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Journal of Aggression, Maltreatment & Trauma
ISSN: 1092-6771 (Print) 1545-083X (Online) Journal homepage: https://www.tandfonline.com/loi/wamt20
Revolutionizing the Clinical Frame
Carol Gomez & Janet Yassen
To cite this article: Carol Gomez & Janet Yassen (2007) Revolutionizing the Clinical Frame,
Journal of Aggression, Maltreatment & Trauma, 14:1-2, 245-263, DOI: 10.1300/J146v14n01_13
To link to this article: https://doi.org/10.1300/J146v14n01_13
Published online: 25 Sep 2008.
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Revolutionizing the Clinical Frame:
Individual and Social Advocacy Practice
on Behalf of Trauma Survivors
Carol Gomez
Janet Yassen
SUMMARY. In this article, we discuss the role of individual and social
advocacy as practices that promote resilience and enhance the ecological relationship between trauma survivors and their communities. Issues of access, comprehension, linguistic and social isolation, cultural disorientation
and displacement, and feelings of powerlessness within governmental and
non-governmental systems encompass common challenges that trauma survivors experience. We discuss two composite cases that explore what individual advocacy and social action entail, how these activities can change a
victim’s relationship with, inform and mobilize health-promoting competencies within the larger community that assist in the healing from trauma.
Included in the article are guidelines and handouts intended to be useful
for service providers who are interested in incorporating advocacy into
their work settings. doi:10.1300/J146v14n01_13 [Article copies available for a
fee from The Haworth Document Delivery Service: 1-800-HAWORTH. E-mail
address: Website:
© 2007 by The Haworth Press, Inc. All rights reserved.]
Address correspondence to: Carol Gomez, Victims of Violence Program, 26 Central Street, Somerville, MA 02143 (E-mail: caroljg@gmail.com).
[Haworth co-indexing entry note]: “Revolutionizing the Clinical Frame: Individual and Social Advocacy
Practice on Behalf of Trauma Survivors.” Gomez, Carol, and Janet Yassen. Co-published simultaneously in
Journal of Aggression, Maltreatment & Trauma (The Haworth Maltreatment & Trauma Press, an imprint of
The Haworth Press, Inc.) Vol. 14, No. 1/2, 2007, pp. 245-263; and: Sources and Expressions of Resiliency
in Trauma Survivors: Ecological Theory, Multicultural Practice (ed: Mary R. Harvey, and Pratyusha
Tummala-Narra) The Haworth Maltreatment & Trauma Press, an imprint of The Haworth Press, Inc., 2007,
pp. 245-263. Single or multiple copies of this article are available for a fee from The Haworth Document Delivery
Service [1-800-HAWORTH, 9:00 a.m. – 5:00 p.m. (EST). E-mail address: docdelivery@haworthpress.com].
Available online at http://jamt.haworthpress.com
© 2007 by The Haworth Press, Inc. All rights reserved.
doi:10.1300/J146v14n01_13
245
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Sources and Expressions of Resiliency in Trauma Survivors
KEYWORDS. Advocacy, trauma, resilience, social action
This article considers innovative advocacy practices based on an outpatient trauma clinic that incorporates a sociopolitical understanding of
interpersonal violence and an approach to clinical care that is informed by
an ecological understanding of psychological trauma (Harvey, 1996).
The Victims of Violence Program (VOV) at the Cambridge Health Alliance (CHA), a teaching hospital of the Harvard Medical School, integrates mental health care with individual and social advocacy on behalf
of victims. The program draws guidance and direction from a community and political perspective that is rooted in the ecological theory of
community psychology and a feminist analysis of violence and abuse
(Harvey, 1996; Harvey, this volume). Clinical and community services
of the program are based on an ecological view of trauma and recovery
from trauma, and are grounded in social movements that stress social
justice. In 2000, with Victims of Crime Act (1984) funds administered
by the Massachusetts Office of Victim Assistance, VOV expanded to
include the Victim Advocacy and Support Team (VAST). VAST was
developed as an expression of the value that VOV places on the aim of
fostering both individual and community resilience through the medium of empowering interventions.
