Becoming Trauma Informed

Growing evidence suggests that most people accessing mental health and addiction
services have experienced trauma at some point in their lives. Community services,
treatment agencies and hospitals are recognizing that they need to understand the
potential effects of trauma on all of their clients and create programs, spaces and
Becoming
policies that are trauma informed.
Becoming Trauma Informed

Becoming Trauma Informed describes trauma-informed practice at the individual,
organizational and systemic levels. The editors and authors bring unique
perspectives from various settings and from the diverse groups with which they
work, sharing how trauma-informed principles have been integrated into different
mental health and addiction treatment and social service environments. They
emphasize how trauma-informed services must take into account an understanding
Trauma
of trauma, and place priority on trauma survivors’ safety, choice and control. These
contributors offer hope and direction for becoming trauma informed, showcasing
their innovation, leadership, practices, ideas and compassion.
I found this book both exciting and inspiring. It should be read by practitioners,
administrators, researchers and educators who work in mental health, addictions,
child welfare, violence against women; in fact, by everyone who labours to improve
Informed
the lives of people who are hurting. The content provides state of the art knowledge
about the transformation in service delivery and improved outcomes that occur when
helping professionals and helping systems are trauma informed.
CAROL A. STALKER, PhD, RSW
professor and associate dean, phd program, faculty of social work,
wilfrid laurier university, waterloo, on
This is an ambitious and powerful book, whose editors and authors have more than risen
to meet the challenge of demonstrating to their colleagues creative ways to think about
delivering care through the lens of trauma. Every health and mental health practitioner
should read this book, whether they believe themselves to be working with trauma
survivors or not. The compassionate, thoughtful and evidence-based information in this
volume will improve quality of care for all patients and clients.
LAURA S. BROWN, PhD, ABPP
author of cultural competence in trauma therapy: beyond the flashback,
and director, fremont community therapy project, seattle, wa Edited by
Nancy Poole
This publication may be available in other formats. Lorraine Greaves
For information about alternative formats or other
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contact Sales and Distribution:
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4566 / 10-2012
E-mail: publications@camh.ca
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A Pan American Health Organization /
Website: www.camh.ca World Health Organization Collaborating Centre
Becoming
Trauma
Informed
Edited by
Nancy Poole
Lorraine Greaves

World Health Organization
Collaborating Centre
Fully affiliated with the University of Toronto
Library and Archives Canada Cataloguing in Publication
Becoming trauma informed / edited by Nancy Poole and Lorraine Greaves.
ISBN: 978-1-77114-058-4 (PRINT)

ISBN: 978-1-77114-059-1 (PDF)
ISBN: 978-1-77114-060-7 (HTML)
1. Psychic trauma—Patients—Care. 2. Psychic trauma—Patients—Mental health services.

3. Drug addiction—Treatment. 4. Mental illness—Treatment. I. Poole, Nancy. II. Greaves,
Lorraine. III. Centre for Addiction and Mental Health.
RC552.T7B42 2012 616.85’21 C2012-904264-1
Printed in Canada
Copyright © 2012 Centre for Addiction and Mental Health
No part of this work may be reproduced or transmitted in any form or by any means electronic or
mechanical, including photocopying and recording, or by any information storage and retrieval system
without written permission from the publisher—except for a brief quotation (not to exceed 200 words)
in a review or professional work.
This publication may be available in other formats. For information about alternative formats or
other CAMH publications, or to place an order, please contact CAMH Publications:
Toll-free: 1 800 661-1111

Toronto: 416 595-6059
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Website: www.camh.ca
This book was produced by CAMH Education.
4566 / 09-2017 / PG140

Contents
vii Acknowledgments
ix Preface
xi Introduction
PART 1: WHAT IS “TRAUMA INFORMED”

IN THEORY AND PRACTICE?
3 Introduction
SECTION 1: THEORY
9 1 A Developmental Understanding of Complex Trauma
Lori Haskell
29 2 Traumatic Learning
Linde Zingaro
37 3 Using a Feminist- and Trauma-Informed Approach in Therapy

with Women
Brenda Toner and Donna Akman
47 4 Anti-oppression Psychotherapy as Trauma-Informed Practice

Roberta K. Timothy
SECTION 2: PRACTICE
59 5 Collaborative Change Conversations: Integrating Trauma-
Informed Care and Motivational Interviewing with Women
Cristine Urquhart and Frances Jasiura
6 Cognitive-Behavioural Therapy for Psychosis: A Trauma-

71
Informed Praxis
Maria Haarmans
89 7 Trauma-Informed Body-Centred Interventions

Steven Hughes and Paul Hyman
PART 2: TRAUMA-INFORMED PRACTICE
FOR DIVERSE CLIENT GROUPS AND IN
SPECIFIC SETTINGS
101 Introduction
ECTION 1: DIVERSE GROUPS

S
109 8 Working in a Trauma-Informed Way with Clients Who Have
a Developmental Disability
Anna M. Palucka and Yona Lunsky
121 9 Trauma-Informed Care for Refugees

Branka Agic
135 10 The Evolution of Trauma-Informed Practice at the

Jean Tweed Centre
Julia Bloomenfeld and Tammy Rasmussen
145 11 Show Not Tell . . . Trauma-Informed Creative Engagement with

Youth Who Have FASD
Mary Harber
151 12 Girls’ Groups and Trauma-Informed Intersectional Practice

Natalie Clark
165 13 Acknowledging and Embracing “the Boy inside the Man”:
Trauma-Informed Work with Men
Roger Fallot and Richard Bebout
175 14 An Intergenerational Trauma-Informed Approach to Care

for Canada’s Aboriginal Peoples
Peter Menzies
SECTION 2: DIVERSE SETTINGS

191 15 Considering Trauma in Outpatient Substance Use Treatment
Planning for Youth
Gloria Chaim, Susan Rosenkranz and Joanna Henderson
201 16 Using a Trauma-Informed Approach to Guide the Journey

of Restraint Prevention
Athina Perivolaris and Ann Pottinger
217 17 Trauma-Informed Work with Families
Sabrina Baker
225 18 Trauma-Informed Care on a Women’s Inpatient

Psychiatric Unit
Donna Akman and Cheryl Rolin-Gilman
235 19 Trauma-Informed Primary Care with Immigrant, Refugee and

Non-status Women Living with HIV/AIDS
Mercedes Umaña
PART 3: CHANGING THE SYSTEM THROUGH

EDUCATION AND INNOVATION
245 Introduction
SECTION 1: EDUCATION
253 20 Building Community Capacity for Trauma-Informed Practice
Barbara K. Peck and Stephanie R. Capyk
263 21 Curricula to Support Trauma-Informed Practice with Women

Stephanie Covington
275 22 Responding to Women’s Self-Harm: A 10-Year Reflection on the

Need for Trauma-Informed Care
Colleen Anne Dell
289 23 A Mother’s Loss: The Unacknowledged Grief of Child

Apprehension for Women Who Use Substances
Tammy MacKenzie and Amy Druker
SECTION 2: INNOVATION
301 24 Collaboration between Child Welfare and Substance
Use Services
Diane Smylie and Carolyn Ussher
311 25 What Do Client Rights Have to Do with Trauma-Informed Care?

Jennifer Chambers
319 26 Integrated Screening, Assessment and Training as Critical
Components of Trauma-Informed Care
Vivian B. Brown
329 27 Breaking Out of the Mould: Creating Trauma-Informed Anti-

violence Services and Housing for Women and Their Children
Lynda Dechief with Janice Abbott
339 28 Integrating Treatment of Tobacco with Other Substances in

a Trauma-Informed Way
Nancy Poole and Judy Lyon
351 29 Responding to the Women: YWCA Toronto Moves Its Practice
to a Trauma-Informed Approach
Lorraine Greaves in conversation with Jennie McKnight, Ruth Crammond
and Heather McGregor
361 Conclusion
367 About the Editors
369 About the Authors

vii
Acknowledgments
As with our previous collaboration on Highs and Lows: Canadian Perspectives on

Women and Substance Use, developing this book has given us the opportunity
to work with many wise and dedicated people across Canada and the United
States. We wish to thank the contributors who were willing to share the lessons
they were learning in the course of pioneering trauma-informed practices,
and to devote many hours of their time to writing and responding to edits.
We profusely thank Julia Greenbaum, our publisher at the Centre for Addiction and
Mental Health, for her wisdom, inspiration and trust. She has offered patient
and important guidance and support throughout the development of this book.
We will miss the warm Toronto gatherings where ideas were generated, debated
and ultimately realized.
We also thank Diana Ballon and Hema Zbogar, who provided developmental
and copy editing support respectively—not easy tasks with such complex
subject matter. Diana patiently and expertly reviewed all of the submissions
numerous times and asked many essential questions that led to more clarity
and better reading. We appreciate all of these editing efforts.
We acknowledge the numerous projects and agencies that have nurtured and
sustained our interests in trauma, violence, mental health and substance use;
most important among these is the British Columbia Centre of Excellence for
Women’s Health, based in Vancouver.
We also thank the many reviewers who very generously volunteered their time
to provide feedback on all or sections of this book: Christine Davis, Lynda Dechief,
Suraya Faziluddin, Janine Gates, Colleen Kelly, Cheryl Peever, Elizabeth Poag,
Wendy Reynolds, Laurie Robinson, Cheryl Rolin-Gilman, Lorrie Simunovic,
Patti Socha and Graham Vardy.
viii
We dedicate this book to the survivors of trauma who have experienced

substance use and mental health concerns. We believe that increased
understanding, services and support are directly needed to reduce trauma,
violence and exploitation. We hope that this book will contribute to the
development of a more comprehensive trauma-informed response in
Canada and beyond.
ix
Preface
Nancy Poole and Lorraine Greaves
Over the past few years, there has been growing recognition of the importance
of considering trauma in the provision of mental health and substance use
services.
Our experiences at the British Columbia Centre of Excellence for Women’s

Health (BCCEWH)—and with many partners across Canada interested in
substance use and violence issues, particularly for women—have made us
aware of how important it is for practitioners and services in different sectors
to make the connections between the issues of trauma, violence, mental
health and substance use. Only by making these connections can we deliver
integrated or holistic care across health, social services, child welfare, justice
and other sectors that responds to the many ways in which trauma influences
people’s lives.
In 2007/2008, BCCEWH was part of the Canadian National Treatment

Strategy Working Group, sponsored by Health Canada and the Canadian
Centre on Substance Abuse, which fostered discussion about tiered levels of
support for people with substance use problems. It was clear that people with
substance use issues were accessing a broad range of agencies and systems in
services not identified as “treatment.” At the same time, a key issue for many
clients and practitioners was seeking support for trauma-related issues.
Linking these often disparate services in the interests of serving people better
became critical.
Our connections with the leaders of the Women, Co-occurring Disorders

and Violence Study, sponsored by the Substance Abuse and Mental Health
Services Administration in the United States, were important in shedding
light on these complex issues. This key American study, which ran from
1998 to 2003, piloted integrated interventions across multiple sites for
women with substance use and mental health concerns and histories of
trauma and violence. The study found that comprehensive trauma-informed
services could be effective without increased cost burden. These findings
x Becoming Trauma Informed
provoked us to think about how we might apply them to encourage similar

improvements in service provision in Canada. This book is one part of our
ongoing work in making some of those linkages and ideas come to life in the
Canadian context.
Maxine Harris and Robert Fallot’s book, Using Trauma Theory to Design Service
Systems (2001), was also pivotal to our thinking. The authors articulated a
systems-level approach to integrating responses to trauma into a range of
systems: housing, mental health, anti-violence, primary care and addiction.
Harris and Fallot introduced the idea of the importance of improvements at
the systemic as well as individual service levels in providing effective support
for people with experience of trauma, mental illness and addiction. We realized
that a collective lack of understanding of trauma experiences rendered existing
systems not very effective in providing services.
All of these resources and processes resonated with the situations we were
encountering. But despite these books, studies and opportunities, it remained,
and remains, a challenge to integrate trauma considerations into the range of
mental health and substance use services in Canada. Nonetheless, there are
numerous emerging examples of people and services working on the ground
or thinking about these issues in their research and education. This book
brings those voices together. Indeed, in editing it, we are intentionally sewing
together some disparate activities and practices in substance use and mental
health services and systems in Canada. In addition, we highlight some
emerging trauma-informed practices in anti-violence and shelter services and
increasingly understand how mental health and substance use issues are
often the effects of abuse, violence and trauma.
Our goal is to encourage ourselves and others to move past simple cross-
training between sectors or blending service provision in a “two-by-two”
approach. Instead, we strive to initiate some higher-level considerations and
examples of integrated design. We hope this book will serve as an impetus
to further and ongoing development of trauma-informed service design and
delivery in the Canadian context, especially, but not only, in substance use
and mental health services.
xi
Introduction
This guidebook is intended to support the work of practitioners in the

substance use and mental health fields in Canada. It signals how a shift in
the paradigm of our work in these fields is underway—a paradigm that
recognizes how central the experience of trauma can be to those with whom
we work, and that prompts us to be responsive to this reality at multiple levels.
In this book, practitioners share their evolving approaches to shaping trauma-
informed services for people with substance use and mental health concerns.
In Canadian mental health and addiction services, designing trauma-

informed care, reflecting it in trauma-informed service and system design
and developing research and evaluation to measure its impact are still an
emergent practice. This book offers a range of examples of practitioner
perspectives and organizational initiatives aimed at attaining these goals,
and sets the stage for improving and developing design and practice in the
coming years. The trauma-informed approaches described in this book
will be relevant to a variety of readers, including practitioners working in
community-based substance use and mental health programs, those
employed in psychiatric settings and those who advocate and champion
trauma-informed care through their work in program planning and
organizational or staff development.
Why Trauma-Informed Care?
Trauma describes experiences that may overwhelm a person’s capacity to cope.

Traumatic events experienced early in life, such as abuse, neglect, witnessing
violence and disrupted attachment, can be devastating. Equally challenging
can be later life experiences that are out of one’s control, such as violence,
accidents, natural disaster, war, incarceration or sudden unexpected loss.
These events can undermine or damage people’s sense of safety, self and self-
efficacy, as well as the ability to regulate emotions and navigate relationships.
People who have experienced trauma often feel terror, shame, helplessness
and powerlessness.
xii Becoming Trauma Informed
A substantial proportion of people who use mental health and substance use
services have histories of trauma that contribute to their mental health and
substance use problems, and affect their accessing of services and their
recovery. A few examples of the connections:
The American Adverse Childhood Experiences study looked at the life

histories of more than 17,000 people to determine the connections of adverse
childhood experiences with health in adulthood (Anda et al., 2006). The
researchers looked at eight categories of adverse childhood experiences
relating to abuse and to growing up in dysfunctional households (including
witnessing violence against the mother). They found that adverse childhood
experiences were vastly more common than recognized and often involved
multiple events and were directly linked to later life substance use and mental
health problems and a range of chronic diseases (Anda et al., 2002; Anda
et al., 2007). For example, the study found that women had a sixfold increased
risk for recent depressive disorders when they reported five or more adverse
childhood experiences (Chapman et al., 2004). The study also found that
people who experienced five or more adverse childhood experiences were
seven to 10 times more likely to report illicit drug use problems and addiction
to illicit drugs (Dube et al., 2003). The authors note the profound implications
for prevention but also for how we treat people for these conditions.
The links between women’s experiences of violence and trauma and mental
health and substance use problems are well documented in the literature
(see, for example, Logan et al., 2002). A recent Canadian study involving six
women’s treatment centres from across the country found that 90 per cent of
the women interviewed reported childhood or adult abuse histories in relation
to their problematic use of alcohol (Brown, 2009). Data gathered at Canadian
women’s addiction treatment centres over the past decade confirm that a sub-
stantial proportion of women entering treatment for substance use problems
have experienced violence and abuse as children and adults, underlining the
need for an integrated response (Nicchols et al., 2009; Poole, 2007; Van Wyck
& Bradley, 2007). Other Canadian studies have similarly identified a very high
rate of sexual abuse among girls, and how, in turn, girls use substances to
cope with trauma (Ballon et al., 2001). It is important to recognize the gendered,
patterned and ongoing nature of these experiences.
Introduction xiii
Canadian substance use and mental health treatment providers are noting
these connections and making service adaptations. In Chapter 15, Gloria
Chaim, Susan Rosenkranz and Joanna Henderson note how the majority of
youth accessing treatment at the Centre for Addiction and Mental Health’s
Youth Addictions and Concurrent Disorder Service have histories of traumatic
stress (90 per cent of female clients and 62 per cent of males), as well as
sexual abuse.
The prevalence of trauma experienced by men and its links to substance use
and mental health problems is less well documented in Canada. In Chapter 13,
Fallot and Bebout cite a 1995 source indicating that more than 50 per cent of
men in the United States have been exposed to at least one traumatic event
(Kessler et al., 1995). Service statistics from the Men’s Trauma Centre in
Victoria, B.C., indicate that among men seeking treatment and/or support for
physical, sexual and emotional trauma in 2008, 32 per cent reported mental
health problems and 50 per cent reported problems with alcohol and other
drugs. Notably, 20 per cent of clients reported experiencing both mental
health and substance use problems (Men’s Trauma Centre, 2009).
For Aboriginal people, experiences of trauma are compounded by the inter-

generational effects of trauma stemming from the legacy of Canada’s
residential schools. Unresolved historic trauma is reflected in high rates
of complex posttraumatic stress disorder (PTSD), substance use, family
disintegration, violence and suicide (Chansonneuve, 2005; Haskell & Randall,
2009; Wesley-Esquimaux & Smolewski, 2004). Research on the mental health
outcomes of residential school survivors in British Columbia revealed that
64.2 per cent were diagnosed with PTSD, 26.3 per cent with substance abuse
disorder and 21.1 per cent with major depression (Corrado & Cohen, 2003).
In short, there is compelling evidence that mental health and substance

use problems are connected to people’s experiences of violence, abuse and
trauma. And as the chapters in this book illustrate, gender, race, class, culture,
disability, immigration status and other forms of diversity interact to increase
vulnerabilities related to trauma, and invite tailored responses.
Not only is trauma pervasive and connected to substance use and mental
health problems; its impact can also be life-altering. In Chapter 1, Lori Haskell
describes key neurobiological, psychological and psychosocial adaptations
xiv Becoming Trauma Informed
linked to the experience of developmental trauma. She identifies how early

abuse can be a defining experience that shapes and distorts the core of a
person’s identity. She cautions that such adaptations to traumatic experiences
—both early and in adulthood—can be missed or misdiagnosed when a
trauma lens is not applied. Trauma affects people’s sense of self and safety in
the world, and greatly affects their confidence about accessing and continuing
to receive assistance from service providers. Clients with trauma histories
can be those most in need of support, yet most difficult to connect with.
Situating Trauma in Substance Use and Mental Health

Practice
Early on, Judith Herman (1992) identified stages of trauma and healing in
the context of understanding responses and recovery from sexual assault
and violence against women, childhood physical and sexual abuse and neglect,
witnessing violence, unexpected losses and many other life events, where
previously the focus had centred on trauma arising from war and natural
disasters. She articulated various stages of intense recovery, starting with
safety, but including intense experiences of mourning and reconnection.
Much of the current work on trauma-informed practice is grounded in
Herman’s insight regarding trauma survivors’ needs to achieve a certain
level of safety and stability before exploring the impact of their traumatic
experiences in depth.
The mental health field has often identified trauma through a clinical diagnosis
of PTSD—a diagnosis that often initiated treatment plans involving medication
and other psychological or psychiatric interventions. For their part, early
addiction treatment approaches often focused on intense, abstinence-oriented
interventions, assuming that the route to recovery required a complete level
of commitment and concomitant system design that accommodated and
supported the single-focus approach.
Numerous shifts have occurred over the years, such as increased consumer
engagement in mental health systems and the introduction of harm reduction
principles within substance use treatment systems. Another shift has been
to embrace recovery principles in treatment services that place clients at the
centre of their treatment planning and care. For the substance use field, harm
Introduction xv
reduction–oriented practice has brought attention to how many people cannot

or will not engage in abstinence-oriented treatment; yet these people deserve and
benefit from less intensive and more accessible support to improve their health.
In the anti-violence field, a greater understanding of how violence, sexual

assault and child sexual abuse produce short- and long-term effects on both
women and men has slowly emerged in the past three decades. Anti-violence
services recognized that existing approaches were not serving all women as
well as they could, especially those with multiple issues such as substance
use and mental health issues.
It has become evident that trauma is a useful concept for knitting together
all of these experiences, services and systems. The important and ground-
breaking Women, Co-occurring Disorders and Violence Study in the United
States set out to explicitly address these intersections and to encourage or
create system design improvements that could be evaluated.
The Need for Systemic Responses
Despite their importance, however, trauma-informed service and system

design remain nascent in their definition and implementation within
addiction and mental health settings. While there have been numerous
important initiatives, the field remains in its early stages of development in
Canada. Similarly, trauma- and substance-informed services in the anti-violence
field are only slowly being built to respond to a wide range of needs emerging
from trauma-related experiences (BC Society of Transition Houses, 2011).
The Centre for Addiction and Mental Health’s (CAMH) practice model of care
(Chan et al., n.d.) and the virtual National Center for Trauma-Informed Care,
sponsored by the Substance Abuse and Mental Health Services Administration
([SAMHSA], 2011) in the United States, are two promising developments in
emergent systemic approaches with the mental health and substance use systems
of care. The CAMH practice model embeds trauma-informed care as one of
the pillars of professional practice across the organization.
Interestingly, a parallel shift in responding to homelessness illustrates a

similar evolution of understanding trauma-informed practice. An implicit and
xvi Becoming Trauma Informed
explicit recognition has emerged that trauma affects people who are
homeless, and that their trauma-related issues should be considered in
designing services to better meet their needs. The homelessness sector has
pioneered trauma-informed practice in shelters; yet there is still much work
to be done in implementing trauma-informed care within homeless services.
As Hopper et al. (2010) comment:
Strategies for implementation are obscure, few program models exist,

and there is limited communication and collaboration among
programs implementing trauma-informed care. The descriptive and
research literature in this area is sparse, with only a handful of studies
examining the nature and impact of trauma-informed care. More
clarification is needed about what exactly defines trauma-informed
care, what changes should be made within systems wishing to offer
trauma-informed care, and how these changes should be
implemented. (p. 81)
Defining Trauma-Informed and Trauma‑Specific Practice
Various terms, such as trauma-informed and trauma-specific practice, describe

the features of service and system responses used in Canada. A wide range
of perspectives, disciplines and practices reflect different training, under-
standing and purpose around trauma. The concept of trauma-informed
practice can be a source of linkage in the support of trauma survivors across
settings, disciplines and sectors.
Trauma-informed services recognize how the experience of trauma can affect

the confidence, beliefs and behaviours of people coming for help for sub-
stance use and mental health concerns. As identified by Maxine Harris and
Roger Fallot in the early 1990s, trauma-informed services take into account
an understanding of trauma in all aspects of service delivery and place priority
on the trauma survivor’s safety, choice and control.
In trauma-informed services, professionals are not required to treat trauma;

rather, they approach their work with the understanding of how common
trauma is among those they serve, how challenging it may be to establish
Introduction xvii
a therapeutic connection and how critical pacing may be. As such, trauma-
informed approaches are similar to harm reduction–oriented approaches.
Trauma-informed services consider issues around client safety and empowerment

in their policies, practices and staff relational approaches. Trauma-informed
services attend to creating a culture of non-violence, learning and collaboration
(Bloom & Yanosy Sreedhar, 2008). Working in a trauma-informed way does
not necessarily require disclosure of trauma; rather, services are provided in
ways that recognize clients’ likely need for physical and emotional safety, and
for choice and control in decisions affecting their treatment. Practitioners
consider safety in their every interaction with clients, and avoid confronta-
tional approaches.
Trauma-specific services more directly address the need for healing from
traumatic life experiences and facilitate trauma recovery through counselling
and other clinical interventions. Psychological treatments such as cognitive-
behavioural treatments, exposure therapy and sensorimotor psychotherapy
are examples of therapeutic models used in trauma-specific services (Hien
et al., 2009). While not the focus of this book, trauma-specific services are
an essential part of a continuum of care.
A continuum view, with an equity orientation, is embedded in many service

designs. For example, skills training to help trauma survivors build coping
strategies to manage overwhelming emotions and enhance self-care can be
included in both trauma-informed and trauma-specific practice. This is
not surprising, given that safety is the core of first-stage trauma treatment
(Haskell, 2003) and is central to trauma-informed practice. As such, many
trauma interventions, such as Seeking Safety (Najavits, 2002) and the
Sanctuary model (Bloom et al., 2003), include both trauma-informed and
trauma-specific elements.
The successful integration of trauma-informed and trauma-specific practice

within services and across systems of care remains an important challenge.
Achieving this integrated continuum of responsiveness to trauma is rendered
even more difficult by the need to take into account how social determinants
of health such as gender, race and class affect the experience of trauma, the
stigmatization of those affected and their capacity to access care.
xviii Becoming Trauma Informed
Principles of Trauma-Informed Practice
In the invitation to submit chapters, we invited contributors to reflect on

principles of trauma-informed practice. As such, you will see attention
to principles as a common thread throughout this book.
Two presentations of principles greatly affected our early thinking on

trauma-informed practice. First, we were influenced by primary care
practitioners in Saskatoon, Sask., who articulated nine principles of
sensitive practice, built on patient-centred care, but that are “so critical
to survivors’ feeling of safety” that they term them principles of “Sensitive
Practice” (Schachter et al., 2008). The principles include respect (to be
sensitive to how diminished survivors may feel), taking time (to address
feelings of depersonalization and devaluing), rapport (to increase people’s
sense of safety), sharing information (to decrease anxiety and support
involvement), respecting boundaries (to avoid retraumatization), fostering
mutual learning, understanding non-linear healing and demonstrating
awareness and knowledge of interpersonal violence.
We were also influenced by an article entitled “Trauma-informed or trauma-

denied” (Elliot et al., 2005), in which clinicians and researchers involved in
the U.S. Women, Co-occurring Disorders and Violence Study presented
10 principles of trauma-informed services for women, beginning with a
principle related to recognition of the impact of violence and victimization
on development and coping strategies. The second principle stresses how
important it is for recovery from trauma to be integrated as a primary concern
in this work, not delivered in sequential or parallel services: this is critical whether
one is providing trauma-informed or trauma-specific services. The authors
discuss at length aspects of employing an empowerment model and striving
to maximize a woman’s choices and control over her recovery, as it applies
to survivors. The fifth principle situates healing in the context of relational
collaboration built on safety, trust and (as much as possible) a flattening of the
hierarchy of power inherent in a helping relationship. The sixth principle concerns
changing the service atmosphere to modify staff approaches, procedures and
even the physical setting to create a place perceived as safe and welcoming
for survivors. The authors make “strengths-based” a principle, and make it
specific to trauma by noting how important it is to highlight adaptations over
symptoms and resilience over pathology. Minimizing the possibilities of
Introduction xix
retraumatization is another principle: the authors point out how often

survivors can be retraumatized by the services they receive, especially when
they are pushed to uncover memories when they are already overwhelmed.
Cultural competence is also considered a key principle, for both understanding
each woman in the context of her life experiences and cultural background
and supporting unique cultural resources that may support healing. Finally
the authors stress, as with harm reduction, how critical it is to solicit consumer
input and involve consumers in designing and evaluating services as a core
principle of trauma-informed practice.
These principles of trauma-informed practice surface and resurface throughout

this book as authors align their work with these values.
Perspectives on Trauma-Informed Practice
In this book, the authors provide varied interpretations of trauma and its
features. The concept of trauma is described according to disciplinary
perspectives, or in the context of the determinants of health, anti-oppression
frameworks or medical diagnostic practices. Not surprisingly, each of these
understandings of trauma implies different responses—from changing social
structures, to various therapeutic approaches, to medication. Different inter
pretations also imply different breadths of response, often involving multiple
perspectives and systems of care.
It is this most expansive experience and broadest systems approach that

inspires this book, building on the assumption that trauma, whether diagnosed
or not, recognized or not, can determine life course and engagement with
and outcome of health services. Further, all three systems —mental health,
addiction and substance use treatment and violence services—have encountered
challenges to understanding one another, and to moulding their services for
clients of the other systems.
So what might trauma-informed systems of care look like? Harris and Fallot
(2001) suggest that experiences of trauma be taken into account in all aspects
of service delivery and design. It is not necessary to disclose or be diagnosed
with trauma to experience and benefit from these services—a universal
approach recommended by several contributors. Trauma-informed systems
xx Becoming Trauma Informed
also avoid retraumatizing people through authoritarian or “power over”

relationships, or by challenging clients to change in daunting or demanding
ways. Harris and Fallot also suggest that in a wholly trauma-informed system,
there would be no need to link to other care systems in order to get trauma-
informed care. In other words, people could turn up at any service and
experience trauma-informed care.
Fallot and Harris (2009) later included trustworthiness of providers and

choice for clients as additional key elements of trauma-informed care.
More recently, SAMHSA has added nuance to these elements from the client
and provider perspectives and identified the need to foster environments that
are physically welcoming and that encourage the building of community
(SAMHSA, 2011). Within these more nuanced and evolving versions of
trauma-informed care, a range of emotions are both validated and tolerated,
allowing space for distress to be enacted without restrictive responses. These,
then, are the rudimentary features of trauma-informed services and systems.
Numerous evolutions are occurring to reflect these concepts. Practitioners are
being encouraged to provide more open environments in a range of settings
that assume and tolerate trauma-related behaviours, without forcing clients
into diagnostic or treatment moulds.
At the same time, a system of trauma-specific treatment responses exists,

where people with diagnoses linked with trauma receive counselling and
interventions such as eye movement desensitization and reprocessing
(EMDR) or medication. There are integrated therapeutic approaches, such as
the Seeking Safety model, that aim to promote healing and the development
of coping skills, as well as the SAMHSA approaches that meld trauma and
addiction treatment responses. These trauma-specific approaches can coexist
in trauma-informed systems. This book provides examples of trauma-
informed approaches that have been applied with trauma-specific settings.
What does equity have to do with being trauma informed? As in other health
issues, the distribution of trauma may reflect particular inequities and may
contribute to the production of ongoing inequities. For example, experiences
of trauma are mediated by individual and group characteristics such as
gender, age, ethnocultural identity or context. Consequently, trauma-informed
systems must be designed to respond to these differences, identities and
contexts as a key part of their approach.
Introduction xxi
While not all diverse experiences can be represented in this book, it remains
clear that a consistent gender and equity lens must be applied to fully under-
stand trauma-informed principles and practices. Each chapter in this book
pays some attention to gender and equity and to designing systems and
services with these factors and goals in mind. In particular, applying an equity
lens to responses to trauma reveals a variety of needs and issues. Robust
trauma-informed responses are not neutral; there is no “one size fits all”;
rather, trauma-informed responses reflect the different needs and features
of various groups and sub-populations.
References
Anda, R.F., Brown, D.W., Felitti, V.J., Bremner, J.D., Dube, S.R. & Giles, W.H. (2007). Adverse
childhood experiences and prescribed psychotropic medications in adults. American Journal
of Preventive Medicine, 32, 389–394.
Anda, R.F., Felitti, V.J., Bremner, J.D., Walker, J.D., Whitfield, C., Perry, B.D. et al. (2006). The
enduring effects of abuse and related adverse experiences in childhood: A convergence of
evidence from neurobiology and epidemiology. European Archives of Psychiatry and Clinical
Neuroscience, 256, 174–186.
Anda, R.F., Whitfield, C.L., Felitti, V.J., Chapman, D., Edwards, V.J., Dube, S.R. et al. (2002).
Adverse childhood experiences, alcoholic parents, and later risk of alcoholism and
depression. Psychiatric Services, 53, 1001–1009.
Ballon, B.C., Courbasson, C.M.A. & Smith, P.D. (2001). Physical and sexual abuse issues among
youths with substance use problems. Canadian Journal of Psychiatry, 46, 617–621.
BC Society of Transition Houses. (2011). Reducing Barriers to Support for Women Fleeing Violence:
A Toolkit for Supporting Women with Varying Levels of Mental Wellness and Substance Use.
Vancouver: Author.
Bloom, S.L., Bennington-Davis, M., Farragher, B., McCorkle, D., Nice-Martin, K. & Wellbank, K.
(2003). Multiple opportunities for creating sanctuary. Psychiatric Quarterly, 74, 173–190.
Bloom, S.L. & Yanosy Sreedhar, S. (2008). The Sanctuary model of trauma-informed
organizational change. Reclaiming Children and Youth, 17(3), 48–53.
Brown, C. (2009, March). The pervasiveness of trauma among Canadian women in treatment for
alcohol use. Paper presented at the Looking Back, Thinking Ahead: Using Research to
Improve Policy and Practice in Women’s Health Conference, Halifax, NS.
Chan, H., Abela-Dimech, F., Chambers, J., Herie, M., Kelly, C., Mawhinney, J. et al. (n.d.).
CAMH Practice Model: Partners in Care. Toronto: Professional Practice Office, Centre for
Addiction and Mental Health.
xxii Becoming Trauma Informed
Chansonneuve, D. (2005). Reclaiming Connections: Understanding Residential School Trauma

among Aboriginal People. Ottawa: Aboriginal Healing Foundation.
Chapman, D., Whitfield, C., Felitti, V.J., Dube, S., Edwards, V. & Anda, R. (2004). Adverse
childhood experiences and the risk of depressive disorders in adulthood. Journal of Affective
Disorders, 82, 217–225.
Corrado, R.R. & Cohen, I.M. (2003). Mental Health Profiles for a Sample of British Columbia’s
Aboriginal Survivors of the Canadian Residential School System. Ottawa: Aboriginal Healing
Foundation.
Dube, S., Felitti, V.J., Dong, M., Chapman, D., Giles, W. & Anda, R. (2003). Childhood abuse,
neglect, and household dysfunction and the risk of illicit drug use: The Adverse Child
Experiences Study. Pediatrics, 111, 564–572.
Elliott, D.E., Bjelajac, P., Fallot, R., Markoff, L.S. & Glover Reed, B. (2005). Trauma-informed or
trauma-denied: Principles and implementation of trauma-informed services for women.
Journal of Community Psychology, 33, 461–477.
Fallot, R. & Harris, M. (July 2009). Creating Cultures of Trauma-Informed Care (CCTIC):
A Self‑Assessment and Planning Protocol. Washington, DC: Community Connections
Harris, M. & Fallot, R.D. (2001). Using Trauma Theory to Design Service Systems. San Francisco,
CA: Jossey Bass.
Haskell, L. (2003). First Stage Trauma Treatment: A Guide for Mental Health Professionals Working
with Women. Toronto: Centre for Addiction and Mental Health.
Haskell, L. & Randall, M. (2009). Disrupted attachments: A social context complex trauma
framework and the lives of Aboriginal Peoples in Canada. Journal of Aboriginal Health,
5(3), 48–99.
Herman, J. (1992). Trauma and Recovery: The Aftermath of Violence—From Domestic Abuse to
Political Terror. New York: Basic Books.
Hien, D., Litt, L.C., Cohen, L.R., Meile, G.M. & Campbell, A. (2009). Trauma Services for Women
in Substance Abuse Treatment: An Integrated Approach. Washington, DC: American
Psychological Association.
Hopper, E.K., Bassuk, E.L. & Olivet, J. (2010). Shelter from the storm: Trauma-informed care in
homelessness services settings. Open Health Services and Policy Journal, 3, 80–100.
Kessler, R.C., Sonnega, A., Bromet, E. & Hughes, M. (1995). Posttraumatic stress disorder in the
National Comorbidity Survey. Archives of General Psychiatry, 52, 1048–1060.
Logan, T., Walker, R., Cole, J. & Leukefeld, C. (2002). Victimization and substance abuse among
women: Contributing factors, interventions and implications. Review of General Psychology,
6, 325–397.
Men’s Trauma Centre (2009). Annual Report. Retrieved from www.menstrauma.com/?page_id=16
Najavits, L.M. (2002). Seeking Safety: A Treatment Manual for PSTD and Substance Abuse.
New York: Guilford Press.
Introduction xxiii
Niccols, A., Dell, C.A. & Clarke, S. (2009). Treatment issues for Aboriginal mothers with
substance use problems and their children. International Journal of Mental Health and
Addiction, 8, 320–335.
Poole, N. (2007). Interconnections among women’s health, violence and substance use:
Findings from the Aurora Centre. In N. Poole & L. Greaves (Eds.), Highs and Lows: Canadian
Perspectives on Women and Substance Use (pp. 211–212). Toronto: Centre for Addiction and
Mental Health.
Schachter, C., Stalker, C.A., Teram, E., Lasiuk, G.C. & Danilkewich, A. (2008). Handbook on
Sensitive Practice for Health Care Practitioners: Lessons from Adult Survivors of Childhood
Sexual Abuse. Ottawa: National Clearinghouse on Family Violence.
Substance Abuse and Mental Health Services Administration. (2011). National Center for
Trauma-Informed Care. Retrieved from www.samhsa.gov/nctic/
Van Wyck, L. & Bradley, N. (2007). A braided recovery: Integrating trauma programming at a
women’s substance use treatment centre. In N. Poole & L. Greaves (Eds.), Highs and Lows:
Canadian Perspectives on Women and Substance Use (pp. 365–372). Toronto: Centre for
Addiction and Mental Health.
Wesley-Esquimaux, C. & Smolewski, M. (2004). Historic Trauma and Aboriginal Healing.
Ottawa: Aboriginal Healing Foundation.
PART 1
WHAT IS “TRAUMA INFORMED”

IN THEORY AND PRACTICE?
3
Introduction
Section 1: Theory
This first section describes the landscape of trauma-informed thinking and
sets out the terrain of this book. Four authors trace the evolution of trauma-
related concepts, ask key questions about trauma and trauma-informed
practice, describe some approaches to therapy and name critical issues
connected to disclosure.
What is trauma and how is it conceptualized? What does it mean to be

trauma informed? What are some examples of trauma-informed practice?
How does disclosing trauma affect both individuals and service providers?
What can be learned from trauma? Raising these questions is critical to
understanding the field of trauma-informed practice and the challenges
faced by service providers in various segments of the system.
The range of questions and disciplines engaged in thinking about trauma-

informed and trauma-specific practice is potentially wide. In Chapter 1,
Haskell outlines essential elements to understanding the bio-psychosocial
implications of trauma. She describes complex, developmental trauma and
how chronic stress affects the brain and body. She provides a succinct and
compelling overview of the importance of attachment to developing the
capacity to regulate physiological arousal and form a sense of identity and
agency. Haskell describes how understanding the impact of trauma on
emotional development and reactivity is essential for anyone working with
people who have been traumatized: this understanding enables the practitioner
to respond to survivors with the message that their lives are understandable
and that their behaviours (including alcohol and other drug use) make sense
when they are interpreted through a trauma-informed framework.
There are many forms of trauma—simple, complex, developmental, inter-

generational—and many variations in how trauma is experienced. While it is
beyond the scope of this book to provide detail on the mechanisms underlying
all trauma responses, Haskell’s discussion of the impact of developmental
trauma is intended to promote understanding of the basis for the trauma-
informed work and to invite the interested reader to seek in-depth exploration
4 Becoming Trauma Informed
of trauma responses beyond these pages. Haskell and other contributors

advocate the use of a trauma lens to help practitioners better understand the
trajectories, coping strategies and strengths of the people seeking help for
mental health and substance use concerns.
In Chapter 2, Zingaro addresses a fundamental but often overlooked set of

questions about the effects of trauma disclosure on practitioners as well as clients,
and what we can learn from trauma. She provides a nuanced commentary
about the processes and dynamics of disclosure. Zingaro’s provocative piece
makes us see the complex aspects of disclosure, a key element in discussions
of trauma-informed practice. Asking certain questions to evoke disclosure,
she argues, is not necessary to trauma-informed work; in fact, it can complicate
the recovery process. Rather, Zingaro suggests that some assumptions can be made
about the universal aspects of trauma experiences and that practices be based on
a “universal precautions philosophy.” Instead of demanding disclosure at intake,
for example, building strong relationships between survivors and service
providers will enable disclosure to take place, possibly, in a more controlled
and safe manner.
Toner and Akman, in Chapter 3, draw parallels between trauma-informed

practices and feminist understandings of helping work. They argue that
feminist therapy is inherently trauma informed; it was feminists who set the
stage for understanding and diagnosing posttraumatic stress disorder. Toner
and Akman suggest that trauma-informed work embodies many components
of feminist paradigms. They describe the dimensions of their Gender Role
Socialization Scale, which measures the effects of general oppressive practices
on women’s mental health. They also present their Enhancing Women’s
Well-Being group intervention that encourages women to examine the effects
of gender-role messages on their mental health. While not solely focused on
trauma, both the scale and the intervention they have developed address the
overarching oppressive circumstances that result in trauma in women’s lives.
In Chapter 4, Timothy describes anti-oppression psychotherapy as a form of

trauma-informed practice. She, too, links trauma to other forms of oppression
and suggests that the treatment of trauma and oppression be carried out
recognizing the intersectional nature of violence—the fact that violence derives
from multiple sources at once. Not only is anti-oppression psychiatry helpful
to clients; it also engages change processes in therapists and communities by
Introduction: Trauma-Informed Theory and Practice 5
encouraging them to “actively resist oppressive practices.” Timothy describes

the steps involved in engaging with anti-oppression psychotherapy with clients,
emphasizing the fluidity of the processes and the change opportunities for
both the client and the practitioner, given continuous reflexivity.
Taken together, these four chapters engage critically with trauma-informed

principles and ask deep questions about the links between societal practices
and oppressive structures and trauma. They also probe the links between
trauma and practice, arguing for overarching, universalist approaches, as well
as continued reflexivity for practitioners and systems as they set the stage—or
not—for disclosure of trauma.
Section 2: Practice
Contributors to Section 2 illustrate various practices or approaches to doing
healing work, describing how they can be, or become, trauma informed.
Three examples are outlined, with trauma-informed questions forming the
basis of these descriptions. These direct applications, or adaptations, of
practice represent hopeful opportunities for modifying practice and evolving
current approaches into more trauma-informed responses.
For example, Urquhart and Jasiura in Chapter 5 discuss motivational interviewing

and how it coincides with trauma-informed practice. They illustrate some
fundamental principles of motivational interviewing that support and enliven
trauma-informed practices, such as collaborating with clients, strengthening
relational ties, building on strengths, avoiding direct confrontation with clients
and not limiting their options or using negative labels. Instead, motivational
interviewing is consistent with Haskell’s trauma-informed recommendation
for reframing problems as coping behaviours and symptoms as adaptations.
Further, motivational interviewing calls on service providers to rein in their
natural inclinations to “fix” the client or her or his problems and to give advice.
In Chapter 6, Haarmans discusses cognitive-behavioural therapy (CBT) for

psychosis and links it to trauma-informed practices. She illustrates how
closely tied are the experiences of trauma and psychosis and how many
typical responses to psychosis, such as forced hospitalization, restraints or
medications, are retraumatizing and may cause posttraumatic stress disorder.
Haarmans argues that psychosis can be viewed as a possible response to

trauma. She also points out the importance of sex/gender in understanding
psychosis in relation to trauma and laments the lack of attention to these
factors. Haarmans suggests that an empowerment model can be integrated
into CBT as trauma-informed practice by normalizing symptoms, collaborating
with clients and teaching coping strategies.
Hughes and Hyman discuss bodywork and trauma and how bodywork can be
trauma informed. In Chapter 7, they argue that trauma often creates a mind/
body separation and that bodywork is a practical way to create reconnections.
Hughes and Hyman link laughter yoga and Brain Gym to stress management
and healing for people with substance use and mental health issues who may
also have trauma histories. In part, bodywork encourages “mindfulness” and
reinforces agency in those with trauma histories who are trying to heal and
recover, without requiring disclosure. These techniques are part of positive
psychology and encourage the development of supportive social environments
for people experiencing trauma.
These three wide-ranging examples of responsive approaches to working with

clients with trauma histories illustrate the adaptability of old forms of therapy,
as well as introducing newer forms into existing therapeutic milieus. These
examples incorporate elements of trauma-informed care, offering innovative,
positive ways for practitioners and clients to deal with symptoms without
necessarily requiring disclosure of past trauma.
PART 1
SECTION 1: THEORY
1 A Developmental Understanding of Complex Trauma
2 Traumatic Learning
3 Using a Feminist- and Trauma-Informed Approach in Therapy

with Women
4 Anti-oppression Psychotherapy as Trauma-Informed Practice

9
Chapter 1
A Developmental Understanding
of Complex Trauma
Lori Haskell
Traumatic experiences shape many aspects of the lives of survivors of abuse.

The changes or alterations in abuse survivors’ cognitions and emotional
regulation are often complicated and varied. When not seen through a trauma
lens, these alterations or changes can be inappropriately labelled as pathological
by service providers instead of being viewed as understandable adaptations a
person has had to make in order to cope with life’s circumstances. It is not a
coincidence that many people struggling with substance use problems have
abuse and trauma histories that have not been addressed. It is critical that
mental health and substance use service providers understand the dynamic
interplay between the traumatic stressors and the complex and often diverse
adaptations that people develop in order to survive.
A trauma lens allows us to appreciate that early abuse and neglect are not
discrete events; instead, they often become defining life experiences that can
shape and even distort core aspects of a person’s identity. These early adverse
experiences are often formative and people respond by constructing a sense of
self, a sense of others and a belief about the world that is profoundly influenced
by these horrific life experiences (Harris & Fallot, 2001). It is important that
people working in the helping professions understand that abuse survivors are
often not able to recall these early adverse experiences; rather, they are evoked
or triggered. A trauma-informed perspective recognizes that people who have
been chronically abused or neglected may have many possible triggers. These
triggers often include situations where clients experience a lack of respect and
safety and an absence of control and choice—experiences that often mimic and
resonate with past traumatic experiences.
Working in a trauma-informed way involves more than adhering to a set of

general principles. It requires service providers to work from a thorough
understanding of the complex and diverse alternations in the many domains
of a traumatized person’s development. This chapter outlines some of the
fundamental ways in which chronic abuse and neglect in childhood lead to
traumatic responses, which can reverberate through many aspects of a person’s
life. These traumatic experiences have developmental impacts on both mind
and body, and can sometimes lead to substance use problems as a way of
coping with overwhelming experiences and intolerable feelings. This chapter’s
goal, therefore, is to inform the practice of service providers in the mental
health and substance use fields about the importance of a trauma-informed
approach when working with trauma survivors.
Understanding Complex Trauma through

a Biopsychosocial Lens
Complex Trauma
People who are abused and neglected in childhood often experience a range
of long-term effects, both psychological and physical. It is well established
in the literature and from clinical experience that survivors of abuse tend to
experience significantly more mental health difficulties, such as depression,
sexual dysfunction, dissociation, anger, suicidality, self-harm and substance
use problems, than people who do not have histories of abuse (Briere & Jordan,
2004). Prolonged childhood abuse can also be associated with harmful long-
term physical health effects. Recent research shows that the more adverse
childhood experiences a person reports, the more likely he or she is to develop
life-threatening illnesses such as heart disease, cancer and stroke (Van der
Kolk, 2005).
Traumatic effects are especially acute when the abuse or neglect is ongoing,
when it begins in childhood and when the perpetrator is someone the person
should have been able to trust. A child’s earliest experiences, even those
Chapter 1 A Developmental Understanding of Complex Trauma 11
beyond conscious recall, play a crucial role in his or her behaviours, attitude
development, relationships and sense of self in later life. Adverse childhood
experiences can alter the young child’s social, emotional, neurological,
physical and sensory development.
Understandably, children who have been abused often have problems with
attachment and forming intimate relationships. They are often unable to
regulate their emotions and impulses and can experience cognitive impairment
and attention deficits, as well as somatic (bodily) disorders like chronic pain.
In many cases, people who endured childhood abuse and neglect develop
what might seem like a bewildering array of problems throughout their lives.
These difficulties can appear to be incomprehensible to those who do not
understand how abuse and trauma can impair a person’s capacities and, in
turn, limit his or her life opportunities. Many service providers, and in many
cases the survivors themselves, can misunderstand these difficulties as self-
inflicted because they do not understand how abuse, trauma and their effects
reverberate throughout a person’s life.
The Potential for Misdiagnosis

Without a clear understanding of how trauma affects people developmentally,
misdiagnosis can be an issue in working with people with substance use and
mental health problems. For example, without applying a trauma lens, coping
mechanisms, such as self-harming, may be given diagnoses such as bipolar
disorder and treated exclusively with drugs and behaviour management
(Van der Kolk, 2005). Borderline personality disorder is another diagnosis that
can be inaccurately applied, especially to women who have experienced trauma.
Trauma experts underline that it is important to understand that people with
complex posttraumatic stress disorder (PTSD) do not have symptoms that
constitute separate, “dual” or comorbid diagnoses, but rather, that these symp-
toms represent the complex somatic, cognitive, affective and behavioural effects
of trauma. A single diagnosis of complex PTSD presents an empirically based,
conceptually coherent and unified set of symptoms as a basis for compassionate
treatment planning (Cloitre et al., 2009).
Because the study of traumatic stress is still an emerging field, psychiatrists,

social workers and psychologists trained in traditional frameworks may under-
estimate the role that abuse and neglect play in both mental health and substance
use problems. We now know, however, that early abuse and neglect can have
diverse and far-reaching effects on attachment, brain development, emotion
regulation and cognition, and that early abuse can disrupt development at
different stages, even when the abuse has stopped.
There have been dramatic developments in our understanding of the nature

and impact of trauma, including the distinction between simple and complex
trauma, in the fields of psychology, psychiatry and neuroscience in recent years.
How Stress Affects the Brain and the Body

When faced by threat or danger, the mind and body protect us by preparing
us to fight or flee. These responses are controlled by the autonomic nervous
system (ANS) and are automatic and unconscious. The ANS has two complemen-
tary divisions: the sympathetic nervous system, which activates our nerves,
organs and muscles into a heightened state of arousal and regulates the “fight
or flight” mechanism, and the parasympathetic nervous system, which controls
the body’s calming mechanisms (as well as the “freeze” response) and is designed
to shut down body systems or return the body to baseline arousal levels.
The standard physiological model of the ANS is of reciprocal tension between the

sympathetic and parasympathetic systems, with the two parts keeping each other
in check. When the sympathetic response goes up, the parasympathetic response
goes down. A good example of optimal autonomic balance can be seen in cats,
which become alert to certain sounds or movements, but return immediately to
a relaxed state as soon as the situation is assessed as safe.
The parasympathetic nervous system comes into operation after the threat
has been responded to and action has been taken. It has the opposite effect
of sympathetic activity, allowing the body to wind down and rebalance. The
activation of the parasympathetic nervous system encourages relaxation
of muscles, slowing the heart rate and lowering blood pressure. It helps
breathing to return to its normal rate; digestive juices flow; bladder and
bowels are ready to function again; the pupils constrict; and immune
functions, such as the production of white blood cells, recommence. The para
sympathetic mode supports rest and sleep.
The fight or flight response is activated by the amygdala, which is located in

the limbic system and is the defensive centre in the brain. (The amygdala can
be seen as having a similar function to a smoke detector.) Sensory threat cues
(sights, sounds, body sensation and smells) are encoded in the amygdala, and
this database of threat cues allows the amygdala to respond to danger quickly
and without thought.
Once a threat is detected, a cascade of neurochemicals from the adrenal glands is

released into the bloodstream and initiates the adrenaline stress response. These
patterns of nerve cell firing and chemical release prepare the body for action:
heart rate and respiration increase; oxygen flow to muscle tissue increases; and
other non-essential organ systems, including the frontal cortex, are turned off.
When the Threat of Danger Becomes Chronic

Survivors of trauma and abuse often live in environments where they constantly
face the threat of danger. This danger can be in the form of emotional or physical
abuse, neglect, abandonment or sexual violation. Living with constant fear
results in a state of constant alertness or hyperarousal, which is extremely taxing
on the nervous system.
People who live in conditions of constant danger eventually experience a

breakdown in the amygdala’s ability to discriminate threat cues. As a result,
survivors of abuse begin to have persistent, recurring, overly defensive
reactions, even to harmless stimuli.
Simply said, when danger is ever-present, the alarm (amygdala) goes off too
frequently, and the brain becomes conditioned to treat all potential threats as
actual threats. When this happens, past and present danger become confused,
and the brain is hyperaroused and reactive to any number of triggers, without
being able to differentiate between real and perceived threats. This state of
alert causes people to be on the lookout for every possible danger. Fear becomes
the lens through which they see the world.
As a result, trauma survivors, who feel chronically on high alert, are easily
triggered to take flight or fight. The thinking brain (prefrontal regions) auto-
matically shuts down in the face of triggers. In this state, people are unable to
reflect or cognitively assess their reactions; instead, they experience states of
anxiety, panic or dissociation.
Complicating this hyperaroused brain state even more is the fact that traumatic
memory is stored and processed differently than normal memory (Van der
Kolk, 1994). Psychiatrist Bessel van der Kolk (1994) explains that traumatic
memories are stored as dissociated sensory and perceptual fragments that may
be triggered by current unrelated life events, like a tone of voice or a facial
expression we notice in someone else. When people are triggered, the present
feels like the past. Survivors are not remembering their traumatic experiences;
they are re-experiencing them.
The physiological adaptations that abuse survivors develop in response to

ongoing threat produces a chronic, underlying state of “dysregulation” or
imbalance in the body, which often results in hyperarousal and hypervigilance
(in which a person seems to overreact to every situation) or listlessness and
dissociation (in which a person seems numb and disconnected in stressful
or dangerous situations). This dysregulation of the brain and body systems
perpetuates mental, emotional and physical distress.
Loss of Optimal Autonomic Balance

Children living in households where they are unsafe, neglected or abused
must learn and grow despite the pervasive experience of threat. Children are
able to do this by adapting to the ongoing state of fear they are experiencing,
but they do so at a great cost to their development. The developing brain is
exquisitely sensitive to stress. Infancy and childhood are the most critical
developmental periods; the human brain completes 75 per cent of its total
development within the first six years of life (Eliot, 2000).
The cumulative effect of the body undergoing the excessive stress of being in
a hyperaroused state, in which the person is constantly prepared to take fight
or flight, eventually takes a toll on physical health. Parasympathetic nervous
system processes are suppressed by overactive sympathetic arousal. As a result
of this imbalance, problems with digestion and sexual dysfunction can

develop. Excessive stress does not always show up as the “feeling” of being
stressed. Many stresses go directly into one’s physical body and may only be
recognized by the physical symptoms the person manifests.
For example, disorders of the autonomic nervous system, such as headaches,

irritable bowel syndrome and high blood pressure, are common in people
with trauma histories. As well, prolonged stress responses may result in
chronic suppression of the immune system, creating susceptibility to infection,
chronic fatigue, depression and autoimmune diseases such as rheumatoid
arthritis, lupus and allergies (Van der Kolk et al., 1996). Traumatic experiences
alter the functioning of the central nervous system, as well as general physio-
logical functioning. In this way, trauma has both emotional and physical effects.
As overwhelming and complex as these changes appear, they are only a part
of the overall picture. Children who experience ongoing neglect and abuse by
their own parents or caretakers are often not soothed or comforted when they
are frightened or overwhelmed. Instead, in an attempt to manage these over-
whelming dysregulated states and chronic stress, abuse survivors often develop
what may appear to be extreme coping strategies.
Abuse survivors frequently engage in self-harm in an attempt to reduce tension

or downgrade high levels of arousal. Neurobiological attempts to cope with the
trauma include self-harm (which may be invasive and involve cutting), suicidality,
eating disorders and addictive behaviour. These signify different ways of modu
lating or managing a dysregulated nervous system. For example, trauma survivors
who feel dead inside or chronically numb may use self-injury and suicidal
ideation to induce adrenaline and endorphin responses. For others who feel
too much, self-starvation and overeating may create feelings of numbness.
Subsequently, addictive behaviours can be tailored to induce either numbing
or increased arousal or a combination of both (Fisher, 2003).
People who have been traumatized become focused on short-term survival and
are not able to consider long-term consequences of their coping strategies.
They will do whatever they can to keep themselves out of pain. They learn to
disconnect from their bodies in order to avoid feeling the overwhelming pain
and stress.
The accumulation of years of prolonged stress and the extreme adaptations

developed to manage these chronic states (e.g., self-harm, substance abuse)
result in greater morbidity and higher mortality from all causes, including
accidents and homicide (Vaccaro & Lavick, 2008).
Attachment, Attunement and

the Development of Core Self-Capacities
A comprehensive overview of a child’s psychological development, attachment
system and social context is required to understand the depth and complexity
of prolonged childhood abuse and neglect. This is because complicating and
amplifying the intense difficulties with chronic physiological arousal is the
added problem of not developing the capacity to regulate and manage physio
logical arousal.
Regulating emotions is fundamental to the development of the self. Attachment

relationships are the primary context within which we learn to regulate affect
and to access, modulate and use our emotions (Fonagy et al., 2002; Schore,
2003). A child requires secure attachment for healthy psychobiological develop
ment. Learning to soothe and calm intense emotional states is a developmental
lesson that is often adversely affected as a result of childhood abuse and neglect.
Parents are required to keep children safe and to teach them how to handle
adversity and emotional upset. When parents are able to provide safety and
predictability and to teach skills to manage different psychological experiences,
children develop important self-capacities. Self-capacities are the inner abilities
that allow individuals to manage their intrapersonal worlds and allow them to
maintain a coherent and cohesive sense of self (McCann & Pearlman, 1990).
The three self-capacities that are thought to be especially important to the

individual’s response to averse events are identity, boundary awareness and
affect regulation (Briere, 1996). The child’s developing capacity to regulate
emotions and develop a coherent sense of self requires sensitive and respon
sive parenting; otherwise the child will develop dysregulated affect (meaning
that he or she cannot regulate the intensity of feelings or problem-solve ways
to manage them).
Maté (2008) explains:
A child’s capacity to handle psychological and physiological stress is

completely dependent on the relationship with her parent. Infants
have no ability to regulate their own stress apparatus. We acquire this
capacity gradually as we mature—or we don’t, depending on our
childhood relationships with our caregivers. (p. 191)
Children who are neglected and abused experience overwhelming emotional

pain without anyone to comfort them. As a result, they do not implicitly learn
problem-solving strategies or means to comfort themselves or self-soothe. The
emotional pain they carry exceeds their capacity to handle pain. This means that
a person who is traumatized early in life not only has higher levels of anxiety, agita
tion and general physiological arousal; he or she also has a diminished ability
to regulate or deal with these intense states. In other words, the trauma survivor
has increased emotional distress and decreased capacities to cope with it.
The Importance of Parental Attunement

In order for children to develop an authentic, foundational sense of who they
are in the world, they require a secure attachment relationship where they
experience a caregiver who is emotionally attuned to them. To “attune” to a
child means having a caregiver who responds to the child’s needs, particularly
emotionally. This results in the child developing a sense of being understood,
cared for and valued. It is often assumed that infants first learn to identify
their emotional states from internal cues. On the contrary, infants learn to
differentiate their internal states on the basis of external cues (parents’ empathic
emotional responses).
Children develop secure attachment as a result of experiencing a parent who

is predictably and consistently responsive to their basic needs, for feeding
and caring for them, as well as for protection and play. Attachment theory
suggests that the care an infant receives becomes a model around which the
child’s developing brain learns to organize his or her behaviour. Sensitive,
responsive care will result in a secure attachment; inconsistent, rejecting,
neglectful or abusive care—when the child’s emotions are ignored, discounted,
humiliated or punished—will produce a child who is insecurely attached or

has other attachment difficulties.
The inability to be safely and securely attached to others undermines the

person’s capacity to develop and rely on relationships to establish a feeling
of security. These experiences can lead to long-standing anxiety and stress,
feelings of rejection and abandonment and continual dissatisfaction with and
distrust of close, intimate relationships. People who have these experiences
can enter similar states as adults without any explicit memory of this experience
(Maté, 2008). They often will describe these feelings as coming out of nowhere.
These implicit memories of shame, degradation and neglect often get triggered
in relationships throughout life.
Early attachment patterns strongly predict how a person will deal with other
relationships throughout the lifespan. Abuse that happens in a primary
attachment relationship undermines the development of the core self,
including the capacity for self-regulation.
The Effect of Abuse and Neglect on Identity

and Agency
Children who have experienced ongoing abuse, parental misattunement and
neglect develop a view of the world that incorporates their betrayal and hurt.
An expectation that they will be harmed permeates their relationships. This
expectation is expressed as negative self-attributions, loss of trust in caretakers
and loss of the belief that someone will look after them and make them feel
safe. These children tend to lose the expectation that they will be protected,
and act accordingly. While these defensive mechanisms may work for a child
who is trying to protect himself or herself from external threats or internal
pain, these coping mechanisms also set up the child for a lifetime of empti
ness, loneliness and emotional isolation. People who have been neglected
and traumatized often do not develop an internal sense of self. Instead, they
defensively withdraw, and this self-protective retreat impairs their ability to
be self-reflective. This results in their lacking the language to refer to internal
states and in a diminished interpretive ability (Siegel, 1999). They tend to
dissociate from both their inner and outer worlds, without knowing what
they are feeling, and they often lack even a basic knowledge of their
emotional states.
Dissociating precludes the need to develop other, more complex affect regulation
skills. At the same time, individuals who have been traumatized become
hypervigilant. This constant external focus pulls attention away from internal
developmental tasks, such as building self-awareness and affect-modulation
skills. As a result, trauma survivors do not have the ability to predict their own
reactions in different situations, so they are unable to anticipate what they may
feel and prepare coping strategies. People require access to their feelings in
order to guide their behaviour. For example, being fearful of walking on a
secluded, dark street usually motivates people to take extra precautions or
avoid the dangerous situation altogether.
One of the most important components of affect regulation is the ability

to correctly perceive and label emotions as they are experienced. Without
knowing what we are feeling, we are at a loss as to how to develop a strategy
to modulate that feeling state. This combination of processes undermines
the individual’s ability to develop affect regulation skills.
The combination of having a deficit in skills or strategies to manage and

tolerate affect and a dysregulated nervous system stemming from early
abuse and neglect results in heightened reactivity. The implication of these
coalescing processes is that people who have been traumatized have a
diminished ability to deal with the stress and challenges of everyday life.
They develop a lower set for their internal stress system and are often anxious,
distressed and triggered easily.
One of the most detrimental effects of early abuse and neglect is the
development of an implicit schema that people are not to be trusted. After
years of feeling hurt and abandoned by their caretakers, traumatized people
often feel separate from others. They often lack the ability to have healthy
and reciprocal relationships, because they have never developed an internal
template for what a healthy relationship is like.
Many people do not understand that individuals who have been traumatized
fear not only being physically or sexually harmed; they also fear being emotion-
ally overwhelmed by what others may trigger in them. They experience people
as threats to emotional well-being and learn to avoid close emotional connection.

