Tools
Trauma-Informed Therapy
Introduction
Trauma, as defined by the Diagnostic and Statistical Manual of Mental Disorders, 5th ed., Text Revision (DSM-5-TR), involves exposure to actual or potential situations such as death, severe injury, or sexual violation. This exposure can occur through directly experiencing traumatic events, witnessing them firsthand, learning about trauma experienced by family or friends, or repeatedly being exposed to distressing details of traumatic events.
In SAMHSA's Concept of Trauma and Guidance for a Trauma-Informed Approach (2014), the United States Substance Abuse and Mental Health Services Administration (SAMHSA) uses a broader definition, "Individual trauma results from an event, series of events, or set of circumstances that is experienced by an individual as physically and emotionally harmful or life-threatening and that has lasting adverse effects on the individual's functioning and mental, physical, social, emotional, or spiritual well-being."
Recognizing the diverse manifestations of trauma and its impact on individuals' lives is crucial for clinicians. Trauma-informed therapy addresses the aftermath of trauma by prioritizing an understanding of the root causes of distress and creating a safe, supportive environment that fosters healing and resilience. Over 70% of individuals experience a traumatic event at least once in their lifetime, with approximately 10% developing posttraumatic stress disorder (PTSD) as a result.[1][2][3] Worldwide, the lifetime occurrence of PTSD ranges from 1.3% to 12.2%, with 12-month prevalence varying from 0.2% to 3.8%.[1][2][3]
Traumatic incidents can distort emotions, memory, consciousness, and self-perception. Trauma also affects interpersonal connections and attachment to others while influencing brain and body function.[1][2] Experiencing trauma can significantly alter an individual's emotional and psychological development. However, not every negative experience qualifies as trauma, and an individual's perception of what is traumatic may not align with the DSM-5-TR or SAMHSA definitions of trauma.
The concept of trauma-informed care was first introduced in 2001 by Harris and Fallot, who recognized the high levels of trauma individuals are exposed to and proposed a paradigm shift. They advocated for considering past trauma experiences in addition to the immediate issue for which the individual is seeking treatment.[4] In Using Trauma Theory to Design Service Systems (2001), Harris and Fallot identified five guiding principles to create trauma-informed systems of care: safety, trustworthiness, choice, collaboration, and empowerment.
Trauma-informed care established a new standard for organizing public mental health and human services, which operates on the assumption that every individual seeking services may be a trauma survivor. This approach empowers individuals to set their own goals and manage their progress. As consumers advocated for patient rights, humane treatment, and involvement in treatment planning, federal agencies such as SAMHSA became instrumental in developing trauma-informed guidelines, policies, and care while coordinating research. In creating these new standards, providers, organizations, and government agencies recognized that public institutions and service systems meant to offer support can sometimes be trauma-inducing. Seclusion and restraints, abrupt removal of an abused child in the welfare system, invasive medical procedures, harsh discipline in schools, and punitive measures in the criminal justice system can all be traumatizing or re-traumatizing and counterproductive. SAMHSA was tasked with developing a framework to help systems communicate with one another and adopt trauma-informed practices.
SAMHSA's trauma-informed approach, as outlined in the Concept of Trauma and Guidance for a Trauma-Informed Approach (2014), is based on 4 key assumptions known as the "4 R's ": "A program, organization, or system that is trauma-informed realizes the widespread impact of trauma and understands potential paths for recovery; recognizes the signs and symptoms of trauma in clients, families, staff, and others involved with the system; and responds by fully integrating knowledge about trauma into policies, procedures, and practices, and seeks to actively resist re-traumatization." [3][5]
In addition, SAMHSA's Concept of Trauma and Guidance for a Trauma-Informed Approach (2014) identifies 6 fundamental principles for implementing a trauma-informed approach across organizations, staff, and the people they serve:
- Safety
- Trustworthiness and transparency
- Peer support
- Collaboration and mutuality
- Empowerment, voice, and choice
- Consideration of cultural, historical, and gender factors
SAMHSA identified 10 implementation domains for developing an organizational trauma-informed approach—governance and leadership; policy; physical environment; engagement and involvement; cross-sector collaboration; screening, assessment, and treatment services; training and workforce development; progress monitoring and quality assurance; financing; and evaluation.
