TRAUMA-INFORMED CARE has become a popular term that is commonly referenced today in a myriad of systems, such as schools, substance use treatment, health care and behavioral health. Yet its application into practice has much variability.

This article appeared in the January-February 2021 issue of Evidence Technology Magazine.
You can view that full issue here.

This article will address:

• What is trauma?
• What is trauma-informed care?
• How can you apply the principles of trauma-informed care into broad-range practices?

Understanding what defines trauma varies from person to person and is dependent on an individual’s life experiences, as well as their personal and professional attributes. Over the last few decades, we have become keenly aware that not everyone who is impacted by trauma is negatively impacted—but for those who are, we must seek to understand what that impact is and what would help that person to heal.

For example, look at the more than 440,000 lives lost to COVID-19 in the United States and the impact each death had on the family of each victim. Consider the impact the pandemic has had on people infected with the virus, the economic challenges, and the racial injustices, including structural racism.

Whether you work with people through legal, health, or community services, understanding how this trauma has impacted an individual helps to inform the way in which you deliver those services. Prevalence of trauma is well documented. Benjet et al conducted general population surveys in 24 countries (n=68,894 adults) across six continents. Researchers assessed for exposures to some 29 traumatic event types. Findings indicated that more than 70% of respondents reported a traumatic event and 30.5% were exposed to four or more traumatic events. Over half of the traumatic events reported in the study included witnessing death or serious injury, the unexpected death of a loved one, being mugged, being in a life-threatening automobile accident, or experiencing a life-threatening illness or injury. Exposures to trauma varied by country and socio-demographic; history of prior traumatic events and further analysis into race and ethnicity would further help to inform root causes. Exposure to interpersonal violence had the strongest association with subsequent traumatic events (Benjet 2016).

Similar large survey studies in the U.S. reveal a high prevalence of traumatic life experiences, with 90% reporting a serious adverse lifetime event. First launched in 2010 by CDC’s National Center for Injury Prevention and Control, the National Intimate Partner and Sexual Violence Survey (NISVS) is an ongoing, nationally representative survey that assesses intimate and sexual violence, stalking, and victimization among adult women and men in the United States (Kilpatrick et al 2013; Breeding et al 2014; Black et al 2011).

A review of the literature finds a wide range of definitions for trauma. According to the Substance Abuse and Mental Health Services Administration (SAMHSA), trauma includes “an event, series of events, or set of circumstances that is experienced by an individual as physically or emotionally harmful or life threatening and has lasting adverse effects on the individual’s health and well-being.” (SAMHSA 2014) For the purpose of this article, trauma will be defined as individual, interpersonal, and collective traumas (Lewis-O’Connor et al 2019).

Individual trauma includes personal experiences, either direct or witnessed. For example, individual trauma may include a poor diagnosis, the loss of a loved one, a fall, a motor vehicle crash, witnessing a traumatic event, or a traumatic medical experience.

Interpersonal trauma includes those experiences that occur in the context of a relationship, such as child maltreatment, domestic and sexual violence, human trafficking (labor and sex), or elder abuse.

Collective trauma refers to the cultural, historical, and socio-political trauma that impacts individuals and communities across generations. Collective trauma includes institutional barriers, and social determinant of health (“isms”, poverty, food and housing insecurity, economic, and education inequities).

These forms of trauma are not mutually exclusive; rather, there is often an intersection between the various forms (Lewis-O’Conner et al 2019), as shown in Figure 1.

Figure 1. The various forms of trauma.

In 1994, SAMHSA convened the Dare to Vision conference, an event that was intentionally designed to bring trauma to the foreground. It was the first national conference in which women who had survived trauma talked about their experiences and ways in which standard practices in hospitals re-traumatized and, often, triggered memories of previous abuse (SAMHSA 2014).

Today, trauma-informed care is represented with six guiding principles. These principles are grounded in evidence and that evidence offers us an opportunity that should inform our policies and procedures.

As we consider the challenges and opportunities to embed trauma-informed approaches systemically, we must consider developing a pedagogy that advances health equity and social justice with mindful attention and intention to traumas that are rooted in structural racism, oppression, explicit bias, and stigma. We provide services to diverse individuals; thus, we must be proactive in employing policies and procedures that use a social-justice lens. One tool that may advance these efforts is applying the six principles of trauma-informed care. Ideally these principles are applied with a triple aim: organizationally (policies and procedures); staff to patient/client; and staff to staff.

GUIDING PRINCIPLES OF TRAUMA-INFORMED CARE
• Safety—Physical & Psychological
• Transparency & Trustworthiness
• Cultural, Historical, & Gender Acknowledgment
• Peer Support
• Empowerment, Voice, and Choice
• Collaboration & Mutuality

As you look at these guiding principles, let’s consider translating these through the eyes of a victim or survivor. This person might be thinking:

What are they going to ask me? Do I have to tell them everything?

Will I react to the questions, and will they think I am crazy because I still get triggered and have body memories? Are they going to do something that hurts? I really have terrible pain tolerance.

I wonder if they will give me choices, will they hear me? Will they repeat things when I don’t understand, or will that annoy them? Will they help me to connect with other professionals that they want me to see, or will I need to figure this out on my own?

Will they understand what I bring with me from my culture, my historical background—my race, my culture, my ethnicity? Gosh I hope they don’t ask: Why did you… Or Why didn’t you…

I wonder, what are they typing into the computer? Who is going to see this and are they capturing what I am saying?

I hope I will feel safe, that I can share, that I can get help and support, that I can find and use my voice and that I can be acknowledged for who I am—not what happened to me.

