Further Implementing Trauma Informed as Social Workers in the United States

Introduction

Hard to acknowledge, and even harder to talk about, is the shocking aftermath of trauma looks like for children in the United States, and around the world. More than two thirds of children in the United States experience a traumatic event or circumstances-such as abuse or neglect, death of a loved one, or community violence-by the time they turn 16. Young children (birth to age five), in particular, are disproportionately exposed to traumatic events and circumstances (Bartlett, 2016).

Exposure to trauma during childhood can dramatically increase a person's risk for 7 out of 10 of the leading causes of death in the U.S. This includes high blood pressure, heart disease, and cancer. Aftermath from childhood trauma is now being treated as a national public health crisis (Harvard, 2015). After several decades of research and investigation, many medical professionals are shifting to utilizing a concept known as 'Trauma Informed Care', so that instead of asking What is wrong with you? the question becomes What happened to you? (Kelly, 2014). According to the Substance Abuse and Mental Health Services Administration (SAMHSA), they define the trauma-informed approach as A system that realizes the widespread impact of trauma and understands potential paths for recovery; 1. Recognizes the signs and symptoms of trauma in clients, families, staff, and others involved with the system 2. Responds by fully integrating knowledge about trauma into policies, procedures, and practices 3. Seeks to actively resist re-traumatization. (SAMHSA, 2018).

The goal of this paper is to educate and emphasis the problem at hand, which is that soldiers are not the only people who experienced horrific traumas: they are our neighbors, siblings, and students. Many of them are children and young adults. As mentioned previously, trauma informed care asks a patient what has happened to them, as an attempt at getting to the root. Children, teens and young adults are some of the most vulnerable populations in our society. Children all over the country, and world, experience trauma and do not have the ability to advocate for themselves. Indicators of trauma include having an alcoholic parent, experiencing sexual abuse, natural disasters, accidents, and human trafficking (Van Der Kolk, 2014). Dr. Van Der Kolk, as well as Dr. Nadine Burke (another famous psychiatrist who has devoted her life to working with trauma victims), and many others believe that the way in which we treat trauma patients can drastically improve not only their quality of life but expected life span as well. With children, this is crucial, and can alter the course of their lives.

The question posed in this paper is this: what mental health professionals can do in implementing Trauma Informed Care for children and teens, who are need of protection due to the traumas that they have experienced. We will be referring to literature written by leading researchers in this field, as well as studies performed on outcomes, in supporting my case.

Trauma Informed Care

We have learned that trauma is not just an event that took place sometime in the past; it also the imprint left by that experience on mind, body, and brain. This imprint has ongoing consequences for how the human organism manages to survive in the present. (Van Der Kolk, 2014)

Humans have been experiencing trauma since the dawn of time, but it is in the last 30 years that it has become widespread through multiple disciplines, as mental health workers, doctors, substance-abuse treatment centers, are more actively aiming to address how trauma does change somebody's life.

The emergence of the feminist movement, and the voices of survivors of interpersonal trauma, (as seen in the rape crisis centers and the domestic violence movements) paired with developments in the scientific world resulted in significant shifts in treatment practices.

In 1985, the International Society for Traumatic Stress was founded in the United States and served as a focal point for professionals searching for answers to support highly traumatized populations. By 1989, the United States Department of Veterans Affairs had created the National Center for Post-Traumatic Stress Disorder (Wilson, Pence, Conradi, 2013).

According to Dr. Bessel Van Der Kolk, author of 'The Body Keeps Score', more than half of the people who seek psychiatric care have been assaulted, abandoned, neglected, raped as children, or witnessed violence in their family (Bessel, 2014). He notes ''I was often surprised by the dispassionate way patient's symptoms were discussed and how much time was spent on trying to manage their suicidal thoughts and self-destructive behavior, rather than on understanding the possible causes of their despair and helpless'. This, of course, occurs in adults who have often spent a life time in misery. If we could identify the event and begin work with children, it could save years of misery.

Another lead figure in TIC, Dr. Nadine Burke stated this in a Ted talk about Trauma Informed Care: instead of writing prescription after prescription, for people drinking water from the same well with the same symptoms, she wants to march up to the well, look inside, and figure out just what is in that well. This is the public health perspective, and patients who have experienced trauma are so widespread and common, that Dr. Burke labels trauma as 'The biggest public health crisis facing our country'.

So, what does it mean to be Trauma-Informed? 2005 marked the creation of the National Center for Trauma- Informed Care (NCTIC). The NCTIC suggested that every part of an organization seeking to be trauma-informed-its organizational structure, its management systems, and its service delivery. To be assessed and potentially modified to include a basic understanding of how trauma affects the life of an individual seeking services. Trauma-informed organizations, programs, and services are based on an understanding of the vulnerabilities or triggers of trauma survivors that traditional service delivery approaches may exacerbate, so that these services and programs can be more supportive and avoid re-traumatization. (National Center for Trauma-Informed Care, 2012). It is crucial to emphasize that the goal is to avoid re-traumatization. The following will list ways in which we can avoid this.