Unfortunately, this often means that they do not have others to draw on as a
source of comfort.
Neglect and abuse impinge on a sense of self-agency and promote a defensive

withdrawal from the mental and emotional world. Many difficulties that people
who have been traumatized experience relate to these two factors—emotional
vulnerability plus deficits in the skills needed to regulate and manage these
vulnerabilities. This dual process of an easily dsyregulated response to stress
and daily emotional challenges and the deficits in core self‑capacities leaves
the individual vulnerable to developing substance use problems.
Trauma-Informed Practice
This chapter has outlined the many different domains of individual functioning
that are affected by prolonged abuse and neglect. It has explained how
different areas of a person’s functioning have been shaped and altered by early
experiences of abuse, neglect, misattuned parenting, insecure attachment
and, often, maladaptive coping. The physiological adaptations resulting from
traumatic stress, as well as the effects of this stress on identity and agency,
have implications for how mental health and substance use services should
be delivered.
Understanding the impact of trauma on emotional development and reactivity

is essential for anyone working with traumatized individuals. This is particu-
larly the case because situations involving control and choice are bound to
occur in the helping relationship.
The most useful interventions are collaborative, meaning that the therapist
or other service provider and the client work together to help the client learn
about his or her interpersonal schemas and triggers. Clients need this
information so they can work actively to create strategies and approaches
for dealing with their triggers, rather than using the information to avoid
situations or interpersonal interactions that resonate and trigger them.
One of the most important components of providing services for people who
have experienced trauma is to respond to survivors with the message that their
lives are understandable and that their behaviours make sense when inter-
preted through a trauma-informed framework. Clients feel understood and
validated, especially when the adaptations they have developed are recognized
as being their best attempts at coping. Many of these coping strategies helped
survivors to endure the abuse while it was occurring. The use of alcohol and
other substances is a common coping strategy to numb emotional pain.
Many of the adaptations that people who have experienced trauma develop to
survive their abuse may be perceived as pathological conditions in intake and
assessment processes that are not trauma informed. For example, clients who
chronically dissociate and imagine a protective spirit whisking them away
from danger may be misunderstood (or incorrectly diagnosed) as having a
psychotic condition. Herman (1992) explains that women who are highly
dissociative as a result of early trauma may be diagnosed with depression
and in some cases schizophrenia. When this happens, clients may be offered
medications to treat their “delusions,” instead of being given a framework
within which to understand the development of their dissociative response.
The importance of the biopsychosocial trauma framework and the insights it

provides mental health and front-line workers is crucial for working from a
trauma-informed approach. Understanding clients with abuse and neglect
histories and substance use problems from a neurobiological perspective
allows treatment to focus on helping them increase their self-capacities.
Specifically, it orients the clinical work toward enhancing clients’ abilities to
self-regulate their emotional states and calm their nervous systems. Rather
than focusing on clients’ narratives of the past, the focus is on their physical
self-experience and self-awareness.
Helping people make necessary therapeutic changes in their lives can be

extraordinarily difficult. In addressing people’s maladaptive coping (such as
drinking), Marsha Linehan (1993) explains the therapeutic challenge in
striking a delicate balance between supporting and reassuring the client and
focusing on the client’s need to make positive and concrete life changes.
Trauma interventions require considerable therapeutic focus on accepting
and validating the client’s current coping, while simultaneously teaching a
broad range of behavioural skills. The therapeutic stance that Linehan
promotes is a focus on acceptance with a corresponding focus on change
(Linehan, 1993).
Although the ultimate goal is to help clients develop more effective coping
strategies, this cannot be effectively done if clients feel that what they have
been attempting to do is invalidated and harshly assessed. Clients with abuse
histories often develop extreme coping to adapt to life demands, even when
these adaptations (e.g., self-harm, dissociation, substance use) create their
own sets of problems. When trauma survivors feel validated and understood,
they are able to start feeling less threatened.
It is important for people who have been traumatized to learn that their
adaptations were developed as responses to overwhelming stressors. It is
also important for them to recognize that the coping strategies they have
developed have a function and purpose. Most important, perhaps, it is
reassuring for survivors to learn more effective ways of coping.
Working with substance use problems using a trauma-informed framework

means assessing the function of the substance use as it relates to the individual’s
abuse history and adaptations. How does this adaptation (substance use) help
this person? What difficulty is being addressed by using substances? What
would this person need in order to cope without this adaptation? For example,
when examining a client’s substance use problem, the therapist, rather than
considering “How do I understand this problem or this symptom?” would, in
keeping with a trauma-informed approach, consider, “How do I understand
this person?” This approach shifts the focus onto the individual and away
from some limited aspect of his or her functioning (Harris & Fallot, 2001).
As Harris and Fallot (2001) explain, it is rarely effective to eliminate the coping
strategy of intoxication without providing alternative solutions that target
specific trauma-related problems. We must understand the specific function
of the substance use problem (e.g., alcohol helps me be social) in order to offer
alternatives. For example, a person who has a schema of unworthiness and
self-loathing may feel a great deal of fear about being social with others and feel
shame about exposing who he or she is to others. However, when the person
drinks alcohol, these fears are obliterated and he or she feels more comfortable
being social.
Linking Trauma-Informed Approaches with

Trauma‑Specific Therapies
There is often a necessary overlap between trauma-informed approaches and
first-stage trauma treatment. State-of-the-art trauma therapies are strongly
influenced by increasing clinical awareness that affect intolerance and dys-
regulation, rooted in our biology and bodies, contribute to ongoing distress in
traumatized clients. Neurobiological research and theory strongly suggest the
need to develop new approaches to treatment to incorporate these insights.
Increasingly, trauma therapists are using treatments that focus on somatic
(body) processing and that teach clients how to calm their nervous system.
The core tasks of these types of therapies are to provide clients with psycho-
education so they better understand their experiences of having overaroused
nervous systems and their automatic trauma reactions or triggers. As well,
clients learn to disrupt their habitual trauma responses by recognizing them
in the moment. In sessions with the clinician, clients are taught mindfulness
instead of reactivity; with carefully paced therapies, clients are typically able to
experience a more regulated nervous system.
Insight and understanding are not enough to keep traumatized clients from
regularly feeling and acting as if they are experiencing trauma all over again.
They need to learn to manage affect intensity and to regulate emotions. The
role of the mental health professional is to facilitate self-awareness and self-
regulation. Clinicians need techniques and approaches that help traumatized
clients become aware of their internal sensations and that help clients know
that it is safe to experience their feelings.
Trauma-Specific Therapies
Some of the current trauma-focused clinical treatments found to be most
effective in reducing the symptoms of trauma tend to link sensorimotor
responses (body movements and sensations) to thoughts and feelings. These
treatments, outlined below, are based on the theory that focusing attention
on the traumatic responses of the body and mind will encourage and facilitate
a client’s inherent self-regulatory abilities. Clients who are interested in
additional stages of support can benefit by being referred to clinicians who

deliver these trauma-specific therapies.
Clinical research has demonstrated the efficacy of these trauma-specific

treatment approaches, provided they are offered by practitioners with
advanced training and a sophisticated clinical skill set. Some of the main
trauma therapy techniques that are currently used include somatic experiencing
and other somatic therapies, mindfulness training, mentalization-based
treatment, eye movement desensitization and reprocessing (EMDR) and
neurofeedback. None of these techniques asks the client to relive or re-experience
trauma in order to heal it (in contrast with prolonged exposure therapy).
Developed by Francine Shapiro (2001), EMDR is a well-researched interven-

tion for the treatment of trauma. Traditionally, the goal of EMDR is to
reprocess and reintegrate traumatic experiences in order to change the
negative interpretations and reduce the distressing physiological arousal
associated with traumatic memories. For somatic processing, specific EMDR
techniques and approaches can help clients learn that they can shift from an
anxious state to a relaxed state through different protocols and strategies.
Somatic experiencing, developed by Peter Levine (1997), is a therapy based on

“restoring the wisdom of the body” as a way to gain access to an individual’s
inner resources, restore the autonomic nervous system’s ability to self-regulate
and repair the damage caused by trauma.
Sensorimotor psychotherapy, developed by Pat Ogden (Ogden et al., 2006),

combines verbal therapy techniques with body-centred interventions that
directly address the neurobiological effects of trauma.
Mindfulness-based stress reduction (MBSR), developed by Jon Kabat-Zinn

(1990, 2005), is a form of mental training involving a series of exercises that
encourages “living in the present.” In his book, Mindsight, Daniel Siegel
(2010) explains that mindful awareness may lead to enhanced well-being by
changing our view of our own mental processes. Siegel explains that figuring
out what the mind is up to helps us control our responses to traumatic events,
painful memories and physical symptoms of trauma.
Mentalization-based treatment, developed by Fonagy et al. (2002), is a form

of psychodynamic therapy that strives to enhance clients’ capacities to
“mentalize” or understand their thoughts, feelings, wishes and beliefs, as well
as those of others, in the context of a safe, secure relationship between client
and therapist.
Neurofeedback training is based on neuroscientific findings that people can

change perceptions and attention by altering the electrical rhythms inside the
brain. Clients treated with this approach are able to alter their own brainwaves
by increasing certain frequencies and decreasing others through feedback
from a computerized program. During neurofeedback, a sensor placed on the
head detects electrical brain activity, and these brain signals are then transmitted
onto a computer screen. The brain is rewarded for making specific brainwaves;
as a result, clients are able to change dysregulated responses.
Conclusion
There are clear links between childhood neglect and abuse and later psycho-
logical, emotional, behavioural, physiological and interpersonal problems.
Cognitive, affective and psychosocial development are shaped and affected
by a combination of chronic abuse; lack of emotionally connected parenting;
and/or the deprivation of basic childhood needs, such as safety, parental
constancy and emotional validation. In order to survive these overwhelming
experiences, people are compelled to make complex adaptations.
The coalescing of chronic dysregulated emotional responses to traumatic

reminders—such as hyperarousal, hypervigilance and emotional numbing,
along with an inadequately developed capacity to regulate emotional distress
—results in a heightened need to find some form of relief. It is not surprising
that many people will turn to substances and other coping behaviours in an
attempt to deal with their overwhelming traumatic responses.
People who have untreated complex trauma often face what can feel like
insurmountable obstacles to receiving effective treatment and support.
Historically, addiction and mental health treatment have been provided
separately. Addiction clients with both substance use problems and trauma
were not provided treatment and support for their related mental health
concerns, such as depression, that could be driving their substance use.

They typically have also not received treatment for their related physical
health concerns, such as gastrointestinal problems. The clients themselves
often do not recognize that these problems are linked to attempts to cope
with dysregulated nervous systems.
Understanding how trauma leads to disturbances in self-regulatory capacities

is useful, as it creates conceptual coherence around the multiple, diffuse and
often contradictory symptoms of complex trauma. Whether in a psychiatric
hospital or a community clinic, service providers working with people with
mental health and substance use problems need to understand client
behaviours, including violent ones, as trauma responses and learn about their
clients’ triggers. It is hoped that increased understanding of the pervasive role
of psychological trauma in the lives of clients with histories of abuse and
neglect will lead to more compassionate and effective treatment and support
approaches in helping them rebuild their lives.
References
Briere, J. (1996). Therapy for Adults Molested as Children: Beyond Survival (2nd ed.). New York:
Springer.
Briere, J. & Jordan, C.E. (2004). Violence against women: Outcome complexity and implications
for treatment. Journal of Interpersonal Violence, 19, 1252–1276.
Cloitre, M., Stolbach, B., Herman, J., van der Kolk, B., Pynoos, R., Wang, J. & Petkova, E. (2009).
A developmental approach to complex PTSD: Childhood and adult cumulative trauma as
predictors of symptom complexity. Journal of Traumatic Stress, 22, 399–408.
Eliot, L. (2000). What’s Going On in There? How the Brain and Mind Develop in the First Five
Years of Life. New York: Bantam.
Fisher, J. (2003, July). Working with the neurobiological legacy of trauma. Paper presented at the
Annual Conference of the American Mental Health Counselors Association, Seattle, WA.
Fonagy, P., Gergely, G., Jurist, E.L. & Target, M. (2002). Affect Regulation, Mentalization, and the
Development of Self. New York: Other Press.
Harris, M. & Fallot, R.D. (Eds.). (2001). Using Trauma Theory to Design Service Systems
[Special issue]. New Directions for Mental Health Services, 89.
Herman, J. (1992) Trauma and Recovery: The Aftermath of Violence—From Domestic Abuse to
Kabat-Zinn, J. (1990). Full Catastrophe Living: Using the Wisdom of Your Body and Mind to Face
Stress, Pain, and Illness. New York: Delacorte Press.
Kabat-Zinn, J. (2005). Wherever You Go, There You Are: Mindfulness Meditation in Everyday Life.
New York: Hyperion.
Levine, P. (1997). Waking the Tiger: Healing Trauma—The Innate Capacity to Transform
Overwhelming Experiences. Berkeley, CA: North Atlantic Books.
Linehan, M. (1993). Cognitive-Behavioral Treatment of Borderline Personality Disorder. New York:
Guilford Press.
Maté, G. (2008). In the Realm of Hungry Ghosts: Close Encounters with Addictions. Toronto:
Alfred A. Knopf.
McCann I.L. & Pearlman, L.A. (1990). Psychological Trauma and the Adult Survivor: Theory,
Therapy and Transformation. New York: Brunner/Mazel.
Ogden, P., Minton, K. & Pain, C. (2006). Trauma and the Body: A Sensorimotor Approach to
Psychotherapy. New York: W.W. Norton.
Schore, A. (2003). Affect Dysregulation and Disorders of the Self. New York: W.W. Norton.
Shapiro, F. (2001). Eye Movement Desensitization and Reprocessing (EMDR): Basic Principles,
Protocols, and Procedures (2nd ed.). New York: Guilford Press.
Siegel, D.J. (1999). The Developing Mind: Toward a Neurobiology of Interpersonal Experience.
Siegel, D.J. (2010). Mindsight: The New Science of Personal Transformation. New York:
Bantam Books.
Vaccaro, G. & Lavick, J. (2008). Trauma: Frozen moments, frozen lives. BETA, 20(4), 31–41.
Van der Kolk, B.A. (1994). The body keeps the score: Memory and the emerging psychobiology
of post traumatic stress. Harvard Review of Psychiatry, 1, 253–265.
Van der Kolk, B.A. (2005). Developmental trauma disorder: Toward a rational diagnosis for
children with complex trauma histories. Psychiatric Annals, 35, 401–408.
Van der Kolk, B.A., McFarlane, A.C. & Weisaeth, L. (Eds.). (1996). Traumatic Stress: The Effects of
Overwhelming Experience on Mind, Body, and Society. New York: Guilford Press.
29
Chapter 2
Traumatic Learning
Linde Zingaro
What does it mean to be trauma informed? One morning as I was driving to

work, I was listening to a “trauma expert” on the radio. He was talking about
the hundreds of children orphaned and traumatized by a tsunami, a hurricane
or some brutal conflict. The interviewer asked this psychologist what could be
done to help these children. His answer was, essentially, that we need to work
to help them realize that the world is a safe place. Of course the psychologist
was speaking in compassionate tones and conveyed a sense of responsibility
and a commitment to providing the kind of care (impossible, in most of those
circumstances) that would give that reassurance. But for me, he was only partly
“trauma informed.” My question to anybody I talked to in the next few days
was “Where does he live that he thinks the world is a safe place?”
One of the main problems for anyone working in health care, social work or
addiction treatment is the struggle to hold on to some version of a safe world for
ourselves when we are seeing the evidence and hearing the stories of trauma
that offer other important and disturbing information: that the world, for very
many people, is not a safe place. Sometimes, in programs that provide services
to people experiencing the most destructive responses to trauma, even the work-
place is unsafe. A trauma-informed program must recognize that many helpers
who provide community-based addiction, mental health and family violence
programs may have their own experiences of trauma or may be unsafe in their
private lives, even while they are offering safety and support to others.
Being trauma informed must go further than believing that traumatic events
occur and knowing what happens to the minds and bodies of those who
experience trauma. Trauma-informed care must go beyond diagnosis and

medication, beyond the application of our therapeutic tools and techniques.
Being trauma informed must include respecting and honouring the fact that
what is learned from the experience of trauma is a kind of knowledge, in the
same way that what we learn about trauma is knowledge. In both cases, what
is known is contextual and deeply nuanced. It is overlaid with historical and
sometimes colonized cultural and personal differences, and is always embodied.
In our most helpful exchanges, both client and service provider are involved
in a relationship of learning about strength and resilience from each other’s
experiences of safety or lack of safety. So maybe the question for trauma-
informed service should be, “How can we create and support the space for
this kind of learning?”
This chapter discusses what survivors learn from traumatic experiences and
how disclosure can amplify the painful consequences. It uses the theory of
“threshold concepts of learning” to help us understand the processes involved
for survivors to shift their learned responses to trauma and how service providers
may pressure survivors in ways that makes this new learning more difficult.
Finally, considerations for practice and policy are discussed, where the negative
effects of forcing a disclosure are understood and a trauma-informed
“universal precautions” approach is advocated.
Learning from Trauma

One of the important practical outcomes of recent work on brain functioning
and traumatic experience has been greater sensitivity to how, for many survivors,
the trauma experience welds an enduring link or association between the par-
ticular sensations, emotions and cognitions coincident with the event. Some
of the most difficult interactions with clients or patients result from what, in
clinical language, we have learned to call “triggers”: external drivers of certain
behaviours based in a previous traumatic experience. What might be seen by
others as an innocuous and unrelated interaction can activate thoughts and
feelings associated with the overwhelming sense of threat experienced in the
original traumatic context. The behaviours that accompany these triggers are
often charged with an urgency and self-protective panic that seem completely
out of proportion to the present context, or that might be appropriate only in a
desperate struggle for survival.
Chapter 2 Traumatic Learning 31
This is one way of thinking about traumatic learning: that the person has
learned, through some extreme life experience, certain ways to handle (or
avoid) the stress of life-threatening or identity-threatening situations. These
trauma-tailored management skills may not be useful in a setting where trauma
is reduced (or in a “safe world”) and are in themselves sometimes dangerous
and self-damaging. Taking trauma into account, it makes sense for service
providers to view a substance use issue as “self-medication” or compulsive
behaviour as “self-soothing,” or to assume that a specific triggering event in
the moment may represent something not actually present in the environment
at the time of the reaction. This connection, however, may not be apparent
to the client.
For the trauma survivor, the emotions of the original event are present in the
exchange, particularly when she or he is questioned about the trauma experience.
With the emotions come the physical sensations and the cognitive or perceptual
evaluations of the environment as dangerous. Clients sometimes say, “I felt
like I was dying,” or “I couldn’t breathe in there” in situations where service
providers feel that they have been acting in completely non-threatening ways.
The sense of being overwhelmed with negative emotion can be stimulated by
“talking about it.” If people have not yet developed alternative skills and strate
gies for handling the feelings and the physical overstimulation generated by
this association, they will often default to the automatic avoidance, self-numbing
or self-damaging behaviour that may have brought them into the helping
relationship in the first place.
In a long practice of caring for vulnerable people, I have often observed a

version of this “triggered” behaviour that also needs to be incorporated into
our understanding of this concept of trauma-based learning as a component
of trauma-informed care. I have called this constellation of learned reactions
and emotions “disclosure consequences.” I became painfully aware of it as a
significant dynamic in the late 1970s as the result of an incident in the emer-
gency group home for street youth that I was operating at the time.
In those years, increasing social awareness of the extent and consequences of

family violence contributed to many changes in welfare policy, including the
introduction of extensive training for child protection workers in the specifics
of child sexual abuse. Our staff had identified a young woman in the emer-
gency shelter as needing to be taken into care, as we believed that she was
unsafe at home. A newly trained social worker came to the house to interview
her in order to support the decision to ask for a court-ordered intervention.
After about an hour with the 15-year-old, the worker came out of the interview
and went to another room to phone her office to make arrangements for the
child, satisfied that her investigation had uncovered enough evidence to justify
a child protection apprehension. The child followed her out of the office, went
directly into the kitchen and—right in front of me as I was cooking—grabbed
a large chopping knife and smashed the blade down onto the back of her hand,
attempting to cut off her fingers.
From observing this immediate demonstration of the pain of disclosure, and

many others where the self-punishment process has taken longer to come into
effect after a disclosure, I came to believe that for some people, “telling” a story
of their experience of trauma, shame or helplessness holds the potential for
this kind of response. I saw how the apparently impulsive and sometimes
inexplicable behaviours that follow this kind of disclosure often function as
demonstrations of an emotional logic based on traumatic learning, which
creates the need to do three things:
• to provide some external evidence to match the internal experience of crisis

and/or helplessness that is the consequence of certain kinds of trauma
• to deflect attention from the person as vulnerable
• to create a diversion that will remove the person from the intimacy of the
present interpersonal situation.
For many people, the pain of a trauma disclosure triggers an urgent need for
them to retract the story—demonstrating their own self-hate, creating in their
own behaviour the proof that they are worthless, that what they are saying
cannot be believed. For some, this self-discrediting impulse involves abusing
alcohol or other drugs, gambling, fighting or sabotaging their work or impor-
tant relationships. For others, the punishment system requires more active
self-harm, self-mutilation or even suicide. It is these internal processes of self-
blame and self-punishment that impose a limit on the person’s ability to make
use of our interventions, even with the best intentions. Being trauma-informed
service providers means that our commitment to providing safety must take
this process into account. We have to work toward protecting all the people in
our care from the specific risks of their own limits, even while we try to help
them learn to protect themselves (Zingaro, 2009).
The Trauma of Learning

Recent research in the area of adult education may offer another explanation
for the prevalence in some settings of disclosure consequences. It suggests
that we attain mastery of any field of endeavour, including developing the
skills for surviving and thriving, by moving through a series of increasingly
complex “threshold concepts,” each of which requires a profound shift in
world view. Cousin (2006) describes the threshold concept as being:
• transformative—we are changed by learning: new understandings become

part of what we know, who we are, how we see and how we feel
• irreversible—once knowledge has been integrated, the learner is unlikely
to forget it and finds it very difficult to think of ever not knowing it
• integrative—it allows the learner to make connections that were previously
hidden
• bounded—there is a potential for the learning to become rigid: it is important
to maintain a position of continued questioning (difficult in trauma)
• “troublesome”—concepts or information that challenges our “common sense”
or previous learning is emotionally disturbing.
Implicit in these conceptual elements is the idea that any significant change
in circumstance or world view implies a loss for the learner, who must give
up some part of her or his previously mastered, familiar world—no matter
how dysfunctional or dangerous that world may be. For any of us, moving into
the unstable space required for the identity shifts that are needed for significant
behavioural change feels threatening and creates in us a need to construct our
own conditions of safety (Cousin, 2006). In fact, for some, the familiar conditions
of safety depend on the behaviours that our programs are intended to change.
Even after a person has learned to identify possible “triggers,” even after
she or he may have processed and integrated the concept of the dynamic
of traumatic associations, the potential is still there for some part of the
response. Some new experience or unexpected external condition may once
again stimulate the automatic responses of traumatic learning because the
deepest learning in some kinds of trauma is the experiential knowledge that
the world is not safe.
This conception of traumatic learning suggests that, in situations such as

treatment for addiction or mental distress, where there is a potential (indeed
a hope) for important changes in behaviour or cognition, we are actually
increasing the pressure on the person’s capacity to cope, thus increasing the
likelihood of “triggered” responses. If we add that pressure to a pre-established
tendency for the automatic self-punishment strategies that often emerge as
disclosure consequences, we must expect that, even with our best intentions,
the necessary structures and systems of control in our programs sometimes
contribute to the lack of safety for our clients. Especially with clients who
display the self-punishing or self-defeating behaviours that can result from
trauma, we, as service providers, must be able to tolerate the painful possibility
that, for any traumatized person, we often start out as just another representative
of an unsafe world.
A trauma-informed position for policy and practice in service delivery requires
some very practical considerations that will affect our everyday actions. One of
the first of these relates to the process of gathering information. Eliciting and
recording the present circumstances and the relevant history of the client is
not a simple housekeeping task; it is actually an obvious place where the whole
definition of trauma-informed care resides. Before we begin, we need to ask
some questions of ourselves and of our programs and listen to the answers
with an awareness of the original lessons of trauma.
If we believe that trauma may be part of the experience of any clients in our
care, and if we understand that trauma has certain predictable if not inevitable
consequences for the person, then what kind of questions do we need to ask?
What do we do with the answers and what can we take for granted in the lives
of people in need of care? What difference will the answers (or lack of them)
make to our practice, to our policies, perhaps to the research that may also be
ongoing as a part of service delivery or advocacy in the therapeutic setting?
Except for the exploration process involved in helping the person understand
her or his own triggers, does knowing or not knowing the particulars of the
trauma change our practice? Do we really need an explicit description of what
we understand as trauma in order to respond to an obvious need for service?
In the context of trauma-informed care, we need to ask ourselves, “What

difference will the questions and the answers, or the lack of them, make to the
client?” Even the simple forms of interrogation for intake and the inevitable
translation of individual experience into generalized clinical language can have a
huge impact on the person seeking help. Being trauma informed does not mean
that we ask no questions. But perhaps instead of requiring a routine set of
questions on intake, we could make use of a “universal precautions” philosophy,
intentionally operating “as if” anyone who comes into our care is likely to be a
trauma survivor. Being attentive to these forms of traumatic learning in this
way will help us to develop policies and practices that will prevent the automatic
behavioural re-enactments that continue to undermine the best intentions
of both the helper and the client—those that in the process endanger the
relationships, the dignity and sometimes the very lives of people who have
been traumatized.
Service providers who are truly informed about traumatic learning commit
to consciously participate in creating greater safety for their clients and for
themselves. The focus of the work then involves building relationships that
take trauma into account as a part of a complex and contexted life experience
that may exist on both sides of the helper/helped divide and providing support,
information and understanding and as much experience of safety as we can
manage. If, in the process, we open a space to hear the story of trauma in
a context of connection, where the person can have some control over the
disclosure experience, then we must be prepared to really hear and respect-
fully attend to the layers of meaning in every unique story of trauma and to
the vulnerability of the telling.
In the same way that universal precautions became standard best practice in
early health care service for populations who were thought to be at risk for HIV,
today’s trauma-informed care should be structured to be safe and appropriate,
even for those living with the most devastating consequences of trauma—
even if we don’t know what the particular trauma is or was. An immediate
effect of this practice would be to reduce the number of program failures and
dramatic reactions that arises from over-disclosure or from some common
screening procedures. A trauma-informed approach with universal precautions
might recognize the existence of trauma in our culture, while dignifying the
particular and personal experience of traumatic learning.
Using this kind of trauma-informed approach can help us fulfil our commit-
ment to support the strength and courage of survivors. Otherwise we risk
finding ourselves engaged in the reductive process of decontextualizing
violence, renaming human tragedy as trauma and attempting to contain social,
economic or historical despair and desperation within the language of a limited
symptom-based treatment paradigm, simply because we have learned some
tools for managing individual behaviour.
References
Cousin, G. (2006). Threshold concepts, troublesome knowledge and emotional capital: An
exploration into learning about others. In J.H.F. Meyer & R. Land (Eds.), Overcoming Barriers
to Student Understanding: Threshold Concepts and Troublesome Knowledge (pp. 134–147).
Oxford, U.K.: Routledge.
Zingaro, L. (2009). Speaking Out: Storytelling for Social Change. Walnut Creek, CA: Left Coast Press.
37
Chapter 3
Using a Feminist- and

Trauma‑Informed Approach in
Therapy with Women
Brenda Toner and Donna Akman
This chapter aims to contextualize trauma-informed care within the larger

framework of feminist psychotherapy theory and practice and describe how
we have integrated feminist theory into our clinical initiatives in the field of
women’s mental health.
Feminist Therapy Is Trauma-Informed Care

Feminist ideologists have been proponents of trauma-informed care from
their earliest writings. As Brown (2004) writes, the diagnosis of posttraumatic
stress disorder owes its existence at least in part to feminist therapists, who
identified gender-based violence as a source of trauma and described the
wide range of consequences for its victims. Brown suggests that, given the
influence of feminist thinkers on the diagnosis and treatment of posttraumatic
experiences, trauma treatment implicitly embodies many feminist paradigms.
Feminist theorists and clinicians have consistently maintained a focus on

violence against women as a major source of women’s problems, while at the
same time drawing attention to other factors that they considered to be oppressive
and unhealthy for women. These factors include women’s experiences of
economic and political disadvantage, body oppression, gender role expectations,
ageism, racism and other systemic disadvantages (Worell & Remer, 2003).
Feminism has sensitized us to the potential consequences of experiencing

these oppressive circumstances, not only when they occur in overt and distinct
ways, such as when a person is subjected to physical or sexual abuse, but also
when they occur in a more subtle, insidious fashion, such as when a person
is subjected to acts of exclusion, dismissal, diminishment and disempower
ment based on race, gender, sexual orientation, age and other personal and
social identities.
From a feminist perspective, these types of oppressive experiences can have

long-standing and far-reaching consequences that can be perceived as trauma
tizing. A trauma-informed approach to therapy assumes that social, economic
and political disadvantages can have a negative effect on women’s health and
well-being and can contribute to or account for some of the mental health
difficulties they experience. In fact, studies suggest that women’s experiences
of sexist events are related to their psychological symptomatology (e.g., Klonoff
et al., 2000; Landrine et al., 1995; Moradi & Subich, 2002, 2003, 2004; Swim
et al., 2001).
Thus, using a trauma-informed lens, attention must be paid to reducing the

oppressive circumstances of women’s lives in order to improve their lives.
A trauma-informed approach considers a wide range of oppressive circumstances
and social structures, including but not limited to violence and abuse, in con-
ceptualizing, investigating and developing clinical interventions for women’s
mental health concerns. Within this framework, trauma-informed care considers
the many influences on women’s health and well-being and helps women effect
change in those areas of their lives that may be oppressive and/or unhealthy.
Using a wide scope includes assessing how social and political factors shape
the experience and naming of trauma and the ways in which trauma is treated
at both the individual and societal levels. This kind of assessment can help
promote a more nuanced understanding of trauma-related difficulties and
ways to effectively intervene (Brown, 2004). By considering the socio-political
circumstances of women’s lives, theorists, researchers, clinicians and con-
sumers can learn to develop and use strategies for change that promote both
personal and political empowerment. The next section will describe how we
have integrated feminist theory into our own research and clinical initiatives
with women.
Chapter 3 Using a Feminist- and Trauma-Informed Approach in Therapy with Women 39
Gender Role Socialization and Women’s

Mental Health
The literature on gender and mental health has discussed the detrimental
impact of adherence to some traditional feminine gender roles on women’s
health and well-being (Worell & Remer, 2003). These discussions have focused
on associations between mental health problems in girls and women and
gender-related expectations, such as societal standards for attractiveness
(Tolman et al., 2006); social norms regarding women’s caretaking role in
relationships, which can involve the expectation that women suppress their
own needs in favour of preserving their relationships and/or promoting the
well-being of others (Jack, 1991); and sanctions against anger expression in
women (Norwood et al., 2011; Van Daalen-Smith, 2008). These discussions
suggest a need to develop research and clinical tools to assess the degree to
which women have internalized these societal messages and the effects of
this internalization process on women’s mental health. We believe that the
onslaught of messages women receive about gender-related expectations, as
well as the societal consequences of not measuring up to these expectations,
can be oppressive and have mental health consequences. To address some of
these concerns, we have developed the Gender Role Socialization Scale for
Women ([GRSS], Toner et al., 2011) as presented in Figure 1.
Identifying Gender Role Oppression

Because many societal standards for women are restrictive and oppressive,
efforts to live up to them can sometimes lead to personal and political
disempowerment and contribute to mental health problems. In our clinical
experience, we have found that there is a lack of measurement tools that
address societal prescriptions for women. To address this gap, we have
developed a scale that measures the internalization of gender role messages
for women. Our interest in developing this tool grew out of our belief that
traditional care providers were framing women’s mental health problems as
arising from internal deficits, and that the focus was on individual pathology
rather than on understanding the contributions of oppressive circumstances
to women’s problems. Further, we were interested in contributing to the
knowledge base regarding women’s mental health by developing a tool to
identify salient gender role messages for women, explore these messages in
clinical practice and further the understanding of the association between
gender role socialization and other aspects of women’s personal, interpersonal
and social functioning.
In keeping with our feminist-informed framework, the GRSS moves the

focus of attention from the individual to the environment. The GRSS is
a 30-item self-report scale specifically designed to measure women’s
internalization of prescribed gender role messages that can be oppressive
and that can affect women’s mental health and well-being. Examples of items
that are rated on a seven-point scale from strongly disagree to strongly agree
include: If I take time for myself, I feel selfish; If I do not like my body, I am
to blame; If I ever feel overwhelmed, it must mean that I am incompetent;
I feel that the needs of others are more important than my own needs;
No matter how I feel I must always try to look my best; If a relationship fails,
I usually feel that it is my fault. I can’t feel good about myself unless I feel
physically attractive. The GRSS can be used for both clinical and research
purposes as an assessment tool and as a predictive and/or outcome measure
in psychotherapy research.
Although the GRSS measures the degree to which women internalize gender
role messages, the aim is to use the scale to help women learn that their
beliefs and behaviours have been influenced by external forces and that their
struggles may be less about personal pathology and more about detrimental
social structures. To the degree that the scale can help women generate a
multifaceted perspective on their problems, it can then help generate a multi
faceted perspective on solutions. Challenging social dictates regarding gender,
identifying and/or developing different expectations for oneself that are not
restricted by gender rules, and finding role models or like-minded individuals
who can support attempts to challenge the systemic discrimination embedded
in gender role messages are all possible outcomes of exploring these messages.
Figure 1: Gender Role Socialization Scale for Women
Please read the following statements and indicate how each one applies to you at
this time in your life. Please circle only one number for each item. There are no right
or wrong answers to these statements.
1) Strongly disagree
2) Disagree
3) Slightly disagree
4) Neutral
5) Slightly agree
6) Agree
7) Strongly agree
1. If I don’t accomplish everything I should, then I must be a failure.

1 2 3 4 5 6 7
2. I am to blame if I have low self-esteem.

1 2 3 4 5 6 7
3. If I don’t get what I need, it is because I ask for too much.

1 2 3 4 5 6 7
4. What I look like is more important than how I feel.

1 2 3 4 5 6 7
5. I feel embarrassed by my own sexual desires.

1 2 3 4 5 6 7
6. I feel that I must always make room in my life to take care of others.
1 2 3 4 5 6 7
7. I will never be happy if I am not in a romantic relationship.

1 2 3 4 5 6 7
8. Compared to men, I am less able to handle stress.

1 2 3 4 5 6 7
9. If I am unhappy, it is because I am too hard to please.

1 2 3 4 5 6 7
10. If I take time for myself, I feel selfish.

1 2 3 4 5 6 7
11. If I do not like my body, I am to blame.

1 2 3 4 5 6 7
12. If other people let me down, it is because I expect too much.

1 2 3 4 5 6 7
13. I have only myself to blame for my problems.

1 2 3 4 5 6 7
14. I can’t feel good about myself unless I feel physically attractive.
1 2 3 4 5 6 7
15. If I ever feel overwhelmed, it must mean that I am incompetent.

1 2 3 4 5 6 7
16. I feel that I must look good on the outside even if I don’t feel good on the inside.
1 2 3 4 5 6 7
17. I feel that the needs of others are more important than my own needs.
1 2 3 4 5 6 7
18. No matter how I feel I must always try to look my best.

1 2 3 4 5 6 7
19. I don’t feel that I can leave a relationship even when I know that it is not
satisfying.
1 2 3 4 5 6 7
20. I feel that I am not allowed to ask that my own needs be met.
1 2 3 4 5 6 7
21. I don’t like to say nice things about myself.

1 2 3 4 5 6 7
22. Whenever I see media images of women, I feel dissatisfied with my body.
1 2 3 4 5 6 7
23. I feel that I must always put my family’s emotional needs before my own.
1 2 3 4 5 6 7
24. I feel as though I should be less sexually forward than men.

1 2 3 4 5 6 7
25. If a relationship fails, I usually feel that it is my fault.

1 2 3 4 5 6 7
26. If I take time for myself, I feel guilty.

1 2 3 4 5 6 7
27. Whenever I am eating, I am always thinking about how it will affect my body size.
1 2 3 4 5 6 7
28. I often give up my own wishes in order to make other people happy.
1 2 3 4 5 6 7
29. I feel as though I can’t reveal the struggles in my life.

1 2 3 4 5 6 7
30. In a relationship, I feel I must always put my partner’s needs before my own.
1 2 3 4 5 6 7
From “Developing a gender role socialization scale,” edited by John L. Oliffe and Lorraine Greaves, 2012, Designing and
Conducting Gender, Sex and Health Research. Los Angeles: Sage. Reprinted with permission.
Enhancing Women’s Well-Being:

A Group Intervention
The Enhancing Women’s Well-Being group is an intervention that was
developed to create a space for women to explore the relationship between
gender role messages and their mental health and well-being. It has been
offered in both inpatient and outpatient settings with women who present
with a variety of mental health concerns. The group aims to create a supportive
and validating space for women to share their experiences and, in doing so,
learn from other women. The group also includes psychoeducation based on
the book Too Good for Her Own Good (Bepko & Krestan, 1990), about gender
role messages and their impact on women’s well-being.
This feminist-informed, trauma-informed intervention offers women a space

to examine the often rigid and conflicting gender role messages they have
received throughout their lives, share common experiences, explore factors
that may be associated with mental health problems and consider a multifaceted
approach to both problems and resolutions. With an enhanced awareness of
social factors that affect women, a wider range of strategies for change can be
identified and used. In this sense, it is an empowerment model, encouraging
women to take more control over their own situations and address those that
may be oppressive, traumatic and silencing.
Using our experience in developing and implementing this intervention, we

are now creating a clinical manual with suggested content for sessions based
on issues or themes that have been identified in the theoretical research
literature and in our clinical and research work in women’s mental health.
However, these issues are meant to serve as guidelines and should be tailored
to the individual goals of clients in partnership with therapists. This manual
will have broad application potential in that its emphasis on the gender role
socialization construct will increase awareness among treatment providers
and the larger community about factors that contribute to women’s health
and well-being. Given that this therapeutic approach aims to cut across diagnostic
categories within women’s mental health, such an intervention can be
implemented, adapted and used in a variety of settings with different client
groups. In addition, because the intervention contains a large component of
education and consciousness-raising, it has the potential to be adapted for
health promotion.
Conclusion
This chapter has positioned trauma-informed care within a larger framework
of feminist theory and psychotherapy. Within this framework, several writers
have argued that various oppressive circumstances and social structures in
the lives of women are traumatizing, including violence, abuse, economic and
political disadvantage, body oppression, gender role socialization, sexism,
ageism and racism. We have highlighted the construct of gender role sociali-
zation to illustrate the development and implementation of a feminist-informed,
trauma-informed assessment tool and group intervention in our work with
women. Our goal is to use these assessment and intervention strategies to
empower women to examine and challenge social structures and situations

that may be oppressive and traumatic.
References
Bepko, C. & Krestan, J. (1990). Too Good for Her Own Good: Searching for Self and Intimacy in
Important Relationships. New York: HarperCollins.
Brown, L. (2004). Feminist paradigms of trauma treatment. Psychotherapy: Theory, Research,
Practice, Training, 41, 464–471.
Jack, D. (1991). Silencing the Self: Women and Depression. Cambridge: Harvard University Press.
Klonoff, E.A., Landrine, H. & Campbell, R. (2000). Sexist discrimination may account for well-
known gender differences in psychiatric symptoms. Psychology of Women Quarterly,
24, 93–99.
Landrine, H., Klonoff, E.A., Gibbs, J., Manning, V. & Lund, M. (1995). Physical and psychiatric
correlates of gender discrimination: An application of the Schedule of Sexist Events.
Psychology of Women Quarterly, 19, 473–492.
Moradi, B. & Subich, L.M. (2002). Perceived sexist events and feminist identity development
attitudes: Link to women’s psychological distress. Counseling Psychologist, 30, 44–65.
Moradi, B. & Subich, L.M. (2003). A concomitant examination of the relations of perceived racist
and sexist events to psychological distress for African American women. Counseling
Psychologist, 31, 451–469.
Moradi, B. & Subich, L.M. (2004). Examining the moderating role of self-esteem in the link
between experiences of perceived sexist events and psychological distress. Journal of
Counseling Psychology, 51, 50–56.
Norwood, S., Bowker, A., Buchholz, A., Henderson, K., Goldfield, G. & Flament, M. (2011). Self-
silencing and anger regulation as predictors of disordered eating among adolescent females.
Eating Behaviors, 12, 112–118.
Swim, J., Hyers, L., Cohen, L. & Ferguson, M. (2001). Everyday sexism: Evidence for its
incidence, natures, and psychological impact from three daily diary studies. Journal of Social
Issues, 57, 31–53.
Tolman, D., Impett, E., Tracy, A. & Michael, A. (2006). Looking good, sounding good:
Femininity ideology and adolescent girls’ mental health. Psychology of Women Quarterly,
30, 85–95.
Toner, B., Tang, T., Ali, A., Akman, D., Stuckless, N., Esplen, N.J. et al. (2011). Developing a
gender role socialization scale. In J.L. Oliffe & L. Greaves (Eds.), Designing and Conducting
Gender, Sex, and Health Research (pp. 189–200). Thousand Oaks, CA: Sage.
Van Daalen-Smith, C. (2008). Living as a chameleon: Girls, anger and mental health. Journal of
School Nursing, 24, 116–123.
Worell, J. & Remer, P. (2003). Feminist Perspectives in Therapy: Empowering Diverse Women
(2nd ed.). New York: Wiley.
47
Chapter 4
Anti-oppression Psychotherapy as
Roberta K. Timothy
Anti-oppression psychotherapy (AOP) is a therapeutic approach that clinicians

can use to support clients as they cope with the effects of oppression, trauma
and intersectional violence in their lives. This chapter is based on the anti-
oppression psychotherapy model created by Continuing Healing Consultants,1
which looks at concrete ways to work with clients around intersectional
violence and trauma.
In AOP, an expanded notion of trauma recognizes that systemic and/or social

problems can present in many different forms, such as racism, sexism, classism,
colonialism, ageism, homophobia/heterosexism, transphobia, ableism, discrimi
nation, and violence based on religion or spiritual affiliation. AOP incorporates
both anti-oppression theories and practices and psychotherapy to understand
and work with individuals and groups who may have experienced intersectional
forms of trauma and violence. This AOP approach involves the therapist first
examining his or her own identities (or “locations”) before working with clients
around these same issues. The therapist explores with the client how his or
her relationships transnationally (connections to people and places in different
countries) and transgenerationally (influenced by past and present familial
generations) affect the client’s experiences of intersectional violence. By examining
these experiences, AOP can provide clients, therapists and their communities
with a catalyst for “empowerment-centred” change.
1. For more information about the anti-oppression psychotherapy model, contact the author at
info@healingconsultants.org.
Figure 1: Intersectional Violence and Trauma
Physical violence
or abuse
War trauma Sexual violence

or abuse
Hate Coercion
crimes Sexism-misogyny and betrayal
Racism Violence due to
gender expression
Colonialism
Transphobia
Witnessing
Classism Violence-hatred violence
Socio-economic due to spirituality or death
Natural exclusion or religious
disasters affiliation
Ableism
Accidents
Ageism
Death of
a loved one Terminal illness
Sudden loss
Adapted from Timothy & Umaña, 2009.
Critical to AOP is helping clients to actively resist oppression and to become

resilient in the face of their experiences so that they do not simply survive or
cope with adversity—but actually thrive (Timothy & Umaña, 2009).
Over the last decades, trauma models have expanded to address the complexities
of the human experience, particularly in relation to intersectionality (Cole, 2009)
—to the interrelationship or connection between factors of identity, including
race, indigeneity, class or socio-economic status, gender/gender identity,
sexual orientation, (dis)ability, age and spirituality. In relation to trauma,
Chapter 4 Anti-oppression Psychotherapy as Trauma-Informed Practice 49
intersectionality speaks to the connection between these factors and different

types of traumas resulting from discrimination and violence against particular
individuals and communities based on their “assumed” or perceived identities.
The trauma of daily experiences of intersectional violence and the potential

for clients to be retraumatized in clinical settings has been documented
extensively (Aponte et al., 1995; Ibrahim & Ohnishi, 2001; Sue et al., 2007).
The following sections introduce ways to work from a trauma-informed
intersectional AOP perspective.
An Expanded Notion of Trauma

Within a trauma-informed approach to violence, AOP therapists recognize the
complexity in their clients’ lives and experiences. Consider the case of Asha, a
sexual assault survivor of African descent. Using an AOP approach, the therapist
facilitates a discussion with Asha about the various influences of violence in
her life—from her being not only a woman, but a black woman, and middle
class. The therapist explores with Asha how a history of African enslavement,
inhumane rape laws and current racist stereotypes of black women as “easy,”
“hypersexual” and “provoking rape” intensify and add complexity to her
traumatic experiences.
Practitioners of AOP must expand their frames of reference not only to

understand how factors of identity and intersectional violence influence
the therapeutic interactions, but also to understand how these factors are
influenced by time and place. For instance, rather than seeing only the here
and now as important, an AOP approach recognizes that the past—and what
is not here—also influences clients’ traumatic experiences and resources.
Asha’s story, for example, must be understood in the context of her legacy as
a sixth-generation African-Canadian, and in light of historical and contemporary
practices of racism and colonialism.
Being trauma informed from an AOP lens enables the “whole picture” of
clients’ distress (trauma) to be known. Using this wider lens, the therapist can
better support the client from an anti-violence praxis and lessen the chance of
her being retraumatized. Using an anti-oppression framework, the therapist
encourages the client to explore who she is holistically—recognizing or including
all aspects of her experiences—so she can feel greater safety. At the same
time, the therapist is aware of how her own personal experiences and social
locations may facilitate or strain the therapeutic interaction with her clients.
Working with Survivors of Intersectional

Violence and Trauma
Within an AOP model, identity trichotomy (Timothy & Umana, 2009) is a
tool to help clients and therapists examine the impact of intersectional violence
in their own lives and in their communities. This tool consists of three tenets
or stages that look at the impact of fixed notions of identity and intersectional
violence in clients’ lives. The tool helps therapists to deconstruct their own
and other people’s biases and assumptions about their clients’ social locations,
and to look at ways clients can make changes through acts of resilience and
resistance.
Clients do not necessarily progress through these tenets in a linear fashion.

Rather, the progression is fluid, with clients and therapist addressing different
tenets at different times, depending on the issue. From the onset, resistance
occurs at different levels—resistance to fixed notions of the self, to a changing
self-concept and to integrating these changes into clients’ lives and community.
Tenet 1: Fixed notions of identity and trauma—the “box”

This first tenet requires therapists and clients to explicitly examine the impact
in clients’ lives of fixed notions of identity. Fixed notions are essentialized
(categorized or stereotyped), discriminatory and prejudiced views prescribed
by individuals, groups or institutions that sanction systems of oppression and
practices of exclusion. For example, the stereotype of an Asian woman as smart,
while seemingly positive, is—like all stereotypes—oppressive because it creates
stress and anxiety for the person to live up to this image. Fixed notions of
identity become “boxes” that limit our understanding of the complexities of
human experience. These static notions of identity are frequently promoted
and re-inscribed in covert ways (e.g., through media stereotypes) and in overt
ways (e.g., by physical, verbal and emotional attacks that are not always
publicly recognized as violent).
Fixed notions of identity are usually created to limit the access of certain
people or groups to various mainstream services and/or resources (e.g., to
health care, education, social supports). They produce “fabrications of
otherness”—where people are separated as “outside of” and “non-deserving”
—or as “uncivil” and “worthless.” These fixed notions generate misleading
explanations for physical, sexual or emotional abuse. For example, a fixed
notion of identity can lead someone to believe that Aboriginal women expe
rience more abuse within their communities or that Israeli women are pushy
or overly aggressive—both perspectives that are insulting to people within
these communities and that oversimplify a perspective as pertaining to all
individuals within a community. Another common fixed notion about trauma
is the erroneous belief that experiencing racism does not affect or exacerbate
mental health issues.
Consider the example of a therapist working with a practising Muslim woman

of Arab descent named Fatima, who comes to therapy in a state of extreme
anxiety after being physically abused by her partner. The therapist working with
Fatima has to explore and challenge his or her own fixed notions of what being
a Muslim woman is in order to provide a safe and less retraumatizing mental
health environment for the client. Part of working with Fatima may involve
addressing other forms of violence she may also have experienced, such as
Islamophobia from the workers at the hostel where she had been seeking
support. But the therapist must first work on his or her own Islamophobia.
Therapists and clients must address their own fixed notions of identity and
trauma both in their own lives and in their clinical settings. Only then can
the therapeutic alliance foster empowerment.
• Some key questions the therapist can reflect on in Fatima’s example are:
• What are my fixed ideas about trauma?
• What are my fixed ideas about Muslim women and abuse?
• Where did I get these messages about Muslim women from (e.g., family,
media, religion, school)?
• How comfortable am I exploring Fatima’s mental health issues related to
Islamophobia as trauma?
• How do I challenge my own fixed notions of her identity and trauma
experiences?
• How do I make her feel safe and empowered and lessen retraumatization?
Tenet 2: Different notions of intersecting identities and trauma

After deconstructing and challenging fixed notions of identity, therapists and
clients examine their intersecting identities and experiences of intersectional
trauma. Tenet 2 invites therapists to talk to clients about their experiences or
stories over time without interpreting them and judging how the clients might
feel or act. The therapeutic interaction acknowledges how clients may experience
multiple oppressions and violence, as well as their own specific experiences
with others based on their intersectional identities: race, indigeneity, gender/
gender identity, class or socio-economic status, sexual orientation, (dis)ability,
age and spirituality. It provides a framework that accommodates the particularities
of the individual’s unique and collective experiences.
The therapeutic interaction becomes a space where clients and therapists

discuss and gain insight into their own identities. This insight is crucial to
understanding clients’ “lived experiences” of trauma and ways they have
actively resisted or shown resilience in the face of this trauma. From exploring
intersecting identities emerges a stronger therapeutic alliance based on trust.
When therapists look at clients’ identities as fluid and intersecting, their
concepts of mental health supports expand to include both their intersectional
experiences of trauma and their resiliency and resistance.
This dialogue can be done using various tools and exercises to facilitate a new
change-oriented narrative over time. Consider a therapist working with
Sean, a gay (two-spirited) man of Ojibwe descent who is severely depressed
after being “outed” at work. The therapist begins by exploring with the client
not just his experience of being exposed as being gay, but also examining
the homophobia he confronted at work and people’s prejudices around
his being Aboriginal and two-spirited. The therapist then explores Sean’s
depression as it relates to his race, gender and sexual orientation and how
these and other important aspects of Sean’s identity are interrelated. The
therapist encourages Sean to discuss how he has been resilient in the past
and how he can actively resist the oppression he has experienced at work;
for example, by honouring his spiritual connection to Ojibwe people by
becoming more involved with his community and its elders. Sean eventually
decides to leave his job and return to school to study Aboriginal identity and
social justice and to speak out about being two-spirited in an Aboriginal
community and about homophobia in and outside of the community.
Some key questions the therapist can reflect on are:
• What do I know and not know about Sean’s identities?

• What do I know and not know about his experiences of trauma?
• How does he identify in relation to intersectional identities and
intersectional trauma?
• What is the impact of his intersectional identities on his experiences of
trauma?
• What is the impact of his indigeneity on his experiences of intersectional
trauma? What transgenerational connections relate to his experiences of
trauma?
• What role does intersectional violence play in relation to his mental health
concerns? Do colonialism, racism, sexism, homophobia and other forms of
intersectional violence intersect, amplifying the client’s experience of trauma?
Tenet 3: Strengthening the therapeutic alliance through negotiating

understanding and using identities for change
When therapists engage clients in an active dialogue, the process helps clients
to reject fixed notions of identity, create their own notions of community and
consider how they can make changes in their lives by reconfiguring notions
of who they are to reflect more fluid and reaffirming aspects of their identities.
This process is particularly important, as it interrupts clients’ prescribed
notions of being “hopeless,” “isolated” and “victimized.” Instead, they form
new understandings of their belonging to different communities that have
resisted intersectional trauma historically and transnationally.
By this stage, the strength of the therapeutic alliance and the coping skills
clients have cultivated can help them resist intersectional forms of trauma
and violence in their lives.
Case study
Consider the case of Sarah, a white Jewish woman of European descent who
has a hearing impairment and has been sexually and verbally abused both
as a child and young adult. Sarah is phobic of people and places and is quite
isolated. She has been having difficulty sleeping since the recent death of
her grandmother.
Applying tenet 1, the therapist assists Sarah to examine and dismantle any
fixed notions of identity and trauma. The therapist explores with Sarah how
she has isolated herself from society, believing that she does not deserve to
be treated well and is not worthy of getting support. Together, Sarah and the
therapist challenge this notion of being “unworthy” and look at ways Sarah can
reach out, find support and actively resist these views of herself as undeserving.
Using tenet 2, the therapist supports Sarah to generate a holistic understanding

of her complex experiences—of anxiety, sleep disturbances, bereavement, as
a survivor of sexual and ableist violence, and of her transgenerational and
transnational experiences of anti-Semitism. With her therapist, Sarah explores
the interconnectedness between her intersectional trauma and identities. For
example, they look at various ways Sarah had been victimized—for being
hearing impaired, as a survivor of sexual abuse, from the legacy of having
a grandmother who had gone through the Holocaust and through current
expressions of anti-Semitism in her community. Exploring these different
forms of violence helps Sarah to understand and frame her experience
differently. She can see various connections with her own experiences of
silencing her trauma, and ways that her unique experiences have influenced
her will to survive.
The therapist also explores the relationship between Sarah’s sleep disturbances
and phobias and her experiences of abuse, loss, ableism and transgenerational
trauma.2 A closer examination of her transnational and transgenerational
connections brings up information about her grandmother with whom she
lived and who was a Holocaust survivor. Sarah recalls the nightmares and
flashbacks her grandmother would have of the atrocities that she experienced
and witnessed in the concentration camps. The therapy addresses how these
experiences, along with the family’s silence around the grandmother’s expe-
riences and Sarah’s own experiences of sexual violence, result in Sarah growing
up feeling that the world is unsafe and hostile.
Using tenet 3 as a therapeutic strategy, the therapist supports Sarah to focus

on building resistance and resilience personally, and with her community.
Sarah and the therapist examine her coping strategies and various options
available to her to make empowering changes in her life. The therapist
supports Sarah to connect with various aspects of her identity more holistically.
2. All case examples in this chapter involve transgenerational trauma.

Sarah decides to get involved with the disability community as well as her
synagogue, where she asks for ASL (American Sign Language) so she can
participate more fully. Sarah talks with her therapist about her shame in asking
for ASL; this dialogue begins to help her feel more deserving by having the
“full picture” of who she is included in the therapeutic space.
Some key questions the therapist can reflect on are:
∙∙ How can I strengthen the therapeutic alliance with clients?

∙∙ What is the relevance of intersectional identity, trauma and transnational
and transgenerational connections in providing supportive mental
health care?
∙∙ How can I incorporate transnational and transgenerational connections into
the case conceptualizations of my clients?
∙∙ Is this client’s mental health issue impacted by transgenerational trauma?
∙∙ How can a client’s intersectional identities and experiences of trauma
provide Clues about resistance/resilience resources needed to deal with
present-day mental health crises?
Conclusion
This chapter highlighted how a trauma-informed AOP approach can support
mental health practitioners with differently located client populations. Exploring
the intersectionality between different forms of trauma and how they affect the
mental health of these populations provides practitioners with a more informed
lens so they can provide supports that better match their clients’ needs.
Exploring clients’ identities, along with experiences of intersectional trauma,

transnational and trangenerational connections and resistance and resilience,
lessens the potential for retraumatization and increases the opportunity for
empowerment-centred, safer mental health practices. Understanding inter-
sectionality is critical to gaining holistic insight into the lived experiences of
clients and to lessen the biases and stigma that often occur when clients are
looked at from a single or monoculturalistic lens. This encourages clients to
engage in a collaborative change process with the therapist, which strengthens
the therapeutic alliance.
To implement the trauma-informed AOP approach effectively, it is highly

recommended that therapists and clinical providers continuously examine the
AOP principles, particularly the identity trichotomy, in their own personal
therapeutic work and in clinical supervision.
References
Aponte, J.E., Rivers, R.Y. & Wohl, J. (1995). Psychological Interventions and Cultural Diversity.
Boston: Allyn & Bacon.
Cole, R. (2009). Intersectionality and research in psychology. American Psychologist, 64, 170–180.
Ibrahim, F. & Ohnishi, H. (2001). Posttraumatic stress disorder and the minority experience. In
D. Pope-Davis & H. Coleman (Eds.), The Intersection of Race, Class, and Gender in Multicultural
Counseling. Thousand Oaks, CA: Sage.
Sue, D.W., Capolidupo, C., Torino, G., Bucceri, J., Holder, A., Nadal, K. et al. (2007). Racial
microaggressions in everyday life: Implications for clinical practice. American Psychologist, 62,
271–286.
Timothy, R. & Umana, M. (2009). Anti-oppression Psychotherapy Training Guide. Toronto:
Continuing Healing Consultants.
PART 1
SECTION 2: PRACTICE
5 Collaborative Change Conversations: Integrating Trauma-Informed
Care and Motivational Interviewing with Women
6 Cognitive-Behavioural Therapy for Psychosis: A Trauma-Informed

Praxis
7 Trauma-Informed Body-Centred Interventions

59
Chapter 5
Collaborative Change Conversations

Integrating Trauma-Informed Care and
Motivational Interviewing with Women
Cristine Urquhart and Frances Jasiura
I still don’t know how you [cocaine] got full control of me. It pisses
me off. I wasn’t supposed to go through that. That wasn’t the road
I was supposed to go down. It makes me angry that I allowed myself
to do those things I did to myself and my son. I am the strong one.
I am not a fall down. I am NOT a FALL DOWN. Never again
will you take me DOWN.
—Written by a participant in a women’s day treatment program
As service providers, we can only imagine the full story behind this woman’s
statement. We hear her passionately reclaiming her identity as someone who
wants and is capable of a better life for herself. Through a motivational inter
viewing lens, we also pay close attention to what she is hearing herself say. By
responding empathically and strategically, we encourage her to keep talking
herself into, and committing to, the change she sees as possible.
With greater awareness of the interconnections between trauma, substance

use and mental health, service providers are broadening their understanding
of the pivotal role of violence in women’s lives. Trauma-informed care recognizes
the larger socio-political-historical influences on women’s lives, and reframes
the question from “What is wrong with her?” to “What has happened to her?”
(Williams & Paul, 2008). Motivational interviewing is one approach that can
guide service providers through these sensitive conversations to support
positive changes in women’s lives. Combining relational, principle-based

work with key skills and strategies, motivational interviewing offers service
providers a language and communication style that is collaborative and strives
to understand the woman’s world view, strengthen her sense of self, accept
her as she is and encourage her to move at her own pace in the direction of
the change she has identified as possible.
Miller and Rollnick define motivational interviewing as “a collaborative, person-

centred form of guiding to elicit and strengthen motivation for change”
(2009, p. 137). With more than 200 published clinical trials to date, this
approach is well documented as measurable and learnable (Miller & Moyers,
2006; Miller & Rose, 2009). It is found to improve engagement, retention
and treatment outcomes across many areas, including substance use and
mental health (Hettema et al., 2005; Rollnick et al., 2008; Rubak et al., 2005).
Research indicates that motivational interviewing is particularly effective with
minority populations, and that it has a synergistic effect when combined with
other methods (Hettema et al., 2005). Evidence supports the use of this
approach to improve the health of women with substance use problems and
related health concerns in both individual and group contexts (Floyd et al.,
2007; Ingersoll et al., 2005; LaBrie et al., 2009; Yahne et al., 2002). Recently,
motivational interviewing was found to be effective in a group program for
young homeless women with multiple risk factors, including substance use,
violence and trauma (Wenzel et al., 2009).
The key components of motivational interviewing, listed in Figure 1, include

spirit, principles, change talk and OARS communication skills.
Chapter 5 Collaborative Change Conversations 61
Figure 1: Key Components of Motivational Interviewing
MI Spirit
collaboration
evocation
respect for autonomy
Change Talk
OARS desire
open-ended questions ability
affirmations reason
reflective listening need
summary commitment
MI Principles taking steps
resist the
“righting reflex”
understand
listen
empower
Adapted from Miller & Rollnick (2002); Rollnick et al. (2008); and Rosengren (2009).
Working in the Spirit of Motivational

Interviewing
Similar to the trauma-informed view that women “grow in connection” (Harris
& Fallot, 2001, p. 65), motivational interviewing indicates that motivation for
change is cultivated within the collaborative relationship between the service
provider and the person seeking help (Rollnick et al., 2008). Central to the spirit
of both motivational interviewing and trauma-informed approaches is the
perspective that women are experts on their own lives. The focus is on under-
standing what each woman values while evoking her own reasons for change.
Thus, autonomy is encouraged while building therapeutic alliance and
evoking her own desire to change.
Research has identified a number of service provider behaviours that

compromise the spirit of motivational interviewing and adversely affect
outcomes (Gaume et al., 2009; Moyers et al., 2007; Moyers et al., 2010).
These include:
• advising without permission and warning

• directing and not offering choice
• confronting by arguing, disagreeing, shaming, labelling
• using labels such as “in denial,” “non-compliant,” “borderline personality,”
“alcoholic,” “drug addict.” Avoiding labels is congruent with the trauma-
informed practice of reframing perceived problem behaviour as attempts to
cope, disorders as responses and symptoms as adaptations (Haskell, 2003).
No One Is Completely Unmotivated

In both trauma-informed practice and motivational interviewing, service
providers seek to strengthen the woman’s safety and sense of self by moving
at her pace and avoiding getting ahead of her readiness. Motivational inter-
viewing understands that ambivalence, getting stuck between the costs and
benefits of change, is normal and that motivation fluctuates. It is one thing
for a woman to know change is important, another to believe she can do it
(as with the writer of the letter to cocaine that opens this chapter) and still
another to be resourced well enough to follow through on her commitment
to change. From the perspective of motivational interviewing, no one is
completely unmotivated (Rollnick et al., 2008), and the service provider
remains curious to discover what—to the person—is relevant, important,
possible and consistent with her world view, personal values, present
capacities and priorities.
Research indicates that individual levels of motivation are significantly

influenced by the communication style of the service provider. This is a
particularly important premise when working with women with trauma/
violence, substance use and mental health concerns. Individual responses
(or lack thereof) and behaviour can often be misinterpreted as not caring
or lacking motivation: “You would think the threat of violence and losing
your children would be enough to leave an abusive relationship/stop using
substances.” That understanding can leave service providers feeling stuck,
frustrated, even helpless. Just as the trauma-informed approach reminds

service providers to honour the complexities of the woman’s situation,
motivational interviewing helps them consciously move away from dismissive,
categorical thinking with the subtle shift from “Why isn’t this person motivated?”
to “For what is this person motivated?” (Miller & Rollnick, 2002, p. 18).
Change Talk: What People Say about

Change Matters
People talk themselves into and out of change. One of the key components of
motivational interviewing is its strategic emphasis on recognizing, drawing
out and reinforcing a specific type of speech identified as change talk. Listening
to what people say about change indicates how likely they are to change
(Rollnick et al., 2008). Change talk, expressed in statements of desire, ability,
reasons and need, forms the building blocks of readiness. Commitment
statements (i.e., I will, I promise) and taking steps have been shown to predict
change (Amrhein et al., 2003). As an example, in the quote that begins this
chapter, change talk is recognized in “I am the strong one” (expressing ability).
Using OARS (as depicted in Figure 1), the service provider guides the conver-
sation toward change by carefully drawing out and strengthening those moments
when the person expresses confidence and commitment to change.
Understanding the mechanism of change talk is crucial when working with

someone who is ambivalent and asking herself “Should I or shouldn’t I change?
Can I/Can’t I? Will I/Won’t I?” The service provider who falls into persuasion,
for example, by offering all the reasons why the woman should leave her abusive
partner, unwittingly elicits her reasons not to change (sustain talk). These exchan
ges lead to “Yes . . . but” conversations, such as when the woman responds to
persuasion with “Yes, but he’s a good father . . . .” The service provider is on
the wrong side of the conversation; as the woman hears herself argue against
change, she consequently becomes more committed to the status quo.
Resisting the “Righting Reflex”

In motivational interviewing, resisting the righting reflex—the natural desire
to fix, give advice, make better or even prevent harm from happening (Miller
& Rollnick, 2002)—aligns with the trauma-informed emphasis on minimizing
potential revictimization and focusing instead on creating safety in the
relationship (Elliot et al., 2005). Rather than telling the woman what to do, and
why she should do it, the service provider effectively draws out the woman’s own
reasons, motivations and possibilities for change.
Instead of acting as the authority or trying to persuade the woman, the service
provider offers a response consistent with motivational interviewing that
respects her autonomy and decisions. Working collaboratively, they together
are curious about the areas in the woman’s life where she does have influence,
such as self-care and safety planning (Motivational Interviewing and Intimate
Partner Violence Workgroup, 2009; Wahab, 2006). Sharing power and
collaborative decision-making are benchmarks in both trauma-informed care
and motivational interviewing. At the same time, it is important to note that
motivational interviewing is not an approach for every situation. Service
providers use their clinical judgment and ethical guidelines to assess situations
and shift to appropriate interventions. For example, they may move to a more
directive style when issues of safety (risk of harm to self or others) arise.
Strategies for Getting Started

