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Trauma-informed practice

Position statement Last updated: Nov 2020 Published in Australia Reference: PS #100

Trauma-informed practice is an evolving concept which emphasises that trauma is a possibility in the lives of all individuals and communities.

Purpose

The Royal Australian and New Zealand College of Psychiatrists (RANZCP) has developed this position statement to affirm the importance of trauma-informed practice (TIP) for psychiatrists. TIP for psychiatrists includes recognising diversity in trauma presentation, appreciating the unique experiences of particular communities, and practicing in a manner that supports recovery and limits risks of re-traumatisation. 

Key messages

  • Trauma-informed practice is an evolving concept which emphasises that trauma is a possibility in the lives of all individuals and communities.
  • Trauma may be defined as the broad psychological and neurobiological effects of an event, or series of events, that produces experiences of overwhelming fear, stress, helplessness or horror.
  • Many people who have experienced trauma, report adverse experiences and outcomes when engaging with psychiatric and/or mental healthcare services.
  • Psychiatrists have a responsibility to practice in a trauma-informed manner, in order that individuals receive care that maximises their potential for recovery and minimises the risk of re-traumatisation.
  • An individual’s experience of a potentially traumatogenic stressor may vary according to a range of factors including; genetics, developmental stage, previous life experiences, cultural beliefs and available social supports.
  • Future approaches to trauma-informed practice must be developed using the complementary expertise of individuals, family, carers and community, psychiatrists and other mental healthcare professionals. 

Defining trauma

TIP is an evolving concept that emphasises the importance of considering trauma in all aspects of mental healthcare.[1-6] Trauma can present in various forms and in varied contexts and may be defined as the broad psychological and neurobiological effects of an event, or series of events, which produces experiences of overwhelming fear, stress, helplessness or horror.[2, 6] The Diagnostic and Statistical Manual of Mental Disorders delimits such events to those which, ‘may cause death or threaten death, serious injury, or sexual violence’.[7] Other definitions emphasise the interpersonal and prolonged nature of trauma,[6, 8] the interplay of power dynamics and vulnerability,[5, 6] subjective experiences of stress levels,[5] and the suddenness and uncontrollability of the stressor/s.[3] 

Complex trauma may arise through a cumulative or repeated exposure to trauma  and is characterised by its profound impact, ‘not only [on the individual’s] range of functions[…] but the development and functioning of the self per se’.[3, 9] Childhood experiences of trauma are particularly devastating, often involving a betrayal of trust in a primary relationship.[9] Importantly, an individual’s experience of a potentially traumatogenic stressor may vary according to a range of factors including; genetics, developmental stage, previous life experiences, cultural beliefs and available social supports.[2, 4] Therefore, what will be experienced as trauma by one person may not be experienced as such by another.[5] 

Trauma invokes protective responses within the body that may result in complex changes to the functioning and structure of the brain and other organs.[10] Trauma may cause a range of co-morbid problems including mental and physical health conditions, suicidality and self-harming behaviours, harmful substance use and addictions, dissociation, self-esteem issues, and contact with the criminal justice system. The consequences of trauma exposure can have a cascading impact throughout families and communities, leading to ongoing relational trauma and intergenerational trauma. 

Trauma survivors are also more likely to encounter problems in their interpersonal and sexual functioning due to emotional distress and distorted thinking patterns emanating from past experiences. They may be at increased risk of re-victimisation through family violence, sexual assaults, homelessness and poverty.[11] This increased risk is experienced particularly by women  and people who have been subject to community violence such as Indigenous peoples, refugees and people who identify as LGBTIQ.[8, 12] 

Trauma survivors with mental illness may experience re-traumatisation due to their experience of coercive interventions or sexual and/or physical abuse in institutional settings, including psychiatric and justice environments.[6] However, assertions that the majority of mental illness, including schizophrenia, are caused by trauma oversimplify current knowledge of the complexity of causes of mental illness.[13] Notwithstanding the above, adverse childhood experiences, including trauma, are significant risk factors for mental illness,[14] including schizophrenia.[15]

