Over the last 20 years there has been increasing recognition of the role that psychological trauma plays in a wide range of health, mental health and social problems. When people think of trauma, they think about experiences like war and the diagnosis of post-traumatic stress disorder. But the reality is that trauma includes a wide range of situations where people are physically threatened, hurt or violated, or when they witness others in these situations. This includes such experiences as childhood physical and sexual abuse, domestic violence, witnessing domestic violence, serious accidents, natural disasters, physical torture, riots, shootings, knifings, being threatened with a weapon, combat, house fire, life-threatening illness, and death of someone close, especially sudden death.
Although, there have been no comprehensive studies of the prevalence of exposure to traumatic events, studies conducted in the United States suggest that exposure to traumatic events occurs in at least 50%-60% of the U.S. population, and rates in clinical settings run much higher (Kessler, 2000); Kessler notes that given that the U.S. has higher crime rates than other developed countries, it may be that these rates are significantly higher in the U.S. than in other developed nations. However, problems like child abuse and domestic violence are challenges faced by almost all the societies on our planet, and natural disasters certainly affect everyone, regardless of national origin.
The impact of living through traumatic events, especially multiple events over the course of a lifetime, can result in a range of behavioral health problems other than post-traumatic stress disorder, including substance abuse, depression, anxiety problems, childhood behavioral disorders, psychosis, and some personality disorder diagnoses (National Trauma Consortium, 2012). Some psychiatrists have suggested that the entire medical model of mental illness needs to be reevaluated in light of the recognition of the role of trauma (e.g. see Canadian psychiatrist, Dr. Colin Ross’s book The Trauma Model)– this is not to say that biology doesn’t play a role in behavioral health problems, only that it doesn’t, by itself, cause them in most circumstances.
The reality is that social workers have been working with trauma survivors from the first day our profession began. However, the growing knowledge base about how trauma affects people is now being used to inform changes in policy and practice to ensure that we support recovery and don’t inadvertently hurt people. Simply stated, trauma-informed practice is policy and practice based on what we know from research about the prevalence of trauma and about how affects people. Within the U.S., trauma-informed practice is usually referred to as Trauma-Informed Care (TIC), a term that is used in national policy efforts initiated by the Substance Abuse and Mental Health Services Administration and the National Child Traumatic Stress Network.
What Does Trauma-Informed Practice Actually Look Like?
Trauma-informed practice incorporates assessment of trauma and trauma symptoms into all routine practice; it also ensures that clients have access to trauma-focused interventions, that is, interventions that treat the consequences of traumatic stress. A trauma-informed perspective asks clients not “What is wrong with you?” but instead, “What happened to you?” However, trauma-informed practice also focuses our attention on the ways in which services are delivered and service systems are organized (Bloom & Farragher, 2011). Recognizing that traumatic events made people feel unsafe and powerless, trauma-informed practice seeks to create programs where clients and staff feel safe and empowered. Generally, trauma-informed practice is organized around the principles of safety/trustworthiness, choice/collaboration/empowerment, and a strengths-based approach (Hopper, Bassuk, & Olivet, 2010).
Trauma-informed organizations ensure that every staff member, from the receptionist to the executive director, understands trauma and trauma reactions. Trauma-informed organizations routinely examine all policies, procedures and processes to ensure they are not likely to trigger trauma reactions or to be experienced as re-traumatizing, that is, putting a client through a process that shares characteristics of the traumas they have lived through. For example, within psychiatric hospitals restraints have long been used for patients who are out of control in some way. However, for a person who has lived through abuse, restraint may well have been associated with being hurt physically or with being sexually abused. Restraints therefore have a high potential to actually re-traumatize a client and trigger more psychiatric symptoms. A trauma–informed perspective recognizes the damaging impact of restraints and focuses on incorporation of psychiatric advanced directives into mental health care. This is just one example of a practice within mental health that can be hurtful to trauma-survivors. For more examples of how our efforts to help can inadvertently hurt people, read the heart-wrenching case study, On Being Invisible in the Mental Health System, that describes the devastating impact of the mental health system on one young woman’s life and provides a compelling example of how our systems can fail trauma survivors.
Why Should We Care?
