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
Which services should be delivering trauma-informed care?
Most of the US literature about trauma-informed care is directed at change in behavioural health services. In Australia there appears to be an emphasis on driving change in the mental health sector. This has the potential to cause confusion about the pathway to providing trauma-informed care in the child, family and community sectors and about what being trauma-informed actually means. One aspect of clarifying these questions is to understand which services should be adopting a trauma-informed approach to human service delivery.
In addition, there are communities and populations for whom violence and intergenerational trauma are a constant reality. Some Indigenous communities, for example, experience the phenomenon of trans-generational trauma whereby trauma is transmitted across a number of generations (Atkinson, 2002). The historical impacts of colonisation on Aboriginal people in Australia have played out in a history of disadvantage and discrimination as traditional Aboriginal life was gradually disrupted and dismantled (Atkinson, 2002; Keel, 2004). The effectiveness of the full range of health and human services in such communities could be enhanced by a trauma-informed approach (Atkinson, 2013).
As outlined in the earlier discussion on principles of trauma-informed care, it is important for services to be culturally attuned and relevant (Atkinson, 2013). This is described by SAMHSA as the principle that the trauma-informed organisation actively moves past cultural and gendered stereotypes and incorporates policies and processes that are responsive to the cultural needs of individuals served, including addressing historical trauma (SAMHSA, 2014) or collective trauma (Atkinson, 2013).
Building on the work of Harris and Fallot, SAMHSA's (2014) Concept of Trauma and Guidance for a Trauma-Informed Approach outlined ten implementation domains:
- governance and leadership;
- physical environment;
- engagement and involvement;
- cross-sector collaboration;
- screening, assessment, treatment services;
- training and workforce development;
- progress monitoring and quality assurance;
- financing; and
- evaluation (p. 12).
This guidance information is designed to provide a starting point for an organisational approach to implementing trauma-informed care. It also indicates that organisations across all settings should consider how trauma-informed approaches could benefit stakeholders regardless of whether they deal with trauma in their day-to-day business. The reality of the prevalence of traumatic experiences in the general population indicates that trauma is not confined to prevention, treatment and recovery settings but is integral in other systems as well (SAMHSA, 2014).
It is important to note that many practices that service providers currently use are likely to already be consistent with a trauma-informed approach, such as conveying empathy and validating the client's experiences (Knight, 2015). What is different about identifying as a trauma-informed service is that there is a paradigm shift in service delivery culture to acknowledge and clearly articulate the importance of trauma in understanding and responding to client presentation.
With the lack of an overarching framework in Australia, there is a danger of developing trauma-informed models and practices that are not sharing a consistent language about what being trauma-informed entails. This issue is discussed in more depth in the section about challenges to implementation later in this paper.
The need for a systems approach to trauma-informed care
Following the lead of the USA, Australian health agencies are moving towards a trauma-informed paradigm for considering health and human service delivery systems (Kezelman & Stavropoulos, 2012) in preference to a medical model of individual illness (DeCanandia, Guarino, & Clervil, 2014).
The effects of traumatic experience often manifest in behaviours that result in people being involved in human service systems that go beyond mental health, such as the criminal justice system (SAMHSA, 2014). A systems approach to trauma-informed care means that implementation goes beyond individual practitioner and service organisation change to extend to whole systems that people who have experienced trauma are likely to interact with. A system, for example, could include the justice, homelessness or child welfare systems. These systems may not include treatment settings but can still affect the people who experience them. In the USA, a range of systems are in the process of adopting a cross-sectoral approach to implementing trauma-informed care and trauma-specific services to support service users (DeCanandia et al., 2014). For example, the behavioural health and health care, veterans' administration, homelessness and education sectors are just a few of the systems that are shifting to a trauma-informed approach (DeCanandia et al., 2014).
The differences between trauma-informed services and trauma-specific services are described in the definitions outlined earlier. It is important to distinguish between them but acknowledge the intersection of the two types. Trauma-specific services are designed to treat the symptoms or manifestations of the effect of a trauma on an individual but these interventions must be delivered in a trauma-informed context. This emphasises an overall philosophy of trauma as a central concept in understanding the presentation of clients within a range of health and welfare settings (Kezelman & Stavropoulos, 2012).