Motivational interviewing involves a combination of relational (empathy and
spirit) and technical skills (differential eliciting and strengthening of change
talk) (Miller & Rose, 2009). Complex reflections are a necessary skill in
motivational interviewing conversations and are used strategically to engage,
understand and guide change. Two strategies that integrate well with trauma-
informed approaches are collaborative agenda setting and providing information
in a way that is consistent with motivational interviewing, known as elicit-
provide-elicit (Rollnick et al., 2008). Although several strategies are practised
within motivational interviewing, if they are used in isolation of the spirit
and principles, it is not a motivational interviewing conversation (Miller &
Rollnick, 2009).
The following dialogue captures segments of a conversation that is consistent

with motivational interviewing between a social worker, nurse, physician or
therapist and a woman who is coming to a substance use or mental health
outpatient clinic for the first time. In this scenario, the woman is 30 years old,
lives by herself and works as a cashier. She has many health and social concerns,
including alcohol and tobacco use, depression, anxiety, financial struggles,
social isolation and a history of trauma. This section is drawn mid-conversation,
without obvious beginnings or endings.
Service provider: Thanks, Sarah, for sharing that information with me. It
isn’t always easy talking to someone you don’t know. . . . Many of the women
I talk with, as we get started, have identified several topics helpful to talk
about, such as nutrition, self-care, substance use, safety. And maybe there
is something else on your mind today that you want to talk about?
Approach: affirmation; collaborative agenda setting; identifying topics and

parameters for the conversation in a non-threatening way. The service
provider makes no assumptions about what is most important to the
woman or where the conversation might start, and instead invites her to
substantially influence the direction of their time together.
Woman: Well, I did want to talk a bit about my sleep. I guess that could fit
under self-care. And I know I should look at exercise.
Service provider: So you have a couple of things coming up—sleep,

exercise. What else?
Approach: reflection; open question
Woman: No, that’s it.
Service provider: So, sounds like this a good place for us to start.
Approach: reflection; collaborative agenda setting
Woman: Yeah, my sleep is really bothering me. That’s part of the reason
going on and he’s on me about my smoking and drinking.
Service provider: Things have changed and you’re not feeling yourself.
Approach: complex reflection; avoids the trap of focusing on one topic too
quickly
Woman: I have been stressing about money big time! My shifts are getting
cut at work. And when I don’t work, I end up staying at home—sometimes
for days at a time. Just too depressed to get off the couch. So I sit and
smoke all day, and in the evenings my neighbour comes by and we have a
couple of drinks.
Service provider: The stress is paralyzing you.
Approach: complex reflection
Woman: Yeah! I need to keep busy or things just fall apart.
Service provider: This has happened before . . . and you have some ideas
about what to do.
Approach: complex reflection; strengthening autonomy and self-efficacy
Woman: Nothing is worse than being in your head all the time.
Service provider: There are things you don’t want to think about, and the
cigarettes and alcohol seem to be helping, and you’re here today trying to
figure this all out.
Approach: complex reflection; working in a trauma-informed way, without

judgment and recognizing attempts to cope
Woman: Yeah, I never thought of it that way. I just need to get some more
sleep. The alcohol helps a bit to get to sleep, but not stay asleep.
Service provider: It doesn’t last. I wonder what you have heard about how
alcohol, depression and sleep relate to one another?
Approach: complex reflection of change talk; open question, moving toward

providing information (eliciting what she already knows)
Woman: I know that sometimes if I drink too much wine, I feel even more
depressed than usual. I always figured alcohol helps you to sleep though.
Service provider: It can be confusing. Would you be interested in hearing a

little bit more about the connection?
Approach: complex reflection; closed question, eliciting permission to share

information
Woman: Sure.
Service provider: [provides information on connections between alcohol,

depression and sleep] . . . I appreciate some of this may be new information
to you, Sarah, and I’m wondering how it might fit for you, if at all?
Approach: open-ended question; eliciting woman’s understanding in her

own words; strengthening autonomy and choice with “if at all”
Woman: Makes sense, I guess. Sounds like I might be doing myself more
harm than good.
REFLECTION EXERCISE
Reflecting on this conversation, the following questions may help you

consider when and how motivational interviewing can support your work
with women:
1. What stands out for you, if anything, about how the agenda was set?
2. What might have happened if the service provider had focused on the
smoking and drinking immediately after the woman mentioned it?
3. Where might you go next with this conversation?
4. Identify examples of the motivational interviewing spirit (autonomy,
collaboration, evocation).
5. What trauma-informed and motivational interviewing principles were
demonstrated in this dialogue?
Conclusion
There are many parallels between working in a trauma-informed way and
motivational interviewing. Both identify a collaborative rather than power- or
expert-based approach. The woman sets the pace and the service provider
avoids getting ahead of her readiness. Both are strengths-based approaches
that aim to amplify the woman’s self-efficacy by guiding the conversation
toward those changes she identifies as possible and important. Motivational
interviewing brings a fresh understanding to change conversations by evoking
and strengthening the woman’s own natural change talk. Strategic use of
specific communication skills and motivational-interviewing strategies equip
service providers to work in a trauma-informed way. The combination of the
technical and relational components of motivational interviewing constitutes
the guiding framework for practice that is consistent with this approach,
making it possible to integrate trauma-informed concepts into collaborative

conversations for change. As a communication style to support change,
motivational interviewing can help to increase service providers’ confidence
and skill when working with women with complex health and social concerns.
A breadth of research supports the success of motivational interviewing in
engaging and retaining people in care and encouraging healthier outcomes
in their lives.
References
Amrhein, P.C., Miller, W.R., Yahne, C.E., Palmer, M. & Fulcher, L. (2003). Client commitment
language during motivational interviewing predicts drug use outcomes. Journal of Consulting
and Clinical Psychology, 71, 862–876.
Elliott, D.E., Bjelajac, P., Fallot, R., Markoff, L.S. & Glover Reed, B. (2005). Trauma-informed or trauma-
denied: Principles and implementation of trauma-informed services for women. Journal of
Community Psychology, 33, 461–477.
Floyd, R.L., Sobell, M., Velasquez, M.M., Ingersoll, K., Nettleman, M., Sobell, L. et al. (2007).
Preventing alcohol exposed pregnancies: A randomized control trial. American Journal of
Preventive Medicine, 32, 1–10.
Gaume, J., Gmel, G., Faouzi, M., & Daeppen, J.B. (2009). Counselor skill influences outcomes
of brief motivational interventions. Journal of Substance Abuse Treatment, 37, 151–159.
Harris, M. & Fallot, R.D. (Eds.). (2001). Using Trauma Theory to Design Service Systems [Special
issue]. New Directions for Mental Health Services, 89.
Haskell, L. (2003). First Stage Trauma Treatment: A Guide for Mental Health Professionals Working
with Women. Toronto: Centre for Addiction and Mental Health.
Hettema, J., Steele, J. & Miller, W.R. (2005). Motivational interviewing. Annual Review of Clinical
Psychology, 1, 91–111.
Ingersoll, K.S., Ceperich, S.D., Nettleman, M.D., Karanda, K., Brocksen, S. & Johnson, B.A.
(2005). Reducing alcohol-exposed pregnancy risk in college women: Initial outcomes of a
clinical trial of a motivational intervention. Journal of Substance Abuse Treatment, 29, 173–180.
LaBrie, J.W., Huchting, K., Lac, A., Tawalbeh, S., Thompson, A.D. & Larimer, M. (2009).
Preventing risky drinking in first-year college women: Further validation of a female-specific
motivational-enhancement group intervention. Journal of Studies on Alcohol and Drugs,
16, 77–85.
Miller, W.R. & Moyers, T.B. (2006). Eight stages in learning motivational interviewing. Journal
of Teaching in the Addictions, 5(1), 3–17.
Miller, W.R. & Rollnick, S. (2002). Motivational Interviewing: Preparing People for Change
(2nd ed.). New York: Guilford Press.
Miller, W.R. & Rollnick, S. (2009). Ten things that motivational interviewing is not. Behavioural
and Cognitive Psychotherapy, 37, 129–140.
Miller, W.R. & Rose, G.S. (2009). Toward a theory of motivational interviewing. American
Motivational Interviewing and Intimate Partner Violence Workgroup. (2009). Guiding as
practice: Motivational interviewing and trauma-informed work with survivors of intimate
partner violence. Partner Abuse, 1, 92–104.
Moyers, T.B., Martin, T., Christopher, P.J., Houck, J.M., Tonigan, J.S. & Amrhein, P.C. (2007).
Client language as a mediator of motivational interviewing efficacy: Where is the evidence?
Alcoholism: Clinical and Experimental Research, 31 (Suppl. 3), 40–47.
Moyers, T.B., Martin, J.K., Miller, W.R. & Ernst, D. (2010). Revised Global Scales: Motivational
Interviewing Treatment Integrity 3.1.1. Retrieved from http://casaa.unm.edu/download/
MITI3_1.pdf
Rollnick, S., Miller, W.R. & Butler, C.C. (2008). Motivational Interviewing in Health Care: Helping
Patients Change Behavior. New York: Guilford Press.
Rosengren, D.B. (2009). Building Motivational Interviewing Skills. New York: Guilford Press.
Rubak, S., Sandbæk, A., Lauritzen, T. & Christensen, B. (2005). Motivational interviewing: A
systematic review and meta-analysis. British Journal of General Practice, 55, 305–312.
Wahab, S. (2006). Motivational interviewing: A client centred and directive counseling style for
work with victims of domestic violence. Areté, 29(2), 11–22.
Wenzel, S.L. D’Amico, E.J., Barnes, D. & Gilbert, M.L. (2009). A pilot of a tripartite prevention
program for homeless young women in the transition to adulthood. Women’s Health Issues,
19, 193–201.
Williams, J. & Paul, J. (2008). Informed Gender Practice: Mental Health Acute Care That Works for
Women. London, UK: National Institute for Mental Health in England.
Yahne, C.E., Miller, W.R., Irvin-Vitela, L. & Tonigan, J.S. (2002). Magdalena pilot project:
Motivational outreach to substance abusing women street sex workers. Journal of Substance
Abuse Treatment, 23, 49–53.
71
Chapter 6
Cognitive-Behavioural Therapy
for Psychosis
A Trauma-Informed Praxis*1
Maria Haarmans
But the word is more than just an instrument which makes

dialogue possible. . . . Within the word we find two dimensions,
reflection and action, in such radical interaction that if one is
sacrificed—even in part—the other immediately suffers. There is
no true word that is not at the same time a praxis. Thus, to speak
a true word is to transform the world.
—Paulo Freire, Pedagogy of the Oppressed
Emerging research is demonstrating clear links between psychosis and

trauma, particularly childhood trauma. Yet trauma within psychosis is often
undiagnosed or untreated (Callcott et al., 2004). Cognitive-behavioural
therapy for psychosis (CBTp) has been gaining considerable attention as
an effective treatment approach. It has advantages over other psychosocial
approaches, such as supportive therapy, in that it is evidence-based and,
unlike biochemical treatments alone, addresses the trauma element in
psychosis. Due to an expanding empirical base for the effectiveness of CBTp,
clinical guidelines recommend its use in several countries, including the
United States, and in the United Kingdom, where the National Health Service
* I have deliberately chosen the term “praxis” to emphasize the importance of collaboration and reflection and
action (or integrating theory with practice). It is important for the therapist and client, through a process
of mutual dialogue, shared reflection and action, to be conscious of and acknowledge how socio-political
conditions affect human experience. Adopting an anti-oppressive practice, or praxis, is a critical part of a
trauma-informed approach.
mandates its use for anyone with a psychosis diagnosis (Addington et al.,
2005; Dixon et al., 2010; Lehman et al., 2004; McGorry, 2005; National
Institute for Clinical Excellence, 2002; National Institute for Health and
Clinical Excellence, 2009).
This chapter focuses on two principles of trauma-informed mental health

care that are integral to CBTp: adopting an empowerment model and linking
current difficulties or symptoms to past trauma. The chapter reviews the
literature on trauma and psychosis and outlines how CBTp is consistent with
a trauma-informed approach. A trauma-informed approach to mental health
care in general has been growing in popularity, not only with service providers,
who may have been frustrated with the limitations of other models to help
their clients, but with clients themselves.
Empirical Support for the Link between

Trauma and Psychosis
Experiences of trauma are increasingly being recognized as common in the lives
of people with psychosis. Mueser et al. (1998) noted that 98 per cent of people
diagnosed with a serious mental illness had a history of trauma and 48 per cent
met criteria for posttraumatic stress disorder (PTSD). Romme and Escher (1989)
found that 70 per cent of people who hear voices developed their hallucinations
following a traumatic event. More recent studies are also finding a high prevalence
of trauma histories in people with psychosis (Bentall & Fernyhough, 2008;
Morgan & Fisher, 2007; Read et al., 2008); in groups at “ultra-high risk” for
psychosis (Bechdolf et al., 2010); in people with psychotic experiences from
large epidemiological samples (Bebbington et al., 2004; Bebbington et al., 2011;
Janssen et al., 2004; Shevlin et al., 2007); and in studies using a case-control
design (Cutajar et al., 2010). In fact, a recent meta-analysis found a strong
association between childhood adversity and psychosis (Varese et al., 2012).
The literature reveals three main possible relationships between trauma and
psychosis:
• an increased understanding of the subjective experience of psychotic

phenomena and their sequelae (e.g., forced hospitalization, medication,
Chapter 6 Cognitive-Behavioural Therapy for Psychosis 73
restraints and seclusion after entering the mental health system and
subsequent victimization in the community or in hospital [sexual assaults on
wards]) as traumas associated with PTSD (Bentall et al., 2006; Jackson
& Birchwood, 2006; Jankowski et al., 2006)
• psychosis and PTSD as part of a spectrum of possible responses to trauma
(e.g., hallucinations as decontextualized trauma flashbacks) (Morrison et al.,
2003; Read, Van Os et al., 2005). Interestingly, Morrison (2001) suggests
that it is the cultural unacceptability of the person’s interpretation of
psychotic phenomena (such as hallucinations) that is related to the person
being diagnosed with psychosis as opposed to being diagnosed with PTSD
symptoms.
• trauma as an etiological pathway of psychosis, particularly the association of
hallucinated voices and childhood sexual abuse (Brabban & Callcott, 2010;
Elklit & Shevlin, 2011; Larkin & Morrison, 2006a; Read et al., 2008).
Severe and Prolonged Abuse Raises Risk

In a comprehensive review of the literature on trauma and psychosis, Read et
al. (2008) found that child maltreatment (i.e., emotional, physical and sexual
abuse, neglect and bullying) was significantly related to psychosis in 10 out of
11 recent general population studies, even after controlling for other variables
such as family history. Eight of these studies found a dose-response, meaning
that the more severe and prolonged the abuse, the more likely the person was
to develop psychosis. In a study examining the effects of cumulative traumas,
people who had experienced three types of trauma (sexual abuse, bullying,
violence in the home) were 18 times more likely to have psychosis than people
who were not abused. People who had experienced five types of trauma were
193 times more likely to have psychosis (Shevlin et al., 2008). Another study,
which followed more than 4,000 Dutch people for three years, revealed that
people abused as children (of which women represented more than half of
the sample) were nine times more likely to develop psychosis and that people
who experienced the most severe level of abuse were 48 times more likely to
develop psychosis (Janssen et al., 2004). The meta-analysis by Varese et al. (2012)
found this 50-fold increased risk in people who had severe and multiple traumas
consistent across the different studies they analyzed.
Lack of Sex- and Gender-Based Analysis

Unfortunately, most studies on schizophrenia do not provide information on
sex separately or examine gender (the sociocultural construct) (Nasser et al.,
2002). In some of the few studies that have recruited large numbers of women,
researchers have “controlled for sex” rather than treating women and gender
as important areas to explore (Read et al., 2008; Taylor & Bragado-Jemenz,
2009). An exception to this is Shevlin et al.’s (2007) analysis of non-institu
tionalized samples in the United States: they found that childhood physical
abuse predicted psychosis in both sexes, with rape being more predictive for
males than females. In a critical review of trauma and childhood abuse in
schizophrenia, Morgan and Fisher (2007) report that females experienced
more sexual abuse than males. Another study that examined the association
of childhood abuse and psychosis by sex found that reports of severe childhood
physical and sexual abuse were associated with psychosis in women but
not in men and that women were 2.6 times more likely to have been either
sexually or physically abused than men (Fisher et al., 2009).
In a study examining the association between trauma history and development

of psychosis in individuals assessed to be at “ultra-high risk,” investigators
found that a history of sexual trauma predicted eventual diagnosis of a psychotic
disorder (Bechdolf et al., 2010), and rates of trauma, especially sexual traumas
—rape and sexual molestation—were significantly higher for females (Thompson
et al., 2010). Another recent study from Denmark found that females who
experienced sexual abuse were 10 times more likely to later receive a diagnosis
of psychosis than those who were not sexually abused (Elklit & Shevlin, 2011).
A more recent study using data from the 2007 Adult Psychiatric Morbidity
Survey in England has revealed in this community sample that the link between
sexual abuse and psychosis was stronger in women than men (Bebbington et
al., 2011). Reviews of inpatient and outpatient samples revealed that family
members were perpetrators in more than half of childhood sexual abuse cases
among girls and in about a quarter of cases among boys (Read et al., 2008).
Read et al.’s (2008) review of 59 studies of inpatients and outpatients revealed
different rates of childhood sexual abuse for males and females, with a weighted
average of 46.9 per cent for females and 28.7 per cent for males. Cutajar et al.
(2010) reported a significantly higher rate of abuse involving penetration for
females than for males. In this study, involving 2,759 children who had
experienced sexual abuse, 79.8 per cent were female. When males and females
with histories of childhood sexual abuse were examined separately, rates for
psychosis were significantly higher for both males and females compared to
controls, and rates of schizophrenic disorders remained significantly higher
for females. However, when cases with penetration only were analyzed, the
difference in rate of schizophrenic disorders between females and males
disappeared. The combination of experiencing penetrative abuse, being over
age 12 and having more than one abuser resulted in a 15-fold increase in risk
of psychosis.
Such studies that have used a sex- and gender-based analysis reveal differential
rates and impacts of trauma, underlining the importance of this approach to
analysis, as well as the need for gender-specific models of CBTp.
Why Don’t More Clinicians in the Psychosis

Field Use a Trauma‑Informed Approach?
While research is advancing our understanding of the complex and multiple
relationships between trauma and psychosis, adapting services to reflect this link
has been much slower (Morrissey et al., 2005; Read, 2005). By privileging a
biogenetic model to explain the etiology of psychosis, many clinicians ignore
trauma-informed approaches that acknowledge the social determinants of mental
health (Larkin & Read, 2008) and are unlikely to assess for abuse in the first place
(Bentall, 2009; Read et al., 2007; Read, Van Os et al., 2005; Young et al., 2001).
Clinicians may also minimize or ignore the significance of trauma because
they lack training in how to ask about and respond to childhood abuse (Read et
al., 2007) or because they assume that the client’s report of trauma is part of
the psychosis and therefore unreliable (Mueser et al., 2002). However, research
demonstrates that such reports are as reliable as those of the general population
(Darves-Bornoz et al., 1995; Goodman et al., 1997).
One of the major implications of this research is recognition that we need to

ask service users about traumatic events in their life history. CBTp experts
assert that failing to do so will “‘impede installation of appropriate treatment
strategies’ and therefore prolong distress unnecessarily” (Read, Morrison et al.,
2005, p. 327).12Failing to assess and treat the trauma element in psychosis

can contribute to vicious cycles that maintain the problem.
CBTp as a Trauma-Informed Practice

According to Denby et al. (2008), “It is not the event that determines whether
something is traumatic, but the individual’s experience of the event” (p. 17).
This is consistent with the underlying philosophy of CBT that it is not the
event (e.g., hallucinated voices) that causes distress, but rather the person’s
interpretation of the event or the meaning he or she ascribes to it; for example,
“This means I am going crazy” or “It is an evil spirit punishing me” (Morrison
et al., 2004). While various clinical research centres around the world have
developed different “brands” of CBTp with varying emphasis and practice
(Tarrier, 2007), all share this underlying philosophy.
The literature identifies several important principles guiding trauma-informed

practice (Burke et al., 2010; Denby et al., 2008; Elliot et al., 2005; Harris &
Fallot, 2001). Two principles of trauma-informed mental health care—using
an empowerment model of practice and linking current difficulties or
“symptoms” to trauma/life experiences—are fundamental to CBTp and are
discussed here, focusing on models from the United Kingdom, where CBTp
has advanced considerably in the last 30 years (Chadwick, 2006; Chadwick
et al, 1996; French & Morrison, 2004; Gumley & Schwannauer, 2006; Larkin
& Morrison, 2006b; Morrison et al., 2004).
Applying these principles is essential in order to prevent retraumatization and/

or premature dropout among clients with trauma histories. Harris and Fallot
(2001) recommend “universal precautions”: “since providers have no way of
distinguishing survivors from non-survivors, best practices are those that treat
all [women] as if they might be trauma survivors. . .” (Elliot et al., 2005, p. 463).
This practice is especially important when working with individuals with a
psychosis diagnosis. One study revealed that the average length of time for
girls to disclose childhood sexual abuse was 16 years (Read et al., 2006).
1. See Read et al. (2007) for an in-depth discussion of trauma assessment.

An Empowerment Model
In trauma-informed practice, an empowerment model is critical for recovery
from the sense of powerlessness and fear related to a history of victimization.
It encompasses the following overlapping principles, with a shared aim of
“increasing the client’s power in personal, interpersonal and political spheres”
(Elliot et al., 2005, p. 465). Empowerment involves:
• collaboration—maximizing the client’s choices and control over the

treatment process in order to provide a corrective to the experience as a
powerless victim (e.g., goals of the work are established collaboratively)
• sharing information, educating and teaching coping strategies
• normalizing responses typically defined as “symptoms” within the medical model
• expanding the client’s resources and support networks and decreasing
reliance on professional services
• understanding the client’s issues as created or shaped by his or her socio-
political and cultural context.
Collaboration
A trauma-informed approach recognizes that the experience of collaboration
provides both the client and service provider with increased self-worth,
competence and comfort in taking action on personal goals (Elliott et al.,
2005). The following are some of the key processes in CBTp, as outlined by
CBT founder Aaron Beck, which aim to achieve this increased sense of self-
efficacy, ensure choice and promote collaboration (Morrison et al., 2004):
• The client decides the problems from his or her problem list with which to
get help. These problems are then prioritized and transformed into short-
and long-term goals for therapy.
• An agenda for what will be covered during the session is decided on
collaboratively at the start of each session.
• The therapist seeks specific feedback from the client about key points
and insights and any negative reactions to both the previous and current
sessions. (One of the aims of this process is to promote mutual
understanding with the meta-message that the client’s perceptions and
feelings are important and respected. Another purpose is to provide
continuity and reinforce important skills and/or knowledge learned.)
• Homework or coping strategies the client has tried in the previous week
are reviewed to assess how well they worked and any conclusions the client
made afterward are discussed.
• Regular capsule summaries and feedback by the therapist to check for
understanding on the part of both therapist and client can be especially
helpful for individuals whose psychotic experiences, such as hearing voices,
may influence communication and information-processing. This process
also helps to acknowledge the client’s viewpoint, allowing him or her to
feel listened to and understood (French & Morrison, 2004).
• The therapist seeks the client’s ideas about what might be helpful to do
between sessions for new homework as opposed to “assigning” a task.
Psychoeducation and teaching coping strategies

According to Schachter et al. (2008), sharing information involves “a mutual
process of information exchange in which both parties feel heard and understood”
(p. 20). CBTp therapists educate clients about the psychological processes involved
in experiences of distress (e.g., anxiety and depression) and the cognitive model of
anomalous experiences. This model explains how hallucinations and unusual
beliefs or delusions influence our thoughts, behaviours, physiological responses
and mood and how these interactions generate or maintain psychotic experiences.
However, clients are considered experts on their experience, and a guided
discovery or “Socratic questioning” approach is used to increase understanding
of these interactions (Padesky, 1993).
Helping clients to build skills and develop coping strategies is also important
in order for clients to manage distressing psychotic experiences, such as
hallucinated voices, recognizing that the goal is not necessarily to eliminate
these experiences (Morrison et al., 2004).
Coping strategies that the client has been using and found effective are
reinforced as demonstrating his or her strength in dealing with the voices. In
addition, coping strategies that other “voice hearers” have found helpful are
shared and presented as options to try. Identifying idiosyncratic triggers or
cues for voice hearing is also empowering, as some people who hear voices do
not recognize that there are triggers for their voices (Chadwick et al., 1996).
This is similar to helping abuse survivors identify emotional triggers to their
trauma, challenging their belief that internal responses arise out of nowhere,
which results in feeling fearful and powerless (Harris & Fallot, 2001).
Triggers can assume various forms, such as internal bodily sensations;

emotional states; thoughts and memories; interpersonal dynamics, such as
being criticized or judged; or sensory experiences, such as sights, sounds and
smells. By identifying these triggers, the person can feel more in control and
less vulnerable. Sometimes these triggers are directly related to abuse; other
times they may be less obviously connected to the trauma survivor’s history
(Harris & Fallot, 2001). For example, one client’s hallucinations were triggered
by the colour red; only after some time did she realize that this was the colour
of her abuser’s shirt. Triggers may also be settings perceived as psychologically
or interpersonally threatening, such as crowded buses or formal situations
(Chadwick et al., 1996).
Learning to use coping strategies such as voice diaries and evaluating the
content of critical hallucinations can increase clients’ sense of control over the
experience and lessen their depression (Morrison et al., 2005). This approach
is consistent with Harris and Fallot’s (2001) emphasis on helping clients to
build skills, rather than simply reduce “symptoms.” Education about abuse
and trauma are provided according to the individual formulation. Individuals
often do not define their experiences as abuse, nor do they have an under-
standing of PTSD. Clients can learn grounding and self-soothing techniques,
such as breathing exercises, to help themselves cope with PTSD symptoms.
Normalizing responses
It is important for clients to learn that their responses are normal, given their
experiences (Harris & Fallot, 2001). In CBTp, helping clients to identify links
between their traumatic experiences and current psychotic phenomena via
the individual formulation also helps to normalize these experiences, reduce
distress and increase perceived control (Morrison et al., 2005).
Normalizing these experiences involves depathologizing unusual perceptual

experiences and beliefs as part of the continuum of normal experience by
presenting information about their prevalence in the general population. For
example, 10 to 25 per cent of the general population has a lifetime incidence for
hearing voices; and up to 70 per cent describe delusional beliefs (Morrison et al.,
2004). High incidences of hallucinations among the general population are

known to occur following trauma, bereavement, sleep deprivation, solitary
confinement, hostage situations, sensory deprivation and upon falling asleep
or waking (Morrison et al., 2004). Presenting this information helps to
improve clients’ self-esteem and reduce their “fear of going mad.” These kinds
of facts are destigmatizing and deshaming and enable clients to feel less
isolated and better understand these experiences as psychological phenomena
(Kingdon & Turkington, 2005). The deshaming process is often twofold for
people with a psychosis diagnosis: they may have internalized stigma of the
diagnosis and shame from the childhood trauma, particularly childhood
sexual abuse.
Expanding the client’s resources and support networks

Expanding the client’s sense of support includes helping clients “become
their own therapist” and use the skills they have learned on their own
(Chadwick, 2006; Morrison et al., 2004) without relying on professionals.
Introducing clients to peer support groups such as the Hearing Voices
Network or INTERVOICE, an international online forum for voice hearers,
will also help them to become less reliant on the mental health system.
Making Sense of Psychotic Experiences:

Connecting Trauma to Current “Symptoms”
One of the fundamental principles of CBTp is that the therapy is based on an
ever-evolving formulation of the client’s difficulties or a “working hypothesis”
of why a problem developed, how it is maintained and how problems are
related to the person’s life history and core beliefs about self, others/world
and future and the experiences that have shaped these beliefs (Bentall &
Fernyhough 2008; Larkin & Morrison, 2006a; Read, 2005). This formulation
involves an ongoing collaborative process of collecting data to develop a
shared understanding of the client’s difficulties, incorporating personal life
history and context (Gumley & Schwannauer, 2006) and should include the
impact of socio-political issues such as culture, race, class and gender. Such
an analysis is part of “conscientization” or critical consciousness-raising
(Freire, 1993, p. 25), which is particularly important for addressing the self-
blame and sense of powerlessness that many trauma survivors experience

and is consistent with a culturally responsive approach (Ivey, 1995). Traumatic
or adverse life events are linked to current psychotic experiences such as
hallucinations and/or delusions, which helps to make sense of and demystify
these phenomena.
Making sense of psychotic experiences may also involve understanding the

meaning in the themes and content of voices and delusions (Bebbington et
al., 2004). While highly personal and idiosyncratic, psychotic phenomena are
not “un-understandable,” as has been supposed since Karl Jaspers in the early
1900s made the distinction between the understandable symptoms of anxiety
and depressive disorders and “un-understandable” symptoms of psychosis,
asserting that the content of delusions and hallucinations were meaningless
(Bentall, 2003). The content is often based, directly or symbolically, on
memories of childhood trauma (Morrison et al., 2003; Read et al., 2008) and
may express the client’s core beliefs about self, others/world and/or future
(Bentall & Fernyhough, 2008; Brabban & Callcott, 2010).
Though many times the difficulties a client experiences may seem quite
unrelated to the trauma, the content of hallucinations or delusions may
be metaphorical or symbolic of the abuse (Shulman, 1996). In studies
examining content of psychotic phenomena, investigators found relationships
between sexual trauma and content of both attenuated and full-blown
psychotic symptoms, such as delusions of being watched in the shower,
hallucinations of sexual content, content of trauma directly corresponding
to the content of hallucinations, and/or themes of trauma corresponding
to themes of hallucinations (Hardy et al., 2005; Thompson et al., 2010).
By making these links and understanding behaviours in context, what are
traditionally labelled as psychotic “symptoms” are reframed as functional
“survival strategies,” especially at the time they developed, though they may
not have changed to reflect the person’s current environment and have
outlived their usefulness (Morrison et al., 2004). Harris & Fallot (2001) write:
This way of looking at behaviours allows trauma survivors to reclaim

the positive coping aspects of their symptoms. . . . As women come
to see the power in their defences and coping strategies, they also
come to believe that they have the strength and the wisdom to make
changes in their lives. (p. 15)
Elliott et al. (2005) point out:
The medical model highlights pathology and inadvertently gives the

impression that there is something wrong with a person rather than
that something wrong was done to that person [italics added]. . . .
Understanding a symptom as an adaptation reduces the client’s guilt
and shame, increases her self-esteem, and provides a guideline for
developing new skills and resources to allow new and better
adaptations to the current situation. (p. 467)
Conclusion
A growing body of empirical evidence supports the link between trauma and
psychosis. Regardless of clinicians’ beliefs about the etiology of psychosis,
a trauma-informed approach to CBTp benefits clients. An integral part of
assessment and developing the CBTp individual formulation is considering
the possible role of trauma in the development and maintenance of
distressing psychotic experiences and asking about it. The role of trauma is
not limited to adverse life experiences, but may also include the traumatic
reaction to the subjective experience of psychosis and traumatization or
retraumatization from forced hospitalization via police; from the use of
physical and/or chemical restraints; or from subsequent victimization
in the community. Read et al. (2007) point out that while not everyone is
convinced that childhood abuse is a risk factor for psychosis and schizophrenia,
“psychiatrists do not have to be convinced of a causal relationship to each and
every diagnostic category to understand the importance of asking the people
they are trying to help what has happened in their lives” (p. 102). And as
Bentall (2009) has poignantly described when advocating complaints-based
research and practice:
By focusing on symptoms rather than diagnoses, we can see how the

experiences of patients arise understandably from their misfortunes.
Far from assuming that abnormal cerebral functioning is the primary
cause of illness, complaints-orientated research shows that the
troubled brain cannot be considered in isolation from the social
universe. Clinically, it leads us to recognize that the stories patients
tell us are important, and that there is a very thin dividing line between
the “them” who are ill and the “us” who are sane. (p. 182)
References
Addington, D., Bouchard, R., Goldberg, J.O., Honer, B., Malla, A., Norman, R. et al. (2005).
Canadian clinical practice guidelines for the treatment of schizophrenia. Canadian Journal of
Psychiatry, 50 (Suppl. 1), 29–36.
Bebbington, P., Bhugra, D., Brugha, T., Singleton, N., Farrell, M., Jenkins, R. et al. (2004).
Psychosis, victimization, and childhood disadvantage: Evidence from the second British
national survey of psychiatric morbidity. British Journal of Psychiatry, 185, 220–226.
Bebbington, P., Jonas, S., Kuipers, E., King, M., Cooper, C., Bhugra, T. et al. (2011). Childhood
sexual abuse and psychosis: Data from a cross-sectional national psychiatric survey in
England. British Journal of Psychiatry, 199, 29–37.
Bechdolf, A., Thompson, A., Nelson, B., Cotton, S., Simmons, M.B., Amminger, G.P. et al. (2010).
Experience of trauma and conversion to psychosis in an ultra-high-risk (prodromal) group.
Acta Psychiatrica Scandinavica, 121, 377–384.
Bentall, R.P. (2003). Madness Explained: Psychosis and Human Nature. London, UK: Penguin.
Bentall, R.P. (2009). Doctoring the Mind: Is Our Current Treatment of Mental Illness Really
Any Good? New York: New York University Press.
Bentall, R.P. & Fernyhough, C. (2008). Social predictors of psychotic experiences: Specificity
and psychological mechanisms. Schizophrenia Bulletin, 34, 1012–1020.
Bentall, S., McGorry, P. & Krstev, H. (2006).The trauma of being psychotic: An analysis of
posttraumatic stress disorder in response to acute psychosis. In W. Larkin & A.P. Morrison
(Eds.), Trauma and Psychosis: New Directions for Theory and Therapy (pp. 239–258). East
Sussex, UK: Routledge.
Brabban, A. & Callcott, P. (2010, May 20–21). CBT and the Treatment of Psychosis, Trauma and
Dissociation. Workshop at the Royal Ottawa Mental Health Centre, Ottawa, ON.
Burke, P., Chapman, C., Hohman, M., Manthey, T., Slack, K., Stout, D. et al. (2010). Guiding as
practice: Motivational interviewing and trauma-informed work with survivors of intimate
partner violence. Partner Abuse, 1, 92–104.
Callcott, P., Standart, S. & Turkington, D. (2004). Trauma within psychosis: Using a CBT model
for PTSD in psychosis. Behavioural and Cognitive Psychotherapy, 32, 239–244.
Chadwick, P. (2006). Person-Based Cognitive Therapy for Distressing Psychosis. Chichester, UK:
John Wiley & Sons.
Chadwick, P.D.J., Birchwood, M.J. & Trower, P. (1996). Cognitive Therapy for Delusions, Voices
and Paranoia. Chichester, UK: John Wiley & Sons.
Cutajar, M.C., Mullen, P.E., Ogloff, J.R.P., Thomas, S.D., Wells, D.L. & Spataro, J. (2010).
Schizophrenia and other psychotic disorders in a cohort of sexually abused children.
Archives of General Psychiatry, 67, 1114–1119.
Darves-Bornoz, J.M., Lemperiere, T., Degiovanni, A. & Gaillard, P. (1995). Sexual victimisation
in women with schizophrenia and bipolar disorder. Social Psychiatry and Psychiatric
Epidemiology, 30, 78–84.
Denby, C., Winslow, C., Willette, C., Bergen, E., Toole, K., Richardson, K. et al. (2008). Trauma-
Informed: The Trauma Toolkit. Winnipeg, MB: Klinic Community Health Centre. Retrieved
from www.trauma-informed.ca
Dixon, L.B., Dickerson, F., Bellack, A.S., Bennett, M., Dickinson, D., Goldberg, R.W. et al.
(2010). The 2009 Schizophrenia PORT psychosocial treatment recommendations and
summary statements. Schizophrenia Bulletin, 36, 48–70.
Elklit, A. & Shevlin, M. (2011). Female victimization predicts psychosis: A case-control study
based on the Danish Registry System. Schizophrenia Bulletin, 37, 1305–1310.
Elliott, D.E., Bjelajac, P., Fallot, R.D., Markoff, L.S. & Reed, B.G. (2005). Trauma-informed or
Fisher, H., Morgan, C., Dazzan, P., Craig, T.K., Morgan, K., Hutchinson, G. et al. (2009).
Gender differences in the association between childhood abuse and psychosis. British Journal
of Psychiatry, 194, 319–325.
Freire, P. (1993). Pedagogy of the Oppressed (rev. ed.). New York: Continuum.
French, P. & Morrison, A.P. (2004). Early Detection and Cognitive Therapy for People at High Risk
of Developing Psychosis: A Treatment Approach. Chichester, UK: John Wiley & Sons.
Goodman, L.A., Rosenberg, S.D., Mueser, K.T. & Drake, R.E. (1997). Physical and sexual assault
history in women with serious mental illness: Prevalence, correlates, treatment, and future
research directions. Schizophrenia Bulletin, 23, 685–696.
Gumley, A. & Schwannauer, M. (2006). Staying Well after Psychosis: A Cognitive Interpersonal
Approach to Recovery and Relapse. Chichester, UK: John Wiley & Sons.
Hardy, A., Fowler, D., Freeman, D., Smith, B., Steel, C., Evans, J. et al. (2005). Trauma and
hallucinatory experience in psychosis. Journal of Nervous and Mental Disease, 193, 501–507.
Harris, M. & Fallot, R.D. (2001). Envisioning a trauma-informed service system: A vital
paradigm shift. In M. Harris & R.D. Fallot (Eds.), Using Trauma Theory to Design Service
Systems [Special issue]. New Directions for Mental Health Services, 89, 3–22.
Ivey, A.E. (1995). Psychotherapy as liberation: Toward specific skills and strategies in
multicultural counseling and therapy. In J. Ponterotto, J. Casas, L. Suzuki & C. Alexander
(Eds.), Handbook of Multicultural Counseling (pp. 53–72). Thousand Oaks, CA: Sage.
Jackson, C. & Birchwood, M. (2006). Trauma and first episode psychosis. In W. Larkin
& A.P. Morrison (Eds.), Trauma and Psychosis: New Directions for Theory and Therapy (pp.
75–100). East Sussex, UK: Routledge.
Jankowski, M.K., Mueser, K. & Rosenberg, S.D. (2006). Psychosis with comorbid PTSD.
In W. Larkin & A.P. Morrison (Eds.), Trauma and Psychosis: New Directions for Theory and
Therapy (pp. 127–147). East Sussex, UK: Routledge.
Janssen, I., Krabbendam, L., Bak, M., Hanssen, M., Vollebergh, W., de Graaf, R. et al. (2004).
Childhood abuse as a risk factor for psychotic experiences. Acta Psychiatrica Scandinavica,
109, 38–45.
Kingdon, D.G. & Turkington, D. (2005). Cognitive Therapy of Schizophrenia. New York:
Guilford Press.
Larkin, W. & Morrison, A.P. (2006a). Relationships between trauma and psychosis: From theory
to therapy. In W. Larkin & A.P. Morrison (Eds.), Trauma and Psychosis: New Directions for
Theory and Therapy (pp. 259–282). East Sussex, UK: Routledge.
Larkin, W. & Morrison, A.P. (Eds.). (2006b). Trauma and Psychosis: New Directions for Theory and
Therapy. East Sussex, UK: Routledge.
Larkin, W. & Read, J. (2008). Childhood trauma and psychosis: Evidence, pathways, and
implications. Journal of Postgraduate Medicine, 54, 287–293.
Lehman, A.F., Kreyenbuhl, J., Buchanan, R.W., Dickerson, F.B., Dixon, L.G., Goldberg, R. et al.
(2004). The Schizophrenia Patient Outcomes Research Team (PORT): Updated treatment
recommendations. Schizophrenia Bulletin, 30, 193–217.
McGorry, P. (2005). Royal Australian and New Zealand College of Psychiatrists clinical practice
guidelines in the treatment of schizophrenia and related disorders. Australian and New
Zealand Journal of Psychiatry, 39, 1–30.
Morgan, C. & Fisher, H. (2007). Environmental factors in schizophrenia: Childhood trauma—A
critical review. Schizophrenia Bulletin, 33, 3–10.
Morrison, A.P. (2001). The interpretations of intrusions in psychosis: An integrative cognitive
approach to hallucinations and delusions. Behavioural and Cognitive Psychotherapy, 29, 257–276.
Morrison, A.P., Frame, L. & Larkin, W. (2003). Relationships between trauma and psychosis: A
review and integration. British Journal of Clinical Psychology, 42, 331–353.
Morrison, A.P., Read, J. & Turkington, D. (2005). Trauma and psychosis: Theoretical and clinical
implications. Acta Psychiatrica Scandinavica, 112, 327–329.
Morrison, A.P., Renton, J.C., Dunn, H., Williams, S. & Bentall, R.P. (2004). Cognitive Therapy for
Psychosis: A Formulation-Based Approach. East Sussex, UK: Brunner-Routledge.
Morrissey, J.P., Jackson, E.W., Ellis, A.R., Amaro, H., Brown, V.B. & Najavits, L.M. (2005).
Twelve-month outcomes of trauma-informed interventions for women with co-occurring
disorders. Psychiatric Services, 56, 1213–1222.
Mueser, K.T., Rosenberg, S.D., Goodman, L.A. & Trumbetta, S.L. (2002). Trauma, PTSD, and the
course of severe mental illness: An interactive model. Schizophrenia Research, 53, 123–143.
Mueser, K.T., Goodman, L.B., Trumbetta, S.L., Rosenberg, S.D., Osher, F.C., Vidaver, R. et al.
(1998). Trauma and posttraumatic stress disorder in severe mental illness. Journal of Consulting
and Clinical Psychology, 6, 493–499.
Nasser, E.H., Walders, N. & Jenkins, J.H. (2002). The experience of schizophrenia: What’s gender got
to do with it? A critical review of the current status of research on schizophrenia. Schizophrenia
Bulletin, 28, 351–362.
National Institute for Clinical Excellence. (2002). Core Interventions in the Treatment and
Management of Schizophrenia in Primary and Secondary Care. London, UK: Author. Retrieved
from www.nice.org.uk/guidance
National Institute for Health and Clinical Excellence. (2009). Schizophrenia: Core Interventions in
the Treatment and Management of Schizophrenia in Adults in Primary and Secondary Care
(Update). London, UK: Author. Retrieved from www.nice.org.uk/guidance
Padesky, C.A. (1993, Sept. 24). Socratic questioning: Changing minds or guiding discovery. Keynote
address delivered at the European Congress of Behavioural and Cognitive Therapies,
London, UK.
Read, J. (2005). The bio-bio-bio model of madness. The Psychologist (UK), 18, 596–597.
Read, J., Fink, P.J., Rudegeair, T., Felitti, V. & Whitfield, C.L. (2008). Child maltreatment and
psychosis: A return to a genuinely integrated bio-psycho-social model. Clinical Schizophrenia
and Related Psychoses, 7, 235–254.
Read, J., Hammersley, P. & Rudegeair, T. (2007). Why, when, and how to ask about childhood
abuse. Advances in Psychiatric Treatment, 13, 101–110.
Read, J., McGregor, K., Coggan, C. & Thomas, D.R. (2006). Mental health services and sexual
abuse: The need for staff training. Journal of Trauma and Dissociation, 7, 33–50.
Read, J., Morrison, A. & Turkington, D. (2005). Trauma and psychosis: Theoretical and clinical
implications. Acta Psychiatrica Scandinavica, 112, 327–329.
Read, J., Van Os, J., Morrison, A.P. & Ross, C.A. (2005). Childhood trauma, psychosis, and
schizophrenia: A literature review with theoretical and clinical implications. Acta
Psychiatrica Scandinavica, 112, 330–350.
Romme, M.A.J. & Escher, A.D. (1989). Hearing voices. Schizophrenia Bulletin, 15, 209–216.
Schachter, C.L., Stalker, C.A., Teram, E., Lasiuk, G.C. & Danilkewich, A. (2009). Handbook on
Sensitive Practice for Health Care Practitioners: Lessons from Adult Survivors of Childhood
Sexual Abuse. Ottawa: Public Health Agency of Canada.
Shevlin, M., Dorahy, M.J. & Adamson, G. (2007). Trauma and psychosis: An analysis of the
National Comorbidity Survey. American Journal of Psychiatry, 164, 166–169.
Shevlin, M., Houston, J.E., Dorahy, M.J. & Adamson, G. (2008). Cumulative traumas and
psychosis: An analysis of the National Comorbidity Survey and the British Psychiatric
Morbidity Survey. Schizophrenia Bulletin, 34, 193–199.
Shulman, R. (1996). Psychotherapy with “schizophrenia”: Analysis of metaphor to reveal
trauma and conflict. The Psychotherapy Patient, 9(3/4), 75–106.
Tarrier, N. (2007). What’s in a name? A commentary on Valmaggia et al.’s “Attention training
with auditory hallucinations.” Cognitive and Behavioral Practice, 14, 144–146.
Taylor, P.J. & Bragado-Jemenz, M.D. (2009). Women, psychosis, and violence. International
Journal of Law and Psychiatry, 32, 56–64.
Thompson, A., Nelson, B., McNab, C., Simmons, M., Leicester, S, McGorry, P.D. et al. (2010).
Psychotic symptoms with sexual content in the “ultra high risk” for psychosis population:
Frequency and association with sexual trauma. Psychiatry Research, 177, 84–91.
Varese, F., Smeets, F., Drukker, M. Lieverse, R., Lataster, T., Viechtbauer, W. et al. (2012).
Childhood adversities increase the risk of psychosis: A meta-analysis of patient-control,
prospective- and cross-sectional cohort studies. Schizophrenia Bulletin, 38, 661–671.
Young, M., Read, J., Barker-Collo, S. & Harrison, R. (2001). Evaluating and overcoming barriers
to taking abuse histories. Professional Psychology: Research and Practice, 32, 407–414.
89
Chapter 7
Trauma-Informed Body-Centred
Interventions
Steven Hughes and Paul Hyman
The places where we cringe are our personal edges. They are the
doors we have never been quite able to walk through, although we
have always known they are waiting for us.
—Stephen Levine
These words describe an experience most of us have felt when we approach

the edges of our current growth, awareness and understanding. We often
hesitate to embrace change and to take that first step into the unknown. For
people who have experienced trauma, taking this kind of risk can be particularly
challenging. Laughter yoga and Brain Gym are emerging as promising practices
that can support people touched by trauma to move forward on their path to
recovery and personal growth and, ultimately, to realize their full potential.
Brain Gym and laughter yoga allow people to experience simple yet powerful
ways to make a body/mind connection. Listening to our bodies allows us to
access our problems at their physiological roots and get in touch with ourselves.
With mind and body working together, we have the potential to access all our
interpersonal and intrapersonal capacities. Activating our bodies in a safe,
non-threatening environment can help change how we feel.
Doing laughter yoga and Brain Gym is fun and a good way to socialize,
release emotions and express ourselves. When these modalities are offered by
organizations, they invite participation in a way that can be less intimidating
than formal therapeutic interventions for trauma healing. Clients can learn to
cope with the effects of trauma without needing to speak directly with a helping
professional about the trauma. Laughter yoga and Brain Gym are levellers in
other ways as well: they provide benefits to staff as well as clients, with the
possibility of integrated sessions where clients and staff participate together.
Trauma and the Body

Trauma profoundly affects the body. Growing scientific evidence indicates
that the dynamics of traumatic stress and its symptoms have significant
biological components (Ogden et al., 2006). One way to look at trauma is as
an out-of-body experience, a separation of the mind and body. People who
have experienced physical, sexual or psychological abuse, or other forms of
trauma, may withdraw unconsciously and be more disconnected from and
less aware of their bodies and how they feel (e.g., pain, tension, pleasure).
Some report simply feeling detached, numb or blank. People who have been
traumatized need to reconnect with their bodies.
The residual effects of trauma and the complex world we live in can trap people
in thoughts about the past and fears about the future. Brain Gym and laughter
yoga are body-centred interventions that offer a pathway to dis-identify from the
jigsaw puzzle of memories, images, affects and bodily sensations—allowing
us to reconnect with joy and playfulness, feel rejuvenated and find hope for a
fulfilling future. Helping professionals and their clients can do these techniques
together to connect to the present moment.
Body-Centred Techniques for Trauma Recovery

A body-focused approach to trauma recovery is rooted in an understanding
that our bodies, emotions and thoughts create a feedback/feed-forward loop.
By using the body (rather than cognition or emotion) as an entry point for
processing trauma, body-centred techniques directly treat the effects of trauma
on the body, which in turn facilitates emotional and cognitive processing.
The mind and body need to work together to facilitate trauma recovery.
Chapter 7 Trauma-Informed Body-Centred Interventions 91
A body-centred approach addresses the whole person, using cognitive and

affective states in combination with sensation to work directly with the
nervous system. Clients are taught to be mindful of inner body sensations—
to the extent that they are capable of observing their internal experience. They
learn to connect what they are thinking (the mind) with what they are feeling
(the body).
These techniques have significant benefits for people recovering from trauma:
• Significant change can be achieved without needing to know the client’s

story of trauma; this is especially useful when symptoms seem to exist for
an unknown reason.
• Body-centred techniques have proven to be effective in addressing
symptoms and effects of abuse, neglect, trauma and complex syndromes,
while minimizing retraumatization and transference (Ogden et al., 2006).
• These techniques use the wisdom of the body and the attunement of the
mind/body to move toward release of trauma in the body and to create
lasting positive change.
• The practitioner can do less therapy, while the client is empowered as an
active participant in recovery.
• These techniques restore self-regulation and return a sense of aliveness,
relaxation and wholeness. Based in a trauma-sensitive approach, these
techniques work from an empowerment model, maximizing the client’s
sense of control and creating an atmosphere that is respectful of his or her
need for safety, respect and acceptance. Besides creating a safe space, self-
regulation techniques allow clients to prepare for therapeutic interventions
and stay grounded and present during and after a session, especially when
they are alone and possibly feeling vulnerable. Clients talk about wanting to
feel grounded: body-centred techniques allow them to experience a visceral
whole-body experience in trauma recovery. (For more about grounding
techniques, see Najavits, 2001).
• Body-centred, non-verbal techniques assist in the management between
hyper- and hypo-arousal trauma states (Ogden et al., 2006). Traumatic stress
symptoms are often expressions of incomplete or fixated functions of fight,
flight and freeze. Whatever the challenge, it stimulates a fight-or-flight
reaction, making the body tense, agitated and eager to do something to
relieve the situation. Using body-centred techniques, clinicians can interacti-
vely modulate clients’ levels of arousal, keeping them from going too far
outside the optimum arousal zone, where it becomes difficult or impossible

to process information without dissociating.
Laughter Yoga
Momentary experiences of positive emotion can build endur-
ing psychological resources and trigger upward spirals toward
enhanced emotional well-being.
—Barbara L. Fredrickson, Positivity
Laughter yoga focuses on the value of laughter as a physical/physiological

experience rather than a cognitive/intellectual construct (Mahony et al., 2002).
It stimulates the physiological phenomenon of “laughter” without requiring
humour as a catalyst. It creates a safe social venue where people can experience
laughter, joy and playfulness in the body. The process of laughter yoga seeks
to bypass the mind and its relentless propensity to judge (and often criticize)
our moment-to-moment experiences. Laughter yoga offers a concrete somatic
experience rather than an intellectual or cognitive appreciation of laughter
and joy.
Laughter yoga is not a form of “treatment”; however, it does have therapeutic

and healing potential as a personal health promotion practice (Davidson et al.,
2006; Mora-Ripoll, 2010; Provine, 2000).
Laughter yoga was developed in 1995 by Madan Kataria, a physician in

Mumbai, India. Kataria was researching the stress management and health
benefits of laughter and decided to form a “laughter club” to test laughter’s
healing potential first-hand. The key to the popularity and success of laughter
yoga is the discovery that laughter can occur without the presence of humour
(Kataria, 1999). Many of us have been conditioned to expect laughter to be
elicited by something funny. Through laughter yoga, we can directly experience
the benefits of laughter without needing to be comedians.
Interest in the idea grew very quickly. There are now estimated to be more than
60,000 laughter clubs in more than 60 countries around the globe. Ironically,
numerous studies in the literature examine humour as an intellectual and
cognitive process, but relatively few reference the pure study of laughter as a
physiological phenomenon (Provine, 2000).
In addition to its physical benefits, laughter yoga can be used to enhance

feelings of self-acceptance and to build social skills and confidence in social
situations. Within the safety of the laughter yoga group setting, participants can
begin to take small interpersonal risks, as the exercises facilitate fun and playful
interaction. The exercises begin with an introduction by the leader, followed by
a community-building segment in which participants get to know one another.
They are reminded that they can opt out of participation at any time if they
begin to feel overwhelmed or uncomfortable in the social context of the session.
Although laughter yoga can challenge the boundaries of people’s comfort

zones, this common experience is articulated, validated and normalized by
the leader. With gentle support and encouragement, each participant begins
to feel liberated from personal limitations associated with feeling self-conscious
or awkward in the group setting. Participants also begin to allow themselves
to let go of self-limiting self-talk and their overarching inner critic as they
begin to reconnect with a sense of joy and, perhaps for the very first time, to
experience the gift of “laughing for no reason.”
Participants can also begin to re-experience a sense of joy in their bodies. This can
be an important benchmark experience for trauma survivors, whose memories
and thoughts about their bodies may be associated with shame, violation and
abuse (Herman, 1992).
Brain Gym
Brain Gym is a program (or practice) that involves using 26 basic movements
—all learned in the first few years of life—as a way to activate different areas
of the brain. They work together to improve cognitive and emotional processing,
facilitate learning and enable people to better cope with the effects of trauma.
People who have experienced trauma can use Brain Gym to help them self-
regulate: it assists them to modulate hyper- and hypo-arousal states and
normalize and stabilize arousal patterns. By working through the body, both
Brain Gym and laughter yoga allow people to feel more grounded and better
able to integrate other aspects of their formal treatment.
Paul Dennison and Gail Dennison (2010), the originators of Brain Gym,
became interested in the latest research about the relationship between the
left and right hemispheres of the brain. They developed intentional integrative
movement activities to help people access cognitive and emotional processes
from the hemispheres that may get blocked from trauma and other stressful
life situations. Brain Gym draws on techniques from many fields, including
developmental optometry, brain research, neurolinguistic programming,
motor development, psychology, acupuncture and dance.
In her book, Smart Moves: Why Learning Is Not All in Your Head (2005),
neurophysiologist Carla Hannaford writes, “Movements awaken and activate
many of our mental capacities: [they] integrate and anchor new information
and experience into our neural networks” (p. 18).
Brain Gym has been used to help with various mental and physical challenges.
It is designed for anyone interested in natural solutions to reducing stress,
improving memory, sharpening skills, strengthening technique, making
effective changes, improving productivity and enhancing performance.
Clients who have done Brain Gym report reduced triggers and symptoms of
depression and fewer episodes of anxiety. Brain Gym is also helpful with
various multicultural groups because it is non-verbal and therefore may be
used with people whose first language is not English.
A pilot of the Problem Gambling Program in Ontario, held at the Donwood

Institute in Toronto in 1996, used Brain Gym as part of its stress reduction
component. Brain Gym activities worked equally well when introduced at
Interval House in Toronto, Canada’s first shelter for women and children
who experienced domestic violence (Hyman, 2006).
Integrating Brain Gym as a coping strategy and learning readiness model has
already demonstrated success (Hyman, 2006). It has worked in the critical
acute phase with people in recovery, and has been incorporated as a life-skill
tool as people have moved forward, accessing more of their resources and
potential for a positive lifestyle change.
Combining Body-Centred Approaches

Doing Brain Gym before and after laughter yoga allows for both modalities to
provide maximum benefits. By harnessing them together, people have the
flexibility to use these grounding techniques and self-regulate their emotions in
different situations and environments. Managing the dynamics of change requires
laser-light focus and agility to flow with resilience (Csikszentmihalyi, 1990).
Giving trauma survivors permission to reconnect with their inner childlike

playfulness is a gift that allows them to release themselves into the present
moment and gain a reprieve from self-negating thoughts and the periodic
painful emotional waves that often affect their daily lives (Beckman et al., 2007).
Although the mind will continue to run its commentary, with persistence,
laughter yoga and Brain Gym can serve as forms of meditation that can help
people temporarily release themselves from an overactive inner critic or a
repetitive inner dialogue.
Incorporating Body-Centred Techniques

within Organizations
It’s almost impossible to maintain any kind of distance or any
sense of social hierarchy when you are just howling with laughter.
—John Cleese, The Human Face
Mind/body modalities can be successfully embedded at the organizational

level, signaling commitment to a non-hierarchical, positive and empowering
culture of care.
Traditionally, many health care environments have been influenced by the

ubiquitous presence of the medical model and its focus on “symptom mana-
gement” and pharmacological interventions. Historically, this approach has
been intertwined with a patriarchal and custodial approach to treatment, where
the clinician is viewed as the expert. The last decade has seen increasing
movement toward embracing integrative medicine and recovery-based models
of care that are sensitive to the power dynamics between care providers and
the recipients of care.
Brain Gym and laughter yoga are modalities or practices connected to the
emerging field of positive psychology (Fredrickson, 2009; Seligman &
Csikszentmihalyi, 2000; Snyder & Lopes, 2002). The value in examining the
positive aspects of human psychology is influencing the new field of positive
organizational scholarship—how we can create organizations that are more
supportive social environments that nurture personal growth, creativity and
collective development (Cameron et al., 2003; Meyer, 2010).
Collective development happens, for example, when Brain Gym or laughter

yoga participants who have used the modalities to deal with their own
challenges go on to teach the techniques to other individuals in distress.
Laughter yoga participants who experience its joy and stress-reducing benefits
have often enrolled in training to become laughter yoga leaders. Therapists
and staff members have commented that laughter yoga has helped them to
manage the insidious impact of vicarious trauma in their lives in a joyful way.
Conclusion
At the height of laughter, the universe is flung into a kaleidoscope
of new possibilities.
—Jean Houston, The Possible Human
A body-centred approach has produced surprising results in dealing with

difficult symptoms arising from trauma. The mind/body connection
integrates body-centred processes with the higher-brain processes of
cognition and feeling, creating a more flexible neurological system and
enhancing the capacity to enjoy a wide spectrum of human experiences.
Brain Gym and laughter yoga are congruent with the emerging trauma-
informed paradigm because they are practices that therapists and clients can
do together and that clients can adopt and practise on their own as part of
their self-managed path to recovery. Since Brain Gym and laughter yoga can
be practised by anyone, they are not burdened with the baggage of treatment
modalities reserved for “psychiatric consumers” or “trauma survivors.” In
other words, they do not carry the stigma that is often attached to more formal
psychiatric and addiction treatment protocols.
Brain Gym and laughter yoga, when offered by health care services and
agencies, become part of a trauma-informed organizational culture,
promoting safety and easing stress in accessible and enjoyable ways.
References
Beckman, H., Regier, N. & Young, J. (2007). Effect of workplace laughter groups on personal efficacy
beliefs. Journal of Primary Prevention, 28, 167–181.
Cameron, K.S., Dutton, J.E. & Quinn, R.E. (Eds.). (2003). Positive Organizational Scholarship:
Foundations of a New Discipline. San Francisco: Berrett-Koehler.
Csikszentmihalyi, M. (1990). Flow: The Psychology of Optimal Experience. New York: HarperCollins.
Davidson, L., Shahar, G., Staeheli Lawless, M., Sells, D. & Tondora, J. (2006). Play, pleasure, and
other positive life events: “Non-specific” factors in recovery from mental illness? Psychiatry, 69,
151–163.
Dennison, G. & Dennison, P. (2010). Brain Gym: Teachers Edition Revised. Ventura, CA: Edu-
Kinesthetics.
Fredrickson, B.L. (2009). Positivity: Top-Notch Research Reveals the 3:1 Ratio That Will Change
Your Life. New York: Three Rivers Press.
Hannaford, C. (2005). Smart Moves: Why Learning Is Not All in Your Head. Salt Lake City, UT:
Great River Publishers.
Hyman, P. (2006). A study linking cocaine clients to ADD characteristics as a foundation to
study Brain Gym and cocaine recovery. TRO Research Annual, 1, 20–24.
Kataria, M. (1999). Laugh for No Reason. Mumbai, India: Madhuri International.
Mahony, D.L., Burroughs, W.J. & Lippman, L.G. (2002). Perceived attributes of health-
promoting laughter: A cross-generational comparison. Journal of Psychology, 136, 171–181.
Meyer, P. (2010). From Workplace to Playspace: Innovating, Learning, and Changing through
Dynamic Engagement. San Francisco: Jossey-Bass.
Mora-Ripoll, R. (2010). The therapeutic value of laughter in medicine. Alternative Therapies, 16(6),
56–64.
Najavits, L.M. (2002). Seeking Safety: A Treatment Manual for PTSD and Substance Abuse.
Provine, R.R. (2000). Laughter: A Scientific Investigation. New York: Penguin Books.
Seligman, M.E. & Csikszentmihalyi, M. (2000). Positive psychology: An introduction. American

Snyder C.R. & Lopes, S.J. (Eds.). (2002). Handbook of Positive Psychology. London, UK: Oxford
University Press.
PART 2
TRAUMA-INFORMED
PRACTICE FOR DIVERSE
CLIENT GROUPS AND
IN SPECIFIC SETTINGS
101
Introduction
Section 1: Diverse Groups
The first section focuses on programs and services for a range of groups or
populations that have characteristics requiring either adaptation or a specific
approach to working in a trauma-informed manner. Identifying the special
needs of such groups is often an emergent process that can arise out of
demand from consumer groups, the experiences of practitioners or evolving
maturation and specialization processes in practice or system design. In this
section, seven groups are discussed as examples of adapted or specialized
approaches. Some of these approaches emerged in response to needs that
presented themselves, as in the case of the program at the Jean Tweed Centre,
while others are designed assuming potential trauma, such as a creative
drama program for young people with fetal alcohol spectrum disorder (FASD).
Using an illustrative vignette, Palucka and Lunsky address the challenges in

responding to trauma experienced by people with developmental disabilities
who are unable to describe or discuss their past trauma. In Chapter 8, they
present a trauma-informed way to reframe a set of responses tailored to this
population. Given the limitations and differences in the abilities of people with
developmental disabilities to communicate and interact with service providers,
applying principles of trauma-informed care and service design requires a
particular sensitivity: this includes providing strength and resilience training,
creating a safe environment that is gender-specific, promoting empowerment
and increasing control and choice, minimizing retraumatization and, most
important, soliciting direct input from the client and his or her support
networks. Palucka and Lunsky highlight the various adaptations that must be
made to take developmental disabilities into account.
Agic discusses the impact of trauma, multiple losses, social disruption and
economic hardship on the health of refugees. In Chapter 9, she describes
how trauma-informed care is an important emerging service provision model
that understands and validates the impact of these multiple stressors, rebuilds
a sense of control, creates a climate of hope and resilience and facilitates
social support. In addition, Agic draws attention to cultural competence in
trauma-informed practice by discussing the important differences among
cultures in what is considered a traumatic event and in how trauma-related

symptoms are expressed and interpreted. She also describes trauma-informed
practices that respect different cultural values and beliefs and that meet the
social, cultural and linguistic needs of refugees.
In Chapter 10, Bloomenfeld and Rasmussen describe the process of developing

trauma-informed practice at the Jean Tweed Centre in Toronto. Observing the
abuse and trauma histories of the women coming for substance use treatment,
the centre took steps to integrate or “braid” an awareness of trauma into all
aspects of its substance use treatment programming and agency structure.
For example, trauma-informed principles were integrated into the training of
receptionist and clerical staff so that women would be greeted in a context of
safety and understanding. The program addresses a wide range of abuse and
trauma issues, including terror and political and social oppressions, affecting
women. The programming emphasizes containment, collaboration, empower
ment and the prevention of retraumatization.
Chapter 11 addresses the challenges of working in a trauma-informed manner

with people who have FASD. Harber likens the effects of FASD to the experience
of trauma and uses creative drama as an approach to working with young
people with FASD dealing with potential trauma histories. Creative drama, as
distinguished from theatre, addresses real issues and scenarios and functions
as a rehearsal for real-life situations. This form of drama uses a range of
principles, such as choice, control, containment and prevention of retrauma-
tization, to make the exercises safe and non-threatening.
Clark, in Chapter 12, describes working with girls using an intersectional

approach, which deliberately addresses the many factors affecting girls’
experiences. She advocates for the importance of girls’ groups and, in light of
the continuum of trauma in girls’ lives, the necessity of making these groups
trauma informed. Clark describes a program for Aboriginal girls aged 8 to 12
that recognizes the impact of cultural experiences and specific rites of passage.
She illustrates trauma-informed principles, such as containing disclosure,
generating externalized views of oppression, developing stronger self-
definitions, learning resistance and acknowledging the effects of gender
discrimination and racism.
Introduction: Diverse Groups and Specific Settings 103
Fallot and Bebout discuss the challenge of working with men with trauma,
violence and abuse histories, ranging from child sexual abuse to military
combat trauma. In Chapter 13, they describe how gendered characteristics and
socialization practices affecting men may prevent them from making certain
disclosures and may inhibit their relational skills and emotional expressions,
all of which affect treatment approaches and systems design. These issues
contribute to difficulties assuming the role of “victim,” displaying a full range
of emotions and self-regulating. Fallot and Bebout contend that these issues
are either magnified in or specific to men and demand particular approaches
in care. They stress the importance of developing mutual relationships,
building on strengths and “connecting the dots” between current issues and
past traumas. They make the critical point that any service provider can
address these processes in any part of the helping system.
In Chapter 14, Menzies describes a tailored response to the specific effects of

intergenerational trauma among Aboriginal people in Canada. He traces the
effects of the residential school system and an assimilationist child welfare
system, both of which removed many Aboriginal children from their families
over the course of a century. These systems created long-term damage and
trauma to Aboriginal people, much of which has become intergenerational in
its effects. The costs of identifying cultural transmission and community and
individual stability were, and are, high. Menzies describes the accommodations
required in trauma counselling to strengthen relationships, cultures and
communities. He stresses the importance of considering cultural affinity and
adapting counselling approaches to align with how survivors see themselves
as Aboriginal. The chapter also highlights the importance of social policy,
past, present and future, in affecting trauma and its solutions.
Section 2: Diverse Settings

The second section highlights several issues about the settings in which services
are provided. Does it matter where people are being cared for or treated? How
does it matter? How can settings such as hospitals become trauma informed?
What change processes are required, and how do these processes work? The
chapters discuss inpatient, primary care and counselling contexts and consider
the processes of creating trauma-informed services and systems.
In Chapter 15, Chaim, Rosenkranz and Henderson describe adaptations in

outpatient services for young people with substance use issues that take
account of trauma. The program is adapted to the developmental stages of
16- to 24-year-olds and services span the continuum of care from outreach to
day treatment services. The program recognizes that many young people,
particularly young women, with serious substance use issues have experienced
or witnessed trauma, abuse or neglect. To increase youth’s commitment and
engagement in treatment, efforts are made to empower and involve youth in
treatment planning using a harm reduction framework. Staff also considers
ways to make the hospital environment more informal and welcoming.
Perivolaris and Pottinger address two contentious procedures in psychiatric

units: restraint and seclusion. In Chapter 16, they explain that while inpatients
with trauma backgrounds often find these procedures retraumatizing, many
service providers see them as methods for reducing aggression and ensuring
their own safety and that of other patients. The authors describe the complex
process of shifting from restraint use to restraint prevention at a large hospital,
the Centre for Addiction and Mental Health in Toronto. Prompted in part by
two patient deaths, the change process involved senior leaders identifying the
need to evaluate best practices around restraint use and included detailed plans
and methods for dealing with resistance to reducing restraint use. Elements
of trauma-informed service systems were critical to the initiative, such as
fostering empowerment, providing flexibility and developing safety planning.
Baker discusses working with families in the context of a family member’s

mental health problems in Chapter 17. She discusses how these processes can
take place in various settings, designed to increase safety and preserve confiden
tiality. Baker illustrates how traumatizing illness and/or hospitalization can be for
all family members and how introducing a strengths-based collaborative and
participatory approach with the family can improve recovery for all. She addresses
how the culture of blame can affect mothers in particular, due to historical
sexism, and how this needs to be directly addressed.
In Chapter 18, Akman and Rolin-Gilman discuss another hospital-based

setting, a dedicated women’s inpatient psychiatric unit. This unit was developed
to provide safety for women with substance use or mental health issues and
was designed to attend to the intersections of these issues with violence and
trauma. The unit aims to promote wellness, not just provide treatment. Client
Introduction: Diverse Groups and Specific Settings 105
empowerment is encouraged by emphasizing each woman’s role in determi-

ning her own treatment goals. In addition, all procedures are continuously
revisited, and specific procedures responding to dangerous situations are
deliberately designed to prevent or reduce retraumatization.
Umaña addresses the challenges of providing trauma-informed service in

primary health care in a community clinic for a specific client group—
immigrant and refugee women with HIV/AIDS. As described in Chapter 19,
this context features numerous factors that contribute to trauma and that
require consideration in providing service. These factors include culture,
circumstances of infection, stigma and isolation. Umaña describes a compre-
hensive enhancement of a primary care service to include community-based
research, community partnerships, multidisciplinary responses, erasure of
wait times and the overarching integration of trauma-informed service and
system improvements.
These examples drawn from various settings show the importance of questioning
practices, designing change management processes and developing client-
centred approaches that empower clients and are sensitive to wide-ranging
trauma. They illustrate the difficulties involved in changing procedures,
practices and service design to include more trauma-informed approaches
and to maintain consciousness and reflexivity while doing so.
The examples presented in Part 2 of this book are in no way meant to represent
all groups for whom trauma-informed practice is important or all settings
where trauma-informed practice is being developed. The differential experien-
ces of trauma experienced by lesbian, gay, bisexual, transgendered, transsexual,
two-spirit, intersex and queer people; women leaving violent relationships;
veterans with posttraumatic stress disorder; people who are incarcerated and
forensic clients have all come to our attention in developing this book. This
awareness underlines the importance of responding in trauma-informed ways
to the specific needs of different groups at the systemic, program and individual
levels. Indeed it is important—as contributors to this book have often achieved—
to see the linkages with health equity and harm reduction processes, as we
develop and apply a trauma-informed framework in our support of people
with mental health and substance use issues.
PART 2
SECTION 1: DIVERSE GROUPS

8 Working in a Trauma-Informed Way with Clients Who Have
a Developmental Disability
9 Trauma-Informed Care for Refugees
10 The Evolution of Trauma-Informed Practice at the Jean Tweed Centre
11 Show Not Tell . . . Trauma-Informed Creative Engagement with Youth

Who Have FASD
12 Girls’ Groups and Trauma-Informed Intersectional Practice
13 Acknowledging and Embracing “the Boy inside the Man”: Trauma-

Informed Work with Men
14 An Intergenerational Trauma-Informed Approach to Care for Canada’s

Aboriginal Peoples
109
Chapter 8
Working in a Trauma-Informed Way with

Clients Who Have a Developmental Disability
Anna M. Palucka and Yona Lunsky
People with developmental disabilities are far more likely to be victimized

than the general population, yet have fewer resources to deal with these
experiences. Their response to the trauma may also be different. Therefore,
trauma-informed practice with this population requires certain modifications.
The goal of this chapter is to demystify the tailored approach to trauma-
informed care for people with developmental disabilities. It addresses the
types of trauma they may experience, the impact of cognitive impairments on
how they may report trauma and how to apply a trauma-informed approach
in work with people who have developmental disabilities.
In general, developmental disability refers to impairments in cognitive

functioning accompanied by impairments in adaptive skills that emerge in
the developmental period (prior to age 18). The term developmental disability1
allows for inclusion of individuals whose IQ might be a little higher but who
nevertheless have significant cognitive and functional difficulties. People with
fetal alcohol spectrum disorders and autism spectrum disorders (ASD) are
also considered to have developmental disabilities. Individuals with ASD may
have ways of understanding and interpreting their social and non-social world
that are different than those of neurotypical individuals.2 They may experience
1. Diagnostic criteria for mental retardation in DSM-IV: Intellectual functioning markedly below average
(IQ below 70–75, or two standard deviations below the mean); impairments in at least two areas of adaptive
functioning; onset before age 18. (The term “mental retardation” will be replaced by “intellectual disability”
in DSM-5.)
2. For more about “social stories” among people with ASD, see www.carolgraysocialstories.com.
relatively minor events, such a falling off a bicycle or losing an object of attachment,
as traumatic. Their difficulties in communicating and interacting socially and
their behaviours associated with ASD will affect how they communicate and
process their experiences.
Working with individuals with developmental disabilities who have experienced

trauma often requires working with caregivers (family members or paid staff),
and depending on the source of trauma, recognizing that abuse is not the only
type of trauma the person may have experienced. The involvement of caregivers
can be crucial, as many people with developmental disabilities do not live inde-
pendently and may need others’ assistance for transportation, decision-making
and implementing treatment strategies. If it is safe to do so, it is these caregivers
who can provide information about personal and clinical history, significant
relationships, dreams and goals or preferences.
The following vignette illustrates key elements of trauma-informed practice

involving a person with a developmental disability and those who work with her.
Tracy is 34 years old but looks and acts like a teenager. She has moderate
intellectual disability and attention-deficit/hyperactivity disorder. She was
admitted to hospital because her group home placement broke down due
to her aggression. On one occasion, she entered a bedroom of another
resident at night and started to punch him. Her records indicate that she
experienced physical and emotional abuse and severe neglect in her family
home. She was sexually assaulted by a stranger when she was 19, but her
family refused the offer of counselling at that point. More recently, after Tracy
left home, her sisters disclosed that they were sexually abused by their father
and suspected that Tracy, too, might have been abused. Group home staff
wanted Tracy to engage in psychotherapy, but following the initial evaluation,
the therapist felt that she would not be able to tolerate it. Behavioural
approaches were unsuccessful and staff continued to request individual
therapy to help with challenging behaviours: Tracy was highly reactive,
impulsive, intrusive and pushy, and at times of distress, she would become
combative and verbally and physically aggressive, display sexualized
behaviour and speak in a deep masculine voice.
In hospital, Tracy presented with high anxiety and agitation, excitability, need
for attention and exaggerated display of somatic complaints, including leg or
Chapter 8 Working in a Trauma-Informed Way with Clients Who Have a Developmental Disability 111
stomach pain and difficulty swallowing. Given her dramatic presentation,

somatic complaints might have been easily dismissed as attempts to engage
staff, particularly since she would settle in response to staff reassurance;
however, medical examination revealed underlying medical conditions. Further
observations identified triggers to her agitation that seemed to be directly
related to her experience of neglect and trauma: triggers included doing
something incorrectly, such as spilling her drink; being criticized, ignored or
dismissed; being sent for time out; perceiving unfairness or rejection; noticing
attention being given to someone else; hearing other people breathing loudly
or making “noises”; and having her family visit her. Attempts to talk with
Tracy about those issues led inevitably and rapidly to behavioural escalation.
The intervention approach was shifted from therapy and behavioural contin-
gencies (i.e., providing consistent consequences for specific behaviours, such
as cancelling an outing if she was verbally aggressive to staff) to a focus on
staff understanding and being sensitive to Tracy’s experiences, both past and
present. To support Tracy, staff had to keep the present impact of her history
of trauma at the forefront of all interactions and acknowledge and validate her
experiences. That was particularly important given the neglect and secrecy she
had experienced with her family.
A trauma-informed plan of care was developed that emphasized the role of

staff in addressing Tracy’s trauma-related behavioural difficulties. It included:
∙∙ educating staff about the effects of trauma on Tracy, her triggers and the
importance of validating her experiences and how to tailor the teaching of
self-soothing skills using visual aids
∙∙ creating a safe environment through recognizing and minimizing situations
and responses that might be retraumatizing, such as sending Tracy for time
out when she was upset about attention given to another client
∙∙ providing choices and increasing opportunities for positive experiences
∙∙ assisting Tracy to use calming strategies, employing specially tailored comic
strips that illustrate deep breathing
∙∙ establishing a working relationship with Tracy’s family
∙∙ developing a support network beyond paid staff; for example, encouraging
Tracy to attend her local church.
Tracy’s story illustrates how helpful trauma-informed practice can be, regardless
of whether clients are able to describe their experiences as related to trauma.
The therapeutic team’s awareness of how trauma may be expressed is critical to
trauma-informed services. With this awareness, the team can support the client
by using creative approaches to applying the practices of creating safety, providing
opportunities for relational connections and teaching skills.
The Nature of Trauma for People with

Developmental Disabilities
In addition to issues such as sexual abuse, as illustrated by Tracy’s story,
there are other sources of trauma for people with developmental disabilities.
Clinicians may not always consider the types of trauma that affect them and
how their response to trauma may be different.
Abuse
People with developmental disabilities are more likely to experience emotional,
physical and sexual abuse and life-threatening neglect than the general
population. As in Tracy’s case, this abuse is more likely to be perpetrated by
someone they know rather than a stranger. They experience high rates of
bullying and teasing by peers in youth and even in adulthood. One in three is
sexually abused before age 18 and women are at higher risk than men of
being victimized and revictimized. People with developmental disabilities
who have been sexually abused may display sexualized behaviour (including
sexual threats or accusations) under stress. Some individuals with developmental
disabilities remain at lifelong risk for repeated trauma: acquiescence, social
naiveté, poor judgment and social skills and a reluctance, fear or inability to
disclose abuse make them more likely to experience traumatic events. Higher-
functioning individuals may repeatedly place themselves in abusive or
exploitive situations because of a desire to present as normal or to have
relationships with “normal people.”
Loss through Separation, Abandonment or Death

Loss can be experienced by being separated from or abandoned by family—
being placed in a foster or group home or institution—or from the death of a
parent. In these situations, the person with a developmental disability is often

removed from the family home and placed in the care of strangers. This means
the person loses not only his or her parent, but a way of life and his or her
possessions. Women with mild developmental disabilities, as with other women,
may experience trauma when they give birth to children they are unable to
care for, or when children are removed from their care. They may continually
re-experience the loss of the mother role through exclusion from the child’s
life, for example, being denied participation in significant events such as
birthdays due to concerns about their behaviour.
Natural Disasters, War, Displacement and Accidents

Caregivers, and sometimes clinicians, can wrongly assume that people with
developmental disabilities are not aware of, or that they can be sheltered from,
the psychological impact of a natural disaster, war, displacement or accident.
Even when individuals are clearly aware of their circumstances, it might be
difficult to determine their actual understanding and experience of the trauma.
For example, a young woman with a mild developmental disability whose
parents and several siblings were killed during Rwanda’s genocide when she
was 14 repeatedly expressed the desire to “go back home.” When looking at
the impact of these events, the clinician may find it helpful to consider how a
similar situation might affect a young child who is reliant on a caregiver who
has been harmed or killed.
Hospitalization
There are several factors to consider in relation to hospitalization and trauma.
People with developmental disabilities experiencing mental health issues are
generally hospitalized for difficulty managing aggression or for displaying
self-injurious or severely disruptive behaviour. These behaviours are often
precipitated by or exacerbated by significant life events in the preceding months
and indicate the person’s difficulties in dealing with them. Being admitted to
hospital can be very traumatic, particularly if it involves the use of force and
police. The hospital environment itself can be traumatizing for people with
developmental disabilities.
FACTORS THAT CONTRIBUTE TO HIGH RISK OF

(RE)TRAUMATIZATION IN HOSPITAL
• use of intrusive interventions such as time out, seclusion, mechanical and

chemical restraints
• being assigned to or being restrained by a staff member of the same sex as
an abuser
• witnessing others being restrained
• being assaulted or witnessing assaults by co-patients (not feeling safe)
• separation from family (caregivers)
• separation from familiar environment and routines
• prolonged admissions
• not understanding reason for hospitalization and not knowing for how long
(forever)
WAYS TO MINIMIZE THE RISK OF

(RE)TRAUMATIZATION IN HOSPITAL
• Assign same-sex staff to assist with personal hygiene (two staff if needed).
• Use least restraint policy: understand escalation continuum and use
prevention; allow person to select preferred mode of restraint when required.
• Address vulnerability: Separate female bedrooms from male bedrooms.
• Debrief incidents that involve or are witnessed by the individual.
• Avoid hospitalization or keep it to a minimum.
• Facilitate caregiver contact and visits.
Impact of Cognitive Impairments on

Reporting Trauma
People with developmental disabilities have a range of cognitive impairments that
affect their ability to understand what has happened to them and to communicate
the trauma to someone else. Impairments may occur in these areas:
Concrete thinking: People with developmental disabilities may have difficulty

identifying their emotional or internal experience. They may actually not
realize that what happened to them was traumatic or wrong, and that they
could talk to someone about it.
Communication issues: They may not have words to explain their experience
and may express it through their behaviour instead, or express it in ways that
are misunderstood by others.
Individuals with developmental disabilities may experience their

own thoughts or memories as voices. Their reporting of voices
telling them upsetting things or telling them to do things may be
misdiagnosed as psychotic.
Attention and memory issues: They may not be able to recall significant
details of a traumatic experience, such as the names of people or places
involved. Or they may confuse details and provide inconsistent information
at different times, so that people do not believe them.
Concept of time: They may not be able to report when things happen and
their report might be confusing, with remote events being reported as recent.
HOW SERVICE PROVIDERS CAN COMPENSATE FOR CLIENTS’

COGNITIVE DIFFICULTIES
• Be explicit about interventions.

