Harry, an 86-year-old man admitted to a skilled nursing facility for rehabilitation after a hip fracture, could be abrasive and belligerent. A previous nursing facility discharged him due to his uncooperative behavior. After speaking with his son, the staff learned that Harry, a WWII veteran, spent two years in a Japanese Prisoner of War (POW) camp as a young man. Although he became a prominent dentist, raised a family, and volunteered in charitable organizations, his trauma as a POW triggered feelings of helplessness as a patient. Harry’s son guided the staff in providing a trauma-informed care approach focusing on giving choices, predictability, and explaining treatments to enhance a greater sense of control and reducing anxiety. Harry’s successful recovery enabled him to return home independently.
What is trauma-informed care?
A trauma-informed approach to care (TIC) shifts the focus from “what is wrong with you?” to “what happened to you?” Trauma-informed care attempts to:
- Realize the impact of trauma and understand recovery path. Bearing witness to a patient’s experience of trauma is a fundamental step in the therapeutic process of helping a patient heal. Bearing witness offers healthcare providers an opportunity to ensure that patients do not feel responsible for their neglect and abuse.
- Recognize the signs and symptoms of trauma in clients, families, and staff.
- Integrate knowledge on the effects of trauma into policies, procedures, and practices.
- Conscientiously prevent re-traumatization.
According to the Adverse Childhood Experience (ACE) study, exposure to abuse, neglect, violence, discrimination, and other adverse experiences increases a person’s lifelong potential to develop severe physical and mental health problems and engagement in risky behaviors. Due to stigma and shame, traumatic experiences become concealed and ignored. The secrecy of trauma often results in unintentional harm and the recreation of trauma in the form of restraints and forced medication.
As healthcare professionals’ awareness grows regarding the harmful consequences of trauma, they realize the importance of providing trauma-informed care. TIC recognizes the need to understand a client’s life experiences for delivering effective care for increased patient engagement, treatment adherence, health outcomes, and staff wellness.
The six core principles of trauma-informed care include:
- Safety: Creating environments and activities that ensure the client’s physical and emotional safety. Predictability and consistency are critical when providing care and building a therapeutic relationship with a patient.
- Trustworthiness and transparency: Building strong relationships relies on trust between management, staff, and patients. Communication with patients should include an acknowledgment that the environment is safe and care is available.
- Peer Support: This term refers to individuals with similar lived experiences of trauma. Peer support fosters safety and hope, build trust, enhances collaboration, and uses survivors’ stories to promote recovery.
- Collaboration and mutuality: This concept addresses discrepancies in perceived power levels between staff and staff and patients. All organization members are equal, and all members, including patients, are part of a team. Every member must commit to practicing universal trauma precautions, meaning that each individual with whom they come in contact has a potential trauma history.
- Empowerment, voice, and choice: Traditionally healthcare organizations have not allowed patients much choice or say in their treatment. For example, some patients are fearful about removing their clothes for an exam or procedure. Offering choices and a say in treatment provides a voice and a sense of control. The trauma-informed care approach is patient-centered with a focus on shared decision-making, care-planning, and treatment goals. Self-advocacy skills are encouraged, and the staff become facilitators rather than controllers of care.
- Recognition of cultural, historical, and gender issues: Cultural and gender stereotypes are disregarded. The organization is gender and culture responsive incorporating policies, procedures, and practices that recognize patients’ ethnic, cultural, biological gender, identity, gender, and racial needs. Lesbian, Bisexual, Gay, Transgender, Queer or Questioning and asexual (LBGTQA+) or allies are a marginalized group, especially adolescents. Many LBGTQA+ adolescents have experienced bullying and physical violence. Furthermore, many of these individuals do not have support systems vital to physical and mental health.
A further step embraces a strengths-based approach focusing on a patient’s resilience. This step requires a mind-shift from viewing the patient as a passive victim to an active agent in their recovery. One of the fundamental experiences of abuse is disempowerment. Benevolent paternalism often present in medical establishments reinforces a cycle of helplessness, and communication on behalf of healthcare providers emphasizing a patient’s strengths is essential for empowerment.
Occupational therapy and trauma-informed care
Although TIC typically occurs in hospitals and mental health settings, schools, community clinics, and residential settings are other environments that can practice trauma-informed care. The core principles are adaptable and applicable to various locations where trauma-exposed populations work, learn, and socialize.