Trauma across populations

The RANZCP acknowledges that some populations are more at risk of experiencing trauma than others and that psychiatrists should incorporate these considerations into their practice:
Indigenous peoples may have been exposed to a range of potentially traumatic stressors, as the result of historical trauma associated with colonisation; such as dispossession, displacement, disease, genocide, cultural assimilation and the disruption of kinship systems. Indigenous peoples may also be exposed to ongoing trauma, stemming from collective trauma, economic deprivation, social marginalisation, discrimination, incarceration and other forms of racism.[16, 17] TIP for Indigenous people requires, ‘the creation of safe places for sharing where the unspeakable can be given voice, where feelings can be felt, and where sense can be made out of what seemed previously senseless’.[18, 19] Recovery should occur within the context of relationships within communities and family/whānau, and should acknowledge the interconnected nature of spirit, body, society and the natural environment. The historical trauma of colonisation has been described as a ‘soul wound’ that can have generational impacts, so TIP must also address individual and collective healing.[17] 

Refugees and asylum seekers may also have a history of traumatic experiences including: resettlement challenges, experiences of torture and persecution, displacement and cultural bereavement.[20] Where family violence is present and disclosed it is important to follow the patient’s lead and correctly identify supportive family members; and to not re-traumatise by seeking collateral information from identified perpetrators. Many people who identify as lesbian, gay, bisexual, transgender, intersex or queer/questioning (LGBTIQ) may have traumatic experiences associated with prolonged marginalisation and discrimination, as well as childhood bullying, puberty, and difficulties associated with ‘coming out’.[21] Research also shows that LGBTIQ persons are at increased risk of interpersonal violence, hate crimes, homelessness and abuse in childhood.[22] It is important to acknowledge that at-risk population groups are not discrete categories; some people are at-risk of multiple and compounding traumas – for example, refugees who have been persecuted for their LGBTIQ status.

All individuals in the workplace may be at increased risk of experiencing trauma through their engagement with the traumas of others. Some groups may also be exposed to traumatic events directly through their occupation, including emergency services personnel and first responders. This type of experience has been theorised to contribute to vicarious traumatisation  and secondary traumatic stress.[23, 24] Mental health workers may also have sustained exposure to secondary, or vicarious traumatic experiences through hearing, seeing and responding to individuals and carers through their work.[25] It is important to acknowledge that mental health workers, in particular Indigenous health workers, may come from a background of trauma exposure and may require additional support to manage trauma outcomes.[26]

TIP and psychiatrists

In recognition of the above, the role of psychiatrists includes the provision of holistic assessment and care, taking account of a person’s ‘body, mind and soul’, which encompasses their physical, psychological, sociocultural and religious/spiritual needs and values. It is also important for traditional customs, including healing practices, to be respected and incorporated into treatment models as appropriate. The relevance and importance of religion and/or spirituality is explored further in RANZCP Position Statement 96.[27] 
A number of key studies and pilot programs have shown that TIP models can help to decrease psychiatric symptoms and substance abuse, and improve daily functioning.[28] Integration of TIP does not necessarily require all clinicians to elicit disclosures of trauma; rather, it requires recognition of the lived experiences of individuals and awareness of triggers which can lead to re-traumatisation.[29] In some settings, TIP may include screening for trauma-related symptoms and disorders, as well as specific trauma characteristics.[30] Where indicated, screening should be followed up with proper assessment and trauma-specific care.[5] 
Psychiatrists should give consideration to how they can utilise TIP principles [7, 9, 31] in their own practice.[32, 33] Some identified principles include:

  • recognising trauma and its impacts, including effects on affect regulation and brain physiology
  • using respectful approaches to eliciting traumatic histories and responding appropriately to suicidality and disclosures of trauma
  • demonstrating awareness of the transgenerational transmission of traumas and being sensitive to gender, sexual orientation, ethnicity and age dimensions of trauma 
  • acknowledging the impacts of trauma as adaptive, and working from a strengths-based framework to facilitate empowerment and recovery
  • instilling hope, optimism and the understanding that recovery and post-traumatic growth is possible
  • facilitating holistic care characterised by integration and continuity of services.[29, 34] 

Psychiatrists should also consider the important role family and carers can play in TIP. This also includes the introduction of those with lived experience of mental health into the workforce (forming a peer workforce), who play an important role in providing sensitive and respectful care.[35] As part of this, family and peer workers should have access to relevant training, education and support, and health professionals need to be aware that family and care workers may also have their own experience of trauma. In the context of family violence, the impact of trauma on all family members should always be considered. 