Each of us chose social work because we want to make a positive difference in the world. Some of us can see clearly where our work has this contribution. Many of us struggle to “do good” within service systems that are broken–we know at a basic level that something is very wrong, even if we manage to bring about positive outcomes much of the time. The systems within which many social workers are employed are often based on principles that are not only not trauma-informed, but instead, reinforce damaging messages to both staff and clients, such as “your voice doesn’t matter here.” Bloom and Farragher (2011) in their book Destroying Sanctuary, have written eloquently about the current crisis facing our human services delivery systems and how the impact of our systems often is the opposite of creating safe and growth-promoting environments, both for clients and staff. While it may not be the only lens that can be helpful in addressing this crisis, a trauma-informed perspective shines a clear light on what’s broken, what needs to change, and what will work instead. It focuses us not only on our direct practice, but on organizations, service systems, and ultimately our paradigms for understanding the work we are doing and the work we would like to do–in other words, it’s a true social work perspective. The paradigm fits well with the values of our profession, it draws attention to all that we know about a systems perspective, and it incorporates a holistic, biopsychosocial perspective on human beings.
It’s because of all of the above reasons that our faculty chose to incorporate a trauma-informed perspective (along with a human rights perspective) into all aspects of our masters in social work program. We feel that this perspective is a missing piece in social work education and that having it will make a difference in our graduates being able to practice effectively at all levels of social work practice, especially in their ability to bring about needed transformations in our service systems. Beyond the growing body of research that I’ve mentioned, part of what brought our faculty to this understanding was the feedback we were receiving from clients and agencies within our own community, Western New York, about the power of this perspective after years of incorporating it into our School’s continuing education programs. Agency directors were becoming increasingly interested in seeking out trauma trainings for everyone in their agencies because of the transformational impact they were seeing with clients and the workforce. One after another, social workers and other human services professionals were describing this as “the missing piece” in their knowledge base and that having this knowledge made a difference in their practice.
Many social workers feel disempowered within the systems in which they work: trauma-informed practice is a framework of system and practice transformation that can provide us with a blueprint for empowerment for ourselves as well as for our clients. I hope I’ve piqued your interest in this concept enough that you’ll consider learning more about it.
Where Can I Learn More About Trauma-Informed Practice?
Many of the resources cited in this post are good places to start to learn more about trauma-informed practice. In addition, try checking out the following:
- Podcast interview (part 1) with Brian Farragher: The Sanctuary Model: Changing the Culture of Care – It Begins with Me (part 1 of 2) Episode #77 of the Living Proof Podcast Series
- Podcast interview (part 2) with Brian Farragher: The Sanctuary Model: Changing the Culture of Care – Transforming Human Services (part 2 of 2) Episode #77 of the Living Proof Podcast Series
- Podcast interview with Dr. Sandra Bloom: The Sanctuary Model: A Trauma-Informed Approach to Treatment and Services, Episode #10 of the Living Proof Podcast Series [note, I recommend listening to this after listening to the Farragher interviews]
- Videos from a conference on trauma and trauma-informed care, including talks from two national presenters, Dr. Sandra Bloom (Sanctuary Model) and Dr. Robert Anda (ACE study)–videos included are Trauma 101, the ACE study, and an overview of the Sanctuary Model, one model of trauma-informed care.
- Creating Cultures of Trauma-Informed Care (CCTIC): A Self-Assessment and Planning Protocol (pdf) by Roger D. Fallot and Maxine Harris, April 2009.
- Power & Social Media: Thoughts for Therapists Working with Trauma Survivors by Nancy J. Smyth, February 18, 2011,
- The book Trauma-informed practices with children and adolescents (2011) by William Steele and Cathy A. Malchiodi. London, Routledge.
- Innovations in Implementation of Trauma-Informed Care Practices in Youth Residential Treatment: A Curriculum for Organizational Change (pdf) by Victoria Latham Hummer, Norín Dollard, John Robst, and Mary I. Armstrong. (article from Child Welfare)
Reference Citations
Bloom, S. L., & Farragher, B. (2011). Destroying sanctuary: the crisis in human services delivery systems. New York: Oxford University Press.
