Presentation on trauma-informed social work delivered at the Factor-Inwentash Faculty of Social Work, University of Toronto, on June 25, 2015

1. Trauma-Informed Social
Work: What is it, and Why
Should We Care?
Nancy J. Smyth, PhD, LCSW
Professor & Dean
University at Buffalo School of Social Work
June 25, 2015
Factor-Inwentash Faculty of Social Work
University of Toronto

2. Overview
• Why should we care?
• Understanding trauma reactions
• Trauma-informed Social Work ? (“Trauma-
informed care”)
Some of this content is from an online workshop developed by Professors Sue Green &
Nancy Smyth on trauma-informed care and creating trauma-informed organizations.

3. Traumatic Experiences: Common in Those
who Need Social Work Services
• High prevalence rates of traumatic
experiences (75%-90%) among people seeking
services (mental health, substance abuse,
homeless)
• Best to assume it’s there and rule it out.
• Trauma-Informed Care (TIC): focuses on how
services are delivered and seeks to create an
environment that supports those with trauma
histories and avoids inadvertent retraumatization

4. Anna
Caroline
Jennings
1960 - 1992

5. Jennings, A. (1994) On being invisible in the
mental health system. Journal of Behavioral
Health Services , 21(4), 374-387.
Excerpts from Anna's
Retraumatization Chart

6. EARLY CHILDHOOD TRAUMA
EXPERIENCE
Unseen, Unheard
COMMON MENTAL HEALTH
INSTITUTIONAL PRACTICES
Anna's child psychiatrist did not inquire into
or see signs of sexual trauma. Anna
misdiagnosed.
Adult psychiatry does not inquire into, see
signs of or understand sexual trauma.
Anna misdiagnosed.
Anna's attempts to tell parents, other
adults, met with denial and silencing.
Reports of past and present abuse
ignored, disbelieved, discredited.
Interpreted as delusional. Silenced.
Only two psychologists saw trauma as
etiology. Their insight ignored by
psychiatric system.
Institutional secretiveness replicates
family's. Priority is to protect institution,
jobs, reputations. Patient abuse not
reported up line; public scrutiny not
allowed.
Secrecy: those who knew of abuse did not
tell. Priority was to protect self, family
relationships, reputations.
Only two grade school psychologists saw
trauma. Their insight ignored by parents.
Patient or staff reporting of abuse is retaliated
against.
Perpetrator retaliation if abuse revealed.

7. EARLY CHILDHOOD TRAUMA
EXPERIENCE
COMMON MENTAL HEALTH
INSTITUTIONAL PRACTICES
Unseen, Unheard Cont.
Abuse occurred at pre-verbal age. No one
saw the sexual trauma expressed in her
childhood artwork.
No one saw the sexual trauma expressed
in her adult artwork with the exception of
one art teacher.
Trapped
Unable to escape perpetrator’s abuse.
Dependent as child on family caregivers.
Unable to escape institutional abuse.
Locked up. Kept dependent: denied
education and skill development
Sexually Violated
Abuser stripped Anna, pulled T-shirt over
her head.
Stripped of clothing when secluded or
restrained, often by or in presence of male
attendants.
Stripped by abuser to “with nothing on
below.”
To inject with medication, patient's pants
pulled down exposing buttocks and thighs,
often by male attendants.
"Tied up," held down, arms and hands "Take down," "restraints"; arms and legs

8. What is “Retraumatization”?
 A situation, attitude, interaction, or environment
that replicates the events or dynamics of the
original trauma and triggers the overwhelming
feelings and reactions associated with them
 Can be obvious - or not so obvious
 Is usually unintentional
 Is always hurtful - exacerbating
the very symptoms that brought
the person into services

9. Examples of StaffMessages/Actions
that can Confirm
Traumogenic Perceptions
• No progress expected
“you’re defective and hopeless”
• Disregarding valid needs/requests
“you don’t matter”
• Over-emphasis on Compliance vs. Collaboration
“you are powerless”

