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Trauma-informed Practice

Complex trauma, intergenerational trauma, complex trauma impact, refugee impact, practice principles, addressing complex trauma, resources, practice challenges, practice approach

Three sections follow:

1. Background Material that provides the context for the topic

2. A suggested Practice Approach

3. A list of Supporting Material / References / Resources

Feedback welcome!

Background Material

Defining trauma

Trauma can present in various forms and in varied contexts. Trauma is the broad psychological and neurobiological effects of an event, or series of events, which produce experiences of overwhelming fear, stress, helplessness or horror. Complex trauma may arise through a cumulative or repeated exposure to trauma and is characterised by its profound impact, not only on the individual’s range of functions, but the development and functioning of the person. Childhood experiences of trauma are particularly devastating, often involving a betrayal of trust in a primary relationship. As an individual’s experience of trauma may vary according to a range of factors including genetics, developmental stage, previous life experiences, cultural beliefs and available social supports, what will be experienced as trauma by one person may not be experienced as such by another (RANZCP, 2020; Wall et al., 2016).


There are two types of trauma: single incident trauma and complex trauma. Single incident trauma consists of a one-off traumatic event and includes PTSD (post-traumatic stress disorder). Complex trauma occurs when a child repeatedly experiences severe stressors or traumatic events over an extended period of time. These stressors start during childhood, at a developmental point in time when the child is considered vulnerable (Hervatin, 2021). Adverse childhood experiences include physical and emotional abuse and neglect; sexual abuse; and growing up in a home with substance abuse, mental illness, domestic violence, an absent parent, or criminality. These experiences are characterized by invalidation, betrayal, and attachment disruptions. Usually caregivers are either needed and dangerous, or unavailable. Children might feel afraid, alone, unwanted, threatened, or ignored by people on whom they are dependent, in the very place that is supposed to feel safest. As a result, over time, a person may adopt coping strategies that are protective in the traumagenic environment but counterproductive in other settings, and cognitive schemas of mistrust or self-blame may be embedded into interpersonal patterns (Levenson, 2020).


The impacts of complex trauma are more extensive and debilitating than those of single incident trauma alone. It is important to recognise that those who experience complex trauma start at a different point: In contrast to the traumatised person who has experienced a sense of safety and wellbeing prior to the onset of the (single incident) trauma, the survivor of complex trauma does not start with this advantage. It has been established, however, that with the right support complex trauma can be resolved; people can and do recover (Blue Knot, 2021).


Intergenerational trauma has a similar impact to complex trauma. Intergenerational trauma occurs when people who have experienced or witnessed trauma have not had an opportunity to heal from that trauma and it is transferred to the next generation and can also be transferred to subsequent generations, as has occurred with the Stolen Generations of Australia’s First Nations people. The ongoing effects of colonisation, dispossession, racism and trauma have resulted in intergenerational trauma for these people. Other groups can also experience intergenerational trauma, e.g. holocaust survivors, refugees and asylum seekers (Blue Knot, 2021).


Impact of complex trauma on the person

Short- and long-term effects of trauma are possible; difficulties arising from complex childhood trauma sometimes persisting into adulthood. This can impact on a range of areas, including family life, employment, productivity and physical and mental health. Supporting infants and young children who experience complex trauma as early as possible can help prevent these longer-term effects. The negative effects of complex trauma tend to be more long-term and severe when the trauma experiences (i) occur earlier in a child’s life, (ii) have a longer duration or (iii) involve multiple forms of complex trauma experiences. However, not all children exposed to complex trauma will show difficulties in their wellbeing or mental health. It is crucial not to make assumptions about the impact these experiences might have.


Some children have positive outcomes. Examples of factors that can support positive outcomes and recovery following complex trauma include having:

  • at least one stable and responsive caregiver

  • a caregiver who applies positive parenting practices (such as being engaged and warm)

  • a caregiver who believes and validates the child’s trauma experiences

  • a caregiver who is able to self-regulate their emotions; and

  • a positive social support network (including those that can provide emotional support) (Hervatin, 2021).

The impacts of trauma, especially childhood trauma, can include the following.

  • Repeated, often extreme interpersonal trauma (e.g. complex trauma) stops people from feeling and being safe.

  • Trauma often includes betrayal. This can make it hard for people to trust, or cause people to trust too easily.

  • Trauma can lead people to feel worthless which in turn leads to struggles with their self-esteem and identity.

  • Trauma can cause strong feelings e.g. sadness, anger, fear, distress, and can lead some people to be impulsive.

