Trauma and violence-informed approaches to policy and practice

Table of Contents

• Introduction
• Why we need trauma and violence-informed approaches
• How trauma and violence are connected
• How gender and culture are connected to trauma and violence
• How to implement trauma and violence-informed approaches
• Addressing the impact on service providers who work with people who have experienced violence and trauma
• Examples of trauma and violence-informed approaches
• References and resources
• Glossary
• Endnotes

Introduction

Trauma-informed approaches are familiar to many organizations and service providers. Recently, this term has been expanded to include "and violence", an important change in the language which underscores the connections between trauma and violence.

Trauma and violence-informed approaches are policies and practices that recognize the connections between violence, trauma, negative health outcomes and behaviours. These approaches increase safety, control and resilience for people who are seeking services in relation to experiences of violence and/or have a history of experiencing violence.

Trauma and violence-informed approaches require fundamental changes in how systems are designed, organizations function and practitioners engage with people based on the following key policy and practice principles:

1. Understand trauma and violence, and their impacts on peoples' lives and behaviours
2. Create emotionally and physically safe environments
3. Foster opportunities for choice, collaboration, and connection
4. Provide a strengths-based and capacity-building approach to support client coping and resilience

Service providers and organizations who do not understand the complex and lasting impacts of violence and trauma may unintentionally re-traumatize. The goal of trauma and violence-informed approaches is to minimize harm to the people you serve—whether or not you know their experiences of violence.

Embedding trauma and violence-informed approaches into all aspects of policy and practice can create universal trauma precautions, which provide positive supports for all people. They also provide a common platform that helps to integrate services within and across systems and offer a basis for consistent ways of responding to people with such experiences.

Why we need trauma and violence-informed approaches

Violence is pervasive in society (for example, globally 1 in 3 of women experienced physical and/or sexual violence by a partner or sexual violence by a non-partner^Endnote i; in Canada 32% adults report that they experienced abuse in childhood^Endnote ii; and 25% of students in grades 6-12 report being bullied^Endnote iii). Because of this, many people seeking services—in health care, housing, justice or other systems—will have histories of violence and trauma.

The goal is to minimize harm, not to treat trauma

Trauma and violence-informed approaches are not about 'treating' trauma, for example, through counselling or chronic pain interventions. Instead, the focus is to minimize the potential for harm and re-traumatization, and to enhance safety, control and resilience for all clients involved with systems or programs. These approaches benefit everyone, whether or not they've experienced trauma in their lives or their personal history is known to service providers.

Three important reasons to implement trauma and violence-informed approaches

1. To increase attention on the impact of violence on people's lives and well-being

Concepts of trauma-informed practice or care have been emerging over the past 15 years. The addition of "and violence" is a recent and important change in language that helps to:

Understand violence and its relationship to trauma

• Recognize that, like past violence, ongoing violence may be a primary cause of trauma responses
• Reduce the tendency to blame/judge people for their psychological or behavioural reactions to experiences of violence, and recognize that these responses may be a result of trauma
• Distinguish how trauma that results from violence is different from trauma caused by other negative events, such as natural disasters

Connect to broader systems

• Draw attention to the cumulative effects of multiple forms of violence including systemic violence, such as racism or discrimination
• Direct attention to the importance of organizational-level actions, such as changes to policies that take clients' safety and experiences of violence into account and that recognize how broader conditions of people's lives (e.g. poverty or unstable housing) increase risk of multiple forms of violence. These could include staff/client ratios, waiting area policies and social policies.

2. To reduce harm

Service providers, organizations and systems may not be aware that they can cause unintentional harm to people who have experienced violence and trauma.

People who interact with systems such as justice, health, housing and child protection can be re-traumatized by their experiences in these systems. Re-traumatization can happen each time an adult or child needs to re-tell their story of abuse when seeking help across sectors, organizations or service providers, or when people experience discrimination, marginalization or stigma.

