Nadia La Rosa is the coordinator at the Manitoba Trauma Information and Education Centre and Klinic Community Health. For more information on TIC, feel free to visit their website.

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What is the definition of trauma informed care (TIC)? 

There are many definitions of Trauma-Informed Care. One I have adopted is from Hopper, Bassuk and Olivet. They describe it as “a strengths-based service delivery approach rooted in the understanding of and responsiveness to the impact of trauma that emphasizes the physical, psychological and emotional safety for both the provider and the clients.” I like this definition because it stresses the importance of safety and includes the provider as well. This really speaks to the significance of creating a trauma-informed environment for everyone within a system or organization. 

A trauma-informed approach recognizes the breadth and depth of trauma and assumes that individual, historical and systemic trauma is present, therefore promoting environments that are safe and conducive to healing is essential. It isn’t necessary to know whether a person has experienced trauma to work from this lens. Taking universal precautions means everyone benefits from a do-no-harm approach. 

SAMHSA (Substance Abuse and Mental Health Services Administration) says that a program, organization or practice that is trauma informed follows the 4 Rs: 

1. Recognizes the widespread impact of trauma and understands potential paths for recovery; 
2. Recognizes the signs and symptoms of trauma for patients, families, staff members and others involved in the system; 
3. Responds by fully integrating knowledge about trauma into policies, procedures and practices thus involving the entire healthcare system; and 
4. Resists re-traumatization.   

What are the principles of TIC? 

The guiding trauma-informed values and principles originally proposed by Drs. Maxine Harris and Roger Fallot are safety (physical and emotional), trustworthiness, choice, collaboration, and empowerment. Given the presence of historical and systemic trauma, true universal precaution requires that we consider cultural, historical and gender issues and actively pursue the participation and involvement of service users and their peers in the planning, implementation and evaluation of services (the principle of peer support). We need to think about how we are addressing the values of diversity, equity, inclusion, and accessibility in our work.  

Where does TIC originate from and/or who developed the concept? Did it exist in practice before formally being introduced in the early 2000s?  

Harris and Fallot first articulated the concept of trauma-informed care (TIC) in 2001, and this approach was introduced in the United States as a response to growing awareness that health services were not designed to recognize the impact of trauma in children, youth and adults and as a result were triggering and re-traumatizing to people accessing them. Researchers and government agencies immediately expanded on the concept. SAMHSA, being one of the first ones to do so, began to measure the effectiveness of TIC programs and formed the National Center for Trauma-Informed Care in 2005. 

However, this concept is not ‘new’ knowledge. Many women’s organizations and anti-violence workers were already operating from this perspective. In fact, when I began working as an advocate and counsellor in our Sexual Assault Crisis Program in 1995, these principles were foundational in how we approached our work.  

Many have said that what underlies a trauma-informed practice is what Elders have always taught, and that is the importance of building relationships. I watched a webinar years ago delivered by Drs. Patricia Mokokis and Margo Greenwood. It was called “What’s New is Really Old: Trauma Informed Practices Through Understanding Historic Trauma.” They talked about how Elders teach the importance of respect for one another, understanding the importance of context, acknowledging our histories, welcoming different perspectives, sharing our points of view, and gaining clarity from one another.  

TIC is about approaching what we do with curiosity rather than making assumptions, and the people we serve are the experts of their own lives. Their lived experience and wisdom are the gifts they share with us, and we learn from them.  

How is TIC different from patient-centred care or cultural humility? How was care reflected in patient’s needs prior to the paradigm shift? 

I don’t think it is different. I see TIC as an umbrella- a framework or approach which brings in knowledge and techniques from other models. A client/person-centered approach is fundamental to humanistic models for example, but it is integral to trauma informed principles such as collaboration, peer support and strengths- based.  

Practicing cultural humility includes a commitment to a lifelong process of self-reflection beginning with an examination of our own beliefs and cultural identities in addition to learning about other cultures. It involves having an awareness of the social, political and cultural context in which trauma occurs and being sensitive to historic realities of violence and oppression against certain groups of people. Practicing cultural humility is one component of creating safety and it is fundamental to the principle of cultural, historical and gender issues.   

How is a person trained in TIC? 

Awareness is at the heart of TIC- mindful self-awareness and awareness about trauma. And because TIC is a way of ‘being,’ I believe it is a journey and a commitment to on-going learning, re-viewing and re-evaluating. How we do things is then informed by an understanding of trauma, an appreciation of its impacts, and the collective wisdom of the people and communities most impacted by it.  

