Trauma Types and Promising Approaches to Assist Survivors

Introduction

Unaddressed trauma and related stress on victims is a growing public health concern. Victims of violent crime may seek help and in the process receive insensitive responses to the trauma they have experienced (e.g., responses that disbelieve victims or blame them for the experience). Researchers and practitioners alike have expressed concern over the impact of such responses and many agencies are adopting a trauma-informed approach. However, a clearer understanding is needed of what adopting a trauma-informed approach entails including models of trauma-informed care and how they should be developed, monitored, and maintained.

Definitions of trauma, descriptions of two trauma-informed care models, and a discussion on implementing the approach are provided in this report. The findings are based on a review of 45 scholarly articles using the terms “trauma-informed care,” “trauma-focused care,” and “trauma care.”

Definitions of Trauma

The two most widely accepted definitions of trauma come from the Diagnostic Statistical Manual of Mental Disorders 5th Edition and the Substance Abuse Mental Health Services Administration.

Diagnostic Statistical Manual of Mental Disorders 5th Edition (DSM – 5). The definition for trauma within the DSM-5 is part of the diagnostic criteria for posttraumatic stress disorder (PTSD). The DSM-5 notes that for an event to be considered traumatic, it must involve “caused or actual death, serious injury, or sexual violence to an individual, family member or close friend” (309.81 [F43.10]). This definition is limited to stressful events that are an immediate threat to life or physical injury, despite their potential to have a great impact on an individual’s life.^[1]

Substance Abuse Mental Health Services Administration (SAMHSA). SAMHSA defines trauma as that which “results from an event, series of events, or set of circumstances that 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.”^[2]

While both definitions incorporate forms of trauma beyond physical experiences, SAMHSA’s definition is more expansive in that it includes repetitive and cumulative trauma, as well as the multiple areas of well-being that trauma may affect.

The Impact of Trauma on Individual Health

Traumatic experiences can leave victims with a multitude of symptoms, including, but not limited to, a loss of hope, excessive fear, strained relationships with family, friends, employers, and others, depression, anxiety, sleep disturbances, and feelings of excessive guilt or self-blame.^[3] Collectively, these symptoms can be referred to as traumatic stress reactions and may be indicators of PTSD. Traumatic stress reactions often impact an individual’s behavioral and physical health, and affect daily functioning.^[4]

Traumatic stress reactions can be grouped into four categories:^[5]

Figure 1

Symptoms of traumatic stress reactions

Description of Traumatic Stress Reaction Symptoms

Re-experiencing includes nightmares and flashbacks, which can be triggered by memories or sensory elements that serve as reminders of a traumatic event.

Avoidance symptoms include avoiding places or objects that remind an individual of a traumatic event, or avoiding thoughts or feelings related to the trauma. These symptoms may also manifest as an overall avoidance of conflict and real or perceived threats to safety. Trauma experiences evoke a sense of powerlessness.

Arousal and reactivity symptoms include a startle reflex, irritability, violent outbursts, hypervigilance, guardedness, difficultly sleeping, and an overall heightened state of awareness and arousal.

Cognitive or mood symptoms include memory suppression, negative views of self and the world, feelings of guilt and shame, isolation, and numbing or inability to feel positive emotions.^[6]

Traumatic stress reactions are normal responses to traumatic events. When these reactions are left unaddressed, they can negatively impact the victim’s quality of life. Negative impacts that affect quality of life may include changes in one’s sense of self, the world, or the future, and in extreme cases may cause changes in one’s sense of all three.^[7]

Secondary Victimization. Traumatic stress reactions also may be triggered by responders and systems that engage in practices that are not sensitive to the impacts of trauma on individuals. Secondary victimization or system-oriented trauma, is a form of re-traumatization where clients feel as though they are experiencing another trauma.^[8] Examples of secondary victimization in a medical or law enforcement setting include victim-blaming responses, limited privacy or personal space, insensitive interviewing techniques, and not involving the client or limiting client participation in treatment or care decisions.^[9] Secondary victimization may be caused by a lack of awareness or training for responders or organizational policies and protocols that fail to consider trauma and its impact.

