Trauma informed care has an explicit focus on instilling hope and supporting recovery, but it is important to acknowledge that therapeutic responses to trauma vary in their complexity.
Supporting recovery involves responding appropriately to the impacts of all types of trauma - past trauma experiences, as well as recent trauma experiences. Supporting recovery may also mean helping to manage risks for future exposure to trauma.
Practitioners need to balance instilling hope with getting the nature and timing of their support right. For example, some trauma reactions might look unhelpful, but can serve important protective functions, and need to be understood in terms of what function they serve for the person. Seeing the world as a dangerous place or seeing people as likely sources of threat are often adaptive and realistic beliefs for people living in risky environments.
Having said this, all practitioners at any point of engagement can play a meaningful role in supporting a young person who has experienced trauma. This role can include:
- providing the person with a positive experience of disclosing a trauma
- providing normalising information about how trauma effects people
- promoting recovery through building on their strengths and current coping strategies
- supporting social connectedness through involving significant others
- supporting a referral to a specialist posttraumatic mental health intervention
The practitioner’s role in the young person’s recovery can depend on the context of the work, the timing of the trauma, the severity of the young person’s reactions to the trauma, and the practitioner’s skill set and training.
Assessing exposure to trauma and managing disclosure
While TIC encourages having an increased awareness of the general prevalence of trauma amongst your service’s clients, where possible it is important to be aware of your client’s specific trauma history. The key principles to asking about a trauma history are to be direct and specific. For example, a good opening question is:
“Have you experienced a particularly frightening or upsetting event?”
To help the young person answer the question it can be useful to give examples of specific potentially traumatic events that they may have experienced, such as:
- serious accident (like a car accident)
- natural disaster (like fire or flood)
- physical attack or assault
- sexual assault
- seeing somebody being badly hurt or killed
- domestic/family violence or abuse
- physical or emotional abuse as a child
- being threatened with a weapon a held captive
- war (as a civilian or in the military)
- torture or an act of terrorism
- any other extremely stressful or upsetting event
Not every disclosure about a traumatic experience needs to go into detail. Sometimes it may be sufficient for the young person to simply let the practitioner know that a traumatic event happened. It is important to help the young person make an informed decision about when, why and how to share the experiences of trauma, for example by saying:
“I’m aware that telling someone about a traumatic experience in detail can be difficult. You are in control of what we talk about today - it might feel like enough to tell me the type of experience you had without going into detail. This will help me better understand your experience without overwhelming you today”
A frequent concern of practitioners is that they may potentially ‘open Pandora’s box’ if they ask about the trauma then not have the skills, resources or time, or be in the appropriate setting, to adequately support the client. It is safe to support a client to open up about the trauma experience, however there are some important considerations to help manage the disclosure safely. Consider:
- the young person’s level of desire to talk about the trauma, and in what level of detail
- the young person’s emotional and physical safety
- the potential duration of engagement with client , that is whether you have 15 minutes, several sessions, or no further opportunities to follow up with the client after the disclosure
- the practitioner’s experience with delivering evidence-based trauma interventions
- the organisation’s capacity for providing support to the young person, and its links with specialist trauma services.
Support recovery through skills strengthening and stabilisation
Many young people who have experienced trauma will benefit from improving their general coping skills. This may be sufficient in and of itself to support their recovery, or can be part of important stabilisation and preparatory work for those people who need to be referred to specialist evidence-based trauma focussed interventions.
Many of the developmentally appropriate evidence-based intervention components that practitioners already use to support clients for their other problems are also helpful for those affected by trauma.
Some such skills include:
Fostering engagement - Despite there being effective treatment available, only a minority of young people with posttraumatic health problems engage in ongoing treatment (McKay, Lynn, & Bannon, 2005), so developing a good therapeutic alliance is a foundation for any further work. Refer here for strategies for keeping adolescents in engaged.
Establishing safety – While important to all TIC, this may require more effort and time to establish with young people who have experienced repeated trauma.
Improving arousal management and distress tolerance skills – Use skills that are tailored to the individual’s needs, with a focus on emotion regulation skills, stress management and cognitive restructuring. Increasing the client’s capacity for emotional awareness and expression may be particularly relevant for those how have experienced repeated trauma. Refer here for some useful strategies.
