What Every New Social Worker Needs To Know...Trauma Informed Care in Social Work

by Elisa Kawam, Ph.D., and Marcos J. Martinez, Ph.D.

     As social workers, we work with populations with long and complex histories of abuse and violence combined with pressing physical, mental, emotional, social, and spiritual needs. Even when we are not serving the most vulnerable, we still may be working with people who have endured a traumatic event, which has affected their lives and their well-being.     

    Due in part to the recognition that traumatic events are increasingly common and that the effects of such can be negative (Briere & Scott, 2014), trauma informed care is becoming popularized among the helping professions. Although trauma and trauma informed care are complicated, understanding them better enables social workers to care for the needs of their clients from a deeply holistic perspective.

    Thus, the intent of this article is to describe the basics of trauma, trauma informed care, and applying trauma informed care in practice and policy settings. Certainly not an exhaustive guide to trauma informed care, this is an overview intended to introduce this subject and stimulate interest in it.  

The Nature of Trauma

    A traumatic event is an experience in which individuals fear for their lives or the lives of those close to them (American Psychiatric Association, 2013). Traumatic events include child maltreatment, domestic violence, poverty, gang/community violence, natural disasters, and war. Traumatic experiences can be experienced directly, or indirectly by witnessing the trauma of another. In this manner, seeing an act of violence against someone else may be traumatic. The frequency, chronicity, and intensity of the event must be considered (Ogden, Minton, & Pain, 2006) in determining the impact on a person. For example, an event that occurs frequently and involves a close family member, such as sexual abuse, will have a different outcome than an event that someone saw once and did not involve anyone known to that person, such as a car accident.

    Trauma does not affect everyone equally, and this is partially dependent on the age/development of the person, gender, existing risks and strengths, and available social supports (Ogden, Minton, & Pain, 2006). Because of differences in hormones and societal norms, women tend to experience trauma more intensely with longer lasting symptoms than men (Ogden, Minton, & Pain, 2006). Additionally, traumatic events that occur at younger ages are thought to have more upsetting effects, as they co-occur with brain and social skill development (Schore, 2001). Finally, existing risks (addiction and mental illness, most importantly), along with the presence of a social support system, must be taken into account when understanding why traumatic events affect people differently.

    Traumatic symptoms can range from mild to debilitating. When symptoms interrupt daily functioning, they may constitute a formal clinical diagnosis of Post-Traumatic Stress Disorder (PTSD), according to the DSM-V (American Psychiatric Association, 2013). Traumatic symptoms are highly individualized and, as a result, can manifest in a multitude of ways. The outcomes of trauma often affect mental functioning, social interactions, and coping mechanisms. Depression and anxiety are common, as well as difficulty eating, sleeping, parenting, and working. In addition, it is not uncommon for someone to experience flashbacks or dreams of the event(s) (intrusion) or to report that they feel easily startled (hypervigilance) by stimuli in their surroundings. Some people may notice that they are dulled to what is going on around them during routine daily activities (dissociation).

    Finally, people with trauma symptoms are prone to social isolation. These individuals attempt to control their surroundings preemptively by evading any person, place, or thing that might serve as a reminder of the trauma (avoidance). Together, these four categories of symptoms not only take away from quality of life, but also make daily interaction and communication difficult.

    Further, those with trauma histories are at an increased risk for addiction, substance use, and other risky behaviors, such as promiscuous sex and illegal activity. It is thought that these symptoms are side effects of traumatic exposure. These behaviors are thought to be ways of learned coping to compensate for a traumatic past. As social workers, we need to address and treat the underlying cause (the trauma) first and then treat the other issues that present (substance use, risky behavior, unemployment, or anxiety). This approach reframes the idea of the presenting problem in that the issues we deem as target behaviors may not really be what the client wants to change. These problems instead may represent the client’s way of living with a trauma history. By treating the presenting problem without screening for trauma, we are, in essence, removing the client’s solution to the larger issue. This approach does not get to the root cause of the problem and may do more harm than good, as a result.

    The key component to understanding trauma is that it is both preventable and treatable (Herman, 1992). This is where the role of social workers comes in—acting as change agents to directly influence the lives of those who have endured traumatic events. This treatment approach is called Trauma Informed Care (TIC).

Trauma Informed Care

    Trauma Informed Care (TIC) is more than a treatment modality or theory. TIC causes a shift in thinking about how we view people and social problems and can be added to any existing therapy. TIC, at its core, seeks to understand human behavior, coping mechanisms (both positive and negative), and any problems that result by examining traumatic events throughout life. TIC aims to understand one’s current functioning in light of past events and does not see presenting problems as needing to be fixed, but rather attempts to understand why these problems exist in the first place.

    Trauma exposure alone is a risk factor for future traumatic events. By default, then, TIC is a preventive approach. Through the systematic screening and treatment of trauma, it is thought that future traumatic events may be avoided. Trauma screening can occur at the primary (population), secondary (at risk), and tertiary (already exposed) levels without extra resources or personnel.

    Apart from being preventive, TIC is inherently strengths-based, as the first principle is that of doing no harm to the client. Those operating from a trauma informed perspective view a client as a unique individual with all the tools necessary to regain healthy functioning. TIC often requires a degree of practice and training that extends past the social worker-client relationship. TIC requires that all persons, regardless of job duty, must be educated on trauma. They must understand what trauma symptoms look like and how they may be triggered, even if they do not work directly with clients, to minimize any chance of re-traumatization during service provision.

