What Does it Mean to be Trauma-Informed? A Multi-System Perspective from Practitioners Serving the Community

The increased awareness of the detrimental consequences of trauma exposure has led researchers to focus their attention in identifying best practices on integrating trauma-informed approaches (TIAs) to child and family services. Yet, terms related to TIAs are often utilized without an adequate definition, and most importantly, without concrete and specific strategies to ensure that services are in fact trauma-informed. Using a multi-methods approach, this project examined important practice considerations that support successful implementation of TIA in school and community-based behavioral health settings. Key informant interviews and electronic surveys were conducted with child and family systems practitioners; interviews inquired about training, current practices, and barriers to service engagement. Data was analyzed, organized, and synthesized in accordance with core domains and specific components proposed by Hanson and Lang’s (2014) trauma-informed care framework. Findings suggest that practice of TIA differed by system and was largely driven by experiential and informal learning experiences. Practitioners also report challenges unique to each system hinder the utilization of screening and intervention best practices. Salient differences included those related to knowledge and accessibility to training, utilization of evidence-based practices, application of screening tools, and availability of resources within their systems. This brings to light the importance of considering both general and system-specific practice mechanism for the successful implementation and sustainability of TIA frameworks. We suggest system-specific strategies to help integrate trauma into services, including prioritizing capacity building efforts within each system by leveraging their natural supports and identifying systems-specific assets for both screening and intervention practices.

     

Perceived lack of training moderates relationship between healthcare providers’ personality and sense of efficacy in trauma-informed care

ABSTRACT

Background and Objectives: Medical patients often have trauma histories that are not routinely assessed, which can adversely affect health outcomes. Despite growing awareness of this issue, there is limited understanding of factors that influence provider competency in trauma-informed care (TIC). The study examined healthcare providers’ personality traits in relation to their sense of TIC efficacy, taking into account perceived barriers to TIC and professional quality of life.

Study Design: The study used cross-sectional survey methods to examine our central hypothesis that provider personality traits and perceived barriers to TIC would be associated with TIC-efficacy, and to explore interactions among study variables.

Methods: Survey data were collected from 172 healthcare providers examining TIC knowledge, TIC-efficacy, perceived barriers to TIC, personality traits, and professional quality of life.

Results: TIC-efficacy was positively correlated with “intellectence/openness” and inversely correlated with “neuroticism” and perceived lack of training as a barrier. “Intellectence/openness” interacted with perceived lack of training to predict TIC-efficacy, suggesting that providers with lower “intellectence/openness” report greater TIC-efficacy when lack of training is not perceived as a barrier.

Conclusions: Provider personality traits and perceived barriers to TIC appear related to providers’ TIC-efficacy. Implications for overcoming barriers to TIC through training and implementation are discussed.     

Trauma-Informed Child Welfare: From Training to Practice and Policy Change

ABSTRACT

Multiple child welfare systems and agencies have embraced efforts to become more trauma-informed in recent years. However, the field of trauma-informed care is still somewhat in its infancy and only recently has the focus shifted from theoretical concepts into concrete practices that can be identified, measured, evaluated, and sustained over time. One of the key resources designed to help support the development of a trauma-informed child welfare system is the Child Welfare Trauma Training Toolkit (CWTTT). The CWTTT was developed in 2008 as a collaborative process that included members of the Child Welfare Committee of the National Child Traumatic Stress Network (NCTSN). Originally, the CWTTT was developed as a training resource to support child welfare professionals in increasing their understanding regarding trauma and its impact on children. Over time, the CWTTT has undergone multiple iterations and has been involved in numerous state and county initiatives to support their efforts in becoming more trauma-informed. This article will provide historical context on the development of the CWTTT, detailing its evolution since 2007, followed by highlighting the current efforts and future directions of the CWTTT.     

Creating Trauma-informed Sports Programming for Traumatized Youth: Core Principles for an Adjunctive Therapeutic Approach

ABSTRACT

Youth who have experienced trauma may find opportunities for recovery in community settings, such as team sports. Sports and other community settings may provide an important structure, a venue for persevering toward goals, and a place to connect with mentors and friends. However, the symptoms with which such youth present, such as hyperarousal and aggression, may serve as a barrier to the potentially supportive environment that sports may provide. The typical means of coaching in such environments may be adapted to increase accessibility to youth. In this article, we describe principles of trauma-informed sports programming, including adaptations to play structures, that draw from gold-standard trauma-informed psychotherapy approaches. These techniques may help youth workers adapt their settings to meet a broader range of needs and aspire to provide clinicians with tools for collateral work with trauma-exposed clients.     

