Trauma Informed Intervention & Prevention

RESEARCH REVIEW

“A trauma-informed approach to the delivery of behavioral health services includes an understanding of trauma and an awareness of the impact it can have across settings, services, and populations. It involves viewing trauma through an ecological and cultural lens and recognizing that context plays a significant role in how individuals perceive and process traumatic events, whether acute or chronic.

“In May 2012, SAMHSA convened a group of national experts who identified three key elements of a trauma-informed approach:

(1) realizing the prevalence of trauma;
(2) recognizing how trauma affects all individuals involved with the program, organization, or system, including its own workforce; and
(3) responding by putting this knowledge into practice” (SAMHSA, 2012, p 4).

Trauma-Informed Care

“TIP endorses a trauma-informed model of care; this model emphasizes the need for behavioral health practitioners and organizations to recognize the prevalence and pervasive impact of trauma on the lives of the people they serve and develop trauma-sensitive or trauma-responsive services.

” Nonetheless,TIC anticipates the role that trauma can play across the continuum of care— establishing integrated and/or collaborative processes to address the needs of traumatized individuals and communities proactively. Individuals who have experienced trauma are at an elevated risk for substance use disorders, including abuse and dependence; mental health problems (e.g., depression and anxiety symptoms or disorders, impairment in relational/social and other major life areas, other distressing symptoms); and physical disorders and conditions, such as sleep disorders. This TIP focuses on specific types of prevention (Institute of Medicine et al., 2009): selective prevention, which targets people who are at risk for developing social, psychological, or other conditions as a result of trauma or who are at greater risk for experiencing trauma due to behavioral health disorders or conditions; and indicated prevention, which targets people who display early signs of trauma-related symptoms. This TIP identifies interventions, including trauma-informed and trauma-specific strategies, and perceives treatment as a means of prevention—building on resilience, developing safety and skills to negotiate the impact of trauma, and addressing mental and substance use disorders to enhance recovery.

“TIC is a strengths-based service delivery approach “that is grounded in an understanding of and responsiveness to the impact of trauma, that emphasizes physical, psychological, and emotional safety for both providers and survivors, and that creates opportunities for survivors to rebuild a sense of control and empowerment” (Hopper, Bassuk, & Olivet, 2010, p. 82). It also involves vigilance in anticipating and avoiding institutional processes and individual practices that are likely to retraumatize individuals who already have histories of trauma, and it upholds the importance of consumer participation in the development, delivery, and evaluation of services.

Trauma-Specific Treatment Services

“These services are evidence-based and promising practices that facilitate recovery from trauma. The term “trauma-specific services” refers to prevention, intervention, or treatment services that address traumatic stress as well as any co-occurring disorders (including substance use and mental disorders) that developed during or after trauma.

National Child Traumatic Stress Network (NCTSN) definition of complex trauma. The term refers to the pervasive impact, including developmental xvi How This TIP Is Organized consequences, of exposure to multiple or prolonged traumatic events. According to the NCTSN Web site (http://www.nctsn.org/trauma-types), complex trauma typically involves exposure to sequential or simultaneous occurrences of maltreatment, “including psychological maltreatment, neglect, physical and sexual abuse, and domestic violence…. Exposure to these initial traumatic experiences—and the resulting emotional dysregulation and the loss of safety, direction, and the ability to detect or respond to danger cues—often sets off a chain of events leading to subsequent or repeated trauma exposure in adolescence and adulthood” (NCTSN, 2013).

Resource NCBI NLM NIH Trauma Protocol

WHAT IS TRAUMA

“A traumatic event is a shocking, scary, or dangerous experience that can affect someone emotionally and physically. Experiences like natural disasters (such as hurricanes, earthquakes, and floods), acts of violence (such as assault, abuse, terrorist attacks, and mass shootings), as well as car crashes and other accidents can all be traumatic. Researchers are investigating the factors that help people cope or that increase their risk for other physical or mental health problems following a traumatic event.

