Prioritizing trauma-informed care

October 2023

Trauma is pervasive and its roots can take hold from an early age. According to the Centers for Disease Control and Prevention (CDC), about 64% of adults reported they had experienced at least one type of adverse childhood experience before age 18, and nearly 17.3% reported they had experienced four or more types of adverse childhood experiences. Cathy Lounsbury, a licensed clinical professional counselor in Maine who specializes in trauma and trauma-informed care, says that most clients seeking mental health services have experienced some traumatic events in their lives that continue to affect their current functioning. Therefore, it’s important that counselors understand the role trauma plays to effectively address the root of some presenting symptoms, she adds. Concerns about the prevalence of trauma and its impact on the individual and society led to the development of trauma-informed care. This foundational framework ensures that health care and other social service organizations recognize and respond to signs, symptoms and risks of trauma and work to reduce the likelihood of retraumatization.

A growing awareness of trauma-informed care

“Over the past few years, we’ve seen a big shift in counseling when it comes to trauma-informed care,” says Allison Dukes, an assistant professor of clinical mental health counseling at Saint Joseph’s University. “More people are recognizing the prevalence of trauma within our lives and the lives of our clients.” In 2014, the Substance Abuse and Mental Health Services Administration (SAMHSA) established six guiding principles for trauma-informed care. These principles provide a framework for how providers can work to reduce the possibility of retraumatization and increase a person’s sense of power and safety. The six guiding principles are:

• Safety
• Trustworthiness and transparency
• Peer support
• Collaboration and mutuality
• Empowerment, voice and choice
• Cultural, historical and gender issues

The guiding principles stress the need for organizations inside and outside of mental health to ensure the safety of clients and staff, promote transparency in decision-making and encourage the sharing of lived experiences between clients and staff. They also call on organizations to foster collaborative relationships, validate the strengths of client and staff, and recognize and address societal biases and stereotypes. Dukes says studying SAMHSA’s principles is a good start for counselors who are new to trauma-informed care and for counselor educators who want to talk about it with their students. Incorporating trauma-informed care in organizations and private practice also requires an understanding and the practice of the Multicultural and Social Justice Counseling Competencies, she adds. “When planning for sessions or considering the effectiveness of interventions, we have to consider the ways in which our clients’ identities and past experiences are impacting their worldview, which is likely impacting their time in therapy and the therapeutic relationship,” Dukes says. Lounsbury, a professor of counseling and dean of the counseling department at Antioch University, says she is not sure how a mental health professional could effectively treat a client who has experienced trauma without integrating a trauma-informed approach. “Since trauma can impact a person physically, emotionally, socially, spiritually and behaviorally, trauma symptomatology is likely to be expressed during a counseling session,” she says. “It is imperative that the counselor understands it as such and responds in a way that is not retraumatizing to the client.” Lounsbury and Dukes both agree that trauma-informed care is becoming the standard in the counseling profession because, as Dukes points out, “it aligns with our profession’s ethical standards and encourages us to look at the deeper reasons for [clients’] presenting concerns.” Jenny L. Cureton, a licensed professional counselor (LPC) and owner of Evolutions Counseling and Consultation in North Canton, Ohio, has also seen growing evidence that counseling is becoming more trauma informed. “We are finally beginning to shift from seeing trauma solely as a niche to also considering it as foundational knowledge and a skill that counselors across specializations should develop and use in collaboration with each other to be responsive to clients, students and ourselves,” she says.