The RANZCP acknowledges that community and mental health organisations across Australia and New Zealand have at times had a poor track record of implementing trauma-informed approaches and to supporting people with trauma.  In relation to health systems, psychiatrists can play an important role in raising awareness of the relationship between trauma and mental health conditions, including complex psychosocial problems.[29] Psychiatrists should also advocate for improvements to education around TIP practice for all members of the multidisciplinary team, including information on the prevalence of trauma, and the primacy of secure, trustworthy and collaborative relationships as the basis for establishing psychological safety.[6, 29]

Recommendations

The RANZCP recommends that:

  • Individual psychiatrists enhance their own knowledge and skills in TIP; in order that individuals receive care that maximises recovery potential, and minimises the risk of retraumatisation for individuals, family, carers and staff.
  • The development of approaches to TIP occurs using the complementary expertise of persons who have experienced trauma, carers, psychiatrists and other mental health professionals. 
  • Health services endorse TIP approaches in practice, incorporating the broad range of relevant TIP principles rather than one specific set of principles. 
  • Principles relevant to TIP are adopted into practice by all members of the multi-disciplinary team, with particularly consideration given to the impact of trauma in working with Indigenous peoples.
  • The needs of people who have experienced trauma be routinely incorporated into mental health systems and processes, recruitment of staff, service funding and hospital design.

Additional resources

Responsible committee: Aboriginal and Torres Strait Islander Mental Health Committee, Community Collaboration Committee and Te Kaunihera 


