A Trauma-Informed Call to Action: Culturally Informed,Multi-Disciplinary Theoretical,and Applied Approaches to Prevention and Healing,Part II

The prevalence of trauma and its negative impact on humankind have 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 Part II of 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 intersectional cultural awareness. Introspective exploration of biases was encouraged to address barriers to implementing trauma-informed care.     

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.     

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.     

Trauma-Informed Care for Infant and Early Childhood Abuse

ABSTRACT

Trauma-informed care for those who experienced early childhood maltreatment is being developed to meet the needs of infant, toddler, and preschool victims of child abuse and neglect. This age group experiences a disproportionate amount of abuse, and the resultant toxic stress during this rapid developmental stage is more damaging than it is in later years. The concept of trauma-informed care in general is presented, followed by a focus on trauma care for early childhood abuse. Trauma-informed care for younger children is united by common principles and is seen as developmental, relational, sensory oriented, and evidence based in nature. Dissemination of knowledge about this unique population to every system that encounters survivors of any age has begun, although it must be broadened and increased. Evidence-based treatment programs for young children are available and effective but limited, especially for age 0–2. Home visiting programs for mothers and babies are effective and cost efficient. Major funding by U.S. Department of Health and Human Services to each state has significant potential for success because it targets mother-child attachment and care, as well as the disproportionate amount of damage resulting from early childhood abuse. Infants and preschoolers are in some ways comparable to children with disabilities due to their developmental limitations. The nature of this population requires a more rigorous and proactive awareness and identification process because these children are physically dependent on surrounding adults. Addressing child abuse in the first years of life offers an excellent opportunity to assist the most vulnerable victims and effectively reduce the impact to families and communities in the ensuing years.     

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 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.     

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.     

Implementing Trauma-Informed Care in Correctional Treatment and Supervision

ABSTRACT

This article provides a rationale for trauma-informed care (TIC) in correctional services, and challenges readers to think about offending behavior through the lens of trauma. Based on interdisciplinary research and cross-theoretical literature, TIC can help in our quest to develop relevant and successful programs, practices, and policies, and the best methods for delivering them. Using Substance Abuse and Mental Health Services Administration (SAMHSA)’s core principles of TIC, this article will make suggestions for the implementation of trauma-informed service delivery and practices across correctional settings. The authors translate trauma-informed concepts into practice behaviors through the acronym SHARE (safety, hope, autonomy, respect, empathy), which honors the principles of TIC recommended by SAMHSA and the principles of effective correctional rehabilitation. TIC in corrections may help improve the desired outcomes of successful re-entry and reduced recidivism.     

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.     

Enhancing Resilience Among Providers of Trauma-Informed Care: A Curriculum for Protection Against Secondary Traumatic Stress Among Non-Mental Health Professionals

Although the call to create trauma-informed services for youth has been clearly sounded, a relatively neglected part of this effort is the need to prepare non-mental health professionals to carry out trauma-informed programming in ways that protect them from secondary traumatic stress (STS). To this end, this article introduces Resilience for Trauma-Informed Professionals, a curriculum that introduces participants to techniques designed to promote resilience in the face of exposure to trauma-related material. Based on the existing evidence base regarding risk and protective factors for STS, six core elements targeted by the curriculum are described—appraisals, self-efficacy, emotional awareness, affect regulation, resilience, and prevention—as they are implemented across three stages: pre-exposure preparation, coping in the presence of trauma, and recovery in the aftermath of exposure.     

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.     

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.     

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.     

Physical activity to address multimorbidity among survivors of sexual violence: A comprehensive narrative review

BackgroundSexual Violence (SV) is highly prevalent and experienced by women and men throughout the United States and world. Survivors of SV often experience poor mental and physical health, and poor health-related quality of life. Studies have explored the associations between SV survivorship and maladaptive health behaviors, but few have examined SV and health promoting activities such as exercise.PurposeThe aim of this narrative review is to describe available peer-reviewed literature regarding SV and physical activity and provide recommendations for future research. Specifically, this review aimed to identify information relevant for promoting and designing exercise interventions that can integrate into clinical treatments for adult survivors of SV.MethodsA search of electronic databases identified 18 articles on SV and exercise behavior.ResultsFour of these studies were exercise interventions, 10 were observational studies, and 4 were qualitative interviews. Results broadly indicate that levels of physical activity among survivors of SV is unclear. Findings from trials indicate exercise may have a positive impact on mental health in survivors of SV. Qualitative interviews found survivors often enjoyed exercising and identified several health benefits, suggesting exercise interventions may be feasible and acceptable in this population. Interviews also identified valuable information about survivors' experiences with exercise.ConclusionsResearch in this area would benefit from: representative samples of adults among populations at high risk for victimization, more consistent and in-depth reporting of SV history and exercise levels, consistent and trauma-informed outcome measurements, and more diverse study designs and interventions. Increased exploration of exercise in this population is warranted given the well-established evidence base indicating the health promoting qualities of exercise for mental and physical health among trauma affected populations.     

