Trauma-informed care

Trauma- and violence-informed care (TVIC) describes a class of models for working with and relating to people who have experienced negative consequences after exposure to dangerous experiences. These models are useful in a wide range of fields and for supporting interpersonal relationships. There is no one single TVIC model, and some go by slightly different names. They can be applied in many contexts including medicine, mental health, law, education, addiction, gender, and culture. The models can be applied by individuals and organizations.

Most TVIC models emphasize the need to understand the scope of what constitutes danger and how resulting trauma impacts human thoughts, feelings, behaviors, communications, and relationships. Exposure to life-altering danger necessitates a need for careful and healthy attention to creating safety within healing relationships. Client-centered and capacity-building approaches are emphasized. Most models are biopsychosocial, attending to biology (body and brain), psychology (mind), and sociology (relationship).

A basic view of trauma-informed care (TIC) involves developing a holistic appreciation of the potential for trauma with the goal of expanding the care-provider's empathy while creating a feeling of safety. Under this view, it is often stated that a trauma-informed approach asks not "What is wrong with you?" but rather "What happened to you?" A more expansive view includes developing an understanding of danger-response. In this view, danger is understood to be broad, include relationship dangers, and can be subjectively experienced. Danger is understood to impact someone's past and present responses to danger, and information processing in the context of danger.

What is trauma and violence?

Trauma can result from a wide range of experiences which expose humans to one or more physical and/or relational dangers.

• Physical. Physical injury, assault, natural disaster, war, pain, and situational harm like vehicle or industrial accidents.
• Relational-adult. Interpersonal trauma, controlling behavior and coercive control, betrayal, gaslighting, DARVO, and intense emotional experiences such as shame and humiliation.
• Relational-child. For children, it can also involve childhood trauma, adverse childhood experiences, separation distress, and attachment experience (controlling, dismissive, inconsistent, harsh, or harmful caregiving environments).
• Social. Social and political, racism, poverty, religious, educational, and cultural environments.
• PTSD. Non-complex or complex post-traumatic stress disorder.
• Psychological and pharmacological. Psychological harm, mental disorders, drug addiction, isolation, and solitary confinement.
• Secondary. Vicarious or secondary exposure to other's trauma.

Van der Kolk describes trauma as an experience and response to exposure to one or more overwhelming dangers, which causes harm to neurobiological functioning, and leaves a person with impaired ability to identify and manage dangers. This leaves them "constantly fighting unseen dangers."

Crittenden describes how relational dangers in childhood caregiving environments can cause chronic trauma. "Some parents are dangerous to their children. Stated more accurately, all parents harm their children more or less, just as all are more or less protective and comforting." Parenting, or caregiver, styles which are dismissive, inconsistent, harsh, abusive or expose children to other physical or relational dangers can cause a trauma which impairs neurodevelopment. The Dynamic-Maturational Model of Attachment and Adaptation (DMM) describes how children's repeated exposure to dangers can result in impairments to information processing, often lasting throughout life.

Prevalence of trauma

Traumatic experiences are extremely common for all humans, although negative and ongoing experience is less common.

Models of TVIC

Trauma- and violence-informed care, or closely related concepts, are also described as trauma- (and violence-) informed care (T(V)IC), and trauma-informed care/practice (TIC/P). Other terms include trauma-informed, trauma-focused, and trauma-sensitive.

Wathen and colleagues describe four integrated principles evolved by key authors in this field:

1. Understand structural and interpersonal experiences of trauma and violence and their impacts on peoples' lives and behaviors.
2. Create emotionally, culturally, and physically safe spaces for service users and providers.
3. Foster opportunities for choice, collaboration, and connections.
4. Provide strengths-based and capacity building ways to support service users.

Landini describes five primary principles from DMM theory for helping people better manage danger response:

1. Define problems in terms of response to danger.
2. The professional acts as a transitional attachment figure.
3. Explore the family's past and present responses to danger.
4. Work progressively and recursively with the family.
5. Practice reflective integration with the client as a form of teaching reflective integration.

Mitchell and colleagues searched for a consensus definition:

1. A trauma-informed early intervention psychosis service will work to protect the service user from ongoing abuse.
2. Staff within a trauma-informed early intervention psychosis service are trained to understand the link between trauma and psychosis and will be knowledgeable about trauma and its effects.
3. A trauma-informed early intervention psychosis service:
   1. Seeks agreement and consent from the service user before beginning any intervention.
   2. Will build a trusting relationship with the service user.
   3. Will provide appropriate training on trauma-informed care for all staff.
   4. Will support staff in delivering safe assessment and treatments for the effects of trauma.
   5. Adopts a person-centred approach.
   6. Will maintain a safe environment for service users.
   7. Will have a calm, compassionate and supportive ethos.
   8. Is trustworthy.
   9. Will acknowledge the relevance of psychological therapies.
   10. Will be sensitive when discussing trauma.
   11. Is empathetic and non-judgmental.
   12. Will provide supervision to staff.
   13. will provide regular supervision to practitioners who are working directly with trauma.

