Trauma Informed Care in a Clinical Setting

Author: Ashke Zinctala

Trauma-informed care is a relatively new topic of conversation in the realm of modern healthcare. With an ever growing body of information on the effects of trauma on individuals, we have begun to fully realize the importance of this conversation for healing a society in pain. 

While there are many aspects to trauma-informed care, much of which I will not cover in this blog post, there are two main categories to understand: 

  1. The physiology and psychology of trauma: how trauma affects the body & the mind, and the inseparable nature of the two. 
  2. How to put this knowledge into action in a clinical setting. 

Understanding Trauma

There are three main categories of trauma: single, repeated, and chronic. A single trauma occurs at a single point in time, such as a rape, a car accident, or the sudden death of a loved one. Some people recover from these traumas relatively well, while others can develop trauma and stress-related disorders, especially those with histories of previous traumas, mental illness, or substance abuse. Repeated trauma is a series of traumatic events happening over a period of time. This can be repeated sexual or physical assaults, frequent exposure to horrific scenes or injuries of others, or a series of unrelated traumatic events happening over the course of one’s lifetime. Chronic or sustained trauma includes things like ongoing abuse, neglect, or poverty. Individuals in chronically stressful, traumatizing environments are particularly susceptible to traumatic stress reactions, substance use, and mental disorders.

What is important to understand is that on a fundamental level, trauma can affect the way our brains respond to stress. The chronic stress caused by trauma can decrease a person’s resilience to stressful situations, causing them to respond with stress hormones more often and for longer periods of time than people with functional stress response systems. 

Each time we activate our fight/flight/freeze response, the brain produces stress hormones via the Hypothalamus-Pituitary-Adrenal (HPA) Axis. When this system is activated too often, it can become dysfunctional. In dysfunction, stress hormones are not properly turned off and are overused, leading to a susceptibility to continued chronic stress. 

The amygdala is a key structure in the brain when it comes to risk assessment, and developmental trauma and long-term heightened stress can cause it to become hyperactive. The amygdala stores how we respond to sensory information in our environment, such as facial expressions, tone of voice, and body language, essentially storing information about what we perceive to be safe or a threat. It is responsible for rapidly sending information down into the hypothalamus and brainstem, which govern our autonomic responses, and sends less information to the areas of the brain which can identify context, options, and opportunities for safety through connection & social engagement. With an overactive amygdala, a person will experience more activations of the stress response. 

The hippocampus is another key structure. It works to identify what is happening in the present by comparing it to stored memories; people who have experienced trauma can have ½ to ¾ the hippocampal volume compared to those who have not. The hippocampus can act in governance of the amygdala to help determine if a perceived threat is actually a threat or not. When the hippocampus atrophies in response to trauma, it decreases its ability to calm the amygdala, causing clients to be more susceptible to chronic stress. 

This cycle of chronic stress can have a number of long term health effects. We now know that there is a correlation between chronic stress and the development of insulin resistance and diabetes, cardiovascular diseases, menstrual cycle irregularities, sleep disorders, gut dysbiosis, IBS, autoimmunity, depression, anxiety, addictions, and other psychological imbalances. As trauma-aware practitioners, whenever we see any of these or other chronic health conditions present, we can screen for trauma. 

A Trauma-Informed Intake

Building trust with a client during an intake is crucial, so consider saving trauma-screening questions for the last half of a session. When we ask if a person has experienced trauma, we can give examples, which may provide the person with the permission they need to talk about their experience. For example, we can ask, “In your childhood or adulthood, are there any traumatic events that have happened such as car accidents, rape, incest, abuse, or others?” Give the person time, presence, and space to answer. Be aware of body language. Look for signs of discomfort or withdrawal; this can be a sign to pull back, check-in, or stop questioning all together to avoid retraumatization. When they respond, acknowledge their response with eye contact and statements like, “I’m so sorry that happened to you.” An important piece to remember is not to ask if you can’t hold space for the answer, as this could compound the trauma the person is sharing with you. 

Developing a Trauma-Informed Protocol 

When putting together a plan for clients, a strong network of holistic referrals is crucial (body workers, holistic therapists, TRE practitioners, acupuncturists, MD/ND’s). 

Make the process of stepping into a protocol as stress-free as possible. For example, if you are referring clients out to other practitioners, consider calling your referrals yourself and asking them to get in contact with your client using your clients preferred contact method. Removing as many barriers to care is important, as chronically stressed individuals may become overwhelmed easily. 

Break protocols down into manageable steps, and plan for setbacks. Add things in before taking things out. Let your client know that you won’t be upset with them if they don’t follow through on something. Let them know that you believe in them, but avoid adding unnecessary expectations to what is likely already a comprehensive protocol. Let them know that failure is OK. This builds trust and can allow for more honest feedback and perhaps even more consistent protocol compliance. 

Provide affordable care. This can be done using a sliding scale, payment plan, pay-it-forward method, or clinical group practice. 