The Oxford University School of Social Work has identified central themes essential for optimal trauma informed care. For the purpose of this paper, these themes will apply for Social Workers specifically.

The first essential component is to maximize physical and psychological safety. The last thing that we should ever do is re-traumatize a patient. In focusing on treatment for those age 18 and under, an example that maximizes the safety of a child or teen, would be in removing a child from a dangerous home setting, and placing them in a physically-safe foster home. The Oxford School of Social Work states, however, that although the child may be physically safer, they may not feel psychologically safe, despite leaving the toxic setting. When feeling psychologically unsafe, we tend to see (often) maladaptive coping mechanisms emerge. This can include substance abuse, aggression and violence, high-risk-taking activities, and self-mutilation. The child (and his or her siblings) may continue to feel psychologically unsafe long after the physical threat has been removed or he or she has been relocated to a physically safe environment. (Wilson et al., 2013).

Secondly is the notion of partnering with clients. Patients should be given choices and an active voice in decision-making on both an individual and systemic level, allowing choice and collaboration. This can help them reclaim the power that was taken away from them during the trauma, enhance their resilience, and provide important information to providers and the system. (Wilson et al., 2013).

Third, it is crucial to identify trauma-related needs of clients. The following includes the 12 Core Concepts of Understanding Traumatic Stress Responses in Childhood, created by The National Child Traumatic Stress Network. The interventions have been written specifically for children.

1. Traumatic events are inherently complex. (NCTSN, 2012)
2. Trauma occurs within a broad context that includes children's personal characteristics, life experiences, and current circumstances. (NCTSN, 2012)
3. Traumatic events often generate secondary adversities, life changes, and distressing reminders in children's daily lives. Examples of adversity include family separations, financial hardship, relocations to a new residence and school, social stigma, ongoing treatment for injuries and/or physical rehabilitation, and legal proceedings.
4. Children can exhibit a wide range of reactions to trauma and loss. (NCTSN, 2012)

Post-traumatic stress and grief reactions can develop over time into psychiatric disorders, including post-traumatic stress disorder (PTSD), separation anxiety, and depression. Children's post-trauma distress reactions can also exacerbate preexisting mental health problems including depression and anxiety. Awareness of the broad range of children's potential reactions to trauma and loss is essential to competent assessment, accurate diagnosis, and effective intervention.

5. Danger and safety are core concerns in the lives of traumatized children.

Exposure to trauma can make it more difficult for children to distinguish between safe and unsafe situations and may lead to significant changes in their own protective and risk-taking behavior. (NCTSN, 2012)

6. Traumatic experiences affect the family and broader caregiving systems. (NCTSN, 2012)
7. Protective and promotive factors can reduce the adverse impact of trauma.

Examples include having a primary caregiver, possessing a strong social support network, the presence of reliable adult mentors, and a supportive school and community environment. (NCTSN, 2012)

8. Trauma and post-trauma adversities can strongly influence development. (NCTSN, 2012)
9. Developmental neurobiology underlies children's reactions to traumatic experiences.

Exposure to multiple traumatic experiences carries a greater risk for significant neurobiological disturbances, including impairments in memory, emotional regulation, and behavioral regulation. Conversely, ongoing neurobiological maturation and neural plasticity also create continuing opportunities for recovery and adaptive developmental progression. (NCTSN, 2012)

10. Culture is closely interwoven with traumatic experiences, response, and recovery. (NCTSN, 2012)
11. Challenges to the social contract, including legal and ethical issues, affect trauma response and recovery. (NCTSN, 2012)
12. Working with trauma-exposed children can evoke distress in providers that makes it more difficult for them to provide good care. (NCTSN, 2012)

IMPLICATIONS FOR SOCIAL WORK

Stated in the last section, we identified the 12 Core Concepts of Understanding Traumatic Stress Responses in Childhood, created by The National Child Traumatic Stress Network. These 12 concepts provide clear cut considerations for working within the framework of Trauma Informed Care. At the same time, there is no manual on how best to treat trauma victims. Much of what a social worker can do exists in the small details. The publication 'Social Work Today' has created a comprehensive list of what it means to be trauma informed. These are things that a client will notice and will help them in treatment.

Environment of Care/Staff Appearance/Staff Behavior

For starters, when a client walks in to your facility, the goal is for them to feel comfortable and safe. Social workers can create a comforting environment with seating arrangement, music, colors, and plants. When working with traumatized children, this is especially crucial. Staff should wear clothing that is not distracting and is professional. When interacting, social workers use eye contact, are speaking clearly, and are attentive to the client (Ko, 2008)

Organizational Understanding

Next there are components on a grander scheme that the company as a whole must practice. First and foremost, the company needs to have a trauma-trauma-informed policy in place. The staff members will have been educated in trauma informed care and are continuously assessing for trauma. Staff should have an organizational plan for handling behavioral crisis. Feedback must be given amongst the staff members, to ensure that they are always growing and communicating (Ko, 2008)

Treatment Considerations

With the patient first mentality, treatment goals should reflect consumer preferences at all times. The treatment will then be implemented across disciplines. We must offer choices as often as possible. Our language should be casual, and responsive. Noticing details such as seating for the client must be taken into consideration. Working in an anti-oppressive manner by considering the culture of origin and incorporating this in the treatment plan is vital.

