Trauma-informed care

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Trauma-informed care (TIC) or Trauma-and violence-informed care (TVIC), is a framework for relating to and helping people who have experienced negative consequences after exposure to dangerous experiences. [1] [2] There is no one single TIC framework, or model, and some go by slightly different names, including Trauma- and violence-Informed Care (TVIC). They incorporate a number of perspectives, principles and skills. TIC frameworks can be applied in many contexts including medicine, mental health, law, education, architecture, addiction, gender, culture, and interpersonal relationships. They can be applied by individuals and organizations.

Contents

TIC principles emphasize the need to understand the scope of what constitutes danger and how resulting trauma impacts human health, thoughts, feelings, behaviors, communications, and relationships. People who have been exposed to life-altering danger need safety, choice, and support in healing relationships. Client-centered and capacity-building approaches are emphasized. Most frameworks incorporate a biopsychosocial perspective, attending to the integrated effects on biology (body and brain), psychology (mind), and sociology (relationship). [3]

A basic view of trauma-informed care (TIC) involves developing a holistic appreciation of the potential effects of trauma with the goal of expanding the care-provider's empathy while creating a feeling of safety. Under this view, it is often stated that a trauma-informed approach asks not "What is wrong with you?" but rather "What happened to you?" A more expansive view includes developing an understanding of danger-response. [1] In this view, danger is understood to be broad, include relationship dangers, and can be subjectively experienced. Danger exposure is understood to impact someone's past and present adaptive responses and information processing patterns. [4]

History

Harris and Fallot first articulated the concept of trauma-informed care (TIC) in 2001. [5] [6] They described trauma-informed as a vital paradigm shift, from focusing on the apparently immediate presenting problem to first considering past experience of trauma and violence. They focused on three primary issues: instituting universal trauma screening and assessment, not causing re-traumatization through the delivery methods of professional services, and promoting an understanding of the biopsychosocial nature and effects of trauma.

Researchers and government agencies immediately began expanding on the concept. In the 2000's, the Substance Abuse and Mental Health Services Administration (SAMHSA) began to measure the effectiveness of TIC programs. The U.S. Congress created the National Child Traumatic Stress Network [7] which SAMHSA administers. SAMHSA commissioned a longitudinal study, the Women, Co-Occurring Disorders and Violence Study (WCDVS) to produce empirical knowledge on the development and effectiveness of a comprehensive approach to help women with mental health, substance abuse, and trauma histories. [8] [9]

Several significant events happened in 2005. SAMHSA formed the National Center for Trauma-Informed Care. [10] Elliott, Fallot and colleagues identified a consensus of 10 TIC concepts for working with individuals. [11] They more finely parsed Harris and Fallot's earlier ideas, and included relational collaboration, strengths and resilience, cultural competence, and consumer input. They offered application examples, such as providing parenting support to create healing for parents and their children. Huntington and colleagues reviewed the WCDVS data, and working with a steering committee, they reached a consensus on a framework of four core principles for organizations to implement. [8]

In 2011 SAMHSA issued a policy statement that all mental health service systems should identify and apply TIC principles. [9] The TIC concept expanded into specific disciplines such as education, child welfare agencies, homeless shelters, and domestic violence services. [9] SAMHSA issued a more comprehensive statement about the TIC concept in 2014, described below. [12]

The term trauma- and violence-informed care (TVIC) was first used by Browne and colleagues in 2014, in the context of developing strategies for primary health care organizations. [13] In 2016, the Canadian Department of Justice published "Trauma- (and violence-) informed approaches to supporting victims of violence: Policy and practice considerations". [14] Wathen and Varcoe expanded and further detailed the TVIC concept in 2023. [15]

In many ways TIC/TVIC concepts and models overlap or incorporate other models, and there is some debate about whether there is a difference. [9] The confusion may be due to whether TIC is seen as a model instead of a framework or approach which brings in knowledge and techniques from other models. A client/person-centered approach is fundamental to Rogerian and humanistic models, and foundational in ethical codes for lawyers [16] and medical [17] professionals. Attachment-informed healing professionals conceptualize their essential role as being a transitional attachment figure (TAF), where they focus on providing protection from danger, safety, and appropriate comfort in the professional relationship. [18] [4] [19] [20] TIC proponents argue the concept promotes a deeper awareness of the many forms of danger and trauma, and the scope and lifetime effects exposure to danger can cause. [11] [9] The prolific use of TIC may be evidence it is a practical and useful framework, concept, model, or set of strategies for helping-professionals.