References

1. Berliner L, Kolko DJ. Trauma informed care: A commentary and critique. Child maltreatment. 2016;21(2):168-72.
2. Wilson C, Pence DM, Conradi L. Trauma-informed care.  Encyclopedia of social work2013.
3. Kira IA. Taxonomy of trauma and trauma assessment. Traumatology. 2001;7(2):73-86.
4. Suarez EB. Trauma in global contexts: Integrating local practices and socio-cultural meanings into new explanatory frameworks of trauma. International Social Work. 2016;59(1):141-53.
5. Substance Abuse and Mental Health Services Administration. SAMHSA’s concept of trauma and guidance for a trauma-informed approach. Rockville, MD: U.S. Department of Health and Human Services; 2014.
6. Isobel S. Trauma informed care: a radical shift or basic good practice? Australasian Psychiatry. 2016;24(6):589-91.
7. Adyanthaya S. Six principles of trauma-informed care: Grafton Integrated Health Network; 2014 [Available from: https://www.grafton.org/six-principles-of-trauma-informed-care/.
8. Jennings A. Models for developing trauma-informed behavioral health systems and trauma-specific services. Alexandria, VA: National Association of State Mental Health Program Directors, National Technical Assistance Center for State Mental Health Planning. 2004.
9. Kezelman C, Stavropoulos P. Practice guidelines for treatment of complex trauma and trauma informed care and service delivery. Sydney: Adults Surviving Child Abuse. 2012.
10. McFarlane AC. The long‐term costs of traumatic stress: intertwined physical and psychological consequences. World Psychiatry. 2010;9(1):3-10.
11. Saakvitne KW, Gamble S, Pearlman LA, Lev BT. Risking connection: A training curriculum for working with survivors of childhood abuse. 2000.
12. Widom CS, Czaja SJ, Dutton MA. Childhood victimization and lifetime revictimization. Child abuse & neglect. 2008;32(8):785-96.
13. Ruby E, Rothman K, Corcoran C, Goetz RR, Malaspina D. Influence of early trauma on features of schizophrenia. Early intervention in psychiatry. 2017;11(4):322-33.
14. Fergusson DM, Horwood LJ, Lynskey MT. Childhood sexual abuse, adolescent sexual behaviors and sexual revictimization. Child abuse & neglect. 1997;21(8):789-803.
15. Van Os J, Kenis G, Rutten BP. The environment and schizophrenia. Nature. 2010;468(7321):203.
16. Krieg A. The experience of collective trauma in Australian Indigenous communities. Australasian Psychiatry. 2009;17(sup1):S28-S32.
17. Wirihana R, Smith C. Historical trauma, healing and well-being in Māori communities. MAI Journal. 2014;3(3):2.
18. Atkinson J. Trauma trails, recreating song lines: The transgenerational effects of trauma in Indigenous Australia: Spinifex Press; 2002.
19. Atkinson J. Trauma-informed services and trauma-specific care for Indigenous Australian children. Canberra, Australia: AIHW; 2013.
20. Bhugra D, Gupta S, Bhui K, Craig T, Dogra N, Ingleby JD, et al. WPA guidance on mental health and mental health care in migrants. World Psychiatry. 2011;10(1):2-10.
21. The Royal Australian and New Zealand College of Psychiatrists. Position Statement 83: Recognising and addressing the mental health needs of the LGBTIQ+ population. Melbourne, Australia: The Royal Australian and New Zealand College of Psychiatrists; 2019.
22. Brown LS, Pantalone D. Lesbian, gay, bisexual, and transgender issues in trauma psychology: A topic comes out of the closet. Traumatology. 2011;17(2):1-3.
23. Devilly GJ, Wright R, Varker T. Vicarious trauma, secondary traumatic stress or simply burnout? Effect of trauma therapy on mental health professionals. Australian & New Zealand Journal of Psychiatry. 2009;43(4):373-85.
24. Pearlman LA, Saakvitne KW. Trauma and the therapist: Countertransference and vicarious traumatization in psychotherapy with incest survivors: WW Norton & Co; 1995.
25. Baird K, Kracen AC. Vicarious traumatization and secondary traumatic stress: A research synthesis. Counselling Psychology Quarterly. 2006;19(2):181-8.
26. Domhardt M, Münzer A, Fegert JM, Goldbeck L. Resilience in survivors of child sexual abuse: A systematic review of the literature. Trauma, Violence, & Abuse. 2015;16(4):476-93.
27. The Royal Australian and New Zealand College of Psychiatrists. Position Statement 96: The relevance of religion and spirituality to psychiatric practice. Melbourne, Australia: RANZCP; 2018.
28. Morrissey JP, Ellis AR, Gatz M, Amaro H, Reed BG, Savage A, et al. Outcomes for women with co-occurring disorders and trauma: Program and person-level effects. Journal of substance abuse treatment. 2005;28(2):121-33.
29. Bateman J, Henderson C, Kezelman C. Trauma-informed care and practice: Towards a cultural shift in policy reform across mental health and human services in Australia. A national strategic direction. Mental Health Coordinating Council. 2013.
30. Substance Abuse and Mental Health Services Administration. Treatment Improvement Protocol [TIP] Series 57, HHS Publication No. [SMA] 13-4801. Rockville, MD: SAMHSA; 2014.
31. Kezelman C. Trauma informed practice. Perspectives [Internet]. 2014 5 September 2019. Available from: https://mhaustralia.org/general/trauma-informed-practice.
32. Committee SaQPS. National Practice Standards for the Mental Health Workforce 2013. Melbourne, Australia: Victorian Government; 2013.
33. Te Pou o te Whakaaro Nui. Competencies for the mental health and addiction service user, consumer and peer workforce. Auckland, New Zealand: Te Pou o te Whakaaro Nui; 2014.
34. Hodas GR. Responding to childhood trauma: The promise and practice of trauma informed care. Pennsylvania Office of Mental Health and Substance Abuse Services. 2006;177.
35. Repper J, Carter T. A review of the literature on peer support in mental health services. Journal of mental health. 2011;20(4):392-411. 

Responsible committee: Faculty of Psychiatry of Old Age 

Disclaimer: This information is intended to provide general guidance to practitioners, and should not be relied on as a substitute for proper assessment with respect to the merits of each case and the needs of the patient. The RANZCP endeavours to ensure that information is accurate and current at the time of preparation, but takes no responsibility for matters arising from changed circumstances, information or material that may have become subsequently available.