These days, mental health organizations and individual practitioners are quick to throw around the term “trauma informed care” when explaining their treatment paradigms. However, not all providers and agencies understand what “trauma informed care” really means. Certainly, many of them recognize the need to incorporate questions about a prior history of trauma, abuse, or neglect. It’s equally important to understand if a client grew up with domestic violence, a depressed, highly anxious, or substance abusing parent, or experiences of marginalization or discrimination. Clinicians should also include questions that assess for the witnessing of trauma- something that can be as impactful as experiencing it firsthand.
But even when these questions do get asked, it’s often before any there is any real therapeutic relationship or trust. In fact, many clinicians have prospective clients disclose this information online, without the safety of a therapeutic presence to check for triggering or dysregulation. I believe these questions should be asked face to face while continuously monitoring clients’ verbal and non-verbal reactions. A critical feature of “trauma informed care” is the clinician’s ability to pace the work, so clients never become emotionally flooded or overwhelmed. It means incorporating good boundaries and making sure that the material that surfaces in session is sufficiently contained to ensure good functioning in the outside world.
“Trauma informed care” mandates that every effort is made to keep clients emotionally, psychologically, and physically safe throughout the treatment process. Practitioners who operate from this paradigm also understand the importance of continually “connecting the dots” for trauma survivors. They help them understand the long-term emotional, physical, behavioral, and psychological impact of trauma, and the ways in which traumatic experiences are processed and stored in the brain. They also focus on the inevitable coping strategies that emerge for survival, and de-pathologize those “symptoms.”
“Trauma informed care” also dictates that expressive, right-brain based modalities must be incorporated into the work for true healing to occur. This means moving beyond 50 minutes of “talk therapy” with immobilized clients. Instead, clients are encouraged to have a greater awareness of body sensations and are supported in incorporating compassionate movement as trauma narratives are disclosed. It also means using art therapeutically including: drawing; collaging, and sand tray narratives so clients can access memories that are stored visually.
The more our profession moves towards a universal understanding and definition of “trauma-informed” assessments and ongoing therapy, the greater the likelihood that clients will receive the safe, non-judgmental, well-paced care they so richly deserve.
Clinicians' Tips
When clients are disclosing painful narratives, the following cues may indicate hyper-arousal or hypo-arousal. In either case, pause the work and help the client to get re-grounded.
Signs of hypo-arousal: flat affect, shifting into detached, numb, passive or submissive presentation, psychomotor retardation, avoidant or withdrawn, non-responsive, manifestations of dissociation or freeze,constricted or collapsed posture, inability to maintain eye contact
Signs of hyper-arousal: psychomotor agitation, increase in hyper-vigilance, rejection sensitivity or emotional overwhelm, exaggerated startle response, belligerence or defensiveness, manifestations of fight or flight