11 Trauma-Informed Communication

Watch and Listen to the Following Media Clip

Introduction: What is a Trauma-Informed Approach?

Many people experience trauma in their lives, many of whom do not seek timely health care. Thus it is essential for all communications with health care professions, to begin with, a foundation of understanding that all persons have experienced trauma at some time in their lives. The approach is called trauma-informed communications. Trauma refers to any experience that may cause intense physical and psychological stress reactions. It can refer to “an event, series of events, or set of circumstances that is experienced by an individual as physically or emotionally harmful or threatening and that has lasting adverse effects on the individual’s functioning and physical, social, emotional, or spiritual well-being” (Substance Abuse and Mental Health Services Administration (SAMHSA), 2019).  To establish effective communication, healthcare professionals need to know the six principles of trauma-informed care: safety, trustworthiness and transparency; peer support; collaboration and mutuality; empowerment, voice and choice; and cultural issues (National Center on Domestic Violence, Trauma & Mental Health, 2019).

Children and young people who have experienced trauma have little space for learning. Their constant state of tension and arousal can leave them unable to concentrate, pay attention, retain and recall new information. Their behaviour is often challenging in the health care environment when the goal is to assist the client. Trauma can also affect a client’s decisions or the ability to trust others, including health care professionals. As a result, it becomes increasingly challenging for the trauma survivors when communicating with others as they tend to protect themselves from reliving the traumatic experience. The traumatized client may feel like danger lurks around the corner constantly.

Assessing What You Already Know

Alternative Text Option

Understanding Trauma

Different types of trauma may include:

• Acute trauma from a singular incident, such as a natural disaster, accident, or acts of violence.
• Chronic trauma is repeated and prolonged, resulting from situations such as domestic violence or abuse.
• Complex trauma is varied, and multiple traumatic events, often of an interpersonal nature, such as abuse or profound neglect, often occur with caregivers.
• Historical trauma may include multigenerational and experienced by a specific cultural, racial or ethnic group, often related to significant events that oppressed a group of people, such as slavery, the Holocaust, forced migration or violent colonization (City of San Diego, n.d.).

One may experience one, some or all these traumatic stresses during their lifetime. Multiple studies show that severe or ongoing exposure to highly stressful or threatening events can significantly impact a client’s ability to function in a socially acceptable manner (Haskell & Randell, 2019; King, 2021; National Child Traumatic Stress Network (NCTSN), 2017). Therefore the health care administrator must be informed in the practice of trauma-informed communication. The American Substance Abuse and Mental Health Service Administration (SAMSHA) defines “a program, organization, or system that is trauma-informed as one that: 1) Realizes the widespread impact of trauma and understands potential paths for recovery; 2) Recognizes the signs and symptoms of trauma in clients, families, staff, and others involved with the system; 3) Responds by fully integrating knowledge about trauma into policies, procedures, and practices; and 4) Seeks to resist re-traumatization actively” (2019).

Why is Utilizing a Trauma-Informed Approach Essential for the Health Care Administrator?

As a professional Health Care Administration, one will work in various settings and encounter very diverse populations. A trauma-informed approach (TIA) addresses vital information about the client’s well-being that considers adverse life experiences and their potential influence on their health care decision-making. A trauma-informed approach is critical to promoting lifelong health and well-being for anyone who has had adverse childhood and adult experiences.
All staff should have initial training on a trauma-informed approach and how to apply trauma-informed principles in every client interaction. The awareness and application of the trauma-informed approach increase trust and reliability in all interactions with clients (OASH, 2021; National Child Trauma Stress Network (NCTSN), 2020). Not all clients will appear as they have experienced past trauma, however, if the HCA develops an awareness of their professional approach it can prevent retraumatizing the client. Retraumatization can occur when a client must explain their story over and over with multiple health care providers or service workers (SAMHSA’s Trauma and Justice Strategic Initiative, 2014).

The HCA helps to avoid re-traumatizing the client can include the HCA reviewing the client’s chart for referral or consultation reports before asking the client questions. Often times the HCA has the information, however, the client must repeat their story. The HCA can use their verbal assessment skills to assess if a client is uncomfortable in a setting and move them to another area. Any sensory can trigger a client to re-experience an event. Consider smells, sights, sounds or touches that may be interpreted as good or bad can take action to change the health care environments. At times the client may cringe when exposed to a particular noise, using the HCA assessment skills of the situation can allow the HCA to be proactive in preventing retraumatizing a client. It may be best to assume that all clients have a past and some may have been trauma-induced.

Media 11.2. What is Trauma-Informed Care? [Video]. From Center for Health Care Strategies, 2019.