A key area to be practiced with the utmost respect is in practicing boundaries for our patients. This includes physical boundaries, being aware of touching the patients: even a handshake is something that could be considered triggering. In addition to physical boundaries there are social boundaries as well. Jokes and certain stories could convey a sense of risk or threat (Ko, 2008).

Social Work: Core Values and Ethics

Trauma Informed Care can be directly applied to the 6 core values and ethics of social workers. The following will discuss ways that the values are best applied to TIC for social workers specifically.

Service

Social workers regularly elevate the needs of others above their own personal interests and use their skills and knowledge (from education and experience) to help people. Social workers often volunteer their time-in addition to their paid services-with no expectation for financial reward' (Social Work Core Values, 2018). This statement is pertinent to TIC because many of the children/young-adults who have experienced trauma and are receiving service are in pain and working with them will likely not be an easy feat.

Social Justice

Social workers advocate on behalf of the oppressed, the voiceless, and others who are unable to advocate for themselves (Social Work Core Values, 2018). Many victims of trauma have unable to fight for themselves, and it is our role as social workers to aide in any way that we can.

Dignity and Worth of the Person

Every person is different, with different cultural and social values. Social workers are mindful of those differences, treating each person with dignity and respect and promoting their clients' capacity and opportunity to address their own needs and improve their personal situations. Social workers must be cognizant of their duties to both individual clients and to society as a whole and seek solutions for their clients that also support society's broader interests.' (Social Work Core Values, 2018).

Respect and dignity are often lacking in the lives of trauma survivors, so it is the social worker's role to help in learning how to ask for respect and dignity, and how to practice it within ourselves.

Importance of Human Relationships

Social workers connect people who need assistance with organizations and individuals who can provide the appropriate help. Social workers recognize that facilitating human relationships can be a useful vehicle for creating change, and they excel at engaging potential partners who can create, maintain, and enhance the well-being of families, neighborhoods, and whole communities.' (Social Work Core Values, 2018). Having some degree of trust between patient and provider are mandatory for practicing TIC effectively. We can build this trust with trauma victims by listening, brainstorming, and doing our best to access as many resources as possible.

Integrity

In order to facilitate these relationships and improve others' lives, social workers must exhibit trustworthiness at all times. Each social worker must be continually aware of the profession's mission, values, and ethical principles and standards, and set a good example of these components for their clients. By behaving honestly and responsibly, social workers can promote the organizations with which they are affiliated while also creating the most value for the populations they serve.' (Social Work Core Values, 2018). In working with a vulnerable population, being trustworthy is the only way to operate.

Competence

The importance of ethics and values in social work is more than just compliance with regulations and requirements. In a profession in which the clients are often vulnerable and unable to advocate for themselves, it's necessary that those advocating for them be passionate about empowering those who are vulnerable, oppressed, or poverty-stricken.' (Social Work Core Values, 2018).

Findings and Conclusions

The question posed in the beginning of this paper asked how best social workers can operate from a trauma informed lens in practice with children and teens under the age of 18. 17,000 people were asked to complete a 10 question survey names ACES (Adverse Childhood Experiences) questionnaire. Doctors found that regardless of social class or race, an alarmingly high number of adults had experienced at least one event that the doctors classified as a traumatic event as children. Two thirds of the 17,000 people in the ACE Study had an ACE score of at least 1. 87 percent of those had more than one. A traumatic event according to ACES includes; witnessing violence in the home, being a victim of sexual or physical abuse, neglect, having a family member in prison, and living with someone using alcohol or drugs excessively. The effects of these traumas have profound impacts. Shortened life span, risk of mental illness, risk of disease and cancer, and risk of forming addictions are what makes this a public health crisis.

Strengths and Limitations

The Body Keeps Score' is a crucial and informative book and holds its place as one of the most influential sources of information about Trauma Informed Care. In addition, the Adverse Childhood Experiences concept, created by Kaiser Permanente, is considered ground breaking. The limitations of TIC are prominent and have resulted in its slow emergence in the medical field. According to some psychologists, TIC is too grand of an idea, that might be too vague to implement on a grand scale. Wisconsin is considered the state to have the most success in being trauma informed, but at a cost. Taxpayer dollars pay for the difference in medical treatment. (Scheeringa, 2017). For now, it is crucial that more longitudinal studies be conducted in proving the efficacy of TIC. For now, it is still a relatively novel concept that has yet to become the staple for how we treat patients.

Moving Forward

In order to treat all people from a trauma informed lens., it is up to the professionals to create a standard for which an entire company will operate. Following the values of TIC, and holding each other accountable in doing so, this can aid in creating a standard for practice. More research must be done, and the long-term effects of trauma scrutinized further. By making Trauma Informed Care a top priority, we can get to the root causes of symptoms, and treat it for what it truly is.

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