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Trauma-Informed Social Work Practice Jill Levenson

Social workers frequently encounter clients with a history of trauma. Trauma-informed care is a way of providing services by which social workers recognize the prevalence of early adversity in the lives of clients, view presenting problems as symptoms of maladaptive cop- ing, and understand how early trauma shapes a client’s fundamental beliefs about the world and affects his or her psychosocial functioning across the life span. Trauma-informed social work incorporates core principles of safety, trust, collaboration, choice, and empowerment and delivers services in a manner that avoids inadvertently repeating unhealthy interpersonal dynamics in the helping relationship. Trauma-informed social work can be integrated into all sorts of existing models of evidence-based services across populations and agency settings, can strengthen the therapeutic alliance, and facilitates posttraumatic growth.

KEY WORDS: adverse childhood experiences; adversity; trauma; trauma-informed care

Social workers frequently encounter clientswith a history of trauma, which is defined asan exposure to an extraordinary experience that presents a physical or psychological threat to oneself or others and generates a reaction of help- lessness and fear (American Psychiatric Association [APA], 2013). The exposure may have occurred in the distant or recent past, and pervasive symptoms such as intrusive thoughts of the event, hyperarousal to stimuli in the environment, negative moods, and avoidance of cues related to the trauma are charac- teristic of both acute and chronic posttraumatic stress disorders (APA, 2013). Traumatic experiences take many forms, but they typically involve an unexpected event outside of a person’s control such as criminal victimization, accident, natural disaster, war, or expo- sure to community or family violence.

An abundance of research has revealed that trau- mas involving early child mistreatment and family dysfunction are especially prevalent and impactful (Centers for Disease Control and Prevention [CDC], 2013). Children may experience other events that also result in trauma, such as bullying, death of a family member, illness, out-of-home placement, and poverty; historical traumas like systemic oppres- sion or discrimination are also prevalent for minority and other marginalized groups. Some traumas are quite overt, like physical and sexual abuse or wit- nessing domestic violence, whereas chronic experi- ences like emotional neglect, an absent parent, or a substance-abusing caretaker may be more subtle

but can leave insidious effects. Individuals are often exposed to multiple related traumas and polyvicti- mization, leading to toxic stress and complex trauma reactions (Cloitre et al., 2009; Finkelhor, Turner, Hamby, & Ormrod, 2011; Maschi, Baer, Morrissey, & Moreno, 2013).

Trauma-informed care (TIC) incorporates an understanding of the frequency and effects of early adversity on psychosocial functioning across the life span (Substance Abuse and Mental Health Ser- vices Administration [SAMHSA], 2014a). TIC is different from trauma-focused therapy, as its primary goal is not to directly address past trauma, but to view presenting problems in the context of a client’s trau- matic experiences (Brown, Baker, & Wilcox, 2012). Trauma-informed social workers rely on their knowl- edge about trauma to respond to clients in ways that convey respect and compassion, honor self- determination, and enable the rebuilding of healthy interpersonal skills and coping strategies. The person- in-environment perspective held by social workers helps us recognize the role that adversity might play in the formation of maladaptive coping pat- terns. Social workers are trained to avoid over- pathologizing behavior and to appreciate the complex nexus between poverty, oppression, and trauma. As well, the core values and mission of social work include promoting social justice for oppressed and vulnerable populations (National Association of Social Workers, 2015). Trauma-informed practice is consistent with these goals.

doi: 10.1093/sw/swx001 © 2017 National Association of Social Workers 105

DEVELOPMENTAL TRAUMA AND ITS EFFECTS The largest study of the scope of adverse childhood experiences (ACEs) surveyed over 17,000 adult patients of the Kaiser Permanente Health System and found that 64 percent of them reported at least one type of childhood maltreatment or household dysfunction, and nearly 13 percent reported four or more (CDC, 2013). Although these numbers dem- onstrate the high prevalence of ACEs, the rates of early trauma among poor, disadvantaged, clinical, and criminal populations are even higher (Christensen et al., 2005; Eckenrode, Smith, McCarthy, & Dineen, 2014; Larkin, Felitti, & Anda, 2014; Levenson, Willis, & Prescott, 2016; Wallace, Conner, & Dass-Brailsford, 2011). As ACEs accumulate, the risk increases for countless medical, mental health, and behavioral problems later in life, including chemical depen- dency, smoking, depression, suicidality, fetal mor- tality, obesity, heart and liver diseases, intimate partner violence, sexually transmitted diseases, and unintended pregnancies (Felitti et al., 1998). The combined effects of early adversity on health and psychosocial well-being are profound and bring with them grave implications for public health and social justice (Anda, Butchart, Felitti, & Brown, 2010; Larkin et al., 2014).