Resource NIMH NIH.gov

According to SAMHSA’s Trauma and Justice Strategic Initiative, “trauma results from an event, series of events, or set of circumstances that is experienced by an individual as physically or emotionally harmful or threatening and that has lasting adverse effects on the individual’s functioning and physical, social, emotional, or spiritual well-being” (SAMHSA, 2012, p. 2). Trauma can affect people of every race, ethnicity, age, sexual orientation, gender, psychosocial background, and geographic region. A traumatic experience can be a single event, a series of events, and/or a chronic condition (e.g., childhood neglect, domestic violence). Traumas can affect individuals, families, groups, communities, specific cultures, and generations. It generally overwhelms an individual’s or community’s resources to cope, and it often ignites the “fight, flight, or freeze” reaction at the time of the event(s). It frequently produces a sense of fear, vulnerability, and helplessness.

Resource NCBI NLM NIH.go v

“Factors that may make people more sensitive to trauma include:

Having direct involvement in the trauma, especially as a victim
Having severe or prolonged exposure to the event
Having a personal history of prior trauma
Having a family or personal history of mental illness or severe behavioral problems
Having limited social support or a lack of caring family and friends
Having ongoing life stressors such as moving to a new home or new school

Resource NIMH NIH.gov

INITIAL TRAUMATIC INJURY SYMPTOMS

“Responses to trauma can be immediate or delayed, brief or prolonged. Most people have intense responses immediately following, and often for several weeks or months after a traumatic event. These responses can include:

Feeling anxious, sad, or angry
Trouble concentrating and sleeping
Continually thinking about what happened

“For most people, these are normal and expected responses and generally lessen with time.

“In some cases, these responses continue for a longer period of time and interfere with everyday life. If they are interfering with daily life or are not getting better over time, it is important to seek professional help. Some signs that an individual may need help include:

Worrying a lot or feeling very anxious, sad, or fearful
Crying often
Having trouble thinking clearly
Having frightening thoughts or flashbacks, reliving the experience
Feeling angry, resentful, or irritable
Having nightmares or difficulty sleeping
Avoiding places or people that bring back disturbing memories and responses.
Becoming isolated from family and friends

“Children and teens can have different reactions to trauma than those of adults. Symptoms sometimes seen in very young children (less than six years old) can include:

Wetting the bed after having learned to use the toilet
Forgetting how to or being unable to talk
Acting out the scary event during playtime
Being unusually clingy with a parent or other adult

“Older children and teens are more likely to show symptoms similar to those seen in adults. They may also develop disruptive, disrespectful, or destructive behaviors. Older children and teens may feel guilty for not preventing injury or deaths. They may also have thoughts of revenge.

Resource NIMH NIH.gov

“Children age 5 and younger may:

Cling to parents or caregivers.
Cry and be tearful.
Have tantrums and be irritable.
Complain of physical problems such as stomachaches or headaches.
Suddenly return to behaviors such as bed-wetting and thumb-sucking.
Show increased fearfulness (for example, of the dark, monsters, or being alone).
Incorporate aspects of the traumatic event into imaginary play.

“Children age 6 to 11 may:

Have problems in school.
Isolate themselves from family and friends.
Have nightmares, refuse to go to bed, or experience other sleep problems.
Become irritable, angry, or disruptive.
Be unable to concentrate.
Complain of physical problems such as stomachaches and headaches.
Develop unfounded fears.
Lose interest in fun activities.

“Adolescents age 12 to 17 may:

Have nightmares or other sleep problems.
Avoid reminders of the event.
Use or abuse drugs, alcohol, or tobacco.
Be disruptive or disrespectful or behave destructively.
Complain of physical problems such as stomachaches and headaches.
Become isolated from friends and family.
Be angry or resentful.
Lose interest in fun activities.

“In addition, children and adolescents may feel guilty for not preventing injury or deaths. They also may have thoughts of revenge.

“Many of these are normal and expected early responses, which for most people will lessen with time. If they last for more than a month, contact a licensed mental health professional.

Resource NIMH NIH.gov

“Physical responses to trauma may also mean that an individual needs help. Physical symptoms may include:

Headaches
Stomach pain and digestive issues
Feeling tired
Racing heart and sweating
Being very jumpy and easily startled

“Individuals who have a mental health condition or who have had traumatic experiences in the past, who face ongoing stress, or who lack support from friends and family may be more likely to develop more severe symptoms and need additional help. Some people turn to alcohol or other drugs to cope with their symptoms. Although substance use may seem to relieve symptoms temporarily, it can also lead to new problems and get in the way of recovery.”

