Motivation and emotion/Book/2021/Trauma-informed therapy

Trauma-informed therapy:
What is trauma-informed therapy and how can it be used to improve psychological interventions?

Multimedia presentation (3 min)

Overview

Trauma can be understood as an emotional response to a tragic event, such as car accidents, terrorism, conflict, sexual assault, and natural disasters. Trauma-informed therapy can be used interchangeably with trauma-informed care, trauma-informed approaches and trauma-informed interventions. The principles of trauma-informed care include safety, trustworthiness, choice, collaboration, empowerment, and cultural, historical and gender issues. As well as this, the four Rs that are used as a guide for trauma informed care are realising the impact (of trauma), recognising the signs, responding by use of knowledge, and resisting re-traumatising individuals. There are many trauma-informed forms of therapy that are used as psychological interventions including prolonged exposure therapy, eye movement desensitisation and reprocessing, and trauma-focused cognitive behavioural therapy. In a survey conducted in 24 countries with 68,894 people by Kessler, R. C., et al. (2017), it was found that 70.4% of respondents who had post-traumatic stress disorder (PTSD) experienced lifetime traumas.

Focus questions What is trauma? What does trauma-informed therapy involve? What are the effects of trauma-informed therapy?

What is trauma?

Trauma

Trauma can be described as an "emotional response" to a tragic event. Examples of traumatic events can include, but are not limited to, car accidents, terrorism, exposure to conflict, sexual assault, and natural disasters (APA, 2021). Following the traumatic event, it is normal for an individual to experience feelings of shock and/or denial. The long-term effects of trauma can include fluctuating emotions, mood swings, flashbacks of the incident, memory loss, difficulty concentrating, withdrawal or detachment, nightmares or night terrors, and even physiological responses such as fatigue, panic attacks and heart palpitations. Although these reactions are typical, many people struggle to function properly in their everyday lives. This is when therapy becomes important and can help survivors find useful methods to control their feelings and emotions.

There are three predominant categories of trauma: acute, chronic, and complex (Center for Substance Abuse Treatment, 2014).

1. Acute trauma often stems from an isolated event.
2. Chronic trauma refers to multiple or ongoing trauma/s.
3. Complex trauma is the subjection to many prolonged and highly invasive traumatic incidents.

Acute trauma

Acute trauma is typically the outcome of a solitary incident, such as surviving a natural disaster, terrorist attack, rape or assault. The result of the incident is severe to the point that it is able to menace the individual’s sense of psychological or physiological well-being. If this trauma is left unattended, without the help of professionals, it can consequently impair the way the survivor views the world around them which is often evident through their behaviours (Center for Substance Abuse Treatment, 2014). Symptoms of acute trauma typically include, but are not limited to, low mood, confusion, feelings of anxiousness, extreme distrust, poor sleep, detachment, lack of focus and concentration, dissociation, and lack of self-care.

Chronic trauma

Chronic trauma usually occurs as a result of ongoing or various instances of traumatic encounters. This form of trauma can occur from cases such as domestic violence, ongoing critical illness, sexual abuse, extensive bullying, or war. If multiple occurrences of acute trauma are left unattended to, this may develop into chronic trauma (Center for Substance Abuse Treatment, 2014). The effects of this type of trauma can sometimes become apparent after an extensive time period following the event. These effects usually present in the following forms: flashbacks, nausea, body aches, sudden outbursts, anxiety, headaches, and distrust - which can in turn lead to strained relationships or the inability to maintain steady careers. Professional help is imperative in overcoming such symptoms.

Complex trauma

Complex trauma is when an individual is exposed to various prolonged and highly invasive traumatic incidents, and can cause them to feel trapped (Center for Substance Abuse Treatment, 2014). Complex trauma may be more apparent in personal relationship contexts; examples include neglect, family disputes, childhood abuse, domestic violence, and other ongoing occurrences, like civil unrest. These events usually have a drastic effect on the individual’s mental states, which can influence their personal relationships, work or academic progress, as well as their mental and physical health.

What does trauma-informed therapy involve?

Figure 1. Counselling session.

Trauma-informed therapy is a framework based on responsiveness to and an understanding of the impact of trauma (SAMHSA, 2014).

Four Rs of trauma-informed care

Realising the impact of the trauma and ways of recovery

All members of the organisation have a fundamental understanding of trauma and realise how trauma can have an effect beyond individuals (U.S. Department of Health and Human Services, 2014). It is understood that the way in which the client may conduct themselves has to do with their ability to cope with the distress of the trauma that they have experienced. There is also an understanding that as a result of trauma, people may turn to various addictions, which should be communicated in a variety of contexts, such as treatment, recovery and prevention settings. Likewise, there is a realisation that trauma is essential to various systems, not simply that of behavioural health, and can sometimes reduce the likelihood of positive outcomes in many other systems as well.

