INTERVENTION: TRAUMA-INFORMED CARE AND
SPECIFIC INTERVENTION MODALITIES
Trauma Informed Care
With increasing recognition of the pervasiveness of child abuse and neglect,
and the impact of traumatic stress on children and families, awareness is growing of
the importance of ‘trauma-informed’ approaches to psychological interventions.
Trauma-informed care refers to the understanding, anticipating, and responding to
issues, expectations, and special needs that a person who has been victimised may
have in a particular setting (Lang et al., 2016). At a minimum, trauma-informed
practitioners must endeavour to do no harm—that is, to avoid re-traumatising or
blaming clients for their efforts to manage their traumatic reactions (Fallot & Harris,
2008). Trauma-informed care requires a commitment from practitioners and services
to understanding traumatic stress and to developing strategies for responding to the
complex needs of survivors. Harris and Fallot (2001) have summarised trauma-
informed care as being grounded in eight key principles. These are:
1. Understanding trauma and its impact
Understanding traumatic stress and how it impacts people and
recognising that many behaviours and responses that may seem
ineffective and unhealthy in the present, represent adaptive responses
to past traumatic experiences.
2. Promoting safety
Establishing a safe physical and emotional environment where basic
needs are met, safety measures are in place, and provider responses
are consistent, predictable, and respectful.
3. Ensuring cultural competence
Understanding how cultural context influences one’s perception of and
response to traumatic events and the recovery process; respecting
diversity, providing opportunities for clients to engage in cultural rituals,
and using interventions respectful of and specific to cultural
backgrounds.
4. Supporting control, choice, and autonomy
Helping clients regain a sense of control over their daily lives and build
competencies that will strengthen their sense of autonomy; keeping
consumers well-informed about all aspects of the system, outlining clear
expectations, providing opportunities for clients to make daily decisions
and participate in the creation of personal goals, and maintaining
awareness and respect for basic human rights and freedoms.
5. Sharing power and responsibility
Promoting democracy and equalisation of the power differentials across
the program; and sharing power and decision-making across all levels
of an organization, whether related to daily decisions or in the review
and creation of policies and procedures.
6. Integrating care
Maintaining a holistic view of consumers and their process of healing
and facilitating communication within and among service providers and
systems.
7. Healing happens in relationships
Believing that establishing safe, authentic, and positive relationships can
be corrective and restorative to survivors of trauma.
8. Recovery is possible
Understanding that recovery is possible for everyone regardless of how
vulnerable they may appear; instilling hope by providing opportunities for
consumer and former consumer involvement at all levels of the system,
facilitating peer support, focusing on strength and resiliency, and
establishing future-oriented goals. In this way, trauma-informed care is
grounded in an understanding of and responsiveness to the impact of
trauma. Such practices emphasise the physical, psychological, and
emotional safety for both providers and survivors, and that creates
opportunities for survivors to rebuild a sense of control and
empowerment. Given the prevalence of childhood adversity, and the
complex nature of assessing for these concerns, the principles of
trauma-informed care form a standard for how interventions and
practices are delivered to all clients – not simply those who are
diagnosed with PTSD, or have disclosed being exposed to traumatic
experiences.
Prevention and Intervention
Counsellors have an important role to play in designing and implementing
primary prevention programmes for child maltreatment. At present, there are relatively
few evidence-based interventions available for children exposed to child maltreatment,
and their families (Altafim & Linhares, 2016). Research on efficacious interventions
following concerns of child abuse and neglect involves a multi-systemic approach –
with a focus on interventions targeted at both the child and significant adults in the
child’s life. While it is beyond the scope of this chapter to provide a detailed of
interventions in detail, the remainder of this section will briefly review some promising
approaches and programs for children of various ages.
Children under five years
For young children, attachment-based interventions focused on improving the
relationships between children and their key attachment figures (often, caregiver) are
recommended. Programs such as the attachment and biobehavioural catch-up
(Dozier et al., 2017) help the caregiver to respond more sensitively to children.
