trauma informed care literature review

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Research Article

Trauma informed interventions: A systematic review

Roles Conceptualization, Data curation, Formal analysis, Funding acquisition, Investigation, Project administration, Resources, Supervision, Writing – original draft, Writing – review & editing

* E-mail: [email protected]

Affiliations School of Nursing, The Johns Hopkins University, Baltimore, Maryland, United States of America, Bloomberg School of Public Health, The Johns Hopkins University, Baltimore, Maryland, United States of America

Roles Formal analysis, Writing – original draft, Writing – review & editing

Affiliation School of Nursing, Duke University, Durham, North Carolina, United States of America

Roles Data curation, Writing – original draft, Writing – review & editing

Affiliation School of Public Health, University of Minnesota, Minneapolis, Minnesota, United States of America

Roles Formal analysis, Writing – review & editing

Affiliation School of Nursing, The Johns Hopkins University, Baltimore, Maryland, United States of America

Roles Data curation, Writing – review & editing

Affiliation School of Nursing, Vanderbilt University, Nashville, Tennessee, United States of America

Affiliation Medstar Good Samaritan Hospital, Baltimore, Maryland, United States of America

Roles Data curation, Formal analysis, Writing – original draft, Writing – review & editing

• Hae-Ra Han, 
• Hailey N. Miller, 
• Manka Nkimbeng, 
• Chakra Budhathoki, 
• Tanya Mikhael, 
• Emerald Rivers, 
• Ja’Lynn Gray, 
• Kristen Trimble, 
• Sotera Chow, 
• Patty Wilson

• Published: June 22, 2021
• https://doi.org/10.1371/journal.pone.0252747
• Reader Comments

Health inequities remain a public health concern. Chronic adversity such as discrimination or racism as trauma may perpetuate health inequities in marginalized populations. There is a growing body of the literature on trauma informed and culturally competent care as essential elements of promoting health equity, yet no prior review has systematically addressed trauma informed interventions. The purpose of this study was to appraise the types, setting, scope, and delivery of trauma informed interventions and associated outcomes.

We performed database searches— PubMed, Embase, CINAHL, SCOPUS and PsycINFO—to identify quantitative studies published in English before June 2019. Thirty-two unique studies with one companion article met the eligibility criteria.

More than half of the 32 studies were randomized controlled trials (n = 19). Thirteen studies were conducted in the United States. Child abuse, domestic violence, or sexual assault were the most common types of trauma addressed (n = 16). While the interventions were largely focused on reducing symptoms of post-traumatic stress disorder (PTSD) (n = 23), depression (n = 16), or anxiety (n = 10), trauma informed interventions were mostly delivered in an outpatient setting (n = 20) by medical professionals (n = 21). Two most frequently used interventions were eye movement desensitization and reprocessing (n = 6) and cognitive behavioral therapy (n = 5). Intervention fidelity was addressed in 16 studies. Trauma informed interventions significantly reduced PTSD symptoms in 11 of 23 studies. Fifteen studies found improvements in three main psychological outcomes including PTSD symptoms (11 of 23), depression (9 of 16), and anxiety (5 of 10). Cognitive behavioral therapy consistently improved a wide range of outcomes including depression, anxiety, emotional dysregulation, interpersonal problems, and risky behaviors (n = 5).

Conclusions

There is inconsistent evidence to support trauma informed interventions as an effective approach for psychological outcomes. Future trauma informed intervention should be expanded in scope to address a wide range of trauma types such as racism and discrimination. Additionally, a wider range of trauma outcomes should be studied.

Citation: Han H-R, Miller HN, Nkimbeng M, Budhathoki C, Mikhael T, Rivers E, et al. (2021) Trauma informed interventions: A systematic review. PLoS ONE 16(6): e0252747. https://doi.org/10.1371/journal.pone.0252747

Editor: Vedat Sar, Koc University School of Medicine, TURKEY

Received: July 1, 2020; Accepted: May 23, 2021; Published: June 22, 2021

Copyright: © 2021 Han et al. This is an open access article distributed under the terms of the Creative Commons Attribution License , which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.

Data Availability: This is a systematic review. All relevant data were extracted from the published studies included in the review.

Funding: This study was supported, in part, by a grant from the Johns Hopkins Provost Discovery Award (HRH). Additional funding was received from the National Center for Advancing Translational Sciences (UL1TR003098, HRH), National Institute of Nursing Research (P30NR018093, HRH; T32NR012704, HM), National Institute on Aging (R01AG062649, HRH; F31AG057166, MN), Robert Wood Johnson Foundation Health Policy Research Scholar program (MN), and Substance Abuse and Mental Health Services Administration (5T06SM060559‐ 07, PW). The funders had no role in study design, data collection and analysis, decision to publish, or preparation of the manuscript. There was no additional external funding received for this study.

Competing interests: The authors have declared that no competing interests exist.

Despite the United States’ commitment to health equity, health inequities remain a pressing concern among some of the nation’s marginalized populations, such as racial/ethnic or gender minority populations. For example, according to the 2016 National Health and Nutrition Examination Survey (NHANES), 29.1% of Mexican Americans and 24.3% of African Americans with diabetes had hemoglobin A1C greater than 9% (the gold standard of glucose control with levels ≤ 7% deemed adequate), compared to 11% in non-Hispanic whites [ 1 ]. The 2016 survey also revealed that 40.9% and 41.5% of Mexican Americans and African Americans with hypertension, respectively, had their blood pressure under control, compared to 51.7% in non-Hispanic whites. In 2014, 83% of all new diagnoses of HIV infection in the United States occurred among gay, bisexual, and other men who have sex with men, with African American men having the highest rates [ 2 ].

Several factors have been discussed as root causes of health inequities. For example, Farmer et al. [ 3 ] noted structural violence—the disadvantage and suffering that stems from the creation and perpetuation of structures, policies and institutional practices that are innately unjust—as a major determinant of health inequities. According to Farmer et al., because systemic exclusion and disadvantage are built into everyday social patterns and institutional processes, structural violence creates the conditions which sustain the proliferation of health and social inequities. For example, a recent analysis [ 4 ] using a sample including 4,515 National Health and Nutrition Examination Survey participants between 35 and 64 years of age revealed that black men and women had fewer years of education, were less likely to have health insurance, and had higher allostatic load (i.e., accumulation of physiological perturbations as a result of repeated or chronic stressors such as daily racial discrimination) compared to white men (2.5 vs 2.1, p <.01) and women (2.6 vs 1.9, p <.01). In the analysis, allostatic load burden was associated with higher cardiovascular and diabetes-related mortality among blacks, independent of socioeconomic status and health behaviors.

Browne et al. [ 5 ] identified essential elements of promoting health equity in marginalized populations such as trauma-informed and culturally competent care. In particular, trauma-informed care is increasingly getting closer attention and has been studied in a variety of contexts such as addiction treatment [ 6 – 8 ] and inpatient psychiatric care [ 9 ]. While there is a growing body of the literature on trauma-informed care, no prior review has systematically addressed trauma-informed interventions; one published review of literature [ 10 ] limited its scope to trauma survivors in physical healthcare settings. As such, the purpose of this paper is to conduct a systematic review and synthesize evidence on trauma-informed interventions.

For the purpose of this paper, we defined trauma as physical and psychological experiences that are distressing, emotionally painful, and stressful and can result from “an event, series of events, or set of circumstances” such as a natural disaster, physical or sexual abuse, or chronic adversity (e.g., discrimination, racism, oppression, poverty) [ 11 , 12 ]. We aim to: 1) describe the types, setting, scope, and delivery of trauma informed interventions and 2) evaluate the study findings on outcomes in association with trauma informed interventions in order to identify gaps and areas for future research.

Five electronic databases—PubMed, Embase, Cumulative Index to Nursing and Allied Health Literature (CINAHL), SCOPUS and PsycINFO—were searched from the inception of the databases to identify relevant quantitative studies published in English. The initial literature search was conducted in January 2018 and updated in June 2019 using the same search strategy.

Review design

We conducted a systematic review of quantitative evidence to evaluate the effects of trauma informed interventions. Due to heterogeneity relative to study outcomes, designs, and statistical analyses approaches among the included studies, we qualitatively synthesized the study findings. Three trained research assistants extracted study data. Specifically, we used the PICO framework to extract and organize key study information. The PICO framework offers a structure to address the following questions for study evidence [ 13 ]: Patient problem or population (i.e., patient characteristics or condition); Intervention (type of intervention tested or implemented); Comparison or control (comparison treatment or control condition, if any), and Outcome (effects resulting from the intervention).

Eligibility

Inclusion criteria..

Articles were screened for their relevance to the purpose of the review. Articles were included in this review if the study was: about trauma informed approach (i.e., an approach to address the needs of people who have experienced trauma) or an aspect of this approach, published in English language and involved participants who were 18 years and older. Also, only quantitative studies conducted within a primary care or community setting were included.

Exclusion criteria.

Exclusion criteria were: studies in or with military populations, refugee or war-related trauma populations, studies with mental health experts and clinicians as research subjects or studies of incarcerated and inpatient populations. Conference abstracts that had limited information on study characteristics were also excluded.

Search strategy and selection of studies

Search strategy..

Following consultation with a health science librarian, peer-reviewed articles were searched in PubMed, Embase, CINAHL, SCOPUS and PsycINFO using MeSH and Boolean search techniques. Search terms included: "trauma focused" OR "trauma-focused" OR "trauma informed" OR "trauma-informed." We also searched for the term trauma within three words of informed or focus ((trauma W/3 informed) OR (trauma W/3 focused), or (traumaN3 (focused OR informed)). Detailed search terms for each database are provided in Appendix 1.

Study selection.

The initial electronic search yielded 7,760 references and the follow-up search yielded 5,207 which were all imported into the Covidence software for screening [ 14 ]. Screening of the references was conducted by 2 independent reviewers and disagreements were resolved through consensus. There were 4,103 duplicates removed from the imported articles and 8,864 studies were forwarded to the title and abstract screening stage. Eight thousand five hundred and twenty-one studies were excluded because they were irrelevant. Three hundred and forty-three abstracts were identified to be read fully. Following this, 311 articles were excluded for focusing on other psychological conditions (n = 120), were non-experimental studies (n = 78) and were in inpatient or incarcerated populations (n = 46). One additional companion article was identified during full text review. Therefore, thirty-three articles met the inclusion criteria and are reported in this review. Fig 1 provides details of the selection process and identifies the reasons why articles were excluded at each stage.

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https://doi.org/10.1371/journal.pone.0252747.g001

Quality assessment

We used the Joanna Briggs Institute quality appraisal tools [ 15 ] for randomized controlled trials (RCTs), quasi-experimental studies, and retrospective studies to assess the rigor of each study included in this review. The Joanna Briggs Institute quality appraisal tools [ 15 ] include items asking about methodological elements that are critical to the rigor of each type of study designs. In particular, one of the items for RCTs addresses participant blinding to treatment assignment. Due to the nature of trauma-informed interventions included in our review, it was decided that participant blinding is not relevant and hence was removed from the appraisal list for RCTs. No studies were excluded on the basis of the quality assessment. The quality assessment process was conducted independently by two raters. Inter-rater agreement rates ranged from 56% to 100% with the resulting statistic indicating substantial agreement (average inter-rater agreement rate = 77%). Discrepancies between raters were resolved via inter-rater discussion.

Overview of studies

Table 1 summarizes the main characteristics of the 32 unique studies included in the review, with one companion article [ 16 ] for a study which was later reported with a more thorough examination of findings [ 17 ] totaling 33 articles. More than half (n = 19) of the 32 studies were RCTs [ 17 – 35 ] whereas twelve studies were quasi-experimental [ 36 – 47 ] and one was retrospective study [ 48 ]. Thirteen studies were conducted in the U.S. [ 17 – 19 , 22 , 26 , 27 , 29 , 35 , 39 – 41 , 45 , 47 ]; five in the Netherlands [ 30 , 31 , 33 , 38 , 48 ]; three in Canada [ 23 , 25 , 46 ]; two in Australia [ 21 , 24 ]; two in the United Kingdom [ 36 , 44 ]; two in Sweden [ 42 , 43 ]; on study in Chile [ 20 ]; Iran [ 32 ]; Haiti [ 37 ]; South Africa [ 34 ]; and Germany [ 28 ]. Fourteen of the studies only included females in their sample [ 18 , 20 , 21 , 23 – 25 , 27 , 28 , 38 – 41 , 45 , 48 ]. The average sample size was 78 participants, with a range from 10 participants [ 38 ] to 297 participants [ 48 ]. Of the studies included, 67% had a sample size above 50 [ 18 – 22 , 26 , 29 – 34 , 36 , 37 , 39 – 42 , 46 – 48 ].

https://doi.org/10.1371/journal.pone.0252747.t001

The studies included in this review recruited their study populations largely based on the type of trauma they were aiming to address, such as individuals that experienced interpersonal traumatic event such as child abuse, sexual assault, or domestic violence [ 16 – 18 , 20 – 22 , 24 – 26 , 35 , 40 – 43 , 45 , 46 ], individuals with substance abuse disorders [ 19 , 47 , 48 ], couples experiencing clinically significant marital issues [ 23 ], individuals with limb amputations [ 38 ], dental phobia [ 28 ], or fire service personnel suffering from post-traumatic stress disorder [ 44 ]. Trauma was self-reported in eight articles [ 16 , 17 , 20 , 22 , 26 , 34 , 35 , 47 ]. In contrast, nine studies clearly identified a measurement of trauma; the Trauma History Questionnaire [ 19 , 45 ], the Childhood Trauma Questionnaire [ 23 , 25 ], the Childhood Maltreatment Interview Schedule [ 23 ], the Revised Conflict Tactics Scale adapted for sex work [ 39 ], the Traumatic Events Screening Instrument for Adults [ 27 ], the Life Events Checklist [ 46 ], and the Adverse Childhood Experiences [ 18 ]. Two studies used a clinical tool (e.g. eye movement desensitization and reprocessing [ 38 ] and Diagnostic and Statistical Manual of Mental Disorders, 4 th edition [ 41 ] to identify or diagnose trauma. Fifteen studies did not include direct measurements for trauma [ 21 , 24 , 28 – 33 , 36 , 37 , 40 , 42 – 44 , 48 ].

Quality ratings

Tables 2 – 4 shows final scores of quality assessment. Quality of the 32 unique studies included in this review varied across individual studies. Twelve of 19 RCTs included in the review were of high quality (i.e., 9 to 11) [ 17 , 18 , 20 , 21 , 24 , 26 , 28 , 29 , 31 , 33 – 35 ] and six were of medium quality (i.e., 5 to 8) [ 19 , 22 , 23 , 25 , 27 , 30 ]. One study scored 4 of 12 [ 32 ]. The low rating study [ 32 ] lacked relevant information to adequately score its methodological rigor. Most RCTs clearly described randomization, group equivalence at baseline, rates and reasons for attrition, study outcomes, and analysis. Blinding of outcomes assessors to treatment assignment was used and described in several RCTs [ 17 , 20 , 21 , 24 , 27 , 35 ], whereas blinding of those delivering treatment was discussed clearly in only one study [ 25 ]. The majority of the quasi-experimental studies were of high quality (i.e., 7 or higher), except two, which scored 2 of 9 [ 37 ] and 6 of 9 [ 39 ], respectively. Six of twelve quasi-experimental studies [ 36 , 41 – 44 , 47 ] had a comparison group to strengthen internal validity of causal inferences by comparing intervention and control groups. Some of these studies, however, noted differences in baseline assessments between groups [ 36 , 43 , 44 ]. Finally, one retrospective study [ 48 ] scored 11 of 11 and hence was rated as high quality.

https://doi.org/10.1371/journal.pone.0252747.t002

https://doi.org/10.1371/journal.pone.0252747.t003

https://doi.org/10.1371/journal.pone.0252747.t004

Characteristics of trauma-informed interventions

Type of intervention..

Table 5 details the trauma informed intervention characteristics included in this review. The two most frequently used interventions were eye movement desensitization and reprocessing (EMDR) [ 28 , 30 , 31 , 33 , 36 , 38 ]—a multi-phase intervention using bilateral stimulation, such as left-to-right eyes movements or hand tapping, to desensitize individuals to a traumatic memory or image—and trauma-focused cognitive behavioral therapy or cognitive behavioral therapy (CBT) [ 26 , 27 , 32 , 46 , 48 ]—a psychological approach to introduce emotional regulation and coping strategies (e.g., deep muscle relaxation, yoga, thought discovery and breathing techniques) to deal with negative feelings and behaviors surrounding a trauma of interest [ 32 , 48 ]. The implementation of CBT varied on the trauma of interest. Other studies implemented interventions using general trauma focused therapy [ 22 , 43 ], emotion focused therapy [ 23 , 25 ], stress reduction programs [ 17 ], cognitive processing therapy [ 24 ], brief electric psychotherapy [ 31 ], present focused group therapy [ 26 ], compassion focused therapy [ 44 ], prolonged exposure [ 45 ], stress inoculation training [ 45 ], psychodynamic therapy [ 45 ], and visual schema displacement therapy [ 30 ]. A number of studies included more than one of these therapies [ 13 , 26 , 30 , 31 , 33 , 36 , 45 ].

https://doi.org/10.1371/journal.pone.0252747.t005

Setting, scope, and delivery of intervention.

Twenty of the interventions were identified to occur in an outpatient clinic/setting [ 19 – 21 , 24 , 25 , 27 – 29 , 31 – 34 , 36 , 39 , 40 , 42 , 43 , 46 – 48 ]. Four of the studies took place in a research lab or office [ 23 , 26 , 41 , 45 ], one study occurred in the community [ 17 ], and one study implemented therapy in three locations, two of which were outpatient and one of which was a residential treatment center [ 47 ]. Lastly, one study occurred in internally displaced people’s camps within a metropolitan area in Haiti [ 37 ]. The remaining studies did not identify a specific setting [ 22 , 35 , 38 , 44 ].

The interventions ranged in length and time, but most often occurred weekly. The longest intervention was done by Lundqvist and colleagues [ 43 ], which lasted a total length of 2-years and included 46 sessions. Several other studies included 20 sessions or more [ 18 , 22 , 23 , 25 , 26 ]. The interventions were most commonly delivered by medical professionals, including but not limited to: psychologists or psychiatrists, therapists, social workers, mental health clinicians and physicians [ 16 , 17 , 20 – 29 , 33 , 36 , 38 , 39 , 41 , 44 – 47 ]. The articles frequently noted that the interventionists were masters-level-prepared or higher in their profession [ 21 , 23 , 25 – 27 , 33 , 40 , 47 ]. In addition to standard education and licensure, many of the professionals implementing the interventions were required to obtain further training in the therapy of interest [ 23 – 25 , 27 – 30 , 33 , 36 , 38 – 40 , 46 , 47 ]. Two studies were identified to be delivered by lay persons [ 34 , 37 ].

Fidelity was addressed in 16 of the included articles [ 16 , 19 , 21 , 23 , 24 , 26 – 30 , 33 – 35 , 45 – 47 ]. The manner in which fidelity was addressed varied by study. Videotaping or audiotaping therapy sessions [ 21 , 23 , 24 , 28 – 30 , 33 , 35 ] were most common, followed by deploying regular supervision of the therapy sessions [ 21 , 23 , 27 , 29 , 33 , 46 ], using a training manual or intervention protocols [ 19 , 21 , 33 , 46 ], or having individuals unaffiliated with the study or blind to the intervention rate sessions [ 21 , 26 , 28 , 35 ]. Additionally, three articles utilized fidelity checks/checklists to ensure components of the intervention were addressed [ 16 , 30 , 47 ] or had patients and/or therapists rate therapy sessions [ 26 , 34 , 45 ]. Finally, one study had quality assurance worksheets completed after each session that were later reviewed by the study coordinator [ 34 ].

Effects of trauma-informed interventions

Trauma-informed interventions were tested to improve several psychological outcomes, such as post-traumatic stress disorder (PTSD), depression, and anxiety. The most frequently assessed psychological outcome was PTSD, which was examined in 23 out of the 32 studies [ 17 , 20 – 27 , 31 , 33 , 35 – 39 , 41 , 42 , 44 – 48 ]. Among the studies that assessed PTSD as an outcome, 11 found significant reductions in PTSD symptoms and severity following the trauma-informed intervention [ 17 , 20 , 21 , 24 , 26 , 28 , 34 , 42 , 45 – 47 ], however, one of these studies, which utilized outpatient psychoeducation, did not find significant differences in reduction between the intervention and control group [ 20 ]. Trauma-informed interventions that were associated with a significant reduction in PTSD were a mindfulness-based stress reduction program [ 16 ], two therapies using the Trauma Recovery and Empowerment Model (TREM) [ 47 ], CBT [ 26 , 46 ], EMDR [ 28 ], general trauma-focused therapy [ 42 ], psychodynamic therapy [ 45 ], stress inoculation therapy [ 45 ], present-focused therapy [ 26 ], and cognitive processing therapy [ 24 ]. In addition, an intervention designed to reduce stress and improve HIV care engagement improved PTSD symptoms; however, this intervention was not intended to treat PTSD [ 34 ].

Other commonly assessed psychological symptoms, including depression and anxiety, were examined in 16 [ 17 – 21 , 24 – 26 , 29 , 31 , 32 , 35 , 40 , 44 , 47 , 48 ] and 10 [ 21 , 24 , 25 , 28 , 29 , 35 , 36 , 44 , 47 , 48 ] studies, respectively. Among these, trauma-informed interventions were associated with decreased or improved depressive symptoms in 9 studies [ 17 , 18 , 20 , 21 , 24 , 32 , 35 , 47 , 48 ] and decreased or improved anxiety in 5 studies [ 21 , 28 , 35 , 47 , 48 ]. For example, Vitriol and colleagues found that outpatient psychoeducation resulted in improved depressive symptoms in women with severe depression and childhood trauma [ 20 ]. Similarly, Kelly and colleagues found that female survivors of interpersonal violence experienced a significantly greater reduction of depressive symptoms in the intervention group (mindfulness-based stress reduction) compared to the control group [ 16 , 17 ]. Other therapies that resulted in improved depressive symptoms were TREM [ 47 ], prolonged exposure therapy [ 21 ], CBT [ 32 , 46 ], psychoeducational cognitive restructuring [ 35 ], and financial empowerment education [ 18 ]. Cognitive processing therapy similarly resulted in large reductions in depression symptoms, however this reduction was also observed in the control group [ 24 ]. The same studies showed that TREM [ 47 ], prolonged exposure therapy [ 21 ], CBT [ 48 ], and psychoeducational cognitive restructuring [ 35 ] were associated with improved anxiety. Lastly, in a separate study than the one highlighted above, EMDR was associated with improved anxiety [ 28 ].

