Trauma-informed care in child/family welfare services
- Trauma terminology
- What is the evidence that a trauma-informed approach is needed?
- What is trauma-informed care?
- Which services should be delivering trauma-informed care?
- Challenges in implementing a trauma-informed approach to care
- Applying trauma-informed care principles
- Moving forward
There has been extensive debate around the classification and terminology for describing the effects of trauma, as well as the relationship to specific diagnostic terms such as post-traumatic stress disorder (Van der Kolk, Roth, Pelcovitz, Sunday, & Spinazzola, 2005; Wall & Quadara, 2014). The latest iteration of the Diagnostic and Statistical Manual of Mental Disorders (American Psychiatric Association, 2013), an international classification system for mental health disorders, has taken a broad approach to the terminology with a category of "Trauma and Stressor Related Disorders" rather than specifically including complex trauma as a diagnostic term.
Any discussion of trauma-informed service delivery requires consideration of the vast array of definitions and terminology that arises around trauma. This section explains some of the different terms, phrases and concepts that are used in the literature to describe trauma and trauma-related service provision.
Recently, there have been attempts to provide consistency in definitions and a shared language around trauma and a trauma-informed approach to care. SAMHSA's (2014) Concept of Trauma and Guidance for a Trauma-Informed Approach puts forward definitions and a working concept of trauma and a trauma-informed approach in order to develop a shared understanding of these concepts for service systems and stakeholders. SAMHSA is a key resource for trauma-informed approaches to care and these definitions are likely to be widely adopted.
What is trauma?
Traumatic events have been described as those that "overwhelm the ordinary human adaptations to life [and] … generally involve threats to life or bodily integrity, or a close personal encounter with violence and death" (Herman, 1992, p. 33). SAMHSA's concept of trauma provides a comprehensive definition that encompasses trauma related to one-off events as well as ongoing adversity:
Individual trauma results from 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 wellbeing. (SAMHSA, 2014, p. 7)
Although not diagnostic terms, complex trauma and complex post-traumatic stress disorder are often used to describe trauma that is the result of stressors that are interpersonal - usually severe, sustained and perpetrated by one human being on another - and where clients may not meet all of the specific diagnostic criteria for post-traumatic stress disorder (PTSD) or where the primary clinical presentation is the associated features due to the global effects of trauma on the person's functioning (Connor & Higgins, 2008a, 2008b). Trauma is particularly damaging when it occurs in childhood. Complex, interpersonally generated trauma is severely disruptive of a person's capacity to manage internal states (Kezelman & Stavropoulos, 2012). Complex trauma symptoms include problems with mood regulation, impulse control, self-perception, attention, memory and somatic disorders (Briere & Jordan, 2004; Burstow, 2003; van der Kolk et al., 2005).
Trauma-informed interventions occur at two levels: trauma-specific interventions and trauma-informed models of care. Organisational responses to trauma tend to occur on a continuum from basic trauma awareness, to trauma sensitivity, trauma responsivity and through to trauma-informed and/or trauma-specific interventions. We argue here that it is helpful for organisations providing services in the child/family welfare domain, and human services more broadly, to think about their organisational responses to trauma based on their particular service and client needs.
Trauma-specific interventions refer to clinical services or programs designed to treat and ameliorate the actual symptoms and presentations of trauma. While it is possible for individual practitioners to deliver trauma-specific interventions (such as trauma-focused cognitive behaviour therapy [CBT]) within the context of a service delivery model or agency that is not trauma-informed at a system level, this is far from ideal. Elements of a service may not be consistent with a trauma-informed approach - such as the waiting room design and operation, interactions with administrative staff or the absence of adjunct services to address other presenting issues for which the trauma-specific intervention might not be effective. Trauma-specific services are best delivered as part of a trauma-informed system of care operating within a trauma-aware organisational context (Elliot, Bjelajac, Fallor, Markoff, & Reed, 2005; Kezelman & Stavropoulos, 2012).
Funded by the Department of Veterans' Affairs, Phoenix Australia (previously known at the Australian Centre for Posttraumatic Mental Health) has developed a database that summarises the evidence for effective trauma-specific interventions related to military and veteran families and communities (see What Emerging Interventions are Effective for the Treatment of Adults with PTSD? <www.evidencecompass.dva.gov.au/home/question/10>). Regarding adults suffering from PTSD, they found a paucity of evidence in relation to the efficacy of emerging therapies.1 Phoenix Australia have also published a variety of resources for practitioners working with people affected by trauma, including fact sheets, clinical guidelines, booklets for clients and a smartphone app for clients with post-traumatic stress symptoms <phoenixaustralia.org/for-practitioners/practitioner-resources>.
