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Essential support for under 25s

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Welcome to The Mix's Get Support section. Here you can visit our discussion boards, use our Group Chat Service and speak to our advisors.

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If you need urgent help

If you are feeling suicidal right now, know that there are people out there who can support you to get through this.
If you are at immediate risk or harm, please call 999 and ask for an ambulance.

What are suicidal feelings?

It is a normal part of life to feel down and sad sometimes.

But if those feelings have become very deep and intense, and you don't know what to do about them, you might think the only solution is to end your life. But there is hope for you, and you can get through this.

How common are suicidal feelings?

You're not the only one who feels this way - many people feel suicidal at some time in their lives. In fact, according to Papyrus, it is estimated that one in four young people experience suicidal thoughts at some point.

What's important for you to know is that there are lots of ways of dealing with these feelings and overcoming them. It's possible to come out the other side and feel okay again.

What causes suicidal feelings?

Anyone can feel suicidal for any reason. You might experience suicidal feelings if you:

are depressed or have another mental illness

struggle with low self-esteem

struggle with a physical health problem or chronic pain

use drugs or alcohol, especially when you're upset

feel anxious about pressures you face today or in the future

feel under pressure from family or your peers

feel alone and as if nobody cares about you

feel trapped and unable to escape from a situation

have experienced a traumatic event, or a difficult life experience

Suicidal feelings can in rare cases be a side effect of certain mental health medications.

If you start to experience suicidal feelings soon after starting medication for your mental health, speak to your GP, psychiatrist or pharmacist immediately.

To find out more, have a look at our medications pages.

They can build up over time

Suicidal feelings can build up over time, or they can develop suddenly. Although we know there is a link between depression and thoughts of suicide, suicidal feelings are not always linked to depression. Some people may even have these thoughts when it feels as though life is otherwise going well.

Research shows that young people who take their own life are more likely to have a history of self-harm, but self-harm is not necessarily a sign of suicidal feelings.

Suicidal feelings can get in the way of everything else - so much that you might find it hard to believe that you can feel better. But you can get better, however tough things feel right now. Whatever the reasons may be that you feel suicidal, they are valid and you deserve help.

Warning signs of suicidal feelings

It may not always be easy to spot when you are having suicidal feelings, especially if they have been building up over a long time.

Here are some warning signs of suicidal feelings:

always talking or thinking about death

deep depression and sadness

losing interest in daily life

having increasing trouble sleeping and eating

feeling helpless or worthless

self-harming

feeling angry and that things can't change

If you experience any of the symptoms above, please don't suffer in silence. You deserve help, and you will find that life is worth living.

What to do about feeling suicidal

Have you hurt yourself, or do you think you might be about to hurt yourself? Call 999 now or go to A&E now. You're not wasting anybody's time - this is an emergency.

Tips for now

It's important to look at the underlying issues that are causing you to feel suicidal and address those. Here are some steps you can take to help look after yourself in the long term.

Is there anything going on that is leading you to view suicide as a solution, such as bullying or problems at school? Is there anything you can do to improve the situation or ask someone you trust like a parent or teacher to help? You may find that if you address any problems like this, the thoughts of suicide become less frequent or stop altogether.

Have a look at our feelings pages for more information and tips on different experiences you might be having, including where to get support.

This can be really daunting, but your GP will have heard from lots of people who are feeling like you are now. They will know what support and services are available in your local area, and they can help you decide if medication like antidepressants might help you.

For more about what a self-soothe box is, how it can help when you're experiencing really intense emotions, and how to make one, read this blog from our blogger Eve or watch the video from our Activists below.

Real stories from young people like you

Our bloggers and Activists share their experiences of having suicidal feelings, getting help and coming out the other side.

What will happen if I tell a doctor or teacher that I feel suicidal?

What treatment is there?

Having suicidal feelings can be really scary, but support is available and you can get through it. Your doctor may suggest:

cognitive behavioural therapy (CBT)

other forms of therapy, such as creative therapy

medication

The important thing is to find what feels right for you. Your doctor, therapist or counsellor can help you with this.

Anything you tell a doctor, counsellor or therapist is confidential, meaning they won't tell anyone else unless you agree otherwise. This includes if you tell them you are having suicidal thoughts.

But, your therapist or counsellor may have to tell someone if they think you or someone else might not be safe. Usually they will try to let you know first. It is very unlikely that they would tell your parent(s) or guardian(s) something you have told them, but they may encourage you to do so.

If you tell a doctor that you are having suicidal feelings, they may refer you to hospital, or to a mental health service. This doesn't necessarily mean you will have to stay in hospital; it's just so that you can get the right help.

For tips on talking to your doctor and more information on confidentiality, have a look at our page on how to speak to your GP about mental health.

More advice on feeling better

Supporting a friend who is feeling suicidal

Unfortunately, there is no simple list of signs that someone might be struggling with suicidal feelings, but here are some signs that may indicate someone is struggling with these thoughts:

changes in behaviour, e.g. becoming more withdrawn or losing interest in things they normally enjoy

talking about death a lot, or mentioning that they feel "hopeless", have "had enough" or that loved ones would be "better off without me"

taking risks with their health, e.g. increased use of drugs or alcohol, or suddenly taking part in dangerous activities

being suddenly calm after a period of distress

If you are worried that a loved one may be struggling with suicidal feelings, it's okay to ask directly. It may feel uncomfortable, but asking about it won't cause it to happen.

Talking about suicide can be a daunting thing to do, but making that move to start a conversation is the first step to supporting your friend and may even bring them a sense of relief. You might be worried that talking about suicide will put the idea into their head, or make them more likely to act on it, but it won't. In fact, it can be really helpful to address it directly, as it can help make your friend feel less alone.

When supporting a friend who is feeling suicidal, it's important to:

Listen without judgement, stay calm and don't overreact.

Use clear wording such as 'suicide' or 'ending your life', as well as direct questions that require yes or no answers, so that there is no confusion.

Be aware it's not your job to take away the pain or make it better. All you can do is be there, even if you don't know what to say (which is okay!).

Try not to downplay what they tell you or brush it off as a "phase". Do your best to see things from their perspective.

Encourage them to open up and help them identify a trusted adult (such as a teacher) they could talk to and who can help them find support. Some young people may be reluctant to talk to a parent in case they 'freak out' or because the parent themselves struggles with mental health problems. In that case, a teacher or family friend may feel more appropriate for them to speak to.

Help them build up a wider support network so they know who to contact 24/7 if they're struggling, such as The Samaritans, Childline or the YoungMinds Shout Textline.

Make sure you talk to someone too. If you're trying to support a friend who's been thinking about suicide, that information can be a heavy burden to carry alone, so share your feelings with someone you trust.

It can be really difficult to know what to do if your friend tells you they are struggling with suicidal feelings but asks you not to tell anybody. You may feel like it's too much responsibility but that telling an adult would make you a bad friend. But if your friend needs more support than you can offer, it can be a good idea to tell a trusted adult.

It is not your responsibility to solve your friend's problems on your own. They may be angry with you at first if you tell an adult what they told you, but if you are doing it in their best interest they will eventually see that.

Supporting a friend with their mental health

Some people may find it difficult to talk about their emotions, especially if they are experiencing suicidal feelings. It can be really hard to watch a friend struggling and not know what to do. It may leave you feeling powerless and frustrated. But if they don't feel able to talk about the thoughts they are experiencing, sometimes it's enough just to sit with them and let them know you are there for them.

Some people may feel more comfortable talking to someone else, such as a family member or teacher, or they may prefer to speak to someone via a helpline. It is really important that they talk to someone, so it can help to talk to them about who they might feel comfortable speaking to. See the 'Getting help' section below for a list of helplines they can use.

Getting help

If you are feeling suicidal right now, you are not alone and there is help out there.

Below are some places that can help you. You can also use Shout's Textline for free by texting ' YM' to 85258 to get help.

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Suicidal Feelings | Help And Advice For Young People

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If you need urgent help If you are feeling suicidal right now, know that there are people out there who can support you to get through this. If you are at immediate risk or harm, please call 999 and ask for an ambulance. What are suicidal feelings?

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Winston's Wish is the UK's childhood bereavement charity. We support children and their families after the death of someone important.

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24/7

You can text us any time, day or night.

Confidential

Your messages with us are confidential and anonymous.

Free

It is free to text Shout from all major mobile networks in the UK.

Get involved

Donations doubled in the Big Give Christmas Challenge

Simply support Shout's Big Give campaign by midday on 5 December, and your donation will be doubled!

Can you help us hit our match funding target of £50,000 and support a further 5,000 people this winter?

Find out more

Get help

Ways to cope with upsetting events in the news

If you're feeling overwhelmed, anxious or sad about what's going on in the news, know that you're definitely not alone. Here are some actions we can take to help us cope better through times like this.

Find out more

I think Shout saved my life tonight... no one has ever made me feel so safe, listened to and understood

Shout texter

GET HELP

Online resources and support

However you're feeling right now, you don't have to face it alone. We're here to support you with your mental health.

Take a look at our resources, information and support, find further help or reach out to one of our volunteers.

Resources for you

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Shout - UK's 24/7 Crisis Text Service for Mental Health Support

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Shout 85258 is the UK's first 24/7 text service for anyone in crisis. Get free, confidential mental health support anytime, anywhere. Text 'SHOUT' to 85258.

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Samaritans works to make sure there's always someone there for anyone who needs someone. Read more.

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HOPELINE247 advisers want to work with you to understand why thoughts of suicide might be present. They also want to provide you with a safe space to talk through anything happening in your life that could be impacting on your or anyone else's ability to stay safe.

For children and young people under the age of 35 who are experiencing thoughts of suicide

For anyone concerned that a young person could be thinking about suicide

Young people

Our advisers are all trained to help you focus on staying safe from suicide. Their training enables them to provide advice and support that may help you to move forward and stay alive.

Concerned others

If you are concerned that a young person is feeling suicidal, advisers can support you to start a conversation about suicide and explore options of how best to support them.

Contact HOPELINE247

If you are having thoughts of suicide or are concerned for a young person who might be you can contact HOPELINE247 for confidential support and practical advice.

Opening hours:

Line are open 24 hours every day of the year (Weekends and Bank Holidays included)

Our Suicide prevention advisers are ready to support you.

Who can PAPYRUS HOPELINE247 help?

Young people, children, family, parents, siblings, partners, carers, grandparents

Concerned friends: at work, in school, college, university

GPs, nurses, teachers, school nurses, A&E staff, pastoral staff

Mental health professionals: CAMHS staff, CPNs, psychiatrists

Education staff: teachers, lecturers, learning mentors, education social workers

Police, ambulance staff, prison staff, drug and alcohol services, probation workers

Feedback from HOPELINE247 users

"I've just searched online to find the service, this is the best advice I've had, and I'm talking about doctors and health professionals. Do you know nobody has just asked me to talk to him; it's really strange when you think about it - so thank you."

"Thank you for helping me - no-one has ever helped me this much before."

"The people at HOPELINE247 are great - I feel understood."

Further help and advice

This page is for information on the PAPYRUS HOPELINE247 service - visit our HOPELINE247 FAQ section for more information about using the service. For further help and advice, including a full list of resources, visit our help and advice resources page.

We understand that not all callers will be able to, or would prefer not to, speak English. You can still access support by requesting Language Line when calling HOPELINE247. Learn more about this service HERE.

Policies
Confidentiality Policy Remit of service policy

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HOPELINE247 | Papyrus UK | Suicide Prevention Charity

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Are you having thoughts of suicide or are concerned for someone who feels suicidal? Then contact HOPELINE247 for free confidential support on 0800 068 4141.

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Trauma-Informed Approaches to Working with Children, Young People and Families

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Oasis Project and Make Good Trouble present: Trauma-Informed Practice: Working with Children/Young People and Families

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Childhood Trauma and the Brain animation and accompanying educational materials for professionals and carers supporting children and young people.

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Most people with trauma-related problems have experienced multiple traumas. The term, complex trauma describes exposure to multiple traumas. It also refers to the impacts of that exposure.

Complex trauma:

· is usually interpersonal i.e. occurs between people

· involves 'being or feeling' trapped

· is often planned, extreme, ongoing and/or repeated

· often has more severe, persistent and cumulative impacts

· involves challenges with shame, trust, self-esteem, identity and regulating emotions.

· has different coping strategies. These include alcohol and drug use, self-harm, over- or under-eating, over-work etc.

· affects emotional and physical health, wellbeing, relationships and daily functioning

How does complex trauma differ from single incident trauma?

Single incident trauma occurs with `one off' events. It is commonly associated with Post Traumatic Stress Disorder (PTSD). Single incident trauma can occur from a bushfire, flood, sexual or physical assault in adulthood, or from fighting in a war.

Can people recover from complex trauma?

Research and survivors' stories both show that people can recover from complex trauma. They need to receive the right help and support to heal. When parents have worked through their trauma their children do better too. Part of this process includes acknowledging survivors' strength and resilience in surviving, and possibilities for recovery. It is also important to hold a sense of hope and optimism that life can and often does get better.

In what situations does complex trauma occur?

Complex trauma commonly occurs with repeated trauma against a child. Sometimes a parent or caregiver has experienced their own trauma, which is still affecting them e.g. from mental illness, drugs and alcohol misuse, or being physically or emotionally unavailable. Many situations can cause complex trauma in childhood.

Complex childhood trauma can be especially damaging. This is not always the case. This includes all forms of child abuse, neglect, adverse childhood experiences, community violence - domestic and family violence, civil unrest, war trauma or genocide, cultural dislocation, sexual exploitation and trafficking.

Complex trauma is not always the result of childhood trauma. It can also occur as a result of adults' experience of violence in the community e.g. domestic and family violence, civil unrest, war trauma or genocide, refugee and asylum seeker trauma, sexual exploitation and trafficking, extreme medical trauma and/or re-traumatisation.

While the concept of complex trauma is long-standing, neither the DSM (US manual of mental health disorders) nor ICD (global classification of mental health disorders) has included it. This is about to change. The diagnosis of Complex PTSD to describe enduring complex trauma will be included in the upcoming ICD 11. This is important as the treatment of complex PTSD is different
Complex post-traumatic stress disorder

to that of PTSD alone. See complex trauma treatment here.

To read complex trauma information in Blue Knot Practice Guidelines for Treatment of Complex Trauma and Trauma-Informed Care and Service Delivery, click here.

To find about training for working with complex trauma clients, click here

For resources on Complex Trauma click here

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Definition of complex trauma versus single incident

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Most people with trauma-related problems have experienced multiple traumas. The term, complex trauma describes exposure to multiple traumas. It also refers to the impacts of that exposure. Complex trauma: · is usually interpersonal i.e.

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Trauma sensitive practice with children in care

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Summarises the evidence in this challenging area of work and aims to support practitioners to reflect on their practice in this context.

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The National Child Traumatic Stress Network

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The National Child Traumatic Stress Network

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CFTSI is a brief (5‐8 session), evidence‐based early intervention for children 7 to 18 years old that reduces traumatic stress reactions and the onset of PTSD. CFTSI is implemented within 30-45 days following a traumatic event or the disclosure of physical or sexual abuse.

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Beacon House is passionate about developing freely available resources so that knowledge about the repair of trauma and adversity is in the hands of those who need it. Please feel free to use our resources in your home or work setting.
All we ask is that you credit our team for the information and design using this credit: Image or information courtesy of Beacon House Therapeutic Services & Trauma Team | 2022 | www.beaconhouse.org.uk
As a specialist trauma service, our resources are written using a 'trauma lens' and offer information, ideas and strategies from this perspective. We know that there are other perspectives and overlapping experiences, meaning that 'one size doesn't fit all'. We are working to be as inclusive as possible and alongside this acknowledge that not everything we produce will be relevant for everyone.