A select number of the studies found associations between trauma-informed interventions and other psychological outcomes such as attachment anxiety, attachment avoidance, psychiatric symptoms or dental distress. For example, the trauma-informed mindfulness-based reduction program implemented by Kelly and colleagues was associated with a greater decrease in anxious attachment, measured by the Relationship Structures Questionnaire, compared to the waitlist group [ 17 ]. Similarly, Masin-Moyer and colleagues found that TREM and an attachment-informed TREM (ATREM) were associated with significant reductions in group attachment anxiety, group attachment avoidance, and psychological distress in women with a history of interpersonal trauma [ 47 ]. Additionally, individuals in an outpatient substance abuse treatment program, consisting of psychoeducational seminars and trauma-informed addiction treatment, experienced significantly better outcomes of psychiatric severity, measured by the Global Appraisal of Individual Needs scale, compared to a control treatment group [ 19 ]. Doering and colleagues found that EMDR, compared to the control group, was associated with significantly greater improvement in dental stress, anxiety and fear in patients with dental-phobia [ 28 ].

There was a series of interpersonal, emotional and behavioral outcomes assessed in the included studies. For example, adult females that were sexually abused in childhood experienced a significant improvement in social interaction and social adjustment after receiving trauma focused group therapy [ 43 ]. Similarly, Dalton and colleagues found that couples that received emotion focused therapy experienced a significant reduction in relationship distress [ 23 ] and MacIntosh and colleagues found that individuals that received CBT reported lower interpersonal problems post-treatment [ 46 ]. Trauma-based interventions were also associated with emotional outcomes. Visual schema displacement therapy and EMDR both were superior to the control treatment in reducing emotional disturbance and vividness of negative memories [ 30 ]. In a separate study, CBT was found to reduce levels of emotional dysregulation in individuals that experienced childhood sexual abuse [ 46 ]. Lastly, trauma-informed interventions were associated with behavioral outcomes, including HIV risk reduction [ 26 ], decreased days of alcohol use [ 27 ], and improvements in avoidance of client condom negotiations, frequency of sex trade under influence of drugs or alcohol, and use of intimate partner violence support [ 40 ]. Interventions that were associated with these behavioral outcomes included trauma focused and present focused group therapy [ 26 ], CBT [ 27 ], and a trauma-informed support, validation, and safety-promotion dialogue intervention [ 40 ].

Publication bias

We analyzed three sets of outcome variables for publication bias: PTSD, depression, and anxiety. Based on Begg and Mazumdar test, there was no evidence of publication bias for PTSD (z = 1.55, p = 0.121) and anxiety (z = 0.29, p = 0.769). However, there was some evidence of publication bias for depression (z = 5.19, p<.001). The statistically significant publication bias for depression appears to be mainly due to large effect sizes in Nixon [ 24 ] and Bowland [ 35 ].

According to our database search, this is the first systematic review to critically appraise trauma-informed interventions using a comprehensive definition of trauma. In particular, our definition encompassed both physical and psychological experiences resulting from various circumstances including chronic adversity. Overall, there was inconsistent evidence to suggest trauma informed interventions in addressing psychological outcomes. We found that trauma-informed interventions were effective in improving PTSD [ 17 , 20 , 21 , 24 , 26 , 28 , 34 , 42 , 45 – 47 ] and anxiety [ 21 , 28 , 35 , 47 , 48 ] in less than half of the studies where these outcomes were included. We also found that depression was improved in less than about two thirds of the studies where the outcome was included [ 17 , 18 , 20 , 21 , 24 , 32 , 35 , 47 , 48 ]. Although limited in the number of published studies included this review, available evidence consistently supported trauma-informed interventions in addressing interpersonal [ 23 , 43 , 46 ], emotional [ 30 , 46 ], and behavioral outcomes [ 26 , 27 , 40 ].

Effective trauma informed intervention models used in the studies varied, encompassing CBT, EMDR, or other cognitively oriented approaches such as mindfulness exercises [ 16 , 24 , 26 , 28 , 32 , 35 , 45 , 46 , 48 ]. In particular, CBT was noted as an effective trauma informed intervention strategy which successfully led to improvements in a wide range of outcomes such as depression [ 32 , 48 ], anxiety [ 48 ], emotional dysregulation [ 46 ], interpersonal problems [ 23 , 46 ], and risky behaviors (e.g., days of alcohol use) [ 27 ]. While the majority of the studies included in the review were focused on interpersonal trauma such as child abuse, sexual assault, or domestic violence [ 16 – 18 , 20 – 22 , 24 – 26 , 35 , 40 – 43 , 45 , 46 ], growing evidence demonstrates perceived discrimination and racism as significant psychological trauma and as underlying factors in inflammatory-based chronic diseases such as cardiovascular disease or diabetes [ 4 ]. Future trauma informed interventions should consider a wide-spectrum of trauma types, such as racism and discrimination, by which racial/ethnic minorities are disproportionately affected from [ 49 ].

While the majority of the trauma informed interventions were delivered by specialized medical professionals trained in the therapy [ 16 , 17 , 20 – 29 , 33 , 36 , 38 – 41 , 44 – 47 ], several of the articles lacked full descriptions of interventionist training and fidelity monitoring [ 20 , 22 , 25 , 36 , 38 – 41 , 44 ]. Two studies were identified to be delivered by lay persons [ 34 , 37 ]. There is sufficient evidence to suggest that lay persons, upon training, can successfully cover a wide scope of work and produce the full impact of community-based intervention approaches [ 50 ]. Given such, there is a strong need for trauma informed intervention studies to clearly elaborate the contents and processes of lay person training such as competency evaluation and supervision to optimize the use of this approach.

There are methodological issues to be taken into consideration when interpreting the findings in this review. While twenty-three of 32 studies were of high quality [ 17 , 18 , 20 , 21 , 24 , 26 , 28 , 29 , 31 , 33 – 36 , 38 , 40 – 48 ], some studies lacked methodological rigor, which might have led to false negative results (no effects of trauma informed interventions). For example, about one-third (31%) had a sample size less than 50 [ 17 , 23 – 25 , 27 , 28 , 35 , 38 , 43 , 45 ]. In addition, half of the quasi-experimental studies [ 37 – 40 , 45 , 46 ] did not have a comparison group or when they had one, group differences were noted in baseline assessments [ 36 , 43 , 44 ]. In several studies, therapists took on both traditional treatment and research responsibilities (e.g., delivery of the intervention) [ 20 , 25 , 29 , 32 , 33 , 36 , 40 , 46 , 47 ], yet blinding of those delivering treatment was discussed clearly in only one study [ 25 ]. This dual role is likely to have led to the disclosure of group allocation, hence, threatening the internal validity of the results. Future studies should address these issues by calculating proper sample size a priori, using a comparison group, and concealing group assignments.

Review limitations

Several limitations of this review should be noted. First, by using narrowly defined search terms, it is possible that we did not extract all relevant articles in the existing literature. However, to avoid this, we conducted a systematic electronic search using a comprehensive list of MeSH terms, as well as similar keywords, with consultation from an experienced health science librarian. Additionally, we hand searched our reference collections, Second, the trauma informed interventions included in this review were implemented to predominantly address trauma related to sexual or physical abuse among women. Thus, our findings may not be applicable to trauma related to other types of incidence such as chronic adversity (e.g., racism or discrimination). Likewise, there were insufficient studies addressing a wider range of trauma impacts such as emotion regulation, dissociation, revictimization, non-suicidal self-injury or suicidal attempts, or post-traumatic growth. Future research is warranted to address these broader impacts of trauma. We included only articles written in English; therefore, we limited the generalizability of the findings concerning studies published in non-English languages. Finally, we used arbitrary cutoff scores to categorize studies as low, medium, and high quality (quality ratings of 0-4, 5-8, and 9+ for RCTs and 0-3, 4-6, 7+ for quasi-experimental studies, respectively). Using this approach, each quality-rating item was equally weighted. However, certain factors (e.g., randomization method) may contribute to the study quality more so than others.

Our review of 33 articles shows that there is inconsistent evidence to support trauma informed interventions as an effective intervention approach for psychological outcomes (e.g., PTSD, depression, and anxiety). With growing evidence in health disparities, adopting trauma informed approaches is a growing trend. Our findings suggest the need for more rigorous and continued evaluations of the trauma informed intervention approach and for a wide range of trauma types and populations.

Supporting information

S1 checklist..

https://doi.org/10.1371/journal.pone.0252747.s001

S1 Appendix. Search strategies.

https://doi.org/10.1371/journal.pone.0252747.s002

Acknowledgments

We would like to express our appreciation to a medical librarian, Stella Seal for her assistance with article search. Both Kristen Trimble and Sotera Chow were students in the Masters Entry into Nursing program and Hailey Miller and Manka Nkimbeng were pre-doctoral fellows at The Johns Hopkins University when this work was initiated.

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• Open access
• Published: 07 August 2023

A scoping review of trauma informed approaches in acute, crisis, emergency, and residential mental health care

• Katherine R. K. Saunders 1 ,
• Elizabeth McGuinness 1 ,
• Phoebe Barnett 2 , 3 , 4 ,
• Una Foye 1 ,
• Jessica Sears 5 ,
• Sophie Carlisle 6 ,
• Felicity Allman 2 , 7 ,
• Vasiliki Tzouvara 8 ,
• Merle Schlief 2 ,
• Norha Vera San Juan 1 ,
• Ruth Stuart 1 ,
• Jessica Griffiths 1 ,
• Rebecca Appleton 2 ,
• Paul McCrone 9 , 10 ,
• Rachel Rowan Olive 11 , 12 ,
• Patrick Nyikavaranda 11 , 12 ,
• Tamar Jeynes 11 ,
• Lizzie Mitchell 11 ,
• Alan Simpson 1 , 7 ,
• Sonia Johnson 2 &
• Kylee Trevillion 1  

BMC Psychiatry volume  23 , Article number:  567 ( 2023 ) Cite this article

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Experiences of trauma in childhood and adulthood are highly prevalent among service users accessing acute, crisis, emergency, and residential mental health services. These settings, and restraint and seclusion practices used, can be extremely traumatic, leading to a growing awareness for the need for trauma informed care (TIC). The aim of TIC is to acknowledge the prevalence and impact of trauma and create a safe environment to prevent re-traumatisation. This scoping review maps the TIC approaches delivered in these settings and reports related service user and staff experiences and attitudes, staff wellbeing, and service use outcomes.

We searched seven databases (EMBASE; PsycINFO; MEDLINE; Web of Science; Social Policy and Practice; Maternity and Infant Care Database; Cochrane Library Trials Register) between 24/02/2022-10/03/2022, used backwards and forwards citation tracking, and consulted academic and lived experience experts, identifying 4244 potentially relevant studies. Thirty-one studies were included.

Most studies (n = 23) were conducted in the USA and were based in acute mental health services (n = 16). We identified few trials, limiting inferences that can be drawn from the findings. The Six Core Strategies (n = 7) and the Sanctuary Model (n = 6) were the most commonly reported approaches. Rates of restraint and seclusion reportedly decreased. Some service users reported feeling trusted and cared for, while staff reported feeling empathy for service users and having a greater understanding of trauma. Staff reported needing training to deliver TIC effectively.

TIC principles should be at the core of all mental health service delivery. Implementing TIC approaches may integrate best practice into mental health care, although significant time and financial resources are required to implement organisational change at scale. Most evidence is preliminary in nature, and confined to acute and residential services, with little evidence on community crisis or emergency services. Clinical and research developments should prioritise lived experience expertise in addressing these gaps.

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Introduction

The concept of providing ‘trauma informed care’ (TIC) in healthcare settings has developed in response to increasing recognition that potentially traumatic experiences throughout the life course are associated with subsequent psychological distress and a range of mental health problems [ 1 , 2 , 3 , 4 ]. ‘Trauma’ has no universally agreed definition. The Substance Abuse and Mental Health Services Administration (SAMHSA) defined trauma as ‘an event, series of events, or set of circumstances that is experienced by an individual as physically or emotionally harmful or life threatening and that has lasting adverse effects on the individual’s functioning and mental, physical, social, emotional, or spiritual well-being’ [ 5 ]. Traumatic experiences include physical, sexual and/or emotional abuse, neglect, exposure to violence or conflict, physical or mental illness (personal experience or that of a family member), and systemic or social traumas [ 6 , 7 ].

Individuals engaged with mental health services report high levels of childhood and adulthood trauma [ 2 , 8 , 9 , 10 ], and there is a high prevalence of trauma among service users in acute services, including among women [ 2 , 11 ], those with psychosis [ 12 , 13 ], and “personality disorder” diagnoses [ 14 ] (which is a particularly controversial diagnosis [ 15 ] as a result of the stigma associated with this diagnostic label and disparities in quality of care experienced [ 16 , 17 , 18 , 19 ]). Electronic health record evidence shows that service users with a history of abuse during childhood have more comorbidities and are more likely to have inpatient admissions versus service users without a similar history [ 20 ]. Similarly, among people with long-term mental health conditions, rates of childhood trauma and adversity are high, with both experiences theorised as aetiological factors for mental health conditions [ 21 , 22 , 23 ]. Staff in acute services are also affected by trauma experienced at work, which are highlighted as a source of stress and create a cycle of ‘reciprocal traumatisation’ [ 24 , 25 ].

Inpatient, crisis, emergency, and residential mental health care settings (typology of care categories adapted from an exploration of the range, accessibility, and quality of acute psychiatric services [ 26 ]) are used by service users experiencing severe mental health episodes. Such settings include acute wards, community crisis teams, psychiatry liaison teams within emergency departments, and mental health crisis houses. These settings can be experienced as destabilising and retraumatising as a result of compulsory detention under mental health legislation, e.g., the Mental Health Act in the UK [ 27 ] and routine staff procedures for managing the behaviour of distressed service users in inpatient settings, including seclusion and restraint [ 6 , 28 ]. These experiences can also constitute a traumatic experience in their own right [ 24 , 29 ]. Power imbalances in these settings can create abusive dynamics, as well as mirror previous abusive relationships and situations [ 6 ], engendering mistrust and creating a harmful environment.

In principle, TIC centres an understanding of the prevalence and impact of trauma, recognises trauma, responds comprehensively to trauma and takes steps to avoid re-traumatisation [ 5 ]. The TIC literature in healthcare is varied and lacks an agreed definition. However, Sweeney and Taggart (2018) [ 6 ], who both write from dual perspectives as researchers and trauma survivors, developed an adapted definition of TIC, [ 5 , 30 , 31 ] which we have used as a working definition throughout this scoping review as a result of its comprehensiveness. They define TIC as ‘a programme or organisational/system approach that: [i] understands and acknowledges the links between trauma and mental health, [ii] adopts a broad definition of trauma which recognises social trauma and the intersectionality of multiple traumas, [iii] undertakes sensitive enquiry into trauma experiences, [iv] refers individuals to evidence-based trauma-specific support, [v] addresses vicarious trauma and re-traumatisation, [vi] prioritises trustworthiness and transparency in communications, [vii] seeks to establish collaborative relationships with service users, [viii] adopts a strengths-based approach to care, [ix] prioritises emotional and physical safety of service users, [x] works in partnership with trauma survivors to design, deliver and evaluate services.’ This comprehensive definition includes elements covered by SAMSHA [ 32 ], the UK Office for Health Improvement & Disparities [ 33 ] and the NHS Education for Scotland (NES) Knowledge and Skills Framework for Psychological Trauma [ 34 ]. Understanding how experiences of trauma impact on individuals presenting in mental health services can support service users to feel heard, understood and able to cope or recover, and can support staff to have a greater understanding of the mental health difficulties and symptoms experienced by service users [ 6 , 31 , 35 ]. For TIC to be implemented, these tenets must be embedded within both formal and informal policy and practice [ 36 ], which can be challenging in these settings.

TIC within inpatient, crisis, emergency, and residential mental health care settings is newly established; there is no research mapping system-wide trauma informed approaches in these settings. The aim of this scoping review is to identify, map and explore the trauma informed approaches used in these settings, and to review impacts on and experiences of service users and staff. We also highlight gaps and variability in literature and service provision. TIC is a broad term, and it has been applied in numerous and varied ways in mental health care. In this review, we describe each application of TIC as a ‘trauma informed approach’.

This scoping review will answer the following primary research question:

What trauma informed approaches are used in acute, crisis, emergency, and residential mental health care?

Within each trauma informed approach identified, we will answer the following secondary research questions:

What is known about service user and carer expectations and experiences of TIC in acute, crisis, emergency, and residential mental health care?

How does TIC in acute, crisis, emergency, and residential mental health care impact on service user outcomes?

What is known about staff attitudes, expectations, and experiences of delivering TIC in acute, crisis, emergency, and residential mental health care?

How does TIC impact on staff practices and staff wellbeing in acute, crisis, emergency, and residential mental health care?

How does TIC in acute, crisis, emergency, and residential mental health care impact on service use and service costs, and what evidence exists about their cost-effectiveness?

Study design

This scoping review was conducted in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses Extension for Scoping Reviews (PRISMA-ScR [ 37 ]), using a framework for conducting scoping reviews [ 38 ]. The PRISMA-ScR checklist can be seen in Appendix 1. The protocol was registered with the Open Science Framework ahead of conducting the searches ( https://osf.io/2b5w7 ). The review was steered by a team including academic experts, clinical researchers, and experts by experience and/or profession, with lived experience researchers contributing to the development of the research questions, the data extraction form, the interpretation, and the manuscript draft.

Eligibility criteria

Service users, or people who support or care for service users, of any age (both adults and children), gender or sexuality, or staff members (of any gender and sexuality) were included.

We included studies that focused (or provided disaggregated data) on care delivered within acute, crisis, emergency settings, or residential mental health settings; acute and crisis settings include inpatient, community-based crisis, hospital emergency department, acute day units and crisis houses. Forensic mental health and substance use acute, crisis and inpatient settings were also included. We excluded studies from general population prison settings, where there is debate as to whether TIC can be delivered in carceral settings ( 39 ), and residential settings where the primary purpose of the setting was not to provide mental health or psychiatric care (e.g., foster care or residential schools).

Intervention

Trauma informed care interventions. Programmes aiming to reduce restrictive practices in psychiatric settings were not included without explicit reference to TIC within the programme.

We included studies reporting any positive and adverse individual-, interpersonal-, service- and/or system-level outcomes, including outcomes from the implementation, use or testing of TIC. Individual-level outcomes are related to service user or staff experiences, attitudes, and expectations; interpersonal outcomes occur because of interactions between staff and service users; service-level outcomes include TIC procedures that occur on an individual service level; and system-level outcomes refer to broader organisational outcomes related to TIC implementation. We included studies exploring service user, staff and carer expectations and experiences of TIC approaches.

Types of studies

We included qualitative, quantitative, or mixed-method research study designs. To map TIC provision, service descriptions, evaluations, audits, and case studies of individual service provision were also included. We excluded reviews, conference abstracts with no associated paper, protocols, editorials, policy briefings, books/book chapters, personal blogs/commentaries, and BSc and MSc theses. We included non-English studies that our team could translate (English, German, Spanish). Both peer-reviewed and grey literature sources were eligible.

Search strategy

A three-step search strategy was used. Firstly, we searched seven databases between 24/02/2022 and 10/03/2022: EMBASE; PsycINFO; MEDLINE; Web of Science; Social Policy and Practice; Maternity and Infant Care Database (formerly MIDIRS); Cochrane Library Trials Register. An example full search strategy can be seen in Appendix 2. Searches were also run in one electronic grey literature database (Social Care Online); two pre-print servers (medRxiv and PsyArXiv), and two PhD thesis websites (EThOS and DART). The search strategy used terms adapted from related reviews [ 40 , 41 , 42 , 43 , 44 , 45 , 46 , 47 , 48 , 49 ]. We added specific health economic search terms. No date or language limits were applied to searches. Secondly, forward citation searching was conducted using Web of Science for all studies meeting inclusion criteria. Reference lists of all included studies were checked for relevant studies. Finally, international experts, networks on TIC in mental health care, and lived experience networks were contacted to identify additional studies.

Study selection

All studies identified through database searches were independently title and abstract screened by KS, KT and NVSJ, with 20% double screened. All full texts of potentially relevant studies were double screened independently by KS and KT, with disagreements resolved through discussion. Screening was conducted using Covidence [ 50 ]. Studies identified through forwards and backwards citation searching and expert recommendation were screened by KS, EMG, and NVSJ.

Charting and organising the data

A data extraction form based on the research questions and potential outcomes was developed using Microsoft Excel and revised collaboratively with the working group. Information on the study design, research and analysis methods, population characteristics, mental health care setting, and TIC approach were extracted alongside data relating to our primary and secondary outcomes. The form was piloted on three included papers and relevant revisions made. Data extraction was completed by KS, EMG, VT, SC, and FA, with over 50% double extracted to check for accuracy by KS and EMG.

Data synthesis process

Data relevant for each research question was synthesised narratively by KS, EMG, JS, UF, VT, FA, and MS. Question 1 was grouped by approach and reported by setting. Where data was available, evidence for questions 2–6 was synthesised within each TIC approach.

Both quantitative and qualitative data were narratively synthesised together for each question. Areas of heterogeneity were considered throughout this process and highlighted. The categorisation and synthesis of the trauma informed approaches were discussed and validated by KS, EMG, JS, and KT.

The database search returned 4146 studies from which 2759 potentially relevant full-text studies were identified. Additional search methods identified 96 studies. Overall, 31 studies met inclusion criteria and were included in this review. The PRISMA diagram can be seen in Fig.  1 . Characteristics of all included studies are shown in Table  1 .

PRISMA diagram demonstrating the search strategy. From: Page MJ, McKenzie JE, Bossuyt PM, Boutron I, Hoffmann TC, Mulrow CD, et al. The PRISMA 2020 statement: an updated guideline for reporting systematic reviews. BMJ 2021;372:n71. doi: https://doi.org/10.1136/bmj.n71 . For more information, visit: http://www.prisma-statement.org/

Study characteristics

The models reported most commonly were the Six Core Strategies (n = 7) and the Sanctuary Model (n = 6). Most included studies were based in the USA (n = 23), followed by the UK (n = 5), Australia (n = 2), and Japan (n = 1). Most studies were undertaken in acute services (n = 16) and residential treatment services (n = 14), while one was undertaken in an NHS crisis house. Over a third of studies were based in child, adolescent, or youth mental health settings (n = 12), while six were based in women’s only services. See Table  1 for the characteristics of all included studies.

Twenty-one studies gave no information about how they defined ‘trauma’ within their models. Of the ten studies that did provide a definition, four [ 51 , 52 , 53 , 54 ] referred to definitions from a professional body [ 5 , 55 , 56 ]; three studies [ 57 , 58 , 59 ] used definitions from peer-reviewed papers or academic texts [ 60 , 61 , 62 , 63 ]; in two studies [ 64 , 65 ], authors created their own definitions of trauma; and in one study [ 66 ], the trauma definition was derived from the TIC model manual. See full definitions in Appendix 3. Some studies reported details on participants’ experiences of trauma, these are reported in Table  1 .

What trauma informed approaches are used in inpatient, crisis, emergency, and residential mental health care?

Thirty-one studies in twenty-seven different settings described the implementation of trauma informed approaches at an organisational level in inpatient, crisis, emergency, and residential settings. The different models illustrate that the implementation of trauma informed approaches is a dynamic and evolving process which can be adapted for a variety of contexts and settings.

