# Motivation and emotion/Book/2023/Trauma-informed care

* Multimedia presentation (3 min)

## Overview

* Figure 1. Trauma can make people feel lonely, isolated, and sad.
* Ariana is a 25-year-old survivor of long-term domestic violence and experiences symptoms of post-traumatic stress disorder (PTSD), such as being easily frightened, trouble sleeping, and nightmares. After years of suppressing her emotions, she finally builds up the courage to seek help and see a psychologist. When she has her first session, the psychologist completely dismisses her experiences and invalidates her feelings. These actions are retraumatising due to not providing the client with a safe and supportive environment. From this experience, she does not pursue future mental health treatment. This results in increased distress throughout her life course, strains in relationships, and the emergence of new symptoms. (See Figure 1).
* This case scenario emphasises the importance of creating a safe and supportive environment for people who have experienced trauma. In healthcare, this is referred to as trauma-informed care. Numerous studies have supported that trauma-informed care is important in ensuring individuals feel respected and empowered. This book chapter explores what exactly trauma-informed care involves, and how it can be implemented.
The failure to recognise and acknowledge trauma within the healthcare systems leads to substandard care, underscoring the significance of addressing trauma-informed care. On estimate, 75% of Australian adults have experienced a traumatic event at least once (Health & Welfare, 2022). Additionally, the prevalence rate of Post Traumatic Stress Disorder (PTSD) in Australia is 7.2% over a lifetime (Cooper et al., 2014). These empirical findings demonstrate the need for trauma-informed care in the healthcare industry because it acknowledges that many people have lived through trauma, causing serious, negative impacts. These can include incorrect diagnoses, inadequate treatment, and re-traumatisation. Unfortunately, the reality is that the lack of acknowledgement of trauma does frequently occur.
Several theories have influenced the current understanding of trauma-informed care. These theories have shed light on the profound psychological, physiological, and emotional impacts of trauma, and proposes evidence-based ideas to describe this phenomenon. The enrichment of trauma-informed care is therefore guided by different influential psychological theories, facilitating a more profound comprehension. Additionally, many different frameworks have been formulated to target trauma-informed care.[vague]
* Focus Questions
* What is trauma?
* What are the impacts of trauma?
* What is trauma-informed care?
* What are theoretical underpinnings of trauma and trauma-informed care?
* How can trauma-informed care be implemented?

## What is trauma?

Trauma can be defined as long-lasting adverse impacts on an individual's wellbeing due to the experience of a distressing event, or series of events (Menschner & Maul, 2016). These experiences can vary widely in nature and intensity, causing a range of emotional, psychological, and physiological responses. Esther Giller (1999) refers to psychological trauma as the unique individual experience of extreme stress that overwhelms the ability to cope emotionally, cognitively, and physically and impacts varying areas of wellbeing. Commonly, the event's conditions involve abuse of power, betrayal of trust, pain, or loss.

### What are different types of trauma?

There are two distinct categories of traumatic experiences, which often result in different impacts on individuals. Type I and type II trauma categories are helpful in developing a better understanding of the multi-layered concept of trauma and appropriate care for individual wellbeing.
* Type I: A single traumatic event at a high level of acute threat.
* Examples: Severe illness, loss, motor vehicle accident, severe injury, medical trauma
* Type II: Repeated of traumatic events that occur over an extended period of time (Stefanovic et al., 2022).
* Examples: Domestic violence, child abuse, child neglect, emotional abuse

### Post-traumatic stress disorder

Post-traumatic stress disorder (PTSD) is a diagnosable disorder stemming from exposure to trauma, characterized by persistent, debilitating symptoms that significantly disrupt daily life (Young & Breslau, 2016). Unlike experiencing trauma, PTSD follows specific diagnostic criteria, measuring the duration and severity of symptoms. Individuals with PTSD experience distressing symptoms such as vivid flashbacks, disrupted sleep, and distressing nightmares, which compound stress and impede restorative rest.

### Impacts of trauma

[Provide more detail]

#### Psychological

Exposure to traumatic events frequently exerts a profound influence on all dimensions of well-being. From a psychological perspective, the experience of trauma renders individuals to be more susceptible to the emergence of a diverse array of mental health disorders[factual?]. A comprehensive study disclosed that 89% of individuals [where?] diagnosed with severe mental health disorders reported a history of exposure to traumatic events (Subica et al., 2012). The enduring repercussions of psychological stress and trauma are substantial, often manifesting in emotional, cognitive, and behavioural challenges. These encompass avoidance behaviours and the struggle to regulate emotions effectively. In more depth, it becomes evident that trauma exposure constitutes a significant risk factor for the development of severe drug use[factual?]. Empirical investigations have explicitly demonstrated a positive correlation between symptoms of PTSD and substance abuse, shedding light on the intricate association between trauma and psychological dependence on alcohol and other drug use (Clark et al., 2001).