• Provide clear explanations, using:
○○ concrete language
○○ short sentences
○○ visual aids (drawings, photos)
○○ frequent repetition.
• Check for understanding (ask clients to explain in their own words).
• Allow time for processing.
• Provide engaging and fun activities.
• Repeat information over several sessions.
• Record sessions so the client can listen or even view them again.
A Trauma-Informed Approach with People

Who Have Developmental Disabilities
This section applies and adapts the principles of trauma-informed practice
articulated by Elliot et al. (2005) to the realities of people with developmental
disabilities.
Recognize the impact of victimization and trauma on the person’s behaviour

and coping strategies. The person’s childhood history may be unknown.
Bizarre or disturbed behaviour might signal that the person is re-experiencing
trauma or extreme distress, or that she or he is trying to self-soothe in the best
way possible. It can be important, as in Tracy’s situation (see p. 110), for the
service provider to consider unrecognized trauma as an explanation for
disturbed behaviour and to seek to understand it.
QUESTIONS ABOUT TRAUMA FOR SERVICE PROVIDERS

TO CONSIDER
• When did the trauma occur?

• What is the nature of the trauma?
• What symptoms has the individual experienced?
• What support and treatment have been received?
• Is there a previous history of trauma? (McCarthy, 2001)
Note: These questions are not intended to be posed directly to the client;
rather they are questions for service providers to keep in mind.
Identify recovery from trauma as a primary goal. Recovery from trauma

should be a primary goal of treatment, as it would be with any other population.
Specialized services—for developmental/dual diagnosis and trauma—need
to be integrated into treatment. Furthermore, trauma work with this group
extends beyond the individual with a developmental disability; when it is safe
to do so, caregivers need to be involved, as their support can be critical to the
recovery process. Caregivers may need education about trauma in general and
about issues specific to the person in their care to better understand the person’s
behaviour and their own comfort level and ability to assist the person.3
Empower the individual. Be aware of a tendency that people with developmental

disabilities have to acquiesce to caregivers or treatment providers. Recognize
that they might feel that they did something wrong and may get in trouble
if they reveal abuse. It is important to teach about privacy in interaction
(e.g., not talking about sensitive or private topics in public places, checking
with the person whether information he or she revealed may be shared with
caregivers) and that saying no or refusing things does not mean the person
is being unco-operative.
Maximize choices and control over recovery. People with developmental

disabilities may have little sense of self-agency. They may not have skills to
identify and express preferences and might need to be taught in small steps.
3. For more information about supporting a person with a disability who is experiencing posttraumatic stress
disorder, see www.dimagine.com.
Provide them with situations where they can choose and assert preferences
(e.g., what to wear or eat, where to go). Emphasize opportunities for positive
experiences such as engaging in fun activities or fostering relationships with
supportive others.
Create an environment that is safe, respectful and accepting. Take time to

understand how the person communicates. Include people the person feels
safe with, even in the therapy itself. Carefully consider the choice of therapist.
This includes considering gender-specific services (i.e., a female therapist for
a female client), or specialized dual diagnosis services, particularly if a diagnosis
of psychotic spectrum disorder is being considered.
Create a predictable and consistent environment. Be aware of clients’ current

living circumstances: if they live somewhere they do not want to be and which
is interpersonally stressful, they may need help to recognize and deal with that.
Emphasize strengths and resilience over pathology. See the person as someone
to be admired rather than as a problem to be solved, recognizing his or her
resilience in the face of impairments and traumas (Wilson & DuFrene, 2008).
Identify and focus on relative strengths or the things the person enjoys doing.
Minimize possibilities for retraumatization. It is important to work with

caregivers whose role is to protect the person from revictimization. Recognize
that the person may be at risk in any placement—in the community as well as
in an institutional setting (jail or hospital).
Be culturally competent and competent around the “culture” of developmental

disability. In addition to being sensitive to the person’s racial and cultural
background, it is important to appreciate the different ways trauma might be
expressed by people with developmental disabilities. Use your creativity to
modify your interactions and treatment interventions to compensate for the
cognitive impairment. You may have to adjust your expectations about what is
helpful; take cues from the person about what type of interactions he or she
finds supportive.
Solicit input from clients with developmental disabilities directly. Soliciting

client input is an important aspect of providing trauma-informed services for
any population. Even if it is more difficult to obtain input from people with
developmental disabilities, try to find ways to elicit feedback and consider it,
even if it is limited (e.g., using simplified visual analogues of rating scales—
smiling/upset faces). We recognize the possible importance of including
caregivers, but not at the cost of excluding the person with the disability
from being central and sharing his or her own perspective and experience of
the services.
Monica is 40 years old and lives semi-independently with limited hours

of support. She was admitted to hospital because of concerns about her
aggressive behaviour, for which she was criminally charged. In contrast to
her relatively high cognitive and adaptive abilities, Monica presented in a
very childlike way in her speech and emotional reactions. In hospital, she
described hearing the voices of her dead parents. She heard her mother,
who had abused, neglected and later abandoned her, telling her to hurt
herself or damage things. Monica was very distressed by hearing this.
The voice of her father, on the other hand, was very protective, telling her
mother to “shut up” or telling Monica to ignore her.
The main intervention was to explore Monica’s experience of the voices and
“give” her power over them. In a concrete way, she decided to use a visual
aid to help her contain the voices—she would “lock her mother (the voice)
in a closet.” This helped her to stop paying attention to her mother’s voice
and stop getting distressed by it.
Conclusion
The concept of trauma should be viewed very broadly in developmental
disabilities; it is important to understand what is traumatizing for the person.
Given the high probability of trauma in the lives of people with developmental
disabilities, all interventions should be trauma sensitive, emphasizing coping,
safety, choice and having a voice. It is also crucial to involve caregivers and
help them understand the person’s behaviours in relation to trauma. The
presence of trauma should become part of the clinical formulation, provide a
framework for understanding the person’s experiences and be taken into account
when planning supports and interventions. Hospitalization should be carefully
considered because it will likely (and potentially unavoidably) be traumatizing.
References
Elliott, D.E., Bjelajac, P., Fallot, R.D., Markoff, L.S. & Reed, B.G. (2005). Trauma-informed or
McCarthy, J. (2001). Post-traumatic stress disorder in people with learning disability. Advances in
Psychiatric Treatment, 7, 163–169.
Wilson, K.G. & DuFrene, T. (2008). Mindfulness for Two: An Acceptance and Commitment Therapy
Approach to Mindfulness in Therapy. Oakland, CA: New Harbinger.
121
Chapter 9
Trauma-Informed Care for Refugees

Branka Agic
Armed conflicts, political repression and massive human rights violations have
forced millions of people to flee their homes and seek refuge in other countries.
As a party to the 1951 Convention relating to the Status of Refugees, Canada
has an obligation to protect refugees facing prosecution.1 Through its refugee
protection system,2 Canada accepts more than 25,000 refugees annually.
Since World War II, Canada has accepted more than one million refugees
(Citizenship and Immigration Canada, 2010).
Research examining the mental health of refugees has consistently found a

high prevalence of trauma-related problems in this population (Cardozo et al.,
2004; Fazel et al., 2005; Kirmayer et al., 2011). Failing to adequately address
the complex mental health needs of refugees who are trauma survivors may
worsen their health and negatively affect the integration process (Blanch, 2008;
Gardiner & Walker, 2010).
This chapter outlines the key determinants of refugee mental health, describes
the impact of trauma and explores the evidence base for trauma-informed
care for refugees.
1. The 1951 Refugee Convention, which established the United Nations High Commissioner for Refugees
(UNHCR), defines a refugee as a person who “owing to a well-founded fear of being persecuted for reasons
of race, religion, nationality, membership of a particular social group or political opinion, is outside the
country of his nationality, and is unable to, or owing to such fear, is unwilling to avail himself of the
protection of that country” (UNHCR, 1951/2003, p. 14).
2. The Canadian refugee system includes the Refugee and Humanitarian Resettlement Program for people
seeking protection from outside Canada and the In-Canada Asylum Program for people making refugee
protection claims from within Canada (Citizenship and Immigration, 2010).
Trauma as a Risk Factor for Mental Health

Problems in Refugees
Most refugees experience traumatic events and difficult situations, such
as violence, persecution, multiple losses, social disruption and economic
hardship, that are associated with adverse mental health outcomes
(Rubinstein & Kohli, 2010). Research reveals high prevalence rates of
psychiatric disorders, particularly posttraumatic stress disorder (PTSD) and
depression, among refugee populations (Fazel et al., 2005; Hollifield et al.,
2002; Karunakara et al., 2004; Mollica et al., 2001). More severe reactions
are associated with a higher degree, duration and frequency of exposure to
traumatic events. Risk factors that may predispose refugees to mental health
problems and disorders include being subject to or witnessing torture,
physical and sexual violence, imprisonment, internment in refugee camps,
prior history of mental illness and loss of family members (Porter & Haslam,
2005; Watters, 2001). Vulnerable groups include children, unaccompanied
minors, adolescents and older adults (Mikus Kos at al., 2011).
Since the second half of the 20th century, civilian populations have increasingly
become subject to widespread human rights violations, with women and girls
constituting the majority of victims. In the past few decades, the frequency and
brutality of sexual violence against women and girls—including rape, sexual
slavery, enforced pregnancy and forced prostitution—have reached alarming
rates in contemporary armed conflicts (Mazurana & Carlson, 2006; Ward &
Marsh, 2006).
Mass rape during armed conflicts has become a strategic weapon of war, ethnic
cleansing and genocide in many settings. Between 20,000 and 50,000 women
and girls were raped during the war in Bosnia in the early 1990s; during the
Rwandan genocide, an estimated 250,000 to 500,000 women and girls were
raped; it is believed that in the Democratic Republic of the Congo, 200,000
women and girls have been raped since 1998 (United Nations, 2009, n.d.).
Despite the high incidence of sexual assault and rape among refugee women,
this crime is largely under-reported because of societal and cultural stigma
attached to it. Victims are often viewed as defiled. They rarely receive medical
Chapter 9 Trauma-Informed Care for Refugees 123
treatment or emotional support. Women who became pregnant are often

ostracized by their families and communities.
Exposure to multiple traumatic events is correlated with a greater negative

impact on health. Evidence shows that stresses experienced after migration
play a significant role in determining the severity of mental health problems.
Trauma can be compounded by daily struggles experienced due to low socio-
economic status, unemployment, social isolation, the uncertain status and
experiences of discrimination and isolation and other life stressors (Porche
et al., 2009; Wilson et al., 2010). The occurrence of mental health problems
in refugees has been repeatedly reported years after traumatic exposure
(Smid et al., 2012).
The impact of trauma can be debilitating, affecting every aspect of refugee

life, including work, interpersonal relationships, parenting and social life.
Trauma can also lead to poor physical health and substance use problems.
To ensure refugees’ successful resettlement and integration into Canadian
society, it is critical to identify and properly address the unique mental health
needs of this population.
Trauma-Informed Care for Refugees

Trauma-informed care is an emerging model for providing refugee-sensitive
mental health services that understand and validate the impact of multiple
stressors; recognize the meaning of trauma and healing within the cultural
context; create a climate of hope and resilience; rebuild the person’s sense of
control; facilitate social support and promote recovery and successful integra-
tion into the host society (Blanch, 2008).
Being Aware of Pre-migration Trauma and

Post‑migration Stressors
Trauma-informed care for refugees recognizes the profound effects of pre-
migration trauma on refugees’ health and validates their experiences of
injustice and the loss of household, social status and social structure that
compound the experience of trauma.
Almost all refugees have at least one traumatic experience that is an important
part of their life history. Yet many refugees are reluctant or emotionally unable
to share their personal story (Harvard Program in Refugee Trauma, 2011),
particularly when it involves being tortured or raped. Concealing these kinds
of experiences creates considerable barriers for service providers to adequately
addressing clients’ mental health needs. Familiarity with the common charac-
teristics of survivors of war or torture trauma is important for providing
appropriate support and preventing more serious problems. Warning signs of
a possible trauma history include but are not limited to a history of civil war in
the country of origin; reluctance to disclose pre-migration experiences; fear of
groups and authority figures; missing, tortured or killed family members; a
history of imprisonment; somatic symptoms with no known physical cause;
and mental health symptoms such as sleep problems, depression, being easily
startled and avoidance (Johnson, 2005).
It is also important to keep in mind that mass violence can directly and
indirectly cause serious medical problems, including injuries, chronic pain,
HIV/AIDS, hypertension, cardiovascular disease and diabetes. Using alcohol
and other drugs to cope with sleep and anxiety problems can lead to substance
use issues (Johnson, 2005). A longitudinal study of Bosnian refugees revealed
serious disability associated with the mental health effects of violence, as well
as premature death related to the negative health effects of chronic depression
in older adults (Mollica et al., 2001). Post-migration stress interferes with
healing and recovery. Simich et al. (2006) found that refugees are 2.6 to 3.9
times more likely to suffer common PTSD symptoms if they suffer from
financial difficulties in their host countries. In Canada, refugees are consistently
overrepresented among the poor. Their increased susceptibility to poverty
creates difficulties in accessing basic needs, such as food and adequate housing
(Kazemipur & Halli, 2001).
Growing evidence shows that the provision of basic needs, such as housing
and income, has a positive effect on refugees’ ability to cope with trauma and
on their general well-being, as well as improving treatment outcomes (Blanch,
2008; Mollica et al., 2002; Vasilevska & Simich, 2010). When asked what will
help them get better, most refugees identify socio-economic factors rather than
psychiatric or medical assistance (Watters, 2001). Therefore, when working
with a refugee client, it is important to ask not only about the person’s pre-
migration experiences, but also about his or her housing situation, ability to
find work and availability of social support.
Trauma-informed service providers recognize the contribution of resettlement

difficulties to refugees’ psychological and social problems and facilitate links
to other services, such as housing assistance, employment support and family
reunification.
The service provider should address the client’s priorities in sequence, from most
immediate or pressing to least pressing. Treatment plans should be adapted to the
client’s most immediate needs. This may include referral to services that assist
in documenting torture or persecution for the refugee determination decision,
language classes, help finding housing and work or addressing other health
issues before moving toward more sensitive mental health issues (Benedek &
Wynn, 2011; Gorman, 2001; Vasilevska & Simich, 2010).
Focus on Safety, Respect and Trust

Because of their experiences of persecution due to ethnic, religious or political
background, many refugees find it difficult to trust anyone again. Even though
the new country is relatively safe and secure, refugees may continue to feel
unsafe after their arrival. Mistrust, particularly of authority figures, is a signifi-
cant barrier to care. Refugees may be reluctant to disclose a trauma history for
fear that the disclosure can be used against them (Tribe, 2002).
Trauma-informed care for refugees works toward developing feelings of safety

and trust. This requires cultural sensitivity and respect, understanding of
linguistic needs and the importance of using qualified interpreters and case
management efforts.
Refugees are more likely to heal if health care providers show empathy and
interest and allow adequate time to develop rapport and a trusting relationship
(Gardiner & Walker, 2010). Becoming aware of the political situation in the
client’s country of origin and core cultural values may be helpful in developing
a trust-based relationship. Addressing refugees’ immediate needs conveys
respect for their rights, well-being and autonomy (Gorman, 2001).
Refugees who are trauma survivors are particularly vulnerable to retrauma

tization (Bemak et al., 2003; Schwarz-Langer et al., 2006) Trauma-informed
services are designed specifically to avoid retraumatizing those who seek
assistance, whether or not they are seeking specific treatment for trauma.
This includes awareness and prevention of potential triggers. For example,
history taking and the assessments and hearings associated with the refugee
determination process often trigger traumatic memories and worsen
symptoms (Benedek & Wynn, 2011). For refugees who have been tortured by
health care providers, routine physical exams may be very stressful and bring
back memories of the torture. Unexpected loud noises can trigger an
exaggerated startle response in survivors of bombing or shooting. Respecting
the client’s wish not to discuss trauma is important (Gardiner & Walker, 2010).
Service providers also need to be sensitive to gender and ethnic issues.

Women who are survivors of sexual violence may feel more comfortable with
female service providers. Refugees who were persecuted by members of their
own cultural group may prefer service providers from a different cultural
group (Allimant & Ostapiej-Piatkowski, 2011).
All clients who are not fluent in English should be offered a professional
interpreter. The client’s preference for someone with a particular ethnicity and
of a certain gender should be respected where possible. Refugees from ethnic
or religious minority groups may not feel comfortable with interpreters from
majority groups responsible for their persecution. If the interpreter is perceived
by the refugee client as biased, the client may not feel comfortable discussing
personal issues (Canadian Council for Refugees & Sojourn House, 2010).
Focus on Strengths and Resilience

Refugees have the capacity to deal with hardship and deprivation and have a
strong motivation to succeed. They should not be viewed as helpless victims
of circumstance, but rather as people with extraordinary coping skills and
resilience (Guyot, 2007; Rubinstein & Kohli, 2010; UNHCR, n.d.). Refugees
should be acknowledged as “active survivors in a new environment”
(Vasilevska & Simich, 2010). Blanch (2008) notes that even people who
display severe trauma-related symptoms in some areas of functioning may
show remarkable resilience in others.
Trauma-informed services build on the refugees’ inner resources, prioritize

skill building, encourage active participation in mental health programs and
aim to expand support networks. Active participation “prevents the harmful
helplessness and enforced dependence which drain their energy” (World
Health Organization, 1996, p. 133).
The loss of family and social support can compound the experience of trauma.
Trauma-informed care encourages refugees to become engaged with social
support networks. For example, programs offered through settlement or social
service agencies, such as a befriending program, that match clients with
volunteers or mutual supports groups, have the potential to break down isolation
and promote mental health (Canadian Centre for Victims of Torture, 2009).
Strong community support decreases resettlement stress, alleviates emotional

distress and promotes refugee mental health (Beiser, 2010; Beiser et al., 2003;
Simich et al., 2004). Beiser (2009) suggests that, at least in the short and
medium term, the availability of a like-ethnic community is one of the strongest
promoters of resilience in refugees.
Rebuilding a Sense of Control

Refugees are victims of circumstances beyond their control and usually have
very few options about where they go or what they do. Being a refugee means
being deprived of power and control, living in exile and depending on others
for such basic needs as food and shelter. Trauma-informed care creates
opportunities for survivors to rebuild a sense of control. Regaining a sense of
control and responsibility for their lives is a part of healing and recovery
(Miller & Rasco, 2004).
The key components of this approach involve empowering refugees to take a

central role in their health and linking them to community resources. This
means that refugees are active participants with choice and control over their
treatment options and care, while service providers are responsive to their
needs and choices.
Refugees are frequently unaware of the impact of trauma on their health and
well-being. Gaining an understanding of the effects of trauma is important to
the healing process. Health education should focus on normalizing trauma

experiences, reducing stigma attached to mental health problems and exploring
available treatment options (Johnson, 2005).
Prolonged disability status and dependence on others are generally not helpful.
The Harvard Program in Refugee Trauma (2011) stresses the critical importance
of actively involving trauma survivors in their own recovery. The areas of
highest therapeutic potential include work, volunteering and spirituality.
Survivors of war or organized violence often find comfort and healing from
trauma through religion and spirituality. Work and volunteering provide
survivors with a sense of worth, structured daily life and opportunities for
socialization. Activities in these areas should be strongly encouraged (Harvard
Program in Refugee Trauma, 2011; Johnson, 2005).
The ability to speak English or French is essential to refugee empowerment.

Language skills help refugees to find employment and increase their access
to services. These skills also provide opportunities for socialization (Beiser,
2010). However, due to trauma-related problems such as lack of concentration,
memory problems or distrust of strangers, some refugees may have difficulties
staying in regular ESL classes. Referral to a language program specially designed
for survivors of war or torture is often helpful (Canadian Centre for Victims of
Torture, 2009).
Refugees’ social world has been destroyed or seriously damaged. Families are
frequently separated for prolonged periods. Family members may have been
killed or are missing. Trust in others has often been diminished by traumatic
pre-migration experiences. Ethnic communities are considered a significant
source of support for refugees. Linking survivors with the community-based
organizations is often effective in reconstructing healthy relationships with
others and increasing social connections (Blanch, 2008; Johnson, 2005).
Cultural Competence
Culturally competent trauma-informed care is increasingly recognized as a
necessity for quality mental health care. Culture plays a key role in mental
health, mental illness and help-seeking behaviour. It influences how people
respond to trauma, how they express and communicate their symptoms, how
they cope and what type of help they prefer (Blanch, 2008; Brown, 2008;
Hinton & Lewis-Fernandez, 2010).
Research has found many commonalities in the way that people from different
cultures react to traumatic events. However, there are also important differences
across cultures in what is considered a traumatic event and how trauma-related
symptoms are interpreted and expressed (Gorman, 2001). For example,
research found that Tibetans consider witnessing the destruction of religious
symbols as more traumatic than imprisonment or torture. For Rwandan
genocide survivors, not being able to perform morning ceremonies and
traditional funerals for the dead is very upsetting, due to cultural beliefs about
the spiritual status of those who have not received those ceremonies (Hinton
& Lewis-Fernandez, 2010).
Trauma-related symptoms in refugees may be missed if service providers are

looking for symptoms that are normative in western populations (Blanch,
2008; Hinton & Lewis-Fernandez, 2010). Mental health problems may be
attributed to many different causes, including witchcraft, voodoo, offending
ancestor spirits, karma transmitting past life sins or soul loss (Johnson, 2005;
Kohrt & Hruschka, 2010). In many refugee groups, local culture-specific
syndromes represent a key response to trauma (Hinton & Lewis-Fernandez,
2010). For example, Hinton et al. (2009) report that Cambodian refugees
tend to interpret nightmares as a sign of physical and spiritual vulnerability
and/or a potential attack by ghosts. This frequently leads to the performance
of specific practices and rituals aiming to force out attacking forces and
protect the victim.
The biomedical approach to mental health problems that western medicine

uses may not fit well into the framework of beliefs held by refugees from
culturally different backgrounds. For example, for some refugees, restoring
dignity may be more important than healing trauma symptoms (Blanch,
2008). Cultural competence is considered a core requirement for mental
health professionals working with culturally diverse clients (Bhui et al., 2007).
Culturally competent trauma-informed care respects different cultural values,
beliefs and practices; reflects a willingness to learn about other cultures;
and tailors services to meet clients’ social, cultural and linguistic needs
(Betancourt et al., 2002).
Conclusion
The assumption that all refugees are severely traumatized and need trauma
treatment is incorrect (Blanch, 2008; Brundtland, 2000). Blanch (2008)
states that trauma-specific services should be available to those who need
them, in particular refugees who display severe and persistent trauma
symptoms, but that the key principles of trauma-informed care—awareness,
safety, respect, choice and empowerment—meet the basic mental health
needs of all refugees, regardless of their experiences.
References
Allimant, A. & Ostapiej-Piatkowski, B. (2011). Supporting women from CALD backgrounds who
are victims/survivors of sexual violence: Challenges and opportunities for practitioners.
ACSSA Wrap, 9. Retrieved from www.aifs.gov.au/acssa/pubs/wrap/wrap9/w9.pdf
Beiser, M. (2009). Resettling refugees and safeguarding their mental health: Lessons learned
from the Refugee Resettlement Project. Transcultural Psychiatry, 46, 539–583.
Beiser, M. (2010, Summer). Compassionate admission and self-defeating neglect: The mental
health of refugees in Canada. Canadian Issues, 39–44.
Beiser, M., Simich, L. & Pandalangat, N. (2003). Community in distress: Mental health needs
and help-seeking in the Tamil community in Toronto. International Migration, 41, 233–245.
Bemak, F., Chi-Ying Chung, R. & Pedersen, P.B. (2003). Counseling Refugees: A Psychosocial
Approach to Innovative Multicultural Interventions. Westport, CT: Greenwood Press.
Benedek, D.M. & Wynn, G.H. (Eds.). (2011). Clinical Manual for Management of PTSD.
Washington, DC: American Psychiatric Publishing.
Betancourt, J., Green, A. & Carrillo, E. (2002). Cultural Competence in Health Care: Emerging
Frameworks and Practical Approaches. New York: The Commonwealth Fund.
Bhui, B., Warfa, N., Edonya, P., McKenzie, K. & Bhugra, D. (2007). Cultural competence in
mental health care: A review of model evaluations. BMC Health Services Research, 7(15).
Blanch, A. (2008). Transcending Violence: Emerging Models for Trauma Healing in Refugee
Communities. Alexandria, VA: National Center for Trauma-Informed Care.
Brown, L.S. (2008). Cultural Competence in Trauma Therapy: Beyond the Flashback. Washington,
DC: American Psychological Association.
Brundtland, G.H. (2000). Mental health of refugees, internally displaced persons and other
populations affected by conflict. Acta Psychiatrica Scandinavica, 102, 159–161.
Canadian Centre for Victims of Torture. (2009). Befriending: Creating a therapeutic bond with the
community.
Canadian Council for Refugees & Sojourn House. (2010). Welcome to Canada: The Experience of
Refugee Claimants at Port-of-Entry Interviews. Retrieved from http://ccrweb.ca/files/poereport.pdf
Cardozo, B.L., Oleg, O., Bilukha, C., Gotway, C., Irshad, S., Wolfe, M. et al. (2004). Mental
health, social functioning and disability in postwar Afghanistan. JAMA, 292, 575–584.
Citizenship and Immigration Canada. (2010). Backgrounder: More support for resettled refugees.
Retrieved from www.cic.gc.ca/english/department/media/backgrounders/2010/2010-03-29.asp
Fazel, M., Wheeler, J. & Danesh, J. (2005). Prevalence of serious mental disorder in 7000
refugees resettled in western countries: A systematic review. The Lancet, 365, 1309–1314.
Gardiner, J. & Walker, K. (2010). Compassionate listening: Managing psychological trauma in
refugees. Australian Family Physician, 39, 198–203.
Gorman, W. (2001). Refugee survivors of torture: Trauma and treatment. Professional Psychology:
Research and Practice, 32, 443–451.
Guyot, J. (2007). Child and youth participation in protracted refugee situations. Children, Youth
and Environment, 17, 159–178.
Harvard Program in Refugee Trauma. (2011). Treatment plan. Retrieved from http://hprt-
cambridge.org/?page_id=69
Hinton, D.E., Hinton, A.L., Pich, V., Loeum, J.R. & Pollack, M.H. (2009). Nightmares among
Cambodian refugees: The breaching of concentric ontological security. Culture, Medicine and
Psychiatry, 33, 219–265.
Hinton, D.E. & Lewis-Fernandez, R. (2010). The cross-cultural validity of post-traumatic stress
disorder: Implications for DSM-5. Depression and Anxiety, 0, 1–19.
Hollifield, M., Warner, T.D., Lian, N., Krakow, B., Jenkins, J.H., Kesler, J. et al. (2002).
Measuring trauma and health status in refugees: A critical review. JAMA, 288, 611–621.
Johnson, D.R. (2005). Helping Refugee Trauma Survivors in the Primary Care Setting. St. Paul,
MN: Center for Victims of Torture. Retrieved from www.cvt.org/resources/publications
Karunakara, U.K., Neuner, F., Schauer, M., Singh, K., Hill, K., Elbert, T. et al. (2004). Traumatic
events and symptoms of post-traumatic stress disorder amongst Sudanese nationals,
refugees and Ugandans in the West Nile. African Health Sciences, 4(2), 83–93.
Kazemipur, A. & Halli, SS. (2001). The changing colour of poverty in Canada. Canadian Review
of Sociology, 38, 217–238.
Kirmayer, L.J., Narasiah, L., Munoz, M., Rashid, M., Ryder, A.G., Guzder, J. et al. (2011).
Common mental health problems in immigrants and refugees: General approach in
primary care. Canadian Medical Association Journal, 183, E959–E967.
Kohrt, B.A. & Hruschka, D.J. (2010). Nepali concepts of psychological trauma: The role of
idioms of distress, ethnopsychology and ethnophysiology in alleviating suffering and
preventing stigma. Culture, Medicine and Psychiatry, 34, 322–352.
Mazurana, D. & Carlson, K. (2006). The Girl Child and Armed Conflict: Recognizing and
Addressing Grave Violations of Girls’ Human Rights. New York: United Nations Division for
the Advancement of Women. Retrieved from www.un.org
Mikus Kos, A., Peren-Klinger, G. Gorenenberg, M., Mollica, R., DeMartino, R. & Petevi, M.
(2011). Draft Guidelines for the Evaluation and Care of Victims of Trauma and Violence.
Retrieved from http://hprt-cambridge.org/?page_id=88
Miller, K.E. & Rasco, L.M. (2004). An ecological framework for addressing the mental health
needs of refugee communities. In K.E. Miller & L.M. Rasco (Eds.), The Mental Health of
Refugees: Ecological Approaches to Healing and Adaptation (pp. 1–64). Mah Wah, NJ:
Lawrence Erlbaum.
Mollica, R.F., Cui, X., McInnes, K. & Massagli, M.P. (2002). Science-based policy for
psychosocial interventions in refugee camps: A Cambodian example. Journal of Nervous and
Mental Disease, 190(3), 158–166.
Mollica, R., Sarajlic, N., Chernoff, M., Lavelle, J., Vukovic, I.S. & Massagli, M. (2001).
Longitudinal study of psychiatric symptoms, disability, mortality, and emigration among
Bosnian refugees. JAMA, 286, 546–554.
Porche, M.V., Fortuna, L.R. & Rosenberg, S. (2009). Community Dialogue and Needs Assessment
for Trauma Informed Systems of Care for Resettled African Refugee Youth in New Hampshire.
Retrieved from www.endowmentforhealth.org
Porter, M. & Haslam, N. (2005). Predisplacement and postdisplacement factors associated with
mental health of refugees and internally displaced persons: A meta-analysis. JAMA, 294,
602–612.
Rubinstein, L. & Kohli, A. (2010). Mental Health Services during and after Armed Conflict: The
State of Knowledge and Practice. Washington, DC: United States Institute of Peace. Retrieved
from www.usip.org
Schwarz-Langer, G., Deighton, R.R, Jerg-Bretzke, L., Weisker, I. & Traue, H.C. (2006).
Psychiatric treatment for extremely traumatized civil war refugees from former Yugoslavia:
Possibilities and limitations of integrating psychotherapy and medication. Torture, 6, 69–80.
Simich, L., Hamilton, H. & Khamisa Baya, B. (2006). Mental distress, economic hardship and
expectations of life in Canada among Sudanese newcomers. Transcultural Psychiatry, 43,
418–444.
Simich, L., Mawani, F., Wu, F. & Noor, A. (2004). Meanings of Social Support, Coping and Help-
Seeking Strategies among Immigrants and Refugees in Toronto. (Toronto CERIS working paper
No. 31). Toronto: Joint Centre of Excellence for Research on Immigration and Settlement.
Smid, G.E., van der Velden, P.G., Gersons, B.P.R. & Kleber, R.J. (2012). Late-onset posttraumatic
stress disorder following a disaster: A longitudinal study. Psychological Trauma: Theory,
Research, Practice, and Policy, 4, 312–322.
Tribe, R. (2002). Mental health of refugees and asylum-seekers. Advances in Psychiatric

Treatment, 8, 240–248.
United Nations. (2009). Violence against women. Retrieved from www.un.org
United Nations. (n.d.). Ending violence against women and girls. Retrieved from www.un.org
United Nations High Commissioner for Refugees. (1951/2003). Convention and Protocol relating
to the Status of Refugees. Geneva, Switzerland: Author. Retrieved from
www.unhcr.org/3b66c2aa10.pdf
United Nations High Commissioner for Refugees. (n.d.). Who are the refugees?
Vasilevska, B. & Simich, B. (2010). A review of international literature on refugee mental health
practices. Canadian Issues, 33–38. Retrieved from http://canada.metropolis.net/publications/
index_e.html
Ward, J. & Marsh, M. (2006, June). Sexual violence against women and girls in war and its
aftermath: Realities, responses, and required resources. Briefing paper prepared for the
Symposium on Sexual Violence in Conflict and Beyond, Brussels, Belgium.
Watters, C. (2001). Emerging paradigms in the mental health care of refugees. Social Science and
Medicine, 52, 1709–1718.
Wilson, R.M., Murtaza, M. & Shakia, Y. (2010). Pre-migration and post-migration determinants
of mental health for newly arrived refugees in Toronto. Canadian Issues, 45–49. Retrieved
from http://canada.metropolis.net/publications/index_e.html
World Health Organization. (1996). Mental health of refugees.
135
Chapter 10
The Evolution of Trauma-Informed

Practice at the Jean Tweed Centre
Julia Bloomenfeld and Tammy Rasmussen
The Jean Tweed Centre was established in Toronto in 1983 as a substance use
treatment centre for women, at a time when understanding of the relationship
between trauma and substance use was just starting to emerge. While Jean
Tweed has always applied a gender-specific lens in working with women, it
was in the early 1990s that we began incorporating a trauma-informed
approach in our substance use services. This chapter describes the genesis
and framework for Jean Tweed’s trauma-informed service model for working
with substance use and gambling concerns, key aspects of providing trauma-
informed care in the residential program and our more recent evolutions in
trauma-informed practice.
The Genesis
Beginning in the late 1980s, clinical reviews confirmed that more than
80 per cent of women using Jean Tweed’s services had experienced abuse.
As we listened to women’s stories, we learned about their use of substances to
cope with trauma. We also saw the impact of trauma on women’s experiences
of treatment. As the centre became more conscious of the multifaceted
impact of trauma, it was apparent that changes were necessary. Jean Tweed
needed to become more knowledgeable about trauma and how it affects
survivors seeking treatment for substance use and to change some of its
traditional practices.
The critical first step was committing to build the infrastructure needed
to provide trauma-informed services. Next, the centre hired an external
consultant to provide intensive clinical training over a six-month period. The
training provided a baseline of knowledge about trauma and its connection to
substance use problems, and a common language for discussions. Over the
years, it has been important to maintain agency-wide training to keep pace
with emerging evidence-based approaches. Because all staff contribute to the
overall atmosphere of safety and comfort that a woman experiences, non-clinical
staff were included in aspects of the training. These sessions provided them
with background and context for the kinds of situations they might encounter,
such as women calling or arriving in distress. This kind of orientation is vital,
as the reception a woman receives at the front door conveys a strong message
about how she will be treated. For clinical staff, ongoing individual supervision,
group consultation and regular team meetings provided a forum to enhance
skills. These meetings also offered opportunities to discuss themes such as
transference, countertransference and vicarious trauma.
The organizational strategies to promote a trauma-informed approach included

changing our hiring practices. We began screening resumés and formulating
interview questions to explore candidates’ attitudes toward, and experience
working with, trauma survivors. Similarly, individual professional development
plans incorporated continued growth in trauma-informed care as a requirement.
The Paradigm Shift

Two pivotal shifts accompanied these strategies. The first was a shift in
thinking: we left behind the notion that substance use and trauma are
unconnected and should be dealt with separately. The leading principle going
forward was that an understanding of the impact of trauma must be braided
into all programs. The second shift involved capacity. Through training and
education, Jean Tweed increased its capacity to provide trauma-informed
programs. Service-level changes flowed out of this transformation. While all
of the programs are now trauma informed, for purposes of illustration here,
we will focus on practice examples drawn from our residential program.
Judith Herman’s model (1992) for working with trauma strongly influenced
the development of Jean Tweed’s approach. The process of change around
Chapter 10 The Evolution of Trauma-Informed Practice at the Jean Tweed Centre 137
substance use problems has commonalities with the three stages outlined in
Herman’s model—safety, remembrance and mourning, and reconnection. In
early-stage work for both trauma and substance use problems, the emphasis
is on creating safety; the time orientation is the present; and the focus is on
self-care. Women in this stage are supported to develop new coping skills.
In terms of women’s safety, the goals related to substance use problems and
trauma recovery centre on establishing external and internal safety. External
safety concerns arise from elements in women’s physical or living environments
that put them at risk. Many of the women who use the services at Jean Tweed,
for example, may be living with an abusive partner, or without stable housing.
Internal safety issues may include intense and difficult feelings, intrusive
memories and physiological difficulties.
In the residential program, the focus remained on substance use problems,

but treatment was delivered within a trauma-informed model. Jean Tweed
created an affirming environment where a woman could name trauma as a
concern, make the links between her substance use and her experience of
trauma and learn positive coping strategies.
This trauma-informed approach was combined with trauma-specific programming.

Hiring a trauma counsellor meant that women in continuing care who were
ready for later-stage trauma work could get individual counselling. A Seeking
Safety (Najavits, 2002) group, open to women across programs, provided a dual
focus on first-stage substance use and trauma work. Initially, Jean Tweed’s trauma
lens focused on issues of abuse that occurred within the family. Over time, as
our understanding of diversity and anti-oppression grew, we became aware of a
much wider spectrum of oppression, terror and other forms of violence and trauma,
politically and socially driven, that affect women on varied levels—within
marginalized groups, such as immigrants, and across generations. With this
awareness, our trauma lens expanded.
What evolved from this new framework was a trauma-informed continuum

of services that encompassed a theoretical model for an integrated approach,
an organizational infrastructure and changes to and expansion of programs.
A parallel transfer of knowledge occurred with the integration of services to
address problem gambling.1
1. Readers interested in a full description of the development of the Jean Tweed Centre’s model will find it in
“A braided recovery: Integrating trauma programming at a women’s substance use treatment centre.” In
N. Poole & L. Greaves (Eds.), Highs and Lows: Canadian Perspectives on Women and Substance Abuse
(pp. 365–371). Toronto: Centre for Addiction and Mental Health.
In a residential environment, specific concerns for trauma survivors may
include physiological reactions, such as sleep disturbances, relational
challenges and affect dysregulation. The literature about trauma-informed
care highlights a number of principles that assist in responding to these
concerns. These principles also influence our clinical decisions related to
individual counselling, group facilitation and workshop content (Moses et al.,
2003). Four of the key principles shaping our work include:
• avoiding retraumatization
• empowering women
• working collaboratively and with flexibility
• recognizing trauma symptoms as adaptations.
Avoiding Retraumatization
A residential treatment setting for substance use and gambling problems
needs to pay special attention to how trauma-related material is woven into
the program to avoid overwhelming women. Early in Jean Tweed’s work with
trauma, workshops were introduced to provide general information about
trauma and managing trauma responses such as flashbacks. However, the
sessions were overwhelming and women were frequently scared to attend.
Some coped through avoidance, for example, by not paying attention or
dissociating; others were triggered into painful memories and flashbacks.
We learned from these experiences that psychoeducation and discussions
about trauma should be “braided” into discussions related to substance use
and gambling issues. For example, a workshop that teaches grounding skills
is relevant to both substance use and trauma recovery. We also learned about
the need to follow a woman’s lead. For example, in relapse prevention,
women often identify situations and emotions related to past trauma that put
them at risk of using substances or gambling. Once women raise these issues,
counsellors are prepared to provide support by identifying and teaching safe
coping skills.
It is equally important to prevent retraumatization by supporting women to

pace themselves. In the past, it was quite common in group therapy for
women to move quickly into giving details of their traumatic history. This
often led women to shut down in subsequent groups, as this level of disclosure
was retraumatizing for the woman sharing the information and/or for other
group members. Now, when trauma stories emerge in group, the therapeutic
emphasis is on identifying the impact of trauma in the present. Linking trauma
to substance use and gambling, and the importance of learning alternative
coping skills, is the focus. This emphasis on the containment of sharing
traumatic details and the focus on developing coping skills are affirmed by
the literature related to first-stage trauma work (Haskell, 2001; Najavits,
2002). Women may want to share some details of their trauma in individual
counselling sessions, where together with the therapist they can assess the
safety and impact of this disclosure.
Empowering Women
Many clients are ashamed and overwhelmed by their trauma responses and
believe they are “crazy.” In the program, psychoeducation is used to help
women better understand and normalize their trauma responses and the
connections to substance use and gambling. The information the counsellor
offers is based on what each woman is able to integrate at a particular time
(Van der Hart et al., 2006). Skill development also promotes a sense of power
and competency. For example, learning to regulate intense and overwhelming
emotions and body sensations through strategies such as grounding and self-
soothing can be empowering, particularly as these sensations are often triggers
for substance use or gambling. Self-awareness, including awareness of
personal strengths, and building upon assertiveness skills further increase
women’s empowerment, making them better able to know and take care of
their needs. The knowledge women have gained, together with the coping
skills they have learned, supports a shift from reacting to trauma triggers
toward more safely and effectively responding to them.
Working Collaboratively and with Flexibility

The residential environment offers a community experience with a clear
structure and set of norms. For many women, this type of experience
promotes a sense of safety. However, for some, this environment can
exacerbate trauma responses such as nightmares, insomnia, self-harm and

recurring flashbacks. There are often women in the program who are making
their first attempt to cope without the use of substances or gambling, and
these trauma reactions can overtake their participation in the program. At
times, a woman may feel like she is experiencing more harm than benefit.
She becomes torn between her desire to stay in the program and the desire
to stop the pain.
Trauma-informed practice has led us to be more flexible about the structure and
expectations of the program. An emphasis on “guidelines” rather than “rules”
expands the space around women for whom “treatment as usual” has created
barriers. Counselling is collaborative. As much as possible, the counsellor will
work with each woman to explore strategies for self-care, with openness to
adjusting a guideline or offering a modified program to reduce the intensity.
Recognizing Trauma “Symptoms” as Adaptations

An important principle of trauma-informed care is the understanding that
“symptoms” related to trauma are actually coping strategies developed to
manage the traumatic experience (Haskell, 2001; Moses et al., 2003). In the
residential program, we often observe relational patterns rooted in past
traumatic experiences, often from childhood. Najavits (2006) identifies
boundaries in relationships as a specific area of concern for survivors of trauma.
Relationships may be “too close” (p. 155), such as when there is “excessive
care-taking of others at the cost of self-care,” or “too distant” (p. 155). Behaviours
such as hostility or aggression can be scary for other participants and negatively
affect the group’s safety. The patterns and their impact are intensified in the
residence, where women share space and tasks of community living. These
patterns are also seen in how women interact with staff.
Prior to adopting a trauma-informed approach, some of these responses might

have been perceived in negative ways—as “difficult” or “resistant”— or
connected exclusively to a woman’s substance use or gambling, whereas the
caretaking behaviour might have been overlooked or even rewarded. A trauma-
informed lens helps us to view these behaviours as coping strategies and to
respond in non-judgmental ways that avoid shaming. Counsellors integrate
education about boundaries in relationships and look for opportunities to
assist women in developing new ways of relating to others. Sometimes, such

as in the case of aggression, a woman is unable to shift her behaviour enough
to maintain group safety, and a transfer to another program is required. In
this situation, the counsellor’s ability to present hope and maintain a trauma-
informed view will support a woman who is struggling with self-esteem and
feelings of shame; it may also help her to maintain a therapeutic connection
to the centre.
Trauma-Informed Evolutions
Harm Reduction
Over the past several years, many service providers have embraced the idea
of incorporating strategies that can reduce the harm of substance use and
gambling problems on people’s lives. Where in the past treatment focused
strictly on stopping substance use, harm reduction expanded the lens of what
is worthy of attention and support. Harm reduction sparked many changes
for the centre. At various stages of healing, many trauma survivors in treatment
may not feel ready or able to manage their trauma responses without using
substances or gambling. Hence, the idea of reducing the harm of substance
use or gambling—without necessarily stopping altogether—is consistent with
a trauma-informed approach: supporting a woman at her own pace, working
with the goals she establishes for herself, promoting choice and acknowledging
her autonomy and control over her own life.
The integration of harm reduction resulted in a greater inclusion of

programming geared to a variety of substance use or gambling-related goals.
We also shifted our language; for example, we moved away from references to
positive urine screens as “dirty” and negative urine screens as “clean,” because
such terms conveyed judgment and elicited shame. The routine practice of
urine screening at Jean Tweed was also reconsidered. While initially the
intention behind screening was to protect group safety, we now recognize that
the practice can reduce trust and evoke trauma responses related to betrayal
of physical and emotional boundaries. As a result, we have moved away from
routine screening in the residential program, although there are times when
urine screening still happens. For example, a woman may request screening
as an external measure to increase her safety, or staff may use screening when
concerns about group safety cannot otherwise be resolved.
The shift to a harm reduction model sometimes created dissonance. To protect

the residence as a safe place, women are asked to not use substances or gamble.
The tendency in the past has been to view any instance of substance use or
gambling as an indication of a lack of readiness for an intensive program or of
too great a risk to other participants. However, when a trauma survivor who
is attending treatment uses a substance or gambles, critical reflection of its
meaning and impact is helpful. The gains in coping skills the woman has learned
are not erased. Instead, the event often consolidates her knowledge of the
connection between her use of substances or gambling and her trauma history.
A deeper focus on building safety skills emerges. Coming to a decision about
how to respond to an instance of substance use requires a skilled counselling
team in order to balance the needs of both the individual and the group.
Mindfulness
As part of adapting our practices and programs to be congruent with a trauma-
informed approach, staff was offered training in mindfulness. Roshchild (2010)
notes that “since the 1990’s mindfulness has increasingly gained respect as a
tried and true asset for trauma recovery. It is even now advocated by many in
the mainstream of trauma treatment and research” (p. 7). Jon Kabat-Zinn (1994)
defines mindfulness as “paying attention in a particular way; on purpose to the
present moment and non-judgmentally” (p. 4).
In our experience, mindfulness can help to minimize retraumatization when

a woman in the program is experiencing the somatic, cognitive and/or emotional
experiences of trauma. By guiding her to observe and report on her experience
in the present moment, which engages the prefrontal cortex of the brain, the
woman “has” an experience rather than “being” it (Ogden et al., 2008). She is
then more able to remain grounded and differentiate the past from the present,
thereby maintaining a sense of safety. Aspects of mindfulness are now integrated
into individual and group work.
Clinical meetings are also guided by a mindfulness approach. This safe and
supportive context provides an opportunity for staff to engage in reflexive
practice. Clinical cases are discussed, as well as the enactments or counter-

transferences that can occur with clients. Grounding the discussions is the
concept that “it is skillful to know when we are not being skillful” in our work
with clients (B. Laskin, community practice discussion, April 21, 2010).
Conclusion
Women who have experienced trauma may turn to substances or gambling—
not as ways to harm themselves, but as ways to keep themselves alive in the
face of overwhelming psychic pain. As an agency dedicated to the empowerment
of women, it is important for us at Jean Tweed to be aware of the incredible
resilience and courage of the women we serve. The transformations that
women make as they shake loose the control that substance use, gambling
and trauma have had over their lives are a reminder of the power of trauma-
informed care. The evolution of trauma-informed practice at Jean Tweed,
while positive and exciting, has challenged our thinking and revealed many
complexities of practice. As the women with whom we work seek to master
skills to heal from trauma and substance use and gambling issues, we seek to
shape a treatment environment in which this may happen.
References
Haskell, L. (2001). Bridging Responses: A Front-Line Worker’s Guide to Supporting Women Who
Have Post-traumatic Stress. Toronto: Centre for Addiction and Mental Health.
Kabat-Zinn, J. (2005). Wherever You Go, There You Are: Mindfulness Meditation in Everyday Life.
New York: Hyperion.
Moses, D., Reed, B., Macelia, R. & D’Ambrosio, B. (2003). Creating Trauma Services for Women
with Co-occurring Disorders: Experiences from the SAMHSA Women with Alcohol, Drug Abuse
and Mental Health Disorders Who Have Histories of Violence Study. Retrieved from
www.nationaltraumaconsortium.org
Najavits, L.M. (2006). Managing trauma reactions in intensive addiction treatment
environments. Journal of Chemical Dependency Treatment, 8, 153–161.
Roshchild, B. (2010). 8 Keys to Safe Trauma Recovery: Take-Charge Strategies to Empower Your
Healing. New York: W.W. Norton.
Van der Hart, O, Nijenhuis, E. & Steele, K. (2006). The Haunted Self: Structural Dissociation and
the Treatment of Chronic Traumatization. New York: W.W. Norton.
145
Chapter 11
Show Not Tell...

Trauma-Informed Creative Engagement with
Youth Who Have FASD
Mary Harber
Trauma-informed practice has been successfully enacted in expressive therapies

often used with children and youth as a way to address the effects of trauma.
This chapter describes how a creative drama intervention called Theatre We
ARE is being used with young people with fetal alcohol spectrum disorder
(FASD) in British Columbia as a way to attend to both their disability and
potential experience of trauma.
Adolescence, FASD and the Experience

of Trauma
The combined effects of having FASD, experiencing trauma and going
through adolescence pose certain challenges for youth with FASD. People
with FASD have difficulty with various issues, including cognition, learning,
communication and executive functions such as memory, sequencing and
cause and effect (Streissguth, 1997). They also experience problems in social,
behavioural and adaptive functioning (Riley et al., 2011).
Like people with FASD, many children who have been traumatized also
have trouble with learning, concentration and attention (Baker & Jaffe,
2007, as cited in Bellamy & Hardy, 2010). They can have difficulty in social
functioning, coping with stress and relationships. According to Putnam (2006),

children and youth who have trauma histories experience lower social
competence, difficulty recognizing their own and others’ emotional states,
cognitive and attention problems, affective mood regulation issues and
difficulty with identity and self-esteem. Henry et al. (2007, as cited in
Bellamy & Hardy, 2010) explain:
The combination of fetal alcohol exposure and a history of trauma is

more damaging to children than trauma alone. Combined, the
neurodevelopmental consequences result in an increased risk for
learning disabilities, poor coping strategies, and inability to control
emotional responses. These developmental deficits result in higher
levels of negative behaviors because traumatized children are more
likely to over-react or shut down in the face of stress. (p. 5)
In addition to FASD and trauma, transitional and developmental issues must

be considered. Developmentally, youth are exploring the meaning of the
world and how they “fit.” Baizerman and Erickson (2000) see this as a time
for exploration and excitement around learning about one’s self. However,
creating emotional safety and supporting identity development for youth with
disabilities can be potentially intimidating for care providers.
Creative Drama
Creative drama focuses on the experience of participants (Way, 1967). It is
“an improvisational, non-exhibitional, process-oriented form of drama,
where participants are guided by a leader to imagine, enact, and reflect on
experiences real and imagined” (Youth Stages, n.d.). The difference between
theatre and creative drama is doing and being (creative drama) and pretending
and performing (theatre). Creative drama explores real-life situations,
problem solving, modelling and rehearsing using potential and actual lived
experiences. This approach to learning appeals to the kinesthetic learning
style of many people with FASD and other brain-based disabilities.
Creative drama offers an externalized form of expression that is important to

feeling safe, while allowing participants to be free to discuss difficult issues; it
is a way to place a unique mark on experiences and feelings. Active engagement
Chapter 11 Show Not Tell 147
also allows youth to experience their feelings without fear of social repercussion
—they cannot draw or take a photo of the “wrong” thing. This provides a sense
of safety, which is critical when engaging youth who have FASD and a history
of trauma. These youth are often in helping systems that are “deficit” oriented
and may have learned to shut down in times of stress in response to anxiety
about making “mistakes.” Youth with FASD need to see their strengths and
be given permission to express who they are in healthy, non-judgmental ways.
Creative drama provides a forum in which to explore healthy relationships and

boundaries that can address the relational needs of adolescents in general and
those with FASD. Young people must have opportunities to form healthy
relationships with others, to feel like they are recognized, that they are important
and that they belong to a larger community.
Drama techniques may mistakenly be seen to lack containment, boundaries

and safety. The concern is that the person may be acting out a scenario or
engaging in an activity that could represent a traumatic event or that could
trigger feelings around an event. This possibility is not a reason to avoid this
type of engagement; rather, it provides an opportunity to incorporate containment
strategies, as described below. Nash and Rowe (2000) recognize the potential
for playback—a form of creative drama using real-life stories of participants—
to bring up difficult and distressing thoughts and feelings, while acknowledging
that many things can potentially act as triggers, whether they be video games,
television or movies, and that risk can only ever been managed and reduced
but never eliminated.
Trauma-Informed Principles Embedded

in Creative Drama Interventions
Creative drama is currently being used with a group of young adults with
FASD and autism spectrum disorders to support the transition to adulthood,
promote community inclusion and develop social skills. The following three
principles of trauma-informed practice are embedded in this work:
1. Choice and control: Practitioners ensure physical and emotional safety by

setting clear tasks and boundaries for participants. Creative drama supports
choice and control for each person, as well as power sharing, collaboration
and skill building. Every measure is taken to reduce potential harm as opposed to
shutting down participants’ examination of their experiences. Representational
expression (acting, art, story metaphor, etc.) provides an opportunity to take a
familiar situation and see it in new ways (Cohen et al., 1995).
2. Preventing retraumatization: Drama is used in a way that facilitates an

understanding of participants’ issues, without reliving any trauma they may
have experienced. Participants who need to deal with individual trauma issues
are referred to trauma-specific services.
3. Creating safety: Various measures are taken to create safety and ensure that
participants have the freedom to express who they are and how they feel
without judgment. Concrete measures are taken to ensure the youths’ safety
while still allowing them freedom, using drama techniques. For example, all
drama activities have a built-in “freeze” component, whereby the leaders or
others can stop a scene during an improvisational skit and move it in another
direction. We also talk about what we saw and what we might do differently if
we were to re-story a scene.
Example 1
Two participants act out a scene in which they are two friends going to a movie.
One person begins by telling the other that he or she doesn’t really like the other’s
choice of movie and would like to see something different. The scene continues on
with the two friends getting into an argument over the choice of movie.
As the scene unfolds, you may notice a participant getting upset or agitated.
At this point, you would say “freeze,” approach the two participants, tap one
of them out of the scene and start a different track. For example, you may
respond with “Well, I understand that you don’t want to see a movie—let’s go
for ice cream.” Any other participant can also call “freeze” and take over a spot
in the scene. Interrupting the scene in this way helps to regulate what is
happening and ensures that a sense of safety remains. The activity can be very
playful and fun, often allowing participants to use their imagination.
Chapter 11 Show Not Tell 149
Example 2
Two participants decide to do a scene about making a difficult life decision. They
ask others to play different people in the scene to help them act out the issue—for
example, taking a job, experiencing a friendship conflict or school problems, dealing
with money.
Once the scene (short time-frame) is finished, the rest of the group debriefs
and talks about how it felt, and offers strategies and advice for dealing with
the presented issue.
Beyond doing this expressive work, Theatre We ARE, which was named by
the group, created an educational presentation for the community. This group
consisted of five youth and two adolescent mentors from the community, and
was facilitated with a co-leader model. This configuration provided support
as well as peer mentoring. The group wrote three scenes that present issues
related to FASD. The scenes reflect participants’ own experiences. The first
scene examines struggles in classroom learning, teaching expectations and
peer relationships. The second scene is about a young person who works in a
retail store and is trying to manage job responsibilities while struggling with
memory and sequencing issues and not wanting to look inept. The final scene
is about understanding the commercial exchange of money, such as buying
a coffee. The scene highlights the difficulty individuals may experience when
they may not understand the cost of an item or the math involved in the
transaction. This is an important scene, as some individuals find this type
of pressure publicly embarrassing.
Conclusion
Through their educational presentations to the community and their own
expressive work as a group, Theatre We ARE participants support one
another, make risk possible and share fears and concerns about their own
lives. They use drama as an avenue for self-expression that respects their voice
and need for control over their own stories. Creative drama has enormous
potential for people with FASD to safely express their experiences in a way
that takes into account and increases understanding of their challenges with
adaptive functioning.
References
Baizerman, M.L. & Erickson J.B. (2000, January). Adolescence is not a medical condition.
CYC-Online. Retrieved from www.cyc-net.org/cyc-online/cycol-0100-adolescence.html
Bellamy, S. & Hardy, C. (2010). Northern Attachment Network Review #4: Trauma, Learning and
Fetal Alcohol Spectrum Disorder. Retrieved from www.fasdoutreach.ca
Cohen, B.M., Barnes, M.M. & Rankin, A.B. (1995). Managing Traumatic Stress through Art:
Drawing from the Center. Baltimore: Sidran Press.
Nash, S. & Rowe, N. (2000). Safety, Danger and Playback Theatre. Retrieved from
http://playbacktheatre.org
Putnam, F.W. (2006). The impact of trauma on child development. Juvenile and Family Court
Journal, 57, 1.
Riley, E.P., Clarren, S., Winberg, J. & Jonsson, E. (2011). Fetal Alcohol Spectrum Disorder:
Management and Policy Perspectives. Weinheim, Germany: Wiley-Blackwell.
Streissguth, A. (1997). Fetal Alcohol Syndrome: A Guide for Families and Communities.
Baltimore: Paul H. Brookes.
Way, B. (1967). Development through Drama. Atlantic Highlands, NJ: Humanities Press.
Youth Stages. (n.d.). What Is Creative Drama? Retrieved from
www.youthstages.com/CreativeDrama/index.asp
151
Chapter 12
Girls’ Groups and Trauma-Informed

Intersectional Practice
Natalie Clark
Girls’ groups provide a space for girls to find their own voices, make
connections and honour relationships in their lives at a time when they often
feel disconnected—from family, peers, their culture, school, community and
themselves (Bell-Gadsby et al., 2006).
The Canadian Women’s Foundation report Girls in Canada (Calhoun Research

and Development/Recherche et développement et al., 2005) defines a gender-
specific girls’ program as a “single-sex program intentionally designed to
respond to the specific needs and strengths of the girls it serves” (p. 55). The
report explains the rationale for these programs: “There is no one experience
of being a girl. Gender combines with race, socio-economic status, sexual
orientation and dis/ability status to shape girls individually and collectively,
and programs for girls reflect such diversity” (p. 55).
Girls’ groups have the potential to provide a unique model to support and identify
young women’s health needs when offered within a trauma-informed intersectional
framework. Research suggests that there is a significant need for gender-specific
girls’ programming, especially within ethno-specific communities, impoverished
neighbourhoods and rural and northern regions. Girl-specific programs have had
overwhelmingly positive results, giving girls the opportunity to address, critique
and develop their ideas, experiences and imaginings.
Unfortunately, despite the growing popularity of girls’ groups in the

community and in schools, and the constant presence of a continuum of
trauma in many girls’ lives, many groups do not apply a trauma-informed or
intersectional and culturally safe model. However, the need for such a model
is evident in research indicating that gender intersects with issues of racism,
violence and abuse in girls’ lives and that these issues must be addressed
together (Jiwani, 1999; McCreary Centre Society, 2004, 2005; Taefi et al.,
2008). From my 20 years of practice and research with girls, I know that girls
often do not disclose abuse and trauma, and many do not seek treatment; as a
result, they engage in high-risk behaviours or “strategies of disconnection.”
They may misuse substances; engage in self-harming behaviours, such as
cutting and disordered eating; have suicidal thoughts or attempt suicide; and
experience emotional outbursts, display high energy and appear disconnected
from others and from systems in their lives. Girls who do seek treatment and
who use these forms of coping are often further labelled and pathologized
within the health care system, rather than being honoured for the creativity
they use to survive or understood for the meaning they attach to these coping
strategies (Clark & Hunt, 2011).
Applying an Intersectional Approach

