Question

Trauma-Informed Care for Social Workers: Theory and Practice

Chapter 11

Jill Levenson

LEARNING OBJECTIVES

By the end of this chapter, you should be able to:

•define trauma and distinguish trauma-informed care from trauma-specific interventions,

•conceptualize client presenting problems through the lens of trauma,

•describe what it means to respond to clients and interact with them in a trauma-informed way, and

•apply ideas that translate trauma-informed principles into practice.

INTRODUCTION: DEFINING AND UNDERSTANDING TRAUMA

I once heard that the children’s television host Mr. Rogers carried a quote in his wallet from a social worker. It said: “Frankly, there isn’t anyone you couldn’t learn to love once you’ve heard their story.” These words bring home the essence of the social work profession: to start where the client is and to understand behavior without judging (Hepworth et al., 2016). The words take on an even more significant meaning when we recognize the prevalence of trauma in the lives of social service clients and realize that trauma symptoms often masquerade as presenting problems and undesirable behavior. In 2018, Oprah Winfrey shared a similar sentiment in an interview on the CBS show 60 Minutes, describing how becoming trauma informed changed how she thinks about everyone in her life. Sandra Bloom (2007), who pioneered the Sanctuary Model of trauma-informed care (TIC), stressed that understanding trauma is not just about acquiring knowledge. It’s about changing the way you view the world. It’s about shifting the helping paradigm from “What is wrong with you?” to “What happened to you?” (Bloom, 2007).

Trauma is very common in American society, and it is therefore important for social workers to intentionally engage in trauma-informed practices (Bent-Goodley, 2018; Substance Abuse and Mental Health Services Administration [SAMHSA], 2014a). Clients are usually referred to social services at times of personal crisis, and the focus of intervention tends to be on the current presenting problem rather than on early traumatic experiences (Knight, 2015). However, current problems can intersect with the legacy of past adversities. Social workers should be aware of the ways that distant trauma can contribute to presenting problems, and how trauma-related dynamics might manifest within the helping relationship. While the terms trauma-informed care and trauma-informed practice are often used interchangeably, “practice is more accurately applied to clinical intervention, while care refers to the organizational context within which services are provided to clients” (Knight, 2018, p. 4). This chapter first describes the definitions of trauma, its prevalence, and the ways in which trauma can impact people throughout their lives. Then, the principles and components of TIC are reviewed. Finally, specific suggestions are offered for translating TIC principles into trauma-responsive social work practices. A case study illustrates the principles and practices of TIC.

WHAT IS TRAUMA?

Trauma results from a direct or witnessed experience that threatens a person’s sense of physical or psychological safety (American Psychiatric Association [APA], 2013). According to SAMHSA (2014a), “[I]ndividual trauma results from an event, series of events, or set of circumstances that is experienced by an individual as physically or emotionally harmful or life-threatening and that has lasting adverse effects on the individual’s functioning and mental, physical, social, emotional, or spiritual well-being” (p. 7). Trauma can take many forms, but usually involves an event that is unexpected and out of a person’s control, leaving them feeling physically or psychologically threatened with a sense of helplessness and fear (Herman, 1997). Following a traumatic event, people may have difficulty sleeping, eating, or concentrating; they might have nightmares, hyperarousal to stimuli in the environment, or negative moods. These are common posttraumatic stress symptoms that can last for a short time or for years following the incident (APA, 2013).

Examples of trauma include victimization, natural disaster, illness, accident, or an unexpected event that leaves a person feeling distressed and that compromises their typical coping skills (Herman, 1997). Acute trauma results from a single incident, while repeated and prolonged exposure is known as chronic trauma (such as experiencing or witnessing domestic violence). Complex trauma occurs when someone is exposed to multiple traumatic events, often accumulating over time, that often include interpersonal victimization (Herman, 1997). Social workers must also be aware that oppression, discrimination, and marginalization of poor and minority groups have roots in the cultural and historical traumas associated with misuse of privilege and power; poverty and social injustice can create a vicious cycle of hopelessness, victimization, and lost potential (Pettus-Davis & Epperson, 2015).

Adverse Childhood Experiences

In 1997, the Centers for Disease Control and Prevention (CDC) began a study involving 17,000 adults to determine rates of specific types of childhood trauma in the United States. They studied 10 types of adverse childhood experiences (ACEs) and devised a scale asking about childhood abuse, neglect, and family dysfunction (Felitti et al., 1998). This groundbreaking ACE study found high reported rates of abuse (emotional = 11%, physical = 28%, and sexual = 21%), neglect (emotional = 15%; physical = 10%), and household dysfunction, which was defined as growing up in a home with domestic violence (13%), an absent parent (23%), substance abuse (27%), mental illness (19%), or an incarcerated (5%) member of the household. The results confirmed that child maltreatment and family dysfunction are common in American families. You can learn more about the ACE study, and download the ACE tool, at https://www.cdc.gov/violenceprevention/aces/index.html.

