Introduction: What is a Trauma-Informed Approach?

Many people experience trauma in their lives, many of whom do not seek timely healthcare. Thus it is essential for all communications with healthcare professionals, to begin with, a foundation of understanding that all persons have experienced trauma at some time in their lives. The approach is called trauma-informed communications. Trauma refers to any experience that may cause intense physical and psychological stress reactions. It can refer to “an event, series of events, or set of circumstances that is experienced by an individual as physically or emotionally harmful or threatening and that has lasting adverse effects on the individual’s functioning and physical, social, emotional, or spiritual well-being” (Substance Abuse and Mental Health Services Administration [SAMHSA], 2019).  To establish effective communication, healthcare professionals need to know the six principles of trauma-informed care: safety, trustworthiness and transparency; peer support; collaboration and mutuality; empowerment, voice and choice; and cultural issues (National Center on Domestic Violence, Trauma & Mental Health, 2019).

Children and young people who have experienced trauma have little space for learning. Their constant state of tension and arousal can leave them unable to concentrate, pay attention, retain and recall new information. Their behaviour is often challenging in the healthcare environment when the goal is to assist the client. Trauma can also affect a client’s decisions or the ability to trust others, including healthcare professionals. As a result, it becomes increasingly challenging for the trauma survivors when communicating with others as they tend to protect themselves from reliving the traumatic experience. The traumatised client may feel like danger lurks around the corner constantly.

Assessing What You Already Know

Understanding Trauma

Different types of trauma may include:

• Acute trauma from a singular incident, such as a natural disaster, accident, or acts of violence.
• Chronic trauma is repeated and prolonged, resulting from situations such as domestic violence or abuse.
• Complex trauma is varied, and multiple traumatic events, often of an interpersonal nature, such as abuse or profound neglect, often occur with caregivers.
• Historical trauma may include multigenerational and experienced by a specific cultural, racial or ethnic group, often related to significant events that oppressed a group of people, such as slavery, the Holocaust, forced migration or violent colonisation (City of San Diego, n.d.).

One may experience one, some or all of these traumatic stresses during their lifetime. Multiple studies show that severe or ongoing exposure to highly stressful or threatening events can significantly impact a client’s ability to function in a socially acceptable manner (Haskell & Randell, 2019; King, 2021; National Child Traumatic Stress Network [NCTSN], 2017). Therefore the healthcare administrator (HCA) must be informed in the practice of trauma-informed communication. The American Substance Abuse and Mental Health Service Administration (SAMSHA, 2019) defines “a program, organisation, or system that is trauma-informed as one that: 1) Realises the widespread impact of trauma and understands potential paths for recovery; 2) Recognises the signs and symptoms of trauma in clients, families, staff, and others involved with the system; 3) Responds by fully integrating knowledge about trauma into policies, procedures, and practices; and 4) Seeks to resist re-traumatisation actively.”

Why is Utilising a Trauma-Informed Approach Essential for the Healthcare Administrator?

As a professional healthcare administrator, one will work in various settings and encounter very diverse populations. A trauma-informed approach (TIA) addresses vital information about the client’s well-being that considers adverse life experiences and their potential influence on their healthcare decision-making. A trauma-informed approach is critical to promoting lifelong health and well-being for anyone who has had adverse childhood and adult experiences.
All staff should have initial training on a trauma-informed approach and how to apply trauma-informed principles in every client interaction. The awareness and application of the trauma-informed approach increase trust and reliability in all interactions with clients (OASH, 2021; NCTSN, 2020). Not all clients will appear as if they have experienced past trauma, however, if the HCA develops an awareness of their professional approach it can prevent re-traumatising the client. Retraumatisation can occur when a client must explain their story over and over to multiple healthcare providers or service workers (SAMHSA’s Trauma and Justice Strategic Initiative, 2014).

The HCA helps to avoid re-traumatising the client and can include the HCA reviewing the client’s chart for referral or consultation reports before asking the client questions. Often times the HCA has the information, however, the client must repeat their story. The HCA can use their verbal assessment skills to assess if a client is uncomfortable in a setting and move them to another area. Any sensory stimuli can trigger a client to re-experience an event. Consider smells, sights, sounds or touches that may be interpreted as good or bad and can take action to change the healthcare environment. At times the client may cringe when exposed to a particular noise, using the HCA assessment skills of the situation can allow the HCA to be proactive in preventing re-traumatising a client. It may be best to assume that all clients have a past and some may have been trauma-induced.

