Prioritizing Trauma Informed Care
trauma informed care is essential for good therapy
Trauma is pervasive and its roots can take hold from an early age. According to the Centers for Disease Control and Prevention (CDC), about 64% of adults reported they had experienced at least one type of adverse childhood experience before age 18, and nearly 17.3% reported they had experienced four or more types of adverse childhood experiences. Cathy Lounsbury, a licensed clinical professional counselor in Maine who specializes in trauma and trauma-informed care, says that most clients seeking mental health services have experienced some traumatic events in their lives that continue to affect their current functioning. Therefore, it’s important that counselors understand the role trauma plays to effectively address the root of some presenting symptoms, she adds. Concerns about the prevalence of trauma and its impact on the individual and society led to the development of trauma-informed care. This foundational framework ensures that health care and other social service organizations recognize and respond to signs, symptoms and risks of trauma and work to reduce the likelihood of retraumatization.
A growing awareness of trauma-informed care
“Over the past few years, we’ve seen a big shift in counseling when it comes to trauma-informed care,” says Allison Dukes, an assistant professor of clinical mental health counseling at Saint Joseph’s University. “More people are recognizing the prevalence of trauma within our lives and the lives of our clients.” In 2014, the Substance Abuse and Mental Health Services Administration (SAMHSA) established six guiding principles for trauma-informed care. These principles provide a framework for how providers can work to reduce the possibility of retraumatization and increase a person’s sense of power and safety. The six guiding principles are:
Safety
Trustworthiness and transparency
Peer support
Collaboration and mutuality
Empowerment, voice and choice
Cultural, historical and gender issues
The guiding principles stress the need for organizations inside and outside of mental health to ensure the safety of clients and staff, promote transparency in decision-making and encourage the sharing of lived experiences between clients and staff. They also call on organizations to foster collaborative relationships, validate the strengths of client and staff, and recognize and address societal biases and stereotypes. Dukes says studying SAMHSA’s principles is a good start for counselors who are new to trauma-informed care and for counselor educators who want to talk about it with their students. Incorporating trauma-informed care in organizations and private practice also requires an understanding and the practice of the Multicultural and Social Justice Counseling Competencies, she adds. “When planning for sessions or considering the effectiveness of interventions, we have to consider the ways in which our clients’ identities and past experiences are impacting their worldview, which is likely impacting their time in therapy and the therapeutic relationship,” Dukes says. Lounsbury, a professor of counseling and dean of the counseling department at Antioch University, says she is not sure how a mental health professional could effectively treat a client who has experienced trauma without integrating a trauma-informed approach. “Since trauma can impact a person physically, emotionally, socially, spiritually and behaviorally, trauma symptomatology is likely to be expressed during a counseling session,” she says. “It is imperative that the counselor understands it as such and responds in a way that is not retraumatizing to the client.” Lounsbury and Dukes both agree that trauma-informed care is becoming the standard in the counseling profession because, as Dukes points out, “it aligns with our profession’s ethical standards and encourages us to look at the deeper reasons for [clients’] presenting concerns.” Jenny L. Cureton, a licensed professional counselor (LPC) and owner of Evolutions Counseling and Consultation in North Canton, Ohio, has also seen growing evidence that counseling is becoming more trauma informed. “We are finally beginning to shift from seeing trauma solely as a niche to also considering it as foundational knowledge and a skill that counselors across specializations should develop and use in collaboration with each other to be responsive to clients, students and ourselves,” she says.
