Book Review - Becoming Trauma Informed

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Publication Date: 
Fri, 2013-04-26

BOOK REVIEW

Becoming Trauma Informed, edited by Nancy Poole and Lorraine Greaves, Centre for Addiction and Mental Health (CAMH), 2012.

Review by Nancy Ross

Becoming Trauma Informed is a timely, ambitious and evidence-based guidebook that provides an impetus for the creation of trauma-informed service design in the Canadian context with implications particularly for substance abuse and mental health services.

This book signals a paradigm shift that highlights a new and growing knowledge base on trauma that acknowledges how central the experience of trauma can be at all stages of life. Slowly, over the past three decades the anti-violence field has provided a greater understanding of how violence, sexual assault and child sexual abuse produce short-and long-term effects on both women and men. It acknowledges that experiences of trauma are pervasive and can result in life altering impacts. The connections to substance use and mental health problems are profound. Readers will recognize that our brains are sculpted by our early experiences and "maltreatment is a chisel that shapes a brain to contend with strife but at the cost of deep enduring wounds." Becoming Trauma Informed provides a compelling rationale to take the necessary steps to equip individuals, organizations and systems to better assist individuals who have experienced trauma.

The editors, Nancy Poole and Lorraine Greaves, emphasize the necessity of making connections between the issues of trauma, including intergenerational and cumulative experiences of trauma, violence, mental health and substance use (including nicotine), if we are to deliver integrated, holistic care across the various sectors that all play a role in healing from trauma: health, social services, child welfare, housing, justice and others.

It profiles examples of pioneering trauma-informed practices where such an approach has been implemented and points out that the successful integration of trauma-informed and trauma-specific practice within services and across systems of care remains an important challenge in most areas of Canada. (See the Table of Contents)

Parts 1 and 2 of the book describe what it means to be trauma informed in both theory and practice and the implications of such a response for diverse groups and settings. Gender, race, class, culture, disability, immigration status and other forms of diversity interact to increase trauma-related vulnerabilities, demanding tailored responses. The authors offer examples of breaking new ground in moulding responsive services for those with developmental disabilities, substance abuse problems and fetal alcohol spectrum disorder. Other chapters focus on the unique needs of refugees, men, girls and Aboriginal people.

While perhaps more could be included about how the information collected in these services will ultimately contribute to a reduction in the rates of trauma in our country, several chapters in this book do highlight the need for an ongoing critique and recognition of the roles that government policies and social and cultural factors play in the perpetuation of trauma. This was particularly well articulated in the chapter “An Intergenerational Trauma-Informed Approach to Care for Canada's Aboriginal Peoples” that decries the role of government policies and frames trauma discourse within a social justice framework.

A chapter that focuses on the unique needs of youth with concurrent disorders, points out that the majority of youth accessing treatment at the Centre for Addiction and Mental Health (CAMH) for both addiction and mental health problems have histories of traumatic stress (90 per cent of female clients and 62 per cent of males), as well as sexual abuse. While rates of experiencing trauma are reported as higher for women; this is not only a women's issue. One author cites research in the United States indicating more than 50 per cent of men had been exposed to at least one traumatic event. This book could be strengthened by a greater focus on the experiences of boys and men, especially in recognition that a high number of male perpetrators of violence have prior experience of trauma and that this can negatively impact on their role as fathers. However, a chapter written by well-known authors Roger Fallot and Richard Bebout specifically focuses on trauma-informed approaches for men.

Part 3 of the book focuses on examples of systemic change through education and innovation. The transformation of systems of care into trauma-informed systems requires an end to working in silos—making collaboration and partnership among service providers, disciplines and sectors essential. This can result in the provision of inter-professional education, integration of screening and other forms of collaborative services. An example of new ways of working together is described in Toronto with a model of a collaboration between child welfare and the substance use fields bridging seemingly disparate mandates to demonstrate how trauma-informed policy practices, program design and services can reduce risks to women and children and also promote opportunities for attachment and healing.

Many of the chapters in this book confirm that while there is considerable evidence that most people attending mental health and substance abuse treatment facilities are survivors of abuse, often service providers ignore their clients' trauma histories. In fact, one author noted that 90 per cent of people with mental health problems have been exposed to trauma and that this connection was particularly prevalent in people who experience psychosis. If this important trauma lens remains unacknowledged it can result in key neurobiological, psychological and psychosocial adaptations to trauma being misdiagnosed. This failure to acknowledge the need for trauma-informed care has meant that services fail to acknowledge that they themselves can traumatize clients. As a result client rights are sometimes compromised. One author explains that the overemphasis on a medical model approach to treatment can diminish the relevance of people's lived experiences, and the needs identified by clients themselves are then eclipsed by expectations to comply with medical instructions.

Throughout the book there is an emphasis on trauma-informed principles. Primary care providers in Saskatoon have articulated nine principles of sensitive practice that are attentive to the need to feel safe. The principles include respect (to be sensitive to how diminished survivors may feel), taking time (to address feelings of depersonalization and devaluing), rapport (to increase people's sense of safety), sharing information (to decrease anxiety and support involvement), respecting boundaries (to avoid retraumatization), fostering mutual learning, understanding non-linear healing and demonstrating awareness and knowledge of interpersonal violence.

The United States Women Co-occurring Disorders and Violence Study presented 10 principles of trauma-informed services for women, beginning with a principle related to recognition of the impact of violence and victimization on development and coping strategies. Chapters that focus on the evolution of services at the Centre for Addiction and Mental Health (CAMH) suggest that trauma-informed principles rest on a foundation of client empowerment. One outcome of this belief is the effort to define the CAMH Bill of Rights and other initiatives to reduce the use of restraints and seclusion in mental health settings. As with harm reduction, it is critical to solicit consumer input and involve consumers in designing and evaluating services as a core principle of trauma-informed practice.

Applying a trauma lens switches the focus from what is wrong with this person to what has happened to them as a key characteristic of trauma-informed service. The chapter written specifically about working with men who have experienced trauma noted that one of the first lessons in a trauma-informed, gender-responsive culture is that service providers need to ask men about their history of exposure to violence.

In trauma-informed services, professionals are not required to treat trauma; rather, they approach their work with the understanding of how common trauma is among those they serve, how challenging it may be to establish a therapeutic connection and how critical pacing may be. In this way, trauma-informed approaches are similar to harm reduction-oriented approaches and imply a universal precautions philosophy intentionally operating "as if" anyone who comes into our care is likely to be a trauma survivor. In a trauma-informed system, trauma is viewed as a defining and organizing experience for the survivor. All staff at human service agencies, including receptionists, security personnel and kitchen staff can benefit from general training in trauma to help them understand that trauma is the expectation not the exception. It is not necessary to disclose or be diagnosed with trauma to experience and benefit from trauma-informed services.

I highly recommend this book to anyone interested in learning more about trauma-informed approaches. Becoming Trauma Informed is inspired by a broad systems approach that builds on assumptions that trauma, whether diagnosed or not, recognized or not, can determine life course and engagement with and outcome of health services. As the editors of this book conclude, "given the scope of the adaptations needed across settings and populations, the structures for learning about trauma and its implications need to be innovative and multiple." Reading this book is a great start!

Nancy Ross's employment in addiction and mental health settings has resulted in a commitment to work towards a reduction in the rates of violence and sexual assault. Her enrolment in a research PhD in Peace Studies, Bradford University, UK incorporates a social justice and trauma-informed approach.