Trauma-informed therapy emphasizes shifting the focus from "What's wrong with you?" to "What happened to you?" This approach provides a framework for understanding and responding to the effects of trauma, prioritizing the creation of a safe, supportive, and empowering environment for individuals who have experienced trauma. This therapy involves recognizing the prevalence and impact of trauma, understanding its effects on individuals, and integrating this awareness into all aspects of therapeutic practice.[6]
Trauma-informed therapy goes beyond merely treating trauma symptoms, offering a holistic approach that acknowledges and addresses the broader effects of trauma on individuals' lives. This approach encompasses various therapeutic methods, including cognitive, emotional, and behavioral techniques, to address traumatic experiences while recognizing trauma as a fundamental aspect of the therapeutic process.[6]
Function
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Function
Trauma-focused psychotherapy is defined as any therapy that uses cognitive, emotional, or behavioral techniques to facilitate the processing of a traumatic experience, with the trauma focus being a central component of the therapeutic process.[7] Trauma-informed therapy encompasses a range of therapeutic modalities aimed at addressing the complex needs of individuals affected by trauma. These therapies are applied in behavioral health contexts to create a safe and supportive environment that fosters healing and resilience while integrating trauma awareness into every facet of care.
Trauma-informed therapy is often used to address a range of mental health conditions where trauma plays a significant role in symptom development or etiology. These conditions include PTSD, acute stress disorder, reactive attachment disorder, disinhibited social engagement disorder, prolonged grief disorder, and adjustment disorders. Although evidence is limited and knowledge on tolerability is insufficient, trauma-informed therapy may also be considered for dissociative disorders, which are closely related to trauma-related conditions.[8][9] Many individuals with borderline personality disorder have a history of trauma. Trauma-informed approaches such as dialectical behavior therapy (DBT), mentalization-based therapy (MBT), and eye movement desensitization and reprocessing (EMDR) can help address trauma-related distress, including flashbacks, nightmares, anxiety, and depression.
Trauma-informed therapy can also improve the management of borderline personality disorder symptoms by promoting skills such as emotional regulation, interpersonal effectiveness, and distress tolerance.[8][10] Integrating trauma-focused cognitive behavioral therapy (TF-CBT) into the treatment of substance use disorders can be particularly effective due to the connection between trauma and substance use.[11][12] Evidence indicates that EMDR, CBT, and other cognitively oriented approaches, such as mindfulness exercises, can be effective trauma-informed therapies for depression and anxiety.[13][14]
Psychosis is a leading global cause of disability and mortality, with evidence suggesting that developmental trauma may contribute to psychotic symptoms in adulthood. Clinicians might find it beneficial to incorporate the following areas into treatment—emotion regulation, psychological acceptance, interpersonal skills, attachment, dissociation, and trauma memory reprocessing.[8][15]
Trauma-Informed Psychotherapies
Modalities such as exposure therapy, TF-CBT, and EMDR have demonstrated efficacy in treating trauma.[16][17][18] These therapies include components designed to help individuals address and work through their traumatic memories, cognitive patterns, and perceptions of traumatic experiences.[17][18][19]
Common elements of trauma-informed therapy include:
- Psychoeducation: Providing information about stress reactions, coping with trauma reminders, and managing distress.
- Emotion regulation and coping skills.
- Imaginal exposure.
- Cognitive processing, restructuring, and meaning-making.
