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Awareness of Trauma-Informed Care
By Scott A. Richardson, LCSW

Social workers meet with various clients in a wide range of settings, and while each client has different needs and goals and requires different care approaches, the common thread that should bind the social workers treating them is an awareness of trauma-informed care (Ko et al, 2008).

According to the Substance Abuse and Mental Health Services Administration, trauma-informed care “organizations, programs, and services are based on an understanding of the vulnerabilities or triggers of trauma survivors that traditional service delivery approaches may exacerbate, so that these services and programs can be more supportive and avoid re-traumatization.”

Trauma-informed care also can be viewed as an overarching philosophy and approach, or even as a set of universal precautions, designed to be both preventive and rehabilitive in nature, in which the relationship among environment, triggers, and perceived dangers is noted and addressed.

Trauma-informed care is based on the understanding that many clients have suffered traumatic experiences, and the provider is responsible for being sensitive to this fact, regardless of whether a person is being treated specifically for the trauma (Huckshorn & Lebel, 2013). Therefore, social workers should initially approach all of their clients as if they have a trauma history, regardless of the services for which the clients are being seen.

Increased Understanding
Statistics from research published in 1995 help demonstrate the need for trauma-informed care. In the National Comorbidity Survey, a research study of 9,282 Americans aged 18 to 54, 60% of men and 51% of women in the United States had experienced at least one traumatic event in their lives, while 17% of men and 13% of women had experienced three or more such events (Kessler, Sonnega, Bromet, Hughes, & Nelson). While these people may not have had a trauma-related diagnosis, they still had the potential to be negatively affected by their experiences.

Considering such statistics, it’s likely that social workers are assisting clients in some state of acute need, and trauma may play a central, if unclear, role. Therefore, it’s important for social workers to understand trauma and how it affects people regardless of their diagnosis or identified need. This means that, in everyday practice, social workers need to recognize how the organizations, programs, and environments in which they practice could potentially act as a trauma trigger for their clients, and social workers should make every effort to address this (Huckshorn & Lebel).

Throughout his career, George Godlewski, MSW, PhD, vice president of the division of quality and safety at Geisinger Medical Center in Danville, PA, has overseen most of the social workers employed at the facility. Based on his experience with these employees and their clients, he says it’s important for social workers to utilize a trauma-informed approach, even with routine tasks such as arranging aftercare for patients because this can significantly influence long-term healing.

“It’s so important for patient activation and engagement to really know who we are working with,” he explains. “A classic example: The driver will pick you up to take you to dialysis. But what if the patient is scared of the driver due to a traumatic experience? Which emotion do you think will win out? When a place is trauma informed, it encourages patients to become more and more self-efficacious.”

Godlewski says providing good trauma-informed care often lies in the details. He shares a story about when the outpatient psychiatry department at Geisinger was relocating to a new floor in the hospital. The waiting room originally was going to have seats that were linked one next to the other, stadium style, offering patients little individual space. He insisted that individual chairs be provided for the waiting patients, knowing that some would want to sit alone, turn aside, or just have a sense of safe space. Without this rather small change, patients with a history of trauma could experience a negative trigger and possibly feel uncomfortable enough in the waiting room that they wouldn’t get much out of their therapy. In fact, they may not have returned to the facility as a result.

Another important component of trauma-informed care is recognizing trauma’s centrality to clients and how this plays into their perception of physical and emotional safety, relationships, and behaviors (Huckshorn & Lebel). When trauma goes unrecognized, it can be difficult to understand a client’s behaviors or attitudes, and a social worker may be tempted to assign unfounded pathologies to the client. A client even may end up being barred from services as a result of what appears to be bizarre behavior or unfounded beliefs.

For example, perhaps there’s a client attending a parenting class who appears unable to manage her baby’s care despite the amount of work being done with her, an individual in recovery who never seems to maintain his sobriety for long, or patients who are chronically inconsistent with their attendance. While these situations can frustrate social workers, such behaviors easily could be linked to a history of trauma that is exacerbated by a setting that is not trauma informed. Adopting a trauma-informed approach allows social workers to better empathize with clients, while the clients are invited to have strong reactions without judgment, rejection, or expulsion.

Godlewski notes that not implementing trauma-informed care may result in a patient being classified as noncompliant or difficult. Often, however, clients’ otherwise challenging behavior is provoked by a legitimate trigger that easily could have been avoided.

Social Work and Trauma-Informed Care
Adopting a trauma-informed care approach also allows social workers to think differently about their potentially traumatized clients by asking “What happened to you?” instead of “What is wrong with you?” This is a far more engaging and respectful approach, especially when working with a person who already may feel broken, unwanted, or unlovable. Also, this approach is a mindset consistent with the profession’s beliefs.

