Trauma-informed care in child/family welfare services

CFCA Paper No. 37 – February 2016

What is trauma-informed care?

Trauma-informed care could be described as a framework for human service delivery that is based on knowledge and understanding of how trauma affects people's lives and their service needs (Harris & Fallot, 2001). This requires consideration of a person's environment beyond the immediate service being provided and of how their symptoms and presentations may be seen as adaptations to trauma rather than as pathologies (Herman, 1992). At the broadest level, trauma-informed care means that services have an awareness and sensitivity to the way in which clients' presentation and service needs can be understood in the context of their trauma history (Knight, 2015). Kezelman and Stavropoulos (2012) noted that trauma-informed health and welfare settings and systems contrast dramatically with traditional settings and systems as they require different ways of operating, and without this understanding, risk re-traumatising service users. Trauma-informed approaches to care could be described as a strengths-based framework that is responsive to the effects of trauma (Bateman et al., 2013).

Principles of trauma-informed care

Principles of trauma-informed care have been articulated in a range of academic literature and guidance publications (Elliot et al., 2005; Hopper et al., 2010; Jennings, 2004; Kezelman & Stavropoulos, 2012; SAMHSA, 2014). These principles vary in length and number depending on the publication but essentially have the same underlying philosophies, that trauma-informed care means services are trauma aware, safe, strengths-based and integrated.

At the very minimum, trauma-informed services aim to do no further harm through re-traumatising individuals by acknowledging that usual operations may be an inadvertent trigger for exacerbating trauma symptoms. SAMHSA's (2014) approach to trauma-informed care makes four key assumptions that must be present as a basis of implementation for trauma-informed care, with a further six key principles to then be applied.

The key assumptions that SAMHSA has identified as needing to be inherent in any trauma-informed approach are based on four "R"s:

  • Realisation at all levels of an organisation or system about trauma and its impacts on individuals, families and communities;
  • Recognition of the signs of trauma;
  • Response - program, organisation or system responds by applying the principles of a trauma-informed approach; and
  • Resist re-traumatisation - of clients as well as staff.

In addition to these assumptions, SAMHSA (2014) then described six key principles of a trauma-informed approach:

  • Safety - Staff and the people they serve feel physically and psychologically safe.
  • Trustworthiness and transparency - Organisational operations and decisions are transparent and trust is built.
  • Peer support - Peers is the terminology SAMHSA use for individuals with lived experience of trauma or their caregivers. Peers are also known as "trauma survivors".
  • Collaboration and mutuality - This principle is about levelling power differentials between staff and clients and amongst organisational staff to ensure a collaborative approach to healing.
  • Empowerment, voice and choice - This principle emphasises the strengths-based nature of trauma-informed care. The organisation - and ideally the whole service delivery system - fosters recovery and healing.
  • Cultural, historical and gender issues - A trauma-informed approach incorporates processes that move past cultural stereotypes and biases, and incorporates policies, protocols and processes that are responsive to the cultural needs of clients.

For an example of an Australian model of trauma-informed care, see Tucci and Mitchell's (2015) outline of the basic understanding of trauma that informs appropriate care underpinning the services and training provided by the Australian Childhood Foundation: 9 Plain English Principles of Trauma Informed Care <www.childhood.org.au/blog/home/2015/april/trauma-informed-care>.

The Berry Street Childhood Institute also provides a number of resources and training on trauma-informed care for children: <www.childhoodinstitute.org.au/Resources>.

Achieving trauma-informed services: Reflection questions for service managers

  • What is the likelihood of clients who have experienced trauma accessing our service?
  • Do we provide access to trauma-specific evidence-based treatments for current psychological difficulties that result from that trauma (e.g. Trauma-focused cognitive-behaviour therapy)?
    • See Trauma-Focused Cognitive Behavioral Therapy for Children Affected by Sexual Abuse or Trauma <www.childwelfare.gov/pubpdfs/trauma.pdf>
  • Do we provide access to effective treatments for complex trauma and complex PTSD (for which trauma-specific treatments may not be as effective)?
    • (See: Connor & Higgins, 2008a, 2008b; Kezelman & Stavropoulos, 2012).
  • Are these trauma-specific interventions provided inhouse, in collaboration with other agencies, or via referral to an external agency (and if so, do we provide active/warm referral)? See:
    • Interagency collaboration: Part A. What is it, what does it look like, when is it needed and what supports it? <aifs.gov.au/cfca/publications/interagency-collaboration-part-what-it-what-does-it>
    • Interagency collaboration: Part B. Does collaboration benefit children and families? Exploring the evidence. <aifs.gov.au/cfca/publications/interagency-collaboration-part-b-does-collaboration-benefi>
    • Effective practices for service delivery coordination in Indigenous communities. <www.aihw.gov.au/uploadedFiles/ClosingTheGap/Content/Publications/2011/ctgc-rs-08.pdf>
  • How do we incorporate restorative justice principles?
    • According to Higgins et al. (2014), restorative justice activities might include:
      • addressing trauma and other mental health consequences through evidence-based therapeutic interventions;
      • repairing the injuries caused to relationships, especially between sons/daughters and parents;
      • providing opportunities for truth-telling, storytelling and acknowledgement; and
      • overcoming shame and recognising past actions through public activities and community awareness campaigns.
    • See: Higgins et al., 2014, pp. 41-46: Forced Adoption Support Services Scoping Study <www.dss.gov.au/our-responsibilities/families-and-children/publications-articles/forced-adoption-support-services-scoping-study>
  • Who in the organisation is likely to come into contact with individuals who have experienced trauma, or be providing information to, or receiving communications from clients experiencing trauma? Thinking from a "client journey" perspective, this might include:
    • phone/intake staff;
    • web/staff with online monitoring;
    • reception;
    • office manager;
    • media and communications staff;
    • other staff or contractors on the premises (e.g. catering, cleaning, security); and
    • project/service delivery professionals and support staff.
  • Who is less likely to be interacting with trauma survivors but who need to understand, and who need to support "front-line" workers and other support staff who do?
    • executive staff (who create the authorising environment);
    • managers and team leaders; and
    • mentors and supervisors.

This suggests the value of whole-of-organisation approaches to trauma-informed service delivery, directed at every level to ensure a focus on what helps clients feel safe.

  • What should training encompass? Training should include:
    • skills in de-escalation or "holding" clients who are experiencing an acute episode of trauma or re-traumatisation;
    • debriefing and staff protocols for responding to difficult situations and clients presenting with complex circumstances and trauma histories;
    • information on staff care and preventing/responding to secondary or vicarious trauma - the psychological term for changes that can occur to people when they are repeatedly exposed to traumatic material (see <aifs.gov.au/publications/feeling-heavy>);
    • organisational supports to prevent or address vicarious trauma for staff including: clinician self-care skills and reflective practice, caseload management, supervision, debriefing, staff and peer support, workplace safety, comfort and supportive work culture that acknowledges the reality of vicarious trauma (Morrison, 2007);
    • types of events/circumstances in clients' lives that may be traumatising;
    • typical modes of reacting - events/triggers for re-traumatisation; and
    • understanding the impacts of trauma (such as behavioural symptoms typical of PTSD, as well as the developmental impacts of victimisation and trauma on an individual's beliefs - about the self, the world, and the future - e.g. see: Janoff-Bulman & Frieze, 1983).

Further to this, SAMHSA also provide a range of sample questions to consider when implementing a trauma-informed approach (PDF 789 KB) <store.samhsa.gov/shin/content//SMA14-4884/SMA14-4884.pdf> (p.14-16).