It is well known that individuals and communities who have experienced trauma, have an elevated risk for mental health problems, substance use disorders, and physical health conditions. Trauma-Informed Care (TIC) protocols recognize the prevalence and pervasive impact of trauma. As an organizational approach, TIC focuses on how trauma affects one’s life and one’s response to the range of services. According to the Substance Abuse and Mental Health Services Administration (SAMHSA), incorporating TIC involves four key elements:
- Realizing the prevalence and widespread impact of trauma
- Recognizing how trauma affects all individuals within a program, organization, or system including the workforce
- Responding by integrating knowledge about trauma into practice and policy and
- Resisting re-traumatization
SAMHSA proposes six guiding tenets for implementing TIC in clinical settings:
- the safety of all people within and served by the agency
- trustworthiness and transparency of operations and decisions
- peer support and mutual self-help
- collaboration and leveling of power differentials across the agency
- empowerment, voice, and choice
- addressing cultural, historical, and gender issues that may affect services.
Besides supporting competent staff, the approach involves community leaders, consumers, family members, and peer support specialists in all aspects of the service system including planning and evaluation. The effects of trauma are viewed as resilient efforts to adapt and survive. Responses to traumatic experiences can reflect creativity, strength, and self-determination. Building on strengths can shift the focus from what is wrong with an individual to what has happened to them and what has worked for them. TIC requires an appreciation of the wider context of trauma including experiences of poverty, social exclusion, inequality, and discrimination. As trauma involves fear, helplessness, and feelings of loss of control, trauma-informed care is called to support control, choice, and autonomy. Survivors of trauma require certain conditions in order to feel the safety and trust required for therapeutic relationships. Organizations must extend the principles to staff. Providers who feel empowered will be best positioned to value client empowerment. TIC is characterized by a non-authoritarian approach.
TIC practices require organizational and administrative commitment. Necessary system components include:
- Mission and value statements speaking to the importance of recognizing trauma
- Interagency and intra-agency collaboration for trauma-specific services
- Referral agreements and networks
- Workforce development strategies
- Strategies to address secondary trauma or compassion fatigue (SAMHSA, 2014)
While trauma-informed care has become a familiar term for many professionals, it has been criticized for lacking an agreed upon definition, clarity of expected outcomes, and consistency in practice. One systematic review and synthesis of trauma-informed care within outpatient mental health settings for young people identified ten components of trauma-informed care as it had been operationalized in practice. Seven were at the system-level: interagency collaboration; service provider training; safety; leadership, governance, and agency processes; youth and family/care provider choice in care; cultural and gender sensitivity; youth and family/care provider participation. Three involved trauma-specific clinical practices: screening and assessment; psychoeducation; and therapeutic interventions. The researchers emphasized that the ten identified components should not be considered to define trauma-informed care but could serve as a starting point for further clarification. They recommended forming an international consortium of experts in the field and including the perspectives of those with lived experience of trauma and behavioral health conditions and their family/care providers. One principle of trauma-informed care is the inclusion of consumers at organizational and planning levels. The researchers also urged inclusion of the perspectives of marginalized groups known to experience high rates of trauma and mental health conditions such as the LGBTQIA and Indigenous communities. While the SAMHSA definition of trauma-informed care includes providing an emotionally and physically safe environment, it was absent from the included studies. No study considered that trauma-informed care training alone was enough for the delivery of trauma-informed care. Training is unlikely to lead to system change (Bendall et al., 2021).
Another project sought consensus on the principles of trauma-informed care in early intervention psychosis services. The endorsed principles included:
- protecting services users from ongoing abuse
- consent seeking from service users prior to the introduction to interventions
- development of trusting therapeutic relationships
- sensitivity when discussing trauma
- values of being trustworthy, empathetic, and non-judgmental
The researchers reviewed how TIC prioritizes emotional and physical safety and emphasized the need for trauma-sensitive practices which promote user choice and control in trauma disclosure (Mitchell, Shannon, Mulholland, & Hanna, 2020).
As the concept of TIC has emerged across care systems, some have asserted that human rights should be incorporated as an essential part of the discourse. A rights-based perspective provides consideration of access to standardized quality care and targets for measuring if TIC provides demonstrable good in accordance with individual best interests (Bargeman, Smith, & Wekerle, 2021). Moving from a clinical to a politicized understanding of trauma shifts the question from what is wrong with someone to an appreciation of the social context of trauma and an emphasis on healing interactions (Voith, Hamler, Francis, Lee, & Korsch-Williams, 2020).
Bargeman, M., Smith, S., & Wekerle, C. (2021). Trauma-informed care as a rights-based “standard of care”: A critical review. Child Abuse & Neglect, 119, 1-8.
Bendall, S., Eastwood, O., Cox, G., Farrelly-Rosch, A., Nicoll, H., Peters, W., Bailey, A., McGorry, P., & Scanlan, F. (2021). A systematic review and synthesis of trauma-informed care within outpatient and counseling health settings for young people. Child Maltreatment, 26 (3), 313-324.
Mitchell, S., Shannon, C., Mulholland, C., & Hanna, D. (2021). Reaching consensus on the principles of trauma-informed care in early intervention psychosis services: A Delphi study. Early Intervention in Psychiatry, 15, 1369-1375
Substance Abuse and Mental Health Services Administration (2014). Trauma-informed care in behavioral health services [Treatment Improvement Protocol (TIP) Series 57, HHS Publication No. (SMA) 13-4801]. Rockville, MD: Author.
Voith, L., Hamler, T., Francis, M., Lee, H., & Korsch-Williams, A. (2020). Using a trauma-informed, socially just research framework with marginalized populations