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Beacon House is passionate about developing freely available resources so that knowledge about the repair of trauma and adversity is in the hands of those who need it. Please feel free to use our resources in your home or work setting.

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Comprehensive family assessment is the ongoing practice of informing decision-making by identifying, considering, and weighing factors that impact children, youth, and their families. Assessment occurs from the time children and families come to the attention of the child welfare system-or before-and continues to case closure.

Many factors, including the child's safety, the risk of future maltreatment, parental protective capacity, and child well-being must be accurately assessed on an ongoing basis. Assessment provides the foundation for assisting children, youth, and families at a number of critical points, including:

When families are presented with new challenges

When there are safety concerns for the child or other family members

When decisions must be made about the need for services or the appropriate type and intensity of interventions or supports

When reviewing service effectiveness and case progress

Comprehensive family assessment is guided by principles of family-centered, culturally competent practice. Whenever possible, families are seen as providing the best care and protection for their children, family represents the focus of all work, and family members are actively involved in the development and implementation of any plan. The family's culture, race, ethnicity, values, and customs must be respected and carefully considered.

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Comprehensive family assessment is the ongoing practice of informing decision-making by identifying, considering, and weighing factors that impact children, youth, and their families. Assessment occurs from the time children and families come to the attention of the child welfare system-or before-and continues to case closure.

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Relational and developmental trauma in children

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Short and long-term impacts

Trauma can have both short-term and long-term impacts on children and young people.

In the short term, experiencing trauma causes individuals to have a stress response. Usually, a child or young person's brain and nervous system work together to help them make sense of incoming information from their senses like sight and sound. When they experience trauma, chemicals (like adrenaline) rush around a child or young person's body, affecting signals between brain and nervous system.

Having a stress response after trauma might make it harder for individuals to:

process information

remember things

concentrate

manage their feelings.

It may also take children and young people who've experienced trauma a long time to calm down after having a stress response.

Long-term, trauma can affect children and young people in lots of different ways that aren't always obvious.

Sometimes things like sights, sounds, smells and movements that remind children and young people of trauma can trigger stress responses again, even if the actual event happened a long time ago. Repeated trauma reactions can be embedded in the brain architecture, meaning that traumatised children and young people are more likely to experience frequent stress responses, even when there's no threat or danger.

It can be difficult for others, such as educators, to understand what's upsetting to a child or young person when they don't know what the trigger is.

Often, a child or young person doesn't understand what made them react in such a way as the response is an instinctual and involuntary response (like fight, flight or freeze) and isn't within their conscious control. Adults can help children and young people understand and manage their feelings if they work with them over time to try and understand what situations, interactions or stimulus seems to set these responses off. For example, a child or young person might often get very distressed when alarms go off or if they feel cornered.

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How trauma affects children and young people - Be You

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Trauma can have both short-term and long-term impacts on children and young people. In the short term, experiencing trauma causes individuals to have a stress response. Usually, a child or young person's brain and nervous system work together to help them make sense of incoming information from their senses like sight and sound.

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TF-CBT Telehealth Resources - Trauma-Focused Cognitive Behavioral Therapy

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Brief MUSC TF-CBT telehealth webinar (English and Spanish): https://www.dropbox.com/sh/acesnn37l9afb6p/AAAiREKk8eX32rY8axEgZ6Q0a?dl=0 with accompanying slides from the webinar (download here) Telehealth Guide from MUSC (download here) Article on Telemental Health Guidelines for providing TF-CBT (download here) Pilot study of TF-CBT via Telehealth (download here) 3-hour video webinar on Implementing TF-CBT via Telehealth (see below) Word Versions of TF-CBT...

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risking connection: 3-day basic training

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Risking Connection: 3-Day Basic Training - ppt download

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Introduction RC 3-Day Basic Training/Day 3 9:00-9:45 Introduction Review feedback Exercise: What makes us who we are? Review Day 3 Agenda Introduction Introduction Review feedback from day 2

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Emotional and Psychological Trauma Helpguide handout.docx

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IMPROVE THE MOMENT WORKSHEET ADVANCED DISTRESS TOLERANCE SKILLS

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COMPLEX PTSD - FROM SURVIVING TO THRIVING

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Working with Traumatic Memory with Bessel van der Kolk, MD Get Access for Free Now × Enter your name and email below to get instant access to: Working With Traumatic Memories - Bessel van der Kolk, MD Name: Email: We deeply respect your privacy. We guarantee that your email will not be rented, sold, or ...

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Strengths-based social work: practice framework and handbook

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The framework and handbook support social workers and social care professionals in applying a strengths-based approach to their work with adults.

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Professor Hanna Pickard

Welcome to the Responsibility without Blame Project.

The Responsibility without Blame Project provides a free and accessible e-learning for anyone interested in thinking about our ideas of responsibility and blame, and finding ways to work and relate more effectively with people with personality disorder or complex needs.

This is not always easy. It requires striking a balance to support people to develop a sense of personal agency and responsibility, without falling into either rescue or blame. The e-learning provides a toolkit to help you better understand these ideas and develop the skill of working with responsibility together with care and compassion.

You can learn more about my story and how the Project came about by watching the video on the Introduction and Registration page.

The Responsibility without Blame Project was created in collaboration with ex-service users from STARS.

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Welcome to the Responsibility without Blame Project. The Responsibility without Blame Project provides a free and accessible e-learning for anyone interested in thinking about our ideas of responsibility and blame, and finding ways to work and relate more effectively with people with personality disorder or complex needs. This is not always easy.

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Resources for Making Sense of Trauma - Making Sense of Trauma

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Webinar Guide Directions for accessing the MSOT Webinar MSOT A Webinar Guide (2018) Webinar PowerPoint notes Jan 2018Helpful WebsitesRecommended Readings Workshop HandoutsTrauma FlowchartWindow of ToleranceSensory Motor Checklist for AdultsActivities for Self RegulationChild Development and Trauma Guide5 4 3 2 1 Relaxation TechniqueFlashback ProtocolHow to Talk to Children about Freeze, Flight, and FightOverview of Tools Big ...

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Finger Puppets

Free Downloadable Handouts

These handouts are for use with the book Once I Was Very Very Scared. Please feel free to use these handouts with children and families. You have the right to use them and make copies for use with families, so long as they are provided free of charge. You may not include them in any other materials.

Click on the image to download the free PDFs.

Squirrel would like you to know that it is ok if grown-ups want to use the handouts too. We could all use a little help sometimes, and coloring is fun.

Which animals are you like?

Draw your picture in the middle of the circle and color the animals that are like you and the things that help you feel safer and better.

Understand the animals

We can begin to help the animals from the story Once I Was Very Very Scared by thinking about what they went through. Children may like using these simple sheets to write or draw the animals' or their own stories.

Help the animals

Let's help the animals from the story Once I Was Very Very Scared. Children can write or draw what the animals do when they are scared, angry, frustrated, embarrassed, or ashamed. You can help them think about what might help the animals and write or draw their answers in the box. While they help the animals, we will be able to help them think about what helps them when they feel this way.

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Finger Puppets These handouts are for use with the book Once I Was Very Very Scared. Please feel free to use these handouts with children and families. You have the right to use them and make copies for use with families, so long as they are provided free of charge.

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Summary:
Briefing on working with children who have experienced trauma in the youth justice system.

This briefing provides information to youth justice practitioners on trauma informed practice. It was produced by the Youth Justice Board for England and Wales (YJB) in response to requests from practitioners for more information in this area. This briefing is about trauma-informed practice in youth justice, the impact on trauma on children and working with children that have experienced trauma.

The YJB has also put together a list of trauma informed interventions and assessments, which can be accessed here.

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Trauma Informed Youth Justice Briefing (2017) - Youth Justice Resource Hub

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Summary: Briefing on working with children who have experienced trauma in the youth justice system. This briefing provides information to youth justice practitioners on trauma informed practice. It was produced by the Youth Justice Board for England and Wales (YJB) in response to reque...

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How do you think things might change if you responded to yourself in the same way you typically respond to a close friend when he or she is suffering? This exercise walks you through it.

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Almost a third of young people in the UK experience trauma during childhood or adolescence that doubles their risk of experiencing a range of mental health disorders, a study funded by the Medical Research Council (MRC) and published in the Lancet Psychiatry has suggested.1

The study looked at data on 2232 children born in England and Wales in 1994-95 enrolled in the Environmental Risk Longitudinal Twin Study assessed by structured interviews at the age of 18 for trauma exposure, post-traumatic stress disorder (PTSD), other psychopathology, risk events, functional impairment, and service use.

Almost a third (31.1%) had experienced trauma and one in four of these (7.8%) met the criteria ...

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Childhood trauma doubles risk of mental health conditions

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Almost a third of young people in the UK experience trauma during childhood or adolescence that doubles their risk of experiencing a range of mental health disorders, a study funded by the Medical Research Council (MRC) and published in the Lancet Psychiatry has suggested.1 The study looked at data on 2232 children born in England and Wales in 1994-95 enrolled in the Environmental Risk Longitudinal Twin Study assessed by structured interviews at the age of 18 for trauma exposure, post-traumatic stress disorder (PTSD), other psychopathology, risk events, functional impairment, and service use.

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ACE study

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Do you ever feel ashamed, embarrassed or confused about your parent's drinking? Perhaps you feel different from other people you know? Or you want to know how you can help your parent?

You are not alone; there are many young people experiencing similar problems. When a parent has a drink problem, it affects the whole family, and can be especially difficult for children and young people.

You can be a child of an alcoholic at 1 or 101. Whatever your age, it doesn't change the fact that your parent, step-parent or carer is, or has been, dependent on alcohol, along with the problems this brings.

These pages offer information and advice that we hope will help. Nacoa is here to help and support you.

To find out more see Help & advice.

You are not alone
Remember the Six "C"s

Kids' Power Too: Words to Grow By

Cathy Brown, Betty LaPorte and Jerry Moe

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Do you ever feel ashamed, embarrassed or confused about your parent's drinking? Perhaps you feel different from other people you know? Or you want to know how you can help your parent? You are not alone; there are many young people experiencing similar problems. When a parent has a drink problem, it affects the whole family, and can be especially difficult for children and young people.

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Hi Everyone,

Emma Roberts from the UK gives us an in-depth look at trauma and many ways to provide relief with EFT. A must read for professionals and serious students.

Hugs, Gary

By Emma Roberts

Trauma comes in all shapes and sizes, as does people's response to it. EFT can be used successfully with all of them but this is one area where it may be appropriate to work with a qualified practitioner, at least initially. The primary concern when working with trauma is your safety or the safety of your client. This is paramount as re-traumatising and abreaction are to be avoided at all costs.

Trauma influences our cognitive schemas at a profound level. It undermines our beliefs in both ourselves and our existence, and also our sense of reality as we know it. The resulting beliefs can seriously disrupt the every day running of our lives without us necessarily even realising it.

EFT's effectiveness in working with trauma is extensive. Whilst it can bring immediate relief from traumatic memories, it is also a gentle tool for revealing the many layers and aspects that may be connected with trauma, working through them systematically and effectively until their emotional charge has gone.

In this article I will look at the different manifestations of trauma and the options for working with them using EFT.
Self Care for Therapists
Before beginning to work with trauma it is vital to look at ourselves as therapists and our own response to trauma in its many forms.

The first step is to work on any unresolved trauma we may still be attached to so that we are not triggered by our clients' experiences. The difference between empathising and colluding with the client needs emphasising. Whilst it is important to feel empathy for the client it is not useful for them if we are accessing our own stuff and we will be getting in the way of the process. As Gary often says, allow the work to be through you not by you. We must be a clear channel in order to fully serve our clients and get maximum results.

Test drive your trauma 'buttons' by imagining different future possible scenarios and/or past events and noticing what, if anything, still gets an emotional response.... Apply EFT to it.

Also recognise that you are human and things can sneak up on you and surprise you. You are likely to hear some horrific stories. If this happens during a client session imagine putting it out of the room, or in a box, remembering to return and work with it at the earliest opportunity. If you are tapping alongside your client you may clear your response during the session anyway.

Using EFT yourself on a regular basis is even more important in trauma work than most areas. Trauma therapists traditionally experience a high level of burnout. EFT gives us the opportunity to change that and be of even more powerful use. Walk your talk!

Trauma can be broadly broken down into four categories:

1) Prolonged past traumatic experiences

Systematic abuse over a prolonged period of time that is over in the present day eg childhood abuse, bullying, war experience etc
2) Ongoing trauma
Systematic abuse continuing today where client is constantly re-traumatised eg domestic violence and marital rape, psychological abuse, bullying at work etc.
3) One-off trauma
Rape, terrorist attack, accident, assault etc
4) Perceived trauma
Trauma not physically experienced by the client but witnessed in a secondary manner via the media, friends, colleagues, stories etc
The Presenting Client
Some clients will need to tell you their story immediately. When they do their energy system will be disrupting massively and you will need to tap continually on them. In order to do this and keep rapport with a new client it is important to preframe this when introducing yourself and your work. I recommend tapping on your clients wherever possible for the following two main reasons:

1) By connecting two energy systems physically the effects can be doubly powerful.

2) It allows the client to focus on their issue without worrying about 'getting the tapping wrong'. Whilst this can be a useful way of unearthing core beliefs, such as not being good enough, I don't consider it to be initially helpful in the context of trauma, rather another door to be returned to when they are in a more comfortable place.

Other clients will present with physical issues such as insomnia, migraines or even cancer where they make no connection to any previous traumatic events. However, when an event happens that challenges our beliefs of the world, and our personal safety, it can create a physiological response as well as an emotional one. In these cases, always start with where the client is at, using your detective skills and careful questioning to gently ease out any specific events that may be contributing to the current state.

Others will have totally detached themselves from the traumatic event/s, they will be unable to access any emotion, and often just present with a general feeling of depression or anxiety. In these cases again you will need to apply all your detective skills to coax out the underlying specific emotional contributors and events.

The following set up statements can be useful here:

Even though I have all these problems I deeply and completely accept myself
Even though life is grim I deeply and completely accept myself
Even though things can only get worse I deeply and completely accept myself
Even though I feel bad and am not sure why I deeply and completely accept myself
Here, Gary's question 'If you could live your life again which person or event would you leave out?' is an excellent way of getting to the specific core issue.

Another client group will be aware of the trauma but anxious about even thinking about it, let alone talking about it. With these clients the first thing to do is, again, to meet them where they are at and work with the presenting anxiety. Some of the following set-up statements can be useful here:
Even though I don't want to go back there again I deeply and completely accept myself
Even though I am anxious even thinking about the event I deeply and completely accept myself
Even though I am frightened to look at that time again I deeply and completely accept myself. Post Traumatic Stress Disorder (PTSD)
PTSD can be caused by one event or by prolonged exposure to traumatic experiences, such as war (see Gary's dvds The EFT Course, Part 1, Video 3, 6 Days at the VA). Sufferers of PTSD store the memories of past events in their minds as thought they are happening today, they replay them through flashbacks, hyper- vigilance, nightmares, jumpiness and other physiological symptoms. They may also have removed themselves from normal life, as the world is seen as unsafe, making them detach and withdraw both from becoming involved both physically and emotionally.
Methods for working with Trauma Tearless Trauma
This is a very gentle way of using double dissociation to keep the client safe from abreaction and is usually the best starting point when working with a specific traumatic event.

Identify a specific traumatic incident from the past. An example might be, "the time my father punched me when I was 12." By contrast, the phrase "my father abused me" would be too broad because, chances are, the abuse took place over many, many incidents.

Get them to make it into a mini movie and put it on a wall away from them

Give it a title.

Ask them to GUESS at what their emotional intensity would be (on a 0-10 scale) IF they were to vividly watch the movie. Instruct them NOT to actually watch it (although some will close their eyes and do this anyway). ThisGUESS is a surprisingly useful estimate...and...it serves to minimize emotional pain.

