What is trauma-informed care?

Trauma-informed care (TIC) shares many principles with patient-centered care. TIC is influenced by an understanding of the impact of interpersonal violence and victimization on an individual’s life and development. “Providers of trauma-informed care incorporate into their routine clinical practice an appreciation of how traumatic experiences may affect their patients’ behaviours and perceptions of their bodies and health” (Zimmerman & Borland, 2009, p. 34).

Preventing retraumatization

Preventing retraumatization is one of the most important goals that a provider can have in any healthcare interaction, and a vital component of providing TIC.  “Making connections between a survivor’s past experiences and their current situation is crucial. This does not mean pushing a survivor to uncover memories when they are already overwhelmed. It does mean understanding the impact of trauma, how current problems relate to past trauma, and the need to provide survivors with an integrated model of recovery.” (Elliott, et al. 2005, p. 468) “Traumatic reactions, or fear of them, prevents many [survivors] from seeking healthcare and may interfere with their ability to hear or remember information given during healthcare visits. Thus, it is important to review this information at several stages, and to monitor whether aspects of an exam or procedure are triggering traumatic reactions. Following an office visit, a survivor may need some time to ground themselves to become ready to travel home safely”  (Elliott, et al. 2005, p. 473).

Goals of trauma-informed care:

The primary goal of trauma-informed care is to avoid retraumatizing the patient.

The goal is NOT to obtain disclosure, or to be a hero for the patient. 

The goal IS to create:

• Trust within the healthcare system

• A safe environment where patients are able to share as little or as much as they want to

• A culture that fosters consent for all kinds of care provided

• An experience that the patient feels comfortable returning to when healthcare is needed in the future 

Six foundations of trauma-informed care:

1. Safety

Throughout the organization, staff and the people they serve feel physically and psychologically safe.

• The healthcare provider uses trauma-informed care for EVERY patient, regardless of trauma disclosed

• The HCP is warm and inviting, patient care is individualized, supportive, non-judgmental, and integrated

• Patient rights and consent are respected at all times

• The HCP informs the patient of the right to translator services and provides these services when requested by the patient

• The HCP emphasizes the patient’s control over the examination and care

2. Trustworthiness and transparency

Organizational operations and decisions are conducted with transparency and the goal of building and maintaining trust among staff, clients, and family members of those receiving services.

• The HCP informs the patient of the right to privacy, confidentiality, and to stop any procedure at any time, for any reason; rights are communicated verbally and written, in patient’s preferred language of communication

• The HCP is aware of mandatory reporting for any patient who discloses a history of sex trafficking and is under 18 years; HCP informs the patient that they are a mandatory reporter

• The HCP and staff believe the patient and their disclosed trauma

3. Peer support and mutual self-help

These are integral to the organizational and service delivery approach and are understood as a key vehicle for building trust, establishing safety, and empowerment.

• The HCP makes every attempt to connect the patient to identified needs, including holistic health services and support organizations to address needs such as food, housing, shelter, education, legal aid and job-skills development.

4. Collaboration and mutuality

There is true partnering and leveling of power differences between staff and clients and among organizational staff from direct care staff to administrators. The organization recognizes that everyone has a role to play in a trauma-informed approach.

• The HCP acknowledges that irritability, withdrawal, or avoidance may be manifestations of post-trauma stress, and do not hold this against the patient

• The HCP acknowledges that every interaction with a patient can create a positive or negative experience, and makes every attempt to create positive experiences

• The HCP strives to do no harm, prevent retraumatization, and support individuals

5. Empowerment, voice, and choice

Throughout the organization and among the clients served, individuals' strengths are recognized, validated, and built on, and new skills developed as necessary. The organization aims to strengthen the staff's, clients', and family members' experience of choice and recognize that every person's experience is unique and requires an individualized approach. This includes a belief in resilience and in the ability of individuals, organizations, and communities to heal and promote recovery from trauma. This builds on what clients, staff, and communities have to offer, rather than responding to perceived deficits.

• Staff communicate all information slowly and clearly to the patient, with accurate and easy to understand language

• The HCP identifies patient strengths and informs and affirms these strengths to the patient; the HCP provides care and assessment from a strengths based approach

• The staff gives every option available for treatment to the individual without bias, and allows the individual to make their own health decisions, regardless of what the HCP believes to be best (informed refusal) 

6. Cultural, historical, and gender issues

The organization actively moves past stereotypes and biases (e.g., based on race, ethnicity, sexual orientation, age, geography and worldview), offers gender responsive services, leverages the healing value of traditional cultural connections, and recognizes and addresses historical trauma.

• The HCP is culturally informed and provides culturally competent care to every individual, regardless of stereotypes and biases

• The patient’s wishes for a provider of the same gender is respected when possible, as well as the patient’s choices about whom they would permit to examine them

• The HCP recognize the importance of religious beliefs in a patient’s recovery, as well as their understanding of the trafficking experience in the context of their religion and cultural beliefs.

Hierarchy of trauma-informed care:

The primary goal of trauma-informed care is to prevent further traumatization of survivors of trauma. It is helpful for the patient to feel a sense of compassion and humanity from their healthcare providers. Providers must assess each patient as an individual person with unique needs and preferences. Empowering the individual occurs through a strengths based approach, and the provider should be aware of their own biases. The ultimate goal is to promote the development of trust.