Key Trauma-Informed Principles

The goal of the helping interview is to achieve and maintain a trusting relationship with the client.
HCA and other professionals model positive, non-shaming communication to support healing for those in need and promote health and well-being for everyone. The HCA should listen patiently without interruption, pleasantly provide information and answers, and ensure all participants have opportunities to speak and be heard.
HCA’s can provide non-judgmental, warm, empathic, and genuine interactions at all times, including ongoing training to connect with their clientele while maintaining healthy professional boundaries (National Child Trauma Stress Network (NCTSN), 2020).

Building safety, transparency and trustworthiness, peer support, collaboration and mutuality, empowerment, voice and choice, and cultural issues are vital principles for a trauma-informed approach (National Child Trauma Stress Network (NCTSN), 2020). The HCA should recognize that responses to trauma can include dismissing feelings, avoiding things that are reminders of previous traumatic experiences, and increased sensitivity to these reminders, people, and the environment. It may be an opportunity for the HCA to provide information for the clients about trauma and its effects.  When possible, offer flexibility and choices as to how a survivor can interact with our programs and staff.

It is essential to take a survivor’s trauma responses seriously (e.g., they may be jumpy or anxious, have a hard time sleeping, or they may need to avoid a neighbourhood that has too many reminders of past experiences). This can be demonstrated by communicating respectfully using appropriate terms and language to build healthy, trusting and professional relationships and be an active listener (OASH, 2021).

Best Practices for Trauma-Informed Communication

• Communicate respectfully. The tone of voice can significantly impact how people receive and react to messages.
• Be respectful of others’ life experiences. Recognize that someone’s mental health issues, substance abuse or physical health concerns may be rooted in “what has happened to them” and not because “something is wrong with them.”
• Build healthy relationships. When interacting with others, treat people with dignity and respect.
• Be an active listener.
• Focus on behaviours and not the person.
• Use appropriate body language.

Creating a Safe environment for all Clients to Communicate Without Fear of Judgement

An emotional safety setting may seem challenging to achieve because it is hard to measure. One definition of emotional safety includes “a feeling that your innermost thoughts, feelings and experience are, and will be, honoured as one honour themselves. You need not prove nor impress; you simply are. When a client feels safe, they feel open, even, at ease, and fluid with the spontaneity of a healthy child.”

The HCA should understand emotional safety. Emotional safety means that one feels accepted; it is the sense that one is safe from emotional attack or harm. Most trauma survivors have probably felt emotionally unsafe or had their sense of “being all right” taken away by others. Many survivors share that the ongoing and unrelenting attacks on their sense of well-being are more painful than a beating (King, 2009). Clients should always feel they are welcome in your health care setting (Washington Coalition of Sexual Assault Programs, 2012).

The health care exposure may help clients manage feelings. Trauma may affect a person’s ability to achieve an emotional balance. Many survivors may experience diverse feelings and worries that make it difficult to make decisions, follow plans, and tend to responsibilities for their health care needs. Thus, HCA can provide clients with a greater sense of control, such as booking appointment times conducive to the client’s schedule. The HCA can activate and engage the client in thinking and planning to gain or lead to a better sense of control. This can also mean providing or offering a caring and calming presence, helping with tasks that appear to be overwhelming, such as completing paperwork or online scheduling of appointments or directions.

When possible the HCA can provide a relaxing place. When providing a calm environment, the message sent to the client is that one cares about their privacy and is interested in attentively listening to how the client feels and their status physically and emotionally. A soothing space may be a quiet corner of a quiet room or a comfortable chair, low lights, a flexible door that can be closed or kept open, a source of quiet music. Alternatively, it could be a room with plants or flowers, videos of beautiful scenery, a radio or CD player, and space for writing. Different things will be soothing at different times and to different types of clients and department settings.

Once again, the HCA can provide information about trauma. Trauma will disrupt a person’s sense of well-being, and it has direct effects on the brain and causes changes in how the person perceives and experiences the world and how they perceive danger (Haskill & Randell, 2019). Learning about trauma triggers can help clients to understand and manage their feelings and increase their sense of control and autonomy.

It is essential for the HCA to provide clear information and avoid surprises. When clients feel emotionally unsafe, they may wonder which people have the power or authority in the health care setting. They may be concerned about what the professionals will do with their information. Providing clear and accurate information about policies, procedures, rules, plans, and activities helps support emotional safety (Schladale, 2013).

The HCA may be able to help trauma survivors feel comforted and in control. Each survivor has a pattern of needs related to emotional safety. For example, one survivor may find it reassuring to have clear directions or information from staff who speak with authority and expertise. For someone else, withdrawing from external stresses to explore their thoughts and feelings will be the jump start they need to plan for their future. An essential aspect of helping survivors feel comforted and in control is ensuring that survivors know they can ask for what they need. Such as asking for tissue, and they may express their opinions and wishes—for example, seeing a particular health care professional or appointment date and time. (OASH, 2021; National Child Trauma Stress Network (NCTSN), 2008).