Watch: What is trauma-informed care? [3:34]

Key Trauma-Informed Principles

The goal of the helping interview is to achieve and maintain a trusting relationship with the client.
HCA and other professionals model positive, non-shaming communication to support healing for those in need and promote health and well-being for everyone. The HCA should listen patiently without interruption, pleasantly provide information and answers, and ensure all participants have opportunities to speak and be heard.
HCA’s can provide non-judgmental, warm, empathic, and genuine interactions at all times, including ongoing training to connect with their clientele while maintaining healthy professional boundaries (NCTSN, 2020).

Building safety, transparency and trustworthiness, peer support, collaboration and mutuality, empowerment, voice and choice, and cultural issues are vital principles for a trauma-informed approach (NCTSN, 2020). The HCA should recognise that responses to trauma can include dismissing feelings, avoiding things that are reminders of previous traumatic experiences, and increased sensitivity to these reminders, people, and the environment. It may be an opportunity for the HCA to provide information for the clients about trauma and its effects.  When possible, offer flexibility and choices as to how a survivor can interact with our programs and staff.

It is essential to take a survivor’s trauma responses seriously (e.g., they may be jumpy or anxious, have a hard time sleeping, or may need to avoid a neighbourhood that has too many reminders of past experiences). This can be demonstrated by communicating respectfully using appropriate terms and language to build healthy, trusting and professional relationships and be an active listener (OASH, 2021).

Best Practices for Trauma-Informed Communication

• Communicate respectfully. The tone of voice can significantly impact how people receive and react to messages.
• Be respectful of others’ life experiences. Recognise that someone’s mental health issues, substance abuse or physical health concerns may be rooted in “what has happened to them” and not because “something is wrong with them.”
• Build healthy relationships. When interacting with others, treat people with dignity and respect.
• Be an active listener.
• Focus on behaviours and not the person.
• Use appropriate body language.

Creating a Safe environment for all Clients to Communicate Without Fear of Judgement

An emotional safety setting may seem challenging to achieve because it is hard to measure. One definition of emotional safety includes “a feeling that your innermost thoughts, feelings and experience are, and will be, honoured as one honour themselves. You need not prove nor impress; you simply are. When a client feels safe, they feel open, even, at ease, and fluid with the spontaneity of a healthy child.”

The HCA should understand emotional safety. Emotional safety means that one feels accepted; it is the sense that one is safe from emotional attack or harm. Most trauma survivors have probably felt emotionally unsafe or had their sense of “being all right” taken away by others. Many survivors share that the ongoing and unrelenting attacks on their sense of well-being are more painful than a beating (King, 2009). Clients should always feel they are welcome in your healthcare setting (Washington Coalition of Sexual Assault Programs, 2012).

The healthcare exposure may help clients manage feelings. Trauma may affect a person’s ability to achieve an emotional balance. Many survivors may experience diverse feelings and worries that make it difficult to make decisions, follow plans, and tend to responsibilities for their healthcare needs. Thus, HCA can provide clients with a greater sense of control, such as booking appointment times conducive to the client’s schedule. The HCA can activate and engage the client in thinking and planning to gain or lead to a better sense of control. This can also mean providing or offering a caring and calming presence, helping with tasks that appear to be overwhelming, such as completing paperwork or online scheduling of appointments or directions.

When possible the HCA can provide a relaxing place. When providing a calm environment, the message sent to the client is that one cares about their privacy and is interested in attentively listening to how the client feels and their status physically and emotionally. A soothing space may be a quiet corner of a quiet room or a comfortable chair, low lights, a flexible door that can be closed or kept open, or a source of quiet music. Alternatively, it could be a room with plants or flowers, videos of beautiful scenery, a radio or CD player, and space for writing. Different things will be soothing at different times and to different types of clients and department settings.