 Ten principles of trauma-informed care

Many individuals who have been physically and/or sexually abused do not utilize healthcare services due to the likelihood that the experience will be retraumatizing. It is imperative that all healthcare workers treat and approach every patient as a potential survivor of trauma, using a trauma-informed approach to their care. 

Below are ten guiding principles for healthcare workers and their facilities to utilize in the implementation of trauma-informed care. All of this information has been gathered and adapted from the article “Trauma-Informed or Trauma-Denied: Principles and Implementation of Trauma-Informed Services for Women” in the Journal of Community Psychology (Elliott, Bjelajac, Fallot, Markoff, Reed, 2005).

1. Trauma-informed services recognize the impact of violence and victimization on development and coping strategies.

• Trauma-informed staff recognize the continuing effects that trauma has on an individual’s life, resulting in lack of engagement in healthcare, hyperarousal, avoidance and coping strategies. A trauma-informed organization recognizes and validates an individual's experiences and ensures their safety. 

2. Trauma-informed services identify recovery from trauma as a primary goal.

• Trauma-informed programs offer care directly related to recovery from past trauma along with holistic healthcare services, recognizing that the two coexist and are not to be treated separately. 

3. Trauma-informed services employ an empowerment model.

• An empowerment model puts the patient in charge of the care, allowing choice and control over the treatment provided. The goals for treatment are mutually established and the patient is validated. The healthcare provider approaches the patient with a strengths based approach, building off of the strengths present in that patient. 

4. Trauma-informed services strive to maximize an individual’s choices and control over their recovery.

• Trauma-informed care ultimately strives to allow for a patient to utilize conscious choice, increased options and a sense of control over their life decisions, taking them away from previous experiences of powerlessness. If a healthcare provider does not understand and/or approve of a choice a patient is making, they will work to gather more information from the patient to aim to understand the patient’s choices.  

5. Trauma-informed services are based in a relational collaboration.

• Trauma-informed services acknowledge that interpersonal trauma must be healed with relationships that are the opposite of traumatic, and are therapeutic. Therapeutic relationships are approached with respect, information, connection and hope (RICH) creating safety and trust. A safe relationship is consistent, predictable, nonviolent, non-shaming, and non-blaming. The helper and helped mentality must be eliminated, and the patient's right to refuse to answer a question, refuse treatment or ask for alternative treatment must be made clear. 

6. Trauma-informed services create an atmosphere that is respectful of survivors’ need for safety, respect, and acceptance.

• Trauma-informed services strive to create a safe space, modifying programs, procedures and the physical setting to create a non-threatening and safe space for survivors. This includes visuals such as magazine covers in the waiting room and sufficient staff to monitor public areas. 

7. Trauma-informed services emphasize individuals’ strengths, highlighting adaptations over symptoms and resilience over pathology. 

• “The medical model highlights pathology and inadvertently gives the impression that there is something wrong with a person rather than that something wrong was done to that person. Trauma-informed practice recognizes symptoms as originating from adaptions to the traumatic event(s) or context. Validating resilience is important even when past adaptations and ways of coping are now causing problems. Understanding a symptom as an adaptation reduces the client's guilt and shame, increases [their] self-esteem, and provides a guideline for developing new skills and resources to allow new and better adaptations to the current situation” (Elliott, et al. 2005, p. 467).

8. The goal of trauma-informed services is to minimize the possibilities of retraumatization.

• Trauma-informed providers acknowledge and understand the potential for retraumatization for patients in a healthcare setting. Invasive or insensitive procedures may trigger trauma-related symptoms and staff actions in stance and communication may induce trauma responses. “Making connections between a survivor’s past experiences and their current situation is crucial. This does not mean pushing them to uncover memories when they are already overwhelmed. It does mean understanding the impact of trauma, how current problems relate to past trauma, and the need to provide survivors with an integrated model of recovery” (Elliott, et al. 2005, p. 468). “Traumatic reactions or fear of them prevents many survivors from seeking health- care and may interfere with their ability to hear or remember information given during healthcare visits. Thus, it is important to review this information at several stages, and to monitor whether aspects of an exam or procedure are triggering traumatic reactions. Following an office visit, a survivor may need some time to ground themselves to become ready to travel home safely” (Elliott, et al. 2005, p. 473).

9. Trauma-informed services strive to be culturally competent and to understand each individual in the context of their life experiences and cultural background.

• Trauma-informed health providers take into consideration a survivor’s cultural context. Understanding the influence of someone’s culture is essential to making an effective therapeutic connection and being a part of a survivor’s recovery. The meaning that one gives violence and trauma can vary by culture. Cultural competence does not require that every provider have detailed knowledge of every culture, but rather that he or she recognize the importance of cultural context. Ask questions, be open to being educated, and try to understand the survivor’s experience and responses through the lens of the cultural context. 

10. Trauma-informed agencies solicit consumer input and involve consumers in designing and evaluating services.

• Trauma-informed services acknowledge the importance of involving survivors in the ongoing creation and evaluation of the services and changes being implemented. Survivors should be integrated and actively involved in the development, delivery and evaluation of services and protocols that are created.