One’s ACE score can range from 0 to 10 and reflects the number of different types of childhood traumas endorsed by the individual (Table 11.1). Higher scores indicate the accumulation of a diverse range of trauma. Multiple forms of child abuse and chaotic family life often occur simultaneously, and having experienced one type of childhood trauma significantly increases the chances of other adversities (Dong et al., 2004; Finkelhor et al., 2011). Research has clearly and consistently demonstrated the detrimental impacts of cumulative childhood trauma on behavioral, medical, and psychosocial well-being in adulthood (Anda et al., 2010; Briere & Elliot, 2003; Felitti et al., 1998; Maschi et al., 2013). As ACE scores increase, so does the risk for a variety of problems later in life, including chemical dependency, suicidality, depression, cigarette smoking, physical diseases, obesity, alcoholism, intimate partner violence, sexually transmitted diseases, and unintended pregnancies (Felitti et al., 1998). The original 10 ACE items are only the tip of an iceberg; clearly there are many other childhood traumas that can impact a young life. Researchers are making efforts to expand and improve the ACE tool by studying additional early adversities such as poverty, bullying, death of family members or other losses, out-of-home placement, and exposure to community violence (Finkelhor et al., 2015).

TABLE 11.1 ACE SCALE ITEMS AND PREVALENCE RATES IN THE CDC SAMPLE

While You Were Growing Up, During Your First 18 Years of Life CDC

1.Did a parent or other adult in the household often or very often swear at you, insult you, put you down, or humiliate you? Or act in any way that made you afraid that you might be physically hurt? 11%

2.Did a parent or other adult in the household often or very often push, grab, slap, or throw something at you? Or ever hit you so hard that you had marks or were injured? 28%

3.Did an adult or person at least 5 years older than you ever touch or fondle you or have you touch their body in a sexual way? Or attempt or actually have oral, anal, or vaginal intercourse with you? 21%

4.Did you often or very often feel that no one in your family loved you or thought you were important or special? Or your family didn’t look out for each other, feel close to each other, or support each other? 15%

5.Did you often or very often feel that you didn’t have enough to eat, had to wear dirty clothes, and had no one to protect you? Or your parents were too drunk or high to take care of you or take you to the doctor if you needed it? 10%

6.Were your parents separated or divorced, or not married to one another? 23%

7.Was your mother or stepmother often or very often pushed, grabbed, slapped, or had something thrown at her? Or sometimes often or very often kicked, bitten, hit with a fist, or hit with something hard? Or ever repeatedly hit at least a few minutes or threatened with a gun or knife? 13%

8.Did you live with anyone who was a problem drinker or alcoholic, or who used street drugs? 27%

9.Was a household member depressed or mentally ill, or did a household member attempt suicide? 19%

10.Did a household member go to prison or jail? 5%

ACE, adverse childhood experience; CDC, Centers for Disease Control and Prevention.

Source: https://www.cdc.gov/violenceprevention/childabuseandneglect/acestudy/about.html.

Impact of Adverse Childhood Experiences

Growing up in a home with chronic abuse, neglect, or other sorts of family problems can introduce profound feelings of powerlessness at a young age (Bloom, 2013). ACEs are considered relational trauma, which occurs when caregivers are simultaneously needed and dangerous or unavailable (Steele et al., 2016). A child might feel afraid or alone, unwanted, threatened, or ignored by people on whom they are dependent, in the very place that is supposed to feel safest. In other cases, parental caretaking may be loving but inconsistent due to physical or mental illness, the stressors of poverty, or substance abuse. Over time, a traumatized child may adopt “maladaptive” coping strategies that are protective in the traumagenic environment but counterproductive in other settings. Cognitive schemas of mistrust or self-blame may become part of one’s interpersonal patterns and worldview (Bloom, 2013; van der Kolk, 2006; Young et al., 2003).

The dynamics of child abuse include betrayal at the hands of a trusted person (often a caregiver), violation of hierarchical boundaries (power differentials inherent in age or role), keeping of secrets, and distortion of reality in a way that reinforces the values, beliefs, and behaviors of the abuser (Elliott et al., 2005; Harris & Fallot, 2001; Teyber & Teyber, 2017). In abusive environments, a victim’s voice is denied or ignored, and the victim feels powerless to alter or leave the relationship (Harris & Fallot, 2001). Invalidation exacerbates the psychological consequences of trauma, but trauma is mitigated when clients are supported in a way that allows their traumatic stress to be expressed and processed (Whitfield, 1998).

There is a complex set of bio-psycho-social links between child trauma and its long-term consequences (Anda et al., 2010). The cumulative stress of childhood adversity increases the production of stress-related hormones associated with fight-or-flight responses, which inhibits the growth and connection of neurons in the brain (van der Kolk, 2006). These changes can contribute to impairments in self-management, attachment, and cognitive processing (Anda et al., 2006, 2010). The reciprocity between the childhood environment and neurobiology is further impacted by accumulating cascade effects: An early disadvantage in one domain impacts functioning and mastery in other developing areas (Masten & Cicchetti, 2010; Rutter et al., 2006).

For instance, changes in the brain from early trauma can affect executive functioning such as impulse control, information processing, and self-regulation. This can lead to behavioral problems in the school setting, which then compromise academic and social competence. A child’s “hyperactive” behavior might make it difficult to learn, and might also elicit negative feedback from teachers and classmates. Teachers may become frustrated, impatient, and critical, or other students may not want to play with a child who cannot take turns, wait in line, or follow the rules of a game. The child may get labeled as naughty or weird. As time goes on, this may place the child at increased risk for anxiety and depression or for association with delinquent peers who provide social acceptance and a sense of belonging (Rutter et al., 2006).