The pathways from early adversity to psychosocial problems are complex, but early toxic environments stimulate hyperarousal and overproduction of neu- rochemicals that activate automated fight-flight- freeze responses and inhibit the natural development and connection of neurons (Anda et al., 2006; van der Kolk, 2006). These changes in the brain over time can destabilize emotional regulation, social attachment, impulse control, and cognitive proces- sing (Anda et al., 2010; Anda et al., 2006; Whitfield, 1998). This is especially true when children are exposed to chronic and persistent adverse condi- tions, enabling maladaptive responses to become extremely well rehearsed. Developmental psy- chopathologists propose that emotional and social adaptations to environmental conditions arise from a reciprocal intersection of thoughts and emotions; we “establish a coherence of functioning as a thinking, feeling human being” through the meaning we affix to our experiences (Rutter & Sroufe, 2000, p. 265). When previously traumatized clients encounter current stress, they may feel intense and intolera- ble emotions, and cope with them through nega- tive behaviors (Brown et al., 2012). Social workers taking psychosocial histories should consider the

damaging effects of child maltreatment and chaotic family environments and their contribution to the exacerbation of presenting problems.

Attachment theory illustrates the linkage between early adversity and adult psychosocial troubles. Attachment theorists argue that children must experi- ence nurturing, consistent, and responsive interactions with primary caretakers to perceive the world as a safe place (Bowlby, 1988). Children who are exposed to maltreatment and family dysfunction suffer inconsis- tent parenting patterns that impair the development of secure attachments to caretakers, and chaotic households often lack good role models for healthy interpersonal functioning across the life span (Carlson & Sroufe, 1995; Cicchetti & Banny, 2014). Early abusive and neglectful relationships are characterized by betrayal and invalidation, which can then manifest in disorganized attachment patterns, distorted cog- nitive schema, boundary violations, and emotional dysregulation (Young, Klosko, & Weishaar, 2003). Early attachment disruptions have been correlated with deleterious long-term impacts including com- promised relational skills, self-regulation difficulties, and mental disorders (Jovev & Jackson, 2004; Loper, Mahmoodzadegan, & Warren, 2008).

TRAUMA-INFORMED PRINCIPLES TIC differs from trauma resolution therapy, although trauma work may be a treatment goal for many clients. Trauma-focused cognitive–behavioral inter- ventions help clients to discuss painful memories and reduce anxiety to a more tolerable level, and to increase their ability to modulate emotion and behavior (Cohen, Mannarino, Kliethermes, & Murray, 2012). Rather than focusing on specific interven- tions, TIC seeks to create a safe environment for clients that enables trust, choice, collaboration, and empowerment across treatment modalities so that clients can experience healthy relationships with others (Elliott, Bjelajac, Fallot, Markoff, & Reed, 2005; Harris & Fallot, 2001). Trauma-informed social workers appreciate how common trauma is, and that violence and victimization can affect psy- chosocial development and lifelong coping strategies; they emphasize client strengths instead of focusing on pathology, and they work on building healthy skills rather than simply addressing symptoms. TIC delivers services in a manner that recognizes the emotional vulnerability of trauma survivors, and most important, the worker avoids inadvertently repeating dynamics of abusive interactions in the helping

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relationship (Elliott et al., 2005; Harris & Fallot, 2001; Knight, 2015; Morrison et al., 2015).

