Trauma is associated with the development of a wide range of mental health disorders. Trauma-informed care is an approach designed to support people with a history of trauma who seek mental health treatment.
Trauma: A Basic Definition
In the broadest sense, trauma is a type of injury. Physical trauma is an injury or wound to the body caused by an external physical force. Most people know terms like blunt force trauma from watching television shows like CSI or Law and Order. This means getting by or hitting an object hit so hard it causes damage. Physical trauma is a common outcome in car accidents, sports injuries, of violent physical interactions with others, including abuse.
That’s not the type of trauma we’re talking about when we talk about trauma-informed care – but it is related, because it can impact the emotional state of the trauma victim. The type of trauma we’re talking about in this article is emotional/psychological trauma.
Here’s how the American Psychological Association (APA) defines this type of trauma:
“Trauma is an emotional response to a terrible event like an accident, rape, or natural disaster. Immediately after the event, shock and denial are typical. Longer term reactions include unpredictable emotions, flashbacks, strained relationships, and even physical symptoms like headaches or nausea.”
Both physical and emotional trauma share one thing in common that many people rarely consider: both can happen in an instant but have consequences that can take a long time to overcome. We know rehabilitation from severe physical trauma can take weeks, months, or years. The same is true for severe emotional trauma – often called complex trauma – which may take weeks, months, or years to overcome.
There’s another component to emotional/psychological trauma that’s important to understand. In some cases, the trauma is ongoing. It’s not one single event. Trauma of this type is associated with people experiencing natural disasters, people living in war zones, or people who experience psychological, physical, or emotional abuse over long periods of time.
That brings us to a specific category of trauma associated with increased mental health disorders: adverse childhood experiences.
Trauma, Mental Health, and Adverse Childhood Experiences (ACEs)
When it was first published in 1998, the ACE Study changed our understanding of the impact of childhood experience on adult physical and mental health outcomes. The study – a joint effort by Kaiser Health and the Centers for Disease Control (CDC), showed that people who exposed to traumatic experience during youth have in increased risk of developing mental health disorders during adulthood.
The ACE Study identified the following as adverse childhood experiences, or ACEs:
- Physical, emotional, or sexual abuse
- Physical or emotional neglect
- Domestic violence
- Divorce of parents
- Living with an individual struggling with substance abuse, an individual diagnosed as mentally ill or an individual who was incarcerated or sentenced to be incarcerated
- Experiencing racism and/or bullying
- Living in foster homes
- Living in an unsafe neighborhood
- Witnessing violence
Exposure to four (4) or more ACEs increases risk of developing PTSD, depression, anxiety, and/or an alcohol or substance use disorder. That aligns with previous research on emotional and psychological trauma experienced at any time during life, which is associated with:
- Post-traumatic stress disorder (PTSD)
- Anxiety disorders (AD)
- Depressive disorders (MDD)
- Mood disorders (BD-1 & BD-2)
- Personality disorders
The importance of the ACE study cannot be overstated. It increased our understanding of mental health disorders and alcohol/substance use disorders, and led to a sea-change in how we evaluate and understand trauma-related mental health challenges – which can cause serious disruption when left untreated.
The Consequences of Trauma
People who haven’t experienced trauma might think it’s possible to simply forget about all those bad things from the past and move on. Unfortunately, in most cases, trauma simply doesn’t work that way. If left unaddressed, traumatic experiences can impact all areas of life. Many people with trauma-related mental health disorders report the following negative consequences:
- Problems with family/family relationships
- Difficulty forming meaningful peer relationships
- Rocky/unstable romantic relationships
- Impaired work or academic performance
- Problems finding and keeping employment
Those negative consequences are the result of the symptoms of trauma-related disorders. The symptoms of trauma include:
- Recurring unwanted memories of the trauma
- Recurring dreams of the trauma
- Flashbacks, or re-experiencing the traumatic event
- Intense physical responses to psychological re-experiencing of the event
- Persistent problems feeling positive emotions
- Problems remembering key details of the trauma
- Extreme efforts to avoid any distressing memory or thought of the trauma
- Extreme efforts to avoid anything reminder of the trauma
- Sleep problems: too little or too much
- Uncharacteristic anger and/or irritability
- Problems concentrating
- Extreme startle response
As we mention above, those symptoms can cause significant disruption in the life of a person with a history of trauma. In some cases, they can not only disrupt relationships, work, and academics, but they can also prevent an individual from carrying out the typical activities of daily life like personal hygiene, healthy eating, and getting enough exercise or activity.
Thankfully, there’s hope for people with trauma-related disorder: trauma-informed care.
