Trauma-Informed Care

Original Editor - Anna Fuhrmann

Top Contributors - Naomi O'Reilly, Jess Bell, Anna Fuhrmann, Wanda van Niekerk, Ewa Jaraczewska and Robin Tacchetti

Introduction

Trauma results from an event, series of events, or set of circumstances. Trauma is "experienced by an individual as physically or emotionally harmful or life threatening and that has lasting adverse effects on the individual’s functioning and mental, physical, social, emotional, or spiritual well-being."

Traumatic events are common and can affect any person from any cultural, socio-economic, ethnic, religious or educational background. They are not specific to gender or age. A traumatic experience can be a single event, a series of events, and/or a chronic condition (e.g., childhood neglect, domestic violence). It can also include second-hand experiences, meaning that someone might have a trauma which they have not experienced themselves but were indirectly affected by.

For some people, reactions to a traumatic event are temporary with immediate psychological and/or physical effects. For others, trauma can have lasting effects on a person’s life and well-being. Some people can have a much more prolonged reaction to trauma. This reaction can become chronic or persistent with more severe, prolonged, or enduring mental health consequences (e.g., post-traumatic stress and other anxiety disorders, substance use and mood disorders) and medical problems (e.g., arthritis, headaches, chronic pain). It can alter individual biology and behaviour over the life course, which can impact both interpersonal and intergenerational relationships.

Due to a high prevalence of unidentified trauma and adverse childhood experiences (ACE), Trauma-Informed Care has become recognised as a valuable part of patient care. In settings of conflict or natural disasters, a mindset within the professional health and social services, which is attentive to past trauma in care-seekers, can prevent re-traumatisation and improve treatment outcomes for individuals who have experienced trauma.

Individuals who have experienced trauma, including adverse childhood experiences, are more vulnerable to a variety of health conditions and diseases, e.g. mental health disorders, substance abuse, cardiovascular diseases, chronic pain disorders, etc. Often, trauma is not detected or dealt with and subconsciously affects a patient's response to treatment. Mindfulness towards trauma and adverse childhood experiences can help to lessen the long-term effects on the physical and mental health of affected individuals by addressing the underlying conditions in a sensitive and respectful matter.

“Trauma-informed services do no harm i.e. they do not re-traumatise or blame survivors for their efforts to manage their traumatic reactions, and they embrace a message of hope and optimism that recovery is possible. In trauma-informed services, trauma survivors are seen as unique individuals who have experienced extremely abnormal situations and have managed as best they could”. - Dr Cathy Kezelman

Principles

The trauma-informed care model is a framework that acknowledges the impact of trauma, and ways to respond to the trauma. It aims to enhance the physical, psychological and emotional safety of both service providers and patients, and provides opportunities for patients to rebuild their self-control and empowerment. There are six key elements of a trauma-informed approach.

Safety

The first and most important principle of trauma-informed care is to ensure a feeling of physical, psychological and emotional safety for both staff and patients. While completing an assessment, the rehabilitation professional should create an environment where patients can feel physically and psychologically safe. A therapist should interact and ask questions in such a way that the patient feels comfortable telling their story and describing their subjective feelings and emotions during the assessment process. The therapist should ensure the patient that if they feel uncomfortable, they can stop the assessment process at any time. The patient is also assured that confidentiality will be maintained between the therapist and the patient.

Trustworthiness and Transparency

An important aspect to develop trustworthiness and transparency includes clarity in communication and decision-making in order to build trust. The decision which is taken and the prepared goal should be transparent, so that patient can trust the rehabilitation professional. The assessment should be client-oriented and the findings should be recorded so that there is consistency between the therapy sessions. The type and behaviour of pain described should be recorded exactly as described by the patient. The patient's autonomy should be respected. While measuring pain, validated outcome measures should be used.

Peer Support

Bringing together patients and professionals with similar experiences can help to integrate individuals into the service or therapy. Peer means the group of people who have faced the same kind of trauma. If the patient feels comfortable being with the peer group, the therapist can offer this option to the patient. 

Many patients may have little knowledge regarding their pain experience as some pain might be due to emotional suffering and central sensitisation. Peer support might provide emotional support, and it can be provided face-to-face, in a group, or via the internet as per the patient's choice.

Collaboration and Mutuality

It is essential to involve the patient in treatment plans. In general, decisions should be shared between staff of different levels/ professions and the individual. The assessment findings should be discussed with the other health professionals for the betterment of the client. Mutual collaboration between health professionals and the caregiver gives a positive outcome. The patient may perceive pain differently at different points of time with different people. So, discussing the patient's pain assessment findings among the caregivers and other members of the team will give us accurate assessment findings. Everyone has a role in trauma-informed care.

Empowerment, Voice and Choice

Both patients and professionals need to be able to make use of their strengths. This principle supports resilience and self-efficacy within therapy and the process of healing by giving back control to the individual. One vital aspect is to provide and encourage opportunities for all involved clients / professionals to make individual choices during all stages of treatment. The therapist can provide emotional and psychological support to the patient, so that they can describe their pain in a comfortable manner. The patient should be involved in the shared decision-making process, goal setting, and strategies to cope with the pain. The physiotherapist should help the patient in developing self-advocacy skills.

Cultural, Historical and Gender Issues

Trauma based on discrimination (e.g. gender, skin colour, ethnicity) is recognised, bias and stereotypes are addressed, and diversity is respected during treatment by both patients and staff. All patients should be treated equally and their cultural / historical background should be respected. During an examination, the patient's privacy and their culture should be considered. For example, it is necessary to get consent and explain a procedure before asking a female patient to undress for an examination. If a patient feels more comfortable with health care professionals of the same gender, the organisation should consider/accommodate the patient's request.

Key Components to Implement Trauma-Informed Care

To implement trauma-informed care, training of clinical and non-clinical staff is necessary. The framework should be founded on the above-mentioned principles. Standard clinical and administrative procedures should be reviewed to ensure these principles are considered. It is also essential to ensure that these procedures are patient-centred.

An approach to trauma-informed care must be made on both an organisational and a clinical level. By training staff (clinical and non-clinical), opening up opportunities for communication about trauma and coping (for both patients and staff) and providing means to include patients and workers into organisational tasks, a workplace can start incorporating these principles. It is also advisable to hire a trauma expert for both consultation and training. Knowing that there is a specialised contact person who can be consulted for trauma-related issues, helps create a safe environment for many individuals. However, the structural requirements have to be created first. The leadership team needs to acknowledge and support the approach as it requires changes within the clinical organisation. The allocation of resources and funding is the first step to establishing a trauma-informed clinical setting. The group overseeing the integration of trauma-informed care into the clinical setting should also include individuals who have experienced trauma, to ensure transparency, trustworthiness and collaboration between health care workers and the patients.

Conclusion

Trauma-informed care is an intervention and organisational approach that focuses on how trauma may affect an individual’s life and their response to behavioural health services, from prevention through to treatment. It focuses on the importance of patient-centred care rather than applying general treatment approaches, and provides patients with more opportunities to engage in services that reflect a compassionate perspective of their presenting problems.

Further Resources

1. For more information and practice implementation strategies, visit the following websites;
   • Trauma-Informed Care Resource Centre
   • ACEs AWARE
     • Chapter.2 Trauma and Trauma Informed Care
2. SAMHSA
   • Guidance for a Trauma-Informed Approach
   • Trauma-Informed Care (TIC) in Behavioural Health Services, A Treatment Improvement Protocol