- Targeting emotions such as trauma, guilt, shame, anger, grief, or sadness.[20][21][22]
Exposure therapy involves exposing individuals to the thoughts, feelings, and situations that individuals fear or avoid.[21][22] This therapy is based on the principle of habituation, which suggests that repeated exposure to feared stimuli leads to a reduction in anxiety over time. Exposure therapy often involves guiding individuals to revisit the trauma using methods such as mental imagery, writing, or recording a detailed account of the event.[21][22] The individual is then encouraged to repeatedly engage with the narrative through listening or reading, which helps build. An alternative method of exposure therapy involves systematically reintroducing cues associated with the traumatic event, using a hierarchy of stimuli to address the trauma.[20][23] Virtual reality is an emerging form of exposure therapy that offers multisensory cues within an interactive and emotionally engaging environment.[24][25][26] This approach potentially provides better control over stimuli, allows for unlimited exposure repetitions, and enables the creation of challenging environments, although it requires further study.[27]
Prolonged exposure therapy is a manualized form of exposure therapy for treating PTSD, comprising 3 main components—psychoeducation, in vivo exposure, and imaginal exposure, followed by processing. In vivo exposure is usually assigned as homework, where the individual confronts safe but trauma-related situations they typically avoid. This therapy generally involves 8 to 15 individual 90-minute sessions, delivered once or twice weekly by mental health clinicians.[23][28] TF-CBT assists individuals in identifying, exploring, and modifying negative beliefs about themselves, others, and the world. This manualized approach addresses issues such as mistrust, self-blame, feelings of inadequacy, and perceptions of danger. TF-CBT also targets maladaptive behaviors that may exacerbate trauma symptoms or impair functioning, such as avoiding certain activities or excessive substance use.[29][30]
Providing information on typical responses to trauma is a fundamental aspect of all TF-CBT treatments, helping to validate the individual's symptoms and offer a rationale for subsequent interventions.[17][18][19] The duration of TF-CBT ranges between 12 and 20 sessions, though the duration may vary based on individual needs and the severity of the trauma. The number and length of sessions are adjusted according to the client's progress, treatment goals, and clinical judgment.[31][32]
TF-CBT utilizes exposure techniques to assist individuals in confronting their traumatic memories and gradually engaging with real-life situations they have been avoiding since the event. This therapy also integrates cognitive restructuring to challenge overly negative views of trauma and its consequences. Cognitive therapy focuses on identifying and modifying individuals' interpretations of the trauma and their evaluations of its effects, such as initial PTSD symptoms and reactions from others. Additionally, TF-CBT addresses behaviors and thought patterns that sustain the condition, including rumination on the trauma and engagement in safety behaviors that disrupt daily functioning.[16][29][31]
Behavioral experiments are incorporated into TF-CBT to illustrate how different maintaining mechanisms operate, such as thought suppression, hypervigilance to danger, and avoidance of triggers. These experiments aid individuals in adopting more effective coping strategies.[29][30][32] The initial TF-CBT sessions prioritize psychoeducation and breathing retraining, while subsequent sessions are divided into segments dedicated to cognitive restructuring. The remaining sessions focus on cognitive restructuring.[7][33]
EMDR is a trauma-informed therapy designed to help individuals reprocess traumatic memories. During EMDR, the therapist guides the individual through side-to-side eye movements while they recall distressing trauma-related images, beliefs, and bodily sensations.[34] This approach was developed by Francine Shapiro, who noticed that her own rapid eye movements reduced distress.[34][35][36] Following this discovery, Shapiro subsequently refined EMDR into a systematic, protocol-driven therapy specifically targeting trauma-related distress. EMDR therapy involves eight phases, during which the individual recalls various aspects of the traumatic event—such as images, thoughts, emotions, and bodily sensations—while receiving bilateral stimulation, typically through eye movements.[34][35][36]
A case conceptualization is developed during the initial session, establishing a hierarchy of relevant traumatic experiences tailored to each patient. Subsequent sessions involve using bilateral eye movements as dual-attention stimuli to process traumatic memories. The number of EMDR sessions varies based on factors such as the severity of the trauma, the individual's response to treatment, and the therapist's clinical judgment.[34][35][36] Typically, EMDR therapy consists of 6 to 12 sessions, each lasting approximately 60 to 90 minutes. In some cases, additional sessions may be required to fully process the traumatic memories and achieve therapeutic goals.