Make your practice inclusive to minority groups. Educate yourself on the history and intricacies of systematic oppression and ancestral traumas of these various groups. When talking about Indigenous Peoples, always use present-tense language. 

Maintain good boundaries with your client to maintain a healthy long-term relationship. Set boundaries around when you are available and when you are not, and maintain a healthy energetic boundary. If your client expresses suicidal tendencies, make sure they are under the care of a trained psychologist and/or psychiatrist before continuing to work with them. 

If obtaining lab tests from their MD/ND, it can be considered trauma-informed to use functional rather than standard lab values, as people can experience compounded trauma within the medical system in the process of waiting for their lab values to get “bad enough” to receive a diagnosis from their primary care practitioner. Functional lab values look for an approaching pathology, rather than one that is outright diagnosable.

A Trauma-Informed Protocol May Include: 

  • Achieving a balanced diet rich in antioxidants and anti-inflammatory foods, proper sleep, nervous system regulation, and stress management. 
  • Addressing nutritional deficiencies and the gut microbiome (chronic stress affects the functioning of the enteric nervous system). 
  • Identify and avoid food allergens & sensitivities. Cut out refined sugars, artificial flavors, processed foods, and caffeine.
  • Supplementation: Mg, Omega 3, B complex, L-tryptophan, 5-HTP, Vitamin C & flavonoids, Melatonin-especially in the case of disrupted sleep).
  • Addressing underlying emotional pain: 
    • Referrals for holistic therapy 
    • Flower Essences, Spiritual Heart care
    • Developing routine 
    • Fostering community 
    • Nurturing a spiritual practice 
    • Meditation, yoga, daily rituals, gratitude practice, prayer
    • Nature healing 
    • Creativity: art, singing, dancing 
    • Animal therapy 
  • Addressing trauma held in the body: 
    • Somatic Therapy 
    • Body work: acupuncture, massage, TRE (Trauma & Tension Relief Exercises)
    • Exercise 
    • Engaging the vagus nerve through shaking, breathwork/breathing, laughter, humming, noises from the throat, gargling, socializing, exposure to cold
    • encouraging cold showers
  • Herbal Therapeutics: 
    • Aromatherapy using essential oils
    • Nervines, Spiritual Heart herbs, nutritives, sedative, anxiolytics, brain tonics, neurotrophorestoratives, prebiotics, liver cleansing, adaptogens

In the realm of western modern medicine (as well as our criminal system), trauma informed care looks like a reform of the way we think about and treat addicts, people with psychological conditions, abusers, and “criminals.” We are all responsible for seeing the dysfunction of our current model, and we will all benefit from participating in breaking the cycle. We will never heal a traumatized society by compounding the trauma of our most traumatized individuals. 

As practitioners, we need to see the human in front of us rather than a problem to be solved. This requires a relationship to each individual that we work with, and a protocol that reflects that individuality and trust-based relationship. At its core, being trauma-informed is the understanding that underneath all traumatized individuals is a healthy person who has either lost their expression or never found it in this life. Being trauma-informed is having the courage to not persecute the abuser, for they have also been a victim of abuse. Being trauma-informed is understanding the effects of intergenerational trauma and the socioeconomic factors that bind its grip. 

Being trauma-informed is also about recognizing the trauma (and coping methods) you carry within yourself. As practitioners, when we acknowledge the traumas calling to be healed within ourselves, and begin to do that work, we can provide deeper and more comprehensive care for our clients. 

Being trauma-informed is being able to look through your lens of compassion to understand that individuals struggling with addictions, mental health conditions of any kind, and/or chronic health issues, whether seen or unseen, are whole people that deserve healthcare, compassion, a warm place to sleep, and nutritious food to eat. Trauma-informed care is about creating a space where a person feels safe enough to begin taking the steps necessary to tend to themselves. 

Join Ashke Zinctala for the first class of a four part series beginning on January 11th, via Zoom, as she unpacks Trauma and Addiction.

Sources: 

Polyvagal Herbalism. Brunem Warshaw. Journal of the American Herbalists Guild, Vol. 19:1, Summer 2021. Pg. 29-36

Trauma-Informed Care in Behavioral Health Sciences. Treatment Improvement Protocol (TIP) Series, No. 57. Center for Substance Abuse Treatment (US). Rockville (MD): Substance Abuse and Mental Health Services Administration (US); 2014.

Cortisol. You and Your Hormones. Jan 2019. https://www.yourhormones.info/hormones/cortisol/

Hypothalamic -Pituitary-Axis. Olivia Guy-Evans. Simply Psychology. Sept 27. 2021. https://www.simplypsychology.org/hypothalamic–pituitary–adrenal-axis.html

Adverse Childhood Experiences. CDC. April 2, 2021. https://www.cdc.gov/violenceprevention/aces/index.html

Lichen Sclerosus: From Trauma to Management. Dana Hutchinson. Wildflower Clinic. 2021. Powerpoint presentation at AHG Symposium.

Herbs for Post-Traumatic Stress Disorder. Green Path Herb School. Elaine Sheff. 2021. Powerpoint presentation at AHG Symposium.

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