Section Five
Trauma-Informed Care Teaching activities and resources
Outcomes
Purpose
This section provides educators with the knowledge and skills required to understand and implement trauma-informed approaches to care in mental health and addiction curricula.
Outcomes
At the end of this section, the educator will:
- Understand trauma and the impacts on health.
- Identify the principles of trauma-informed care.
- Understand and implement trauma-informed approaches to care.
- Relate trauma-informed approaches to care to universal precautions, cultural competence and safety, and creating safe space.
CASN/CFMHN Competencies
Trauma-Informed Care
Trauma is defined as an experience that overwhelms an individual’s capacity to cope (CCSA, 2012). Traumatic experiences occur at any age, and may include experiences such as child abuse and neglect to violence and war (CCSA, 2012). Trauma can interfere with a person’s sense of safety, self and self-efficacy as well as the ability to regulate emotions and navigate relationships (CCSA, 2012).
For those who have faced multiple traumatic events, repeated experiences of abuse, or prolonged exposure to abuse, trauma is overwhelming and may have a significant impact on living (CCSA, 2012; Klinic Community Health Centre, 2013; National Child Traumatic Stress Network, 2008). Moreover, people who access mental health and substance use treatments report trauma and violence as being common (CCSA, 2012). Specifically, evidence shows individuals who have experienced trauma are at greater risk for developing a substance use disorder (Macy & Goodbourn, 2012). People who have experienced trauma view their use of substances as a coping tool; however this can make them more vulnerable to substance use problems (CCSA, 2012). Trauma also affects a person’s mental health and can affect thinking, memory, attention and concentration (CAMH, 2012).
Trauma-Informed Approaches
Educators in partnership with students need to develop an understanding of trauma-informed approaches to care and emphasize their use when assessing and treating all clients who use substances and/or may have a mental health condition, even when trauma is not suspected in clients (RNAO, 2015d).
Trauma-informed services focus on establishing a safe environment, where clients with trauma have choice and control; however, disclosure of trauma is not required (CCSA, 2012). Moreover, the use of trauma-informed approach in treatment does not require nurses to treat trauma, but rather a trauma-informed perspective results in a particular approach and acknowledges how common trauma is among clients who use substances, and the manifestation of trauma in their lives (RNAO, 2015d).
There are four key principles of trauma-informed approaches as outlined by the Canadian Centre on Substance Abuse. They include:
| Trauma Awareness | All services taking a trauma-informed approach begin with building awareness among staff and clients of: how common trauma is; how its impact can be central to one’s development; the wide range of adaptations people make to cope and survive; and the relationship of trauma with substance use, physical health and mental health concerns. This knowledge is the foundation of an organizational culture of traumainformed care. |
| Emphasis on Safety and Trustworthiness | Physical and emotional safety for clients is key to trauma-informed practice because trauma survivors often feel unsafe, are likely to have experienced boundary violations and abuse of power, and may be in unsafe relationships. Safety and trustworthiness are established through activities such as: welcoming intake procedures; exploring and adapting the physical space; providing clear information about the programming; ensuring informed consent; creating crisis plans; demonstrating predictable expectations; and scheduling appointments consistently. The needs of service providers are also considered within a trauma-informed service approach. Education and support related to vicarious trauma experienced by service providers themselves is a key component. |
| Opportunity for choice, collaboration and connection | Trauma-informed services create safe environments that foster a client’s sense of efficacy, self-determination, dignity and personal control. Service providers try to communicate openly, equalize power imbalances in relationships, allow the expression of feelings without fear of judgment, provide choices as to treatment preferences, and work collaboratively. In addition, having the opportunity to establish safe connections – with treatment providers, peers and the wider community – is reparative for those with early/ongoing experiences of trauma. This experience of choice, collaboration and connection is often extended to client involvement in evaluating the treatment services, and forming consumer representation councils that provide advice on service design, consumer rights and grievances. |
| Strengths based and skill building | Clients in trauma-informed services are assisted to identify their strengths and to further develop their resiliency and coping skills. Emphasis is placed on teaching and modelling skills for recognizing triggers, calming, centering and staying present. In her Sanctuary Model of trauma-informed organizational change, Sandra Bloom described this as having an organizational culture characterized by ‘emotional intelligence’ and ‘social learning.’ Again, parallel attention to staff competencies and learning these skills and values characterizes trauma-informed services. |
Reprinted from “Essentials of ... Trauma-informed Care,” by N. Poole, 2012, Canadian Network of Substance Abuse and Allied Professionals. Copyright 2012 by the Canadian Centre on Substance Abuse. Reprinted with permission.