#### Physiological

Trauma can cause varying physiological impacts on the body. High-reported Adverse Childhood Experiences (ACEs) correlate with increased adult prevalence of health issues like cancer, lung disease, and obesity (Felitti et al., 1998). Psychological trauma can lead to a range of serious health illnesses because traumatic events dysregulate the hypothalamic-pituitary-adrenal axis (HPA), sympathetic nervous system, and the inflammatory response (Kendall-Tackett, 2009). The HPA axis can be shown in Figure 2. By overusing the stress response, increased cortisol levels and prolonged activations can result from dysregulating the normal function of the HPA axis. This then leads to further various consequences on both psychological and physical health. People with PTSD have also shown to have significant alterations in brain structure and function in response to trauma-related condition (Bremner, 2022). This can be explained by prolonged increases in cortisol and norepinephrine, leading to disruptions in certain brain functions (Bremner, 1999). Additionally, further studies have revealed that chronic stress leads to adverse effects on cardiovascular functioning because of prolonged alterations to systolic blood pressure (D’Andrea et al., 2011). Increased surges in hormones in the body when it is under stress makes the heart to beat faster and narrows the blood vessels, causing the blood pressure to increase for a extensive time (Turner, 1994). This results in lasting changes to cardiovascular function.

#### Social

Trauma significantly affects social environments, particularly interpersonal relationships, often leading to communication difficulties and strained connections. Research shows that individuals who have experienced trauma tend to develop lower trust levels and negative beliefs about others (Bell et al., 2019). This stems from direct experiences of betrayal or harm, shaping expectations for future social interactions, as explained by Attribution theory (Williams et al., 1993). Additionally, confirmation bias further deepens mistrust by reinforcing existing beliefs. Collective trauma also has profound societal effects, influencing community dynamics and leading to issues like generational trauma.

## What is trauma-informed care?

Trauma-informed care constitutes a comprehensive approach to evidence-based treatment and organisational delivery practices[factual?]. This approach acknowledges the widespread influence of trauma and highlights the importance of creating a safe environment. The multi-layered concept of safety allows individuals to feel comfortable and supported, which is foundational in recovery and healing[factual?]. The fundamental aim is to equip healthcare providers with a better insight and understanding of how trauma significantly influences individuals, opening a pathway to more effective client engagement and better health outcomes (Wilson et al., 2013). Being trauma-informed extends beyond therapeutic environments and can apply to all organisational practices[factual?]. Studies on ACE and trauma over time have been evolutionary to the development and progression of holistic trauma informed care (Oral et al., 2016). The valuable awareness of ACEs is crucial in tailoring service delivery to minimise the risk of triggers and maximise positive experiences[factual?]. Such studies[factual?] allow a shift towards a more empathetic, sensitive, and influential approach to delivery and yield more comfort for individuals seeking assistance.
Another valuable benefit is that increased awareness of trauma and its potential manifestations in different settings helps ensure that people are not inadvertently exposed to situations that may activate distressing emotions and trigger their trauma. In terms of social impacts, trauma-informed care can lead to the improvement of relationships through emphasising empathy and open communication. The acknowledgement of trauma creates an environment where people are more likely to feel validated and empowered.[factual?]
* Case study: After enduring her symptoms for an extended period, Ariana decided to try seek help again, despite her previous negative experience. The compassionate approach of the entire team, from receptionists to clinicians, created a comfortable environment for her. The psychologist conducted a thorough and sensitive assessment, acknowledging her traumatic experiences with respect for her safety and boundaries. This led to significant improvements in Ariana's psychological, physical, and social wellbeing. She continued attending appointments and felt at ease sharing her experiences, resulting in appropriate and effective treatment.

## What are the theoretical underpinnings of trauma and trauma-informed care?

[Provide more detail]

### Ferenczi's trauma theory

Sándor Ferenczi's theory was one of the early theories in the field of psychoanalysis and laid the foundation for modern theories on trauma (Frankel, 1998). Through his studies of trauma, particularly early childhood, he discovered and emphasised the importance of empathetic responses in building trust in therapeutic relationships. The emphasis on empathy within therapeutic relationships is advocated in this theory by recognising that unresolved trauma can increase quantities of symptoms. Ferenczi's apprehension expanded Sigmund Freud's earlier ideas on trauma, offering a more refined understanding of its complex impacts on people and emotions. The modern-day understanding of trauma continues to build upon Ferenczi's understanding of trauma (Mészáros, 2010).

