Trauma-Informed Practice: Fundamentals for Therapists

This article explores the fundamentals of trauma-informed practice in clinical settings, with a focus on practical applications, and tools for implementation.  

Related articles: Trauma-Informed Supervision: Supporting Therapists Who Treat Trauma, Assessing and Treating Trauma, Epigenetics and Intergenerational Trauma.

Related discussion: Trauma-informed practice.

Introduction

Trauma-informed practice (TIP) represents a paradigm shift in mental health care, prioritising safety, trust, and empowerment for clients who have experienced trauma. Trauma affects not only individuals but also their relationships, communities, and access to care. For mental health professionals, integrating trauma-informed principles is essential to fostering healing environments and delivering effective therapeutic interventions.

This article explores the fundamentals of trauma-informed practice in clinical settings, with a focus on practical applications, and tools for implementation. By understanding the core principles and adapting therapeutic approaches, therapists can better support clients on their journey towards recovery.

The origins of trauma

Trauma refers to an emotional response to deeply distressing or disturbing events that overwhelm an individual’s ability to cope. These events may include abuse, violence, accidents, natural disasters, or significant loss.

The impact of trauma varies widely and may manifest as post-traumatic stress disorder (PTSD), anxiety, depression, dissociation, or somatic symptoms. Key characteristics include:

• Individualised responses: What is traumatic for one person may not be for another.
• Long-term effects: Trauma can alter brain function, emotional regulation, and interpersonal relationships.
• Reactivation triggers: Certain situations, sounds, or images can bring past trauma to the surface.

This article further explores what trauma is, how to identify its symptoms and diagnose it in your clients, and what some of the common treatment approaches are.

Principles of trauma-informed practice

Trauma-informed practice is grounded in six core principles outlined by the Substance Abuse and Mental Health Services Administration (SAMHSA, 2014):

1. Safety: Clients must feel physically and emotionally safe within the therapeutic environment.
2. Trustworthiness and transparency: Open communication builds trust between clients and therapists.
3. Peer support: Incorporating shared experiences fosters understanding and hope.
4. Collaboration and mutuality: Therapy is a partnership, recognising the client’s role in their healing process.
5. Empowerment, voice, and choice: Clients are encouraged to take an active role in their treatment.
6. Cultural, historical, and gender considerations: Therapists must address cultural and identity factors influencing a client’s trauma and recovery.

Practical applications of TIP in therapy

Implementing trauma-informed practice requires therapists to integrate knowledge of trauma into every aspect of client care. Below are actionable strategies aligned with the core principles:

Creating a safe therapeutic space

• Use warm, neutral decor in therapy rooms.
• Establish predictable routines and clear boundaries.
• Validate client experiences without judgment.

Active listening and building trust

• Use reflective statements to demonstrate understanding.
• Explain therapeutic processes and address any questions.
• Follow through on commitments to establish reliability.

Adapting techniques for trauma survivors

Therapists should tailor interventions to accommodate trauma responses. Following are some techniques and approaches that can be useful:

• Grounding techniques: Help clients stay present during sessions. Example: Breathing exercises or naming objects in the room.
• Somatic interventions: Address body memories of trauma. Examples of body-based approaches include: Sensorimotor Psychotherapy, Somatic Experiencing (SE), breathwork, Dance/Movement Therapy (DMT), Mindfulness-Based Stress Reduction (MBSR), and many others.
• Cognitive Processing Therapy (CPT): Focuses on identifying and challenging distorted beliefs related to the trauma.

Tools and frameworks for trauma-informed practice

Several tools and frameworks can aid therapists in implementing trauma-informed care:

• Adverse Childhood Experiences (ACEs) Questionnaire: Helps identify past traumatic events and their potential impacts. Learn more about ACEs in this article
• Trauma Symptom Checklist (TSC): Measures trauma-related symptoms, including anxiety and dissociation.
• Window of Tolerance (Siegel, 1999): A visual tool to understand clients’ arousal levels and help them stay within their optimal zone for processing. Learn more about the window of tolerance in this article.
• Psychoeducation materials: Provide clients with information about trauma responses and recovery.
• Mindfulness-based apps: Tools like Headspace or Calm can support clients in managing anxiety outside sessions.

Addressing secondary trauma and therapist self-care

Working with trauma survivors can expose therapists to secondary traumatic stress (STS) or compassion fatigue, characterised by emotional exhaustion, reduced empathy, and a diminished sense of professional efficacy.

Prolonged exposure to clients’ trauma narratives without adequate self-care can result in burnout, impacting both personal well-being and clinical effectiveness. To maintain resilience and effectiveness, therapists should consider adopting the following strategies:

• Supervision and peer support: Regular supervision (especially trauma-informed supervision) offers a platform for therapists to discuss challenging cases and gain fresh perspectives. Peer support groups provide an opportunity to share experiences and strategies, fostering a sense of community and understanding.

• Self-care practices: Engage in activities that promote relaxation and restoration. This may include physical exercise, mindfulness practices, creative hobbies, or spending time with loved ones. Mindfulness meditation and yoga are particularly beneficial for reducing stress and enhancing emotional regulation. Also, effectively manage burnout by understanding its signs, and acting early.

• Setting boundaries: Clearly define professional boundaries to avoid overextending oneself. This includes managing caseloads effectively and ensuring adequate time for rest and recovery.

• Professional development: Attend training on managing secondary trauma and stress. Staying informed about new developments in trauma care can bolster confidence and competence in addressing client needs. Here’s a list of MHA courses covering therapist self-care as a central topic.