Recognising the symptoms of trauma

Members of the organisation must also have the ability to recognise the symptoms of trauma. Such signs can include age, gender, and may be apparent through people desiring or providing services in related settings (U.S. Department of Health and Human Services, 2014). 

Responding by integrating knowledge about trauma

In all operating areas, the organisation responds through the use of the trauma-informed care principles. It also includes knowledge about trauma and applies it to their standard operating procedures, policies and best-practice guides. For example, following mandatory trauma-informed staff training, staff will be able to alter their behaviours and language to help those utilising their services (U.S. Department of Health and Human Services, 2014). The organisation makes sure that they provide an environment which encourages honesty, equality and trust, making it an emotionally and physically safe setting to be.

Resisting re-traumatising individuals

This principle focuses entirely on resisting re-traumatisation of both individuals seeking help as well as colleagues and other staff. It is not uncommon for organisations to unintentionally bring about settings that may impede on the survivors’ recovery, as well as the health and well-being of members of the organisation (U.S. Department of Health and Human Services, 2014). In these organisations, staff learn to recognise how some of the practices which the organisation employs may be triggering for some clients, which carries the risk of re-traumatising them.

Principles of trauma-informed care

In most contexts, trauma-informed therapy and trauma-informed mean the same thing since their purpose is the provision of ‘care’ for survivors of traumatic events. Various guidance publications and the academic literature in general have provided a number of principles for trauma-informed care (Elliot et al., 2005; Hopper et al., 2010; Jennings, 2004; Kezelman & Stavropoulos, 2012; SAMHSA, 2014). Based on the publication, the number and length of the principles differ, however they are all founded upon an underlying idea that trauma-informed therapy done correctly must be safe, integrated, based on strengths and aware of the trauma. The objective of trauma-informed services is, at minimum, to prevent additional anguish through re-traumatising survivors through recognition that customary methods and standards can potentially be an unintentional triggers that could provoke symptoms of trauma. According to SAMHSA (2014) there are four main foundational standards that need to exist as a premise for trauma-informed therapy to take place, and an additional six key principles must then be applied as the therapy takes place.

Safety

Individuals are met with a sense of safety, both emotionally and physically. Privacy is respected and the physical environment is safe while interactions with others encourage feelings of safety Harris & Fallot, 2001).

Trustworthiness

All actions are taken with honesty and with the objective of creating and keeping trust, as well as consistency with individuals, their families, fellow colleagues, and any others involved in the organisation responsible for trauma-informed care (Elliott et al., 2005).

Peer support

The word ‘peers’ alludes to people who have had traumatic experiences. This principle is essential for providing a sense of hope, feelings of safety, foundational trust, greater interactions, and attempts to make use of stories to encourage the healing and recovery process.

Collaboration

For effective collaboration, the importance of working together is emphasised, together with the equalising of different positions of power amongst staff and personnel - this is to reflect an environment where power and decision-making responsibilities are shared which also helps to foster relationship healing (Harris & Fallot, 2001). It is also acknowledged that each person has a part to play in any approach that reflects trauma-informed care.

Empowerment and choice

Central to the fostering of empowerment and choice is ensuring that the strengths and experiences of individuals are acknowledged and consolidated (Elliott et al., 2005). The fact that clients often have had their voices and choices diminished means that organisations responsible for trauma-informed care will implement measures to ensure that the notion of power differentials is well understood. Individuals become involved in developing their plan of action by taking part in the goal setting and decision-making processes. Organisations emphasise the importance of clients having and making their own choices in determining their action plan, which fosters a sense of empowerment.

Cultural, historical and gender issues

This principle notes that there should be no cultural stereotypes and biases, inclusive services must be offered, and historical trauma acknowledged.

What are the effects of trauma-informed therapy?

Generally speaking, there are various effects of trauma-informed therapy. These effects can help change patients' mental, emotional and behavioural states. They can include, but are not limited to: enhancing daily function and regulating the nervous system, terminating or diminishing symptoms of trauma, empowering individuals, rehabilitating clients from addictions linked with trauma, increasing understanding on methods that will assist in averting relapse, and shifting the client’s focus to the present.

Examples of trauma treatment approaches

Figure 2. Trauma Coverage is a company in America that helps with trauma education and recovery

There are various forms of therapy that are considered as trauma treatment, these include:

Prolonged Exposure Therapy (PE Therapy)

Prolonged exposure therapy is usually conducted weekly over a period of 12 weeks (Foa & Rothbaum, 1998). Each session generally goes for approximately one to two hours. The session starts with the therapist providing the client with a rundown of what to expect throughout the therapy, as well as gaining some insight into previous experiences that the client has had. In this time, the therapist will typically educate the client on breathing methods to help them control any anxious feelings that may arise.