Resource NIMH NIH.gov

DISORDERS WITH NO TRAUMATIC INTERVENTION

TRAUMA PREVALENCE

“Traumatic experiences are events—a series of events or a set of circumstances—experienced by individuals as emotionally or physically harmful (SAMHSA, 2014). An event becomes traumatic when it overwhelms our neurophysiological system for coping with stress and leaves people feeling unsafe, vulnerable, and out of control (Herman, 1992; Macy, Behar, Paulson, Delman, & Schmid, 2004). These experiences, whether real or perceived, threaten one’s life and/or bodily integrity; invoke intense feelings of helplessness, powerlessness, and/or terror; and, in the absence of protective supports, can have lasting and devastating effects on an individual’s physical, mental, and spiritual health (American Psychological Association (APA), 2008; SAMHSA, 2014). Exposure to traumatic stress is increasingly understood as a common denominator for children, youth, and adults across social service systems.

Prevalence of Trauma Across Service Systems

Justice 96% of female offenders have experienced trauma, often in the form of sexual abuse and intimate partner violence (Jennings, 2008). 75%–93% of youth involved with juvenile justice have experienced trauma (Justice Policy Institute, 2010).

Homeless 93% of homeless mothers have a lifetime history of interpersonal trauma (Bassuk et. al., 1997; Bassuk, E. L., Buckner, J. C., Perloff, J. N., & Bassuk, S. S. (1998); Hayes, Zonneville, & Bassuk, 2013; Weinreb, Buckner, Williams, & Nicholson, 2006). 83% of homeless children have been exposed to at least one serious violent event by age 12 (Buckner, Beardslee, & Bassuk, 2004).

Mental and Behavioral Health 93% of psychiatrically hospitalized adolescents have histories of physical and/or sexual and emotional trauma (Lipschitz, Winegar, Hartnick, Foote, & Southwick, 1999). 75% of clients in substance abuse treatment settings report histories of significant trauma (Jennings, 2004).

Veterans 81%–93% of women veterans have been exposed to trauma over their lifetimes (Zinzow, H., Grubaugh, A., Monnier, J., Suffoletta-Malerie, S., & Freuh, B. (2007). Child Welfare 50% of children and youth in the child welfare system have experienced trauma (National Center for Children in Poverty, 2007).

Education 25% of school-aged children have been exposed to a traumatic event (APA, 2008; National Child Traumatic Stress Network, 2008).

Resource White Paper Trauma Informed Care

TRAUMA INFORMED

‘A trauma-informed child and family service system is one in which all parties involved recognize and respond to the impact of traumatic stress on those who have contact with the system including children, caregivers, and service providers. Programs and agencies within such a system infuse and sustain trauma awareness, knowledge, and skills into their organizational cultures, practices, and policies. They act in collaboration with all those who are involved with the child, using the best available science, to maximize physical and psychological safety, facilitate the recovery of the child and family, and support their ability to thrive.

‘A service system with a trauma-informed perspective is one in which agencies, programs, and service providers:

Routinely screen for trauma exposure and related symptoms.
Use evidence-based, culturally responsive assessment and treatment for traumatic stress and associated mental health symptoms.
Make resources available to children, families, and providers on trauma exposure, its impact, and treatment.
Engage in efforts to strengthen the resilience and protective factors of children and families impacted by and vulnerable to trauma.
Address parent and caregiver trauma and its impact on the family system.
Emphasize continuity of care and collaboration across child-service systems.
Maintain an environment of care for staff that addresses, minimizes, and treats secondary traumatic stress, and that increases staff wellness.

‘These activities are rooted in an understanding that trauma-informed agencies, programs, and service providers:

Build meaningful partnerships that create mutuality among children, families, caregivers, and professionals at an individual and organizational level.
Address the intersections of trauma with culture, history, race, gender, location, and language, acknowledge the compounding impact of structural inequity, and are responsive to the unique needs of diverse communities.

