Trauma-Informed Care and Mental Health

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Butler, L. D., Critelli, F. M., & Rinfrette, E. S. (2011).Traumainformed care and mental health. Directions in Psychiatry, 31, 197-210.

Trauma-Informed Care and Mental Health Lisa D. Butler, PhD; Filomena M. Critelli, PhD, LCSW; and Elaine S. Rinfrette, PhD, LCSW-R No commercial support was used in the development of this CME lesson.

KEY WORDS: Trauma informed care • Trauma • PTSD • Mental health • Retraumatization LEARNING OBJECTIVES: Clinicians will (1) be able to distinguish trauma informed care from trauma specific interventions, (2) review the prevalence of trauma histories among those seeking mental health services, (3) learn the 5 principles of trauma informed practice and the characteristics of a trauma informed organization/department, and (4) review standard clinical practices that may be retraumatizing for patients with trauma histories. LESSON ABSTRACT: To be trauma informed is to understand the involvement and impact of violence and victimization in the lives of most consumers of mental health, substance abuse, and other services. It is also to apply that understanding in providing services and designing service systems to accommodate the requirements and vulnerabilities of trauma survivors and to facilitate their participation in treatment. This lesson will explain the difference between trauma informed care and trauma specific interventions, briefly review trauma history prevalences among consumers of mental health services, describe the development of a trauma informed perspective in mental health, and discuss how standard clinical practices may inadvertently retraumatize those with trauma histories. This lesson will also outline the central features of a trauma informed organization/department and the 5 principles of trauma informed practice. Given the prevalence of traumatic experiences, especially those during development, and their long standing effects on patients’ lives, the trauma informed perspective offers a compelling and humane organizing principle for conceptualizing and addressing many of the problems and challenges facing those seeking mental health and other services.

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Trauma-Informed Care: Introduction and Definition An elderly woman was admitted to a major urban hospital for Xrays and treatment of a hip fracture. Her children also requested that she receive a psychiatric evaluation and observation while admitted because she had been “quite down” and at times confused since the death of her husband 8 months before. In the week fol lowing her admission, the woman deteriorated rapidly, becoming generally uncommunicative and withdrawn, refusing to eat or bathe, and voicing paranoid and suicidal ideation when she did communicate. Her daughter also mentioned that since admission her mother had complained of fatigue and having nightmares. During a review of the case with her physician, family members revealed that the woman was a Holocaust survivor; however, this information was not in her chart because no trauma history had been conducted at intake.

Given the woman’s history and her dramatic decline following admission, it is reasonable to consider whether customary hospital activities and procedures played a role in precipitating her psychological deterioration. Healthcare providers applying a “trauma informed” per spective would consider, for example, whether the expe riences of being separated from her family and stripped of her clothes, undergoing medical examinations and blood draw, and wearing a wristband with a patient number (or other aspects of her hospital experience) could have reactivated the anguish and dehumanization of her early trauma, plunging her into her current despair. The potential for reactivation or “triggering” is one of the lasting effects of such experiences for trauma 1,2 survivors. To be “traumainformed” is (1) to understand how violence and victimization have figured in the lives of most consumers of mental health, substance abuse, and other services and (2) to apply that understanding in providing services and designing service systems so that they accommodate the needs and vulnerabilities of trauma survivors and facilitate

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client participation in treatment. This shift in per spective and practice implies a significant adaptation in how mental health patients are understood and cared for by helping professionals, as well as in the conduct of support staff and administration. A trauma informed 3 5 approach to care (see Table 1) perceives trauma not simply as a past event but as a formative one that may be contributing to the client’s current state or circum stances. To be trauma informed is to understand clients and their symptoms in the context of their life experi ences and cultures, with an appreciation that some symptoms may represent efforts at coping. Conse quently, and importantly, the clinical understanding emphasizes “what happened to the person” rather than the implied judgment of “what is wrong with the per son.” Additionally, efforts are made so no more harm is done and client safety is ensured by minimizing the possibilities of injury or retraumatization in clin ical or other service settings.

Trauma-Informed Versus Trauma-Specific Services

“Traumainformed” services and “traumaspecific” services are not the same. Traumainformed services are informed about, and sensitive to, the potential for traumarelated issues to be present in patients, regardless of whether the issues are directly or obvi Table 1 Principles of Trauma-Informed Services

Trauma-Informed Services: • Recognize the impact of violence and victimization on development and coping strategies • Identify recovery from trauma as a primary goal • Employ an empowerment model • Strive to maximize client choices and control of her or his recovery • Are based in a relational collaboration • Create an atmosphere that is respectful of the survivors’ need for safety, respect, and acceptance • Emphasize the clients’ strengths, highlighting adaptations over symptoms and resilience over pathology • Strive to minimize the possibilities of retraumatization • Strive to be culturally competent, understanding clients in the context of their life experiences and cultural background • Solicit consumer input and involve consumers in the design and evaluation of services Adapted from Elliot and colleagues.