Service providers can inadvertently re-traumatize or trigger their clients when they:

• touch without warning or permission
• speak in a way that conveys negative judgement or blame, such as, "Oh, you're back again", or, "Why don't you just leave your partner?"
• interpret a client's reaction or behaviour as being out of proportion or unwarranted without considering the experiences which may have contributed to the reaction or behaviour
• use forceful or demanding language to tell a client to complete a task—such as fill out a medical history form or remove clothing for an examination

3. To improve system responses for everyone

Trauma and violence-informed approaches can help make systems and organizations more responsive to the needs of all people and provide opportunities for practitioners to provide the most effective support to their clients.

These approaches aim to increase the safety, control and resilience of all clients, regardless of whether or not they have experienced violence or trauma sometime in their lives.

Disclosure of violence and trauma is not the goal in trauma and violence-informed approaches. Service providers do not necessarily need to know peoples' violence histories to provide appropriate support.

By practicing universal trauma precautions, service providers can offer safe care or support, even when individuals choose not to disclose their trauma history. Here are some of the many reasons why individuals may choose not to disclose:

• it is unsafe to disclose
• the history is not central to the immediate service being provided
• a client has limited or no memory of their history
• the client finds it too distressing to disclose

How trauma and violence are connected

Trauma occurs when people experience an overwhelmingly negative event or series of events, including violence.

Violence can take many different forms and can be experienced once or many times. Violence is often the result of intentional actions to control or abuse someone, but can also have unintended consequences, such as when children are exposed to intimate partner violence. Experiences of violence can also be systemic and less visible. For many marginalized populations, discrimination and systemic violence are everyday experiences.

Different forms of violence can have interrelated traumatic effects

Examples:

• Child maltreatment can increase a person's vulnerability to interpersonal violence in adulthood
• Children's exposure to intimate partner violence can result in negative health and social outcomes similar to those resulting from more direct forms of abuse^Endnote iv
• Exposure to systemic violence (such as racism) can increase a person's vulnerability to all other forms of violence
• Over time, experiences of systemic violence can result in historical and intergenerational trauma
• Self-directed violence often arises in the context of exposure to interpersonal  forms of violence

Trauma can cause neurobiological changes which impact health and behaviour across the lifespan

While people are capable of recovering from adverse events, the trauma they experience at the time of the event, and throughout their lifetime, can contribute to a range of negative outcomes.^Endnote v

• For example, child abuse, including neglect and exposure to intimate partner violence, can impact children's emotional and social development— including lifelong patterns of anxiety, chronic pain, substance use or difficulty controlling anger.

How gender and culture are connected to trauma and violence

Trauma and violence-informed approaches recognize that experiences and effects of violence are strongly linked to gender and culture.

Gender

Trauma and violence-informed policies and practices recognize that violence and trauma are shaped by gender stereotypes and inequities, and thus tailor services and programming to individual needs. Adults, children and youth of all gender identities face different levels and types of risks, as well as varying access to service and support.

• Overall, rates of intimate partner violence are higher for women compared to men in every age group. Certain groups of women experience higher rates of violence than other women, particularly Indigenous women and women with disabilities^Endnote vi. Violence against women is rooted in gender inequity and women are more likely to:
  • report ongoing violence, physical injury, more serious types of injuries and greater health issues
  • experience coercive control
  • have greater fear of physical injury and death
  • experience sexual violence^Endnote vi
• Girls have a higher risk than boys of being sexually abused^{Endnote viii}
• Boys have a higher risk than girls of being physically abused^Endnote ix
• Men are socialized away from disclosing family violence and seeking help^Endnote x
  • While women and men experience emotional/psychological intimate partner violence at similar rates, men experience it along with fear of ridicule, humiliation and degradation^Endnote xi
• Transgender people, which includes people who may also identify as lesbian, gay, bisexual, and two-spirited, experience much higher rates of domestic and community violence than the general population and face extensive barriers to service^Endnote xii

Culture

Culture is also important in the Canadian context where Indigenous people experience multiple forms of disadvantage, interrelated with disproportionately high rates of violence. Newcomers, some people of colour and people from other groups that are marginalized in Canada, face assumptions about how their culture contributes to experiences of violence. Such assumptions can create barriers to effective service and support. For example, service providers may assume that women from racialized ethnic communities who experience intimate partner violence will have high levels of support from their communities, whereas in reality, the women may be ostracized.

