LAC Department of Mental Health Public Portal

CLINICAL QUALITY OF CARE – PRACTICE PARAMETERS

Office of the Chief Medical Officer
Clinical Operations

Trauma-Informed Care

ClinP-03

Category: Clinical Programs
Published Date: May 2022

PARAMETER GOAL
1. Define and educate staff on a trauma-informed lens
2. Contextualize trauma-informed care within a public mental health safety net
3. Embed trauma-informed practice within a framework responsive to social justice
4. Integrate knowledge about trauma into clinical practice
5. Understand and prevent vicarious trauma for practitioners
6. Understand that trauma recovery is not a linear process and there are no timeframes
TERMINOLOGY
1. Adverse Childhood Experiences (ACEs): Potentially traumatic events that occur in childhood (0-17 years), including aspects of a child’s environment that can undermine their sense of safety, stability, and bonding. ACEs are linked to chronic health problems, mental illness, and substance use problems in adulthood.
2. Resiliency-Informed Practice: Recognizes the strengths and natural ability to overcome adverse reactions to trauma and develop additional coping mechanisms to better manage current and future traumas.
3. Trauma: An emotional response to a terrible event that causes emotional pain, distress, or inability to cope.
4. Trauma-Informed Care: A framework that involves:
  1. Acquiring knowledge about the prevalence and effects of trauma
  2. Utilizing best practices
  3. Integrating knowledge about trauma into treatment planning
  4. Avoiding re-traumatization by approaching clients with non-judgmental support
MEASURES
1. Before screening clients for exposure to ACEs:
  1. Establish proficiency in trauma screening
  2. Ensure sensitivity to cultural, ethnic, and socioeconomic characteristics
  3. Utilize care coordination to avoid rescreening:
    1. Obtain consent to share results across treatment settings and reduce the potential for re-traumatization
2. Utilize screening information strategically to support a client's health
  1. Screen for trauma after establishing a relationship with a client
  2. Gather information about social and systemic inequities experienced by the client, their family, or their caregiving network. This may include:
    1. Historical or current discrimination or oppression (e.g., racism, sexism, ableism, xenophobia, homophobia, transphobia)
    2. Housing insecurity or homelessness
    3. Financial insecurity
    4. Un(der)employment and/or challenges with education or vocational training
  3. Inquire about internal and external resources that can build upon strengths and foster resilience:
    1. Internal resources:
      1. Effective coping strategies
      2. Insight into one’s own inner processes and lived experience
      3. Other intrapersonal traits or skills
    2. External resources:
      1. Social support networks
      2. Healthcare services
      3. Other sources of safety and sustainability
  4. The identification of trauma and its impacts on behavioral responses and developmental milestones of children and adults is a critical aspect of the initial and ongoing assessment process.
    1. In pediatric populations, screen for exposure to ACEs periodically (exposure may occur after initial screening and throughout childhood and adolescence).
3. Assessment considerations for trauma impact:
  1. Trauma affects everyone differently:
    1. Personality and characteristics of the person
    2. Type and chronicity of the event
    3. Developmental processes
      1. Trauma experiences that occur in childhood affect:
        