Once again, the HCA can provide information about trauma. Trauma will disrupt a person’s sense of well-being, and it has direct effects on the brain and causes changes in how the person perceives and experiences the world and how they perceive danger (Haskill & Randell, 2019). Learning about trauma triggers can help clients understand and manage their feelings and increase their sense of control and autonomy.

It is essential for the HCA to provide clear information and avoid surprises. When clients feel emotionally unsafe, they may wonder which people have the power or authority in the healthcare setting. They may be concerned about what the professionals will do with their information. Providing clear and accurate information about policies, procedures, rules, plans, and activities helps support emotional safety (Schladale, 2013).

The HCA may be able to help trauma survivors feel comforted and in control. Each survivor has a pattern of needs related to emotional safety. For example, one survivor may find it reassuring to have clear directions or information from staff who speak with authority and expertise. For someone else, withdrawing from external stresses to explore their thoughts and feelings will be the jump start they need to plan for their future. An essential aspect of helping survivors feel comforted and in control is ensuring that survivors know they can ask for what they need. Such as asking for a tissue, and they may express their opinions and wishes – for example, seeing a particular healthcare professional or appointment date and time. (OASH, 2021; NCTSN, 2008).

Understanding Symptoms as Adaptations

In trauma-informed settings, a survivor’s behaviour reflects adaptations to a world that has not always been safe. Instead of trying to fix a client’s behaviour, one needs to understand multiple variables such as brain chemistry, genetic tendencies, and life experience as well as the person’s access to resources) affect how the world looks to them, what feels safe, what they think may happen, and how they ask for and use healthcare services (National Center on Domestic Violence, Trauma & Mental Health, 2011). If survivors have a mental illness, they know that they neither have to hide it nor disclose it to get the help they are seeking.
Of course, this does not mean that the HCA will not have reactions if a person’s behaviour is troublesome, disrespectful, or dangerous. It does mean that the way the HCA communicates their reactions should not shame or embarrass the client. Saying, “We want everyone to be safe and comfortable here. You have been shouting for a while, and that worries some of us,” is better than saying, “You cannot keep making all that noise; you need to sit down and please be quiet” (National Center on Domestic Violence, Trauma & Mental Health, 2011). Both statements let the client know that people are reacting to their behaviour, but be respectful and acknowledge that the survivor is doing the best they can (Haskell & Randall, 2019).

The Impact of Trauma on LGBTQIA+ Youth

The following video introduces the HCA to the needs of lesbian, gay, bisexual, transgender, queer, questioning, two-spirited, and other (LGBTQIA+) youth who have experienced trauma. “As with many cultures, language, acronyms, and approaches are fluid and can change over time; most importantly, what is accepted may differ between individuals (Rowe, 2020).” This video discusses creating safe, welcoming and inclusive environments for youth who have experienced trauma and identify as LGBTQIA+.

Watch: Safe spaces, safe places: Creating welcoming and inclusive environments for traumatized LGBTQ youth [24:33]

Trauma-Informed Communication Strategies

What can the HCA do? By using focused eye contact and engaging body language can create open non-threatening communication. The HCA can ask open-ended questions to answer the who, what, when, where and how of discussed topics. When the client speaks, avoid interruptions, judgement and do not try to fix things. Also, remember to focus on behaviours and not the person (NCTSN, 2008; NCTSN, 2020; Family Violence Prevention Fund, 2004).

Check your Understanding

Assessing What You Already Know Descriptions

Question 1

Have you ever been in an uncomfortable situation where you continued to ponder the exchange or incident? Did you: (Select all that apply)

1. Create other resolutions to the incident?
2. Think about the incident for the day?
3. Think about the incident before falling asleep?
4. Discuss the incident with others more than once?

The correct response is option one, two, three and four. Remember we can all respond is differing ways when pondering an uncomfortable situation. What one feels is not wrong.

Question 2

Have you ever been exposed to something where it reminded you of a past experience?

Such as a smell that reminded you of a place or person. The response to the scent may create a trigger, good or bad, and is very individual to their individual experience. How do you feel when you smell pizza? (select all that apply)

1. it reminds me of my friends
2. it makes me feel happy
3. it makes me feel hungry
4. it reminds me of my family
5. it makes my stomach feel upset
6. it makes my mouth water.