Trauma-focused cognitive behaviour therapy (TF-CBT) is an evidence-based treatment approach for children who have experienced sexual abuse, exposure to domestic violence or similar traumas.2 TF-CBT features on a range of databases of evidence-based practices, including the California Evidence-Based Clearinghouse for Child Welfare (CEBC) Program Registry: <www.cebc4cw.org>. Training in TF-CBT is available online from the Medical University of South Carolina website: <tfcbt.musc.edu>. However, a full discussion of evidence-based trauma-specific interventions is beyond the scope of this paper.3
Similarly, in relation to adults affected by childhood trauma, Connor and Higgins (2008a, 2008b) outlined a model of trauma-specific intervention for clients who experience complex trauma (who may not meet the criteria for PTSD). Evaluating the model, they found qualitative and quantitative evidence from a small-scale pilot study of the effectiveness of their combined individual and group therapy approach focused on the following elements (using the mnemonic "HEALTH"):
- having a supportive therapist;
- ensuring personal safety;
- assisting with daily functioning;
- learning to manage core PTSD symptoms (self-regulation);
- treating complex PTSD symptoms; and
- having patience and persistence to enable "ego strengthening".
However, there have been criticisms made of trauma-specific interventions. For example:
- complex trauma is often inter-relational in nature, so the degree to which research on the treatment of combat-related PSTD applies in these circumstances has been questioned (e.g. for those exposed to prolonged child sexual abuse, particularly if it has resulted in personality or dissociative disorders and is associated with disturbances to affect regulation, self-concept and interpersonal relationships);
- treatment sessions may need to be more frequent and over a longer duration than typical structured programs;
- evaluations of cognitive-based interventions often focus on statistically significant effect sizes rather than clinically meaningful symptom reduction; and
- the value of non-cognitively based interventions, which have been poorly evaluated or not evaluated, are easily overlooked (see: van der Kolk, 2014).
The primary purpose of the paper is not to review the effectiveness - or limitations - of trauma-specific interventions, or even to look specifically at complex trauma and complex PTSD (see: Wall & Quadara, 2014); but rather to explore the broader issue of the value and role of trauma-informed care in child and family welfare service provision.
Trauma-informed model of care
The available literature suggests that there is a continuum from being trauma aware (seeking information out about trauma and its implications for organisations) to being trauma-informed (a cultural shift at the systemic level). One useful resource sets out the progression in four stages (see Figure 1):
- trauma aware: seek information out about trauma;4
- trauma sensitive: operationalise concepts of trauma within the organisation's work practice;
- trauma responsive: respond differently, making changes in behaviour;
- trauma informed: entire culture has shifted to reflect a trauma approach in all work practices and settings.
Figure 1: Practical steps to get from trauma aware to trauma informed
Source: Adapted by Antonia Quadara from Mieseler & Myers (2013)
Figure 1 for screen readers
SAMHSA's definition of a trauma-informed approach to service is:
A program, organisation or system that is trauma-informed realises the widespread impact of trauma and understands potential paths for recovery; recognises the signs and symptoms of trauma in clients, families, staff and others involved with the system and responds by fully integrating knowledge about trauma into policies, procedures and practices and seeks to actively resist retraumatisation (SAMHSA, 2014, p. 9)
The main aim of this paper is to explore trauma-informed approaches to care and service delivery specifically in the child and family welfare sectors. While the focus is on how child/family welfare services can be trauma informed, the need extends to other service delivery areas. The trauma literature indicates that trauma survivors are clients in a very broad range of human services such as:
- homelessness (Hopper et al., 2010; Morrison 2009);
- mental health (Kezelman & Stavropoulos, 2012; Muskett, 2014);
- substance abuse treatment; and
- correctional systems (Stathopoulos, 2012).
These types of services have a clear connection to the impacts of trauma, particularly trauma arising from interpersonal victimisation, which has been identified as a driver of human service use (Huntington, Moses, & Veysey, 2005). The term "complex needs" is sometimes used to describe the span of need for an array of services required over a lifetime (Wall & Quadara, 2014). These agencies and services would benefit from being - at a minimum - "trauma aware".
1 The emerging interventions included in their review were: mindfulness, acceptance and commitment therapy, meditation, transcendental meditation, acupuncture, power therapies, and experiential psychotherapies including adventure therapy, art therapy, music therapy, and canine- and equine-assisted psychotherapy. See: <evidencecompass.dva.gov.au/home/question/10>.
2 See: Trauma-Focused Cognitive Behavioral Therapy for Children Affected by Sexual Abuse or Trauma(Child Welfare Information Gateway, 2012) <www.childwelfare.gov/pubpdfs/trauma.pdf>.
3 See Approaches Targeting Outcomes for Children Exposed to Trauma Arising From Abuse and Neglect: Evidence, Practice and Implications (Australian Centre for Posttraumatic Mental Health & Parenting Research Centre, 2014) for a discussion of the evidence of the effectiveness of trauma-specific and trauma-informed practices pertaining specifically to children who have experienced abuse and neglect.
4 At its most basic level, organisations that are trauma aware incorporate trauma awareness into their work. Staff have an understanding of trauma and how symptoms and behavioural presentations in individuals may be responses to traumatic experiences so that behaviours that appear self-destructive or self-defeating can be acknowledged as being adaptive behaviours to trauma that have become maladaptive over time (Hopper, Bassuk, & Olivet, 2010; Markoff, Fallot, Reed, & Elliot, 2005). This applies particularly to broader human service delivery agencies (beyond child/family welfare), particularly if they are not primarily focused on delivering trauma-specific interventions and/or trauma-informed models of care.