Defining ‘trauma informed practice’
Trauma informed practice is “A model that is grounded in and directed by a complete understanding of how trauma exposure affects service users’ neurological, biological, psychological, and social development.”
The impact of trauma on the physical and mental health of survivors has been known and understood for decades with work done by practitioners and researchers from Abraham Kardiner’s 1941 publication ‘Trauma Neuroses of War’, to the latter part of the 20th century with Judith L Herman, Bessel van der Kolk, Peter Levine, Gabor Mate, Liz Kelly, Nancy Lombard, and Janina Fisher, as well as the seminal research carried out by Lori Heise et al on behalf of the World Bank in 1994, ‘Violence Against Women: The Hidden Health Burden (World Bank discussion paper No 255)’. These are just a few of the trauma experts in the US and the UK who have contributed to our understanding of the impact of trauma on the physical and mental health of trauma survivors.
Across services, including healthcare, criminal justice, social work and welfare benefits, and counselling and support services, we come into contact with trauma survivors every day we are at work. Not only are trauma survivors using these statutory and third sector services but with current estimates from the United Nations showing a figure of 1 in 3 women worldwide experiencing some form of physical, sexual, or emotional abuse in their lifetimes, we will know trauma survivors in our families, friendship groups, and workplaces.
Understanding trauma and the short and long term impact it has on the lives of survivors, can not only improve our work practice and provide better services for trauma survivors, but adopting trauma informed practice in all aspects of our lives, can improve our interactions with everyone with whom we have contact.
“The journey towards becoming a trauma informed organisation will require organisations to move beyond their traditional models of service delivery and to re-evaluate their entire organisational practices and policies through a trauma informed lens. As part of this reconceptualization of services, organisations will need to reframe complex behaviours as potential responses to trauma related triggers and will be required to prioritise the building of trusting, mutual relationships above all else.”
Scottish Government National Trauma Training programme; Trauma Informed Practice: Toolkit (March 2021)
What does a trauma informed service look like?
A trauma informed service has a workforce that can define trauma, and understands the widespread impact it has on people and seeks to actively resist retraumatising those who are trauma survivors.
Harris and Follot (2001) stated that trauma informed means “… to understand the role that violence and victimisation play in the life of most consumers of … services and to use that understanding to design services and systems that accommodate the vulnerabilities of trauma survivors and allow services to be delivered in a way that will facilitate consumer participation in treatment.”
Services can become ‘trauma informed’ in that they can respond to issues other than trauma (such as homelessness, substance misuse, criminal justice, mental health services) by building capacity within those services or systems where trauma survivors may present. The root cause of the trauma may not be the presenting issue
But regardless of the service’s main focus for service delivery, a trauma informed response commits to providing services in a way that is welcoming and appropriate to the specific needs of the individual trauma survivor.
Trauma survivors often have increased sensitivity to cues of threat, may be hypervigilant and alert to potential harm. As sexual violence robs the survivor of any measure of control, it’s vital that the survivor has control over some aspects of the service and decisions about her treatment, or the service being provided.
For example, a forensic medical examination can be a terrifying experience for rape or child sexual abuse survivors. The power differential, being asked to remove clothing or having an invasive examination could lead to a flashback to the traumatic incident or to earlier traumatic experiences. This can result in survivors shying away from reporting or even speaking out about sexual violence trauma.
How can we ensure that our service is trauma informed?
Depending on the nature of the service being provided, practitioners can aim to:
- Steer services more towards becoming trauma informed by ensuring that all practices and procedures are geared towards creating a safe and supportive environment for the survivor.
- Work with partners to ensure safe spaces for the survivor to have a forensic medical examination make a statement to police, or for any reason that the survivor may use your service.
- Understand that the survivor may be hypervigilant, have heightened responses and a keen sensitivity to cues of threat, so that there is less chance of creating an environment that feels unsafe for the survivor.
- Understand that physical safety is paramount to the trauma survivor. She has been in an unsafe, threatening, possibly even life-threatening situation, so her ability to trust a worker on first or second meeting may be reduced. But there are ways to help build that trust and give the survivor increased feelings of physical and psychological safety.
- Understand that psychological safety can include ensuring the survivor understands the limitations of your service and the limitations of the level of confidentiality you can provide. Establishing boundaries and delivering a consistent service can be crucial in building a trusting relationship with survivors. If you are able to deliver a consistent service, it can increase the survivor’s trust. If you are able to deliver a consistent service, it can increase the survivor’s trust.
A trauma informed approach begins with the understanding of the physical, social and emotional impact of the traumatic event on the individuals as well as the professionals who help them.
Our interactions with one another are always important. They are especially important for people living with the impact of trauma. Trauma interrupts the connection between different systems of functioning in the brain. People recover from trauma when disruptions between different levels of functioning – physical, emotional or cognitive, become connected again.
How can we have survivor centred practice?
- Understand the prevalence of trauma and the impact it has on the lives of survivors.
- Understand that practitioners may contribute to retraumatising the survivor by intrusive questioning and victim blaming attitudes:
- If you have to ask intimate questions, explain why you are asking or how the information is important
- If any kind of physical contact is required, explain to the survivor what is going to happen and why
- Assure the survivor that if she asks to stop, you will do this immediately. Do this even if the procedure or questioning is almost finished.
- Put this knowledge into practice
- Understand the danger of vicarious trauma on staff and work to mitigate this risk.
How can we build a trauma informed service throughout our organisation or agency?
- Review your agency’s policies and procedures to identify and remove any that are potentially unsafe and harmful to survivors of any form of sexual violence or abuse.
- Provide education and training to staff, including those who work directly with the survivors of sexual violence and abuse.
- Screen for trauma in multiple settings (in health boards across Scotland, there is a practice of Sensitive and Routine Enquiry) – http://www.healthscotland.scot/health-topics/gender-based-violence/gender-based-violence-overview/routine-enquiry-of-abuse
- Ensure safety and meet basic service needs.
- Build long term sustainable relationships and provide opportunities for regaining valued social roles.
- Provide access to trauma specific treatment services.
- Understand the role that culture plays in resilience and the importance of community resources as potentially mediating the trauma experience.
- Engage survivors in the development of programmes.
“Trauma informed practice is a strengths based framework grounded in an understanding of, and responsiveness to, the impact of trauma, that emphasises physical and emotional safety for everyone, and creates opportunities for survivors to rebuild a sense of control or empowerment.”
Hopper et al (2010)
 Trauma and Recovery: From domestic abuse to political terror (1991), Dr Judith Lewis Herman
 The Body Keeps the Score (2014) Dr Bessel van der Kolk
 Waking the Tiger (1997), Dr Peter Levine
 In the realm of the hungry ghosts (2008), Dr Gabor Mate
 Surviving Sexual Violence (1988), Prof Liz Kelly CBE
 Violence Against Women: Current Theory and Practice in Domestic Abuse, Sexual Violence and Exploitation (2012), Prof Nancy Lombard
 Healing the Fragmented Self (2017), Dr Janina Fisher