Translating Trauma-Informed Principles into Trauma-Responsive Practices

Why Trauma Matters

Research on trauma has produced two certain conclusions. First, trauma is prevalent. More than half of Americans report having at least one adverse childhood experience (ACE),¹ and many adults also endure potentially life-altering traumatic events.² Second, exposure to trauma at any point in the life course can limit human potential and compromise quality of life. In fact, trauma is one of the leading environmental causes of disorder, disability, disease, and death.³

In light of its widespread prevalence and impact, trauma should count as one of the most urgent human rights issues of our time. Framing trauma as a human rights issue communicates that society is compelled to take actions that prevent avoidable trauma for all people. Because most trauma is the byproduct of human action, it is alterable through human intervention.

At the same time, trauma is a matter of social justice because its burden is borne disproportionately by economically disadvantaged and vulnerable populations.⁴ Therefore, society should allocate resources equitably to benefit individuals and groups that are at the greatest risk of trauma. Whether through direct practices with individuals and families or policies that modify social and economic conditions, we can promote greater equity in health and well-being by preventing trauma or alleviating the harm it causes.

Trauma Frameworks

Trauma-Informed Care
There is a critical need for organizing frameworks that can guide trauma prevention and intervention responses. One framework that serves this function is trauma-informed care (TIC). TIC is a broad philosophy and intervention approach that calls for system-wide awareness of trauma and its effects. Building on the work of Harris and Fallot⁵ and other seminal contributions, the Substance Abuse and Mental Health Services Administration (SAMHSA) issued six TIC principles that guide service agencies in recognizing and responding to trauma.⁶

Despite its contributions, TIC has been criticized for its lack of specificity and practical applications. In response, scholars have started to outline how TIC principles manifest as practice elements such as screening, assessment, and referral to treatment.⁷ As a prime example, Trauma Screening, Brief Intervention and Referral to Treatment (T-SBIRT) is a 10-minute protocol that aims to increase access to mental health services.⁸ Due to its brevity and uncomplicated design, T-SBIRT can readily be implemented by general practitioners in many service settings. While assessing for trauma exposure and symptoms, T-SBIRT practitioners engage clients by using three other TIC practices: psychoeducation, cognitive and emotion regulation techniques, and motivation enhancement techniques. The sidebar to the right provides a list of five TIC practice elements that many professionals can implement effectively with a moderate level of training.

Trauma-Focused Treatment

Corresponding with the rise of TIC, there has been a significant increase in the availability of trauma-focused treatments. Whereas TIC practices focus on promoting client engagement and can be implemented by a broad class of general practitioners, trauma-focused treatment should be provided by highly trained specialists. Thus, TIC practices should be distinguished from therapies that require rigorous training and supervision to deliver. At the same time, TIC is complementary to trauma-focused treatment, in that the former facilitates the latter by way of assessment and referral.

One example of a trauma-focused treatment is Seeking Safety, which is a present-focused coping skills therapy for adults. Another example, trauma-focused cognitive behavioral therapy (TF-CBT), is a well-validated treatment for children and youth with emotional and behavioral difficulties. While these and other trauma-focused treatments differ in their target populations and approaches, they share the assumption that trauma is at the root of many mental health symptoms and that addressing the impact of trauma on an individual’s life can help to facilitate trauma recovery.

It is also important to acknowledge that there are many interventions that were not designed to be trauma-focused, but that are still highly effective in promoting the well-being of trauma-exposed children and adults. For instance, parent-child interaction therapy (PCIT) has been shown to significantly reduce emotional and behavioral challenges in young children who have experienced abuse and neglect. Dialectical behavioral therapy (DBT) is another model that was not originally conceived as trauma-focused, but that has been shown to be highly effective in treating mental and behavioral health problems in traumatized adults.

