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.
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.
Organizational applications and techniques of TIC[edit]
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[edit]
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[edit]
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.