Many girls who are disadvantaged and marginalized by society do not see
themselves or their unique needs reflected in mainstream girls’ group program-
ming (Clark & Hunt, 2011). Girls who are marginalized due to intersecting
factors such as race, class and geography often experience even higher rates
of violence, daily acts of sexual harassment and racism (Jiwani, 1998). The
Alliance of Five Research Centres on Violence, in one of the few studies
examining violence and girls through an intersectional lens, described effective
programs as recognizing “how gender, race, class, sexuality, disability, and age
intersect in particular ways to shape women’s and girls’ experiences of violence
and their access to programs and services” (Blaney, 2004, p. vi).
Intersectionality, a concept and framework developed by indigenous and

African-American feminist activists and coined by critical race scholar
Kimberlé Crenshaw (1989), is an important component of any trauma-
informed practice. The term describes the oppression produced structurally
and experienced and resisted individually and collectively through and across
Chapter 12 Girls' Groups and Trauma-Informed Intersectional Practice 153
diverse social categories of identity simultaneously. Intersectionality, as Jessica

Yee (2011) describes it, is not new to indigenous peoples—it is the way they
have always thought. Indigenous communities, prior to colonization, had
multiple categories of gender and holistic understandings and approaches
to health. Many had strong matrilinear traditions and complex systems of
governance and systems of treaty and peacemaking processes. There is growing
recognition that the concept of intersectionality “complements growing
discussions about the complexity and multiplicities involved in being indige-
nous, in the category of indigeneity, and in indigenous people’s health and
well-being” (De Leeuw & Greenwood, 2011, p. 54).
Through a trauma-informed and intersectional approach, the groups that my

colleagues and I have developed provide girls with the opportunity to explore
their experiences of abuse, sexual exploitation, body image and violence, as
well as their strengths, diversity and daily lived realities in a safe and non-
threatening environment (Bell-Gadsby et al., 2006; Clark & Hunt, 2011).
My current work in partnership with the Aboriginal community and school

district has involved developing a culturally safe model for Aboriginal girls’
groups within a framework that reintroduces indigenous cultural teachings of
girlhood, or “rites of passage.” The model for the group was developed in a
unique format—with youth, elders, community leaders and practitioners in
a traditional circle and facilitated by an elder in the community. This talking
circle identified the key issues for Aboriginal youth in our community and
how to address them. Through partnerships with community, the school
district and elders, the goal of these groups is to provide Aboriginal/First
Nations girls, aged eight to 18, with a safe space in which to explore issues
affecting their daily lives.
Aboriginal adolescent girls begin to identify themselves by their race at a time

when there are strong societal messages about who is and who is not desirable.
The groups support the girls to resist societal stereotypes and develop healthy
definitions of themselves as Aboriginal/First Nations girls. Research has
found that strong cultural beliefs and values provide a protective resilience for
youth and are linked to positive health outcomes and decreased risk factors,
including achievement, self-esteem and less risky drug and sex activities
(Chandler & Lalonde, 2008; McCreary Centre Society, 2005). Specifically,
research has linked cultural rites of passage groups for African-American
girls with fewer risk factors and greater protective factors in these areas
(Belgrave et. al., 2004; Constantine et al., 2006).
A trauma-informed and intersectional girls’ group locates the source of girls’

challenges within structural and systemic problems such as racism, poverty,
sexism and the intersections of these in their lives. We support the young
women in healthy resistance to these problems and in their efforts to move
back into connection with themselves and others. We do this through a range
of trauma-informed strategies of naming, educating and supporting healthy
resistance strategies1 (Robinson & Ward, 1991).
Key Trauma-Informed Practices

Trauma-informed practice allows us to provide girls with safety, support and
the tools to deal with trauma and its effects in their daily lives within an
intersectional framework. Key trauma-informed practices that inform my
work include truth-telling and conscious use of self; safety and containment;
naming and noting; and fostering healthy resistance strategies, as adapted
from the It’s A Girl Thang: A Manual on Creating Girls Groups (Bell-Gadsby
et al., 2006). These practices are elaborated on below.
Truth-Telling and Conscious Use of Self

A specific strategy for facilitators is “truth-telling,” or directly naming and
challenging negative cultural messages, such as those about gender or race.
Service providers can introduce girls to role models, such as youth activists
like Jessica Yee, who have spoken up or resisted racism or sexism.2 I have
brought books or speakers to girls’ groups that provide examples of girls and
women resisting violence and speaking up about oppression and trauma.
Girls were hungry for their stories. I realized that they needed to hear from
other girls like themselves and from Aboriginal women and role models who
had resisted violence and abuse and ultimately colonization. The girls wanted
1. For more information on resistance, see Robinson & Ward’s (1991) article, “A belief in self far greater than
anyone’s disbelief: Cultivating resistance among African American Female Adolescents,” in Women and
Therapy, 11, 87–104. The authors present two different forms of resistance to oppression—healthy resistance
(liberating) and survival resistance (survival oriented).
2. For more information about Jessica Yee’s work with the Native Youth Sexual Health Network, visit
http://nativeyouthsexualhealth.com/aboutourfounder.html.
to hear the specific strategies that these women used, whether they were
political, legal, artistic or therapeutic.
Service providers may also choose to share their own strategies for resisting
violence and oppression and tell stories that provide the girls with under-
standing, tools and strategies for coping with daily challenges. In my groups,
I share my experiences of growing up with a solo parent living on income
assistance and some of the ways I resisted the limitations of our financial
situation by, for example, buying clothes at thrift stores. This strategy is then
used in the group: we take the girls to a thrift store, where they shop for
themselves and another on a limited budget. We discuss how we can resist
societal marketing and messages about what one should wear, while practising
self-expression through what we wear. I tell the story of going to a school
counsellor after feeling judged by a teacher who said he felt sorry for me. The
counsellor encouraged me to share the impact of this comment with this
teacher, even pulling him out of class. I still recall the power I felt walking
down the hall and interrupting his class to share my anger about his comments.
When I did, the teacher cried. I contrast how I coped in this situation with
other times when I would get into fights.
Having self-awareness is key, as group facilitators will be challenged to share

aspects of their own lives and struggles. Articulating these experiences can
be difficult, as we have often been socialized to be silent about these issues.
Thoughtful use of self-disclosure means ensuring that you tell stories where
you have found resolution and that you focus on how what you are disclosing
will be relevant or beneficial to the girls, rather than what it will mean for you
personally. Central to this practice is the importance of grounding in your
own experience and considering the intersections of power and privilege
within your own life. The girls I have worked with often ask who I am and
why I care. We must be ready to answer these questions.
From the work of bell hooks (1999) and others, we know that assisting girls
to develop an “oppositional gaze” is crucial: in other words, supporting them
to resist stereotypes and to replace these with strong and affirming messages
and images of themselves. This includes naming and challenging negative
cultural messages and abuse of power and its sources in society. Sharing
strategies for coping with sexual harassment, racism or other abuses of power
is an important skill. For example, in the Aboriginal girls’ groups, we often
invite Aboriginal young women as role models to share their own stories and
strategies of how they negotiated adolescence.
Safety and Containment

Addressing issues of safety and containment in the group and within
individual relationships is key to allowing girls the opportunity to learn and
grow. Dealing with issues of trauma and abuse and challenges related to
identity and development is also important. In the group setting, the onus is
on the facilitator to create a feeling of safety.
Strategies for creating safety include:
• beginning and/or ending each group with a circle where each girl’s voice
is heard
• providing weekly reminders of confidentiality and limits
• gently and consistently interrupting if a girl is about to disclose or share
too much
• providing girls with the opportunity to disclose individually, if you think
they want to disclose, rather than in a group format. (If they do disclose,
remind them of the limits of confidentiality and that the therapist is
required to report the abuse and provide support and follow-up.)
• encouraging and supporting a girl’s choice to speak and share her truth,
and introducing breathing, journaling and other tools to help contain the
impact of strong emotions
• sharing power with the girls through group decision-making models;
creating agendas and topics for the groups; and inviting the girls to assist
with the group in as many ways as possible, such as creating the calendar of
events, choosing the name of the group or the time the group happens.
Addressing physical, emotional, mental, spiritual and cultural safety is crucial

to trauma-informed practice. Cultural safety means allowing the user of the
health service to define if the service feels safe for her:
The main themes of cultural safety are that we are all bearers of
culture and that we need to be aware of and challenge unequal power
relations at the level of individual, family, community, and society.
Cultural safety draws our attention to the social, economic, and

political position of certain groups within society, such as the Maori
people in A/NZ or Aboriginal peoples in Canada. Cultural safety
reminds us to reflect on the ways in which our health policies,
research, education, and practices may recreate the traumas inflicted
upon Aboriginal peoples. (University of Victoria Continuing Studies, n.d.)
With girls’ groups, this means that not only is the group informed by and
understanding of the history of colonization and residential schools, but also
that it recognizes the ongoing impact of colonization in the girls’ lives. In
contrast to cultural competence, where the service provider determines the
competence of the participants, usually based on their attending training,
cultural safety puts the receiver of the service, in this case the girls, in the
role of identifying whether the group is culturally safe for them.
Naming and Noting

Naming and noting involves embracing the intersections of who the girls are
and who we are as facilitators by naming and noting experiences of racism,
sexism and trauma. This helps girls to connect across differences, rather than
pretend that we are all the same or that differences do not exist. Within the
group, girls are given the analytical tools to situate themselves within larger
power systems and institutions, and to then problematize ideals around
girlhood, health and other norms. Through this process, the girls can identify
how their lives are shaped by intersecting societal processes and can explore
creative ways to question or undermine the hold these processes have on their
lives. Rather than asking “What is wrong with me and how can I better fit into
society’s ideals?,” the girls are encouraged to ask “What is wrong with societal
norms, and what ideals do I hold true for my own vision of health?”
This questioning involves directly naming and identifying the girls’ strengths
and special skills. Girls exist within a society that often makes them feel
hypervisible, or under the gaze of others, but not truly “seen.” By naming and
noting, we help girls to develop their gifts and provide tools, such as writing
and art workshops and beadwork, to make these gifts visible.
Fostering Healthy Resistance

A trauma-informed practice with girls reframes their coping and resistance
as strategies to meet their needs in the here and now and survive in an
environment or society that is oppressing them. This is adapted from the
groundbreaking work of Robinson and Ward (1991), who examined African-
American girls’ strategies of resistance. However, girls’ resistance strategies
often do not challenge the source of the problem, and are instead a form of
dissociation that involves “loss to the conscious self of knowledge or feelings
that have become dangerous to know and feel” (Gilligan et al., 1995, p. 26).
Service providers can encourage girls to name the true source of their
problems, and assist them with strategies that demand change in the structural
environment, including policies and programs that are oppressing them
(Gilligan et al., 1995).
A recent study by Peled and Cohavi (2009) examined the experiences of girls
in Israel running away from home, and concluded that understanding Israeli
girlhood “requires a consideration of layers of social marginality other than
those of gender and age, such as race, class and immigration status” (p. 740).
The researchers explored the shifting meaning that society has attached to
running away, from labelling it as youth rebellion, to the current practice of
viewing girls who run away as victims of abuse and violence. The authors
acknowledge that most runaway girls identify histories of sexual abuse as
the reason for leaving home and have higher rates of posttraumatic stress
disorder and substance abuse. Peled and Cohavi (2009) also identify and
name the strength of these girls
in [their] ability to give up their homes and oppose familial and

cultural norms in order to care for themselves, to save their bodies
and souls from abuse, rejection, and humiliation. . . [in so doing, they
work to] facilitate a change in their life situations, and to make their
voices heard above the silence imposed on them. (p. 747)
A strengths-based approach focuses on making girls’ strengths and resistance

visible. Girls are encouraged to express themselves creatively by publishing
their writing and displaying their art. While girls often do not report or speak
about incidents of date rape and violence in their interpersonal relationships,
through art-based methods they are able to tell these stories and express their
feelings about them, even if they aren’t comfortable disclosing them more
directly. In this way, the girls are introduced to new ways of coping that
increase their sense of power and agency, rather than leaving them feeling
further pathologized.
Shifting away from self-blame and demanding change

We work with the girls to shift the blame from themselves and support them
in moving from “survival” resistance strategies, such as dropping out of school
to avoid seeing the boys, to naming the issues and demanding change. The
girls created a poster that said, “Hey, do you want to get laid?” and then went
on to identify the conditions under which rape occurs, including their own
date rape experiences. The poster was then displayed in a central place in the
youth centre these boys attended, and remained there, unmarked, for a number
of years. This clearly told the boys at the centre about the girls’ resistance. The
girls also discussed safety strategies, such as using a buddy system; always
having a friend with them who doesn’t drink alcohol; and, if they choose to
drink or use substances, taking a harm reduction approach, rather than binge
drinking, which often resulted in blackouts.
Identifying strategies to cope with anger

Another example of helping girls shift to healthy resistance is asking them to
identify how they cope daily with their anger (e.g., attacks on one another,
cutting and other self-harming strategies) and then move toward identifying
the true source of their anger (racism, violence against women, sexual harass-
ment). The girls then make a collage of the real things they are angry about,
such as abuse and racism, and throw the plate with their collage against the
wall (wearing safety goggles). From this activity, they learn to move from daily
coping strategies for anger to naming the structural issues about which they
are actually angry. Throwing the plate teaches them that there can be safe
ways to release anger in the body. The girls then pick one piece of the broken
plate that they will keep to make something creative from their anger. Through
such activities, girls’ groups can reinforce and provide tools for healthy
resistance and self-expression.
Framing Trauma Discourse within a Social

Justice Framework
Two questions, adapted from Jennifer White (2009), encapsulate a social
justice approach that views girls’ strategies as resistance and recognizes how
trauma discourse is often part of Aboriginal girls’ ongoing colonization.
• What are the consequences of locating risk and trauma within girls or
specific types of girls (i.e., racialized or Aboriginal girls)? What about
placing it within society and structural barriers?
• What fresh possibilities might be opened up by thinking about girls and
trauma in other ways? For example, what difference does it make, if any, to
understand and locate their coping within oppressive social practices, such
as colonization, and structural racism?
Education about Trauma and Resistance

Trauma is a constant presence in the lives of the girls we work with. In
educating the girls about trauma, girls’ groups frame the girls’ experiences as
resistance strategies to oppose a system or relationships that are oppressing
or abusive to them. The girls are encouraged to see the links between their
individual behaviour and coping mechanisms, and their resistance to abuse,
violence and daily experiences of oppression within society. Girls are encour
aged to name and centralize the location of the problem outside of themselves.
With more than 53 per cent of girls experiencing sexual harassment and body-
based harassment daily in schools (McCreary Centre Society, 2004), health
care practitioners need to recognize that trauma includes more than direct
experiences of violence. Trauma can also be experienced by racism, sexism
and the intersections of these in girls’ lives. In a study of violence and young
women of colour in British Columbia, most girls identified racism as the
number one form of violence they experienced. Many of these young women,
particularly those in rural communities, have few safe places or services to
access (Jiwani, 2006). It is important that girls understand that trauma
exists on a continuum and that their choices and resistance exist within a
framework that allows them to name their experiences of sexism and racism.
Conclusion
In my practice and writing about girls’ groups, my colleagues and I have
developed a model that widens the lens for situating and responding to the
experience of trauma. We caution that trauma-informed practice must not
further label and pathologize girls. Even the definitions of “trauma” and
“PTSD” are medicalized terms and are culturally bound and limited. A focus
on trauma as an individual health problem prevents and obscures a more
critical, historically situated focus on social problems under a (neo)colonial
state that contribute to violence. We need programs that provide safer spaces
for girls to address their intersecting and emergent health needs, without
furthering the discourse and construction of indigenous girls and women as
being at risk. Programs such as rites of passage groups that resist medical
and individual definitions of trauma, and use an intersectional framework
that shifts from the individual as the problem, help girls to understand and
locate their coping as responses to larger structural and systemic forces,
including racism, poverty, sexism, colonialism and a culture of trauma. Even
when educating girls about the biological impact of trauma (e.g., understanding
triggering and fight-or-flight responses), it is important to frame their reactions
and coping within a social justice approach that views these strategies as
resistance, and names and understands how current trauma discourse and
services are often part of the ongoing colonization of Aboriginal girls.
References
Bell-Gadsby, C., Clark, N. & Hunt, S. (2006) It’s A Girl Thang: A Manual on Creating Girls
Groups. Vancouver: McCreary Youth Foundation.
Belgrave, F.Z., Reed, M.C., Plybon, L.E., Butler, D.S., Allison, K.W. & Davis, T. (2004). An
evaluation of Sisters of Nia: A cultural program for African American girls. Journal of Black
Psychology, 30, 329–343.
Blaney, E. (2004). PRISM: Probing Rural Issues—Selecting Methods to Address Abuse of Women
and Girls: (E)valu(at)ing “Better” Practices and Reflexive Approaches. Fredericton, NB:
Muriel McQueen Fergusson Centre for Family Violence Research.
Calhoun Research and Development/Recherche et développement, C. Lang Consulting &
Savoie, I. (2005). Girls in Canada 2005. Toronto: Canadian Women’s Foundation.
Chandler, M.J. & Lalonde, C.E. (2008). Cultural continuity as a moderator of suicide risk among
Canada’s First Nations. In L. Kirmayer & G. Valaskakis (Eds.). Healing Traditions: The Mental
Health of Aboriginal Peoples in Canada (pp. 221–248). Vancouver: UBC Press.
Clark, N. & Hunt, S. (2011). Navigating the crossroads: Exploring rural young women’s
experiences of health using an intersectional framework. In O. Hankivsky (Ed.), Health
Inequities in Canada: Intersectional Frameworks and Practices (pp. 131–146). Vancouver:
UBC Press.
Constantine, M.G., Alleyne, V.L, Wallace, B.C. & Franklin-Jackson, D.C. (2006). Africentric
cultural values: Their relation to positive mental health in African American adolescent girls.
Journal of Black Psychology, 32, 141–154.
Crenshaw, K. (1989). Demarginalizing the intersection of race and sex: A black feminist critique
of antidiscrimination doctrine, feminist theory and antiracist politics. University of Chicago
Legal Forum, 1989, 139–167.
De Leeuw, S. & Greenwood, M. (2011). Beyond borders and boundaries: Addressing indigenous
health inequities in Canada through theories of social determinants of health and
intersectionality. In O. Hankivsky (Ed.), Health Inequities in Canada: Intersectional
Frameworks and Practices (pp. 53–70). Vancouver: UBC Press.
Gilligan, C. Taylor, J.M. & Sullivan, A. (1995). Between Voice and Silence: Women, Girls, Race and
Relationship. Cambridge: Harvard University Press.
hooks, b. (1999). The oppositional gaze: Black female spectators. In S. Thornham (Ed.), Feminist
Film Theory: A Reader. Edinburgh, UK: Edinburgh University Press.
Jiwani, Y. (1998). Violence against Marginalized Girls: A Review of the Current Literature.
Vancouver: FREDA Centre for Research on Violence against Women and Children.
Jiwani, Y. (1999). Violence Prevention and the Girl Child: Phase One Report. Vancouver: FREDA
Centre for Research on Violence against Women and Children.
Jiwani, Y. (2006). Discourse of Denial: Mediations of Race, Gender, and Violence. Vancouver:
UBC Press.
McCreary Centre Society. (2004). Healthy Youth Development: Highlights from the 2003 Adolescent
Health Survey III. Retrieved from http://mcs.bc.ca/pdf/AHS-3_provincial.pdf
McCreary Centre Society. (2005) Raven’s Children II: Aboriginal Youth Health in B.C. Retrieved
from www.mcs.bc.ca/pdf/Ravens_children_2-web.pdf
Peled, E. & Cohavi, A. (2009). The meaning of running away for girls. Journal of Child Abuse and
Neglect, 33, 739–749.
Robinson, T. & Ward, J.V. (1991). A belief in self far greater than anyone’s disbelief: Cultivating
resistance among African American female adolescents. In C. Gilligan, A. Rogers & D.
Tolman (Eds.). Women, Girls and Psychotherapy: Reframing Resistance (pp. 87–104). New York:
Haworth Press.
Taefi, N., Czapska, A., Webb, A. & Aleem, R. (2008). Submission to UN Committee on the
Elimination of All Forms of Discrimination against Women at Its 7th Periodic Review of Canada.
Retrieved from www2.ohchr.org/english/bodies/cedaw/docs/ngos/CEDAW_Submission-
FINAL.pdf
University of Victoria Continuing Studies (n.d.). Cultural Safety: Module 2: Peoples’ Experiences of
Oppression (online course). Victoria, BC: Author. Retrieved from http://web2.uvcs.uvic.ca/
courses/csafety/mod2/glossary.htm
White, J. (2009, February). Doing Youth Suicide Critically: Interrogating the Knowledge Practice
Relationship. Victoria, BC: School of Child and Youth Care, University of Victoria.
Yee, J. (Ed.). (2011, November). Presentation to Intersectionality Reading Group, Simon Fraser
University, Vancouver.
165
Chapter 13
Acknowledging and Embracing

“the Boy inside the Man”
Trauma-Informed Work with Men
Roger Fallot and Richard Bebout
The core values of a trauma-informed culture of care are safety, trustworthiness,

choice, collaboration and empowerment (Fallot & Harris, 2008). For both men
and women, for both consumers and staff members, these values pervade
trauma-informed programs. They stand as necessary antidotes to the toxic
effects of violence in the lives of trauma survivors. To the extent that a program
embodies these five values in every contact, every physical setting, every activity
and every relationship, it can claim to be “trauma informed.” However, because
of the powerful effect of gender role socialization, these values may be enacted
differently for men and women. Therefore, it is equally important for programs
to be “gender responsive,” considering the unique needs of men and women
in their services and service settings (Covington et al., 2008). In this chapter,
as we discuss the assumptions guiding our work with male trauma survivors,
we also highlight the simultaneous and overlapping development of trauma-
informed, gender-responsive organizational cultures.
Prevalence, Impact and Disclosure

Experiences of violence are pervasive in the lives of men and boys. Community
surveys in the United States indicate that more than 50 per cent of men have been
exposed to at least one traumatic event (Kessler et al., 1995). In metropolitan
urban areas, these numbers may be even higher; in one survey, men reported,
on average, 5.3 distinct traumatic events in their lives, with people who are
poor, non-white and less educated experiencing more violence than others
(Breslau et al., 1998). Men diagnosed with severe mental health problems
have reported even higher rates of exposure to violence than the general
population. Mueser et al. (1998) found that more than 35 per cent of these
men reported childhood sexual abuse, and 25 per cent reported sexual assault
in adulthood; nearly half indicated that they had been physically assaulted
with a weapon in adulthood.
The oft-cited “culture of violence” among men is thus extremely broad,

including emotional, physical and sexual violence, as well as community or
street violence, institutional violence (e.g., jail, prison, shelter, psychiatric
hospitals) and military and combat trauma. The consequences of traumatic
violence for men are similarly broad: posttraumatic stress disorder (though
at lower rates than women), anger, aggression and other interpersonal
difficulties; substance use problems; depression; and physical health
problems. Though boys and men are more likely to “externalize” their
responses to trauma than are girls and women, they also have a full range
of emotional and physical sequelae.
Partly because of the power of male gender role socialization (see below),
men often under-report the occurrence of traumatic violence and frequently
minimize its impact on their lives. Men who learn not to show vulnerability
are unlikely to acknowledge “victimization.” Because they participate in the
same culture of masculinity, service providers frequently under-recognize the
prevalence and impact of violence among men.
One of the first lessons in a trauma-informed, gender-responsive culture of

care for men is straightforward: service providers need to ask men about their
history of exposure to violence as early as possible in the intake process.
Framing this as exposure to “violence” is more likely to elicit disclosure than
using language addressing “abuse” or “trauma,” both of which may tap into
men’s fears of appearing weak. Prefacing questions with some data about the
pervasiveness of violence and its broad impact may also make it easier for
men to discuss their histories. For those men whose initial response is
positive, service providers can then follow up with a more comprehensive
trauma assessment, include that assessment in a collaborative recovery plan
Chapter 13 Acknowledging and Embracing “the Boy inside the Man” 167
and refer interested men to trauma-specific services (those that focus directly
on the sequelae of trauma and on facilitating trauma recovery). For men
whose initial response is negative, providers may revisit the questions later,
after a working, collaborative relationship has been established.
Core Assumptions of Trauma-Informed,

Gender‑Responsive Care
Assumption 1
Although men and women experience overlapping types of traumatic
events and often exhibit similar short- and long-term sequelae, gender role
expectations dramatically colour not only the initial experience of trauma,
but also the survivor’s narrative explanation and responses to trauma.
Consequently, it is essential for male survivors, and trauma-informed service
providers seeking to engage them, to examine the impact of male gender role
socialization on men’s experiences of traumatic violence. Without this kind of
analysis, men will be less willing or able to seek and accept help. Culturally
held messages about what it means to be a “real man” emphasize toughness
and independence and substantially limit the range of emotions that men are
allowed to express publicly and even to acknowledge privately. And yet, the
ability to tolerate vulnerability, to risk connection and to accurately label a
range of negative and positive emotions is essential for recovery to proceed.
Before engaging effectively in explicit trauma-specific work, men may need to

address and strengthen different basic skills than women. In particular, men
need time and support to gain comfort with and expand their emotional
vocabulary. Whereas women may enter trauma services already able to
acknowledge vulnerability and common emotions associated with trauma,
many men find it difficult to label, describe and perhaps experience a wide
range of emotions, especially the “softer” ones. Similarly, the most common
narratives of male development emphasize growth toward independence
and self-sufficiency; relationships are often decidedly secondary in men’s
socialization. Gender-responsive and trauma-informed service settings help
men to accurately label experiences, to develop a shared vocabulary of
emotional and relational life and to heighten men’s awareness of connections

between current struggles and past experiences of violence.
To facilitate a safe and trustworthy environment of care, service providers need

both to understand these gender-related patterns and to be cautious in pacing
their expectations about men’s deeper engagement in services. A man who is
reluctant to talk about his emotional or relational life is not necessarily “resis-
tant” or “in denial.” He may simply have a limited ability to express himself in
ways more common in a “therapeutic” culture. Slowing the expected rate of
disclosure and open discussion, for example, enhances these men’s sense of
safety.
Assumption 2
Male trauma survivors face a “disconnection dilemma,” an almost irresolvable
conflict between their identity as men and their experiences of powerlessness
and vulnerability associated with violent victimization. Acknowledging fear and
loss of control is tantamount to weakness and threatens their core identity as
men. Many men resolve this dissonance by cutting off thoughts and feelings tied
to victim experiences. Being “a man” is incompatible with being “a victim,” yet
both sets of experiences carry a strong emotional “charge.” Just as the like-
poles of magnets repel, men are unable to stably hold together their images of
themselves as “man enough” with their experiences of victimization and the
unacceptable feelings of fear and vulnerability they engender. If men are
defined by strength, courage, toughness and control, there is no room for
experiences of victimization and fear.
Because of this potential for disconnection, it is crucial to explore the relation-

ship between experiences of trauma and male gender role expectations.
Exploring the pervasive messages boys and men get about the way “real men”
think, feel and act can reduce their magnetic charge and begin to make it
possible for men to bring both parts of self with them into services.
Service providers who acknowledge the importance of these gendered

messages convey that they are not “blaming the victim;” this acknowledgment
enhances the provider’s image as safe and trustworthy and strengthens the
possibility of meaningful collaboration. By empathizing with the disconnection
dilemma and by drawing explicit attention to it, service providers communicate

that they are willing to follow the consumer’s lead in any discussion of trauma-
related concerns.
Assumption 3
Many male trauma survivors display all-or-nothing responses in their approach
to emotional and relational issues throughout their lives. For example, men
may express only extremes of rage or timidity, and either easy trust or pervasive
mistrust. The subtle beauty of grey is lost.
Developing a broader range of options for expressing emotions and for being
in relationships is a key trauma recovery skill for men. A trauma-informed,
gender-responsive system for men must recognize a range of typical male
adaptations, including hard-shelled withdrawal (think armadillos) and
aggressive posturing (think bears or porcupines) as preferred stances. These
masks are moulded both by the real and perceived danger men have faced
and by the “male code.” Service providers must recognize the adaptive inevita-
bility of these positions and develop helpful responses that gradually allow
men to cope in more flexible and less automatic ways.
Staff members who realize that men frequently cope with stressors by
enacting common male gender role messages therefore have an alternative
way to think of the angry, aggressive male consumer. Knowing that scared
people scare others, just as hurt people hurt others, helps reduce the likelihood
that staff will react in counterproductive ways and will instead seek ways to
increase everyone’s sense of safety. De-escalation techniques (e.g., speaking in
a low, even tone and asking questions rather than making demands) are more
likely to make sense to, and be used successfully by, staff members who under-
stand the connections between traumatic violence and anger.
Assumption 4
For both men and women, trauma frequently severs core connections to
family, community and ultimately to the self. For men, these experiences
reinforce the need to maintain at least the appearance of interpersonal self-

sufficiency and emotional control.
Broad-based recovery work in a trauma-informed system aims not only at the

reconnecting skills of emotional, cognitive and behavioural self-recognition
but also of relational mutuality. In a society where men are often expected
to exercise power and assert authority, men who have experienced the abuse
of power are left with unique knowledge of its interpersonal dangers.
Men become more open to collaborative relationships with service providers

who offer to share meaningful power in a way that gives consumers maximum
choice and voice in their recovery and life goals. Trauma-informed providers
shift from the more traditional stance of “Here is what I can do to fix you”
to one that asks, “How can you and I work together to meet your goals for
recovery and healing?” Men who have been sensitized to the abuse of power
in previous relationships may need to hear this message repeatedly and in a
variety of contexts.
Assumption 5
People who experienced repeated trauma in childhood have often been
deprived of the opportunity to develop a range of skills for coping and self-
regulation necessary for effectively managing in an adult world. Growing up
in an unsafe, often chaotic environment means living in “survival mode,”
where a limited number of skills are acquired and get used repeatedly.
Trauma-informed systems of care adopt a skills-oriented approach to recovery

work and provide formal and informal opportunities for psychoeducation.
All service providers, not just trauma clinicians, learn to recognize and
underscore the connections between abuse histories and current skill deficits.
Motivational interviewing techniques are among the primary ways in which

choice and control become consumer priorities. Repeated invitations for men
to examine the advantages and disadvantages of alternative responses are
important tools for engaging men in experimenting with new, potentially less
costly behaviours. Developing needed skills is a way clients can feel empowered,
without actually engaging in “treatment.” For example, staff may support
men in learning and practising relaxation skills as an alternative way to cope

with anger and excessive anxiety.
Assumption 6
While certain abilities may have been adversely affected by violence and abuse,
trauma survivors nonetheless bring an array of skills and strengths to the
recovery process.
Acknowledging the genuinely miraculous strength and courage men have

shown, simply that they are “still standing,” helps to resurrect hope and
motivate men to engage in further recovery. Helping men to remember and
to own even small successes and to recognize budding new skills encourages
them to continue in their recovery efforts. Men who have had good friendships,
for example, may be able to use these experiences to explore the ingredients
necessary to trust and to risk appropriate self-disclosure. Or men who have
exhibited emotional self-control skills at work may be able to transfer those
skills to more intimate relationships. There is no better avenue to empower-
ment than by acknowledging existing strengths. Recognition of this sort may
be “water in the desert” for male survivors who have heard only how their
behaviour and attitudes are destructive to themselves or others.
Assumption 7
We assume that some dysfunctional behaviours and/or “symptoms” may have
originated as legitimate coping responses to trauma.
Reframing specific problematic behaviours—distrust, hypervigilance, hair-

trigger aggression—as reflections of understandable attempts to cope with
abuse is a key element in trauma recovery. Recognizing the necessity and
adaptive health embedded in actions or feelings that appear so unhealthy is
often a pivotal step that gradually frees men to try another way. Reframing is
in itself empowering, in that the person can attribute a different meaning to
something without shaming or blaming himself, and learn about himself in
the process, as a prelude to choosing other ways of coping.
Assumption 8
All attempts to cope with trauma have advantages and disadvantages, benefits
and costs. The advantages or disadvantages may be physical (e.g., survival),
emotional (e.g., minimizing distressful feelings), cognitive (e.g., developing
certain beliefs about oneself and the world), behavioural (e.g., avoiding
potentially dangerous situations) or spiritual (e.g., considering life to be
meaningless or without purpose).
Focused on simply managing the effects of trauma, many survivors are

unclear about the full range of costs and benefits involved in their coping
strategies. Opportunities to clarify the advantages and disadvantages of
various coping styles can occur in different contexts. Male survivors benefit
from seeing this kind of “cost-benefit” analysis. It helps them to accept and
reframe some of the problems associated with their coping attempts—and to
see more explicitly the often hidden or minimized negative consequences.
Trauma-informed values emphasize both choice and empowerment, expanding
men’s freedom to choose the most helpful and least costly coping methods
and highlighting their capacity to develop the requisite recovery skills for
meeting life goals.
Trauma-Specific Treatment
This book’s focus is on trauma-informed care rather than trauma-specific
treatment, so we devote the majority of this chapter to practice examples
not tied directly to the relief of posttraumatic stress or related symptoms.
However, much of our most intimate knowledge about men’s trauma
recovery comes from developing, implementing and training clinicians in
the Men’s Trauma Recovery and Empowerment model (M-TREM), a group
approach that features a 24-week psychoeducational curriculum geared
specifically to men. The model builds on extensive experience with, and
empirical support for, the Trauma Recovery and Empowerment model
developed by Harris (Fallot & Harris, 2002; Harris, 1998).
The model has been implemented in many mental health and addiction
treatment settings, homeless programs and in jail diversion and other
criminal justice settings. Perhaps of special interest are several initiatives
to modify M-TREM for work with military veterans. One of the central insights
of that work is the extent to which military culture and “warrior ideals” amplify
the male messages and masculine gender-role ideals we have discussed. As
with men in general, a key component of work with veterans is finding safe
ways for soldiers to access and express otherwise unacceptable thoughts,
feelings and behaviour patterns and reframe them as normal responses to
trauma, in a way that is fundamentally countercultural.
Conclusion
Promoting recovery within a trauma-informed, gender-responsive culture of
care becomes everybody’s job. All staff within trauma-informed systems of care
—not just trauma clinicians but case managers, addiction counsellors and
housing and employment specialists—have opportunities to assist men to
accurately label and modulate emotional states, to increase the range of
options available to them to manage their lives and to cope with their trauma
experiences. Any service provider in any encounter can help connect the dots
in new ways so that current problems become understandable in light of bad
things that have happened in the past. Exploring the connections between
violence on one hand and psychological, substance use and interpersonal
problems on the other occurs throughout the care system. Greater self-awareness
and access to a wider range of emotional experiences create the possibility
of a correspondingly expanded repertoire of coping and healing responses.
Recognizing feelings or relationship patterns early on, and accurately, for
example, is a starting point for increased control and self-expression in the
relatively unexplored middle ground, or grey area, of the continuum.
Men in mental health and addiction treatment—like men nearly everywhere

—commonly go to extraordinary lengths to hide and protect “the boy inside
the man,” as Antwone Fisher (2001) describes it in a poem featured in his
autobiography, Finding Fish. At the very least, it is incumbent on us all to
recognize that boy and nurture him, and to make our systems of care places
where he might feel safe enough to show himself and risk opening himself
to a different kind of human connection that will allow him to heal.
References
Breslau, N., Kessler, R., Chilcoat, H., Schultz, L. Davis, G. & Andreski, P. (1998). Trauma and
posttraumatic stress disorder in the community: The 1996 Detroit Area Survey of Trauma.
Archives of General Psychiatry, 55, 626–632.
Covington, S.S., Burke, C., Keaton, S. & Norcott, C. (2008, November). Evaluation of a trauma-
informed and gender-responsive intervention for women in drug treatment. Journal of
Psychoactive Drugs, 40(Suppl. 5), 387–398.
Fallot, R.D. & Harris, M. (2002). The Trauma Recovery and Empowerment model (TREM):
Conceptual and practical issues in a group intervention for women. Community Mental
Health Journal, 38, 475–485.
Fallot, R.D. & Harris, M. (2008). Trauma-informed services. In G. Reyes, J.D. Elhai & J.D. Ford
(Eds.), Encyclopedia of Psychological Trauma (pp. 660–662). Hoboken, NJ: John Wiley & Sons.
Fisher, A.Q. (2001). Finding Fish: A Memoir. With M.E. Rivas. New York: HarperCollins.
Harris, M. (1998). Trauma Recovery and Empowerment: A Clinician’s Guide for Working with
Women in Groups. New York: Free Press.
Kessler, R.C., Sonnega, A., Bromet, E., Hughes, M. & Nelson, C.B. (1995). Posttraumatic stress
disorder in the National Comorbidity Survey. Archives of General Psychiatry, 52, 1048–1060.
Mueser, K.T., Goodman, L.B., Trumbetta, S.L., Rosenberg, S.D., Osher, F.C., Vidaver, R. et al.
(1998). Trauma and posttraumatic stress disorder in severe mental illness. Journal of
Consulting and Clinical Psychology, 66, 493–499.
175
Chapter 14
An Intergenerational
Trauma‑Informed Approach to Care
for Canada’s Aboriginal Peoples
Peter Menzies
Helping professionals have only recently learned how historical public

policies that disadvantaged and isolated Aboriginal families and communities
continue to have ripple effects throughout many Aboriginal communities
today. Understanding these historical policies, including the Indian Act, the
residential school system and child welfare legislation, is important when
providing therapeutic intervention with Canada’s Aboriginal Peoples. Recent
research on intergenerational trauma is helping to inform new healing
strategies for Aboriginal individuals, families and communities. As a therapist
with more than three decades of experience in individual and family counselling,
I offer my own evolved methodology for working with Aboriginal people that
includes exploring intergenerational trauma with the client. This chapter
explores the impact of Canada’s public policies on Aboriginal Peoples and
offer intervention strategies using a trauma-informed approach.
Canadian Public Policy

Canadian historical social policy around Aboriginal Peoples has been criticized
for deliberately trying to “remov[e] the Indianness out of the Indian” (Titley,
1986, p. 75) by systematically eradicating the values, beliefs and way of life of
Canada’s First Peoples and assimilating them into mainstream Canadian
culture (Churchill, 1995).
The Indian Act

The Indian Act, 1876, gave the federal government the power to set out the
terms and conditions by which Aboriginal Peoples would be treated within
Confederation. First, it established the federal government as “guardian” of
Aboriginal Peoples. The act gave Ottawa the right to define who was and who
was not Aboriginal, to create reserves and to impose hierarchy and decision-
making authorities that did not reflect traditional values and practices. The
act restricted the mobility of Aboriginal Peoples within the country, outlawed
ceremonies and trading with settlers, denied legal counsel and the right
to vote and forced communities to relocate. In effect, the Indian Act gave
authority to Ottawa to control the everyday life of Aboriginal Peoples (Royal
Commission on Aboriginal Peoples, 1996).
More recent attempts have been made to redress some of the act’s most
blatant shortcomings by addressing the bias against Aboriginal women in
relationships with non-Aboriginal men with the passing of Bill C-31 in 1985.
However, the Indian Act continues to fuel significant discourse within
Aboriginal communities and among Canada’s legislators as the debate for
self-government continues.
Residential Schools
Through partnership with Christian institutions, including the Anglican,
Catholic, United and Presbyterian churches, an estimated 100,000 Aboriginal
children were placed in the residential school system between 1840 and 1983
(United Church of Canada, 1994). Residential schools were designed to
civilize or “westernize” the children, remove their Indian identity and integrate
them into mainstream Canadian society (Royal Commission on Aboriginal
Peoples, 1996). A statement in 1920 by the head of the Department of Indian
Affairs, Duncan Campbell Scott, best demonstrates the harsh attitude of
government officials toward Canada’s Aboriginal population:
I want to get rid of the Indian problem. I do not think as a matter of

fact, that the country ought to continuously protect a class of people
who are able to stand alone. . . . Our objective is to continue until there
is not a single Indian in Canada that has not been absorbed into the
Chapter 14 Trauma-Informed Care for Canada’s Aboriginal Peoples 177
body politic and there is no Indian question, and no Indian

Department, that is the whole object of this Bill. (Titley, 1986, p. 50)
This policy resulted in the forced removal of children from their families for
months, even years at a time. Parents refusing to hand over their children were
threatened with imprisonment and other consequences, including reduced
food rations. Many children attending these schools lost their language,
culture, identity and spiritual beliefs, as well as a sense of belonging to family,
community and nation. Many children experienced physical, sexual, emotional,
spiritual and psychological abuse (Assembly of First Nations, 1994; Royal
Commission on Aboriginal Peoples, 1996). This public policy was embraced
by governments for more than a century, with the last residential school in
Canada not closing until 1996 (Thatcher, 2005).
Child welfare policies

With the closing of residential schools, child welfare systems became the new
vehicles of assimilation. In 1983, researcher Patrick Johnston introduced the
term “the Sixties Scoop” to identify the overwhelming number of Aboriginal
children removed from their communities by child welfare authorities. Many
parents who had attended residential schools as children were so overwhelmed
by their experiences that they were unable to care for their children. Issues
such as abandonment, neglect, alcohol abuse, poor parenting skills and lack
of supervision became the predominant grounds for apprehension.
Many child welfare workers had no understanding of Aboriginal traditions,

culture and history. Taking a crisis intervention approach to child welfare
meant that services to support children in their home were non-existent
(Andres, 1981; Johnston, 1983; Richard, 1989; Timpson, 1990). In 2006,
an estimated 27,000 Aboriginal children were in the care of child welfare
agencies across Canada (Assembly of First Nations, 2006). Child welfare
institutions have now replaced residential schools as instruments of assimilation.
Establishing a Therapeutic Framework for

Intervention with Aboriginal People
The impact of these policies has resulted in the loss of self, family and
community ties. In order to work effectively with Aboriginal people, we
need a therapeutic framework that recognizes the role of public policies on
individuals, families and communities.
Understanding the Individual

Across North America, various theories—such as residential school syndrome
and split feather syndrome—have been developed over the past three decades
to help therapists broaden their understanding of how public policies related
to Aboriginal Peoples have affected individual behaviours. These theories
attempt to explain a range of behaviours presented by Aboriginal people who
have been separated from their families as a result of residential school
programs or child welfare systems. Intergenerational trauma extends the
focus of the trauma beyond the individual’s experience to include the social
context of family, community and all First Nations.
Residential school syndrome

Many writers (Corrado & Cohen, 2003; Stout & Kipling, 2003) have
documented the abuses and harm experienced by Aboriginal children who
attended residential schools. Brasfield (2001) and Chrisjohn and Young
(1997) developed assessment models of Aboriginal people who attended
residential schools by modelling the criteria after the Diagnostic Statistical
Manual of Mental Disorders (DSM), which classifies disorders identified in
modern psychiatry and provides descriptions to assist in diagnosis and
treatment. Chrisjohn and Young describe residential school syndrome as:
. . . a personality disorder manifested in an individual’s specific

behavioral action of (1) obliterating another people’s way of life by
taking the children of the group away from their parents and having
them raised in ignorance of, and/or with contempt for, their heritage;
while (2) helping himself/herself to the property of the target group.

(p. 84)
The diagnosis is based on a collection of individual behaviours, including

recurrent intrusive memories, nightmares, flashbacks, lack of personal
insight, detachment from others, relationship difficulties, diminished interest
and participation in Aboriginal cultural activities, anger management
difficulties, impaired concentration, inadequate parenting and abuse of
alcohol or other drugs.
Split feather syndrome

The impact of social policies on Aboriginal children is not only isolated within
the Canadian policy realm. American researcher Carol Locust (1998) found
that Indian children who entered the child welfare system in the United States
tended to lose their identity and culture. Locust’s research noted that Indian
children in care experienced the loss of family, culture, heritage, language,
spiritual beliefs and tribal affiliation, as well as having the sense of growing
up being different. These children reported that the cultural isolation and loss
of familial connections left them feeling isolated from both mainstream and
Indian culture. Without belonging to either culture, many described their
socialization as being split between two worlds. This split resulted in long-
term emotional and psychological problems. Locust (1998) maintains that
these problems are the result of a deeply felt connection with the birth culture
while living outside of that reality. While the research on split feather syndrome
is primarily American based, the effects of removing children from their
unique cultural and social norms through child welfare systems cannot be
disregarded when assessing their behaviour (Archibald, 2006).
Intergenerational Trauma
Only within the last two decades has intergenerational trauma been offered
as a broader framework from which we can better understand the legacy of
government public policies (Braveheart-Jordan & De Bruyn, 1995; Gagne,
1998; Lederman, 1999; Waldram, 1997). Removing children from the home
for long periods has diminished opportunities for family values, parenting
knowledge and community behaviour to be transmitted between generations
(Payukotayno, 1988; Van de Sande, 1995). The cumulative impact of trauma

experienced by both children and their parents as a result of Canada’s
residential school policy continues to have consequences for subsequent
generations of children. The Aboriginal Healing Foundation (2001) has noted:
Many passed the abuse they suffered on to their children, thereby

perpetuating the cycle of abuse and dysfunction arising from the residential
school system. Subsequent generations of children were left with the
consequences of what happened to their parents and grandparents. They
grew up without the opportunity to learn their language, to have
traditions and cultural knowledge passed down to them, or to be a
part of a strong and healthy family and community. (p. 7)
Like the residential institutions where their parents, grandparents and great
grandparents were sent, the foster care and adoption system created another
generation of children who have been subjected to psychological, emotional,
sexual and physical abuse. Isolation from families and Aboriginal identity was
intensified when some children were sent for adoption to other countries,
including the United States (Bagley et al., 1993). Lederman (1999) observed:
Children’s Aid Societies perpetuated the same beliefs as residential

schools: that a well-meaning White, cultural institution was better
than a Native child’s family and community. Many, perhaps even
most, of the child welfare workers were compassionate and well-
intentioned. But, however well-meaning Children’s Aid Society
intrusions may have been, they further continued the traumatization
of Native people and likely compounded it. (p. 64)
Nadjiwan and Blackstock (2003) noted that these societies failed to recognize
Aboriginal traditions:
Ethnocentric child welfare practices based on Euro-western models

did not take into account First Nations values, beliefs, responsibilities,
and child care practices and continued to marginalize First Nations’
efforts to care for their own children despite the pervasive failure of
mainstream approaches in the residential school system. (p. 17)
Trauma is attributed to external factors, which significantly influence

individual, family and community behaviours. By externalizing trauma,
the therapist enters into a relationship with the client that explores the
impact of history on the client’s presenting issues.
Posttraumatic Stress Disorder

Although professionals have often used a diagnosis of posttraumatic stress
disorder (PTSD) to understand Aboriginal addiction and mental health issues,
recent literature suggests that this diagnosis ignores the role of intergenerational
issues. A PTSD diagnosis does not connect the individual’s experience to
broader, systemic conditions that perpetuate and exacerbate the individual’s
experience (Waldram, 2004).
Gagne (1998) also noted that the effect of the residential school experience
was felt beyond the generation that attended the school: “At least two
subsequent generations were also ‘lost.’ The children of these students
became victims of abuse as their parents became abusers because of the
residential school experience” (p. 363).
The impact of trauma, as a result of social history, has to be carefully considered

within the context of the individual’s lived experience, rather than simply
focusing on individual pathology. However, therapeutic intervention must
consider the external influence of trauma as experienced by the individual.
Indicators of Intergenerational Trauma

Although the literature describes intergeneration trauma and notes its causes
in historical events, I conducted a study that took a step further and presented
clinical indicators of intergenerational trauma (Menzies, 2006). The study,
which focused on Aboriginal homeless men, used a qualitative methodology
involving interviews with men from different age categories, a focus group,
and interviews with key Aboriginal stakeholders who work with homeless
Aboriginal men. The findings revealed certain behaviours and psychological
responses among Aboriginal men who were directly and indirectly affected
by public policies related to Aboriginal Peoples. The responses were grouped

into four indicator areas: individual, family, community and nation.
Individual indicators: Lack of a sense of “belonging,” identification, or

affiliation with a specific family, community, culture, or nation; feeling of
“abandonment” by caregivers; limited or no information about one’s culture
of birth, including language, customs, belief systems, spirituality; one or more
“flight” episodes from a caregiver environment as a youth; inability to sustain
personal or intimate relationships; being present-oriented, not future-oriented;
low self-esteem; limited education and employment history; history of substance
misuse; history of involvement with the criminal justice system, precipitated
by substance misuse; and involvement with the mental health system.
Family indicators: Chronic or episodic family violence, including physical,

sexual, emotional, and/or verbal abuse of children by adults in the household;
lack of emotional bonding between parents, siblings, and extended family
members; denial of cultural heritage by older family members; perpetuation
of negative stereotypes within the family of birth or caregiver environment;
irregular contact or the absence of contact with caregiver family members;
and concealed misuse of alcohol and other drugs that crosses generations.
Community indicators: Unconcealed misuse of alcohol and other drugs among

community members; lack of cultural opportunities, including transmission
of language skills, history, traditional values, and spirituality; unwillingness to
“reclaim” community members; and low levels of social capital (Putnam, 2000),
including trust, reciprocal helping relations, and social engagement.
Nation indicators: Popularization of negative stereotypes through mainstream

media; social policies that perpetuate colonialization of Aboriginal peoples
on an individual family and community basis; lack of support for holistic
programs and services targeting Aboriginal needs; and lack of support for
community self-determination.
While the research focused on the experiences of Aboriginal men, my

extensive experience in working with Aboriginal communities over two
decades would support extrapolating these indicators as also relevant to the
experiences of women and youth. Further research is needed to confirm
and expand the indicators for other Aboriginal subpopulations.
Identity
To work effectively with Aboriginal people, it is important to find out how the
individual perceives himself or herself as an Aboriginal person. McKenzie
and Morrissette (2003) developed a framework for working with Aboriginal
people, which involves asking clients to identify how they express their cultural
awareness across a continuum ranging from “traditional” to mainstream” to
“non-traditional.” Along this continuum, there is transition to and from each
of the three main cultural strata. The three main forms of cultural expression
are outlined below:
Traditional
Within this category, individuals express their cultural identity as distinct
from mainstream society, in some cases removing themselves from dominant
society to live according to traditional lifestyle and spirituality. In other cases,
the traditionalist may leverage some practices from mainstream society, such
as working and living within the mainstream culture, while still asserting his
or her unique Aboriginal identity.
Mainstream
This category includes individuals who struggle to integrate traditional
values into their primarily Euro-Canadian world view. They may recognize
the historical impact that cultural conflicts have had on the evolution of
Aboriginal Peoples in Canada, but are more likely to share the values and
belief systems of mainstream society. They often have shifting views or may
be ambivalent about the values within traditional Aboriginal culture, but
may be open to exploring their situation or leveraging traditional practices
in their healing.
Non-traditional
This group includes individuals who have been assimilated into dominant
society and are merely spectators of Aboriginal culture and those who have
been marginalized or alienated from their traditions and belief systems.
Individuals in the latter group struggle with both their Aboriginal identity
and their sense of belonging to the dominant society. They are not comfortable
in either world. Without a sense of identity that is linked to a collective,
individuals may drift into other groups or organizations as they seek a sense
of belonging in other types of “community.”
By understanding how individuals express their relationship to their

culture, the therapist can help clients build their own understanding of
how their issues relate to broader issues within their family, community
and nation.
Working with Aboriginal People

Aboriginal healing seeks to restore a balance between the mental, spiritual,
emotional and physical well-being of the person (Hart, 2002). As individuals
are strengthened, their family, community and nation will benefit from a
process of healing that seeks to reconnect and strengthen social supports.
Working with Aboriginal people requires the therapist to develop trust, respect,
openness and honesty so that the client will feel safe and secure within the
therapeutic environment. Given the extensive impact that public policies have
had on Aboriginal people, many seeking service will come from traumatized
backgrounds, so developing a trusting therapeutic relationship may take
longer to nurture.
Determining the level of trauma and degree of assimilation is the next point
in the assessment process. Asking clients a series of questions about their
family and personal history, their thoughts about being Aboriginal and where
they see themselves as Aboriginals can provide insight into where the
imbalances exist in their lives. Through this assessment process, the therapist
can help the client gain insight into how public policies have affected them
and how these policies have contributed to the development of their identity.
In the therapeutic process, clinicians must be prepared to understand

and leverage the cultural context of the client and be prepared to adapt
conventional counselling techniques to effectively meet the needs of their
Aboriginal clients (Morrissette, 2008). By helping clients to establish their
cultural affinity and explore their personal and family histories in relation to
public policy, the therapeutic relationship shifts the client’s understanding
of his or her externalized behaviours as being self-driven to seeing them
within a broader social context. This allows the therapist and client to explore
individual externalized behaviours in a new way.
Given that this is a process of discovery, the therapist should partner with
other helpers, such as elders, cultural teachers and Aboriginal counsellors.
Aboriginal ceremonies and celebrations can be used as part of the treatment
intervention strategy.
Conclusion
Aboriginal Peoples have been affected by centuries of colonization. Too many
interventions focus on the individual’s behaviour without acknowledging the
impact of public policies. Awareness of colonization and the impact it has had
on Aboriginal people can guide the therapist in the counselling relationship.
Intergenerational trauma can be an explanation for the array of mental health
and substance use issues that Aboriginal people are experiencing today.
Therapists need to acknowledge the role of public policy in severing the
physical, mental, emotional and spiritual ties among Aboriginal people, and
consider the implications of intergenerational trauma on individuals,
families, communities and nations.
References
Aboriginal Healing Foundation. (2001). Program Hand Guide (3rd ed.). Ottawa: Author.
Andres, R. (1981). The apprehension of Native children. Ontario Indian, 46, 32–37.
Archibald, L. (2006). Decolonization and Healing: Indigenous Experiences in the United States,
New Zealand, Australia and Greenland. Ottawa: Aboriginal Healing Foundation.
Assembly of First Nations. (1994). Breaking the Silence. Ottawa: Author.
Assembly of First Nations. (2006). Leadership Action Plan on First Nations Child Welfare. Ottawa:
Author.
Bagley, C., Young, Y. & Scully, A. (1993). International and Transracial Adoptions: A Mental Health
Perspective. Brookfield, VT: Avebury.
Brasfield, C.R. (2001). Residential school syndrome. BC Medical Journal, 43, 78–81.
Braveheart-Jordan, M. & De Bruyn, L. (1995). So she may walk in balance: Integrating the
impact of historical trauma in the treatment of Native American Indian women. In J.
Adelman & G. Enguidanos (Eds.), Racism in the Lives of Women: Testimony, Theory and
Guides to Ethnoracist Practice (pp. 345–369). New York: Haworth Press.
Chrisjohn, R. & Young, S. (1997). The Circle Game: Shadow and Substance in the Residential
School Experience in Canada. Penticton, BC: Theytus Books.
Churchill, W. (1995). Since Predator Came: Notes from the Struggle for American Indian Liberation.
Littleton, CO: Aigis.
Corrado, R.R. & Cohen, I.M. (2003). Mental Health Profiles for a Sample of British Columbia’s
Aboriginal Survivors of the Canadian Residential School System. Ottawa: Aboriginal Healing
Foundation.
Gagne, M. (1998). The role of dependency and colonialism in generating trauma in First
Nations citizens. In Y. Danieli (Ed.), International Handbook of Multigenerational Legacies of
Trauma (pp. 355–372). New York: Plenum Press.
Hart, M. (2002). Seeking Mino-Pimatisiwin: An Aboriginal Approach to Healing. Halifax, NS:
Fernwood.
Johnston, P. (1983). Native Children and the Child Welfare System. Ottawa: Canadian Council on
Social Development.
Lederman, J. (1999). Trauma and healing in Aboriginal families and communities. Native Social
Work Journal, 2, 59–90.
Locust, C. (1998). Split feathers: Adult American Indians who were placed in non-Indian
families as children. Pathways, 13, 1–5.
McKenzie, B. & Morrissette, V. (2003). Social work practice with Canadians of Aboriginal
background: Guidelines for respectful social work. Envision: The Manitoba Journal of Child
Welfare, 2(1), 13–39.
Menzies, P. (2006). Intergenerational trauma and homeless Aboriginal men. Canadian Review
of Social Policy, 58, 1–24.
Morrissette, P. (2008). Clinical engagement of Canadian First Nations couples. Journal of Family
Therapy, 30, 60–77.
Nadjiwan, S. & Blackstock, C. (2003). Caring Across the Boundaries: Promoting Access to Voluntary
Sector Resources for First Nations Children and Families. Ottawa: First Nations Child and
Family Caring Society of Canada.
Payukotayno: James and Hudson Bay Family Services & Tikinagan Child and Family Services.
(1988). As Long As the Sun Shines: From Generation to Generation. Moosonee, ON: Author.
Putnam, R. (2000). Bowling Alone: The Collapse and Revival of American Community. New York:
Simon & Schuster.
Richard, K. (1989). Kenn Richard fights racism within child welfare. Metropolis, 2(11), 3–4.
Royal Commission on Aboriginal Peoples. (1996). Report of the Royal Commission on Aboriginal
Peoples. Volume 1: Looking Forward, Looking Back. Ottawa: Supply and Services Canada.
Stout, M.D. & Kipling, G. (2003). Aboriginal People, Resilience and the Residential School Legacy.
Ottawa: Aboriginal Healing Foundation.
Thatcher, R. (2005). Residential school abuse and its legacy: A backgrounder and updates.
Circle Talk, 1(3), 10–14.
Timpson, J.B. (1990). Indian and native special status in Ontario’s child welfare legislation.
Canadian Social Work Review, 7, 49–68.
Titley, E.B. (1986). A Narrow Vision: Duncan Campbell Scott and the Administration of Indian
Affairs in Canada. Vancouver: University of British Columbia Press.
United Church of Canada. (1994). Residential Schools. Toronto: Author.
Van de Sande, A. (1995). Native and mainstream parenting programs. Native Studies Review,
10(1), 1–20.
Waldram, J. (1997). The Aboriginal Peoples of Canada. In I. Al-Issa & M. Tousignant (Eds.),
Ethnicity, Immigration and Psychopathology (pp. 169–187). New York: Plenum Press.
Waldram, J. (2004). Revenge of the Windigo: The Construction of the Mind and Mental Health of
North American Aboriginal Peoples. Toronto: University of Toronto Press.
PART 2
SECTION 2: DIVERSE
SETTINGS
15 Considering Trauma in Outpatient Substance Use Treatment Planning
for Youth
16 Using a Trauma-Informed Approach to Guide the Journey of Restraint

Prevention
17 Trauma-Informed Work with Families
18 Trauma-Informed Care on a Women’s Inpatient Psychiatric Unit
19 Trauma-Informed Primary Care with Immigrant, Refugee and

Non‑status Women Living with HIV/AIDS
191
Chapter 15
Considering Trauma in Outpatient

Substance Use Treatment Planning
for Youth
Gloria Chaim, Susan Rosenkranz and Joanna Henderson
The Youth Addiction and Concurrent Disorders Service (YACDS) at the Centre
for Addiction and Mental Health in Toronto works with youth, aged 16 to 24,
who have substance use concerns, frequently with concurrent mental health
and related concerns, and their families. We offer a broad range of services
that span the continuum of care from outreach and early intervention to
day treatment.
The overall program philosophy incorporates a youth-centred, developmentally

sensitive perspective with an appreciation of how social determinants of health,
including sex, gender and diversity, affect development (Dell & Poole, 2009).
The program’s developmental approach recognizes that protective and risk
factors, both internal and external to the youth, interact throughout development
to give rise to the strengths youth possess and the challenges they face when
they enter treatment. This perspective also understands that youth in this age
range, who are transitioning out of adolescence into adulthood, are moving
toward increasing autonomy, independence and responsibility. Our program
appreciates the many risks and challenges associated with this stage of life,
and the numerous life changes youth of this age are often negotiating.
Our program also recognizes that many youth who face substance use problems
and related concerns have experienced traumatic events during their
development (e.g., Clark et al., 1997). YACDS recently conducted research
revealing that youth entering the service had had high rates of exposure to
physical, sexual and emotional abuse, as well as other potentially traumatic
events. Approximately two-thirds of youth report exposure to emotional abuse
or neglect, one third report exposure to physical abuse or witnessing domestic
violence and approximately 20 per cent report experiences of sexual abuse
(Rosenkranz et al., 2012).
These findings are consistent with a large body of research indicating the
prevalence of substance use problems among youth with trauma histories
(e.g., Clark et al., 1997). Also consistent with much research in this area (e.g.,
Ballon et al., 2001; Titus et al., 2003) are our findings that rates of maltreatment
and trauma tended to be higher among females, though a number of males
entering our service had also experienced potentially traumatic events. For
example, approximately 40 per cent of females reported a sexual abuse history,
compared to 7 per cent of males; and 40 per cent of females reported a physical
abuse history, compared to 24 per cent of males (Rosenkranz et al., 2012).
Females were more likely to report exposure to multiple forms of maltreatment
or trauma. Thus gender is an important factor in considering trauma when
supporting youth with substance use problems.
We found that trauma-related symptoms were elevated among youth with

histories of potentially traumatic events, and that many of these youth believed
their use of substances was connected to their histories of traumatic experiences
(Rosenkranz & Henderson, 2009). Youth who reported trauma or maltreatment
histories tended to report more severe substance use problems than youth
without such histories (Chaim & Henderson, 2009). They also experienced
more severe negative consequences of their use (Rosenkranz et al., 2012).
Findings also suggest that trauma history may affect the degree and source of
motivation for accessing treatment, with potential implications for treatment
engagement (Rosenkranz et al., 2011). We found that people with trauma or
abuse histories may be motivated to enter treatment because of the shame
associated with their substance use. However, research has demonstrated
that motivation characterized by high levels of shame is not associated with
greater treatment engagement (Wild et al., 2006). Knowing that shame may
motivate people to enter, but not stay in, treatment, it will be important to
enhance other, more positive forms of motivation to encourage people to
continue to attend.
Chapter 15 Considering Trauma in Outpatient Substance Use Treatment Planning for Youth 193
These findings point to the importance of using a trauma-informed perspective

in our service. In order to be responsive to our clients’ needs, assessment and
treatment planning are conducted in a trauma-informed way. The overarching
principles that guide our assessment and treatment planning—creating safety
and empowering youth—reflect this trauma-informed approach, but also
respond to the needs of youth who do not report trauma histories. This chapter
describes the trauma-informed treatment planning conducted in our program.
We include specific examples of practices where possible, and the voices of
our youth and staff throughout.
Empowerment in Treatment Planning

Treatment planning is a collaborative process between client and clinician,
guided by the assessment results, and considering the client’s interests and
preferences. Within a harm reduction framework, treatment plans aim to create
safety in the lives of youth and to empower them to make positive changes.
Individual treatment plans are developed to address the specific needs of each
client. Treatment options include a motivational interviewing–based group
to enhance motivation for change, cognitive-behavioural therapy groups for
co-occurring depression or anxiety and substance use, a skills-building group
emphasizing the development of coping skills, and Seeking Safety, a manualized
intervention designed to address co-occurring trauma symptoms and substance
use (Najavits, 2002). Individual treatment and case management are available,
as are psychological assessment and psychiatric consultations. Recreation,
cooking, art, music and health groups are also offered.
Involvement and Control in Goal Setting

Youth are often told “what is good for them,” what changes they “need” to make,
what their goals should be, what their treatment plan should look like and who
should be involved in their treatment. Recognizing that a significant aspect
of healthy development for youth who are transitioning from adolescence into
adulthood is increased autonomy, our staff empowers youth to contribute to
the development of their own treatment plans. This focus on empowering
youth also allows for those who have had little control over previous experiences
(e.g., trauma) to have new experiences in which the control for the direction
their lives will take is placed back in their hands. Staff members partner with
youth to help them formulate their own goals, and to work with them in
achieving the goals through engaging in the services they choose. In the
words of one client:
When I came here I was given the ability to choose what substances
I wanted to work on, and what I didn’t. I was able to set my own goals,
no one was telling me “You’re doing this,” which I think has happened
to me in a lot of other programs. That was cool—that you’re able to
set your own goals and work at your own pace. When I talk to my case
manager, he asks “Is this cool, does this work?” (Nick, age 20)
Harm Reduction
Harm reduction and minimizing risk are crucial in addressing the needs of
youth. The choices and pacing in the approach are a good fit for youth who
are seeking autonomy, and this approach fits with the recognition that some
amount of substance use is developmentally normative for youth.
I went to a different program before this that was abstinence based

and 12-step. It was kind of a culture shock coming here, but not in
a bad way. I was really surprised to find how easygoing it was. I think
that’s why a lot of people are resistant to treatment, they expect it
to be very moralistic and uncomfortable. I think [a harm reduction
approach] took the fear of change and the fear of help away.
(Nick, age 20)
Choice about Family Involvement

As a part of treatment planning, youth are encouraged to consider the extent
to which they want family to be involved in their treatment. Family involvement
in youth treatment has been shown to increase retention and improve treatment
outcomes (see Hogue & Liddle, 2009). The benefits of including family in
treatment are balanced with recognition of the importance of youth empower-
ment, as well as a trauma-informed approach. Recognizing that family may
be a source of support for some, a source of trauma for others and at times
a combination of both, youth are empowered to make decisions regarding
family involvement in their treatment. Guided by staff, youth identify who is
important in their lives, whom they consider to be family and whom they
would like to engage in the treatment process with them.
Choice in Treatment Options

Non-traditional treatment options are included in the choices available to
youth. Through satisfaction surveys and annual focus groups, youth have
identified that the opportunities to participate in music, art, recreation and
cooking groups as adjuncts to traditional treatment are engaging and increase
motivation to attend the program. These program components also provide
alternative ways for youth to express themselves and connect with others.
The program integrates some of these opportunities into the program schedule
on an ongoing basis, and also arranges special events through community
collaborations, such as inviting a DJ to lead a workshop for the youth and
engaging a yoga instructor to lead yoga classes.
Making Connections between Trauma and

Current Coping Strategies
Youth with trauma histories often engage in risky behaviours that put them at
risk for further traumatic experiences. Self-endangering behaviours, such as
excessive substance use, self-harming, unhealthy eating and involvement in
emotionally or physically dangerous interpersonal interactions and relationships
(e.g., abusive relationships, risky sexual behaviours), may be ineffective coping
strategies that youth have developed to deal with distressing situations or
memories. For these youth, assistance in connecting their current behaviours
and feelings to their past experiences can help them develop an alternative
self-understanding that is not laden with negative judgments. This can help
youth to begin making choices that will reduce their current risks and harms.
I think it is important to take the opportunity to normalize and validate

behaviour and choices that a person might otherwise judge harshly
and blame themselves for, to encourage them to consider their

choices in light of past experience over which they may have had no
control, and to help them develop skill in self-compassion.
(Chris, social worker)
[Acknowledging the impact of trauma] can be a lot more validating

than carrying a diagnosis or a label, like “borderline personality
disorder.” (Susan, psychiatrist)
A focus on learning and practising alternative coping skills can be very

effective in reducing the potential for harm and increasing a sense of self-
efficacy and self-worth. Assisting youth in developing coping skills is a key
component of our program and is a central part of many of our group and
individual interventions.
I smoke a lot less pot now because I used to do it as a reaction to

being upset. When you have other coping skills you have other things
you can do. When you learn other coping skills, you might still use
on the weekends or whatever, but it’s not the only method you have
for calming down. (Alex, age 20)
Creating Safety
Creating a sense of emotional and physical safety is central to a trauma-
informed program. To mitigate the potential for treatment to be traumatizing
or retraumatizing (i.e., to trigger painful memories or replicate elements of
past experiences), creating a safe environment is essential, as is considering
factors that may be uncomfortable or distressing for youth. Considerations
include using respectful language, clarifying youth rights and responsibilities,
paying attention to self-endangering behaviours, assessing each client’s
readiness to engage in group treatment, considering aspects of the physical
environment and attending to staff safety.
We strive to give youth an opportunity to have a different experience

. . . to have a safe experience; their experience of the world is that it’s
dangerous, unsafe. . . . We want to make that different.
(Joanne, manager)
Levelling Power Imbalances

Youth rights and responsibilities are discussed when youth enter the program,
and again at the outset of the various treatment components to ensure that
youth are well informed about what they are entitled to and what they may
expect. A focus on youth rights and responsibilities acknowledges and attempts
to address the potential impact of the power imbalance and dynamics inherent
in a therapeutic environment. Attention paid to confidentiality, language,
respect and other strategies for maintaining safety aim to reduce the power
imbalance and increase a sense of comfort and safety for youth. In groups, youth
have the opportunity to contribute to the establishment of group rules and
norms, to help them feel as safe and comfortable as possible within the group.
. . . with regard to maintaining an environment that is emotionally

safe for staff and clients—I was thinking about how we as a whole are
aware of the importance of language—making certain that we use
terms and discuss topics that are appropriate and anti-oppressive,
for example, gay-positive language, inclusive language, addressing
issues related to all marginalized communities and racialized groups.
I think this is extremely critical in the work we do and the way in which
we communicate with one another. (Saadia, social worker)
Expressing Distress Safely

Throughout the program, staff members make a particular priority of attending
to youth distress and self-endangering behaviours. All staff have participated
in training in cognitive-behavioural therapy, dialectical behaviour therapy, the
trauma-informed approaches emphasized in the Seeking Safety program,
mindfulness and grounding techniques and crisis management. In group and
individual treatment settings, staff members work with youth in teaching,
practising and evaluating strategies for distress tolerance and affect regulation.
On a regular basis, staff members check in with clients regarding safety.