The correct response is all of the above. Often smells will remind us of something. How we feel or interpret the feeling will differ between individuals. How one feels is not wrong.

Active Listening and Attending Behaviours

As discussed previously, listening is an essential part of communication. The three main listening types are competitive, passive, and active. Competitive listening happens when we are focused on sharing our point of view instead of listening to someone else. Passive listening occurs when we are not interested in listening to the other person and assume we understand what the person is communicating correctly without verifying. During active listening, we communicate verbally and nonverbally that we are interested in what the other person is saying while verifying our understanding with the speaker. Active listening is essential to facilitate your understanding of and the integration of clients’ experiences, preferences, and health goals into their care. You might show that you are an active listener by eye contact and open posture. You can also use facilitation strategies that show active listening and encourage the client to elaborate, such as nodding and responding by saying “uh huh,”  “tell me more,” or restating what the client said and then verifying if our understanding is correct. This feedback process is the main difference between passive listening and active listening.

Therapeutic Communication Techniques

Therapeutic communication techniques are specific methods to provide clients with support and information while focusing on their concerns. Health professionals assist clients in setting goals and selecting strategies for their care plan based on their needs, values, skills, and abilities. It is essential to recognise the client’s autonomy to make decisions, maintain a nonjudgmental attitude, and avoid interrupting. Depending on the developmental stage and educational needs of the client, appropriate terminology should be used to promote client understanding and rapport. When using therapeutic techniques, health professionals often ask open-ended statements and questions, repeat information, or use silence to prompt clients to work through problems independently; a variety of such techniques are described below (American Nurse, 2023).

Clear and Simple Language

Avoiding or limiting medical and professional language clients may not understand is best. Remember, knowledge is power; using language others may not understand reinforces subordination and exclusion. By speaking simply and clearly, you include clients regardless of their professional or educational point of reference.

Use of a Broad Opening Remark

This gives the patient the freedom to choose what he/she wishes to talk about, for example, “Please tell me more about yourself.”

Open-Ended Questions

This type of question allows the patient to discuss their views. In this way, what the patient sees as essential, their intellectual capacity, and how well-orientated they are, become apparent. This encourages the patient to say more and does not limit answers to yes or no. There are two techniques you can use. Open-ended questions begin with who, what, when, where, and how. Probing questions that elicit additional information include questions that begin with “Tell me more …”

Examples:

“How did you experience the pain?”

“When did you start feeling dizzy?”

“Tell me more about the accident?”

Clarification

This helps the health professional to understand and the client to communicate more clearly.

Examples:

“What do you mean by everybody?”

“Just to clarify, what do you mean by everybody?”

Paraphrasing

This conveys an understanding of the client’s basic message.

Examples:

“From what I hear you saying, the most important problem is your mobility.”

“The lack of affordable housing is your main concern.”

Sharing Observations

This shows that you know what is happening to the patient and encourage them to talk about it.

Example:

“I notice you limp when you walk. Are you in pain?”

Summarising

Organising and checking what the client said, especially after a detailed discussion. This technique indicates that a specific part of the discussion is ending and that the HCA should check to see if the client wishes to say any more.

Example:

“You went for a walk and then felt the sharp pain in your lower back, which radiated down your leg. Is that right?”

Silence

Silence is a strategy that aids active listening. It can be beneficial when the client is talking about something personal or struggling to find the words they want to say. Sometimes silence can be uncomfortable, and health professionals want to fill the void with words. It is better to show interest and understanding and give the client time to think about how they best want to say what they want. Silence also allows a health professional to observe the client. However, health professionals should avoid silences that last too long because they can make the client anxious.

Example:

If the client feels awkward about taking too much time to think, you can say, “It is ok. Take your time.”

Honesty

Be honest. Part of therapeutic communication involves being authentic and truthful. To do so, you should be straightforward with clients and compassionately talk to them. If discussing a problematic or emotionally laden topic, demonstrate compassion by sitting down, maintaining eye contact, and being aware of your vocal intonation.

