Chapter Nine: Trauma-Informed Care

Trauma from Natural Causes

Natural traumatic experiences can directly affect a small number of people, such as a tree falling on a car during a rainstorm, or many people and communities, as with a hurricane. Natural events, often referred to as “acts of God,” are typically unavoidable. Human-caused traumas are caused by human failure (e.g., technological catastrophes, accidents, malevolence) or by human design (e.g., war). Although multiple factors contribute to the severity of a natural or human-caused trauma, traumas perceived as intentionally harmful often make the event more traumatic for people and communities. How survivors of natural trauma respond to the experience often depends on the degree of devastation, the extent of individual and community losses, and the amount of time it takes to reestablish daily routines, activities, and services (such as returning to school or work, being able to do laundry, having products to buy in a local store).

The amount, accessibility, and duration of relief services can significantly influence the duration of traumatic stress reactions and recovery. Alongside the disruption of daily routines, the presence of community members or outsiders in affected areas may add significant stress or create traumatic experiences in and of themselves. It is not just the natural disaster or event that can challenge an individual or community; often, the event’s consequences and behavioral responses from others within and outside the community push survivors away from effective coping or toward resilience and recovery.

Trauma Caused by Humans

Human-caused traumas are fundamentally different from natural disasters. They are either intentional, such as a convenience store robbery at gunpoint, or unintentional, such as the technological accident of a bridge collapse that occurred in Pittsburgh, Pennsylvania, on January 28, 2022 (Puskar & Scolforo, 2022). The subsequent reactions to these traumas often depend on their intentionality. However, a person or group of people is typically the target of anger and blame from survivors. Survivors of an unintentionally human-caused traumatic event may feel angry and frustrated because of the lack of protection or care offered by the responsible party or government, particularly if there has been a perceived act of omission. After intentional human-caused acts, survivors often struggle to understand the motives for performing the act, the calculated or random nature of the act, and the psychological makeup of the perpetrator(s).

Trauma Affecting Communities and Cultures

Trauma that affects communities and cultures covers a broad range of violence and atrocities that erode the sense of safety within a given community, including neighborhoods, schools, towns, and reservations. These may involve violence in the form of physical or sexual assaults, hate crimes, robberies, workplace or gang-related violence, threats, shootings, or stabbings—for example, the school shooting at Virginia Polytechnic Institute and State University in 2007. They also include actions that attempt to dismantle systemic cultural practices, resources, and identities, such as making boarding school attendance mandatory for Native American children or placing them in non-Native foster homes. Cultural and/or community-based trauma can also occur via indifference or limited responsiveness to specific communities or cultures that are facing a potential catastrophe. Cultural traumas are events that, whether intentionally or not, erode the heritage of culture—as with prejudice, disenfranchisement, and health inequities (e.g., late prenatal care, inability to afford medications, limited access to culturally appropriate health education, vicinity, and quality of affordable medical services), among other examples.

Objective Characteristics of Trauma

Trauma can involve a single event, numerous or repeated events, or sustained/chronic experiences. A single trauma is limited to a single point in time. A rape, an automobile accident, or the sudden death of a loved one, these are examples of a single trauma. Some people who experience a single trauma recover without any specific intervention. But for others—especially those with histories of previous trauma or mental or substance use disorders, or those for whom the trauma experience is particularly horrific or overwhelming—a single trauma can result in traumatic stress symptoms and trauma- and stress-related disorders. Single traumas do not necessarily have a lesser psychological impact than repeated traumas.

Some repeated traumas are sustained or chronic. Sustained trauma experiences tend to wear down resilience and the ability to adapt. Some examples include children who endure ongoing sexual abuse, physical neglect, or emotional abuse; people who are in violent relationships; and people who live in chronic poverty. Individuals in chronically stressful, traumatizing environments are particularly susceptible to traumatic stress reactions, substance use, and mental disorders.