Safety plans are developed proactively with all youth identified to be at high
risk for suicidality or self-harming behaviour. If safety concerns are anticipated,
staff members collaborate with one another, as well as with youth and families,
to develop a plan that minimizes risk. Resources for crisis intervention
services are regularly provided to youth and posted in staff offices and waiting
areas. In addition, groups are co-facilitated, so that if a crisis should arise,
there is the capacity to respond to the person requiring attention, as well as
attend to the needs of the group.
A lot of our groups are co-facilitated, and we try to run our evening
groups at the same times, meaning that there are many team
members around . . . if there is a crisis, then there are others to help.
We’re all in the same hallway, so if you are expecting a client who
might be a higher-risk client, you can knock on your neighbour’s door
and let them know. (Stacy, child and youth worker)
Tailoring for Readiness and Gender-Specific Needs

Treatment planning considers the varying backgrounds and presentations
of youth and offers modifications to content as appropriate (e.g., stress
management activities may be part of a treatment plan, but grounding may be
emphasized rather than relaxation). Prior to referring youth to groups, staff
determines whether they are group-ready in order to ensure safety and a
positive therapeutic experience for the youth and other group members.
Youth must be able to contain talk of self-harm, stay sufficiently present and
focused to access the content of the group, manage aggressive and impulsive
behaviour and, if they have a psychotic illness, be stable. Group content can
be offered individually for youth who are not yet able or willing to participate
in groups. Considerations are also made regarding group composition
(e.g., gender-specific groups) and therapist gender matching.
[For the Seeking Safety group, we think] about whether we want to

have males and females in the same group. . . . Also sensitivity to
issues such as if a female was assaulted by a male, you would think
about that before recommending a male therapist for that client.
(Allison, psychologist)
If they’re triggered by questionnaires, before they leave, we make sure

they feel safe and have had an opportunity to talk to someone and
there’s been an opportunity to address any triggers.
(Janis, psychologist)
Building a Safe and Welcoming Environment

The physical environment of the program should create a sense of warmth,
welcoming and belonging. Informal furnishings, artwork and magazines in
the waiting area contribute to an atmosphere that is not institutional, despite
the program being housed in a large hospital. Posters and brochures offer
information about issues and programs that respond to the diversity of youth
presenting to the program. Attention is paid to minimizing the presence of
objects and artwork that may trigger distressing memories and harmful
behaviours. Hospital regulations also require regular review of the physical
environment, including the space, for any items that may be used to cause
harm to self or others.
Ensuring Staff Safety

In order to provide trauma-informed and sensitive service, staff members
require a safe space to address their own issues related to working with a
challenging population with complex needs. Staff members attend regular
team meetings to discuss youth needs and treatment plans, as well as staff
issues and concerns related to the work. Discussions and education ensure
that staff members have the required competence, confidence and support.
The program takes staff safety into account . . . when there have been
issues in a group, making sure that staff have people they can turn
to, to talk about events that have occurred. Supervision, staff
meetings, having somebody available if you’re feeling upset about
this event, somebody is present for clinician support.
(Janis, psychologist)
Conclusion
This trauma-informed approach to treatment planning is an essential aspect
of the YACDS. It is integral to our understanding of, and ability to address,
the needs of youth with substance use, mental health and related concerns.
Integrating a trauma-informed and sensitive perspective has been an evolving
process. Youth and staff feedback, along with emerging new evidence, is
regularly sought to further inform a model and approach that aims to be truly
responsive to youth needs.
References
Ballon, B.C., Courbasson, C.M.A. & Smith, P.D. (2001). Physical and sexual abuse issues among
youths with substance use problems. Canadian Journal of Psychiatry, 46, 617–623.
Chaim, G. & Henderson, J. (2009, March). From data to the right services. Paper presented at the
Looking Back, Thinking Ahead Conference: Using Research to Improve Policy and Practice
in Women’s Health, Halifax, NS.
Clark, D.B., Lesnick, L. & Hegedus, A.M. (1997). Traumas and other adverse life events in
adolescents with alcohol abuse and dependence. Journal of Child and Adolescent Psychiatry, 36,
1744–1751.
Dell, C. & Poole, N. (2009). Applying a Sex/Gender/Diversity-Based Analysis within the National
Framework for Action to Reduce Harms Associated with Alcohol and Other Drugs and
Substances in Canada. Ottawa: Canadian Centre on Substance Abuse. Retrieved from
www.ccsa.ca
Hogue, A., & Liddle, H.A. (2009). Family-based treatment for adolescent substance abuse:
Controlled trials and new horizons in services research. Journal of Family Therapy, 31, 126–154.
Rosenkranz, S. & Henderson, J. (2009, June). Perceived use of substances to cope with traumatic
stress: Association with treatment motivation among youth. Symposium conducted at the
70th annual convention of the Canadian Psychological Association, Montreal.
Rosenkranz, S.E., Henderson, J.L., Muller, R.T. & Goodman, I.R. (2011). Motivation and
maltreatment history among youth entering substance abuse treatment. Psychology of
Addictive Behaviors, 26(1), 171–177.
Rosenkranz, S.E., Muller, R.T. & Henderson, J.L. (2012). Psychological maltreatment in relation
to substance use severity among youth. Child Abuse & Neglect, 36, 438–448.
Titus, J.C., Dennis, M.L., White, W.L., Scott, C.K. & Funk, R.R. (2003). Gender differences in
victimization severity and outcomes among adolescents treated for substance abuse. Child
Maltreatment, 8, 19–35.
Wild, T.C., Cunningham, J.A. & Ryan, R.M. (2006). Social pressure, coercion, and client
engagement at treatment entry: A self-determination theory perspective. Addictive Behaviors, 31,
1858–1872.
201
Chapter 16
Using a Trauma-Informed Approach

to Guide the Journey of Restraint
Prevention
Athina Perivolaris and Ann Pottinger
This chapter describes one journey of restraint and seclusion prevention

using a trauma-informed approach so that others working on similar
initiatives may learn from the experience. It discusses the relationship
between trauma and restraint use, organizational readiness for restraint
prevention and trauma-informed strategies for use in inpatient mental health
settings. This chapter also addresses the tensions between professional and
client perspectives on safety—between professionals who often view the
restraint as a means to provide safety and clients who can experience emotional
distress, which can negatively affect the therapeutic relationship.
Challenging the Use of Restraints

to Ensure “Safety”
Many people who come to a psychiatric unit as inpatients have been abused or
have experienced other trauma. Some have self-harmed. They generally enter the
hospital hoping to feel safe, heal and recover while they are there. Unfortunately,
professional actions based on good intentions to provide safety can end up
harming clients. What professionals interpret as safety for both themselves and
for clients is diametrically opposed to what clients often experience as feeling
safe. Professionals need to reflect on certain “safety” practices, such as the use of
restraints, and their potential to harm. They must also explore the relationship
between trauma and the use of restraint and seclusion.
For decades, restraints have been used for safety purposes. Despite broad
evidence of their risks and a lack of evidence to support any therapeutic
value (Silas & Fenton, 2000), restraints continue to be used based on the
assumption that they keep people safe. Staff tends to look at the end point
of aggression or escalating behaviour and therefore sees limited options for
preventing the aggressive event or for envisioning alternative strategies.
Yet the use of seclusion and restraint is unsafe, harmful and traumatizing,
especially for clients who have already experienced trauma. Restraint use can
also traumatize staff and others who observe a person being restrained.
Potential for Retraumatization

Clients with mental health and substance use issues have often experienced
violence, abuse and abandonment that predispose them to being retraumatized.
Ninety per cent of people with mental health problems have been exposed to
trauma (Cusack et al., 2004). One in 10 people in Canada experience posttraumatic
stress disorder (“Trauma-informed,” n.d.). Sixty-seven per cent of people in
substance use treatment report histories of childhood abuse and neglect, and
34 to 53 per cent of them have experienced childhood sexual or physical abuse
(National Association of State Mental Health Program Directors, 2005). Being
in seclusion or physical restraint can make traumatic experiences resurface.
The very act of being restrained can evoke negative memories of physical and
sexual abuse. Being locked in a room alone may stir up previous feelings of
fear and abandonment.
Many clients with childhood trauma histories have a heightened or pronounced

response to certain triggers that cause them to relive past trauma experiences.
Part of being trauma informed is understanding that “our brains are sculptured
by our early experiences. Maltreatment is a chisel that shapes a brain to contend
with strife, but at the cost of deep, enduring wounds” (Teicher, 2000, pp. 66–67).
There is a synergistic relationship between trauma-informed care and restraint
reduction: a trauma-informed approach reduces restraint use, and reduction in
restraint use minimizes trauma and retraumatization. Fostering this synergy is
foundational in an organization’s restraint prevention journey.
Chapter 16 Using a Trauma-Informed Approach to Guide the Journey of Restraint Prevention 203
Within hospital environments, there is a tendency to rely on rules and

methods of external control that disempower and traumatize clients rather
than using approaches that foster empowerment, resiliency, healing
and recovery. Power, control and coercive practices in such settings are
represented, for example, by the use of locks and keys, the condescending
demeanor and harsh tone of staff members, labelling clients through
stigmatizing language and applying rigid disciplinary practices and focusing
on tasks in a way that overshadows a person-centred approach. Thinking
that all clients must follow the same rules is flawed. Applying rigid discipline
is not only a barrier to restraint prevention; it can also precipitate aggression
(Curran, 2007).
Consider a client who wants to have a warm shower before bed as a way
to relax and cope with intense feelings. He is told that showers are only
permitted in the morning. The client is adamant about the need for a shower
and starts to shout, scream and bang on the locked bathroom door, while the
staff remains focused on enforcing the rule. Eventually the client’s distress
and behaviour escalate to a point where other clients become distressed and,
in trying to contain the situation, staff find themselves involved in a physical
altercation. The client challenges the rule and the situation escalates into an
aggressive episode resulting in the use of restraint. This scenario highlights
how what staff often perceives as a simple rule can lead to a power struggle.
Staff members may have been unaware that it was the power struggle and
rule enforcement that precipitated or caused the aggression. Instead, they
simply focused on the aggression itself. Enabling the client to have a warm
shower would have been therapeutic and empowering. Instead the power
struggle resulted in the use of restraints, which likely traumatized the client
and negatively affected his therapeutic relationship with staff.
Shifting the Focus to Restraint Prevention

An organization begins its transformative journey toward restraint prevention
with simple actions to initiate a complex change process. As a result of
various factors and events, including recommendations from an internal task
force,1 the Centre for Addiction and Mental Health (CAMH) in Toronto
1. Visit www.camh.ca and search for “Restraint minimization taskforce.” Also, see the jury recommendations
from the Jeffrey James inquest at www.sse.gov.on.ca/mohltc/PPAO/en/Documents/sys-inq-jam.pdf.
shifted its focus from restraint reduction to restraint prevention. To guide the
prevention journey, CAMH in 2008 articulated its vision: “CAMH aspires
to provide safe therapeutic care and services in a restraint and seclusion free
environment” (internal corporate website, 2008). A clear vision and goals
act as a reminder and motivator to integrate practice change. At CAMH, the
following goals were established and communicated to all stakeholders at the
beginning of the journey:
• to develop strategies, systems and processes to promote a least-restrictive

environment and respect for client rights
• to safely reduce or replace the use of restraint and seclusion and increase
the use of alternatives
• to improve quality of care for clients and quality of work life for the care teams.
Reviewing Current Practices

Guided by a trauma-informed approach, the process of developing a restraint
and seclusion prevention initiative involves an in-depth reflection and review
of values and commitment to quality care and safety and how these are lived
in day-to-day practice. The organization must identify gaps between the
current context and future aspirations.
In Ontario, the Psychiatric Patient Advocate Office (PPAO) completed a

review of seclusion and restraint practices in Ontario provincial psychiatric
hospitals in October 2001. The review indicated that many clients who were
restrained did not know why they were restrained and did not even know how
they needed to behave in order to be released from restraints. This experience
parallels that of abusive situations, in which people who have been abused do
not know what they did or what they need to do to make things “okay,” which
leaves them feeling powerless.
Supporting and Advocating for Clients

CAMH addressed this lack of clarity around restraint use early in our restraint
prevention journey by revising the policy and building supports and capacity
to better inform clients of the reason for restraint and the behavioural criteria
for release. We developed a focused strategy to help staff discuss issues

around restraints with clients. This strategy included encouraging clients to
share and communicate their feelings while being restrained and debriefing
the experience after they were released from restraint. A brochure, “Partnering
to Prevent the Use of Restraint and Seclusion” (corporate internal website,
2010), was developed and used with clients and families, highlighting ways to
work together to keep everyone safe.
We discussed how best to involve the PPAO in supporting and advocating for
clients who experienced a restraint event. Discussions focused on the tension
between automatically notifying the PPAO when a client is restrained versus
requiring client consent to inform the PPAO. Privacy and confidentiality were
at the heart of these discussions. Initially, we decided that privacy and consent
were essential; however, we agreed that the threshold for consent was low,
as PPAO involvement carried little risk and offered potential benefits to the
client in terms of access to advocacy and support. Clients at the time of the
restraint event would be asked, several times if needed, if they would like to
speak to a PPAO advocate; if they said yes, staff informed the PPAO. Toward
the end of the initiative—and following many ongoing discussions on the
importance of providing client support and advocacy—we implemented an
automatic notification policy. Automatic notification addressed the issue of
staff needing to spend time dealing with the complex and emergency needs
surrounding the reason for the restraint event, which often affected PPAO
notification. When the restraint event is entered in the client’s electronic
health record, the PPAO is notified of the event. The PPAO advocate then
meets with the client and explains the advocate role and obtains consent to
act on the client’s behalf based on his or her needs and wishes. As well as
respecting client rights, this process has strengthened CAMH’s relationship
with the PPAO, which is a key stakeholder in contributing to our progress.
Supporting clients also involves creating a debriefing procedure to learn

what happened, how to prevent future restraint episodes and to re-establish
the therapeutic relationship. In the process of developing a client debriefing
procedure, we debated who should conduct the debriefing. We explored several
options: creating a peer support “debriefer” position; dedicating a staff position
involving specialized skills to conduct all debriefings; and asking clients to
identify with whom they felt most comfortable having this important discussion.
We were not able to identify best practices in the literature about this aspect of
client debriefing. Given our value of client involvement, we felt that their
comfort and relationships were key aspects in making the debriefing process
effective. Therefore, as an organization, we opted to have clients identify the team
member with whom they felt they had the best relationship to conduct the
debriefing. Another key aspect that we struggled with was when to approach the
client to initiate the debriefing; based initially on feedback from other organiza
tions, we started with three hours post-release, but our clinical observation
indicated that this time frame was too early because most clients still felt
overwhelmed or unable to participate. The final decision was to offer the
debriefing within 24 hours of release from restraint or of administration of a
chemical restraint. This time frame has been better received, but for various
reasons, most clients decline to participate. Some clients are too ill to participate;
in other cases, there were trust and disempowerment issues.
Leadership Explores Best Practices

Leadership plays a key role in shaping the organizational architecture for
addressing the gap between current and desired end states for restraint use
(Golden, 2006). At CAMH, senior leadership identified the need to explore
best practices in reducing the use of restraints. This need arose as a result of
several events. There were two sentinel events within a year in which clients
died while in or shortly following release from mechanical restraints.
One of the deaths was that of Jeffrey James in 2005, who died shortly after
being released from restraints. His death resulted in a coroner’s inquest in
2008. The inquest generated increased awareness of the risks associated with
restraint use and furthered a commitment to explore strategies to facilitate
restraint-free environments. Also, the move from manual to electronic data
collection increased the amount of information about restraint use events. The
least restraint policy was also due for revision. Leaders questioned this policy’s
focus on minimizing restraints—when and how to safely apply and care for
people in restraints—as opposed to preventing their use. This question served
as a catalyst for future work in the areas of policy, education and practice that
would focus on how to prevent restraints and how to use alternatives. An
environmental scan identified a gap between practice and policy expectations;
for example, there were discrepancies around staff members’ understanding
of what constitutes the use of restraints as a last resort.
Part of the commitment to move forward with identifying best practices to

support the use of restraint alternatives involved creating an inter-professional
task force to review a broad base of evidence. This included reviewing policies,
resources and lessons learned from site visits and telephone interviews in
order to recommend effective strategies and approaches for reducing restraint
use and suggesting strategies and resources for implementing identified
best practices. It was important for task force members to learn from other
organizations about the essential components in their restraint reduction
journeys. The task force activities and recommendations, along with an
extensive literature review on effective strategies on restraint reduction, were
summarized in the CAMH Restraint Minimization Taskforce report (Restraint
Minimization Taskforce, 2008). A priority recommendation was to invest in a
three-year full-time position for an advanced practice nurse to lead, manage
and integrate the initiative across the organization.
As part of the task force review, a small group participated in a two-day

restraint reduction training program by the National Training Assistance
Center (NTAC), a division of the National Association of State Mental Health
Program Directors. This training emphasized the importance of creating
trauma-informed care environments and provided an overview of the neuro
biology of trauma and therapeutic implications. Following one of the task force
recommendations, all senior leaders, clinical, finance and human resources
staff and security (more than 300 people) participated in the training. Client
and family representatives were acknowledged as key stakeholders and were
also included.
Full participation by clients and families at all levels within the organization is
critical to success in planning and implementing safety initiatives. The lived
experiences of clients and families contribute to the breadth and innovation
by “thinking beyond the box” and challenging established norms and processes
in recommending trauma-informed strategies. Clients and families continuously
reminded us of how policies and processes affect clients at the human level
and challenged us to remain accountable to our values of client-centred and
family-sensitive care.
Communicating Goals
To advance in our journey, we focused on communicating our vision and goals
to all staff and clients and outlined for everyone the need for change and the
safety benefits for clients and staff. The goals of the initiative comprised a
large part of the content included in the initial communication strategy.
The expertise of and collaboration with our public affairs department were
important to the success of this communication strategy. The public affairs
director, who also attended the NTAC training, worked collaboratively to
establish a communication strategy and support, which included providing
updates on the staff intranet, sharing success stories and increasing awareness
of areas for further development or areas requiring accountability.
One example of how this collaboration enhanced our communication strategy

and effectiveness is in our Partnering to Prevent Aggressive Behaviour (PPAB)
education program. The communication strategy for the program highlighted
why we were focusing on building capacity around prevention and alternative
strategies rather than de-escalation, crisis and emergency management, given
a long-time association between restraint use and safety.
Part of communicating goals is letting people know how our efforts are making
a difference. The ongoing use, collection and sharing of data in a timely
manner at all levels of the organization are important in furthering the journey
of restraint prevention. Data analysis and sharing are often neglected or not
consistently done at the team level, despite the fact that data discussions at the
team level help to identify improvement opportunities. In December 2010, as
we entered the final year of our initiative, we communicated an overview of
activities and achievements through an article on CAMH’s internal website.
We shared that since 2008, there was a substantial reduction in the percentage
of clients in all types of restraints: more than a 50 per cent reduction in the
percentage of clients in restraint and a 37 per cent reduction in the percentage
of clients in seclusion (internal corporate document, 2010). The Canadian
Institute of Health Information (CIHI) data pertaining to mechanical and
chemical restraint events during a three-day period following admission was
also shared (see Table 1). In this report, CAMH compared favourably to other
psychiatric facilities and various mental health facilities in Ontario.
TABLE 1
CIHI Restraint Data for Three-Day Period Post-admission (2010)
ADMISSION PERIOD DATA CAMH PEERS PROVINCE
Mechanical restraint 1.6% 5.1% 5.7%
Chemical restraint 10.0% 14.7% 16.9%
Over the three years of the initiative, we also achieved substantial decreases
in mechanical restraint and seclusion without an increased use of chemical
restraint. The number of clients we serve increased by 10.7 per cent; use of
mechanical restraint decreased from 4.2 per cent (2008–2009) to 2.2 per cent
(2010–2011); use of seclusion decreased from 5.3 per cent to 3.4 per cent; and
use of chemical restraint decreased from 4.8 per cent to 3.0 per cent during
this same time period.
Revising Policy
The Prevention of Restraint and Seclusion Advisory Committee took the lead
in revising our policy. Based on the task force recommendations, best practices
and coroner’s recommendations in the Jeffrey James inquest, we revised and
renamed the least restraint policy to the emergency use of chemical restraint,
seclusion and mechanical restraint.
Renaming the policy increased awareness that restraint is to be used only in

an emergency situation where there is imminent harm to self or others, and
only as a last resort. The revision process involved extensive consultation and
dialogue with stakeholders, families, clients, patient advocates and staff.
Even before the policy was revised, such dialogues highlighted the gap between
policy expectations and practice and identified areas for policy clarification;
for example, some identified gaps—the use of seclusion as therapeutic quiet
time, administering chemical restraint as needed and minimal use of alterna
tives to help clients self-soothe—required further discussion, education and
practical support.
Implementing Policy
The issue of restraint reduction brings out many strong perspectives and
concerns about safety. As we started the implementation, staff and leadership
expressed concern that safety for clients and staff would be compromised.
These concerns were particularly challenging at a time of increased focus on
workplace safety and violence prevention. Despite many engaging conversations
during which important issues were raised, not everyone supported the
changes. We responded to these concerns through ongoing communication,
reinforcing that we would evaluate and adjust our strategies as needed. We
did not wait for unanimous agreement to proceed with our journey; yet we
continued to acknowledge concerns and emphasize key concepts such as
assumptions that restraints keep people safe and that there are negative
consequences to their use.
Strong communication and supports are critical. In our experience, all the
concerns, the “what ifs . . . ,” did not end up presenting as safety concerns.
The increased awareness of criteria for restraint use in complex clinical
situations has resulted in intense dialogue regarding the use and non-use
of restraints among team members, within various professional disciplines
and between departments such as security and clinical teams.
Clinical teams were also engaged in planning discussions that focused on

how to minimize the effects of potentially distressing situations for clients
that can lead to aggression; for example, informing clients that they will have
to remain in hospital involuntarily despite feeling ready to leave. A trauma-
informed approach would include upfront discussion about how people cope
with bad news and how staff can best support clients and their internal
coping mechanisms in these situations.
Sharing our journey and collaborating with other organizations continues to

be important to furthering our work. A recommendation from the Jeffrey
James inquest was for CAMH to take a leadership role by sharing our revised
policy with all psychiatric and Schedule 1 facilities, including provincial and
specialty psychiatric hospitals and many general hospitals throughout Ontario
in which people can be detained under the Mental Health Act. We continue to
share our policy and expertise with other organizations at the provincial and
national levels.
Building Capacity
At CAMH, we reviewed the staff development program that at the time focused
on crisis intervention and to a lesser extent physical containment. Based on
the review, a curriculum committee was formed, with input from diverse
stakeholders, including direct care staff, clinical facilitators (new role), client
and family representatives and education specialists who developed a new,
more targeted and comprehensive education program to meet various staff
development needs across the organization.
The new PPAB education program emphasizes prevention and trauma-

informed care through core clinical competencies and inter-professional
collaboration. It was decided that the focus would be as follows: 90 per cent
prevention, eight per cent de-escalation and, when all else fails, one to two
per cent restraint and seclusion use with rigorous monitoring and de-restraining
attempts. Unlike the previous program delivered over two days, this new
program uses modules delivered over the course of a month as in-services
in the clinical area throughout the entire organization.
The PPAB modules are designed to optimize team discussion and learning
using core competencies and the integration of learning in relevant clinical
scenarios. The clinical facilitator, who is a direct care clinical staff member and
an informal leader within the team, facilitates the modules and the team dis
cussion. The program comprises nine modules based on core competencies
such as team collaboration, trauma-informed care, developing safety plans
and using a model of care to guide assessment and interventions. Each
module has a key message and a champion to communicate and increase
awareness and dialogue among staff and teams. The communication of the
theme and messaging for each monthly module was greatly facilitated by
active partnership with our public affairs department.
Trauma-Informed Strategies for Inpatient

Mental Health Settings
A trauma-informed setting is based on a prevention or upstream approach,
whereby root causes or precipitants of aggression and violence are addressed
before a situation escalates and becomes a crisis. Such environments begin

with a welcoming and open approach where staff members routinely check in
with clients around their comfort and listen to their concerns.
Developing a Safety Plan

Part of the education and practice expectations is that staff will work with
clients to develop a safety plan. This involves discussing safety with each
client and initiating a safety plan upon or as close as possible to admission.
Developing a safety plan is essential: it allows clients to identify triggers,
emotions and coping strategies to prevent or manage a crisis, giving them
a sense of control and empowerment. It also provides staff the opportunity
to do a trauma history assessment and understand certain behaviours from
a trauma lens. In turn, a trauma lens may inform the use of alternative and
self-identified strategies to cope with distressing and overwhelming feelings
and symptoms.
Allowing for Flexibility

A main component in creating a trauma-informed environment is to help
staff recognize that coercive interventions often cause trauma and retrauma
tization and must be avoided. One key activity is for each clinical team, with
client and family input, to review established norms and rules. Rules that
contribute to power struggles between clients and staff must be eliminated as
much as possible. This process must include discussing how to achieve and
maintain a safe, trauma-informed environment. It may mean doing some
things differently; for example, having ongoing access to healthy snacks
may replace a practice of having access to food only at specified meal times.
Practices that support the establishment of clients’ day and night routines are
often helpful; however, staff must also be empowered to adjust such practices
or rules to meet individual client needs. For example, when clients require
access to music outside of established times as a way of helping them self-
soothe, staff must be able to assess such needs, take a flexible approach and
have the resources to meet the needs.
Providing Alternative Ways to Promote a Sense of

Calm and Safety
An “Alternatives to Restraint and Seclusion” booklet was developed to support
staff in identifying and using alternatives (corporate internal website, 2011).
This booklet includes various activities; for example, art, sensory, relaxation,
movement, and reading and writing activities and other calming strategies to
help staff work with clients who are experiencing distress, fear or anger. The
guide also lists products that are designed to help soothe clients through
sensory modalities. Some examples include weighted blankets, stress balls and
aromatherapy. Other suggested activities range from instructions on deep
breathing and other relaxation techniques to short journaling exercises and
ways to facilitate clients’ artistic expression. The main benefit of this booklet is
that it increases awareness of activities and provides step-by-step instructions,
along with a rationale for each activity, making it a readily available and
accessible resource for staff. It is helpful to have a guide outlining various
activities that help to engage clients in purposeful and meaningful activities
that support their comfort, safety and security.
Debriefing with Clients and Staff

Creating a trauma-informed environment requires valuing ongoing learning
as part of daily practice. Establishing a debriefing process for care needs,
restraint events and crisis situations assists in preventing the future use of
restraint, minimizes the negative effects, addresses organizational problems
and fosters a trauma-informed environment.
Client debriefing promotes healing, recovery and learning and starts to rebuild
the therapeutic relationship with the client. This debriefing is about learning
from and with the client, as it facilitates obtaining the client’s feedback and
perspective. Client debriefings can inform care planning and safety plans by
identifying triggers and precipitating behaviour that may have resulted in the
restraint or crisis.
Two other components of a comprehensive debriefing process are the immediate

post-event debriefings with staff and formal team debriefing with staff and
leadership. These debriefings often assist in identifying team, program and
organizational themes and patterns in the areas of staff training, culture, hiring
practices, policies and support and supervision for staff to create a trauma-
informed work and care environment. For these debriefings to be effectively
implemented, leadership must be committed to this process. Leadership needs
to help staff value the process, primarily by communicating and demonstrating
how key learnings from the debriefings have led to positive change.
Providing Staff Development

An organization that aims to provide trauma-informed care and reduce
and prevent restraint use must attend to staff development needs. The
development of competencies that focus on quality care and interprofessional
collaboration are crucial.
Healthy teams are essential to trauma-informed care. This is the main reason
for focusing educational strategies on working and learning as teams. Such
teams have members that practise together and respect and trust one another.
They are aware of one another’s roles and offer support, supervision and
recognition that promote therapeutic relationships, building on clients’
strengths, and minimize coercive practices.
Conclusion
The CAMH journey demonstrates the multi-component nature of developing
a restraint prevention policy. It also highlights the need for a long-term
sustained commitment to these many components to achieve success.
CAMH has developed the systems and processes to support restraint
prevention and a trauma-informed approach. Our journey now focuses on
continued implementation of these initiatives into daily practice and ongoing
reflection and integration of best practices. Trauma-informed care can guide
an organization in working through the complexity of providing care in a
dynamic health care environment. The journey is complex: there are many
side streets and occasional detours, but stay the course. Commit and
recommit to the prevention journey!
STRATEGIES TO PREVENT RESTRAINT AND SECLUSION
Help to prevent restraint and seclusion by implementing the following

strategies. They are based on good practice principles, and are not exclusive to
any one treatment facility:
• Use restraint only for imminent danger of serious bodily harm to self and
others (as outlined under Ontario’s Mental Health Act).
• Use restraint as a measure of last resort.
• Recognize that coercive interventions cause traumatization and

retraumatization and are to be avoided.
• Value and respect the client in all aspects of care.
• Develop individualized, flexible plans and approaches to care.
• Focus on the client.
• Remove both overt and covert expressions of power or control in practices,

policies and procedures, especially within the context of unit-based rules.
• Examine and change language that reflects power and control over clients.
• Offer a variety of programming to meet clients’ needs.
• Provide staff education on the use of preventive and alternative strategies.
• Work in partnership with clients and families when using the above good
practice principles; their ideas, experiences and suggestions are essential
for success.
References
Curran, S. (2007). Staff resistant to restraint reduction: Identifying and overcoming barriers.
Journal of Psychosocial Nursing, 45(5), 45–50.
Cusack, K, Frueh, B. & Brady, K. (2004). Trauma history screening in a community mental
health center. Psychiatric Services, 155, 157–162.
Golden, B. (2006). Change: Transforming healthcare organizations. Healthcare Quarterly, 10,
10–19.
National Association of State Mental Health Program Directors. (2005). Training Curriculum for
Reduction of Seclusion and Restraint: Draft Curriculum Manual. Alexandria, VA: Author.
Restraint Minimization Taskforce. (2008). Restraint Minimization Taskforce Final Report.
Retrieved from www.camh.ca
Silas, E. & Fenton, M. (2000). Seclusion and restraint for people with serious mental illnesses.
Cochrane Database of Systematic Reviews, 2000(1).
Teicher, M.H. (2000). Wounds that time won’t heal: The neurobiology of child abuse.
Cerebrum, 2(4), 50–67.
Trauma-informed. (n.d.). Retrieved from www.trauma-informed.ca
217
Chapter 17
Trauma-Informed Work
with Families
Sabrina Baker
Susan’s Story
When Susan Brown* was 24 years old, she was brought to the emergency
department of the psychiatric hospital in 2010 for beating up her 28-year-old
sister, Karen, and threatening to kill her two-year-old nephew at a family
brunch. Susan accused Karen of “doing the devil’s work” and had left Karen
badly bruised before the police responded to the 911 call put out by their
mother, Pam.
All the Brown family, including Susan, were traumatized by this event. Susan
had reportedly “not been herself” since she was 18. Susan dropped out of her
first year of college and spent most of her time “holed up in her bedroom.”
Pam thought she seemed different—suspicious even—but attributed this to
“being depressed, hanging out with the wrong crowd and smoking a lot of
marijuana.” Pam also thought that Susan was depressed as a result of breaking
up with her first serious boyfriend. Pam blamed herself for not realizing
earlier that Susan was ill.
After the brunch incident, Susan began displaying noticeable symptoms of

psychosis and described having voices telling her not to have anything to do
with her family. She was very angry at her family for putting her into hospital,
*“Susan” is based on a composite of clients with whom the author worked.

as she believed there was nothing wrong with her. Pam was designated as
Susan’s substitute decision-maker during hospitalization.
Gradually, Susan began to make steady progress in the hospital, as she

responded to the medication and the protected environment of the inpatient
psychiatric department. She was still angry with her family and did not want
to have anything to do with them. Pam was still upset by Susan’s violence and
said that Susan was “not welcome to come home [the two had been living
together before the incident] unless she receives a depot injection of her anti
psychotic medication and meets regularly with her treatment team.” Pam had
decided to take a “tough love” approach with her daughter, believing that this
was the only way to “save” Susan and keep the rest of the family safe. She was
frightened that Susan would become ill again and feared for her own safety.
Susan was not willing to agree to her mother’s demands and asked her clinical
team not to have anything to do with her mother following her discharge
from the hospital.
Pam was referred to meet with the family worker, as she was clearly distressed
and needed support, education and counselling in her own right to help her
through this crisis.
The Family’s Story

Fortunately, Susan’s care team included a separate family worker who could
provide support to Pam and Karen, while the rest of the team (a psychiatrist and
case manager) worked with Susan. Since Susan did not want her family to
receive any information about her status, the family worker respected this.
The family worker decided that it would be easier for her to support the family
and adhere to confidentiality principles by not accessing any information about
Susan from the rest of the team and by opening a separate chart for Pam.
Pam’s hope was to eventually involve the entire family once they were all ready
to do this work. In the interim, the work was done separately.
The family worker (a social worker at the hospital) introduced herself and
described her role and function as the family worker on the team. She welcomed
the family warmly, and invited them to tell their story. Meetings with the family
were conducted at an outpatient clinic away from the hospital, reducing any
Chapter 17 Trauma-Informed Work with Families 219
chance of Susan running into her family and creating safety for the family. The
worker gave them the time to share their experience in their own way and time,
not rushing them or bombarding them with questions. The recent incident with
Susan had triggered unfinished business for Pam, as her ex-husband had been
verbally abusive to her while they were still married. (He left the family when
Susan was 14, and had not had any contact with the family since.)
Pam and Karen said that they felt abandoned by the mental health system,
which created stress for them. They recounted examples of taking Susan to
various hospitals and asking for help for Susan, only to be told that unless
Susan was a danger to herself or others their hands were tied. Pam felt that
some professionals were ignoring and blaming her for not being “a good
enough parent” to Susan. She also felt that Susan’s treatment team perceived
her as a “bad” mother for not agreeing to take Susan home from the hospital,
regardless of whether Susan agreed to Pam’s conditions or not.
The family worker validated Pam’s decision to set limits with Susan; this
in turn empowered her to feel strong enough to “stay the course” with her
daughter. Pam stated that she knew that there was something wrong with
Susan but had “no idea how to help her or to make sense of the mental health
system and get the necessary help for her.” She had hoped that the hospital-
ization would allow her daughter to get the care that she needed, but she now
realized that Susan’s recovery would be more complicated and take longer
than she had originally anticipated. Pam realized that she would need to be
there for her daughter for a long time, “maybe for as long as she lives.” Pam
also agreed with the family worker that she would need to take care of herself
during this process so she did not “run out of steam and jeopardize my own
physical and mental well-being.”
Karen was seeing a psychiatrist to address issues that had arisen for her about
her parents’ separation when she was a child, and felt that it was important
that she and her mother receive separate help at this time. For her part, Pam
wanted to continue to meet with the family worker for education, support and
counselling because she was feeling anxious and frightened about the future.
She expressed “not knowing who else to turn to in my time of need.” Pam
felt isolated and alone and withdrew from her usual support system because
she felt it would be disloyal to reveal what happened in the family and felt
stigmatized by having a daughter with mental illness. The current crisis was
also bringing up unresolved issues about loss and abandonment that Pam
preferred to process one-on-one.
Pam was anxious to reconnect with her daughter and to become an ally in her
recovery. She hoped that being close before the illness would enable them to
eventually get together and “thrive.” Pam still believed the team thought she
was “a cold and heartless mother for drawing a line in the sand and not
allowing Susan to be discharged into my care.” However, she maintained
her conviction that the only way to “save” Susan was to adopt a tough love
approach with her. The family worker supported Pam emotionally during this
difficult time and held the hope for Pam that, in time, when Susan availed
herself of help, she would start “to reclaim her life” and reconnect with Pam,
Karen, her brother-in-law and nephew. In the interim, the family worker
helped Pam to grieve, adjust to her current reality and work toward building
on her strengths and competencies.
The worker empathized warmly with Pam as she described recent events
leading up to Susan’s hospitalization. Pam continued to blame herself for not
getting help earlier and potentially averting this crisis in her family. She was
concerned that her “messy divorce from a verbally abusive man may have
caused or contributed to Susan’s psychosis.” Pam worried that she might be the
cause of rather than the solution to her daughter’s recovery. Education about
etiology, treatment and recovery from psychosis helped to reduce Pam’s stress
levels and increase her coping skills. Pam benefited from having a safe place to
vent her feelings and deal with the sense of loss involved in having a loved one
with mental health issues. She said that it was useful to make the connections
between the past and present and be reminded of some of the strategies that
had been helpful in getting through other difficult times in her life.
Six months after Susan was discharged from the hospital, Pam learned that
the police had brought Susan into hospital again. She decided that this was a
good time to reach out to her daughter. Susan was responsive to meeting with
Pam; she had started to miss having her mother in her life. The family worker
and psychiatrist on the unit facilitated brief meetings that had been arranged
for the two of them. They ensured that Pam had easy access to a door because
she did not feel completely safe with her daughter and wanted to have an
escape route should the dynamics between them become heated.
As Susan started to have a positive response to her medication, the former

closeness between mother and daughter began to be rekindled. This time,
Susan was eager to live with her mother after being discharged and agreed to
receive the depot injection and continue to see her treatment team regularly—
the terms her mother had set for this arrangement. Susan went home for a
few weekends before being discharged, which went well, so Pam was happy
to have Susan living back at home, particularly knowing her daughter was
receiving medical and psychosocial support from the treatment team. Pam
was clear about providing a calm home atmosphere but was adamant that
she would continue to set limits with Susan.
The family worker continued to support Pam individually and an additional

regular family meeting was scheduled for Pam, Susan, Susan’s case manager
and the family worker to build on the family’s strengths and help to facilitate
communication between mother and daughter. Pam is a dedicated advocate for
her daughter and is an ally in Susan staying well and eventually re-integrating
into the community. As Susan gradually developed a better understanding of
her illness, she started to understand her mother’s expectations that she accept
treatment to “regain her life.” Susan was motivated to reconnect with her sister,
Karen, and believed that if she demonstrated that she was “stable,” this relation
ship would be resurrected. Reuniting with her nephew provided her with a
strong motivation to stay well.
Pam and Susan developed a strong relationship. Initially, Pam noticed that
Susan seemed to have “regressed” to a former stage of development and was
more dependent on her for help with daily living. Pam’s ultimate aim was to
help her daughter to become independent and autonomous; she sometimes
struggled in determining how involved she should be in Susan’s life. Having
a separate family worker to speak to about these matters was helpful to Susan.
Having a case manager to help Susan achieve her goals helped Pam to feel
that she was not alone in caring for Susan.
Today, Susan is taking some college courses and feels hopeful about her
future. She is starting to develop friendships and feels “more like my old
self.” Susan says that “losing mom and Karen was devastating and helps me
remember to take my medication every day and do everything that I can not
to land back in hospital.”
Trauma-Informed Family Work

Family-centred trauma-informed care focuses on meeting the needs of both
the person with mental health or substance use issues and his or her family.
It builds on the strengths and interconnectedness that exists in families.
A trauma-informed model builds on the core practices of a family-centred

approach, which involves listening, responding to and supporting the family’s
concerns, opinions, values, beliefs and cultural background. A family-centred
approach may or may not include the family member being seen for a mental
health or substance use problem. Regardless, in no way does the term “family-
centred” intend to remove control from the recovering person. A family-centred
approach simply recognizes that all family members deserve support, even if
the recovering person chooses not to have his or her family members involved.
In these situations, families are offered support, whether or not the client
chooses to participate. The approach to care and decision-making is collabora
tive, with each person recognizing the skills, expertise and experience of the
other people involved (Baker et al., 2007).
A trauma-informed approach is not simply family-centred: it attends to how the

events surrounding the hospitalization of a family member may be traumatizing
for others in the family, and how the present events may elicit fears and
(mal)adaptive responses to past trauma on the part of family members. Being
well supported and listened to, family members can work on their own responses
and feel empowered to continue to be allies in their relative’s recovery, while
also taking care of themselves.
Attending to family members’ needs and realizing that they go through their
own parallel recovery process is important. This is unlike what has happened
historically, when parents, especially mothers, have been blamed for causing
mental illness and behavioural problems in their offspring—a perspective
that continues to affect the field of psychiatry and traumatize families today.
In 1948, Frieda Fromm-Reichmann coined the term “schizophrenogenic
mother” to describe what she saw as domineering, overprotective, rejecting
mothers, who she believed were causing their children’s schizophrenia. This
culture of blame persisted until the early 1970s.
In trauma-informed family work, the family worker acknowledges this legacy

of blame. Most family members express how helpful it is to explore this
matter, as they have often been affected by family-blaming theories and can
think that they are the cause rather than part of the solution for their relative’s
recovery. Shame can affect family members’ interest in accessing professional
and peer support and their ability to get past feelings that the illness is
somehow their fault.
In Susan’s situation, the family worker attended to the immediate safety

needs of the family, such as Pam’s need to be near the door in early meetings
with her daughter and setting limits requiring her daughter to be on medication
if she were to live at home. Support for Pam’s expression of limits was likely
critical to her safety and empowering given her history of having an abusive
husband. The worker was able to focus on Pam’s strengths, resilience and
competency and encouraged her to take care of herself during this difficult
time. She acknowledged Pam’s fears and stress without pathologizing them.
Pam started attending a yoga course with a friend and found this beneficial in
keeping her stress levels down.
Listening to other families at different stages of the recovery process can be

invaluable and provide families with hope for the future. After Pam had five
months of individual work, she attended a family psychoeducation group.
She worried that other family members would judge her for her “tough love”
approach but was pleasantly surprised at how unconditional other participants
were toward her. Pam felt supported in the group and other participants
shared some of her issues. She expressed that knowing that Susan was
experiencing adverse situations in her life and feeling helpless to stop what
was happening to her daughter still stressed her. The family worker continued
to work with Pam while she participated in the group to help Pam cope with
these feelings. Eventually, Pam started to feel calmer and stronger in herself.
Timely trauma-informed care enabled Pam to work through her feelings

about her daughter, acknowledge her own experience of violence, mobilize
her own strengths and competency and eventually reunite with her daughter.
Pam felt that the illness “robbed” her of the daughter she knew but she
believes that out of adversity—separately and together—they have both
managed to start living their lives in a positive way, appreciative of the family
ties they have all developed over a difficult two years.
Susan attributes her current success in large part to her mother’s support and
help in lobbying for services for her. Pam reports that this experience helped
her to re-evaluate her life and make a career change. She is applying to become
a social worker as a result of her experiences with Susan.
References
Baker, S., Baker, K. & Collette, E. (2007). Family Protocol for Early Intervention Programs in
Ontario. Unpublished manuscript.
Fromm-Reichmann, F. (1948). Notes on the development of treatment 0f schizophrenics by
psychoanalytic psychotherapy. Psychiatry, 11, 253–273.
225
Chapter 18
Trauma-Informed Care on
a Women’s Inpatient
Psychiatric Unit
Donna Akman and Cheryl Rolin-Gilman
The Women’s Inpatient Unit (WIU) at the Centre for Addiction and Mental
Health (CAMH) is a residential service for women who have complex mental
health problems and a history of trauma, and who may also have substance use
issues. The majority of clients have histories of interpersonal trauma, including
but not limited to experiences of sexual, physical and emotional abuse in child
hood and/or adulthood. Further, many of our clients contend with various
forms of challenging and oppressive social circumstances, such as social isolation,
economic difficulties and discrimination. In recognition of the difficult and often
disempowering circumstances of our clients’ lives, our model of care is trauma
informed and feminist informed, with an emphasis on safety and empowerment
through validation, skill development and self-determination. Our program is
unique in that it is the only all-women inpatient psychiatric service in Canada
dedicated to clients with a history of trauma.
Although a full description of the philosophy and interventions used in the WIU
is beyond the scope of this chapter, we describe key practices and policies that
reflect our trauma-informed, feminist-informed model of care. These practices
and policies include our approach to self-harm and suicidality, substance and
alcohol use, admission goals and discharge planning and co-client relationships;
and policies regarding locked doors on our unit, the use of physical restraints
and managing potentially dangerous clinical situations.
Key Trauma-Informed Principles in

the Women’s Inpatient Unit
The WIU is an inpatient psychiatric service for adult women who present with
complex mental health problems and trauma histories, and who may also have
substance use issues. It was developed in response to a recognized need for an
all-women psychiatric unit that provides women with a safe community where
they could get psychoeducation about the relationship between mental health,
addiction, gender and trauma; access a wide range of treatment approaches to
reduce distress and increase wellness; and develop and practise skills that support
well-being and empowerment. As a feminist-informed, trauma-informed service,
the WIU aims to create a therapeutic environment in which women can experience
a sense of safety and community, be validated for their strengths and resilience
and engage in activities and interactions that promote mastery and empowerment.
It is based on the Sanctuary model (Bloom, 1994, 2000), which uses trauma-
based and feminist-informed approaches to create a therapeutic community.
Within the Sanctuary model, treatment is guided by four aspects of trauma
recovery—safety, affect management, grief and emancipation (Bloom, 2000).
Within this framework, establishing a safe therapeutic milieu is necessary if
recovery is to progress. Affect management refers to the stage of recovery in
which people learn to manage their emotional arousal in less destructive ways.
Grief refers to the loss, sadness and despair that are components of having
experienced trauma, and that must be worked through if recovery is to progress.
Emancipation refers to aspects of full recovery, such as social reconnection and
the restoration of meaning to one’s life through empowerment. These four
concepts are guiding features of the principles and practices of the WIU.
Not Just Symptom Reduction, but Wellness

Many of the women who are admitted to the WIU have long-standing
difficulties with complex and overlapping symptoms, including depression,
suicidality, self-injury, affect dysregulation, flashbacks and dissociation. Our
clients typically meet criteria for mood and/or anxiety disorders, including
posttraumatic stress disorder, and have received previous treatment in inpatient
and/or outpatient settings. Given that a significant proportion of our clients
present with past or current suicidality and self-harm behaviours, our
Chapter 18 Trauma-Informed Care on a Women’s Inpatient Psychiatric Unit 227
population is considered at high risk for safety concerns. Thus, a main

treatment priority is to reduce acute symptoms, increase psychiatric stability
and improve overall functioning in our clients. However, rather than focusing
solely on symptom reduction or psychiatric stability, the WIU aims to help
clients move toward wellness by identifying and validating their strengths
and resilience and encouraging them to engage in activities and interactions
that promote mastery and empowerment.
A Learning and Sharing Environment Embedded in

a Treatment Setting
The WIU focuses on helping women identify and harness both internal and
external resources in order to increase personal and social empowerment.
As such, we use a biopsychosocial approach to reduce symptom distress and
increase well-being. In addition to medications and psychotherapy, our approach
includes psychoeducation about psychosocial factors that may be influencing
mental health difficulties. We aim to create an environment in which women
can learn and practise a range of skills and self-care strategies, and we assist
women in gaining access to social support and community resources. These
features of the WIU are practised within a framework that supports and
encourages clients to recognize, value and share their own expertise and
wisdom with one another.
A Broad Lens for Trauma

As a trauma-informed program, we use a wide scope in assessing for trauma
experiences and related symptoms. We inquire about women’s experiences of
past or current physical, sexual and emotional abuse, as well as other experiences
of physical or sexual violence or intimidation. We assess for childhood expe
riences of invalidation, neglect and family instability or violence. In addition to
inquiring about these more overt forms of traumatic experiences, we consider the
many ways that women’s daily lives may be affected by unsafe, destabilizing and
disempowering experiences, such as low status and low-paying jobs, various forms
of harassment and discrimination and gender role expectations that pressure
women to assume a disproportionate amount of caretaking responsibilities,
meet rigid standards for female attractiveness and adhere to social dictates
against anger expression in women. Given our knowledge of each woman’s

unique history of abuse and violence and of the ways in which all women can
be subjected to marginalizing and disempowering social and interpersonal
experiences, the WIU uses trauma-informed interventions and policies.
Service from a Trauma-Informed Lens

The program itself is semi-structured and emphasizes group interventions as
a way of providing clients with opportunities to develop skills in a supportive,
validating environment, where women can learn about and from other
women. A variety of groups are offered each day, and while clients are
expected to attend groups, it is up to the client, ideally in collaboration with
her treatment team, to determine which groups she would find the most
beneficial. Thus, each client decides for herself, in collaboration with her
treatment team, what her treatment goals are and how best to achieve them
while on the WIU. Clients also meet individually with their psychiatrist,
primary nurse and other members of the treatment team. They are offered
opportunities to engage in a variety of leisure and physical activities on the
unit and/or on community outings.
Safety, Coping and Sharing Wisdom

The group interventions that are offered on the WIU are wide-ranging
and often comprise psychoeducation, skill development and support. The
interventions aim to promote safety, self-care, contextualization of women’s
experiences, self-determination, validation of women’s experiences and
expertise, opportunities for women to connect with and learn from other
women and self-advocacy. Some groups are more skills-based and focus on
developing cognitive, emotional and behavioural skills and strategies to
promote safety and increase distress tolerance and affect regulation. There are
also groups that have a psychoeducational focus in which clients learn about
biopsychosocial factors that are related to their health and well-being. Other
groups use the group setting as a venue for women to discover commonalities
with other women and share knowledge and information about resources and
strategies for wellness and coping. Still other groups are directed more toward
enhanced self-awareness. In all of the groups, regardless of the content
or focus, women are invited to recognize and value their individual and
collective wisdom and resilience.
Trauma-Informed Policies and Practices
Agency in Determining Admission Goals and

Treatment Planning
Women learn of the WIU primarily through our emergency department,
other CAMH programs and community psychiatrists. Often women know
little about the WIU, other than that it is a women-only psychiatric service.
Thus, once a woman is seen for potential admission to the WIU, she receives
information about our program and how it may be able to meet her needs.
She is provided with an overview of the groups offered, the focus of individual
sessions, what she can expect in terms of contact with the various members
of the team and, if possible, a tour of the unit. Regardless of whether a woman
is referred through the emergency department, another CAMH program or
the community, she is invited to consider how the WIU can meet her needs,
and she is asked to identify goals for her admission. As a woman’s stay on the
WIU progresses, her treatment goals are likely to be revisited and revised, in
collaboration with the treatment team.
A Focus on Keeping Safe: Addressing Self-Harm

and Suicidality
From the perspective of the WIU, self-harm is a coping strategy that women
develop to manage distress; somewhat paradoxically, in many cases it has
helped women survive. With that in mind, psychoeducation is provided to
clients about the link between trauma, emotional distress and self-harm.
While clients are validated for their resilience and creativity in finding ways to
manage their distress and survive in the face of often extremely challenging
circumstances, a main focus of treatment is to help them develop other, more
effective coping skills. Women on the unit are asked to make a commitment
to not engage in self-harm behaviour, and instead to practise using the skills
they are learning as part of their treatment. However, clients do sometimes
engage in self-injury while on the unit; when that happens, it is viewed as an

opportunity to explore the possible precipitants of the behaviour and consider
factors that may have prevented the woman from using alternative strategies.
Individualized safety plans, developed to help women identify factors that

precipitate distress, cues of distress and strategies for coping with distress
that do not include self-injury or suicide, are created within 72 hours of
admission and are continually revised and adapted as clients develop new
awareness and skills. Each client creates her safety plan in collaboration with
her primary nurse, other members of the treatment team and in a group
called Keeping Safe, which focuses on teaching women skills to incorporate
into their safety plans. Within the group, women are encouraged to share
with one another what they have learned about themselves with regard to
their own distress signals and strategies for coping. This is encouraged to
help women recognize and solidify their capacity for growth and to reinforce
women’s value to one another through shared experiences and knowledge.
Substance Use Issues

Similar to our approach to self-harm, alcohol and other forms of substance
use are seen as a way of coping with distress. Women are asked to make a
commitment not to use alcohol or other drugs during their admission to
the WIU. However, if they do engage in substance use, their experience is
used as an opportunity to consider the precipitants for the use, the consequences
of the behaviour and the development of alternative more effective coping
strategies. Part of the discussion often revolves around how substance use
may have affected the other women on the unit, particularly if clients have
been noticeably intoxicated in the presence of other clients. In that case, the
safety and stability of the therapeutic community can be negatively affected.
It is also explained to clients that continued use of alcohol or other substances
is likely to interfere with prescription medications and the ability to take part
in group programs. Thus, while each situation is assessed on an individual
basis, if it is determined that a woman is not able to abstain from substance
use during her admission, she may be asked to leave and invited to return
when she can. It may be that the client would be better suited to a program
that is primarily addiction-oriented, or one that relies less extensively on the
role of a safe and stable therapeutic community.
Self-Awareness and Learning through

Co-client Relationships
For many women who attend the WIU, establishing healthy interpersonal
relationships can be challenging. Histories of abuse and neglect, along with
gender-related socialization to assume responsibility for relationships and to
prioritize others’ needs ahead of their own, often lead women to have difficulty
developing secure and healthy relationships with family, friends and intimate
partners. Recognizing, asserting and respecting the need for appropriate
boundaries in relationships is often part of the treatment goals for women in
our program. For many of our clients with little social support, the WIU offers
an opportunity to develop connections with other women that sometimes
transform into ongoing friendships. While we aim to support the opportunities
for women to reduce social isolation and establish valued relationships with
other women, we also strive to help them identify and assert their own needs
in the connections they make with one another. This can lead to challenging
interpersonal situations in which the goals of one client to establish connections
with other women may clash with the goals of another client to set interpersonal
boundaries. For this reason, as well as to promote safety and community on
the unit, sexual and/or exclusive relationships between clients are discouraged.
However, with regard to co-client relationships, as with other situations that

arise, staff takes into account the context of each circumstance in determining
how best to approach a complex clinical matter. Clients are encouraged to
engage in open discussions among themselves and with members of the
treatment team to explore possible advantages and disadvantages of establishing
co-client relationships. The perspective of the WIU is that clients have the
right to make their own decisions about the relationships they establish, and
that if the choices made lead to problems, those situations are opportunities
for further learning and self-awareness. The goal of the WIU is not to protect
women from making what some may consider to be bad decisions, but to
help women make informed decisions and empower them to deal with the
outcomes of the choices they make.
Safety and Empowerment through Open Doors

Whereas many psychiatric units tend to be locked, the WIU is an open-door
unit, offering women the freedom to come on and off the unit as they wish.
Our trauma-informed perspective holds that for many women, being in an
inpatient psychiatric setting can lead to numerous situations in which there
is actual or perceived disempowerment. Thus, we try to establish policies and
practices that support women’s self-efficacy and empowerment. Having a
locked unit, in which permission to enter or exit must be requested, can be
experienced as retraumatizing and/or disempowering. The philosophy of the
WIU is that all members of the therapeutic community are responsible for
establishing a sense of safety for themselves and the community. Women
are therefore encouraged to determine for themselves how best to use the
therapeutic milieu in a way that promotes safety. This includes encouraging
them to assess their comfort level with leaving the unit for outings. Clients
who may be experiencing suicidal ideation or engaging in self-injury or
substance use are encouraged to work with their treatment team to evaluate
their readiness to leave the unit and establish alternative self-soothing
strategies. There are times when the WIU is locked for brief periods as a way
of assisting clients who feel significantly at risk and who identify that locking
the unit may be helpful, and at times when staff members have identified
a client who is considered at acute risk. It is recognized that having locked
doors, even for short periods, may be anxiety provoking for other clients, and
this is acknowledged and discussed whenever possible.
De-escalating Potentially Dangerous Situations

In most psychiatric inpatient settings, there are times when clients may
respond or behave in ways that may require de-escalation in order to maintain
safety for all involved. A range of interventions can be used in these situations,
from verbally interacting with clients to using physical restraints. At times,
staff from other units within the hospital may be called in to assist (“code white”).
These interventions, while sometimes necessary, can be retraumatizing and
disempowering for clients who are likely already experiencing a loss of control.
From a trauma-informed framework, interventions should be chosen with the
aim of promoting safety while minimizing the potential for retraumtization
and disempowerment. With this in mind, physical restraints are rarely used
on the WIU, and a code white is called when other attempts to intervene have
been ineffective or when there is a recognized need for immediate support.
When a code white is called on the WIU, staff who come to assist are guided
to stay in the background in order to reduce the potential for retraumatizing
the client, who may have a trauma history. Staff members are educated on ways
to intervene that are as collaborative as possible. This often includes helping
staff understand the importance of taking the time to negotiate with clients,
rather than relying on strategies such as the use of restraints, which may be
more efficient, but are also more disempowering. Within this framework,
crises are viewed as opportunities to help clients use skills they have learned
in treatment, rather than react in familiar but unhelpful, and sometimes
dangerous, ways.
Conclusion
As illustrated throughout this chapter, working within trauma-informed
and feminist-informed frameworks has helped us to identify how residential
psychiatric services can offer women opportunities for safety and empowerment.
The practices and policies we have described have been developed over many
years of collaboration between WIU staff and clients. These practices and
policies are continuously revisited, reconsidered and sometimes revised in
order to be responsive to the multiple and sometimes competing needs of
clients, staff and the WIU community as a whole.
References
Bloom, S. (1994). The Sanctuary model: Developing generic inpatient programs for the treatment
of psychological trauma. In M.B. Williams & J.F. Sommer, Jr. (Eds.), Handbook of Posttraumatic
Therapy: A Practical Guide to Intervention, Treatment, and Research (pp. 474–491).
Westport, CT: Greenwood Press.
Bloom, S. (2000). Creating sanctuary: Healing from systematic abuses of power. Therapeutic
Communities: The International Journal for Therapeutic and Supportive Organizations,
21(2), 67–91.
235
Chapter 19
Trauma-Informed Primary Care

with Immigrant, Refugee and
Non‑status Women Living with
HIV/AIDS
Mercedes Umaña
At Women’s Health in Women’s Hands, a Toronto-based community health

centre, we use a trauma-informed framework to facilitate each woman’s
journey living with HIV/AIDS. Working with immigrant, refugee and non-status
(IRN) black women and women of colour,1 we recognize that each woman
comes from particular social locations, which create their own challenges and
strengths, depending on the complexity of their circumstances.2
This chapter discusses how Women’s Health in Women’s Hands implements

a trauma-informed primary health care model for IRN women living with
HIV/AIDS—both in the wake of an HIV-positive test result and as part of
chronic management of this condition.
Services for these women include general health monitoring by family

physicians and nurse practitioners, psychotherapy, nutritional counselling,
HIV-related health literacy and prevention, and community development
1. Women’s Health in Women’s Hands Community Health Centre provides services for black women and
women of colour from the Latin American, Caribbean, African and South Asian communities within the
Greater Toronto Area. Throughout this chapter, for the sake of brevity, we use the term “IRN women living
with HIV/AIDS” to refer to women from the priority populations served at the centre, many of whom are
immigrants, refugees or women with precarious immigration status.
2. Social location refers to intersecting identities based on factors such as ethnoracial background,
socio‑economic status, immigration status, age, gender, (dis)abilities, sexual orientation and spirituality.
Social locations are an important element for understanding the differential impact of the social
determinants of health.
initiatives/programs. Some clients seek our services shortly after getting a

positive test result from an anonymous testing site; others have known about
their HIV status for a long time, having contracted the virus while fleeing
their countries of origin and seeking refuge in Canada.
Living with HIV/AIDS may or may not be the central health concern for the
women we see, because determinants of health—the impact of unemployment,
homelessness, under-housing, settlement difficulties and other social and
economic concerns—may create more pressing problems for the client. In
other words, issues such as securing immigration status in Canada or finding
ways to support children being bullied at school may appear to be a greater
priority for clients than trauma-related issues. Critically examining determinants
of health is crucial when providing trauma-informed services for any client,
but particularly for IRN women living with HIV/AIDS.
A Trauma-Informed Approach
The centre has integrated a trauma-informed framework during two crucial
stages of working with IRN women living with HIV/AIDS: during or
immediately after a positive HIV test result and throughout ongoing care
(chronic management).
Providing Safe and Welcoming Services

Dissociation, sadness, intense fear, confusion, anger and powerlessness are
all normal responses to receiving a positive HIV test result, just as they are for
all traumatic experiences, as has been extensively documented in the literature
(Herman, 1992). Stigma associated with HIV/AIDS remains a distinct element
that amplifies the potential traumatic nature of receiving an HIV-positive
diagnosis and living with the virus. HIV/AIDS stigma is linked to misunderstanding
of the illness; misconceptions about how the virus is transmitted; lack of
access to treatment; irresponsible media reporting on the epidemic; the
incurability of AIDS; and prejudice and fears relating to issues including
sexuality, disease, death and drug use (Joint United Nations Programme on
HIV/AIDS, 2005). As a result of stigma, discrimination and shame, people
living with HIV/AIDS often do not seek or are not offered treatment, care and
Chapter 19 Immigrant, Refugee and Non-status Women Living with HIV/AIDS 237
support, making them vulnerable to blame, depression, suicidality and self-

imposed isolation (African and Caribbean Council on HIV/AIDS in Ontario,
2006; Joint United Nations Programme on HIV/AIDS, 2005).
It is crucial for services to be welcoming to people with HIV/AIDS, recognizing

how stigma, cultural beliefs, discrimination and trauma may interact, making
it difficult for immigrant, refugee and non-status women to access help.
Taking Time and Promoting Agency and Empowerment

Given the serious life-changing implications of a positive HIV test result, it is
important for service providers to understand that clients may need extra time
to process the information and may require assistance in establishing a plan
of action. Health care providers should allocate the time and space necessary
to help IRN women living with HIV/AIDS assimilate the information and
express any emotions or reactions to such news.
This kind of support is crucial not just at the time of hearing the diagnosis,
but at any point in a woman’s journey with HIV/AIDS. A nurse from the centre
describes how she extended her appointment time to respond to questions an
HIV-positive client had about her difficulties taking an iron supplement. In
this conversation, the client tearfully commented on how taking one extra pill
in addition to the anti-retroviral medication reminded her of her HIV status
and her fears of death, stigma and community rejection. This conversation
opened new avenues for the client to continue processing her emotions and
building resilience, and for the nurse to be able to provide her with reassurance
and empathic understanding.
Interdisciplinary Support That Acknowledges the Many

Layers of Trauma
Implementing a trauma-informed framework also involves understanding
that a positive HIV test result may bring up traumatic content associated with
the circumstances that resulted in the client becoming infected. Unravelling
other layers of trauma can be acknowledged by setting up sufficient time for
the appointment, not rushing into providing detailed biological explanations
about HIV and being open to assisting the client in processing her most
immediate reactions or questions.
In our experience, discussing sensitive issues related to HIV/AIDS care and

prevention in addition to disclosing new positive HIV test results has required
more effective interdisciplinary work, with physicians regularly consulting and
collaborating with psychotherapists and community health promoters to
facilitate the client’s journey living with HIV/AIDS. For example, community
health promoters and psychotherapists may sit in with family physicians
during any appointment where a positive test result will be communicated to
help the client process her most immediate reactions to the diagnosis and to
let her know of any other community initiatives from which she could benefit.
This collaborative linkage helps to break the stigma and isolation that often
result in further revictimization.
Providing immediate referrals to psychotherapists reaffirms the availability

of resources to support the client. However, referrals are offered cautiously,
specifying to the client that psychotherapy is available as a resource to support
her in continuing to process her new reality if she feels the need to talk to
someone about the diagnosis or any other current life circumstance. Because
some people still believe that psychotherapy and other mental health services
are for people who are “crazy,” it is crucial to take the time to explain how
emotional distress is a normal reaction to a new HIV-positive diagnosis or
other critical issues in living with HIV/AIDS and how psychotherapy or
counselling services can help women cope.
To enhance access to mental health services, Women’s Health in Women’s

Hands has established a policy where any woman seeking mental health
services gets immediate access to counselling and psychotherapy services.
Reassuring clients about confidentiality is another important aspect in
providing trauma-informed services for IRN women living with HIV/AIDS
at all stages, given how small some communities are and the need to prevent
stigma. In some African and Caribbean communities in Toronto, for example,
being in certain areas or attending certain community events is perceived
as affording little privacy, which can contribute to fear of disclosure (African
and Caribbean Council on HIV/AIDS in Ontario, 2006). As a result, IRN
clients who are HIV-positive may appear to resist referral for ethno-specific
counselling or psychotherapy services out of fear that their privacy could be

compromised.
Supporting Women’s Priorities

Service providers need to understand clients’ social locations and how
determinants of health might influence treatment planning and outcomes.
They may want to consider the following issues in their conversations with
newly diagnosed HIV clients:
• Immigration status: Treatment planning will usually require community

and legal referrals if the client is dealing with precarious immigration
status or a refugee claim process, being sponsored or waiting for a
humanitarian and compassionate grounds application or a pre-removal risk
assessment. In many instances, primary health care providers need to be
available to help lawyers document evidence in support of refugee claims,
as the traumatic nature of the narratives often requires therapeutic support
to deal with clients’ traumatic symptoms immediately after discussing their
life histories.
• Family relations: Is there a member of the client’s family or immediate
support network on whom she can rely to help her maintain focus on the
here and now, and into the future? Connecting with the woman’s broader
support network can be extremely delicate, as women newly diagnosed as
HIV-positive are required to disclose information about anyone whom
they could have exposed to the virus. This procedure is usually managed
collaboratively by public health officers and physicians who contact third
parties so they can be directed to the appropriate services. Service providers
need to take necessary measures to screen for any potential circumstances
that could lead to HIV-positive women being revictimized in the process of
disclosing their new status: for example, disclosure of HIV by women who
are in an abusive relationship or who have precarious immigration status
could result in increased violence, deportation and even forced separation
from their children.
• Pregnancy and breastfeeding: Service providers need to follow guidelines
around reducing mother-child HIV transmission via breastfeeding and
pregnancy: this includes helping women who are newly diagnosed as HIV-
positive to access support as they cope and make decisions about their
diagnosis and treatment choices while continuing to fulfil their roles as

mothers and caregivers.
• Dissociative symptoms: At the time a client receives a positive diagnosis,
health providers should understand that dissociative responses may result
in her struggling to stay present, to listen or even to figure out a way to get
back home. Sometimes clients who appear to be “unco-operative” are in
reality expressing normal dissociative responses. At Women’s Health in
Women’s Hands, one of the main priorities at this stage is securing
continuity of care through an interdisciplinary approach.
With the development of more effective drugs to treat HIV/AIDS, trauma-

informed care has become crucial to chronic management of the disease. For
IRN women living with HIV/AIDS, this new reality involves understanding the
complexities in women’s lives, as certain emotional reactions to living with
the virus may also become chronic. What may appear as chronic depression—
with catastrophic or fatalistic thinking patterns, fear and chronic feelings of
hopelessness—may be the natural reactions to a traumatic event that turned
chronic, such as living with the HIV virus and the potential collapse of the
immune system over time. Service providers need to understand and support
IRN women living with HIV/AIDS in accepting the difficult challenge of
continuing to resist the virus, while reclaiming their entitlement to building
a fulfilling future as women.
Building a Greater Sense of Community and

Empowerment
Another important element that the centre has incorporated in its trauma-
informed framework relates to the Greater Involvement of People Living with
HIV/AIDS (GIPA)3 and health literacy/capacity building with women living
with HIV/AIDS.
After organizing several workshops and educational activities for IRN women
living with HIV/AIDS, the centre acknowledged the requests from a large
group of community members for leadership by women who are HIV-positive
3. GIPA is a guiding principle that refers to the need for active and meaningful participation of people living
with HIV in the inception, development, implementation, monitoring and evaluation of policies and
programs (International HIV/AIDS Alliance & Global Network of People Living with HIV, 2010).
in initiatives geared toward building skills and HIV/AIDS health literacy.