• Therapeutic support for therapists: Engaging in personal therapy can help therapists process their own emotional responses and maintain their mental health. Read this article to understand why therapists need therapy.

A case study: TIP in clinical practice

Maria, a 28-year-old survivor of domestic violence, sought therapy after struggling with anxiety, flashbacks, and difficulties maintaining relationships. Soon after leaving her abusive ex-husband, she noticed difficulty sleeping at night and concentrating during the day. Memories of him beating her would flash, unbidden, before her mind, eclipsing all other endeavours, such as trying to complete assignments for her work as a copywriter. Already anxious over many matters, Maria became worried about keeping her job. She presumed, though, that these symptoms would pass over time. She knew she was lucky to have escaped with her life. But as the months unfolded, she realised that the trauma went deeper than she had originally thought.

For one thing, she noticed that she seemed to be changing romantic partners as often as someone might change their bed linens! Whether she found the man on her favourite dating app or just happened to meet him, the romance would follow a typical pattern of love bombing on the man’s part followed by subtle but definite attempts at coercive control of her. She was clear; she had been there, done that, and wanted no repeat performance of such relationships. But she didn’t seem to be meeting any other sort of man. It was discouraging and heightened Maria’s sense of being unsafe in relationships and in life.

Also, she realised she was now quite jumpy. Upon hearing a loud engine nearby or footsteps outside her door, Maria would race around to make sure all doors were locked. The hypervigilance soon extended to sudden noises anywhere. Maria came to realise that her startle response was extreme, and that she was well outside her window of tolerance most of the time.

During the initial sessions, her therapist began by using active listening to build trust and establish a safe environment. She allowed Maria to set the pace for sharing her experiences.

As Maria began discussing her trauma, she frequently dissociated. The therapist introduced grounding techniques, such as focusing on her breathing or holding a comforting object, to help her stay present during sessions; Maria particularly liked the Box Breathing technique. While these techniques took a few sessions to bear fruit, they eventually enabled Maria to process her emotions without becoming overwhelmed.

Because the therapist sensed that Maria was experiencing levels of shame and guilt about her situation, she also incorporated psychoeducation, explaining the physiological effects of trauma and normalising Maria’s symptoms. Over time, Maria came to realise that she was strong for having escaped and survived, not weak (as she feared) for having gotten into a violent relationship in the first place. Using the Window of Tolerance framework, they worked together to identify signs of hyperarousal (more common for Maria) and hypoarousal and practised strategies to regulate Maria’s intense emotional swings.

Over time, Maria expressed interest in addressing her distorted beliefs about self-worth and safety. The therapist introduced Cognitive Processing Therapy (CPT) to challenge and reframe these beliefs. Through this approach, Maria began to see herself as capable rather than damaged, although she still noted lapses into a sense of worthlessness. Re-establishing a sense of safety was the most difficult aspect, taking up most of the therapeutic journey; Maria did not feel safe in most environments for a long time.

To support Maria’s healing outside of therapy, the therapist recommended mindfulness exercises via apps like Calm and encouraged her to journal about her progress. Recognising the cultural context of Maria’s experiences, the therapist also referred her to a local support group for women from similar backgrounds, providing peer support to further empower her. Maria was surprised to learn how many women from her region had experienced similar intimate partner violence; she recognised their collective cultural taboo against talking about such things, so she experienced significant healing from the sharing of those experiences.

After a year of therapy, Maria reported significant reductions in anxiety and flashbacks, with improved sleep and concentration at work. She felt better equipped to establish healthy relationships, although with her burgeoning confidence, she was in no hurry to re-establish a romantic relationship. This case highlights how trauma-informed principles—safety, trust, empowerment, and cultural sensitivity—can transform a client’s journey toward recovery.

Conclusion

Trauma-informed practice is a vital framework for mental health professionals, ensuring that clients feel safe, supported, and empowered. By understanding trauma’s effects, adhering to core principles, and applying practical strategies, therapists can create environments that promote healing. Equally important is the therapist’s commitment to ongoing education and self-care to sustain their capacity to support clients effectively.

By integrating these principles into everyday practice, mental health professionals can make a profound difference in the lives of trauma survivors.

Key takeaways

• Trauma-informed practice prioritises safety, trust, and empowerment for clients.
• Understanding trauma’s impact is essential for tailoring therapeutic interventions.
• Core principles of TIP include safety, trustworthiness, collaboration, and cultural sensitivity.
• Practical tools, such as grounding techniques and psychoeducation, enhance trauma-informed care.
• Therapists must practise self-care to manage the demands of trauma work effectively.

References

• Substance Abuse and Mental Health Services Administration. (2014). SAMHSA’s Concept of Trauma and Guidance for a Trauma-Informed Approach. https://www.samhsa.gov
• Siegel, D. J. (1999). The Developing Mind: How Relationships and the Brain Interact to Shape Who We Are. Guilford Press.
• van der Kolk, B. A. (2015). The Body Keeps the Score: Brain, Mind, and Body in the Healing of Trauma. Penguin Books.
• Courtois, C. A., & Ford, J. D. (2020). Treating Complex Traumatic Stress Disorders in Adults: Scientific Foundations and Therapeutic Models. Guilford Press.
• Levitt, J. T., & Cloitre, M. (2005). A Clinician’s Guide to STAIR/MPE: Treatment for PTSD Related to Childhood Abuse. Cognitive and Behaviour Practice, 12, 40-52. https://doi.org/10.1016/S1077-7229(05)80038-0