A key aspect of being a trauma-informed practitioner is to integrate an understanding of trauma, and the ways it can affect people into all aspects of your work. As previously discussed, more two-thirds of young people will have experienced a traumatic event by the age of 16 (Copeland et al, 2007), with higher rates amongst young people who use substances (e.g., Funk, Mcdermeit, Godley, & Adams, 2003; Ozer & Weinstein, 2004).

As practitioners working with young people experiencing mental illnesses, substance use issues, or other forms of social disadvantage it is particularly important to be aware of the high likelihood of trauma exposure and its impacts on the young person.

Increasing your trauma awareness includes:

• Understanding responses to trauma - the effects, symptoms and other impacts that trauma can have on the people you support
• Clearly communicating and providing psychoeducation about trauma, its impacts, how people can recover, and about effective treatments for posttraumatic mental health conditions. 

Understand the responses to trauma:

No two people are affected in the same way after a traumatic event. Some common reactions that young people might experience include:

• Reliving the event  - having upsetting memories of the event (e.g. through nightmares, or even feeling as if the event is actually happening again); feeling really upset and scared when reminded of the trauma
• Feeling wound up (i.e., physiological arousal) – being unable to concentrate; having problems sleeping; always feeling on edge; self-harming; taking more risks than usual.
• Avoiding reminders – avoiding people, places or situations that are reminders of the trauma; avoiding ever talking about the trauma; having specific fears and avoidance behaviours related to the trauma. Often these patterns of avoidance may not be immediately obvious (e.g., an adolescent who develops a fear of crowds after being assaulted on public transport uses substances as a way to tolerate being in crowded spaces).
• Negative feelings and thoughts – being constantly irritable, anxious, afraid, angry, guilty or ashamed, feeling numb or flat; having little interest in usual activities; feeling cut off from friends and family; having a confronting awareness of mortality; experiencing survivor guilt
• Dissociative experiences – this is a rarer reaction and involves losing touch with the here and now. People can describe it as:  “ though I wasn’t even there”, “…as though time was standing still…”, “…I felt like I was watching things happening from above…” ,“…I can’t remember most of what happened…”

Note that in young people abusing substances these symptoms may be masked. For example, individuals may use alcohol or drugs in an attempt to manage or self-medicate their feelings (e.g., anxiety, low mood, anger, grief), or their physiological arousal.  Substance use can also serve as a way of managing distressing memories of the trauma, or other reminders of the trauma.

It is important to remember that most people do in fact recover following exposure to trauma. Strong reactions following a trauma are usual and expected responses for most people, but the majority recover in the weeks following a trauma on their own (and especially if they have the support and help of friends and family).

Some people do experience these reactions for a longer time and a minority of people go on to develop diagnosable mental health disorders. As mentioned previously, PTSD is only one of the mental health conditions that people may experience after trauma; other common posttraumatic mental health conditions include depression, anxiety and substance use problems.

Complex trauma

Lucy – 17 year old female

Lucy has been attending the service ‘on and off’ for the past couple of years for assistance with managing her cannabis and psychostimulant use. Lucy has had few stable social supports, and describes patterns of intense on and off relationships. Her workers have at times seen Lucy make significant progress with her substance use and engage very well, only then ‘disappear’ for a few months when things seemed to be going well. Lucy will often re-present following times of crisis, report having had a period of heavy substance use, risk taking and overwhelming, ‘unmanageable’ emotions. This pattern of coming in and out of the service continues despite the best efforts of her workers to engage with her.

During Lucy’s recent appointment, she discloses that she was sexually abused by her step father between the ages of 11 and 13. Lucy is reluctant to provide more detail as “that was dealt with ages ago with police and the courts and whenever she thinks about it she just starts to fall apart”.  Lucy can see that these experiences may be relevant to what she is seeing her worker for (her substance use), but can’t see how things can change.

Adopting a trauma informed approach, Lucy’s worker validates Lucy’s decision to not discuss the details of her abuse, but offers an opportunity to start to consider the possible links between Lucy’s trauma experience, her substance use, and her difficulties with remaining engaged with supports and services.