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Although “patient” is the term traditionally used in medical writing, in this lesson we have used the term “client” because it is more broadly applicable to persons who seek services from various types of mental health professionals and across a variety of settings. Additionally, “client” (or the term “consumer”) is typically used in works that embrace a trauma informed perspective so that the language is consistent with the collaborative emphasis of this approach. The term “patient” has been retained in the present article when the content is about medical procedures or settings or when “patient” was used in the original material being described.

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ously related to the presenting complaint or condi tion. Moreover, trauma informed services are not designed to treat the sequelae of physical and sexual abuse or other traumatic experience. Traumaspecific services, in contrast, are designed expressly to treat the symptoms and syndromes related to current or past 3,4 trauma.

Background of the TraumaInformed Care Movement Documentation of the Prevalence of Traumatic Events:

The impetus for the development of a trauma informed care perspective in mental health and social service deliv ery came in part from growing recognition over the past two decades of the wide prevalence of early traumatic events and their associations with later psychological 6 9 and physical difficulties and disorders. In particular, findings from the Adverse Childhood Experiences (ACE) 10,11 Study, which was initiated in 1995, highlighted the role of early psychological trauma in physical and men tal difficulties throughout the lifespan. This investiga tion found that early adverse experiences tend to be 12 interrelated, and that a strong graded relationship char acterized the association between the number of differ ent types of maltreatment/family dysfunction experi enced in childhood and adolescent/adult health risk behaviors and an astonishing array of subsequent mental 10,11 health and medical conditions. In mental health settings, reports indicate exceed ingly high rates of trauma histories among psychiatric patients. In 1 study examining psychiatric outpatient 13 charts, 50% were positive for a history of trauma (e.g., physical and sexual abuse and catastrophic events that threatened physical integrity were assessed). Among poor inner city youth using an urban outpatient mental health clinic, 94% had experienced at least 1 lifetime trauma (most commonly physical attack, rape, or being threat ened with a weapon), and 42% met criteria in the previ 14 ous year for posttraumatic stress disorder (PTSD). Rates are also high in adult inpatients. In 1 study, 81% of the participants had experienced physical or sexual abuse, and two thirds of that group had experienced the abuse 15 in childhood. Acute inpatient adolescents also report

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high rates of childhood abuse: 86% reported physical 16 abuse, and 71% reported sexual abuse in 1 sample, with about a third of those exposed to childhood traumatic 17 events meeting criteria for current PTSD. An association has also been documented between substance abuse disorders and PTSD among men and 18 21 women with trauma histories. The presence of either PTSD or substance abuse increases the risk of develop ing the other condition, and among current female sub stance abusers, histories of childhood physical and/or 20 sexual abuse range from 32% to 66%. In the general population, PTSD is associated with some of the highest 14,22,23 rates of medical and mental health service use. Other studies have found that women with severe mental illness (SMI) have rates of lifetime physical or sexual assault ranging from 51% to 97%, with a sig nificant number experiencing multiple victimiza 24 tions. Recent physical and sexual victimizations were also found in samples drawn from inpatient and outpa 25 tient settings, with women being 16 times more likely and men 10 times more likely to report a violent victim ization in the past year when compared to women and men, respectively, in a community sample. Childhood abuse histories, substance use, frequent psychiatric hos pitalizations, and homelessness were each associated with increased risk of recent victimization among those with SMI. 26 Mueser and his colleagues documented that 98% of 1 SMI sample reported lifetime exposure to at least 1 traumatic event. About a third of the men in the sample had been sexually assaulted during childhood, and about half as adults had been physically attacked with a weapon. Notably, the prevalence of PTSD was 43% among those with trauma exposure, yet this diagnosis was charted in only 2% of those patients. The authors note that “PTSD appears to be a common comorbid disorder for patients (p 497) with severe mental illness.” There are also high rates of trauma symptoms among those with co occurring disorders (e.g., those with a major 27,28 mental disorder and a substance abuse disorder). Among women with co occurring disorders, 48% to 90% 29 32 report histories of interpersonal violence. Indeed, trauma histories have been so widely docu mented over the past 2 decades that some experts have concluded that virtually all users of services in the public 179

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mental health and substance abuse systems have histo 3,4 ries of trauma.

