoking cessation medications: nicotine replacement therapy, varenicline and bupropion. Despite the efficacy of these, there is a continual need to diversify the range of medications so that the needs of tobacco users are met. This paper compares the first-line smoking cessation medications to: 1) two variants of these existing products: new galenic formulations of varenicline and novel nicotine delivery devices; and 2) twenty-four alternative products: cytisine (novel outside of central and eastern Europe), nortriptyline, other tricyclic antidepressants, electronic cigarettes, clonidine (an anxiolytic), other anxiolytics (e.g. buspirone), selective 5-hydroxytryptamine (5-HT) reuptake inhibitors, supplements (e.g. St John’s wort), silver acetate, nicobrevin, modafinil, venlafaxine, monoamine oxidase inhibitors (MAOI), opioid antagonist, nicotinic acetylcholine receptors (nAChR) antagonists, glucose tablets, selective cannabinoid type 1 receptor antagonists, nicotine vaccines, drugs that affect gamma-aminobutyric acid (GABA) transmission, drugs that affect N-methyl-D-aspartate receptors (NMDA), dopamine agonists (e.g. levodopa), pioglitazone (Actos; OMS405), noradrenaline reuptake inhibitors, and the weight management drug lorcaserin. Six criteria are used: relative efficacy, relative safety, relative cost, relative use (overall impact of effective medication use), relative scope (ability to serve new groups of patients), and relative ease of use (ESCUSE). Many of these products are in the early stages of clinical trials, however, cytisine looks most promising in having established efficacy and safety and being of low cost. Electronic cigarettes have become very popular, appear to be efficacious and are safer than smoking, but issues of continued dependence and possible harms need to be considered

Issues in Integrating Trauma Curriculum into a Graduate Counseling Psychology Program

Globally, human trauma due to natural disasters, war, and other events has been of concern to researchers and practitioners (Kalayjian & Jaeger, 1995; Recognizing that teaching about intense content material, such as would occur with trauma studies, is not without its challenges, we explore the necessity of providing faculty with appropriate training so they are prepared to teach trauma courses, to integrate trauma material into existing courses, and to appropriately advise students. Finally, we address future directions and the need for culturally and ecologically appropriate standards for trauma training in counseling psychology programs. Trainee Selection and Readiness One of the first considerations in implementing a trauma counseling training program is the readiness of trainees and their suitability as trauma workers. Before enrolling in our program, students are required to participate in group or individual interviews. These interviews are conducted by core faculty and provide faculty with insight into why the students are specifically choosing a trauma specialization. The faculty interviewer strives to determine whether the student is motivated for personal or professional reasons, and to assess what the student hopes to achieve from the training. Most importantly, the interview provides faculty in the program with an opportunity to assess a student's readiness for the program. For example, if a student has a trauma history, we will want to know whether the student has been able to work through the issues sufficiently so that it would not interfere with being available and helpful to traumatized clients. Given the anticipated intensity of the coursework, we also try to ascertain whether students would be able to handle the intensity of trauma-related material. 69 Susan H. Gere, Priscilla Dass-Brailsford, & Lisa Tsoi Hoshmand It is well established that individuals who encounter traumatic information or who work with traumatized clients can be profoundly impacted by the experience Research indicates that the level of therapeutic experience a counselor possesses is an important mediating factor in STS, with more experienced therapists suffering less symptomatology than less experienced therapists As therapeutic practitioners, we have a responsibility to ourselves and our clients to know about secondary trauma and to develop self-care strategies to avoid becoming traumatized. Recognizing this responsibility, Munroe (1995) argued that therapeutic practitioners have an obligation 70 Integrating Trauma Curriculum into a Counseling Program to deal with issues of self-care and that neglecting this problem may be a violation of professional ethics. Traumatized therapists and counselors make poor caregivers and may be damaging to clients. Providing training that includes a focus on the effects of working with traumatized clients and on developing strategies to ameliorate symptoms is thus an important, though an often neglected, aspect of preparing students for their roles as future professionals. The Program and Curriculum Issues The main issue in trauma counseling training concerns its unique knowledge base, which is partly a function of how we conceptualize psychological trauma and adaptation to traumatic stress. Educators need to be clear about their philosophical and theoretical perspectives on human responses to trauma. The philosophical assumption of our program is that psychological and behavioral adaptations to trauma are expressions of pain and efforts to cope with unacceptable environmental demands and stressors. They are therefore not necessarily pathological, and are often grounded in cultural systems of meaning making The role of the counseling practitioner is perceived as locating and utilizing the strength and resilience inherent within individuals, families and communities, and empowering them toward healing and recovery. We also subscribe to a bio-psychosocial, relational, and ecological view of trauma and adaptation In addition, the trauma field has reached a beginning consensus on core competences such as identified in the training guidelines of the International Society for Traumatic Stress Studies In offering a trauma studies program, it is crucial to ensure that students have had a solid foundation in counseling and psychology. Educators who plan to deliver trauma counseling training need to identify the core courses students should have completed before Integrating Trauma Curriculum into a Counseling Program families, and communities is emphasized. Students are trained in assessment and intervention from a strength-and resilience-based perspective. In addition, the bio-psychosocial framework is emphasized, and students gain skills in conducting structured interviews, informal protocols, behavioral/symptom checklists and other forms of assessment. Current integrative intervention models and strategies including play therapy, art therapy, and activity-oriented therapies with children and adolescents are also discussed in this course. An understanding of the importance of interdisciplinary collaboration is emphasized. Practitioners in the school, community, medical, legal and public agency settings are encouraged to work together to support children and adolescents who experience trauma and trauma-related crises. Finally, students examine the role of therapeutic issues such as transference and countertransference when dealing with trauma-related material. The fourth course in the trauma studies specialization is Special Topics in Trauma Studies. In addition to providing further understanding of trauma as a clinical