Seeing the whole person
Both clients and counselors benefit from agencies and organizations implementing trauma-informed care practices. For example, a trauma-informed lens can help counselors gain a deeper understanding of the client and see them more fully, says Cureton, an associate professor of counselor education and supervision at Kent State University who specializes in trauma-informed care and education. Trauma-informed care “calls us to depathologize,” she explains. “We make the compassionate and realistic assumption that the problems someone presents are their body’s, brain’s and heart’s best attempts to live through something awful; this broadly helps us maintain unconditional regard and empathy.” Taking a trauma-informed approach helps counselors be more discerning, especially with differential diagnosis and comorbidity of traumatic stress and disorders, Cureton continues. For example, without understanding trauma, a counselor might inadvertently attribute a client’s stress-related symptoms to an anxiety disorder when it might in fact be a traumatic stress response instead, she says. “A key component to engaging in trauma-informed care principles is to be a safe, trustworthy and empowering counselor [and] to transparently and collaboratively understand the client holistically and in cultural contexts,” she adds. A trauma-informed lens also helps practitioners build a more effective relationship with clients. “Past and ongoing trauma makes trusting deeply uncomfortable,” Cureton says. “When you’ve experienced trauma, it can feel too dangerous to trust others and even to trust yourself. Without being trauma informed, a counselor might misjudge a client’s reticence to share or even their no-show behavior as ‘resistant’ and even give up on providing truly quality care.” Cureton finds that counselors who are trauma-informed are better able to gauge the status of the counseling relationship, timing for interventions and their own state in the moment of providing care. “Establishing and maintaining trust is not just an ideal counselors aim for. Decades of research on the common factors of counseling show that the counselor-client relationship is crucial for successful counseling,” she notes. Jessica Meléndez Tyler, an LPC-supervisor and partner and clinical therapist at The Wandering Mind, a private practice in Columbus, Georgia, says a trauma-informed approach recognizes and respects the impact of trauma on clients’ lives, bodies, community and even their descendants. “Trauma-informed care cultivates a sense of safety and empowerment that extends past the therapeutic relationship [and moves] away from approaches that put counselors as the expert and providers of therapeutic interventions,” she explains. “Counselors can co-create an environment of understanding, sensitivity and collaboration that has been absent for survivors of trauma.”
Challenges implementing trauma-informed care
Despite the benefits associated with trauma-informed care, efforts to fully implement this foundational framework across mental health agencies have resulted in a mix of successes and challenges. Some mental health organizations have successfully enacted trauma-informed policies that benefit both clients and staff, but others have not yet addressed the issue. “In reality, the implementation of trauma-informed care still varies by the work setting,” says Cureton, president of the Ohio Association for Resiliency and Trauma Counseling. She’s noticed that more agencies and nonprofit organizations have enacted trauma-informed care to align with funding initiatives from the grant and government entities that support them. For example, Cureton says some organizations that have been practicing trauma-informed care have been able to apply for funding to support its evaluation or enhancement. In other cases, trauma-informed initiatives did not exist within the organization until it became a requirement to qualify or keep funding. “[I think] the push from some funding sources for interprofessional and cross-institutional work has supported the growth in trauma-informed care,” she says. “For instance, states that have received and distributed federal funding involving trauma-informed care often have more trauma-informed care across their systems, such as foster care, substance use treatment and K-12 education.” Cureton says some school and school districts, as well as colleges and universities, have “truly stepped forward as leaders on creating a trauma-informed culture,” whether at the level of the counseling center, department or institution. However, she notes that counselors who work in settings such as the criminal justice system or serve resource-strapped communities such as refugees or immigrants often feel they are still waiting for the trauma-informed approach to be acknowledged and supported. “It comes down to the readiness to change to address trauma among leaders in the immediate setting and beyond (e.g., organizational headquarters, county or state boards and legislatures),” Cureton explains. “Counseling settings with leaders who are aware of and responsive to reports of trauma from those they serve and employ are simply more likely to work to prioritize trauma-informed care funding and implementation. However, when society and leaders of counseling settings devalue some lives (e.g., BIPOC [Black, Indigenous and people of color] communities, people with offenses, people from other countries), we give them fewer resources for trauma-informed care and other needs.” Melissa Youngblood, an LPC and certified clinical trauma professional at Therapeia, a group practice in Royal Oak, Michigan, says trauma and trauma-informed care are often not given the attention they deserve. “I think there is a lack of emphasis on trauma in our training programs and clinical internships,” she says. “There is often a