Lucy and her worker establish that her trauma experiences are having a continued impact– on her attempts to manage her substance use, on how she tends to relate to people and see her own self-worth. They identify that feelings of loss of control in relationships echo aspects of the abuse and are associated with difficulties in managing her feelings, urges to use and a tendency to withdraw from supports.  Lucy finds that understanding these patterns as coping strategies that she uses in response to reminders of her trauma, rather than mistakes, is helpful.  This recognition allows Lucy and her worker to prioritize strengthening skills for recognising and managing high risk situations. They are also able to check in regularly on whether feelings of being out of control might be impacting on the therapeutic relationship as this poses a risk for Lucy staying engaged with the service.

Repeated trauma (especially when it occurs early in life) can lead to more pervasive and complex difficulties, and lead to greater needs for support. Complex trauma presentations require more sophisticated approaches to engagement, support and treatment.

Some responses associated with complex trauma include:

• Difficulty managing emotions – including problems with recognising emotions, having extreme emotional reactions such as anger, shame or despair, having difficulties in changing feelings, and taking a long time for unpleasant feelings to settle. Dissociative reactions may also be a feature.
• Impulsive, reckless or self-destructive behaviour – such as excessive risk taking, or having frequent thoughts of suicide and self-harm
• Difficulties with relationships – attachment issues such as having difficulty trusting people, feeling hostile and separate from others, and having difficulty establishing or maintaining safe relationships

For clients that workers consider as ‘complex’, ‘challenging’ or ‘hard to engage’, it may be worth considering whether they have a history of complex trauma. Considering complex trauma as a backdrop to your client’s difficulties can mean:

• You have a greater chance of understanding the impact of a person’s experiences, and being able to empathise accurately and sensitively
• You have a greater chance of putting in place effective supports and treatments
• You may be in a better place to understand and work with barriers to recovery

Adolescence is one of the most change-heavy periods of development in the entire lifespan. Models of psychosocial development such that proposed by Erik Erikson (Erikson, 1950) suggest that adolescents have substantially more developmental challenges and conflicts to master than adults. It is helpful to keep this in mind when working with adolescents with posttraumatic mental health problems. For instance, a 40 year old who is assaulted physically is less likely than a thirteen year old to develop attachment problems. In other worlds, adolescents have a greater potential to be either become developmentally ‘stuck’ or regressed by trauma.

Find out More:  The neurobiology of trauma

Trauma can have a significant impact on the development of young brains.  The extent of this impact is influenced by a range of factors including the young person’s age and stage of development at the time of the trauma, the type of trauma experienced, the trauma’s duration, the young person’s resilience and protective factors and the amount of social support they receive.  Whilst not all young people will be impacted in the same way, there is increasing evidence that severe trauma can result in changes to the structure and function of vulnerable brain regions.  These include areas such as the prefrontal cortex (responsible for planning, organising and co-ordinating our thinking and behaviour), the amygdala (involved in emotion regulation and fear response) and the hippocampus (an important memory centre and part of the emotional processing system), resulting in secondary impacts on attention, memory and learning. 

Recent studies show that extended periods of neglect, deprivation and abuse can significantly alter the developmental trajectory of neural pathways that are informed by our experiences and the nature of our interpersonal relationships (Bremner, 2003; De Bellis, 2010).  Changes in neurobiological stress response systems have also been well documented.  The function of the hypothalamic-pituitary-adrenal axis (HPA) which controls cortisol levels and the sympathetic-adrenal-medullary system (SAM), which controls our production of adrenaline, as well as our heart and respiratory rate, can both be permanently altered by exposure to cumulative or prolonged traumatic experiences.  As a result the stress response can be left permanently `switched on’ resulting in constant high levels of arousal, hypervigilance, emotional reactivity and poor attentional control (Child, 2012; Vasterling & Brewin, 2005).

In adolescence, the pre-frontal cortex (PFC) is undergoing significant growth and development.  Both early childhood trauma and exposure to significant trauma during adolescence can disrupt this developmental process, resulting in problems with executive skills including planning and organisation, attentional control, emotional regulation, impulsivity, poor self-monitoring, inefficient memory and learning and poor problem solving skills.  In PTSD the dampening down of the PFC can lead to flashbacks and nightmares as the amygdala and hippocampus are left without effective executive control.