Trauma-Informed Medical Care: Patient Response to a Primary Care Provider Communication Training

Trauma exposure predicts mental disorders and health outcomes; yet there is little training of primary care providers about trauma’s effects, and how to better interact with trauma survivors. This study adapted a theory-based approach to working with trauma survivors, Risking Connection, into a 6-hour CME course, Trauma-Informed Medical Care (TI-Med), to evaluate its feasibility and preliminary efficacy. We randomized four primary care sites to training or wait-list conditions; PCPs at wait-list sites were trained after reassessment. Primary care providers (PCPs) were Family Medicine residents (n = 17; 2 sites) or community physicians (n = 13; 2 sites). Outcomes reported here comprised a survey of 400 actual patients seen by the PCPs in the study. Patients, mostly minority, completed surveys before or after their provider received training. Patients rated PCPs significantly higher after training on a scale encompassing partnership issues. Breakdowns showed lower partnership scores for those with trauma or posttraumatic stress symptoms. Future studies will need to include more specific trauma-related outcomes. Nevertheless, this training is a promising initial approach to teaching trauma-informed communication skills to PCPs.     

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.

     

Foster Parents’ Knowledge of Child Trauma: An Exploratory Study

To promote trauma-informed professional supports and services to maltreated youth, it is imperative that researchers explore foster parents’ knowledge of child trauma. However, there is a dearth in the literature related to this topic. This exploratory study utilizes a convenience sample (N = 219) of foster parents in one southeastern state. Variables of interest include actual and perceived knowledge about child trauma. After a terse review of background literature, this paper will explicate key results, discuss these findings, and identify salient practice and policy implications derived from this study. The paper will conclude by delineating apposite areas for future research.     

Pilot Evaluation of a University-Based Training in Trauma-Informed Services for Gang Intervention Workers

The purpose of this pilot study was to investigate the feasibility and efficacy of a course designed to bring trauma-informed practices into community-based intervention programming for gang-involved youth and families. There have been no formally evaluated trauma trainings for gang intervention workers to date. Thirty gang intervention workers completed a University-based course on trauma, which aimed to raise the level of knowledge regarding trauma exposure and its effects on youth, increase intervention workers’ confidence in their ability to identify and respond to posttraumatic stress reactions among clients, and build resilience among staff. Pre-post results revealed that participants significantly improved in their knowledge related to trauma and confidence in their ability to respond to trauma among clients. Participants also rated themselves significantly higher on these domains compared to gang intervention workers who did not take the course. Participants rated the course positively on dimensions that are associated with staff members’ willingness to implement evidence-based interventions following training. The findings indicate a number of important recommendations for supporting gang intervention workers and integrating trauma-informed practices into gang intervention services.     

Understanding Strengths in Relation to Complex Trauma and Mental Health Symptoms within Child Welfare

Strengths can have a potent effect in mitigating the impact of trauma on mental health needs and functioning. Yet, evidence is limited on the role that strengths may have in ameliorating trauma-related or mental health symptoms over time. Providing a comprehensive assessment that includes strengths, as well as needs, is an important step in making appropriate service recommendations for youth in child welfare. This study assessed 7,483 children and adolescents entering an intensive stabilization program through the Illinois child welfare system. The interaction of individual, child strengths in relation to complex trauma exposure, traumatic stress symptoms, risk behaviors, and other mental health needs were examined. Results indicated strengths are relatively stable over time and inversely associated with several negative outcomes, including risk behaviors (?.32, p?<?.001), emotional/ behavioral needs (?.33, p?<?.001) and overall functioning (?.47, p?<?.001). Traumatic stress symptoms were also related to increases in these negative outcomes. Overall, strengths had a buffering effect on traumatic stress symptoms and outcomes over time. The role of strengths in relation to traumatic stress symptoms, however, was less consistent. Youth with histories of complex trauma exposure had significantly fewer useable strengths than youth without this exposure. However, strengths improved for both youth with and without complex trauma exposure over the course of stabilization services. These findings suggest that early identification and development of child strengths can mitigate risk-taking behaviors, mental health, and functional difficulties among youth in the child welfare system. Implications for more targeted trauma-informed and strengths-based assessment, and treatment/service planning are discussed.     

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.