general approach in outpatient clinics that overlooks having staff trainings and psychoeducation about trauma-informed care for our clients.” The general approach in most clinics is to develop basic skills in diagnostics and treatment planning, but trainings often overlook the need to have staff develop advanced capabilities in trauma modalities and trauma-informed care, Youngblood explains. Work settings and institutional factors also play a role in the success of implementing trauma-informed care principles. Agencies working with mandated or incarcerated populations, for example, often do not have the support or buy-in to incorporate this type of care because the administrations and staff do not understand how these principles promote rehabilitation, says Tyler, an associate professor of the practice in the Department of Human and Organizational Development at Vanderbilt University. Adapting existing practices and policies to align with trauma-informed care principles can also be met with logistical challenges and institutional resistance to change, she adds. “This requires education and collaboration with colleagues, administrators and stakeholders to foster a culture that supports trauma-informed approaches,” she says. According to Lounsbury, some of the challenges facing mental health counseling systems that want to adopt trauma-informed care include the mental health worker shortage, a lack of funding for mental health services and disparities in funding for mental health treatment. “Because some agencies do not have enough counselors to meet the need, resulting in waiting lists in services for clients, and because these agencies are reliant upon billable hours to keep their doors open, it can be challenging to take clinical staff ‘offline’ for training and supervision,” she says. Another pressing factor is the fact that counselors often do not have the space to support their own wellness at some mental health agencies, which can result in secondary traumatic stress and burnout. So Lounsbury stresses that a trauma-informed care approach must acknowledge the impact the work has on counselors. Counselors sometimes struggle to enact trauma-informed care because their work setting has procedures that conflict with its principles. For example, Cureton says a school or college counselor who works in an educational setting or state that requires them to avoid specific topics or words (such as “gay”) or to report specific details about a student’s identity are faced with potentially compromising the client’s safety, retraumatizing the client and essentially withholding trauma-informed care. “Sometimes this is the nature of any work in systems — policies aimed at fairness, which then overly restrict counselors from making informed decisions customized to specific clients,” she adds. “Other times, it is structures that enact values centered more on money and power than on care and human dignity.”
Advocates for trauma-informed care
Despite these obstacles, clinicians can play a pivotal role in helping to ensure that trauma-informed care is the standard for treatment and workplace development in mental health. In fact, Tyler says counselors’ clinical expertise and understanding of the impact of trauma on the micro and macro levels help position them as advocates for change regarding trauma-informed care. Counselors can educate public agencies on the effects of trauma and guide institutional and agency staff in recognizing signs of trauma, she notes. “They can collaborate with interdisciplinary teams to develop policies and practices that prioritize safety, choice and empowerment for clients,” Tyler continues. “Furthermore, counselors can champion a culture of continuous learning and sensitivity, ensuring that staff are equipped to provide trauma-informed care effectively.” Working to ensure that trauma-informed care is the prevailing mindset in mental health and that all clients are viewed through a trauma-informed lens is a valuable goal for counselors, particularly after COVID-19. “I think that post COVID-19, there is a shared trauma that we experienced as a community enduring a pandemic,” Youngblood says. “We can no longer say ‘this client has no history of trauma,’ and we must begin to assess the impact of COVID on their mental health. We must acknowledge and support our clients in processing the impact for years to come.” Dukes agrees. “Every client we work with for the next 10 or so years will have been impacted in some way,” she says. “Practicing trauma-informed care will allow us to discuss not only the trauma of the pandemic but also how our identities and histories impacted our understanding and overall experience of the pandemic.” Lisa R. Rhodes is a senior writer for Counseling Today. Contact her at lrhodes@counseling.org.Opinions expressed and statements made in articles appearing on CT Online should not be assumed to represent the opinions of the editors or policies of the American Counseling Association.
Article originally appeared in Counseling Today, October 2023 by Lisa Rhodes https://www.counseling.org/publications/counseling-today-magazine/article-archive/article/legacy/prioritizing-trauma-informed-care
Trauma-Informed Therapy: How It Works & Why It’s Important
What is Trauma Informed Therapy?
Trauma-informed therapy asks, “What happened to you?” rather than, “What is wrong with you?” This shifts the tone from victim-blaming to recognizing the person as a survivor. Trauma-informed therapy is not a specific modality, rather it is a set of guiding principles that recognizes that trauma has significant effects on people and is often under-recognized and under-reported.
A trauma-informed therapist will assume that you have had experiences that may have deeply affected you, and they recognize and respond to you in a way that emphasizes safety, collaboration, and empowerment.
