Trauma-informed care


Trauma-informed care, trauma-informed practice, or trauma-and violence-informed care , is a framework for relating to and helping people who have experienced negative consequences after exposure to dangerous experiences. There is no one single TIC or TVIC framework or model. Various frameworks incorporate a number of perspectives, principles and skills. TIC frameworks can be applied in many contexts including medicine, mental health, law, education, architecture, addiction, gender, culture, and interpersonal relationships. They can be applied by individuals and organizations.
TIC principles emphasize the need to understand the scope of what constitutes danger and how resulting trauma impacts human health, thoughts, feelings, behaviors, communications, and relationships. People who have been exposed to life-altering danger need safety, choice, and support in healing relationships. Client-centered and capacity-building approaches are emphasized. Most frameworks incorporate a biopsychosocial perspective, attending to the integrated effects on biology, psychology, and sociology.
A basic view of trauma-informed care involves developing a holistic appreciation of the potential effects of trauma with the goal of expanding the care-provider's empathy while creating a feeling of safety. Under this view, it is often stated that a trauma-informed approach asks not "What is wrong with you?" but rather "What happened to you?" A more expansive view includes developing an understanding of danger-response. In this view, danger is understood to be broad, include relationship dangers, and can be subjectively experienced. Danger exposure is understood to impact someone's past and present adaptive responses and information processing patterns.

History

Trauma researchers Maxine Harris and Roger Fallot first articulated the concept of trauma-informed care in 2001. They described trauma-informed as a vital paradigm shift, from focusing on the apparently immediate presenting problem to first considering past experience of trauma and violence. They focused on three primary issues: instituting universal trauma screening and assessment; not causing re-traumatization through the delivery methods of professional services; and promoting an understanding of the biopsychosocial nature and effects of trauma.
Researchers and government agencies immediately began expanding on the concept. In the 2000's, the Substance Abuse and Mental Health Services Administration in the United States began to measure the effectiveness of TIC programs. The U.S. Congress created the National Child Traumatic Stress Network, which SAMHSA administers. SAMHSA commissioned a longitudinal study, the Women, Co-Occurring Disorders and Violence Study to produce empirical knowledge on the development and effectiveness of a comprehensive approach to help women with mental health, substance abuse, and trauma histories.
Several significant events happened in 2005. SAMHSA formed the National Center for Trauma-Informed Care. Elliott, Fallot and colleagues identified a consensus of 10 TIC concepts for working with individuals. They more finely parsed Harris and Fallot's earlier ideas, and included relational collaboration, strengths and resilience, cultural competence, and consumer input. They offered application examples, such as providing parenting support to create healing for parents and their children. Huntington and colleagues reviewed the WCDVS data, and working with a steering committee, they reached a consensus on a framework of four core principles for organizations to implement.
  • Organizations and services must be integrated to meet the needs of the relevant population.
  • Settings and services for this population must be trauma-informed.
  • Consumer/survivor/recovering persons must be integrated into the design and provision of services.
  • A comprehensive array of services must be made available.
In 2011 SAMHSA issued a policy statement that all mental health service systems should identify and apply TIC principles. The TIC concept expanded into specific disciplines such as education, child welfare agencies, homeless shelters, and domestic violence services. SAMHSA issued a more comprehensive statement about the TIC concept in 2014, described below.
The term was first used by Browne and colleagues in 2014, in the context of developing strategies for primary health care organizations. In 2016, the Canadian Department of Justice published "Trauma- informed approaches to supporting victims of violence: Policy and practice considerations". Canadian researchers C. Nadine Wathen and Colleen Varcoe expanded and further detailed the TVIC concept in 2023.
In many ways TIC/TVIC concepts and models overlap or incorporate other models, and there is some debate about whether there is a difference. The confusion may be due to whether TIC is seen as a model instead of a framework or approach which brings in knowledge and techniques from other models. For example, most TIC frameworks incorporate a client/person-centered approach, which is fundamental to Rogerian and humanistic models, and foundational in ethical codes for lawyers and medical professionals.
Attachment-informed healing professionals conceptualize their essential role as being a transitional attachment figure, where they focus on providing protection from danger, safety, and appropriate comfort in the professional relationship.
TIC proponents argue the concept promotes a deeper awareness of the many forms of danger and trauma, and the scope and lifetime effects exposure to danger can cause. The prolific use of TIC may be evidence it is a practical and useful framework, concept, model, or set of strategies for helping-professionals.