How to implement trauma and violence-informed approaches

Trauma and violence-informed approaches require fundamental changes in how practitioners engage with people, how organizations function and how systems (such as the health system and the justice system) are designed. These approaches can result in more beneficial ways to view and treat people, which can lead to more successful outcomes for clients.

For individual practitioners, a change in strategy means attempting to eliminate assumptions about people who experience violence and trauma and their actions. For organizations and systems, it means supporting a culture of learning and capacity-building to create safe environments for clients and staff.

Four principles for implementing trauma and violence-informed approaches

The following information outlines four key principles and sample implementation strategies for service providers and organizations.  These strategies can be applied to many different sectors, including justice, health, anti-violence, social work and housing.^Endnote xiv

1. Understand trauma and violence and their impacts on peoples' lives and behaviours

See this principle in action.

2. Create emotionally and physically safe environments

See this principle in action.

3. Foster opportunities for choice, collaboration, and connection

See this principle in action.

4. Provide a strengths-based and capacity-building approach to support client coping and resilience

See this principle in action.

Addressing the impact on service providers who work with people who have experienced violence and trauma

Service providers who work directly with people who have experienced violence often hear difficult stories and witness the impact of these experiences.

Second-hand exposure to experiences of violence can result in vicarious or secondary trauma^Endnote xvi, with negative health impacts which are similar to those experienced by people with first-hand experiences of violence, such as:

• depression, emotional exhaustion and anxiety
• sleep disturbances and intrusive thoughts
• trigger responses to external events, some of which may seem harmless to others

Organizations can help reduce secondary trauma for service providers

The negative impacts of secondary trauma are associated with employee burnout and high turnover, both common in sectors where service providers work directly with people who experience violence.

Organizations can help reduce secondary trauma for their employees with trauma and violence-informed policies and practices that:

• actively support the well-being and self-care of service providers who are repeatedly exposed to others' stories of violence
• help providers to understand peoples' responses to violence, including their own
• help to prevent 'trigger responses' for both clients and providers

When they are well-supported by trauma and violence-informed approaches and workplace wellness programs, service providers can find satisfaction and growth in their work, despite the challenges.

Examples of trauma and violence-informed approaches

Principles in action

The following examples of trauma and violence-informed programs and policies have been implemented in a wide range of sectors in Canada. They are organized according to the four guiding principles for implementing trauma and violence-informed approaches.

Principle 1— Understand trauma and violence and their impacts on peoples' lives and behaviours

Housing

Supportive policies for women mean better access to safe and affordable housing

Atira Women's Resource Society provides housing across the lower mainland of BC to women who have experienced violence. The Society serves women with a range of health and other support needs, and women who experience multiple forms of marginalization and systemic violence.

A core premise of Atira's policy and practice is recognition that violence and trauma contribute to many of the challenges women face to secure safe and affordable housing.

Here are some ways that Atira has changed its policies:

• It does not require women to disclose experiences of abuse in order to access housing
• It creates opportunities for extended and specialized forms of housing for women, rather than an earlier policy which had a 30-day limit for women in shelters
• It hires women with lived experience^{Endnote xvii} of violence and homelessness
• It is inclusive of women who use substances

Community Health Centre

Reducing stress for clients and staff through a change in clinic practices

Cool Aid Community Health centre, which serves clients who live on low-incomes, used a trauma and violence-informed approach to review their practices.

They recognized that when clients had to line up on the street to wait for the clinic to open, they were exposed to forms of violence, including demeaning behaviour by people passing by.  For example, vulnerable clients were intimidated by drug dealers, asking to 'share' their prescriptions. Clients often had inadequate clothing to protect them from the elements, particularly in winter. Additionally, clinic receptionists were negatively impacted when witnessing these situations and felt responsible for the clients' well-being.