Trauma informed approaches are described by model category and by setting. Child and adolescent only settings are reported separately. Full descriptions of the trauma informed approaches can be seen in Appendix 3. Summaries of results are presented; full results can be seen in Appendix 4.

Six Core Strategies

Seven studies conducted in four different settings implemented the Six Core Strategies model of TIC practice for inpatient care [ 51 , 59 , 65 , 67 , 68 , 69 , 70 ]. The Six Core Strategies were developed with the aim of reducing seclusion and restraint in a trauma informed way [ 71 ]. The underpinning theoretical framework for the Six Core Strategies is based on trauma-informed and strengths-based care with the focus on primary prevention principles.

Inpatient settings: child and adolescent services

Four studies using Six Core Strategies were conducted in two child and adolescent inpatient settings using pre/post study designs [ 59 , 67 , 68 , 69 ]. Hale (2020) [ 67 ] describes the entire process of implementing the intervention over a 6-month period and establishing a culture change by 12 months, while Azeem et al’s (2015) [ 69 ] service evaluation documents the process of implementing the six strategies on a paediatric ward in the USA over the course of ten years.

Inpatient settings: adult services

Two studies focused on the use of the Six Core Strategies in adult inpatient and acute settings [ 51 , 65 ]. One further study, Duxbury (2019) [ 70 ], adapted the Six Core Strategies for the UK context and developed ‘REsTRAIN YOURSELF’, described as a trauma informed, restraint reduction programme, which was implemented in a non-randomised controlled trial design across fourteen adult acute and inpatient wards in seven hospitals in the UK.

How does the Six Core Strategies in inpatient, crisis, emergency, and residential mental health care impact on service user outcomes?

Five studies, only one of which had a control group [ 70 ], reported a reduction in restraint and seclusion practices after the implementation of the Six Core Strategies [ 59 , 67 , 68 , 69 , 70 ]. Two studies [ 51 , 65 ] did not report restraint and seclusion data.

What is known about staff attitudes, expectations, and experiences of delivering the Six Core Strategies in inpatient, crisis, emergency, and residential mental health care?

Staff reported an increased sense of pride in their ability to help people with a background of trauma [ 59 ], which came with the skills and knowledge development provided [ 51 ]. Staff also showed greater empathy and respect towards service users [ 51 , 65 ].

Staff recognised the need for flexibility in implementing the Six Core Strategies, and felt equipped to do this; as a result they reported feeling more fulfilled as practitioners [ 51 ]. Staff shifted their perspectives on service users and improved connection with them by viewing them through a trauma lens [ 65 ]. Staff also reported improved team cohesion through the process of adopting the Six Core Strategies approach [ 51 ]. It was emphasised that to create a safe environment, role modelling by staff was required [ 65 ].

How does the Six Core Strategies impact on staff practices and staff wellbeing in inpatient, crisis, emergency, and residential mental health care?

Service users were reportedly more involved in their own care; they reviewed safety plans with staff, and were involved in their treatment planning, including decisions on medication [ 51 , 65 ]. Staff and service users also engaged in shared skill and knowledge building by sharing information, support, and resources on healthy coping, and trauma informed care generally [ 51 , 65 ]. Staff adapted their responses to service user distress and adopted new ways of managing risk and de-escalating without using coercive practices [ 51 , 59 ]. Finally, service user-staff relationships were cultivated through a culture of shared learning, understanding, and trust [ 65 ].

How does the Six Core Strategies in inpatient, crisis, emergency, and residential mental health care impact on service use and costs and what evidence exists about their cost-effectiveness?

One study reported a reduction in the duration of hospital admission [ 59 ], which was largely attributed to the reduction in the amount of documentation that staff had to complete following crisis interventions.

The Sanctuary Model

Six studies, referring to five different settings [ 57 , 58 , 72 , 73 , 74 , 75 ], employed the ‘Sanctuary Model’ [ 76 ] as a TIC model of clinical and organisational change. One further study [ 72 ] combined the ‘Sanctuary Model’ with ‘Seeking Safety’, an integrated treatment programme for substance misuse and trauma. All studies were conducted in child and adolescent residential emotional and behavioural health settings in the USA.

The Sanctuary Model is a ‘blueprint for clinical and organisational change which, at its core, promotes safety and recovery from adversity through the active creation of a trauma-informed community’ [ 76 ]. It was developed for adult trauma survivors in short term inpatient treatment settings and has formally been adapted for a variety of settings including adolescent residential treatment programmes. No studies explored the use of the Sanctuary Model as a TIC approach in adult inpatient or acute settings, and no studies specifically tested the efficacy of The Sanctuary Model in child and adolescent settings. Studies employing the Sanctuary Model used a range of designs including longitudinal, qualitative methods, service evaluations/descriptions and a non-randomised controlled design.

What is known about service user and carer expectations and experiences of the Sanctuary Model in acute, crisis and inpatient mental health care?

In a service description, Kramer (2016) [ 57 ] reported that service users experienced clear interpersonal boundaries with staff, facilitated by healthy attachments and organisational culture. Service users also experienced staff responses as less punitive and judgemental.

How does the Sanctuary Model in acute, crisis and inpatient mental health care impact on service user outcomes?

Kramer (2016) [ 57 ] described decreasing rates of absconscion, restraint, and removal of service users from the programme post-implementation of the Sanctuary Model, which the authors hypothesised was due to the safe environment, and the movement towards a culture of hope.

What is known about staff attitudes, expectations, and experiences of delivering the Sanctuary Model in acute, crisis and inpatient mental health care?

Staff received the Sanctuary Model positively [ 72 , 73 ] and it gave them a sense of hopefulness [ 75 ]. However, it was widely acknowledged that it was resource intensive for staff to implement TIC in practice and additional training may be needed [ 73 ].

Korchmaros et al. (2021) [ 72 ] reported that the Sanctuary Model components most likely to be adopted were those that staff found most intuitive, though staff generally did not believe the model was acceptable in its entirety for their clinical setting. As staff communication improved, so did physical safety for staff and service users, and team meeting quality [ 75 ]. Staff appreciated the improved safety – or perception of such – after implementing the Sanctuary Model [ 73 , 75 ].

Staff reported that the Sanctuary Model promoted a healthy organisational culture with a commitment to a culture of social responsibility, social learning [ 57 ] and mutual respect [ 73 ].

How does the Sanctuary Model impact on staff practices and staff wellbeing in acute, crisis and inpatient mental health care?

Following implementation, staff focused more on service user recovery through teaching service users adaptive ways of coping and encouraging empathy and compassion towards service users [ 58 , 73 , 75 ]. Staff reported a holistic and compassionate understanding of the associations between trauma, adversity and service user behaviour [ 73 ]. Staff also reported sharing more decisions with service users [ 73 ] and collaboratively involving service users in their treatment care, safety plans, and in the development of community rules [ 73 , 75 ]. Staff felt able to communicate information, ideas, and their mistakes more openly, and their ability to model healthy relationships was seen as a fundamental to treatment [ 75 ].

How does the Sanctuary Model in acute, crisis and inpatient mental health care impact on service use and costs and what evidence exists about their cost-effectiveness?

One study reported a reduction in staff compensation claims due to a reduction in harms from physical interventions [ 72 ].

Comprehensive tailored trauma informed model

We categorised eight models [ 52 , 53 , 77 , 78 , 79 , 80 , 81 , 82 ] as ‘comprehensive tailored TIC models’. This reflects models that are holistic and multi-faceted, but do not closely follow an established TIC intervention model or blueprint and have instead been developed locally or to specifically complement the needs of a specific setting.

Residential settings: child and adolescent services

Three studies describe comprehensive tailored trauma informed models in child and adolescent residential treatment settings [ 77 , 78 , 79 ]. At an organisational level, key features of the tailored approaches include whole staff training using a trauma informed curriculum [ 77 , 78 , 79 ], creating a supportive, therapeutic environment and sense of community, using a family-centred approach, structured programmes of psychoeducational, social and skills groups [ 77 , 79 ] and collaborative working across different agencies [ 78 , 79 ].

Residential settings: adult women-only substance misuse service

Three studies [ 53 , 80 , 81 ] describe a gender-specific trauma informed treatment approach in a female only environment. Key components include providing training for all staff on trauma and trauma informed approaches, team support and supervision from a trained trauma therapist, social and life skills groups [ 53 ]; individual therapy and family support programme [ 81 ]; trauma informed group therapies and psychoeducation [ 53 , 80 ]; the implementation of a ‘gender specific, strengths based, non-confrontational, safe nurturing environment’ and strategic level meetings to identify structural barriers and gaps across different agencies [ 80 ]. Zweben et al. (2017) [ 81 ] focused specifically on family-centred treatment for women with severe drug and alcohol problems.

Inpatient settings: adults and children/adolescents

The ‘Patient Focussed Intervention Model’ [ 82 ] was implemented in a variety of settings including residential child and adolescent, adult acute and adult longer term inpatient stays. This model was developed using a collaborative process with involvement from service users, staff, administrators, and external collaborators with continuous quality improvement. The model incorporated (i) an individual TIC treatment model, which emphasised a patient-centred approach to building a culture and environment which is soothing and healing (e.g., by making changes to the physical environment and providing animal assisted therapy), (ii) the Sorensen and Wilder Associates (SWA) aggression management program [ 83 ] and (iii) staff debriefing after incidents of aggression.

Inpatient settings: women-only forensic service

Stamatopoulou (2019) [ 52 ] used qualitative research methods to explore the process of transitioning to a TIC model in a female forensic mental health unit [ 52 ] using the ‘trauma informed organisational change model’ [ 84 ]. Components included (i) staff training on trauma-informed care, (ii) co-produced safety planning through five sessions of Cognitive Analytic Therapy [ 85 ], (iii) a daily ‘Trauma Champion’ role for staff, and (iv) reflective practice groups for staff and service users.

What is known about service user and carer expectations and experiences of comprehensive tailored trauma informed models in inpatient, crisis, emergency, and residential mental health care?

In a study by Tompkins & Neale (2018) [ 53 ], service users reported being unaware that the service they were attending was trauma informed and were therefore not anticipating being encouraged to confront and reflect on their traumas [ 53 ]. However, the daily structure and routine timetable created a secure environment for their treatment experience. Service users who remained engaged with the service felt cared for by staff, and that the homely atmosphere in the service supported them to feel secure.

How do comprehensive tailored trauma informed models in inpatient, crisis, emergency, and residential mental health care impact on service user outcomes?

Three studies reported data on seclusion and restraints; all indicated a decrease [ 78 , 81 , 82 ]. Brown et al. (2013) [ 78 ] quantitatively reported reductions in the use of both seclusion and restraint in the year following Trauma Systems Therapy implementation, and the reduction in use of physical restraints was significant and sustained over the following eight years. Goetz et al. (2012) [ 82 ] also quantitatively reported that seclusion and restraint rates halved following implementation of the Patient Focused Intervention Model, as well as reductions in: (i) staff injuries, (ii) hours in seclusion and restraint and (iii) the number of aggressive patient events. However, while the number of seclusion room placements was lower, the average number of restraints among children and young people was higher in TIC compared to usual care.

Using a pre-post design, Zweben et al. (2017) [ 81 ] reported that service users receiving TIC reported fewer psychological and emotional problems after a month, compared to on entry to the programme, as well as reduced drug and alcohol misuse. Service user average length of stay was higher among those in the programme, compared to those not enrolled. Finally, as court and protective services became aware of the service users’ improvements, reunifications with children approached 100%.

What is known about staff attitudes, expectations, and experiences of delivering comprehensive tailored trauma informed models in inpatient, crisis, emergency, and residential mental health care?

Two papers reported on staff attitudes and experiences [ 52 , 53 ]. Some staff experienced introduction of TIC as overwhelming, leaving them unsure about what was expected from them throughout the training and implementation process, and that it might have been more successful had it been implemented in stages [ 52 ]. Some staff also felt unsure of what TIC entailed even after training, and it took time for staff to feel competent and confident [ 53 ]. Staff who had the least awareness of TIC experienced the greatest change anxiety when they were told of its implementation. When there were conflicting views within the team, the consistency of implementation was reduced [ 52 ]. Conversely, however, staff reported a sense of achievement in having implemented TIC and consequently an increased sense of job satisfaction.

Staff reported that their own traumatic experiences can inform the way they communicate and react to situations in the clinical environment, and they needed help to set boundaries and avoid emotional over involvement [ 53 ]. Implementing TIC broke down barriers between their private and professional selves, and there was an increased awareness of the personal impact of their work.

How do comprehensive tailored trauma informed models impact on staff practices and staff wellbeing in inpatient, crisis, emergency, and residential mental health care?

Stamatopoulou (2019) [ 52 ] reported that with the introduction of TIC, staff moved away from a solely diagnosis-based understanding of distress and developed an ability to formulate connections between service users’ backgrounds and their clinical presentations. As a result, staff showed empathy and respect towards service users and approached sensitive situations with service users more mindfully. Staff adopted new ways of managing risk [ 52 ] and service users were collaboratively involved in the development of treatment care plans [ 53 ]. Goetz et al. (2012) [82] also reported reduced staff injuries in the first year after implementing TIC.

There was an increased focus on staff wellbeing as well as greater awareness of staff personal boundaries and experiences of trauma and adversity, which led to staff feeling as though they had more in common with service users than expected [ 52 ]. Staff also discussed the importance of protecting their wellbeing by maintaining personal and professional boundaries, practicing mindfulness, and attending mutual aid groups [ 53 ].

Wider group relationships were reportedly redefined, and the impact of the work on staff wellbeing was acknowledged, specifically the ways in which staff’s own trauma informed their reactions to incidents on the ward [ 52 ]. Staff reported a greater sense of team connectedness, and that their individual professional identities were reconstructed.

How do comprehensive tailored trauma informed models in inpatient, crisis, emergency and residential mental health care impact on service use and costs and what evidence exists about their cost-effectiveness?

Staff had concerns over the sustainability of the model, especially in an organisation that could not offer the time or money required for service development [ 52 ]. Fidelity to a model varied depending on which staff were working; for instance, when agency staff or new joiners were working, fidelity was low and crisis incidents increased.

Adolescents in residential treatment receiving TIC spent significantly less time in treatment compared to those receiving traditional treatment, with the receipt of trauma informed psychiatric residential treatment (TI-PRT) accounting for 25% of the variance in length of stay [ 77 ]. Similarly, authors observed reduced length of hospital admissions after the introduction of their TIC approach [ 79 ].

Safety focused tailored trauma informed models

Two studies [ 86 , 87 ] tailored their own trauma-informed approach to create a culture of safety and (i) reduce restrictive practices and (ii) staff injuries. A third study [ 88 ] utilised a Trauma and Self Injury (TASI) programme, which was developed in the National High Secure Service for Women.

Inpatient settings: adults and child/adolescent services

Blair et al. (2017) [ 86 ] conducted a pilot trauma informed intervention study with the aim of reducing seclusions and restraints in a psychiatric inpatient hospital facility. Intervention components included the use of Broset Violence Checklist (BVC) [ 89 , 90 , 91 ]; 8-hour staff training in crisis intervention; two-day training in “Risking Connections” [ 92 ]; formal reviewing of restraint and seclusion incidents; environmental enhancements; and individualised plans for service users.

Borckardt et al. (2011) [ 87 ] reported a ‘trauma informed care engagement model’ to reduce restraint and seclusion across five various inpatient units (acute, child and adolescent, geriatric, general and a substance misuse unit). The intervention components included TIC training, changes in rules and language to be more trauma sensitive, patient involvement in treatment planning and physical changes to the environment.

Jones (2021) [ 88 ] reported the TASI programme in a high security women’s inpatient hospital, which aimed to manage trauma and self-injury with a view to reducing life threatening risks to service users and staff. The programme: (i) promotes understanding of trauma through staff training, staff support and supervision on the wards, (ii) provides psychoeducation and wellbeing groups for service users, (iii) focuses on the improvement of the therapeutic environment, (iv) promotes service users’ ability to cope with their distress, and (v) provides individual and group therapy.

What is known about service user and carer expectations and experiences of safety focused tailored trauma informed models in inpatient, crisis, emergency, and residential mental health care?

In Jones (2021) [ 88 ], some women reported feeling initially overwhelmed by and underprepared to acknowledge and work on their trauma experiences, and sometimes felt their distress was misunderstood by the nurses in their setting, which could lead to an escalation [ 88 ]. Service users felt connected to themselves, to feel safe and contained, particularly in comparison to previous inpatient experiences. Overall, however, the service did not make the women feel as though their problems were fully understood.

How do safety-focused tailored trauma informed models in inpatient, crisis, emergency, and residential mental health care impact on service user outcomes?

Reductions in the number of seclusions and restraint were reported [ 86 , 87 ]. Specifically, the trauma informed change to the physical therapeutic environment was associated with a reduction in the number of both seclusion and restraint [ 87 ]. The duration of restraints reportedly increased, while duration of seclusion decreased [ 86 ].

What is known about staff attitudes, expectations, and experiences of delivering safety focused tailored trauma informed models in inpatient, crisis, emergency, and residential mental health care?

In Jones (2021) [ 88 ], nurses emphasised that shared understanding and trust were instrumental in connecting and communicating with the women in their service [ 88 ]. Nurses also cultivated service user-staff therapeutic relationships, which they experienced as intensely emotional. The nurses reported becoming more critical of other staff members they perceived as lacking compassion towards the service users. Finally, staff felt that a barrier to the nurse-service user relationship was the staff’s inability to share personal information and vulnerability back to the service user.

How do safety focused tailored trauma informed models impact on staff practices and staff wellbeing in inpatient, crisis, emergency, and residential mental health care?

Staff developed new tools and adapted their responses to trauma and distress, and service users were also involved in some, but not all, staff training [ 88 ]. There were changes to information sharing practices [ 52 ]; information on service users’ history and intervention plans were more openly shared within the team to ensure all staff had the same information and did not need to risk re-traumatising service users by asking for information again. Service users also reported being more involved in their treatment planning [ 51 , 87 ] and medication decisions [ 65 ].

Trauma informed training intervention

Three studies focused on trauma informed training interventions for staff [ 66 , 93 , 94 ]. All studies used a pre/post design to evaluate effectiveness.

Gonshak (2011) [ 66 ] reported on a specific trauma informed training programme called Risking Connections [ 92 ] implemented in a residential treatment centre for children with ‘severe emotional disabilities’. Risking Connections is a training curriculum for working with survivors of childhood abuse and includes (i) an overarching theoretical framework to guide work with trauma and abuse (ii) specific intervention techniques (iii) a focus on the needs of trauma workers as well as those of their clients.

Niimura (2019) [ 93 ] reported a 1-day TIC training intervention, covering items including the definition of trauma, evidence on trauma and behavioural, social, and emotional responses to traumatic events, on attitudes of staff in a psychiatric hospital setting. Aremu (2018) [ 94 ] reported a training intervention to improve staff engagement which they identified as a key component of TIC. The intervention was a 2-hour training on engaging with patients, however the specific content of the training is not specified.

What is known about staff attitudes, expectations, and experiences of delivering trauma informed training interventions in inpatient, crisis, emergency, and residential mental health care?

Following training, half of staff reported feeling their skills or experience were too limited to implement changes and also that staff experienced difficulties when trying to share the principles of trauma informed care with untrained staff [ 93 ]. However, TIC training did produce positive attitude shifts towards TIC.

How do trauma informed training interventions impact on staff practices and staff wellbeing in inpatient, crisis, emergency, and residential mental health care?

Staff modified their communication with service users by altering their tone and volume, and adopted new ways of managing risk without using coercive practices [ 93 ]. There was also a reported a reduction in the use of as-needed medication [ 94 ].

How do trauma informed training interventions in inpatient, crisis, emergency, and residential mental health care impact on service use and costs and what evidence exists about their cost-effectiveness?

One study reported that educating staff about TIC in residential settings was time intensive and may require frequent or intense “booster” sessions following the initial training [ 66 ]. In terms of evaluation, it took time to implement TIC in the residential setting and then to collect related outcome data.

Other TIC models

This category reports studies which have made attempts to shift the culture towards trauma-informed approaches but have not made full-scale clinical and organisational changes to deliver a comprehensive trauma informed model [ 28 , 54 , 64 , 95 ].

Isobel and Edwards’ (2017) [ 64 ] case study on an Australian inpatient acute ward described TIC ‘as a nursing model of care in acute inpatient care’. This intervention was specifically targeted at nurses working on acute inpatient units but did not involve members of the multi-disciplinary team.

Beckett (2017) [ 95 ] conducted a TIC improvement project on an acute inpatient ward (which primarily received admissions through the hospital emergency department) using workforce development and a participatory methodology. Staff devised workshops on trauma informed approaches, through which six key practice areas were identified for improvement by the staff team.

Jacobowitz et al. (2015) [ 54 ] conducted a cross-sectional study in acute psychiatric inpatient wards to assess the association between TIC meetings and staff PTSD symptoms, resilience to stress, and compassion fatigue. Neither the content nor the structure of the ‘trauma informed care meetings’ were described in further detail.

Crisis house setting

Prytherch, Cooke & March’s (2020) [ 28 ] qualitative study of a ‘trauma informed crisis house’, based in the UK, gives a partial description of how trauma informed approaches were embedded in the service delivery and design.

What is known about service user and carer expectations and experiences of other TIC models in inpatient, crisis, emergency, and residential mental health care?

Prytherch, Cooke and March (2020) [ 28 ] reported that their TIC model created a positive experience for service users by making them feel worthwhile, respected and heard by staff [ 28 ]. Service users valued being trusted by staff, for example, to have their own room keys and to maintain their social and occupational roles, which were a key source of self-worth. While service user experiences were often positive, they found being asked directly about trauma challenging. This was invalidating for those who did not initially identify as having experienced trauma. Some service users also felt the TIC programme could only support them so far, as it did not incorporate or address wider societal injustices, such as issues related to housing and benefits, that can contribute to and exacerbate distress.

How do other TIC models in inpatient, crisis, emergency, and residential mental health care impact on service user outcomes?

Beckett et al. (2017) [ 95 ] reported that in the three years after the TIC workshops, rates of seclusion dropped by 80%, as did the length of time spent in seclusion, with most seclusions lasting less than an hour.

What is known about staff attitudes, expectations, and experiences of delivering other TIC models in inpatient, crisis, emergency, and residential mental health care?

Staff found an increased sense of confidence and motivation in managing emotional distress and behavioural disturbance [ 95 ]. Staff also showed increased respect, understanding and compassion towards service users.

Similarly, staff expressed hope for improved care in future, on the basis that they were better skilled to deliver care that was consistent and cohesive, while also being individual and flexible [ 64 ]. They reported a need for clarity and consistency in their role expectations and felt that changes in practice needed to be introduced slowly and framed positively. Conversely, others felt the changes introduced were too minimal to be significant and did not much vary from existing practice. Some staff expressed a fear of reduced safety that could follow changes to longstanding practice. Ambivalence to change stemmed from different degrees of understanding of TIC among staff, and others felt personally criticised by the newly introduced approach, specifically that their previous practice had been labelled traumatising.