When working with people affected by trauma it is important to be mindful of the impacts that these neurobiological changes can have on your treatment plan. For example, consider strategies including reducing environmental distractions, chunking and repeating key information, providing written information and using memory aids (e.g. smartphone reminders).

Clearly communicate and provide psychoeducation to your client about the trauma, its impacts, treatment and recovery

Whilst talking about trauma can sometimes be a distressing and confronting experience, each discussion about the trauma can be an opportunity to support the young person. Not only can talking about the trauma in a safe environment help the young person feel heard and understood, but it can also increase the young person’s awareness of trauma’s impacts, thereby ‘normalising’ their own experiences (i.e. that their reactions and responses are understandable). By providing a way of understanding how the effects of trauma can impact on all areas of functioning, it can help people recognise that they are not ‘going mad’, that they are understood, and are not alone in sorting through these experiences.

Managing discussion about traumatic experiences sensitively is a key skill for trauma informed workers. A general recommendation is to support those who want or need to talk about their trauma experiences, but not to push those who prefer not to talk about it. For many situations, a full account of a traumatic experience is neither necessary nor therapeutic (consider, for example a triage/intake assessment before entering a service).  It may be important to let the person know that they can tell you the type of experiences they have had, rather than the details of that experience.

There are several recommendations when providing psychoeducation to young people who have experienced trauma:

1. Use this as an opportunity to promote hope. You can convey hope by:

• reminding the young person that many people recover in a few weeks on their own, or with the help of friends and family (where trauma has happened very recently) OR  that recovery from the distressing effects of trauma can happen any time – especially with adequate support and effective treatment.
• beginning to explore, highlight and enhance the strengths, skills, supports and resources they already have available to them
• reinforcing that effective supports and treatments are available for people whose problems continue 
• reassuring the young person that you are engaged with being part of their recovery

2. Acknowledge the impacts of all difficult experiences, whilst not giving the impression that all difficult experiences lead to being ‘traumatised’.

3. Match your explanation of trauma, its impacts and recovery with the developmental stage, cultural background and mental health status of the young person. See link for more information on delivering developmentally appropriate information.

4. Provide the young person with an opportunity to ask questions, and provide them with the information in a written form to take home (see sidebar for documents)

Working with Trauma: What can I do to look after myself?
Practitioners who support young people with substance use and other mental health difficulties can themselves be impacted by their work, and experience ‘burnout’. Burnout can also occur when working with people affected by trauma, but notably research suggests these rates of burnout or ‘secondary traumatisation’ are actually quite low (Devilly, Wright, & Varker, 2009). This means that there is nothing necessarily ‘traumatising’ about working with people affected by trauma. Indeed, if general burnout factors are already being managed effectively at a practitioner and organisational level, then trauma-informed care work is already being supported.  Refer to the module on worker self-care for information on managing general burnout factors. Below are some ways practitioners can help prevent burnout that are specific to trauma-informed care:

• Encourage your organisation to apply trauma-informed care principles across the service
• Be aware of your practice limitations (i.e. the roles you have been trained to undertake) and the limitations of the service context in which you work, and try not to work outside of those boundaries
• Develop and maintain your trauma literacy by accessing available training, as well as ongoing professional development and supervision
• Take an active role in your own self-care through recognising and managing those factors that contribute to your wellbeing in your work

Working with Trauma: What can my organisation do to support me?
It is important to aim for not only trauma-informed practitioners, but for trauma-informed services and organisations. Below are some ways organisations can support their practitioners in providing TIC:

• Ensure that all levels of staff, from intake and reception to practitioners and managers, are aware of trauma informed care principles.
• Provide clear guidance to staff about the expectations and limitations of their role as it relates to supporting recovery from trauma
• Provide training, reflective practice opportunities (such as peer supervision or consultation), ongoing professional development and access to structured supervision to staff in order to improve and maintain staff and service trauma literacy
• Ensure topics related to trauma are discussed during regular supervision or team meetings
• Strengthen referral pathways with posttraumatic mental health specialist services
• Review organisational policies and ensure that they are consistent with TIC principles. Include staff and service user input into these policies and procedures.