To create a safer environment for their clients and workers, the centre changed its clinic opening procedures to allow people to wait indoors.^{Endnote xviii}

Principle 2—Create emotionally and physically safe environments for both clients and service providers

Integrated Service Provision

Children's Advocacy Centres provide child-centred approaches for victims of abuse

Children's Advocacy Centres (CACs) are child-friendly centres that coordinate the investigation, intervention and treatment of child abuse, while helping abused children and their non-offending family members navigate service systems and recover from experiences of violence. CACs provide a comprehensive response by a multidisciplinary team of service providers who work in areas including:

• child protection
• health
• victim advocacy
• justice

By conducting joint interviews during the investigative phase of the work, this multidisciplinary team is able to minimize the number of times a child needs to re-tell their story of abuse. Overall, the CAC approach creates a more efficient and effective investigation of child abuse cases than traditional approaches. CACs also offer a range of treatment and support services for children, youth and their families, with fewer services overlapping or conflicting. Child-friendly space is included in the design of CAC offices to help children feel comfortable and safe.

Child and Youth Advocacy Centres is the national network of CACs, and include the Regina Children's Justice Centre, BOOST Child and Youth Advocacy Centre, Zebra Child Protection Centre and the Sheldon Kennedy Child Advocacy Centre.

Sexual Assault Centre

Self-care for service providers as an integral component of ethical care and case management

Fredericton Sexual Assault Centre (FSAC) provides trauma support and counselling to people affected by sexual and dating violence.  The Centre is grounded in the concept of trauma stewardship, a trauma and violence-informed approach that ensures that service providers care for themselves while they are providing ethical care and management of other people's trauma.

Being a steward of other people's trauma can have real consequences for the service provider, including vicarious or secondary trauma, compassion fatigue and burnout. It can also lead to serious physical and mental health issues and can compromise the ability of staff and volunteers to provide optimal care and support. The focus of trauma stewardship is to recognize the impacts of working with survivors of trauma. It identifies strategies for individual service providers and for the organization to mitigate these adverse consequences and promote staff well-being.

FSAC uses three strategies under their trauma stewardship program:

1. Debriefing that limits staff and volunteer exposure to stories of trauma. This low-impact approach encourages people to:
   • ask permission from colleagues before sharing information, to warn them that they may be hearing something difficult
   • talk about a situation as part of their self-care
   • start from the "outside edges of the story", and work their way in, focusing on their feelings about the interaction with a client rather than on the intense details of the incident
2. Weekly, trauma-informed Yin yoga sessions for staff, during staff hours and at no cost
3. A mandatory crisis line report form requires volunteers to indicate how they are feeling after a call and what self-care practices they plan to use. If a more active debrief is necessary, they are encouraged to contact a peer support system

Principle 3—Foster opportunities for choice, collaboration and connection

Corrections Services

Giving back promotes meaningful engagement for men in prison

Work to Give is a program that supports men in prison to produce needed items for First Nations families and children who live in poverty in central BC.  The men produce food, furniture, clothing, toys and cultural items—such as drums, rocking ravens, orcas and keepsake boxes.

This program is a partnership between Correctional Service Canada (Pacific Region), the Tsilhqot'in National Government, their communities and the Punky Lake Wilderness Camp Society.

Work to Give is based on a recognition that Canada's colonial history, policies and practices have led to the significant overrepresentation of Indigenous people in prisons.

The program acknowledges that:

• incarcerated people often have histories of being abused
• resilience, rehabilitation and re-offending rates are improved through meaningful work opportunities to give back to communities

Emergency Room Care

Collaborating with Indigenous communities to create a welcoming environment

An Australian emergency room (ER) that serves a large suburban area is making a commitment to provide equitable, respectful care to all patients, including the Indigenous communities they serve.

Research evidence from other contexts suggests that displaying Indigenous art may improve access to services, since the art demonstrates openness to Indigenous people and an acceptance of diversity.^Endnote xix Based on this evidence, ER leaders partnered with local Indigenous communities to select Indigenous art to create a welcoming environment for Indigenous people.

As a step toward reconciliation, ER leaders hope that this process will help to develop meaningful relationships with the Indigenous communities they serve.