The Principles of Trauma-Informed Care
Typical treatment for mental health disorders includes a combination of therapy, counseling, lifestyle changes, peer/community support, medication when needed, and various complementary or adjunct therapeutic techniques.
The idea behind trauma-informed care is to adapt as many of these modalities as possible to avoid re-traumatization of the individual seeking treatment and support. To achieve that end, the Substance Abuse and Mental Health Services Administration (SAMHSA) created a set of best practices and guidelines in a 2014 publication called SAMSHA’s “Concept of Trauma and Guidance for a Trauma-Informed Approach.”
Experts at SAMHSA and the Trauma-Informed Care Implementation Resource Center identify three foundational directives for doctors, psychiatrists, therapists, counselors and staff who work with people with a history of trauma:
- Realize the impact trauma can have on a person and understand the various techniques and approaches that can help people with a history of trauma.
- Recognize the symptoms, consequences, and warning signs of past trauma.
- Avoid re-traumatization of patients during all phases of treatment and recovery.
After accepting, internalizing, and applying these fundamental directives, clinicians working with trauma survivors should adhere to the following core principles of trauma-informed care.
The Six Principles of Trauma-Informed Care
1. Safety
This is essential. People with a history of trauma often live in a constant, heightened state of fear without realizing it. When they do – and start to feel safe in certain situations – they can begin to change. Therefore, establishing an environment where patients feel safe and secure is the first goal of any trauma-informed approach to treatment.
2. Trustworthiness and Transparency
After safety, trust is the next most important component of a relationship between a clinician and a person with a history or trauma. Making all decisions and plans about treatment in an open, transparent manner promotes a successful bond between clinician and patient.
3. Peer Support
People with a history of trauma benefit from interacting with and learning from other people with similar histories and experiences. The lived example of a healthy, thriving trauma survivor can have a significant positive impact on a person early in recovery from trauma.
4. Collaboration
This concept addresses the power structure of therapeutic milieu. It’s important for a trauma survivor to witness a “leveling of power” between everyone involved in the treatment experience, from administration to clinicians to staff to patients. Everyone plays a part in healing, and virtually every interaction – if managed intentionally – can be therapeutic.
5. Empowerment, Voice, and Choice
SAMSHA recommends clinicians and other providers adapt their perspective when supporting people with trauma. They should see themselves as recovery/healing facilitators rather than the final arbiters or ultimate experts on what is an isn’t appropriate for each trauma survivor. Clinicians should not only recognize patients as experts on their lived experience of trauma, but also teach them practical skills that enable them to direct their own recovery process and advocate for their personal recovery needs.
6. Cultural, Historic, and Gender Issues
Treatment providers must recognize and actively work to counter stereotypes. Assumptions about race, ethnicity, gender, gender identity, sexual orientation, age, religion, can undermine the therapeutic relationship and impair progress. In addition, providers need to recognize and accept the facts that historical and institutional trauma contribute to trauma-related mental health disorders. Finally, providers should recognize and honor the distinct cultural needs of each patient and family, and welcome their perspectives and contributions with humility and respect.
When providers welcomes a new patient and performs a comprehensive assessment, they must look for any sign of past trauma that may impact present mental health. Many patients know and understand their history of trauma affects their current physical, emotional, and psychological experience, while others need help recognizing the presence of trauma in order to heal and move forward.
Evidence-Based, Trauma-Informed Mental Health Treatment
When an assessment indicates a history of trauma, providers create a trauma-informed treatment plan that includes the three directives and the six principles of trauma-informed care we list above. Plans for each individual vary by their specific needs. What works for one patient may not work for another. Therefore, the final treatment plan should always be the result of an open an honest collaboration between provider and patient.
The most common, evidence-based, trauma-informed therapeutic approaches include:
- Trauma-focused cognitive behavioral therapy (TF-CBT)
- Trauma-focused dialectical behavior therapy (TF-DBT)
- Eye movement desensitization & reprocessing (EMDR)
- Prolonged exposure therapy (PE)
- Cognitive processing therapy (CPT)
- Prolonged exposure therapy (PE)
New approaches that can help people with a history of trauma include:
In addition, patients may participate in trauma education and process groups, and wellness groups that include adjunct therapies like yoga, mindfulness, and practical stress reduction, distress tolerance, and symptom management techniques.
When these standard, new, and adjunct therapies are administered by experienced, qualified clinicians, people with trauma-related mental health disorder increase their chances of achieving sustainable recovery and living a full and fulfilling life on their own terms, rather than those dictated by the symptoms of their mental health disorder.
Gianna Melendez
Jodie Dahl, CpHT