Understanding Symptoms as Adaptations

In trauma-informed settings, a survivor’s behaviour reflects adaptations to a world that has not always been safe. Instead of trying to fix a client’s behaviour, one needs to understand multiple variables such as brain chemistry, genetic tendencies, and life experience as well as the person’s access to resources) affect how the world looks to them, what feels safe, what they think may happen, and how they ask for and use healthcare services (National Center on Domestic Violence, Trauma & Mental Health, 2011). If survivors have a mental illness, they know that they neither have to hide it nor disclose it to get the help they are seeking.
Of course, this does not mean that the HCA will not have reactions if a person’s behaviour is troublesome, disrespectful, or dangerous. It does mean that the way the HCA communicates their reactions should not shame or embarrass the client. Saying, “We want everyone to be safe and comfortable here. You have been shouting for a while, and that worries some of us,” is better than saying, “You cannot keep making all that noise; you need to sit down and please be quiet.” (National Center on Domestic Violence, Trauma & Mental Health, 2011). Both statements let the client know that people are reacting to their behaviour, but be respectful and acknowledge that the survivor is doing the best they can (Haskell & Randall, 2019).

The Impact of Trauma on LGBTQ2S+ Youth

The following video introduces the HCA to the needs of lesbian, gay, bisexual, transgender, queer, questioning, two-spirited, and other (LGBTQ2S+) youth who have experienced trauma. “As with many cultures, language, acronyms, and approaches are fluid and can change over time; most importantly, what is accepted may differ between individuals (Rowe, 2020).” This video discusses creating safe, welcoming and inclusive environments for youth who have experienced trauma and identify as LGBTQ2S+.

Media 11.3. Safe spaces, safe places: Creating welcoming and inclusive environments for traumatized LGBTQ youth. [Video]. From National Child Traumatic Stress Network, 2017.

Trauma-Informed Communication Strategies

What can the HCA do? By using focused eye contact and engaging body language can create open non-threatening communication. The HCA can ask open-ended questions to answer the who, what, when, where and how of discussed topics. When the client speaks, avoid interruptions, judgment and do not try to fix things. Also, remember to focus on behaviours and not the person. (National Child Trauma Stress Network (NCTSN), 2008; National Child Trauma Stress Network (NCTSN), 2020; Family Violence Prevention Fund, 2004).

Check your Understanding

Summary

In this chapter you have:

• Developed the understanding of a trauma-informed approach to communication.
• Developed a trauma-informed approach in the health care settings.
• Developed an awareness of the client’s reactions or behaviours that may be related to past trauma.
• Created safe and less traumatic environments for clients who may have experienced trauma.

Key Terms:

Active listener: The act of listening carefully.

Adaptations: The act of changing to fit in.

Adverse Effects: Something that can go wrong during a treatment that can affect an individual for the rest of their life.

Attentively: The act of being observant.

Authority: The power an individual has to give orders and make rules.

Autonomy: An individual acting differently and separating from others (Merriam Webster, n.d).

Circumstances: Something happening where nobody has control of it.

Clientele: Customers/clients.

Conducive: The act of being more flexible for a client.

Disrespectful: The act of being rude and going against the rules.

Emotional Safety: A feeling that your innermost thoughts, feelings, and experiences are, and will be, honoured as one honours themselves.

Empathic: The act of being understanding.

Environment: The place you are surrounded by.

Event: Something happening.

Genuine: The act of being real, truthful and sincere.

Helping Interview: An interview with a person seeking help and the people providing that help.

Interactions: The involvement with another individual.

Judgment: To make considered decisions or come to conclusions about another based on past experience, stereotyping or prejudice.

Multigenerational: Being related to multiple generations.

Perceive: The act of being aware of something.

Reaction: A response to words and actions.

Severe: Very bad/ serious.

Shame: A feeling of humiliation.

Spontaneity: The state of being spontaneous (Merriam Webster, n.d).

Survivor: To continue to function after a traumatic experience.

Tendencies: An individual’s thoughts and actions. (Marriam-Webster, n.d.)

Trauma: Pertains to a deeply distressing or disturbing experience. A psychological or physical injury (Merriam Webster, n.d).

Trauma-informed: The act of recognizing trauma within individuals.

Traumatic: The act of being emotionally stressed to the point where it can affect an individual mentally and emotionally.

Triggers: Something that causes an individual to have trauma.

Troublesome: Being difficult.

Well-being: Being happy and healthy (Merriam Webster, n.d).