Principle 4—Provide strengths-based and capacity-building approaches to support client coping and resilience

Treatment Program

Addressing structural violence for Inuit people through collective healing

Mamisarvik Healing Centre in Ottawa is the only Inuit-run residential trauma and addictions treatment program in Canada and addresses trauma within Inuit healing approaches. The word Mamisarvik means, A Place of Healing.

The Centre not only considers the histories of individuals and families, but also addresses structural violence— how Inuit people have suffered historical experiences of colonization and cultural oppression. The program helps clients understand how these experiences continue to contribute to "present-day suffering, preventing the resolution of grief and trauma and driving many people to alcohol and drug abuse 'to numb the pain'."^Endnote xx

Mamisarvik clients say that the collective experience of reconstructing their shared histories is healing.

Health Promotion

Trauma-sensitive yoga supports positive body movement in safe spaces

Yoga Outreach is a non-profit organization in British Columbia which trains volunteers to offer strength-based, trauma-sensitive yoga programs for people without resources who otherwise would be unable to participate. Its work is inspired by research conducted by the Trauma Center at the Justice Resources Institute.

In trauma-sensitive yoga, teachers adapt how they lead their classes to help participants build a sense of safety and control over their bodies. This approach is particularly important for people who have 'disassociated' from their bodies after experiences of violence and trauma.

There are no physical assists or touching in trauma-sensitive yoga. To minimize visual triggers, the lights are kept on, curtains are drawn and there are no mirrors. Teachers stay on their mats to avoid 'lurking above' participants. Rather than offer direct instruction such as, "Put your hand on your hip," teachers offer an invitation to participants by saying, "If this feels good for you, I invite you to put your hand on your hip."

References and resources

Guides

Trauma- and violence-informed care: A tool for health and social service organizations and providers
Equip Health Care: Research to Equip Primary Health Care for Equity (University of British Columbia, University of Victoria, University of Northern British Columbia, Western University)

Trauma-informed Practice Guide
BC Centre of Excellence in Women's Health

Trauma-informed: A resource for service organizations and providers to deliver services that are trauma-informed
Klinic Community Health Centre

Books and journal articles

Browne, A.J., Varcoe, C., Ford-Gilboe, M. & Wathen, N. (2015). EQUIP Healthcare: An overview of a multi-component intervention to enhance equity-oriented care in primary health care settings. International Journal for Equity in Health, 14, 152.

Covington, S. (2008). Women and addiction: A trauma-informed approach.  Journal of Psychoactive Drugs: 377-385.

Elliot, D.E., Bjelajac, P., Fallot, R.D., Markoff, L.S. & Reed, B.G. (2005). Trauma-informed or trauma-denied: principles and implementation of trauma-informed services for women. Journal of Community Psychology 33 (4), 461-477.

Green, B.L., Saunders, P.A., Power, E., Dass-Brailsford, P., Bhat Schlbert, K., Giller, E., Wissow, L., Hurtado-de Mendoza, A., &  Mete, M. (2015). Trauma-informed medical care: CME communication training for primary care providers. Family Medicine, 47 (1), 7-14.

Harris, M. & Fallot, R.D. (2001). Envisioning a trauma-informed service system: A vital paradigm shift. New Directions for Mental Health Services 89, 3-22.

Hopper, E.K., Bassuk, E.L. & Oliver, J. (2010). Shelter from the storm: Trauma-informed care in homelessness services settings. The Open Health Services and Policy Journal 3, 80-100.

Kirmayer, L. (2013). Embracing uncertainty as a path to competence: Cultural safety, empathy, and alterity in clinical training. Culture, Medicine & Psychiatry, 6, 365-372.

Middleton, J.S. & Potter, C.C. (2015). Relationship between vicarious traumatization and turnover among child welfare professionals. Journal of Public Child Welfare, 9 (2), 195-216.

Ponic, P., Varcoe, C. and Smutylo, T. (2016). Trauma- (and violence-) informed approaches to supporting victims of violence: Policy and practice considerations. Victims of Crime Research Journal, 9, 3-15.

