By A.K Seneviratne
Former Senior Tutor
(Public Health)
NIHS – Kalutara

Trauma Informed Care (TIC) is a global health care and social services framework to recognizing the vast prevalence of psychological trauma and shifts the core operational question “What is wrong with you.” to asking “What happened to you”

Trauma

Substance Abuse and Mental Health Services Administration (SAMHSA) defines Trauma as “An event, series of events or set of circumstances experienced by an individual as physically or emotionally harmful or life threatening with lasting adverse effects on the individual’s functioning and mental, physical, social, emotional or spiritual well-being”

Trauma in Greek relates to a wound which is difficult to heal. It can be simple, complex, collective, racial, financial or even national as Sri Lanka experienced the Covid-19, Ditwah or the recently flood-hit Nepal. It can even origin from our cultural backgrounds, beliefs and how we interfere with the field.

The intense nature of trauma is reflected in the upper case T referring to trauma consequent to eg. rape, war, violence, and incidents of such magnitude while the lower case t reflects trauma that goes unnoticed eg. prolong bullying, disturbing relationships, neglect, abandonment and trauma that affects one’s nervous system developing into Post Traumatic Stress Disorder.

Trauma begins as early as in childhood and carries over to adulthood and late life and some such trauma remain submerged or lie low due to;

– some do not like to talk about trauma

– some do not remember eg. experiences in childhood

– some remember bits and pieces of trauma and not in full, while some might recollect when they are safe

Global data from WHO indicates that over 70% of the global population has experienced at least one traumatic event in their lifetime, demonstrating that trauma is a universal public health issue rather than an isolated phenomenon. Global exposure rate is accounted to be approximately 70.4% of people worldwide have experienced trauma averaging 3.2 per person. Mostly, stressors of trauma accounted for are sudden death of a loved one (30.5%), witnessing violence (21.8%) and interpersonal violence (18.8%)

Regional variations – Western nations like US show higher rates of assault and gun related violence and others – developing or politically unstable regions experience higher baseline rates of collective trauma from war, displacement, poverty and natural disasters. It has also been found that adverse childhood experiences have a direct global link between childhood adversity and chronic adult physical and mental health illness. It has also revealed that in a nearly 90% of adults in a US national sample survey that adversity in childhood can lead to sub optimal physical and mental health outcomes throughout the life course.

Trauma Informed Care (TIC)

Trauma Informed Care (TIC) acknowledges that healthcare organisations and care teams need to have a complete picture of the patient’s life situations – past and present in order to provide effective health care services with a health orientation

Adopting a TIC approach practice can potentially improve patient engagement treatment adherence and health outcomes as well as provider and staff wellness. It can also reduce avoidable care and excess costs for both the healthcare and social service sectors.

The TIC approach can be enriched by adhering to the seven core principles viz;

1. Safety – stipulates that consumers of care and staff within an organisation feel safe both physically and psychologically.

2. Trust worthiness and transparency – which is a key driver to building trust which includes in engaging effective communication.

3. Peer support – support from those with lived experiences of trauma survivors. Peer support plays a significant role in safety, hope and trust.

4. Collaboration – which refers to power sharing and decision-making between the provider of care and consumer which results from a co-partnership and collaboration where corroboration, too, plays a contributory role in gathering much data.

5. Empowerment – whereby strengths of consumers and family members are assessed to better syphon them to develop life skills. Strengths can also be employed to empower individuals in treatment and to support and develop skills as staff may have lived and living experiences of trauma. This is anticipated through organised support.

6. Voice and choice – which is the recognition that the organisation believes that even individual’s experiences is unique and that they have a capacity to offer. This approach emphasizes choice for the individual, their families and support persons.

7. Culture, historical and gender issues – where organisations incorporate policies and protocols that are gender responsive and receptive to cultural needs of individuals.

While the TIC principles lay down its ideology, there are four assumptions of a TIC approach denoted by 4Rs:

1. Realize – Understand the widespread impact of trauma and recognize that trauma can affect people’s physical, emotional, social and behavioral health. Trauma is common and can influence how people think, feel, learn, and interact with others.