What is trauma and violence?

Trauma can result from a wide range of experiences which expose humans to one or more physical, emotional, and/or relational dangers.

Van der Kolk describes trauma as an experience and response to exposure to one or more overwhelming dangers, which causes harm to neurobiological functioning, and leaves a person with impaired ability to identify and manage dangers. [1] This leaves them "constantly fighting unseen dangers". [1] : 67 

Crittenden describes how relational dangers in childhood caregiving environments can cause chronic trauma: [4] "Some parents are dangerous to their children. Stated more accurately, all parents harm their children more or less, just as all are more or less protective and comforting." [4] : 2  Parenting, or caregiver, styles which are dismissive, inconsistent, harsh, abusive or expose children to other physical or relational dangers can cause a trauma which impairs neurodevelopment. Children adapt to achieve maximum caregiver protection, but the adaptation may be maladaptive if used in other relationships. [4] : 11  The Dynamic-Maturational Model of Attachment and Adaptation (DMM) describes how children's repeated exposure to dangers can result in lifespan impairments to information processing. [31]

Because danger to humans is so widespread, trauma is extremely common, although the effects of negative and ongoing experience is less common. [32] [33] [34] [35] The effects are dimensional and can vary in scope and degree.

TIC frameworks

Trauma- and violence-informed care, or closely related concepts, are also described as trauma- (and violence-) informed care (T(V)IC), and trauma-informed care/practice (TIC/P). [36] Other terms include trauma-informed, trauma-informed approach, trauma-informed perspective, trauma-focused, trauma-based, trauma-sensitive, and trauma-informed practice (TIP). There are many TIC-related concepts, [12] principles, [37] approaches, [38] frameworks, [39] or models, [40] some general and some more context specific.

The U.S. government's Substance Abuse and Mental Health Services Administration (SAMHSA) is an agency which has given significant attention to trauma-informed care. SAMHSA sought to develop a broad definition of the concept. [12] It starts with "the three E's of trauma": Event(s), Experience of events, and Effect. SAMHSA offers four assumptions about a TIC approach with the four R's: Realizing the widespread impact of trauma, Recognizing the signs and symptoms, Responding with a trauma-informed approach, and Resisting re-traumatization. SAMHSA gives six key principles: safety; trustworthiness and transparency; peer support; collaboration and mutuality; empowerment, voice and choice, and; cultural, historical and gender issues. They also list 10 implementation domains: 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.

Researchers Wathen and colleagues describe four integrated principles evolved by key authors in this field. [36]

  1. Understand structural and interpersonal experiences of trauma and violence and their impacts on peoples' lives and behaviors.
  2. Create emotionally, culturally, and physically safe spaces for service users and providers.
  3. Foster opportunities for choice, collaboration, and connections.
  4. Provide strengths-based and capacity building ways to support service users.

By comparison, Landini, a child and adolescent psychiatrist, describes five primary principles from DMM theory for helping people better manage danger response. [41]

  1. Define problems in terms of response to danger.
  2. The professional acts as a transitional attachment figure.
  3. Explore the family's past and present responses to danger.
  4. Work progressively and recursively with the family.
  5. Practice reflective integration with the client as a form of teaching reflective integration.

Bowen and Murshid identified a framework of seven core TIC principles for social policy development. [39]

  1. Safety
  2. Trustworthiness
  3. Transparency
  4. Collaboration
  5. Empowerment
  6. Choice
  7. intersectionality

Researchers Mitchell and colleagues searched for a consensus of TIC principles among early intervention specialists. [42]

  1. A trauma-informed early intervention psychosis service will work to protect the service user from ongoing abuse.
  2. Staff within a trauma-informed early intervention psychosis service are trained to understand the link between trauma and psychosis and will be knowledgeable about trauma and its effects.
  3. A trauma-informed early intervention psychosis service will:
    1. Seek agreement and consent from the service user before beginning any intervention;
    2. Build a trusting relationship with the service user;
    3. Provide appropriate training on trauma-informed care for all staff;
    4. Support staff in delivering safe assessment and treatments for the effects of trauma;
    5. Adopt a person-centred approach;
    6. Maintain a safe environment for service users;
    7. Have a calm, compassionate and supportive ethos;
    8. Be trustworthy;
    9. Acknowledge the relevance of psychological therapies;
    10. Be sensitive when discussing trauma;
    11. Be empathetic and non-judgmental;
    12. Provide supervision to staff;
    13. Provide regular supervision to practitioners who are working directly with trauma.