Have the client develop a phrase using the movie title for the EFT process such as "this father-punch emotion" and then proceed with a round of tapping.

After this round of tapping, ask the client to GUESS again around ask them to state their new number.

Perform more rounds of EFT (numbers. In my experience, a total of 3 or 4 rounds will bring just about everyone down to GUESSES of 0 to 3.

Once the client is down to acceptably low GUESSES, then perform another round of tapping and, after this round, ask them how they would feel about watching the movie. Notice that this is the first time you are asking them to do this. All previous times have been relatively painless GUESSES.

If they are OK with that get them to watch the movie, instructing them to stop at any part that still 'gets' them and tap on it.

Keep going until they are able to watch their whole movie with no emotional attachment. Often they will say something like 'It is like watching someone else' or 'I cant see it clearly any more'.

In Brief:

Locate specific trauma

Make it into a movie and put it on the wall away from you

What is it's title?

Don't look at it, draw a curtain over it

Estimate 0 - 10 intensity if you were to watch it (guess)

Create Reminder Phrase using movie title for the EFT process

Do EFT on it

Guess at the intensity again

Do more EFT rounds until 'guessed' intensity is low

Watch the movie, stopping at any part that still 'gets you'

More rounds of EFT as necessary

The Movie Technique
This is the same principle as Tearless Trauma only without the double dissociation. If the trauma is not perceived as too intense then this would be a safe starting place too.

Create a mini movie of the specific event

How intense do they feel about watching it (using SUDS scale 0 -10)

If high intensity rating revert to Tearless Trauma above

If OK run movie, stopping at any point where there is emotional intensity and tap

Keep going until whole movie is clear of any emotional intensity

Telling the Story
Telling The Story is an excellent way of testing your results and clearing up any remaining undetected aspects. Ideally, use this once you feel you have reduced the intensity to an acceptable level, or cleared it completely. However, sometimes you will need to use it immediately, as detailed above.

Have your client tell their story of the event/memory/trigger.

As soon as any emotional disturbance is detected stop and tap on the last statement the client made.

Test by having the client re-tell that part of the story. They should be able to go past the previous emotional point easily. If not, there are further aspects to be addressed.

When the client is calm on the first point, have them continue to tell the story. Stop and tap on each emotional disturbance.

Test by asking your client to tell the entire story from start to finish. Your work is completed when your client can do this and remain calm throughout.

The Tsunami Technique
In these days of mass disasters, natural or otherwise, we thought you might be interested in an EFT phenomena which came to the fore during Sue Beer and I's recent trauma workshop at The EFT Centre, London.

The workshop was for a small group of Level 2 and 3 EFT practitioners and focussed more on working with clients than self application. However, we wanted to give them an experience of Tearless Trauma so they would know how it would be for a client.

Thinking that the most contained way of doing this as a teaching example would be to go for a group experience, we asked them to each pick a specific memory/image/photograph from the Tsunami that still 'got' them now. We knew that no one had had any direct experience of the Tsunami. Most of them had a problem even finding this memory.

We did a group tap on these 'Tsunami emotions' and it quickly became apparent that each and every one of them had associated into something completely unrelated to the Tsunami. It seemed that when the slight Tsunami emotion had cleared other powerful, seemingly unconnected emotions and past events surfaced.

Whilst this in itself is not particularly unusual with EFT, it did come as a surprise in this environment. It revealed new aspects of earlier specific traumas that they thought they had cleared, and in a couple of cases specific events were recalled that had hitherto been repressed.

Obviously we then had to take a detour from the course content and help them clear these issues - swiftly achieved.

Again, none of the above may be a surprise, and although unexpected, all the responses were easy to clear and some important work was done. However, these were an unusual group in that they were all dedicated EFT practitioners who had worked consistently through their own issues and who were using EFT on an ongoing basis daily and considered they had cleared the big trees from their emotional forests.

We now use the 'Tsunami technique' with some clients who seem stuck as a way to facilitate unearthing underlying trauma, where there doesn't seem to be an obvious door to go through and it ALWAYS gets results. In a seemingly roundabout way, something good and positive has emerged from the appalling events of that Boxing Day.

Check no direct emotional involvement with Tsunami

Pick Tsunami memory/image/photograph

Put it on screen, behind a curtain (as in Tearless Trauma)

Tap on this 'Tsunami emotion'

Keep tuned into client and monitor emotional response

What does it remind you of?

Tap on whatever comes up, following the chain until emotions are fully resolved

Test results with both the emergent specific event and also original memory

Imagination Technique
I sometimes introduce this as a game, and it can be particularly useful when working with children.

Sometimes people may only have a sense of having experienced trauma. This can be to do with the age at which the trauma occurred, if it was pre-verbal and stored in pre verbal memory, and how much is stored cognitively. In cases where there is no actual memory, just a physical sense of something having happened, or a knowledge that it did, but no memory, get the client to 'make it up'. It is not important whether it is true or not, what is important is the resultant limiting behaviours and beliefs that are showing up today. Imagining and guessing in the west is what the east call sixth sense... it comes from somewhere, trust it and go with it, it is often an important door.

However, be careful to never ever suggest trauma or abuse has occurred and to frame the Imagination Technique as a game, and not the truth.

To conclude, EFT is an exciting new tool in working with Trauma. It allows the client to get immediate relief from traumatic experiences and gently opens the door to revealing and clearing the multiple layers of aspects and beliefs which may be present in a pain free, systematic manner. Trauma can be experienced at many different levels and there is no fixed formula for specific trauma groups. However, as a general rule, the higher the intensity the more the need to dissociate the client, using the Movie Technique or Tearless Trauma. For unfeeling clients, the Tsunami and Imagination Techniques are useful.

In order to achieve maximum results when working with clients it is important to keep more flexible than your clients, and whilst the above techniques provide a valuable framework within which to work, allow your creativity to flow and your intuition to guide you!

Emma Roberts

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A Detailed and Masterful Article on Using EFT for Trauma

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loadposition article-preamble} Hi Everyone, Emma Roberts from the UK gives us an in-depth look at trauma and many ways to provide relief with EFT. A must read for professionals and serious students. Hugs, Gary By Emma Roberts Trauma comes in all sha...

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PTSD Coach - PTSD: National Center for PTSD

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Information about a desktop and mobile app to help you cope with the symptoms related to PTSD that commonly occur following trauma.

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Traditional psychotherapy addresses the cognitive and emotional elements of trauma, but lacks techniques that work directly with the physiological elements, despite the fact that trauma profoundly affects the body and many symptoms of traumatized individuals are somatically based.

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https://www.oneinfour.org.uk/

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Awareness Day resource list for Child Traumatic Stress.

Bullying

StopBullying.gov
This resource provides information from various government agencies on what bullying is, what cyberbullying is, who is at risk, and how you can prevent and respond to bullying.

Child Welfare

Chadwick Center for Children and Families, Rady Children's Hospital, San Diego. Trauma System Readiness Tool (PDF | 2.1 MB)
The TSRT is a self-report measure that was designed for child welfare systems to use as they assess the trauma-informed nature of their own system. The TSRT was designed to be administered to multiple informants across all levels of the organization, including caseworkers, supervisors, managers, and administrators. It can be completed across regions within a state or county. Results from the TSRT provide cross-informant data to each system detailing how front-line case workers' responses from the survey are similar to or different from those of supervisors and administrators.

Chadwick Trauma-Informed Systems Project, Creating Trauma-Informed Child Welfare Systems: A Guide for Administrations (PDF | 5.1 MB)
This guide will help transform the wider community child welfare system, which includes all the major systems that impact children and families involved with public child welfare, including children's mental health, into a multi-dimensional, trauma-informed, and evidence-based system better able to meet the unique needs of abused and trauma-exposed children.

Developing a Trauma-Informed Child Welfare System
This issue brief discusses the steps that may be necessary to create a child welfare system that is more sensitive and responsive to trauma.

NCTSN Child Welfare Trauma Training Toolkit: 2nd Edition
This webinar will share how the Child Welfare Trauma Training Toolkit (CWTTT) has been implemented in three different states by nonprofit organizations in partnership with their child welfare jurisdictions.

Understanding Trauma-Informed Care in the Texas Child Welfare System Data and Recommendations from the Field (PDF | 3.7 MB)
The report is an analysis of data and information gathered by Texas CASA related to trauma-informed training, services, and practice.

Drug Addiction

Virtual Opioid Addiction Treatment (OAT) ECHO Technical Assistance Initiative
The teleECHO clinic links expert specialist teams at an academic or medical "hub" with primary health care team members in local communities - the "spokes" of the model. Every teleECHO clinic includes a 30-minute talk followed by case discussions. Didactic topics include ACEs, opioid use disorder in special populations (adolescents, pregnancy), pain management, and addressing substance use disorder-related comorbidities.

Domestic Violence and Sexual Abuse

HRSA's Strategy to Address Intimate Partner Violence (PDF | 391 KB)
In September 2017, HRSA launched a 3-year agency-wide strategy to address intimate partner violence through the provision of training, developing partnerships to raise awareness, increasing access to care, and addressing gaps in knowledge.

"Missing Children, State Care, and Child Sex Trafficking: Engaging the Judiciary in Building a Collaborative Response" (PDF | 1.5 MB)
This technical assistance brief is intended to educate judges about steps to be taken to assist in the location and recovery efforts for children missing from care by ensuring the legal guardians, social workers, and child advocates within child-serving agencies are aware of and engage assistance from the National Center for Missing & Exploited Children on behalf of these endangered missing children.

National Center on Domestic Violence, Trauma, and Mental Health: A Systematic Review of Trauma-Focused Interventions for Domestic Violence Survivors (PDF | 712 KB)
This paper reviews the trauma-based treatments that have been designed or modified specifically for intimate partner violence survivors and provides cautions and recommendations for moving forward.

Early Childhood

Early Childhood Trauma Collaborative Innovation Network (COIN)
The HRSA-led Early Childhood Trauma Collaborative Innovation Network (COIN), a subgroup of HRSA's Infant Mortality Collaborative Improvement and Innovation Network, is composed of more than 50 individuals from 15 states, the District of Columbia, and 31 academic and local organizations to create infrastructures, systems, and supports in order to spread awareness and build resilience against early childhood trauma and toxic stress. For additional information about COIN, please contact CPruitt@hrsa.gov.

Putting the Pieces Together: A Toolkit on Developing Early Childhood Systems of Care (PDF | 4.1 MB)
This toolkit focuses on intervening early to promote positive mental health, prevent mental health challenges, and address mental health problems to achieve the best possible outcomes.

Justice System

Effective Strategies in Addressing Trauma in Children of Incarcerated Parents (1 hour, 27 minutes)
This webinar addressed trauma in children of incarcerated parents across systems; behavioral health, primary care, law enforcement, and community-based.

Prevention

National Suicide Prevention Lifeline
If you or someone you know is experiencing signs of distress, please reach out to a mental health professional or get anonymous, 24/7, free support: text 741-741 or call 1-800-723-TALK (8255).

Primary Care

Health Partners Toolkit on Intimate Partner Violence
This HRSA toolkit is designed to assist primary care providers in establishing formal partnerships with local domestic violence programs to support trauma-informed care for survivors of intimate partner violence.

Providing Trauma-Informed Care at Health Centers for HIV-Positive Men Who Have Sex with Men (PDF | 4.4 MB)
This HRSA issue brief offers health centers an introduction to providing trauma-informed care for HIV-positive men who have sex with men (MSM). The overall aims are to help health center staff understand the disproportionate prevalence of trauma and stress-related disorders among HIV-positive MSM, recognize the relationship of trauma to overall health and decreased engagement in primary care among HIV-positive MSM, and apply promising practices in trauma-informed care to improve engagement of HIV-positive MSM in behavioral health and primary care.

Center of Excellence for Integrated Health Solutions (CIHS)
This is a national resource for technical assistance on the bi-directional integration of care (primary care in behavioral health settings and behavioral health in primary care settings).

Trauma-Informed Care

Taking Care of Yourself and Others Following a Tragic or Traumatic Event
This Jed Foundation resource provides guidance on how to address and cope with trauma as an individual and community.

Advancing Trauma-Informed Care Issue Brief: Key Ingredients for Successful Trauma-Informed Care Implementation (PDF | 350 KB)
Advancing Trauma-Informed Care Issue Brief provides a framework for organizational and clinical changes that can be practically implemented across the health care sector to address trauma.

ARTIC (Attitudes Related to Trauma Informed Care)
The ARTIC is one of the first psychometrically valid measures of trauma-informed care (TIC) to be published in peer-reviewed literature. The ARTIC is a measure of professional and paraprofessional attitudes favorable or unfavorable toward TIC.

Creating Trauma-Informed Care Environments: Organizational Self-Assessment for Trauma-Informed Care Practices in Youth Residential Settings (PDF | 293 KB)
This organizational assessment form can be used for organizations just beginning or already practicing principles of trauma-informed care. The assessment tracks the potential use of one or more sources of data and the extent to which it is occurring in the organization for the purpose of determining existing components of trauma-informed care that need further assessment, planning, data collection, and implementation while highlighting those components where progress has been made.

Georgetown University Center for Trauma and the Community Resources
This resource is a comprehensive collection of resources on trauma-informed care perspectives and resources; trauma and depression resources; and assessment instruments developed by the Center for Trauma and the Community (CTC) and others.

GUCCHD (NTTAC) Trauma Informed Care Perspectives and Resources
A comprehensive web-based, video-enhanced resource tool comprised of issue briefs, video interviews, and resource lists tells a story of implementation of trauma-informed services and offers guidance and resources to help you on your implementation journey.

Home Visiting Issues and Insights: Creating a Trauma-Informed Home Visiting Program (PDF | 218 KB)
This HRSA issue brief focuses on how to incorporate a trauma-informed approach into home visiting programs.

NCTSN What is a Trauma-Informed Child and Family Service System?
This fact sheet details the components of a trauma-informed child and family service system.

Pathways Issue on Trauma-Informed Care for the Older Youth/Young Adult Population
This issue of Focal Point focuses on trauma-informed care and its growing relevance in research, official policy, practice methods, and organizational structure.

The Center for Health Care Strategies (CHCS) is leading an initiative on TIC (all ages, not specific to children/youth)
Advancing Trauma-Informed Care is a national initiative aimed at understanding how trauma-informed approaches can be practically implemented across the health care sector.

Trauma-Informed Schools

POSTVENTION: A Guide for Response to Suicide on College Campuses (PDF | 2.1 MB)
This Higher Education Mental Health Alliance (HEMHA) resource is intended for use by colleges and universities that are affected by and/or want to be prepared for campus crises and campus deaths. Suicide postvention efforts address the need for predetermined strategies to effectively and sensitively respond to campus deaths after they occur.

"National Association of School Psychologists, Creating Trauma-Sensitive Schools: Supportive Policies and Practices for Learning"
This handout outlines brief tips and policy recommendations for creating trauma-sensitive schools.

NCTSN Creating, Supporting, and Sustaining Trauma-Informed Schools: A System Framework (PDF | 881 KB)
This resource provides a system framework for trauma-informed schools.

UCLA Center for Mental Health in Schools, Responding to Crisis at a School (PDF | 2.9 MB)
This resource provides an overview of crisis assistance and prevention and resources needed for a school to be able to plan and implement a response to crises.

Understanding Trauma

The BHARP System of Care Trauma Resources
This tab includes various resources and references on understanding trauma and ways to address its impact.

Mental Health Connection of Tarrant County Trauma Resources
This resource provides a collection of publications on trauma, its causes, symptoms, and how to help.

NCTSN.org
The primary website of the National Child Traumatic Stress Network (NCTSN), NCTSN.org offers information on various aspects of child traumatic stress, including trauma types, treatments and practices, and trauma-informed care; the site also provides access to over 875 free resources (including training curricula, fact sheets, resource guides, and videos) to help child-serving professionals as well as parents and caregivers better support children who have experienced trauma.