Mental Health Consumer and Institutional Support: As documentation of the prevalence of early trauma accumulated, there were also concurrent and widespread 3,4,33 calls for improvements in mental health care delivery by ex patients and groups that represent them (e.g., National Coalition for Mental Health Recovery). As one 33 commentator noted, “The consumer/survivor/expatient’s gross dissatisfaction with the existing mental health system is not a denial of the need for help, but rather a criticism of (p 22) what is passing for help.” Consequently, buy in by mental health consumers (and some providers) was essential (A. Jennings, written communication, July 17, 2009). Momentum for the trauma informed care move ment was also boosted by the leadership of the Substance and Mental Health Services Administration 4 (SAMHSA), which, among other efforts, implemented a large scale research program—the Women, CoOccurring 34,35 Disorders and Violence Study (1998 2003)—and sup ported the founding of the National Center for Trauma 36 Informed Care and the National Child Traumatic Stress 37 Network. Around the same time, publication of Harris and Fallot’s Using Trauma Theory to Design Service Sys 38 tems clarified the conceptualization of trauma informed care and provided the needed vocabulary, rationale, and plan for implementing this type of care. During the same period, the final report of the Presi 39 dent’s New Freedom Commission on Mental Health called for a fundamental transformation in the country’s approach to mental health care and recommended that the Department of Health and Human Services (through the National Institutes of Health) embark on a sustained pro gram of research examining, in part, the consequences of trauma for the mental health of at risk populations, such as children, women, and the victims of violent crime. This convergence of factors—accumulating trauma prevalence data, institutional leadership and innovation, elucidation of conceptual frameworks, and consumer demand and support—catalyzed into an appreciation of the need for a fundamental change in mental health delivery. In short, that it become trauma informed. 180

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Why Is Trauma-Informed Care Important? Regardless of the event or circumstance that brings an individual to the attention of a mental health practi tioner, the client’s trauma history is rarely explored or conceptualized as determinative in presenting problems. Furthermore, addressing such histories may not be viewed as critical to successful treatment in many mental 4,40,41 health settings. Indeed, most individuals seeking mental health or other services are never screened, assessed, or treated for their trauma experiences. As Har 3 ris and Fallot have noted, “Systems serve survivors of childhood trauma without treating them for the conse quences of that trauma; more significant, systems serve indi viduals without even being aware of the trauma that (p. 3) occurred.” This lack of awareness can result in (1) a failure to understand fully the presenting issues and their context; (2) a failure to treat or make appropriate (trauma spe cific) referrals; and/or (3) retraumatization of patients with standard clinical procedures or inadvertent trigger ing events, which may slow patient progress, reduce 42 44 openness to treatment, or derail therapy altogether. A woman is receiving case management ser vices and medication for her schizophrenic ill ness. She collaborates in her treatment and attends all scheduled meetings. After the Christmas holidays with her family, she begins missing appointments. Her case manager sus pects that she is no longer taking her medica tions. When several attempts to make contact fail, the case manager requests that an emer gency psychiatric team go to her home and evaluate her for possible hospitalization. During the evaluation, she becomes verbally abusive; she is restrained, handcuffed, and taken to a state psychiatric hospital. At the hospital, she appears frightened, does not speak, and spends hours staring into space. She remains hospitalized for several weeks. No one who is part of her inpatient or outpatient treat ment team knows that she is a survivor of sex 3(p 4) ual and/or physical abuse.


Potentially Retraumatizing Practices and Behaviors One distinguishing and essential feature of trauma informed care is the focus on ensuring that treatment environments do not inadvertently retraumatize patients. This emphasis is significant because psychiatric settings can be particularly disturbing for patients. Hos pitalizations involve a range of standard clinical proce dures that can iatrogenically trigger trauma symptoms or reenactments of previous responses to trauma (e.g., in particular, flashbacks/dissociation, physiological reactiv ity, depression, withdrawal, aggression, and self injuri ous behaviors). Rather than deescalating a patient crisis, some procedures may exacerbate or precipitate one because of their manifest (or symbolic) resemblance to aspects of past experiences of abuse or violence. Such procedures/experiences include seclusion, being put in restraints, body searches, forced or threatened medica tions, involuntary commitment, night bed checks, boundary violations (including, but not limited to, touching without permission, walking into the patient’s room without knocking), angry altercations or name calling among patients or between staff and patients, take downs, being handcuffed by police, or exposure to 29,42,43,45 49 very sick or frightening patients. Indeed, the use of restraints has been compared by some patients to being raped or physically abused, according to Blanch 47 and Parrish, and seclusion has been described as “a 50(p 288) form of torture.” In some cases, simply observing others experiencing such events can be activating. Moreover, in a subset of cases—such as those that involve experiencing or witnessing physical or sexual assault—patients may be newly or additionally trauma 29 tized. Although exposure to these types of events could be upsetting for any patient, those with sexual or physi cal abuse histories tend to be the most severely distressed 29 by these events. Survivors of other types of trauma are likely to have additional event specific triggers that need 51,52 to be identified. In addition to standard clinical procedures, there may be messages implicit in the manner or commu nication of care delivery that can also be triggering for a trauma survivor if he or she recapitulates aspects of the betrayal, boundary violation, objectifi cation, powerlessness, vulnerability, and lack of


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agency experienced during the original trauma. For 45,54 example, insensitive exchanges that communicate that “no progress is expected” can signal to the patient that he or she is viewed as defective and hopeless. Disre gard by staff of the valid needs of and/or requests by patients can indicate that “you don’t matter.” Patient care that overemphasizes compliance (rather than collab oration) conveys the message “you are powerless.” Expe riences of being excluded from treatment planning or having information withheld can also be infantilizing and reminiscent of the helplessness induced by trauma. Indeed, for many who were traumatized, the trauma came at the hands of an authority figure and was sanc tioned, ignored, or denied by caretakers and the wider social system. Consequently, being the object of the ministrations of an expert in a medical setting could be experienced as a reenactment of aspects of the power dif ferential inherent in the original trauma. A difficulty for practitioners in traditional medical settings, then, is that operating within the norms of those structures may essentially undermine patient trust and treatment progress.

