Trauma-Informed Care and Practice

Regardless of its mandate, every system and organization is impacted by trauma and will benefit from being traumainformed. Service organizations are confronted by the signs and symptoms of trauma every day, and yet often fail to see it and make the necessary connections. Trauma hides in plain view. Every system and organization has the potential to retraumatize people and interfere with recovery, and to support healing.

People affected by trauma from abusive relationships will frequently encounter services that mirror the power and control they experienced in those relationships.

Trauma-informed services do not need to be focused on treating symptoms or syndromes related to trauma. Rather, regardless of their primary mission – to deliver primary care, mental health, addictions services, housing, etc - their commitment is to provide services in a manner that is welcoming and appropriate to the special needs of those affected by trauma (Harris & Fallot, 2001).

Although trauma may be central to many people’s difficulties and awareness of it pivotal to their recovery, in public mental health and social service settings their trauma is seldom identified or addressed. The symptoms that are the creative and necessary adaptations to the effects of trauma are often not recognized as associated with the prior trauma by survivors or clinicians.

Having an awareness of how trauma impacts people is essential to the healing process. Subsequently, working from a trauma-informed orientation has an impact on this healing and the quality of service provided.

At its core, the trauma-informed model replaces the labelling of clients or patients as being “sick,” resistant or uncooperative with that of being affected by an “injury.” Viewing trauma as an injury shifts the conversation from asking “What is wrong with you?” to “What has happened to you?”

Trauma-informed systems and organizations provide for everyone within that system or organization by having a basic understanding of the psychological, neurological, biological, social and spiritual impact that trauma and violence can have on individuals seeking support. Trauma-informed services recognize that the core of any service is genuine, authentic and compassionate relationships.

A trauma-informed service provider, system and organization:

• Realizes the widespread impact of trauma and understands potential paths for healing;
• Recognizes the signs and symptoms of trauma in staff, clients, patients, residents and others involved in the system; and
• Responds by fully integrating knowledge about trauma into policies, procedures, practices and settings.

The core trauma-informed principles are:

• Acknowledgement – recognizing that trauma is pervasive
• Safety
• Trust
• Choice and control
• Compassion
• Collaboration
• Strengths-based

When systems and organizations are committed to integrating these principles at every level, they should consider the following:

• Power and control – whose needs are being served, and do policies empower those being served or those providing the service (e.g., is emphasis being placed on control rather than the comfort of those being served)
• Doing with and not doing to
• Explaining what, why and how
• Offering real choices
• Flexibility
• Understanding and being able to identify fight, flight and freeze responses
• Focusing on strengths, not deficits
• Examining power issues within the organization and promoting democratic principles. (Poole, 2013)

Sandra Bloom M.D. (The Sanctuary Model - www.sanctuaryweb.com) identified seven commitments that trauma-informed organizations make. These are commitments to:

• Non-violence – helping to build safety skills and a commitment to a higher purpose
• Emotional intelligence – helping to teach emotional management skills
• Social learning – helping to build cognitive skills
• Open communication – helping to overcome barriers to healthy communication, learning conflict management, reducing acting out, enhancing self-protective and selfcorrecting skills, teaching healthy boundaries
• Social responsibility – helping to build social connection skills, establish healthy attachment relationships, and establish a sense of fair play and justice  
• Democracy – helping to create civic skills of self-control, self-discipline, and administration of a healthy authority
• Growth and change – helping to work through loss and prepare for the future

Trauma-informed organizations also place a priority on teaching skills in the following areas to clients, patients, residents and staff:

• Self-soothing
• Self-trust
• Self-compassion
• Self-regulation
• Limit setting
• Communicating needs and desires
• Accurate perception of others

Emerging practice standards for working with people who have experienced trauma are rooted in the following areas:

• Build relationships based on respect, trust and safety.
• Use a strengths-based perspective.
• Frame questions and statements with empathy, being careful not to be judgmental.
• Frame the client’s coping behaviours as ways to survive, and explore alternative ways to cope as part of the recovery process.
• Respond to disclosure with belief and validation that will inform practical issues related to care (Havig, 2008).
• Help the client regulate difficult emotions before focusing on recovery.
• Acknowledge that what happened to the client was bad, but that the client is not a bad person.
• Recognize that the client had no control over what happened to them. Let them know that the way they survived during the traumatic experiences was actually their way of resisting what was happening to them and of saying no, even if it did nothing to stop the person behaving abusively.
• Provide an appropriate and knowledgeable response to the client that addresses any concerns they may have about the services offered to them, and then use this knowledge to guide service delivery.
• Watch for and try to reduce triggers and trauma reactions.

When providing and receiving information:

• Inquire about trauma history, and facilitate a supportive discussion with the client while keeping it focused on the present moment.
• Make sure the client is comfortable with the conversation and knows they do not need to answer questions and/or go into detail.
• Check in with the client to make sure the discussion of trauma feels safe and not overwhelming.
• Make time for questions and concerns that the client may have.
• Write things down for clients who may dissociate during encounters.
• Provide a suicide risk assessment where indicated and follow up with the client when the risk has passed.
• Inquire about a possible history of trauma if a client has behaved or is currently behaving abusively themselves.

To create a climate of hope and resilience:

• Acknowledge the client’s abilities to survive and even grow from adversity.
• Acknowledge the strength it takes to get to where the client currently is.
• Refer to the client as “someone who has experienced trauma,” and who is more than what has happened to them. Focus on healing and recovery as “possible.”
• Move beyond mere survival to the context of a healing process, and let the client decide what their path to healing consists of.
• Let the client know that you believe in them and support their efforts to heal.

When providing choices:

• Involve the client in the decision-making process with regard to treatment/service options.
• Inquire about counselling in the past and offer referrals if indicated.
• Ensure that the client feels comfortable during invasive assessments and procedures, and make adjustments to these processes when the client requests it.
• Allow the client to set the pace, slow down and take breaks as required.
• Continually inform the client of what is happening during health-care encounters and assessments (Havig, 2008).
• Where possible, give the client choices about referrals.
• Involve other service providers that are already involved in the client’s care.
• Strive to be culturally appropriate and informed.
• Learn about and develop skills to work within the client’s culture by asking them about it, and understand how your own cultural background can influence transactions with the client (Elliot et al., 2005).
• Understand the meaning the client gives to the trauma from their own cultural perspective.
• Understand what healing means to the client within their cultural context.
• Be open to learning and asking questions about the client’s culture.
• Be open to referring clients to traditional healing services, and become educated in traditional Aboriginal healing ways.
• Become involved in the cultural community that is being served
• .Advocate on behalf of clients who speak English as a second language or are new to negotiating Canadian human services.
• Work through historical distrust – issues may exist from the past that interfere with effective service provision. Understanding that this is normal and not personal will help to build a strong relationship (Brokenleg, 2008).
• Teach Western ways as skills, not as identity replacement (Brokenleg, 2008).

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