General applications and techniques of TIC

SAMHSA's National Center for Trauma-Informed Care provides resources for developing a trauma-informed approach, including: (1) interventions; (2) national referral resources; and (3) information on how to shift from a paradigm that asks, "What's wrong with you?" to one that asks, "What has happened to you?" [43]

Understand

Gaining knowledge about and understanding the effects of trauma may be the most complicated component of TIC, because it generally requires going beyond surface level explanations and using multiple explanatory theories and models or complex biopsychosocial models.

Trauma related behaviors, thoughts, feelings, and current experiences can seem confusing, perplexing, dysfunctional, or dangerous. [1] These are usually adaptions to survive extreme contexts, methods to cope in the current moment, or efforts to communicate pain. [4] Whatever the cause and adaptation, the professional's response can cause more harm, or some measure of emotional co-regulation, lessening of distress, and healing.

Safety

The opposite of danger is safety, and most or all TIC models emphasize the provision of safety. Van der Kolk describes how the "Brain and body are [neurobiologically] programmed to run for home, where safety can be restored and stress hormones can come to rest." [44]

Safety can be enhanced by anticipating danger. Leary and colleagues describe how interpersonal rejection may be one of the most common precursors to aggression. [45] While boundary-holding is a key aspect of TIC, avoiding a sudden and dramatic devaluation in an interpersonal relationship can reduce the subjective experience of rejection and reduce the risk violent aggression.

Relationship

The nature and quality of the relationship between two people talking about trauma can have a significant impact on the outcome of the discussion.

Communication

Traumatic experiences, including childhood attachment trauma, can impact memory function and communication style.

Katz describes some experiences working with her legal clients and how she adjusts her relational and communication approach to meet their needs. [46] Some clients need information delivered in short pieces with extra time to process, and some need to not have unannounced phone calls and be informed by email prior to verbal discussions. TIC helped her shift from thinking about how to develop a "litigation strategy" for clients, to thinking about developing a "representation strategy", which is a major shift in thinking for many lawyers.

Nurses can use enhanced communication skills, such as mindful presence, enhanced listening skills including the use of mirroring and rephrasing statements, allowing short periods of silence as a strategy to facilitate safety, and minimizing the use of "no" statements to facilitate patients sense of safety. [47]

Resilience and strength building

Building psychological resilience and leveraging a person's existing strengths is a common element in most or all TIC models.

Integration of principles

Safety and relationship are intertwined. Roger's person-centered theory is founded on this basic principle. [48] Attachment theory describes how a child's survival and well-being are dependent on a protective relationship with at least one primary caregiver. [49] Badenoch's first principle of trauma-informed counseling is to use the practice of nonjudgmental and agendaless presence to create a foundation of safety and co-regulation. [50] "Once the [client] sees (or feels) that the [professional] understands, then together they can begin the dangerous journey from where the [client] is, across the chasm, to safety." [4] : 151 

Talking about trauma

Researchers and clinicians describe how to talk about trauma, particularly when people are reluctant to bring it up. [51] [52] Read and colleagues offer comprehensive details for mental health professionals navigating difficult discussions. [53]

There are numerous barriers for professionals which can inhibit raising discussions about trauma with clients/patients. They include lack of time, being too risk-averse, lack of training and understanding of trauma, fear of discussing emotions and difficult situations, fear of upsetting clients, male or older clients, lack of opportunity to reflect on professional experiences, over-reliance on non trauma-informed care models (such as traditional psychology, and biomedical and biogenetic models of mental distress). [53] [51]

Sweeney and colleagues suggest trauma discussions may include the following techniques and principles. [51]