        Behavior
        
        Emotional regulation
        
        Health
        
        Relationships
        
        Social perceptions
        
        Attainment of developmental milestones
        
        Brain function
    4. Subjective meaning of the trauma to the person
    5. Sociocultural factors
  2. Trauma can include:
    1. A single occurrence
    2. Multiple occurrences
    3. Chronic repetitive events
  3. Common feelings resulting from trauma include:
    1. Loss of control
    2. Disempowerment
    3. Trapped
  4. Initial reactions to trauma:
    1. Shock, powerlessness, guilt, self-blame
    2. Resilient responses (e.g., seeking social support, helping others)
  5. Longer-term reactions include:
    1. Emotional dysregulation
    2. Flashbacks
    3. Strained relationships
    4. Physical symptoms
  6. Indicators of more severe responses include:
    1. Continuous distress without periods of relative calm
    2. Severe dissociative symptoms
    3. Intense intrusive recollections despite a return to safety
  7. Delayed responses to trauma include:
    1. Persistent fatigue
    2. Sleep disorders
    3. Nightmares
    4. Fear of recurrence
    5. Anxiety focused on flashbacks
    6. Depression
    7. Avoidance of emotions, sensations, or activities associated with the trauma
TREATMENT STRATEGY
1. Address trauma as a vital component of all service delivery:
  1. Multi-pronged approach
  2. Multi-agency approach
  3. Public education to promote awareness
  4. Prevention
  5. Early identification
2. Provide clients with psychoeducation about the various ways that trauma can affect their mood, behaviors, and relationships by:
  1. Recognizing reactions to traumatic stress
  2. Recognizing how behaviors reflect adaptive responses to traumatic experiences
  3. Utilizing existing tools and strategies to navigate traumatic experiences
3. Utilize a resilience framework:
  1. Recognize client strengths (e.g., what the client has experienced, how they have persevered)
  2. Incorporate the development of effective coping strategies to:
    1. Build supportive networks
    2. Increase self-efficacy and empowerment
    3. Promote prevention and resilience
4. Prioritize trauma recovery and resilience building:
  1. Address the role of trauma on clients’ development of coping strategies
    1. Recognize ineffective or maladaptive coping strategies
  2. Understand how to help families, children, and youth through transitions
    1. Proactive planning for trauma reactions that may cause placement disruptions
    2. Foster coping strategies that prevent or respond effectively to maladaptive behaviors
5. Promote and offer trauma-specific services, including evidence-based and community-driven practices
PROVISION OF SERVICES
1. Minimize risks for re-traumatization
  1. Recognize inadvertent occurrences that may result from common program practices, procedures, or policies
  2. Use a trauma-informed approach to acknowledge clients' feelings:
    1. Listen to venting
    2. Validate expressions of anger
    3. Process grief and loss
2. Support client's physical and emotional safety through:
  1. Consistency in communication and program processes
  2. Environment
  3. Dependability
  4. Transparency
  5. Compassion
  6. Sense of control
  7. Autonomy
  8. Empowerment
  9. Collaboration
  10. Person-centered approach
3. Meaningfully integrate peer specialists to promote values of:
  1. Collaboration
  2. Shared decision-making
  3. Community expertise
  4. Lived experience
4. Encourage linkage to appropriate local agencies that provide community healing
OUTCOMES AND MONITORING
1. Questions to consider in the provision of trauma-informed care:
  1. Are peer voices and perspectives included in services?
  2. Has space been provided to practice self-care?
  3. Do staff recognize and address aspects of the physical environment that may be re-traumatizing and work with clients on developing strategies to manage this?
  4. Is staff aware of how the physical environment promotes a sense of safety, calming, and de-escalation?
  5. Do staff help clients identify strategies that contribute to feeling comforted and empowered?
  6. What strategies are used to reduce the sense of power differentials between staff and clients?
  7. Are transparency and trust between staff and clients promoted?
  8. Are staff mindful that clients who are frightened or overwhelmed may have difficulty processing information?
  9. Is there communication regarding trauma-informed decisions with partner agencies working with the client?
  10. Are collaborative partners trauma-informed?
  11. Do staff identify community providers and referral agencies that have experience delivering evidence-based trauma services?
STAFF TRAINING
1. Staff should increase their understanding of the prevalence and impact of trauma:
  1. Recognize how trauma impacts individuals as well as their partners, families, peer networks, and communities
  2. Maintain awareness of the impacts of trauma on service providers and clinical teams
  3. Recognize vicarious traumatization, compassion fatigue, and burn-out when providing trauma-informed care
  4. Increase understanding of multigenerational or historical trauma:
    1. Collective emotional and psychological injury
    2. Individual lifespan
    3. Across generations
2. Trauma and resiliency-informed care
  1. Discipline-specific training
  2. Job-specific training
3. Self-care and well-being sessions to avert and reduce vicarious trauma and compassion fatigue
SUPERVISION AND CONSULTATION
1. Supervisors should receive training in:
  1. Trauma-informed clinical practice
  2. Trauma-informed supervision
2. Supervisors should be aware of the signs of secondary trauma and its impact on employees:
  1. Avoidance related to clinical service provision or discussing client care in supervision
  2. Heightened reactions to disclosed trauma memories or experiences by clients
  3. Changes in mood, thinking patterns, or affect (particularly numbness, diminished affect, or depressed mood)
  4. Isolation and detachment
3. Supervisors should support staff in learning about secondary trauma and engage in effective coping strategies.
RESOURCES