Types of trauma

Trauma can result from a wide range of experiences which expose humans to one or more physical, emotional, and/or relational dangers.
Psychiatrist and PTSD researcher Bessel van der Kolk describes trauma as an experience and response to exposure to one or more overwhelming dangers, which causes harm to neurobiological functioning, and leaves a person with impaired ability to identify and manage dangers. This leaves them "constantly fighting unseen dangers".
Developmental psychologist Patricia Crittenden describes how relational dangers in childhood caregiving environments can cause chronic trauma: "Some parents are dangerous to their children. Stated more accurately, all parents harm their children more or less, just as all are more or less protective and comforting." Parenting, or caregiver, styles which are dismissive, inconsistent, harsh, abusive or expose children to other physical or relational dangers can cause a trauma which impairs neurodevelopment. Children adapt to achieve maximum caregiver protection, but the adaptation may be maladaptive if used in other relationships. The Dynamic-Maturational Model of Attachment and Adaptation describes how children's repeated exposure to these dangers can result in lifespan impairments to information processing.
Adverse childhood experiences scores are a common measure to assess trauma experienced by children and adults. A higher ACE score is associated with an increased chance of developing chronic diseases or mental health conditions, as well an increased propensity to commit violent acts. Similarly, social determinants of health, such as economic insecurity, can also indicate increased risk for injury or development of trauma, contributing to a higher ACE score for individuals at high-risk for re-injury/traumatization.
Trauma is common. In a meta study of U.S. and international ACEs prevalence studies nearly two thirds of school-aged youth experienced significant adverse events. The prevalence rate varies by an individual trauma type. Emotional abuse and coercive control are as high as 80% and 84% respectively. In a meta study of interpersonal violence experienced by women 37% had experienced it in their lifetime. The effects are dimensional and can vary in scope and degree.

TIC frameworks

There are many TIC-related concepts, principles, approaches, frameworks, or models, some general and some more context specific. Other terms include trauma-informed, trauma-informed approach, trauma-informed perspective, trauma-focused, trauma-based, trauma-sensitive, trauma-informed care/practice, and trauma-informed practice.
The U.S. government's Substance Abuse and Mental Health Services Administration is an agency which has given significant attention to trauma-informed care. SAMHSA sought to develop a broad definition of the concept. It starts with "the three E's of trauma": Event, Experience of events, and Effect. SAMHSA offers four assumptions about a TIC approach with the four R's: Realizing the widespread impact of trauma, Recognizing the signs and symptoms, Responding with a trauma-informed approach, and Resisting re-traumatization.
SAMHSA highlights six key principles: safety; trustworthiness and transparency; peer support; collaboration and mutuality; empowerment, voice and choice, and; cultural, historical and gender issues. They also list 10 implementation domains: governance and leadership; policy; physical environment; engagement and involvement; cross sector collaboration; screening, assessment and treatment services; training and workforce development; progress monitoring and quality assurance; financing; and evaluation.
Researchers Kaitlin Casassa and colleagues interviewed sex trafficking survivors to search for how trauma bonds can be broken and healing can occur. The survivors identified three essential elements:
  1. Education, or a framework, to understand trauma experience and trauma bonding.
  2. Building a safe and trusted relationship, where brutal honesty can happen.
  3. Cultivating self-love.
Researchers Wathen and colleagues describe four integrated principles evolved by key authors in this field.
  1. Understand structural and interpersonal experiences of trauma and violence and their impacts on peoples' lives and behaviors.
  2. Create emotionally, culturally, and physically safe spaces for service users and providers.
  3. Foster opportunities for choice, collaboration, and connections.
  4. Provide strengths-based and capacity building ways to support service users.
In contrast, Landini, a child and adolescent psychiatrist, describes five primary principles from DMM attachment theory for helping people better manage danger response.
  1. Define problems in terms of response to danger.
  2. The professional acts as a transitional attachment figure.
  3. Explore the family's past and present responses to danger.
  4. Work progressively and recursively with the family.
  5. Practice reflective integration with the client as a form of teaching reflective integration.
Bowen and Murshid identified a framework of seven core TIC principles for social policy development.
  1. Safety
  2. Trustworthiness
  3. Transparency
  4. Collaboration
  5. Empowerment
  6. Choice
  7. intersectionality
Researchers Mitchell and colleagues searched for a consensus of TIC principles among early intervention specialists.
  1. A trauma-informed early intervention psychosis service will work to protect the service user from ongoing abuse.
  2. Staff within a trauma-informed early intervention psychosis service are trained to understand the link between trauma and psychosis and will be knowledgeable about trauma and its effects.
  3. A trauma-informed early intervention psychosis service will:
  4. # Seek agreement and consent from the service user before beginning any intervention;
  5. # Build a trusting relationship with the service user;
  6. # Provide appropriate training on trauma-informed care for all staff;
  7. # Support staff in delivering safe assessment and treatments for the effects of trauma;
  8. # Adopt a person-centred approach;
  9. # Maintain a safe environment for service users;
  10. # Have a calm, compassionate and supportive ethos;
  11. # Be trustworthy;
  12. # Acknowledge the relevance of psychological therapies;
  13. # Be sensitive when discussing trauma;
  14. # Be empathetic and non-judgmental;
  15. # Provide supervision to staff;
  16. # Provide regular supervision to practitioners who are working directly with trauma.