If trauma-informed care is viewed as a paradigm shift, it can be seen as one that’s ideal for social workers. Part of social work’s overarching value set is to approach people with compassion, caring, and empathy and to offer them assistance wherever they are. The trauma-informed care approach merely asks that social workers use that compassion and empathy to be aware of the likelihood of trauma in their clients’ past.

Lloyd Lyter, PhD, LSW, MSW, a professor in the School of Social Work and Administrative Studies at Marywood University in Scranton, PA, and long-time social work provider, has seen the slow move toward increased trauma awareness within social work settings during the course of his career. “Over the years, I’ve seen more programs and providers recognize the importance of dealing with the cause, not just the consequence,” he says. “Many types of programs, including mental health, chemical dependence, crime victims, women’s shelters, children’s services, and others have moved in the direction of trauma-informed care.”

Lyter notes that social workers are specifically qualified to work within—or to encourage the creation of—trauma-informed settings. “Social workers are uniquely prepared to deal with issues of trauma,” he says. “Practicing from a biopsychosocial-spiritual base and using an ecological perspective, social workers are trained to take into account not only the client and what is happening within him or her, but multiple layers of systems that may have contributed to the trauma or may be helpful and supportive in dealing with the effects of the trauma.”

Trauma-Informed Care in Today’s Health Care Settings
Godlewski acknowledges that the pressures of modern health care and the pace of a major medical center can make it hard for social workers to always implement a trauma-informed approach. Most modern medical practice is based on seeing the greatest number of patients as quickly as possible, and medical social work largely has followed that cue. Ultimately, the difficulties are irrelevant compared with the need to have trauma-informed social workers in all settings.

“My advice would be to slow down, evaluate and reevaluate policy that either helps or hinders being trauma informed, and take the time to assess everyone’s potential for trauma in their past,” Godlewski says. “The medical system isn’t perfect, and it even creates pressure to not do trauma- informed care, but it’s necessary. So we need to look at the system as it is, think carefully about the limits and confines of it, and figure out how to make it work within these boundaries.”

— Scott A. Richardson, LCSW, is a therapist in the outpatient psychiatry clinic and intensive outpatient program at Geisinger Medical Center in Danville, PA.

Earmarks of a Trauma-Informed Care Environment

When looking at what makes a good trauma-informed facility or program, it’s best to start by using a multidimensional approach. Listed below are several elements that indicate a good, trauma-informed program (Huckshorn & Lebel):

Environment of Care
• Clean and well maintained
• Soothing colors for decor and paint
• Overall quiet; soft music
• Neutral or pleasant aroma
• Individual chairs with discrete seating areas
• Clear, welcoming entry sign
• Individual bathroom options

Staff Appearance
• Good general hygiene
• Attire connotes professionalism; easy to identify staff members
• Clothing not sexually provocative
• No religious icons; discreet jewelry choices

Staff Behavior
• Clearly demonstrate proper manners and respect
• Respond to requests for help
• Make every effort to minimize delays
• Speak in clear, normal tones
• Make eye contact
• Smile and demonstrate a generally pleasant demeanor
• Open physical stance, nodding
• Initiate greetings
• Offer water/other beverage if available but do not drink or eat in front of client
• Open to change

Organizational Understanding
• Trauma policy/philosophy in place
• Commitment to trauma-informed care articulated
• All staff/clients/family members taught about trauma and its impact
• Universal trauma screenings for all clients
• Trauma status continually assessed
• Clear organization plan for dealing with behavioral crises
• Discrete areas for calming or crisis management identified
• Feedback valued and concerted outreach efforts made

Treatment Considerations
• Treatment goals reflect consumer preferences
• Treatment integrated across disciplines
• Consent for treatment explained and revised as needed
• Offering choice of treatment provider when possible
• Everyday language used
• Respond to all statements of abuse
• Sensitivity to seating configuration and proximity of seating options
• Co-occurring treatment needs assessed and incorporated into service provided
• Culture of origin respected and incorporated into service planning
• Recognize the importance of physical boundaries and aware that touch—sometimes even a handshake—could trigger trauma
• Recognize the importance of social boundaries and that jokes, story telling, innuendo, and double entendres can convey risk or threat

References
Huckshorn, K., Lebel, J. L. (2013). Trauma-informed care. In Yeager, K., Cutler, D., Svendsen, D., & Sills, G. (Eds.) Modern community mental health: An interdisciplinary approach. (pp. 62-83) Oxford, England: Oxford University Press.

Kessler, R. C., Sonnega, A., Bromet, E., Hughes, M., & Nelson, C. B. (1995). Posttraumatic stress disorder in the National Comorbidity Survey. Archives of General Psychiatry, 52(12), 1048-1060.

Ko, S. J., Ford, J. D., Kassam-Adams, N., et al. (2008). Creating trauma-informed systems: Child welfare, education, first responders, health care, juvenile justice. Professional Psychology: Research and Practice, 39(4), 396-404.