Understanding Trauma
Trauma is a strong, negative, emotional response to a terrible event. Commonly, people think of events like a sexual assault, serious injury or disease, violence, or abuse. However, many other experiences cause trauma as well and can result in negative symptoms. Some people experience chronic trauma as a result of repeated exposure to traumatic events. Trauma itself is very common, with studies in the U.S. showing trauma rates at 50-60% in the general population.1
Trauma & PTSD
Trauma has been linked with increased risk of mental and physical health problems.2 Not everyone who experiences trauma will develop post-traumatic stress disorder (PTSD), but it is estimated that 7.8% of Americans will have PTSD at some point in their lifetime.3 Often, care is not available or people wait a very long time to get professional help. If you have experienced a traumatic event, it is very important not to wait to get help. There are many evidence-based therapies available to help you recover.
What Does Trauma Informed Mean?
Trauma-informed refers to a concept based on the assumption that trauma can often be present in someone’s life and that this should be considered in the way they are served. This translates into a protocol that acknowledges the devastating effect trauma can have on a person’s physical, emotional, and mental well-being. Trauma-informed practices can typically be found in different sectors such as healthcare facilities, mental health clinics, schools, and social service agencies to ensure that trauma survivors have a safe and validating environment supporting their unique challenges and needs.2
What Is Trauma Informed Therapy?
Trauma-informed therapists assume that, more likely than not, their client has experienced trauma that should be addressed safely and compassionately. Additionally, trauma-informed care providers recognize the impact of cultural, historical, and gender issues and how they may affect a person.
Trauma-informed therapists work first to establish a sense of safety and trust before trying to dive deep into someone’s trauma history. They start by developing a strong collaborative and supportive relationship. Trauma-informed clinicians will work to empower their clients by honoring their voice and their choice on what they want and need from their therapy. Compassion and respect are the foundation of trauma-informed care.
Why Finding Trauma-Informed Care Is Important for Trauma Survivors
Traumatic experiences often happen in the context of relationships. When a trusted person hurts us, our sense of ourselves and of the world often changes in some very negative ways. Trauma-informed therapists recognize and understand this, and work hard to make sure that their clients are not retraumatized by providing a safe place for them to express those feelings without worrying about judgment or repulsion.
Healing is more likely to happen when a person is allowed to experience safety and care in the hands of an expert who understands how to listen and validate their feelings. Although all therapists have these basic skills, a trauma-informed therapist is typically going to have advanced training in treating trauma and they will have more experience helping someone who has experienced trauma.
Trauma-informed therapists will focus on making a strong working relationship grounded in safety and connection and use evidence-based treatments to help you recover.
How Does Trauma Informed Therapy Work?
Trauma-informed care is for everyone regardless of personal history, and oftentimes, you may not realize that your life experiences were indeed traumatic. Often, therapy for healing trauma will move slower in the beginning, taking time to establish trust before bombarding you with questions about all the details of your life. Trauma-informed therapists use many different styles and techniques and they generally tend to see clients weekly for approximately 50-minute sessions depending on the needs and preferences of the client.
Techniques of Trauma Informed Therapy
Although there is no standard definition of trauma-informed therapy and no national standards or directories, there are some basic practices that trauma-informed therapists will all follow. Generally, a therapist or healthcare professional will be familiar with the impact and consequences of trauma as well as its prevalence. They will identify appropriate trauma-related screenings and assessments and learn when and how to use and interpret them.
Key principles of trauma-informed care include:4
1. Safety
Safety begins at the front door, where privacy is respected and the area is welcoming to all people. There is a focus on the physical and emotional sense of safety of every client, ensuring that they have an understanding of what will happen next.
2. Choice
Choice refers to the client having clear control of what happens during their care, and consent is obtained by making sure the client fully understands their rights and can provide continuous consent.
3. Collaboration
Collaboration happens when the therapist, rather than acting as the expert to the “sick” person, asks the client to share power and make decisions on what treatment goals they would like to work on. They have a significant role as the expert in their care.
4. Trustworthiness & Transparency
Trustworthiness means always being honest, clear, and consistent, especially with maintaining boundaries and never violating the client’s trust.
5. Peer Support
This key principle in trauma-informed care values peer support and connection, which can be of great importance, particularly for those who have experienced trauma. Peer support respects the survivor’s wellbeing and seeks to prevent the re-traumatization cycle, permitting them to have a chance to start the recovery process and choose the treatment or support that enhances it. The peer role is deep-rooted in the mindset of not trying to “fix” people, but instead empower them to become the person they envision themselves to be.