Adult Trauma

Of course, interpersonal traumas that parallel ACEs can occur in adulthood too. For instance, adults can be victimized by physical or emotional abuse, domestic violence, or sexual assault. Substance addiction can be a way to self-medicate after trauma, and it can also contribute to trauma for self and for family members. Mental health problems (and related hospitalizations and/or suicidality) can have traumatic impacts on self and loved ones, as can arrest or incarceration. Finally, divorce can create much pain and loss and usually represents a traumatizing life transition. Other forms of psychological injury in adulthood include highly stressful life events, a toxic workplace, or cultural, historical, and community trauma related to poverty, marginalization, and discrimination (Kuelker, 2019; St. Vil et al., 2019). Adult traumatic experiences can also lead to neurobiological impacts and maladaptive coping.

CONCEPTUALIZING PRESENTING PROBLEMS THROUGH THE TRAUMA LENS

There is a paradigm shift that occurs when we begin to conceptualize presenting problems as symptoms of trauma. By shifting the paradigm to view client problems as survival and coping skills that developed in response to traumagenic experiences, we can begin to ask not “What’s wrong with you?” but “What happened to you?” In this way, we can understand the meaning attached to those experiences, which profoundly shaped the ways clients think about themselves and others, and their expectations that the world is not a safe place. We can reframe client behaviors as a set of skills that were once adaptive in a threatening early environment but now tend to interfere with the client reaching their personal goals and establishing intimate connections with others. Like with evolution of species, adaptation behaviors evolve to help individuals adjust to the demands of the environment.

Social workers understand behavior from a person-in-environment perspective that assumes a complex intersection of bio-psycho-social factors (Kondrat, 2008). We’ve all engaged in the “nature versus nurture” debate about whether behavior is innate or learned. The truth is that nature intermingles with nurture; everyone is born with a temperament that may predispose them to certain characteristics, and this foundation of personality interacts reciprocally with the environment. Our relationships become a series of windows and mirrors: we learn by observing the behavior of others, and we see ourselves reflected in the ways that others treat us.

TIC emphasizes a holistic understanding of clients by thinking about problematic behaviors as rehearsed responses that once helped them cope with or adapt to a threatening environment. ACEs can disrupt neurobiological and social development, alter one’s sense of self and identity, and reinforce maladaptive coping and interaction styles (Bloom, 2013; Cicchetti & Banny, 2014; van der Kolk, 2006). Developmental psychopathologists describe how we integrate past experiences into our expectations of the world (Rutter & Sroufe, 2000). In a reciprocal process, our experiences inform our expectations, and our expectations are projected onto new interactions. A pathogenic childhood environment may deprive children of relational skills that foster healthy functioning—creating a cycle of eliciting the very responses they expect and fear (Alexander, 2013).

Relational theories of social work propose that client patterns will be reenacted in the helping relationship, creating a parallel process that provides an opportunity for a corrective experience (Rasmussen & Mishna, 2018; Tosone, 2013). When our clients present for services, they may have a range of problems for which services are needed. Viewed through the lens of trauma, however, such behaviors are better conceptualized as symptoms rather than problems. Remember that early trauma induces hyperarousal, and when people grow up constantly scanning the environment for danger, they are primed to expect threats and to respond accordingly. Some people develop a sense of learned helplessness, and others take on a stance of proactive aggression. Their self-protective survival mechanisms may show up as aggressive, combative, or provocative behavior (fight response); avoidance of intimacy or tendency to self-medicate with substances, food, or compulsive behavior (flight response); or passive compliance, dependency, and difficulties setting boundaries (freeze response).

Different children in the same family can experience early life in distinctly dissimilar ways. Take, for instance, three siblings who respond to domestic violence between their parents very differently: One hides under the bed covering her ears; one tries to intervene by yelling and fighting back; and one attempts to step in and reason with the violent parent. These children are demonstrating diverse methods for dealing with distress. They grow up to interact quite differently in relationships, especially when it comes to resolving conflict and trusting others. The first tried to de-escalate her own fear by withdrawal; she becomes very passive as an adult, avoiding conflict by acquiescing to the demands of others. The second child tried to manage the intensity of their chaotic family by becoming confrontational; as an adult, his family describes him as a bully who is quick to agitation and escalation of emotions, and who has intense negative responses to any disagreement. Finally, the third child, who attempted to “make peace” and negotiate between her parents, became an attorney; the courtroom is the only place she feels in control and where she successfully uses the skills that were futile in her childhood home.

By understanding the meaning attached to traumatic events and the dynamics of early relationships, the clinician can conceptualize the role of coping strategies that were once adaptive in the abusive childhood environment but prove to be unhealthy or harmful to self or others across various domains of adult functioning. TIC emphasizes a holistic understanding of the individual in the context of their collective life experiences. Maladaptive (sometimes irrational or even abusive) attempts to cope with emotional distress are reframed as survival skills that were programmed by painful life experiences, have been well rehearsed, and have become ingrained. Maladaptive coping was once necessary to survive in a traumagenic environment and sometimes interferes with the capacity to establish healthy interpersonal relationships and boundaries. In some cases, however, it transforms into resilience.

FOCUS ON STRENGTHS AND RESILIENCE

Clearly, many children are quite resilient and thrive despite difficult circumstances. Social workers view clients with a focus on their strengths (Saleebey, 2011). Resilience is an individual’s ability to effectively adapt to stress and adversity in a healthy and integrated way over the passage of time (Southwick et al., 2014). Resilience develops through human connections with supportive others, internal strengths, and external resources. Research indicates that a robust predictor of resilience for children is having at least one adult who believes in them and provides support, guidance, validation, and hope (Fraser et al., 2004; Shonkoff, 2016). In healthier families, parents provide this for their children. In families where nurturing caregivers are absent, children may find support through relatives, teachers, or parents of friends. It is never too late to build and fortify resilience through collaborative and empowering relationships with our clients. We can help them focus on their strengths, increase hope toward the future, cultivate emotional awareness, enhance effective communication, improve self-regulation, establish support networks, and develop a flexible repertoire of coping skills.