Implementing Trauma-Informed Care in Primary Medical Settings: Evidence-Based Rationale and Approaches

ABSTRACT

Chronic stress stemming from trauma exposure and posttraumatic stress disorder (PTSD) leads to many health problems that are typically seen by primary care providers. Unfortunately, providers rarely identify trauma as the root cause of patient difficulties. The present paper provides an evidence-based rationale for implementing trauma-informed care principles and processes into medical primary care systems. Beginning with a review of prevalence of trauma exposure and PTSD in primary care clinics, this article elucidates relationships between trauma exposure and behavioral and medical health problems, as well as clinical and physiological pathways that lead from trauma exposure to illness. The article concludes with exposition of trauma-informed interventions that can be implemented in primary care clinics, and discussion of future directions.     

An Overview of Trauma-Informed Care and Practice for Eating Disorders

ABSTRACT

This article reviews concepts and principles of trauma-informed care and trauma-informed practice for those with eating disorders (EDs). EDs are not universally recognized to be associated with traumatic events, despite substantial research evidence indicating that individuals with EDs report very high rates of childhood maltreatment, other lifetime traumatic events, as well as adverse consequences from trauma. Using national representative samples, higher prevalence rates of PTSD and other trauma-related comorbidities have been reported in those with EDs, particularly those with bulimic symptoms (binge eating and/or purging). Evidence suggests that those prone to develop EDs appear to be especially sensitive to the effects of stress/adversity and have high rates of premorbid anxiety disorders, personality traits, and neuropsychological features that predispose them to PTSD and its symptoms. This article also reviews some of the important principles for treating individuals with EDs comorbid for PTSD and other trauma-related disorders, including the necessity of moving beyond sequential treatment to the development of integrated treatment protocols. Integration of existing evidence-based treatments, including family therapy, cognitive behavioral therapy, dialectical behavior therapy, cognitive processing therapy, prolonged exposure, and eye movement desensitization reprocessing are recommended. Recent research suggests that ED clinicians view integrated treatment for individuals with ED and PTSD as a top priority, yet they have several concerns about administering such a treatment. As trauma-informed care is embraced by all clinicians and treatment programs that assess and treat eating and related disorders, better outcomes are anticipated.     

Evaluation of a Trauma-Informed School Intervention with Girls in a Residential Facility School: Student Perceptions of School Environment

In response to the high nationwide prevalence of psychological trauma among court-involved youth who have been exposed to abuse and neglect and the associated far-reaching adverse consequences, there are calls to develop a trauma-informed workforce across the various systems (child welfare, juvenile justice, mental health, and education) designed to serve this population. We describe a pilot test of a modified version of the Heart of Teaching and Learning (HTL) curriculum, an intervention designed to increase trauma-informed practices in education settings. This program was implemented in a public charter school that exclusively serves court-involved youth placed in residential treatment. The intervention was associated with decreases in trauma symptoms experienced by youth. Because student perceptions of teachers were high both before and after implementation of the curriculum, no statistically significant changes were observed. The article concludes with a discussion of the ways in which the curriculum can be used to help prepare a national education workforce capable of implementing trauma-informed evidence-based practices in school settings.     

Helping Callers to the National Suicide Prevention Lifeline Who Are at Imminent Risk of Suicide: The Importance of Active Engagement,Active Rescue,and Collaboration Between Crisis and Emergency Services

In 2012, the SAMHSA‐funded National Suicide Prevention Lifeline (Lifeline) completed implementation of the first national Policy for Helping Callers at Imminent Risk of Suicide across its network of crisis centers. The policy sought to: (1) provide a clear definition of imminent risk; (2) reflect the state of evidence, field experience, and promising practices related to reducing imminent risk through hotline interventions; and (3) provide a uniform policy and approach that could be applied across crisis center settings. The resulting policy established three essential principles: active engagement, active rescue, and collaboration between crisis and emergency services. A sample of the research and rationale that underpinned the development of this policy is provided here. In addition, policy implementation, challenges and successes, and implications for interventions to help Lifeline callers at imminent risk of suicide are detailed.     

