Unveiling new Millenniums: A Journey towards Trauma Informed Care

Written by: Patmateertha (3rd year) Department Of Applied Psychology

A survivor, who led a traumatized life, shared an experience of being misdiagnosed with bipolar disorder for 10 years, despite experiencing symptoms of childhood trauma. He eventually realized that his trauma had led to “bad” behaviors like substance use, self-harming, and hypersexual behavior.

Realizing you’ve never truly experienced restful sleep, and instead have been left with fading hopes that once seemed vibrant, can be overwhelming. Fear and the inability to express emotions often compound such struggles. Before seeking psychiatric intervention, it's crucial to be trauma-informed—not only to gain better insight into an individual’s experience but also to understand trauma’s evolving impact in the modern age.

But first, let's define what it means to be "trauma-informed" and how this approach benefits both individuals and professionals.

To be trauma-informed is to recognize the significant role that violence and victimization play in the lives of many who seek mental health, substance abuse, and other related services. It involves integrating this understanding into the way services are designed and delivered, ensuring they meet the specific needs and vulnerabilities of trauma survivors. The goal is to create an environment that fosters client participation and safety while minimizing the risk of re-traumatization.

A trauma-informed approach doesn’t focus solely on past traumatic events; it also takes into account current circumstances that may contribute to ongoing struggles. It emphasizes understanding clients' symptoms within the broader context of their life experiences and cultures, recognizing that some behaviors might be adaptive coping mechanisms.

Ultimately, being trauma-informed means asking, "What happened to this person?" instead of "What’s wrong with this person?" By doing so, efforts are made to ensure no further harm is caused, and client safety is prioritized.

WHAT IS TRAUMA?

Trauma can be defined as “an event or series of events that causes moderate to severe stress reactions, sometimes lasting a lifetime. Traumatic events are often characterized by a sense of horror, helplessness, or the threat of serious injury or death, affecting those who experience loss or injury." According to scientist Gabor Maté, trauma “is not what happens to you; it is what happens inside you as a result of what happens to you. It is not the blow to the head, but the concussion I get." Maté views trauma as something that holds potential for growth, a challenge to be overcome, rather than a cause for despair.

Janet (1889), a well-known French psychologist, defined trauma as an event or series of events that overwhelm a person’s coping mechanisms and lead to a dissociation of their memories, with a particular focus on the role of dissociation.

Trauma has been defined in numerous ways and has been a subject of study for decades. However, treatment approaches have historically been less than satisfactory. This has led to the evolution of trauma-informed care.

WHAT IS TRAUMA INFORMED CARE (TIC)?

Trauma-informed care (TIC) can be defined as “a strength-based service delivery approach grounded in an understanding of, and responsiveness to, the impact of trauma. It emphasizes physical, psychological, and emotional safety for both providers and survivors, and creates opportunities for survivors to rebuild a sense of control and empowerment.” Emerging evidence has shown that the adoption of TIC can positively change outcomes in both clinical and organizational settings.

 Trauma-informed care, built on foundational principles, creates an optimal healing environment for patients, while also supporting the well-being of healthcare providers and staff. When all providers and staff in a clinic or hospital are trained to understand that trauma and its effects can impact everyone—including co-workers—and that many forms of trauma are often hidden, it deepens respect for the resilience of both patients and colleagues. A shared understanding that maladaptive behaviors or relationship patterns often have roots in traumatic experiences fosters a climate of mutual compassion and respect.

 The traumatic effects of structural violence, such as racism and sexual violence, can be highlighted and directly addressed through TIC. Historical trauma and its legacy are also integrated into developing effective coping mechanisms. Clinical environments can implement support systems based on a deeper understanding of the challenges trauma survivors face. A trauma-informed system strives to create an atmosphere of calm, safety, and compassion.