Another example of such promising intervention is the circle of security parenting
program (Cooper et al., 2009). The program focuses on attachment. COSP takes an
innovative approach to help caregivers increase their capacities to serve as a source
of security for their children (i.e., to provide a secure base) (Bowlby, 1988), with the
idea that this increases caregiver sensitivity and reduces the risk of insecure and
disorganised attachment. This intervention was designed with implementation
efficiencies and value in mind, in collaboration with staff from the real-world contexts
in which it is to be implemented and the diverse at-risk families it is intended to serve
(e.g., early childhood programs) (Cooper et al., 2009). Similarly, the program child-
parent psychotherapy (CPP) (Lieberman et al., 2006) uses the attachment relationship
as the vehicle for improving the child’s emotional, cognitive, and social functioning.
The child and caregiver are seen in joint sessions that focus on promoting emotion
regulation in both the child and the caregiver (Lieberman et al., 2006).
Children aged 12 and under
Significant research has focused on interventions aimed at improving
parenting/caregiving skills amongst families using principles of behavioural theory and
operant conditioning (Skinner, 1972). For example, Pathways’ triple P (Petra & Kohl,
2010), a modified version of the evidence-based parenting program triple P (Sanders
et al., 2003), has shown promise in improving parenting/caregiving skills and attitudes,
increasing parenting/caregiving efficacy, and reducing child behaviour problems of at-
risk children and families (Sanders et al., 2004). Certain interventions have aimed to
help parents/caregivers with other psychological problems which are not exclusively
associated with the parenting/caregiving role, such as anger management, mood
regulation, and addressing drug abuse. For example, the parenting under pressure
(PUP) program (Harnett & Dawe, 2008) is an intensive, home-based intervention
underpinned by two key constructs: (i) that child wellbeing is dependent on the
parent/caregiver’s capacity to provide a sensitive, responsive and nurturing caregiving
environment; and (ii) that in order for this to occur, a parent/caregiver needs to be able
to understand and manage their own affect both in relation to parenting/caregiving and
to managing substance abuse problems (Barlow et al., 2013). The emergence of
neuroscientific impacts of child maltreatment on the brain has spurred the
development of programs such as the neurosequential model of therapeutics (NMT)
(Perry, 2006). NMT offers assessments to children exposed to maltreatment and other
forms of trauma, to support the sequencing of interventions (educational, enrichment,
and therapeutic) in a way that reflects the child’s specific developmental needs in a
variety of key domains, and is sensitive to core principles of neurodevelopment (Perry,
2008). With older children, the negative self-evaluative beliefs and beliefs about power
and violence in relationships that evolve in response to the experience of abuse may
be addressed in individual therapy (e.g., trauma focused cognitive behaviour therapy
(TF-CBT) (Cohen et al., 2012), or even group therapy (e.g., dialectical behaviour
therapy for adolescents (DBT-A) (Rathus & Miller, 2014).
Children and young people aged 17 and under
Interventions for older adolescents have focused on the wider system and aim
to reduce stress and increase social support. Programs such as the multisystem
therapy for child abuse and neglect (MST-CAN) (Swenson & Schaeffer, 2014) offer
interventions that are tailored to the ecology of the family as mapped out during the
assessment process. Some examples of interventions are working with the extended
family to increase the amount of support they offer the child’s primary caretaker;
arranging a befriender, a home help or a counsellor home-visiting service for an
isolated parent; arranging participation in a local parent support self-help group; or
organising a place for the child and caretaker in a local mother and toddler group
(Swenson & Schaeffer, 2014). In this way, the program acknowledges the factors
across various systems impacting a child and their family, and works to modify aspects
of these environments to mitigate the risks of child maltreatment in the future.
PROFESIONAL ISSUES: SECONDARY TRAUMATIC STRESS AND SELF-CARE
Learning about child maltreatment often invokes strong feelings among health
professionals. For example, some counsellors develop a strong urge to protect the
child at all costs – minimising or denying any loyalty the child may have towards their
caregivers, or any potential for change on the part of the caregivers. Another common
reaction can be a strong urge to protect or rescue the caregivers. In these cases, the
counsellor may defend criticisms raised about the caregivers by other professionals,
explain away or deny any caregiving shortcomings. These reactions may get in the
way of professionals cooperating with each other and working in the best interests of
the family. For example, many counsellors have had some personal loss or even
traumatic experience in their own life (e.g., loss of a family member, death of a close
friend). To some extent, the pain of experiences can be “re-activated.” Therefore, when
professionals work with an individual who has suffered similar trauma, the experience
often triggers painful reminders of their own trauma. Developing self-awareness of
such reactions and finding ways of being reflective of our work and thoughtful in our
interactions, are important for working in cases involving child maltreatment. The
following section will briefly describe common reactions to working with child
maltreatment and childhood trauma. Strategies to manage one’s own reactions will be
reviewed, and practical strategies for self-care to prevent burnout among counsellors.