### Maslow's hierarchy of needs

Abraham Maslow's (1943) Hierarchy of Needs is a psychological theory that outlines a crucial model of understanding human needs. The theory posits that more basic needs that are lower down on the pyramid, such as physiological and safety needs, need to be satisfied before attending to higher needs, such as esteem, and self-actualisation (McLeod, 2007). Figure 2 visually presents Maslow's Hierarchy. In the context of trauma-informed care, this hierarchy offers insight into recognising that individuals who have experienced trauma may have compromised basic needs that need to be addressed.
The use of Maslow's theory in trauma-informed care goes beyond meeting basic needs and encompasses the aspiration of self-actualisation for individuals who have experienced trauma. The matrix attempts to explain how the best practice for trauma-informed care is not only to meet safety and physiological needs but to be supportive in achieving self-actualisation for individuals (Laser-Maira et al., 2019). This aspect of the theory underscores the importance of fostering the capacity of personal development and growth. By incorporating this understanding, health professionals must strive to create an environment that fosters resilience and highlights individual capacity. Overall, this theory builds a foundation for holistic approaches to trauma-informed care by addressing the comprehensive spectrum of needs for wellbeing.

### Polyvagal theory

The Polyvagal Theory by Dr. Stephen Porges (1990) holds a significant relevance in comprehending trauma, ultimately shaping interventions for effective trauma-informed care. This theory draws upon the important role of the autonomic nervous system (ANS) when responding to stress. According to this theory, there are distinct parts of the ANS that are associated with physiological and behavioural responses to stress. For example, the sympathetic nervous system (SNS) is associated with the "fight or flight" response and prepares the body for perceived threats. People who have experienced trauma may have a more sensitive and responsive SNS, highlighting the importance of providing a safe environment to engage in valuable interactions (Hastings & Miller, 2014). Through understanding how trauma affects the autonomic nervous system, appropriate interventions that respond to physiological responses can be employed that are tailored to the body's reactions to distressing experiences. For instance, breathing exercises can be utilised to activate the ventral vagal complex, which is associated with the relaxation process and regulates the autonomic nervous system (Porges, 2011).

## How can trauma-informed care be implemented

Trauma-informed care, grounded in psychological theories[factual?], requires a secure and supportive environment that prioritises individual autonomy and empowerment. Recognising the impact of trauma on various dimensions of an individual's well-being fosters improved collaboration between individuals and their healthcare providers[factual?]. This approach encompasses sensitivity to triggers and employs appropriate framework and therapeutic strategies to promote overall well-being.

### Framework

The SAMHSA Concept of Trauma and Guidance for Trauma-Informed Approach is a widely used framework that provides a comprehensive outline for implementing trauma-informed care (Huang et al.,2014). It underpins the importance of safety, choice, trustworthiness, collaboration, and empowerment as principles for impactful care towards people who have experienced trauma. These principles provide a clear foundation for trauma-informed care:
* Safety addresses the critical importance of fostering an environment where people can feel both physically and emotionally protected.
* The principle of choice highlights the significance of providing individuals with autonomy in their decision-making by respecting their personal preferences and providing a sense of freedom.
* The next fundamental concept of trustworthiness relates to demonstrating reliable and integral support by cultivating transparency.
* Collaboration and empowerment are two essential elements that facilitate a healing and secure environment. Collaboration accentuates the value of fostering collaborative professional relationships by ensuring all active stakeholders are engaged in the care process. Empowerment showcases the need to provide individuals with the resources they need to play an active position in their healthcare journey. Encouraging self-advocacy and person-centred recovery are examples of empowerment.
The SAMHSA framework also provides a detailed definition that emphasises how critical it is for professionals to completely understand the concept of trauma when related to health and service systems. The definition is formatted as the three "E's" of trauma and is sourced by the DSM-5:
* Events: The particular occasion of physical or psychological threat and harm that causes psychological distress.
* Experience: The individuals[grammar?] perception of the event and interpretation of the traumatic experience. The importance of this is to highlight individuality in trauma and that the impact of trauma can vary amongst people.
* Effects: The lasting impacts sourced from trauma on people's wellbeing.
This framework addresses trauma in a holistic and direct methodology, which showcases all essential foundations for trauma-informed care.

