TRAUMA-

INFORMED PRACTICE

What is Trauma is an experience that overwhelms an

individual’s emotional and psychological ability to cope EXAMPLES OF POTENTIALLY
TRAUMA? and can result in lasting mental and physical effects. TRAUMATIC EVENTS
• Physical, sexual and
emotional abuse
TRAUMA = • Childhood neglect
• Severely impaired caregiver
• Forced displacement
EVENTS + EXPERIENCE + EFFECTS • Cultural and
intergenerational trauma
• Injuries, accidents
• May occur once or be • Same event may be • Adverse effects may • Illnesses, painful medical procedures
repeated over time experienced as traumatic occur immediately or • Natural disasters
by one person and not over time • War, terrorism, political violence
Can include: another • Experience of psychosis
• The connections • Bullying / harassment
• Actual or • Subjective experience between traumatic • Intimate partner violence
threatened harm may be influenced by a events and the impact • Witnessing violence
host of factors including of trauma may not (including domestic)
• Severe withholding of culture, social context be clear • Homelessness
resources for healthy and developmental stage • Abandonment
development • Traumatic / multiple losses,
separation, bereavement
• Betrayal of trust by caregiver
• Experience of racism, homophobia

What can be
THE IMPACT Many areas of development and functioning can be affected by trauma.
People are affected by trauma differently; not everyone who experiences it has a lasting impact.
OF TRAUMA? The mind and body are very connected in trauma experiences; responses are both physiological and psychological.

COGNITIVE LEARNING
• intrusive thoughts/memories • inattention, memory impairments, disorganization, difficulty planning
• rigid and generalized beliefs based in danger • perfectionism
(“I’m not safe”, “the world is dangerous”, “my own thoughts about • school disengagement
the world frighten me”)
• denial, confusion
• self-blame PHYSICAL
• poor decision-making
• poor perspective taking • disrupted physiological (e.g., metabolism) and cognitive
(e.g., intellectual) maturation/processing
• increased startle response, hyperarousal
INTERPERSONAL • gastrointestinal problems, headaches, fatigue, impaired immune response
• sleep disturbance
• disrupted attachment, mistrust, fear
• chronic pain
• problems with interpersonal boundaries
• social withdrawal / isolation
ENVIRONMENTAL
• family separations, financial hardship
BEHAVIOURAL • social stigma
• avoidance of trauma reminders
• defiance or resistance to perceived control by others
• developmental regression (i.e., physical, intellectual) EMOTIONAL
• impulses and aggression (motivated by self-protection) • sadness, grief, lack of pleasure from activities
are difficult to manage • emotional dysregulation
• risk taking • anxiety, fear
• substance use • helplessness
• delinquency • guilt, shame
• self-harming behaviours • emotional numbing (affect is “turned off”)
• sexualized behaviour • difficulty reading others’ emotional state
• hypervigilance
 Trauma-informed practice is a broad approach to service delivery that applies
WHAT IS the principles and practices highlighted below to all clients, regardless of trauma
disclosure. Everyone in a clinical setting can practice in a trauma-informed way,
TRAUMA-INFORMED PRACTICE? even if trauma-specific treatment is not within their role.

PRINCIPLES PRINCIPLES
ACKNOWLEDGEMENT: The prevalence of trauma and the pervasiveness of its impact are acknowledged; trauma responses are an individual’s
attempts to cope with trauma and adapt to its impact.
SAFETY: The environment and interpersonal interactions support physical and psychological safety.
CHOICE, CONTROL & COLLABORATION: Transparent decision-making, clarity, choice and collaboration foster trust and allow clients to experience control.
STRENGTHS-FOCUSED: Recognize the client’s courage and build on strengths to foster resilience.
UNIVERSALLY APPLIED: Trauma-informed practice can be applied to all clients, regardless of whether a client discloses a trauma history, or
whether trauma-specific treatment is being provided.

PRACTICES

UNDERSTAND ACCEPT
• Understand the client in the context of their experiences and help the • Take a non-judgmental stance that supports the client in moving from
client do the same: “What has happened?” instead of “What is wrong?” self-judgment to self-acceptance and compassion for self.
• Place the client’s experience, coping and recovery within their cultural,
social and developmental context (e.g. gender, age, socioeconomic
status, education).
RECOGNIZE
• Be aware of possible triggers in the environment and in your
interactions with the client related to: power differentials; decision-
COLLABORATE making; changes or transitions; feelings of vulnerability; and positive
attention (e.g. oppositionality when therapist is seen to be exerting
• Take a collaborative approach to working with the client to learn about control; client shutting down when the therapist behaves in a nurturing
their history and the ways it may be affecting their present life. way or, conversely, when client perceives cues of abandonment).
• Collaborate in setting treatment goals and working toward them. • Be sensitive to the client’s discomfort in talking about difficult topics.
• Be transparent regarding therapeutic planning, process and decision-making. Ask for their input on how to make this more comfortable.
• Be vigilant for the client’s fight, flight and freeze responses.
DE-ESCALATE
• Recognize when the client may be in a triggered state and be aware SAFE COPING
that feelings of safety must be re-established before other work can be
done. • Help the client to recognize triggers in their current life and teach safe
coping strategies when faced with these triggers.
• Allow for pauses in discussions and shifts of focus; take a moment
to coach coping skills. (e.g. “let’s pause and take some deep breaths
together”). PREPARE
• Orient the client to the discussion of trauma by explaining that many
OFFER CHOICE clients who have mental health and/or substance use difficulties have also
• Ensure the client understands that they have the option to not answer experienced trauma, and that there can be many different kinds of impacts
or to not go into detail. The client may not yet have the skills to do it on their lives.
safely. • Explain that the goal of asking questions is to understand what these
•P
 rovide options for ways through which the client can provide information impacts could be for the client.
(e.g. interview or written questionnaires). • Explain the need to report specific disclosures (e.g. current child abuse,
imminent danger to self or others) as a way of protecting the client and
helping them through a difficult time; acknowledge the possibility that this
DON’T ASSUME
will be experienced as betrayal and further trauma.
• Remember that someone may have experienced trauma without having
disclosed.
VALIDATE
• Use validation to communicate that the client’s emotions and behaviours
SUPPORT
make sense given what they have gone through.
• Check in with the client to ensure any discussion of trauma feels safe
and not overwhelming.
PERSEVERE
• Move at the client’s pace; respect their desire to share details or not.
• Understand that behaviours that develop in response to trauma can be
• Respond to any disclosures with belief.
strongly entrenched, particularly when traumatic events were ongoing,
• Assess current safety; develop a safety and comfort plan that recognizes frequent and started at an early age.
and strengthens coping skills - and establishes a therapeutic agreement
• Treatment can be a long-term process; whether providing long-term
on how to manage extreme distress and to maximize health and well-
or brief support ensure the client experiences success by working on
being.
achievable goals.
CLINICIANS AND TRAUMA-INFORMED PRACTICE

