Trauma Informed Practice: Better Late Than Never

I was 21 years old, fresh out of University and had taken a position as a Child and Youth Worker at a boys group home. After my first day on the job, my roommates were shocked to hear that I had spent the better part of my day protecting myself from being stabbed with a protractor and dodging flying bricks from a wildly out of control 13 year old. I had physically restrained him over a dozen times and at the end of the day, I left exhausted and doubtful that I had a future in this field.

The training I had received focused on behavioral management techniques as many group homes at that time operated as token economies. In reality, this meant that a great deal of focus from staff was connected to the behaviors that the children/adolescents exhibited. If they presented with positive, desirable behaviors, they would be rewarded by moving up a level, or receiving some form of token reinforcement. In turn, if they exhibited undesirable or negative behaviors, they would lose tokens, privileges, control, and status.

It wasn’t until several years later that I began to understand the shortcomings of this model when used in isolation. I was working in the Yukon Territory in a similar setting but had now been trained in ‘Trauma Informed Care’. The children/adolescents in both settings had many similarities despite ethnic, geographical and social differences. They presented with a pervasive pattern of emotional dysregulation, they had problems with attention, concentration, and impulse control, and for the most part, they struggled with getting along with themselves and others.

Most importantly, they were all survivors of some form of childhood trauma. As brain science and studies such the ACE study from the Centers for Disease Control and Prevention are showing, childhood abuse and neglect is the most costly public health issue to date. One look at the Adverse Childhood Experiences (ACE) study and you can see that traumatic life experiences such as physical, emotional or sexual abuse, neglect, and other household issues during childhood/adolescents leads to an increased likelihood of developing mental health disorders, addictions, learning & behavioral problems as well as coming in contact with the criminal justice system, along with countless other social issues.

This study and others have also connected early trauma to workplace absenteeism, financial problems, drug use, unintended pregnancies, prescription painkiller use and even a higher chance of developing COPD, heart disease, liver disease and cancer due to the ongoing stress in the body. Despite this study and countless others, we live in a health care system that often ignores trauma and it’s impact on brain and body development.

In some cases, the ongoing practices and policies even further traumatized and victimize those who touch foot into the system. For those that have worked in agencies and organizations that aren’t ‘trauma informed’, you are not alone, and it is not too late. As I reflect back on the shift to becoming ‘trauma-informed’, I began seeing that the client’s behaviors were really a unique language that provided a glimpse into how childhood abuse, neglect and adverse experiences had impacted their physical, emotional, social and mental well-being.

Providing trauma-informed practice means that creating a safe and non-judgmental environment is one of the most important aspects of working with vulnerable populations. As such, building relationships with our clients are the entry point into their healing, and ruptures in relationships (i.e. being attacked with a protractor) can be opportunities to teach emotional regulation, demonstrate how to repair relationships and develop meaningful connections.

As a result, clients begin to feel more empowered, have more control, and have more predictability in their environment. For staff, this means less energy is spent on managing behaviors and more focus is on creating an environment where clients have a chance to heal their broken attachment systems and learn how to calm their physiological responses that were so prone to living in fear and danger. Trauma informed practice is strengths based. It means safety and trust over obedience. For clients, it means that having an emotional or aggressive episode is met by support,

For clients, it means that having an emotional or aggressive episode is met by support, comfort, and learning rather than fewer privileges, shame, and isolation. As health care professionals, we have to turn our focus to the early attachment issues and traumatic experiences that many of our clients have faced.

We have to view behaviors as a language and not as the root problem. We have to become trauma-informed to truly create a safer, healthier and balanced society for future generations to come.

Trauma Informed Care: What Is It and Why Should We Care?

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.

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 such as Kessler’s Posttraumatic stress disorder: The burden to the individual and to society 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. However, problems like child abuse and domestic violence are challenges faced by almost all 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.

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 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. 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.

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 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 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 master’s 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 learning 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.
  • 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)
  • Podcast I did for World Social Work Day: Trauma-Informed Social Work Practice: What Is It and Why Should We Care? (March 2012).
  • Online Trauma-Informed Clinical Foundation Certificate Program through our  Continuing Education department (University at Buffalo School of Social Work)
  • A list of all the inSocialWork podcasts on trauma.

Boy Held Captive Teaches Us About Good Child Protection Practice

Canadian media have been covering the story of a 10 year old boy who was rescued by child protection workers in London, Ontario. They boy, who cannot be named in accordance with typical Canadian child protection legislation, had been locked in a bedroom of his aunt and uncle’s house for between 18-24 months. The room, like the rest of the house, police and social workers described as squalid. As the Globe and Mail newspaper reports, he was found in the master bedroom. His bed and his pajamas were soiled with urine and the room had left overs of his fast food diet. Feces were also found in the room.