    Specifically, TIC has several key components that help solidify thinking on the subject. The first is understanding trauma itself in terms of prevalence, risks, triggers, symptoms, and effects on physical, mental, and social health. Traumatic exposure, we are learning, is common, with many adults having experienced one to two adverse childhood events as well as two to three adverse events during adulthood (Felitti, 2002). Trauma symptoms may manifest as physical symptoms such as fatigue, pain, headaches, and digestive problems. Understanding that trauma is widespread, and not assuming that physical ailments are psychosomatic, helps to stress the benefits in becoming a trauma informed social worker.

    The second key component uses the social work method of “person in environment” to see the whole person, not just the problems that are presented. Known to social workers as being strengths-based and client centered, TIC aligns perfectly with our Code of Ethics. Given its individualized nature, TIC places the client’s culture, beliefs, and desires first. In this manner, our transition to a TIC perspective is perhaps easier when compared to other helping professions.

    The third core element of TIC is that it requires that services provided should return a sense of empowered control to the client. Many people who have endured trauma have lost their sense of self and may have a reduced or weakened self concept as a result. It is thought that this weakened self-concept may be associated with risk taking and health damaging behaviors that we often address in our agency settings. Returning this sense of power to the client is critical.

    The last main, and arguably most important, element of TIC is safety.  Working to provide someone with physical, mental, and social safety—away from any threats to well being—is a powerful trauma informed tool. This may mean helping a client move away from an abuser, assisting a client to process anxiety, or connecting clients to a positive and strong social network in case a safety need does arise. All of these aspects concerning increasing safety can aid in both treating past trauma and in preventing additional traumatic events in the future. Traumatic exposure itself is a risk for additional traumatic exposure. The phrase “trauma begets trauma” is salient, to say the least. A natural counterpart to what we are already doing, TIC can be used in all policy, practice, and community settings without shifting the focus on those who are served. An enhancement to our work, applications of TIC can be improved with the input of social workers with a passion for this topic.

Trauma Informed Care in Application

    With an understanding of trauma and TIC, it is important to think about practical applications of such principles in social work practice and policy. In practice settings, it is important to understand trauma and its effects. This may sound like a minor detail. However, once a social worker learns about traumatic events, that social worker cannot help but assess for them during intake, engagement, and case management. In this manner, trauma screening becomes normalized in the services provided. Similarly, ensuring that we educate each other on trauma will go far in serving clients who have experienced trauma. If a trauma screen indicates some exposure or symptoms, we must then be sensitive to that in the language we use, services we refer to, triggers, and other behaviors that may exist.

    From a policy perspective, social workers involved in macro work must advocate for communities in which violence, substance use, and child maltreatment occur. We must educate and work with our legislators, as well as argue for the coverage of trauma treatment for those who are affected. Likewise, we must be wary of penalizing those with addiction, anger, social isolation, or chronic instability when trauma has occurred, considering that these are all symptoms of a larger root cause. This approach is key to being trauma informed.

    These broad suggestions work with what already exists in social work and will likely lead to better client outcomes and a more successful work environment. Social work is the preeminent profession to become trauma informed and to take on this enhanced service on behalf of those who are hidden and most vulnerable.

References

American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders (5th ed). Washington, DC.

Briere, J., & Scott, C. (2014). Principles of trauma therapy: A guide to symptoms, evaluation, and treatment, (2nd ed), DSM-5 update. Thousand Oaks, CA: Sage.

Felitti, V. (2002). The relationships of adverse childhood experiences to adult health: Turning gold into lead. Med Psychotherapy, 48(4), 359-369 Retrieved from http://www.acestudy.org/files/Gold_into_Lead-_Germany1-02_c_Graphs.pdf

Herman, J. (1992). Trauma and recovery. New York, NY: Perseus Book Group.

Ogden, P., Minton, K., & Pain, C.

(2006). Trauma and the body: A sensorimotor approach to psychotherapy. New York, NY: W.W. Norton & Company.

Schore, A. (2001). The effects of early relational trauma on right brain development, affect regulation, and infant mental health. Infant Mental Health Journal, 22(1-2), 201-269.

Additional Resources

Foa, E., Keane, T., Friedman, M., & Cohen, J. (2009). Effective treatments for PTSD. New York, NY: The Guilford Press.

SAMHSA. (2015). National center for trauma-informed care. Retrieved from http://www.samhsa.gov/nctic

United States Department of Health and Human Services. (2015). The national child traumatic stress network. Retrieved from http://www.nctsn.org/

Elisa Kawam, BSW, MSW, Ph.D., serves as the Executive Director of the NASW New Mexico chapter. Her areas of specialty are child welfare, DV, trauma/PTSD, and prevention/intervention. Her work also includes trauma assessment and treatment within criminal justice, public health, nonprofit as well as behavioral health/substance use. She also maintains a teaching, research, and publication portfolio.

Dr. Marcos Martinez, MSW, Ph.D., is a social work graduate of Arizona State University, New Mexico Highlands University, and Dana College. His work has focused on the development, adaptation, implementation, and evaluation of culturally sensitive prevention programming targeting substance use and risky sexual behavior among Hispanic and American Indian families.