Trauma-Informed Care: Progressive Mental Health Care
9.6 Ten Principles of Trauma-Informed Care Services
Given that discomfort in talking about the trauma, at least in part because of the cli- ent’s distrust of others, this behaviour can be a useful proxy indicator of progress/
continuing difficulty. Hence, the closeness or degree of openness and trust within the therapeutic relationship also serves as an important piece of the assessment ‘pic- ture’. Assessment in Trauma-Informed Care is made more complicated or nuanced by the necessity of respecting the client’s rights (and understandable reluctance) to answer questions about trauma. And while this may make assessment more nuanced and protracted, the therapeutic potential and value of treating the relationship as primary (e.g. putting relationship building needs first) outweighs any delay in com- pleting one’s assessment.
and Care for Women 2004). The situation vis-a-vis the limited progress on incor- porating the principles and practices of TIC into substance misuse facilities leads the British Columbia Centre of Excellence for Women’s Health (2009, p. 3) to state that:
…we have a long way to go towards building a seamless, compassionate, integrated response.
Similarly, the second edition of the so-called Trauma-Informed Toolkit (Klinic Community Health Centre 2013), for instance, states that although trauma may be central to many people’s difficulties and awareness of it pivotal to their recovery, in public mental health and social service settings, their trauma is seldom identified or addressed. As several authors have noted (see Grenard et al. 2007; Mitchell and O’Connor 2013; Sypniewski 2016), mental health practitioners report little to no education on and lack of effective guidance on TIC per se. Yet, according to Elliot et al. (2005), when mental health-care staff recognize and acknowledge these for- mative experiences and the significant effects they can and do have on clients, then client experiences and difficulties are validated. Such is the alleged value of so doing that Elliot et al. (2005) go on to assert that doing so promotes the client’s sense of safety and hope.
If one accepts the findings cited above, then there appears to be a need to update and amend relevant curricula, training/education materials and incorporate theoreti- cal models, relevant empirical findings, policy and discursive material pertinent to TIC. Reeves (2015 p. 706) advances a similar argument, stressing the need for addi- tional training and education in TIC stating:
The empirical and theoretical publications included in this synthesis provide support for the creation of provider training programs on trauma-informed practice.
Such material ought in the view of the authors to be included in all nursing cur- ricula but perhaps has an even more urgent need to be woven into P/MH nursing curricula and substance misuse worker curricula.
9.6.2 Trauma-Informed Services Identify Recovery from Trauma as a Primary Goal
Elliot et al. (2005) make the case that trauma-informed services either offer programs and services to deal with and recover from past trauma or integrate their care delivery with an agency that already provides such services. The authors extend Elliot et al.’s exhortations and advocate that mental health and substance misuse facilities should, similarly, offer programs/interventions to deal with past trauma. Fortunately, there are some examples where this need has been recognized and where this has already occurred (see, e.g. Cutcliffe and Travale 2016; Cutcliffe et al. 2016; United States Department of Veteran Affairs: National Center for PTSD 2016). In such facilities, it is recognized that a reduction (or abstinence) in substance use is a parallel goal to
facilitating recovery from one’s traumatic background. If one accepts the self- medication hypothesis of substance use and applies this to the context of TIC, then people have developed substance abuse problems in an attempt to manage their dis- tress associated with the effects of trauma exposure and traumatic stress symptoms (National Child Traumatic Stress Network 2016). Accordingly, to address and help the person recover from his/her traumatic past and ipso facto, there could/should be a reduction in substance consumption. Thus, as Jennings (2008) argues, substance mis- use facilities must introduce and incorporate services, programs and interventions deigned to facilitate and assist with the client’s recovery from specific trauma experi- ences, for instance, trauma-focused groupwork, personal trauma- focused counselling, somatic experiencing (Levine 1997) or art therapy.
9.6.3 Trauma-Informed Services Employ an Empowerment Model
Empowerment, though bedevilled with various and at times conflicting definitions and conceptualisations (Grant 2003), is (at least partly) concerned with individuals and/or groups gaining more power and control over their lives and choices. It is concerned with a fundamental shift in the (invisible) power imbalance that service users highlight (Cutcliffe and Happell 2009). The authors will not belabour the the- oretical and clinical parallels between promoting individual control in TIC services and mental health/substance misuse services. Each domain of practice share increased personal control as a key clinical goal (see also Hipolito et al. 2014).