Bidirectional relationships exist between trauma and substance use as well as trauma and mental illness. For example, abuse of alcohol and drugs increases the risk of a traumatic experience and creates greater vulnerability to the effects of trauma; substance use reduces a person’s ability to take corrective and remedial actions that might reduce the impact of the trauma. Likewise, traumatic stress leads to a greater likelihood of substance use that, in turn, increases the risk of additional exposure to trauma. Paralleling this bidirectional relationship, mental illness increases vulnerability to the effects of trauma and raises the risk of substance use disorders and additional traumatic events. So too, early exposure to ACEs (adverse childhood experiences) is associated with traumatic stress reactions and subsequent exposure to trauma in adult years.

Subjective Characteristics of Trauma

An important clinical issue in understanding the impact of trauma is the meaning that the survivor has attached to the traumatic experience. Survivors’ unique cognitive interpretations of an event—their beliefs and assumptions—contribute to how they process, react to, cope with, and recover from the trauma. Does the event represent retribution for past deeds committed by the individual or their family? How does the individual attach meaning to their survival? Do they believe it signifies a greater purpose not yet revealed?

People interpret traumatic events in vastly different ways, and many variables shape how an individual assigns meaning to the experience (framing the meaning through culture, family beliefs, prior life experiences and learning, personality and other psychological features, etc.). Even in an event that happens in a household, each family member may interpret the experience differently. Likewise, the same type of event can occur at two different times in a person’s life, but the person’s interpretation of the events may differ considerably because of developmental differences acquired between events, current cognitive and emotional processing skills, availability of and access to environmental resources, and so forth.

Individual Factors

Several factors influence one’s ability to deal with trauma effectively and increase one’s risk for traumatic stress reactions. Individual factors pertain to the individual’s genetic, biological, and psychological makeup and history because they influence the person’s experience, interpretation, and reactions to trauma. However, many factors, not just individual characteristics, influence individual responses to trauma. Failing to recognize that multiple factors, aside from individual attributes and history, influence experiences during and after trauma can lead to blaming the victim for having traumatic stress.

Trauma Reactions

A variety of reactions are often reported and/or observed after trauma. Most survivors exhibit immediate reactions, yet these typically resolve without severe long-term consequences. This is because most trauma survivors are highly resilient and develop appropriate coping strategies, including the use of social support, to deal with the aftermath and effects of trauma. Most recover with time, show minimal distress, and function effectively across major life areas and developmental stages. Even so, clients who show little impairment may still have subclinical symptoms or symptoms that do not fit the diagnostic criteria for acute stress disorder (ASD) or PTSD. Only a small percentage of people with a history of trauma show impairment and symptoms that meet the criteria for trauma-related stress disorders, including mood and anxiety disorders. See Table 9.2 for common responses to trauma.

Screening

Screening begins by determining whether the person has a history of trauma and whether the person has trauma-related symptoms. Screening obtains answers to “yes” or “no” questions: “Has this client experienced a trauma in the past?” and “Does this client at this time warrant further assessment regarding trauma-related symptoms?” If someone acknowledges a trauma history, then further screening is necessary to determine whether trauma-related symptoms are present. However, the presence of such symptoms does not necessarily say anything about their severity, nor does a positive screen indicate that a disorder exists. Positive screens indicate only that assessment or further evaluation is warranted, and negative screens do not necessarily mean that an individual does not have symptoms that warrant intervention.

Screening procedures should always define the steps to take after a positive or negative screening. That is, the screening process establishes precisely how to score responses to screening tools or questions and clearly defines what constitutes a positive score (called a “cutoff score”) for a particular potential problem. The screening procedures detail the actions to take after a client scores in the positive range. Clinical supervision is helpful—and sometimes necessary—in judging how to proceed. Trauma-informed screening is essential to the intake evaluation and treatment planning process, but it is not an end in itself. Screening processes can be developed that allow staff without advanced degrees or graduate-level training to conduct them, whereas assessments for trauma-related disorders require a mental health professional trained in assessment and evaluation processes.

