Part Two: A Trauma-Informed Approach
What do we mean by a Trauma-informed Approach? The Three R's
A trauma-informed approach refers to how a program, agency, organization, or community thinks about and responds to those who have experienced or may be at risk for experiencing trauma; it refers to a change in the organizational culture. In this approach, all components of the organization incorporate a thorough understanding of the prevalence and impact of trauma, the role that trauma plays, and the complex and varied paths in which people recover and heal from trauma. A trauma-informed approach is designed to avoid re-traumatizing those who seek assistance, to focus on "safety first" and a commitment to "do no harm," and to facilitate participation and meaningful involvement of consumers and families, and trauma survivors in the planning of services and programs. It also requires, to the extent possible, closely knit collaborative relationships with other public sector service systems (Harris and Fallot, 2001)1.
A definition of trauma-informed approach incorporates three key elements: (1) realizing the prevalence of trauma; (2) recognizing how trauma affects all individuals involved with the program, organization, or system, including its own workforce; and (3) responding by putting this knowledge into practice.
A program, organization, or system that is trauma-informed realizes the widespread impact of trauma and understands potential paths for healing; recognizes the signs and symptoms of trauma in staff, clients, and others involved with the system; and responds by fully integrating knowledge about trauma into policies, procedures, practices, and settings.
In a trauma-informed approach, all people at all levels of the organization or system have a basic realization about trauma and understand how trauma can affect families, groups, organizations, and communities as well as individuals. There is an understanding that trauma plays a role in mental and substance use disorders and should be systematically addressed in treatment and recovery settings. Similarly, there is a realization that trauma is not confined to the behavioral health specialty service sector, but is integral to other systems (e.g., child welfare, criminal justice, primary health care, peer-run and community organizations) and often a barrier to effective outcomes in those systems as well.
People in the organization or system are also able to recognize the signs of trauma. These signs may be gender, age, or setting-specific and may be manifest by individuals seeking or providing services in these settings. Trauma screening and assessment procedures assist in the recognition of trauma. Staff recognize how organizational practices may trigger painful memories and retraumatize people with trauma histories. For example, they recognize that using restraints on a person who has been sexually abused or placing a child who has been neglected and abandoned in a seclusion room may be retraumatizing and interfere with healing and recovery.
The program, organization, or system responds by applying the principles of a trauma-informed approach to all areas of functioning. People in every part of the organization, from the person who greets clients at the door to the executives and the governance board, have changed their language, behaviors. and policies to take into consideration the experiences of trauma among children and adult users of the services and among staff providing the services. This is accomplished through staff and leadership training on trauma, a budget that supports this ongoing training, and leadership that realizes the role of trauma in the lives of their staff and the people they serve. Some organizations have established "trauma work groups", a cross section of staff that strategize how to apply the lessons about trauma into daily program practices. The organization has a meaningful definition of trauma that is contained in mission statements and staff handbooks and manuals and promotes a culture based on beliefs about resilience, recovery, and healing from trauma. The organization has practitioners trained in evidence-based trauma practices. The organization is committed to providing a physically and psychologically safe environment. The physical space is not taken for granted but is intentionally well-maintained, clean, well-lighted, and inviting. Leadership ensures that staff work in an environment that promotes trust, fairness and transparency.
What is the difference between trauma-specific interventions and services, trauma-informed care, and a trauma-informed approach?
The varied language around trauma has the potential to create confusion in the field. The concepts of "trauma-specific interventions," "trauma-specific services," "trauma-informed care," and "trauma-informed approach" are often used interchangeably; however, they actually refer to different processes.
Trauma-specific interventions refer to specific practices that have been developed to address the trauma experienced by individuals, families, and communities. These practices are most often used by a practitioner trained in the use of these interventions. Generally, these practices have been shown to work with specific age groups (e.g., Trauma-focused Cognitive Behavioral Therapy2; Child-Parent Psychotherapy3); settings (Cognitive Behavioral Interventions for Trauma in Schools4); and types of trauma (e.g., Seeking Safety5 for interpersonal or domestic violence).
