Trauma and Trauma Informed (TI) Approaches to Care:Applications to Occupational Therapy Practice

by Mirtha Montejo Whaley, PhD, MPH, OTR/L

Trauma is widespread and has profound effects that can lead to emotional and physical distress throughout the lifespan. Statistics from the Center for Disease Control and Prevention (CDC) on abuse and violence in the United States indicate the following:

•  One in four children experiences some sort of maltreatment (physical, sexual, or emotional abuse).
•  One in four women has experienced domestic violence
•  One in five women and one in 71 men have experienced rape at some point in their lives — 12% of these women and 30% of these men were younger than 10 years of age when they were raped.

While awareness of childhood trauma and Post Traumatic Stress Disorder related to war and political conflict has increased, other forms of trauma and other populations are less known. Trauma-informed approaches to care are congruent with OT values and principles, and have been adopted by health and social service professionals and policy-makers. This article aims to raise awareness of trauma and Trauma Informed Care and stimulate a discussion of their application across age cohorts and practice settings in occupational therapy.

What is trauma?

An event, series of events, or set of circumstances that is experienced by an individual as physically or emotionally harmful or life threatening and that has lasting adverse effects on the individual’s functioning and mental, physical, social, emotional, or spiritual wellbeing (SAMHSA, 2012, p. 2).

Trauma can include direct and indirect exposure to violence, abuse, neglect, natural and man-made disasters, accidents, terrorism, traumatic grief, bullying, refugee trauma, secondary trauma, and food insecurity to name just a few (Fette, Lambdin-Pattavina & Weaver, 2019; SAMHSA, 2014).

Who is at risk:

Individuals of any age, race, gender, sexual orientation, religion, level of education, and socioeconomic status (Huang et al., 2014). Traumatic events affect individuals (including those who provide care for victims of trauma), families, and communities. There are individuals who are at higher risk of experiencing and/or having exposure to trauma.

•  Youth in foster care due to a higher risk of experiencing violence, abuse, neglect (Fratto, 2016 p. 440)
•  Children and adolescents who are substance users or have substance-abusing parents
•  Adults experiencing financial stress which impacts ability to support a family and frequently experience loss of needed community organizations or services. Children in these families and communities are also at risk
•  Military and veteran families who experience stressors related to deployment, repeated moves, disrupted social relationships, etc.,
•  Individuals who have intellectual and developmental disabilities (trauma from needed medical and surgical procedures; physical, emotional, sexual abuse; restraint and seclusion)
•  Individuals who are homeless, particularly homeless youth, due to the loss of home, community, friends, daily routines and occupations, sense of safety and stability Additionally, many homeless youth have been victims of early childhood and multiple trauma in the past
•  Individuals who identify as LGBTQ, particularly youth in this population, as they experience bullying, stigma, rejection, and harassment; intimate partner violence, and physical and sexual abuse

Are there any protective factors?

• A strong support system
• Limited or no prior traumatic experiences
• Resilience

What’s the issue?

• Response to a traumatic event is very personal and effects can be lifelong, affect well-being and quality of life, and increase the risk for premature death
• Survivors of trauma may not seek services specifically for trauma, primary care visits are likely to miss indications of trauma (Barnes & Andrews, 2019)
• Effects of trauma are frequently misdiagnosed as mental illnesses, leading to stigmatization and retraumatization
• Neurologically, traumatic experiences in childhood can disrupt normal emotional, cognitive, and social development; development of self-esteem; coping, self-regulation, and critical thinking skills; academic performance; and motivation (O’Connell, Boat, & Warner, 2009)
• Children and youth who experience trauma may make lifestyle choices and engage in behaviors later on that affect their health, safety, and occupational well-being (CDC, 2019)
• Occupationally, children and youth who have experienced trauma are at higher risk for limited role and occupational opportunities throughout the lifespan, due to the effect of the trauma on their ability to develop health relationships, complete their education, have access to employment opportunities, income, and health care
• Trauma increases the risks for future victimization, including human trafficking, as well as the risk for becoming perpetrators of violence

What is Trauma-Informed Care (TIC) and why do we need to know about it?

The implementation of Trauma Informed Care is actually very similar to the response to the HIV/ AIDS epidemic in 1985, through the establishment of Universal Precautions. We learned to use personal protection while treating all individuals, as if everyone was a potential source of infection and doing so, helped reduced the stigma of HIV/AIDS. Our interactions with all our clients should be such, that we prevent retraumatization through understanding that any of our clients may have experienced some sort of trauma. TIC interventions shift the focus from treating trauma-related symptoms, to addressing symptoms within the context of the individual’s history (Hales et al., 2019 p. 529). Individuals who develop dementia or Alzheimer’s disease may, in their disorientation, re-experience traumatic events at a time when they have the least resources to deal with their fears and pain. We may have in our caseloads older adults who are survivors of the Holocaust, veterans of wars, immigrants who suffered incredible pain and adversities, adults who were victims of childhood trauma. We should exercise care in our interactions with them as well. In the end, TIC is about safety, trust, choice, collaboration, and empowerment (Mihelicova, 2018 p. 144; SAMHSA, 2014).

There are several evidence-based TIC interventions, all of which require training and may be the domain of specific disciplines. But there are also opportunities to enhance our knowledge and skills, as we are likely to encounter children and adults who have experienced trauma in their lives.Working with these clients will require that we:

• Think outside of our traditional professional box(es)
• Explore and accept our roles in TIC and our potential for engaging in evidence-based interventions
• Know the contexts and conditions that promote ACEs as well as those that reduce or prevent negative effects and outcomes
• Become aware of available resources, including the research evidence and guidelines available through the CDC and other public health agencies
• Seek training in TraumaInformed Care from a reputable source (CDC and organizations involved in injury prevention, local crisis centers, etc.)
• Articulate our unique contributions in creating supportive environments and helping individuals cope through empowerment, mastery, reinstatement of roles, occupations, routines, habits
• Collaborate across all contexts, i.e., our work environments, communities, as well as local, state and federal governments to ensure conditions that will protect individuals from traumatic experiences, and to advocate for evidence based programs and interventions to assist those who have already been affected.

Because trauma and the reaction to trauma are bound by geographic, cultural, ethnic, and religious beliefs, and values, we need to be mindful and culturally aware. How individuals and societies interpret trauma and whether and how they seek help or remain silent are part of the cultural context (SAMHSA, 2014 p.26). Social inequalities and stigma are frequent barriers to help-seeking that can lead to retraumatization. Victims of trauma are also at risk for retraumatization when service providers interact with them in ways that are intrusive, uncaring, and unsupportive. https://www. nctsn.org/trauma-informed-care/ culture-and-trauma.