Teaching and Learning Activities
The following are teaching and learning activities that can be employed in the classroom to further support nurses in the integration of theory, principles and best practices related to trauma-informed approaches to care.
- Trauma-informed safety plan—Appendix F
- Case study suggestions (Section 9.3):
- A person with a diagnosis of schizophrenia begins heavy alcohol use after a sexual assault: Where do you start?
- A person who has had a close friend or relative die by suicide.
- A refugee who has witnessed or experienced violence.
- A veteran who has recurrent nightmares and substance use after returning from service.
- Simulation
- Lived client experience/family experience—Appendix H
- Planning a physical environment that does not re-traumatize
- Handout with Learner Engagement Questions (below)
- Arts-based approaches
- Photography
- Music
- Poetry
Learner Engagement Questions
The following are thought-provoking and engaging learner questions that can be used to further discussions with nursing students regarding using trauma-informed approaches to care. These questions can be used either to stimulate discussion, engage students in critical thinking or be tied to class assignments and/or reflection exercises.
- What is the impact of different restraints in relation to trauma?
- What is the difference between trauma therapy and trauma-informed care?
- How might someone dull the pain of trauma in ways that could be helpful and not helpful?
- How are residential schools related to trauma for First Nations, Aboriginal, Inuit and Métis people?
- How can trauma be experienced on the intergenerational level and over the individual and family lifespan?
- What is the relationship between trauma and homelessness (and other social determinants of health)?
- When is a good time to discuss trauma? How do you engage in this topic? When might you delay the discussion?
- What is a trigger and how would you recognize that someone is experiencing trauma-related distress?
- How might a person with a history of trauma have behaviour that could be interpreted as “noncompliance” or non-adherence?
- Who is vulnerable to trauma?
Evaluation and Self-reflection
The following tools can be used to evaluate students in their understanding and application of trauma-informed approaches:
- Care plans reflecting trauma-informed approaches to care
- Tests of theoretical concepts
- Applications with case studies
SELF-REFLECTION
- Reflection question: What personal experience do you have of trauma and how might this influence your care?
- Journaling experiences—Appendix E
Resources
Websites
The Sanctuary Model by Dr. Sandra L. Bloom
Government of Nova Scotia - Trauma Informed Practices – Discussion Guides
- #1: An Introduction and Discussion Guide For Health and Social Service Providers.
- #2: Recognizing and responding to the effects of trauma.
- #3: Trauma-informed practice in different settings and with various populations.
- #4: Trauma-informed practice at the interagency and leadership levels
- Safewards by Len Bowers
- Trauma Informed Care Project
RNAO TOOLS
- Registered Nurses’ Association of Ontario. (2012). Promoting safety: Alternative approaches to the use of restraints. Toronto, ON: Registered Nurses’ Association of Ontario.
- RNAO, 2015 Engaging Clients Who Use Substances. Toronto, ON: Registered Nurses’ Association of Ontario.
GUIDES
- British Columbia Provincial Mental Health and Substance Use Planning Council. (2013). Trauma-informed practice guide. Vancouver, BC: Author.
- Substance Abuse and Mental Health Services Administration. (2014). Trauma-informed care in behavioral health services. Part 3: A review of the literature. Treatment Improvement Protocol (TIP) Series 57. Rockville, MD: Author.
- The Jean Tweed Centre (2013). Trauma Matters: Guidelines for trauma-informed practices in women’s substance use services.
BOOKS
Poole, N. & Greaves, L. (2012). Becoming Trauma Informed. Toronto: ON. Centre for Addiction and Mental Health.
Mate, G. (2009). In the realm of hungry ghosts. Berkely, CA: North Atlantic Books.