By using a strengths-based approach, we help our clients transcend trauma and enable posttraumatic growth. In this way, we can help clients decrease problematic behavior, choose more healthy relationships, deal with crises more effectively, and parent and protect their own children in a more nurturing and responsive manner—thereby interrupting the often intergenerational cycle of trauma and victimization (Harris & Fallot, 2001; Tedeschi et al., 2015). Strengths-based and trauma-informed social work services help clients to engage in better reality testing and self-correction, and to face vulnerability with healthy coping, intact boundaries, and an expanded range of problem-solving skills.

WHAT IS TRAUMA-INFORMED CARE?

TIC is a model of service delivery that incorporates evidence about the prevalence, neuroscience, and impact of early trauma on behavior across the lifespan. Early advocates for TIC recognized that social and psychiatric services designed to help patients could actually re-traumatize them (Bloom, 2013; Harris et al., 2001). Health and mental health services should provide a sanctuary from harm—a place where it is safe to be vulnerable and to heal. These TIC pioneers argued for ensuring that important basic components are integrated into the way care is delivered. Safety, trust, choice, collaboration, and empowerment should be consistently interwoven and applied throughout the intake, assessment, treatment, and discharge process. Within an organization, from the top down and the bottom up, every employee has a role to play in a trauma-informed approach: “One does not have to be a therapist to be therapeutic” (SAMHSA, 2014a, p. 11). When put into practice, adherence to these concepts minimizes the likelihood of re-enacting disempowering dynamics in the helping relationship. They capitalize on the opportunity to create a corrective experience for traumatized clients, generating new expectations of hope and connection.

PRINCIPLES OF TRAUMA-INFORMED CARE

Principles of TIC fit well within the environmental context and bio-psycho-social frameworks of evidence-based social work (Drisko & Grady, 2015; Knight, 2015; Kondrat, 2008; Mishna et al., 2013; Saleebey, 2011; Uehara et al., 2013). Trauma-informed social workers create service environments where emotional safety is paramount, with client-centered practices that facilitate trust, respect, choice, collaboration, hope, and shared power (Bloom, 2013; Brown et al., 2012; Fallot & Harris, 2009; Harris et al., 2001; Levenson, 2017; SAMHSA, 2014a). According to the concept of TIC put forth by SAMHSA, there are four core guiding principles to TIC, called the “Four Rs.” A program, organization, or system that is trauma informed:

1.Realizes the widespread impact of trauma and understands potential paths for recovery;

2.Recognizes the signs and symptoms of trauma in clients, families, staff, and others involved with the system;

3.Responds by fully integrating knowledge about trauma into policies, procedures, and practices; and

4.Seeks to actively Resist Re-traumatization in the service delivery setting. (SAMHSA, 2014a, p. 9)

SAMHSA’s trauma-informed approach adheres to these core principles rather than to a prescribed set of practices, interventions, or procedures (SAMHSA, 2014a). These principles generalize across diverse service delivery settings, although terminology and application may differ according to the specific problem or population. SAMHSA emphasizes the importance of helping relationships in the recovery and resilience of individuals and families impacted by trauma. Trauma-informed services are different from targeted interventions that have been tested in experimental designs; rather, they are built on a foundation of evidence from neuro- biological, psychological, and social research about the etiology and impact of trauma. They incorporate this knowledge into effective clinical practices to prioritize and enhance consumer engagement, empowerment, and collaboration (SAMHSA, 2014a).

TIC is constructed on the client’s need to be respected, informed, connected, and hopeful regarding their own recovery (Bloom & Farragher, 2013; Harris et al., 2001). Many clients have encountered disdain, contempt, or judgment from others in their lives, even from helping professionals. Clients need social workers who can listen with curiosity, compassion, kindness, and respect, asking questions that give the message: “I’m genuinely interested in understanding your experience.” SAMHSA’s Concept of Trauma and Guidance for a Trauma-Informed Approach describes the six key fundamental features of TIC (SAMHSA, 2014a, pp. 11–12):

Safety: Throughout the organization, all staff and clients (whether children or adults) should feel physically and psychologically safe. The physical setting and interpersonal interactions promote a sense of safety, which clients contribute to defining. Simply recognizing the possible existence of traumatic history goes a long way in developing safe service environments. Warm and welcoming surroundings will create a sense of serenity and safe space for clients (Elliott et al., 2005). Safe relationships are consistent, predictable, and non-shaming.

Trustworthiness and transparency: Policies and practices that impact clients and staff are implemented with transparency. Within the organizational hierarchy, maintaining trust with clients, employees, and stakeholders is a prominent goal. When the client’s need for safety, respect, and acceptance is recognized, an atmosphere of trust can be established (Elliott et al., 2005). Trust is earned and demonstrated over time. By eliminating ambiguity and vagueness, clients can anticipate what is expected of them and what they can expect from their service providers (Harris & Fallot, 2001).

Peer support: Peer support and mutual self-help are key vehicles for establishing hope that healing and change are possible. The term “peers” (often other trauma survivors) refers to individuals with similar experiences who become reciprocal caregivers in their own collective recovery. There is almost nothing more reassuring than sitting with others who seem to “get it.” This shared humanity and connection are vital to decreasing shame and isolation. Listening to the narratives and lived experiences of consumers also helps workers understand what they need to promote recovery and healing.