References

Center for Health Care Strategies. (2019, January 23). What is trauma-informed care? [Video]. YouTube. https://youtu.be/fWken5DsJcw

City of San Diego. (n.d.). Trauma informed resources. Commission on Gang Prevention and Intervention. https://www.sandiego.gov/gangcommission/directory/trauma

Family Violence Prevention Fund. (2004, August). Identifying and responding to domestic violence: Conesensus recommendations for child and adolescent health. Futures Without Violence. http://www.futureswithoutviolence.org/userfiles/file/HealthCare/pediatric.pdf [opens a PDF file]

Haskell, L., & Randall, M. (2019, January 1). Impact of trauma on adult sexual assault victims: What the criminal justice system needs to know. SSRN. https://papers.ssrn.com/sol3/papers.cfm?abstract_id=3417763

King, J. (2009). Emotional abuse: The lack of emotional safety as an internal indicator in abusive relationships. Prevent Abusive Relationships. https://www.preventabusiverelationships.com/articles/emotional_safety.php

National Center on Domestic Violence, Trauma & Mental Health. (2011, August). Tips for creating a welcoming environment. Creating Trauma-Informed Services: Tipsheet Series. http://nationalcenterdvtraumamh.org/wp-content/uploads/2012/01/Tipsheet_Welcoming-Environment_NCDVTMH_Aug2011.pdf

National Center on Domestic Violence, Trauma & Mental Health. (2019). Creating trauma-informed services tipsheet series. http://www.nationalcenterdvtraumamh.org/publications-products/creating-trauma-informed-%20services-tipsheet-series-for-advocates/

National Child Trauma Stress Network (NCTSN). (2008, October). Child trauma toolkit for educators. https://www.nctsn.org/resources/child-trauma-toolkit-educators

National Child Trauma Stress Network (NCTSN). (2020). Child welfare trauma training toolkit: Supplemental handouts questions for mental health providers. https://www.nctsn.org/print/1145

National Child Traumatic Stress Network (NCTSN). (2017, July 17). Safe spaces, safe places:  Creating welcoming and inclusive environments for traumatized LGBTQ youth [Video]. YouTube. https://www.youtube.com/watch?v=8zNbQ_8KRew

OASH. (2021). Meaningful youth engagement. Office of Population Affairs.  https://opa.hhs.gov/adolescent-health/positive-youth-development/meaningful-youth-engagement

Robert Wood Johnson Foundation. (2013, May 12). The truth about ACEs [Infographic]. https://www.rwjf.org/en/library/infographics/the-truth-about-aces.html?cid=xsh_rwjf_pt

Rowe, K. (2020). Improving provider confidence and partnership with LGBT patients through inclusivity and education. Doctor of Nursing Practice Projects, 5. https://scholarworks.seattleu.edu/dnp-projects/5

Schladale, J. (2013). A trauma-informed approach for adolescent sexual health. Resources for Resolving Violence. https://foster-ed.org/wp-content/uploads/2017/01/A-Trauma-Informed-Approach-for-Adolescent-Sexual-Health-2013.pdf [opens a PDF file]

Substance Abuse and Mental Health Administration (SAMHSA). (2019, August 2). Trauma and violence. U.S. Department of Health & Human Services. https://www.samhsa.gov/trauma-violence

SAMHSA’s Trauma and Justice Strategic Initiative. (2014, July). SAMHSA’s concept of trauma and guidance for a trauma-informed approach. https://ncsacw.samhsa.gov/userfiles/files/SAMHSA_Trauma.pdf [opens a PDF file]

Washington Coalition of Sexual Assault Programs. (2012). Creating trauma-informed services: A guide for sexual assault programs and their system partners. WCSAP. https://www.nsvrc.org/sites/default/files/publications/2018-04/Trauma-Informed-Advocacy.pdf [opens a PDF file]

Assessing What You Already Know Descriptions

Question 1

Have you ever been in an uncomfortable situation where you continued to ponder the exchange or incident? Did you: (Select all that apply)

1. Create other resolutions to the incident
2.  Think about the incident for the day
3. Think about the incident before falling asleep
4. Discuss the incident with others more than once

The correct response is option one, two, three and four. Remember we can all respond is differing ways when pondering an uncomfortable situation. What one feels is not wrong.

Question 2

Have you ever been exposed to something where it reminded you of a past experience?

Such as a smell that reminded you of a place or person. The response to the scent may create a trigger, good or bad, and is very individual to their individual experience. How do you feel when you smell pizza? (select all that apply)

1.  it reminds me of my friends
2. it makes me feel happy
3.  it makes me feel hungry
4.  it reminds me of my family
5.  it makes my stomach feel upset
6. It makes my mouth water

The correct response is all of the above. Often smells will remind us of something. How we feel or interpret the feeling will differ between individuals. How one feels is not wrong. Return to Activity