### Implementation

The SAMHSA framework outlines thorough steps for successfully implementing the key principles of trauma-informed care within an organisation. The steps include various aspects that are tailored to be easily carried out. According to the SAMHSA framework, the following domains are the appropriate steps to implementing trauma-informed care as an entirely new concept in an organisation:
[Add APA style table caption here]
| Steps | Description |
| 1. Leadership | Leadership refers to the essential role that the leaders within the organisation play in sustaining the implementation of trauma-informed care. This involves the measure of organisational support for trauma-informed approaches and that it is essential for leaders to commit to overseeing change. |
| 2. Policy | Written policies for staff helps outline specific steps to adhere for trauma-informed care and to avoid damaging results. It should also incorporate how trauma-informed care will be maintained long-term, such as training expectations and quality assurance. |
| 3. Physical environment | The physical environment must promote a sense of safety and security through staff serving an inviting, transparent and supportive environment. For example, comfortable physical spaces that foster a comfortable atmosphere through warm and non-threatening furnishings. |
| 4. Engagement | Engagement involves the active participation of people who have lived experienced of trauma in the development, execution, and evaluation of trauma-informed practices in the organisation. This step differentiates many other frameworks from the SAMHSA guidelines as it encompasses the invaluable insight from personal experiences on developing sensitive practices. |
| 5. Cross sector collaboration | This domain of implementing trauma-informed care is stems from ensuring a shared awareness of trauma is found amongst different services. |
| 6. Screening, assessment, treatment services | The use of appropriate and evidence-based trauma screening is a vital aspect of implementing individually catered treatments and care. It is an important step in facilitating trauma-specific services for individuals through considering concepts, such as culture and severity. |
| 7. Training and workforce development | The ongoing training in trauma-informed care is demonstrated through providing education and ongoing support to staff within the organisation. Not only does this better equip the staff with a better understanding needed to implement successful trauma-informed services, but cultivates a trauma aware workplace. |
| 8. Progress and quality monitoring | This involves the ongoing assessment and monitoring of implemented trauma-informed principles. The aim of this is to assess the outcomes and alter the practices as needed to reach trauma-informed goals. |
| 9. Financing | The financial aspect of trauma-informed care involves a structure that allocates the resources for training and workforce development, screening tools, peer-support, and program development. It also involves the long-term sustainability of the plan. |
| 10. Evaluation | The final domain of evaluation measures the strategies and framework implemented. It is needed to evaluate whether all previous steps efficiently increases trauma understanding and use of trauma-informed strategies. Most importantly, gaining feedback from staff and service consumers assists in evaluating effectiveness of practices (Huang et al., 2014). |
* Feature box
* Can you think of any other areas or environments that require trauma-informed care?

### Quiz
## Conclusion

Trauma-informed care provides a theoretical and evidence-based approach to understanding trauma and providing services for people who have lived experience. It entails an exhaustive understanding of the physiological, psychological, emotional and social repercussions that trauma can have on an individual. A crucial aspect of trauma-informed care is the emphasis on person-centred recovery because everyone experiences different consequences as a result of traumatic stress. The multifaceted consequences of trauma and appropriate modalities to provide sensitive support for healing and recovery are heavily sourced from theoretical underpinnings. Avoidance of the physiological challenges of trauma and prolonged stress on bodily functions can be achieved by strategies that reduce stress levels and activation of stress-related brain structures. This can be supported by the Polyvagal theory of trauma (Porges, 1990). Prioritising safety is a preeminent factor towards successful trauma-informed care, aligning with Ferenczi's (1998) trauma theory which underscores that establishing a secure and sheltered environment is fundamental for the recovery process. Additionally, many other needs must be met to ensure appropriate care towards people who have experienced trauma. Without trauma-informed organisations and providers, there is a significant risk of inadvertent re-traumatisation and heightened emotional distress. Having a negative experience can hinder the healing process and reinforce individuals' confirmation bias, perpetuating their existing beliefs.
Implementation of trauma-informed care is achievable through the SAMHSA framework. It offers a detailed explanation of the essential principles involved in being trauma-informed and understanding exactly what trauma is. It also provides a comprehensive guide on how to successfully execute trauma-informed practices in an organisation. By adopting the domains from this invaluable framework, a culture of empathy and understanding can be nurtured. This ultimately leads to a transformation in current practices and creates a more holistic healthcare system. In practice, trauma-informed care offers a well-rounded approach to supporting trauma survivors. The promotion of healing from trauma depends on a collective understanding that trauma manifests in diverse contexts, scenarios, and presentations. The key take-home message is that the implementation of trauma-informed care is based on a culture of safety, empathy, and tailored interventions to address the unique needs of individuals who have experienced a traumatic event and distress.