There are ethical guidelines for treating trauma survivors.

General applications and techniques of TVIC

Safety

The opposite of danger is safety, and most or all TVIC models emphasize the provision of safety. Van der Kolk describes how the "Brain and body are [neurobiologically] programmed to run for home, where safety can be restored and stress hormones can come to rest."

Communication

Katz describes some experiences working her legal clients and how she adjusts her relational and communication approach to meet their needs. Some clients need information delivered in short pieces with extra time to process, and some need to not have unannounced phone calls and be informed by email prior to verbal discussions. TVIC helped her shift from thinking about how to develop a ″litigation strategy″ for clients, to thinking about developing a ″representation strategy,″ which is a major shift in thinking for many lawyers.

Resilience and strength building

Building psychological resilience and leveraging a person's existing strengths is a common element in most or all TVIC models.

Specific applications and techniques of TVIC

Trauma- and violence-informed practices can be or are addressed in mindfulness programs, yoga, education, obstetrics and gynaecology, cancer treatment, psychological trauma in older adults, military sexual trauma, cybersex trafficking, sex trafficking and trafficking of children, child advocacy, decarceration efforts, and peer support. HDR, Inc. incorporates trauma-informed design principles in prison architecture.

Many therapy models utilize TVIC principles, including trauma focused cognitive behavioral therapy, trauma-informed feminist therapy, Trauma systems therapy which utilizes EMDR, trauma focused CBT, and a number of other techniques, The Art of Yoga Project, the Wellness Recovery Action Plan, music therapy, and internet-based treatments for trauma survivors.

TVIC principles are applied in child welfare services, child abuse, social work, psychology, medicine, Nursing, pediatric nursing, correctional services. They have been applied in interpersonal abuse situations including domestic violence, elder abuse.

Culturally-focused applications, often considering indigenous-specific traumas have been applied in minoritized communities, Maori culture.

TVIC principles are widely used in domestic violence and intimate partner violence (IPV)situations. For working with survivors, TVIC has been combined with yoga, motivational interviewing, primary physician care in sexual assault cases, improving access to employment, cases involving HIV and IPV, and cases involving PTSD and IPV.

Organizational applications and techniques of TVIC

TVIC principles have been applied in organizations, including behavioral health services, policy analysis.

The Connecticut Department of Children and Families (DCF) implemented wide-ranging TVIC policies, which were analyzed over a five year period by Connell and colleagues in a research study. TVIC components included 1) workforce development, 2) trauma screening, 3) supports for secondary traumatic stress, 4) dissemination of trauma-focused evidence-based treatments (EBTs), and 5) development of trauma-informed policy and practice guides. The study found significant and enduring improvements in DCF's capacity to provide trauma-informed care. DCF employees became more aware of TVIC services and policies, although there was less improvement in awareness of efforts to implement new practices. The Child Welfare Trauma Toolkit Training program was one program implemented.

Organizations and people promoting TVIC

Organizations which have or support TVIC programs include the Substance Abuse and Mental Health Services Administration (SAMHSA), National Center for Trauma-informed care, the National Child Traumatic Stress Network, the Surgeon General of California, National Center for Victims of Crime, The Exodus Road, Stetson School, and the American Institutes for Research.

Diana Fosha developed the accelerated experiential dynamic psychotherapy (AEDP) for adults suffering the effects of childhood attachment trauma and abuse. Ricky Greenwald applies eye movement desensitization and reprocessing (EMDR) and founded the Trauma Institute & Child Trauma Institute. Lady Edwina Grosvenor promotes a trauma informed approach in women's prisons in the United Kingdom. Joy Hofmeister promotes trauma-informed instruction for educators in Oklahoma. Anna Baranowsky developed the Traumatology Institute.

Other notable people who have developed or promoted TVIC programs include Tania Glyde, Carol Wick, Pat Frankish, Michael Huggins, Liz Mullinar, Brad Lamm, Barbara Voss, Cathy Malchiodi, Omar Bah, Ruthie Bolton, Caoimhe Butterly, and Gang Badoy.