Vicarious trauma. Staff who provide services or support to persons who have been traumatized may be affected via indirect exposure to trauma. Commonly termed “vicarious trauma” or “compassion fatigue,”^[10] this form of trauma occurs when providers experience traumatic stress reactions resulting from exposure to another’s traumatic experiences, rather than from direct exposure. Indirect exposure occurs upon hearing or learning about others’ victimization. Those affected by vicarious trauma may undergo the same physical, psychological, and cognitive changes experienced by those directly impacted by trauma.^[11] These reactions typically manifest themselves as changes in one’s worldview, such as thinking the world is an evil or bad place, or changes in one’s sense of self including one’s self-image (e.g., blaming themselves for the victimization). These reactions may impact the quality of service delivery; therefore, it is critically important for organizations to provide adequate staff support and ongoing supervision and incorporate protocols and policies that encourage staff to take care of themselves and each other. Team building exercises and instituting days off for overall well-being and mental health can curb the impact of vicarious trauma.^[12]

Trauma-Informed Care and What It Entails

Trauma-informed care is an approach used to combat the effects of unaddressed trauma, secondary victimization, and vicarious trauma within organizations. Trauma-informed care principles may be applied across a variety of organizations and systems. Incorporating trauma-informed care requires addressing organizational policies and practices that may re-traumatize or trigger traumatic memories.^[13] However some systems may face limitations to what policies can be changed to align with trauma-informed principles, such as in prisons (e.g., routine strip searches in order to ensure safety of others as discussed in Trauma-Informed and Evidence-Based Practices and Programs to Address Trauma in Correctional Settings). However, administrators in such settings can explore how the practices and behaviors employed to carry out these policies are aware of and sensitive to the potential trauma histories of those who participate in their setting.

“Trauma-informed” refers to a philosophical and organizational approach that integrates awareness and understanding of trauma. Trauma-informed care is about creating a safe environment where individuals do not experience further trauma or harm because of service delivery.^[14] The trauma-informed approach is most commonly applied in mental and behavioral health service settings,^[15] but the approach may be applied in corrections, homeless services, child welfare systems, and school settings. At its core, “trauma-informed” is an overarching framework that guides the decision-making, behavior, and structure of an entire organization with implications for both clients and staff.^[16]

For clients. Trauma-informed organizations strive to create physically and emotionally safe spaces and prioritize practices that honor victim voice and choice.^[17] Implementing trauma-informed care requires changes to the practices and policies at all levels of the organization to ultimately prevent re-traumatization of clients seeking services. In being trauma-informed in their approaches, many systems presume every person who walks through their doors has been exposed to abuse, violence, neglect, or other traumatic event(s).^[18] When implemented properly, trauma-informed care fosters resilience in victims. Resilience is the capacity to cope with stress, overcome adversity, and thrive in life, despite one’s victimization experience or other life challenges. Building resilience in victims is an ongoing process that requires continual time and effort from both the victim and service provider.^[19] Organizations can build resilience by helping victims build connections with others, encouraging self-care activities, such as meditating, relaxing, or exercising (for both clients and staff), promoting understanding of trauma and being aware that many individuals may have been affected by trauma, encouraging discussion of traumatic experiences and resulting traumatic reactions in an effort to normalize topics that historically have been regarded as taboo, and encouraging goal-setting.^[20]

For organizations. In the spirt of understanding and being aware of trauma, organizations that deliver trauma-informed care need to address that staff may experience vicarious trauma due to indirect exposure within their role. Without proper support, secondary exposure can cause staff members to suffer from emotional or psychological impairment, negatively impacting their ability to provide quality care to clients. This can contribute to large turnover within behavioral health and victim service fields.^[21] Trauma-informed agencies can minimize the prevalence of vicarious trauma by implementing organizational strategies such as:

• Implementing workload policies and practices to manage caseloads.
• Increasing support by promoting team building activities.
• Providing regular supervision that includes checking in about how the staff person is coping with exposure to traumatic material.
• Engaging staff in decision making so that they feel empowered within the organization.
• Discussing of vicarious trauma which historically has been regarded as taboo.^[22]

Organizations implementing these practices should engage in ongoing evaluation to gauge how multiple stakeholders, including clients, staff, and management, are supported.^[23] This evaluation may include formal reviews of policies and procedures, analysis of staff workloads, staff surveys about how well strategies are implemented, and client surveys about their experiences interacting with staff within the organization.