TRANSFERENCE & COUNTERTRANSFERENCE

• Transference refers to feelings and experiences from the • Countertransference refers to reactions and responses
past that clients transfer or project onto the clinician in that a clinician can have towards a client.
the current therapeutic relationship.
• Countertransference reactions are based on the clinician’s
• Themes of power and control are common transference own history and personal issues; they include the
reactions. clinician’s response to a client’s transference reactions.

• A common therapeutic intervention is to support clients • Countertransference is normal and can be a useful
(who are able) to reflect on and understand feelings therapeutic tool when the clinician recognizes and
elicited with the therapeutic relationship. questions their own thoughts and feelings; it can provide
insight into the emotional content of the therapeutic
relationship and the client’s interpersonal dynamics
beyond the therapeutic setting.

HOW TO BE AWARE OF COUNTERTRANSFERENCE

• Am I aware of my countertransference? What personal
feelings are being elicited through my work generally
“The expectation that we can be
– and with this client specifically? How are they affecting immersed in suffering and loss
my clinical work?
• Am I feeling overwhelmed, angry, or hopeless in my daily and not be touched by it
work with this client? is as unrealistic as expecting
• Am I speeding up / slowing down the therapeutic
process to meet my own emotional needs? to be able to walk through
• What is hardest and worries me most about work with
clients who have lived through trauma?
water without getting wet.”
• How has my clinical work changed me over time? - Naomi Remen
• What am I doing to take care of myself?

TRAUMA EXPOSURE RESPONSE

(“Vicarious Trauma” / “Compassion Fatigue”)
TRAUMA EXPOSURE RESPONSE

Trauma exposure response is the impact on a clinician of working directly with clients who have experienced or been affected by trauma.

SIGNS OF TRAUMA EXPOSURE RESPONSE

As with a client’s response to trauma, the trauma exposure response is on a continuum; clinicians may experience one or
more of the following indicators to varying degrees:

• hyposensitive to emotional material: numbed and discouraged about work with clients
• hypersensitive to emotional material: over-identified and over-involved with clients
• increased sense of personal vulnerability
• feeling isolated and guilty over emotional experience of work with clients
• deliberate avoidance of clients
• absenteeism at work
 RISK AND PROTECTIVE FACTORS FOR TRAUMA EXPOSURE RESPONSE
Risk factors Protective factors

• having a history of trauma • social support in and out of work

• lack of experience • clinical support / supervision
• working exclusively with clients who have lived through trauma • trauma-specific training
• experiencing negative clinical outcomes
• not attending to personal emotional and physical health
indicators

BUILDING CLINICIAN RESILIENCE: The ABC Model of Clinician Self-Care

A: Awareness B: Balance C: Connection

When possible, Maintain a

work with a balanced caseload
clinical team
Set realistic
expectations

A
for yourself and
your clients
Seek out
clinical supervision
Awareness of your for support and
limits, resources, guidance
emotions, needs
Set clear
boundaries

B C
Validate and
Balance among Connection normalize
personal and to oneself, your reactions
professional others and
Ensure your work
time and personal time activities something larger
involve rest and other
interests

Develop and use

a support network
Reduce (sharing experiences
exposure with a colleague is a
to traumatic way to get support and
media Access therapy
for yourself perspective)

Resources: Trauma-Informed: The Trauma Toolkit, Second Edition, 2013 (Klinic Community Health Centre, Winnipeg) / Trauma Matters: Guidelines
for Trauma-Informed Practices in Women’s Substance Use Services, 2013 (Jean Tweed Centre For Women and Their Families, Toronto) / Trauma
& Resilience: An Adolescent Provider Toolkit, 2013 / Understanding and Transforming Compassion Fatigue and Vicarious Trauma, (2013) (Francoise
Mathieu) / The 12 Core Concepts: Concepts for Understanding Traumatic Stress Responses in Children and Families, 2012 (National Child
Traumatic Stress Network) / Helping Traumatized Children Learn, 2009, (Massachusetts Advocates for Children, Boston) / Child Development and
Trauma Guide, 2012, (Victoria State Government of Australia, Melbourne) / Trauma-Informed Care in the Prevention and Management of Aggressive
Behaviour (draft), 2014 (CAMH Education Services, Toronto); Compassion Fatigue Solutions, www.compassionfatigue.ca