Jennings, A. (1994). On being invisible in the mental health system. Journal of Behavioral Health Services and Research, 21(4), 374-387. Available online at: http://www.theannainstitute.org/obi.html or http://www.theannainstitute.org/OBI.pdf
Kessler, R.C. (2000). Posttraumatic stress disorder: The burden to the individual and to society. Journal of Clinical Psychiatry, 61(supplement 5), 4-12.
National Child Traumatic Stress Network (2012). http://www.nctsnet.org/ retrieved March 17, 2012
National Trauma Consortium (2012). http://www.nationaltraumaconsortium.org/ retrieved March 17, 2012.
Ross, C.A. (2011). The trauma model: A solution to the problem of comorbidity in psychiatry (Kindle Edition). Austin, TX: Greenleaf Book Group.
Substance Abuse and Mental Health Services Administration (2012). National Center for Trauma-Informed Care. http://www.samhsa.gov/nctic/ retrieved March 17, 2012.
Join us on World Social Work Day (Tuesday, 20-March-2012) at 8:00 PM GMT / 4:00 PM EDT to discuss and explore the “Global Agenda for Social Work and Social Development” in a rich and lively Twitter Debate @SWSCmedia.
Dr. Nancy Smyth (@njsmyth) is Professor and Dean of School of Social Work at University at Buffalo and Associate Research Scientist at Research Institute on Addictions. She is also a member of @SWSCmedia Expert Panel.
I think you are dead on that biology does not just spontaneously produce mental illness but that biology in conjunction with a traumatic life event(s) can be a major trigger of the onset of mental illness. I would love to learn more about trauma-informed practice in social work.
I’m glad to hear it resonates with you! It certainly seems to be clear from emerging research and I know it fits the histories of most of the people that I have worked with over the years in settings for people recovering from mental health problems.
FYI, almost all the resources that I listed for learning more are actually links–for some reason they just don’t look like links…so you can start learning more online whenever you are ready!
Thank you, Nancy, for such a detailed and informative post on trauma-informed practice.
I had been wondering what topics you would recommend for social workers to pursue in terms of continuing education over the next couple of years. In light of this article, I will definitely be adding trauma-informed practice to my list.
You were most thoughtful in providing such a wonderful list of resources to start tackling this task with!
Glad to help Dorlee! I would definitely recommend getting some training on this topic–most people feel that it transforms the way they work with their clients. I’ve seen people who made no progress in psychotherapy for years finally reclaim their lives when this approach was taken, in combination with some good trauma treatment interventions (like EMDR and other trauma-focused treatment methods). And sadly, I’ve heard of other cases where people ended up dead because they didn’t have access to these services. The case study I mention (“On Being Invisible…”) tells of such a case and I’ve known of others personally. By the way, our Continuing Education office puts on a wonderful summer institute in July–over two weeks there are a number of great workshops and also some graduate clinical electives (1 credit) that can be taken as courses or as workshops. And then you can see Niagara Falls, Letchworth Park (“grand canyon of the east”), Frank Lloyd Wright architecture, and come to visit me!
Seriously, you might be interested in checking it out: http://www.socialwork.buffalo.edu/conted/summer-institute.asp Right now I think that they have only the elective courses listed, but more workshops will be listed soon.
I’m glad to hear it resonates with you! It certainly seems to be clear from emerging research and I know it fits the histories of most of the people that I have worked with over the years in settings for people recovering from mental health problems.
FYI, almost all the resources that I listed for learning more are actually links–for some reason they just don’t look like links…so you can start learning more online whenever you are ready!
Thank you Dr. Nancy for your wonderful insight to Trauma informed practice. From my perspective as a student within the MSW program I understand the need and urgency for social workers to be trauma informed. In working with clients at my field placement having this knowledge has helped a great deal, there is a stronger connection with the client and also a readiness to accept intervention. Trauma informed care empowers the client as well as provides an environment where the client feels safe to reveal the event that has so deeply affected them, it is also beneficial to the social workers in that we become more aware of what services are delivered and what policies need to be implemented to make services better.
The Social workers knowledge of Trauma informed care will definitely make an impact on future policy change as well as influence other social workers around them who are not trained in TIC to want to seek the knowledge. In my opinion the social work system must empower itself before it can empower others and be effective agents of change. Overall this blog was both educational and inspirational and provides evidence that the work we do does not go unnoticed.