Becoming trauma-informed encourages us to identify areas of development related to self-awareness (i.e. how to take care of ourselves, how to settle and regulate our nervous systems, how to recognize and manage our triggers, how to recognize and challenge our own biases, and all other potential barriers to connecting with people) and professional development. Such training could include:  

• Historical, cultural and contemporary experiences of trauma 

• Cultural Safety, Diversity and Inclusion 

• Good customer service skills applied in a health care setting 

• Motivational Interviewing  

• Non-Violent Crisis Intervention and/or De-escalating Potentially Violent Situations 

• Mitigation Strategies around Vicarious Trauma, Burnout and fostering well-being in the workplace 

How is TIC applied in end-of-life care? 

A trauma-informed approach to end-of-life care is critical because previous traumatic experiences and/or unresolved trauma may become intensified causing patients to feel out of control, powerless and unsafe. As health care providers we can create environments that feel safer.  

My role as a facilitator is to share information about trauma, what it is, what it looks like, the impact and the principles. Participant roles are to reflect and translate this knowledge into action according to their respective roles, remembering that: 

• Anyone can be trauma informed. We don’t need to be trauma experts to make a difference. 

• It’s not about healing the trauma, or even addressing it. 

• It’s about taking universal precautions and doing no harm 

• It’s a paradigm shift that replaces the question “what’s wrong with you?” to “what happened to you? How does that continue to live on in your life? What do you need now?” 

• It is about intentionally ensuring the physical and emotional safety, trustworthiness, choice, collaboration and empowerment of the individuals and communities you are working with. 

• It’s about reflecting on how trauma informed our work environments are and identifying what we could be doing to be more trauma sensitive? 

There are many excellent online resources and checklists that can help us evaluate how trauma informed we are as practitioners according to what systems we work in as well as how trauma informed our organizations are.  

Can you share 1-2 examples of TIC in health care practice? 

With safety and trustworthiness, you may consider the physical environment such as adapting the physical safe space to be less threatening, which might include increasing comfort and privacy. We also want to think about people’s emotional safety and building trust. We can do this by: 

• Demonstrating predictable expectations, using informed consent, and having clear boundaries.  

• Think about how we engage- the space we take up, the volume and timing of our voice, our body language and facial expressions.  

• Slowing down and ensuring the appointment is not rushed so we can take the time to really listen and reflect back on what we are hearing, which can help people feel seen, heard and valued. 

• Using a trauma lens, we can ask non-threatening, open-ended questions to assess for a history of abuse. Example: “Is there anything that you would like me to know in treating you? Are there parts of this treatment that are difficult for you?” 

Trauma survivors can feel a loss of control so including patients in the care process by offering choice whenever possible can help restore a sense of power. Collaboration might enlighten us to what some of the barriers are to following a treatment plan. This gives us an opportunity to meet people where they are and support their wishes and needs in care delivery. Some additional considerations include: 

• Asking permission before touching someone; noticing non-verbal discomfort or anxiety  

• Explaining what will be done and how while giving the choice to stop or take a break at any point  

• Presenting many options and supporting their decisions, including not engaging in care  

• Rather than labeling difficult or challenging behaviours as resistant, uncooperative or manipulative, see them as coping behaviours or survival skills  

• Making time for questions and concerns and inviting follow up 

• Writing key pieces of information down for the patient to look at later  

With respect to culture, historical and gender awareness, consider incorporating processes that are sensitive to a patient’s culture, ethnicity, and personal and social identity, such as the case with 2SLGBTQIA+ patients and those whose gender do not fall within the gender binary.  

• Challenging our own stereotypes and biases 

• Connecting with and learning about the communities we are supporting  

• Reading the final report of the Truth & Reconciliation Commission, the UN Declaration on the Rights of Indigenous Peoples and the 231 Calls to Justice in the National Inquiry into Missing & Murdered Indigenous Women, Girls and 2SLGBTQIA and thinking about how we can enact what is laid out in the 94 Calls to Action 

How can we intentionally and actively incorporate TIC in our daily lives? 

TIC is a way of being in the world all the time. It is how we approach and interact with the people we serve and our colleagues at work as much as it is the way we interact with family, friends and the strangers we encounter on the street. It is an active, ongoing commitment to maintaining a basic understanding of trauma and adversity, recognizing and reflecting on how one’s self-view and worldview influences our interpretation of everything, practicing self-awareness and being intentional about how we care for and replenish our whole selves. It’s an approach that requires some humility to be able to approach the world with a curiosity and a willingness to learn. 

We can intentionally and actively incorporate TIC in our daily lives by reflecting on ways we can embody the following list of qualities and characteristics with intention:  

• Willingness to be empathic  

• Able to regulate own emotions 

• Able to treat those affected by trauma as equal 

• Good listener 

• Willingness to debrief 

• Willingness to connect emotionally 

• Able to talk openly 

• Self –aware 

• Flexible 

• Willingness to learn from those affected by trauma 

• Comfortable with the unknown