Trauma-specific interventions are aimed at re- ducing symptoms resulting from the negative sequelae of trauma in the life of the individual. TIC models of service delivery, on the other hand, reflect the needs of survivors to connect with others, to be respected, and to become hopeful regarding their own recovery (Bloom & Farragher, 2013; Harris & Fallot, 2001; SAMHSA, 2013). Recog- nizing that presenting problems, in actuality, often are indicators of trauma and interrelated emotional wounds, trauma-informed social workers develop partnerships with consumers in a way that empowers them. Social services can be oppressive, and margin- alized clients often approach services with a mistrust of authority figures and a wariness of professional helpers. Instead of interpreting this response as hos- tility, lack of motivation, or resistance to services, social workers should view it as a normal protective reaction when an individual feels vulnerable. Social workers recognize that the burden is on us to facili- tate trust and that this requires a compassionate and respectful way of engaging with clients.

A trauma-informed approach views presenting problems as maladaptive coping and regards trauma not as a distinct event but as a framework for understanding experiences that can define and deeply affect the core of a person’s identity (Harris & Fallot, 2001; SAMHSA, 2014a). By understand- ing how early adversity shapes a client’s fundamen- tal beliefs about the world, the trauma-informed social worker helps the client to construct new ways to organize feelings, coping skills, behaviors, and relationships (Knight, 2015; Morrison et al., 2015). The social worker can conceptualize nega- tive behaviors as coping strategies that were once adaptive in the traumagenic environment but which have become self-destructive or harmful across different domains of human functioning. By viewing the collective experiences of the individ- ual in this holistic way, client behaviors that seem irrational, self-destructive, or even abusive are re- conceptualized as survival skills that once helped the individual respond to threatening encounters but which now impede the ability to tolerate distress and set boundaries (Levenson, 2014). Con- sistent with a strengths-based approach to posttrau- matic growth, trauma-informed workers can help clients change problematic behavior, manage crises more successfully, and parent their own children in

a more nurturing and responsive fashion (Levenson, 2014; SAMHSA, 2014a). These strategies are es- sential to interrupting the intergenerational cycle of victimization (Harris & Fallot, 2001; Larkin et al., 2014).

TIC prescribes a set of basic principles: safety, trust, choice, collaboration, and empowerment (Elliott et al., 2005; Fallot & Harris, 2009; Harris & Fallot, 2001; SAMHSA, 2014a). These concepts are consis- tently interwoven and applied throughout the intake, assessment, engagement, treatment, and termination phases of social work services. The principles, when infused into practice, minimize the likelihood of repeating dysfunctional dynamics in the helping rela- tionship and capitalize on the opportunity to create a corrective experience for consumers of services.

The next sections describe the components of TIC. At the micro level, social workers can begin to engage in TIC by treating everyone with kindness and respect, and listening with curiosity and compassion. At the systems or macro level, implementation of TIC requires a paradigm shift within the organizational culture of an agency. It is beyond the scope of this article to address systemic application of TIC principles, but the reader can refer to other resources. For instance, SAMHSA has published guidelines for TIC imple- mentation including TIP 57, which offers strategies for incorporating TIC in behavioral health settings (SAMHSA, 2014b). There are also several tools avail- able to measure TIC attitudes, readiness for change, and operational barriers. The new ARTIC scale (Baker, Brown, Wilcox, Overstreet, & Arora, 2016) can be used to assess employees’ perspectives through- out the process of adopting TIC protocols. The scale comprises seven domains including attributions of causes for underlying problematic client behavior, preferred ways of responding to client symptoms, and systemwide support for TIC. Readers may even use the ARTIC tool as a self-assessment. Another instrument, the TICOMETER (Bassuk, Unick, Paquette, & Richard, 2016), can measure TIC in organizations at different points in time, making it useful for monitoring changes in service delivery, determining training needs, and refining agency policies and procedures.

Safety Recognizing the likely existence of a traumatic history in the lives of social services consumers is the first step in facilitating safety in the physical

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environment and in relationships between clients and providers (including staff). Warm and welcom- ing surroundings will create a sense of serenity for clients (Elliott et al., 2005; Fallot & Harris, 2009). Just the experience of a smiling receptionist can be calming and comforting for some clients. Physical safety can be ensured through facilitating protection from hazards or dangers that might emerge within the physical space. For instance, good lighting, disability accommodations, and maintenance of the property can reduce the risk of physical injury. Security precautions can prevent threats from indi- viduals both within and outside the office. Respect- ful language, boundaries, and use of power can establish and model safe and appropriate limits with- out recreating the oppressive dynamics of authority figures in the lives of many clients (Harris & Fallot, 2001). In essence, safe relationships are consistent, predictable, and nonshaming (Elliott et al., 2005).