Normally, following the initial assessment and first session, exposure commences. Due to the nature of this therapy, the therapist actively ensures that the the client recognises the environment as a safe space for experiencing unpleasant stimuli.

Eye Movement Desensitisation and Reprocessing (EMDR)

Eye Movement Desensitisation and Reprocessing (EMDR) therapy was originally conducted while treating clients with post-traumatic stress disorder (PTSD). EMDR is a solitary therapy which generally occurs over 6-12 sessions about one or two times a week. This therapy differs from others as it is directed specifically on a specific traumatic memory, and aims to alter the way in which the brain stores it, causing the troublesome symptoms to progressively diminish (Maxfield et al., 2021). During EMDR, the use of eye movements and other types of bilateral (e.g. left-right) stimulation (BLS) is incorporated. Throughout this process, clients briefly recall the traumatic memory whilst experiencing BLS; this causes the emotion and vividness associated with the memory to be reduced (Shapiro, 2007).

A formalised eight-step approach is used for EMDR therapy. The first step involves history-taking. Next, the client is prepared. Third, an assessment of the target’s memory is conducted. Afterwards, the memory is processed to adaptive resolution in steps four to seven. Finally, the results of the treatment are evaluated.

The key differences between EMDR and other similar treatments is that extended exposure to the traumatic memories is not part of the therapy. Further, it also excludes the requirement to challenge dysfunctional beliefs, having take-home assignments or giving specific descriptions of the traumatic event.

Trauma-Focused Cognitive Behavioural Therapy (TF-CBT)

As the name suggests, Trauma-Focused Cognitive Behaviour Therapy (TF-CBT) is a type of cognitive behaviour therapy which focuses on treating the exact psychological needs of survivors who are finding it difficult to deal with the harmful damage of early trauma. Since in these scenarios clients are typically young, TF-CBT is particularly cognisant of the types of issues that young people with PTSD typically have, as well as the illnesses or disorders that arise from grief, abuse or other forms of violence. Family therapy can also be incorporated into TF-CBT which involves caregivers and non-offending parents (Ramirez de Arellano et al., 2014).

TF-CBT normally takes between eight to 25 sessions which can also occur in various settings. Techniques learnt in this therapy can be applied to change negative thinking, as well as damaging reactions and behaviours.

PTSD can include, but is not limited to, symptoms such as problems with sleep and concentration, intrusive or unwanted memories, as well as severe emotional and physical reactions to triggers of the traumatic memory. TF-CBT has the capacity to alleviate some of these symptoms by incorporating methods and theories of various other interventions and treatments.

Conclusion

Trauma is an emotional response to a tragic event which often leads individuals to experience shock or denial. The long-term effects of trauma can be severe and include fluctuating emotions, mood swings, flashbacks of the incident, memory loss, difficulty concentrating, withdrawal or detachment, nightmares or night terrors, and even physiological responses such as fatigue, panic attacks and heart palpitations.

The three most common types of trauma are acute trauma, which is typically caused from an isolated event, chronic trauma, which occurs from ongoing traumatic encounters, and complex trauma, which stems from prolonged and highly invasive traumatic incidents.

There are four foundational standards which are necessary for trauma-informed therapy to occur and six principles which should be applied while the therapy occurs. The four standards have been termed the ‘four Rs of trauma-informed care’: realising the impact of the trauma and ways of recovery, recognising the symptoms of trauma, responding by integrating knowledge about trauma, and resisting re-traumatising individuals. The six generally accepted principles of trauma are safety, trustworthiness, peer support, collaboration, empowerment and choice, and cultural, historical and gender issues.  

The most common forms of therapy for trauma are prolonged exposure therapy, eye movement desensitisation and reprocessing, and trauma-focused cognitive behavioural therapy. Overall, these types of therapy are likely to help improve a patient’s mental, emotional and behavioural states.