Click here for a printable version of the NCTSN definition of a Trauma-Informed Child and Family Service System.
Resource National Child Trauma Stress Network

SOME TRAUMA TREATMENT OPTIONS

Advice to Counselors: Core Actions in Preparing To Deliver Psychological First Aid

Contact and engagement
Safety and comfort
Stabilization
Information gathering: Current needs and concerns
Practical assistance
Connection with social supports
Information on coping
Linkage with collaborative services

NCBI NLM NIH.gov Resource National Child Traumatic Stress Network & NCPTSD

“Trauma Affect Regulation: Guide for Education and Therapy (TARGET; Ford & Russo, 2006; Frisman, Ford, Lin, Mallon, & Chang, 2008) uses emotion and information processing in a present-focused, strengths-based approach to education and skills training for trauma survivors with severe mental, substance use, and co-occurring disorders across diverse populations. TARGET helps trauma survivors understand how trauma changes the brain’s normal stress response into an extreme survival-based alarm response that can lead to PTSD, and it teaches them a seven-step approach to making the PTSD alarm response less distressing and more adaptive (summarized by the acronym FREEDOM: Focus, Recognize triggers, Emotion self-check, Evaluate thoughts, Define goals, Options, and Make a contribution).

TARGET: The Seven-Step FREEDOM Approach

“Focus: Being focused helps a person pay attention and think about what’s happening right now instead of just reacting based on alarm signals tied to past trauma. This step teaches participants to use the SOS skill (Slow down, Orient, Self-check) to pay attention to body signals and the immediate environment and to use a simple scale to measure stress and control levels.

“Recognize triggers: Recognizing trauma triggers enables a person to anticipate and reset alarm signals as he or she learns to distinguish between a real threat and a reminder. This step helps participants identify personal triggers, take control, and short-circuit their alarm reactions.

“Emotion self-check: The goal of this skill is to identify two types of emotions. The first are “alarm” or reactive emotions such as terror, rage, shame, hopelessness, and guilt. Because these emotions are the most noticeable after trauma, they are the alarm system’s way of keeping a person primed and ready to fend off further danger. The second type of emotion, “main” emotions, include positive feelings (e.g., happiness, love, comfort, compassion) and feelings that represent positive strivings (e.g., hope, interest, confidence). By balancing both kinds of emotions, a person can reflect and draw on his or her own values and hopes even when the alarm is activated.

“Evaluate thoughts: When the brain is in alarm mode, thinking tends to be rigid, global, and catastrophic. Evaluating thoughts, as with identifying emotions, is about achieving a healthier balance of positive as well as negative thinking. Through a two-part process, participants learn to evaluate the situation and their options with a focus on how they choose to act—moving from reactive thoughts to “main” thoughts. This is a fundamental change from the PTSD pattern, which causes problems by taking a person straight from alarm signals to automatic survival reactions.

“Define goals: Reactive goals tend to be limited to just making it through the immediate situation or away from the source of danger. These reactive goals are necessary in true emergencies but don’t reflect a person’s “main” goals of doing worthwhile things and ultimately achieving a good and meaningful life. This step teaches one how to create “main” goals that reflect his or her deeper hopes and values.

“Options: The only options that are available when the brain’s alarm is turned on and won’t turn off are automatic “flight/fight” or “freeze/submit” reactive behaviors that are necessary in emergencies but often unhelpful in ordinary living. This step helps identify positive intentions often hidden by the more extreme reactive options generated by the alarm system. This opens the possibility for a greater range of options that take into consideration one’s own needs and goals as well as those of others.

“Make a contribution: When the brain’s alarm is turned on and reacting to ordinary stressors as if they were emergencies, it is very difficult for a person to come away from experiences with a feeling that they have made a positive difference. This can lead to feelings of alienation, worthlessness, or spiritual distress. The ultimate goal of TARGET is to empower adults and young people to think clearly enough to feel in control of their alarm reactions and, as a result, to be able to recognize the contribution they are making not only to their own lives, but to others’ lives as well.

Resource NCBI NLM NIH.gov Advanced Trauma Solutions

Trauma Recovery and Empowerment Model

“The trauma recovery and empowerment model (TREM) of therapy (Fallot & Harris, 2002; Harris & Community Connections Trauma Work Group, 1998) is a manualized group intervention designed for female trauma survivors with severe mental disorders. TREM addresses the complexity of long-term adaptation to trauma and attends to a range of difficulties common among survivors of sexual and physical abuse. TREM focuses mainly on developing specific recovery skills and current functioning and uses techniques that are effective in trauma recovery services. The model’s content and structure, which cover 33 topics, are informed by the role of gender in women’s experience of and coping with trauma.