“In my opinion the social work system must empower itself before it can empower others and be effective agents of change” What a wonderful observation, Ayana. I agree completely that as social workers we need to focus on empowerment at all levels, including for ourselves and within our own systems.
Dr. Smyth, I was very fascinated by your information on TIC. As a first year MSW student at UB I found this information very applicable to the program and it resonated well. I was shocked by the statistic that 50-60% of people have experienced trauma. However, then I began thinking of people I know and I began to wonder if that number is actually lower than what it should be.
My favorite thing about the TIC perspective is switching the question from “What’s wrong with you” to” What happened to you?” Unfortunately, we live in a society that often blames people for their problems. The more I’ve learned about poverty and upward mobility the more I’ve realized that everyone does not really have a fair chance. I’ve tried to explain this concept to so many people since starting the program and most of them cannot understand it.
I believe that TIC may be able to help social workers to steer away from judging and getting fed up with the system. It seems to look at everyone as an individual and try to understand where they’ve been and how that effects where they are now. I am very excited to begin the TIHR class in the fall. Thank you for all of this clear information on a very important topic.
Katrin, you make some excellent points! Regarding the prevalence rate issue: I did a podcast to complement this blog post (http://swscmedia.wordpress.com/2012/03/20/podcast-trauma-informed-social-work-practice-what-is-it-and-why-should-we-care-by-dr-nancy-smyth-swscmedia-swweek-series-gaswsc-wswday-unswday/#comment-412) and there I talk a little about some different definitions of trauma. The prevalence rate numbers will vary depending on how the researchers defined trauma. The numbers I reported here may well be low because they were conducted with the older DSM-III definition of trauma. There hasn’t been a national study conducted with the new, broader DSM-IV definition (which includes deaths of significant others that have a traumatic impact)–I believe that Kessler talks about that in his article. We really need another national study in the U.S. looking at prevalence rates with this new definition, and we need these types of studies done in other countries as well.
Thanks for commenting Alicia. I’m glad you feel this perspective has been helpful in enhancing your understanding of your clients and of your own experiences. Self-awareness and self-care are so important for social workers. While I’m sure you’ve seen this resource on self-care, I’ll link it here for readers who have not: http://www.socialwork.buffalo.edu/students/self-care/
Katrin, you make some excellent points! Regarding the prevalence rate issue: I did a podcast to complement this blog post (http://swscmedia.wordpress.com/2012/03/20/podcast-trauma-informed-social-work-practice-what-is-it-and-why-should-we-care-by-dr-nancy-smyth-swscmedia-swweek-series-gaswsc-wswday-unswday/#comment-412) and there I talk a little about some different definitions of trauma. The prevalence rate numbers will vary depending on how the researchers defined trauma. The numbers I reported here may well be low because they were conducted with the older DSM-III definition of trauma. There hasn’t been a national study conducted with the new, broader DSM-IV definition (which includes deaths of significant others that have a traumatic impact)–I believe that Kessler talks about that in his article. We really need another national study in the U.S. looking at prevalence rates with this new definition, and we need these types of studies done in other countries as well.
Thank you for posting this! It really helped me to reorganize what I learned about trauma-informed care in this year. Through case studies in the classroom and my field work experience, I saw a lot of cases which are related to trauma. Like you said, trauma can be evoked in various situations; the concept of trauma is not only for an extreme situation, but for everyday experiences of individuals. Your explanation about the reality of trauma reminded me about my seminar class which discussed about the definition of trauma. I remember that every classmate has different perspective about trauma, but no one was wrong. It helped me to have broader perspective about the realm of social work which is related to trauma-informed care.
I think that we, potential social workers, need to have wide and in-depth knowledge of trauma-informed care because it can be useful to understand the client’s situation and help to find appropriate solutions for that. Thus, it is very fortunate for me being a member of UB School of Social Work which is specialized in trauma-informed care. I am eager to learn more about TIC in next semester, and apply it to my field work and future career. Thank you again for this useful post.
Jun-Pyo, I’m glad that my post could help you recognize all that you have learned!