6. Cultural, Historical, & Gender Awareness
This integral pillar in Trauma-informed care involves appreciating and acknowledging someone’s cultural background, experiences, and identities as important components to effective trauma-informed services. This entails looking past cultural stereotypes/biases based on race, ethnicity, sexual orientation, etc., providing access to gender-affirming care, appreciating the healing value of traditional cultural bonds, and integrating guidelines that are sensitive to the racial, ethnic, and cultural necessities of the people being helped, as well as identifying and addressing historical and intergenerational trauma.
7. Empowerment
Finally, empowerment means that you should always feel heard, cared for, and validated by all staff as they focus on helping you build more coping skills and learn to regulate your emotions.
These basic principles were developed to promote healing and work to reduce retraumatization. These principles ensure that all people feel safe, listened to, and are given a voice.
The Benefits of Trauma Informed Therapy
Trauma-informed therapies treat people within the context of their trauma in a safe environment that’s conducive to their healing and recovery process.
Here are some of the key benefits of trauma-informed therapy:2
Helps the client learn about trauma: Trauma-informed therapies educate clients about their trauma, symptoms, triggers, etc. and how therapy can help.
Re-establishes safety: Any type of trauma-informed intervention attempts to bring a sense of physical, mental, and emotional safety by creating a space where the person feels protected and not at risk of becoming retraumatized.
Identifies triggers to help someone cope & heal: During visits, the therapist has the proper understanding and sensitivity to know how and when to help the person identify triggers and ways to effectively deal with their trauma.
Decrease in trauma stress symptoms: As clients better understand their trauma, its effects, and different strategies to cope, their trauma-related symptoms and unhealthy responses decrease.
How Do I Know if a Therapist Is Trauma Informed?
Trauma-informed therapists have an understanding and education around the implications of trauma and the impact trauma has on someone’s therapy journey. Trauma-informed therapists will understand that your experiences shape you, and that trauma is part of that experience. They will ask with compassion and curiosity about your trauma to learn more about you, as opposed to looking at that trauma as solely a source of pathology.
If you’re unsure, ask your potential therapist the following questions to determine if they have a trauma-informed approach to therapy:
How do you make sure clients feel safe?
What is your training on trauma?
What does trauma-informed mean to you?
How do you treat trauma in sessions?
What trauma-related scenarios have you treated?
What to Know When Starting Trauma Therapy
It can take time to understand how therapy can be helpful, as recounting your trauma can be difficult. It’s important to know that you can speak up if something feels too overwhelming for you. If you are not sure if you are getting much out of therapy or you don’t feel completely safe with your therapist, getting another opinion can be helpful.
Not All Therapists Are Trauma-Informed
Some therapists may state they have trauma training, however that can vary drastically as it is a very subjective statement. Trauma-informed therapists have specialized training in working with trauma. They view trauma from a unique lens and bring a sense of safety to sessions. If you are not sure if your therapist has that training or is trauma-informed, asking more about this is encouraged.
You May Be Asked About Your Trauma History During the First Session
Your first therapy session can be overwhelming. The therapist may request an extensive history, but it is important to speak up about how you are feeling recounting the trauma and stating what your boundaries may be at this time. Even though therapy is designed to be a safe space, it can still take time to get comfortable talking about your history.
The first session involves a lot of data-gathering, so understand that the direction of your session is not a reflection of you, but is part of the clinical process of crafting a treatment plan. It’s important to go in with an open mind and also understand that it can take a toll emotionally working through all of your difficult emotions and memories.
How to Find a Trauma Informed Therapist
First, call your insurance company if applicable. They will assist you in finding someone qualified within your network and they will explain what your mental health benefits are and how to use them. You should ask about possible referrals, copays, coinsurances, and deductibles. Although your therapist may be able to bill your insurance, it is your responsibility to verify your coverage as many plans are different, even within the same insurance company. Knowing your costs beforehand can save you frustration down the road.
Alternatively, you may want to start with your primary care physician. If your insurance requires a referral, this is a necessary step. Additionally, they may know of someone qualified and specialized in the area you need. Your primary care physician will do an evaluation of any physical symptoms, and can be a great first step in getting the right care.
Once you know your benefits and how to use them, you might try using an online therapist directory in which you can search for a licensed mental health provider that specializes in trauma. All of our staff are trained in trauma-informed counseling.
Many behavioral health providers offer free phone or video consultations where you can ask questions like:
“Have you worked with trauma survivors before?”