Laying the Groundwork: Conceptualizing a Trauma-Informed System of Care in Juvenile Detention

ABSTRACT

Youth involved in the juvenile-justice system experience trauma at a disproportionately higher rate compared with the general population. Posttraumatic stress reactions place youth at greater risk for penetrating deeper into the juvenile justice system and being placed in secure detention settings. Juvenile detention settings with a systemic approach to addressing youth traumatic stress reactions promote an environment positioned to support the physical and psychological safety of youth and detention center staff. This article reviews key elements of a trauma-informed juvenile detention system and explores implications for trauma-informed interventions and cross-system collaboration.     

Re-Storying the Trauma Narrative: Fostering Posttraumatic Growth in Cambodian Refugee Women

ABSTRACT

The purpose of this article is to provide clinical recommendations in fostering positive well-being among Cambodian refugee women living in the United States. We first present a brief overview of Cambodian refugee women’s history and cultural background to highlight their experiences of shared and gender-based trauma, as well as their process of recovery. Next, as informed by the posttraumatic growth model and evidence-based practices, we provide clinical recommendations with an emphasis on trauma-informed components and interventions influenced by feminist and narrative perspectives in facilitating the process of surviving trauma and thriving post-migration. Finally, we present a composite case illustration, highlighting cultural considerations to aid mental health providers in fostering posttraumatic growth in Cambodian refugee women.     

Countering Correctional Discourse

SUMMARY

This article discusses the development of a feminist support group for women prisoners enrolled in a six-month substance abuse treatment program in an adult correctional facility in Guam. After the completion of five Group cycles, a follow-up study was conducted in the community using qualitative, feminist, and participatory methods. Results indicate that the Group was successful in helping women prisoners to address trauma, addiction, and the stresses associated with incarceration. Nevertheless, participants reported having significant difficulty transitioning into the community upon release and 23% were sent back to prison for parole violations. Recommendations are outlined for gender-responsive programming, both within women's prisons and in the community, to support women offenders after release.     

A Trauma-Informed Call to Action: Culturally-Informed,Multidisciplinary Theoretical and Applied Approaches to Prevention and Healing

ABSTRACT

The prevalence of trauma and its negative impact on humankind has created a burgeoning awareness of the need for systems that are trauma-informed across the lifespan. A collaborative project with the National Partnership to End Interpersonal Violence (NPEIV) sought out research as a call-to-action to mitigate the impact of trauma. The following is an introduction to a special double-issue focused on theoretical and applied approaches to using trauma-informed care in multi-disciplinary, mental and physical health, criminal justice, school-based, and community settings. Consideration is given to essential issues such as resilience, self-care, and cultural awareness.     

Trauma-Informed Police Responses to Rape Victims

ABSTRACT

Rape victims can benefit from trauma-informed approaches when reporting rape to police. Police interviewing skill can prevent survivor re-victimization while eliciting useful crime statements. However, rape myth acceptance and police culture may pose obstacles to a trauma-informed approach. Client empowerment, demystification, trigger reduction, and expressed concern for victim safety can be implemented by police agencies. Interdisciplinary collaboration, combating sexual harassment, gender balancing, emotional debriefing of officers, accountability to victims, new reporting methods, and advanced training protocols are elements of a trauma-informed approach.     

Via Kundalini: Psychosomatic excursions in transpersonal psychology

Abstract

A model of psychosomatic mysticism (PM) is proposed that reintroduces the body into transpersonal psychology. The argument for PM develops links between transpersonal psychology and neuroimmunology and includes scientific notions of the mind as embodied not just in the brain but more widely throughout the body, as well as the comparative analyses of perspectives on the body in various spiritual traditions. PM is used to examine how transpersonal psychology can integrate the body, thus meeting the goals of the clinician, the standards of the researcher, and the emerging needs of psychosomatic medicine. The core principles of PM are explicated, such as: 1) decentralized consciousness, 2) structural phenomenological correlations between the psyche and the body, 3) in‐depth understanding of energy as intentionality, and 4) the possibility of actualizing cosmic awareness in the individual psyche. Examples of the clinical use of psychospiritual practices of PM show practical applications of these principles. It is concluded that the studies of the embodied consciousness and subtle energies through PM can help to develop both transpersonal theory and applications.     