10. Impacts of Retraumatization on
Service Recipients
 Decrease or loss of trust
 Higher rates of self-injury
 Significantly less willingness to engage in any treatment
 Increase of intrusive memories, nightmares and flashbacks
 Reexperiencing of symptoms and emotions from previous
trauma – when extreme may take on delusional intensity
 Increase in chronicity of stress with greater risk for psychiatric
morbidity, e.g. PTSD, chronic depression

11. Examples of Service Systems that
Can Be Retraumatizing
• Health care services
– Impact of colonoscopy for a sexual abuse survivor
– Dental care for an oral abuse survivor
– Any medical care for a survivor of torture at hands of
medical personnel
• Correctional Services
• Mental health and substance abuse
• Schools
• Nursing homes

12. The Impact of Trauma
Once bitten by a snake, you are even
frightened by a rope that resembles a
snake
Chinese Proverb

13. Defining Trauma
McCann and Pearlman (1990)
Psychological trauma:
• is sudden, unexpected, or non-normative.
• Exceeds the individual’s perceived ability to
meet its demands
• Disrupts the individual’s frame of reference
and... psychological needs...

14. DSM-5 Definition of
Traumatic Event
(American Psychiatric Association, 2013)
• The person was exposed to: death, threatened
death, actual or threatened serious injury, or
actual or threatened sexual violence

15. Consequences of Trauma
Increased:
– Fight, flight, freeze response
– Hypervigilance, arousal, paranoia
– Perceptual and information processing distortions
– Pain tolerance
– Emotional blunting
– Numbing
– Aggression and irritability

16. Consequences of Trauma
Decreased:
– Memory processing and retrieval
– Reality testing
– Body and emotional awareness
– Immune response

17. Impact on Cognitions
People will hurt me
I’m helpless to prevent bad things from happening
I’m defective
I don’t matter
I’m helpless
I’m worthless
I can’t trust anyone
You will hurt me

18. Information Processing & The
Brain
Left Hemisphere
• Language Production
• Stores Narrative
Data
• Cognitive Analysis
• Declarative/Explicit
Right Hemisphere
• Evaluates emotional
sense data
• Integrates Sense Data
• Non-
declarative/Implicit

19. Traumatic Memory Fragmentation
• The Compartmentalization of Experience:
elements of a trauma are not integrated into a
whole narrative or sense of self.
• BASK Model of Memory (Braun)
– Behavior: What we do
– Affect: What we feel
– Sensation: What we perceive in our bodies
– Knowledge: What we think and remember

20. Normal vs. Traumatic Memory
Event
B A S K
Event
B A
S
K

21. Trauma Reactions
• Type I: Short-term, unexpected event
– Examples: One time rape, car accident, natural disaster
– Likely to result in typical PTSD sx
• Type II: (Complex Trauma): Sustained,
repeated ordeal stressors
– Examples: ongoing physical/sexual abuse, combat
– More likely to result in long-standing characterological &
interpersonal problems, dissociation, substance abuse

22. Trauma-Informed Care
• Seeks to avoid inadvertent retraumatization,
and to enhance clients’ participation in all
aspects of services
• Is strengths based:
– Instead of asking “What is wrong with this
person?”
– Asks “What has happened to this person?”
• Is a value-framework through which services
can be organized and delivered

23. Trauma-Informed Care
• May not be specifically designed to treat the actual
trauma, but services are:
– Are based on knowledge about trauma reactions
– Sensitive to trauma related issues present in survivors and
communities
– Allows clients to
• feel safe
• be accepted
• be understood
by everyone who may come in contact with the patient
• Ensures access to trauma-specific treatments

24. 5 Guiding Principles of TIC
1. Safety
2.
Trustworthiness
3. Choice4. Collaboration
5. Empowerment