Collaboration and mutuality: Importance is placed on partnering with clients and neutralizing power imbalances. Healing happens in relationships through shared power and decision-making; we facilitate self-determination and autonomy by supporting and guiding clients to explore their options and identify their best choices (National Association of Social Workers [NASW], 2018). The inherent power disparities in the worker–client relationship require constant attention. Because many ACE survivors were betrayed by those who were supposed to protect and care for them, the helping relationship is fraught with potential for re-traumatization. Clients may be motivated to please others, conform to authority, and to seek acceptance and attention; they may be inclined toward instinctive compliance and may need to be reminded that they have the right to ask questions, refuse treatment, or make requests. A truly collaborative therapeutic relationship is one in which treatment goals are discussed and agreed upon together, based on the social worker’s professional knowledge along with the client’s expertise about their own life history and scope of coping responses.

Empowerment, voice, and choice: Workers and agency leaders should recognize and build on strengths, fostering a belief in resilience, and in the ability of individuals, organizations, and communities to heal and thrive. Organizational leaders understand the salience of power differentials and ways in which clients, historically, have been denied voice and choice and are often recipients of coercive or oppressive treatment. Thus, collaborative decision-making and goal setting is modeled to help clients develop self-advocacy skills. Social workers facilitate recovery instead of trying to control it with paternalistic or moralistic case planning. Trauma-informed services strive to maximize clients’ choices and control over their own recovery, helping them to transform from victims to survivors who direct and own their life decisions and the associated outcomes (Elliott et al., 2005). True empowerment occurs with a strength-based approach that reframes symptoms as adaptation and highlights resilience over pathology. Above all, TIC ensures that disempowering dynamics are avoided by professionals in the helping relationship.

Cultural, historical, and gender issues: Social workers should seek to avoid cultural stereotypes and be aware of implicit biases (e.g., based on race, ethnicity, sexual orientation, age, religion, gender identity, socioeconomic status). TIC appreciates the value of cultural connections. Agency values should promote policies and practices that are responsive to the diverse racial, ethnic, and cultural needs of client populations. Some racial, ethnic, and sexual minority groups have long legacies of historical trauma due to slavery, denial of civil rights, and social policies that have created enormous and unjust obstacles for them. We know that historical trauma can be transmitted intergenerationally, epigenetically, and through family dynamics. Early adversity is linked to social problems, and, though interventions for individuals are important, communities also need to invest in human capital in the interest of public good (Larkin et al., 2014).

TRAUMA-INFORMED PRACTICES: WHAT TO SAY, WHAT TO DO, AND HOW TO DO IT

Some clients seek trauma-specific therapy after a specific event that has caused difficulties coping. There are many evidence-based interventions to reduce traumatic stress symptoms and assist with developing coping strategies, such as cognitive therapies, memory reconsolidation techniques, and mindfulness strategies (Cohen et al., 2012; Najavits, 2002; Strand et al., 2013; van der Kolk, 2014). TIC, however, is a framework for understanding the nexus between current presenting problems and maladaptive survival skills that evolved due to early adversity. TIC doesn’t just treat trauma; it produces corrective encounters to change the way clients experience the world.

SAMHSA (2014a) describes the three Es of trauma: events, experience, and effects. Events and circumstances can be very frightening and cause psychological harm. It is the individual’s experience of the trauma that can determine its longer term impact. In other words, people attach meaning to the things that happen to them, and this meaning can shape their view of the world, themselves, and others. For more resilient people, a terrible trauma can mean that hard things happen, but you learn you can get through it, and still perceive the world as a generally safe place. In other circumstances, someone might interpret their experience as something they deserved because they believe they are bad. These interpretations, which reflect an intersecting web of thoughts, feelings, and experiences, can lead to effects of trauma that vary in duration and severity for each unique individual.

TIC fosters an alliance of human connection to counteract the effects of trauma through a corrective experience that helps create a new narrative of meaning (Harris et al., 2001; Knight, 2015). Many agencies have adopted TIC initiatives and many social workers are familiar with its basic principles; it is challenging, however, to translate these ideals into real-world service delivery (Berliner & Kolko, 2016). Following are some ideas for translating TIC into action (Levenson, 2020).

Use Person-First Language

Disparaging or stigmatizing labels can become internalized into one’s personal narrative and self-concept (Goffman, 1963; Maruna et al., 2004). Self-fulfilling prophecies evolve when an individual adopts assumptions made by others and then behaves in a way that is consistent with those notions (Paternoster & Iovanni, 1989). Our “looking-glass self” is formed by seeing ourselves reflected in how others treat us, and in this way, we construct our social identity (Cooley, 1902). Person-first language avoids labeling and separates the behavior from the person (Willis, 2017). The NASW code of ethics strongly values personal dignity and worth, and requires us to use respectful and non-derogatory language to describe those with whom we work (NASW, 2018). The Publication Manual of the American Psychological Association guides us to use neutral language that puts the person first (American Psychological Association, 2010). Words that are negative or pejorative ignore strengths-based principles and reinforce stigma. For instance, social workers should avoid labels like “offender” or “junkie,” instead describing a client as someone who has engaged in criminal behavior or struggled with addiction (Robinson, 2017). Instead of saying “he’s bipolar” or “she’s an abuser,” person-first language would state “he is a person with bipolar disorder” or “she engaged in abusive behavior.”