How do other TIC models impact on staff practices and staff wellbeing in inpatient, crisis, emergency, and residential mental health care?

Some staff modified their communication with service users, e.g., reducing clinical jargon and focusing on the strengths of the service users [ 95 ]. Regular opportunities for service users and staff to discuss and reflect on information, concerns, and experiences were established. Staff received training in physical safety and de-escalation procedures; subsequently, the need for security staff on the ward decreased. Finally, in terms of staff wellbeing, staff PTSD symptoms increased with an increase in signs of burnout and length of time between attending trauma-informed care meetings [ 54 ].

Key findings

TIC approaches implemented in acute, crisis, emergency, and residential mental health settings were broad and varied. Studies that utilised either the Six Core Strategies model [ 71 ] or the Sanctuary Model [ 76 ] followed a clear structure to enact organisation and clinical change. Other studies implemented TIC models tailored to their specific settings, some with a particular emphasis on improving safety. The value of staff training was highlighted across studies, but the content of training was often described in limited detail, making it difficult to draw inferences around its comprehensiveness. Two principles from Sweeney and Taggart (2018) [ 6 ] that were often underrepresented in the TIC models were (i) recognising social traumas and the intersectionality of multiple traumas and (ii) working in partnership with trauma survivors to design, deliver and evaluate services. This indicates missed opportunities to use lived experience to develop services. Trauma itself was poorly defined, raising the question of whether TIC implementation can be truly meaningful without a clear framework of what trauma itself entails.

Service users were able to engage with their traumatic experiences and the implementation of TIC practice improved their ability to communicate their traumas. However, it is important to highlight that service users should not be required to share their experiences of trauma. The focus of TIC approaches in relation to empowering service users should also extend to giving them autonomy over when and how they disclose their traumatic experiences to staff [ 96 ]. While service users felt cared for, trusting, and trusted by staff working in TIC services, some distressing elements of service user experiences were not reflected in the TIC materials e.g., lack of access to housing or benefits, indicating a need for closer adaptation of TIC to the needs of service user populations.

Staff initially felt overwhelmed, anxious, criticised, and even reluctant at the introduction of TIC, though TIC positively influenced staff empathy, compassion, and wellbeing. Staff required time to build their skills and confidence, which once developed, led to pride and satisfaction in their roles. There were potential implications of delivering TIC for staff with histories of trauma also, e.g., providing staff with support and supervision to process those experiences. Future research could explore how trauma informed changes impact on staff turnover, a key concern in providing consistent care in inpatient and residential care settings.

Reductions in restraint and seclusion were observed, although the quality of evidence is limited as most studies are pre/post designs and lacked a comparison group. However, a broader question remains around whether services that continue to use restraint and seclusion (even in a reduced capacity) can be considered trauma informed.

There was a lack of economic evidence available, which highlights an area for future research. If TIC reduces rates of seclusion and restraint, reduces length of stays, as well as creates a more therapeutic environment (as reported in this review), this may have a positive economic impact, as conflict is costly [ 97 ] and patient satisfaction is associated with reduced costs [ 98 ]. There was also a lack of data on carers, perhaps due to our focus on specific settings, and very little evidence on hospital emergency departments (where care may be experienced as traumatising [ 99 ]), and on community-based crisis assessment services, home treatment, or acute day units, which future research could investigate.

Strengths and limitations

Our broad literature search retrieved evidence on TIC approaches in a variety of mental health settings. However, by nature of reviewing existing academic and grey literature, we are behind the curve of survivor thought and experience of TIC implementation. For example, information on the potential harms of poorly implemented TIC has been documented by people with lived experience [ 100 ], such as feeling required or coerced to confront their traumatic experiences. There was heterogeneity in the reporting of outcome measures across studies, limiting the generalisability of our conclusions. There was more data on residential mental health care settings compared to other settings, mirroring other review findings [ 101 ]; this may be due to their longer-term nature, which may be more amenable to the implementation and evaluation of TIC. This limits our understanding of TIC implementation and outcomes in other settings.

Although scoping review methodology does not require a quality assessment process, we noted significant methodological weaknesses across the included studies; they were primarily cross sectional, with few employing a control group or a randomised design, limiting our ability to draw causal conclusions about the impacts of TIC. Given the nature of this topic, particularly around mental healthcare reform, it is likely that work published in this area is subject to a range of potential biases that we were not able to examine in this study.

Implications for policy

A central tenet of TIC is empathy and understanding of the role of trauma in shaping mental health outcomes, which are positioned as being at the core of how mental health services can best support service users. Arguably, these principles should be a basic requirement of all mental health services, whether labelled as trauma informed or not. Introducing TIC into services may be a method by which basic practices can be integrated and maintained in a structured way [ 6 ]. This requires system-level change, which may be both time and financially resource intensive depending on, for example, the size of the organisation and staff, the time needed to design and provide training, and the policies and procedures which require revising. In theory, the introduction of TIC may challenge pre-existing clinical hierarchies through increased control and autonomy offered to service users and front-line staff, and so buy-in [ 58 ] and positive role modelling [ 65 ] from senior leaders within the service is vital for successful implementation.

Implications for practice

Delivering TIC in inpatient and residential settings requires clear and decisive leadership as well as clear staff roles [ 36 ]. In addition, TIC needs to be implemented, reviewed and evaluated collaboratively with service users to ensure it is delivering safe and appropriate care, otherwise services may continue to cause significant harm [ 100 ]. TIC could be included in pre-registration education across healthcare professions [ 102 , 103 ] and new starters may benefit from training as part of their inductions. Consistent staff supervision also supports the effective delivery of TIC [ 104 ]. These requirements result in a sustainability challenge as the creation and delivery of training is resource intensive, and staff turnover rates are high [ 105 ]. Clinicians should be aware of the intersection between trauma experiences, mental health, and social disadvantage, and the practical role that they may play at this intersection (e.g., providing supporting letters for housing or benefits). Clinical staff should also understand that issues relating to housing and welfare benefits, for example, can exacerbate mental health problems and responses to previous traumas, or even constitute traumatic experiences themselves [ 106 , 107 ]. Finally, clinicians should be conscious not to cause further harm through the delivery of TIC [ 100 ]; confronting and dealing with trauma should always be the choice of the service user, and receipt of TIC should not be dependent on service user willingness to engage with their traumatic experiences.

Implications for future research

We have identified significant evidence gaps around TIC implementation in non-inpatient acute care, including emergency, crisis teams, crisis houses, and acute day hospitals. Most evidence is concentrated within the USA, and there is a paucity of data on TIC elsewhere. Very few studies included control or comparison groups, crucially limiting our ability to determine the nature and strength of change due to TIC. With the development of other approaches to improving inpatient care, for example, Safewards [ 108 ], robust research methodologies must clarify the specific advantages of TIC. Future primary research could explore implementation of TIC in emergency and crisis mental health care settings, where it may be more difficult to implement a consistent and sustainable TIC approach as service users are engaged for shorter time periods. Future research could also consider the potential negative and harmful impacts of TIC. The present study could be extended to map the use of TIC in forensic settings, where poor mental health and experiences of trauma are also highly prevalent.

This scoping review has demonstrated the range of TIC approaches used in acute, crisis, and residential settings as well as a range of outcomes relating to service users and staff experiences, attitudes, and practises. TIC implementation requires commitment and strong leadership to enact organisational change, as well as appropriate training and supervision for staff and the involvement of service users in the design and delivery of approaches. Future research requires robust methods to accurately measure the impacts of TIC approaches and their potential benefits over existing care practices, through the utilisation of comparator conditions to TIC models. Research would also benefit from exploring how TIC impacts on carers; how trauma is understood in emergency services (settings that are frequently used by trauma survivors); and prioritising the expertise and views of those with lived experience with respect to how best to deliver TIC across mental health services.

Lived experience commentary

Written by LM and RRO.

As survivors of trauma from both within and outside mental health services, we welcome approaches which recognise its importance, and are pleased to see the range of perspectives which have been studied. We hope future research can engage with more work from outside the global north, which dominates in this paper.

However, from reading this literature, we do not know whether as patients we could always distinguish a trauma-informed service from any other - particularly given implementation challenges described in services with high levels of inconsistency, agency staff, new starters, and/or staff scepticism. At times trauma-informed care seems to be a means to an end which should already be universal, i.e., treating service users with respect and supporting our autonomy.

It does not particularly matter to us whether a service is trauma-informed on paper if the support staff change day by day and cannot or will not put the theory into practice. Nor does it matter that staff believe themselves to be validating our trauma, if they also retain power: if we can be physically held down; if the versions of ourselves written in their notes overwrite our autobiographies; if we have to surrender control of our most painful experiences in exchange for care. We have experienced some of these; we have heard about others happening to our peers, sometimes in the name of TIC (e.g. https://www.psychiatryisdrivingmemad.co.uk/post/trauma-informed-care-left-me-more-traumatised-than-ever ).

We welcome several studies showing reductions in restraint in trauma-informed environments (although note that this was not a universal finding). But we question whether a system founded on such violence can be anything other than traumatising in its own right. A version of TIC implemented in an under-resourced, fundamentally carceral system carries all the risks of harm associated with that system - with the added gaslighting of framing it as trauma-informed harm. As such, everyone involved in providing care they view as trauma-informed should consider what power over our stories and our bodies they are willing and able to give back.

Data availability

Data sharing is not applicable to this article as no datasets were generated or analysed during the current study.

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Acknowledgements

We would like to thank the NIHR LEWG for their contributions to this project, including researcher T.K. We would like to acknowledge the academic and lived experience experts who shared resources with us, and recommended papers for inclusion.

This paper presents independent research commissioned and funded by the National Institute for Health Research (NIHR) Policy Research Programme, conducted by the NIHR Policy Research Unit (PRU) in Mental Health. The views expressed are those of the authors and not necessarily those of the NIHR, the Department of Health and Social Care or its arm’s length bodies, or other government departments. JS was funded by an NIHR pre-doctoral clinical academic fellowship (2021–2022) and by the Psychiatry Research Trust in partnership with KCL (2022–2023).

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Formulating the research question(s): SJ, KT, AS, KS, PB, PM, NVSJ, RS, RRO, TJ, PN, TK, LM. Designing the study: SJ, KT, AS, KS, PB, PM, NVSJ, RS, LM, RRO, TJ, PN, TK. Conducting the study (including analysis): KS, KT, EM, JS, UF, FA, PB, SC, VT, MS, NVSJ, JG. Writing and revising the paper: KS, KT, SJ, AS, EM, JS, RS, UF, PB, SC, VT, MS, NVSJ, RA, JG, RRO.

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Saunders, K.R.K., McGuinness, E., Barnett, P. et al. A scoping review of trauma informed approaches in acute, crisis, emergency, and residential mental health care. BMC Psychiatry 23 , 567 (2023). https://doi.org/10.1186/s12888-023-05016-z

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Barriers and enablers for the implementation of trauma-informed care in healthcare settings: a systematic review

• Yan Huo 1 ,
• Leah Couzner 1 ,
• Tim Windsor 1 ,
• Kate Laver 2 ,
• Nadeeka N. Dissanayaka 3 , 4 , 5 &
• Monica Cations   ORCID: orcid.org/0000-0002-9262-0463 1  

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Healthcare services can be re-traumatising for trauma survivors where they trigger memories of past distressing events and exert limits to a survivor’s sense of autonomy, choice, and control. The benefits of receiving trauma-informed healthcare are well established; however, factors that promote or impede the implementation of trauma-informed care are not yet well characterised and understood.

The aim of this review was to systematically identify and synthesise evidence regarding factors that promote or reduce the implementation of TIC in healthcare settings.

This systematic review followed the Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) 2.0 guidelines. Scopus, MEDLINE, Proquest, PsycINFO and grey literature were searched for original research or evaluations published between January 2000 and April 2021 reporting barriers and/or facilitating factors for the implementation of trauma-informed care in a healthcare setting. Two reviewers independently assessed the quality of each included study using the Mixed Methods Appraisal Tool (MMAT) Checklist.

Twenty-seven studies were included, 22 of which were published in the USA. Implementation occurred in a range of health settings, predominantly mental health services. The barriers and facilitators of implementing trauma-informed care were categorised as follows: intervention characteristics (perceived relevance of trauma-informed care to the health setting and target population), influences external to the organisation (e.g. interagency collaboration or the actions of other agencies) and influences within the organisation in which implementation occurred (e.g. leadership engagement, financial and staffing resources and policy and procedure changes that promote flexibility in protocols). Other factors related to the implementation processes (e.g. flexible and accessible training, service user feedback and the collection and review of initiative outcomes) and finally the characteristics of individuals within the service or system such as a resistance to change.

Conclusions

This review identifies key factors that should be targeted to promote trauma-informed care implementation. Continued research will be helpful for characterising what trauma-informed care looks like when it is delivered well, and providing validated frameworks to promote organisational uptake for the benefit of trauma survivors.

Registration

The protocol for this review was registered on the PROSPERO database (CRD42021242891).

Peer Review reports

Contributions to the literature

The impacts of psychological trauma have important implications for the provision and receipt of healthcare.

This systematic review identifies key factors that should be targeted to promote trauma-informed care implementation, including interagency collaboration, staff and leadership buy-in, aligning implementation strategies with existing policies and procedures, allocation of adequate human and financial resources, flexibility in organisational policies and procedures, ongoing and tailored training, participatory co-design, and the collection and monitoring of data.

Identifying factors that influence implementation success across trauma-informed care initiatives can help to inform the selection of implementation strategies and planning.

Up to 70% of the population will experience exposure to one or more psychologically traumatic event in their lifetime [ 1 ]. Psychologically traumatic events are those events perceived by the individual as threatening to their safety and/or overwhelming to their ability to understand and make sense of the experience [ 2 ]. While most people will recover from traumatic stress, exposure to these events can have lasting adverse effects including reduced quality of life and risk for psychological disorders, non-suicidal self-injury, and suicide [ 3 , 4 ].

The impacts of psychological trauma on interpersonal skills, perception, problem-solving, and other core abilities and experiences have important implications for the provision and receipt of healthcare. Healthcare services can present risk for re-traumatisation where they trigger memories of past distressing events and exert limits to a survivor’s sense of autonomy, choice, and control [ 5 , 6 ]. Hypervigilance to threat and impaired emotion regulation skills mean that care behaviours and environments can trigger a fight or flight response that can manifest as externalising (e.g. aggression) or internalising behaviour (e.g. withdrawal). This can result in the use of seclusion and restraint, which have major negative impacts on quality of life and quality of healthcare services [ 7 ].

Recognition of these impacts prompted the development of trauma-informed care in mental health and other settings where most service users have experienced psychological trauma [ 7 , 8 , 9 ]. Trauma-informed care (TIC) is a care approach in which services are organised to ensure that all staff have a basic understanding of the potential impact of traumatic stress and can amend care to promote safety, choice, autonomy, collaboration, and respect. Staff in TIC settings are not necessarily expected to treat the symptoms of trauma, but pathways for care recipients to access treatments for trauma are known and used by all staff [ 10 ].

Organisational interventions aiming to promote the delivery of trauma-informed care have been implemented in healthcare settings in several contexts, including mental health services, inpatient emergency departments, hospital wards, and palliative care [ 10 , 11 ]. For the purposes of this review, trauma-informed organisational interventions refer to organisation-level interventions (as opposed to individual clinician or service user interventions) aiming to improve staff awareness and understanding of traumatic stress across an organisation (or within a specific group of staff), and/or establishing organisational policies and processes to meet trauma-related needs. Efforts to improve the capability of clinicians to deliver trauma therapies and treatments are out of scope of this review.

Research has demonstrated that organisational interventions to promote delivery of trauma-informed healthcare can promote well-being among survivors, improve staff skills and collaboration, reduce the use of seclusion and restraint, and reduce the prevalence of the secondary effects of trauma including drug and alcohol use [ 6 ]. However, the implementation of TIC involves a paradigm shift that requires a complex organisational change process encompassing workforce upskilling, organisational change, development of clear referral pathways, environmental change, and other implementation strategies [ 12 , 13 ]. Such broad change requires significant time and resources, and evaluation of outcomes at the organisational and/or systems level. Factors that promote or impede implementation of TIC are not yet well characterised and understood [ 10 ]. Understanding contextual, organisational, and implementation-specific factors that promote the uptake and effectiveness of an intervention can help to guide more efficient and sustainable implementation. This review, which sits on the ‘green line’ of the implementation science subway [ 14 ], is a critical step toward identifying and designing effective implementation strategies to implement TIC more widely.

As such, the aim of this review was to systematically identify and synthesise evidence regarding factors that promote or reduce the effectiveness and/or implementation of TIC in healthcare settings.

The research questions to be answered were:

What facilitating factors improve the effectiveness and/or implementation of TIC in healthcare settings?

What factors act as barriers that limit the effectiveness and/or implementation of TIC in healthcare settings?

We conducted a systematic review following the guidance of the Cochrane Qualitative and Implementation Methods Group Guidance Series and report our findings according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses 2.0 (PRISMA 2.0) guidelines [ 15 ]. A checklist of PRISMA 2.0 items is presented in Supplementary Table S 1 . The review protocol was registered on the PROSPERO database (CRD42021242891).

Data sources and searches

We conducted a search of Scopus, MEDLINE, Proquest, and PsycINFO for English language studies published from January 2000 to April 2021. The search strategy is presented in Supplementary Table S 2 and combined concepts related to the intervention (TIC), the setting (healthcare settings), and the outcome (barriers and facilitating factors for implementation). Reference lists of all included studies were hand-searched for additional records. We also searched grey literature via a Google search, Open Grey Europe, the Grey Literature Report, Web of Science, and report publications from relevant peak bodies (e.g. the International Society for Traumatic Stress Studies, American Psychiatric Association, Phoenix Australia).

Eligibility criteria

We included studies published since the year 2000 and in English, reporting original research or evaluation, and that reporting barriers and/or facilitating factors for the effectiveness or implementation of a TIC initiative in a healthcare setting. Studies published prior to 2000 were excluded because the TIC framework was not well-defined in research before this time [ 8 ]. Studies were excluded if they did not report original research or evaluation data (e.g. literature reviews, study protocols), were published prior to the year 2000, could not be accessed by the research team, or were not available in English.

Intervention and implementation strategies

Studies included in this review described strategies to implement TIC. TIC has been criticised for lacking an agreed operational definition [ 16 ] and what constitutes ‘trauma-informed care’ varies between settings. For this review, interventions or systems of care specifically described as “trauma-informed” were included. Similarly to previous reviews on TIC (e.g. [ 17 ]), we were deliberately broad in accepting the authors’ definition of TIC given the lack of an existing operational definition. Broadly, we accepted studies that described efforts to improve staff awareness and understanding of psychological trauma and organisational policies and processes to better to meet trauma-related needs.

Included studies described implementation at the organisational level. In this case, ‘initiative’ is used to describe a discrete strategy or set of strategies aiming to implement the principles of TIC within the organisation. An organisational initiative was defined as any initiative listed in the Cochrane Effective Practice and Organisation of Care Review Group data collection taxonomy [ 18 ] Sects. 2.1.3 (e.g. revision of professional roles, environmental changes, consumer participation in governance) or educational strategies listed in 2.1.1 (e.g. distribution of educational materials, local opinion leaders) as long as they were conducted at an organisation level. That is, educational strategies had to be delivered within an organisation/system to all staff or key staff who were expected to diffuse the information to others. System-level interventions to improve access or pathways to suitable trauma treatments were included.

Studies describing interventions targeted at individual clinicians (e.g. professional development to deliver a particular therapy for PTSD) or individual service users (e.g. evaluating the effectiveness of particular PTSD treatments) were excluded.

‘Healthcare organisations’ included primary, secondary and tertiary healthcare settings (e.g. acute and subacute hospital services, primary care, outpatient clinics, residential mental health treatment centres, ambulatory care, etc.). Mental health services, including drug and alcohol services, were included. Child welfare and out-of-home care services (including residential welfare centres) were excluded unless they included a healthcare component.

Finally, included studies were required to measure and report quantitative and/or qualitative data regarding factors that influenced initiative or implementation outcomes. Barriers were defined as any factor reported to impede implementation efforts, and facilitators were any factors reported to enable implementation.

Study screening and data extraction

One reviewer (YH) screened all titles and removed irrelevant papers. Abstracts and full texts were screened for eligibility by two reviewers (YH and MC) using an eligibility checklist based on the criteria described above. Disagreements about inclusion were resolved via discussion between the reviewers, and a third reviewer (LC) was consulted where consensus could not be reached. Study authors were contacted where more information was required to confirm eligibility for inclusion in this review. Data extraction was conducted by one reviewer (YH) using a data extraction spreadsheet that was piloted with five studies before being finalised and being used with the remaining studies. The accuracy of data extraction was validated by a second reviewer. Extracted data included the study’s first author and year of publication, design, setting, population, number of sites, initiative elements (e.g. implementation strategies), outcome data type (e.g. qualitative, quantitative, mixed), evaluation method, implementation outcomes reported, barriers identified, and facilitating factors identified. Intervention outcomes were out of scope of this review so were not reported here.

Quality assessment

The Mixed Methods Appraisal Tool (MMAT) Checklist, shown in Supplementary Table S 3 , was used to assess the quality of each included study. The validity, robustness, and applicability of each included study was appraised by two team members (YH and BW-H) independently and in duplicate [ 19 ].

Data management, analysis, and synthesis

The implementation strategies used in each study were synthesised into broad categories and mapped to the ERIC compilation of implementation strategies independently by two authors (YH and MC). These authors examined the features of each strategy and aligned these features with the most closely related category, and disagreements (which occurred for 8 out of 27 studies) were resolved on discussion with a third reviewer (LC).

The core aim of this paper was the synthesise data about barriers and facilitating factors for implementation. As such, this process involved a more detailed, two-step process modelled on the method of a recent review of barriers and facilitating factors for person-centred care in long-term care settings [ 20 ]. First, two authors (YH and MC) independently used a thematic analysis approach to group barriers and facilitating factors into recurrent themes (e.g. lack of collaboration, time constraints). Themes were consolidated on discussion and a second independent round of coding was conducted by both reviewers with new emerging themes added to the codebook iteratively. A final, third round of coding was conducted by one reviewer for refinement (MC). In the second step of the synthesis, the themes were mapped to the Consolidated Framework for Implementation Research (CFIR) by both reviewers [ 21 ]. All discrepancies were resolved via discussion. Mapping to CFIR aimed to provide organised guidance to researchers, service providers, and policy makers about the key contextual and initiative features that promote or limit success when implementing TIC. CFIR is a determinant framework designed to predict or explain barriers and facilitators to implementation success [ 22 ], and is therefore well suited to our aim of capturing, organising and describing common barriers and facilitators to implementing TIC organisational interventions.

The initial search identified 3051 original results, of which 170 were retrieved in full text and screened against the review inclusion and exclusion criteria. Most exclusions were due to the implementation occurring in a non-health-related care setting. A total of 27 studies were included, reported across 28 publications (Supplementary Figure S 1 ).