For this boy, his confinement must have been even more confusing as he had a 9 year old cousin, the daughter of the aunt and uncle, who was not confined. But somehow, she must have been ingratiated into the need for secrecy as she went about her life outside the home.

The boy is not originally from Canada and has limited English. He has not been registered in school and thus was not known to educational officials. Therefore, his absence from school did not ring any bells – he just wasn’t known.

Media have also interviewed neighbors who also did not know of the boy, adding to his invisibility. Yet, somehow, child protection received a tip that he existed and went out to investigate. Knocks on the door went unanswered but the social worker noted a shadow moving. Police were summoned and the boy was found.

The good child protection practice here is being inquisitive and paying attention to what you see. The boy has been severely neglected bot physically and emotionally. He reportedly now wants normal food and the chance to go to school. This suggests that he had a connection to the average life experience of a child prior to being imprisoned by the aunt and uncle who now face criminal charges.

His case also reminds us of how powerful families can be in keeping abuse hidden. One has to imagine how isolated the boy was but knowing that just on the other side of the window were children and families going about their day. The home was in a typical residential neighborhood that might be seen anywhere in Canada or the USA. Children lived in the homes around this boy and he would have heard him them out playing. What power existed with the aunt and uncle that he would have remained so invisible? This is a lesson for child protection.

But so too is the apparent strength of his early life. Trauma informed therapy can build upon that helping him to realize the dream of going to school. Inside that dream will be many chapters that might range from connecting to other kids on up to building a future for himself.

No doubt in the weeks to come we will learn more about this story but it reminds us of the need to act, be alert to the data as it comes to you and to think critically about what the data means.

Exploring The “CRAZY”: Looking Deeper Than Labels In Mental Health

I frequently meet great people who identify as “bi-polar” or are labeled with “schizoid personality disorder,” often times both labels have been assigned amongst an array of other diagnoses such as schizophrenia, borderline and ADHD. When I ask them, “How long have you been diagnosed”?  Some of them say “forever”, and/or they often give me an age like “since I was 12.”

dsm5Many people place judgement at this point and see them as permanently damaged with a life sentence of living in chaos due to labels in mental health. Even worse, many of the diagnosed individuals place their identity in “being” a label/diagnosis and become more vulnerable to stigma and discrimination.

It is no surprise that one might find their identity in a diagnoses as this is fully supported by the medical model of health care that is all-too-often inappropriately utilized in mental health services across America.

For example, if you “are” a type 1 diabetic that is something that you cannot control, for the most part.  A doctor can pinpoint an incurable illness or disease and the patient receives an answer with a plan of care.  There is never a need to ask “why?” because there is nothing we can change to reverse or “heal” the illness.

In social work and health care we often become bitter and burnt out with the same old problems.  The revolving door in emergency departments and mental health units is a timeless joke heard across the country by both professionals and clients (sadly).  It is also the epitome of a lack of asking “why?”

When we fail to ask why then we fail to address the root problem and in turn we fail to provide quality services.  When we fail to provide quality services then we do not follow through with equipping clients with the skill-sets for mental and emotional well being.  Instead, we make the assumption that an individual is “too damaged” or a “hopeless cause” because they have continually failed treatment.

We must remember that a mental health diagnosis is nothing more than a description of symptoms.  In addressing mental health, such symptoms are generally a list of behaviors, attitudes and actions that decrease an individual’s ability to maintain a feeling of safety, security and happiness.

So, when someone tells me that they were diagnosed at age 12, I simply ask “why?”  Most of the time they are shocked by the question because nobody has ever taken the time to listen.  They usually struggle offer a response.  At that time, I re-phrase the question by asking, “What happened when you were 12?”

I have not done extensive trials or studies on this, but for the past two years I have specifically focused on asking “why” or “what happened” in my work as a Crisis Worker and 100% of the time they give me a very direct answer.  For example: “I was beaten and raped by my dad when I was 12” or “I didn’t have parents and my only family was my grandma and she died then.”

Instead of focusing on improving emotional wellness and family dynamics, we settle for the poor practice of pushing pills.  Instead of offering validation followed by guidance, we belittle and talk down or, even worse, don’t talk at all.  My challenge for you is to inspire hope in the hopeless and simply listen.  There are lots to be heard and learned, even from those who just don’t seem to “get it.”  Everyone needs to be shown the way before they can start on the right path.  Be the one person that it takes to shine a light on the hard work of personal growth and emotional intelligence.

There is always a reason behind behavior. Instead of judging, lets ask “Why?”  This is the starting point for providing Trauma Informed Care which is now being trickled down from the federal level by the Substance Abuse and Mental Health Services Administration (SAMHSA).

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