  1. Ask every client about trauma experience, especially in initial assessment of general psychosocial history.
  2. To establish relational safety and trust, or rapport, approach people sensitively while attuning to their emotions, nonverbal expressions, what they are saying, and what they might be excluding from their narrative. Badenoch suggests a stance of "agendaless presence" helps professionals reduce judgmentalism. [50]
  3. Consider confidentiality needs. Some people may be hesitant to disclose some or all of their experience, and may wish to maintain control over to whom or in what context it is disclosed. [54] Attorney-client privilege, so long as not waived and there is no mandatory reporting requirement, offers the strongest protection for chosen non-disclosure. [55]
  4. It may be difficult for clients to process trauma topics in the middle of crisis situations, although creating a measure of safety and trust within the relationship may help facilitate the discussion.
  5. Clients may not be able or willing to admit traumatic experiences, but may display effects of traumatic experiences.
  6. Prefacing trauma questions with brief normalizing statements, such as "That is a common reaction" might facilitate deeper discussions about trauma.
  7. Asking for details about the experience may be traumatizing for the client. In situations where detail disclosure is necessary, such as law enforcement or litigation, certain approaches may be needed. [56]
  8. Specific questions rather than generalized questions may help if detail is needed, such as "Were you hit/pushed/spat on/held down?" as opposed to "Were you assaulted?" or "Was there domestic violence?"
  9. Prior disclosures can be asked about, and if so, what the person's experience of that was.
  10. Circumstances around intense emotions, such as shame and humiliation, may difficult to explore.
  11. Discussions may be paced according to the person's needs and abilities. [57]
  12. Giving choices may provide agency, including whether to talk about it or not, and what to do about it.
  13. Working collaboratively, in partnership with the person to explore appropriate solutions may be acceptable to the client.
  14. Professionals might reflect on their own understanding of current research about safety and danger.
  15. The offer of relatively comprehensive support for trauma and safety plan options may ease and promote discussions. Particularly if the discussion about trauma is extensive, a lack of follow up support options may lead to re-traumatization.
  16. Concluding questions about how the client is feeling may be useful.
  17. Follow-up appointments and questions about what the client plans to do next may be useful.

A literature review of women and clinicians views on trauma discussions during pregnancy found that both groups thought discussions were valuable and worthwhile, as long as there was both adequate time to have the conversation and support available for those who need it. Women wanted to know in advance that the issue would be raised and to speak with a clinician they knew and trusted. [58] [59]

Specific applications and techniques of TIC

TIC principles are applied in child welfare services, [60] child abuse, [61] social work, [62] psychology, [63] medicine, [64] [65] oral health services, [66] nursing, [67] correctional services. [68] They have been applied in interpersonal abuse situations including domestic violence, elder abuse. [69]

Wathen and Varcoe offer specific suggestions for specific disciplines, such as primary health care clinics, emergency rooms, and for contexts involving interpersonal, structural, or any form of violence. One simple suggestion, in order to enhance the perception of care, safety and agency in the first phone call, is to provide calm phrasing and tone, minimize hold times, and offer brief explanations for delays. [15]

Trauma- and violence-informed practices can be or are addressed in mindfulness programs, yoga, education, [70] obstetrics and gynaecology, cancer treatment, [71] psychological trauma in older adults, military sexual trauma, cybersex trafficking, sex trafficking and trafficking of children, child advocacy, decarceration efforts, and peer support. HDR, Inc. incorporates trauma-informed design principles in prison architecture.

Many therapy models utilize TIC principles, including psychodynamic theory, [72] trauma focused cognitive behavioral therapy, trauma-informed feminist therapy, Trauma systems therapy which utilizes EMDR, trauma focused CBT, and a number of other techniques, The Art of Yoga Project, the Wellness Recovery Action Plan, music therapy, [73] internet-based treatments for trauma survivors, and aging. [74]

Culturally-focused applications, often considering indigenous-specific traumas have been applied in minoritized communities, [75] and Maori culture. [76]

Domestic violence

Trauma- and violence-informed (TVIC) principles are widely used in domestic violence and intimate partner violence (IPV) situations. [77] [78] [79] [80] [81] For working with survivors, TVIC has been combined with yoga, [82] motivational interviewing, [83] primary physician care in sexual assault cases, [84] improving access to employment, [85] cases involving HIV and IPV, [86] and cases involving PTSD and IPV. [87]

In 2015 Wilson and colleagues reviewed literature describing trauma-informed practices (TIP) used in the DV context. [88] They found principles organized around six clusters. Promoting safety, giving choice and control, and building healthy relationships are particularly important TVIC concepts in this field.