“TREM can be adapted for shorter-term residential settings and outpatient substance abuse treatment settings, among others. Adaptations of the model for men and adolescents are available. The model was used in SAMHSA’s Women, Co-Occurring Disorders and Violence Study for three of the nine study sites and in SAMHSA’s Homeless Families program, and it is listed in SAMHSA’s NREPP. This model has been used with clients in substance abuse treatment; research by Toussaint, VanDeMark, Bornemann, and Graeber (2007) shows that women in a residential substance abuse treatment program showed significantly better trauma treatment outcomes using TREM than they did in treatment as usual, but no difference in substance use.

“TREM PROGRAM: Each session includes an experiential exercise to promote group cohesiveness. The 33 sessions are divided into the following general topic areas:

Part I–empowerment introduces gender identity concepts, interpersonal boundaries, and self-esteem.
Part II–trauma recovery concentrates on sexual, physical, and emotional abuse and their relationship to psychiatric symptoms, substance abuse, and relational patterns and issues.
Part III–advanced trauma recovery issues addresses additional trauma issues, such as blame and the role of forgiveness.
Part IV–closing rituals allows participants to assess their progress and encourages them to plan for their continued healing, either on their own or as part of a community of other survivors.
Part V–modifications or supplements for special populations provides modifications for subgroups such as women with serious mental illness, incarcerated women, women who are parents, women who abuse substances, and male survivors.

Resource NCBI NLM NIH.gov Mental Health America Centers for Technical Assistance

POST TRAUMATIC STRESS DISORDER

“PTSD is a disorder that some people develop after experiencing a shocking, scary, or dangerous event.

“It is natural to feel afraid during and after a traumatic situation. This fear triggers many split-second changes in the body to respond to danger and help a person avoid danger in the future. This “fight-or-flight” response is a typical reaction meant to protect a person from harm. Nearly everyone will experience a range of reactions after trauma, yet most people will recover from those symptoms naturally. Those who continue to experience problems may be diagnosed with PTSD. People who have PTSD may feel stressed or frightened even when they are no longer in danger.

“Anyone can develop PTSD at any age. This includes war veterans as well as survivors of physical and sexual assault, abuse, car accidents, disasters, terror attacks, or other serious events. Not everyone with PTSD has been through a dangerous event. Some experiences, like the sudden or unexpected death of a loved one, can also cause PTSD.

“According to the National Center for PTSD, about seven or eight of every 100 people will experience PTSD at some point in their lives. Women are more likely to develop PTSD than men. Some traumas may put an individual at a higher risk and biological factors like genes may make some people more likely to develop PTSD than others.

“It is important for anyone with PTSD to be treated by a mental health professional who is experienced with PTSD. The main treatments are psychotherapy (“talk” therapy), medications, or both. Everyone is different, and PTSD affects people differently, so a treatment that works for one person may not work for another. People with PTSD need to work with a mental health professional to find the best treatment for their symptoms.

“If someone with PTSD is living through an ongoing trauma, such as being in an abusive relationship, both of the problems need to be addressed. Other ongoing problems can include panic disorder, depression, substance abuse, and feeling suicidal. Research shows that support from family and friends can be an important part of recovery.

Resource NIMH NIH.gov

COMPLEX POST TRAUMATIC STRESS DISORDER

Resource NCBI NLM NIH Trauma Protocol

TRAUMATIC TRIGGERS

RED FLAGS OF TRAUMA

TRAUMATIC INTERVENTION FOR PARENTS

“After a traumatic event, parents and family members should identify and address their own feelings—this can allow them to help others. Explain to children what happened and let them know that:

You love them.
The event was not their fault.
You will do your best to take care of them.
It’s okay for them to feel upset.