Elements of a Trauma-Informed Department or Organization

Becoming trauma informed has implications for the practitioner and the setting or system in which care is provided. At a systems level, to become a trauma informed organization or department necessitates multi 3,45 level changes across many domains. All aspects of services and programs need to be organized with an awareness of the pervasiveness of trauma, its impact, and its selfperpetuating nature, as well as familiarity concerning the multiple and complex paths to heal 3,55 ing and recovery. Administrative support for integrating knowledge of trauma and violence into all aspects of an organization’s functioning is essential. This support includes (where appropriate) explicit mention of the issue in mission and policy statements, as well as administrative resolve to ensure the availability of resources for disseminating information. Additionally, a review of institutional poli cies and procedures must be undertaken to improve sen sitivity to the potential for retraumatization of patients. 181

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Education and training in basic information about trauma are necessary for all staff, even in set tings where there is administrative support for clini cians to receive specialized trauma training and supervision. In other words, as noted by Elliot and col 56 leagues, “To provide trauma informed services, all staff of an organization, from the receptionist to the direct care workers to the board of directors, must understand how violence impacts the lives of the people being served, so that every interaction is consistent with the recovery process and reduces the possibility of retrauma (p 462) tization.” Universal screening of all patients for trauma his tories is also fundamental to a traumainformed 3,57 organization. Even in settings where traumaspe cific services are not available, a thorough trauma history screening can increase practitioner awareness of issues that may need consideration in treatment planning. Screening can also increase the client’s knowl edge of the potential impact that trauma has had in his or her life and the importance of addressing these issues in treatment. Maintenance of accurate records of trauma histories/screens is necessary so that, should readmission be necessary, the client is not required to retell his or her trauma story, which itself can be retraumatizing. Addi tionally, where appropriate, clinicians should provide appropriate referrals for patients in need of trauma spe cific services.

Principles of Trauma-Informed Practice

In addition to organizational features that reflect and implement a traumainformed approach to care, Fal 55 lot and Harris have identified 5 principles to guide practice: safety, trustworthiness, choice, collabora tion, and empowerment.

Safety: The treatment setting, as well as the provision of care, must ensure physical and emotional safety. The assur ance of safety is a necessary precondition to any effective therapeutic work with trauma survivors because an atmosphere that is respectful of survivors’ need for safety, respect, and acceptance is fundamental for build 53 ing trust and therapeutic engagement. Considerations 182

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may include the locations (including parking) of service settings and times when services are offered, availability of security personnel, whether doors are left open or locked, the appearance of the waiting and consultation rooms, and whether staff are trained to recognize patient discomfort and are trauma sensitive in interactions. A patient with a serious back injury was referred by a pain management clinic to outpatient men tal health treatment due to “lack of progress.” The referral noted that she had attended her pain appointments rarely and was anxious, pre occupied, and somewhat uncooperative when she was present. She had never been asked about a possible trauma history while attending the pain clinic. Once such a history was conducted, she was found to have an extensive background of childhood sexual abuse and had witnessed extreme physical abuse of her mother and sib lings by her father. She reported that the signif icant loss of mobility and strength due to her accident had left her feeling extremely vulnera ble to further victimization by her father. When she realized that the pain clinic was located in his small neighborhood, and that she might run into him in the vicinity, she reported that she suffered acute anxiety, and became so agitated that she often felt compelled to cancel. Her new therapist provided her with information about alternative (safely located) pain management clinics to choose from, helped her develop a per sonal safety plan, and referred her to a trauma specific program to address her reactivated trauma symptoms. 45

In inpatient settings, additional consideration should to be given to physically separating male and female patients; making safe and comfortable time out space available; respecting patient privacy and personal modesty (with respect to bathing, sleeping, and using the bathroom); training staff appropriately in deescalation strategies; keeping patients fully informed of ward rules, procedures, and expectations; having unambiguous policies on how reports of abuse (by another patient, a visitor, or a staff member) are addressed; and helping the patient identify emotional triggers as well as calming strategies that can reinstate feelings of control.


Trustworthiness: Given the betrayal that many trauma survivors experi enced in their past relationships, trust in the therapist and the therapeutic relationship may have to be earned. Steps in building trust include efforts to understand and accomplish what is necessary for the client to feel safe, including respecting their emotional limits and not pressuring clients to disclose. By making client responsibilities and tasks clear, explaining procedures and tests, and addressing confusions and ambiguities, the clinician can also enhance the client’s feelings of safety and trust. Respectful and consistent practice of informed consent and strict confidentiality are essen tial, as is the maintenance of appropriate and respectful professional boundaries. A drug company representative was referred to a psychiatrist for evaluation of a possible hypo manic episode. Upon initial evaluation, the man disclosed a history of childhood physical abuse by his father. The client also indicated that he believed that he was a good salesman because he had learned to talk his way out of his father’s threatened beatings. The client was charming, gregarious, and eager to ingratiate himself to his new therapist. As the therapy progressed, the patient began bringing “freebies” from his com pany as presents for his therapist, explaining that his job was to give them away anyway and “so what was the harm?” Each time, however, his therapist gently but firmly refused these gifts and explained how if he accepted them it would blur the boundaries of their therapeutic relation ship. After a number of sessions, the patient con fided that looking back he appreciated that the therapist “couldn’t be bought off.”