Indeed, Elliot et al. (2008, p. 465) go as far as to state that:
the empowerment model is essential to recovery from the overwhelming fear and helpless- ness that is the legacy of victimisation.
9.6.4 Trauma-Informed Services Strive to Maximize a Client’s Choices and Control Over His/Her Recovery
Hummer et al. (2010) provide examples of trauma-informed mental health-care ser- vices that promote and realize service user choice. Hummer et al. (2010) show how child and youth clients choose their own clothing and food, they have some input into which staff members they work with and children can express their preferences regarding how they wish to be responded to during any de-escalation situations.
Similarly, substance use facilities have the capacity to incorporate and promote cli- ent choice; indeed a theoretical model of substance misuse treatment (and associ- ated care/responses) predicated on notion of choice was advanced as long ago as 1999 (Glasser 1999). In keeping with the practice example described above, within substance misuse facilities, choices can be offered in terms of the specific program of groups and activities that clients engage in, which ‘work program’ clients decide on and some choice in which members of staff they work with primarily, and per- haps—most obviously—clients do have choice as to whether or not they engage in
recovery per se. And preparation for discharge and aftercare invariably needs to be a consultative, collaborative process involving soliciting the views and preferences of the client. Somewhat ironically, the authors recognize that successful substance misuse programs do require clients to choose to engage and participate, and thus it should be emphasized that clients do indeed have a choice to engage or not.
9.6.5 Trauma-Informed Services are Based in a Relational Collaboration
For many P/MH nurses, situating their clinical work within a therapeutic relation- ship is de rigueur (Cutcliffe 2008); thus, it may seem redundant to emphasize the relational context to mental health and substance misuse facilities that embrace TIC. However, the literature is clear in indicating that there are P/MH nurses who apparently do not share this view (see Cutcliffe 2008; Cutcliffe et al. 2013). The nature and constituency of therapeutic relationships, and more importantly, relation- ships that promote the growth of trust and help recovery from traumatic experiences have been well described (see Cutcliffe 2008; Cutcliffe et al. 2013, 2015; Hipolito et al. 2014; Hummer et al. 2010; Perry et al. 1995). Similarly, the need for and value of working on and within relationships has been well documented in substance mis- use care; the work of Fals-Stewart et al. (1996, 2001) perhaps underscoring how lasting recovery from substance use depends, in part, on making relationships bet- ter. Arguably, accepting the primacy of relationships in TIC takes on an even greater significance given that the client’s past experiences of abuse and trauma very often occur within the context of a relationship, with well over 40% of cases of child abuse involving a family member and even higher numbers involving someone known to the victim (SAMHSA 2015). The importance of such relationships to Trauma-Informed Care is captured in best practice guidelines, such as those authored by Ferenick and Rameriz-Hammond (2016, p. 81) who state:
Healing and recovery cannot occur in isolation but within the context of relationships.
Relationships fostered with persuasion rather than coercion, ideas rather than force, and empathy rather than rigidity will encourage trust and hope with survivors.
9.6.6 Trauma-Informed Services Create an Atmosphere that is Respectful of Survivors Need for Safety, Respect
and Acceptance
Numerous studies and reports have been published during recent years, and in many different nations, regarding the type of services that mental health SUs wish to encounter. The major themes evident in these findings are as follows: (a) SUs prefer a mental health-care experience personified by personal (human-to-human) con- tacts. (b) SUs want to have a service where they feel they are being listened to, understood and responded to empathically. (c) Similarly, SUs stress the importance of feeling safe and the presence of the ‘quality of caring’ within interpersonal
relationships established with the P/MH professionals as important elements of a successful experience (Cutcliffe et al. 2015). Trauma-informed services have to ensure that staff interactions, program content, the philosophy of care and any pro- cedures/interventions help create a ‘space’ that is perceived and experienced as wel- coming, safe and ‘caring’ (Elliott et al. 2005). This ‘space’ refers to both the physical space or environment and the interpersonal ‘environment’ (see Bloom et al. 2003;
Borge and Fagermoen 2008; Green et al. 2005; Hummer et al. 2010; Lowe and Balfour 2015; Mende 2010). Practice guidelines emanating from the Society for the Study of Addiction (2014) stress the same attitudes and skills: stating the need for establishing a positive relationship, one that is empathic and warm; the need to com- municate effectively through appropriate use of empathic statements, reflection, clarification and verbal and non-verbal behaviours; and, importantly, the need to be non-judgemental and non-confrontational.