The most important domains to screen among individuals with trauma histories include these:

• Trauma-related symptoms
• Depressive or dissociative symptoms, sleep disturbances, and intrusive experiences
• Past and present mental disorders, including typically trauma-related disorders (e.g., mood disorders)
• Severity or characteristics of a specific trauma type (e.g., forms of interpersonal violence, adverse childhood events, combat experiences)
• Substance use
• Social support and coping styles
• Availability of resources
• Risks for self-harm, suicide, and violence
• Health screenings

Assessment

When a client has substance use disorder, trauma-related symptoms, or mental disorders, the agency or counselor should follow up with an assessment. A positive screening calls for more action—an assessment that determines and defines presenting struggles to develop an appropriate treatment plan and to make an informed and collaborative decision about treatment placement. The assessment determines the nature and extent of the client’s problems; it might require the client to respond to written questions, or it could involve a clinical interview by mental health or substance use professionals qualified to assess the client and arrive at a diagnosis. A clinical assessment delves into a client’s past and current experiences, psychosocial and cultural history, and assets and resources. Assessment protocols can require more than a single session to complete and should also use multiple avenues to obtain the necessary clinical information, including self-assessment tools, past and present clinical and medical records, structured clinical interviews, assessment measures, and collateral information from significant others, other health professionals, and agencies.

Qualifications for conducting assessments and clinical interviews are more rigorous than for screening. Advanced degrees, licensing or certification, and special training in administration, scoring, and interpretation of specific assessment instruments and interviews are often required. For people with histories of traumatic life events who screen positive for possible trauma-related symptoms and disorders, a thorough assessment gathers all relevant information necessary to understand the role of the trauma in their lives; appropriate treatment objectives, goals, planning, and placement; and any ongoing diagnostic and treatment considerations, including reevaluation or follow-up. Overall, the assessment may indicate symptoms that meet diagnostic criteria for a substance use or mental disorder or a milder form of symptomatology that does not reach a diagnostic level, or it may reveal that the positive screen was false and that there is no significant cause for concern.

Information from an assessment is used to plan the client’s treatment. The plan can include such domains as a level of care, acute safety needs, diagnosis, disability, strengths and skills, support network, and cultural context. Assessments should recur throughout treatment. Ongoing assessment during treatment can provide valuable information by revealing further details of trauma history as clients’ trust in staff members grows and by gauging clients’ progress.

Strategies for Screening and Assessments

The success of treatment can be enhanced by paying careful attention to the approach to the screening and assessment process by using the following strategies:

• Clarify to the client what to expect in the screening and assessment process
• Approach the client in a matter-of-fact and supportive manner
• Respect the client’s personal space
• Adjust tone and speech volume to suit the client’s level of engagement and comfort in the interview process
• Provide culturally appropriate symbols of safety in the physical environment
• Be aware of one’s own emotional responses to hearing clients’ trauma histories
• Overcome linguistic barriers via an interpreter
• Elicit only the information necessary for determining a history of trauma and the possible existence and extent of traumatic stress symptoms and related disorders
• Use self-administered, written checklists rather than interviews (when possible) to assess trauma
• Interview the client if they have trouble reading or writing or cannot complete a checklist
• Allow time for the client to become calm and oriented to the present if the client has very intense emotional responses when recalling or acknowledging a trauma
• Avoid phrases that imply a judgment about the trauma
• Provide feedback about the results of the screening
• Be aware of the possible legal implications of assessment

Barriers to Screening and Assessment

Without screening, it is not necessarily easy or obvious to identify an individual who has survived trauma. Moreover, some clients may deny that they have encountered trauma and its effects even after being screened or asked direct questions to identify the occurrence of traumatic events.