Poole, N. & Greaves, L. (Eds). (2012). Becoming Trauma Informed. Toronto: Centre for Addiction and Mental Health.

Raja, S., Hasnain, M., Hoersch, M., Gove-Yin, S. & Rajagopalan, C. (2015). Trauma informed care in medicine: Current knowledge and future research directions. Family and Community Health, 38 (3), 216-236.

Savage, A., Quiros, L., Dodd, S. & Bonavota, D. (2007). Building trauma informed practice: appreciating the impact of trauma in the lives of women with substance abuse and mental health problems. Journal of Social Work Practice in the Addictions, 7(1-2), 91-116.

Strand, V., Popescu, M., Abramovitz, R. & Richards, S. (2015). Building agency capacity for trauma-informed evidence- based practice and field instruction.  Journal of Evidence-Informed Social Work, 13(2), 1-19.

Van der Kolk, B. (2000). Posttraumatic stress disorder and the nature of trauma. Dialogues in Clinical Neuroscience 2 (1), 7-22.

van Mol, M., Erwin, M.C., Kompanje, J.O., Benoit, D.D., Bakker, J. & Nijkamp, M.D.  (2015). The prevalence of compassion fatigue and burnout among healthcare professionals in intensive care units: A systematic review. PLoS ONE, 10 (9), 1-22.

Varcoe, C. & Browne, A.J. (2015). Culture and cultural safety: Beyond cultural inventories. In Fundamentals: Perspectives on the Art and Science of Canadian Nursing. C. D. Gregory, L. Raymond- Seniuk, L. Patrick and T. Stephen (Eds.), 216-231. Philadelphia: Lippincott Williams & Wilkins.

Watt, M. E. & Scrandis, D.A. (2013). Traumatic childhood exposures in the lives of male perpetrators of female intimate partner violence. Journal of Interpersonal Violence, 28 (14), 2813-2830.

Glossary

Definitions related to violence

Violence is the intentional use of physical force or power, threatened or actual, against oneself, another person, or against a group or community, which either results in or has a high likelihood of resulting in injury, death, psychological harm, maldevelopment, or deprivation.

Interpersonal violence refers to violence between individuals, and is subdivided into family and community violence. Family violence includes child maltreatment; intimate partner violence; and elder abuse. Community violence includes acquaintance and stranger violence, youth violence; violence related to property crimes; and violence in workplaces and other institutions.

Collective violence refers to violence committed by larger groups of individuals and can be subdivided into social, political and economic violence.

Self-directed violence refers to violence in which the perpetrator and the victim are the same individual and is subdivided into self-abuse and suicide.

Systemic violence is violence perpetrated against people through systems often as a result of widespread beliefs and socio-political systems, for example, ethnic-based genocide such as the Holocaust, the colonization of Indigenous peoples, or the normalization of gender-based sexual violence. The terms systemic and structural violence are often used interchangeably.

• Learn more about other forms of violence

Definitions related to trauma

Trauma is both the experience of, and a response to, an overwhelmingly negative event or series of events, such as interpersonal violence, personal loss, war or natural disaster. In the context of violence, trauma can be acute (resulting from a single event) or complex (resulting from repeated experiences of interpersonal and/or systemic violence).

Historical trauma refers to the ways in which political processes and systemic violence (such as the Holocaust or forced relocations of Indigenous people) impact individual experience, and in turn the effects of individual experiences on those political processes. Some researchers suggest that the idea of historical trauma has been used both to recognize the impact of historical violence on Indigenous people and to pathologize Indigenous people.

Intergenerational trauma refers to the ways that multiple generations are impacted by trauma both through the effects of one generation of people on the next, as well as by the ongoing conditions in which people live.

Other related definitions

Resilience is a dynamic process that enables an individual to develop, maintain, or regain their health and well-being despite experiences of significant adversity or trauma. Resilience is developed through a range of individual (i.e. psychological, biological) and environmental (i.e., social, political, and cultural) factors that can help people positively adapt to difficult life circumstances.