9.6.7 Trauma-Informed Services Emphasize Client’s Strengths, Highlighting Adaptations Over Symptoms and Resilience Over Pathology
According to Elliot et al. (2005), some mental health and substance misuse pro- grams too often focus intently on problems that in so doing, practitioners miss the strengths that clients possess. It is unclear if this is an unavoidable outcome of using the medical model, with its emphasis on pathology, trauma-informed services and, as a result, some substance misuse facilities adopt and operationalize a comprehen- sively different conceptualization. Rather than focusing on the person’s pathology and his/her clinical presenting problems, such facilities and approaches (see, e.g.
Clark 2002; Manthey et al. 2011; SAMHSA 2009) emphasize a strengths-based approach. Such approaches are underpinned by the belief that clients are most suc- cessful at achieving their goals when they identify and utilize their strengths, abili- ties and assets (Rapp 2006), even when they may not recognize such strengths within themselves (Greene et al. 2005). Supporting this view, Ferenick and Rameriz- Hammond (2016, p. 5) declare that:
A trauma-informed approach is based on the recognition that many behaviors and responses expressed by survivors are directly related to traumatic experiences.
As a result, so-called symptoms are seen as originating from adaptations to their previous traumatic experience(s) (Elliott et al. 2005; Harris and Fallot 2001;
Saakvitne et al. 2000).
9.6.8 The Goal of Trauma-Informed Services is to Minimize the Possibilities of Re-traumatization
It might sound somewhat tautological to state that mental health and substance mis- use services ought not to re-traumatize, or traumatize for that matter, the very clients
to whom they claim to be providing help and services. However there is, regrettably, a large body of evidence which indicates this is precisely what happens at times (see, for instance, Gallop et al. 1999; Holmes et al. 2004; Larue et al. 2013;
McAllister et al. 2002). For mental health/substance misuse services that wish to adopt a trauma-informed approach, the power dynamics present between mental health-care providers and clients have to be acknowledged and minimized if not removed (see Cutcliffe 2008). Given the power differential present in abusive rela- tionships, the contrary experience to this must be provided; P/MH nurses therefore eschew power over clients and seek to empower clients as one way of avoiding repeats of or re-traumatizing experiences.
9.6.9 Trauma-Informed Services Strive to be Culturally
Competent and to Understand Each Client in the Context of His/Her Life Experiences and Cultural Background
Culture, according to the relevant literature, can play a significant role both in con- tributing to/exacerbating a substance misuse problem and in framing the treatment/
response (Abbott and Chase 2008). It is well documented that substance misuse consumption is a cultural phenomenon with different patterns in substance of choice and frequency of use, in addition to the presence of risk and protective patterns that can be idiosyncratic to specific cultures, to significant variation in responses to drug users (see for instance, Heath 2001; Horigian et al. 2006; Lombardi and van Servellen 2000; Murphy-Parker and Martinez 2001). Culture in this instance refers to both ethnic- or national-based culture in addition to gender-based cultural nuances and differences. According to Elliot et al. (2005, p. 468):
understanding the influence of someone’s culture is essential to making an effective thera- peutic connection…healing takes place within the woman’s cultural context.
Accordingly, trauma-informed substance misuse services will then need to be cognizant of both the individual, particularized life story of the client but similarly locate that life story within the client’s culture (or cultures).
9.6.10 Trauma-Informed Agencies Solicit Consumer Input and Involve Consumers in Designing
and Evaluating Services
In keeping with other exhortations regarding improving formal mental health ser- vices, trauma-informed substance misuse services should be informed by the input of the survivors/clients (Rutter et al. 2004; Simpson and House 2002; Tait and Lester 2005). Ideally, this consultation should occur before the services are estab- lished, but even where and when this is not possible, formal service evaluation and development must include survivor input. As with the increasing (and most wel- come) inclusion of clients on educational program advisory boards and in various
educational roles as such as ‘expert by experience’ (Forest et al. 2000; Simpson et al. 2008), survivors of trauma have invaluable information that needs to be lis- tened to and considered by boards/managers of substance misuse facilities.
9.7 Psychiatric/Mental Health Nursing Responses Within