Seeing the whole person

Both clients and counselors benefit from agencies and organizations implementing trauma-informed care practices. For example, a trauma-informed lens can help counselors gain a deeper understanding of the client and see them more fully, says Cureton, an associate professor of counselor education and supervision at Kent State University who specializes in trauma-informed care and education. Trauma-informed care “calls us to depathologize,” she explains. “We make the compassionate and realistic assumption that the problems someone presents are their body’s, brain’s and heart’s best attempts to live through something awful; this broadly helps us maintain unconditional regard and empathy.” Taking a trauma-informed approach helps counselors be more discerning, especially with differential diagnosis and comorbidity of traumatic stress and disorders, Cureton continues. For example, without understanding trauma, a counselor might inadvertently attribute a client’s stress-related symptoms to an anxiety disorder when it might in fact be a traumatic stress response instead, she says. “A key component to engaging in trauma-informed care principles is to be a safe, trustworthy and empowering counselor [and] to transparently and collaboratively understand the client holistically and in cultural contexts,” she adds. A trauma-informed lens also helps practitioners build a more effective relationship with clients. “Past and ongoing trauma makes trusting deeply uncomfortable,” Cureton says. “When you’ve experienced trauma, it can feel too dangerous to trust others and even to trust yourself. Without being trauma informed, a counselor might misjudge a client’s reticence to share or even their no-show behavior as ‘resistant’ and even give up on providing truly quality care.” Cureton finds that counselors who are trauma-informed are better able to gauge the status of the counseling relationship, timing for interventions and their own state in the moment of providing care. “Establishing and maintaining trust is not just an ideal counselors aim for. Decades of research on the common factors of counseling show that the counselor-client relationship is crucial for successful counseling,” she notes. Jessica Meléndez Tyler, an LPC-supervisor and partner and clinical therapist at The Wandering Mind, a private practice in Columbus, Georgia, says a trauma-informed approach recognizes and respects the impact of trauma on clients’ lives, bodies, community and even their descendants. “Trauma-informed care cultivates a sense of safety and empowerment that extends past the therapeutic relationship [and moves] away from approaches that put counselors as the expert and providers of therapeutic interventions,” she explains. “Counselors can co-create an environment of understanding, sensitivity and collaboration that has been absent for survivors of trauma.”