VAST was established on July 1, 2000 with the goal of developing
advocacy services for crime victims throughout the multi-site public
healthcare system of the CHA. The first 18 months of the program concentrated on intensive outreach to the various departments within the
hospital setting. Today, VAST advocates assess client needs, assess the
risk and safety of clients, offer supportive counseling, link clients to
community resources, provide consultation to hospital staff and community settings to ensure appropriate care to clients in crisis, and initiate
systemic and community change and interventions to improve the quality of care for survivors of violence. Now in its fourth year, VAST is a
recognized and heavily utilized service. During the period July 1, 2003
until June 30, 2004, for example, VAST advocates served 116 crime
victims, referred by six major service units within the hospital. Events
precipitating these referrals included patient disclosures of contemporary or past partner or family violence, sexual assault, stranger assault,
stalking, bias crime, workplace harassment, trafficking and labor exploitation, and torture and trauma experienced in home countries. Services rendered included centralized case coordination, safety planning,
court accompaniment, legal advocacy (including probate, child custody
and support, restraining order applications, immigration, and criminal
Carol Gomez and Janet Yassen
247
court issues), emergency funds for food, clothing, and transportation,
and housing and shelter advocacy.
This paper describes the VAST concept of advocacy; how it functions; how it provides individual, systemic, and community advocacy;
and how it addresses barriers to collaboration. Incorporated into the text
are guidelines designed to assist other settings as they incorporate advocacy into their service delivery system.
ADVOCACY AS INDIVIDUAL AND SOCIAL JUSTICE
Ad-vo-cate n. 1. One that pleads the cause of another before a tribunal or judicial court v. to plead in favor of, support (Merriam
Webster’s Collegiate Dictionary, 1994)
The term advocacy is used throughout this article. What is meant by
the role and practice of advocacy in working with victims of violence
and trauma survivors in a mental health and healthcare setting? It is important to emphasize that the practice of advocacy in a mental health
setting may be undertaken by clinicians, social workers, nurses, victim
service professionals, psychiatrists and other physicians, health educators, medical interpreters, and hospital administrators; it may also be
performed by those whose professional identity is that of Advocate. The
work of advocacy constantly moves between the ecological realms of
micro and macro, individual and sociopolitical, intra-psychic and relational. Examples of macro-level or systems-based advocacy include
creating hospital policy that requires domestic violence screening by all
physicians; educating child protective services workers about the complexities facing a mother escaping domestic abuse; and advocating for
the state legislature to reinstate funding for rape crisis centers. These advocacy efforts are interrelated and interdependent. Advocates provide
care in the contexts of community and institutional cultures. They identify and recognize gaps or obstacles in the provision of services.
ADVOCACY IN THE AFTERMATH OF VIOLENCE:
A CLIENT EXAMPLE
(Based on a Composite of VAST Clients)
Christina is a 36-year-old woman who was referred to VAST by
her primary care physician at the hospital. Christina’s husband
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had been abusive to her throughout their ten year marriage. In the
last three years, the violence had escalated. Ray had hit her numerous times and demanded sex from her regardless of her consent. Eight months ago, Christina fled to a battered women’s
shelter but returned home after two weeks, hoping that things at
home would improve. However, nothing changed. In fact, even
though the physical violence decreased, her husband’s emotional
and psychological abuse of her worsened. Christina had not been
sleeping well for months, was depressed, anxious, and easily startled. She complained of debilitating headaches. Christina confided in her doctor about the stresses in her relationship, when the
doctor provided routine screening for domestic violence. She disclosed that Ray had raped her the night before. In addition to her
physical care, which included a Sexual Assault Nurse Examine
(SANE), her physician encouraged her to seek counseling and advocacy at VAST to help her deal with her situation, plan for her
safety, and make decisions about criminal prosecution.
In order to help clients effectively, mental health care providers must
understand the complex interactions of clients with their social environments and consider how to facilitate client access services that are appropriate for them within these environments. VAST worked with
Christina to help her assess her needs and her safety, and to sort through
her ambivalence about leaving her husband. Christina did not accept the
abuse or believe that she deserved such treatment. She did, however,
hold on to the hope that her husband would change and would begin to
respect her as an equal and to treat her with kindness and dignity. As a
result of the years of abuse, and of at times being embarrassed and humiliated in public, Christina was socially isolated. Her self-esteem and
social confidence had eroded. She never felt comfortable or safe making connections that her husband was certain to sabotage. Christina
worked a minimum wage job as a sales assistant. She and Ray jointly
owned their home. She contemplated separation, but felt terrified about
how could support herself or continue the mortgage payments.