As a result, the centre developed a program where HIV-positive women play
a central role in setting the agenda and bringing speakers of interest. Through
this initiative, women who are HIV-positive provide peer support to newly
diagnosed women, strengthening their leadership and creating a greater sense
of community and empowerment. This effort has crystallized in monthly skills-
building/HIV health literacy gatherings, where attendance has reached more
than 100 IRN women living with HIV/AIDS from the Greater Toronto Area.
Conclusion
Much work and research remain to be done in broadening our understanding
of how determinants of health, along with structural and institutional
practices of exclusion, negatively affect certain populations. Research, policy
and programming still need to be developed to ensure that health care
services respond to the specific needs of diverse populations who experience
acute or chronic traumatic reactions.
Our journey in developing a trauma-informed model of care with IRN women

living with HIV/AIDS started with community member demands for primary
health care services, research and health promotion initiatives addressing
HIV/AIDS. Over the last 11 years, Women’s Health in Women’s Hands has
implemented changes in its primary health care model for HIV-positive women,
making it more accessible by reducing wait times, enhancing our interdiscipli
nary model of care by incorporating an understanding of the role of traumatic
stress in living with HIV/AIDS, hiring HIV-positive staff dedicated to facilitating
skills-building programs with HIV-positive women, engaging in partnerships
with organizations that deliver services for this population, conducting
community-based research and engaging in knowledge translation initiatives.
Our organizational process has resulted in a significant increase in the number
of women who are HIV-positive being served at the centre, development of
community partnerships creating synergy in program delivery, increased
satisfaction from HIV-positive clients and client involvement in leadership
roles in the broader community.
It is our hope that more primary health care service providers and community
members will use some of the insights shared in this chapter to create and
expand trauma-informed models to their specific contexts.
References
African and Caribbean Council on HIV/AIDS in Ontario & HIV Social, Behavioural and
Epidemiological Studies Unit, University of Toronto. (2006). HIV/AIDS Stigma, Denial,
Fear and Discrimination: Experiences and Responses of People from African and Caribbean
Communities in Toronto. Toronto: Author. Retrieved from www.accho.ca/pdf/
hiv_stigma_report.pdf
International HIV/AIDS Alliance & Global Network of People Living with HIV. (2010). Greater
Involvement of People Living with HIV: Good Practice Guide. Brighton, UK: International HIV/
AIDS Alliance. Retrieved from www.aidsalliance.org
Joint United Nations Programme on HIV/AIDS. (2005). HIV-Related Stigma, Discrimination and
Human Rights Violations: Case Studies of Successful Programmes. Geneva, Switzerland:
Author. Retrieved from http://data.unaids.org/publications/
irc-pub06/jc999-humrightsviol_en.pdf
PART 3
CHANGING THE SYSTEM

THROUGH EDUCATION
AND INNOVATION
245
Introduction
Part 3 looks specifically at the opportunities in the mental health and substance
use treatment systems to become more trauma informed. The processes of
change differ depending on a range of factors, such as setting, social determi
nants of health and health equity, as discussed in Part 2. However, solid
processes of change rest on education and innovation. The chapters in Part 3
provide examples of the training and education involved in building trauma-
informed services and systems and describe innovative programs that are
putting this approach into practice.
Section 1: Education
In Chapter 20, Peck and Capyk describe how they came to recognize their
leadership role in providing education on trauma-informed practice with
community-based agencies that work with girls and women. A service such as
theirs, with its mandate of healing, education and prevention of sexualized
violence, can play an important role in helping other women-serving agencies
at the community level understand trauma and avoid becoming overwhelmed
by girls’ and women’s need for counselling around trauma-related issues.
Peck and Capyk describe their introduction of training to community support
workers in youth-serving agencies, including the processes and structures
involved in creating advisory committees to collaboratively build tailored
training on trauma-informed practice. They also advocate the application
of a trauma lens at the organizational level to identify potential changes to
managerial and administrative processes and systems that might lessen the
chances of traumatizing or retraumatizing clients in a range of settings.
Covington, in Chapter 21, describes curricula to develop trauma-informed

practice for working with women who have substance use issues. Her work
is based on international findings that women experience poor responses to
their substance use issues for reasons such as shame, stigma, fear of losing
their children and a general lack of well-funded and well–co-ordinated women-
centred services. Taking these issues into account, Covington describes why
women-specific services are needed and what they would look like. She pays
particular attention to retraumatizing practices and behaviours, such as
restraints, seclusion, body searches, incarceration and yelling. Covington’s
work reminds us of the importance of gender and how developing women-

specific approaches is especially important when trauma, violence and
substance use issues coexist. Covington identifies the critical need for training
in trauma-informed practice and explains how the curricula used in service
delivery can also serve as a basis for practitioner training.
Dell addresses a trauma-informed approach with a group of incarcerated

women who have self-harmed. In Chapter 22, she describes a women-centred
perspective on self-harm and views the behaviour through a trauma lens. Dell
describes the process of community-based research that identified prison
responses to women who self-harm. These ideas led to the development of
videos and other products to assist in educating, training and setting the
foundation for future research in creating trauma-informed community and
correctional systems. Dell highlights the need for education to address how
women have been unfairly stigmatized for self-harming and how the act of
self-harming has been misunderstood. Training for service providers should
include information about the influence of trauma in these women’s lives.
In Chapter 23, MacKenzie and Druker describe an emergent practice

stemming from a pilot study in Toronto with women who had lost custody
of their children to child welfare services. They review the literature on the
grief and bereavement associated with child apprehension, noting that
apprehension itself can be traumatic. This trauma can lead to self-blame,
guilt, shame and anger and can engender substance use. These issues
underlie the goal of the Grief and Loss Education and Action group in
Toronto, co-sponsored by a community health centre and a women’s
substance use treatment centre. The 15-week pilot group, which is now
in its third cycle, has created a venue for women who have experienced
loss to come together and share their stories. The women who have parti
cipated in this pilot are acting on their identified interest in educating
child welfare and other service providers about this form of trauma
through public speaking.
Section 2: Innovation
The chapters in Section 2 feature initiatives that have created new
approaches to providing trauma-informed care as a way to rectify problems
Introduction: Education and Innovation 247
in programs or services when trauma was not considered a potential part of

the women’s experiences.
In Chapter 24, Smylie and Ussher describe a more open and client-centred
collaboration between child welfare and substance use treatment services.
In Canada, these sectors have historically been divided, leading to further
traumatization for women, as their respective practices and goals conflicted
with one another. Smylie and Ussher stress the importance of linking services
in a seamless manner, establishing three-way communication between the
parents, substance use services and child welfare agencies, as well as advocating
for and supporting mothers. The program at the Jean Tweed Centre grew out
of the observation that trauma was affecting the women accessing the centre’s
substance use treatment services. The centre’s response was a highly collabo
rative initiative in Toronto that engaged five agencies. Together, they developed
a common agenda aimed at prevention in a strengths-based trauma-informed
program that has evolved over two decades. This innovation breaks through
the silos of child welfare and substance use treatment by moving toward a
cross-sectoral system aimed at understanding more fully the trauma-related
experiences of the families in their care.
Chambers describes development of an empowerment council for clients and

patients at the Centre for Addiction and Mental Health (CAMH) in Toronto.
When CAMH defined trauma-informed care as a priority, Chambers recognized
that assessing the organization’s own internal culture was a priority. In
Chapter 25, she describes the debates surrounding the evolution of the
Empowerment Council. After an extensive consultation process, the council
created the CAMH Bill of Client Rights. While the rights do not guarantee
appropriate practice, they do outline what clients can expect and what they are
entitled to. The document also outlines a set of boundaries that helps clients
to defend their integrity and agency within a psychiatric hospital environment.
This aspect is particularly important for people with trauma histories.
Brown discusses integrated screening as a component of trauma-informed

care in Chapter 26. The development of a trauma-informed screening tool was
based on the experience of people working in mental health and substance use
services at the state level in California. This tool includes questions about
mental health, substance use and trauma and violence histories. A second
innovation is a tool assessing a woman’s priorities for change, which she is
asked to rank in four main areas. Brown addresses the comprehensive

training required at the agency level, involving everyone from receptionists
to kitchen staff, from managers and supervisors to clinical staff. She argues
for a paradigm shift that is transformative—not one more feature of the
service, but rather a new approach informed by positive, strengths-based, safe
and respectful elements that permeates every interaction and development of
the service.
In Chapter 27, Dechief and Abbott provide another example of a transformative

process in the evolution of trauma-informed, harm reduction–oriented
supportive housing services for women in British Columbia. The clientele
accessing the shelter-related services at Atira Women’s Resource Society
includes women who are homeless, pregnant and mothering and who are
dealing with many issues, such as mental health and substance use problems
and violence. Dechief and Abbott describe the agency’s transition from its
abstinence-oriented policy for admission to transitional housing services to a
more realistic and honest approach, where a woman can open up about any
issues she might have, without fear of being refused treatment. The shift also
involves creating an ever-evolving organizational culture that reflects this new
approach. Indeed, through experience and practice, the agency intuitively
developed trauma-informed principles and applied them in its various shelter
service locations as they began to deal directly with substance use and mental
health issues. The shift was organic and highly informed by values of respect,
equality, responsiveness and empowerment.
Poole and Lyon, in Chapter 28, describe efforts to introduce tobacco treatment
services at the Aurora Treatment Centre, a women’s residential addiction
recovery program. The introduction of tobacco treatment into addiction
programs has had a rocky history, despite compelling scientific evidence
linking smoking and other types of substance use problems. Poole and Lyon
link this evidence to trauma and violence in women and make a compelling
case for this innovation. Nonetheless, the introduction of tobacco treatment
into addiction treatment required a paradigm shift, calling into question
criteria for admission, measures of success and staff and client receptivity.
Referral networks were also implicated in this innovation, as they, too, had to
address the new paradigm, prepare their clients and assess their own attitudes
toward tobacco use. Again, the success of this program integration is based
on respect, rapport and relational collaboration, with an emphasis on
Introduction: Education and Innovation 249
empowering clients through choice, all of which are elements of trauma-

informed care.
Finally, Greaves and representatives of YWCA Toronto discuss how the

organization brought trauma-informed principles and practices into its
shelter services for women with complex violence-related and mental health
issues. The trauma-informed approach was first applied to the development
of the ARISE shelter model in 2000. It was extended to other existing
violence against women shelters and is now guiding the development of a
large new residence on Elm Street for women living on low income and with
mental health and substance use challenges. Chapter 29 provides excellent
practical examples of changes made in daily operational rules and practices,
in relational support for women, in building multidisciplinary staff teams and
in providing community-level support in the achievement of trauma-informed
goals. YWCA staff members eloquently describe the ongoing challenges and
the many rewards of trauma-informed practice in the course of this work.
This part of the book on education and innovation captures a range of

activities in progress, as practitioners and services work out new approaches
to care, service and system design that are trauma informed. These examples
illustrate some of the enormous commitment, insight and energy associated
with these changes and provide a strong basis for moving forward.
PART 3
SECTION 1: EDUCATION
20 Building Community Capacity for Trauma-Informed Practice
21 Curricula to Support Trauma-Informed Practice with Women
22 Responding to Women’s Self-Harm: A 10-Year Reflection on the Need

for Trauma-Informed Care
23 A Mother’s Loss: The Unacknowledged Grief of Child Apprehension

for Women Who Use Substances
253
Chapter 20
Building Community Capacity for

Barbara K. Peck and Stephanie R. Capyk
At the 1998 conference of the American Psychological Association, then-

president Philip Zimbardo challenged the psychological community to “give
psychology away,” to take the insights and practices of their discipline and
share them with the broader community to enhance the human condition.
The Trauma-Informed Practice and Support training (TIPS)1 at the Victoria
Women’s Sexual Assault Centre (VWSAC) in British Columbia was created in
an effort to “give away” what we know, and thereby increase the community’s
capacity to respond with support and skill to survivors of sexualized violence
and trauma.
The VWSAC has a mandate of healing, education and prevention of sexualized

violence and has provided intervention and prevention services since 1982.
These services have included various educational initiatives with partner
organizations that provide a large range of community services, such as housing,
youth services and reproductive health services, but that do not provide trauma
counselling per se. Education sessions have focused on raising awareness of
the prevalence and societal context of sexualized violence, describing the many
ways a survivor may be affected and clarifying the referral process to our
services. We do not provide in-depth information about trauma counselling,
as it is a specific type of work requiring specialized skills and organizational
capacity. The target audience for this training is people who work in human
1. For more information about the TIPS training curriculum, contact the Victoria Women’s Sexual Assault
Centre at info@vsac.ca.
services and provide support for a range of issues, some of which may be
trauma related. Community support workers are sometimes relieved when we
tell them that their role is to be trauma informed in interactions with clients
and to refer them to trauma counselling services, rather than to provide
trauma counselling.
As awareness and understanding of trauma have increased in recent years,

more complex questions have emerged, with corresponding requests for a
greater depth of information. Whether or not it is the focus of their work,
community support workers are often present with clients struggling with the
complex interweaving of traumatic responses that include triggers, flashbacks
and overwhelming emotions. Workers may support clients who disclose
histories of abuse but who are neither interested in, nor ready for, trauma
counselling, as well as clients with addiction or mental health issues that seem
to have roots in traumatic experiences. Providing general support and infor-
mation about referrals has become insufficient to address the complex and
urgent issues that community support workers face with trauma survivors.
Our work at the VWSAC is structured around the three-stage model of

trauma healing (Herman, 1992). The focus of the first and foundational stage
of healing is to educate survivors about the effects of trauma on the whole self
and to increase their safety and stability. In early 2008, with funding from
Human Resources and Social Development Canada and the United Way of
Greater Victoria, we formed an advisory committee with members from a
range of youth-serving agencies, including a friendship centre, a child abuse
prevention and counselling agency, a children’s hospital and an alternative
school. We chose to focus on youth-serving agencies because youth are at a
critical stage of development where the “right” support can make a huge
difference, yet they are least likely to access trauma-specific counselling.
This advisory committee created a curriculum for community support

workers that would help them to develop “first stage” support skills and
learn how trauma, substance use and mental health issues and challenging
behaviours or responses may be interconnected. In providing this training to
seven youth-serving agencies, we hoped that youth in our community would
receive trauma-informed care in as many places as possible, with support that
consistently integrated an understanding of trauma into every interaction.
Chapter 20 Building Community Capacity for Trauma-Informed Practice 255
The committee generally met monthly and provided guidance regarding

training content and methods.
In 2010 we received a grant from the Victoria Foundation to offer the training
to local agencies that provide services to people experiencing poverty, home
lessness, addiction and marginalization. This has allowed us to expand and
adapt our TIPS curriculum to be relevant for community support workers
who interact with a wider variety of people in different life situations. Like
the original TIPS training for youth-serving agencies, working with diverse
community agencies has infused our work with a greater understanding of
our clients and the web of community agencies that provide critical support
services in greater Victoria.
The TIPS Training

“We’d like to begin by inviting you to take a nice deep breath. Notice your feet
on the floor. . . ”
And so we start the TIPS training, just as we begin our groups for survivors
of sexualized violence. The purpose of beginning with this type of exercise is
fourfold:
• to provide an example of how to guide clients through a grounding activity

• to allow workers to experience how their clients might be affected by the
activity
• to convey that the skills and tools we are teaching are applicable to both
clients and workers
• to help participants to be more present for the workshop.
This simple starting point reflects our appreciation of experiential learning

and the importance of the well-being of both client and worker and our
emphasis on developing safety skills, which we do throughout the training.
We use an exercise that facilitates self-regulation because trauma can disrupt
this ability (Van der Kolk & Saporta, 1991). Encouraging workers to use this
tool for themselves supports the information presented later in the training
that witnessing trauma can have similar effects as experiencing trauma
directly (Pearlman & Saakvitne, 1995).
The full TIPS training currently runs for two days. One of its strengths is the
integration of information in three main areas:
• the survivor (effects of trauma, context of survivors’ lives, etc.)

• the helping relationship (skills for safely supporting survivors, integrating
TIPS into the workplace)
• the worker (positive and negative effects of working with survivors, ways to
mitigate negative effects).
We also emphasize that the training builds on information and skills that
community support workers already have and encourage them to modify the
tools and information according to their context.
Program Evaluation
As each agency underwent the training, the advisory committee member from
that agency provided feedback about how the training was received, as well as
its subsequent impact on their co-workers’ practice over time. The committee
also discussed the overarching goal of building community capacity.
We hired an external research and communications consultant to further

evaluate the project. She played an important role, not only in creating the
evaluations and analyzing the data, but also in guiding the content and
pedagogy. Using an iterative process of curriculum development, participant
feedback from each training session informed us about how to shape subsequent
training. With each new round of training, the curriculum underwent significant
modifications in format, content and/or ways of teaching, based on feedback
from previous trainings. Some of the modifications were agency specific,
depending on the populations served, and many were general improvements.
The most consistent feedback was that there was not enough time for all of
the content and participation that was planned. As we experimented with
various formats, the curriculum evolved to have flexible units of training
that can be reorganized or excluded based on participants’ needs. Written
materials for each unit continued to be provided for self-study.
Components of TIPS
Various models of trauma-informed practice have been proposed, each
emphasizing somewhat different components or key messages. Different
models are described in Harris and Fallot’s 2001 special journal issue, Using
Trauma Theory to Design Service Systems, and Jennings’ (2004) report on
trauma-informed care, as well as work by Yoe et al. (2007). Based on these
models and our own extensive experiences working with survivors of trauma,
we found it helpful to group the aspects of trauma-informed practice into four
overarching components: trauma competence, understanding the client/
survivor, client empowerment and safety (see Table 1). TIPS training
addresses factors from each of these components.
TABLE 1
Components of Trauma-Informed Practice and Support
TRAUMA UNDERSTANDING THE CLIENT

COMPETENCE CLIENT/SURVIVOR EMPOWERMENT
• Be aware of prevalence • See client as a whole • Maximize choices.

of trauma. person. • Give voice to clients (at
• Recognize effects of • Use strengths individual and
trauma on whole perspective. organizational levels).
person. • Recognize the context • Allow client control
• Understand that in which the survivor where possible.
behaviours and lives (family, social, • Treat clients with
responses may reflect community, cultural, respect.
attempts to cope with sociopolitical). • Validate client
effects of trauma. • Collaborate with experiences and
• Minimize possibilities supporters. responses.
of retraumatization. • Collaborate on goals.
• Be aware of the impact • Foster client self-
on workers and how it advocacy skills.
may influence their
work.
SAFETY
• Understand safety as fundamental to healing.

• Recognize need for safety in all realms (physical, spiritual, mental, emotional).
• Foster trust between service provider and client.
• Have and teach tools for building safety.
• Recognize difference between trauma-informed and trauma-specific practice and
support.
Reprinted with permission from the Victoria Women’s Sexual Assault Centre.
Trauma competence is largely about understanding what trauma is and how

it can affect people in various areas of their being and their lives, including
understanding the potential impact of secondary exposure to trauma, which
involves hearing about a traumatic experience through another person’s story.
We provide a broad definition of trauma based more on how it affects the
person than on the details of the trauma story, and include such concepts as
colonial trauma, intergenerational trauma and developmental trauma (attach
ment disruption). Also necessary for trauma competence is the knowledge
that traumatic experiences are not rare and unusual events. Recognizing the
prevalence of trauma, particularly among certain populations, does not mean
making assumptions about clients’ experiences; rather, it means being aware
that the experience of trauma is a very real possibility. One does not need to
know whether or not particular clients have experienced trauma to provide
trauma-informed services.
Understanding the client/survivor is rooted in the strengths perspective that

is woven into the TIPS training. We do not elaborate on this concept because
the agencies and support workers we encounter are already working from this
perspective. Instead, we allot more time to increasing awareness of how the
context of people’s lives may interact or intersect with their experiences of
trauma. That is, systemic and contextual factors may influence a person’s
likelihood of experiencing or witnessing trauma, the nature of the trauma, the
responses of the survivor to the trauma and how others respond to the trauma
survivor. Contextual factors include family, culture, socio-economic status,
ethnic background, gender, sexual orientation and historical context of country
of origin. Although many workers have been exposed to these ideas in varying
degrees, direct service work is often narrowly focused on the individual. A
trauma-informed perspective requires that we recognize that trauma does not
happen in a vacuum.
Client empowerment is another concept that support workers are familiar

with; yet the practical application of empowerment can conflict with safety
issues. For example, empowerment would suggest that clients have the right
to make their own choices about exposing themselves to a risky situation. But
from the perspective of safety, this may mean that the client makes a choice that
puts him or her in harm’s way. The TIPS training explores these challenges. In
one exercise, for example, participants consider the costs of too much control
in the supportive relationship (e.g., resistance, loss of connection, reinforcing
negative beliefs of incompetence, little sense of agency, undermining

confidence) and the costs of too little control (e.g., not providing a safe
container or secure base, lack of safety, staff feeling disempowered). The
trainers acknowledge how tricky it can be to achieve the right balance.
Safety is key to working from a trauma-informed perspective. Because trauma

can affect people in all aspects of their lives, safety must be considered
holistically. Support workers are often more familiar with attending to
external safety issues; therefore, the training focuses more on tools related
to internal safety (e.g., deep breathing, grounding, containment, safe place,
mindfulness, self-compassion), which can be used with a range of clients,
whether or not they have experienced trauma. We do not want survivors to
open up about the specifics of their trauma when they do not have the safety
to do so, for example, when they are with a worker who is not trained to
provide trauma-specific services or when there is no organizational or program
infrastructure to provide appropriate support. Some workers struggle with the
concept of how to honour a client’s story while providing containment and
safety. The history that many survivors and groups of marginalized people
have of being silenced is a legitimate concern; thus, careful attention is paid
to this issue in the TIPS training. Table 1 summarizes some differences
between trauma-informed and trauma-specific services. We are very clear that
the TIPS training is not trauma specific.
We introduce many of these ideas through an opening story in which the

same scenario is presented from two perspectives, the second being more
trauma informed. (The story we choose can be modified to reflect the clientele
the workers are likely to encounter.) The group then discusses how each
approach might affect the client, the worker’s understanding of the client,
the relationship between the client and worker, the outcome and the worker.
As a starting point, this approach is well received and provides a tangible
framework for people to grasp a number of key messages about trauma-
informed practice in a short time.
TABLE 2
Differences between Trauma-Informed and Trauma-Specific Services
TRAUMA-INFORMED PRACTICE AND TRAUMA-SPECIFIC PRACTICE

SUPPORT (TIPS)
A perspective/lens that can be A kind of therapy designed to treat the

integrated at all levels of the actual sequelae or aftermath of trauma.
organization.
Conducted by a person with specific
training in trauma treatment.
Applicable to any client, whether or not The client has acknowledged her or his
he or she has a trauma history, and trauma history.
whether or not that history is known.
Main focus of practice: Main focus of practice:
Increasing safety through development Addressing the three phases of trauma

of self-management skills (e.g., treatment: safety and stabilization;
grounding and containment) for current remembrance and mourning (trauma
distress. processing); and reconnection.
Building on client strengths. Using specific techniques for trauma

processing, such as EMDR, somatic
Recognizing that some “problematic”
experiencing, art therapy or other
behaviours may reflect coping strategies
modalities that allow the client to
that were intended to increase survival.
explore, come to terms with and
Supporting clients in reducing harm that integrate traumatic experiences.
may arise from unintended
consequences of coping strategies.
The worker does not solicit or go into The counsellor may go into the details
details of the trauma with the client. The or specifics of the trauma with the client
focus is not on a diagnosis or on the in a paced and contained way.
specific nature of the traumatic event(s).
The client has not consented to trauma The client has given informed consent
counselling. for trauma counselling.
Trauma-informed practice and support Best practices indicate that all trauma-
does not include trauma-specific specific work should also be trauma
practice (and may involve a referral to informed.
trauma-specific practice).
Applying a Trauma Lens to an Organization

To provide safe and effective services, employees at all levels of human service
organizations, not only front-line workers, should be trauma informed. The
full TIPS training asks participants to apply a trauma lens at a program or
organizational level. As most participants are front-line workers, the consistent
feedback has been that many want practical tools and skills for working directly
with clients, along with clear direction on when and how to apply the tools.
The training, therefore, evolved to have a greater practical emphasis. An
experiential approach increased both acceptance of the tools and confidence
in using them. The desire for direct-service tools, while not surprising from a
practical perspective, may also reflect a sense of powerlessness that workers
feel when they are exposed to trauma through their clients. Part of our learning
process has been to clarify our target audience and to make sure the curriculum
applies to them. A TIPS training for management and administration is one
of our hopes for the future.
At this stage, the TIPS training is ready to be shared more broadly as a package
with facilitator and participant workbooks. VWSAC has begun to offer fee-for-
service training for agencies beyond the greater Victoria area. We have learned
that one of the core strengths of this training is the intrinsic partnership
between the trainers and the learners. TIPS is not intended as a new way of
working; it is a lens that can be shared and integrated into all facets of supporting
people wherever they seek help.
References
Harris, M. & Fallot, R.D. (2001). Envisioning a trauma-informed service system: A vital
paradigm shift. In M. Harris & R.D. Fallot (Eds.), Using Trauma Theory to Design Service
Systems [Special issue]. New Directions in Mental Health Services, 89, 3–22.
Herman, J.L. (1992). Trauma and Recovery: The Aftermath of Violence—From Domestic Abuse to
Jennings, A. (2004). Models for Developing Trauma-Informed Behavioural Health Systems and
Trauma-Specific Services: An Update of the 2004 Report. Cambridge, MA: Abt Associates.
Retrieved from www.theannainstitute.org/MDT2.pdf
Pearlman, L.A. & Saakvitne, K.W. (1995). Trauma and the Therapist: Countertransference and
Vicarious Traumatization in Psychotherapy with Incest Survivors. New York: W.W. Norton.
Van der Kolk, B.A. & Saporta, J. (1991). The biological mechanisms and treatment of intrusion
and numbing. Anxiety Research, 4, 199–212.
Yoe, J.T., Conway, K., Hornby, S., Goan, H. & Teirnan, C. (2007). Development of a trauma-
informed system of care assessment tool [PowerPoint slides]. Retrieved from www.maine.gov/
dhhs/QI/Florida_Conference-SKG-handout.pdf
263
Chapter 21
Curricula to Support Trauma-

Informed Practice with Women
Stephanie Covington
Over the past 30 years, we have greatly improved our understanding of the
treatment needs of women with substance use problems. Research reveals
that the vast majority of these women have experienced violence and other
forms of abuse and that a history of serious traumatic experiences plays an
often-unrecognized role in a woman’s physical and mental health problems
(Felitti & Anda, 2010; Felitti et al., 1998; Messina & Grella, 2006). A history
of being abused drastically increases the likelihood that a woman will develop
substance use problems.
In 2004, the United Nations Office on Drugs and Crime published a monograph
on treating drug addiction among women around the world. In the course of
developing the monograph, it was discovered that many of the issues with which
women with addiction struggle are universal. These include:
• shame and stigma

• physical and sexual abuse
• relationship issues
-- fear of losing children
-- fear of losing a partner
-- needing a partner’s permission to obtain treatment
• treatment issues
-- lack of services for women
-- lack of understanding of women’s treatment
-- long waiting lists

-- lack of child care services
• systematic issues
-- lack of financial resources
-- lack of clean/sober housing
-- poorly co-ordinated services (Covington, 2008a, p. 378).
Helping professionals around the world report an association between

addiction and all forms of violence and abuse (physical, sexual and emotional)
in women’s lives (United Nations Office on Drugs and Crime, 2004).
Recent research also demonstrates that addiction treatment services for women and
girls need to be based on a holistic, female-centred approach that acknowledges
women’s psychosocial needs (Grella, 1999; Grella et al., 2000; Orwin et al.,
2001). In my writing, gender-responsive/woman-centred services refers to
creating an environment—through site selection, staff selection, program
development and program content and materials—that reflects an understanding
of the realities of women’s and girls’ lives and that addresses and responds to
their challenges and strengths.
This chapter discusses the rationale for gender-responsive trauma-informed

practice and describes five evidence-based and best practices curricula
that service providers may find helpful when advocating for and designing
adaptations to programming.
Responding to Gender Differences in

Experiences of Violence and Trauma
Risk for abuse is gendered. Both female and male children are at relatively
equal risk from family members and people known to them. However, as
males age, they are more likely to be harmed by enemies or strangers, whereas
women are more likely to be harmed by their intimate partners (Covington,
1999, 2003a; Kendall-Tackett, 2005).
In adolescence, boys in the United States and many other white majority
countries are at risk if they are gay, young men of colour or gang members.
Chapter 21 Curricula to Support Trauma-Informed Practice with Women 265
Their risk comes from people who dislike or hate them. For a young woman,
the risk is in her relationship with an intimate partner. For an adult man, the
risk for abuse comes from being in combat or being a victim of crime. His
risk is from “the enemy” or from a stranger. For an adult woman, the primary
risk is again in her relationship with an intimate partner. To generalize, this
may account for the higher rate of mental health problems among women: it
is more confusing and distressing to have the person who is supposed to love
and care for you do harm to you than it is to be harmed by someone who
dislikes you or is a stranger (Covington, 1999, 2003a; Kendall-Tackett, 2005).
Women have different responses to violence and abuse. Some women may not
be traumatized by abuse because they have coping skills that are effective for a
specific event. Sometimes trauma occurs but is not recognized immediately
because the violent event is perceived as normal. Many women who used to
be considered “treatment failures” because they relapsed are now recognized
as trauma survivors who returned to alcohol or other drugs to medicate them
selves from the pain of trauma. By integrating trauma services with addiction
treatment, we reduce the risk of trauma-based relapse.
Trauma can skew a woman’s relational experiences and hinder her psycho-
logical development. Because it can affect how a woman relates to staff
members, her peers and the therapeutic environment, it is helpful to ask,
“Is this person’s behaviour linked to her trauma history?” However, traditional
addiction and/or mental health treatment often does not deal with trauma
issues in early recovery, even though trauma is a primary trigger for relapse
among women and may underlie their mental health issues. Many treatment
providers do not know what is needed in order to do this work. Here are
three important things that can be done in treatment programs to address
trauma issues:
1. Educate women about what abuse is, what trauma is and how abuse can
sometimes—though not always—cause trauma. Women often do not know
that they have been abused—and they often do not understand posttraumatic
stress disorder.
2. Normalize women’s reactions. It is important that women learn that their

responses are normal, given their experiences. Trauma responses are
normal reactions to abnormal or extreme situations.
3. Provide coping skills. There are grounding and self-soothing techniques

(e.g., breathing exercises) that women can learn to help themselves cope
with their traumatic experiences (Covington, 2003a, 2011).
Avoiding Revictimization and Retraumatization

A woman who has experienced a traumatic event feels more vulnerable. She
may have difficulty tolerating, expressing and/or modulating her emotions.
This results in what is called emotional dysregulation. An example of this is
when she over-responds to neutral cues and under-responds to danger cues.
Therefore, traumatized women are at increased risk of similar, repeated
revictimization. Retraumatization refers to the psychological and/or physio
logical experience of being triggered. A single environmental cue related to
the trauma—such as the time of year, a smell or a sound—can trigger a full
fight-or-flight response. Often, providers of substance abuse treatment
hesitate to provide trauma services for women in their programs because of
the fear of retriggering them. Although triggers in the environment cannot
be completely eliminated, it is important to create a safe environment in
which women can learn coping skills. This is the reason that the therapeutic
environment is so important for women. They must feel safe.
Understanding the impact of trauma and the issue of triggers is particularly

important when working with women in the criminal justice system.
Unfortunately, standard management practices—such as searches,
seclusion and restraint—may traumatize or retraumatize many women.
Experiences in the criminal justice system can trigger memories of earlier
abuse. It can be retraumatizing when a survivor of sexual abuse has a body
search or must shower with male correctional officers nearby. It can be
retraumatizing when a battered woman is yelled at or cursed at by a staff
member. Incarceration can be traumatizing in itself, and the racism and
class discrimination that are characteristic of the criminal justice system
can be even more traumatizing.
As the understanding of traumatic experiences increases among clinicians,

mental health theories and practices are changing. It is important for service
providers to understand trauma theory as a conceptual framework for clinical
practice and to provide trauma-informed services for their clients. According

to Harris & Fallot (2001), trauma-informed services:
• take the trauma into account

• avoid triggering trauma reactions or retraumatizing the woman
• adjust the behaviour of counsellors and staff members to support the
woman’s coping capacity
• allow survivors to manage their trauma symptoms successfully so that they
are able to access, retain and benefit from the services.
The Trauma-Informed Environment

In women’s treatment programs, sensitivity to trauma-related issues is critical
for creating a healing environment. A calm atmosphere that respects privacy
and maximizes the choices women can make promotes healing. Staff members
should be trained to recognize the effects of trauma, and clients should have a
clear understanding of the rules and policies of the program. A trauma-informed
environment includes various features:
• Attention to boundaries—between staff members and participants, among

participants and between participants and visitors. For example, clients
should be given permission to say “no” to hugs. Hugging may be an
expression of positive emotion for some women, but for those who have
been traumatized it could represent an undesired intrusion into their
personal spaces.
• Language that communicates the values of empowerment and recovery.
Punitive approaches, shaming techniques and intrusive monitoring are
not appropriate.
• Staff members who adopt the “do no harm” credo to avoid damaging
interactions. Conflict is dealt with through negotiation.
• A feeling of safety for staff. Women often work in environments where they
feel harassed and/or disrespected. Many female staff members also have
histories of abuse.
Assisting Service Providers with Trauma- and

Gender-Informed Practice
The recurring theme of the interrelationship between substance use problems
and trauma in women’s lives indicates the need for a multi-focused approach
to services. I have developed the Women’s Integrated Treatment model, which
is based on:
• the definition of gender-responsive services provided in an earlier section

• a theoretical foundation that integrates the theories of addiction,
psychological development (relational-cultural theory) and trauma
• multi-dimensional therapeutic interventions.
This model is unique from most other trauma programs that do not have a
gender-specific focus and use a unidimensional cognitive-behavioural approach.
Three completed studies (Messina et al., in press; Messina et al., 2010;

San Diego Association of Governments, 2007) and the final report to the
National Institute on Drug Abuse on a randomized-control-group study in
drug court (Bond et al., 2010) show positive results for the Women’s
Integrated Treatment model.
Curricula have been developed that help service providers bring this theoretically
and evidence-based approach into the delivery of trauma-informed and
trauma-specific services.
Five Gender-Responsive, Trauma-Informed Curricula

In developing gender-responsive services, the curriculum or material used
is a crucial ingredient to the success of treatment. The following are five
manualized curricula I have designed for working with women and girls.
They are theoretically based and trauma informed, each with a facilitator’s
guide and a participant’s workbook. Each curriculum uses cognitive-
behavioural, relational and expressive arts techniques. These materials not

only help to provide services, but can also be used to educate staff.1
1 Helping Women Recover: A program for treating addiction

This newly revised resource provides a comprehensive, 17-session curriculum
that includes the information and tools that counsellors, mental health
professionals and program administrators need to implement an effective
program for women’s recovery in varied settings. Helping Women Recover
(2008b) is organized into four modules that address key areas that women in
treatment identify as triggers for relapse: self, relationships, sexuality and
spirituality. The material addresses self-esteem, sexism, family of origin,
relationships, domestic violence and trauma. The curriculum is built upon
the integration of theories of women’s psychological development, trauma
and addiction.
A step-by-step facilitator’s guide and a participant’s workbook, entitled

A Woman’s Journal, is filled with self-tests, checklists and exercises to enable
each participant to create a personalized guide to recovery. The Helping
Women Recover program can be implemented by helping professionals with
a range of training and experience (Covington, 2008b).
Helping Women Recover is widely used in addiction treatment programs,

mental health clinics, eating disorder programs and domestic violence
services. There is also a special edition for women in the criminal justice
system. This version provides specific information about women in
correctional settings to staff working in these programs.
2 Beyond Trauma: A Healing Journey for Women

Beyond Trauma: A Healing Journey for Women is designed for practitioners
to use in any setting (outpatient, residential, therapeutic community, criminal
justice or private practice) to help women understand trauma and its impact
and to develop coping strategies. It includes a facilitator’s guide and a
workbook for women, as well as facilitator training videos and a client video.
1. More information on the curricula described in this chapter, as well as other gender-responsive and trauma-
informed materials for women, can be found on two websites: www.stephaniecovington.com and
www.centerforgenderandjustice.org.
The curriculum’s 11 sessions cover topics such as the connections between

violence, abuse and trauma, reactions to trauma, grounding skills, the mind/
body connection and healthy relationships.
The curriculum draws upon psychoeducational, cognitive-behavioural,

expressive arts and relational therapeutic approaches to support a strengths-
based framework responsive to women’s gender-specific needs for healing
and support.
This Beyond Trauma curriculum is designed to be used alone or along with

the Helping Women Recover curriculum to expand and deepen the trauma
work in the Helping Women Recover curriculum.
3 Healing Trauma: Strategies for abused women

This five-session intervention is designed for women who have been abused.
There is introductory material on trauma for the facilitator and detailed
instructions (specific lesson plans) for the group sessions. The session topics
include the process of trauma, power and abuse, grounding and self-soothing
and healthy relationships. There is a strong emphasis on grounding skills.
Healing Trauma is an adaptation of Beyond Trauma. It is particularly

designed for settings requiring a shorter intervention: short-term addiction
treatment, domestic violence agencies, sexual assault services and jails.
The materials (facilitator guide and participant handbook) focus on the three
core elements that both staff and clients need to know: an understanding of
what trauma is; its process; and its impact on both the inner self (thoughts,
feelings, beliefs and values) and the outer self (behaviour and relationships).
4 Voices: A program of self-discovery and empowerment for girls

Voices was created to address the unique needs of adolescent girls and young
women (Covington, 2004). It encourages them to seek and celebrate their
“true selves” by providing a safe space, encouragement, structure and the
support they need to embrace their journeys of self-discovery. The program
includes modules on self, connecting with others, healthy living and the journey
ahead, which can be delivered in 18 group sessions. Each session has an
opening section, a teaching on a topic, an interactive element (discussion of

issues, questions, etc.), an experiential component (exercises to try out new
skills and learning) and a closing section to facilitate reflection. The program has
theoretical foundations in gendered psychological development, attachment,
resilience, addiction and trauma. Trauma is addressed in the program both
explicitly and implicitly through attention to such issues as self‑esteem, connec-
tions with others, body image, emotional wellness and good decision-making.
The Voices program is used in many settings (e.g., outpatient and residential
substance use treatment, schools, juvenile justice, private practice). It includes
a facilitator’s guide and a participant’s workbook. The participant’s journal
uses a research-based process called Interactive Journaling. In the context of
girls’ lives, structured journaling provides an outlet for creativity, personal
expression, exploration and application of new concepts and skills.
5 A Woman’s Way through the Twelve Steps

A Woman’s Way through the Twelve Steps (2003b) includes the original self-
help book based on interviews with recovering women about their experiences
and understanding of the 12 steps, plus a participant’s workbook, a facilitator’s
guide and a DVD for clients, family members and facilitators who want to
learn how women and girls can use the 12 steps in a safe, nurturing way.
(Covington, 1999, 2003b, 2009).
When offered as a 13-session program, A Woman’s Way through the Twelve

Steps includes an opening session followed by one session for each of the
12 steps of Alcoholics Anonymous. It uses interactive exercises to help
women understand the principles or themes in each step. Practitioners who
participate in A Woman’s Way training groups are able to develop a deeper
understanding of the basic tools for living that are embedded in the steps.
Learning the Curricula: Staff Development

If a program uses a specific curriculum with women, one of the best ways to
train staff, supervisors and administrators is to have them participate in the
curriculum themselves as a group. This has been done in a variety of settings,
including residential, outpatient and correctional programs. An hour or an
hour-and-a-half session can be conducted in a weekly staff meeting or over

lunch, with a different staff member facilitating each week. For the program
director, these sessions offer a team-building tool and also help to reveal staff
members’ strengths and challenges.
When planning to implement this process, it is important to be able to explain

the differences between a therapy group and the learning (training) group.
TABLE 1
Differences between Training Groups and Therapy Groups
TRAINING GROUP THERAPY GROUP
Focus is on: Focus is on:
• learning as a group • individual growth

• using the group for experiential • using the group to recreate family-of-
learning by means of activities origin dynamics
• having support from outside • using the group for support for
the group (for individual issues) individual issues
• sequential learning • process
Conclusion
Historically, substance use treatment programs were designed for the needs
of a predominantly male client population. Over the past three decades,
researchers and treatment providers have begun to identify the characteristics
and components of successful treatment programs for women. A solid body
of knowledge has now been developed that reflects the needs of women in
treatment, and there is both a definition of and principles for the development
of gender-responsive treatment. Women’s exposure to violence has emerged
as a critical factor in treatment. Therefore, it is imperative that substance use
treatment services become integrated, incorporating what we have learned
from relational-cultural theory (women’s psychosocial development), addiction
theory and trauma theory. A gender-responsive and trauma-informed
program can provide the safe, nurturing and empowering environment that
women need to find their inner strengths, heal and recover. For both service
providers and the women survivors who access services, it is important to
understand what trauma is, its process and its impact on thoughts, feelings,
beliefs, values, behaviour and relationships. Structured curricula and client
workbooks can be helpful in providing such integrated treatment and support.
References
Bond, K., Messina, N. & Calhoun, S. (2010). Enhancing Substance Abuse Treatment and HIV
Prevention for Women Offenders: Final Report. (Report to the National Institute on Drug
Abuse, Grant No. 1 R01 DA022149-01). Unpublished manuscript.
Covington, S. (1999). A Woman’s Way through the Twelve Steps. Center City, MN: Hazelden.
Covington, S. (2003a). Beyond Trauma: A Healing Journey for Women. Center City, MN: Hazelden.
Covington, S. (2003b). A Woman’s Way through the Twelve Steps: Workbook. Center City,
MN: Hazelden.
Covington, S. (2004). Voices: A Program of Self-Discovery and Empowerment for Girls. Carson City,
NV: The Change Companies.
Covington, S. (2008a). Women and addiction: A trauma-informed approach. Journal of
Psychoactive Drugs (Suppl. 5), 377–385.
Covington, S. (2008b). Helping Women Recover: A Program for Treating Addiction (rev. ed.).
San Francisco: Jossey-Bass.
Covington, S. (2009). A Woman’s Way through the Twelve Steps: Facilitator Guide and DVD.
Center City, MN: Hazelden.
Covington, S. (2011). Healing Trauma: Strategies for Abused Women. [CD-ROM]. Center City, MN:
Hazelden.
Felitti, V.J. & Anda, R.F. (2010). The relationship of adverse childhood experiences to adult
medical disease, psychiatric disorders and sexual behaviour: Implications for healthcare. In
R. Lanius, E. Vermetten & C. Pain (Eds.), The Effects of Early Life Trauma on Health and
Disease: The Hidden Epidemic (pp. 77–87). New York: Cambridge University Press.
Felitti, V.J., Anda, R.F., Nordenberg, D., Williamson, D.F., Spitz, A.M., Edwards, V. et al. (1998).
Relationship of childhood abuse and household dysfunction to many of the leading causes
of death in adults: The Adverse Childhood Experiences (ACE) study. American Journal of
Preventive Medicine, 14, 245–258.
Grella, C. (1999). Women in residential drug treatment: Differences by program type and
pregnancy. Journal of Health Care for the Poor and Underserved, 10, 216–229.
Grella, C., Joshi, V. & Hser, Y. (2000). Program variation in treatment outcomes among women
in residential drug treatment. Evaluation Review, 24, 364–383.
Harris, M. & Fallot, R. (Eds.). (2001). Using Trauma Theory to Design Service Systems [Special
issue]. New Directions for Mental Health Services, 89.
Kendall-Tackett, K. (2005). Introduction: Women’s experiences of stress and trauma. In
K. Kendall-Tackett (Ed.), Handbook of Women, Stress and Trauma (pp. 1–5). New York:
Brunner-Routledge.
Messina, N., Calhoun, S. & Wanda, N. (in press). Enhanced drug court treatment for women
offenders: A randomized experiment. Criminal Justice and Behavior.
Messina, N. & Grella, C. (2006). Childhood trauma and women’s health outcomes: A California
prison population. American Journal of Public Health, 96, 1842–1848.
Messina, N., Grella, C., Cartier, J. & Torres, S. (2010). A randomized experimental study of
gender-responsive treatment for women in prison. Journal of Substance Abuse Treatment, 38,
97–107.
Orwin, R., Francisco, L. & Bernichon, T. (2001). Effectiveness of Women’s Substance Abuse
Treatment Programs: A Meta-Analysis. (NEDS contract no. 270–97–7016). Arlington, VA:
Substance Abuse and Mental Health Services Administration, Center for Substance Abuse
Treatment.
San Diego Association of Governments. (2007, April). Beyond trauma: Providing trauma-
informed services to women in drug treatment. CJ Bulletin, 1–11.
United Nations Office on Drugs and Crime. (2004). Substance Abuse Treatment and Care for
Women: Case Studies and Lessons Learned. New York: United Nations Publications. Retrieved
from www.unodc.org/pdf/report_2004-08-30_1.pdf
275
Chapter 22
Responding to Women’s Self-Harm

A 10-Year Reflection on the Need for
Trauma‑Informed Care
Colleen Anne Dell
One of the first artworks that Darcie made was a small, stitched train
cast in wax; and all around the train there were delicate, red threads
sticking out of the wax. She said that when she stopped self-harming,
she would remove the threads. Darcie has passed on now, and the
train with the threads is still here. . . . She taught us all that we have
so much to learn about how to care for each other.1
Trauma-informed work with women who need opportunities for healing

requires additional considerations when they are engaged in self-harming
behaviours. Historically, there has been limited awareness about self-harm.
It was not until the 1990s that the media, research studies and the experiences
of front-line service providers began to bring awareness to the issue of self-
harm, mainly among women and girls. It was around the same time that the
need to account for the impact of trauma on women’s healing and well-being
began to gain attention.
Our current understanding of self-harm is situated for the most part as an

individualized problem, reflective of the majority of “cases” having been
1. This is a dedication to Darcie Hall from Edith and all the girls and women in the Crossing Communities Art
Project and the Elizabeth Fry Society of Manitoba Self-Harm Research Project team. This quote appears in
Community Mobilization for Women and Girls Who Self-Harm: An Environmental Scan of Manitoba Service
Providers, available from www.addictionresearchchair.com.
encountered within the health care system. The criminal justice system
has also notably dealt with self-harming behaviours, particularly among
female prisoners. Given that self-harm among women and girls is a recent
acknowledgment, and alongside growing understanding about trauma-
informed care, there is much to be considered about how the two areas
intersect, so that supportive and effective responses are available. A beginning
point is prioritizing the wisdom offered from the complex lived experiences
of women and girls. Service providers need to consider a women-centred
perspective and their own interpretations of trauma in order to better
understand self-harming behaviours.
Understanding Self-Harm
In the past decade, self-harm has often been used interchangeably with terms
such as self-injury and self-mutilation. Conventionally, this language has
imparted descriptions of individuals inflicting visible, physical harm onto
their bodies, including slashing, cutting, head banging and bone breaking.
There has been misunderstanding about the intent of the behaviour, with
people often believing it to be the result of a weak or failed suicide attempt.
In response, women’s self-harm has historically been met with shock, even
repulsion. It has also been widely characterized as manipulative, attention-
seeking behaviour. This kind of judgment has translated into disempowering
forms of care emphasizing control and punishment, particularly within
the medical and criminal justice fields: it leaves clients feeling isolated,
stigmatized and shameful, and is contrary to current approaches to trauma-
informed care.
Self-injury, as listed in the Diagnostic and Statistical Manual of Mental Disorders

([DSM-IV-TR], American Psychiatric Association, 2000), is commonly seen as
a symptom of borderline personality disorder. It is also linked with diagnostic
categories, including depression, anxiety and addiction —all common diagnoses
for women who have experienced DSM-IV-TR–diagnosed trauma. Emerging
research over the past decade has challenged solely individualized, medical-
based definitions of self-harm. There is also a growing concern that self-harm
is increasingly being identified as a symptom of a mental health issue, instead
of being viewed primarily as a coping strategy (Kilty, 2006).
Chapter 22 Responding to Women’s Self-Harm 277
A trauma lens recognizes self-harm as a sign of emotional distress, defining it

as any behaviour, be it physically, emotionally, socially or spiritually founded,
that a woman commits with the intention to cause herself harm. This ranges
from physical injury to self-destructive behaviours, including problematic
substance use and sexual risk-taking (Adams et al., 2005; Fillmore & Dell,
2001; Huntington, 2001; Kilty, 2006). Self-harm is seen as a coping and
survival mechanism for dealing with emotional pain and distress, isolation
and oppressive conditions in women’s lives, including childhood and adult
experiences of abuse and violence (Adams et al., 2005; Fillmore & Dell, 2005;
Groves, 2004; Hyman, 1999; McCreary Centre Society, 2006). Although it
is unhealthy, self-harm provides women with identifiable coping responses,
including a sense of release and cleansing, a means to feel, a sense of control
and a way to communicate internal pain (Adams et al., 2005; Fillmore & Dell,
2001; Hyman, 1999; Snow, 2002).
Women who self-harm may have experienced trauma as children or adults:

from family substance use problems, dysfunctional family relationships,
parental death, partner violence or childhood experiences of abuse and
violence (Abrams & Gordon, 2003; Babiker & Arnold, 1997; Borrill et al.,
2005; Gladstone et al., 2004; Noll et al., 2003; Turell & Armsworth, 2003;
Van der Kolk et al., 1991; Wichmann et al., 2002). Marginalized women, such
as those who are incarcerated, may encounter additional factors, including
the fear of losing child custody, poor relations with staff and other prisoners,
confinement in segregation and general stressful living conditions (Arbour,
1996; Boritch, 2000; Kilty, 2006; Martel, 1999). Contributing factors to
self‑harm can vary, and are not necessarily rooted in what health care and
other practitioners conventionally conceive of as traditional forms of trauma
(e.g., direct experience of abuse and violence).
The personal experiences of women I have worked with who self-harmed

revealed a breadth and depth of contributing factors. In a course on addictions
that I recently taught at the University of Saskatchewan, a student, Jo-Anne
[a pseudonym], challenged the traditional conceptualization of self-harm,
commenting that her self-harming behaviours were not connected to a brutal
act in her childhood or adulthood, but rather, that she was traumatized by her
distress and struggle with feelings of disconnection from herself as a teen.
She explained:
Most people ask[ed] me why I would cut myself and my response was
that it was the way I could deal with intense emotions, it made me
feel better. When you cut yourself, your physiological reaction is that
you get a rush of endorphins, like an adrenaline high. I was using the
cutting as a coping method to deal with what I later found out to be
panic attacks.
The fact that Jo-Anne responded by self-harming stridently communicates the

traumatic effects of her lived experience with anxiety, and cutting as a means
to cope with her feelings of “going crazy.”
The clear message here is that Jo-Anne’s experience was traumatic, but not in the
way many service providers traditionally conceive of it. Just as the DSM-IV-TR
can be criticized for focusing on extreme traumatic events in an individual’s
life, so too can interpretations of self-harm. Adler and Adler (2007) discuss
their research with primarily adult women, commenting how “most people
discussed past verbal, physical, or sexual abuse, and some traced their current
emotional distress or pain to the relatively common traumas of adolescence,
such as peer rejection or parent–sibling favoritism, but others insisted that
their childhood had been basically happy” (pp. 541–542). We need to recognize
the inherent limitations of our current conceptualizations of what trauma is
in women’s lives, its relationship to self-harm and its subsequent influence
on our responses.
Conceptualizing Trauma
A women-centred perspective recognizes that trauma can occur with less
acute/dramatic or direct experiences, such that individual experiences of
trauma defy a traditional DSM-IV-TR definition. Recent work on self-harm
has highlighted that many “believe or feel that the traumas [experienced in
their lives] were not that severe” (Marsh, 2010, p. 3) and conversely that
“simply learning about traumatic events carries traumatic potential” (Marsh,
2010, p. 2). First Nations, Métis and Inuit women have experienced historical
trauma through a loss of culture as a result of devastating colonial government
policies and practices in Canada. These include residential schooling; the
“Sixties Scoop,” during which Aboriginal children were apprehended and
fostered or adopted by middle-class white families; and the Indian Act.
Locust (2000) explains that residential schools and their associated trauma

have been a “de-feathering process” that has stripped Aboriginal Peoples of
their knowledge, spirituality, physical and emotional well-being and sense of
community.
It is necessary for service providers to integrate the historical and contempo

rary social contexts of women’s lives in their conventional perceptions of
traumatic life experiences. They need to account for the complexity of women’s
lives, particularly among those who are marginalized, and address whatever
concerns are most immediate for them, whether this be finding employment
or housing or coping with child care issues. Problems such as these may
present a greater urgency for women than treating the traumatic event in
their lives. For example, deprivations in housing, nutrition and child care
are common in the lives of criminalized women; a criminalized woman is
typically young, a mother, poorly educated, under-employed, single or involved
in an unstable relationship and a survivor of childhood and/or adult violence.
Adler and Adler (2007) identify physical forms of self-harm as most prevalent
among socially vulnerable groups, including youth who are homeless or in
foster care, prisoners and individuals who are structurally disadvantaged in
society. A 2010 study in the United Kingdom found that young black women
were most likely to self-harm, and noted the link between their self-harming
and a preponderance of social problems, such as being more likely to be
unemployed and report housing problems (Cooper et al., 2010). It is difficult
to identify the traumatic precursor to women’s self-harming behaviour.
Trauma may be experienced as a culmination of an individual’s direct and
indirect lived experiences.
It follows that a woman-centred perspective of self-harm differs from a

DSM‑IV-TR definition of self-injury, in that the focus is not centred on the
perceived threat of death or other serious injury. Current research disputes
the long-standing perception that self-harm and suicide attempts are one
and the same. It suggests that self-harm and suicide attempts have different
intents, etiologies, bodily harms, frequency and methods (Fillmore & Dell,
2005; Harris, 2000; Paul et al., 2002; Vanderhoff & Lynn, 2001; Wichmann
et al., 2002). Suicidal acts are oriented toward ending pain and suffering by
ending life, while self-harm is viewed as a behaviour that enables women to
cope within their lives, albeit in an unhealthy manner (Borrill et al., 2005;
Burstow, 1992; Fillmore & Dell, 2001; Vanderhoff & Lynn, 2001).
Controlling and Punitive Responses to

Self-Harm and Trauma
In 2001 and 2005, I co-led two research studies in collaboration with Cathy
Fillmore of the University of Winnipeg and the Elizabeth Fry Society of
Manitoba. These studies emerged from the Elizabeth Fry Society identifying
an urgent need to better understand the alarming increase it saw in the
number of women involved in the criminal justice system who identified as
engaging in self-harm. We examined the supports available to criminalized
women who engaged in self-harming behaviours and the responses—both
helpful and unhelpful—of service providers in correctional institutions and
community settings (Fillmore & Dell, 2001, 2005). We concluded that non-
controlling and non-punitive responses were most helpful.
Recent literature and practices on trauma-informed care highlight the need to

emphasize empowerment, choice, readiness and prevention planning when
working with women with substance use problems (Covington, 2008). However,
it is well known that health and correctional staff often continue to respond to
women’s self-harm with judgment and confusion. Such stigmatization invokes
feelings of guilt and shame in the women, which in turn decreases their like
lihood of accessing required medical and therapeutic attention, particularly
for pregnant and parenting women. A 2007 study of 115 women in Regina,
Saskatchewan, who injected drugs concluded that the women had an ongoing
fear of having their children apprehended and felt they needed to hide their
injection drug use and not access essential health and social services in order
to maintain custody of their children (Stadnyk et al., 2007).
In correctional institutions, women’s reluctance to disclose physical forms

of self-harm is compounded by the fear of punitive responses, such as
segregation, as well as being assigned a higher risk-assessment score, which
may result in their being housed within a higher security level (Canadian
Association of Elizabeth Fry Societies, 2003; Faith, 1993; Fillmore & Dell, 2001;
Kilty, 2006; Martel, 1999). Presse and Hart’s (1999) study of 26 patients
admitted to the Intensive Healing Program at the Prairie Regional Psychiatric

Centre in Saskatchewan found that 73 per cent of women engaged in self-
injurious behaviour before being admitted and 50 per cent continued afterwards.
A more recent study of federally incarcerated women in Canada concluded
that the vast majority had engaged in physical self-harming behaviours prior
to incarceration and had also attempted suicide (Power, 2010).
A 2010 community forum hosted by the Forensic Behaviour Science and

Justice Studies initiative at the University of Saskatchewan addressed prison
responses to women’s physical self-harm. Correctional, community and
academic attendees agreed that increasing security (e.g., restricting visits with
children) and isolation (e.g., placement in segregation) among prisoners who
self-harm contributes to deterioration in their mental, physical, emotional and
spiritual health. Nonetheless, while this meeting was taking place, only a few
kilometres away, an imprisoned woman was being restrained to a body board
for her 32nd consecutive day because of her self-harming behaviours. She was
identified as a threat to the correctional facility and herself. Two interrelated
considerations are allowing for such a response—continued misunderstanding
of self-harm, which contributes to overly controlling and punitive responses,
and the consequent impact of shame associated with self-harming behaviours.
The destructive effects of controlling and punitive responses—based on a

misunderstanding of self-harm—is illustrated in Pictures of Self-Harm, a film
produced by the Crossing Communities Art Project in Winnipeg, Manitoba
([CCAP], 2008). CCAP is a not-for-project organization where artists meet
with women and youth on the margins of society to create art for social
change. In Pictures of Self-Harm, women used video cameras to reflect on
their substance use, cutting, the sex trade/sexual exploitation and eating
disorders. They interviewed artists, sociologists, prison guards, community
members and medical practitioners to explore why women self-harm, how
it is responded to and what can be done to help.
The film shares Tonya’s experience of the impacts of others’ unhelpful

responses to her self-harming, especially within the health field. Tonya
describes in the film how she felt abandoned and punished in a hospital
emergency ward where she went after physically harming herself: “I sat there
for three hours. No one was there to help me. They just glared at me like I
was taking up space for more important illnesses. I eventually left,” she says.
“The only thing I wanted was for someone to put their hand on my head or
on my hand and say, ‘You know what, you are going to be OK.’ That’s all
I wanted.”
A guard with the Winnipeg Remand Centre shared the practice of controlling
with physical restraints women who self-harmed:
It is just this huge plethora of self-harm, and here is me thinking, oh,

keep her isolated, keep her safe, you know, put her in the zute suit, to,
you know, so she doesn’t hurt herself. You know, if we can get all the
counsellors kind of trained and understanding of you know, what the
whole concept of self-harm is, then I mean at least that is a baby step
in the right direction. It’s a long way to go from the institutional level.
Jo-Anne’s story has a similar controlling theme. She comments,
In January 2002, I had a complete mental breakdown. I cut my arm

up worse then ever before. I looked down and realized that if I did not
get help, I may kill myself. I packed a bag and had my friend drive me
to the hospital. The doctor didn’t want to admit me, but [wanted] to
[instead] send me to my original psychiatrist in the morning. I told
him he could admit me now or I’d come back in half an hour and he
could give me a blood transfusion because I would slit my wrists. By
law he had to admit me.
Accounting for the effects of trauma within the women’s lives, whether
defined narrowly in terms of a violent experience or more broadly and linked
with social determinants of health, is overlooked in controlling and punitive
responses to women’s self-harm. No further explanation is required than
consideration of the potential retraumatizing effects of physical restraints on
an individual with a history of victimization and who is searching for control
through her self-harming behaviour.
Overcoming Misunderstanding:
A Trauma-Informed Approach
Women who self-harm desperately need medical and allied health professionals
to understand why they are harming themselves and acknowledge the etiological
role of trauma in their coping responses. Client-centred responses are
increasingly being recognized in trauma-informed approaches to care. A client-
centred approach can assist women who self-harm to overcome internal stigma
(e.g., based in feelings of shame and guilt) and external stigma (e.g., based in
controlling and punitive responses). For Aboriginal women in Canada, stigma
needs to also be understood in the context of women disowning their cultural
reality via internalized shame because of external governmental actions
(Niccols et al., 2010).
Practitioners also need to abandon patriarchal attitudes that involve punishing

women as a way to control what they see as “unfeminine” self‑harming
behaviours (Dell et al., 2009). This is especially true of the corrections
environment, in which punishment is the cornerstone of regulating the
institution. It is critical that service providers’ responses do not further
stigmatize women’s behaviour, but that they instead promote acceptance,
understanding, compassion, care, respect and support for women’s
empowerment.
A three-minute stop-motion film, Stigma, Barriers, Change (Crossing

Communities Art Project, 2009), produced at the 2009 International Custody
and Caring Conference workshop, “Implications for Women’s Healing from
Problematic Substance Abuse,” provides some insight. Created under the
guidance of the Crossing Communities Art Project, the film made by conference
attendees illustrates how stigma, steeped in misunderstanding, acts as a
barrier to women accessing services. Key messages included not judging
others, caring for everyone, having hope, listening to others, caring for
children, loving, overcoming barriers and creating individualized responses.
Another recent project examined the role of stigma and the important skills
and traits of treatment providers who work with Aboriginal women healing
from illicit drug use. They concluded that treatment providers need to:
• relay empathy for women’s struggles