Trust Erikson (1993) proposed that trust in our earliest relationships with caretakers is foundational for establishing a healthy personality, and that with- out the successful acquisition of trust, subsequent developmental tasks of autonomy, initiative, compe- tence, and intimacy will likely be compromised. According to Maslow’s hierarchy, all humans have the same basic needs including survival, physical and psychological safety, social connection, self- esteem, and actualization (Maslow, 1943). When a client’s basic needs for safety, respect, and accep- tance in the helping relationship are understood, an atmosphere of trust can be established (Elliott et al., 2005). Trust is earned and demonstrated over time. By eliminating ambiguity and vagueness, the social worker can assist clients to clearly anticipate what is expected of them and what they can expect from their worker, diminishing the anxiety that comes with uncertainty and unpredictability (Harris & Fallot, 2001). For instance, workers can clearly explain the eligibility criteria, the process of receiv- ing services, and the expectations for successful program completion, as well as information about confidentiality, sharing of information, attendance, and fees. The style of interaction should be genuine and authentic, and in initial sessions, pressure should not be put on clients to disclose information they are not ready to share. There are stages of intimacy that all relationships go through, and by allowing the consumer’s risk-taking and disclosure to proceed

at his or her own pace, the worker actually models a healthy process of establishing trust based on deter- mining whether another individual is listening, hearing, and responding in a truly reliable and con- sistent fashion.

For example, a social worker noticed that soap and toilet paper were missing from the restroom after a criminal offender rehabilitation group meet- ing. Instead of confronting the group about the incident and reminding them of the consequences for stealing, she asked herself, “Who steals soap and toilet paper?” and remembered that some clients in the group are homeless. She got permission to use some petty cash to buy a basket and filled it with soap, toothpaste, toilet paper, and small bottles of laundry detergent. She placed it in the group room and said nonchalantly to all of them at the next meeting: “Here are some hygiene items, feel free to take a few if you need them.” The worker’s implicit message was clear: I hear you, I understand what you need, and I won’t shame you, so next time you need help you can ask me.

Choice Trauma-informed services attempt to embolden client decision making and a sense of control over one’s recovery (Fallot & Harris, 2009). All clients progress at their own pace as they explore their unique experiences and realize how those en- counters primed them to respond in a certain fash- ion to environmental stressors. As clients develop an expanded repertoire of coping strategies, they begin to recognize that they cannot always control others or the environment, but they can control their own responses. As a result, clients gain a new sense of control in the service delivery environment, while workers promote and reinforce autonomy and self-determination, which can transform a client from a powerless, overwhelmed victim to a survivor who directs and owns his or her life decisions and the associated outcomes (Elliott et al., 2005). Emo- tional and behavioral dysregulation can reinforce negative beliefs about oneself (“I’m a failure”), so it is important to help clients to improve impulse con- trol and problem solving by reframing their trig- gered fight-flight-freeze responses to environmental stress as only one of several alternatives available to them. As they learn and practice new skills, they increase their repertoire of available choices.

Facilitating choice can include asking clients about their preferences in service delivery, helping

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clients to identify options and ponder alternatives for themselves, and guiding clients in their own informed decision making. For instance, instead of shaming or punitive responses to resistance behav- ior, workers can help clients to assess their readiness for change; in doing so, we enable them to own their lifestyle choices and to explore obstacles to their goals. Sometimes, clients express preferences about their practitioners (for example, race, gen- der, ethnicity), and these requests should be dis- cussed and processed with clients in a way that gives voice to their underlying comfort level. For instance, a client may ask, “Do you have children? You look young. I want a worker who has kids.” The worker might respond, “I think you are won- dering if I can understand what it is like for you as a parent. Either way, my parenting experience would be different from yours; I really want to understand your situation, so that together we can work on finding solutions that are right for your family. Would you be willing to try that?”