Challenges implementing trauma-informed care

Despite the benefits associated with trauma-informed care, efforts to fully implement this foundational framework across mental health agencies have resulted in a mix of successes and challenges. Some mental health organizations have successfully enacted trauma-informed policies that benefit both clients and staff, but others have not yet addressed the issue. “In reality, the implementation of trauma-informed care still varies by the work setting,” says Cureton, president of the Ohio Association for Resiliency and Trauma Counseling. She’s noticed that more agencies and nonprofit organizations have enacted trauma-informed care to align with funding initiatives from the grant and government entities that support them. For example, Cureton says some organizations that have been practicing trauma-informed care have been able to apply for funding to support its evaluation or enhancement. In other cases, trauma-informed initiatives did not exist within the organization until it became a requirement to qualify or keep funding. “[I think] the push from some funding sources for interprofessional and cross-institutional work has supported the growth in trauma-informed care,” she says. “For instance, states that have received and distributed federal funding involving trauma-informed care often have more trauma-informed care across their systems, such as foster care, substance use treatment and K-12 education.” Cureton says some school and school districts, as well as colleges and universities, have “truly stepped forward as leaders on creating a trauma-informed culture,” whether at the level of the counseling center, department or institution. However, she notes that counselors who work in settings such as the criminal justice system or serve resource-strapped communities such as refugees or immigrants often feel they are still waiting for the trauma-informed approach to be acknowledged and supported. “It comes down to the readiness to change to address trauma among leaders in the immediate setting and beyond (e.g., organizational headquarters, county or state boards and legislatures),” Cureton explains. “Counseling settings with leaders who are aware of and responsive to reports of trauma from those they serve and employ are simply more likely to work to prioritize trauma-informed care funding and implementation. However, when society and leaders of counseling settings devalue some lives (e.g., BIPOC [Black, Indigenous and people of color] communities, people with offenses, people from other countries), we give them fewer resources for trauma-informed care and other needs.” Melissa Youngblood, an LPC and certified clinical trauma professional at Therapeia, a group practice in Royal Oak, Michigan, says trauma and trauma-informed care are often not given the attention they deserve. “I think there is a lack of emphasis on trauma in our training programs and clinical internships,” she says. “There is often a general approach in outpatient clinics that overlooks having staff trainings and psychoeducation about trauma-informed care for our clients.” The general approach in most clinics is to develop basic skills in diagnostics and treatment planning, but trainings often overlook the need to have staff develop advanced capabilities in trauma modalities and trauma-informed care, Youngblood explains. Work settings and institutional factors also play a role in the success of implementing trauma-informed care principles. Agencies working with mandated or incarcerated populations, for example, often do not have the support or buy-in to incorporate this type of care because the administrations and staff do not understand how these principles promote rehabilitation, says Tyler, an associate professor of the practice in the Department of Human and Organizational Development at Vanderbilt University. Adapting existing practices and policies to align with trauma-informed care principles can also be met with logistical challenges and institutional resistance to change, she adds. “This requires education and collaboration with colleagues, administrators and stakeholders to foster a culture that supports trauma-informed approaches,” she says. According to Lounsbury, some of the challenges facing mental health counseling systems that want to adopt trauma-informed care include the mental health worker shortage, a lack of funding for mental health services and disparities in funding for mental health treatment. “Because some agencies do not have enough counselors to meet the need, resulting in waiting lists in services for clients, and because these agencies are reliant upon billable hours to keep their doors open, it can be challenging to take clinical staff ‘offline’ for training and supervision,” she says. Another pressing factor is the fact that counselors often do not have the space to support their own wellness at some mental health agencies, which can result in secondary traumatic stress and burnout. So Lounsbury stresses that a trauma-informed care approach must acknowledge the impact the work has on counselors. Counselors sometimes struggle to enact trauma-informed care because their work setting has procedures that conflict with its principles. For example, Cureton says a school or college counselor who works in an educational setting or state that requires them to avoid specific topics or words (such as “gay”) or to report specific details about a student’s identity are faced with potentially compromising the client’s safety, retraumatizing the client and essentially withholding trauma-informed care. “Sometimes this is the nature of any work in systems — policies aimed at fairness, which then overly restrict counselors from making informed decisions customized to specific clients,” she adds. “Other times, it is structures that enact values centered more on money and power than on care and human dignity.”

Advocates for trauma-informed care

Despite these obstacles, clinicians can play a pivotal role in helping to ensure that trauma-informed care is the standard for treatment and workplace development in mental health. In fact, Tyler says counselors’ clinical expertise and understanding of the impact of trauma on the micro and macro levels help position them as advocates for change regarding trauma-informed care. Counselors can educate public agencies on the effects of trauma and guide institutional and agency staff in recognizing signs of trauma, she notes. “They can collaborate with interdisciplinary teams to develop policies and practices that prioritize safety, choice and empowerment for clients,” Tyler continues. “Furthermore, counselors can champion a culture of continuous learning and sensitivity, ensuring that staff are equipped to provide trauma-informed care effectively.” Working to ensure that trauma-informed care is the prevailing mindset in mental health and that all clients are viewed through a trauma-informed lens is a valuable goal for counselors, particularly after COVID-19. “I think that post COVID-19, there is a shared trauma that we experienced as a community enduring a pandemic,” Youngblood says. “We can no longer say ‘this client has no history of trauma,’ and we must begin to assess the impact of COVID on their mental health. We must acknowledge and support our clients in processing the impact for years to come.” Dukes agrees. “Every client we work with for the next 10 or so years will have been impacted in some way,” she says. “Practicing trauma-informed care will allow us to discuss not only the trauma of the pandemic but also how our identities and histories impacted our understanding and overall experience of the pandemic.”  

---

Lisa R. Rhodes is a senior writer for Counseling Today. Contact her at lrhodes@counseling.org.

---

Opinions expressed and statements made in articles appearing on CT Online should not be assumed to represent the opinions of the editors or policies of the American Counseling Association.