Christina’s greatest source of anxiety, however, was that she was a
dependant spouse of a United States citizen. She holds a passport from a
country in South Asia, and Ray must sponsor her application for legal
permanent residency (also commonly referred to as a “green card”).
Since their relocation to the U.S., Ray had been tardy in completing the
application papers. He constantly reminded Christina that her only hope
of remaining in this country legally was through him and he used this re-
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minder as a means to secure her compliance and her silence. When he finally did file her papers, which allowed her conditional residency and
employment authorization, he undermined the process by writing a letter to immigration authorities withdrawing his support.
Advocacy with Christina included supportive, non-judgmental counseling aimed at empowering her to make decisions for herself and regain control over her life while supporting her choices and helping her
move forward at a pace that was comfortable to her. The VAST advocate helped Christina continuously assess her risk and safety, validated
her perceptions and instincts, and most importantly, offered her clear,
accurate information about her options and the protections available to
her as a victim of domestic violence. VAST advocacy helped Christina
forge connections with a network of supportive resources, including a
probate attorney, an immigration attorney familiar with domestic violence case law, and court-based victim witness advocates in case she decided to obtain a restraining order and file criminal charges against Ray.
Christina also joined a community-based support group for battered
women that helped her realize that she was not alone in her situation,
and to receive positive validation, gain confidence, connect socially
with others, and believe in her own worth and potential.
A year and a half after coming to VAST, Christina made the difficult
decision to obtain a restraining order and remove her abusive husband
from her home. Christina has rented the extra room in her house in order
to secure additional income to support her mortgage payments. She is
also embarking on two new business ventures in catering and as a cosmetologist, aside from her regular job, which both supplements her income and allows her to make use of her creative talents and of her
natural social inclinations. She is beginning to organize women in her
community to support each other and break their isolation. While her
life is still intertwined with Ray because of various court actions still in
process, and although she still fears him, she is able to face court appearances with more confidence, feels entitled to live her life free from
abuse, has expanded her social network, and enjoys her liberation from
a life of daily terror.
Clients who are referred to VAST often experience factors in their
lives that increase their vulnerability, limit their access to more traditional services, and need to be taken into consideration when developing a comprehensive treatment plan. The tools of advocacy need to be
expanded to incorporate these added vulnerabilities. For instance, if
Christina had been a part of a same-sex couple, safety planning and intervention would need to consider the dynamics and realities of the gay,
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lesbian, bisexual, transgender, and queer (GLBTQ) communities they
may belong to. Screening for abuse, particularly emotional and psychological violence, with same-sex couples can be complex and perhaps
less evident, given a presumed parity of gender roles. In addition, since
services specific to GLBTQ communities are limited within any service
region, it may be common for both parties to be seeking services and
utilizing the same limited resources. If Christina had been a woman who
spoke little or no English or was hearing impaired, intervention might
have looked a little different from what was offered to her by VAST.
The advocate would have had to work closely with an interpreter or find
a service provider with specialized expertise who might be able to offer
her advocacy and counseling in her own language. If there were no service providers in the local area who might be able to work directly with
her, then the advocate would offer to work in close consultation and collaboration with service providers and specialized services from outside
the region to ensure Christina’s safety.
ADVOCACY PRACTICE:
SAFETY PLANNING, RISK ASSESSMENT,
AND NEEDS ASSESSMENTS
Many victims of crime or violence do not need in-depth therapy to begin reconstructing life after victimization. Effective intervention, building links with appropriate resources, and education about rights and
reassurance that what they are feeling and experiencing in the aftermath
is normal can be equally important resources toward restoring equilibrium and promoting resilient response to violent and abusive circumstances. Essential components of crisis intervention and advocacy
include client needs assessment, continuous safety planning, and risk assessment. Three main areas of safety that require assessment are: (a) safety
from perpetrators of violence; (b) safety from re-traumatization and adverse consequences of being involved in community systems, such as the
criminal justice system, shelter, child protective services; and (c) availability of resources to meet basic needs such as sustenance, shelter, clothing,
medical and mental health care, income/ employment, mobility/transportation, immigration status, ability to communicate/linguistic, and able-ness
access.