Nonviolent Childhood Discipline

Summary

Interpersonal violence is a leading cause of death and injury in this country. Parents normalize and validate violence when they use corporal punishment. If the legitimization of violence in the name of discipline is to end, physicians and other professionals must be convinced that spanking is harmful and unnecessary. They must help parents learn effective, nonviolent parenting practices. This article presents a program to help health educators teach physicians and others to counsel parents on nonviolent parenting practices.     

The Role of Trauma in Conduct Disorder

Summary

Trauma is proposed as a key to understanding the development and persistence of conduct disorder, in conjunction with other contributing factors. Trauma history is ubiquitous in the conduct disordered population, and trauma effects can help to account for many features of conduct disorder, including lack of empathy, impulsivity, anger, acting-out, and resistance to treatment. The current standard of care fails to fully address trauma, which may partially explain the low success rate of extant treatment approaches. A trauma-informed perspective is introduced to current models of conduct disorder. Research, prevention, and treatment implications are discussed.     

A Mother,A Baby,and Two Treatment Approaches: Discussing A Switch Case from CBT and Mentalization Perspectives

ABSTRACT

As the literature on perinatal depression and anxiety grows, there is an increased need for dialogue among theoretical approaches for mother-infant mental health. This article describes a community mental health program incorporating a range of treatment models for pregnant and postpartum women experiencing issues during the transition to parenthood. Perinatal distress can affect parenting practices, from breastfeeding to health care access, creating the need for targeted, practical, and concrete interventions. Interventions that aim to foster secure attachment relationships and mentalization capacities can also help increase maternal sensitivity and attunement and joy in caregiving, and reduce withdrawn/hostile behaviors that may be associated with perinatal distress. The article describes psychotherapy with a mother and her newborn that began from a cognitive-behavioral approach and transitioned to a psychodynamic mentalization-focused treatment. Working principles and examples of two additional components of treatment, a group psychotherapy and research measures, are discussed. The case helps demonstrate how attachment theory can inform treatment and build a bridge between alternative approaches.     

A Feminist Examination of Boot Camp Prison Programs for Women

Abstract

Penal law in the United States reflects a strict moral ideology. This moral philosophy has dictated the laws that govern women and the punishments that they receive. Therefore, correctional programming for women has been focused on punishment and has not addressed the needs and problems of women inmates. Boot camp programs (shock incarceration), a low-cost, short-term alternative to traditional prison programming, are one example of such programming. Correctional boot camps teach discipline and responsibility by “breaking down and building up” inmates so that they will no longer commit crimes. However, the assumption that female offenders commit crimes because they are lacking in discipline and responsibility has not been substantiated by research. In addition, feminist therapy theory is not consistent with some boot camp practices. This paper will examine the social context of female criminality and the resulting implications for prison programming for women, and boot camp practices will be examined in the context of feminist therapy practices.     

The (social) construction of the world – at the crossroads of Christianity and Humanism

Abstract

In early modem philosophy the motive of logical creation emerged in reaction to the Greek-Medieval legacy of a realistic metaphysics. The dominant nominalistic trends of thought since Thomas Hobbes and Inimanuel Kant explored its rationalistic implications. The latter drew the radical (humanistic) conclusion that the laws of nature are present in human thought a priori (i.e. before all experience). The irrationalistic side of nominalism emphasized the uniqueness and individuality of events - thus leading to the historicism of the 19th century and the subsequent linguistic turn. Kant influenced Husserl who, in turn, provided the point of departure for the ideas of Schutz, Berger and Luckmaim - compare the joint work of Berger and Luckmann: Social construction of reality (1967). The contemporary “postmodem” idea that we create the world in which we live (either through thought, through language or through social practices) merely continues core elements of (early) modem philosophy.

The underlying idea of autonomy highlights the difference between modern Humanism and a Christian view of reality, for in the latter human subjectivity is appreciated as being correlated with universal and constant principles that can only assume a positive shape through human activities of positivization (form-giving). The autonomy ideal of modern Humanism reifies the typical human freedom to positivize underlying principles. At the same time this reification on the one hand collapses the distinction between conditions and being conditioned and on the other it does not provide a basis for supra-individual standards of behaviour.