Unconditional Positive Regard

Accept and respect that each client has the agency to believe and behave how they want or feel is best. You do not have to agree or approve, but your acceptance of their self-determination should not be conditional on its alignment with your beliefs or behaviours. This approach involves accepting that clients are generally doing their best. Avoid judging or blaming them for their beliefs, behaviours, or conditions. You should avoid questions that begin with “why,” as this can imply blame. For example, avoid “Why do you smoke?” You can reframe this inquiry to be positive.

Examples:

“Tell me the reasons that you smoke.”

“Tell me the reasons that you exercise.”

Permission Statements

Use permission statements to open conversations that may be difficult. Permission statements are a combination of statements and questions that suggest to the client that an experience or feeling is expected or normal.

Examples:

“Often, children your age experience changes in their body that they have questions about.”

“Clients that have experienced your type of surgery often have questions about sex. What if any questions do you have for me?”

“Many people your age begin to experience problems with urinary incontinence. Have you had any issues?”

Ask One Question at a Time

Ask one question at a time so the client understands it, and you are more likely to receive a clear answer. You should avoid asking multiple questions at once because this can confuse clients. Here is an example: “Tell me about your support system. Your brother seems like he is a great help, right? Do you have anyone else to support you?”

Example: Instead of multiple questions, try it this way.

“Tell me about your support system?” – then, wait for an answer. You can probe with follow-up questions depending on what the client says.

Work Collaboratively

Work collaboratively with the client during the interview so that they are an active agent with self-determination. Using a relational inquiry approach and working collaboratively, you can focus on what is important to the client. Focusing on what is important to the client involves providing information they identify as relevant. Ask the client if they are interested in learning more about a topic.

Nontherapeutic Responses

Health professionals and health professional students must be aware that certain nontherapeutic communication techniques should be avoided as they do not assist in the recovery of the client and do not have any therapeutic value.

Closed Questions

These questions require only a single word when specific information is needed. If this question is used often, the client is less inclined to give the information and may interpret it as an interrogation. Closed questions begin with “Have you?” “Should you?” Would you?” or “Do you?.”

Examples:

“Do you have pain in your arm?”

“Did you drive to this appointment?”

Closed-ended questions require context to be deemed appropriate. They are relevant when a client has difficulty speaking, a health professional is attending an emergency or has limited time to acquire information. Otherwise, open-ended questions should be used.

“Why” Questions

These questions demand that the client explain behaviours, feelings, or thoughts they often do not understand. These questions are often asked early in a conversation when the health professional cannot even be certain that the client wants to explain themselves to you. They also may be considered judgmental or blaming the client based on the tone often used in conjunction with what is being asked.

Example:

“Why are you upset?”

It is better to rephrase the question as “You seem upset. What is on your mind?”

Passing Judgment

The health professional passes judgment on the client’s behaviour, thoughts, or feelings and, in doing so, places themselves in the position of an adversary or a person who knows better and more.

Example:

“As a Christian, I do not think you should terminate this pregnancy.”

Health professionals should avoid this technique and ask questions for understanding. “Tell me how you feel about terminating this pregnancy?”

Giving Advice

The health professional tells the client how they should feel, think or act. This implies that the health professional knows the correct information better than the patient. This is particularly problematic when the advice is based on limited assessment and knowledge of the patient and the situation.

Example:

“I think you must …”

Instead, health professionals should use open-ended or empathetic responses.

Defensiveness

The health professional tries to defend someone or something the client criticised. This places the nurse and the client on opposite sides and does not promote further openness on the part of the client.

Example:

“We are very short-staffed, so we cannot help everyone at the same time.”

Instead, a more therapeutic response would be, “I apologise for the wait. I know your appointment was at 3:00, and it is 4:30. You are next to see the social worker.”

Changing the Subject

Changing the subject when someone tries to communicate with you demonstrates a lack of empathy and blocks further communication. A client may interpret this as indicating that you do not care about them or what they say.

Example:

“Let’s not talk about your family problems; it is time for your walk now.”

A more therapeutic response would be, “After your walk, let’s talk more about what is going on with your family.”

Sympathy

Sympathy focuses on feeling compassion for a client’s situation from your perspective.

Example:

“I am sorry this is happening to you.”

A more therapeutic response would be an empathetic response. “This has been a difficult time for you. Tell me how you are coping?”