The research suggests that exposure to childhood trauma impacts occupational performance areas such as social interaction, play, and academic achievement. Chronic exposure to trauma affects memory, problem-solving, impaired intellectual and executive functioning, decreased ability to focus, irritability, conduct problems, and substance abuse. Children exposed to trauma often experience difficulties interacting with their peers in meaningful ways and participating in regular school activities.
Research indicates that play skills are significantly affected in this population, with problems observed during recess and unstructured classroom activities. Additionally, children exposed to trauma experience limited social-emotional awareness in both self and others, including perspective-taking. Exposure to trauma can also cause increased aggression, anxiety, and challenges with regulation and impaired sensory processing with touch, sound, and movement. Children exposed to trauma often operate in a hyper aroused state. The stress response from the hypothalamic-pituitary-adrenal axis becomes overstimulated and prevents appropriate arousal regulation through the nervous system.
A collaborative model for trauma-informed intervention by school occupational therapists
Using a public health model to address the critical needs of traumatized children, utilize the Multi-Tiered System of Support (MTSS), which includes Universal (Tier 1), Small Group (Tier 2), and Targeted/Individual (Tier 3) associated with the core principles of TIC informing all facets of the school community and members. The tenets of TIC are compatible with best practices in the school environment. These universal precautions not only benefit children exposed to trauma but are promising for all students.
Three core concepts infusing intervention for traumatized children include:
- Therapeutic alliance: Occupational therapists acknowledge the importance of “therapeutic use of self” to gain student trust. Utilizing a strengths-based, client-centered approach creates a base for the student to be an active participant in their therapeutic plan. Student involvement in goal setting and identifying strengths sends a message to the child that they are heard and valued.
- Interoceptive awareness: Interoceptive awareness is the sensory system that experiences physiological bodily sensations associated with emotional reactions. In typical development, interoception supports the formation of this awareness. Traumatized individuals report an under-or-over responsiveness to interoceptive feelings leading to difficulty using body signals to apprise an authentic emotional experience. When a student may not be conscious of muscle tension, a full bladder, or a grumbling stomach, the missed cues lead to the student’s inability to promptly seek regulation strategies. A student may yell out in class or hit another student when the physiological needs do not get met. Incorporating interoception interventions are critical to develop self-regulation and coping skills. Noticing body signals and connecting the body to meaningful emotions empowers emotional awareness and appropriate responses commensurate with the situation.
- Intentional collaboration by all providers: Positive behavioral outcomes depend on consistency in interventions through partnership. The intentional partnership ensures student experiences predictable, consistent expectations and responses from all providers.
Occupational therapy strategies in Tier 1, 2 & 3
Tier 1 includes:
- Establishing a safe environment with access to food, nutrition, and movement.
- Communicating predictable schedules and routines.
- Identifying signs/symptoms of trauma.
- Facilitating trauma-informed policies on lockdowns, fire, and other safety drills.
- Improving interoceptive awareness for staff and students to promote self-regulation, co-regulation, and emotional well being.
Tier 2 includes:
- Co-lead small groups to develop social, sensory, and regulation in the classroom
- Recommend social activities to promote success during free play, recess, and lunchtime
- Classroom instruction to recognize and interpret interoception signals during daily routines.
- Incorporating interoception into daily routines to develop the ability to identify and interpret body sensations. Providing positive practice opportunities to develop concrete awareness of calmness, safety, and security.
- Classroom environmental modifications such as a safe space, change in lighting, temperature, and music.
Tier 3 includes:
- The OT will identify and address specific barriers to school participation through the IEP or 504 plan.
- The OT will implement an individualized sensory-based school life-style embedded in classroom routines.
- The OT will tailor environmental, task, and routine modifications for the individual student.
- The OT’s recommendations are to combine sensory and cognitive strategies to promote a positive self-image and improve participation in the school environment.
- The OT provides compensatory and remedial strategies for a “just right” challenge to ensure success.
The pervasiveness of traumatized individuals due to abuse, neglect, violence, discrimination, and natural disasters, necessitates a trauma-informed approach to improve health outcomes, treatment engagement, and adherence, in addition to staff well-being. TIC is an inclusive model involving all team members at various levels to recognize how adverse events impact individuals across the lifespan. By using a public health model, TIC is adaptable to diverse settings. Each member of the team has a unique contribution to the success of implementing this empowering approach for populations impacted by trauma.
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Menscher, C. & Maul, A. (2016). Key Ingredients for Successful Trauma-Informed Implementation. Robert Wood Johnson Foundation. https://www.samhsa.gov/sites/default/files/programs_campaigns/childrens_mental_health/atc-whitepaper
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