Trauma-Specific Services

Trauma-informed care supports the delivery of trauma-specific services or trauma-focused services.^[24] Distinct from trauma-informed care, trauma-specific services are interventions or programs designed and proven to address and reduce trauma symptoms to promote healing. ^[25] Trauma-focused cognitive behavioral therapy and Seeking Safety are evidence-based, trauma-specific interventions. Evidence-informed or -based practices and programs are those that research has proven to contribute to positive outcomes when implemented with fidelity. For a full description of how programs and practices become evidence-based see Implementation Science in Criminal Justice: How Implementation of Evidence-based Programs and Practices Affects Outcomes. Trauma-specific services are distinct from trauma-informed services because these services seek to target and reduce the symptoms of trauma. Trauma-specific services may be offered within a trauma-informed program or as stand-alone services.^[26]

SAMHSA’s Concept of Trauma-Informed Care

SAMHSA’s model of trauma-informed care is one commonly cited approach. SAMHSA defines trauma-informed care as “a strengths-based framework that is grounded in an understanding of and responsiveness to the impact of trauma, that emphasizes physical, psychological, and emotional safety for both providers and victims, and that creates opportunities for victims to rebuild a sense of control and empowerment.” ^[27]

SAMHSA’s model of trauma-informed care incorporates four key elements:

Figure 2

SAMHSA’s elements of trauma-informed care

Key principles of trauma-informed care further build on these program elements by emphasizing values that create a trauma-informed setting. They include:

Figure 3

SAMHSA’s principles of trauma-informed care

Description of SAMHSA’s Principles

Safety: Staff and clients feel physically and psychologically safe.

Trustworthiness and Transparency: Organizational operations and decisions are conducted with transparency to build and maintain trust among clients and their family members, staff, and others involved within the organization.

Peer Support: Maintaining adequate social support within an organization will help prevent isolation and depression in clients and staff. Peer support enables clients and staff to share their story and life experiences with others to promote recovery and healing. Specifically, for staff, peer support can help prevent secondary trauma.

Collaboration and Mutuality: Collaboration and mutuality involves partnering and the leveling of power differences between staff and clients and among organizational staff. Everyone has an important role in the recovery process.

Empowerment, Voice, and Choice: Organizations actively involve clients in the decision-making process. Empowering clients by giving them voice in turn fosters resilience and a sense of validation in clients.

Cultural, Historical, and Gender Issues: The organization demonstrates cultural competency. By doing this, the organization actively resists biases and cultural stereotypes, understands the healing value of traditional cultural connections, offers gender-responsive services, and recognizes and addresses the existence of historical trauma in both children and adults.^[28]

Incorporating these elements and principles, SAMHSA’s model of trauma-informed care seeks to help acknowledge individuals’ histories of trauma, understand their responses to trauma, and recognize the pathways victims take in navigating safety and recovery.^[29]

The Sanctuary Model of Trauma-Informed Care

Also widely recognized is the Sanctuary Model of trauma-informed care. Created in 1980, the Sanctuary Model is considered an evidence-supported practice by the National Child Traumatic Stress Network.^[30] The Sanctuary Model is a systematic theory-based approach that focuses both on those who seek services and those who provide the services. The approach has been used in juvenile detention centers, domestic violence shelters, schools, and community-based mental health programs.^[31] The philosophy of the Sanctuary Model is informed by the scientific study of attachment and child development. This model seeks to shape a system that acknowledges the impact of adversity, toxic stress, and trauma on individuals and on groups.^[32]

According to model creator Dr. Sandra L. Bloom, the Sanctuary Model rests on four “pillars:”

Figure 4

Four pillars of the Sanctuary Model

The goals of the Sanctuary Model include working more effectively with traumatized clients, creating a collaborative treatment environment, and improving staff morale. This model has been shown to produce promising outcomes for both clients and organizations. ^[33] According to Sanctuary Web, some expected outcomes following implementation include systemic understanding of trauma, abuse, and adversity among both clients and staff; decreased staff and management turnover; shared decision-making at all levels within the organization; and better ability to articulate goals and create strategies for change. In 2015, approximately 300 programs nationally and internationally had implemented this model of trauma-informed care.^[34]