concept and human experience within a sociocultural, political, and moral context, it enables students to learn more about cultural-ecological and resilience-based approaches as they relate to global and community trauma, address assessment and therapeutic issues in trauma work, and consider preventive and empowering approaches that involve community and spiritual support, posttraumatic growth, and social action. Through group projects and presentations, students research the needs of special populations such as victims of organized violence and human trafficking, veterans with dual diagnoses, clients with complex trauma history, and groups with multiple vulnerabilities. They also become familiar with resources for program development and guidelines for evidence-based trauma practice. We do not view our trauma specialty courses as exhaustive of all 75 Susan H. Gere, Priscilla Dass-Brailsford, & Lisa Tsoi Hoshmand possibilities in the design of a trauma curriculum. In offering these courses, we are learning from experience as to how much redundancy is required at different points of the trauma counseling training, and to adapt our teaching to the varying needs of the students as a function of their prior clinical experience. These are issues that need to be reviewed and discussed periodically by any training faculty. The training described here is meant to provide graduate students with an important trauma lens, giving them grounding in trauma-focused interventions. It is by no means aimed at making them experts, but merely providing them with a specialization and the development of skills necessary for working with trauma survivors. We describe next the academic environment that we have found from experience to be essential to the delivery of a trauma counseling program. We believe that many training issues arise from the nature of the training environment and how well the training faculty manages the delicate nature of trauma teaching. The Academic Environment Davis (1993) observes that learning evolves through the interaction of a specific setting, a specific subject, a specific student, and a specific teacher and that all four factors contribute to the outcome. Graduate mental health education involves engaging students to think, observe, and analyze along a number of dimensions. Course work demands the assimilation of a particular knowledge base. Fieldwork challenges students to put knowledge into action. Additionally, faculty members may invite students into an educational culture that emphasizes selfreflection, self-disclosure, and the deliberate integration of personal and professional wisdom. Graduate mental health educators are always teaching content, skills, metaphorical clinical thinking, and metacognitive awareness of one's own meaning perspectives simultaneously 76 Integrating Trauma Curriculum into a Counseling Program that explicitly integrates these domains of learning is crucial to the development of skilled trauma counselors. Since trauma counseling may be thought of as an advanced form of "best practices in mental health," sophisticated training environments are essential. The optimal academic environment for training trauma counselors recognizes that the person of the counselor-in-training is an important tool in the helping process Self-reflective approaches in counseling psychology training encourage critical thinking about psychosocial processes and the self that are crucial to the development of skilled practitioners. Among the benefits of self-reflective pedagogies are opportunities to explore beliefs and assumptions about others and the world that form the foundation of developing multicultural competence and minimize possibilities that counseling practitioners may do harm through an inadequate understanding of social and institutional forces. Examples of such harmful assumptions might be that traumatic life events are rare, or that they are equally distributed throughout populations, or that the actions of individuals caused the bad things that happened to them. Self-reflective pedagogies also encourage sufficient transparency in the trainee that problems that surface in coursework, supervision, and practice can be addressed. However, it is equally important that training programs recognize the social aspects of public self-reflection or disclosure. On the one hand, the sharing of the self-reflective insights has profoundly positive implications for developing cohesive learning communities and for transforming student's previously held ideas and personal limitations. On the other hand, there is always a possibility that students may be wounded in the process of disclosing both ideas and personal data. Thus, care must be taken by the instructor to train students to evaluate the risks and value of personal disclosures for themselves and their classmates. 77 Susan H. Gere, Priscilla Dass-Brailsford, & Lisa Tsoi Hoshmand Jourard (1971) found that, at an interpersonal level, being the recipient of intimate disclosure increases trust in and liking for the discloser and tends to provoke reciprocal disclosure at a comparable level of intimacy. However, one exception to Jourard's maxim of reciprocity is the effect that the disclosure of psychological distress has on others. Recognizing the importance of anticipating and addressing the emotional difficulties students experience in graduate-level courses on trauma and violence, we seek to integrate an awareness of student responses to emotionally difficult course material and the traumatic experiences of clients from the outset of the trauma specialization program. We regularly communicate to our graduate students in both clinical and trauma courses the significance of practicing effective self-care skills in order to cope effectively with the reactions they are likely to experience while learning about violence and trauma and working with clients who are confronted with such issues. Using Herman's (1997) model of trauma treatment, we view the initial goal of teaching trauma courses as the building of safety. According to Herman, therapists guide clients through this stage by establishing a safe environment. Similarly, we increase safety in the classroom by having explicit ground rules for the course. To accomplish these goals, we make sure that as instructors we are available to our students to discuss their responses to class material and when appropriate, we also provide referrals to campus agencies, such as the counseling or health centers. In addition, we predict and prepare students by outlining the emotional nature of the content of the trauma courses and emphasizing the importance of self-care. 78 Integrating Trauma Curriculum into a Counseling Program At the same time, we make it clear that we are teaching an academic course, not leading a therapy group. Salient ground rules discussed in the first class session are confidentiality, the importance of setting limits on disclosure of personal experiences, and developing appropriate support mechanisms for the duration of the course They indicate that providing these guidelines early in the program prepares them emotionally, provides opportunities to predict and prepare themselves. All these factors enhance their safety. In addition, they appreciate opportunities for small group work where material can be discussed more intimately; debriefing sessions that are usually conducted after students watch videos or interact with material of significant trauma content are also described as useful