Choice: Emphasizing and encouraging consumer choice and control in the client’s treatment, where possible, is essential and may include choices for clients over aspects of the services they receive (e.g., type of inter vention, time of day, gender of clinician). A clear delin eation of clients’ rights and responsibilities is also necessary.


A female client with a history of domestic vio lence (DV) was very reluctant to leave individual therapy to enter a group developed to address the needs of DV survivors, although her thera pist thought that was appropriate. In discussing the options, the therapist suggested that the client attend 4 group sessions to evaluate whether she felt it would be a good therapeutic setting for her and that they meet after the sec ond and fourth group meetings to discuss her impressions of the group and to address any concerns. At the second meeting, she was given the choice to return to individual work or con tinue in the group. The client stated that although initially anxious in group, she had overcome her reservations about starting some thing new, begun to make connections with other group members, and saw the value of group for her progress. She decided that she wanted to continue in the group setting as her primary treatment intervention.

Collaboration: Trauma informed practice involves practitioner client collaboration and the sharing of power. The experience of collaboration is best instantiated in an atmosphere where the client is treated as the expert on his or her own life. In such a climate, the practitioner and client work with each other, rather than the more traditional treatment approach of things being done to or for the client. To achieve this, the client must have a signifi cant role in planning and evaluating the services he or she receives. Clients’ preferences should be heard and honored where possible in setting goals and developing treatment priorities. A middleaged, recently divorced woman sought treatment for longstanding dysthymia. In her first session, she revealed that she was a closeted lesbian with a history of childhood sexual abuse by her own mother (now deceased). She stated that she now believed that she had been living a lie and that to be true to herself (and to alleviate her depression) she had to reveal this informa tion to her schoolaged children and exhus band. The clinician had a somewhat different 183

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initial conceptualization of the presenting issue (one emphasizing that the abuse history proba bly needed to be worked through), as well as concerns about whether the client’s approach would achieve what she was seeking. He also rec ognized the significance of respecting the insights and objectives declared by his client. The clinician acknowledged the client’s view and voiced his concerns about proceeding too quickly and without due consideration of the timing, method, content, and potential impact of her disclosures. He helped the client explore her beliefs about what she sought to achieve, her fantasies about how her family members would react, how she would feel if her disclosures were received with confusion, anger, disbelief, or other negative responses, and what the possible ramifications might be for her relationships with each family member. The clinician and client examined these issues in detail over several ses sions. Ultimately, the client decided that disclo sure of her abuse history to her young children was not desirable at that time. The client and therapist then turned to developing a plan for how she could reveal her sexual orientation to her family and exploring the impact of her abuse history on her life.

Empowerment: Emphasizing strengths and resilience, as well as explor ing coping strategies and sources of personal strength that have been used in the past, is empowering. By rec ognizing the abilities and skills that clients bring to their experience, the therapist can help the client deploy these resources to cope with the challenges he or she faces. A focus on wellness rather than illness is vital and empow ering. Additionally, educating clients about trauma and how their past experiences may be contributing to their current circumstances and/or reactions can help clients achieve insight into how to be more effective in antici pating and managing their responses. Furthermore, clients need to be encouraged to build a realistic sense of hope about the future and the skills that can maximize future successes.

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A young man with a history of childhood neglect was very adept at helping others address their needs and achieve their goals. Not only was he skilled at problemsolving and creating opportu nities, but he also was a supportive friend and quite fearless in his efforts to help those he cared about. He had very poor selfesteem, however, and although he had always wanted to start an animal rescue organization, he could not imag ine ever being successful. His therapist worked with him to acknowledge how effective he was in assisting others (and himself, in the past), and to identify the strengths and the skills he employed in those efforts. In doing so, his confidence was boosted, and he began to identify the additional skills he needed to develop and the steps he needed to take to achieve his personal goals.

Although the focus in trauma informed care has been primarily concerned with the consumers of mental health and other services, the approach has wider impli cations. These principles can be infused systemically so that clinical and support staff operate in a trauma informed milieu as well, reaping the benefits of a work setting that is safe, trustworthy, collaborative, and empowering, and where staff can exercise choice and some measure of control in their dealings with each 55,58 59 other and the administration. As Rivard has observed, “the treatment environment is a core modality for healthy relationships among interdependent com (p 3) munity members.”