Trauma specific services refer to programs that address trauma with a continuum of interventions from screening to treatment to recovery supports. An increasing number of promising and evidence-based practices address trauma-related conditions such as Post-Traumatic Stress Disorder (PTSD) and other consequences of trauma, especially for people who often bring other vulnerabilities (e.g., substance use, serious mental health problems, homelessness, child welfare, or criminal justice involvement) to the service setting. Trauma-specific services recognize that recovery occurs within the context of relationships characterized by belief in persuasion and trust rather than coercion, ideas rather than force, and mutuality rather than authoritarian control – precisely the beliefs that were shattered by the original traumatic experience (Herman, 1992)6. Trauma-specific services focus directly on the sequelae of trauma and facilitate recovery (Fallot and Harris, 2001).7
Trauma-informed care is similar in meaning to a trauma-informed approach. However, some sectors do not identify as "care-giving," such as the criminal and juvenile justice or employment sectors, so the term "approach" is preferred. Trauma-informed care may still be used in such systems as primary and behavioral health care or child welfare; however, SAMHSA recognizes that the term trauma-informed approach is more applicable across a broad range of systems.
What are the Key Principles of a Trauma-informed Approach?
A trauma-informed approach reflects the adoption of underlying principles rather than a specific set of procedures. These principles are generalizable across all settings, although language and application may be setting- or sector-specific. Basic principles of a trauma-informed approach8 include:
- Safety: throughout the organization, staff and the people they serve feel physically and psychologically safe; the physical setting is safe and interpersonal interactions promote a sense of safety.
- Trustworthiness and transparency: organizational operations and decisions are conducted with transparency and the goal of building and maintaining trust among staff, clients, and family members of people being served by the organization.
- Collaboration and mutuality: there is true partnering and leveling of power differences between staff and clients and among organizational staff from direct care staff to administrators; there is recognition that healing happens in relationships and in the meaningful sharing of power and decision-making.
- Empowerment: throughout the organization and among the clients served, individuals' strengths are recognized, built on, and validated and new skills developed as necessary.
- Voice and choice: the organization aims to strengthen the staff's, clients', and family members' experience of choice and recognize that every person's experience is unique and requires an individualized approach.
- Peer support and mutual self-help: are integral to the organizational and service delivery approach and are understood as a key vehicle for building trust, establishing safety, and empowerment.
- Resilience and strengths based: a belief in resilience and in the ability of individuals, organizations, and communities to heal and promote recovery from trauma; builds on what clients, staff and communities have to offer rather than responding to their perceived deficits.
- Inclusiveness and shared purpose: the organization recognizes that everyone has a role to play in a trauma-informed approach; one does not have to be a therapist to be therapeutic.
- Cultural, historical, and gender issues: the organization addresses cultural, historical, and gender issues; the organization actively moves past cultural stereotypes and biases (e.g. based on race, ethnicity, sexual orientation, age, geography, etc.), offers gender responsive services, leverages the healing value of traditional cultural connections, and recognizes and addresses historical trauma.
- Change process: is conscious, intentional and ongoing; the organization strives to become a learning community, constantly responding to new knowledge and developments.
Tell us your views on the definition of and the guiding principles for a trauma-informed approach.
- Harris, M. & Fallot, R. (2001). Using trauma theory to design service systems.
- Cohen, J., Mannarino, A., Deblinger, E., (2004). Trauma-Focused Cognitive Behavioral Therapy. http://tfcbt.musc.edu
- Lieberman, A.F., Van Horn, P., & Ghosh Ippen, C. (2005). Child-Parent Psychotherapy.
- RAND Corporation, (1999). The Cognitive-Behavioral Intervention for Trauma In Schools (CBITS). http://www.rand.org/pubs/research_briefs/RB4557-2.html
- Najavits, L.M., (2002). Seeking Safety: A Treatment Manual for PTSD and Substance Abuse.
- Herman, J. (1992). Trauma and recovery: The aftermath of violence – from domestic abuse to political terror.
- Harris, M. & Fallot, R. (2001). Using trauma theory to design service systems.
- Adapted from Harris, M. & Fallot, R. (2001). Using trauma theory to design service systems.
Last updated: 12/10/2012