Once these areas are identified, it is important to empower the client
to take steps to reclaim and resume control of her life. Education about
rights, legal information, strategy, and linkages to appropriate resources
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are tools for empowering clients and helping them to achieve safety,
control, and self-confidence. It is important to make clients aware of all
options and information available, and with input, to fully allow the client to make decisions about her strategy herself.
IT TAKES A VILLAGE . . . CREATING A COORDINATED
COMMUNITY RESPONSE
(Created from Composite Referrals)
Anita was a 29-year-old computer engineer. She had recently
gone out on a date with a young man she had met over the Internet.
The date was uneventful and Anita did not feel any strong connection to this person. However, over the next five months, Anita was
stalked by this individual. He had tracked down her home address,
her sister’s home address, constantly left messages on her voicemail, and sent her barrages of unwanted email messages, some of
which were sexually threatening and explicit. He implied that
since he knew where her sister and her family lived he would be
paying them a visit soon if she did not return his overtures. She
made phone contact with him a few times in an attempt to set
boundaries and politely reject his unwanted advances, but he persisted. She found notes on her car, flowers sent to her home, phone
calls to her workplace. Her life was altered and she was living in
constant fear. She believed his threat to harm her family, which
paralyzed her. She was too afraid to call the police and worried
that they would not take her seriously. Moreover, she did not understand that what was happening to her was a criminal act. She
came in for counseling and advocacy. She was pale, drawn, anxious, and had lost a great deal of weight due to the stress.
The VAST advocate offered Anita supportive counseling and spent
time strategizing with her how to keep herself safe and also what legal
and civil recourse she might have available to her. Over the next few
weeks, she made some small but practical changes, such as deciding to
change her cell phone number and email account. With the advocate’s
support, Anita decided that she needed to get her workplace involved in
her safety plan, since she was getting both unwanted calls and emails
from him at the office. She met with her manager, with the support of
her advocate who provided consultation to the process. Together, Anita,
her manager, and the advocate developed a plan for ensuring her safety
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at work. This included having the receptionist screen all calls coming
into her line and having her computer support department place a block
on incoming emails from the stalker’s address.
Anita also chose to make use of the criminal justice system. With her
permission, the advocate contacted the detective in her neighborhood to
explain Anita’s plight. The advocate and the detective spent time thinking of workable safety strategies. One strategy was to put Anita in touch
with her local neighborhood watch, with detailed information about the
stalker. The detective then reached out to Anita, by offering to meet
with her and her sister at their homes in order to develop a detailed
safety plan and provide them with extra security patrols in their respective neighborhoods. Anita was not comfortable about pressing charges
against the stalker, but just wanted the behavior to stop. The detective
also directly confronted the stalker and issued him a severe warning
about his conduct. Anita also expressed an interest in getting trained in
self-defense. She joined a self-defense course that helped her gain confidence.
The result of these varied efforts was a multifaceted safety strategy
that entailed close coordination of safety planning by the advocate,
Anita, the detective, her parents, her workplace supervisor and staff, the
neighborhood watch crew and the self-defense instructors. It was a tailor-made intervention strategy that eventually ended the perpetrator’s
behavior and resulted in Anita feeling safe, well cared for, and secure
with the intervention and with the response of her community. She became less anxious, her appetite resumed, and she slowly began to resume
normal function. Once safe, Anita began the journey of acknowledging
the emotional and physical fear that she lived under at that time and the
effects on future relationships.
BEYOND CLINICAL WALLS
The World Health Organization defines health as “a state of physical, mental and social well being, not just the absence of disease or ailment.”1 This includes emotional, social, and physical welfare and is
determined not only by biology, but also by social, political, and economic welfare. In her recommendations for advocacy practice within
healthcare settings, labor rights activist and researcher Lora Jo Foo relates best practices in achieving health to the “public health” model
(Foo, 2002). Health providers and their patients work in partnership to
move patients from “communities of recovery” to “communities of re-
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sistance”; to become empowered and knowledgeable; and to recognize
and, when safe and possible, to resist systemic and individual oppression, as survivors, activists, mothers, sisters, brothers, and/or healers in
our communities (Foo, 2002).