  • Many people blame themselves for their challenges even though being abused is never a person’s fault. Many people also feel deep shame which can stop them reaching out for help.

  • Trauma can make it harder for us to engage socially. This limits connections and can leave people isolated and alone. Therefore, people with traumatic experiences can find it hard to make friends and build solid relationships, including intimate relationships.

  • Many survivors experience feelings of anxiety and depression, disconnection, being ‘spaced out’, confusion and other forms of mental distress. Physical health problems are common as well.

  • When children need to focus on survival they miss out on learning and exploring. This can affect their education and employment opportunities later.

  • Trauma can affect thinking, concentration and memory.

  • Trauma can make people less flexible and more rigid, e.g. less able to respond to new experiences and more likely to want to control things (Blue Knot, 2021).

There can be other impacts.

  • Trauma may cause a range of co-morbid problems including mental and physical health conditions, suicidality and self-harming behaviours, harmful substance use and addictions, dissociation, self-esteem issues, and contact with the criminal justice system. The consequences of trauma exposure can have a cascading impact throughout families and communities, leading to ongoing relational trauma and intergenerational trauma.

  • Trauma survivors may be at increased risk of re-victimisation through family violence, sexual assaults, homelessness and poverty. This increased risk is experienced particularly by women and people who have been subject to community violence such as Indigenous peoples, refugees and people who identify as LGBTIQ.

  • Trauma survivors with mental illness may experience re-traumatisation due to their experience of coercive interventions or sexual and/or physical abuse in institutional settings, including psychiatric and justice environments (RANZCP, 2020).

Trauma can have an adverse impact on refugees on resettlement due to potential marginalization, socioeconomic disadvantage, acculturation difficulties, loss of cultural and social support, and cultural bereavement. Refugee families may resettle into temporary or unstable housing and face employment and financial stressors. In addition, studies of post-migration challenges that refugees in developed countries face have documented exposure to community violence, limited social networks, difficulty finding formal childcare, and food-related challenges (Ostrander et al., 2017).


Knight (2015) lists a range of difficulties / consequences for adults who experience childhood trauma.

  • Emotional and psychological reactions such as depression, low self-esteem, and suicidal ideation; physical problems like chronic pain; psychiatric problems such as anxiety/panic, borderline post-traumatic stress, and dissociative identity disorders; and behavioral problems including substance abuse, eating disorders, domestic violence, and self-injury.

  • Childhood trauma also distorts survivors’ thinking about their social world leading to social isolation and problems with attachment.

  • Childhood trauma robs its victims of a stable sense of self. This results in a lack of the ‘‘self-capacities’’ that allow individuals to maintain a consistent sense of identity and positive self-esteem, e.g. the ability to sooth and comfort oneself, to be alone with oneself, regulate emotions, and accept criticism.

  • There also is increasing evidence to suggest that exposure to trauma in childhood leads to neurobiological changes in the developing brain. These changes are sometimes permanent and reinforce the previously identified social, emotional, and behavioral consequences of the abuse.

Common reactions to trauma can include:

  1. Re-experiencing the trauma through thoughts, feelings, memories, and other means (e.g. nightmares, flashbacks)

  2. Avoiding reminders of past trauma (e.g. by using drugs or alcohol, by avoiding certain activities, people, places, conversations)

  3. Experiencing negative thoughts or feelings that may not seem to relate directly to the trauma

  4. Hyperarousal (e.g. becoming irritable, difficulty in concentrating, difficulty sleeping, feelings of anxiety, risky or impulsive behaviours) (Therapist Aid, 2018b).

Principles

Five key principles underpinning trauma-informed practice include:

  • Safety—People are feeling physically and psychologically safe.

  • Trustworthiness and transparency—Organisational operations and decisions are transparent, and trust is built.

  • Collaboration and mutuality—Power differentials between staff and clients and amongst organisational staff are levelled to ensure a collaborative approach to healing.

  • Empowerment, voice and choice—Trauma-informed care is strengths-based to foster recovery and healing.

  • Cultural, historical and gender issues—A trauma-informed approach moves past cultural stereotypes and biases, and incorporates policies, protocols and processes that are responsive to the cultural needs of clients (Rhodes, 2023; Wall et al., 2016).

Levenson (2020) agrees with the above, stresses the importance of recognising that childhood trauma is very common and can have obvious and less obvious impacts on physical and mental health over the lifespan. Levenson sees trauma-informed practice as consistent with the environmental context and biopsychosocial framework of strengths-based social work.


