Over the last 20 years there has been increasing recognition of the role that psychological trauma plays in a wide range of health, mental health and social problems. When people think of trauma, they think about experiences like war and the diagnosis of post-traumatic stress disorder. But the reality is that trauma includes a wide range of situations where people are physically threatened, hurt or violated, or when they witness others in these situations. This includes such experiences as childhood physical and sexual abuse, domestic violence, witnessing domestic violence, serious accidents, natural disasters, physical torture, riots, shootings, knifings, being threatened with a weapon, combat, house fire, life-threatening illness, and death of someone close, especially sudden death.
Although, there have been no comprehensive studies of the prevalence of exposure to traumatic events, studies conducted in the United States suggest that exposure to traumatic events occurs in at least 50%-60% of the U.S. population, and rates in clinical settings run much higher (Kessler, 2000); Kessler notes that given that the U.S. has higher crime rates than other developed countries, it may be that these rates are significantly higher in the U.S. than in other developed nations. However, problems like child abuse and domestic violence are challenges faced by almost all the societies on our planet, and natural disasters certainly affect everyone, regardless of national origin.
The impact of living through traumatic events, especially multiple events over the course of a lifetime, can result in a range of behavioral health problems other than post-traumatic stress disorder, including substance abuse, depression, anxiety problems, childhood behavioral disorders, psychosis, and some personality disorder diagnoses (National Trauma Consortium, 2012). Some psychiatrists have suggested that the entire medical model of mental illness needs to be reevaluated in light of the recognition of the role of trauma (e.g. see Canadian psychiatrist, Dr. Colin Ross’s book The Trauma Model)– this is not to say that biology doesn’t play a role in behavioral health problems, only that it doesn’t, by itself, cause them in most circumstances.
The reality is that social workers have been working with trauma survivors from the first day our profession began. However, the growing knowledge base about how trauma affects people is now being used to inform changes in policy and practice to ensure that we support recovery and don’t inadvertently hurt people. Simply stated, trauma-informed practice is policy and practice based on what we know from research about the prevalence of trauma and about how affects people. Within the U.S., trauma-informed practice is usually referred to as Trauma-Informed Care (TIC), a term that is used in national policy efforts initiated by the Substance Abuse and Mental Health Services Administration and the National Child Traumatic Stress Network.
What Does Trauma-Informed Practice Actually Look Like?
Trauma-informed practice incorporates assessment of trauma and trauma symptoms into all routine practice; it also ensures that clients have access to trauma-focused interventions, that is, interventions that treat the consequences of traumatic stress. A trauma-informed perspective asks clients not “What is wrong with you?” but instead, “What happened to you?” However, trauma-informed practice also focuses our attention on the ways in which services are delivered and service systems are organized (Bloom & Farragher, 2011). Recognizing that traumatic events made people feel unsafe and powerless, trauma-informed practice seeks to create programs where clients and staff feel safe and empowered. Generally, trauma-informed practice is organized around the principles of safety/trustworthiness, choice/collaboration/empowerment, and a strengths-based approach (Hopper, Bassuk, & Olivet, 2010).
Trauma-informed organizations ensure that every staff member, from the receptionist to the executive director, understands trauma and trauma reactions. Trauma-informed organizations routinely examine all policies, procedures and processes to ensure they are not likely to trigger trauma reactions or to be experienced as re-traumatizing, that is, putting a client through a process that shares characteristics of the traumas they have lived through. For example, within psychiatric hospitals restraints have long been used for patients who are out of control in some way. However, for a person who has lived through abuse, restraint may well have been associated with being hurt physically or with being sexually abused. Restraints therefore have a high potential to actually re-traumatize a client and trigger more psychiatric symptoms. A trauma–informed perspective recognizes the damaging impact of restraints and focuses on incorporation of psychiatric advanced directives into mental health care. This is just one example of a practice within mental health that can be hurtful to trauma-survivors. For more examples of how our efforts to help can inadvertently hurt people, read the heart-wrenching case study, On Being Invisible in the Mental Health System, that describes the devastating impact of the mental health system on one young woman’s life and provides a compelling example of how our systems can fail trauma survivors.
Why Should We Care?
Each of us chose social work because we want to make a positive difference in the world. Some of us can see clearly where our work has this contribution. Many of us struggle to “do good” within service systems that are broken–we know at a basic level that something is very wrong, even if we manage to bring about positive outcomes much of the time. The systems within which many social workers are employed are often based on principles that are not only not trauma-informed, but instead, reinforce damaging messages to both staff and clients, such as “your voice doesn’t matter here.” Bloom and Farragher (2011) in their book Destroying Sanctuary, have written eloquently about the current crisis facing our human services delivery systems and how the impact of our systems often is the opposite of creating safe and growth-promoting environments, both for clients and staff. While it may not be the only lens that can be helpful in addressing this crisis, a trauma-informed perspective shines a clear light on what’s broken, what needs to change, and what will work instead. It focuses us not only on our direct practice, but on organizations, service systems, and ultimately our paradigms for understanding the work we are doing and the work we would like to do–in other words, it’s a true social work perspective. The paradigm fits well with the values of our profession, it draws attention to all that we know about a systems perspective, and it incorporates a holistic, biopsychosocial perspective on human beings.