Despite theoretical and social awareness, clients who are trauma survivors often find it difficult to find adequate care. There are very few
programs that understand the need for both individual care and an ecological approach to providing care. On the contrary, there is evidence of
considerable tension between community-oriented groups and mental
health providers. For instance, a survey conducted in 1994 by the National Resource Center on Domestic Violence indicated that over half
(53%) of statewide domestic violence coalitions did not feel that mental
health professionals understood the dynamics of battering and/or how
to assist in safety planning for women and children (Gondolf, 1997).
Despite pockets of better working relationships, this mistrust continues
today, with reports of mental health providers not valuing or respecting
the experience of community advocates. Philosophical and practical
differences can be experienced as obstacles to care and confusing for
victims of violence, who may be caught in differences of value systems.
The setting and mission in which mental health services are delivered
shape the response and services that victims of violence receive. It is,
therefore, important to understand some of the challenges that impede
the delivery of comprehensive services within a mental health setting
and to consider recommendations or opportunities for enhancing your
effectiveness as a clinician and advocate. Advocacy involves taking
care of clients beyond the confines of the clinical hour and the location
of the therapeutic environment. It requires taking an active stand against
violence and voicing that premise with your client.
INSIDER, OUTSIDER
The role of advocacy is determined and affected by the context in
which it occurs. Over the last 30 years, advocates for crime victims and
battered women have expanded beyond domestic violence shelter programs and rape crisis centers and are now located within court systems,
police departments, housing developments, children’s services, and
healthcare settings. Different contexts provide diverse theoretical approaches and multiple and sometimes conflicting goals for advocacy
(Davies, 1998). Victim advocates housed within established institutional
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structures are in a unique position of being both part of the system and being critical toward and challenging that same system, when necessary.
Clinical practice and advocacy practice are interdependent. The
inter-relationship of each discipline can assist in accountability to the
inherent goal of being client and community centered. Both lend equal
value to the other through the expansion of context for providing holistic and client centered care.
IMPLICATIONS FOR PRACTICE:
GUIDELINES FOR EFFECTIVE ADVOCACY
What can you do to become an effective advocate in your clinical
work? Ten attributes are described in the following section as underpinnings of effective clinical advocacy practice.
1. Become Knowledgeable About the Systems
with Which Victims of Violence May Interface
Why it is important. Your anticipation of the strengths and barriers
of the system can help you help your client maneuver within the system smoothly and can prepare the client to face those systems effectively. Preparing your client for potential barriers within systems can
be useful in preventing and reducing secondary victimization and can
help her make more informed choices about steps she can take to keep
safe. This systems knowledge will also help you gain understanding
and empathy for your client’s struggles with the system. When we
consider Christina and Anita’s cases, a lack of awareness of resources,
legal information, or how to utilize systems effectively can create additional difficulties for them both. For instance, if clinicians or medical care providers are not aware that most states have specialized
Sexual Assault Nurse Examiners, who are trained to conduct comprehensive medical and forensic examinations for sexual assault survivors, then critical evidence to a criminal case against an offender may
be lost. Being an undocumented immigrant, homeless, and/or without
health insurance creates additional complications for any client and
compromises their emotional functioning.
Clinicians should take the time to become aware of local resources to
help clients with these survival needs. In rural areas, you may be less
likely to be able to locate the services that someone like Christina might
need. Therefore, it may be necessary to lobby for more state funds to en-
Carol Gomez and Janet Yassen
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ter your area for services and to develop relationships with social services and informal community network in your area for consultation,
information, and resource sharing.
What you can do.
• Educate yourself about relevant systems. Build alliances with other
providers in your own agency or system, and familiarize yourself
with in-house resources.
• Build alliances in the community (e.g., with immigration attorneys, probation departments).
• Contact probate lawyers, child protective services workers, domestic violence detectives in local precincts, and victim witness advocates in local prosecutors offices. Offer cross training to each other’s
staffs. Participate in or initiate community-wide efforts to develop
new services, resources, or prevention initiatives. Resource development can diminish the powerlessness that clinicians can feel in
the face of inadequate support for their clients.