Study characteristics and implementation strategies

Characteristics of the included studies are described in Table 1 . Of the 27 included studies, 22 described efforts to implement TIC into healthcare settings in the United States of America (USA). The remaining five studies were conducted in Australia ( n  = 3) and Canada ( n  = 2). Implementation occurred in mental health settings ( n  = 15), maternal and women’s health settings ( n  = 2), paediatric health settings ( n  = 2), primary care clinics ( n  = 3), emergency departments ( n  = 1), or across whole systems within a geographical area including health, policy, child welfare, and other social services ( n  = 4). Implementation occurred within single health sites for eight studies, and the remainder reported implementation in multiple sites or across a whole service system. Nine of the studies explicitly described using existing implementation frameworks, theories and/or models to design and evaluate their implementation strategies, including the Exploration, Preparation, Implementation and Sustainment (EPIS) framework [ 23 , 24 ], the Service Integration Framework [ 25 , 26 ], Chen’s theoretical framework for program evaluation [ 27 , 28 ], CFIR [ 21 , 29 ], and models of rapid cycle implementation [ 30 , 31 ]. Other studies conducted a review of TIC implementation literature but did not explicitly design their strategy or evaluation against a specific framework (e.g. [ 32 , 33 ]).

Strategies used to implement the principles of TIC were similar across the included studies. Mapped to the ERIC compilation of implementation strategies [ 55 ], all but one study included some form of staff education and training, ranging from a single educational meeting (e.g. [ 41 , 43 ]), implementing train-the-trainer strategies [ 32 , 50 , 53 ], providing regular clinical supervision [ 27 , 36 , 38 , 52 ], creating learning collaboratives [ 32 , 47 ], modelling change [ 37 , 40 , 41 , 34 ], developing educational materials for new employees [ 32 , 42 , 48 , 34 ], to conducting ongoing training (e.g. [ 39 ]). Some programs identified and prepared ‘champions’, who received (or had pre-existing) a higher level of training and were available as peer mentors [ 47 , 34 ], while others committed resources to the ongoing availability of experts for consultation [ 25 , 35 , 36 , 37 , 44 , 45 ].

Most studies paired staff training and education with other implementation strategies to embed TIC throughout services. Several initiatives included activities to build buy-in and a shared rationale for implementing TIC within the organisation, including by developing position statements (e.g. [ 25 ]), aligning strategic planning with the TIC principles (e.g. [ 54 , 34 ]), conducting team building exercises (e.g. [ 44 , 45 ]), and establishing written agreements between participating agencies (e.g. [ 54 ]). Several initiatives chose to establish a team of staff responsible for implementation and monitoring [ 29 , 35 , 38 , 42 ] while others elected a single staff member to drive and oversee implementation (e.g. [ 27 ]). Other common implementation strategies included organising quality monitoring systems, including increasing the availability and/or routine use of screening for trauma-related needs [ 23 , 25 , 30 , 40 , 41 , 44 , 45 , 52 ], education outreach activities to other agencies [ 23 , 44 , 45 ], mandating change via policy and procedure change [ 32 , 33 , 36 , 39 , 40 , 42 , 54 , 34 ], and clinical team group debriefing and care planning after critical incidents [ 36 , 40 , 42 , 44 , 45 , 47 , 34 ].

Evaluation methods and quality appraisal

Most of the included studies examined barriers and facilitating factors for implementation of TIC using mixed-methods including staff interviews and/or focus groups, process data (e.g. uptake of screening tools and training attendance), and outcome data (e.g. rates of seclusion and restraint use). Eight studies reported across nine papers described author reflections on barriers and facilitating factors for implementation rather than reporting formal data [ 27 , 32 , 36 , 38 , 40 , 42 , 44 , 45 , 34 ]. This approach is subject to a high risk of bias, as assessed using the MMAT (see Supplementary Table S 4 for full methodological quality appraisal). The methodological quality of the other included studies was moderate, with most reporting clear research questions, well-justified data collection methods, and representative data collection from a diverse group of staff and/or service users. Common methodological limitations included that few of the studies reporting quantitative data considered the impact of confounding factors in their analysis, and the mixed-methods studies rarely attempted or described their approach to data integration. Importantly, none of the included studies explicitly compared implementation strategies to each other and so could not identify which were more effective than others.

Barriers and facilitating factors for implementation

Barriers and facilitating factors for implementing TIC across the included studies are described in Table 2 and mapped to the CFIR framework in Table 3 .

Intervention characteristics

Characteristics of the intervention (TIC) were reported to influence implementation across seven studies, always related to the perceived relevance of TIC to the setting and their target population. Three studies reported that staff did not perceive that the principles of TIC were suitable for their organisation or that their service users were too diverse to make delivery of TIC possible [ 23 , 27 , 29 ]. Four other studies reported that a high level of perceived relevance of TIC among staff was a facilitating factor for implementation in their sites [ 41 , 44 , 48 , 52 ].

Outer setting

Seven studies reported barriers and facilitating factors associated with the outer setting (that is, influences external to the organisation itself). One study noted that other services implementing TIC set a precedent and created a sense of peer pressure for the organisation to also pursue implementation [ 40 ]. A culture of interagency collaboration was noted as a facilitating factor in some studies, particularly where funding was allocated for administrative support to coordinate and monitor the collaboration [ 44 , 45 , 53 , 54 ]. Simonich et al. [ 53 ], Huntington et al. [ 44 ] and Mantler et al. [ 49 ] all noted that the implementation of TIC in other agencies servicing their clients was important to implementation success in their own organisation. That is, even where clients received TIC services from their organisation, this was undermined by other agencies delivering care that reduced client trust and sense of safety with healthcare providers. Outreach and training to other organisations was a facilitating factor for implementation in two of these studies [ 44 , 53 ]. Broader policy, funding arrangements, and regulation (external to the organisation) that was not consistent with the delivery of TIC was noted as a barrier to implementation in one study [ 48 ].

Inner setting

Factors related to the inner setting (the organisation or system in which implementation occurred) were reported as barriers or facilitating factors for implementation across 25 of the 27 studies. In many cases, this referred to the culture of the organisation and climate for implementation. Common facilitating factors included high levels of engagement and commitment from organisational leadership [ 23 , 25 , 32 , 36 , 40 , 42 , 44 , 45 , 54 , 34 ], the alignment of TIC with existing organisation strategic plans or policies [ 32 , 42 , 34 ], a culture of support for staff and evidence-based practice (including giving staff adequate time to learn and adopt new practices) [ 27 , 30 , 39 ], and allocation of adequate financial and staffing resources to promote implementation [ 23 , 27 , 40 , 54 ]. Where financial resources were not allocated to the initiative, or these were insufficient, this was a barrier to implementation [ 32 , 35 , 44 , 47 , 48 , 49 ]. One study also noted that although the provision of financial resources was a facilitating factor, the uneven distribution of these resources (favouring changes to the physical environment over investment in staff and human resources) was a barrier to change [ 27 ].

Other common barriers to implementation included competing priorities and staff time constraints [ 23 , 25 , 29 , 30 , 32 , 35 , 40 , 41 , 43 , 44 , 45 , 46 , 47 , 48 ], a lack of collaboration between teams within the organisation [ 27 ], and policies that were incompatible with delivering TIC. In particular, organisational policies that afforded limited flexibility to how staff delivered services and how service users engaged with the service were key barriers to implementation. Policy and procedure change that promoted flexibility in care protocols and offered service users more choice and control over their care were noted as facilitating factors across studies [ 33 , 37 , 39 , 42 , 44 , 45 , 48 , 49 ].

Characteristics of individuals

Characteristics of individuals were reported as barriers and facilitating factors for implementation in nine studies. In all cases, this focussed on staff resistance to change as a barrier [ 23 , 25 , 27 , 30 , 40 , 44 , 45 , 48 , 50 ] and staff openness as a facilitating factor for implementation success [ 27 , 29 , 50 ].

All but one of the included studies noted barriers and facilitating factors related to the process of implementation. Most studies identified design and delivery elements of their staff training program as promoting or limiting implementation success. For example, delivery of training to a variety of staff at all levels of the organisation, a flexible format that could be tailored according to needs, practical training elements (e.g. role plays), onsite delivery, ongoing trainings and availability of resources, (as opposed to a once-off session), embedding training into new employee orientation, and making training compulsory were identified as facilitating factors across several studies [ 25 , 29 , 30 , 46 , 47 , 48 , 50 , 51 , 52 , 53 ]. Provision of ongoing modelling, mentoring, and expert consultation promoted uptake and practice change [ 25 , 29 , 35 , 36 , 37 , 40 , 41 , 42 , 47 , 48 , 34 ]. Three studies noted that while staff knowledge and confidence in delivering TIC improved, these staff noted a lack of skills training and process changes to actually implement TIC within their organisation [ 33 , 35 , 48 ].

Several studies noted that including service users in implementation efforts promoted implementation success. Relevant strategies included involving a service user as a co-facilitator of training programs, service user inclusion in senior leadership positions and/or implementation teams, seeking regular service user feedback, and designing initiatives in collaboration with service users [ 36 , 40 , 44 , 50 , 51 , 34 ]. Huntington et al. [ 44 ] noted that resources and flexibility had to be embedded into the initiative to promote service user engagement (e.g. payment for involvement, prioritising service user schedules). In contrast, a lack of engagement of service users was noted as a barrier to implementation in one study [ 25 ].

Finally, several studies reported that establishing mechanisms to collect and regularly review data about the uptake and outcomes of the initiative was a key facilitating factor for change [ 30 , 36 , 40 , 42 , 34 ]. Others noted a lack of data collection and evaluation within their study as a barrier to implementation, particularly sustainability [ 25 , 38 , 54 ].

This systematic review sought to identify and synthesise evidence about barriers and facilitating factors for implementing TIC into healthcare settings. Given the very high community prevalence of psychological trauma exposure (up to 90% across the lifespan) [ 1 ], and the important impacts of trauma exposure when receiving healthcare [ 5 , 6 ], TIC aims to ensure that care services are safe, empowering, collaborative, and restore power to the care recipient [ 7 ]. Implementing TIC into healthcare settings usually requires change at the organisation level to ensure that all staff understand the impacts of psychological trauma, and that processes are in place to modify care behaviour to reduce the risk of re-traumatisation [ 10 , 39 ]. Like other complex interventions, adaptation of the TIC principles is required for implementation in each specific organisational context [ 56 ]. Identifying factors that influence implementation success across initiatives can help to inform the selection of implementation strategies and planning.

Results of this review demonstrate that factors related to the inner organisational setting and process of implementation are most often reported as influencers of TIC implementation success. Implementation was promoted where organisation leadership were highly engaged and committed to TIC and where sufficient resources were allocated to making change in practice. These facilitating factors are commonly reported as essential in efforts to implement innovation in healthcare [ 57 , 58 , 59 ], and staff who report having inadequate time for change (whether this is real or perceived) are less likely to implement innovation [ 58 ]. Strategies that build innovation into existing processes and procedures are most likely to be sustained and become the ‘normal’ thing to do [ 60 ]. For example, in a TIC initiative, this may mean building debriefing into existing case conferencing processes or adding screening items to existing procedures. Several studies included in this review noted that the addition of new processes on top of the existing workload was difficult to facilitate particularly where these processes did not fit into standard consultation times (e.g. 29).

Training staff about psychological trauma is also an essential step in the delivery of TIC particularly in health settings where mental health is not the primary focus of treatment [ 61 ]. The mental health literacy of the workforce in these settings can be low, especially where there are limited mental health clinicians on staff [ 6 , 10 , 11 ]. In our review, implementation strategies related to education and training were more comprehensive and multicomponent in non-mental health settings (e.g. primary care, maternal health) than in mental health settings where mental health literacy was high. Our review demonstrates that training efforts are more likely to lead to TIC implementation where they are targeted to staff across all levels of an organisation, with a flexible delivery format, and delivered on an ongoing basis rather than once-off. Training must also be compulsory, as voluntary trainings are unlikely to be well attended [ 50 , 51 ]. The ongoing availability of experts and mentors (also known as change agents ) was also an important facilitating factor across studies, consistent with evidence that regular, individualised follow-up is an integral component of success in quality improvement efforts [ 62 ]. This may be particularly important for TIC as service users may have complex needs as they contend with the physical, mental, and socio-economic sequelae of their experiences [ 7 ].

The process of implementing TIC is promoted where both staff and service users are engaged in both designing the implementation strategy and monitoring its ongoing progress. The value of engaging service users in the co-design of quality improvement initiatives is increasingly recognised and is mutually beneficial for both the service provider and the service user [ 63 ]. In the case of TIC, service users can provide nuanced insights about how services can be delivered flexibly and prioritise the needs and preferences of the care user [ 44 ]. Flexibility in organisational policy and procedure was a key facilitating factor for implementation across the included studies [ 33 , 37 , 39 , 42 , 44 , 45 , 48 , 49 ]. In addition, several studies included in this review described the value of infrastructure to collect and monitor data in initiatives to implement TIC. Data collection and monitoring facilitates ongoing review of resource allocation to strategies that are most effective and promotes staff engagement and buy-in [ 64 ].

Factors related to the characteristics of the intervention (TIC) and the individuals within the service generally focused on the sense of relevance of TIC for the service and service users, as well as staff openness to change. This is consistent with evidence that any intervention perceived by staff as not useful, not applicable to their clients, or not harmonious with their current practice is difficult to implement in practice [ 58 ]. Efforts to build ‘buy-in’ among staff are a crucial element of the knowledge-to-action pipeline [ 65 ]. Identifying and upskilling key opinion leaders and advocates for the intervention among the staff (including frontline staff who are well regarded among their peers), aligning the intervention with existing organisational policies and procedures, and creating incentives for use that are meaningful to the staff are key strategies to build staff buy-in [ 66 ]. Using participatory co-design methods together with staff to design implementation strategies can help to increase openness to change [ 67 ]. These were identified as facilitating factors in studies included in this review [ 32 , 42 , 34 ]. Failure to build staff buy-in can result in low staff morale and staff turnover [ 66 ]. Strategies should ensure that staff recognise the prevalence of trauma exposure among their clients and the impacts of these experiences when receiving care, and demonstrate how implementing TIC can support progress toward organisational goals (e.g. reducing responsive behaviour, need for seclusion and restraint, and staff and patient injury) [ 68 ].

Strengths and limitations

Key strengths of most of the identified studies included detailed information about the setting in which implementation occurred and examination of how these factors influenced implementation outcomes. The use of mixed-methods in 15 studies allowed an in-depth triangulation of data [ 27 , 29 , 30 , 35 , 36 , 38 , 39 , 41 , 42 , 43 , 46 , 52 , 53 , 54 , 34 ]. However, limitations included that most of the included studies were case studies describing a discrete implementation site or region, without a control condition. This limits comparability. In addition, eight studies reported the reflections of the authors, rather than the collection and analysis of empirical data [ 27 , 32 , 36 , 38 , 40 , 42 , 44 , 45 , 34 ]. The results of these studies should therefore be interpreted with caution. None of the included studies explicitly compared the effectiveness of different implementation strategies to each other, and this would be helpful in future work to guide strategy selection and design. Finally, very few studies included a critical analysis of the author’s own role in the implementation and presentation of results. Given that authors were commonly actively involved in implementation, their underlying assumptions, beliefs and experiences are likely to have influenced data collection, analysis and reporting. Future efforts to reduce bias might include the use of external evaluation teams or the inclusion of reflexivity statements in analysis and reporting [ 69 ].

Strengths of this review include our broad search strategy that captured initiatives to implement TIC across countries and healthcare settings. Our synthesis generated common themes across diverse initiatives and mapped them to an existing framework to maximise interpretability. Limitations of this review include that we excluded any papers not published in English and this may limit the generalisability of the results. The lack of an operational definition of TIC and the breadth of interventions delivered at the system or organisation level in the included studies may also limit comparability and the conclusions that can be drawn from the results. However, core elements of the implementation strategies were common across studies (e.g. staff training, routine screening) promoting comparability. Future reviews may be helpful for synthesising common implementation strategies used for TIC in more depth. Our coding and mapping to the CFIR framework may have been influenced by subjectivity, though our use of multiple coders and multiple rounds of coding reduces this risk. In addition, we did not assess the relative strength of each influencing factor. That is, factors that were reported less often across studies may nonetheless have a more powerful influence on implementation. The exclusion of an evaluation of relative strength of the influencing factors was primarily determined by few of the included studies providing such an analysis. Future studies that examine the strength of influence of each factor on implementation outcomes will be helpful for filling this research gap.

There have been recent calls to implement TIC as a universal model of care across healthcare [ 68 ], aged care [ 6 ], and social care services [ 9 ] in recognition of the major impacts of trauma exposure in the receipt of care and the potential harm to care recipients and providers that can result from inappropriate care. However, implementing TIC usually requires a complex organisational change process including both staff behaviour change and organisational policy and procedure change to facilitate staff change [ 10 ]. This review identifies key factors that should be targeted to promote TIC implementation, including interagency collaboration, staff and leadership buy-in, aligning implementation strategies with existing policies and procedures, allocation of adequate human and financial resources, flexibility in organisational policies and procedures, ongoing and tailored training, participatory co-design, and the collection and monitoring of data. Continued research will be helpful for characterising what TIC looks like when it is delivered well, and providing validated frameworks to promote organisational uptake for the benefit of trauma survivors.

Availability of data and materials

The datasets used and/or analysed during the current study are available from the corresponding author on reasonable request.

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Acknowledgements

The authors would like to acknowledge the contribution of Dr Bethany Wilton-Harding to screening and data extraction for this review.

This study is funded by the South Australian Hospital Research Foundation and the Australian Government Medical Research Future Fund. MC is supported by an Early Career Fellowship from the South Australian Hospital Research Foundation and a National Health and Medical Research Council Medical Research Future Fund Emerging Leadership Investigator Grant. KEL is supported by an Australian Research Council Discovery Early Career Researcher Award. ND is supported by a NHMRC Boosting Dementia Research Leadership Fellowship.

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YH screened all titles, abstracts and full-text articles, performed data extraction and analysis and assessed the validity, robustness and applicability of each included study. LC resolved disagreements regarding the inclusion of studies, performed data extraction and contributed to drafting the manuscript. TW, KL and ND contributed to the planning and concept and editing of the review. MC initiated the concept of the review, undertook analysis and was responsible for drafting the manuscript. All authors read and approved the final manuscript.

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Huo, Y., Couzner, L., Windsor, T. et al. Barriers and enablers for the implementation of trauma-informed care in healthcare settings: a systematic review. Implement Sci Commun 4 , 49 (2023). https://doi.org/10.1186/s43058-023-00428-0

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To round out your studies, you will complete a 4-step dissertation on a topic you’re passionate about. Each step of the dissertation is 1 semester long – giving you ample opportunity to think, research, write, and edit.

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Center for Substance Abuse Treatment (US). Trauma-Informed Care in Behavioral Health Services. Rockville (MD): Substance Abuse and Mental Health Services Administration (US); 2014. (Treatment Improvement Protocol (TIP) Series, No. 57.)

Trauma-Informed Care in Behavioral Health Services.

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Chapter 1 Trauma-Informed Care: A Sociocultural Perspective

Many individuals who seek treatment in behavioral health settings have histories of trauma, but they often don’t recognize the significant effects of trauma in their lives; either they don’t draw connections between their trauma histories and their presenting problems, or they avoid the topic altogether. Likewise, treatment providers may not ask questions that elicit a client’s history of trauma, may feel unprepared to address trauma-related issues proactively, or may struggle to address traumatic stress effectively within the constraints of their treatment program, the program’s clinical orientation, or their agency’s directives.

By recognizing that traumatic experiences and their sequelae tie closely into behavioral health problems, front-line professionals and community-based programs can begin to build a trauma-informed environment across the continuum of care. Key steps include meeting client needs in a safe, collaborative, and compassionate manner; preventing treatment practices that retraumatize people with histories of trauma who are seeking help or receiving services; building on the strengths and resilience of clients in the context of their environments and communities; and endorsing trauma-informed principles in agencies through support, consultation, and supervision of staff.

This Treatment Improvement Protocol (TIP) begins by introducing the scope, purpose, and organization of the topic and describing its intended audience. Along with defining trauma and trauma-informed care (TIC), the first chapter discusses the rationale for addressing trauma in behavioral health services and reviews trauma-informed intervention and treatment principles. These principles serve as the TIP’s conceptual framework.

• Scope of the TIP

Many individuals experience trauma during their lifetimes. Although many people exposed to trauma demonstrate few or no lingering symptoms, those individuals who have experienced repeated, chronic, or multiple traumas are more likely to exhibit pronounced symptoms and consequences, including substance abuse, mental illness, and health problems. Subsequently, trauma can significantly affect how an individual engages in major life areas as well as treatment.

This TIP provides evidence-based and best practice information for behavioral health service providers and administrators who want to work more effectively with people who have been exposed to acute and chronic traumas and/or are at risk of developing traumatic stress reactions. Using key trauma-informed principles, this TIP addresses trauma-related prevention, intervention, and treatment issues and strategies in behavioral health services. The content is adaptable across behavioral health settings that service individuals, families, and communities—placing emphasis on the importance of coordinating as well as integrating services.

• Intended Audience

This TIP is for behavioral health service providers, prevention specialists, and program administrators—the professionals directly responsible for providing care to trauma survivors across behavioral health settings, including substance abuse and mental health services. This TIP also targets primary care professionals, including physicians; teams working with clients and communities who have experienced trauma; service providers in the criminal justice system; and researchers with an interest in this topic.

• Before You Begin

This TIP endorses a trauma-informed model of care; this model emphasizes the need for behavioral health practitioners and organizations to recognize the prevalence and pervasive impact of trauma on the lives of the people they serve and develop trauma-sensitive or trauma-responsive services. This TIP provides key information to help behavioral health practitioners and program administrators become trauma aware and informed, improve screening and assessment processes, and implement science-informed intervention strategies across settings and modalities in behavioral health services. Whether provided by an agency or an individual provider, trauma-informed services may or may not include trauma-specific services or trauma specialists (individuals who have advanced training and education to provide specific treatment interventions to address traumatic stress reactions). Nonetheless, TIC anticipates the role that trauma can play across the continuum of care—establishing integrated and/or collaborative processes to address the needs of traumatized individuals and communities proactively.

Individuals who have experienced trauma are at an elevated risk for substance use disorders, including abuse and dependence; mental health problems (e.g., depression and anxiety symptoms or disorders, impairment in relational/social and other major life areas, other distressing symptoms); and physical disorders and conditions, such as sleep disorders. This TIP focuses on specific types of prevention ( Institute of Medicine et al., 2009 ): selective prevention, which targets people who are at risk for developing social, psychological, or other conditions as a result of trauma or who are at greater risk for experiencing trauma due to behavioral health disorders or conditions; and indicated prevention, which targets people who display early signs of trauma-related symptoms. This TIP identifies interventions, including trauma-informed and trauma-specific strategies, and perceives treatment as a means of prevention—building on resilience, developing safety and skills to negotiate the impact of trauma, and addressing mental and substance use disorders to enhance recovery.