SAMHSA Serious Mental Illness and Trauma: A Literature Review and Issue Brief (DOC | 41 KB)
This paper summarizes the current science on the relationship between trauma and serious mental illnesses.

Understanding Child Trauma and the NCTSN (PDF | 372 KB)
This resource provides an overview of child traumatic stress and the National Child Traumatic Stress Network.

Understanding Trauma and Promoting Resilience in Vulnerable Children (1 hour, 7 minutes)
This webinar discusses how resilience can be developed and nurtured, and what parents can do to build resilient children.

What is Child Traumatic Stress? (PDF | 600 KB)
This fact sheet, produced by the National Child Traumatic Stress Network, provides an overview of child trauma, describes traumatic stress symptoms, and identifies ways children may be affected by trauma.

YMN Understanding Trauma Guide
This guide, produced by Youth M.O.V.E. National, provides a youth-focused overview on trauma, its symptoms, resources, and what an individual can do to help.

Resources for Caregivers

Age-Related Reactions to a Traumatic Event (PDF | 290 KB)
This fact sheet, produced by the National Child Traumatic Stress Network, describes how young children, school-age children, and adolescents react to traumatic events and offers suggestions on how parents and caregivers can help support them.

Arnold Palmer Hospital for Children
This resource is a list of archived articles for caregivers on mental health and youth.

Resources for Clinicians and Providers

Bright Futures: Guidelines for Health Supervision of Infants, Children, and Adolescents, 4th Ed
This HRSA-supported initiative provides health care professionals and maternal and child health programs updated recommendations for pediatric health promotion, health supervision, and anticipatory guidance for well-child visits. The Bright Futures/American Academy of Pediatrics Periodicity Schedule (PDF | 159 KB) presents the screenings, assessments, physical examinations, procedures, and timing of anticipatory guidance recommended for each age-based visit.

Bruns, et al. (2010). Intervening in the Lives of Youth with Complex Behavioral Health Challenges and Their Families: The Role of the Wraparound Process. American Journal of Community Psychology
This paper provides a review of the place of the wraparound process in behavioral health, including a discussion of the opportunities it presents to the field, needs for further development and research, and recommendations for federal actions that have the potential to improve the model's positive contribution to child and family well‐being.

Family Trauma Assessment: Tip Sheet for Clinicians, NCTSN
This fact sheet provides information on how to get families to embrace the need for trauma assessment, the best practices in and appropriate domains for family trauma assessment, how to choose instruments and decide what to measure, and how to present results to the family.

HRSA's Area Health Education Centers (AHEC)
Through community-based interdisciplinary training programs that partner with academic institutions, AHECs identify, motivate, recruit, train, and retain a diverse health care workforce committed to underserved and rural populations. Today, 49 AHEC programs with more than 260 centers operate in most states and the District of Columbia. Some regional AHECs sponsor provider trainings on trauma-informed care.

NCTSN Learning Center for Child and Adolescent Trauma
This source for online training offers free courses and resources on various aspects of child traumatic stress, including hundreds of webinars, eLearning modules, and videos (many offered for continuing education credit) on special populations, clinical training, service systems, and Psychological First Aid.

NCTSN Screening and Assessment: Considerations for Implementation
This fact sheet offers guidelines to consider when selecting trauma screening or assessment tools to implement in a given system.

Trauma Screening
This resource provides trauma-informed screening and assessment practices that help providers identify children's and families' needs early in the process and to tailor services to meet those needs.

Trauma Transformed
San Francisco Bay Area center created through a 2014 SOC grant award that promotes a trauma-informed system by providing trainings and policy guidance to systems of care professionals and organizations.

Trauma-Informed Oregon
This database is a collection of trauma-informed resources for fields of practice, organizations, training and education, and individuals and families.

Resources for Tribal Nations

National Indian Child Welfare Association Trauma-Informed Care Fact Sheet (PDF | 295 KB)
This fact sheet provides an overview on trauma, its effects, trauma-informed care as it relates to Indian Country.

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Resources for Child Trauma-Informed Care

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Awareness Day resource list for Child Traumatic Stress. StopBullying.gov This resource provides information from various government agencies on what bullying is, what cyberbullying is, who is at risk, and how you can prevent and respond to bullying. Chadwick Center for Children and Families, Rady Children's Hospital, San Diego.

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TRAUMA INFORMED CARE | Ideas for putting theory into practice

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5 Ways Trauma-Informed Care Supports Children’s Development - Child Trends

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Many individuals who seek treatment in behavioral health settings have histories of trauma, but they often don't recognize the significant effects of trauma in their lives; either they don't draw connections between their trauma histories and their presenting problems, or they avoid the topic altogether. Likewise, treatment providers may not ask questions that elicit a client's history of trauma, may feel unprepared to address trauma-related issues proactively, or may struggle to address traumatic stress effectively within the constraints of their treatment program, the program's clinical orientation, or their agency's directives.

By recognizing that traumatic experiences and their sequelae tie closely into behavioral health problems, front-line professionals and community-based programs can begin to build a trauma-informed environment across the continuum of care. Key steps include meeting client needs in a safe, collaborative, and compassionate manner; preventing treatment practices that retraumatize people with histories of trauma who are seeking help or receiving services; building on the strengths and resilience of clients in the context of their environments and communities; and endorsing trauma-informed principles in agencies through support, consultation, and supervision of staff.

This Treatment Improvement Protocol (TIP) begins by introducing the scope, purpose, and organization of the topic and describing its intended audience. Along with defining trauma and trauma-informed care (TIC), the first chapter discusses the rationale for addressing trauma in behavioral health services and reviews trauma-informed intervention and treatment principles. These principles serve as the TIP's conceptual framework.

Before You Begin

This TIP endorses a trauma-informed model of care; this model emphasizes the need for behavioral health practitioners and organizations to recognize the prevalence and pervasive impact of trauma on the lives of the people they serve and develop trauma-sensitive or trauma-responsive services. This TIP provides key information to help behavioral health practitioners and program administrators become trauma aware and informed, improve screening and assessment processes, and implement science-informed intervention strategies across settings and modalities in behavioral health services. Whether provided by an agency or an individual provider, trauma-informed services may or may not include trauma-specific services or trauma specialists (individuals who have advanced training and education to provide specific treatment interventions to address traumatic stress reactions). Nonetheless, TIC anticipates the role that trauma can play across the continuum of care-establishing integrated and/or collaborative processes to address the needs of traumatized individuals and communities proactively.

Individuals who have experienced trauma are at an elevated risk for substance use disorders, including abuse and dependence; mental health problems (e.g., depression and anxiety symptoms or disorders, impairment in relational/social and other major life areas, other distressing symptoms); and physical disorders and conditions, such as sleep disorders. This TIP focuses on specific types of prevention ( Institute of Medicine et al., 2009): selective prevention, which targets people who are at risk for developing social, psychological, or other conditions as a result of trauma or who are at greater risk for experiencing trauma due to behavioral health disorders or conditions; and indicated prevention, which targets people who display early signs of trauma-related symptoms. This TIP identifies interventions, including trauma-informed and trauma-specific strategies, and perceives treatment as a means of prevention-building on resilience, developing safety and skills to negotiate the impact of trauma, and addressing mental and substance use disorders to enhance recovery.

This TIP's target population is adults. Beyond the context of family, this publication does not examine or address youth and adolescent responses to trauma, youth-tailored trauma-informed strategies, or trauma-specific interventions for youth or adolescents, because the developmental and contextual issues of these populations require specialized interventions. Providers who work with young clients who have experienced trauma should refer to the resource list in Appendix B. This TIP covers TIC, trauma characteristics, the impact of traumatic experiences, assessment, and interventions for persons who have had traumatic experiences. Considering the vast knowledge base and specificity of individual, repeated, and chronic forms of trauma, this TIP does not provide a comprehensive overview of the unique characteristics of each type of trauma (e.g., sexual abuse, torture, war-related trauma, murder). Instead, this TIP provides an overview supported by examples. For more information on several specific types of trauma, please refer to TIP 36, Substance Abuse Treatment for Persons With Child Abuse and Neglect Issues ( Center for Substance Abuse Treatment [CSAT], 2000b), TIP 25, Substance Abuse Treatment and Domestic Violence ( CSAT, 1997b), TIP 51, Substance Abuse Treatment: Addressing the Specific Needs of Women ( CSAT, 2009d), and the planned TIP, Reintegration-Related Behavioral Health Issues in Veterans and Military Families (Substance Abuse and Mental Health Services Administration [SAMHSA], planned f).

This TIP, Trauma-Informed Care in Behavioral Health Services, is guided by SAMHSA's Strategic Initiatives described in Leading Change: A Plan for SAMHSA's Roles and Actions 2011- 2014 ( SAMHSA, 2011b). Specific to Strategic Initiative #2, Trauma and Justice, this TIP addresses several goals, objectives, and actions outlined in this initiative by providing behavioral health practitioners, supervisors, and administrators with an introduction to culturally responsive TIC.

Specifically, the TIP presents fundamental concepts that behavioral health service providers can use to:

Become trauma aware and knowledgeable about the impact and consequences of traumatic experiences for individuals, families, and communities.

Evaluate and initiate use of appropriate trauma-related screening and assessment tools.

Implement interventions from a collaborative, strengths-based approach, appreciating the resilience of trauma survivors.

Learn the core principles and practices that reflect TIC.

Anticipate the need for specific trauma-informed treatment planning strategies that support the individual's recovery.

Decrease the inadvertent retraumatization that can occur from implementing standard organizational policies, procedures, and interventions with individuals, including clients and staff, who have experienced trauma or are exposed to secondary trauma.

Evaluate and build a trauma-informed organization and workforce.

The consensus panelists, as well as other contributors to this TIP, have all had experience as substance abuse and mental health counselors, prevention and peer specialists, supervisors, clinical directors, researchers, or administrators working with individuals, families, and communities who have experienced trauma. The material presented in this TIP uses the wealth of their experience in addition to the available published resources and research relevant to this topic. Throughout the consensus process, the panel members were mindful of the strengths and resilience inherent in individuals, families, and communities affected by trauma and the challenges providers face in addressing trauma and implementing TIC.

What Is Trauma?

According to SAMHSA's Trauma and Justice Strategic Initiative, "trauma results from an event, series of events, or set of circumstances that is experienced by an individual as physically or emotionally harmful or threatening and that has lasting adverse effects on the individual's functioning and physical, social, emotional, or spiritual well-being" ( SAMHSA, 2012, p. 2). Trauma can affect people of every race, ethnicity, age, sexual orientation, gender, psychosocial background, and geographic region. A traumatic experience can be a single event, a series of events, and/or a chronic condition (e.g., childhood neglect, domestic violence). Traumas can affect individuals, families, groups, communities, specific cultures, and generations. It generally overwhelms an individual's or community's resources to cope, and it often ignites the "fight, flight, or freeze" reaction at the time of the event(s). It frequently produces a sense of fear, vulnerability, and helplessness.

See Appendix C to read about the history of trauma and trauma interventions.

Often, traumatic events are unexpected. Individuals may experience the traumatic event directly, witness an event, feel threatened, or hear about an event that affects someone they know. Events may be human-made, such as a mechanical error that causes a disaster, war, terrorism, sexual abuse, or violence, or they can be the products of nature (e.g., flooding, hurricanes, tornadoes). Trauma can occur at any age or developmental stage, and often, events that occur outside expected life stages are perceived as traumatic (e.g., a child dying before a parent, cancer as a teen, personal illness, job loss before retirement).

It is not just the event itself that determines whether something is traumatic, but also the individual's experience of the event. Two people may be exposed to the same event or series of events but experience and interpret these events in vastly different ways. Various biopsychosocial and cultural factors influence an individual's immediate response and long-term reactions to trauma. For most, regardless of the severity of the trauma, the immediate or enduring effects of trauma are met with resilience-the ability to rise above the circumstances or to meet the challenges with fortitude.

For some people, reactions to a traumatic event are temporary, whereas others have prolonged reactions that move from acute symptoms to more severe, prolonged, or enduring mental health consequences (e.g., posttraumatic stress and other anxiety disorders, substance use and mood disorders) and medical problems (e.g., arthritis, headaches, chronic pain). Others do not meet established criteria for posttraumatic stress or other mental disorders but encounter significant trauma-related symptoms or culturally expressed symptoms of trauma (e.g., somatization, in which psychological stress is expressed through physical concerns). For that reason, even if an individual does not meet diagnostic criteria for trauma-related disorders, it is important to recognize that trauma may still affect his or her life in significant ways. For more information on traumatic events, trauma characteristics, traumatic stress reactions, and factors that heighten or decrease the impact of trauma, see Part 1, Chapter 2, "Trauma Awareness," and Part 1, Chapter 3, "Understanding the Impact of Trauma."

Trauma Matters in Behavioral Health Services

The past decade has seen an increased focus on the ways in which trauma, psychological distress, quality of life, health, mental illness, and substance abuse are linked. With the attacks of September 11, 2001, and other acts of terror, the wars in Iraq and Afghanistan, disastrous hurricanes on the Gulf Coast, and sexual abuse scandals, trauma has moved to the forefront of national consciousness.

Trauma was once considered an abnormal experience. However, the first National Comorbidity Study established how prevalent traumas were in the lives of the general population of the United States. In the study, 61 percent of men and 51 percent of women reported experiencing at least one trauma in their lifetime, with witnessing a trauma, being involved in a natural disaster, and/or experiencing a life-threatening accident ranking as the most common events ( Kessler et al., 1999). In Wave 2 of the National Epidemiologic Survey on Alcohol and Related Conditions, 71.6 percent of the sample reported witnessing trauma, 30.7 percent experienced a trauma that resulted in injury, and 17.3 percent experienced psychological trauma ( El-Gabalawy, 2012). For a thorough review of the impact of trauma on quality of life and health and among individuals with mental and substance use disorders, refer to Part 3 of this TIP, the online literature review.

Rationale for TIC

Integrating TIC into behavioral health services provides many benefits not only for clients, but also for their families and communities, for behavioral health service organizations, and for staff. Trauma-informed services bring to the forefront the belief that trauma can pervasively affect an individual's well-being, including physical and mental health. For behavioral health service providers, trauma-informed practice offers many opportunities. It reinforces the importance of acquiring trauma-specific knowledge and skills to meet the specific needs of clients; of recognizing that individuals may be affected by trauma regardless of its acknowledgment; of understanding that trauma likely affects many clients who are seeking behavioral health services; and of acknowledging that organizations and providers can retraumatize clients through standard or unexamined policies and practices. TIC stresses the importance of addressing the client individually rather than applying general treatment approaches.

TIC provides clients more opportunities to engage in services that reflect a compassionate perspective of their presenting problems. TIC can potentially provide a greater sense of safety for clients who have histories of trauma and a platform for preventing more serious consequences of traumatic stress ( Fallot & Harris, 2001). Although many individuals may not identify the need to connect with their histories, trauma-informed services offer clients a chance to explore the impact of trauma, their strengths and creative adaptations in managing traumatic histories, their resilience, and the relationships among trauma, substance use, and psychological symptoms.

Two Influential Studies That Set the Stage for the Development of TIC

The Adverse Childhood Experiences Study ( Centers for Disease Control and Prevention, 2013) was a large epidemiological study involving more than 17,000 individuals from United States; it analyzed the long-term effects of childhood and adolescent traumatic experiences on adult health risks, mental health, healthcare costs, and life expectancy.

The Women, Co-Occurring Disorders and Violence Study ( SAMHSA, 2007) was a large multisite study focused on the role of interpersonal and other traumatic stressors among women; the interrelatedness of trauma, violence, and co-occurring substance use and mental disorders; and the incorporation of trauma-informed and trauma-specific principles, models, and services.