The EMDR treatment process involves the following sequential steps:
- Introducing the EMDR protocol and developing coping strategies.
- Evaluating treatment targets.
- Desensitization and reprocessing.
- Integrating positive cognitions.
- Conducting a body scan to address any lingering negative bodily sensations.
- Using relaxation techniques to restore emotional stability if distress arises.
- Conducting re-evaluation sessions.[34][35][36]
Clinical Significance
Discussing trauma can be challenging for individuals, especially during initial consultations for healthcare concerns. Considering sociodemographic characteristics and comorbid conditions such as mood disorders, anxiety, substance use, attention-deficit/hyperactivity disorder, and personality disorders, individuals with lifetime PTSD are more likely to be diagnosed with conditions such as hypertension, angina pectoris, tachycardia, other heart diseases, gastritis, and arthritis.[37]
Trauma-informed therapies, such as exposure therapy, have proven effective for treating adult PTSD. A meta-analysis demonstrated that exposure therapy outperformed both waitlist and treatment-as-usual groups. Larger effect sizes were noted in studies with fewer sessions and younger participants. Effect sizes were also more significant in studies involving refugees and civilians compared to military samples, in individual therapy versus group therapy, and for specific types of trauma, such as natural disasters and transportation-related trauma.[38]
Ross offers valuable guidance for clinicians navigating the complex relationship between trauma experiences and mental health outcomes in youth.[39] The study found TF-CBT effective across most measures of PTSD. The study also evaluated trauma chronicity as a moderator and assessed TF-CBT's effectiveness in youth with complex PTSD according to ICD-11 criteria. TF-CBT proved cost-effective, applicable to individuals from diverse backgrounds, and suitable for clients with complex trauma histories and reactions.[39]
Enhancing Healthcare Team Outcomes
As frontline caregivers, nurses are critical in advancing trauma-informed care within healthcare settings. They practice holistically, contributing significantly to creating a supportive, healing environment essential for trauma-informed care. Beginning with thorough assessments to identify trauma-related symptoms, nurses collaborate closely with psychotherapists and the treatment team to develop comprehensive care plans that incorporate trauma-informed approaches and therapies. They provide ongoing emotional support, help patients manage anxiety and distress, and teach coping strategies for daily life.[40]
Nurses play a vital role in ensuring the treatment environment is safe and stable, aligning with the first tenet of trauma-informed care. Those trained in psychiatry and mental health can serve as therapy facilitators within trauma-informed healthcare settings. They facilitate communication between patients and other healthcare team members, ensuring a comprehensive approach to patient well-being. By integrating their nursing skills with psychological expertise, nurses are essential to the holistic care of patients undergoing trauma therapy.[40][41]
Enhancing healthcare outcomes through trauma-informed therapy requires a collaborative approach among multidisciplinary healthcare teams. This approach involves integrating a range of professionals—including psychiatrists, primary care physicians, advanced care practitioners, pharmacists, psychologists, behavioral specialists, social workers, rehabilitation therapists, and nurses—each contributing unique perspectives and interventions tailored to various aspects of an individual's needs. Collaborative decision-making leads to comprehensive treatment plans that address both mental health and physical well-being.
Cultural factors significantly impact trauma experiences, coping methods, and engagement in therapy. Understanding a patient's cultural background enables therapists and other treatment team members to recognize how cultural beliefs and practices shape the individual's experience of trauma and their coping strategies. Incorporating cultural considerations into assessments ensures that treatment plans are culturally sensitive and appropriate, which enhances therapeutic outcomes. This approach fosters a more respectful and supportive therapeutic environment, improving patient trust and engagement in the therapy process.
The interprofessional team of healthcare providers advocates for individuals affected by trauma, empowering them to actively participate in their recovery journey. By offering education, support, and empowerment, patients gain resilience, coping skills, and access to resources that promote healing and wellness. This collaborative and integrated approach to trauma-informed care ultimately leads to improved outcomes and a better quality of life for those affected by trauma.[40][42]
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