2. Recognize – Identify the signs and symptoms of trauma in individuals, families, staff, and others involved in the system. Signs may include anxiety, hyper vigilance, difficulty trusting others, emotional regulations, or avoidance.

3. Respond – Integrate knowledge about trauma into policies, procedures, practices, and interactions. This means creating environments and relationships that promote safety, trust collaboration, empowerment, and cultural responsiveness.

4. Resist Re-traumatization – Actively avoid practices that could unintentionally recreate traumatic experiences or trigger and distress. Examples include respecting personal boundaries, offering choices whenever possible, explaining procedures before performing them, and using person-centered communication.

The 4Rs thus form the foundation of TIC and support the broader principles of safety, trustworthiness, peer support, collaboration, empowerment and cultural, historical, and gender awareness

Contrary to the widely prevalent belief that the TIC approach is applied in mental health work, it can similarly be applied beyond mental health as trauma can affect a person’s behaviour, relationships, communication, learning, physical health and ability to engage with services.

This makes TIC particularly valuable across health education, child and youth services, disability, aged care, community services, family violence, homelessness, justice and emergence services.

A hypothetical example of a situation where a youth was experiencing risk of harm from emotional abuse:

A youth aged 18 years exposed to domestic violence; Father partially employed with a low income. Mother housewife with three children, father alcoholic and drug addicted exhibiting anger, irritability and violent reactions, frequently assaulting the client and mother. Client is deprived of basic facilities for education. He also experiences the father abusing the mother for want of meals after returning from work. He refuses to attend household work. The client’s education is disturbed, lives with fear of assault from the father resulting in neglect, hopelessness and isolation from family meaning complete breaks in psycho social relations and his own well being. He is thoroughly dis regulated.

How a youth worker employed the TIC approach?

This was a hypothetical illustration of an integrated, compassionate, client centered approach that began with trust and confidence building and that eventually lead to trauma assessment.This helped the care provider to improvise a comprehensive plan of action beneficial to both the client as well as the provider of care.

Based on this scenario, the following represents a critical analysis of the TIC approach made simple that one could adhere to in a TIC approach. (See Table)

Benefits of TIC

Following benefits reflect research findings and provider experience over the recent past;

Increased

-Emotional safety within patient-staff relationship-staff relationships by engaging in meaningful inquiry

-Patient satisfaction, self efficacy, perceived partnership, confidence in care

-Emotional functioning

-Patient comfort

-Practitioner understanding of the patient as a unique person

-Staff recognition of the prevalence of trauma exposure among their patients

-Practitioner sympathy

-Organizational readiness to provide TIC and changes in the organizational culture

-Therapeutic relations

Limitations

Despite TIC approach being considered beneficial, it is met with challenges and constraints for its successful implementation.

Consumer related

-Consumer perception of lack of autonomy

-Consumer perception of the impact on the consumer management

Structural and resource barriers

-Severe resource limitations eg; high patient – staff ratios, strict time constraints and inadequate funding

-Lack of efficient training or piece meal training modules

-Inflexible data and screening protocols – rigid trauma screening clinical rather than supportive

-High staff turnover – constant workforce disruption

Cultural and leadership barriers

Implementing TIC in an organizational set up requires a deep cultural shift that fundamentally changes how an organization operates.

-Weak leadership commitment – lack of dedicated oversight or clear policy direction leaves staff without structural reinforcement

-Conflicting external pressures – eg. Funding arrangements often demand high productivity which undermines patient centred care.

-Staff resistance to change

Re- traumatization (RT) Synonyms – Re victimization, Trauma Reactivation, Trauma Resurfacing and Trauma Re triggering

The process where a person who has previously experienced trauma encounters new stressors or environment that consciously or unconsciously activates the trauma. This term is associated in the TIC process where one of the main objectives of TIC stands to either restrict trauma to reoccur or eliminate by engaging in therapeutic steps that help mitigate stressors.