Principle 1: Safety—Physical & Psychological
When considering the principle of safety, you want to consider physical and psychological safety. What are the individual’s strengths? How do they best cope with stress? What triggers them, and what is helpful? For example, a patient who suffered a non-fatal strangulation might share that she plays a musical instrument, that she does not like her neck or mouth examined, and that she copes best when receiving small amounts of information at a time.

Principle 2: Transparency & Trustworthiness
Transparency and trustworthiness are key principles for people who have experienced trauma, violence, or abuse. Many victims and survivors trusted someone who hurt them, and sometimes the systems that were intended to help actually re-traumatized individuals. State with clarity what you can and can’t do.

Principle 3: Cultural, Historical, & Gender Acknowledgment
Acknowledge how structural barriers and bias have marginalized people of color. Cultural, historical, and gender acknowledgment requires everyone to receive training on unconscious bias and stigma, self-reflection, and a commitment to system changes.

Principle 4: Peer Support
Peer support is not only the support we put in place for patients and clients, but also the support we build into our structures to support each other. Do you hold optional debriefs? Do you have trained peer supporters? Do you assess staff for compassion fatigue or burnout? Do you promote opportunities for team building? For patients and clients, do you always assess their available resources? Do you assess for social determinants of health and connect the patient to additional services needed?

Principle 5: Empowerment, Voice, and Choice
While this principle is likely one to which we might all personally relate, it is often the principle that we might fall short on. Do you do things for or to a patient or client, or do you do things with them? Do you lift their strengths, or do you focus only on deficits and pathology? Do you accept an individual’s decision even when you don’t agree?

Principle 6: Collaboration & Mutuality
Finally, collaboration and mutuality begs a few questions: 1) How is information shared among team members, and are there ways to improve? and 2) What are the barriers to collaboration, and how are they being addressed? Addressing this principle will require due diligence and commitment to address barriers, access, and engagement to allow for optimal collaboration and mutuality.

How can you apply the principles of trauma-informed care into broad-range practices?
For the past decade, I have been reflecting and pondering how the principles of trauma-informed care can be integrated into all service areas that provide care to victims and survivors. While my area of practice has been primarily health care, I work with an interdisciplinary team including law enforcement, community, and social-service agencies. When these principles are applied across integrated systems, the process and outcomes often have a notable impact.

I recommend that you start with forming a task force across your organization and service lines, including senior sponsorship. I suggest co-chairs (or tri-chairs) of diverse colleagues. Invite anyone with interest in trauma-informed care, or those wanting to learn. Eventually, a group forms and you get some traction! Set meeting dates for the year, include agenda items, and after the meeting, send out a short summary with actionable items. Let the principles of trauma-informed care guide your work: be inclusive, listen, learn, and share together. Consider holding an annual symposium where you share your accomplishments and set goals for the upcoming year.

Trauma-informed care is a theoretical framework that offers organizations and practices, staff, and patients approaches that promote healing and wellness.

About the Author
Dr. Annie Lewis-O’Connor is a dually board-certified Pediatric and Women’s Health Nurse Practitioner. She is the founder and director of the C.A.R.E Clinic (Coordinated Approach to Resiliency & Empowerment) at Brigham and Women’s Hospital in Boston, Massachusetts. Lewis-O’Connor addresses violence from four pillars: research, policy, education, and clinical practice. Currently, she is a clinical scholar with the Robert Wood Johnson Foundation (2018-2021). Since 2012, Lewis-O’Connor has served as co-chair of the MGB Trauma-Informed Care Initiative. She received her Master’s in Nursing from Simmons College in Boston, a Master’s in Public Health from Boston University, and her PhD from Boston College.

References

Benjet, C., E. Bromet, E. G. Karam, R. C. Kessler, K. A. McLaughlin, A. M. Ruscio, V. Shahly, D. J. Stein, M. Petukhova, E. Hill, et al. 2016. The epidemiology of traumatic event exposure worldwide: Results from the World Mental Health Survey Consortium. Psychological Medicine. 2016(46): 327–343. https://doi.org/10.1017/S0033291715001981

Black, M. C., K. C. Basile, M. J. Breiding, et al. 2011. The National Intimate Partner and Sexual Violence Survey (NISVS): 2010 summary report. Atlanta, GA: National Center for Injury Prevention and Control, Centers for Disease Control and Prevention.

Breiding, M. J., S. G. Smith, K. C. Basile, et al. 2014. Prevalence and characteristics of sexual violence, stalking, and intimate partner violence victimization—National Intimate Partner and Sexual Violence Survey, United States, 2011. MMWR Surveillance Summaries. 63(8): 1–18.

Kilpatrick, D. G., H. S. Resnick, M. E. Milanak, et al. 2013. National estimates of exposure to traumatic events and PTSD prevalence using DSM-IV and DSM-5 criteria. Journal of Traumatic Stress. 26(5): 537–547.

Lewis-O’Connor, A., A. Warren, J. V. Lee, N. Levy-Carrick, S. Grossman, M. Chadwick, H. Stoklosa, E. Rittenberg. 2019. State of the science on trauma-inquiry. Women’s Health. 15: 1–17.

SAMHSA. 2014. SAMHSA’s Concept of Trauma and Guidance for a Trauma-Informed Approach. SAMHSA’s Trauma and Justice Strategic Initiative. Retrieved 1 Feb 2021: https://ncsacw.samhsa.gov/userfiles/files/SAMHSA_Trauma.pdf