“Do:

Allow children to be sad or cry.
Let children talk, write, or draw pictures about the event and their feelings.
Limit viewing of repetitive news reports about traumatic events. Young children may not understand that news coverage is about one event and not multiple similar events.
Give extra attention to children who have trouble sleeping. Let them sleep with a light on or let them sleep in your room (for a short time).
Try to keep your usual routines (or create new routines), such as reading bedtime stories, eating dinner together, or playing games.
Help children feel in control when possible by letting them make decisions for themselves, such as choosing meals or picking out clothes.
Contact a health professional if, after a month in a safe environment, children are not able to perform their usual routines.
Contact a health care provider if new behavioral or emotional problems develop, particularly if these symptoms occur for more than a few weeks:
- Flashbacks (flashbacks are the mind reliving the event)
- A racing heart and sweating
- Being easily startled
- Being emotionally numb
- Being very sad or depressed

“Don’t:

Expect children to be brave or tough.
Make children discuss the event before they are ready.
Get angry if children show strong emotions.
Get upset if they begin bed-wetting, acting out, or thumb-sucking.

“Children’s reactions to trauma are strongly influenced by adults’ responses to trauma. Parents can help children by being supportive, by remaining as calm as possible, and by reducing other stressors, such as:

Frequent moves or changes in place of residence
Long periods away from family and friends
Pressures to perform well in school
Fighting within the family

“When monitoring healing, remember:

Healing takes time.
Do not ignore severe reactions.
Pay attention to sudden changes in behaviors, speech, language use, or strong emotions.

Resources NIMH NIH.gov

TRAUMATIC INTERVENTION FOR FIRST RESPONDERS

“During and after a traumatic experience, rescue workers can help by:

Identifying children, adolescents, and families in need of urgent and immediate medical or mental health services.
Staying with and helping to calm children and adolescents in acute distress. Signs of acute distress include trembling, rambling, becoming mute, or exhibiting erratic behavior.
Protecting children and adolescents from physical danger, exposure to additional traumatic sights and sounds, and onlookers and the media.
Kindly but firmly directing children and adolescents away from the event site.
Connecting—and keeping—children and adolescents with family and friends.

“Rescue workers can reduce survivors’ fear and anxiety by using compassionate communication. When communicating with survivors, rescue workers should:

Clearly identify themselves and their role in disaster response.
Communicate calmly, slowly, and with empathy.
Be factual, avoid answering questions outside their area of expertise, and avoid speculation.
Acknowledge and be tolerant of strong emotions and behaviors.

Resources NIMH NIH.gov

TRAUMATIC INTERVENTION FOR COMMUNITY

“After a traumatic event, community members should identify and address their own feelings as this may allow them to help others more effectively.
Community members can help children and adolescents by:

Offering their buildings and institutions as gathering places to promote support
Helping families identify mental health professionals who can counsel children
Helping children develop coping skills, problem-solving skills, and ways to deal with fear
Holding parent meetings to discuss the event, their child’s response, and how parents can help their child
Being sensitive to different cultural responses to trauma and stress

Resources NIMH NIH.gov

RESOURCES

Two Influential Studies That Set the Stage for the Development of TIC

The Adverse Childhood Experiences Study (Centers for Disease Control and Prevention, 2013) was a large epidemiological study involving more than 17,000 individuals from United States; it analyzed the long-term effects of childhood and adolescent traumatic experiences on adult health risks, mental health, healthcare costs, and life expectancy.

The Women, Co-Occurring Disorders and Violence Study (SAMHSA, 2007) was a large multisite study focused on the role of interpersonal and other traumatic stressors among women; the interrelatedness of trauma, violence, and co-occurring substance use and mental disorders; and the incorporation of trauma-informed and trauma-specific principles, models, and services.

SAMHSA National Child Traumatic Stress Network
DOJ Crime Victims.
NMHI Helping Children and Adolescents Cope with Disasters and Other Traumatic Events: What Parents, Rescue Workers, and the Community Can Do
NMHI Post-Traumatic Stress Disorder
Centers for Disease Control and Prevention: Caring for Children in a Disaster
Disaster Assistance Improvement Program
Federal Emergency Management Agency
National Child Traumatic Stress Network
Ready—A national public service campaign
Substance Abuse and Mental Health Services Administration: Disaster Preparedness, Response, and Recovery
Uniformed Services University: Center for the Study of Traumatic Stress
U.S. Department of Justice Office for Victims of Crime: Help for Crime Victims
U.S. Department of Veterans Affairs: National Center for PTSD (Post-Traumatic Stress Disorder)

CDC CAN Preventing Child Abuse
CDC CAN Fact Sheet