Trauma-Informed Therapy

Trauma, as defined by the Diagnostic and Statistical Manual of Mental Disorders, 5th ed., Text Revision (DSM-5-TR), involves exposure to actual or potential situations such as death, severe injury, or sexual violation. This exposure can occur through directly experiencing traumatic events, witnessing them firsthand, learning about trauma experienced by family or friends, or repeatedly being exposed to distressing details of traumatic events.

In SAMHSA's Concept of Trauma and Guidance for a Trauma-Informed Approach (2014), the United States Substance Abuse and Mental Health Services Administration (SAMHSA) uses a broader definition, "Individual trauma results from an event, series of events, or set of circumstances that is experienced by an individual as physically and emotionally harmful or life-threatening and that has lasting adverse effects on the individual's functioning and mental, physical, social, emotional, or spiritual well-being."

Recognizing the diverse manifestations of trauma and its impact on individuals' lives is crucial for clinicians. Trauma-informed therapy addresses the aftermath of trauma by prioritizing an understanding of the root causes of distress and creating a safe, supportive environment that fosters healing and resilience. Over 70% of individuals experience a traumatic event at least once in their lifetime, with approximately 10% developing posttraumatic stress disorder (PTSD) as a result. Worldwide, the lifetime occurrence of PTSD ranges from 1.3% to 12.2%, with 12-month prevalence varying from 0.2% to 3.8%.

Traumatic incidents can distort emotions, memory, consciousness, and self-perception. Trauma also affects interpersonal connections and attachment to others while influencing brain and body function. Experiencing trauma can significantly alter an individual's emotional and psychological development. However, not every negative experience qualifies as trauma, and an individual's perception of what is traumatic may not align with the DSM-5-TR or SAMHSA definitions of trauma.

Trauma-Informed Care (Systems Level)

The concept of trauma-informed care was first introduced in 2001 by Harris and Fallot, who recognized the high levels of trauma individuals are exposed to and proposed a paradigm shift. They advocated for considering past trauma experiences in addition to the immediate issue for which the individual is seeking treatment. In Using Trauma Theory to Design Service Systems (2001), Harris and Fallot identified five guiding principles to create trauma-informed systems of care: safety, trustworthiness, choice, collaboration, and empowerment.

Trauma-informed care established a new standard for organizing public mental health and human services, which operates on the assumption that every individual seeking services may be a trauma survivor. This approach empowers individuals to set their own goals and manage their progress. As consumers advocated for patient rights, humane treatment, and involvement in treatment planning, federal agencies such as SAMHSA became instrumental in developing trauma-informed guidelines, policies, and care while coordinating research. In creating these new standards, providers, organizations, and government agencies recognized that public institutions and service systems meant to offer support can sometimes be trauma-inducing. Seclusion and restraints, abrupt removal of an abused child in the welfare system, invasive medical procedures, harsh discipline in schools, and punitive measures in the criminal justice system can all be traumatizing or re-traumatizing and counterproductive. SAMHSA was tasked with developing a framework to help systems communicate with one another and adopt trauma-informed practices.

SAMHSA's trauma-informed approach, as outlined in the Concept of Trauma and Guidance for a Trauma-Informed Approach (2014), is based on 4 key assumptions known as the "4 R's ": "A program, organization, or system that is trauma-informed realizes the widespread impact of trauma and understands potential paths for recovery; recognizes the signs and symptoms of trauma in clients, families, staff, and others involved with the system; and responds by fully integrating knowledge about trauma into policies, procedures, and practices, and seeks to actively resist re-traumatization."

In addition, SAMHSA's Concept of Trauma and Guidance for a Trauma-Informed Approach (2014) identifies 6 fundamental principles for implementing a trauma-informed approach across organizations, staff, and the people they serve:

1. Safety

2. Trustworthiness and transparency

3. Peer support

4. Collaboration and mutuality

5. Empowerment, voice, and choice

6. Consideration of cultural, historical, and gender factors

SAMHSA identified 10 implementation domains for developing an organizational trauma-informed approach—governance and leadership; policy; physical environment; engagement and involvement; cross-sector collaboration; screening, assessment, and treatment services; training and workforce development; progress monitoring and quality assurance; financing; and evaluation.

Trauma-Informed Care (Clinician Level)

Trauma-informed therapy emphasizes shifting the focus from "What's wrong with you?" to "What happened to you?" This approach provides a framework for understanding and responding to the effects of trauma, prioritizing the creation of a safe, supportive, and empowering environment for individuals who have experienced trauma. This therapy involves recognizing the prevalence and impact of trauma, understanding its effects on individuals, and integrating this awareness into all aspects of therapeutic practice.

Trauma-informed therapy goes beyond merely treating trauma symptoms, offering a holistic approach that acknowledges and addresses the broader effects of trauma on individuals' lives. This approach encompasses various therapeutic methods, including cognitive, emotional, and behavioral techniques, to address traumatic experiences while recognizing trauma as a fundamental aspect of the therapeutic process.