False Reassurance

False reassurance is when a health professional assures or comforts the client about something not based on fact. People tend to automatically respond when someone voices fear or anxiety by assuring them that everything will be okay.

“It will be okay” when a client says, “I am scared I might die.”

This kind of response is not honest and does not open up communication. It is more effective and honest to say, “Tell me more.”

Watch the following videos for another example of false reassurance and how to avoid it.

Watch: False reassurance [0:27]

Watch: How to avoid false reassurance [0:42]

Activity: Check Your Understanding

References

American Nurse. (2023). Therapeutic communication techniques. https://www.myamericannurse.com/therapeutic-communication-techniques/

City of San Diego. (n.d.). Trauma informed resources. Commission on Gang Prevention and Intervention. https://www.sandiego.gov/gangcommission/directory/trauma

Family Violence Prevention Fund. (2004, August). Identifying and responding to domestic violence: Consensus recommendations for child and adolescent health. Futures Without Violence. http://www.futureswithoutviolence.org/userfiles/file/HealthCare/pediatric.pdf

Haskell, L., & Randall, M. (2019, January 1). Impact of trauma on adult sexual assault victims: What the criminal justice system needs to know. SSRN. https://papers.ssrn.com/sol3/papers.cfm?abstract_id=3417763

King, J. (2009). Emotional abuse: The lack of emotional safety as an internal indicator in abusive relationships. Prevent Abusive Relationships. https://www.preventabusiverelationships.com/articles/emotional_safety.php

National Center on Domestic Violence, Trauma & Mental Health. (2011, August). Tips for creating a welcoming environment. Creating Trauma-Informed Services: Tipsheet Series. http://nationalcenterdvtraumamh.org/wp-content/uploads/2012/01/Tipsheet_Welcoming-Environment_NCDVTMH_Aug2011.pdf

National Center on Domestic Violence, Trauma & Mental Health. (2019). Creating trauma-informed services tipsheet series. http://www.nationalcenterdvtraumamh.org/publications-products/creating-trauma-informed-%20services-tipsheet-series-for-advocates/

National Child Trauma Stress Network. (2008, October). Child trauma toolkit for educators. https://www.nctsn.org/resources/child-trauma-toolkit-educators

National Child Trauma Stress Network. (2020). Child welfare trauma training toolkit: Supplemental handouts questions for mental health providers. https://www.nctsn.org/print/1145

National Child Traumatic Stress Network. (2017, July 17). Safe spaces, safe places: Creating welcoming and inclusive environments for traumatized LGBTQ youth [Video]. YouTube. https://www.youtube.com/watch?v=8zNbQ_8KRew

OASH. (2021). Meaningful youth engagement. Office of Population Affairs.  https://opa.hhs.gov/adolescent-health/positive-youth-development/meaningful-youth-engagement

Robert Wood Johnson Foundation. (2013, May 12). The truth about ACEs [Infographic]. https://www.rwjf.org/en/library/infographics/the-truth-about-aces.html?cid=xsh_rwjf_pt

Rowe, K. (2020). Improving provider confidence and partnership with LGBT patients through inclusivity and education. Doctor of Nursing Practice Projects, 5. https://scholarworks.seattleu.edu/dnp-projects/5

Schladale, J. (2013). A trauma-informed approach for adolescent sexual health. Resources for Resolving Violence. https://foster-ed.org/wp-content/uploads/2017/01/A-Trauma-Informed-Approach-for-Adolescent-Sexual-Health-2013.pdf

Substance Abuse and Mental Health Administration. (2019, August 2). Trauma and violence. U.S. Department of Health & Human Services. https://www.samhsa.gov/trauma-violence

SAMHSA’s Trauma and Justice Strategic Initiative. (2014, July). SAMHSA’s concept of trauma and guidance for a trauma-informed approach. https://ncsacw.samhsa.gov/userfiles/files/SAMHSA_Trauma.pdf

Washington Coalition of Sexual Assault Programs. (2012). Creating trauma-informed services: A guide for sexual assault programs and their system partners. WCSAP. https://www.nsvrc.org/sites/default/files/publications/2018-04/Trauma-Informed-Advocacy.pdf