Hospice care

In hospice situations, Feldman describes a multi-stage TIC process. [91] [92] [93] In stage one practitioners alleviate distress by taking actions on behalf of clients. This is unlike many social work approaches which first work to empower clients to solve their own problems. Many hospice patients have little time or energy to take actions on their own. In stage two, the patient is offered tools, psychoeducation and support to cope with distress and trauma impacts. Stage three involves full-threshold PTSD treatment. The last stage is less common based on limited prognosis.

Ethical guidelines

Ethical guidelines and principles imply and support TIC-specific frameworks.

Rudolph describes how to conceptualize and apply TIC in health care settings using egalitarian, relational, narrative and prinicplist ethical frameworks. [94] (The clinical case vignette in Rudolph's article is informative.)

Vadervort and colleagues describe how child welfare workers can experience trauma participating in legal proceedings and how understanding professional ethics can reduce their trauma experiences. [95]

Organizational applications and techniques of TIC

TIC principles have been applied in organizations, including behavioral health services, and policy analysis. [39]

The Connecticut Department of Children and Families (DCF) implemented wide-ranging TIC policies, which were analyzed over a five year period by Connell and colleagues in a research study. [96] TIC components included 1) workforce development, 2) trauma screening, 3) supports for secondary traumatic stress, 4) dissemination of trauma-focused evidence-based treatments (EBTs), and 5) development of trauma-informed policy and practice guides. The study found significant and enduring improvements in DCF's capacity to provide trauma-informed care. DCF employees became more aware of TIC services and policies, although there was less improvement in awareness of efforts to implement new practices. The Child Welfare Trauma Toolkit Training program was one program implemented.

Organizations and people promoting TIC

Organizations which have or support TIC programs include the Substance Abuse and Mental Health Services Administration (SAMHSA), National Center for Trauma-informed care, the National Child Traumatic Stress Network, the Surgeon General of California, National Center for Victims of Crime, The Exodus Road, Stetson School, and the American Institutes for Research.

Psychologist Diana Fosha promotes the use of therapeutic models and approaches which integrate relevant neurobiological processes, including implicit memory, and cognitive, emotional and sensorimotor processing. [97] Ricky Greenwald applies eye movement desensitization and reprocessing (EMDR) [40] and founded the Trauma Institute & Child Trauma Institute. [98] Lady Edwina Grosvenor promotes a trauma informed approach in women's prisons in the United Kingdom. [99] Joy Hofmeister promotes trauma-informed instruction for educators in Oklahoma. [100] Anna Baranowsky developed the Traumatology Institute and addresses secondary trauma [101] and effective PTSD techniques. [102]

Other notable people who have developed or promoted TIC programs include Tania Glyde, Carol Wick, Pat Frankish, Michael Huggins, Brad Lamm, Barbara Voss, Cathy Malchiodi, Activists, journalists and artists supporting TIC awareness include Liz Mullinar, Omar Bah, Ruthie Bolton, Caoimhe Butterly, and Gang Badoy.

Effectiveness

Some efforts have been made to measure the effectiveness of TIC implementations.

Wathen and colleagues conducted a scoping review in 2020 and concluded that of the 13 measures they examined which assess TIC effectiveness, none fully assessed the effectiveness of interventions to implement TVIC (and TIC). [36] The measures they examined mostly assessed for TVIC principles of understanding and safety, and fewer looked at collaboration, choice, strength-based and capacity-building. They found several challenges to assessing the effectiveness of TVIC implementations, or existence of vicarious trauma. There was an apparent lack of clarity on how TVIC theory related to the measure's development and validation approaches so it was not always clear precisely what was being investigated. Another is the broad range of topics within the TVIC framework. They found no assessment measured for implicit bias in professionals. They found conflation of "trauma focused", such as may be used in primary health care, policing and education, with "trauma informed" where trauma specific services are routinely provided.