Implementing Trauma-Informed Care

Implementing trauma-informed care can be complex and requires changes within the structures and environment of the organization.^[35] These structures may include the mission, staffing, policies, protocols, procedures, culture, and the physical environment of the organization. SAMHSA offers these domains that should be considered during implementation of trauma-informed care:

• Governance and Leadership: Support and fully invest in implementation and sustainability.
• Policy: Establish and reinforce trauma-informed care as the organizational mission.
• Physical Environment: Foster a sense of safety and collaboration.
• Victim Engagement and Involvement: Actively involve victims and their voices actively in all aspects of decision-making within the organization.
• Cross Sector Collaboration: Promote a shared understanding of trauma-informed aspects and principles across all sectors.
• Screening, Assessment, Treatment Services: Complete trauma assessment and screening to guide the care plan. A referral system must be in place for treatment services that the organization is unable to deliver.
• Training and Workforce Development: Conduct ongoing training and development of staff.
• Progress Monitoring and Quality Assurance: Engage in ongoing assessment, tracking, and monitoring of trauma-informed practices for quality assurance.
• Financing: Build financial structures to support and plan for sustainability.
• Evaluation: Create evaluation designs that reflect an understanding of trauma and utilize appropriate trauma-oriented research instruments.^[36]

To be fully implemented, trauma-informed care should change both organizational and direct service levels. Experts recommend implementing organizational changes before service changes when transitioning to a trauma-informed care approach. While training staff is beneficial, if the organizational changes necessary to support and reinforce the trauma-informed care approaches are not yet in place, the process is weakened and often unsustainable.^[37]

Implementation is a continual process that requires ongoing conversation throughout all levels of the organization and across all service sectors.^[38] Implementation will be different for each organization and will depend on available resources and capacity. Thus, there is no uniform framework for implementing trauma-informed care. But scholars and organizations that have successfully implemented trauma-informed care have offered guidance for implementation.

According to the Center for Health Care Strategies Advancing Trauma-Informed Care Project, the 10 key ingredients of Trauma-Informed Care are:

Organizational changes:

1. Lead and communicate about the process of transitioning from traditional models of care to trauma-informed care.
2. Engage patients in organizational planning.
3. Train staff members at all levels (i.e., administrative, direct service, management and executive staff).
4. Create a safe environment.
5. Establish processes to prevent vicarious trauma in staff.
6. Hire a trauma-informed workforce.

Direct Service Changes:

7. Involve patients in the process of designing their care plan.
8. Screen for trauma.
9. Train direct service staff on how to be responsive to trauma and clinical staff in trauma-specific treatment approaches.
10. Engage referral sources and partner organizations.^[39]

Other guides toward implementation emphasize agency assessment of whether current policies, procedures, and operations either support trauma-informed care or interfere with its development.^[40] This assessment process should be a continual practice within agencies implementing trauma-informed care approaches. Regular, routine assessment and adjustment of behaviors, practices, and policies to ensure quality care and model fidelity is a core component of being trauma-informed.

Conclusion

Traumatic experiences and exposure to violence can leave a lifelong impact on an individual, especially when left untreated. Public health officials have recognized the need for comprehensive victim-centered approaches to understanding and addressing the impact of trauma. Organizations who assist and support individuals may respond in ways that are harmful, potentially re-traumatizing individuals seeking help. Moreover, staff who hear or learn about others’ victimizations can over time experience vicarious trauma, potentially impacting service delivery and staff retention. To reduce harm and better serve victims, service organizations can implement a trauma-informed approach that is beneficial to the clients, staff members, and to the success of an entire organization. By adopting a trauma-informed care approach across various levels, organizations can foster a safe environment that empowers both clients and staff. Policy changes may be limited in scope within some systems, such as in prisons. However, administrators in such settings can evaluate how behaviors and practices within those policy constraints demonstrate an awareness and sensitivity to the potential trauma histories and vicarious trauma of staff.