The two main barriers to evaluating trauma and its related disorders in health care settings are clients not reporting trauma and nurses and other health care providers overlooking trauma and its effects. Concerning the first main barrier, some events affect the person’s responses to them and the meanings they attach to the event. Certain situations make it more likely the event will be experienced as traumatic by one person but considered nontraumatic by another. A history of trauma encompasses the experience of a potentially traumatic event and the likelihood that the client will not be forthcoming about traumatic events or their responses to those events. Some clients might not have ever thought of a particular event or their response to it as traumatic and thus might not report or even recall the event. Some clients might be reluctant to discuss something that they sense might bring up uncomfortable feelings (especially with a counselor they have met only recently). Clients may avoid openly discussing traumatic events or have difficulty recognizing or articulating their experience of trauma for other reasons, such as feelings of shame, guilt, or fear of retribution by others associated with the event (e.g., in cases of interpersonal or domestic violence). Others may deny their history because they are tired of being interviewed or asked to fill out forms and may believe it does not matter anyway.

Grounding Techniques

Grounding techniques are important skills for assessors and all other behavioral health service providers who interact with traumatized clients (e.g., nurses, security, administrators, clinicians). Even if you do not directly conduct therapy, knowledge of grounding can help defuse an escalating situation or calm a client who is triggered by the assessment process. Grounding strategies help a person who is overwhelmed by memories or strong emotions or is dissociating; they help the person become aware of the here and now. A useful metaphor is an experience of walking out of a movie theater. When the person dissociates or has a flashback, it’s like watching a mental movie; grounding techniques help the person step out of the movie theater into the daylight and the present environment. The client’s task is not only to hold on to moments from the past but also to acknowledge that what they were experiencing is from the past. Try the following techniques (Melnick & Bassuk, 2000):

1. Ask the client to state what they observe.

Guide the client through this exercise by using statements like these: “You seem to feel very scared/angry right now. You’re probably feeling things related to what happened in the past. Now, you’re in a safe situation. Let’s try to stay in the present. Take a slow deep breath, relax your shoulders, and put your feet on the floor; let’s talk about what day and time it is, notice what’s on the wall, … What else can you do to feel okay in your body right now?”

2. Help the client decrease the intensity of the effect.

“Emotion dial”: A client imagines turning down the volume on their emotions. Clenching fists can move the energy of emotion into fists, which the client can then release. Guided imagery can be used to visualize a safe place.

Distraction (see Item 3, next). Use strengths-based questions (e.g., “How did you survive?” or “What strengths did you possess to survive the trauma?”).

3. Distract the client from unbearable emotional states.

Have the client focus on the external environment (e.g., naming red objects in the room).

Ask the client to focus on recent and future events (e.g., “to do” list for the day). Help the client use self-talk to remind themself of current safety. Use distractions, such as counting, to return the focus to current reality. Somatosensory techniques (e.g., toe-wiggling, touching a chair) can remind clients of current reality.

4. Ask the client to use breathing techniques.

Ask the client to inhale through the nose and exhale through the mouth. Have the client place their hands on their abdomen and then watch the hands go up and down while the belly expands and contracts.

Psychoeducation

Trauma-informed education informs clients about traumatic stress and trauma-related symptoms and disorders and the consequences of trauma exposure. It focuses on giving information to clients to help normalize presenting symptoms, highlighting potential short- and long-term consequences of trauma and various paths to recovery, and underscoring the message that recovery is possible. Education frequently takes place before or immediately following an initial screening as a way to prepare clients for hearing results or to place the screening and subsequent assessment findings in the proper context.

However, education does not necessarily constitute a stand-alone treatment; rather, it can be conceptualized as a first step and/or component of a more comprehensive treatment. Nonetheless, education may be a prevention and intervention strategy for individuals with histories of trauma without current consequences or symptoms and/or those who have reported a resolution of past trauma(s). For example, some clients may have significantly delayed onset of traumatic stress symptoms. In this scenario, earlier education can enhance the recognition of symptoms and ease the path to seeking treatment. Some clients do not recognize the link between their current difficulties and their trauma histories; education can help them understand the possible origin of their difficulties.