Trauma-Sensitive Services

Although the boundaries between TIC and trauma-focused treatment are becoming clearer, there is a need to understand what differences there are, if any, between trauma-informed and trauma-sensitive services. The term trauma-sensitive has been used most frequently in reference to school-based initiatives that train teachers and administrators to consider children’s trauma when developing and implementing policies and procedures. Like TIC, a trauma-sensitive approach aims to raise awareness of trauma, which can lead to changes in how classrooms are structured, how staff interact with students, and how discipline is dispensed.⁹ If there is a difference between a trauma-informed and trauma-sensitive framework, a trauma-sensitive approach may apply to settings where staff are not trained to implement certain TIC practices. Thus, a trauma-sensitive approach would be appropriate for systems and organizations where all trauma-focused and many trauma-informed approaches are beyond the scope of practice for most staff, but where greater awareness of trauma and certain TIC applications can still enhance the services that staff provide.

To illustrate, there are many reasons why school teachers should not be asked to conduct formal trauma assessments with their students. However, teachers who are trained to recognize the signs and symptoms of trauma will be better equipped to understand the needs of trauma-exposed students and create safe, structured environments in which these children can thrive. Teachers who are aware of the signs and symptoms of trauma also can help to link children to school-based mental health staff who are properly trained to implement TIC practices such as screening, assessment, and referral to treatment.

Emerging evidence indicates that, when school staff receive trauma-sensitive training, rates of suspension and absenteeism decrease while grades, test scores, and graduation rates increase. For example, since the introduction of a trauma-sensitive initiative, San Francisco area schools have seen a 27 percent decrease in student absences and an 89 percent decrease in suspensions.¹⁰

Summary

Trauma is one of the most urgent human rights and social justice issues of our time. The TIC movement has increased awareness of trauma across multi-sector systems, including health and human services, juvenile and criminal justice, education, and workforce development. Still, it is imperative that we move from trauma awareness to trauma responsiveness by translating TIC principles into practices that mitigate the effects of trauma or prevent it altogether. Evidence-based TIC practices such as screening, assessment, and referral can also help to increase access to trauma-focused treatments and other interventions that foster resilience and recovery. Policy and system changes are also needed to increase access to trauma-focused, trauma-informed, and trauma-sensitive services that enhance the health and well-being of individuals, families, and communities — especially those who are at the greatest risk of trauma and its consequences. In so doing, we have the potential to protect human rights, promote social justice, and produce large-scale changes in population health and health equity.

References

¹ Bynum, L., et al. (2010). Adverse childhood experiences reported by adults — five states, 2009. Morbidity and Mortality Weekly Report, 59(49), 1609-1613.

² Mersky, J. P., Janczewski, C. E., & Nitkowski, J. C. (2018). Poor mental health among low-income women in the US: The roles of adverse childhood and adult experiences. Social Science & Medicine, 206, 14-21.

³ Hughes, K., Bellis, M. A., Hardcastle, K. A., Sethi, D., Butchart, A., Mikton, C., … & Dunne, M. P. (2017). The effect of multiple adverse childhood experiences on health: A systematic review and meta-analysis. The Lancet Public Health, 2(8), e356-e366.

⁴ Mersky, J. P., Topitzes, J., & Britz, L. (in press). Promoting evidence-based, trauma-informed social work practice. Journal of Social Work Education.

⁵ Harris, M. E., & Fallot, R. D. (2001). Using trauma theory to design service systems. Jossey-Bass.

⁶ Substance Abuse and Mental Health Services Administration (2014b). SAMHSA’s concept of trauma and guidance for a trauma-informed approach. HHS Publication No. (SMA) 14-4884. Rockville, MD: Author.

⁷ Berliner, L., & Kolko, D. J. (2016). Trauma informed care: A commentary and critique. Child Maltreatment, 21(2), 168-172.

⁸ Topitzes, J., Berger, L., Otto-Salaj, L., Mersky, J. P., Weeks, F., & Ford, J. D. (2017). Complementing SBIRT for alcohol misuse with SBIRT for trauma: A feasibility study. Journal of Social Work Practice in the Addictions, 17(1-2), 188-215.

⁹ Plumb, J. L., Bush, K. A., & Kersevich, S. E. (2016). Trauma-sensitive schools: An evidence-based approach. School Social Work Journal, 40(2) 37-60.

¹⁰ Dorado, J. (2013). Transforming trauma’s effects on the developing brain: How educators, judges and other professionals can help to foster resilience and promote school success. Presented at the Keeping Kids in School and Out of Court Summit, Anaheim, CA.