It causes the individual to re experience the intense emotions, bodily reactions and feelings of powerlessness as if the original event is happening all over again.

Understanding causes of re traumatization is key to formulate strategies to address them.

Emotional stages of trauma

1. Shock and denial 2. Pain and guilt 3. Anger and bargaining 4. Depression 5.Reconstruction 6.Acceptance and hope

Triggers particularly causing RT in clients

1. Negative interaction with care providers due to agressivity

2. Lack of interest

3. Lack of empathy

VICARIOUS TRAUMA ((VT) Synonyms – Secondary Traumatic Stress, Compassion Fatigue

The emotional and psychological stress that happens when you are repeatedly exposed to other people’s trauma. These stresses could alter one’s worldview and sense of safety.

Signs of VT indicated are – inclusive memories, avoidance, hyper vigilance, sleep disorders, mood swings and unexplained physical symptoms

This aspect is either disregarded or given less importance within a care organization, but quite significant and exerts a profound impact on staff wellbeing.

VT arises from empathetic engagement and exposure to emotional suffering eg. Clinicians, social workers, first responders, emergency personnel and care givers are especially susceptible due to consistent empathetic involvement with traumatized populations.

Identification involves

Recognizing subtle emotional, cognitive or behaviour shifts that accumulate gradually. Such persons report persistent emotional exhaustion, diminished empathy, intrusive imagery or memories and emotional numbness

Consequences of VT

Psychological impacts

Heightened anxiety, depression, irritability, emotional detachment, diminished empathy, feeling helplessness, self doubt

Physiological impacts

Chronic fatigue, sleep disturbances, altered immune function, somatic complaints (headache), reduced immune responsiveness, altered cardio vascular reactivity

Occupational impacts

Decreased job satisfaction, reduced productivity, diminished effectiveness with clients, withdrawal from professional responsibilities, absenteism, job turnover or career abandonment (in severe cases)

Strategies to counteract VT

Professional clinical supervision, strict psychological boundary setting

Conclusion

Trauma is a global public health issue that can affect individuals across physical, psychological, and emotional domains, as well as at national, cultural, and belief-system levels. Trauma-informed care (TIC) is gaining increasing recognition globally as an approach in which caregivers engage with clients in a compassionate, respectful, and collaborative manner, empowering them to participate actively in independent health-care decisions.

The TIC framework is guided by seven core principles that provide an evidence-based approach to the delivery of health care. In addition, the 4 Rs—Realize, Recognize, Respond, and Resist re-traumatization—represent key assumptions underpinning TIC and support health-care providers in delivering compassionate and responsive care. The approach offers numerous benefits, including the development of positive therapeutic relationships, improved trauma assessment, and the formulation of appropriate strategies and plans of care.

However, the implementation of TIC is not without challenges. A major limitation is the organisational and cultural context in which services operate. Other barriers include limited leadership commitment, resource constraints, inadequate staff training, and resistance to organizational change. Addressing these barriers is essential for the successful and sustainable implementation of TIC.

Preventing re-traumatization is a fundamental component and intended outcome of TIC. Health-care providers therefore require appropriate knowledge, skills, and resources to recognize trauma-related needs and respond to them in a timely and sensitive manner.

Vicarious trauma (VT) is another important consideration that may receive insufficient attention. Health-care providers who are repeatedly exposed to clients’ traumatic experiences can themselves experience significant physical and emotional consequences. These may include fatigue, anxiety, depression, emotional exhaustion, and other health-related concerns. Consequently, supporting the well-being of caregivers should be considered an integral component of trauma-informed practice.

Overall, TIC extends beyond the mental health and broader health-care sectors. Its principles can be applied across a range of social welfare, community, and human-service programs. A central objective of TIC is to minimise the risk of trauma being repeated or exacerbated by services and to address the stressors that may contribute to further harm. Therefore, adopting a trauma-informed approach has the potential to promote safer, more compassionate, collaborative, and empowering environments for both service users and care providers.