Implementing trauma-informed services can improve screening and assessment processes, treatment planning, and placement while also decreasing the risk for retraumatization. The implementation may enhance communication between the client and treatment provider, thus decreasing risks associated with misunderstanding the client's reactions and presenting problems or underestimating the need for appropriate referrals for evaluation or trauma-specific treatment. Organizational investment in developing or improving trauma-informed services may also translate to cost effectiveness, in that services are more appropriately matched to clients from the outset. TIC is an essential ingredient in organizational risk management; it ensures the implementation of decisions that will optimize therapeutic outcomes and minimize adverse effects on the client and, ultimately, the organization. A key principle is the engagement of community, clients, and staff. Clients and staff are more apt to be empowered, invested, and satisfied if they are involved in the ongoing development and delivery of trauma-informed services.

An organization also benefits from work development practices through planning for, attracting, and retaining a diverse workforce of individuals who are knowledgeable about trauma and its impact. Developing a trauma-informed organization involves hiring and promotional practices that attract and retain individuals who are educated and trained in trauma-informed practices on all levels of the organization, including board as well as peer support appointments. Trauma-informed organizations are invested in their staff and adopt similar trauma-informed principles, including establishing and providing ongoing support to promote TIC in practice and in addressing secondary trauma and implementing processes that reinforce the safety of the staff. Even though investing in a trauma-informed workforce does not necessarily guarantee trauma-informed practices, it is more likely that services will evolve more proficiently to meet client, staff, and community needs.

Advice to Counselors: The Importance of TIC

The history of trauma raises various clinical issues. Many counselors do not have extensive training in treating trauma or offering trauma-informed services and may be uncertain of how to respond to clients' trauma-related reactions or symptoms. Some counselors have experienced traumas themselves that may be triggered by clients' reports of trauma. Others are interested in helping clients with trauma but may unwittingly cause harm by moving too deeply or quickly into trauma material or by discounting or disregarding a client's report of trauma. Counselors must be aware of trauma-related symptoms and disorders and how they affect clients in behavioral health treatment.

Counselors with primary treatment responsibilities should also have an understanding of how to recognize trauma-related reactions, how to incorporate treatment interventions for trauma-related symptoms into clients' treatment plans, how to help clients build a safety net to prevent further trauma, how to conduct psychoeducational interventions, and when to make treatment referrals for further evaluations or trauma-specific treatment services. All treatment staff should recognize that traumatic stress symptoms or trauma-related disorders should not preclude an individual from mental health or substance abuse treatment and that all co-occurring disorders need to be addressed on some level in the treatment plan and setting. For example, helping a client in substance abuse treatment gain control over trauma-related symptoms can greatly improve the client's chances of substance abuse recovery and lower the possibility of relapse ( Farley, Golding, Young, Mulligan, & Minkoff, 2004; Ouimette, Ahrens, Moos, & Finney, 1998). In addition, assisting a client in achieving abstinence builds a platform upon which recovery from traumatic stress can proceed.

Trauma and Substance Use Disorders

Many people who have substance use disorders have experienced trauma as children or adults ( Koenen, Stellman, Sommer, & Stellman, 2008; Ompad et al., 2005). Substance abuse is known to predispose people to higher rates of traumas, such as dangerous situations and accidents, while under the influence ( Stewart & Conrod, 2003; Zinzow, Resnick, Amstadter, McCauley, Ruggiero, & Kilpatrick, 2010) and as a result of the lifestyle associated with substance abuse ( Reynolds et al., 2005). In addition, people who abuse substances and have experienced trauma have worse treatment outcomes than those without histories of trauma ( Driessen et al., 2008; Najavits et al., 2007). Thus, the process of recovery is more difficult, and the counselor's role is more challenging, when clients have histories of trauma. A person presenting with both trauma and substance abuse issues can have a variety of other difficult life problems that commonly accompany these disorders, such as other psychological symptoms or mental disorders, poverty, homelessness, increased risk of HIV and other infections, and lack of social support ( Mills, Teesson, Ross, & Peters, 2006; Najavits, Weiss, & Shaw, 1997). Many individuals who seek treatment for substance use disorders have histories of one or more traumas. More than half of women seeking substance abuse treatment report one or more lifetime traumas ( Farley, Golding, Young, Mulligan, & Minkoff, 2004; Najavits et al., 1997), and a significant number of clients in inpatient treatment also have subclinical traumatic stress symptoms or posttraumatic stress disorder (PTSD; Falck, Wang, Siegal, & Carlson, 2004; Grant et al., 2004; Reynolds et al., 2005).

Trauma and Mental Disorders

People who are receiving treatment for severe mental disorders are more likely to have histories of trauma, including childhood physical and sexual abuse, serious accidents, homelessness, involuntary psychiatric hospitalizations, drug overdoses, interpersonal violence, and other forms of violence. Many clients with severe mental disorders meet criteria for PTSD; others with serious mental illness who have histories of trauma present with psychological symptoms or mental disorders that are commonly associated with a history of trauma, including anxiety symptoms and disorders, mood disorders (e.g., major depression, dysthymia, bipolar disorder; Mueser et al., 2004), impulse control disorders, and substance use disorders ( Kessler, Chiu, Demler, & Walters, 2005).

Traumatic stress increases the risk for mental illness, and findings suggest that traumatic stress increases the symptom severity of mental illness ( Spitzer, Vogel, Barnow, Freyberger & Grabe, 2007). These findings propose that traumatic stress plays a significant role in perpetuating and exacerbating mental illness and suggest that trauma often precedes the development of mental disorders. As with trauma and substance use disorders, there is a bidirectional relationship; mental illness increases the risk of experiencing trauma, and trauma increases the risk of developing psychological symptoms and mental disorders. For a more comprehensive review of the interactions among traumatic stress, mental illness, and substance use disorders, refer to Part 3 of this TIP, the online literature review.

Trauma-Informed Intervention and Treatment Principles

TIC is an intervention and organizational approach that focuses on how trauma may affect an individual's life and his or her response to behavioral health services from prevention through treatment. There are many definitions of TIC and various models for incorporating it across organizations, but a "trauma-informed approach incorporates three key elements: (1) realizing the prevalence of trauma; (2) recognizing how trauma affects all individuals involved with the program, organization, or system, including its own workforce; and (3) responding by putting this knowledge into practice"( SAMHSA, 2012, p. 4).

TIC begins with the first contact a person has with an agency; it requires all staff members (e.g., receptionists, intake personnel, direct care staff, supervisors, administrators, peer supports, board members) to recognize that the individual's experience of trauma can greatly influence his or her receptivity to and engagement with services, interactions with staff and clients, and responsiveness to program guidelines, practices, and interventions. TIC includes program policies, procedures, and practices to protect the vulnerabilities of those who have experienced trauma and those who provide trauma-related services. TIC is created through a supportive environment and by redesigning organizational practices, with consumer participation, to prevent practices that could be retraumatizing ( Harris & Fallot, 2001c; Hopper et al., 2010). The ethical principle, "first, do no harm," resonates strongly in the application of TIC.

"A program, organization, or system that is trauma-informed realizes the widespread impact of trauma and understands potential paths for healing; recognizes the signs and symptoms of trauma in staff, clients, and others involved with the system; and responds by fully integrating knowledge about trauma into policies, procedures, practices, and settings."

( SAMHSA, 2012, p. 4)

TIC involves a commitment to building competence among staff and establishing programmatic standards and clinical guidelines that support the delivery of trauma-sensitive services. It encompasses recruiting, hiring, and retaining competent staff; involving consumers, trauma survivors, and peer support specialists in the planning, implementation, and evaluation of trauma-informed services; developing collaborations across service systems to streamline referral processes, thereby securing trauma-specific services when appropriate; and building a continuity of TIC as consumers move from one system or service to the next. TIC involves reevaluating each service delivery component through a trauma-aware lens.

The principles described in the following subsections serve as the TIP's conceptual framework. These principles comprise a compilation of resources, including research, theoretical papers, commentaries, and lessons learned from treatment facilities. Key elements are outlined for each principle in providing services to clients affected by trauma and to populations most likely to incur trauma. Although these principles are useful across all prevention and intervention services, settings, and populations, they are of the utmost importance in working with people who have had traumatic experiences.

Advice to Counselors: Implementing Trauma-Informed Services

Recognizing that trauma affects a majority of clients served within public health systems, the National Center for Trauma-Informed Care (NCTIC) has sought to establish a comprehensive framework to guide systems of care in the development of trauma-informed services. If a system or program is to support the needs of trauma survivors, it must take a systematic approach that offers trauma-specific diagnostic and treatment services, as well as a trauma-informed environment that is able to sustain such services, while fostering positive outcomes for the clients it serves. NCTIC also offers technical assistance in the implementation of trauma-informed services. For specific administrative information on TIC implementation, refer to Part 2, Chapters 1 and 2, of this TIP.

Promote Trauma Awareness and Understanding

Foremost, a behavioral health service provider must recognize the prevalence of trauma and its possible role in an individual's emotional, behavioral, cognitive, spiritual, and/or physical development, presentation, and well-being. Being vigilant about the prevalence and potential consequences of traumatic events among clients allows counselors to tailor their presentation styles, theoretical approaches, and intervention strategies from the outset to plan for and be responsive to clients' specific needs. Although not every client has a history of trauma, those who have substance use and mental disorders are more likely to have experienced trauma. Being trauma aware does not mean that you must assume everyone has a history of trauma, but rather that you anticipate the possibility from your initial contact and interactions, intake processes, and screening and assessment procedures.

Even the most standard behavioral health practices can retraumatize an individual exposed to prior traumatic experiences if the provider implements them without recognizing or considering that they may do harm. For example, a counselor might develop a treatment plan recommending that a female client-who has been court mandated to substance abuse treatment and was raped as an adult-attend group therapy, but without considering the implications, for her, of the fact that the only available group at the facility is all male and has had a low historical rate of female participation. Trauma awareness is an essential strategy for preventing this type of retraumatization; it reinforces the need for providers to reevaluate their usual practices.

Becoming trauma aware does not stop with the recognition that trauma can affect clients; instead, it encompasses a broader awareness that traumatic experiences as well as the impact of an individual's trauma can extend to significant others, family members, first responders and other medical professionals, behavioral health workers, broader social networks, and even entire communities. Family members frequently experience the traumatic stress reactions of the individual family member who was traumatized (e.g., angry outbursts, nightmares, avoidant behavior, other symptoms of anxiety, overreactions or under reactions to stressful events). These repetitive experiences can increase the risk of secondary trauma and symptoms of mental illness among the family, heighten the risk for externalizing and internalizing behavior among children (e.g., bullying others, problems in social relationships, health-damaging behaviors), increase children's risk for developing posttraumatic stress later in life, and lead to a greater propensity for traumatic stress reactions across generations of the family. Hence, prevention and intervention services can provide education and age-appropriate programming tailored to develop coping skills and support systems.

So too, behavioral health service providers can be influenced by exposure to trauma-related affect and content when working with clients. A trauma-aware workplace supports supervision and program practices that educate all direct service staff members on secondary trauma, encourages the processing of trauma-related content through participation in peer-supported activities and clinical supervision, and provides them with professional development opportunities to learn about and engage in effective coping strategies that help prevent secondary trauma or trauma-related symptoms. It is important to generate trauma awareness in agencies through education across services and among all staff members who have any direct or indirect contact with clients (including receptionists or intake and admission personnel who engage clients for the first time within the agency). Agencies can maintain a trauma-aware environment through ongoing staff training, continued supervisory and administrative support, collaborative (i.e., involving consumer participation) trauma-responsive program design and implementation, and organizational policies and practices that reflect accommodation and flexibility in attending to the needs of clients affected by trauma.

Recognize That Trauma-Related Symptoms and Behaviors Originate From Adapting to Traumatic Experiences

A trauma-informed perspective views trauma-related symptoms and behaviors as an individual's best and most resilient attempt to manage, cope with, and rise above his or her experience of trauma. Some individuals' means of adapting and coping have produced little difficulty; the coping and adaptive strategies of others have worked in the past but are not working as well now. Some people have difficulties in one area of life but have effectively negotiated and functioned in other areas.

Individuals who have survived trauma vary widely in how they experience and express traumatic stress reactions. Traumatic stress reactions vary in severity; they are often measured by the level of impairment or distress that clients report and are determined by the multiple factors that characterize the trauma itself, individual history and characteristics, developmental factors, sociocultural attributes, and available resources. The characteristics of the trauma and the subsequent traumatic stress reactions can dramatically influence how individuals respond to the environment, relationships, interventions, and treatment services, and those same characteristics can also shape the assumptions that clients/consumers make about their world (e.g., their view of others, sense of safety), their future (e.g., hopefulness, fear of a foreshortened future), and themselves (e.g., feeling resilient, feeling incompetent in regulating emotions). The breadth of these effects may be observable or subtle.

Once you become aware of the significance of traumatic experiences in clients' lives and begin to view their presentation as adaptive, your identification and classification of their presenting symptoms and behaviors can shift from a "pathology" mindset (i.e., defining clients strictly from a diagnostic label, implying that something is wrong with them) to one of resilience-a mindset that views clients' presenting difficulties, behaviors, and emotions as responses to surviving trauma. In essence, you will come to view traumatic stress reactions as normal reactions to abnormal situations. In embracing the belief that trauma-related reactions are adaptive, you can begin relationships with clients from a hopeful, strengths-based stance that builds upon the belief that their responses to traumatic experiences reflect creativity, self-preservation, and determination.

This will help build mutual and collaborative therapeutic relationships, help clients identify what has worked and has not worked in their attempts to deal with the aftermath of trauma from a nonjudgmental stance, and develop intervention and coping strategies that are more likely to fit their strengths and resources. This view of trauma prevents further retraumatization by not defining traumatic stress reactions as pathological or as symptoms of pathology.

View Trauma in the Context of Individuals' Environments

Many factors contribute to a person's response to trauma, whether it is an individual, group, or community-based trauma. Individual attributes, developmental factors (including protective and risk factors), life history, type of trauma, specific characteristics of the trauma, amount and length of trauma exposure, cultural meaning of traumatic events, number of losses associated with the trauma, available resources (internal and external, such as coping skills and family support), and community reactions are a few of the determinants that influence a person's responses to trauma across time. Refer to the " View Trauma Through a Sociocultural Lens " section later in this chapter for more specific information highlighting the importance of culture in understanding and treating the effects of trauma.

Trauma cannot be viewed narrowly; instead, it needs to be seen through a broader lens-a contextual lens integrating biopsychosocial, interpersonal, community, and societal (the degree of individualistic or collective cultural values) characteristics that are evident preceding and during the trauma, in the immediate and sustained response to the event(s), and in the short- and long-term effects of the traumatic event(s), which may include housing availability, community response, adherence to or maintenance of family routines and structure, and level of family support.

To more adequately understand trauma, you must also consider the contexts in which it occurred. Understanding trauma from this angle helps expand the focus beyond individual characteristics and effects to a broader systemic perspective that acknowledges the influences of social interactions, communities, governments, cultures, and so forth, while also examining the possible interactions among those various influences. Bronfenbrenner's (1979) and Bronfenbrenner and Ceci's (1994) work on ecological models sparked the development of other contextual models. In recent years, the social-ecological framework has been adopted in understanding trauma, in implementing health promotion and other prevention strategies, and in developing treatment interventions ( Centers for Disease Control and Prevention, 2009). Here are the three main beliefs of a social-ecological approach ( Stokols, 1996):

Environmental factors greatly influence emotional, physical, and social well-being.

A fundamental determinant of health versus illness is the degree of fit between individuals' biological, behavioral, and sociocultural needs and the resources available to them.

Prevention, intervention, and treatment approaches integrate a combination of strategies targeting individual, interpersonal, and community systems.