Strengthening social connectedness – As discussed previously, social supports is a key predictor of recovery from trauma, and there are established methods for improving a person’s social connectedness. For young people who have experienced repeated interpersonal trauma, more attention may need to be paid to relationships and attachments within and outside the family context, and interpersonal emotional and physical safety skills.
Preparing for trauma specific interventions (if applicable) – Pay particular attention to the management of current crises or stressors before commencing trauma-focused therapy
Relapse prevention – Apply the same principles of relapse prevention for substance use to the trauma related issues i.e., identify triggers, warning signs, helpful strategies (and strategies to be avoided) and available supports.
Practical detail on how to deliver each of these intervention components is not the focus of this module. If you are not confident with delivering these components with young people affected by trauma, you may find it useful to seek further professional development on these topics.
Substance use and posttraumatic mental health comorbidity
Whenever possible address the young person’s substance use problems and other posttraumatic mental health concurrently. However, there may be situations when the practitioner needs to prioritise AOD treatment, for example, if the young person’s use is compromising other treatment outcomes, greatly exacerbating their comorbid symptoms or they are using substances at high risk levels. Reduced AOD use sometimes results in an improvement in mood & anxiety symptoms, establishing the ‘true’ baseline in relation to the young person’s other symptoms.
Provide an effective referral for specialist trauma interventions
A significant minority of young people will develop a mental health disorder after a trauma, and a referral for a specialist and evidence-based posttraumatic mental health intervention may be required. The referring practitioner has an important role in:
- linking the young person with an appropriate specialist (e.g., psychologist, psychiatrist with experience in evidence-based interventions)
- letting the young person (and their caregiver if applicable) know how to access specialist care. For example, accessing a psychologist through Medicare with a referral from their GP .
- educating and familiarising the young person (and their caregiver if applicable) with what to expect when they attend an appointment for trauma focussed interventions
- developing any shared care arrangements with the specialist practitioner i.e., it may be that you agree to continue one aspect of their care while the specialist focusses on the specific trauma work, or there may be a pause in your work with the young person that resumes after a period of appointments with the specialists.
Below is information on evidence-based interventions for working with young people with common mental health disorders:
Include family, significant others and other health professionals to support the young person
Adolescents are part of a system (typically a family) meaning that their symptoms have the potential to both influence, and be influenced by, anything that is happening within the system they live. It is especially important to involve a significant other when working with a young person affected by trauma as there is evidence that perceived social support plays a role in promoting recovery and resilience after a traumatic event (Ozer & Weinstein, 2004).
Significant others could include a parent, grandparent or other family member, their partner, carer or friend, as well as other health professionals involved in the young person’s care. The significant others’ involvement could occur in several ways:
- As gatekeepers to support - encouraging continued engagement with therapy
- As another perspective - providing another perspective on the young person’s reactions and recovery
- As coaches - reinforcing strategies discussed during your appointments and direct involvement in ‘homework’ tasks
- As role models – modelling helpful or less helpful ways of dealing with traumatic stress
- As a social support - through simply being another social connection for the young person
For more information on involving family and significant others, click here
In the case of young people who have experienced trauma, especially complex trauma, it is important to consider the impact this has on their relationships with others - difficulty trusting people, feeling hostile and separate from others, and difficulty establishing or maintaining safe relationships. Particular considerations include:
- When an adult caregiver and young person have experienced a shared trauma and are both experiencing posttraumatic health problems, their symptoms may exacerbate each other’s. For this reason, it may be preferable to encourage the caregiver to access treatment first or in parallel.
- Seek agreement from the young person on which person(s) to involve in their recovery, and potentially attend joint appointments. Ensure that you are aware of the significant other’s relationship with, or experience of, the traumatic event.
- Set up clear confidentiality boundaries with the significant others i.e. that they do not disclose the trauma to others without permission.
- Be aware that the significant other may have been unaware of the trauma until now. Moreover, even if the young person does not yet wish to disclose the trauma to the significant other, there is still a useful support role that they can play.
From an organisation level, supporting a young person’s recovery from trauma can be achieved through:
- providing training, ongoing professional development and supervision to staff in order to improve and maintain staff and service trauma literacy.
- establishing strong referral links with local specialist trauma services. This could even involve moving toward having a specialist provider located within the organisation.