Remember What People Need in a Crisis

Though childhood trauma is not uncommon, most clients initiate services for a recent crisis and not for past trauma (Knight, 2018). The crisis can leave a client feeling helpless and scared, reactivating posttraumatic stress. Help-seeking itself can produce feelings of vulnerability and further exacerbate hyperarousal and dysregulation (Pattyn et al., 2014). To those who grew up in abusive or neglectful homes, asking for help can seem futile or dangerous. Asking for help may activate shame, which is reinforced if clients encounter worker judgment or disdain. Thus, many clients enter our service systems with apprehension. Social service bureaucracies can be oppressive and disempowering, and many clients have encountered professionals who responded with paternalistic authoritarianism (i.e., telling clients what they should or must do). We should also be cognizant of the many ways in which our clients (especially impoverished, minority, and marginalized groups) have had limited voice and choice (SAMHSA, 2014b). In a crisis, people need to regain a sense of control and to break problems down into manageable parts so that they can explore and evaluate their alternatives. However, at times of high stress, it can be difficult to focus and problem-solve effectively. From the first point of entry into services, social workers and agency staff who exhibit a calm, warm, and welcoming demeanor provide hope that, perhaps for the first time ever, there is more to be gained than lost by relying on others for help.

Safe Relationships Are Predictable, Consistent, and Nonshaming

Helping relationships must feel safe, and safe relationships are predictable, consistent, and nonshaming. Relationship safety occurs when expectations are clear, foreseeable, and consistent, and rules are transparent and imposed impartially. However, boundaries must also be flexible enough to respond to unique circumstances without unnecessary rigidity (Najavits, 2009). Social workers are often viewed as authority figures, so it is important to demonstrate trustworthiness, dependability, and fairness. When social workers make mistakes, we should take responsibility, apologize when appropriate, and correct our actions, modeling permission for imperfection along with accountability and humility.

Safety can also be enhanced with social worker authenticity and clear relational boundaries (Covington, 2007; Tosone, 2013). Due to early relational trauma, some clients may be mistrustful and wary of professional helpers (Alexander, 2013). A lack of trust can be adaptive—skepticism protects the client from an expectation of betrayal, which is based on past experiences. What might appear at first glance to be a lack of motivation or resistance to services might actually be viewed as a useful and protective defense against feelings of vulnerability (Steele et al., 2016).

The social worker’s style of interaction should be genuine and nonthreatening, warm, and positive (Rogers, 1961), allowing people to disclose information at their own pace and build trust gradually. This can be challenging when agencies require documentation of assessment reports shortly after a first intake session. Remember, though agency documentation is important, assessment is actually an ongoing process, not a one-time event. There are stages of intimacy that all relationships go through, and by respecting self-determination in this way, the worker models a process of establishing trust through active listening and responding in a truly reliable and consistent manner. In this way we build rapport, which is essential in eliciting the information that helps us make an accurate assessment. By modeling respectful boundaries, language, and collaboration, clients learn to play an interactive role in intended outcomes and to assert needs in appropriate ways (Knight, 2015). In this way, we support the cultivation of self-advocacy and self-efficacy skills. Treating everyone with compassion and respect is crucial in building trust and interpersonal safety. It is simple but not always easy.

Create Safe Spaces

Clients need physical and psychological safety in the helping environment, and these must exist from the initial point of contact (Bloom et al., 2013; Brown et al., 2012). Call centers or hotlines should be staffed with pleasant and comforting voices that calm the anxiety of reaching out for help. Conversely, robotic telephone menus and automated responses, while efficient, can seem cold and detached without personal connection. Waiting rooms should be clean and welcoming, as opposed to one that is dingy, where toys are broken or dirty, or where the furniture feels hard and institutional. A warm entry space creates a sense of serenity and sends the message: “Your comfort is important to us, and you are important.” When a receptionist or practitioner smiles and greets a client by saying “We are glad you are here,” a welcoming and engaging atmosphere is projected. Many of our clients’ experiences have left them feeling demeaned, judged, vulnerable, or invisible. Trauma-informed environments seek to make clients feel important, valued, and respected (Elliott et al., 2005). Strategies for creating physical and psychological comfort and security offer a single message: “This is a safe environment and we won’t let bad things happen here.”

Ask, Don’t Tell

Perhaps the most important thing we can do to empower clients is to avoid giving advice. This can be challenging, especially when clients are stuck or seem prone to repeating what we perceive to be poor choices. Social work engagement skills emphasize active listening and open-ended questions (Hepworth et al., 2016). This translates to a process by which workers listen with curiosity and compassion, sending the message: “I want to hear what you think, I want to get to know you, and I need your input!” Therapeutic engagement begins with conveying that the worker is interested in understanding the client’s unique experience and perspective.

By asking questions, we collaborate with our clients to define their own goals and the means for achieving them. When we can help them view their problems as manageable and their goals as realistic, we offer hope that the self-improvements they desire are possible. When you catch yourself wanting to give advice or tell someone what to do, change it into the form of a question instead. By asking rather than telling, we honor autonomy and self-determination, which will allow the client to meaningfully prioritize their own goals and evaluate their options to figure things out for themselves (Saleebey, 2011). The worker becomes a coach, allowing the client to direct the process while collaborating with the client to model planning and decision-making skills. This fosters the empowerment that is such a critical part of TIC.