This TIP uses a social-ecological model to explore trauma and its effects ( Exhibit 1.1-2). The focus of this model is not only on negative attributes (risk factors) across each level, but also on positive ingredients (protective factors) that protect against or lessen the impact of trauma. This model also guides the inclusion of certain targeted interventions in this text, including selective and indicated prevention activities. In addition, culture, developmental processes (including the developmental stage or characteristics of the individual and/or community), and the specific era when the trauma(s) occurred can significantly influence how a trauma is perceived and processed, how an individual or community engages in help-seeking, and the degree of accessibility, acceptability, and availability of individual and community resources.

Depending on the developmental stage and/or processes in play, children, adolescents, and adults will perceive, interpret, and cope with traumatic experiences differently. For example, a child may view a news story depicting a traumatic event on television and believe that the trauma is recurring every time they see the scene replayed. Similarly, the era in which one lives and the timing of the trauma can greatly influence an individual or community response. Take, for example, a pregnant woman who is abusing drugs and is wary of receiving medical treatment after being beaten in a domestic dispute. She may fear losing her children or being arrested for child neglect. Even though a number of States have adopted policies focused on the importance of treatment for pregnant women who are abusing drugs and of the accessibility of prenatal care, other States have approached this issue from a criminality standpoint (e.g., with child welfare and criminal laws) in the past few decades. Thus, the traumatic event's timing is a significant component in understanding the context of trauma and trauma-related responses.

The social-ecological model depicted in Exhibit 1.1-2 provides a systemic framework for looking at individuals, families, and communities affected by trauma in general; it highlights the bidirectional influence that multiple contexts can have on the provision of behavioral health services to people who have experienced trauma (see thin arrow). Each ring represents a different system (refer to Exhibit 1.1-3 for examples of specific factors within each system). The innermost ring represents the individual and his or her biopsychosocial characteristics. The "Interpersonal" circle embodies all immediate relationships including family, friends, peers, and others. The "Community/Organizational" band represents social support networks, workplaces, neighborhoods, and institutions that directly influence the individual and his/her relationships. The "Societal" circle signifies the largest system-State and Federal policies and laws, such as economic and healthcare policies, social norms, governmental systems, and political ideologies. The outermost ring, "Period of Time in History," reflects the significance of the period of time during which the event occurred; it influences each other level represented in the circle. For example, making a comparison of society's attitudes and responses to veterans' homecomings across different wars and conflicts through time shows that homecoming environments can have either a protective or a negative effect on healing from the psychological and physical wounds of war, depending on the era in question. The thicker arrows in the figure represent the key influences of culture, developmental characteristics, and the type and characteristics of the trauma. All told, the context of traumatic events can significantly influence both initial and sustained responses to trauma; treatment needs; selection of prevention, intervention, and other treatment strategies; and ways of providing hope and promoting recovery.

Case Illustration: Marisol

Marisol is a 28-year-old Latina woman working as a barista at a local coffee shop. One evening, she was driving home in the rain when a drunk driver crossed into her lane and hit her head on. Marisol remained conscious as she waited to be freed from the car and was then transported to the hospital. She sustained fractures to both legs. Her recovery involved two surgeries and nearly 6 months of rehabilitation, including initial hospitalization and outpatient physical therapy.

She described her friends and family as very supportive, saying that they often foresaw what she needed before she had to ask. She added that she had an incredible sense of gratitude for her employer and coworkers, who had taken turns visiting and driving her to appointments. Although she was able to return to work after 9 months, Marisol continued experiencing considerable distress about her inability to sleep well, which started just after the accident. Marisol describes repetitive dreams and memories of waiting to be transported to the hospital after the crash. The other driver was charged with driving under the influence (DUI), and it was reported that he had been convicted two other times for a DUI misdemeanor.

Answering the following questions will help you see how the different levels of influence affect the impact and outcome of the traumatic event Marisol experienced, as well as her responses to that event:

1. Based on the limited information provided in this illustration, how might Marisol's personality affect the responses of her family and friends, her coworkers, and the larger community?

2. In what ways could Marisol's ethnic and cultural background influence her recovery?

3. What societal factors could play a role in the car crash itself and the outcomes for Marisol and the other driver?

Explore the influence of the period of time in history during which the scenario occurs-compare the possible outcomes for both Marisol and the other driver if the crash occurred 40 years ago versus in the present day.

Minimize the Risk of Retraumatization or Replicating Prior Trauma Dynamics

Trauma-informed treatment providers acknowledge that clients who have histories of trauma may be more likely to experience particular treatment procedures and practices as negative, reminiscent of specific characteristics of past trauma or abuse, or retraumatizing-feeling as if the past trauma is reoccurring or as if the treatment experience is as dangerous and unsafe as past traumas. For instance, clients may express feelings of powerlessness or being trapped if they are not actively involved in treatment decisions; if treatment processes or providers mirror specific behavior from the clients' past experiences with trauma, they may voice distress or respond in the same way as they did to the original trauma. Among the potentially retraumatizing elements of treatment are seclusion or "time-out" practices that isolate individuals, mislabeling client symptoms as personality or other mental disorders rather than as traumatic stress reactions, interactions that command authority, treatment assignments that could humiliate clients (such as asking a client to wear a sign in group that reflects one of their treatment issues, even if the assignment centers on positive attributes of the client), confronting clients as resistant, or presenting treatment as conditional upon conformity to the provider's beliefs and definitions of issues.

Clients' experiences are unique to the specific traumas they have faced and the surrounding circumstances before, during, and after that trauma, so remember that even seemingly safe and standard treatment policies and procedures, including physical plant operations (e.g., maintenance, grounds, fire and safety procedures), may feel quite the contrary for a client if one or more of those elements is reminiscent of his or her experience of trauma in some way. Examples include having limited privacy or personal space, being interviewed in a room that feels too isolating or confining, undergoing physical examination by a medical professional of the same sex as the client's previous perpetrator of abuse, attending a group session in which another client expresses anger appropriately in a role play, or being directed not to talk about distressing experiences as a means of deescalating traumatic stress reactions.

Although some treatment policies or procedures are more obviously likely to solicit distress than others, all standard practices should be evaluated for their potential to retraumatize a client; this cannot be done without knowing the specific features of the individual's history of trauma. Consider, for instance, a treatment program that serves meals including entrees that combine more than one food group. Your client enters this program and refuses to eat most of the time; he expresses anger toward dietary staff and claims that food choices are limited. You may initially perceive your client's refusal to eat or to avoid certain foods as an eating disorder or a behavioral problem. However, a trauma-aware perspective might change your assumptions; consider that this client experienced neglect and abuse surrounding food throughout childhood (his mother forced him to eat meals prepared by combining anything in the refrigerator and cooking them together).

Advice to Counselors and Administrators: Sending the Right Message About Trauma

How often have you heard "We aren't equipped to handle trauma" or "We don't have time to deal with reactions that surface if traumatic experiences are discussed in treatment" from counselors and administrators in behavioral health services? For agencies, staff members, and clients, these statements present many difficulties and unwanted outcomes. For a client, such comments may replicate his or her earlier encounters with others (including family, friends, and previous behavioral health professionals) who had difficulty acknowledging or talking about traumatic experiences with him or her. A hands-off approach to trauma can also reinforce the client's own desire to avoid such discussions. Even when agencies and staff are motivated in these sentiments by a good intention-to contain clients' feelings of being overwhelmed-such a perspective sends strong messages to clients that their experiences are not important, that they are not capable of handling their trauma-associated feelings, and that dealing with traumatic experiences is simply too dangerous. Statements like these imply that recovery is not possible and provide no structured outlet to address memories of trauma or traumatic stress reactions.

Nevertheless, determining how and when to address traumatic stress in behavioral health services can be a real dilemma, especially if there are no trauma-specific philosophical, programmatic, or procedural processes in place. For example, it is difficult to provide an appropriate forum for a client to address past traumas if no forethought has been given to developing interagency and intra-agency collaborations for trauma-specific services. By anticipating the need for trauma-informed services and planning ahead to provide appropriate services to people who are affected by trauma, behavioral health service providers and program administrators can begin to develop informed intervention strategies that send a powerful, positive message:

Both clients and providers can competently manage traumatic experiences and reactions.

Providers are interested in hearing clients' stories and attending to their experiences.

As a treatment provider, you cannot consistently predict what may or may not be upsetting or retraumatizing to clients. Therefore, it is important to maintain vigilance and an attitude of curiosity with clients, inquiring about the concerns that they express and/or present in treatment. Remember that certain behaviors or emotional expressions can reflect what has happened to them in the past.

Foremost, a trauma-informed approach begins with taking practical steps to reexamine treatment strategies, program procedures, and organizational polices that could solicit distress or mirror common characteristics of traumatic experiences (loss of control, being trapped, or feeling disempowered). To better anticipate the interplay between various treatment elements and the more idiosyncratic aspects of a particular client's trauma history, you can:

Work with the client to learn the cues he or she associates with past trauma.

Maintain a supportive, empathetic, and collaborative relationship.

Encourage ongoing dialog.

Provide a clear message of availability and accessibility throughout treatment.

In sum, trauma-informed providers anticipate and respond to potential practices that may be perceived or experienced as retraumatizing to clients; they are able to forge new ways to respond to specific situations that trigger a trauma-related response, and they can provide clients with alternative ways of engaging in a particularly problematic element of treatment.

Create a Safe Environment

The need to create a safe environment is not new to providers; it involves an agency-wide effort supported by effective policies and procedures. However, creating safety within a trauma-informed framework far exceeds the standard expectations of physical plant safety (e.g., facility, environmental, and space-related concerns), security (of staff members, clients, and personal property), policies and procedures (including those specific to seclusion and restraint), emergency management and disaster planning, and adherence to client rights. Providers must be responsive and adapt the environment to establish and support clients' sense of physical and emotional safety.

Beyond anticipating that various environmental stimuli within a program may generate strong emotions and reactions in a trauma survivor (e.g., triggers such as lighting, access to exits, seating arrangements, emotionality within a group, or visual or auditory stimuli) and implementing strategies to help clients cope with triggers that evoke their experiences with trauma, other key elements in establishing a safe environment include consistency in client interactions and treatment processes, following through with what has been reviewed or agreed upon in sessions or meetings, and dependability. Mike's case illustration depicts ways in which the absence of these key elements could erode a client's sense of safety during the treatment process.

Neither providers nor service processes are always perfect. Sometimes, providers unintentionally relay information inaccurately or inconsistently to clients or other staff members; other times, clients mishear something, or extenuating circumstances prevent providers from responding as promised. Creating safety is not about getting it right all the time; it's about how consistently and forthrightly you handle situations with a client when circumstances provoke feelings of being vulnerable or unsafe. Honest and compassionate communication that conveys a sense of handling the situation together generates safety. It is equally important that safety extends beyond the client. Counselors and other behavioral health staff members, including peer support specialists, need to be able to count on the agency to be responsive to and maintain their safety within the environment as well. By incorporating an organizational ethos that recognizes the importance of practices that promote physical safety and emotional well-being, behavioral health staff members may be more likely to seek support and supervision when needed and to comply with clinical and programmatic practices that minimize risks for themselves and their clients.

Case Illustration: Mike

From the first time you provide outpatient counseling to Mike, you explain that he can call an agency number that will put him in direct contact with someone who can provide further assistance or support if he has emotional difficulty after the session or after agency hours. However, when he attempts to call one night, no one is available despite what you've described. Instead, Mike is directed by an operator to either use his local emergency room if he perceives his situation to be a crisis or to wait for someone on call to contact him. The inconsistency between what you told him in the session and what actually happens when he calls makes Mike feel unsafe and vulnerable.

Beyond an attitudinal promotion of safety, organizational leaders need to consider and create avenues of professional development and assistance that will give their staff the means to seek support and process distressing circumstances or events that occur within the agency or among their clientele, such as case consultation and supervision, formal or informal processes to debrief service providers about difficult clinical issues, and referral processes for client psychological evaluations and employee assistance for staff. Organizational practices are only effective if supported by unswerving trauma awareness, training, and education among staff. Jane's case illustration shows the impact of a minor but necessary postponement in staff orientation for a new hire-not an unusual circumstance in behavioral health programs that have heavy caseloads and high staff turnover.

Identify Recovery From Trauma as a Primary Goal

Often, people who initiate or are receiving mental health or substance abuse services don't identify their experiences with trauma as a significant factor in their current challenges or problems. In part, this is because people who have been exposed to trauma, whether once or repeatedly, are generally reluctant to revisit it. They may already feel stuck in repetitive memories or experiences, which may add to their existing belief that any intervention will make matters worse or, at least, no better. For some clients, any introduction to their trauma-related memories or minor cues reminiscent of the trauma will cause them to experience strong, quick-to-surface emotions, supporting their belief that addressing trauma is dangerous and that they won't be able to handle the emotions or thoughts that result from attempting to do so. Others readily view their experiences of trauma as being in the past; as a result, they engage in distraction, dissociation, and/or avoidance (as well as adaptation) due to a belief that trauma has little impact on their current lives and presenting problems. Even individuals who are quite aware of the impact that trauma has had on their lives may still struggle to translate or connect how these events continue to shape their choices, behaviors, and emotions. Many survivors draw no connection between trauma and their mental health or substance abuse problems, which makes it more difficult for them to see the value of trauma-informed or trauma-specific interventions, such as creating safety, engaging in psychoeducation, enhancing coping skills, and so forth.

Case Illustration: Jane

Jane, a newly hired female counselor, had a nephew who took his own life. The program that hired her was short of workers at the time; therefore, Jane did not have an opportunity to engage sufficiently in orientation outside of reviewing the policies and procedure manual. In an attempt to present well to her new employer and supervisor, she readily accepted client assignments without considering her recent loss. By not immersing herself in the program's perspective and policies on staff well-being, ethical and clinical considerations in client assignments, and how and when to seek supervision, Jane failed to engage in the practices, heavily supported by the agency, that promoted safety for herself and her clients. Subsequently, she felt emotionally overwhelmed at work and would often abruptly request psychiatric evaluation for clients who expressed any feelings of hopelessness out of sheer panic that they would attempt suicide.

As a trauma-informed provider, it is important that you help clients bridge the gap between their mental health and substance-related issues and the traumatic experiences they may have had. All too often, trauma occurs before substance use and mental disorders develop; then, such disorders and their associated symptoms and consequences create opportunities for additional traumatic events to occur. If individuals engage in mental health and substance abuse treatment without addressing the role that trauma has played in their lives, they are less likely to experience recovery in the long run. For example, a person with a history of trauma is more likely to have anxiety and depressive symptoms, use substances to self-medicate, and/or relapse after exposure to trauma-related cues. Thus, collaboration within and between behavioral health agencies is necessary to make integrated, timely, trauma-specific interventions available from the beginning to clients/consumers who engage in substance abuse and mental health services.

Support Control, Choice, and Autonomy

Not every client who has experienced trauma and is engaged in behavioral health services wants, or sees the need for, trauma-informed or trauma-specific treatment. Clients may think that they've already dealt with their trauma adequately, or they may believe that the effects of past trauma cause minimal distress for them. Other clients may voice the same sentiments, but without conviction-instead using avoidant behavior to deter distressing symptoms or reactions. Still others may struggle to see the role of trauma in their presenting challenges, not connecting their past traumatic experiences with other, more current difficulties (e.g., using substances to self-medicate strong emotions). Simply the idea of acknowledging trauma-related experiences and/or stress reactions may be too frightening or overwhelming for some clients, and others may fear that their reactions will be dismissed. On the other hand, some individuals want so much to dispense with their traumatic experiences and reactions that they hurriedly and repeatedly disclose their experiences before establishing a sufficiently safe environment or learning effective coping strategies to offset distress and other effects of retraumatization.