Trauma-informed practice should also:

  • recognise coping strategies as attempts to cope with underlying trauma

  • recognise the importance of respect, dignity and hope

  • recognise trauma and its impacts, including effects on feelings, emotional regulation and brain physiology

  • use respectful approaches to elicit traumatic histories, being careful not to cause re-traumatisation

  • demonstrate awareness of the intergenerational transmission of traumas

  • be sensitive to gender, sexual orientation, ethnicity and age dimensions of trauma

  • work from a strengths-based framework to facilitate empowerment and recovery

  • instil hope, optimism and the understanding that recovery and post-traumatic growth is possible

  • facilitate holistic care characterised by integration and continuity of services (Blue Knot, 2021; RANZCP, 2020).


Trauma-informed practice

Trauma can arise from single or repeated adverse events that threaten to overwhelm a person’s ability to cope. When it is repeated and extreme, occurs over a long time, or is perpetrated in childhood by care-givers it is called complex trauma. The adult survivors of complex trauma often present to services seeking help in other areas like addiction, mental health, child welfare and as a consequence of justice system involvement. These survivors may not necessarily link their current problems to past trauma, but clinicians should be aware that past trauma may lie beneath current presenting issues, otherwise complex trauma will often remain unrecognised, unacknowledged, and unaddressed (Kezelman, 2014).


Unfortunately social workers and other clinicians often feel ill-equipped to be helpful to trauma survivors, mistakenly assuming they lack the required knowledge and expertise; they often overlook the past trauma. In fact, practitioners who do not recognise and deal with, however briefly, survivors’ past trauma, and the relationship it plays to the present, undermine their ability to deal with the present-day challenges that brought them into treatment in the first place (Knight, 2015; Levenson, 2020). As Wall et al. (2016) explain, responses to trauma exist on a continuum from basic trauma awareness to trauma sensitivity, trauma responsivity and through to trauma-informed and/or trauma-specific interventions. Trauma-informed interventions occur at two levels: trauma-specific interventions (relevant to single-event trauma) and trauma-informed practice (relevant to complex trauma).


Single-incident trauma

Specialised trauma-centered interventions are used with people who have experienced single-incident trauma, including PTSD. Trauma-focused cognitive behaviour therapy is an evidence-based treatment approach for children who have experienced sexual abuse, exposure to domestic violence or similar traumas (Wall et al., 2016). Other specialized single-event trauma interventions include cognitive behaviour therapy (e.g. exposure activities – Therapist Aid (2019), guided imagery, hypnosis, and eye movement desensitization and reprocessing (EMDR). These trauma-centred interventions should be delivered by a practitioner trained in their use. They empower survivors to learn to relax, self-soothe and express and manage feelings. They should only be used with appropriate training (Knight, 2015). Using the search function on the Therapist Aid site (2016-23) will reveal a number of resources around single-incident trauma. https://www.therapistaid.com/


Complex trauma

Unlike single-incident trauma, where dealing with the underlying trauma is the primary focus of the intervention, trauma-informed practice helps survivors develop their capacities for managing distress and overcoming issues. It focuses on engaging in more effective daily functioning rather than the traumatic past. The effects of the past childhood trauma aren’t ignored, but extensive and detailed immersion in traumatic material itself is not encouraged, because this tactic is destabilizing and counter-productive. The four-fold approach of trauma-informed practice is to:

  • normalise and validate clients’ feelings and experiences;

  • assist them in understanding the past and its emotional impact;

  • empower survivors to better manage their current lives; and

  • help them understand current challenges in light of the past victimization.

Directly addressing trauma before the survivor is psychologically and emotionally ready may serve to re-traumatise the individual and affirm feelings of powerlessness. In contrast, assisting a survivor in, for example, staying clean, finding employment, or remaining emotionally stable by taking necessary medications, is an essential step in addressing the long-term effects of the trauma. When the survivor is better able to manage present-day challenges, her or his self-capacities are enhanced, and this addresses the past trauma in a powerful and important way (Knight, 2015).


Strategies that are traditionally used in social work practice have been found to be effective when working with survivors of childhood trauma. Most fundamentally, the ability to convey empathy and understanding affirms and validates the survivor’s feelings and experiences, reducing isolation and feelings of being alone and different. Normalising and validating experiences are also relevant and often essential. Cognitive behavioural strategies, solution-focused techniques, writing, art, other physical activities are all relevant approaches to use with survivors to strengthen self-capacities, manage feelings and experiences, and express feelings in alternative non-verbal ways (Knight, 2015).