In trauma-informed systems, respectful approaches that build patients' and communities' trust, foster resilience, promote positive coping strategies, and empower individuals are prioritized. Access to educational resources and checkups is made easier. Programs that help trauma-affected patients overcome barriers to care—such as peer advocacy, patient navigation, case management, and community outreach—improve the quality of care and extend support beyond the clinic. 

Healthcare organizations must also reflect on their role in perpetuating inequities and commit to equitable partnerships that support community resilience and social justice. Trauma-informed systems are also crucial for building and supporting the resilience of healthcare providers and staff. Provider and staff well-being is essential to maintaining a safe and compassionate environment for patients. It is especially important to address the personal traumatic experiences of providers and the phenomenon of “vicarious traumatization” (VT), defined as “the negative transformation in the helper that results from empathic engagement with trauma survivors and their trauma material, combined with a commitment or responsibility to help them.” Addressing VT allows providers to respond with empathy to patient stories of interpersonal and structural trauma.

Overall, trauma-informed care is a transformative approach that benefits both clients and staff, and it is indispensable in modern healthcare settings.

The 4 R's of TIC

The Substance Abuse and Mental Health Services Administration (SAMHSA) outlines four essential principles that define trauma-informed care:

1. Realization: Recognizing the widespread impact of trauma and understanding paths to recovery.

2. Recognition: Identifying the signs and symptoms of trauma, not just in individuals seeking care but also in families, staff, and others involved in the system.

3. Response: Fully integrating this knowledge into practices, policies, and procedures.

4. Resisting Re-traumatization: Actively working to prevent triggering or re-traumatizing individuals while they receive care.

These principles form the foundation of a trauma-informed approach, ensuring that care providers remain sensitive to the complex dynamics of trauma, from initial contact to ongoing treatment.

CREATING TRAUMA INFORMED CARE: THE 4 C’s

Building a trauma-informed system requires more than just awareness—it demands a proactive approach to creating supportive environments that prioritize:

1. Calm: From a practitioner's perspective, it is crucial to remain calm before attending to a patient's needs. Taking deep breaths and calming oneself can help model and promote a sense of calm for both patients and co-workers. Practicing calming exercises, such as deep breathing and grounding techniques, with patients can be especially helpful in reducing anxiety. A deep understanding of trauma and its effects fosters a calm, patient-centered approach toward others, whether they are patients or colleagues.

   Despite the heavy trauma burden experienced by many of Dr. Jorge García's patients, his diabetic patients have better control over their condition compared to the health system’s average. Dr. García attributes this success to several evidence-based factors, including his compassion, exceptional clinical skills, attention to detail, and his ability to connect culturally and linguistically with his Latino patients. - The Redwoods Healthcare System

2. Contain: In trauma-informed care, "containment" involves gathering just enough information about a patient’s trauma history to ensure their emotional and physical safety, while also respecting the constraints of the healthcare interaction. This allows practitioners to offer appropriate treatment options without overwhelming the patient. Containment also includes providing education, resources, and referrals for trauma-specific care without requiring the patient to disclose every detail of their trauma. This approach helps both the patient and the provider avoid emotional overload during their interaction.

3. Care: Practitioners must practice self-care and extend compassion to themselves, their patients, and their coworkers. Cultivating a compassionate attitude towards oneself and others helps promote healing. This includes sharing supportive messages, de-stigmatizing maladaptive coping behaviors, and practicing cultural humility. Such an approach fosters a nurturing environment for both recovery and emotional resilience.

4. Cope: Effective trauma-informed care emphasizes the importance of coping skills, positive relationships, and interventions that build hope and resilience. Practitioners should inquire about practices that help patients feel better and offer evidence-based treatments for trauma-related issues such as substance use and mental illness. Celebrating cultural practices can enhance well-being and strengthen social connections.

Each of these "4 C’s" contributes to a therapeutic environment where individuals feel supported and understood.