This TIP’s target population is adults. Beyond the context of family, this publication does not examine or address youth and adolescent responses to trauma, youth-tailored trauma-informed strategies, or trauma-specific interventions for youth or adolescents, because the developmental and contextual issues of these populations require specialized interventions. Providers who work with young clients who have experienced trauma should refer to the resource list in Appendix B . This TIP covers TIC, trauma characteristics, the impact of traumatic experiences, assessment, and interventions for persons who have had traumatic experiences. Considering the vast knowledge base and specificity of individual, repeated, and chronic forms of trauma, this TIP does not provide a comprehensive overview of the unique characteristics of each type of trauma (e.g., sexual abuse, torture, war-related trauma, murder). Instead, this TIP provides an overview supported by examples. For more information on several specific types of trauma, please refer to TIP 36, Substance Abuse Treatment for Persons With Child Abuse and Neglect Issues ( Center for Substance Abuse Treatment [CSAT], 2000b ) , TIP 25, Substance Abuse Treatment and Domestic Violence ( CSAT, 1997b ), TIP 51, Substance Abuse Treatment: Addressing the Specific Needs of Women ( CSAT, 2009d ), and the planned TIP, Reintegration-Related Behavioral Health Issues in Veterans and Military Families (Substance Abuse and Mental Health Services Administration [SAMHSA], planned f).

This TIP, Trauma-Informed Care in Behavioral Health Services , is guided by SAMHSA’s Strategic Initiatives described in Leading Change: A Plan for SAMHSA’s Roles and Actions 2011– 2014 ( SAMHSA, 2011b ). Specific to Strategic Initiative #2, Trauma and Justice, this TIP addresses several goals, objectives, and actions outlined in this initiative by providing behavioral health practitioners, supervisors, and administrators with an introduction to culturally responsive TIC.

Specifically, the TIP presents fundamental concepts that behavioral health service providers can use to:

• Become trauma aware and knowledgeable about the impact and consequences of traumatic experiences for individuals, families, and communities.
• Evaluate and initiate use of appropriate trauma-related screening and assessment tools.
• Implement interventions from a collaborative, strengths-based approach, appreciating the resilience of trauma survivors.
• Learn the core principles and practices that reflect TIC.
• Anticipate the need for specific trauma-informed treatment planning strategies that support the individual’s recovery.
• Decrease the inadvertent retraumatization that can occur from implementing standard organizational policies, procedures, and interventions with individuals, including clients and staff, who have experienced trauma or are exposed to secondary trauma.
• Evaluate and build a trauma-informed organization and workforce.

The consensus panelists, as well as other contributors to this TIP, have all had experience as substance abuse and mental health counselors, prevention and peer specialists, supervisors, clinical directors, researchers, or administrators working with individuals, families, and communities who have experienced trauma. The material presented in this TIP uses the wealth of their experience in addition to the available published resources and research relevant to this topic. Throughout the consensus process, the panel members were mindful of the strengths and resilience inherent in individuals, families, and communities affected by trauma and the challenges providers face in addressing trauma and implementing TIC.

• Structure of the TIP

Using a TIC framework ( Exhibit 1.1-1 ), this TIP provides information on key aspects of trauma, including what it is; its consequences; screening and assessment; effective prevention, intervention, and treatment approaches; trauma recovery; the impact of trauma on service providers; programmatic and administrative practices; and trauma resources.

Exhibit 1.1-1

TIC Framework in Behavioral Health Services—Sociocultural Perspective.

Note: To produce a user-friendly but informed document, the first two parts of the TIP include minimal citations. If you are interested in the citations associated with topics covered in Parts 1 and 2 , please consult the review of the literature provided in Part 3 (available online at http://store.samhsa.gov ). Parts 1 and 2 are easily read and digested on their own, but it is highly recommended that you read the literature review as well.

• What Is Trauma?

According to SAMHSA’s Trauma and Justice Strategic Initiative, “trauma results from an event, series of events, or set of circumstances that is experienced by an individual as physically or emotionally harmful or threatening and that has lasting adverse effects on the individual’s functioning and physical, social, emotional, or spiritual well-being” ( SAMHSA, 2012 , p. 2). Trauma can affect people of every race, ethnicity, age, sexual orientation, gender, psychosocial background, and geographic region. A traumatic experience can be a single event, a series of events, and/or a chronic condition (e.g., childhood neglect, domestic violence). Traumas can affect individuals, families, groups, communities, specific cultures, and generations. It generally overwhelms an individual’s or community’s resources to cope, and it often ignites the “fight, flight, or freeze” reaction at the time of the event(s). It frequently produces a sense of fear, vulnerability, and helplessness.

See Appendix C to read about the history of trauma and trauma interventions.

Often, traumatic events are unexpected. Individuals may experience the traumatic event directly, witness an event, feel threatened, or hear about an event that affects someone they know. Events may be human-made, such as a mechanical error that causes a disaster, war, terrorism, sexual abuse, or violence, or they can be the products of nature (e.g., flooding, hurricanes, tornadoes). Trauma can occur at any age or developmental stage, and often, events that occur outside expected life stages are perceived as traumatic (e.g., a child dying before a parent, cancer as a teen, personal illness, job loss before retirement).

It is not just the event itself that determines whether something is traumatic, but also the individual’s experience of the event. Two people may be exposed to the same event or series of events but experience and interpret these events in vastly different ways. Various biopsychosocial and cultural factors influence an individual’s immediate response and long-term reactions to trauma. For most, regardless of the severity of the trauma, the immediate or enduring effects of trauma are met with resilience—the ability to rise above the circumstances or to meet the challenges with fortitude.

For some people, reactions to a traumatic event are temporary, whereas others have prolonged reactions that move from acute symptoms to more severe, prolonged, or enduring mental health consequences (e.g., posttraumatic stress and other anxiety disorders, substance use and mood disorders) and medical problems (e.g., arthritis, headaches, chronic pain). Others do not meet established criteria for posttraumatic stress or other mental disorders but encounter significant trauma-related symptoms or culturally expressed symptoms of trauma (e.g., somatization, in which psychological stress is expressed through physical concerns). For that reason, even if an individual does not meet diagnostic criteria for trauma-related disorders, it is important to recognize that trauma may still affect his or her life in significant ways. For more information on traumatic events, trauma characteristics, traumatic stress reactions, and factors that heighten or decrease the impact of trauma, see Part 1, Chapter 2 , “Trauma Awareness,” and Part 1, Chapter 3 , “Understanding the Impact of Trauma.”

• Trauma Matters in Behavioral Health Services

The past decade has seen an increased focus on the ways in which trauma, psychological distress, quality of life, health, mental illness, and substance abuse are linked. With the attacks of September 11, 2001, and other acts of terror, the wars in Iraq and Afghanistan, disastrous hurricanes on the Gulf Coast, and sexual abuse scandals, trauma has moved to the forefront of national consciousness.

Trauma was once considered an abnormal experience. However, the first National Comorbidity Study established how prevalent traumas were in the lives of the general population of the United States. In the study, 61 percent of men and 51 percent of women reported experiencing at least one trauma in their lifetime, with witnessing a trauma, being involved in a natural disaster, and/or experiencing a life-threatening accident ranking as the most common events ( Kessler et al., 1999 ). In Wave 2 of the National Epidemiologic Survey on Alcohol and Related Conditions, 71.6 percent of the sample reported witnessing trauma, 30.7 percent experienced a trauma that resulted in injury, and 17.3 percent experienced psychological trauma ( El-Gabalawy, 2012 ). For a thorough review of the impact of trauma on quality of life and health and among individuals with mental and substance use disorders, refer to Part 3 of this TIP, the online literature review.

Rationale for TIC

Integrating TIC into behavioral health services provides many benefits not only for clients, but also for their families and communities, for behavioral health service organizations, and for staff. Trauma-informed services bring to the forefront the belief that trauma can pervasively affect an individual’s well-being, including physical and mental health. For behavioral health service providers, trauma-informed practice offers many opportunities. It reinforces the importance of acquiring trauma-specific knowledge and skills to meet the specific needs of clients; of recognizing that individuals may be affected by trauma regardless of its acknowledgment; of understanding that trauma likely affects many clients who are seeking behavioral health services; and of acknowledging that organizations and providers can retraumatize clients through standard or unexamined policies and practices. TIC stresses the importance of addressing the client individually rather than applying general treatment approaches.

TIC provides clients more opportunities to engage in services that reflect a compassionate perspective of their presenting problems. TIC can potentially provide a greater sense of safety for clients who have histories of trauma and a platform for preventing more serious consequences of traumatic stress ( Fallot & Harris, 2001 ). Although many individuals may not identify the need to connect with their histories, trauma-informed services offer clients a chance to explore the impact of trauma, their strengths and creative adaptations in managing traumatic histories, their resilience, and the relationships among trauma, substance use, and psychological symptoms.

Two Influential Studies That Set the Stage for the Development of TIC

The Adverse Childhood Experiences Study ( Centers for Disease Control and Prevention, 2013 ) was a large epidemiological study involving more than 17,000 individuals from United States; it analyzed the long-term effects of childhood and adolescent traumatic experiences on adult health risks, mental health, healthcare costs, and life expectancy.

The Women, Co-Occurring Disorders and Violence Study ( SAMHSA, 2007 ) was a large multisite study focused on the role of interpersonal and other traumatic stressors among women; the interrelatedness of trauma, violence, and co-occurring substance use and mental disorders; and the incorporation of trauma-informed and trauma-specific principles, models, and services.

Implementing trauma-informed services can improve screening and assessment processes, treatment planning, and placement while also decreasing the risk for retraumatization. The implementation may enhance communication between the client and treatment provider, thus decreasing risks associated with misunderstanding the client’s reactions and presenting problems or underestimating the need for appropriate referrals for evaluation or trauma-specific treatment. Organizational investment in developing or improving trauma-informed services may also translate to cost effectiveness, in that services are more appropriately matched to clients from the outset. TIC is an essential ingredient in organizational risk management; it ensures the implementation of decisions that will optimize therapeutic outcomes and minimize adverse effects on the client and, ultimately, the organization. A key principle is the engagement of community, clients, and staff. Clients and staff are more apt to be empowered, invested, and satisfied if they are involved in the ongoing development and delivery of trauma-informed services.

An organization also benefits from work development practices through planning for, attracting, and retaining a diverse workforce of individuals who are knowledgeable about trauma and its impact. Developing a trauma-informed organization involves hiring and promotional practices that attract and retain individuals who are educated and trained in trauma-informed practices on all levels of the organization, including board as well as peer support appointments. Trauma-informed organizations are invested in their staff and adopt similar trauma-informed principles, including establishing and providing ongoing support to promote TIC in practice and in addressing secondary trauma and implementing processes that reinforce the safety of the staff. Even though investing in a trauma-informed workforce does not necessarily guarantee trauma-informed practices, it is more likely that services will evolve more proficiently to meet client, staff, and community needs.

Advice to Counselors: The Importance of TIC

The history of trauma raises various clinical issues. Many counselors do not have extensive training in treating trauma or offering trauma-informed services and may be uncertain of how to respond to clients’ trauma-related reactions or symptoms. Some counselors have experienced traumas themselves that may be triggered by clients’ reports of trauma. Others are interested in helping clients with trauma but may unwittingly cause harm by moving too deeply or quickly into trauma material or by discounting or disregarding a client’s report of trauma. Counselors must be aware of trauma-related symptoms and disorders and how they affect clients in behavioral health treatment.

Counselors with primary treatment responsibilities should also have an understanding of how to recognize trauma-related reactions, how to incorporate treatment interventions for trauma-related symptoms into clients’ treatment plans, how to help clients build a safety net to prevent further trauma, how to conduct psychoeducational interventions, and when to make treatment referrals for further evaluations or trauma-specific treatment services. All treatment staff should recognize that traumatic stress symptoms or trauma-related disorders should not preclude an individual from mental health or substance abuse treatment and that all co-occurring disorders need to be addressed on some level in the treatment plan and setting. For example, helping a client in substance abuse treatment gain control over trauma-related symptoms can greatly improve the client’s chances of substance abuse recovery and lower the possibility of relapse ( Farley, Golding, Young, Mulligan, & Minkoff, 2004 ; Ouimette, Ahrens, Moos, & Finney, 1998 ). In addition, assisting a client in achieving abstinence builds a platform upon which recovery from traumatic stress can proceed.

Trauma and Substance Use Disorders

Many people who have substance use disorders have experienced trauma as children or adults ( Koenen, Stellman, Sommer, & Stellman, 2008 ; Ompad et al., 2005 ). Substance abuse is known to predispose people to higher rates of traumas, such as dangerous situations and accidents, while under the influence ( Stewart & Conrod, 2003 ; Zinzow, Resnick, Amstadter, McCauley, Ruggiero, & Kilpatrick, 2010 ) and as a result of the lifestyle associated with substance abuse ( Reynolds et al., 2005 ). In addition, people who abuse substances and have experienced trauma have worse treatment outcomes than those without histories of trauma ( Driessen et al., 2008 ; Najavits et al., 2007 ). Thus, the process of recovery is more difficult, and the counselor’s role is more challenging, when clients have histories of trauma. A person presenting with both trauma and substance abuse issues can have a variety of other difficult life problems that commonly accompany these disorders, such as other psychological symptoms or mental disorders, poverty, homelessness, increased risk of HIV and other infections, and lack of social support ( Mills, Teesson, Ross, & Peters, 2006 ; Najavits, Weiss, & Shaw, 1997 ). Many individuals who seek treatment for substance use disorders have histories of one or more traumas. More than half of women seeking substance abuse treatment report one or more lifetime traumas ( Farley, Golding, Young, Mulligan, & Minkoff, 2004 ; Najavits et al., 1997 ), and a significant number of clients in inpatient treatment also have subclinical traumatic stress symptoms or posttraumatic stress disorder (PTSD; Falck, Wang, Siegal, & Carlson, 2004 ; Grant et al., 2004 ; Reynolds et al., 2005 ).

Trauma and Mental Disorders

People who are receiving treatment for severe mental disorders are more likely to have histories of trauma, including childhood physical and sexual abuse, serious accidents, homelessness, involuntary psychiatric hospitalizations, drug overdoses, interpersonal violence, and other forms of violence. Many clients with severe mental disorders meet criteria for PTSD; others with serious mental illness who have histories of trauma present with psychological symptoms or mental disorders that are commonly associated with a history of trauma, including anxiety symptoms and disorders, mood disorders (e.g., major depression, dysthymia, bipolar disorder; Mueser et al., 2004 ), impulse control disorders, and substance use disorders ( Kessler, Chiu, Demler, & Walters, 2005 ).

Traumatic stress increases the risk for mental illness, and findings suggest that traumatic stress increases the symptom severity of mental illness ( Spitzer, Vogel, Barnow, Freyberger & Grabe, 2007 ). These findings propose that traumatic stress plays a significant role in perpetuating and exacerbating mental illness and suggest that trauma often precedes the development of mental disorders. As with trauma and substance use disorders, there is a bidirectional relationship; mental illness increases the risk of experiencing trauma, and trauma increases the risk of developing psychological symptoms and mental disorders. For a more comprehensive review of the interactions among traumatic stress, mental illness, and substance use disorders, refer to Part 3 of this TIP, the online literature review.

• Trauma-Informed Intervention and Treatment Principles

TIC is an intervention and organizational approach that focuses on how trauma may affect an individual’s life and his or her response to behavioral health services from prevention through treatment. There are many definitions of TIC and various models for incorporating it across organizations, but a “trauma-informed approach incorporates three key elements: (1) realizing the prevalence of trauma; (2) recognizing how trauma affects all individuals involved with the program, organization, or system, including its own workforce; and (3) responding by putting this knowledge into practice”( SAMHSA, 2012 , p. 4).

TIC begins with the first contact a person has with an agency; it requires all staff members (e.g., receptionists, intake personnel, direct care staff, supervisors, administrators, peer supports, board members) to recognize that the individual’s experience of trauma can greatly influence his or her receptivity to and engagement with services, interactions with staff and clients, and responsiveness to program guidelines, practices, and interventions. TIC includes program policies, procedures, and practices to protect the vulnerabilities of those who have experienced trauma and those who provide trauma-related services. TIC is created through a supportive environment and by redesigning organizational practices, with consumer participation, to prevent practices that could be retraumatizing ( Harris & Fallot, 2001c ; Hopper et al., 2010 ). The ethical principle, “first, do no harm,” resonates strongly in the application of TIC.

“A program, organization, or system that is trauma-informed realizes the widespread impact of trauma and understands potential paths for healing; recognizes the signs and symptoms of trauma in staff, clients, and others involved with the system; and responds by fully integrating knowledge about trauma into policies, procedures, practices, and settings.” ( SAMHSA, 2012 , p. 4)

TIC involves a commitment to building competence among staff and establishing programmatic standards and clinical guidelines that support the delivery of trauma-sensitive services. It encompasses recruiting, hiring, and retaining competent staff; involving consumers, trauma survivors, and peer support specialists in the planning, implementation, and evaluation of trauma-informed services; developing collaborations across service systems to streamline referral processes, thereby securing trauma-specific services when appropriate; and building a continuity of TIC as consumers move from one system or service to the next. TIC involves reevaluating each service delivery component through a trauma-aware lens.

The principles described in the following subsections serve as the TIP’s conceptual framework. These principles comprise a compilation of resources, including research, theoretical papers, commentaries, and lessons learned from treatment facilities. Key elements are outlined for each principle in providing services to clients affected by trauma and to populations most likely to incur trauma. Although these principles are useful across all prevention and intervention services, settings, and populations, they are of the utmost importance in working with people who have had traumatic experiences.

Advice to Counselors: Implementing Trauma-Informed Services

Recognizing that trauma affects a majority of clients served within public health systems, the National Center for Trauma-Informed Care (NCTIC) has sought to establish a comprehensive framework to guide systems of care in the development of trauma-informed services. If a system or program is to support the needs of trauma survivors, it must take a systematic approach that offers trauma-specific diagnostic and treatment services, as well as a trauma-informed environment that is able to sustain such services, while fostering positive outcomes for the clients it serves. NCTIC also offers technical assistance in the implementation of trauma-informed services. For specific administrative information on TIC implementation, refer to Part 2, Chapters 1 and 2 , of this TIP.

Promote Trauma Awareness and Understanding

Foremost, a behavioral health service provider must recognize the prevalence of trauma and its possible role in an individual’s emotional, behavioral, cognitive, spiritual, and/or physical development, presentation, and well-being. Being vigilant about the prevalence and potential consequences of traumatic events among clients allows counselors to tailor their presentation styles, theoretical approaches, and intervention strategies from the outset to plan for and be responsive to clients’ specific needs. Although not every client has a history of trauma, those who have substance use and mental disorders are more likely to have experienced trauma. Being trauma aware does not mean that you must assume everyone has a history of trauma, but rather that you anticipate the possibility from your initial contact and interactions, intake processes, and screening and assessment procedures.

Even the most standard behavioral health practices can retraumatize an individual exposed to prior traumatic experiences if the provider implements them without recognizing or considering that they may do harm. For example, a counselor might develop a treatment plan recommending that a female client—who has been court mandated to substance abuse treatment and was raped as an adult—attend group therapy, but without considering the implications, for her, of the fact that the only available group at the facility is all male and has had a low historical rate of female participation. Trauma awareness is an essential strategy for preventing this type of retraumatization; it reinforces the need for providers to reevaluate their usual practices.

“Trauma-informed care embraces a perspective that highlights adaptation over symptoms and resilience over pathology.” ( Elliot, Bjelajac, Fallot, Markoff, & Reed, 2005 , p. 467)

Becoming trauma aware does not stop with the recognition that trauma can affect clients; instead, it encompasses a broader awareness that traumatic experiences as well as the impact of an individual’s trauma can extend to significant others, family members, first responders and other medical professionals, behavioral health workers, broader social networks, and even entire communities. Family members frequently experience the traumatic stress reactions of the individual family member who was traumatized (e.g., angry outbursts, nightmares, avoidant behavior, other symptoms of anxiety, overreactions or under reactions to stressful events). These repetitive experiences can increase the risk of secondary trauma and symptoms of mental illness among the family, heighten the risk for externalizing and internalizing behavior among children (e.g., bullying others, problems in social relationships, health-damaging behaviors), increase children’s risk for developing posttraumatic stress later in life, and lead to a greater propensity for traumatic stress reactions across generations of the family. Hence, prevention and intervention services can provide education and age-appropriate programming tailored to develop coping skills and support systems.

So too, behavioral health service providers can be influenced by exposure to trauma-related affect and content when working with clients. A trauma-aware workplace supports supervision and program practices that educate all direct service staff members on secondary trauma, encourages the processing of trauma-related content through participation in peer-supported activities and clinical supervision, and provides them with professional development opportunities to learn about and engage in effective coping strategies that help prevent secondary trauma or trauma-related symptoms. It is important to generate trauma awareness in agencies through education across services and among all staff members who have any direct or indirect contact with clients (including receptionists or intake and admission personnel who engage clients for the first time within the agency). Agencies can maintain a trauma-aware environment through ongoing staff training, continued supervisory and administrative support, collaborative (i.e., involving consumer participation) trauma-responsive program design and implementation, and organizational policies and practices that reflect accommodation and flexibility in attending to the needs of clients affected by trauma.

Recognize That Trauma-Related Symptoms and Behaviors Originate From Adapting to Traumatic Experiences

A trauma-informed perspective views trauma-related symptoms and behaviors as an individual’s best and most resilient attempt to manage, cope with, and rise above his or her experience of trauma. Some individuals’ means of adapting and coping have produced little difficulty; the coping and adaptive strategies of others have worked in the past but are not working as well now. Some people have difficulties in one area of life but have effectively negotiated and functioned in other areas.

Individuals who have survived trauma vary widely in how they experience and express traumatic stress reactions. Traumatic stress reactions vary in severity; they are often measured by the level of impairment or distress that clients report and are determined by the multiple factors that characterize the trauma itself, individual history and characteristics, developmental factors, sociocultural attributes, and available resources. The characteristics of the trauma and the subsequent traumatic stress reactions can dramatically influence how individuals respond to the environment, relationships, interventions, and treatment services, and those same characteristics can also shape the assumptions that clients/consumers make about their world (e.g., their view of others, sense of safety), their future (e.g., hopefulness, fear of a foreshortened future), and themselves (e.g., feeling resilient, feeling incompetent in regulating emotions). The breadth of these effects may be observable or subtle.

Once you become aware of the significance of traumatic experiences in clients’ lives and begin to view their presentation as adaptive, your identification and classification of their presenting symptoms and behaviors can shift from a “pathology” mindset (i.e., defining clients strictly from a diagnostic label, implying that something is wrong with them) to one of resilience—a mindset that views clients’ presenting difficulties, behaviors, and emotions as responses to surviving trauma. In essence, you will come to view traumatic stress reactions as normal reactions to abnormal situations. In embracing the belief that trauma-related reactions are adaptive, you can begin relationships with clients from a hopeful, strengths-based stance that builds upon the belief that their responses to traumatic experiences reflect creativity, self-preservation, and determination.