25. includes where services are offered; time of day that
services are offered; security personnel available,
open doors or locked and the affect that each has on
consumers; waiting room appearance; are all staff
members attentive to signs of consumer discomfort
and do they recognize these signs in a trauma
informed way?
(Fallot and Harris, 2006)
1. Safety
Safety
2.
Trustworthiness
3. Choice4. Collaboration
5. Empowerment

26. includes providing clear information about what will be done,
by whom, when, why and under what circumstances;
respectful and professional boundaries; is unnecessary
consumer disappointment avoided; is informed consent taken
seriously on a consistent basis?
(Fallot and Harris, 2006)
Trustworthiness
1. Safety
2.
Trustworthiness
3. Choice4. Collaboration
5. Empowerment

27. Choice
1. Safety
2.
Trustworthiness
3. Choice4. Collaboration
5. Empowermentincludes how much choice consumers
have over the services they receive (such
as time of day, gender preferences for
service providers, etc.); are consumers
provided a clear and appropriate message
about their rights and responsibilities?
(Fallot and Harris, 2006)

28. Collaboration
1. Safety
2.
Trustworthiness
3. Choice4. Collaboration
5. Empowermentincludes giving consumers a significant role in planning
and evaluating services; consumer preference is given in
areas of service planning, goal setting, and developing
treatment priorities; cultivating an atmosphere of doing
“with” rather than doing “to” or “for”; conveying the
message that the consumer is the expert in their own life?
(Fallot and Harris, 2006)

29. Empowerment
1. Safety
2.
Trustworthiness
3. Choice4. Collaboration
5. Empowerment
includes recognizing consumer strengths and skills;
building a realistic sense of hope for the client’s future;
provide an atmosphere that allows consumers to feel
validated and affirmed with each and every contact at the
agency

30. Culture Change in Service Provision
Service-Level Changes:
• Program Procedure and Settings
• Formal Service Policies
• Trauma Screening
(Creating Cultures of Trauma-Informed Care (CCTIC): A Self-Assessment and Planning Protocol,
2009)

31. Culture Change in Human Service
Programs
Systems-level/Administrative Changes
• Program-Wide Trauma Informed Services
• Staff Trauma Training and Education
• Human Resources Practices
(Creating Cultures of Trauma-Informed Care (CCTIC): A Self-Assessment and Planning Protocol,
2009)

32. Walking our own Journey

33. Resources
• The Anna Institute: http://www.theannainstitute.org/
• Podcasts (free audio recordings) on UBSSW website:
http://insocialwork.org and sort on categories, then trauma
• National Child Traumatic Stress Network:
http://www.nctsn.org/
• National Center for Trauma-Informed Care:
http://www.samhsa.gov/nctic/
• UBSSW Institute on Trauma and Trauma-Informed Care:
http://socialwork.buffalo.edu/social-research/institutes-
centers/institute-on-trauma-and-trauma-informed-care.html

34. Trauma-Informed Care Principles
(Fallot and Harris, 2006)
1. Safety includes where services are offered; time of day that services are offered; security
personnel available, open doors or locked and the affect that each has on consumers; waiting
room appearance; are all staff members attentive to signs of consumer discomfort and do they
recognize these signs in a trauma
2. Trustworthiness includes providing clear information about what will be done, by whom, when,
why and under what circumstances; respectful and professional boundaries; is unnecessary
consumer disappointment avoided; is informed consent taken seriously on a consistent basis?
3. Choice includes how much choice consumers have over the services they receive (such as time
of day, gender preferences for service providers, etc.); are consumers provided a clear and
appropriate message about their rights and responsibilities?
4. Collaboration: includes giving consumers a significant role in planning and evaluating services;
consumer preference is given in areas of service planning, goal setting, and developing
treatment priorities; cultivating an atmosphere of doing “with” rather than doing “to” or “for”;
conveying the message that the consumer is the expert in their own life?
5. Empowerment: includes recognizing consumer strengths and skills; building a realistic sense of
hope for the client’s future; provide an atmosphere that allows consumers to feel validated and
affirmed with each and every contact at the agency