Trauma-Informed Care: Understanding the Many Challenges of Toxic Stress

what is trauma-informed care

The journey toward mental wellness and self-care can be especially challenging for trauma survivors. “Trauma literally means ‘wound, injury, or shock,'” according to the International Society for the Study of Trauma and Dissociation (ISSTD). “It refers to extreme stress that overwhelms a person’s ability to cope,” writes Esther Giller of the Sidran Institute. The impact of trauma makes it difficult for survivors to understand their own experiences, and can interfere with their ability to get the help they need.

A trauma-informed therapist develops skills to become mindful of the impact of trauma to aid in working with clients. This awareness is the basis for a therapeutic relationship that is responsive to the needs of trauma survivors. Understanding the trauma-informed approach is important because it can help all of us recognize the challenges trauma survivors face when seeking healing and support.

What Makes an Experience Traumatic?

Individuals have different coping skills and levels of resilience. Not every crisis will be traumatic. But when a person is not yet able to come to terms with threatening events, that person is “left with a host of intense responses and symptoms that ‘tell the story’ without words and without the knowledge that we are remembering events and feelings from long ago,” says Janina Fisher, PhD, therapist, author and educator.

Unresolved trauma negatively impacts physical, emotional and psychological health. “The survival response system may become chronically activated, resulting in long-term feelings of alarm and danger, tendencies to flee or fight under stress, debilitating feelings of vulnerability and exhaustion, or an inability to assert and protect ourselves,” explains Fisher.

A study of Adverse Childhood Experiences (ACE’s) among 17,500 adults found that childhood trauma “dramatically increased the risk for seven out of 10 of the leading causes of death in the United States,” says Dr. Nadine Burke Harris, TED speaker and founder of the Center for Youth Wellness.

The researchers discovered that the incidence of traumatic experience is more common than anyone expected. Dr. Harris explains: “What they found was striking. Two things: Number one, ACEs are incredibly common. Sixty-seven percent of the population had at least one ACE, and 12.6 percent, one in eight, had four or more ACEs. The second thing that they found was that there was a dose-response relationship between ACEs and health outcomes: the higher your ACE score, the worse your health outcomes.”

A Wide Range of Adverse Events Can Cause Trauma

Some causes of trauma are easy to recognize. We can well understand that going to combat or war, or witnessing someone being killed is traumatic. Childhood sexual abuse or physical abuse can also cause trauma. Domestic violence is traumatic for the person experiencing it and for those who witness it happen. Rape causes both physical and psychological trauma.

However, a trauma-informed therapist must recognize that potentially traumatic events may be subtle and hidden as well.

Trauma can occur from neglect of a child’s emotional experience. It could be that a parent is just not emotionally present for their child, even if the child’s financial and physical needs are met. A relationship does not have to be abusive to inflict trauma. Having a non-protective parent can also be traumatizing. For example, ignoring when a child is bullied at school can leave a child feeling abandoned and helpless. The experience of getting lost in the mall as a child may not seem traumatizing to adults, but it is the child’s view that matters.

Attachment-based trauma arises from a lack of nurture that children need to develop understanding and resilience. Long periods of separation when a parent travels can be traumatic for a child, depending on how the family addresses it. Trauma can occur when the child’s feelings about the absence are not discussed, or there is no communication about where the parent is. A major illness in the family can be traumatizing, depending on the way it is handled.

A parent’s substance abuse causes both visible and hidden injury during a child’s development. A parent may misuse drugs or alcohol and become unable to care for children responsibly, including driving the car while intoxicated. This is neglect. A parent’s outbursts of anger or rage can create hidden trauma through the interpersonal relationship with the child.

Watching devastating events on the news can be traumatizing for people at any age. For some, repeatedly viewing broadcasts showing terrorist attacks and shootings can trigger overwhelming stress and a sense of despair. Trauma-informed therapists are aware of these sensitivities, and can help clients take better care of themselves by thoughtfully choosing or limiting what they watch.

What Does a Trauma-Informed Therapist Do?

A trauma-informed approach seeks an awareness of the widespread impact of trauma, recognizing its role in the outlook, emotions and behavior of a person with a trauma history. Therapists need to use their education and awareness of the trauma-informed approach in their work with all clients, because so few people know about the after-effects of unhealthy stress. Clients may not have considered their life experience to include trauma. A trauma-informed therapist is responsible for noticing and understanding how to help someone heal from adverse experiences, even when that person does not identify as a trauma survivor.

The first priority, and biggest effort when starting trauma-informed care, is the foundation of safety. “If people don’t feel safe here, nothing else is going to happen.” notes Pamela Woll, MA, CADP, in her presentation, A Strength-based Approach Toward Trauma-informed Treatment and Recovery Support for Women.”