See also

• Creative arts and trauma (Book chapter, 2021)
• EMDR (Wikipedia)
• Post-traumatic growth (Book chapter, 2020)
• Post-traumatic stress disorder and emotion (Book chapter, 2024)
• Post-traumatic stress disorder (Wikipedia)

References

Black, P., Woodworth, M., Tremblay, M., & Carpenter, T. (2012). A Review of Trauma-Informed Treatment for Adolescents. Canadian Psychology-Psychologie Canadienne - CAN PSYCHOL-PSYCHOL CAN, 53, 192–203. https://doi.org/10.1037/a0028441

Center for Substance Abuse Treatment, (2014). A Review of the Literature. Trauma-Informed Care in Behavioral Health Services. Substance Abuse and Mental Health Services Administration (US). https://www.ncbi.nlm.nih.gov/books/NBK207192/ Elliott, D., Bjelajac, P., Fallot, R., Markoff, L., & Reed, B. G. (2005). Trauma‐informed or trauma‐denied: Principles and implementation of trauma‐informed services for women. Journal of Community Psychology, 33, 461–477. https://doi.org/10.1002/jcop.20063

Experiencing EMDR Therapy. (2021). EMDR International Association. https://www.emdria.org/about-emdr-therapy/experiencing-emdr-therapy/

Foa, E., Hembree, E., Rothbaum, B., & Rauch, S. (2019-08). Prolonged Exposure Therapy for PTSD: Emotional Processing of Traumatic Experiences - Therapist Guide. New York, NY: Oxford University Press. https://www.oxfordclinicalpsych.com/view/10.1093/med-psych/9780190926939.001.0001/med-9780190926939.

Han H-R, Miller HN, Nkimbeng M, Budhathoki C, Mikhael T, Rivers E, et al. (2021) Trauma informed interventions: A systematic review. PLoS ONE 16(6): e0252747. https://doi.org/10.1371/journal.pone.0252747

Harris, M., & Fallot, R. (2001). Using trauma theory to design service systems. New directions for mental health services.

Hoppen, T. H., & Morina, N. (2019). The prevalence of PTSD and major depression in the global population of adult war survivors: A meta-analytically informed estimate in absolute numbers. European Journal of Psychotraumatology, 10(1), 1578637. https://doi.org/10.1080/20008198.2019.1578637

Kessler, R. C., Aguilar-Gaxiola, S., Alonso, J., Benjet, C., Bromet, E. J., Cardoso, G., Degenhardt, L., de Girolamo, G., Dinolova, R. V., Ferry, F., Florescu, S., Gureje, O., Haro, J. M., Huang, Y., Karam, E. G., Kawakami, N., Lee, S., Lepine, J.-P., Levinson, D., … Koenen, K. C. (2017). Trauma and PTSD in the WHO World Mental Health Surveys. European Journal of Psychotraumatology, 8(sup5), 1353383. https://doi.org/10.1080/20008198.2017.1353383

Maxfield, S. thanks to L., PhD, Solomon, R. M., PhD, & Description, F. T. C. to T. (2017). Eye Movement Desensitization and Reprocessing (EMDR) Therapy. https://www.apa.org/ptsd-guideline/treatments/eye-movement-reprocessing

Menschner C, Maul A. (2016) In: Advancing Trauma-Informed Care: Key Ingredients for Successful Trauma-Informed Care Implementation. Centre for Healthcare Strategies Inc.; Robert Wood Johnson Foundation.

Prolonged Exposure (PE). (2020). https://www.apa.org/ptsd-guideline/treatments/prolonged-exposure

Ramirez de Arellano, M. A., Lyman, D. R., Jobe-Shields, L., George, P., Dougherty, R. H., Daniels, A. S., Ghose, S. S., Huang, L., & Delphin-Rittmon, M. E. (2014). Trauma-Focused Cognitive Behavioral Therapy: Assessing the Evidence. Psychiatric Services (Washington, D.C.), 65(5), 591–602. https://doi.org/10.1176/appi.ps.201300255

Shapiro, F. (2007). EMDR, Adaptive Information Processing, and Case Conceptualization. Journal of EMDR Practice and Research, 1(2), 68–87. https://doi.org/10.1891/1933-3196.1.2.68

Strand V, Popescu M, Abramovitz R, Richards S. (2016). Building Agency Capacity for Trauma-Informed Evidence-Based Practice and Field Instruction. Journal of EvidenceInformed Social Work, 13(2):179–197.Trauma-infographic.pdf. https://www.thenationalcouncil.org/wp-content/uploads/2013/05/Trauma-infographic.pdf?daf=375ateTbd56

Trauma-informed care in child/family welfare services. (2016). Child Family Community Australia. https://aifs.gov.au/cfca/publications/trauma-informed-care-child-family-welfare-services

U.S. Department of Health and Human Services, SAMHSA’s Concept of Trauma and Guidance for a Trauma-Informed Approach. (2014). 27. Trauma-Focused Cognitive Behavior Therapy | SAMHSA’s Trauma and Justice Strategic Initiative. http://store.samhsa.gov/product/SAMHSA-s-Concept-of-Trauma-and-Guidance-for-a-Trauma-Informed-Approach/SMA14-4884.

What Are the 3 Types of Trauma? (2021). MedicineNet., https://www.medicinenet.com/what_are_the_3_types_of_trauma/article.htm

External links

• Trauma (APA)