Building a trauma-informed practice process

Trauma-informed practice tips can be incorporated at every stage of service delivery, regardless of discipline and clinical role. 

Most healthcare providers’ services consist of three distinct stages: initial assessment, intervention, and discharge. 

Trauma-informed practice tips include:

• Make a routine query about trauma history
• Recognize the signs and symptoms of trauma history
• Respond to signs and symptoms of self-harm
• Recognize when a patient is being triggered
• Respond to disclosures, and
• Assess risk and refer

Trauma-aware healthcare providers are alert to the signs of trauma history at all times. Therefore, each of these practice tips can be incorporated at any point in the interaction with clients.

A query about patients’ trauma history should be considered part of every intake assessment and subsequent care. Before asking about trauma history, it’s recommended that HCPs provide brief psychoeducation about the prevalence and consequences of trauma. Providing this context helps normalize the experience and opens the door for the client to disclose at a later time, even if they don’t feel ready to talk at the moment.

For example, a healthcare provider might say: “Many people have had traumatic experiences in their life. Situations in which they felt their safety was threatened. We ask about our patients’ trauma histories because we know it can have a big impact on their health. You don’t have to answer the question if you don’t want to, but is there anything I should know about your history that will help us to work together in a way that will make you feel safe?”

If signs and symptoms of trauma history are noted, rather than labeling the client, a trauma-informed HCP might say, “I notice that you haven’t picked up your diabetes medication in three months. Sometimes people have difficulty with their schedules and planning to pick up medication. Is there anything I can do to help?”

It’s important to convey compassion and non-judgment. Accept what the client is saying and try to understand their perspective. This helps create a safe space for them to ask for further help.

People with a history of trauma sometimes engage in self-harming behaviours, which means they’re hurting their body on purpose. These behaviours can include cutting, hair pulling, scratching, picking, and burning. The intent isn’t to end one’s life, but to “stop painful feelings” or self-punish. 

Self-harm may indicate that the client is struggling to cope and additional support is required. When making this assessment, it’s important to determine the intent behind the self-harm and its associated level of risk. Was it an instance of self-injury or a genuine suicide attempt?

Self-injury can be a troubling symptom for clinicians to recognize and respond to. Lack of training on the topic can create uncertainty in how to navigate the conversation with patients who are self-harming. Maintaining a compassionate and respectful attitude, while avoiding expressions of judgment or alarm can help create a safe space in which clients may disclose more information. For example, the healthcare provider might say, “I notice that you have several cuts on your hands. Can you tell me what happened?”

A trigger is a sensory experience (smell, sight, taste, touch, sound) that reminds one of a past traumatic event. Once triggered, the person is brought back into their traumatic memory. They may lose awareness of the present moment.

Healthcare procedures and practices can bring back memories of trauma and trigger a fight, flight, freeze, or shut down response for patients. This is called retraumatization. Healthcare providers should be alert to signs that a client is being triggered and try to understand the meaning behind the behaviour. 

Using grounding techniques can help the client to return to the present moment. One way is to ask the client to become aware of their physical body. Using grounding cues such as asking the client to feel their feet on their ground or their back against the chair can help bring them back to the present moment. For example, an HCP noticing their client suddenly become very still might provide grounding by saying, “Susie, are you okay? Can you hear me? I notice you have become very quiet and seem distracted. I am right here and want to help. Can you look around the room?” Ensure the patient is fully present before continuing. 

Clients may feel shame after a triggering situation. Healthcare providers can offer understanding and compassion by validating and normalizing the client’s response. Explain that this is unfortunately common for clients who have a history of trauma. Discuss with the client how to proceed in order to reduce the likelihood of this happening again.

The ability to disclose a history of trauma will vary for survivors. Some may have no concrete memories, others only fragments. Some may be afraid to disclose and feel as if they won’t be believed. Some may disclose their history when asked, while others may drop hints as they try to assess whether it is safe to tell you.

Disclosing a history of trauma requires trust on the part of the survivor. Healthcare providers should honour this trust by responding with respect, belief, and compassion. Expressing shock, pity, or anger at the perpetrator is not helpful.

For example, a healthcare provider might say, “I am so sorry that happened to you. It is okay to cry. I realize it took courage for you to tell me this.” 

It’s important that healthcare providers don’t challenge or ignore what the client is saying. Rather, validate their experience. After, help the client plan how they will take care of themselves when they leave, as disclosure can cause delayed or visceral reactions.

A note on responding to disclosures and the importance of self-care

Healthcare providers are frequently exposed to their patients’ trauma (see The impact of trauma).

While having a client disclose their trauma history to their healthcare provider is an indication of trust, it can also expose that provider to vicarious and/or secondary trauma:

• Vicarious trauma results from empathic engagement with trauma survivors, such as witnessing and empathizing with others’ pain and loss.
• Secondary trauma is experienced when the trauma of patients in the provider’s care triggers memories of the provider’s own trauma history.

Healthcare is a high-risk occupation for trauma exposure. Healthcare providers should intentionally build in self-care strategies to take care of themselves when exposed to trauma.

To help yourself, you can:

• Lean on your loved ones: Reach out to your friends and family for support. While maintaining patient privacy and confidentiality, you might talk to them about your experience and your feelings. You can also ask loved ones to help you with household tasks or other obligations to relieve some of your daily stress.
• Prioritize self-care: Do your best to eat nutritious meals, get regular physical activity, and get a good night’s sleep. Seek out other healthy coping strategies such as art, music, meditation, relaxation, and spending time in nature.
• Seek help: Not everyone requires treatment for traumatic stress. Most people recover on their own with time. If your distress is interfering with your relationships, work, or daily functioning, seek out professional help.

For more information, visit “How to cope with traumatic stress” (APA) or Healthcare Salute’s own #Care4Carers campaign.

Suicidality is common among those with PTSD. The presence of major depression further increases the risk of suicidal behaviour. Some clients may report having suicidal thoughts but have no intention of acting on those thoughts. Determining risk and what action to take is therefore critical for the healthcare provider.

It is important to remember that asking about suicidal intention does not increase the risk of suicide. A healthcare provider might ask, “Do you have thoughts of suicide? Do you have a plan? What is it? Do you have the means to carry out your plan?”

In non-mental-healthcare settings, asking about suicidal intention may be an uncommon practice. Staff may feel uncomfortable asking about suicidal ideation. 

Providing training to staff in risk assessment, regardless of their practice setting, is important for establishing a TIC process. 

The final module in this course offers information and strategies for building trauma-informed organizations.

TIC invites a shift in perspective. This shift in perspective is best captured in the words of Thich Nhat Hanh, “When another person makes you suffer, it is because he suffers deeply within himself, and his suffering is spilling over. He does not need punishment; he needs help. That’s the message he is sending.”