Related Research Articles

Psychological trauma is an emotional response caused by severe distressing events that are outside the normal range of human experiences. It must be understood by the affected person as directly threatening the affected person or their loved ones with death, severe bodily injury, or sexual violence; indirect exposure, such as from watching television news, may be extremely distressing and can produce an involuntary and possibly overwhelming physiological stress response, but does not produce trauma per se. Examples include violence, rape, or a terrorist attack.

Developmental disability is a diverse group of chronic conditions, comprising mental or physical impairments that arise before adulthood. Developmental disabilities cause individuals living with them many difficulties in certain areas of life, especially in "language, mobility, learning, self-help, and independent living". Developmental disabilities can be detected early on and persist throughout an individual's lifespan. Developmental disability that affects all areas of a child's development is sometimes referred to as global developmental delay.

Complex post-traumatic stress disorder is a stress-related mental disorder generally occurring in response to complex traumas, i.e., commonly prolonged or repetitive exposures to a series of traumatic events, within which individuals perceive little or no chance to escape.

The recovery model, recovery approach or psychological recovery is an approach to mental disorder or substance dependence that emphasizes and supports a person's potential for recovery. Recovery is generally seen in this model as a personal journey rather than a set outcome, and one that may involve developing hope, a secure base and sense of self, supportive relationships, empowerment, social inclusion, coping skills, and meaning. Recovery sees symptoms as a continuum of the norm rather than an aberration and rejects sane-insane dichotomy.

Childhood trauma is often described as serious adverse childhood experiences (ACEs). Children may go through a range of experiences that classify as psychological trauma; these might include neglect, abandonment, sexual abuse, emotional abuse, and physical abuse, witnessing abuse of a sibling or parent, or having a mentally ill parent. These events have profound psychological, physiological, and sociological impacts and can have negative, lasting effects on health and well-being such as unsocial behaviors, attention deficit hyperactivity disorder (ADHD), and sleep disturbances. Similarly, children whose mothers have experienced traumatic or stressful events during pregnancy have an increased risk of mental health disorders and other neurodevelopmental disorders.

The National Center for Trauma-Informed Care is a United States based medical charity, funded by the Center for Mental Health Services (CMHS). Created in 2005, it assists publicly funded agencies, programs, and services in making a cultural shift to a more trauma-informed environment — an environment intended to be more supportive, comprehensively integrated, and empowering for trauma survivors.

Vicarious trauma (VT) is a term invented by Irene Lisa McCann and Laurie Anne Pearlman that is used to describe how work with traumatized clients affects trauma therapists. The phenomenon had been known as secondary traumatic stress, a term coined by Charles Figley. In vicarious trauma, the therapist experiences a profound worldview change and is permanently altered by empathetic bonding with a client. This change is thought to have three requirements: empathic engagement and exposure to graphic, traumatizing material; exposure to human cruelty; and the reenactment of trauma in therapy. This can produce changes in a therapist's spirituality, worldview, and self-identity.

Trauma bonds are emotional bonds that arise from a cyclical pattern of abuse. A trauma bond occurs in an abusive relationship wherein the victim forms an emotional bond with the perpetrator. The concept was developed by psychologists Donald Dutton and Susan Painter.

<span class="mw-page-title-main">Transgenerational trauma</span> Psychological trauma

Transgenerational trauma is the psychological and physiological effects that the trauma experienced by people has on subsequent generations in that group. The primary modes of transmission are the uterine environment during pregnancy causing epigenetic changes in the developing embryo, and the shared family environment of the infant causing psychological, behavioral and social changes in the individual. The term intergenerational transmission refers to instances whereby the traumatic effects are passed down from the directly traumatized generation [F0] to their offspring [F1], and transgenerational transmission is when the offspring [F1] then pass the effects down to descendants who have not been exposed to the initial traumatic event - at least the grandchildren [F2] of the original sufferer for males, and their great-grandchildren [F3] for females.

<span class="mw-page-title-main">Management of domestic violence</span>

The management of domestic violence deals with the treatment of victims of domestic violence and preventing repetitions of such violence. The response to domestic violence in Western countries is typically a combined effort between law enforcement, social services, and health care. The role of each has evolved as domestic violence has been brought more into public view.