This will help build mutual and collaborative therapeutic relationships, help clients identify what has worked and has not worked in their attempts to deal with the aftermath of trauma from a nonjudgmental stance, and develop intervention and coping strategies that are more likely to fit their strengths and resources. This view of trauma prevents further retraumatization by not defining traumatic stress reactions as pathological or as symptoms of pathology.

View Trauma in the Context of Individuals’ Environments

Many factors contribute to a person’s response to trauma, whether it is an individual, group, or community-based trauma. Individual attributes, developmental factors (including protective and risk factors), life history, type of trauma, specific characteristics of the trauma, amount and length of trauma exposure, cultural meaning of traumatic events, number of losses associated with the trauma, available resources (internal and external, such as coping skills and family support), and community reactions are a few of the determinants that influence a person’s responses to trauma across time. Refer to the “ View Trauma Through a Sociocultural Lens ” section later in this chapter for more specific information highlighting the importance of culture in understanding and treating the effects of trauma.

Trauma cannot be viewed narrowly; instead, it needs to be seen through a broader lens—a contextual lens integrating biopsychosocial, interpersonal, community, and societal (the degree of individualistic or collective cultural values) characteristics that are evident preceding and during the trauma, in the immediate and sustained response to the event(s), and in the short- and long-term effects of the traumatic event(s), which may include housing availability, community response, adherence to or maintenance of family routines and structure, and level of family support.

To more adequately understand trauma, you must also consider the contexts in which it occurred. Understanding trauma from this angle helps expand the focus beyond individual characteristics and effects to a broader systemic perspective that acknowledges the influences of social interactions, communities, governments, cultures, and so forth, while also examining the possible interactions among those various influences. Bronfenbrenner’s (1979) and Bronfenbrenner and Ceci’s (1994) work on ecological models sparked the development of other contextual models. In recent years, the social-ecological framework has been adopted in understanding trauma, in implementing health promotion and other prevention strategies, and in developing treatment interventions ( Centers for Disease Control and Prevention, 2009 ). Here are the three main beliefs of a social-ecological approach ( Stokols, 1996 ):

• Environmental factors greatly influence emotional, physical, and social well-being.
• A fundamental determinant of health versus illness is the degree of fit between individuals’ biological, behavioral, and sociocultural needs and the resources available to them.
• Prevention, intervention, and treatment approaches integrate a combination of strategies targeting individual, interpersonal, and community systems.

This TIP uses a social-ecological model to explore trauma and its effects ( Exhibit 1.1-2 ). The focus of this model is not only on negative attributes (risk factors) across each level, but also on positive ingredients (protective factors) that protect against or lessen the impact of trauma. This model also guides the inclusion of certain targeted interventions in this text, including selective and indicated prevention activities. In addition, culture, developmental processes (including the developmental stage or characteristics of the individual and/or community), and the specific era when the trauma(s) occurred can significantly influence how a trauma is perceived and processed, how an individual or community engages in help-seeking, and the degree of accessibility, acceptability, and availability of individual and community resources.

Exhibit 1.1-2

A Social-Ecological Model for Understanding Trauma and Its Effects.

Depending on the developmental stage and/or processes in play, children, adolescents, and adults will perceive, interpret, and cope with traumatic experiences differently. For example, a child may view a news story depicting a traumatic event on television and believe that the trauma is recurring every time they see the scene replayed. Similarly, the era in which one lives and the timing of the trauma can greatly influence an individual or community response. Take, for example, a pregnant woman who is abusing drugs and is wary of receiving medical treatment after being beaten in a domestic dispute. She may fear losing her children or being arrested for child neglect. Even though a number of States have adopted policies focused on the importance of treatment for pregnant women who are abusing drugs and of the accessibility of prenatal care, other States have approached this issue from a criminality standpoint (e.g., with child welfare and criminal laws) in the past few decades. Thus, the traumatic event’s timing is a significant component in understanding the context of trauma and trauma-related responses.

The social-ecological model depicted in Exhibit 1.1-2 provides a systemic framework for looking at individuals, families, and communities affected by trauma in general; it highlights the bidirectional influence that multiple contexts can have on the provision of behavioral health services to people who have experienced trauma (see thin arrow). Each ring represents a different system (refer to Exhibit 1.1-3 for examples of specific factors within each system). The innermost ring represents the individual and his or her biopsychosocial characteristics. The “Interpersonal” circle embodies all immediate relationships including family, friends, peers, and others. The “Community/Organizational” band represents social support networks, workplaces, neighborhoods, and institutions that directly influence the individual and his/her relationships. The “Societal” circle signifies the largest system—State and Federal policies and laws, such as economic and healthcare policies, social norms, governmental systems, and political ideologies. The outermost ring, “Period of Time in History,” reflects the significance of the period of time during which the event occurred; it influences each other level represented in the circle. For example, making a comparison of society’s attitudes and responses to veterans’ homecomings across different wars and conflicts through time shows that homecoming environments can have either a protective or a negative effect on healing from the psychological and physical wounds of war, depending on the era in question. The thicker arrows in the figure represent the key influences of culture, developmental characteristics, and the type and characteristics of the trauma. All told, the context of traumatic events can significantly influence both initial and sustained responses to trauma; treatment needs; selection of prevention, intervention, and other treatment strategies; and ways of providing hope and promoting recovery.

Exhibit 1.1-3

Understanding the Levels Within the Social-Ecological Model of Trauma and Its Effects.

Case Illustration: Marisol

Marisol is a 28-year-old Latina woman working as a barista at a local coffee shop. One evening, she was driving home in the rain when a drunk driver crossed into her lane and hit her head on. Marisol remained conscious as she waited to be freed from the car and was then transported to the hospital. She sustained fractures to both legs. Her recovery involved two surgeries and nearly 6 months of rehabilitation, including initial hospitalization and outpatient physical therapy.

She described her friends and family as very supportive, saying that they often foresaw what she needed before she had to ask. She added that she had an incredible sense of gratitude for her employer and coworkers, who had taken turns visiting and driving her to appointments. Although she was able to return to work after 9 months, Marisol continued experiencing considerable distress about her inability to sleep well, which started just after the accident. Marisol describes repetitive dreams and memories of waiting to be transported to the hospital after the crash. The other driver was charged with driving under the influence (DUI), and it was reported that he had been convicted two other times for a DUI misdemeanor.

Answering the following questions will help you see how the different levels of influence affect the impact and outcome of the traumatic event Marisol experienced, as well as her responses to that event:

• Based on the limited information provided in this illustration, how might Marisol’s personality affect the responses of her family and friends, her coworkers, and the larger community?
• In what ways could Marisol’s ethnic and cultural background influence her recovery?
• What societal factors could play a role in the car crash itself and the outcomes for Marisol and the other driver?

Explore the influence of the period of time in history during which the scenario occurs—compare the possible outcomes for both Marisol and the other driver if the crash occurred 40 years ago versus in the present day.

Minimize the Risk of Retraumatization or Replicating Prior Trauma Dynamics

Trauma-informed treatment providers acknowledge that clients who have histories of trauma may be more likely to experience particular treatment procedures and practices as negative, reminiscent of specific characteristics of past trauma or abuse, or retraumatizing—feeling as if the past trauma is reoccurring or as if the treatment experience is as dangerous and unsafe as past traumas. For instance, clients may express feelings of powerlessness or being trapped if they are not actively involved in treatment decisions; if treatment processes or providers mirror specific behavior from the clients’ past experiences with trauma, they may voice distress or respond in the same way as they did to the original trauma. Among the potentially retraumatizing elements of treatment are seclusion or “time-out” practices that isolate individuals, mislabeling client symptoms as personality or other mental disorders rather than as traumatic stress reactions, interactions that command authority, treatment assignments that could humiliate clients (such as asking a client to wear a sign in group that reflects one of their treatment issues, even if the assignment centers on positive attributes of the client), confronting clients as resistant, or presenting treatment as conditional upon conformity to the provider’s beliefs and definitions of issues.

Clients’ experiences are unique to the specific traumas they have faced and the surrounding circumstances before, during, and after that trauma, so remember that even seemingly safe and standard treatment policies and procedures, including physical plant operations (e.g., maintenance, grounds, fire and safety procedures), may feel quite the contrary for a client if one or more of those elements is reminiscent of his or her experience of trauma in some way. Examples include having limited privacy or personal space, being interviewed in a room that feels too isolating or confining, undergoing physical examination by a medical professional of the same sex as the client’s previous perpetrator of abuse, attending a group session in which another client expresses anger appropriately in a role play, or being directed not to talk about distressing experiences as a means of deescalating traumatic stress reactions.

Although some treatment policies or procedures are more obviously likely to solicit distress than others, all standard practices should be evaluated for their potential to retraumatize a client; this cannot be done without knowing the specific features of the individual’s history of trauma. Consider, for instance, a treatment program that serves meals including entrees that combine more than one food group. Your client enters this program and refuses to eat most of the time; he expresses anger toward dietary staff and claims that food choices are limited. You may initially perceive your client’s refusal to eat or to avoid certain foods as an eating disorder or a behavioral problem. However, a trauma-aware perspective might change your assumptions; consider that this client experienced neglect and abuse surrounding food throughout childhood (his mother forced him to eat meals prepared by combining anything in the refrigerator and cooking them together).

Advice to Counselors and Administrators: Sending the Right Message About Trauma

How often have you heard “We aren’t equipped to handle trauma” or “We don’t have time to deal with reactions that surface if traumatic experiences are discussed in treatment” from counselors and administrators in behavioral health services? For agencies, staff members, and clients, these statements present many difficulties and unwanted outcomes. For a client, such comments may replicate his or her earlier encounters with others (including family, friends, and previous behavioral health professionals) who had difficulty acknowledging or talking about traumatic experiences with him or her. A hands-off approach to trauma can also reinforce the client’s own desire to avoid such discussions. Even when agencies and staff are motivated in these sentiments by a good intention—to contain clients’ feelings of being overwhelmed—such a perspective sends strong messages to clients that their experiences are not important, that they are not capable of handling their trauma-associated feelings, and that dealing with traumatic experiences is simply too dangerous. Statements like these imply that recovery is not possible and provide no structured outlet to address memories of trauma or traumatic stress reactions.

Nevertheless, determining how and when to address traumatic stress in behavioral health services can be a real dilemma, especially if there are no trauma-specific philosophical, programmatic, or procedural processes in place. For example, it is difficult to provide an appropriate forum for a client to address past traumas if no forethought has been given to developing interagency and intra-agency collaborations for trauma-specific services. By anticipating the need for trauma-informed services and planning ahead to provide appropriate services to people who are affected by trauma, behavioral health service providers and program administrators can begin to develop informed intervention strategies that send a powerful, positive message:

• Both clients and providers can competently manage traumatic experiences and reactions.
• Providers are interested in hearing clients’ stories and attending to their experiences.
• Recovery is possible.

As a treatment provider, you cannot consistently predict what may or may not be upsetting or retraumatizing to clients. Therefore, it is important to maintain vigilance and an attitude of curiosity with clients, inquiring about the concerns that they express and/or present in treatment. Remember that certain behaviors or emotional expressions can reflect what has happened to them in the past.

Foremost, a trauma-informed approach begins with taking practical steps to reexamine treatment strategies, program procedures, and organizational polices that could solicit distress or mirror common characteristics of traumatic experiences (loss of control, being trapped, or feeling disempowered). To better anticipate the interplay between various treatment elements and the more idiosyncratic aspects of a particular client’s trauma history, you can:

• Work with the client to learn the cues he or she associates with past trauma.
• Obtain a good history.
• Maintain a supportive, empathetic, and collaborative relationship.
• Encourage ongoing dialog.
• Provide a clear message of availability and accessibility throughout treatment.

In sum, trauma-informed providers anticipate and respond to potential practices that may be perceived or experienced as retraumatizing to clients; they are able to forge new ways to respond to specific situations that trigger a trauma-related response, and they can provide clients with alternative ways of engaging in a particularly problematic element of treatment.

Create a Safe Environment

The need to create a safe environment is not new to providers; it involves an agency-wide effort supported by effective policies and procedures. However, creating safety within a trauma-informed framework far exceeds the standard expectations of physical plant safety (e.g., facility, environmental, and space-related concerns), security (of staff members, clients, and personal property), policies and procedures (including those specific to seclusion and restraint), emergency management and disaster planning, and adherence to client rights. Providers must be responsive and adapt the environment to establish and support clients’ sense of physical and emotional safety.

Beyond anticipating that various environmental stimuli within a program may generate strong emotions and reactions in a trauma survivor (e.g., triggers such as lighting, access to exits, seating arrangements, emotionality within a group, or visual or auditory stimuli) and implementing strategies to help clients cope with triggers that evoke their experiences with trauma, other key elements in establishing a safe environment include consistency in client interactions and treatment processes, following through with what has been reviewed or agreed upon in sessions or meetings, and dependability. Mike’s case illustration depicts ways in which the absence of these key elements could erode a client’s sense of safety during the treatment process.

Neither providers nor service processes are always perfect. Sometimes, providers unintentionally relay information inaccurately or inconsistently to clients or other staff members; other times, clients mishear something, or extenuating circumstances prevent providers from responding as promised. Creating safety is not about getting it right all the time; it’s about how consistently and forthrightly you handle situations with a client when circumstances provoke feelings of being vulnerable or unsafe. Honest and compassionate communication that conveys a sense of handling the situation together generates safety. It is equally important that safety extends beyond the client. Counselors and other behavioral health staff members, including peer support specialists, need to be able to count on the agency to be responsive to and maintain their safety within the environment as well. By incorporating an organizational ethos that recognizes the importance of practices that promote physical safety and emotional well-being, behavioral health staff members may be more likely to seek support and supervision when needed and to comply with clinical and programmatic practices that minimize risks for themselves and their clients.

Case Illustration: Mike

From the first time you provide outpatient counseling to Mike, you explain that he can call an agency number that will put him in direct contact with someone who can provide further assistance or support if he has emotional difficulty after the session or after agency hours. However, when he attempts to call one night, no one is available despite what you’ve described. Instead, Mike is directed by an operator to either use his local emergency room if he perceives his situation to be a crisis or to wait for someone on call to contact him. The inconsistency between what you told him in the session and what actually happens when he calls makes Mike feel unsafe and vulnerable.

Beyond an attitudinal promotion of safety, organizational leaders need to consider and create avenues of professional development and assistance that will give their staff the means to seek support and process distressing circumstances or events that occur within the agency or among their clientele, such as case consultation and supervision, formal or informal processes to debrief service providers about difficult clinical issues, and referral processes for client psychological evaluations and employee assistance for staff. Organizational practices are only effective if supported by unswerving trauma awareness, training, and education among staff. Jane’s case illustration shows the impact of a minor but necessary postponement in staff orientation for a new hire—not an unusual circumstance in behavioral health programs that have heavy caseloads and high staff turnover.

Identify Recovery From Trauma as a Primary Goal

Often, people who initiate or are receiving mental health or substance abuse services don’t identify their experiences with trauma as a significant factor in their current challenges or problems. In part, this is because people who have been exposed to trauma, whether once or repeatedly, are generally reluctant to revisit it. They may already feel stuck in repetitive memories or experiences, which may add to their existing belief that any intervention will make matters worse or, at least, no better. For some clients, any introduction to their trauma-related memories or minor cues reminiscent of the trauma will cause them to experience strong, quick-to-surface emotions, supporting their belief that addressing trauma is dangerous and that they won’t be able to handle the emotions or thoughts that result from attempting to do so. Others readily view their experiences of trauma as being in the past; as a result, they engage in distraction, dissociation, and/or avoidance (as well as adaptation) due to a belief that trauma has little impact on their current lives and presenting problems. Even individuals who are quite aware of the impact that trauma has had on their lives may still struggle to translate or connect how these events continue to shape their choices, behaviors, and emotions. Many survivors draw no connection between trauma and their mental health or substance abuse problems, which makes it more difficult for them to see the value of trauma-informed or trauma-specific interventions, such as creating safety, engaging in psychoeducation, enhancing coping skills, and so forth.

Case Illustration: Jane

Jane, a newly hired female counselor, had a nephew who took his own life. The program that hired her was short of workers at the time; therefore, Jane did not have an opportunity to engage sufficiently in orientation outside of reviewing the policies and procedure manual. In an attempt to present well to her new employer and supervisor, she readily accepted client assignments without considering her recent loss. By not immersing herself in the program’s perspective and policies on staff well-being, ethical and clinical considerations in client assignments, and how and when to seek supervision, Jane failed to engage in the practices, heavily supported by the agency, that promoted safety for herself and her clients. Subsequently, she felt emotionally overwhelmed at work and would often abruptly request psychiatric evaluation for clients who expressed any feelings of hopelessness out of sheer panic that they would attempt suicide.

As a trauma-informed provider, it is important that you help clients bridge the gap between their mental health and substance-related issues and the traumatic experiences they may have had. All too often, trauma occurs before substance use and mental disorders develop; then, such disorders and their associated symptoms and consequences create opportunities for additional traumatic events to occur. If individuals engage in mental health and substance abuse treatment without addressing the role that trauma has played in their lives, they are less likely to experience recovery in the long run. For example, a person with a history of trauma is more likely to have anxiety and depressive symptoms, use substances to self-medicate, and/or relapse after exposure to trauma-related cues. Thus, collaboration within and between behavioral health agencies is necessary to make integrated, timely, trauma-specific interventions available from the beginning to clients/consumers who engage in substance abuse and mental health services.

Support Control, Choice, and Autonomy

Not every client who has experienced trauma and is engaged in behavioral health services wants, or sees the need for, trauma-informed or trauma-specific treatment. Clients may think that they’ve already dealt with their trauma adequately, or they may believe that the effects of past trauma cause minimal distress for them. Other clients may voice the same sentiments, but without conviction—instead using avoidant behavior to deter distressing symptoms or reactions. Still others may struggle to see the role of trauma in their presenting challenges, not connecting their past traumatic experiences with other, more current difficulties (e.g., using substances to self-medicate strong emotions). Simply the idea of acknowledging trauma-related experiences and/or stress reactions may be too frightening or overwhelming for some clients, and others may fear that their reactions will be dismissed. On the other hand, some individuals want so much to dispense with their traumatic experiences and reactions that they hurriedly and repeatedly disclose their experiences before establishing a sufficiently safe environment or learning effective coping strategies to offset distress and other effects of retraumatization.

As these examples show, not everyone affected by trauma will approach trauma-informed services or recognize the impact of trauma in their lives in the same manner. This can be challenging to behavioral health service providers who are knowledgeable about the impact of trauma and who perceive the importance of addressing trauma and its effects with clients. As with knowing that different clients may be at different levels of awareness or stages of change in substance abuse treatment services, you should acknowledge that people affected by trauma present an array of reactions, various levels of trauma awareness, and different degrees of urgency in their need to address trauma.

Appreciating clients’ perception of their presenting problems and viewing their responses to the impact of trauma as adaptive—even when you believe their methods of dealing with trauma to be detrimental—are equally important elements of TIC. By taking the time to engage with clients and understand the ways they have perceived, adjusted to, and responded to traumatic experiences, providers are more likely to project the message that clients possess valuable personal expertise and knowledge about their own presenting problems. This shifts the viewpoint from “Providers know best” to the more collaborative “Together, we can find solutions.”

How often have you heard from clients that they don’t believe they can handle symptoms that emerge from reexperiencing traumatic cues or memories? Have you ever heard clients state that they can’t trust themselves or their reactions, or that they never know when they are going to be triggered or how they are going to react? How confident would you feel about yourself if, at any time, a loud noise could initiate an immediate attempt to hide, duck, or dive behind something? Traumatic experiences have traditionally been described as exposure to events that cause intense fear, helplessness, horror, or feelings of loss of control. Participation in behavioral health services should not mirror these aspects of traumatic experience. Working collaboratively to facilitate clients’ sense of control and to maximize clients’ autonomy and choices throughout the treatment process, including treatment planning, is crucial in trauma-informed services.

For some individuals, gaining a sense of control and empowerment, along with understanding traumatic stress reactions, may be pivotal ingredients for recovery. By creating opportunities for empowerment, counselors and other behavioral health service providers help reinforce, clients’ sense of competence, which is often eroded by trauma and prolonged traumatic stress reactions. Keep in mind that treatment strategies and procedures that prioritize client choice and control need not focus solely on major life decisions or treatment planning; you can apply such approaches to common tasks and everyday interactions between staff and consumers. Try asking your clients some of the following questions (which are only a sample of the types of questions that could be useful):

• What information would be helpful for us to know about what happened to you?
• Where/when would you like us to call you?
• How would you like to be addressed?
• Of the services I’ve described, which seem to match your present concerns and needs?
• From your experience, what responses from others appear to work best when you feel overwhelmed by your emotions?

Likewise, organizations need to reinforce the importance of staff autonomy, choice, and sense of control. What resources can staff members access, and what choices are available to them, in processing emotionally charged content or events in treatment? How often do administrators and supervisors seek out feedback on how to handle problematic situations (e.g., staff rotations for vacations, case consultations, changes in scheduling)? Think about the parallel between administration and staff members versus staff members and clients; often, the same philosophy, attitudes, and behaviors conveyed to staff members by administrative practices are mirrored in staff–client interactions. Simply stated, if staff members do not feel empowered, it will be a challenge for them to value the need for client empowerment. (For more information on administrative and workforce development issues, refer to Part 2, Chapters 1 and 2 .)

Case Illustration: Mina

Mina initially sought counseling after her husband was admitted to an intensive outpatient drug and alcohol program. She was self-referred for low-grade depression, resentment toward her spouse, and codependency. When asked to define “codependency” and how the term applied to her, she responded that she always felt guilty and responsible for everyone in her family and for events that occurred even when she had little or no control over them.

After the intake and screening process, she expressed interest in attending group sessions that focused primarily on family issues and substance abuse, wherein her presenting concerns could be explored. In addition to describing dynamics and issues relating to substance abuse and its impact on her marriage, she referred to her low mood as frozen grief. During treatment, she reluctantly began to talk about an event that she described as life changing: the loss of her father. The story began to unfold in group; her father, who had been 62 years old, was driving her to visit a cousin. During the ride, he had a heart attack and drove off the road. As the car came to stop in a field, she remembered calling 911 and beginning cardiopulmonary resuscitation while waiting for the ambulance. She rode with the paramedics to the hospital, watching them work to save her father’s life; however, he was pronounced dead soon after arrival.

She always felt that she never really said goodbye to her father. In group, she was asked what she would need to do or say to feel as if she had revisited that opportunity. She responded in quite a unique way, saying, “I can’t really answer this question; the lighting isn’t right for me to talk about my dad.” The counselor encouraged her to adjust the lighting so that it felt “right” to her. Being invited to do so turned out to be pivotal in her ability to address her loss and to say goodbye to her father on her terms. She spent nearly 10 minutes moving the dimmer switch for the lighting as others in the group patiently waited for her to return to her chair. She then began to talk about what happened during the evening of her father’s death, their relationship, the events leading up to that evening, what she had wanted to say to him at the hospital, and the things that she had been wanting to share with him since his death.