As these examples show, not everyone affected by trauma will approach trauma-informed services or recognize the impact of trauma in their lives in the same manner. This can be challenging to behavioral health service providers who are knowledgeable about the impact of trauma and who perceive the importance of addressing trauma and its effects with clients. As with knowing that different clients may be at different levels of awareness or stages of change in substance abuse treatment services, you should acknowledge that people affected by trauma present an array of reactions, various levels of trauma awareness, and different degrees of urgency in their need to address trauma.

Appreciating clients' perception of their presenting problems and viewing their responses to the impact of trauma as adaptive-even when you believe their methods of dealing with trauma to be detrimental-are equally important elements of TIC. By taking the time to engage with clients and understand the ways they have perceived, adjusted to, and responded to traumatic experiences, providers are more likely to project the message that clients possess valuable personal expertise and knowledge about their own presenting problems. This shifts the viewpoint from "Providers know best" to the more collaborative "Together, we can find solutions."

How often have you heard from clients that they don't believe they can handle symptoms that emerge from reexperiencing traumatic cues or memories? Have you ever heard clients state that they can't trust themselves or their reactions, or that they never know when they are going to be triggered or how they are going to react? How confident would you feel about yourself if, at any time, a loud noise could initiate an immediate attempt to hide, duck, or dive behind something? Traumatic experiences have traditionally been described as exposure to events that cause intense fear, helplessness, horror, or feelings of loss of control. Participation in behavioral health services should not mirror these aspects of traumatic experience. Working collaboratively to facilitate clients' sense of control and to maximize clients' autonomy and choices throughout the treatment process, including treatment planning, is crucial in trauma-informed services.

For some individuals, gaining a sense of control and empowerment, along with understanding traumatic stress reactions, may be pivotal ingredients for recovery. By creating opportunities for empowerment, counselors and other behavioral health service providers help reinforce, clients' sense of competence, which is often eroded by trauma and prolonged traumatic stress reactions. Keep in mind that treatment strategies and procedures that prioritize client choice and control need not focus solely on major life decisions or treatment planning; you can apply such approaches to common tasks and everyday interactions between staff and consumers. Try asking your clients some of the following questions (which are only a sample of the types of questions that could be useful):

What information would be helpful for us to know about what happened to you?

Where/when would you like us to call you?

How would you like to be addressed?

Of the services I've described, which seem to match your present concerns and needs?

From your experience, what responses from others appear to work best when you feel overwhelmed by your emotions?

Likewise, organizations need to reinforce the importance of staff autonomy, choice, and sense of control. What resources can staff members access, and what choices are available to them, in processing emotionally charged content or events in treatment? How often do administrators and supervisors seek out feedback on how to handle problematic situations (e.g., staff rotations for vacations, case consultations, changes in scheduling)? Think about the parallel between administration and staff members versus staff members and clients; often, the same philosophy, attitudes, and behaviors conveyed to staff members by administrative practices are mirrored in staff-client interactions. Simply stated, if staff members do not feel empowered, it will be a challenge for them to value the need for client empowerment. (For more information on administrative and workforce development issues, refer to Part 2, Chapters 1 and 2.)

Case Illustration: Mina

Mina initially sought counseling after her husband was admitted to an intensive outpatient drug and alcohol program. She was self-referred for low-grade depression, resentment toward her spouse, and codependency. When asked to define "codependency" and how the term applied to her, she responded that she always felt guilty and responsible for everyone in her family and for events that occurred even when she had little or no control over them.

After the intake and screening process, she expressed interest in attending group sessions that focused primarily on family issues and substance abuse, wherein her presenting concerns could be explored. In addition to describing dynamics and issues relating to substance abuse and its impact on her marriage, she referred to her low mood as frozen grief. During treatment, she reluctantly began to talk about an event that she described as life changing: the loss of her father. The story began to unfold in group; her father, who had been 62 years old, was driving her to visit a cousin. During the ride, he had a heart attack and drove off the road. As the car came to stop in a field, she remembered calling 911 and beginning cardiopulmonary resuscitation while waiting for the ambulance. She rode with the paramedics to the hospital, watching them work to save her father's life; however, he was pronounced dead soon after arrival.

She always felt that she never really said goodbye to her father. In group, she was asked what she would need to do or say to feel as if she had revisited that opportunity. She responded in quite a unique way, saying, "I can't really answer this question; the lighting isn't right for me to talk about my dad." The counselor encouraged her to adjust the lighting so that it felt "right" to her. Being invited to do so turned out to be pivotal in her ability to address her loss and to say goodbye to her father on her terms. She spent nearly 10 minutes moving the dimmer switch for the lighting as others in the group patiently waited for her to return to her chair. She then began to talk about what happened during the evening of her father's death, their relationship, the events leading up to that evening, what she had wanted to say to him at the hospital, and the things that she had been wanting to share with him since his death.

Weeks later, as the group was coming to a close, each member spoke about the most important experiences, tools, and insights that he or she had taken from participating. Mina disclosed that the group helped her establish boundaries and coping strategies within her marriage, but said that the event that made the most difference for her had been having the ability to adjust the lighting in the room. She explained that this had allowed her to control something over which she had been powerless during her father's death. To her, the lighting had seemed to stand out more than other details at the scene of the accident, during the ambulance ride, and at the hospital. She felt that the personal experience of losing her father and needing to be with him in the emergency room was marred by the obtrusiveness of staff, procedures, machines, and especially, the harsh lighting. She reflected that she now saw the lighting as a representation of this tragic event and the lack of privacy she had experienced when trying to say goodbye to her father. Mina stated that this moment in group had been the greatest gift: "...to be able to say my goodbyes the way I wanted... I was given an opportunity to have some control over a tragic event where I couldn't control the outcome no matter how hard I tried."

Create Collaborative Relationships and Participation Opportunities

This trauma-informed principle encompasses three main tenets. First, ensure that the provider-client relationship is collaborative, regardless of setting or service. Agency staff members cannot make decisions pertaining to interventions or involvement in community services autocratically; instead, they should develop trauma-informed, individualized care plans and/or treatment plans collaboratively with the client and, when appropriate, with family and caregivers. The nonauthoritarian approach that characterizes TIC views clients as the experts in their own lives and current struggles, thereby emphasizing that clients and providers can learn from each other.

The second tenet is to build collaboration beyond the provider-client relationship. Building ongoing relationships across the service system, provider networks, and the local community enhances TIC continuity as clients move from one level of service to the next or when they are involved in multiple services at one time. It also allows you to learn about resources available to your clients in the service system or community and to connect with providers who have more advanced training in trauma-specific interventions and services.

The third tenet emphasizes the need to ensure client/consumer representation and participation in behavioral health program development, planning, and evaluation as well as in the professional development of behavioral health workers. To achieve trauma-informed competence in an organization or across systems, clients need to play an active role; this starts with providing program feedback. However, consumer involvement should not end there; rather, it should be encouraged throughout the implementation of trauma-informed services. So too, clients, potential clients, their families, and the community should be invited to participate in forming any behavioral health organization's plans to improve trauma-informed competence, provide TIC, and design relevant treatment services and organizational policies and procedures.

Trauma-informed principles and practices generated without the input of people affected by trauma are difficult to apply effectively. Likewise, staff trainings and presentations should include individuals who have felt the impact of trauma. Their participation reaches past the purely cognitive aspects of such education to offer a personal perspective on the strengths and resilience of people who have experienced trauma. The involvement of trauma survivors in behavioral health education lends a human face to subject matter that is all too easily made cerebral by some staff members in an attempt to avoid the emotionality of the topic.

Consumer participation also means giving clients/consumers the chance to obtain State training and certification, as well as employment in behavioral health settings as peer specialists. Programs that incorporate peer support services reinforce a powerful message-that provider-consumer partnership is important, and that consumers are valued. Peer support specialists are self-identified individuals who have progressed in their own recovery from alcohol dependence, drug addiction, and/or a mental disorder and work within behavioral health programs or at peer support centers to assist others with similar disorders and/or life experiences. Tasks and responsibilities may include leading a peer support group; modeling effective coping, help-seeking, and self-care strategies; helping clients practice new skills or monitor progress; promoting positive self-image to combat clients' potentially negative feelings about themselves and the discrimination they may perceive in the program or community; handling case management tasks; advocating for program changes; and representing a voice of hope that views recovery as possible.

Familiarize the Client With Trauma-Informed Services

Without thinking too much about it, you probably know the purpose of an intake process, the correct way to complete a screening device, the meaning of a lot of the jargon specific to behavioral health, and your program's expectations for client participation; in fact, maybe you're already involved in facilitating these processes in behavioral health services every day, and they've become almost automatic for you. This can make it easy to forget that nearly everything clients and their families encounter in seeking behavioral health assistance is new to them. Thus, introducing clients to program services, activities, and interventions in a manner that expects them to be unfamiliar with these processes is essential, regardless of their clinical and treatment history. Beyond addressing the unfamiliarity of services, educating clients about each process-from first contact all the way through recovery services-gives them a chance to participate actively and make informed decisions across the continuum of care.

Familiarizing clients with trauma-informed services extends beyond explaining program services or treatment processes; it involves explaining the value and type of trauma-related questions that may be asked during an intake process, educating clients about trauma to help normalize traumatic stress reactions, and discussing trauma-specific interventions and other available services (including explanations of treatment methodologies and of the rationale behind specific interventions). Developmentally appropriate psychoeducation about trauma-informed services allows clients to be informed participants.

Incorporate Universal Routine Screenings for Trauma

Screening universally for client histories, experiences, and symptoms of trauma at intake can benefit clients and providers. Most providers know that clients can be affected by trauma, but universal screening provides a steady reminder to be watchful for past traumatic experiences and their potential influence upon a client's interactions and engagement with services across the continuum of care. Screening should guide treatment planning; it alerts the staff to potential issues and serves as a valuable tool to increase clients' awareness of the possible impact of trauma and the importance of addressing related issues during treatment.

Nonetheless, screenings are only as useful as the guidelines and processes established to address positive screens (which occur when clients respond to screening questions in a way that signifies possible trauma-related symptoms or histories). Staff should be trained to use screening tools consistently so that all clients are screened in the same way. Staff members also need to know how to score screenings and when specific variables (e.g., race/ethnicity, native language, gender, culture) may influence screening results. For example, a woman who has been sexually assaulted by a man may be wary of responding to questions if a male staff member or interpreter administers the screening or provides translation services. Likewise, a person in a current abusive or violent relationship may not acknowledge the interpersonal violence in fear of retaliation or as a result of disconnection or denial of his or her experience, and he or she may have difficulty in processing and then living between two worlds-what is acknowledged in treatment versus what is experienced at home.

In addition, staff training on using trauma-related screening tools needs to center on how and when to gather relevant information after the screening is complete. Organizational policies and procedures should guide staff members on how to respond to a positive screening, such as by making a referral for an indepth assessment of traumatic stress, providing the client with an introductory psychoeducational session on the typical biopsychosocial effects of trauma, and/or coordinating care so that the client gains access to trauma-specific services that meet his or her needs. Screening tool selection is an important ingredient in incorporating routine, universal screening practices into behavioral health services. Many screening tools are available, yet they differ in format and in how they present questions. Select tools based not just on sound test properties, but also according to whether they encompass a broad range of experiences typically considered traumatic and are flexible enough to allow for an individual's own interpretation of traumatic events. For more information on screening and assessment of trauma and trauma-related symptoms and effects, see Chapter 4, "Screening and Assessment," in this TIP.

View Trauma Through a Sociocultural Lens

To understand how trauma affects an individual, family, or community, you must first understand life experiences and cultural background as key contextual elements for that trauma. As demonstrated in Exhibit 1.1-2, many factors shape traumatic experiences and individual and community responses to it; one of the most significant factors is culture. It influences the interpretation and meaning of traumatic events, individual beliefs regarding personal responsibility for the trauma and subsequent responses, and the meaning and acceptability of symptoms, support, and help-seeking behaviors. As this TIP proceeds to describe the differences among cultures pertaining to trauma, remember that there are numerous cross-cutting factors that can directly or indirectly influence the attitudes, beliefs, behaviors, resources, and opportunities within a given culture, subculture, or racial and/or ethnic group ( Exhibit 1.1-4). For an indepth exploration of these cross-cutting cultural factors, refer to the planned TIP, Improving Cultural Competence (SAMHSA, planned c).

Culture and Trauma

Some populations and cultures are more likely than others to experience a traumatic event or a specific type of trauma.

Rates of traumatic stress are high across all diverse populations and cultures that face military action and political violence.

Culture influences not only whether certain events are perceived as traumatic, but also how an individual interprets and assigns meaning to the trauma.

Some traumas may have greater impact on a given culture because those traumas represent something significant for that culture or disrupt cultural practices or ways of life.

Culture determines acceptable responses to trauma and shapes the expression of distress. It significantly influences how people convey traumatic stress through behavior, emotions, and thinking immediately following a trauma and well after the traumatic experience has ceased.

Traumatic stress symptoms vary according to the type of trauma within the culture.

Culture affects what qualifies as a legitimate health concern and which symptoms warrant help.

In addition to shaping beliefs about acceptable forms of help-seeking behavior and healing practices, culture can provide a source of strength, unique coping strategies, and specific resources.

When establishing TIC, it is vital that behavioral health systems, service providers, licensing agencies, and accrediting bodies build culturally responsive practices into their curricula, standards, policies and procedures, and credentialing processes. The implementation of culturally responsive practices will further guide the treatment planning process so that trauma-informed services are more appropriate and likely to succeed.

Use a Strengths-Focused Perspective: Promote Resilience

Fostering individual strengths is a key step in prevention when working with people who have been exposed to trauma. It is also an essential intervention strategy-one that builds on the individual's existing resources and views him or her as a resourceful, resilient survivor. Individuals who have experienced trauma develop many strategies and/or behaviors to adapt to its emotional, cognitive, spiritual, and physical consequences. Some behaviors may be effective across time, whereas others may eventually produce difficulties and disrupt the healing process. Traditionally, behavioral health services have tended to focus on presenting problems, risk factors, and symptoms in an attempt to prevent negative outcomes, provide relief, increase clients' level of functioning, and facilitate healing. However, focusing too much on these areas can undermine clients' sense of competence and hope. Targeting only presenting problems and symptoms does not provide individuals with an opportunity to see their own resourcefulness in managing very stressful and difficult experiences. It is important for providers to engage in interventions using a balanced approach that targets the strengths clients have developed to survive their experiences and to thrive in recovery. A strengths-based, resilience-minded approach lets trauma survivors begin to acknowledge and appreciate their fortitude and the behaviors that help them survive.

"Trauma-informed care recognizes symptoms as originating from adaptations to the traumatic event(s) or context. Validating resilience is important even when past coping behaviors are now causing problems. Understanding a symptom as an adaptation reduces a survivor's guilt and shame, increases their self-esteem and provides a guideline for developing new skills and resources to allow new and better adaptation to the current situation."

( Elliot et al., 2005, p. 467)

Advice to Counselors and Administrators: Using Strengths-Oriented Questions

Knowing a client's strengths can help you understand, redefine, and reframe the client's presenting problems and challenges. By focusing and building on an individual's strengths, counselors and other behavioral health professionals can shift the focus from "What is wrong with you?" to "What has worked for you?" It moves attention away from trauma-related problems and toward a perspective that honors and uses adaptive behaviors and strengths to move clients along in recovery.

Potential strengths-oriented questions include:

The history that you provided suggests that you've accomplished a great deal since the trauma. What are some of the accomplishments that give you the most pride?

What would you say are your strengths?

How do you manage your stress today?

What behaviors have helped you survive your traumatic experiences (during and afterward)?

What are some of the creative ways that you deal with painful feelings?

You have survived trauma. What characteristics have helped you manage these experiences and the challenges that they have created in your life?