TRAUMA INFORMED CARE TREATMENT:

Trauma-informed care (TIC) treatments include a variety of therapies and practices that can help people heal from trauma, including:

1. Eye movement desensitization and reprocessing (EMDR): Uses rhythmic eye movements to help release blocked emotions which is one of the most important techniques.

2. Cognitive behavioral therapy (CBT): A type of therapy that can help with trauma-related distress. This technique is used for treating depression.

3. Trauma-focused cognitive behavioral therapy (TF-CBT): A type of CBT that's designed for children and adolescents. The major focus is on unhealed or wounded memories

4. Prolonged exposure (PE): A mode of therapy that involves exposing the patient to the source of their fear until they no longer fear it.

5. Cognitive processing therapy (CPT): A therapy that challenges the patient's perspective on the traumatic event and the beliefs they've developed since it's occurrence.

6. Internal family systems (IFS) therapy: A therapy that helps patients identify and work with different "parts" of themselves that they think, became fragmented after trauma

7. Art and music therapy: Can help boost mental health and support healing through practice.

8. Psychodynamic therapy: Helps patients understand how their past experiences have affected their current emotions and behavior and how they can deal them.

Other TIC practices include: Mindfulness -based approaches, Self-regulation techniques, Group therapy, and Talk therapy.

Effectiveness of TIC

The effectiveness of TIC has far-reaching advantages, which can shape an organization, client, or institution entirely. A scenario can be explained with The National Association of State Mental Health Program Directors (NASMHPD)  model of TIC, consisting of environmental changes, staff training, and purposeful client-staff partnerships, for their latest evaluation. In evaluating the NASMHPD model, researchers Azeem, Aujla, Rammerth, Binsfeld, and Jones (2011) found that TIC was strongly correlated with a marked decrease in seclusion and restraints among youth residents in a state psychiatric hospital. Notably, seclusion and restraints are acute catalysts for re-traumatization among both adult and adolescent clients in psychiatric inpatient settings, which accounts for grave concerns. Their reduction is not only a key aspect of TIC but also has palpable advantages for staff, clients, and the organization (LeBel & Goldstein, 2005; LeBel et al., 2004). LeBel and Goldstein (2005) also found a relationship between reducing seclusion and restraints and desirable outcomes such as reduced staff and client injuries, client recidivism, and reduced staff sick time. Furthermore, the principles of TIC were found to have an advantageous impact on mental health, substance use, drug addiction, and trauma symptomology in the Women, Co-Occurring Disorders, and Violence Study (WCDVS; Morrisey et al., 2005).

The impact of implementing TIC approaches within agencies will also benefit staff by creating healthy work conditions and emphasizing self-care. Staff satisfaction is enhanced through interpersonal and organizational mechanisms, as safety, trust, choice, collaboration, and empowerment are fostered in the agency milieu (Fallot & Harris, 2009). There are few examples of empirical research supporting the connection between TIC and staff satisfaction. Popular ones include Hales et al. (2017), who found a positive, though modest, relationship, providing support for the impact TIC can have on staff satisfaction and commitment.

There is some evidence regarding the implementation of TIC, suggesting that it may be cost-effective for the organization and the broader society by providing more effective treatment than "treatment as usual" (Hopper, Bassuk, & Olivet, 2010; Morrisey et al., 2005). TIC may be more effective and responsive to client needs, its implementation may increase client engagement and retention in treatment. Client retention can contribute to the overall health of the organization by ensuring stability in funding from insurance companies. As TIC has been found to increase staff satisfaction (Hales et al., 2017), this may help reduce turnover rates within agencies and lessen the associated costs of continuously training newly hired staff.

TRAUMA INFORMED CARE IN INDIA 

In India, trauma resulting from violence, abuse, poverty, natural disasters, and systemic inequities makes TIC particularly relevant. However, formal research on the implementation of TIC in India is still emerging. Below are some areas of research and key findings:

Research conducted by the Ministry of Women and Child Development (MWCD) in 2007 revealed that 53% of children in India reported some form of abuse. The National Mental Health Survey of India (2015-16) also found that 7.3% of children and adolescents experience mental health conditions, many of which are linked to trauma.