Avoid Confrontation

Confrontational methods are sometimes found in programs for addictions, interpersonal violence, or mandated services, and are ostensibly used to encourage client accountability and challenge rationalizations used to justify undesirable behavior. Recognizing and altering flawed thinking are important goals of behavioral change (Miller & Rollnick, 2002). Confrontation, however, can replicate disempowering dynamics similar to those in abusive families. When clients are challenged in ways that seem judgmental or threatening, hyperarousal can be reactivated. A defensive posture emerges, paradoxically reinforcing the client’s own unhelpful ideas. Responding to clients in a negative way can stimulate shame and fear, disrupting the therapeutic alliance and preventing clients from being forthcoming (Binder & Strupp, 1997; Streeck-Fischer & van der Kolk, 2000). It is easy to underestimate how confrontation can undermine engagement. On the other hand, nonthreatening methods like motivational interviewing (Miller & Rollnick, 2002) and active listening can eliminate the need for defensiveness. This allows the clients to safely explore problems and solutions, accept feedback, and improve communication skills.

Boundaries can be fair, firm, and consistent without being punitive. In fact, people learn best from natural or logical consequences. Punitive consequences alone are usually insufficient to facilitate change. Clients need opportunities to learn how to self-correct. Most important, practitioners should help clients examine what emotional needs might be getting met through the maladaptive behavior and explore how to meet those needs in more healthy ways.

Reframe Resistance

The TIC paradigm views client problems as well-rehearsed strategies for surviving traumagenic experiences, and workers can begin by asking “What happened to you?” instead of “What’s wrong with you?” (SAMHSA, 2014a). Clients’ thinking about self and others is shaped by the meaning they have attached to their experiences. These perceptions are projected into expectations of others and inevitably replicated in the helping relationship (Pearlman & Courtois, 2005; Tosone, 2013). Survivors of ACEs may be predisposed to lack of trust, anxiety about being judged, avoidance of conflict, and fear of authority figures (or, alternatively, hostility and aggression, perhaps to compensate for feelings of vulnerability).

Resistance can be reframed as ambivalence, which usually reflects a simultaneous struggle between a genuine desire to change and the need to maintain what is familiar. It is difficult for anyone to give up coping strategies without knowing what will replace them, especially when they have served to protect the individual from perceived interpersonal danger. We may sometimes doubt that a client is being honest with us, or wonder why clients sabotage success if true motivation for change really exists. The social worker should expect and embrace resistance and provide an accepting environment for reflection about the pros and cons of change.

Coach De-escalation, Self-Regulation, and Relational Skills

Emotional competence and self-regulation are important pathways to self-efficacy, which is the capacity to achieve goals, accomplish tasks, and respond effectively to challenges (Bandura, 1977). Have you ever become frustrated with a client who doesn’t learn from experience or repeatedly engages in self-sabotage? Growing up with adversity or family dysfunction can make it difficult to observe one’s inner self and manage thoughts, emotions, and impulses. If healthy coping and self-control were not taught and modeled in the early home environment, clients don’t know what they don’t know. A trauma-informed worker recognizes that chronic early adversity can alter the architecture of the brain, possibly compromising executive functioning and self-regulation. Workers can coach clients to learn to self-soothe and de-escalate their emotions through grounding and mindfulness techniques.

In some psychiatric or correctional settings, the use of restraints and seclusion might be employed when a threat to self or others is present. Although maintaining safety and security is important, these methods can re-traumatize people with early histories of abuse or neglect (Frueh et al., 2005). Instead, de-escalation strategies can be used to diffuse the situation by asking questions in calming tones to assess the person’s inner state, validate feelings, avoid invasion of personal space, and give people a chance to choose from an enumerated range of acceptable options. Restoring an internal locus of control can help build a flexible repertoire of coping skills to be used in various situations. In this way, we can teach skills for self-regulation and self-correction within a context of personal and environmental safety (Frueh et al., 2005).

Neutralize Power Struggles and Model Shared Power

It is important to neutralize power differentials between practitioners and clients, as there are subtle and unintended ways that power dynamics can intrude in a helping relationship. Because past relational trauma often involved betrayal by someone in a caretaking role, the potential for re-traumatization within social work practice must be carefully avoided (Pearlman et al., 2005; Tosone, 2013). Some survivors may be motivated to please others, avoid conflict, and passively comply with authority figures, creating a tendency to acquiesce to professionals. On the other hand, negative countertransference can lead practitioners to respond to challenging clients in a dogmatic, coercive, or rejecting manner (Binder & Strupp, 1997; Teyber & Teyber, 2017). “Bullying the bully” can replicate traumatic experiences in abusive families, and clients might resort to defensiveness or aggression to gain the upper hand in a power struggle. Instead, social workers can model shared power, demonstrating skills of cooperation, dialogue, perspective taking, negotiation, and compromise. By being aware of our own reactions and resisting controlling responses, we model how to respect the viewpoints of others and resolve conflict. Our therapeutic demeanor says: “I want to listen to you and understand your experience, but I have no need to win a debate or get into a power struggle with you.”