In other words, trauma-informed practices incorporate knowledge of trauma into services by (a) conceptualizing client problems, strengths, and coping strategies through the trauma lens and (b) responding in ways that create safety, collaboration, trust, and empowerment. By hypothesizing how early relational trauma might be contributing to current interpersonal difficulties, the worker can support the person to work on correcting the presenting issues using the core principles of safety, trustworthiness, choice, collaboration, empowerment and cultural awareness mentioned above (Levenson, 2020).


Trauma-informed practice: Challenges

Knight (2015) raises three challenges that clinicians who work in the complex trauma area may face.

  1. The client may not make any reference to past trauma or may have no memory of it. Directly but subtly asking about possible childhood trauma conveys to the client that she or he can discuss it when ready and also normalizes and affirms her or his experiences. However, if the client has no memory of trauma it is important not to reach for memories to confirm actions the worker suspects may have happened (e.g. sexual abuse). This can lead to re-traumatisation.

  2. A second challenge is related to mandatory reporting requirements. The practitioner should adhere to three principles. First, the worker must be well-versed in what her or his legal responsibilities actually are. Second, the worker should uphold legal mandates in a way that minimizes risk to survivors. Finally, the worker should assist the client in determining what courses of action to take and avoid making those decisions for him or her. The worker takes a neutral stance, providing support, information, and guidance to the client about available options but not telling the client what to do.

  3. A final challenge when working with adult survivors reflects the impact that this has on workers, themselves. Survivors often present themselves as overwhelmed with myriad problems and with heightened feelings of mistrust and hostility towards the practitioner. Further, their disclosures about what happened to them, their ‘‘trauma narratives’’, can be extremely hard to hear and their reactions to the narrative can be hard to witness. Workers can be at risk of being indirectly traumatized through their work with survivors. Ling et al. (2014) found evidence that indirect traumatisation can occur. In their study they found practitioners who understood this was a possibility but were confident they could manage it were able to maintain their empathic balance, and this enhanced the positive aspects of their work. The use of supervision, peer support, and ongoing training proved to be important support factors as well as being involved in a range of activities, such as teaching, or policy or program development, as adjunct to direct counselling work.

Practice Approach

What follows is a practice approach around supporting people with complex trauma. As mentioned above, treating single-incident trauma appears to be the province of specialist trauma counsellors and requires specific training. Complex trauma, on the other hand, may be an underlying of issue that social workers meet in their day-to-day practice.


As mentioned above, people can seek out social workers for a number of issues that may have a link to past trauma, e.g. depression, low self-esteem, suicidal ideation, substance abuse, eating disorders, domestic violence, self-injury and criminality. Unless past trauma is dealt with, albeit via acknowledgement rather than in depth, social workers risk not actually addressing the issues for which support is being sought.


Social workers manage this by taking it into account as the one of the underlying causes of the presenting issues. But the presenting issues, not the underlying trauma, should be the focus of support. Delving too deeply into the previous trauma could result in re-traumatisation. On the other hand, assisting a trauma survivor to better manage present-day challenges enhances her or his self-capacities, and this addresses the past trauma in a powerful and important way (Knight, 2015).


The following suggestions for practice are a synthesis of material from Knight (2015) and Levenson (2020). Remember the core principles of safety, trustworthiness, choice, collaboration, empowerment and cultural awareness outlined above. The social worker should ensure safety from harm and re-traumatisation, emphasise strength building and skill acquisition rather than symptom management, and foster true collaboration and power sharing between workers and those seeking help.

  • Normalise and validate clients’ feelings and experiences. The social worker’s style of interaction should be genuine, nonjudgmental, and nonthreatening. Build trust, as traumatised people often have a history of being unable to depend on others to be loyal, supportive, nurturing, or responsible.

  • Use active listening and nonthreatening methods like motivational interviewing. Choice also involves authentic informed consent and awareness of the limits of confidentiality.

  • Assist people in understanding the past and its emotional impact, i.e. conceptualizing client problems, strengths, and coping strategies with appropriately paced discussion of traumatizing events and the meaning attached to them. Help clients gain emotional competence and self-regulation. Mindfulness approaches or grounding techniques such as those outlined by Therapist Aid (2018a) will help with self-regulation.

    • If the client becomes hyperaroused (visibly agitated) and/or hypoaroused (dissociated or `spaced out’) interaction is no longer therapeutic and re-traumatisation may occur. The zone of optimal arousal is called `the window of tolerance’. Attempts to elicit a visible reaction from clients who are hypoaroused are anti-therapeutic and potentially retraumatising. In both cases clients should be assisted to return to `the window of tolerance’ via appropriately tailored self-regulatory skills (Blue Knot, 2021).