Applying Trauma-Informed Care Principles to Special Populations: Immigrants and Refugees

Much of the trauma informed literature was spawned by, and reflects the concerns of, adult survivors of child hood maltreatment. However, certain populations— such as children, the elderly, religious and ethnic minorities, the lesbian, gay, bisexual, and transgender (LGBT) community, veterans, the disabled, and immi grants and refugees—have elements to their histories that suggest distinct vulnerabilities and needs specific to their experience as a member of that group. Although


trauma informed care principles are widely applicable, they may also need to be tailored to the distinctive exi gencies of the population being assessed or treated. To illustrate this, we describe in the following a number of distinct trauma related issues that pertain to the immi grant and refugee experience and how the 5 principles of trauma informed care apply to working with this partic ular group. We have chosen to highlight this group because it represents an increasing sector of the Ameri can population and it provides an excellent example of how population specific the application of trauma informed principles may need to be. Immigrants and refugees are a large and rapidly growing segment of our population and are likely to be seen by practitioners in all service systems, so it is essen tial that clinicians are knowledgeable about the trauma experiences of these groups. Immigrants, as persons who enter and become established in a country where they are not natives, are a very heterogeneous group. Refugees are defined as persons legally admitted to the United States and who cannot return to their country because of a “well founded fear of persecution on account of race, religion, nationality, membership in a 60(p 1) particular social group, or political opinion.” Asylees must meet the same criteria, except that they face an arduous process of applying for political asylum once in the United States and cannot work until such status is granted. Refugees and asylees have been forced or obliged to flee or to leave their homes. Many are sur vivors of persecution, political repression, torture, civil war, rape and other violations of human rights, or are persons who may have been victims of trafficking or suf fered the “disappearance” of friends and family. Between 5% and 35% of the world’s refugees and 61 asylees are estimated to have been tortured. Refugees leave their home countries involuntarily, usually do not have a choice about where to resettle, may have little time to plan or prepare for their migration, and cannot return home because of continuing danger of persecu tion. Although other types of immigrants tend to migrate in a more planned fashion, undocumented immigrants may also experience traumatic transits with abuses by smugglers or “coyotes.” Undocumented immi grants are often victims of assaults, rape, thefts, drown 62 ing, and other bodily harm. As unauthorized residents,


they live “hidden lives” preoccupied by fear of discovery. Recognizing that immigrants and, in particular, refugees are likely to have experienced significant stres sors and traumatic events throughout an often lengthy process of migration and resettlement, a trauma informed approach is clearly relevant with this popula tion. Understanding the complex interplay of trauma, dislocation, and adjustment in the migration process is an essential foundation for a trauma informed perspec tive. The migration process consists of multiple stages, 63 and each stage contains a number of potential stressors. Premigration stressors, such as traumatic exposure in the country of origin, are often compounded by the loss of extended family and kinship networks. The migration or transit stage often involves difficult journeys includ ing hunger, fear, hiding, separations from loved ones, and death of traveling companions. For refugees, deten tion in refugee camps often takes place for prolonged periods with chronic deprivation of basic needs. The post migration stage and survival in the host nation’s social and economic structure present further challenges, and acculturative stress associated with this process is 64,65 common. As a result of the many stressors immi grants and refugees face during their physical and psy chological odyssey, they are at high risk for mental 66,67 health problems. Among adults, the main problems reported are depression and anxiety disorders, particu 68 71 larly posttraumatic stress disorders. Torture and cumulative trauma are the strongest predictors of post traumatic stress disorder and are associated with chronic 72 physical and mental health problems. Trauma informed principles of safety, trustworthi ness, choice, collaboration, empowerment, all strong practice principles, are helpful for all treatment of immi grants and refugees regardless of their specific experi ences. A brief discussion of these principles and their rel evance for this special population follows.

Safety: Immigrants and refugees face a number of barriers that can contribute to the underutilization of mental health services, including the stigma associated with mental ill ness and treatment in their countries of origin, a dearth of clinicians who speak refugees’ languages, low priority given to mental health because of other, overwhelming 185

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needs of newly immigrated families, and lack of 73 resources to pay for services. Histories of violence and human rights abuses may also create fear that seeking assistance may put the refugees at risk of further harm or 64 vulnerability. Lack of fluency in the host language is frustrating, shameful, and sometimes terrifying for new comers. Negative interactions, unwelcoming environ ments, and language barriers communicate a devalued status and power differentials that can provoke reexperi encing of traumatic symptoms and emotions from pre 74 vious trauma. Even if these are unintentional, the result is a decrease in trust and willingness to engage in ser vices. Attention to cultural and linguistic barriers in reception, phone services and clinical services, and awareness of various legal statuses can promote a sense 63 of safety. Medical interpreters, “culture brokers,” bilin gual and bicultural mental health practitioners, and clin ician training in cultural competence can also mitigate 75,76 these potential barriers.