Parallel Process and Use of Self

Trauma-informed practices emphasize attention to process over content so that the helping relationship becomes a model for improving relational and self-regulatory skills (Knight, 2015; Pearlman et al., 2005; Tosone, 2013). Attending to parallel process and use of self allows the social worker to respond to relational themes as they present themselves in the therapeutic encounter (Knight, 2018; Teyber & Teyber, 2017). Clients may engage therapists in replicating a parallel process that occurs in other areas of their life; similarly, we may be repeating a process that dominates the interactions in our own world of personal experience. The reciprocal nature of interpersonal communication gives social workers an abundance of ongoing opportunities to alter the interactions they have with clients in real time. Using trauma-informed practices, a social worker models boundaries and relational strategies they want the client to experience and take back to their other relationships (Bloom, 2010). This strategy requires, of course, self-awareness, self-reflection, and a willingness to engage in an authentic human relationship with our clients.

The use of self in therapy is different from self-disclosure (which usually refers to the sharing of personal information about the clinician with the client). Our code of ethics and best practices caution that personal sharing can bring with it many risks: It can take the focus off the client and onto the worker and may change the boundaries of the professional encounter in subtle ways. Use of self, however, does not require disclosure of personal information. Rather, it is a process by which the therapist explicitly or implicitly shares with the client the experience of being in a relationship together, in a way that is designed to promote perspective taking and gently alter ingrained patterns (Arnd-Caddigan & Pozzuto, 2008).

Clients’ responses to workers often replicate their relational styles with others and reflect past relational trauma. Learn from your own reactions. What feelings does the client elicit in you? What does that tell you about what the client elicits in others? How can you respond differently than others to create a corrective experience? When you think about it this way, you can de-personalize it, and use your experience of being in a relationship with the client as a way to understand and help them. Clients will be able to practice new interpersonal skills within the helping relationship and then generalize them to others in their lives, enhancing their relationships and overall well-being.

CASE STUDY 11.1

Julie, a nurse who experienced early emotional neglect by her parents and was raped by a peer as a teen, developed beliefs that “others will reject, abandon, or hurt me; the world is a dangerous place; if people really knew me they would not love me.” In order to self-medicate her internal pain and loneliness, she abused alcohol. She engaged in sexual activity with many men in order to manage her inner conflict about being close to others. Ambivalence about emotional intimacy led her to interact with others in ways that pushed people away, creating exactly what she expected and believed she deserved. These entrenched beliefs and interpersonal styles repeated themselves in the relationship with the social worker when the client was referred for substance abuse treatment after an arrest for drinking and driving.

She was a person for whom others were not inclined to feel much sympathy; Julie seemed to bring on her own problems and not learn from her past mistakes. The new DUI was a relapse after 3 years in recovery. In treatment, she was overtly hostile, demanding, defensive, and rejecting, sitting in group therapy sessions with her arms folded and insisting she’d been forced into treatment she did not need. She refused to talk in the group. The worker could have said: “Groups therapy is what we do here, and being in a group will help you get peer support from others. If you don’t participate, I’ll have to report to your parole officer that you aren’t complying.” Instead, he validated feelings and tried to partner with the client in seeking a solution: “I can see you are angry, and that being in a group is so uncomfortable for you,” he said. “I want to know why that is. Can you try to help me understand?” The client raised her voice: “All you need to understand is that I just had a few drinks one night after being sober for years. I’m not going to drink again.” The worker empowered her to make a choice: “Would you be willing to have an individual session? After that, if you want to leave, you can.” She angrily agreed and sat down with a scowl.

By validating her feelings, paraphrasing content, and asking open-ended questions, the worker helped her articulate her belief learned in childhood that her “own business is private, and people shouldn’t talk with others about their problems.” She readily admitted her disdain for the other group members and scoffed: “[H]ow are other addicts going to tell me what to do? They can’t manage their lives either.” The worker conceded the logic in this and then said: “It seems like it is hard for you to believe that others have anything to offer you. And the truth is that you are very self-sufficient. But I wonder if that feels lonely sometimes?” This led to a discussion about the need to keep people at a distance because “you can’t count on anyone but yourself.” She then described how the relapse occurred while watching a football game at the home of a coworker. She recognized that her drinking had always been a way of managing her social anxiety to feel less awkward around others; these feelings had been triggered while at the football party. She acknowledged the double bind that she was better able to remain sober when she isolated herself from others, but that this meant not having a support network. The worker had created a corrective experience by listening nonjudgmentally, and instead of insisting on a one-size-fits-all treatment plan of group therapy, he continued to see her individually to allow trust to build.

CONCLUSION

Carl Rogers (1961) described unconditional positive regard, as well as therapist authenticity, as foundational elements of the therapeutic encounter. When a client’s basic need for safety and acceptance in the helping relationship is recognized, an atmosphere of trust can be established (Elliott et al., 2005). Trauma-informed practices model a healthy process of reliability, respect, collaboration, compassion, and genuineness. The relational elements of TIC help restore client value and self-worth through reinforcing and modeling healthy interactions.

Regardless of the problem, population, or intervention, when we listen with curiosity and kindness, we help our clients feel the power of human connections. In these important ways, social workers can avoid replicating dismissive or disempowering dynamics similar to those in troubled families. By allowing clients to participate in determining the course and process of treatment, we reinforce strengths and self-determination. By understanding each client in the context of their own life experiences and cultural background, therapists can engage clients in a collaborative process and dislodge barriers to healing. Using the helping relationship as a therapeutic tool, the collaborative partnership facilitates connection to others and thus exposure to a corrective emotional experience. This is the healing power of trauma-informed social work.

SUMMARY POINTS

•examine trauma and distinguish TIC from trauma-specific interventions,

•conceptualize client presenting problems through the lens of trauma,

•describe what it means to respond to clients and interact with them in a trauma-informed way, and

•explore ideas that translate trauma-informed principles into practice.