  • Avoid giving advice. Ask questions to assist clients to define their own goals and the means of achieving them. Empower clients to view their problems as manageable and goals as realistic. The worker becomes coach and partner in planning and decision-making.

  • View client problems as coping strategies that may stem from surviving a traumagenic childhood. It is difficult for anyone to give up coping strategies without knowing what will replace them, especially when they have served protective functions.

  • Cognitive behavioural strategies, solution-focused techniques, writing, art, other physical activities are all relevant approaches to use with survivors to strengthen self-capacities, manage feelings and experiences, and express feelings in alternative non-verbal ways.

  • Because past relational trauma often involved betrayal by someone in a caretaking or authority role, the potential for re-traumatization within social work practice must be carefully avoided. Model transparency and fairness. Say what you mean and mean what you say. Admit mistakes, apologise and correct actions.

  • Be aware of the impact that supporting people through their trauma can have on social workers. As mentioned above, Ling et al. (2014) suggest the use of supervision, peer support, and ongoing training as important support factors. Being involved in a range of activities, such as teaching, or policy or program development, as adjunct to direct counselling work can also help.

Supporting Material / References / Resources

(available on request)

References


Blue Knot. (2021). Empowering recovery from complex trauma. https://blueknot.org.au/


Bray, B. (2023, January 25). Generational trauma: Uncovering and interrupting the cycle.            Counseling Today  https://ct.counseling.org/2023/01/generational-trauma-uncovering-and-interrupting-the-cycle/ 


British Columbia Provincial Mental Health and Substance Use Planning Council.  (2013). Trauma-informed practice guidehttps://cewh.ca/wp-content/uploads/2022/01/2013_TIP-Guide.pdf


Hervatin, M. (2021). Complex trauma through a trauma-informed lens: Supporting the wellbeing of infants and young children. Emerging Minds. https://emergingminds.com.au/resources/complex-trauma-through-a-trauma-informed-lens-supporting-the-wellbeing-of-infants-and-young-children/?audience=practitioner


Kezelman, C. (2014). Trauma informed practice. https://mhaustralia.org/general/trauma-informed-practice


Knight, C. (2015). Trauma-informed social work practice: Practice considerations and challenges. Clinical Social Work Journal, 43, 25-37. doi: 10.1007/s10615-014-0481-6


Levenson, J. (2020). Translating trauma-informed principles into social work practice. Social Work, 65(3), 288-298. doi: 10.1093/sw/swaa020


Ling, J., Hunter, S. V., & Maple, M. (2014). Navigating the challenges of trauma counselling: How counsellors thrive and sustain their engagement. Australian Social Work, 67(2), 297-310. https://doi.org/10.1080/0312407X.2013.837188



Ostrander, J., Melville, A., & Berthold, S. M. (2017). Working with refugees in the U.S.: Trauma-informed and structurally competent social work approaches. Advances in Social Work, 18(1), 66-79. doi: 10.18060/21282


RANZCP: Royal Australian and New Zealand College of Psychiatrists. (2020). Trauma-informed practice: Position statement 100. Melbourne, Vic.: Royal Australian and New Zealand College of Psychiatrists. https://www.ranzcp.org/clinical-guidelines-publications/clinical-guidelines-publications-library/trauma-informed-practice


Rhodes (2023, October). Prioritizing trauma-informed care. Counseling Today. https://ct.counseling.org/2023/10/prioritizing-trauma-informed-care/


Therapist Aid. (2018a). Grounding techniques. https://www.therapistaid.com/therapy-worksheet/grounding-techniques


Therapist Aid. (2018b). Common reactions to trauma. https://www.therapistaid.com/therapy-worksheet/trauma-reactions


Therapist Aid. (2019). Creating an exposure hierarchy. https://www.therapistaid.com/therapy-worksheet/creating-an-exposure-hierarchy


Therapist Aid. (2016-2023). https://www.therapistaid.com/


Wall, L., Higgins, D., & Hunter, C. (2016). Trauma-informed care in child/family welfare services. CFCA Paper, 37. https://aifs.gov.au/resources/policy-and-practice-papers/trauma-informed-care-childfamily-welfare-services


Resources


Hervatin (2021 provides a comprehensive list of resources for professionals around complex trauma. They include e-learning courses, webinars, podcasts, useful links to organisations, open access journals, and suggested resources for parents. These resources are available at this link: https://emergingminds.com.au/resources/complex-trauma-through-a-trauma-informed-lens-supporting-the-wellbeing-of-infants-and-young-children/?audience=practitioner


RANZCP (2020) suggest the following additional resources for both complex and single-event trauma:


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