SECONDARY TRAUMATIC STRESS AND COUNSELLORS
Secondary traumatic stress is a risk we incur when we engage empathically
with an adult or child who has been traumatised. Secondary traumatic stress is
commonly defined as a set of natural, consequent behaviours resulting from
knowledge about a traumatising event experienced by a significant other (Figley,
1995). It is the stress resulting from wanting to help a traumatised or suffering person.
It has only been recently that researchers and practitioners have acknowledged that
professionals who work with or help people with childhood maltreatment or trauma are
indirectly or secondarily at risk of developing the same symptoms as persons directly
affected by the traumatic events. Counsellors who listen to adults or children describe
the trauma are at risk of absorbing a portion of the trauma (Carr, 2015).
Practice Implications: Self-care for Individuals; Prevention and Management
Training, support, and professional supervision can all reduce the risk of
counsellors developing secondary traumatic stress disorder. Understanding what
secondary trauma is and what causes it reduces a person’s vulnerability and increases
resilience. Training in managing stress will increase a counsellor’s ability to respond
to stress in ways that are less damaging. Similarly, training aimed at personal
development also increases the counsellor’s sense of having an identity outside of
work. Improving skills in a sport, or some other pursuit such as music or dance,
increases the sense of joy in living which helps to protect us from the effects of stress
(Brady, 2012). An audit of one’s social support network, and methods to increase the
quality of the support one is receiving, is possibly the most useful exercise in self-care.
Informal support may come from people within the individual’s network who are
familiar with the concept of secondary traumatic stress disorder and who recognise
the signs. Regular de-briefing or feedback session that looks for any changes that
might indicate that the person is developing a secondary stress disorder is critical for
good self-care (Salloum et al., 2015). For counsellors in Australia, professional
development and involvement with counselling associations, such as Psychotherapy
and Counselling Federation of Australia (PACFA) or Australian Counselling
Association (ACA), offer counsellors opportunities to network with other counsellors,
seek peer support, and participate in group supervision.
Secondary Traumatic Stress and Organisations
It is important to note here that self-care is not solely the responsibility of the
counsellors themselves. In fact, without sufficient recognition or support from service,
teams, or organisations, many of the self-care strategies fall short of protecting
counsellors from burnout. Social services and counselling organisations working in the
child welfare sector often find themselves operating in the face of recurrent or constant
crises. When left unchecked, such chronic stress has been found to influence
organisational culture, leading to staff being unable to constructively confront
problems, engage in complex problem-solving, and be involved in all levels of staff
decision making processes (Bloom, 2008). In her seminal work on the impact of
traumatic stress on organisations, Sandra Bloom (Bloom & Farragher, 2013) describes
‘parallel processes’ within organisations, where communication networks tend to break
down under stress, much like they do within vulnerable families that are the clients of
the services. When communication networks break down in these services, so too do
the feedback loops that are necessary for consistent and timely error correction
(Bloom, 2008). As decision- making becomes increasingly non-participatory and
problem-solving more reactive, an increasing number of short-sighted policy decisions
are made that appear to compound existing problems. Fallot and Harris (2008)
describe a process by which organisations can start by looking at shared assumptions,
goals, and existing practices with staff from various levels of the organisation. Trauma-
informed processes have been found to improve staff morale, as the leadership is
seen as being open to new sources of information. Such organisational practices
emphasise the development of more democratic, participatory processes is critical as
these are the processes most likely to lend themselves to promoting self-awareness
amongst staff, and support in the development of solutions to the often complex
problems facing the organisation (Bloom, 2008).