Dr. Smyth, thank you very much for spreading the word about Trauma-Informed Care. When I applied to UB’s MSW program, I did not even realize that it was TIC-focused; I partially believe this is due to the fact that I did not know what this meant. Having (almost) completed my Foundation Year in this program however, I have realized what a great strength this is to have (even in my area of interest: macro-level social work).
I found it very interesting how you wrote that even a receptionist of an organization needs to be aware of TIC, and how trauma can effect the population being served. Also as you noted, traumatic events can happen in all different forms, and it is essential that every member of an organization be aware of this. I believe that this is especially important for organizations who are primarily focused on secondary and tertiary prevention. Coming from a Public Health background, it is pretty remarkable the difference between these programs, in regards to a humanistic viewpoint. While taking my MPH classes, besides learning to be culturally sensitive, there were very few things we learned in regards to understanding how to approach people and their situations. I believe that even the School of Public Health would greatly benefit from hearing of our school’s success with TIC, and potentially integrate it into their coursework! If Public Health and Social Worker professionals alike can understand that benefits of TIC, then our world can slowly start to become a better place.
Thanks again for spreading the word, and I highly recommend sharing it with the other schools at UB!
I’m glad you’ve found the content on Trauma-Informed Care to be so relevant. I would encourage you to share your insights with the Public Health faculty–And I know that public health has a lot to teach social work, as well. As you move into your advanced studies I hope you’ll share your insights about what public health can bring to Trauma-Informed Care perspective too!
Dr. Smyth, as a first year MSW student at UB I found your blog to help me comprehend the necessity and applicability of TIC in the field of social work. To be honest I struggled my first semester to understand the meaning of TIC. After learning the main principles of TIC I came to appreciate the TIC paradigm. As your blog explained TIC goes beyond addressing barriers at the individual level but it also examines the implications of various systems on a client. The blending of micro and macro social work is what I value most about TIC as it is why I entered the field. Your insight on the need to apply TIC to not only client care but to organizational functioning is very interesting. I agree that field needs to improve creating an empowering environment for its workers. Current policy has lead to bureaucratic agencies causing disservices to clients and constant ethical struggles for social workers. Your blog has continued my education on TIC and I hope to apply this knowledge to my practice of social work.
“The blending of micro and macro social work is what I value most about TIC as it is why I entered the field.” This is wonderful to hear, Blair. I think this is one of the reasons why I think that TIC is such compatible perspective for social workers. Best of luck with your learning and growth in your advanced year of the MSW!
Dr. Smyth, I believe that your blog provides a great and well in-depth perspective that truly grasps the concept of trauma-informed care. As I am finishing up my foundation year in the MSW program, I have begun to learn the context and significance of providing trauma-informed care to clients. As you have discussed, trauma is a complex and unique experience for each individual who experiences it. Even more so, with the alarming high rates of those who suffer from trauma, it amazes me that more graduate programs have not yet incorporated this “missing piece” into their curriculum. As a student, I am proud to be apart of this changing perspective on how to treat clients. However, I undoubtedly believe that in time with more literature and more positive feedback, trauma-informed care will become a requirement of many more human services organization and schools.
Additionally, what I enjoyed the most from your blog is your description of how to incorporate trauma-informed care into one’s practice from the moment of engagement. My greatest take away from my foundation year is from my Interventions I course with Professor Dinger. She always spoke of the importance of never saying “why,” as it can appear intrusive and culpability of one’s situation. Instead, we should always question with “how” or as you have stated, “what happened to you?” because it is more open, invited and makes the client feel as though they truly are in a safe place. I believe that the engagement phase is the most important step with a client and trauma-informed care truly emphasizes this stage as well. It astounds me how making a simple change, such as word choice, can weigh heavily on your success with a traumatized client. Overall, I believe that your blog provides a great overview as to why it is necessary in the social work profession and the University at Buffalo’s Masters Program. Thank you for this posting.
I’m glad I was able to convey some sense about how to integrate this approach into your moment-by-moment practice. It’s a very powerful approach for both working with clients and with larger systems.
More schools of social work are beginning to get interested in the changes we’ve made in our curriculum, so I am hopeful that our profession will incorporate these perspectives at some point in the future. It’s wonderful to know that students like you, from the University at Buffalo, will help to make that happen, as well!
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