Therapy starts slowly. The therapist does not start by asking about the details of the trauma. The effect of this can be re-traumatizing.

Grounding and Resourcing

The trauma-informed approach is about building a relationship first, and then developing grounding and resourcing skills. Grounding means you are able to stay mindful of the present place and time, and speak for your emotions without uncontrollably flashing back or reliving the trauma.

Building a list of resources means becoming aware of the support and strengths available to you, inside and out. This is the strengths-based approach, which is part of trauma-informed therapy. You develop a list of your own skills and abilities (such as examples of your courage and persistence, and methods for self-soothing) and people you can rely on. You identify outside sources such as twelve-step groups, understanding friends, family members, co-workers, and organizations you trust to support your healing and mental health.

Your resources can include new, healthier ways to calm and soothe strong emotions (see links below under More Resources). You may discuss and discover:

  • Working with mandalas – detailed patterns to color, which has a deeply calming effect
  • Reaching out to people you trust
  • CARESS, a set of techniques to help manage emotions when moving beyond self-destructive behavior (Communicate Alternatively, Release Endorphins, Self-Soothe)
  • Relying on new-found responses that draw on your strengths, such as a love of nature, music, meditation, reading, or journaling

If you are using substances such as drugs, alcohol, pornography, or food, or using behaviors like gambling or self-harm to cope with or numb out your feelings, this needs to be addressed to establish sobriety and safety. We can’t process trauma (safely reflect upon what has happened), until there is a foundation of safety and clean and sober stability.

We know that sobriety is most successful when you have learned some new coping skills to manage the emotions you feel.   No one enjoys feeling pain and heartache, but using substances (or any numbing activity) as a means of coping prevents you from developing the mindfulness, grounding and resources that allow healing to take place.

The work of processing trauma requires you to have the ability to regulate your affect (thoughts and feelings) using healthy coping skills. A helpful resource is Letting Go of Self Destructive Behaviors, a Workbook of Hope and Healing by Lisa Ferentz (which includes details about the CARESS technique).

If need be, the therapist may enlist a psychiatrist to help begin and manage medication. This can help stabilize the brain chemistry to provide a foundation for the therapy. This foundation includes building safety and a ‘window of tolerance,’ meaning that the feelings experienced during therapy and in life remain within the person’s ability to regulate and manage them.

Processing the Trauma

The process of building a safe place, trust, grounding exercises, your resource network, and empowerment can take some time and work in therapy. You set the pace that feels safe to you. Once you have developed that foundation of safety and stabilization, the work of going deeper and processing the more traumatic experiences can begin. You and the therapist will look at the details of what happened gradually and slowly. The therapist can use many trauma-informed tools and skills to help guide you. You may toggle back and forth between talking about the past and what you notice and, returning to the present and noticing your safety.

The therapist may push a little bit, guiding the conversation to address the trauma, and then pull back and reground; then push a little bit further, and then pull back again so you can see how to navigate painful memories and emotions within your window of tolerance, without being overcome by them.

One of the goals of trauma-informed care is to support a level of containment (a skill taught by trauma-informed therapists to their clients). Even after looking closely at events that have been toxic or traumatic, you are able to leave the therapy session feeling a sense of stability and you are able to function in daily life.

As you progress, you may learn more about the nature of your own trauma and understand that

  • You do not need to feel ashamed or ‘crazy’ for what you are going through
  • You can take the time you need to review and recover (the trauma will not be resolved by the fourth session, for example, and your pace is okay – trauma therapy takes time)
  • You have support and can use reliable resources
  • You can understand and learn to set healthier boundaries and use self-care
  • You feel hope

A Trauma-Informed Approach Inspires Hope

The process of repair or recovery begins only when you have the resources — skills, strengths and support systems in place — that you can rely on going forward.

As a therapist, the trauma survivors I see in my practice are often amazing people. They have been through so much hardship, and they have developed tremendous personal strengths. In spite of everything they have been through, they often possess keen intuition, sensitivity, empathy and ability to support others. They are incredible survivors!

I am inspired to see so many take up the hard work of therapy despite tremendous obstacles – collaborating and connecting, creating a place for themselves of emotional safety, and beginning to learn to trust when it’s safe.

For Dr. Nadine Burke Harris, understanding the impact of trauma on health is “actually where the hope lies, because when we have the right framework, when we recognize this to be a public health crisis, then we can begin to use the right tool kit to come up with solutions.”

A trauma-informed approach helps all of us become more aware of the extent of trauma’s impact upon individuals we may know – including ourselves. It encourages us to develop the awareness to better support the healing process whether we are therapists, trauma survivors, or fellow human beings.

More Resources

Resources for Survivors of Abuse

  • Survivors of Incest Anonymous

Resources for Traumatic Stress, PTSD and Dissociation

  • The Sidran Foundation
  • The Trauma Center

Other Reading

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