• Accompany your client to their appointments in court or with
their divorce/probate attorney or to the welfare office when possible and appropriate. This helps you to learn first hand what it
takes for you and your client to interface with often complicated
agencies. Consult the Internet, as many community agencies now
have their resources posted and can help familiarize you with local services.
• Include resources packets in all training and orientation materials.
2. Advocate for Your Clients in Community Settings
Why this is important. Pro-active outreach on the part of a provider to
a collateral system provider can go a long way in creating a respectful
connection and safe pathway for your client to the referral agency. This
particularly rings true in environments, such as police departments,
emergency rooms, or child protective services, where crime victims are
easily overlooked, lost, or misunderstood. Take this opportunity to educate providers in other systems about the impact of trauma on a crime
victim, in order that they are sensitized to the common reactions to
trauma that a client may be experiencing.
What you can do. A simple call ahead from you as an advocate or
representative of healthcare agency fulfills several functions. Accompanying your client to daunting institutions can offer a great deal of
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emotional relief and give courage to your client in that situation. This
can be an opportunity to forge a trusting relationship with the providers
on the other side, not only for your client, but also for future clients who
may need their services.
3. Facilitate Collaboration, Communication, and Coordinated
Response
Why this is important. Teamwork and a coordinated community response create a strong safety net for our clients and for future clients.
The relationship built with another provider can enhance creative
problem solving. Coordinated teamwork will also help build confidence of the client and reduce the likelihood of oversights, errors, and
miscommunication being made within the system.
What you can do. Keep communication lines among clients and providers open (within the requirements of client and professional confidentiality). Try to resolve interpersonal disputes or disagreements with
colleagues outside of the professional setting, so that these will not interfere with the care of the client. Take time to communicate clearly
with one another about differing perspectives of intervention and care
of the client. Do not hold the individual provider in each system at fault
for institutional policies over which they have no control. Realize that
together we have the power to effect change and paradoxically to transform our own powerlessness within the system.
4. Provide and Get Support from Other Providers
Why this is important. Providing services to crime victims and abuse
survivors often involves complicated negotiations and can produce a
great deal of anxiety, stress, and compassion fatigue in a caregiver, particularly if a client is still living in an unsafe situation. Positive working
relationships with all providers from the various systems involved with
the trauma survivor can help lessen the stress and burden of responsibility for the safety of our clients. The support given and received can help
reduce secondary trauma for providers.
What you can do. Genuinely support each other. Check in periodically,
if only to leave a quick message or email note validating one another’s
work, venting constructively about systemic glitches, and acknowledging
how scared, frustrated, or pleased we are about the case.
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257
5. Expand and Enhance Your Training and Education Curriculum
Why this is important. Mental health providers often do not receive
training in their professional education regarding assessment of violence-related factors affecting mental health outcomes. Although many
professional schools do offer a trauma-related curriculum, it is often not
a requirement. Given our growing awareness of the prevalence of violence in the general population, it is important that mental health training include attention to the social realities of client’s lives and to the role
of other community-based resources in improving mental health. It is
crucial, too, that mental health education and training include attention
to cultural forces and offer the clinician opportunities to explore one’s
own racial, class, and ethnic identity, sexual orientation, and blind
spots, which influence how and by whom services are delivered.
What can you do.
• Evaluate the professional training curriculum available to you and
develop onsite training that includes universal screening for violence and abuse.
• Participate in community-based task forces that inform members
about the resources of their own community agencies.
• Develop protocols to assess and provide services for victims of violence that are systemically available and user friendly.
• Assess your setting’s multi-cultural curriculum, being sure that it
includes opportunities for self-evaluation and growth in order to
manage possible unintentional clinical failures and counter-transference traps.
6. Actively Learn About and Integrate Different Theoretical
Approaches
Why this is important. Most mental health clinicians are trained in
medical model approaches to providing treatment, which emphasize individual pathology, family dysfunction, and early development. Within
this model, there is less awareness of the mental health consequences of
violence and abuse. Consequently, medical model approaches to evaluation, diagnosis, and treatment of survivors of violence can constrain or
even be harmful to survivors seeking treatment. For instance, if the clinician who first met with Christina h