It’s because of all of the above reasons that our faculty chose to incorporate a trauma-informed perspective (along with a human rights perspective) into all aspects of our masters in social work program. We feel that this perspective is a missing piece in social work education and that having it will make a difference in our graduates being able to practice effectively at all levels of social work practice, especially in their ability to bring about needed transformations in our service systems. Beyond the growing body of research that I’ve mentioned, part of what brought our faculty to this understanding was the feedback we were receiving from clients and agencies within our own community, Western New York, about the power of this perspective after years of incorporating it into our School’s continuing education programs. Agency directors were becoming increasingly interested in seeking out trauma trainings for everyone in their agencies because of the transformational impact they were seeing with clients and the workforce. One after another, social workers and other human services professionals were describing this as “the missing piece” in their knowledge base and that having this knowledge made a difference in their practice.
Many social workers feel disempowered within the systems in which they work: trauma-informed practice is a framework of system and practice transformation that can provide us with a blueprint for empowerment for ourselves as well as for our clients. I hope I’ve piqued your interest in this concept enough that you’ll consider learning more about it.
Where Can I Learn More About Trauma-Informed Practice?
Many of the resources cited in this post are good places to start to learn more about trauma-informed practice. In addition, try checking out the following:
- Podcast interview (part 1) with Brian Farragher: The Sanctuary Model: Changing the Culture of Care – It Begins with Me (part 1 of 2) Episode #77 of the Living Proof Podcast Series
- Podcast interview (part 2) with Brian Farragher: The Sanctuary Model: Changing the Culture of Care – Transforming Human Services (part 2 of 2) Episode #77 of the Living Proof Podcast Series
- Podcast interview with Dr. Sandra Bloom: The Sanctuary Model: A Trauma-Informed Approach to Treatment and Services, Episode #10 of the Living Proof Podcast Series [note, I recommend listening to this after listening to the Farragher interviews]
- Videos from a conference on trauma and trauma-informed care, including talks from two national presenters, Dr. Sandra Bloom (Sanctuary Model) and Dr. Robert Anda (ACE study)–videos included are Trauma 101, the ACE study, and an overview of the Sanctuary Model, one model of trauma-informed care.
- Creating Cultures of Trauma-Informed Care (CCTIC): A Self-Assessment and Planning Protocol (pdf) by Roger D. Fallot and Maxine Harris, April 2009.
- Power & Social Media: Thoughts for Therapists Working with Trauma Survivors by Nancy J. Smyth, February 18, 2011,
- The book Trauma-informed practices with children and adolescents (2011) by William Steele and Cathy A. Malchiodi. London, Routledge.
- Innovations in Implementation of Trauma-Informed Care Practices in Youth Residential Treatment: A Curriculum for Organizational Change (pdf) by Victoria Latham Hummer, Norín Dollard, John Robst, and Mary I. Armstrong. (article from Child Welfare)
Bloom, S. L., & Farragher, B. (2011). Destroying sanctuary: the crisis in human services delivery systems. New York: Oxford University Press.
Jennings, A. (1994). On being invisible in the mental health system. Journal of Behavioral Health Services and Research, 21(4), 374-387. Available online at: http://www.theannainstitute.org/obi.html or http://www.theannainstitute.org/OBI.pdf
Kessler, R.C. (2000). Posttraumatic stress disorder: The burden to the individual and to society. Journal of Clinical Psychiatry, 61(supplement 5), 4-12.
National Child Traumatic Stress Network (2012). http://www.nctsnet.org/ retrieved March 17, 2012
National Trauma Consortium (2012). http://www.nationaltraumaconsortium.org/ retrieved March 17, 2012.
Ross, C.A. (2011). The trauma model: A solution to the problem of comorbidity in psychiatry (Kindle Edition). Austin, TX: Greenleaf Book Group.
Substance Abuse and Mental Health Services Administration (2012). National Center for Trauma-Informed Care. http://www.samhsa.gov/nctic/ retrieved March 17, 2012.
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Dr. Nancy Smyth (@njsmyth) is Professor and Dean of School of Social Work at University at Buffalo and Associate Research Scientist at Research Institute on Addictions. She is also a member of @SWSCmedia Expert Panel.