Psychoeducation presents trauma-related symptoms that follow a trauma as normal reactions. Identifying the source of clients’ current difficulties and framing them as normal thoughts, emotions, and behaviors in response to trauma helps trauma survivors. Many report a reduction in the intensity of the difficulties or symptoms. Often, a client will express relief that their reactions are normal. The U.S. Department of Veterans Affairs National Center’s PTSD educational handouts on traumatic stress reactions may be useful here. Psychoeducation goes beyond identifying traumatic stress symptoms and/or learning about trauma’s psychological, cognitive, and physical impacts. Numerous curricula are available that use psychoeducation as a first-line or complementary approach to trauma-specific therapies to enhance coping strategies in key areas, including safety, emotional regulation, help-seeking, avoidant behavior, and so forth. An example is S.E.L.F., a trauma-informed psychoeducational group curriculum with educational components related to trauma recovery in the following areas: creating Safety, regulating Emotions, addressing Loss, and redefining the Future (Bloom et al., 2021).

Normalize Symptoms

Symptoms of trauma can become serious barriers to recovery from substance use and mental disorders, including trauma-related ones. Counselors should know how trauma symptoms can present and how to respond to them when they do appear. A significant step in addressing symptoms is normalizing them. People with traumatic stress symptoms need to know that their symptoms are not unique and that their reactions are common to their experience(s). Often, normalizing symptoms gives considerable relief to clients who may have thought that their symptoms signified some pervasive, untreatable mental disorder.

Identify Triggers and Trauma

Many clients who have traumatic stress are caught off guard by intrusive thoughts, feelings, sensations, or environmental cues of the trauma. This experience can be quite disconcerting, but often, the individual does not draw an immediate connection between the internal or external trigger and their reactions. At other times, the trigger is so potent that the individual is unable to discern the present trigger from the past trauma and begins to respond as if the trauma is reoccurring. A key step in identifying triggers is to reflect on the situation, surroundings, or sensations before the strong reaction. This step may enable the connections among these cues, the past trauma(s), and the client’s reaction to be determined. Once the cue is identified, the next step is to discuss how it is connected to past trauma. For some cues, there will be an obvious and immediate connection (e.g., having someone say “I love you” in a significant relationship as an adult and connecting this to an abuser who said the same thing before a sexual assault). Other cues will not be as obvious. With practice, the client can begin to track back through what occurred immediately before an emotional, physical, or behavioral reaction and then examine how that experience reminds them of their past.

Teach Balance

A thin line is walked when addressing trauma. On the one hand, too much work focused on highly distressing content can turn a desensitization process into a session whereby the client dissociates, shuts down, or becomes emotionally overwhelmed. On the other hand, too little focus by the client or counselor can easily reinforce avoidance and confirm the client’s internal belief that it is too dangerous to deal with the aftermath of the trauma.

Several trauma-specific theories offer guidelines on acceptable levels of distress associated with the traumatic content that the therapy addresses. For example, some traditional desensitization processes start at an incredibly low level of subjective distress, gradually working up through a hierarchy of trauma memories and experiences until those experiences produce minimal reactions when paired with some coping strategy, such as relaxation training. Other desensitization processes start at a higher level of intensity to provide more rapid extinction of traumatic associations and to decrease the risk of avoidance—a behavior that reinforces traumatic stress.

Working with trauma is a delicate balancing act between the development and/or use of coping strategies and the need to process the traumatic experiences. Individuals will choose different paths to recovery; it is a myth that every traumatic experience needs to be expressed and every story told. For some individuals, the use of coping skills, support, and spirituality are enough to recover. Regardless of theoretical beliefs, counselors must teach coping strategies as soon as possible. Retraumatization is a risk whenever clients are exposed to their traumatic histories without sufficient tools, support, and safety to manage emotional, behavioral, and physical reactions.