Collaboration Trauma-informed programming is based on shared power between worker and client so the relation- ship offers a true alliance in healing (Elliott et al., 2005; Fallot & Harris, 2009; Morrison et al., 2015). The inherent power imbalance in the helping rela- tionship requires constant attention to the many (often subtle and insidious) ways that feelings of vulnerability and subsequent resistance can be gen- erated for clients. Because many ACE survivors were betrayed by those who were supposed to pro- tect and care for them, the helping relationship is fraught with potential for retraumatization when reminders of the capricious nature of past authority figures are activated. Most of us are motivated to please others, to conform to authority, and to seek acceptance and attention, generating opportunities for some people in a position of authority to exploit those in subordinate positions. Abuse survivors are particularly vulnerable to instinctive compliance and may need to be reminded that they have the right to ask questions, decline services, or make requests. A truly collaborative worker–client relationship is one in which the worker’s professional knowledge is combined with the client’s expertise about his or her own life narrative and scope of coping responses. By understanding each client’s life history and cultural background, and by allowing clients to participate in determining the course of the intervention, social

workers can engage clients and dislodge barriers to change. Using the helping relationship as a thera- peutic tool, the collaborative partnership facili- tates connection to others and thus exposure to an emotionally corrective experience.

Empowerment True empowerment occurs with a strengths-based approach that reframes symptoms as adaptation and highlights resilience instead of pathology. Too often, an intense focus on fixing problematic beha- viors neglects the importance of acknowledging and reinforcing strengths. Instead of asking “What’s wrong with you?” we should get in the habit of ask- ing, “What happened to you?” (SAMHSA, 2014a). Survivors of childhood trauma experience a pro- found sense of powerlessness when choice and predictability are absent from their daily existence. In fact, the very term “survivor” was designed to offset the helplessness implied by the word “victim” (Harris & Fallot, 2001). Bandura (1977) described the crucial role of self-efficacy, defined as belief in one’s own capacity to achieve goals, accomplish tasks, and respond competently to challenges. By reframing trauma responses as normal reactions to threatening encounters, social workers can cele- brate survival strategies, channel those instincts into healthier relationship skills, and help clients to achieve a sense of control in one’s daily life. In this way, we can fertilize the seeds of self-efficacy to assist the survivor to embrace hope and belief that change is possible.

APPLYING TRAUMA-INFORMED PRINCIPLES TO SOCIAL WORK PRACTICE By recognizing the possible existence of a trau- matic history, we can make it a priority to establish physically and psychologically safe therapeutic en- vironments. Early trauma (especially familial abuse) often breeds a sense of wariness and a mistrust of caregivers and authority figures. A salient need for clients, therefore, is to encounter environments and relationships that challenge their expectations of the world as an unsafe place in which relation- ships are fraught with danger and disappointment. Safe relationships are consistent, predictable, and nonshaming. Social workers should model respectful interpersonal boundaries, language, and use of power so that safe and appropriate limits can be set without recreating the oppressive actions of others

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that featured prominently in the lives of many clients (Bloom & Farragher, 2013; Harris & Fallot, 2001).

For example, when a client did not like an answer he was given, he became combative and then stood up to storm out the door, saying, “I need to leave before I do something I regret.” Instead of confronting or chastising the client, the social worker responded, “I can see that you are upset, and I appreciate that you want to control your temper. Let’s take some deep breaths together, and talk about what’s making you so mad right now.” After he calmed down, the social worker kindly observed, “I bet I’m not the first person to tell you that you can be a little scary when you’re mad.” The client laughed and agreed that his mother and girlfriend tell him that all the time. This opened a conversation about how his anger can sometimes be used to intimidate others into acquiescing to his desires, that this was similar to what he observed in his father growing up, and how better conflict resolution skills might reduce his tendency to violate the boundaries of others in this way.

Motivational interviewing (Miller & Rollnick, 2012) is commonly used with a variety of at-risk populations by infusing cognitive–behavioral ther- apies with humanistic principles to adopt a more client-centered approach. People who engage in addictive, self-destructive, or victimizing behaviors may be judged by social workers as disturbed or unstable; with these clients it can be easy to over- look a history of trauma and attribute their be- havior to an unrelated cause, such as bad moral character or lack of motivation for change. When social workers view clients as being defective, we tend to intervene paternalistically and exacerbate the very problems that would be better addressed through TIC (Levenson, 2014). Instead, we should validate the mixed feelings and inner conflicts about change that naturally emerge in counseling, emphasize strengths, and help clients identify and reduce barriers to personal growth.