Trustworthiness: It is critical to remember that U.S. social institutions operate under a different worldview than is familiar to many immigrants and refugees, so it cannot be assumed that clients understand the purpose of programs and ser vices and the laws and regulations that govern their oper ation. Trustworthiness is maximized by making the tasks involved in treatment clear, consistent, and transparent, with clear explanations of times for service delivery such as appointment systems, referrals, waiting lists, fees, and why certain information is needed. These areas may require much explanation, particularly regarding how professional boundaries are defined. Boundaries must also be maintained through use of qualified, appropriate interpreters, rather than children or other family mem bers. Disclosing traumatic experience through relatives, family members or, particularly, children is inappropriate 76 and can be traumatic for all involved. Issues of confi dentiality and trust must also be worked through when working with someone from a small language commu nity, as the client may be anxious about being identifiable and mistrustful of an interpreter’s professionalism.

Choice and Control: Maximizing client choice and control is a priority espe 186

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cially considering that experiences of prolonged deten tion in refugee camps with limited control over one’s life, torture as a means to gain power or to silence oppo sition, and confinement by traffickers or smugglers are common experiences among this population. Some refugee clients may regard therapeutic intervention as a threat since a diagnosis may have consequences for their future, and silence or withdrawal seems a safer strategy than talk and self revelation. Fearing sanctions, some 77 choose to avoid confrontations and exposure. Allowing the client to determine the pace of disclosure is a key aspect of maximizing choice and control. Interactions and interventions should be focused on ways to assist 78 clients without pathologizing them. Since psychother apy and psychiatric treatment are generally unfamiliar in most of the world’s cultures, it is important to explain these processes and ensure that clients are comfortable. Assessments may be experienced as invasive. Clinicians should also avoid probing too deeply in the first session or avoid making assumptions about trauma, unless the client indicates a readiness or willingness to do so. Push ing for early disclosure of traumatic events may result in 79 more harm than benefit. Moreover, most people exposed to extreme trauma do not go on to develop chronic, disabling PTSD. Meta analyses indicate that on average only 20% of those who experience traumatic 80 events develop PTSD. Alertness for signs and symp toms of posttraumatic stress disorder and unexplained somatic symptoms, sleep disorders, or mental health dis orders such as depression or panic disorder is recom 79 mended. Trauma specific treatment should be available for those with severe and persistent trauma related 78,79 symptoms. Client choice is also enhanced by the availability of walk in appointments and evening hours since many immigrants and refugees are employed in low paying jobs and are unable to miss work without 81 losing income or putting their employment at risk.

Collaboration: Clinicians must educate themselves and become sensi tive to their clients’ cultural history and background. A culturally competent trauma informed approach views clients as a partner in this process. “Cultural humility” acknowledges that the clinician is not the expert and accepts responsibility for learning about the client’s cul


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tural identity. Knowledge of cultural norms regarding appropriate levels of emotional expression and with whom it is considered culturally appropriate to share emotions is critical. Awareness of cultural variations in presentation of symptoms (i.e., somatic symptoms), ways of coping, and the stigma attached to mental health problems are necessary to improve detection and treat 76 ment of any psychiatric conditions. Power sharing is also developed through trauma education focused on normalizing trauma experiences and symptoms, which 81 can also help minimize the stigma of mental health care.

Empowerment: Immigrants and refugees may lose a sense of coherence and find that capacities that the migrants have relied upon throughout their lives may not work in their new setting. Social and economic strain, discrimination, and 83 loss of status pose additional stresses. Interventions that engage and support existing strengths and capabilities and incorporate traditional support mechanisms are rec ommended. Fostering social agency and the enterprise that traditionally characterizes migrants should also be 74,78 84(p 520) emphasized. As Muecke notes: “Refugees present perhaps the maximum example of the human capacity to survive despite the greatest losses and assaults on human identity and dignity.” Messages that focus on resilience and wellness are empowering and facilitate positive adaptation.

Efforts to Make Mental Health Settings More Trauma-Informed

Calls to make trauma assessments routine and to pro vide specialized trauma related services in mental health settings have been increasing over the past decade, as has the groundswell of support for implementing trauma 3,4,46 informed treatment protocols. As one commentator put it, “Although childhood trauma experienced by individ uals may be core to their condition and central to their healing, it has seldom been addressed or viewed as a central issue in the treatment of adults within public health set 4 tings.” Cusack et al. demands for reducing or eliminat ing potentially traumatizing or retraumatizing mental 29,40,47,50,85 health practices have been heard for even longer, and in some cases effective actions have been taken.