Weeks later, as the group was coming to a close, each member spoke about the most important experiences, tools, and insights that he or she had taken from participating. Mina disclosed that the group helped her establish boundaries and coping strategies within her marriage, but said that the event that made the most difference for her had been having the ability to adjust the lighting in the room. She explained that this had allowed her to control something over which she had been powerless during her father’s death. To her, the lighting had seemed to stand out more than other details at the scene of the accident, during the ambulance ride, and at the hospital. She felt that the personal experience of losing her father and needing to be with him in the emergency room was marred by the obtrusiveness of staff, procedures, machines, and especially, the harsh lighting. She reflected that she now saw the lighting as a representation of this tragic event and the lack of privacy she had experienced when trying to say goodbye to her father. Mina stated that this moment in group had been the greatest gift: “…to be able to say my goodbyes the way I wanted… I was given an opportunity to have some control over a tragic event where I couldn’t control the outcome no matter how hard I tried.”

Create Collaborative Relationships and Participation Opportunities

This trauma-informed principle encompasses three main tenets. First, ensure that the provider–client relationship is collaborative , regardless of setting or service. Agency staff members cannot make decisions pertaining to interventions or involvement in community services autocratically; instead, they should develop trauma-informed, individualized care plans and/or treatment plans collaboratively with the client and, when appropriate, with family and caregivers. The nonauthoritarian approach that characterizes TIC views clients as the experts in their own lives and current struggles, thereby emphasizing that clients and providers can learn from each other.

The second tenet is to build collaboration beyond the provider–client relationship . Building ongoing relationships across the service system, provider networks, and the local community enhances TIC continuity as clients move from one level of service to the next or when they are involved in multiple services at one time. It also allows you to learn about resources available to your clients in the service system or community and to connect with providers who have more advanced training in trauma-specific interventions and services.

The third tenet emphasizes the need to ensure client/consumer representation and participation in behavioral health program development, planning, and evaluation as well as in the professional development of behavioral health workers . To achieve trauma-informed competence in an organization or across systems, clients need to play an active role; this starts with providing program feedback. However, consumer involvement should not end there; rather, it should be encouraged throughout the implementation of trauma-informed services. So too, clients, potential clients, their families, and the community should be invited to participate in forming any behavioral health organization’s plans to improve trauma-informed competence, provide TIC, and design relevant treatment services and organizational policies and procedures.

Trauma-informed principles and practices generated without the input of people affected by trauma are difficult to apply effectively. Likewise, staff trainings and presentations should include individuals who have felt the impact of trauma. Their participation reaches past the purely cognitive aspects of such education to offer a personal perspective on the strengths and resilience of people who have experienced trauma. The involvement of trauma survivors in behavioral health education lends a human face to subject matter that is all too easily made cerebral by some staff members in an attempt to avoid the emotionality of the topic.

Consumer participation also means giving clients/consumers the chance to obtain State training and certification, as well as employment in behavioral health settings as peer specialists. Programs that incorporate peer support services reinforce a powerful message—that provider–consumer partnership is important, and that consumers are valued. Peer support specialists are self-identified individuals who have progressed in their own recovery from alcohol dependence, drug addiction, and/or a mental disorder and work within behavioral health programs or at peer support centers to assist others with similar disorders and/or life experiences. Tasks and responsibilities may include leading a peer support group; modeling effective coping, help-seeking, and self-care strategies; helping clients practice new skills or monitor progress; promoting positive self-image to combat clients’ potentially negative feelings about themselves and the discrimination they may perceive in the program or community; handling case management tasks; advocating for program changes; and representing a voice of hope that views recovery as possible.

Familiarize the Client With Trauma-Informed Services

Without thinking too much about it, you probably know the purpose of an intake process, the correct way to complete a screening device, the meaning of a lot of the jargon specific to behavioral health, and your program’s expectations for client participation; in fact, maybe you’re already involved in facilitating these processes in behavioral health services every day, and they’ve become almost automatic for you. This can make it easy to forget that nearly everything clients and their families encounter in seeking behavioral health assistance is new to them. Thus, introducing clients to program services, activities, and interventions in a manner that expects them to be unfamiliar with these processes is essential, regardless of their clinical and treatment history. Beyond addressing the unfamiliarity of services, educating clients about each process—from first contact all the way through recovery services—gives them a chance to participate actively and make informed decisions across the continuum of care.

Familiarizing clients with trauma-informed services extends beyond explaining program services or treatment processes; it involves explaining the value and type of trauma-related questions that may be asked during an intake process, educating clients about trauma to help normalize traumatic stress reactions, and discussing trauma-specific interventions and other available services (including explanations of treatment methodologies and of the rationale behind specific interventions). Developmentally appropriate psychoeducation about trauma-informed services allows clients to be informed participants.

Incorporate Universal Routine Screenings for Trauma

Screening universally for client histories, experiences, and symptoms of trauma at intake can benefit clients and providers. Most providers know that clients can be affected by trauma, but universal screening provides a steady reminder to be watchful for past traumatic experiences and their potential influence upon a client’s interactions and engagement with services across the continuum of care. Screening should guide treatment planning; it alerts the staff to potential issues and serves as a valuable tool to increase clients’ awareness of the possible impact of trauma and the importance of addressing related issues during treatment.

Nonetheless, screenings are only as useful as the guidelines and processes established to address positive screens (which occur when clients respond to screening questions in a way that signifies possible trauma-related symptoms or histories). Staff should be trained to use screening tools consistently so that all clients are screened in the same way. Staff members also need to know how to score screenings and when specific variables (e.g., race/ethnicity, native language, gender, culture) may influence screening results. For example, a woman who has been sexually assaulted by a man may be wary of responding to questions if a male staff member or interpreter administers the screening or provides translation services. Likewise, a person in a current abusive or violent relationship may not acknowledge the interpersonal violence in fear of retaliation or as a result of disconnection or denial of his or her experience, and he or she may have difficulty in processing and then living between two worlds—what is acknowledged in treatment versus what is experienced at home.

In addition, staff training on using trauma-related screening tools needs to center on how and when to gather relevant information after the screening is complete. Organizational policies and procedures should guide staff members on how to respond to a positive screening, such as by making a referral for an indepth assessment of traumatic stress, providing the client with an introductory psychoeducational session on the typical biopsychosocial effects of trauma, and/or coordinating care so that the client gains access to trauma-specific services that meet his or her needs. Screening tool selection is an important ingredient in incorporating routine, universal screening practices into behavioral health services. Many screening tools are available, yet they differ in format and in how they present questions. Select tools based not just on sound test properties, but also according to whether they encompass a broad range of experiences typically considered traumatic and are flexible enough to allow for an individual’s own interpretation of traumatic events. For more information on screening and assessment of trauma and trauma-related symptoms and effects, see Chapter 4 , “Screening and Assessment,” in this TIP.

View Trauma Through a Sociocultural Lens

To understand how trauma affects an individual, family, or community, you must first understand life experiences and cultural background as key contextual elements for that trauma. As demonstrated in Exhibit 1.1-2 , many factors shape traumatic experiences and individual and community responses to it; one of the most significant factors is culture. It influences the interpretation and meaning of traumatic events, individual beliefs regarding personal responsibility for the trauma and subsequent responses, and the meaning and acceptability of symptoms, support, and help-seeking behaviors. As this TIP proceeds to describe the differences among cultures pertaining to trauma, remember that there are numerous cross-cutting factors that can directly or indirectly influence the attitudes, beliefs, behaviors, resources, and opportunities within a given culture, subculture, or racial and/or ethnic group ( Exhibit 1.1-4 ). For an indepth exploration of these cross-cutting cultural factors, refer to the planned TIP, Improving Cultural Competence (SAMHSA, planned c).

Exhibit 1.1-4

Cross-Cutting Factors of Culture.

Culture and Trauma

• Some populations and cultures are more likely than others to experience a traumatic event or a specific type of trauma.
• Rates of traumatic stress are high across all diverse populations and cultures that face military action and political violence.
• Culture influences not only whether certain events are perceived as traumatic, but also how an individual interprets and assigns meaning to the trauma.
• Some traumas may have greater impact on a given culture because those traumas represent something significant for that culture or disrupt cultural practices or ways of life.
• Culture determines acceptable responses to trauma and shapes the expression of distress. It significantly influences how people convey traumatic stress through behavior, emotions, and thinking immediately following a trauma and well after the traumatic experience has ceased.
• Traumatic stress symptoms vary according to the type of trauma within the culture.
• Culture affects what qualifies as a legitimate health concern and which symptoms warrant help.
• In addition to shaping beliefs about acceptable forms of help-seeking behavior and healing practices, culture can provide a source of strength, unique coping strategies, and specific resources.

When establishing TIC, it is vital that behavioral health systems, service providers, licensing agencies, and accrediting bodies build culturally responsive practices into their curricula, standards, policies and procedures, and credentialing processes. The implementation of culturally responsive practices will further guide the treatment planning process so that trauma-informed services are more appropriate and likely to succeed.

Use a Strengths-Focused Perspective: Promote Resilience

Fostering individual strengths is a key step in prevention when working with people who have been exposed to trauma. It is also an essential intervention strategy—one that builds on the individual’s existing resources and views him or her as a resourceful, resilient survivor. Individuals who have experienced trauma develop many strategies and/or behaviors to adapt to its emotional, cognitive, spiritual, and physical consequences. Some behaviors may be effective across time, whereas others may eventually produce difficulties and disrupt the healing process. Traditionally, behavioral health services have tended to focus on presenting problems, risk factors, and symptoms in an attempt to prevent negative outcomes, provide relief, increase clients’ level of functioning, and facilitate healing. However, focusing too much on these areas can undermine clients’ sense of competence and hope. Targeting only presenting problems and symptoms does not provide individuals with an opportunity to see their own resourcefulness in managing very stressful and difficult experiences. It is important for providers to engage in interventions using a balanced approach that targets the strengths clients have developed to survive their experiences and to thrive in recovery. A strengths-based, resilience-minded approach lets trauma survivors begin to acknowledge and appreciate their fortitude and the behaviors that help them survive.

“Trauma-informed care recognizes symptoms as originating from adaptations to the traumatic event(s) or context. Validating resilience is important even when past coping behaviors are now causing problems. Understanding a symptom as an adaptation reduces a survivor’s guilt and shame, increases their self-esteem and provides a guideline for developing new skills and resources to allow new and better adaptation to the current situation.” ( Elliot et al., 2005 , p. 467)

Advice to Counselors and Administrators: Using Strengths-Oriented Questions

Knowing a client’s strengths can help you understand, redefine, and reframe the client’s presenting problems and challenges. By focusing and building on an individual’s strengths, counselors and other behavioral health professionals can shift the focus from “What is wrong with you?” to “What has worked for you?” It moves attention away from trauma-related problems and toward a perspective that honors and uses adaptive behaviors and strengths to move clients along in recovery.

Potential strengths-oriented questions include:

• The history that you provided suggests that you’ve accomplished a great deal since the trauma. What are some of the accomplishments that give you the most pride?
• What would you say are your strengths?
• How do you manage your stress today?
• What behaviors have helped you survive your traumatic experiences (during and afterward)?
• What are some of the creative ways that you deal with painful feelings?
• You have survived trauma. What characteristics have helped you manage these experiences and the challenges that they have created in your life?
• If we were to ask someone in your life, who knew your history and experience with trauma, to name two positive characteristics that help you survive, what would they be?
• What coping tools have you learned from your _____ (fill in: cultural history, spiritual practices, athletic pursuits, etc.)?
• Imagine for a moment that a group of people are standing behind you showing you support in some way. Who would be standing there? It doesn’t matter how briefly or when they showed up in your life, or whether or not they are currently in your life or alive.
• How do you gain support today? (Possible answers include family, friends, activities, coaches, counselors, other supports, etc.)
• What does recovery look like for you?

Foster Trauma-Resistant Skills

Trauma-informed services build a foundation on which individuals can begin to explore the role of trauma in their lives; such services can also help determine how best to address and tailor interventions to meet their needs. Prevention, mental health, and substance abuse treatment services should include teaching clients about how trauma can affect their lives; these services should also focus on developing self-care skills, coping strategies, supportive networks, and a sense of competence. Building trauma-resistant skills begins with normalizing the symptoms of traumatic stress and helping clients who have experienced trauma connect the dots between current problems and past trauma when appropriate.

Nevertheless, TIC and trauma-specific interventions that focus on skill-building should not do so at the expense of acknowledging individual strengths, creativity in adapting to trauma, and inherent attributes and tools clients possesses to combat the effects of trauma. Some theoretical models that use skill-building strategies base the value of this approach on a deficit perspective; they assume that some individuals lack the necessary tools to manage specific situations and, because of this deficiency, they encounter problems that others with effective skills would not experience. This type of perspective further assumes that, to recover, these individuals must learn new coping skills and behavior. TIC, on the other hand, makes the assumption that clients are the experts in their own lives and have learned to adapt and acquire skills to survive. The TIC approach honors each individual’s adaptations and acquired skills, and it helps clients explore how these may not be working as well as they had in the past and how their current repertoire of responses may not be as effective as other strategies.

Advice to Administrators: Self-Assessment for Trauma-Informed Systems

NCTIC has developed a self-assessment package for trauma-informed systems to help administrators structurally incorporate trauma into programs and services. The self-assessment can be used by systems of care to guide quality improvement with the goal of establishing fully trauma-informed treatment and recovery efforts (NCTIC, Center for Mental Health Services, 2007). Behavioral health treatment program administrators can use these materials and NCTIC as resources for improvement in delivering TIC.

Demonstrate Organizational and Administrative Commitment to TIC

Becoming a trauma-informed organization requires administrative guidance and support across all levels of an agency. Behavioral health staff will not likely sustain TIC practices without the organization’s ongoing commitment to support professional development and to allocate resources that promote these practices. An agency that wishes to commit to TIC will benefit from an organizational assessment of how staff members identify and manage trauma and trauma-related reactions in their clients. Are they trauma aware—do they recognize that trauma can significantly affect a client’s ability to function in one or more areas of his or her life? Do the staff members understand that traumatic experiences and trauma-related reactions can greatly influence clients’ engagement, participation, and response to services?

Agencies need to embrace specific strategies across each level of the organization to create trauma-informed services; this begins with staff education on the impact of trauma among clients. Other agency strategies that reflect a trauma-informed infrastructure include, but are not limited to:

• Universal screening and assessment procedures for trauma.
• Interagency and intra-agency collaboration to secure trauma-specific services.
• Referral agreements and networks to match clients’ needs.
• Mission and value statements endorsing the importance of trauma recognition.
• Consumer- and community-supported committees and trauma response teams.
• Workforce development strategies, including hiring practices.
• Professional development plans, including staff training/supervision focused on TIC.
• Program policies and procedures that ensure trauma recognition and secure trauma-informed practices, trauma-specific services, and prevention of retraumatization.

TIC requires organizational commitment, and often, cultural change. For more information on implementing TIC in organizations, see Part 2, Chapter 1 of this TIP.

Develop Strategies To Address Secondary Trauma and Promote Self-Care

Secondary trauma is a normal occupational hazard for mental health and substance abuse professionals, particularly those who serve populations that are likely to include survivors of trauma ( Figley, 1995 ; Klinic Community Health Centre, 2008 ). Behavioral health staff members who experience secondary trauma present a range of traumatic stress reactions and effects from providing services focused on trauma or listening to clients recount traumatic experiences. So too, when a counselor has a history of personal trauma, working with trauma survivors may evoke memories of the counselor’s own trauma history, which may increase the potential for secondary traumatization.

The range of reactions that manifest with secondary trauma can be, but are not necessarily, similar to the reactions presented by clients who have experienced primary trauma. Symptoms of secondary trauma can produce varying levels of difficulty, impairment, or distress in daily functioning; these may or may not meet diagnostic thresholds for acute stress, posttraumatic stress, or adjustment, anxiety, or mood disorders ( Bober & Regehr, 2006 ). Symptoms may include physical or psychological reactions to traumatic memories clients have shared; avoidance behaviors during client interactions or when recalling emotional content in supervision; numbness, limited emotional expression, or diminished affect; somatic complaints; heightened arousal, including insomnia; negative thinking or depressed mood; and detachment from family, friends, and other supports ( Maschi & Brown, 2010 ).

Working daily with individuals who have been traumatized can be a burden for counselors and other behavioral health service providers, but all too often, they blame the symptoms resulting from that burden on other stressors at work or at home. Only in the past 2 decades have literature and trainings begun paying attention to secondary trauma or compassion fatigue; even so, agencies often do not translate this knowledge into routine prevention practices. Counselors and other staff members may find it difficult to engage in activities that could ward off secondary trauma due to time constraints, workload, lack of agency resources, and/or an organizational culture that disapproves of help-seeking or provides inadequate staff support. The demands of providing care to trauma survivors cannot be ignored, lest the provider become increasingly impaired and less effective. Counselors with unacknowledged secondary trauma can cause harm to clients via poorly enforced boundaries, missed appointments, or even abandonment of clients and their needs ( Pearlman & Saakvitne, 1995 ).

Essential components of TIC include organizational and personal strategies to address secondary trauma and its physical, cognitive, emotional, and spiritual consequences. In agencies and among individual providers, it is key for the culture to promote acceptability, accessibility, and accountability in seeking help, accessing support and supervision, and engaging in self-care behaviors in and outside of the agency or office. Agencies should involve staff members who work with trauma in developing informal and formal agency practices and procedures to prevent or address secondary trauma. Even though a number of community-based agencies face fiscal constraints, prevention strategies for secondary trauma can be intertwined with the current infrastructure (e.g., staff meetings, education, case consultations and group case discussions, group support, debriefing sessions as appropriate, supervision). For more information on strategies to address and prevent secondary trauma, see Part 2, Chapter 2 of this TIP.

The Impact of Trauma

Trauma is similar to a rock hitting the water’s surface. The impact first creates the largest wave, which is followed by ever-expanding, but less intense, ripples. Likewise, the influence of a given trauma can be broad, but generally, its effects are less intense for individuals further removed from the trauma; eventually, its impact dissipates all around. For trauma survivors, the impact of trauma can be far-reaching and can affect life areas and relationships long after the trauma occurred. This analogy can also broadly describe the recovery process for individuals who have experienced trauma and for those who have the privilege of hearing their stories. As survivors reveal their trauma-related experiences and struggles to a counselor or another caregiver, the trauma becomes a shared experience, although it is not likely to be as intense for the caregiver as it was for the individual who experienced the trauma. The caregiver may hold onto the trauma’s known and unknown effects or may consciously decide to engage in behaviors that provide support to further dissipate the impact of this trauma and the risk of secondary trauma.

Advice to Counselors: Decreasing the Risk of Secondary Trauma and Promoting Self-Care

• Peer support. Maintaining adequate social support will help prevent isolation and depression.
• Supervision and consultation. Seeking professional support will enable you to understand your own responses to clients and to work with them more effectively.
• Training. Ongoing professional training can improve your belief in your abilities to assist clients in their recoveries.
• Personal therapy. Obtaining treatment can help you manage specific problems and become better able to provide good treatment to your clients.
• Maintaining balance. A healthy, balanced lifestyle can make you more resilient in managing any difficult circumstances you may face.
• Setting clear limits and boundaries with clients. Clearly separating your personal and work life allows time to rejuvenate from stresses inherent in being a professional caregiver.

Provide Hope—Recovery Is Possible

What defines recovery from trauma-related symptoms and traumatic stress disorders? Is it the total absence of symptoms or consequences? Does it mean that clients stop having nightmares or being reminded, by cues, of past trauma? When clients who have experienced trauma enter into a helping relationship to address trauma specifically, they are often looking for a cure, a remission of symptoms, or relief from the pain as quickly as possible. However, they often possess a history of unpredictable symptoms and symptom intensity that reinforces an underlying belief that recovery is not possible. On one hand, clients are looking for a message that they can be cured, while on the other hand, they have serious doubts about the likely success of any intervention.

Clients often express ambivalence about dealing with trauma even if they are fully aware of trauma’s effects on their lives. The idea of living with more discomfort as they address the past or as they experiment with alternative ways of dealing with trauma-related symptoms or consequences is not an appealing prospect, and it typically elicits fear. Clients may interpret the uncomfortable feelings as dangerous or unsafe even in an environment and relationship that is safe and supportive.

How do you promote hope and relay a message that recovery is possible? First, maintain consistency in delivering services, promoting and providing safety for clients, and showing respect and compassion within the client–provider relationship. Along with clients’ commitment to learning how to create safety for themselves, counselors and agencies need to be aware of, and circumvent, practices that could retraumatize clients. Projecting hope and reinforcing the belief that recovery is possible extends well beyond the practice of establishing safety; it also encompasses discussing what recovery means and how it looks to clients, as well as identifying how they will know that they’ve entered into recovery in earnest.

Providing hope involves projecting an attitude that recovery is possible. This attitude also involves viewing clients as competent to make changes that will allow them to deal with trauma-related challenges, providing opportunities for them to practice dealing with difficult situations, and normalizing discomfort or difficult emotions and framing these as manageable rather than dangerous. If you convey this attitude consistently to your clients, they will begin to understand that discomfort is not a signal to avoid, but a sign to engage—and that behavioral, cognitive, and emotional responses to cues associated with previous traumas are a normal part of the recovery process. It’s not the absence of responses to such triggers that mark recovery, but rather, how clients experience and manage those responses. Clients can also benefit from interacting with others who are further along in their recovery from trauma. Time spent with peer support staff or sharing stories with other trauma survivors who are well on their way to recovery is invaluable—it sends a powerful message that recovery is achievable, that there is no shame in being a trauma survivor, and that there is a future beyond the trauma.

• As You Proceed

This chapter has established the foundation and rationale of this TIP, reviewed trauma-informed concepts and terminology, and provided an overview of TIC principles and a guiding framework for this text. As you proceed, be aware of the wide-ranging responses to trauma that occur not only across racially and ethnically diverse groups but also within specific communities, families, and individuals. Counselors, prevention specialists, other behavioral health workers, supervisors, and organizations all need to develop skills to create an environment that is responsive to the unique attributes and experiences of each client. As you read this TIP, remember that many cross-cutting factors influence the experiences, help-seeking behaviors, intervention responses, and outcomes of individuals, families, and populations who have survived trauma. Single, multiple, or chronic exposures to traumatic events, as well as the emotional, cognitive, behavioral, and spiritual responses to trauma, need to be understood within a social-ecological framework that recognizes the many ingredients prior to, during, and after traumatic experiences that set the stage for recovery.

• Cite this Page Center for Substance Abuse Treatment (US). Trauma-Informed Care in Behavioral Health Services. Rockville (MD): Substance Abuse and Mental Health Services Administration (US); 2014. (Treatment Improvement Protocol (TIP) Series, No. 57.) Chapter 1, Trauma-Informed Care: A Sociocultural Perspective.
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