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Trauma focused cognitive behavioral therapy (TF-CBT) is an evidence-based psychotherapy or counselling that aims at addressing the needs of children and adolescents with post traumatic stress disorder (PTSD) and other difficulties related to traumatic life events. This treatment was developed and proposed by Drs. Anthony Mannarino, Judith Cohen, and Esther Deblinger in 2006. The goal of TF-CBT is to provide psychoeducation to both the child and non-offending caregivers, then help them identify, cope, and re-regulate maladaptive emotions, thoughts, and behaviors. Research has shown TF-CBT to be effective in treating childhood PTSD and with children who have experienced or witnessed traumatic events, including but not limited to physical or sexual victimization, child maltreatment, domestic violence, community violence, accidents, natural disasters, and war. More recently, TF-CBT has been applied to and found effective in treating complex posttraumatic stress disorder.

Betrayal trauma is defined as a trauma perpetrated by someone with whom the victim is close to and reliant upon for support and survival. The concept originally introduced by Jennifer Freyd in 1994, betrayal trauma theory (BTT), addresses situations when people or institutions on which a person relies for protection, resources, and survival violate the trust or well-being of that person. BTT emphasizes the importance of betrayal as a core antecedent of dissociation implicitly aimed at preserving the relationship with the caregiver. BTT suggests that an individual, being dependent on another for support, will have a higher need to dissociate traumatic experiences from conscious awareness in order to preserve the relationship.

Adverse childhood experiences (ACEs) include childhood emotional, physical, or sexual abuse and household dysfunction during childhood. The categories are verbal abuse, physical abuse, contact sexual abuse, a battered mother, household substance abuse, household mental illness, incarcerated household members, and parental separation or divorce. The experiences chosen were based upon prior research that has shown to them to have significant negative health or social implications, and for which substantial efforts are being made in the public and private sector to reduce their frequency of occurrence. Scientific evidence is mounting that such adverse childhood experiences (ACEs) have a profound long-term effect on health. Research shows that exposure to abuse and to serious forms of family dysfunction in the childhood family environment are likely to activate the stress response, thus potentially disrupting the developing nervous, immune, and metabolic systems of children. ACEs are associated with lifelong physical and mental health problems that emerge in adolescence and persist into adulthood, including cardiovascular disease, chronic obstructive pulmonary disease, autoimmune diseases, substance abuse, and depression.

Ethical guidelines for treating trauma survivors can provide professionals direction to enhance their efforts. Trauma survivors have unique needs and vary in their resilience, post-traumatic growth, and negative and positive outcomes from their experiences. Numerous ethical guidelines can inform a trauma-informed care (TIC) approach.

Out-of-home placements are an alternative form of care when children must be removed from their homes. Children who are placed out of the home differ in the types and severity of maltreatment experienced compared to children who remain in the home. One-half to two-thirds of youth have experienced a traumatic event leading to increased awareness and growing literature on the impact of trauma on youth. The most common reasons for out-of-home placements are due to physical or sexual abuse, violence, and neglect. Youth who are at risk in their own homes for abuse, neglect, or maltreatment, as well as youth with severe emotional and behavior issues, are placed out of the home with extended family and friends, foster care, or in residential facilities. Out-of-home placements aim to provide children with safety and stability. This temporary, safe environment allows youth to have their physical, mental, moral, and social needs met. However, these youth are in a vulnerable position for experiencing repeated abuse and neglect.

In psychology, Trauma-informed feminist therapy is a model of trauma for both men and women that incorporates the client's sociopolitical context.

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LGBT trauma is the distress an individual experiences due to being a lesbian, gay, bisexual, trans, queer person or from possessing another minoritized sexual or gender identity. This distress can be harmful to the individual and predispose them to trauma- and stressor-related disorders.

Trauma-informed approaches in education (TIE) are educational techniques that acknowledge the prevalence of adverse childhood experiences and other traumas on students and attempt to mitigate the widespread impact of such trauma. By adopting trauma-informed principles, educational organizations aim to create a supportive environment that facilitates learning and promotes the emotional well-being of students. Trauma-informed education is referred to with varying terminology. As articulated by the National Child Traumatic Stress Network (NCTSN), trauma-informed approaches in education aim to engage school personnel and community members in interventions that aim to identify and respond to the potential negative effects of traumatic stress within the school system.

References

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