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In one instance, spearheaded by the Massachusetts Department of Mental Health (DMH), the impetus to reduce the use of child and adolescent in patient restraints and seclusion (R/S) issued from findings that the rates of these practices in 1999 and 2000 were 5 6 times higher for children and adolescents than they were for adults in that state. This appalling statistic, along with growing national unease about such practices and mounting knowledge of the trauma history rates among 17 these youth, prompted the development and imple mentation of statewide R/S reduction strategy. This effort included articulation of the goal to reduce or elim inate R/S practices statewide; a charge to all licensed or contracted facilities/units to develop a R/S reduction strategic plan; considerable clinical consultation, train ing, and technical assistance provided by the DMH; and ongoing use of quantitative, facility/unit specific data monitoring and feedback. This statewide effort paid off. Examination of comparable 3month periods before and after the interventions revealed substantial reductions in total R/S episodes (per 1000 patient days) and hours: episodes decreased by 65.9% in child units, 37.7% in adolescent units, and 67% in mixed (child and adolescent) units, with hours per episode decreasing by 31% for adolescents, 19% for children, and 16.7% for mixed units. Notably, and contrary to original concerns, the use of involuntary medication decreased markedly, as did injuries to staff and patients. Positive findings have also been 8789 reported in other mental health systems. Notably, in 2005 the National Association of State Mental Health Program Directors (NASMHPD) unani mously passed a position paper recognizing trauma as “pervasive, highly disabling and largely ignored.” The NASMHPD also launched a major initiative to reduce the practice of seclusion and restraint in mental health settings and pledged their support for the “implementa tion of trauma informed systems and trauma specific services in our national mental health systems and set tings,” establishing criteria for trauma informed mental health service systems that a number of states have since 90 implemented or are endeavoring to implement. More broadly, implementation of integrated mental health programs and protocols that adhere to trauma informed care principles has begun. Efforts include 187

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those developed by SAMHSA’s Children’s Mental 91 Health Initiative and the National Child Traumatic 92,93 Stress Network, and by psychiatrist, Sandra Bloom, 58,94 97 98,99 with her Sanctuary Model, among others, with promising results.

Conclusion

To be trauma informed is to understand the involvement and impact of violence and victimization in the lives of most consumers of mental health, substance abuse, and other services. It is also to apply that understanding in providing services and designing service systems to accommodate the requirements and vulnerabilities of trauma survivors and to facilitate their participation in treatment. This shift in perspective and practice implies important changes in mental health settings and in the provision of care, particularly in the recognition that

Lesson 13

symptoms may reflect coping efforts and of the potential for inadvertent client retraumatization in practice settings. Trauma informed care is not a treatment per se; it is an approach that starts with the premise that practitioners do no (more) harm, and proceeds with sensitivity to the dis tinctive issues that arise in the context of trauma and broader client centered principles of practice. Some have described the trauma informed perspective as a paradigm 3 shift inasmuch as this perspective represents a change in the framework for understanding clients and the context of their presenting complaints. Given the prevalence of traumatic experiences, especially those endured during development, and their longstanding effects on clients’ lives, the trauma informed perspective offers a compelling and humane organizing principle for conceptualizing and addressing many of the problems and challenges facing those seeking mental health and other services.

About the Faculty Lisa D. Butler: Dr. Butler is Associate Professor School of Social Work, University at Buffalo, State University of New York, Buffalo, NY. Filomena M. Critelli, PhD, LCSW: Dr. Critelli is Assistant Professor, School of Social Work, University at Buffalo, Buffalo, NY. Elaine S. Rinfrette, PhD, LCSW-R: Dr. Rinfrette is Assistant Professor, Department of Social Work, Edinboro University of Pennsylvania, Edinboro, PA. 188



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References 91. SAMHSA. Helping children and youth who have experienced traumatic events http://www.samhsa.gov/children/SAMHSA_Short_Report_2011.pdf. (HHS Publica tion No. SMA 11 4642). Accessed May 4, 2011. 92. National Child Traumatic Stress Network. NCCTS Leadership: Trauma Informed Systems. http://www.nctsn.org/sites/default/files/assets/pdfs/ TraumaInformedSer vices_InfoBrief_FINAL.pdf. Published November, 2009. Accessed June 15, 2011. 93. Pynoos RS, Fairbank JA, Steinberg AM, et al. The National Child Traumatic Stress Network: Collaborating to improve the standard of care. Prof PsycholRes Pr. 2008;29(4):389 395. 94. Bloom SL. Creating sanctuary: Healing from systematic abuses of power. Therapeutic Community. 2000;21(2):67 91. 95. Bloom SL, Bennington Davis M, Farragher B, McCorkle D, Nice Martini K, Wellbank J. Multiple opportunities for creating sanctuary. Psychiat Quart. 2003;74(2): 173 190. 96. Rivard JC, Bloom SL, McCorkle D, Abramovitz R. Preliminary results of a study examining the implementation and effects of a trauma recovery framework for youths in residential treatment. Therapeutic Community. 2005;26(1):83 96. 97. Wright DC, Woo WL, Muller RT, Fernandes CB, Kraftcheck ER. An investigation of trauma centered inpatient treatment for adult survivors of abuse. Child Abuse Negl. 2003;27:393 406. 98. Fallot RD, Harris M. Integrated trauma services teams for women survivors with alcohol and other drug problems and co occurring mental disorders. Alcoholism Treat ment Quarterly. 2004;22(3):181 199. 99. Cocozza JJ, Jackson EW, Hennigan K, et al. Outcomes for women with co occurring disorders and trauma: Program level effects. J Subst Abuse Treat. 2005;28: 109–119.

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