Dr. Nicole Tefera is a Pediatric Psychologist at Advocate Children’s Hospital-Behavioral Health Services, which serves the southwest and south suburban areas of Chicago. An Affiliate of The National Child Traumatic Stress Network, Dr. Tefera’s clinical interests and expertise center on helping underserved and minority populations cope with trauma. In the following interview, she discusses what she has learned about treating this population.
How did you become interested in treating trauma in marginalized populations?
I was raised in Chicago and studied at the Chicago School of Professional Psychology. I was very intentional about wanting to work in my hometown. I knew that I wanted to focus on working with children, adolescents, and their families, as well as underserved and minority populations. The rates of traumatization I was seeing in that population made me realize that I needed to know more about trauma.
Through internships, post-docs, and work experience first at an inpatient psychiatric unit in Gary, Indiana, followed by Sinai Health System’s Under the Rainbow Program, and then at La Rabida Children’s Hospital, I got a lot of training in working with children who have experienced abuse, and neglect, and other types of trauma. After working at La Rabida for eight years, I decided that I wanted to take a break and moved into academia for a short while. During my time in academia, as Director of Applied Professional Practice at The Chicago School of Professional Psychology, I went to the Erikson Institute and earned a certificate in infant mental health.
In my current position at Advocate Children’s Hospital, I see a wide range of clinical presentations, but trauma remains very prevalent.
How does trauma differ in underserved and minority populations?
Most trauma theories lack understanding of the contextual factors those populations experience. I don’t think our field has done much to address how to work with children who have community violence exposure or witnessed intimate partner violence. Nor does it take into account families who feel threatened or targeted or criminalized by police and other people who are supposed to keep them safe. Those particular trauma types have not been addressed very well.
In my work, I see all types of trauma, including children experiencing complex trauma, that is, when a child has experienced more than one type of trauma and/or more than a single event. For instance, a child might come to see me following a car accident, but as I conduct a trauma assessment, I discover that he is not just symptomatic because of the car accident, but also because he lives in a very violent neighborhood, or because she was physically abused in day care or has a history of sexual abuse. My clients experience a myriad of trauma exposures and types affecting their current clinical presentation. I don’t think our current diagnostic manual captures the way trauma affects them, so we end up seeing kids who have been given four or five or six diagnoses.
What interventions have you found most useful?
I am trained in a variety of evidence-based trauma therapies: Child-Parent Psychotherapy (CPP), Trauma Focused Cognitive Behavioral Therapy (TF-CBT), and Attachment, Self-Regulation and Competency (ARC). I am most drawn to CPP, for which I am a national trainer. I like it because it has roots in psychodynamic practice, infant-parent psychotherapy, trauma theory with a huge emphasis on sociocultural components. The modality is play-based and integrates components of attachment, trauma, and developmental psychology. It feels comprehensive and flexible and I have found CPP to be highly effective in my work with very young children and their parents who have experienced trauma.
Where do the interventions fall short?
I know I am supposed to use TF-CBT with fidelity, but I don’t. It is a very linear and rigid treatment. There are modifications for attending to systemic factors, parent-child dyads, and culture, but they are not sufficient. It still feels rigid. The first phase of TF-CBT also doesn’t feel natural to me. TF-CBT starts treatment with psychoeducation about trauma, but I don’t approach it that way.
What sorts of modifications do you make?
I start with a relational perspective. Families do not automatically view a therapist as a safe person with their best interest at heart. I find this to be especially true when working with underserved or marginalized populations. It is one of the first barriers that needs to be addressed. There is a need to lengthen and deepen the engagement phase, build trust, and focus on the relationship and understanding the issues through the client’s lens. I spend more time engaging in play and conversation in an effort to assess how trauma impacts the youth and his or her development. I also provide more normalization and validation.
I tend to modify the skill building modules. While skill building is important, the skills outlined in the treatment manuals are not always the most useful. Families are not a one size fits all. It is better for clients to find ways that are helpful in managing their symptoms than having me impose skills. Sometimes what helps is praying, daily affirmations, talking to important members of the community, utilizing supports–activities that are more in line with their cultural practices and beliefs. I want to support and validate what is helpful to them.
Lastly, I spend more time on contextual factors and issues. It is important to understand the secondary adversities that occur after a trauma. For instance, if a family is undergoing legal proceedings, it is important to learn how that affects them, impacts their symptoms, and/or what it means for them. I also try to understand how clients perceive their neighborhoods, what are their community’s strengths and resources, how they navigate them, and what can be done to advocate for them.
Sometimes, it is really hard to address what clients are up against. Societal ills such as structural and systemic racism perpetuate clients’ feeling unsafe, threatened, and under-resourced. As a therapist, I can do little about those inequities.
How do you work with clients who do not have a lot of experience with and trust in psychotherapy?
Our clinic at Advocate Children’s Hospital is an outpatient clinic, but its purpose is to support the work of the pediatricians. Our pediatricians are culturally an extension of the patients’ families. The are valued and respected by the clients, which helps when clients are referred to us. For example, we recently evaluated a teenager from an immigrant, non-English speaking family who was experiencing a psychotic episode. He had a previous bad experience in an inpatient unit. We felt he needed to be hospitalized, and he also wanted to be hospitalized, but not in same place as before. But his mother was fearful because of the previous bad experience and found it difficult to accept his diagnosis and our recommendations. In this instance, we utilized the support of the pediatrician to explain what was going on and to assist the mother in recognizing the need for her son to be hospitalization for stabilization. The pediatrician was from the same background as the family and spoke the same language. He was able to convince the family to accept the recommendation. Overall, it is important to partner with professionals who have earned the trust of the families.
What has it been like for you as a person of color in the field?
I have found it very rewarding because I feel a lot of purpose and meaning. It’s not just a job to me. I live in the community. There is both pride of having grown up on the south side of Chicago at the same time as I experience many of the challenges and fears and frustrations that are within the African American community. I also need to be mindful of how to navigate my professional world while affording my children a quality education. The downside is that at times I can feel isolated. I do not have a lot of colleagues who share my experiences and background.