If we were to ask someone in your life, who knew your history and experience with trauma, to name two positive characteristics that help you survive, what would they be?

What coping tools have you learned from your _____ (fill in: cultural history, spiritual practices, athletic pursuits, etc.)?

Imagine for a moment that a group of people are standing behind you showing you support in some way. Who would be standing there? It doesn't matter how briefly or when they showed up in your life, or whether or not they are currently in your life or alive.

How do you gain support today? (Possible answers include family, friends, activities, coaches, counselors, other supports, etc.)

What does recovery look like for you?

Foster Trauma-Resistant Skills

Trauma-informed services build a foundation on which individuals can begin to explore the role of trauma in their lives; such services can also help determine how best to address and tailor interventions to meet their needs. Prevention, mental health, and substance abuse treatment services should include teaching clients about how trauma can affect their lives; these services should also focus on developing self-care skills, coping strategies, supportive networks, and a sense of competence. Building trauma-resistant skills begins with normalizing the symptoms of traumatic stress and helping clients who have experienced trauma connect the dots between current problems and past trauma when appropriate.

Nevertheless, TIC and trauma-specific interventions that focus on skill-building should not do so at the expense of acknowledging individual strengths, creativity in adapting to trauma, and inherent attributes and tools clients possesses to combat the effects of trauma. Some theoretical models that use skill-building strategies base the value of this approach on a deficit perspective; they assume that some individuals lack the necessary tools to manage specific situations and, because of this deficiency, they encounter problems that others with effective skills would not experience. This type of perspective further assumes that, to recover, these individuals must learn new coping skills and behavior. TIC, on the other hand, makes the assumption that clients are the experts in their own lives and have learned to adapt and acquire skills to survive. The TIC approach honors each individual's adaptations and acquired skills, and it helps clients explore how these may not be working as well as they had in the past and how their current repertoire of responses may not be as effective as other strategies.

Advice to Administrators: Self-Assessment for Trauma-Informed Systems

NCTIC has developed a self-assessment package for trauma-informed systems to help administrators structurally incorporate trauma into programs and services. The self-assessment can be used by systems of care to guide quality improvement with the goal of establishing fully trauma-informed treatment and recovery efforts (NCTIC, Center for Mental Health Services, 2007). Behavioral health treatment program administrators can use these materials and NCTIC as resources for improvement in delivering TIC.

Demonstrate Organizational and Administrative Commitment to TIC

Becoming a trauma-informed organization requires administrative guidance and support across all levels of an agency. Behavioral health staff will not likely sustain TIC practices without the organization's ongoing commitment to support professional development and to allocate resources that promote these practices. An agency that wishes to commit to TIC will benefit from an organizational assessment of how staff members identify and manage trauma and trauma-related reactions in their clients. Are they trauma aware-do they recognize that trauma can significantly affect a client's ability to function in one or more areas of his or her life? Do the staff members understand that traumatic experiences and trauma-related reactions can greatly influence clients' engagement, participation, and response to services?

Agencies need to embrace specific strategies across each level of the organization to create trauma-informed services; this begins with staff education on the impact of trauma among clients. Other agency strategies that reflect a trauma-informed infrastructure include, but are not limited to:

Universal screening and assessment procedures for trauma.

Interagency and intra-agency collaboration to secure trauma-specific services.

Referral agreements and networks to match clients' needs.

Mission and value statements endorsing the importance of trauma recognition.

Consumer- and community-supported committees and trauma response teams.

Workforce development strategies, including hiring practices.

Professional development plans, including staff training/supervision focused on TIC.

Program policies and procedures that ensure trauma recognition and secure trauma-informed practices, trauma-specific services, and prevention of retraumatization.

TIC requires organizational commitment, and often, cultural change. For more information on implementing TIC in organizations, see Part 2, Chapter 1 of this TIP.

Develop Strategies To Address Secondary Trauma and Promote Self-Care

Secondary trauma is a normal occupational hazard for mental health and substance abuse professionals, particularly those who serve populations that are likely to include survivors of trauma ( Figley, 1995; Klinic Community Health Centre, 2008). Behavioral health staff members who experience secondary trauma present a range of traumatic stress reactions and effects from providing services focused on trauma or listening to clients recount traumatic experiences. So too, when a counselor has a history of personal trauma, working with trauma survivors may evoke memories of the counselor's own trauma history, which may increase the potential for secondary traumatization.

The range of reactions that manifest with secondary trauma can be, but are not necessarily, similar to the reactions presented by clients who have experienced primary trauma. Symptoms of secondary trauma can produce varying levels of difficulty, impairment, or distress in daily functioning; these may or may not meet diagnostic thresholds for acute stress, posttraumatic stress, or adjustment, anxiety, or mood disorders ( Bober & Regehr, 2006). Symptoms may include physical or psychological reactions to traumatic memories clients have shared; avoidance behaviors during client interactions or when recalling emotional content in supervision; numbness, limited emotional expression, or diminished affect; somatic complaints; heightened arousal, including insomnia; negative thinking or depressed mood; and detachment from family, friends, and other supports ( Maschi & Brown, 2010).

Working daily with individuals who have been traumatized can be a burden for counselors and other behavioral health service providers, but all too often, they blame the symptoms resulting from that burden on other stressors at work or at home. Only in the past 2 decades have literature and trainings begun paying attention to secondary trauma or compassion fatigue; even so, agencies often do not translate this knowledge into routine prevention practices. Counselors and other staff members may find it difficult to engage in activities that could ward off secondary trauma due to time constraints, workload, lack of agency resources, and/or an organizational culture that disapproves of help-seeking or provides inadequate staff support. The demands of providing care to trauma survivors cannot be ignored, lest the provider become increasingly impaired and less effective. Counselors with unacknowledged secondary trauma can cause harm to clients via poorly enforced boundaries, missed appointments, or even abandonment of clients and their needs ( Pearlman & Saakvitne, 1995).

Essential components of TIC include organizational and personal strategies to address secondary trauma and its physical, cognitive, emotional, and spiritual consequences. In agencies and among individual providers, it is key for the culture to promote acceptability, accessibility, and accountability in seeking help, accessing support and supervision, and engaging in self-care behaviors in and outside of the agency or office. Agencies should involve staff members who work with trauma in developing informal and formal agency practices and procedures to prevent or address secondary trauma. Even though a number of community-based agencies face fiscal constraints, prevention strategies for secondary trauma can be intertwined with the current infrastructure (e.g., staff meetings, education, case consultations and group case discussions, group support, debriefing sessions as appropriate, supervision). For more information on strategies to address and prevent secondary trauma, see Part 2, Chapter 2 of this TIP.

The Impact of Trauma

Trauma is similar to a rock hitting the water's surface. The impact first creates the largest wave, which is followed by ever-expanding, but less intense, ripples. Likewise, the influence of a given trauma can be broad, but generally, its effects are less intense for individuals further removed from the trauma; eventually, its impact dissipates all around. For trauma survivors, the impact of trauma can be far-reaching and can affect life areas and relationships long after the trauma occurred. This analogy can also broadly describe the recovery process for individuals who have experienced trauma and for those who have the privilege of hearing their stories. As survivors reveal their trauma-related experiences and struggles to a counselor or another caregiver, the trauma becomes a shared experience, although it is not likely to be as intense for the caregiver as it was for the individual who experienced the trauma. The caregiver may hold onto the trauma's known and unknown effects or may consciously decide to engage in behaviors that provide support to further dissipate the impact of this trauma and the risk of secondary trauma.

Advice to Counselors: Decreasing the Risk of Secondary Trauma and Promoting Self-Care

Peer support. Maintaining adequate social support will help prevent isolation and depression.

Supervision and consultation. Seeking professional support will enable you to understand your own responses to clients and to work with them more effectively.

Training. Ongoing professional training can improve your belief in your abilities to assist clients in their recoveries.

Personal therapy. Obtaining treatment can help you manage specific problems and become better able to provide good treatment to your clients.

Maintaining balance. A healthy, balanced lifestyle can make you more resilient in managing any difficult circumstances you may face.

Setting clear limits and boundaries with clients. Clearly separating your personal and work life allows time to rejuvenate from stresses inherent in being a professional caregiver.

Provide Hope-Recovery Is Possible

What defines recovery from trauma-related symptoms and traumatic stress disorders? Is it the total absence of symptoms or consequences? Does it mean that clients stop having nightmares or being reminded, by cues, of past trauma? When clients who have experienced trauma enter into a helping relationship to address trauma specifically, they are often looking for a cure, a remission of symptoms, or relief from the pain as quickly as possible. However, they often possess a history of unpredictable symptoms and symptom intensity that reinforces an underlying belief that recovery is not possible. On one hand, clients are looking for a message that they can be cured, while on the other hand, they have serious doubts about the likely success of any intervention.

Clients often express ambivalence about dealing with trauma even if they are fully aware of trauma's effects on their lives. The idea of living with more discomfort as they address the past or as they experiment with alternative ways of dealing with trauma-related symptoms or consequences is not an appealing prospect, and it typically elicits fear. Clients may interpret the uncomfortable feelings as dangerous or unsafe even in an environment and relationship that is safe and supportive.

How do you promote hope and relay a message that recovery is possible? First, maintain consistency in delivering services, promoting and providing safety for clients, and showing respect and compassion within the client-provider relationship. Along with clients' commitment to learning how to create safety for themselves, counselors and agencies need to be aware of, and circumvent, practices that could retraumatize clients. Projecting hope and reinforcing the belief that recovery is possible extends well beyond the practice of establishing safety; it also encompasses discussing what recovery means and how it looks to clients, as well as identifying how they will know that they've entered into recovery in earnest.

Providing hope involves projecting an attitude that recovery is possible. This attitude also involves viewing clients as competent to make changes that will allow them to deal with trauma-related challenges, providing opportunities for them to practice dealing with difficult situations, and normalizing discomfort or difficult emotions and framing these as manageable rather than dangerous. If you convey this attitude consistently to your clients, they will begin to understand that discomfort is not a signal to avoid, but a sign to engage-and that behavioral, cognitive, and emotional responses to cues associated with previous traumas are a normal part of the recovery process. It's not the absence of responses to such triggers that mark recovery, but rather, how clients experience and manage those responses. Clients can also benefit from interacting with others who are further along in their recovery from trauma. Time spent with peer support staff or sharing stories with other trauma survivors who are well on their way to recovery is invaluable-it sends a powerful message that recovery is achievable, that there is no shame in being a trauma survivor, and that there is a future beyond the trauma.

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Many individuals who seek treatment in behavioral health settings have histories of trauma, but they often don't recognize the significant effects of trauma in their lives; either they don't draw connections between their trauma histories and their presenting problems, or they avoid the topic altogether.

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Creating a Psychologically Informed Environment - 2015

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Dr Daniel Siegel presenting a Hand Model of the Brain

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Pooky Knightsmith: Neurodivergence & Mental Health

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ANXIETY | Top phrases for calming anxious children

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How to Help Kids Control Their Anger | Anger Management

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Best Techniques To Understand Anger Management In Children | Parenting Tips

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stress, distress and trauma. Free resource

NN COVID-19 Stress, Distress & Trauma Series

The videos in this series with Dr. Bruce Perry are provided to view and share. We have closed captioned each video. To change captions from English to another language, select "settings" (cog at bottom right), select "Subtitles/CC" then select "Auto-translate" and finally select the language of your choice.

In this brief (20 min) video, Dr. Bruce Perry discusses 'emotional contagion' and talks about the power of calm. The concept of power differential is discussed in context of human interactions and discusses the importance of calm, regulated leadership in times of stress and distress.

This brief (25 min) video discusses elaborates on the importance of the "pattern" of stress and stress activation with a focus on the concept of 'dosing.' What is considered a "moderate" dose of stress - why is this important in building resilience? And what is the power of the moment? This video presents some important background for understanding the importance of small but powerful relational moments.

This (30 min) video provides an overview of the power of distributed leadership. The awareness of the neurobiological 'preferences' that we have for small group functioning and dynamics provides some insight to the inefficient forms of large group planning and program development that characterize our current child welfare, mental health, juvenile justice and early childhood systems.

During "office hours," Dr. Perry will be online and available to answer questions and for discussion. Feel free to join for any/all of the sessions that your schedule allows. Sessions will be recorded and links will be posted on this page.

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To be announced

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Previously Recorded Office Hours:

Wed. March 25, 2020: State-dependence

Fri., March 27, 2020: Emotional Contagion

Wed., April 1, 2020: Understanding Regulation

Mon., April 6, 2020: Self-care & Organizational Care
Wed., April 8, 2020: Connecting Under Duress Mon., April 13, 2020: Collaborative Problem Solving with Stuart Ablon, PhD
Fri., April 17, 2020: Maladaptive Regulation: Risk from Substance Use

Teaching Under Pressure with Steve Graner & Jessica Pfeiffer Part 1 ;

Fri., May 22, 2020: Distributed Leadership -Examining the "Original" Model of Leadership in Human Groups
Wed., June 10, 2020: Structural Racism with Habeebah Grimes - Racism in our Educational, Mental Health, Child Welfare & Juvenile Justice Systems
Anti-racism Resources
Monday, June 15, 2020: Equity, Transgenerational Trauma & Racism with Lea Denny & Stephen Bradley

COVID-19 Webinars featuring Dr. Bruce Perry

We Coach: A Conversation on Stress & Sport Dr. Bruce Perry and We Coach Founder, Megan Bartlett discuss the unique healing power of sport. Topics include strategies that coaches use to buffer stress and why coaches and sport programs would be on the front lines of supporting young people through this crisis.

Staying Sane while Parenting with Shelter-in-Place! For parents - a conversation about the challenges for parents during this COVID-19 pandemic

Bruce Perry, MD, PhD. Staying Emotionally Close In The Time of COVID19

How do we manage in the midst of COVID-19? I reached out to one of our field's most inspiring figures: @BDPerry. Thanks, Dr. Perry for joining me on The Trauma Therapist Podcast at such short notice and for sharing your guidance for these crazy times. - Guy Macpherson

Face Book discussion with Dr. Bruce Perry, Dr. Liz McIngvale and Jim "Mattress Mac" McIngvale focusing on the impact that Coronavirus has on children, families, and the community.

Leadership Challenges during the COVID-19 Pandemic focused on the challenges posed by the current COVID-19 pandemic as we support our health care and mental health colleagues

Mental Health First Aid for Health Care Providers

Prevent Child Abuse America - A conversation with Dr. Bruce Perry

"Hope for Mental Health Community" Kay Warren with Dr. Bruce Perry - This conversation between Kay Warren and Dr. Bruce Perry focuses on the stress and challenges of the current pandemic .

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stress, distress and trauma. Free resource NN COVID-19 Stress, Distress & Trauma Series The videos in this series with Dr. Bruce Perry are provided to view and share. We have closed captioned each video. To change captions from English to another language, select "settings" (cog at bottom right), select "Subtitles/CC" then select "Auto-translate" and finally select the language of your choice.

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Opening Doors: Trauma Informed Practice for the Workforce

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This animation was developed by NHS Education for Scotland, in partnership with the Scottish Government. It is designed to be relevant to all workers within the Scottish workforce. It aims to support workers to know how to adapt the way they work to make a positive difference to people affected by trauma and adversity. If you work with children and young people, consider also viewing “Sowing Seeds” https://vimeo.com/334642616  an animation created by  NHS Education for Scotland to support people to make a positive difference to the lives of children and young people affected by trauma. Trauma is everybody’s business.
A freely available workshop, Taking a Trauma Informed Lens to your Work: Opening Doors, can be accessed here: https://vimeo.com/411406138  This workshop guides you through how to use the animation to further support the strengthening and development of trauma informed practice within your own work and/or wider service/organisation.
For further information on the NTTP and all the available resources, please visit our website: https://www.traumatransformation.scot/

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A Test to Judge How Good Your Parents Were