“What does trauma-informed counseling mean to you?”
“How do you help survivors of trauma recover?”
It’s a Good Idea to Talk to More Than One Potential Therapist
If you can, try to do a phone interview with 2-3 therapists and determine which one you feel the most natural level of comfort with and whom you could see yourself trusting to help you on this journey. It is crucial to your recovery that you feel comfortable and trust the person you chose to help you. The consultation is a chance for you both to determine if they are a good fit for your needs.
Example of Non Trauma-Informed vs Trauma-Informed Care
So what does trauma-informed care look like in action? Here is a fictional client, Mary, and her two hypothetical experiences, the first with a healthcare provider that is not specifically trauma-informed and the second, with a trauma-informed therapist.
Example of Non-Trauma-Informed Care
Mary is a 40-year-old mother of three, who reaches out for help for her depression and marital stress. In the first meeting, she is asked to complete seven different forms without understanding their purpose. The questions seem very private and personal and she is worried about lying but also feels uncomfortable sharing details of her previous sexual and physical abuse she experienced as a child. She answers more questions when she meets the therapist, who is male, as he explains that he is there to complete her intake but will not be her actual therapist. He explains that it is a low-cost clinic, and as such, she may not choose her counselor.
Two weeks later, she meets with another new person and they ask her the same questions over again. At the end of the 2nd meeting, she is given a diagnosis and asked to sign a treatment plan that the counselor made based on her disorder and the goals they believe she needs to work on. She is told she needs to see a psychiatrist because she is too severely ill to be seen without also taking medications. She is told she must meet with the doctor and do what he tells her otherwise she could be discharged for non-compliance.
Mary leaves feeling bad about herself. The doctor again asks her in great detail about her trauma history and sends her home with two medications he thinks she needs. She goes home and never returns to the clinic.
Example of Trauma-Informed Care
Mary attends her first meeting with the therapist that first reviews her rights to privacy, confidentiality and safety. She is offered to sit wherever she feels comfortable and is asked by the therapist if she feels comfortable with the door closed to protect her privacy. She asks Mary if she would prefer to have a therapist of another gender or race, making sure that Mary is comfortable talking with her more before proceeding.
Mary is asked to tell the therapist about her experience of her problems and she is also asked about her previous experience with other therapists. She is not asked to fill out any assessments or detailed questions about her personal history. Mary tells her that her previous therapist asked a lot of questions and then told her she had PTSD, and they made her see a doctor who put her on meds that made her feel sick. This left her feeling more depressed and helpless, and unsure of what, if anything, would be done to help her.
The therapist listens warmly, showing compassion, and asks Mary if it would be ok to try something different—and Mary agrees. She offers Mary to meet weekly for the next month and together they would create a plan for Mary’s care based on what Mary needs and prefers as they develop trust and understanding.
During that first month, the therapist asks questions about Mary’s experiences and environment, making sure to clarify why she needs to know certain things and reminding Mary that she can always choose not to answer if she feels uncomfortable. She ends each session asking Mary for feedback on what is working and what is not and what can be done to continue to support her. Together they develop goals that Mary feels will most improve her relationships and her depression.
The latter example highlights the focus on safety, developing trust, and working collaboratively to help Mary understand how her life experiences have impacted her, maintaining focus on Mary’s needs and preferences at all times.
If you have ever had a bad experience with a therapist, you know the difference between the two almost intuitively. Good therapy feels safe, comfortable, and always under your control. These basic principles help to ensure that you are not retraumatized and that your unique needs can be met with compassion and respect for your autonomy and dignity.
Final Thoughts on Trauma-Informed Care
Treatment for trauma is measured in months, not weeks, so be prepared to commit to your process and expect therapy at times to be difficult. Although therapy is generally safe and promotes your wellbeing, there are always risks with treatment. Recalling and describing significantly disturbing events can sometimes affect your mood and mental health. However, with the help of a skilled professional therapist and with your feedback, you should be able to feel better quickly. Remember to be honest about your struggles and know that recovery from trauma is possible.
Therapeia is here to help and we serve all of Michigan.
Author: Melissa Youngblood, MA LPC, CCTP
Medical Reviewer: Lynn Byars, MD
Published: September 28, 2023, @ ChoosingTherapy.com