Mental health professionals in India are increasingly recognizing the need for TIC in clinical settings. For instance, a study on post-traumatic stress disorder (PTSD) in survivors of natural disasters (e.g., the 2004 tsunami) highlighted gaps in care and emphasized the importance of trauma-sensitive approaches to mental health treatment. This generated significant interest in the approach.

Women from marginalized communities, especially in rural areas, face multi-layered trauma due to factors like domestic violence, sexual exploitation, and limited access to healthcare. Efforts to implement trauma-informed approaches in women’s health, particularly in the context of reproductive and maternal health, have been initiated by organizations like Jan Swasthya Abhiyan.

Despite ongoing discussions on these topics, the implementation of TIC in India faces its own challenges, including:

1. Lack of Awareness: One significant barrier is the lack of awareness among professionals about the principles of TIC. There is limited formal training in trauma-informed approaches for healthcare workers, teachers, and social workers.

2. Cultural Sensitivity: Implementing TIC in India requires adapting global frameworks to be sensitive to local cultural, social, and religious contexts. Researchers have noted that traditional forms of healing and community structures play a major role in trauma recovery, and TIC needs to incorporate these elements to be effective.

Further research could focus on:

1. Policy Advocacy: The need for trauma-informed policies in education, healthcare, and social services is critical. Advocacy for integrating TIC into national health and education policies could significantly improve outcomes for trauma survivors.

2. Capacity Building and Training: Government programs and NGO initiatives should focus on building capacity for healthcare and social service professionals to incorporate TIC into their practice. Structured training programs and collaborations with international TIC experts could help in this regard.

3.  Research on Indigenous Models: There is scope for further research into indigenous healing practices and how they can be integrated with TIC in the Indian context. Studies focusing on community-based trauma healing could provide valuable insights.

Conclusion

Trauma-informed services are no longer out of reach in the present scenario. The feeling of being unable to share emotions or living a life filled with despair can now be addressed through increased awareness and informed care. Unveiled by numerous efforts, trauma-informed care is a modern reality that can be fully realized with proper implementation. However, awareness around trauma-informed care remains limited, and cultural sensitivity concerns further hinder progress.

Despite limited research and practice, TIC has already positively impacted the lives of many, including those affected by abuse and survivors of natural disasters. Let us look forward to a day when everyone can hope for a better future, and no one is left with shattered dreams.

References

1. Fallot, R. D., & Harris, M. (2008). Trauma-informed approaches to systems of care. Trauma, Violence, & Abuse, 9(1), 19-34. https://doi.org/10.1177/1524838007312462

2. Gabor, M. (n.d.). Trauma: It’s not what happens to you. The Trauma Foundation.

3. Hales, T. W., Green, S. A., Bissonette, S., Warda, M., & Malberg, K. A. (2017). Trauma-informed care outcome study. Journal of Trauma & Dissociation, 18(1), 132-147.

4. Janet, P. (1889). The major symptoms of hysteria. Macmillan.

5. LeBel, J., & Goldstein, R. (2005). The role of trauma-informed care in reducing seclusion and restraint use in youth treatment settings. American Journal of Orthopsychiatry, 75(4), 641-648.

6. Ministry of Women and Child Development. (2007). Study on child abuse: India 2007. Government of India.

7. Morrisey, J. P., Ellis, A. R., Gatz, M., Amaro, H., Reed, B. G., Savage, A., & Finkelstein, N. (2005). Outcomes for women with co-occurring disorders and trauma: Program-level effects. Journal of Substance Abuse Treatment, 28(2), 121-133.

   
   
   
   

   Written by: Patmateertha

   
   

   Reviewed by:

   Shreeyanshi (Editor-in-cheif | Senior Content Team Coordinator)

   Kashvi Magan ( Senior Deputy Content Team Coordinator)