When practitioners fail to respond in a validating or empathic manner to resistant, antagonistic, or hostile clients, a negative interaction occurs, ob- structing client engagement and producing a rup- ture in the therapeutic alliance (Binder & Strupp, 1997; Teyber & McClure, 2000). When clients display resistance, clinicians in all disciplines some- times respond in ways that seem rejecting, judg- mental, or disapproving (Binder & Strupp, 1997). Social workers may be especially susceptible to

this detrimental process with nonvoluntary clients, because these individuals may enter mandated in- tervention programs with defensiveness or denial. Binder and Strupp (1997) cautioned that negative process is a contributor to treatment failures in all psychotherapy modalities serving a range of client populations. Indeed, those with the most off-putting behavior may be most in need of trauma-informed responses. Social workers should reflect on the ways that their own beliefs, values, attitudes, and experi- ences might hamper their engagement style and unwittingly reproduce disempowering dynamics in the helping relationship (Levenson, 2014).

Gender-specific services are also important, as women have specific empowerment needs that reflect the link between poverty, violence, and mental health symptoms (Covington & Bloom, 2007; East & Roll, 2015; Elliott et al., 2005; Topitzes, Mersky, & Reynolds, 2011). Men with childhood abuse histories also require relevant interventions (Easton, Coohey, Rhodes, & Moorthy, 2013; Levenson et al., 2016). For instance, responses to family dysfunction may manifest in different ways: Teenage boys may gravi- tate toward gangs or delinquency for a sense of con- nection and inclusion, and teenage girls may be prone to early pregnancy if they long for someone to love them. These problems are better viewed as symptoms of underlying trauma, and TIC interven- tions include simply interacting with clients in ways that convey that they are special, important, and valuable.

It is not uncommon for social services clients to present with a history of poor self-regulatory capaci- ties. Households that lacked modeling of effective emotional and behavioral management often rein- force maladaptive coping methods that provided an antidote to anxiety or internal distress. When emo- tional dysregulation and flawed cognitive schema are well rehearsed in the context of coping with chronic toxic stress, they can become deeply en- trenched in personality traits (Bloom & Farragher, 2013). Traumatic reenactment occurs in the social services setting when negative clinician responses contribute to self-fulfilling prophecies of failure, which in turn fortify anxiety and reinforce inflexible coping, thus dissuading clients from help seeking. For example, responding to a client who is consis- tently late to group therapy sessions with a critical reminder about rules and consequences for tardiness can reproduce shame and fear. Instead, the social worker might remember that this client grew up in

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a home with parents who were hoarders and who provided no modeling of routine, structure, order, or scheduling; the client had learned that disengage- ment from peers was a way to avoid the embarrass- ment of her household. The social worker might acknowledge the client’s discomfort of being in a group of people and can then help the client process her avoidant tendencies, check the bus schedule, plan what time to leave the house, and further develop and refine skills of time management. Some clients need social workers to provide a mentoring role that their parents lacked, and to alter expectations accordingly.

As a result of early experiences of oppression, marginalization, discrimination, or child mistreat- ment, social services clients often display an as- sortment of relational problems that stem from long-standing core schema about themselves and others (Teyber & McClure, 2011; Young et al., 2003). These thematic beliefs underlie interper- sonal skill deficits and associated behaviors, and can generate a repetitive cycle of maladaptive distress-relieving strategies and problematic rela- tional patterns. The helping relationship offers an opportunity for intervention when the professional responds to the vulnerability activating the negative interaction instead of directly challenging the behav- ior itself (Teyber & McClure, 2011; Young et al., 2003). For instance, a client became angry when asked to change to a different group session. “I like this group! I don’t want to start over with others!” Instead of pulling rank and forcing the switch, the social worker responded, “You make a good point. You are reminding me that your feeling of connec- tion with members in this group is more important than my need to assign you elsewhere.” When the client continued the rant, the social worker observed, “Your expectation that others won’t respect your wishes seems to be causing you to talk louder, which means that you haven’t been able to hear me agree with you.” This led to a great conversation about the anxiety and escalating agitation that are triggered when feeling disrespected by others.

SUMMARY AND CONCLUSIONS Trauma-informed social work can be integrated into all sorts of existing models of evidence-based services, but TIC can strengthen the therapeutic alliance and facilitate posttrauma

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