• be accepting of their past behaviours
• inspire them through role modeling
• recognize the role of trauma in their healing
• support non-hierarchical communication with them
• show they care
• support the linkage to spirituality in their healing
• assist them in moving toward the future while acknowledging but not
staying “stuck” in the past (Dell et al., 2010).
These skills and traits speak to the need to guide individuals along their
healing journeys and not direct and attempt to control them. Service providers
also need to support women in the face of the stigma they commonly
experience in accessing services.
There are three key ways that service providers can work to understand self-
harm, conceptualize trauma and respond in an integrated way.
First, there needs to be increased educational opportunities and training

around self-harm for community service providers, hospital personnel and
correctional staff. Particular attention should be paid to debunking the myth
that self-harm is strictly a form of manipulation or indicative of suicidal
intention. Emphasis should also be placed on increasing understanding about
the underlying issues associated with self-harm and women’s lived contexts.
This requires an inclusive understanding of the role of trauma, based on
women’s understanding. For Aboriginal women, this also requires recognizing
intergenerational trauma and culture-based ways of knowing and healing.
Second, research should be undertaken that evaluates access to self-harm

treatment and healing approaches, interventions, programs, supports, policies
and services, with particular emphasis on those accessed by criminalized
women. For example, it would be useful to study the impact of adopting a
women-centred policy in correctional facilities that would not “isolate women
during crisis and would strive to recognize the voices of the individual women
to secure a more individualized approach to ‘intervention’” (Kilty, 2006).
A study by Messer and Fremouw (2008) affirms the need for models, or
integrated models, to best understand and respond to youth self-mutilation.
Finally, as discussed, there is a need to address the destructive impact of

stigma on women’s access to integrated self-harm and trauma-informed
health and social services. Women-centred approaches need to be adopted that
recognize the connections between women’s experiences of marginalization and
disenfranchisement (e.g., poverty, abuse, sexism, colonization) and how these
relate to women’s criminalization, self-harm and trauma. Multidisciplinary
therapeutic approaches that identify self-harm as a sign of emotional distress
and contextualize the client as a trauma survivor should be examined.
Responses should be directed based on women’s readiness and position.
Conclusion
Ideally, addressing these three components will allow us 10 years from now to
reflect back on progress we have made toward understanding and effectively
responding to women’s self-harm. Applying a trauma-informed approach to self-
harm would help women deal with the roots of their self-destructive behaviours
in non-threatening ways and ultimately live healthier lives. Attention to a trauma-
informed approach is particularly important in our current governmental
context of increased control and punishment of marginalized individuals in
Canada, including women prisoners.
References
Abrams, L. & Gordon, A. (2003). Self-harm narratives of urban and suburban young women.
Affilia, 18, 429–444.
Adams, J., Rodham, K. & Gavin, J. (2005). Investigating the “self” in deliberate self-harm.
Qualitative Health Research, 15, 1293–1309.
Adler, P.A. & Adler, P. (2007). The demedicalization of self-injury: From psychopathology to
sociological deviance. Journal of Contemporary Ethnography, 36, 537–570.
American Psychiatric Association. (2000). Diagnostic and Statistical Manual of Mental Disorders
(4th ed., text rev.). Washington, DC: Author.
Arbour, L. (1996). Commission of Inquiry into Certain Events at the Prison for Women in Kingston
(Catalogue No. JS42-73/1996E). Ottawa: Solicitor General of Canada. Retrieved from
www.justicebehindthewalls.net/resources/arbour_report/arbour_rpt.htm
Babiker, G. & Arnold, L. (1997). The Language of Injury: Comprehending Self-Mutilation. Leicester,
UK: British Psychological Society.
Boritch, H. (2000). Women in prison in Canada. In B. Schissel & C. Brooks (Eds.), Marginality and
Condemnation (pp. 309–328). Halifax, NS: Fernwood.
Borrill, J., Snow, L., Medlicott, D., Teers, R. & Paton, J. (2005). Learning from “near misses”:
Interviews with women who survived an incident of severe self-harm in prison. Howard
Journal of Criminal Justice, 44(1), 57–69. doi: 10.1111/j.1468-2311.2005.00355.x
Burstow, B. (1992). Radical Feminist Therapy: Working in the Context of Violence. Newbury Park,
CA: Sage.
Canadian Association of Elizabeth Fry Societies. (2003). Submission of the Canadian Association
of Elizabeth Fry Societies (CAEFS) to the Canadian Human Rights Commission for the Special
Report on the Discrimination on the Basis of Sex, Race and Disability Faced by Federally
Sentenced Women. Retrieved from www.elizabethfry.ca/submissn/specialr/4.htm
Cooper, J., Murphy, E., Webb, R., Hawton, K., Bergen, H., Waters, K. et al. (2010). Ethnic
differences in self-harm, rates, characteristics and service provision: Three-city cohort study.
British Journal of Psychiatry, 197, 212–218.
Covington, S. (2008). Women and addiction: A trauma-informed approach. Journal of
Psychoactive Drugs, 40(Suppl. 5), 377–385.
Crossing Communities Art Project. (Producer) & Regier, E. (Director). (2008). Pictures of
Self‑Harm [video]. Winnipeg, MB.
Crossing Communities Art Project (Producer). (2009). Stigma, Barriers, Change [video].
Retrieved from http://lookinginspeakingout.com
Dell, C.A., Fillmore, C.J. & Kilty, J.M. (2009). Looking back 10 years after the Arbour Inquiry:
Ideology, policy, practice, and the federal female prisoner. Prison Journal, 89, 286–308.
Dell, C., Kilty, J., Fillmore, C., Grantham, S., Lyons, T., Clarke, S. et al. (2010). Turtle Finding
Fact Sheet: The Role of the Treatment Provider in Aboriginal Women’s Healing from Illicit Drug
Abuse (Community-Engaged Scholarship for Health, Product ID No. Z3KNXKHD).
Retrieved from www.ces4health.info
Faith, K. (1993). Unruly Women: The Politics of Confinement and Resistance. Vancouver: Press Gang.
Fillmore, C. & Dell, C. (2001). Prairie Women, Violence and Self-Harm. Winnipeg, MB: Elizabeth
Fry Society of Manitoba. Retrieved from www.pwhce.ca/pdf/self-harm.pdf
Fillmore, C. & Dell, C. (2005). Community Mobilization for Women and Girls Who Self-Harm: An
Environmental Scan of Manitoba Service Providers. Winnipeg, MB: Elizabeth Fry Society of
Manitoba. Retrieved from www.addictionresearchchair.ca
Gladstone, G., Parker, G., Mitchell, P., Malhi, G., Wilhelm, K. & Austin, M. (2004). Implications
of childhood trauma for depressed women: An analysis of pathways from childhood sexual
abuse to deliberate self-harm and revictimization. American Journal of Psychiatry, 161, 1417–1425.
Groves, A. (2004). Blood on the walls: Self-mutilation in prisons. Australian and New Zealand
Journal of Criminology, 37(1), 49–64.
Harris, J. (2000). Self-harm: Cutting the bad out of me. Qualitative Health Research, 10, 164–173.
Huntington, A. (2001). Childhood maltreatment and adult self injury: A woman’s account.
Practice: Social Work in Action, 13(2), 31–42. doi: 10.1080/09503150108411509
Hyman, J.W. (1999). Women Living with Self-Injury. Philadelphia: Temple University Press.
Kilty, J. (2006). Under the barred umbrella: Is there room for a women-centred self-injury policy
in Canadian corrections? Criminology and Public Policy, 5(1), 161–182.
Locust, C. (2000). Split feathers: Adult American Indians who were placed in non-Indian
families as children. Ontario Association of Children’s Aid Societies Journal, 44(3), 11–16.
Marsh, T. (2010). Enlightenment Is Letting Go! Healing from Trauma, Addiction, and Multiple Loss.
Bloomington, IN: AuthorHouse.
Martel, J. (1999). Solitude and Cold Storage: Women’s Journeys of Endurance in Segregation.
Edmonton, AB: Elizabeth Fry Society of Edmonton.
McCreary Centre Society. (2006). Self-Harm: Pain from the Inside Out. Ottawa: Canadian Health
Network. Retrieved from www.canadian-health-network.ca
Messer, J. & Fremouw, J. (2008). A critical review of explanatory models for self-mutilating
behaviors in adolescents. Clinical Psychology Review, 28, 162–178.
Niccols, A., Dell, C. & Clarke, S. (2010). Treatment for Aboriginal mothers with substance use
problems and their children. International Journal of Mental Health and Addiction, 8, 320–335.
Noll, J.G., Horowitz, L.A., Bonanno, G.A., Trickett, P.K. & Putnam, F.W. (2003). Revictimization
and self-harm in females who experienced childhood sexual abuse: Results from a
prospective study. Journal of Interpersonal Violence, 18, 1452–1471.
Paul, T., Schroeter, K., Dahme, B. & Nutzinger, D.O. (2002). Self-injurious behavior in women
with eating disorders. American Journal of Psychiatry, 159, 408–411.
Power, J. (2010). Preliminary Results from the Women’s Self-Injurious Behaviour Study (Emerging
Research Results, No. 10-1R). Ottawa: Correctional Service of Canada.
Presse, L.D. & Hart, R.D. (1999). Variables associated with parasuicidal behaviors by female
offenders during a cognitive-behavioral treatment program. Canadian Psychology, 40(2a), 108.
Snow, L. (2002). Prisoners’ motives for self-injury and attempted suicide. British Journal of
Forensic Practice, 4(4), 18–29.
Stadnyk, B., Kennedy, K. & Smith, C. (2007). Women Who Inject Drugs, Who We Are: The View
from Here. Regina, SK: AIDS Programs South Saskatchewan.
Turell, S.C. & Armsworth, M.W. (2003). A log-linear analysis of variables associated with self-
mutilation behaviors of women with histories of child sexual abuse. Violence against Women,
9, 487–512.
Vanderhoff, H. & Lynn, S.J. (2001). Assessment of self-mutilation: Issues and considerations.
Journal of Threat Assessment, 1(1), 91–109.
Van der Kolk, B.A., Perry, J.C. & Herman, J.L. (1991). Childhood origins of self-destructive
behavior. American Journal of Psychiatry, 148, 1665–1671.
Wichmann, C., Serin, R. & Abracen, J. (2002). Women Offenders Who Engage in Self-Harm: A
Comparative Investigation (Catalogue no. PS83-3/123E-PDF). Ottawa: Correctional Service of
Canada. Retrieved from http://publications.gc.ca
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Chapter 23
A Mother’s Loss
The Unacknowledged Grief of Child
Apprehension for Women Who Use Substances
Tammy MacKenzie and Amy Druker
A mother’s experience of loss, grieving and trauma from having a child

apprehended by child welfare authorities often goes unrecognized and
unresolved. While grief is the expected emotion following loss and is
generally viewed as a “normal” and healthy reaction, little research and few
resources exist to help mothers deal with the devastating effects of losing
custody of their children to child welfare authorities.
Many women accessing the Pathways to Healthy Families program at the Jean
Tweed Centre in Toronto feel a devastating sense of grief when they lose custody
of a child to child welfare. This loss is complicated by feelings of shame, helpless
ness, anger and emotional numbness. The fact that this form of grief is rarely
acknowledged as legitimate traps women in their experience of loss and heightens
their isolation. The apprehension of a child, while it may be necessary, alters a
woman’s sense of self and can result in many of the symptoms we have come to
recognize as trauma and posttraumatic stress. As noted by Cantwell-Bartl (n.d.),
yearning, searching and loneliness are the hallmarks of the anguish of separation.
This often runs concurrent with the experience of numbness, disbelief, distrust,
anger and a sense of futility about the future.
This chapter describes our experience with “complicated” and potentially

traumatic grief with mothers who have lost custody of their children to child
welfare. We discuss the gap in services, emerging themes and practical

strategies to support these women. We also highlight the effect this work can
have on service providers and describe an emerging practice that is based on
feedback from bereaved mothers.
Unresolved Grief as Trauma

Unresolved grief as trauma is a new concept in clinical practice. Bringing a
trauma-informed perspective to services for women who have lost custody
of their children should start with a more formal acknowledgment that the
woman may be struggling with parallel manifestations of both grief and trauma.
It is also important to recognize that women with trauma histories are more
likely to experience subsequent grief as complex trauma (Cantwell-Bartl, n.d.).
This is particularly relevant to our work, since more than 80 per cent of the
women we see at the Jean Tweed Centre for help with substance use have also
experienced trauma.
According to Jacobs (1999), the criteria for traumatic grief must include the
death of someone close to the mourner. The apprehension of a child may be
seen as a logical extension of this criterion, as a series of losses that have a
cumulative effect rather than as a single defining event. Further, we know that
people who have experienced grievous loss feel varying degrees of anger, guilt,
sadness, depression, hopelessness and numbness (Doka, 1989). In cases of
“disenfranchised grief”—that is, when the grief is connected with a loss that
cannot be openly acknowledged, publicly mourned or socially supported—
these feelings can persist for a very long time.
Unlike a “normal” profound loss, such as the death of a loved one, there are no
rituals or rites to facilitate and validate the maternal grieving process involved
in a loss of custody: there is no announcement of the loss of custody, no
recognition of the loss of the child’s place in relation to others, no allowance
for public expression of grief, no opportunity for community members to
come together to offer empathy and support. Mourners who feel alienated
from their community and lack recognition of their loss often experience grief
more intensely than they might otherwise have done (Robinson, 2001). Indeed,
when feelings are denied, especially when they are cemented in place by
shame and fear, they can become more powerful.
Chapter 23 A Mother’s Loss 291
In recent years, our Toronto-based community partners have identified gaps

in services for women dealing with custodial loss. The participation of
bereaved mothers in research conducted by the South Riverdale Community
Health Centre (Bannerman et al., 2009), has deepened our understanding of
common themes that underline the ways in which women’s grief mirrors
trauma responses.
In 2006, the Young Parents with No Fixed Address Committee of Toronto

commissioned a study on service interventions and gaps in services for
women who have lost custody of their children. A literature review and
interviews with health practitioners found that women who experience
custody loss/apprehension are likely to be vulnerable and disadvantaged
mothers, often marginalized because of poverty, socio-economic status,
race, mental health and substance use problems and immigration status
(Novac et al., 2006). Perhaps not by coincidence, the women who experience
this type of unacknowledged and often unresolved grief are primarily an
invisible population of women whose voices are often silenced. In Canada,
poor women, Aboriginal women and women of colour are the most
vulnerable to arrest, child apprehension and poor health outcomes (Boyd
& Marcellus, 2007).
Mirroring Trauma Responses

The need for a trauma-informed perspective to support women through
and beyond the loss of child custody is highlighted by the women’s
descriptions of their feelings and behaviours. The following common
trauma-like responses emerged from the stories shared in research
conducted on grief and loss with women who experienced child custody
loss (Bannerman et al., 2009).
Numbing/self-punishment: As a coping strategy, women increased their

drug use to manage feelings of shame, guilt, “dead aloneness” or
isolation, loneliness, hopelessness, pain and anger. Self-punishing
behaviours, including unsafe drug use and lifestyles and even deliberately
putting oneself in harm’s way, were common responses to the shame and
pain associated with child apprehension. In the words of one woman:
It f***** me up for years [when my child was taken into care]. I was
on another planet for the next five years. I was devastated. I pretty
much tried to kill myself for the next five years. No one checked on
me afterward.
Powerlessness: Feeling powerless was associated with many situations,

including the absence of supportive services for bereaved mothers. Women
also described feeling separate from the legal process after their children were
apprehended. Court dates come and go, and some mothers are left feeling
like they were not involved in the process. According to another woman:
We are ants facing an elephant. We are women who have survived

abuse, poverty, lack of parenting role models and have been negatively
labelled by society.
Betrayal: Women reported having confided in their child welfare worker, only
to have the information used in proceedings against them. This leaves them
wondering who “their worker” is.
Silencing: The vast majority of women whose children have been apprehended
are assigned a legal aid representative. While some of these lawyers may be
very committed, they are not always informed or able to meet with clients
before their first appearance in court to explain the legal proceedings and to
ask for their directives. As a result, women feel they do not have a voice in
legal proceedings, which determine, among other things, the nature and
extent of access to their children.
Shame: As discussed earlier, society continues to judge some mothers as not

fit to parent. The court process of custodial loss can be very humiliating; not
only are the women’s parenting skills being called into question, but also their
lifestyles. These judgments may be internalized and women begin to doubt
their ability to parent.
Unrealistic expectations: For mothers to regain custody, they must respond to

a barrage of expectations (e.g., urine screens, hair strand tests, mental health
assessments, substance use treatment, supervised access visits). They may be
required to attend programs; however, lengthy waitlists, lack of transportation
and other barriers associated with poverty make it more difficult for women to
meet all of the requirements. In the process, they likely do not feel in control
of what is happening and feel excluded from decisions about what it is they
actually need.
Feeling “dead alone”: These were the words a woman used to describe her
experience of losing custody of her child. When a child is made a Crown ward
with no access for the purposes of adoption, the mother will often ask for
photographs and updates. However, once a child is adopted, the adoptive
parents are under no legal obligation to provide any information. Birth
mothers are often left feeling alone, isolated, angry, confused, ashamed and
utterly devastated.
Strategies to Minimize the Trauma

of Apprehension
Schachter et al. (2009) developed nine principles of sensitive practice for
health care practitioners supporting adult survivors of childhood sexual abuse.
These principles parallel support strategies for women who have lost custody
of their children to child welfare.
1. Nurture respect: Mistrust of professionals is common. It is important to

acknowledge and validate this response; in so doing, trust may develop.
2. Take time: Spend time listening. Women want to feel genuinely heard and
valued. Offer your time to participate in meetings with child welfare workers,
doctors, nurses and other professionals as a support/advocate. Help women
obtain a legal aid certificate; accompany them to court/legal appointments if
they think this is helpful.
3. Establish rapport: This is a very difficult time for a mother; she can often
feel alone and like she is “just another client.” Stay connected to her, even
when she finds it hard to connect. Many service providers withdraw support
when there is no longer a child involved. It is important to stay involved with
the woman before, during and after she gives birth, regardless of whether the
child is in her care.
4. Share information: Provide practical, non-judgmental information about

substance use, pregnancy and parenting. With pregnant women, explore
what they want in terms of their birth plan and substance use (whether it is
abstinence, safer use or reduction) and parenting goals. Provide information
and referrals to community resources. It is important to help women feel they
have choices. Demonstrating your belief that they know best what they need
may be the most helpful service you provide.
5. Share control: When a referral to child welfare is deemed necessary, it is

important, whenever possible, to involve the mother in a discussion and
support her in making the call herself where possible. If the woman is pregnant
(especially if she has had previous child apprehensions), ensure that a plan is
in place before the birth. If an apprehension is going to happen, explore how
the woman would feel best supported through the process. Who should be
present when the baby is taken into care? How soon after the apprehension
will she have access to her child? If this is an apprehension at birth and the
mother has identified parenting as her goal, advocate with hospital staff and
child welfare authorities a plan that supports the bonding of mother and child
immediately following birth. Explore alternative parenting arrangements as
appropriate. Does the mother have family or friends who might be willing to
care for the child as an interim measure, or longer if necessary?
6. Respect boundaries: Women must be aware of your limits to confidentiality

and how their information may or may not be shared. Giving women some
choice at the outset about how information is shared will go a long way in
building trust and minimizing feelings of betrayal.
7. Foster mutual learning: This will be a difficult time for both the woman
and you as a helping professional. Every woman’s experience is different and
support needs will vary. Being honest about your knowledge of the process
and your potential areas for learning can help to foster a relationship with the
mother in which she feels like she has a “partner” in the process.
8. Understand non-linear healing: Just as women’s experiences of losing

child custody will be different, so will their healing processes. Women will
have varying degrees of tolerance for support and treatment. Support women
to share with you how they are feeling, if they are ready and interested in
treatment and what type of services they feel would be most beneficial.
9. Demonstrate knowledge about interpersonal violence: Promote a

collaborative and trauma-informed response with other service providers
involved with the mother and child.
Effects of Child Apprehension on

Service Providers
According to Novac et al. (2006), service providers who work with women
whose children have been apprehended are often affected by the intensity of
this work and the implications of their actions, sometimes triggering their
own experiences with grief, loss and trauma. This has sometimes been referred
to as vicarious trauma (McCann & Pearlman, 1990). Service providers may
face various challenges:
Tension/role conflict: Service providers who work with mothers face their
own stress, including a tension between service provision and the duty to
report harm to a child. They often report feeling conflicted about when to
refer to child welfare services. This situation is always difficult and may affect
the relationship mothers have with service providers.
Uncertainty/lack of clarity: There are definite grey areas involved when working
with mothers whose children have been apprehended. One of these can be
the range of responses from child welfare in relation to substance use. The
use of cannabis is one example where views differ; alcohol use is sometimes
treated differently than illicit use of other drugs, and prescription drug use
may also be viewed differently.
Stress: Role conflict between service providers can cause tension and stress.
Although child welfare and support workers hope to work collaboratively, differences
in mandate sometimes make it difficult to achieve a collaborative response.
Stretched: With limited funding and resources, many service providers,

including child welfare workers, are dealing with increased caseloads and
more onerous documentation requirements. They may feel stretched by these
demands, which may be reflected in their interactions with mothers, other
service providers and their own families.
Emotional response: When there is a close working relationship with a

woman and she loses her child, we empathize with her pain and may feel the
loss of our own relationship with the child. Service providers who are not
aware of their own emotional response and who do not have access to clinical
supervision may become cynical, harsh or burned out. This may manifest
itself in stress-related illness (Schmid, as cited in Novac et al., 2006, p. 30).
Schmid recommended that service providers address the following questions
to prepare them to deal with their clients and their own grief:
• How do I help my clients recognize their pain and work through this?
• How does their pain affect me?
• Is there grief and loss for me as a support worker, and what do I do about it?
• What is our agency doing to enable and equip me to deal with my response
to the losses our clients have encountered?
Creating a Space for Women to Use

Their Voices
The catalyst for a new partnership program between the Jean Tweed Centre
and the South Riverdale Community Health Centre was a 2009 research
project, in which women were invited to share their experiences of losing
child custody. Women said that this project marked the first time they had
been invited to share their stories about apprehension. It was also their first
opportunity to explain how they felt during and after the loss and what they
needed now to carry on. One participant described having searched for
services to address her grief and trauma for the past 16 years. Almost all of
the women spoke of a critical need for programs in this area and said that
they would participate if such programs existed.
After extensive study of the women’s responses, a 15-week pilot group was
proposed—the Grief and Loss Education and Action Group. The goal was to
provide an opportunity for women to speak and to be heard and acknowledged
around experiences of grief, loss and resilience—one mother to another. The
group was organized around the central themes of telling stories, building on
and learning new coping strategies, consciousness-raising, creating art and
taking social action, which included engaging in a dialogue with child welfare
representatives to support a shift in practice toward a harm reduction

philosophy (Kenny & Druker, 2011).
The Grief and Loss Education and Action Group recently completed a third
cycle and is into the fourth cycle. Women from the first, second and third
groups continue to meet once a month to support one another and advance
their work on action-oriented goals. In response to women’s ideas of wanting
to raise awareness among service providers about this under-recognized form
of grief, women were trained in public speaking and have used this new skill
to educate service providers, social work students and women living in the
shelter system who may have had similar experiences.
Conclusion
Given the judgment that pregnant and parenting women who use substances
face in society, it is not surprising that the grief/trauma response to child
apprehension is complicated for both the mothers and those who work with
them. Service providers have much work to do to bring attention to this
under-recognized form of grief. We must shift how we engage women who
use substances toward an approach that respects and acknowledges women’s
grief and expertise—the skills and knowledge they have gained in their lives
in responding to the effects of trauma. Women need to feel understood and
that they are valued collaborators. In this way, service providers and women
together can turn angst into action.
Many thanks to the women whose life experiences inspired this chapter.
References
Bannerman M., Kenny K. & Judge C. (2009). Women and CAS: Experiences of Grief and Loss.
Toronto: South Riverdale Community Health Centre.
Boyd, S.C. & Marcellus, L. (Eds.). (2007). With Child: Substance Use during Pregnancy. A Woman-
Centred Approach. Halifax, NS: Fernwood.
Cantwell-Bartl, A. (n.d.). Is This Person Suffering Grief or Trauma or Traumatic Grief?
Doka, K.J. (1989). Disenfranchised Grief: Recognizing Hidden Sorrow. Lexington, MA:
Lexington Books.
Jacobs, S. (1999). Traumatic Grief: Diagnosis, Treatment and Prevention. New York: Bruner/Mazel.
Kenny, K. & Druker, A. (2011). “Ants facing an elephant”: Mothers’ grief, loss, and work for
change following the placement of children in care of child protection authorities. In D.
Barrett (Ed.), Children of the Drug War: Perspectives on the Impact of Drug Policies on Young
People (pp. 151–170). New York: International Debate Education Association.
McCann, I.L. & Pearlman, L.A. (1990). Vicarious traumatization: A framework for understanding
the psychological effects of working with victims. Journal of Traumatic Stress, 3(1), 131–149.
Novac, S., Paradis, E., Brown, J. & Morton, H. (2006). A Visceral Grief: Young Homeless Mothers
and Loss of Child Custody (Research Paper 206). Toronto: Centre for Urban and Community
Studies, University of Toronto.
Robinson, E. (2001). Adoption and loss: The hidden grief. Retrieved from www.ccnm-mothers.ca/
English/articles/Robinson.htm
Schachter, C.L., Stalker, C.A., Teram, E., Lasiuk, G.C. & Danilkewich, A. (2009). Handbook on
Sensitive Practice for Health Practitioners: Lessons from Adult Survivors of Childhood Sexual
Abuse. Ottawa: Public Health Agency of Canada.
PART 3
SECTION 2: INNOVATION
24 Collaboration between Child Welfare and Substance Use Services
25 What Do Client Rights Have to Do with Trauma-Informed Care?
26 Integrated Screening, Assessment and Training as Critical Components

of Trauma-Informed Care
27 Breaking Out of the Mould: Creating Trauma-Informed Anti-violence

Services and Housing for Women and Their Children
28 Integrating Treatment of Tobacco with Other Substances in a

Trauma‑Informed Way
29 Responding to the Women: YWCA Toronto Moves Its Practice to a

Trauma-Informed Approach
301
Chapter 24
Collaboration between Child

Welfare and Substance Use Services
Diane Smylie and Carolyn Ussher
Traditionally, the mandates of child welfare services and services for women
with substance use problems have been viewed as competing, with child
welfare focusing on the children and the substance use sector focusing on the
women, making the two services incompatible. For the many women1 and
children who have had traumatic experiences and who are involved with both
sectors, this polarization can contribute to further traumatization.
This chapter explores how collaboration between the child welfare and
substance use fields is a trauma-informed practice. A broader, interconnected
understanding of child safety and the impact of trauma on parents can lead to
better outcomes for both children and women involved with substance use
and child welfare services. The chapter focuses on what this collaboration
means for service delivery and policies in both sectors and on the corresponding
need for collaboration at the practitioner, organizational and system levels.
The Context
The link between a history of trauma and problematic substance use has been
well documented in the literature and is captured in other chapters in this
book. However, this link is often not reflected in service responses for women
1. While this chapter focuses on collaboration as it relates to services for mothers, there is also a need to think
about how services can respond to the needs of fathers or male partners with a history of trauma.
who are involved with child welfare and substance use services. In the
Canadian Incidence Study of Reported Child Abuse and Neglect, Trocme et al.
(2005) noted that in substantiated child maltreatment cases, alcohol and other
drugs were identified in 14 to 18 per cent of cases involving female caregivers
and 17 to 30 per cent of cases involving male caregivers. In the United States,
it is estimated that 50 to 80 per cent of parents involved in the child welfare
system have substance use problems (Child Welfare League of America, 1998,
as cited in Marsh & Cao, 2005, p. 1262). Given this situation, it is important
to understand the links among trauma, substance use and involvement with
child welfare and find ways to support multi-burdened women as they negotiate
these two systems of service and attempt to provide a healthy environment for
their children.
A growing body of literature illustrates the connection between early childhood

trauma and changes in brain development. “Research suggests that too much
negative stimulation (in the form of abuse) or too little positive stimulation (in
the form of neglect) can both upset the delicate balance between higher and
lower regions in the young brain” (Perry, 1997, p. 13). This imbalance contri
butes to various problems, including difficulties coping with environmental
stressors (Mustard & Cynader, 1997). Neglect and abuse put the child on a
“chronic alert for danger,” and “as that child grows older, any perceived threat
in the environment, however slight, may cause a powerful surge of stress
hormones through all body systems, which greatly reduces the individual’s
capacity to cope with challenges” (Mustard & Cynader, 1997, p. 13). People who
experience childhood trauma are at a higher risk of adopting unsafe coping
behaviours, which include problematic substance use (National Executive
Training Institute, 2005).
Parents—both mothers and fathers—may have had child welfare involvement

over the course of their lives. A traumatic experience, such as having been
removed from their own parents’ care as children, can increase the complexity
and stress of their current interactions with child welfare and should be
considered by both child welfare and substance use service providers when
developing service responses. This is an example of how retraumatization in
the course of interactions with child welfare has the potential to increase the
risk of unsafe substance use, which may in turn affect child safety and well-
being. For many people who have experienced trauma, the very presence
of child welfare, no matter how well-intentioned, can trigger shame and
Chapter 24 Collaboration between Child Welfare and Substance Use Services 303
humiliation when they feel that their parenting and lifestyle are under investi
gation, and they may respond aggressively in response to these feelings
(National Executive Training Institute, 2005). Such responses are often
misunderstood by child welfare workers and can be seen as “resistance” or
“lack of insight,” further complicating the situation and increasing stress.
Overall, the real or perceived threat of losing custody of a child creates a

situation of “power over” parents that would be very difficult for most people to
manage, and for those with histories of trauma, can trigger responses related
to past situations over which they had no control and were overwhelmed. The
stress that parents experience in their interactions with child welfare may result
in a return to previous or more risky patterns of substance use that can in turn
undermine their parenting capacity and custody goals. Acknowledging the
power imbalance and the related potential for retraumatization is a central step
in developing approaches that are supportive rather than coercive or punitive.
Issues related to trauma and child welfare are compounded for mothers. Not
only are women more likely to have frequent child welfare involvement related
to their substance use, but also the stigma directed to pregnant and parenting
women who have problems with substances remains firmly entrenched
(Greaves & Poole, 2005). The presence of child welfare, combined with a
trauma history and a fear of losing children, places women at high risk for
acute trauma responses and more chaotic substance use (Greaves et al., 2004).
It is because of this context that the child welfare and substance use services
must collaborate in a way that ensures that the mother (parental)/child
relationship remains at the centre of service planning and communication.
However, despite this clear need for collaboration, achieving it has often been
challenging (Drabble & Poole, 2011).
Collaboration as a Trauma-Informed Approach

Family preservation, child safety, healing from trauma and trauma prevention
are interconnected goals for women accessing both child welfare and substance
use services. While these two sectors have historically operated separately, some
jurisdictions are now moving to a more collaborative, integrated approach.
Through collaboration, dialogue and knowledge exchange, substance use and

child welfare service systems can work toward integrated service delivery that
minimizes the risk for further trauma and promotes healing for parents with
trauma histories. This is key to helping parents meet their custody goals and
support the development of safer family environments for their children.
Implications for Direct Service

in the Substance Use Field
Three-way communication: When working with a woman seeking assistance
for a substance use problem, the service provider can discuss the benefits of
three-way communication among the client, the substance use counsellor and
the child welfare worker. Two benefits are the opportunity to report strengths
and progress to child welfare rather than only reporting child-related risks as
required by legislation, and to support and advocate for the parent throughout
the child welfare process. While it may be difficult at the outset to explain the
concept of open communication between the sectors, this is an important step
toward service co-ordination that can improve outcomes for both child and
mother. In some cases, child welfare may contact the substance use clinician
first and, with signed consents, discussion can inform the substance use
assessment and service planning. Child welfare often has a wealth of information
that can help to support caregivers and children.
Support for parenting: Mothers involved in child welfare are often under-
standably anxious about their children and the threat of losing custody.
Understanding this anxiety and working collaboratively to support parenting
that enhances safety and well-being of the children gives parents a sense of
competence. The service provider has an opportunity to help normalize
parental reactions and educate parents about how trauma responses may be
playing a role in coping and parenting. It is important for substance use
counsellors to be open to hearing about child functioning and safety and how
the parent’s substance use and other coping behaviours may affect parenting
and hence the child’s safety.
Seamless, supportive planning: When service plans are co-ordinated and

inform one another, care and support is neither disjointed nor adversarial.
Safety plans for both mother and child can be negotiated in a way that
minimizes fear and shame and supports the mother’s engagement.

Conversely, lack of communication among child welfare, substance use
services and the client can result in blind advocacy for the mother (or child),
which reinforces maternal feelings of powerlessness, limits healing and
compromises safety for both mother and child.
Reducing the potential for retraumatization through advocacy: Professionals

working in the substance use sector can act as allies in the child welfare
journey by attending case conferences and helping the client to process child
welfare information. If there is concern about the child having been exposed
to potentially traumatic situations, child welfare may recommend a trauma
assessment for the child and a co-ordinated approach with the parent. In some
situations, trauma may affect attachment and development, and service
providers can lend their expertise to encourage interventions that collaboratively
support the mother and child.
An example of this trauma-informed, collaborative work in action is the

Pathways to Healthy Families program based at the Jean Tweed Centre in
Toronto. A comprehensive day program, specifically for women and their
children, is offered, as well as various outreach components. Representatives
from child welfare agencies in Toronto were consulted during the development
of the seven-week day program. The program provides an opportunity to
address attachment, parenting and substance use concerns. One objective
that was identified through the development process is improved relationships
between child welfare and participating women. Two program components
promote this objective: a mid-point meeting between participants and their
child welfare workers, where women are encouraged to speak about their
progress; and a workshop with a child welfare staff member, where women
can consult with someone other than their worker and question policies,
options and rights without discussing their specific relationships and history
with child welfare. This program has extremely high satisfaction and
retention rates.
System-Level Collaboration for Trauma‑Informed

Child Welfare and Substance Use Services
Although trauma-informed service planning and policy developments have
not always been the stated goal underlying collaboration, the corresponding
shift away from a siloed approach has promoted a range of trauma-informed
services. The following section describes how child welfare and substance use
service systems in Toronto have built collaborative bridges that have expanded
and strengthened trauma-informed practice.
For more than 25 years, the Jean Tweed Centre has been providing substance
use programming for women. In the course of the agency’s development, it
became apparent that women seeking assistance with their substance use
were often dealing with a history of trauma and child welfare involvement. In
response, the centre began designing a trauma-informed service that focuses
on supporting mothers and their children. This has involved ongoing learning
about the effects of trauma, particularly women’s concerns about their
parenting abilities as the consequence of growing up in unsafe and non-
nurturing environments themselves.
A growing awareness of the relationship between trauma, substance use and

mothering became the impetus to connect with local service providers in the
allied fields of children’s mental health, child development and child welfare.
Dialogue between these stakeholders about the need for more integrated ways
of working in partnership led to the development of Breaking the Cycle, a program
for substance-using pregnant women and new mothers and their children in
downtown Toronto.
When funding became available through the province’s Early Childhood

Development Addictions Initiative (ECDAI), stakeholders worked with the
Jean Tweed Centre to develop an expanded model of service, which included
forming an outreach counselling service in partnership with various community-
based agencies and child development and child care services. Through this
initiative, the centre also began to work closely with the child welfare sector in
a service co-ordination capacity and provide training to child welfare workers
on topics such as problematic substance use, harm reduction, trauma,
parenting and stigma. To support cross-sectoral training, regular consultation
sessions were arranged with two local child welfare agencies. Every six weeks,
supervisors from the Children’s Aid Society of Toronto and the Catholic
Children’s Aid Society of Toronto provided consultation to staff working with
mothers involved in child welfare. These consultations yielded insights into
the concerns and perspectives of child welfare and served as a front-line
forum for dialogue that encouraged a better understanding of sector-specific
mandates and how these shaped service delivery.
Knowledge exchange was further supported by ECDAI funding of an annual

conference for Ontario service providers, featuring speakers and workshops
on issues related to substance use, parenting and child development. Another
initiative developed through the ECDAI was the collaborative development of
Practice Guidelines between Toronto Substance Abuse Treatment Agencies and
Children’s Aid Societies (Working Group, 2005). This marked the first time
that representatives of all four of the city’s child welfare agencies worked
collaboratively with staff from five substance use service agencies to develop
a policy document.
A significant contribution to embracing a collaborative climate was the intro-

duction of the Transformation Agenda 2005 (Ministry of Children and Youth
Services, 2005) to the child welfare sector in Ontario. This policy supported a
move away from service delivery that focused primarily on risk and deficits to a
system that supports a flexible approach to child welfare and linkages across
systems. Key in this approach is the differential response model that emphasizes
focusing on strengths and needs, identifying community resources and
engaging families voluntarily in supportive child welfare service. It strengthens
the working relationship between the child welfare and substance use service
sectors and sets the stage for improved collaboration and service provision,
consistent with a trauma-informed approach. In taking a more holistic
approach to supporting and engaging women with substance use problems,
this approach facilitates improved understanding of how trauma may be
shaping current interactions with child welfare, parenting and substance use
services. This understanding is the foundation of a more compassionate and
helpful approach on the part of all systems of care in a position to assist parents.
Funding to achieve the goals of the Transformation Agenda supported

the Jean Tweed Centre and the Centre for Addiction and Mental Health to
work with child welfare to deliver Strengthening Families for the Future,2
a prevention program for families affected by substance use and/or mental
health issues. This collaboration has provided a unique opportunity for child
welfare staff to co-facilitate a strengths-based, trauma-informed drug prevention
program with service providers from the substance use treatment sector.
More recently, the Ministry of Children and Youth Services has funded
a three-pronged initiative that supports:
1. the introduction to children’s aid societies (CAS) of a Jean Tweed Centre

substance use consultant who accompanies child welfare staff to client
meetings in the community and provides case consultation and team-based
training to intake staff
2. the collaborative development of child welfare practice guidelines

for intake
3. provincial online training on substance use problems and addiction

for child welfare service providers.
In all three projects, trauma-informed care in a child welfare context has been
identified as a central theme. It was included as a module in the online training
and a principle in the practice guidelines and was integrated throughout
consultations and training for CAS intake.
The collaboration in Toronto has been the product of many people and
organizations understanding the need to move toward a shared philosophy
and values to better serve women and their families. It has led to a cross-
sectoral system that is much more responsive, staffed by managers and
service providers who have a far deeper understanding of how trauma often
affects the families with whom they work. Moreover, the collaboration has
equipped front-line workers with the tools to increase child safety in a way
that values and supports healing for parents who themselves grew up in
unsafe environments. This movement has occurred slowly over the past two
decades. It has required all those involved to stretch and challenge themselves,
2. Strengthening Families for the Future is a 14-week manualized program, updated with input from Ontario
treatment agencies from the original Strengthening Families program designed by Karol Kumpfer.
Visit www.camh.ca and do a keyword search.
to be willing to engage in dialogue, to find ways of building bridges to connect

and support mandates that were once deemed incompatible. Further progress
requires continued commitment and expanded implementation of trauma-
informed practices.
Conclusion
When trauma-informed support for women with substance use problems and
safety for women and their children are understood to be interconnected,
service responses can avoid contributing to further traumatization. When
services, program design and policy practices recognize how traumatic
experiences can shape interactions with the child welfare and substance use
systems, we can not only reduce risks to women and children, but also promote
opportunities for attachment and healing.
The efforts made in Toronto are a model of how trauma-informed practices

can bridge the seemingly disparate mandates of child welfare and substance
services for women. While the model may not be replicable in other
jurisdictions with different community contexts, it can provide ideas and
inspiration for improving trauma-informed collaboration between these
two sectors.
References
Drabble, L. & Poole, N. (2011). Collaboration between addiction treatment and child welfare fields:
Opportunities in a Canadian context. Journal of Social Work Practice in the Addictions, 11, 124–149.
Greaves, L., Pederson, A., Varcoe, C., Poole, N., Morrow, M., Johnson, J. et al. (2004). Mothering
under duress: Women caught in a web of discourses. Journal of the Association for Research
on Mothering, 6(1), 16–27.
Greaves, L. & Poole, N. (2005). Victimized or validated? Responses to substance-using pregnant
women. Canadian Woman Studies, 24(1), 87–92.
Marsh, J.C. & Cao, D. (2005). Parents in substance abuse treatment: Implications for child
welfare practice. Children and Youth Services Review, 27, 1259–1278.
Ministry of Children and Youth Services. (2005). Child Welfare Transformation 2005: A Strategic
Plan for a Flexible, Sustainable and Outcome Oriented Service Delivery Model. Ottawa: Author.
Mustard, F. & Cynader, M. (1997, Spring). Brain development, competence and coping skills.
Entropy, 1(1), 5–6.
National Executive Training Institute. (2005). Training Curriculum for Reduction of Seclusion and
Restraint. Draft Curriculum Manual. Alexandria, VA: National Association of State Mental
Health Program Directors, National Technical Assistance Center for State Mental Health
Planning.
Perry, B.D. (1997). Incubated in terror: Neurodevelopmental factors in the “cycle of violence.” In
J.D. Osofsky (Ed.), Children in a Violent Society. New York: Guilford.
Trocme, N., Fallon, B., MacLaurin, B., Daciuk, J., Felstiner, C., Black, T. et al. (2005). Child
Incidence Study of Reported Child Abuse and Neglect–2003: Major Findings. Ottawa: Minister of
Public Works and Government Services.
Working Group for Practice Guidelines between Toronto Substance Abuse Treatment Agencies
and Children’s Aid Societies. (2005). Practice Guidelines between Toronto Substance Abuse
Treatment Agencies and Children’s Aid Societies. Retrieved from www.jeantweed.com/
wp-content/themes/JTC/pdfs/Knowledge.pdf
311
Chapter 25
What Do Client Rights Have to Do

with Trauma-Informed Care?
Jennifer Chambers
Abuse and other experiences of trauma are about violations: of our bodies,
our minds, our basic human needs, our choices. There is considerable
evidence that most people attending mental health facilities are survivors of
abuse (Cusack et al., 2003; Firsten, 1991; Rose, 1991; Weaver et al., 1994) and
that abuse survivors have a high likelihood of developing an addiction (Bryer
et al., 1987; Rose, 1991). One might reasonably expect that mental health
services would be structured to acknowledge and address this reality. Yet mental
health service providers typically ignore people’s trauma histories (Firsten,
1991; Frueh et al., 2001; Weaver et al., 1994). This is particularly true of people
labelled “seriously mentally ill” (Bryer et al., 1987), who are most likely to
spend time in a psychiatric institution and for whom a history of trauma is
often disregarded, as if they are “too sick” for that to be significant (Grubaugh
et al., 2011).
This failure to grasp the need for trauma-informed care has meant that
treatment services fail to acknowledge that they themselves can be
traumatizing (Cusack et al., 2003; Nibert et al., 1989). As a result, rights
that could protect clients from further trauma are often seen as interfering
with care. In fact, client rights are essential to any good care, especially
trauma-informed service.
Rights are about who gets to exercise power and control over a person or
group and the resources they need. People with trauma histories have
experienced a loss of control over their own lives, and service providers need
to be aware of how their approach to care can be experienced by clients as
another traumatizing experience—yet another context where control is not in
their hands.
Rights are about boundaries that protect individuals from harm. Recognizing
and respecting client rights can be seen as a guide to creating a safe environment,
without which nothing good can happen.
For decades, clients and their supporters have been describing how mental
health services can be frighteningly coercive. Only now has this reality begun
to be recognized. In the systemic overemphasis on the medical model approach
to treatment, people’s life experiences and how these interact with their
environment are often treated as irrelevant. Self-identified needs are eclipsed
by the expectation that clients comply with medical instructions, despite
evidence that self-identified needs are a better predictor of good outcomes
and that empowerment promotes recovery (Crane-Ross et al., 2006; Roth &
Crane-Ross, 2002).
The Empowerment Council

The evolution of trauma-informed care at the Centre for Addiction and
Mental Health (CAMH) rests on a foundation of client empowerment.
Change that affects individuals who access health care services does not occur
in a vacuum; it needs support at a policy level, including commitment to an
organizational culture that respects client rights and input. To guide the
process of creating a healing space, there needs to be an independent voice
that both represents and is accountable to the people that services are
intended to help. The establishment of the Empowerment Council at CAMH
in 2001 and the subsequent development of the CAMH Bill of Client Rights
illustrate the convergence of trauma-informed care and fundamental
principles promoting informed choice, safety and self-determination.
The Empowerment Council is an independent, client-run organization.

Members, the board and staff are current or former clients of mental health
and/or addiction services. In the early 1990s, the Ontario government
directed all of the psychiatric hospitals in the province to set aside funding to
Chapter 25 What Do Client Rights Have to Do with Trauma-Informed Care? 313
create and sustain their own patient councils. Each council was intended to be
a voice for the people on the receiving end of these hospital services. After two
mental health and two addiction facilities in Toronto were merged into the
Centre for Addiction and Mental Health, CAMH decided that it needed a voice
to represent clients at all four sites. (Previously only the Queen Street Mental
Health Centre had an organization representing clients, known as the Queen
Street Patients’ Council.) In March 2001, people with personal experience of
the mental health and addiction systems met to decide on the mission and
purpose of their new organization and to elect representatives from among
themselves to move this mission forward. In time, the organization was
named the Empowerment Council.
Historically, the rights of users of health care services and the approach of
service providers have seemed to be at odds with each other. The creation of
the Empowerment Council was a means for clients to have their own voice.
One of the most important things clients have had to say involves the impact
of traumatic experience. If this were really heard and understood, it would
fundamentally change the way mental health facilities operate.
How Trauma-Informed Care Converged

with Client Rights
In 2005, the CAMH Bill of Client Rights was created to “emphasize the rights
of clients rather than organizational convenience” (Centre for Addiction and
Mental Health, 2005, Preamble). Throughout the three-and-a-half year
process of developing it, the Empowerment Council consulted extensively
with CAMH clients, negotiated with CAMH on behalf of all of the people who
use its services, then went back to clients with the organization’s response on
each proposed right. Each of the 10 rights is based on actual client experiences:
CAMH took seriously clients’ rendition of their bad experiences and their
suggestions on how to remedy problems through the bill.
The discussion process highlighted the vulnerability of people interacting with

a psychiatric institution when it comes to respect for basic human rights.
Initially, there was some debate about whether to follow the tradition of many
hospitals and create a “rights and responsibilities” document. The Empowerment
Council pointed out that no other oppressed group has responsibilities

attached to its rights. Do women get equal pay for equal work only if they also
do the dishes? Rights are meant to rebalance inequity; they are not privileges
that must be earned. It was particularly important to clarify this point, given
that basic human needs have often been treated as “privileges” in the environ-
ment of a psychiatric institution. The bill also went beyond the 10 vague
“motherhood” statements that often comprise hospital bills of patient rights.
Clients stated, and CAMH agreed, that in order to be meaningful, rights need
to be specific.
There was lively discussion about such concerns as whether the word “rights”
should be changed. It was suggested that the word “rights” is too confrontational
(as it supported clients having expectations about how they deserved to be
treated), and that this could interfere with staff goals requiring clients to
compromise these same rights: for example, a voluntary client gave up her
right to go outside because she was threatened with a withdrawal of all
services if she did not comply. The Empowerment Council asked whether
anyone would find this idea acceptable if it were applied to the rights of another
group of oppressed people. Should rights related to racial discrimination be
removed in order not to interfere with compromises sought by white people?
The question was also asked why patients should have rights when staff does
not have rights. A CAMH human resources professional pointed out that this
was a ridiculous statement; staff does have rights: it has a collective agreement.
It helps to have champions among the powerful.
In another instance, a senior physician said that there was no need to include
the right not to be abused “because it never happens.” A CAMH manager
openly disagreed, observing that abuse does occur, and that is why CAMH
needs the Empowerment Council and the bill. “The right to be free from
physical, sexual, verbal, emotional and financial abuse” has been enshrined in
Right #2: Right to freedom from harm. The development of the bill provided
opportunities for these kinds of ethically inconsistent perspectives to come
forward and be addressed. Clearly, it is far better that the rights of clients be
sorted out in boardrooms than having to be fought for by vulnerable people
alone on a ward.
If a mental health facility decides that trauma-informed care is a priority, it

must first look to itself and whether it is a source of healing or a contributor
to further trauma. While there has been very little attention to the psychiatric
hospital as a source of trauma, what research does exist has found that a
substantial percentage of people have experienced traumatic events while in
the institution (Cusack et al., 2003; Nibert et al., 1989). CAMH adopted a
client-driven bill of rights as both a process and an end product, and it has
continued to support these rights through ongoing education. Although it is
not always possible to ensure that rights are respected in practice, having a
common understanding and awareness of their rights grants clients the safety
of knowing what to expect, with a means of getting assistance or appealing if
their rights are not respected. (At CAMH, individual advocacy is available to
clients through the Psychiatric Patient Advocacy Office and the client relations
officer, with systemic advocacy by the Empowerment Council.)
Many of the rights endorsed in the bill pertain to self-determination and the
opportunity to exercise meaningful choice. A pervasive complaint by users of
mental health and addiction services is that choice is meaningless when people
are subject to coercion if one particular treatment recommendation (almost always
for a psychiatric medication) is not accepted. Thus, Right #4 states: “Every
client has the right to a choice of services, and will not be denied other options
if the client does not choose one treatment or service.” Coercion is not care, and
service providers must give up the notion that compliance is a desirable goal.
Trauma-informed care mirrors the concept of individualized care, meaning

that a person’s self-identified needs, not diagnostic categories or institutional
convenience, drive the structure and content of the care plan. One must be wary
when implementing changes that the same old ways are not just being repackaged.
(For example, a client goal recorded as “he wants to comply with medication”
was a clue that a care plan was just a pretense of client self-determination.)
The CAMH Bill of Clients Rights and the Empowerment Council illustrate
the need for providers of trauma-informed care to lead by example. Both are
designed to maximize client safety, actual and perceived. Rights violations are
about the undue imposition of one person’s will on another. If people who
are supposed to care for others trample their rights and violate their personal
boundaries, they are hurting people, not helping them. Clients defending
their rights is a sign of self-respect that should be encouraged. Client rights
are about being treated as full citizens, even in the mental health and
addiction treatment systems. Creating an environment in which these rights

flourish is the first step to making a space for real healing.
CAMH BILL OF CLIENT RIGHTS
1: Right to Be Treated with Respect
2: Right to Freedom from Harm
3: Right to Dignity and Independence
4: Right to Quality Services That Comply with Standards
5: Right to Effective Communication
6: Right to Be Fully Informed
7: Right to Make an Informed Choice, and Give Informed Consent to

Treatment
8: Right to Support
9: Rights in Respect of Research or Training
10: Right to Complain
For the complete CAMH bill of client rights, visit www.empowermentcouncil.ca

or www.camh.ca.
References
Bryer, J., Nelson, B.A., Miller, J.B. & Krol, P.A. (1987). Childhood sexual and physical abuse as
factors in adult psychiatric illness. American Journal of Psychiatry, 144, 1426–1430.
Centre for Addiction and Mental Health. (2005). Centre for Addiction and Mental Health Bill of
Client Rights. Retrieved from www.camh.ca
Crane-Ross, D., Lutz, W.J. & Dee, R. (2006). Consumer and case manager perspectives of
service empowerment: Relationship to mental health recovery. Journal of Behavioral Health
Services and Research, 33(2), 142–155.
Cusack, K.J., Frueh, B.C., Hiers, T., Suffoletta-Maierle, S. & Bennett, S. (2003). Trauma within
the psychiatric setting: A preliminary empirical report. Administration and Policy in Mental
Health, 30, 453–460.
Firsten, T. (1991). Violence in the lives of women on psychiatric wards. Canadian Woman
Studies, 11(4), 45–48.
Frueh, B.C., Cusack, K.J., Hiers, T.G., Monogan, S., Cousins, V.C. & Cavenaugh, S.D. (2001).
Improving public mental health services for trauma victims in South Carolina. Psychiatric
Services, 52, 812–814.
Grubaugh, A.L., Zinzow, H.M., Paul, L., Egede, L.E. & Frueh, B.C. (2011). Trauma exposure and
possttraumatic stress disorder in adults with severe mental illness: A critical review. Clinical
Psychology Review, 31, 883–889.
Nibert, D., Cooper, S. & Crossmaker, M. (1989). Assaults against residents of a psychiatric
institution: Residents’ history of abuse. Journal of Interpersonal Violence, 4, 342–349.
Rose, S. (1991). Acknowledging abuse backgrounds of intensive case management clients.
Community Mental Health Journal, 27, 255–263.
Roth, D. & Crane-Ross, D. (2002). Impact of services, met needs and service empowerment on
consumer outcomes. Mental Health Services Research, 4(1), 43–56.
Weaver, P., Varvaro, F.F., Connors, R. & Regan-Kubinski, R.J. (1994). Adult survivors of
childhood sexual abuse: Survivor’s disclosure and nurse therapist’s response. Journal of
Psychosocial Nursing, 32(12), 19–25.
319
Chapter 26
Integrated Screening, Assessment and

Training as Critical Components of
Trauma-Informed Care
Vivian B. Brown
The chapter focuses on the experiences of PROTOTYPES1, a large non-profit

agency in Southern California, in bringing a trauma-informed approach to its
services for women and children. The catalyst for offering a more integrated
approach to treating women with substance use, mental health and health issues
was the agency’s involvement in the Women, Co-0ccurring Disorders and
Violence Study (WCDVS). PROTOTYPES was one of the nine study sites. As
part of this groundbreaking research, the agency designed and implemented
a trauma-informed approach to treatment in its large residential programs in
Pomona and Ventura and, later, in its large outpatient program for women and
men and its low-cost housing facility for women and their families in Pomona.
The WCDVS was an important study, in that it represented the first federal
initiative in the United States to address the failure of existing services
to address the complex needs of women with co-occurring substance use
and mental health issues and histories of physical and/or sexual abuse.
The five‑year study, funded by the Substance Abuse and Mental Health
Services Administration, found that attending to trauma in addiction and
mental health treatment improves the effectiveness of treatment for women
(Gatz et al., 2007; Morrissey et al., 2005). The study also showed that women
diagnosed with serious mental illness and addiction disorders found trauma-
1. The legal, trademarked name of the agency is PROTOTYPES: Centers for Innovation in Health, Mental
Health, and Social Services.
informed, integrated treatment to be more responsive to their needs and those

of their children than treatment as usual. Lessons learned from the study included
specific steps that were effective in transforming systems from a traditional
approach to a trauma-informed one (see www.nationaltraumaconsortium.org).
Through its participation in WCDVS, PROTOTYPES made significant

changes in its program policies; integrated trauma with its substance use,
mental health, physical health and housing services; and involved consumers in
all aspects of service design and research. The agency has also been influential
in helping the local service system in Los Angeles County to become more
trauma informed. This chapter will outline some of these changes, with a focus
on creating the tools and structural support needed to screen and assess for
multiple concerns in an integrated, trauma-informed way.
Being “Trauma Informed”

Harris and Fallot (2001) state that to be trauma informed means to know
the history of past and current abuse or trauma in the life of the consumer
with whom one is working. It involves understanding the role that violence
and victimization play in the lives of most consumers of substance use and
mental health services and using that understanding to design service
systems that accommodate the vulnerabilities of trauma survivors and
facilitate consumer participation in treatment. In a trauma-informed system,
trauma is viewed as a defining and organizing experience for the survivor.
Facilitating Trust and Safety

In all aspects of trauma-informed approaches to providing treatment, including
screening and assessment, safety is key. Programs need to establish an
environment that is safe, warm, nurturing and welcoming. This environment
gives the women the sense that their recovery matters and that they are
worthy of care and respect. Staff members are trained to treat all women with
respect and warmth and to avoid behaviours that are shaming or aggressively
confrontational.
Chapter 26 Integrated Screening, Assessment and Training 321
As part of an environmental scan, programs need to look at all their

procedures through a trauma lens to avoid or minimize retraumatization.
Trauma survivors may feel vulnerable in situations that might seem non-
threatening under normal circumstances. One potentially upsetting aspect of
care for consumers is not being fully informed of program rules and procedures.
Just as women should be told prior to screening about the kinds of questions
to anticipate, once they are in the program, daily activities they are expected to
attend should be described in detail. Staff members need to be mindful that
the women who may be frightened and overwhelmed may also have difficulty
processing even the most basic information. Therefore, it is helpful to have
the same information repeated a number of times in non-threatening and
non-shaming ways.
An ideal residential treatment program provides the essentials of what Sandra Bloom

(1997) has called “sanctuary.” Program policies and procedures should provide
physical and emotional safety. While seclusion and restraint are obvious examples
of practices that consumers often experience as retraumatizing, many other
procedures, such as how we ask about the multiple issues women may be facing,
need to be similarly examined for their potential to retraumatize.
Discussing these issues is key to an open and genuine collaboration between

provider and consumer in a trauma-informed system. Whenever possible,
consumers choose where, how and when they will receive services. They help
to set service priorities and determine which services will be delivered first.
As Herman (1992) describes, the core experiences of psychological trauma

for the survivor are disempowerment and disconnection. Recovery, therefore,
must involve empowerment and connection. Yet trauma has affected
the survivor’s ability to trust. On one hand, the trauma survivor yearns
for someone she can trust and depend on; on the other hand, she fears that
she will once again be traumatized by any helper.
Trust and safety must be earned and demonstrated over time. By beginning
the new service relationship with an open question about what the woman
wants and what would make her feel more comfortable and safe, the service
provider takes the first step toward establishing safety. Disclosing trauma is
not a requirement to receiving trauma-informed services.
In addition, program staff needs to recognize the impact of historical and

intergenerational trauma for a number of cultures (e.g., African-Americans,
Aboriginal people, people fleeing war-torn countries) and use that understanding
to inform services.
An Integrated and Trauma-Informed Approach to

Screening and Assessment
All service agencies need to begin by screening the women who enter their
programs for trauma histories, as well as for substance use and mental
health issues. The screening can be relatively brief and non-threatening,
following a sensitive and culturally competent process. Consumers should
be told during intake that they will be asked some questions that might be
sensitive. If they do not want to answer specific questions, they should have
the option to say “I do not want to answer.” Historically, we have often taught
our clients to “lie” to us when they feel they have to answer questions that
are uncomfortable or that may lead to negative consequences. For example,
when a program, such as a domestic violence program known not to admit
women with substance use problems, asks potential clients about their
substance use, the women may lie about their substance use in order to be
admitted. If a woman says she does not want to answer a question about
domestic violence, we should respect her choice and understand that
something may be happening in her life that she is reluctant to disclose.
This reluctance to disclose may mean that she fears a negative response; she
was told to be silent by her family or her abuser; or she is feeling shame and/
or guilt. And if the woman does disclose, it is important that we validate the
disclosure and express empathy and caring.
A brief screening instrument was developed in California under the Co-occurring

Joint Action Council (COJAC),2 a state-wide coalition focused on co-occurring
disorders. The COJAC Co-occurring Disorders Screening Tool (Table 1) consists
of nine questions: three about substance use, three about mental health and
2. Members of the COJAC screening subcommittee: Vivian Brown, chair; Richard Browne, LA County Alcohol
and Drug Program Administration; Carmen Delgado, State of California Alcohol and Drug Programs; Joan
Hirose, State of California Department of Education; Rollin Ives, State of California Department of Mental
Health; Lisa Melchior, The Measurement Group; Tom Metcalf, Sutter County; John Mills, LA County Mental
Health Department; Terry Robinson, Alcohol and Drug Policy Institute; Al Senella, Tarzana Treatment
Programs; John Sheehe, LA County Mental Health Department; Karen Streich, LA County Mental Health
Department; Wayne Sugita, LA County Alcohol and Drug Program Administration.
three about traumatic events history. The screener was designed to help integrate
trauma-informed services into treatment—not to exclude anyone from services.
TABLE 1
Co-occurring Disorders Screening Tool
Step 1: Ask the primary screening questions:
3 Questions for mental health:

▫▫ Have you ever been worried about how you are thinking, feeling or acting?
▫▫ Has anyone ever expressed concerns about how you were thinking, feeling
or acting?
▫▫ Have you ever harmed yourself or thought about harming yourself?
3 Questions for alcohol and drug use (Health Canada Best Practice Report):
▫▫ Have you ever had any problem related to your use of alcohol or other
drugs?
▫▫ Has a relative, friend, doctor or other health worker been concerned about
your drinking or other drug use or suggested cutting down?
▫▫ Have you ever said to another person, “No, I don’t have an alcohol or drug
problem,” when around the same time you questioned yourself and felt,
maybe I do have a problem?
3 Questions for trauma/domestic violence:

▫▫ Have you ever been in a relationship where your partner has pushed or
slapped you?
▫▫ Before you were 13, was there any time when you were punched, kicked,
choked or received a more serious physical punishment from a parent or
other adult?
▫▫ Before you were 13, did anyone ever touch you in a sexual way or make you
touch them when you did not want to?
Step 2: If participant answers 2 questions with “yes” (1 mental

health and 1 substance abuse or 1 substance abuse and 1 trauma):
▫▫ Use GAIN Short Screener or Modified MINI for further assessment.
Adapted with permission from the Canadian Collaborative Mental Health Initiative, and Co-morbidity Screen, Boston
Consortium of Services for Families in Recovery.
In the pilot test of the screener, which involved a number of agencies and
participants ranging from high-school age through adulthood, no participant
showed resistance to answering the screening questions; the screener
identified many individuals who might have co-occurring disorders. After
the screener was adopted by COJAC, some counties and service providers
throughout California began implementing it across both mental health
and substance use systems, as well as in emergency rooms.
PROTOTYPES has implemented an online screening, using the COJAC

screener, for anyone seeking information on the agency’s website. The
individual can answer the questions and is given direction for follow-up;
for example, if she answers “yes” to question #3 (harming yourself) or #7
(partner has pushed or slapped you), she is encouraged to call to speak to
someone as soon as possible. If she answers “yes” to two or more questions,
she is encouraged to arrange an appointment or, if she prefers, someone will
call her. If she answers “no” to all questions, but would still like to speak to
someone, she gets a message to call for an appointment.
We developed another assessment tool, the Readiness to Change Measure

(Brown et al., 2000), based on our work on level of burden for women with
multiple needs/problems. The level of burden refers to the findings that most
women in PROTOTYPES’ substance use treatment programs had four or
more needs and that they were not ready to deal with all of those needs at
once. The women are asked to complete a simple, non-threatening measure
with four ladders. The four ladders represent four common areas of need:
substance use, emotional issues, domestic violence and HIV and other health
issues. The ladders represent different levels of change, from contemplation
to action. The woman is guided through the steps of change and rates where
she puts herself on all four ladders. In this way we ascertain which problem
she is most ready to start with, which problem to work on next and so on.
When we respond to the problem for which the woman rates herself as
“most ready,” she is more engaged and motivated and feels we are listening
to her concerns: we are truly “starting where the client is.”
Another area for assessment is de-escalation. In every trauma-informed

program, women should be assisted in developing an inventory of triggers,
not only for substance use, but also for feeling out of control or overwhelmed.
Identifying and learning to recognize triggers restores a sense of safety. After
they can recognize triggers that precede feeling out of control, the women
should have the opportunity to complete an assessment designed to help them
and us identify the strategies that contribute to feeling comforted and in
control. This assessment should include the activities that women can do on
their own, such as writing or drawing in a journal or taking a walk, as well as
activities that require another person, such as talking to a friend or joining a
group activity. The Task Force on the Restraint and Seclusion of Persons Who
Have Been Physically or Sexually Abused (Carmen et al., 1996) has developed an
excellent tool to assess potential trauma triggers and potential calming strategies.
Training
All staff members at a human services agency can benefit from general
training in trauma to help them understand that trauma is the expectation,
not the exception. This includes receptionists, security personnel and kitchen
staff. Training should focus on what trauma is and how it manifests itself
in our clients. The purpose of training is to help everyone become more
sensitive to issues of trauma and less likely to frighten or retraumatize
women seeking services. In the case of non-clinical staff, training also helps
them to feel that they too play a significant role in assisting trauma survivors
and reduces their discomfort around responding to survivors. In our experience,
it is very powerful to have the training co-led by a professional staff member
and a survivor staff member.
The trauma training, while not designed to go into traumatic experiences

in-depth, may raise unresolved trauma experiences for some staff members.
Secondary trauma is an important issue that can be discussed as part of the
training. Numerous recovering staff were able to tell us during the trainings
that they never dealt with their trauma experiences in their recovery, and that
they now would like to take that step. A segment on staff self-care and staff
group support should, therefore, be an important part of the training.
A second level of training focuses on trauma-informed care. This training, for

managers, supervisors and clinical staff, explores what trauma-informed care
is and what it looks like. This begins the journey into looking at all program
procedures and practices that may be retraumatizing and leads to changes
in policies and procedures. As part of training, specific components of
treatment, such as vocational training, are looked at through the trauma lens.
Issues are then addressed, such as helping women to learn coping skills for
situations where an employer might raise his or her voice and be frightening.
A third level of training, for clinical staff, involves specific modifications for
trauma survivors in their program areas, including residential, case management,
outpatient and screening/assessment, as well as trauma-specific interventions,
such as Seeking Safety.
Conclusion
Often our systems operate with a multitude of services. We talk about
integrating services, but are so siloed into disciplines and problem areas that
we generally give only token support to service integration. Even when we do
organize services around the family, we are still deficiency-oriented; that is,
we are primarily interested in the family’s needs, deficiencies and diagnoses.
Working in partnership with other services, disciplines and sectors on inter-

professional education, integration of screening and services and other forms
of collaboration also underpins the transformation of systems of care into
trauma-informed systems. This transformation requires a paradigm shift. At
first, thinking about trauma seems like one more thing to be considered in
the clinical assessment of every client. However, trauma-informed transfor-
mation involves a shift in how consumers and their behaviours are viewed,
how staff responds to consumers and how services are delivered. Authentic
acknowledgment of each client’s strengths, rather than her deficiencies or
problems, will allow for a true recovery community that values diversity.
Co-creating our services in partnership with our clients will lead us to a truly
responsive service system focused on safety, respect, skills building and
mutual learning.
References
Bloom, S. (1997). Creating Sanctuary: Toward the Evolution of Sane Societies. New York: Routledge.
Brown, V.B., Melchior, L.A., Panter, A.T., Slaughter, R. & Huba, G.J. (2000). Women’s steps of
change and entry into drug abuse treatment: A multidimensional stages of change model.
Journal of Substance Abuse Treatment, 18, 231–240.
Carmen, E., Crane, B., Dunnicliff, M., Holochuck, S., Prescott, L., Rieker, P. et al. (1996).
Massachusetts Department of Mental Health Task Force on the Restraint and Seclusion of Persons
Who Have Been Physically and Sexually Abused: Report and Recommendations. Boston:
Massachusetts Department of Mental Health.
Gatz, M., Brown, V., Hennigan, K., Rechberger, E., O’Keefe, M., Rose, T. et al. (2007).
Effectiveness of an integrated, trauma-informed approach to treating women with
co-occurring disorders and history of trauma: The Los Angeles site experience. Journal of
Community Psychology, 35, 863–867.
Harris, M. & Fallot, R. D. (Eds.). (2001). Using Trauma Theory to Design Service Systems
[Special issue]. New Directions for Mental Health Services, 89.
Morrissey, J.P., Jackson, E.W., Ellis, A.R., Amaro, H., Brown, V.B. & Najavits, L. (2005).
12-month outcomes of trauma-informed interventions for women with co-occurring
disorders. Psychiatric Services, 56, 1223–1232.
329
Chapter 27
Breaking Out of the Mould

Creating Trauma-Informed Anti-violence
Services and Housing for Women and
Their Children
Lynda Dechief with Janice Abbott
Atira Women’s Resource Society, located in Greater Vancouver, offers

17 supportive housing programs, including emergency shelter, low-barrier
independent living and first- and second-stage transition houses for women
aged 16 and older, as well as their children.1 It serves women with a range of
needs: women who are homeless; who are pregnant or new mothers; who
struggle with mental wellness and/or substance use; who have experienced
violence and abuse; or who face additional barriers to securing and maintaining
housing due to sexism, racism, transphobia and other forms of oppression.
With a commitment to offering services to women from a harm reduction
perspective and within a feminist and anti-oppression framework, the orga-
nization is uniquely positioned to shed light on trauma-informed practice in
anti-violence and housing contexts.
When Atira opened its first transition house—now called Durrant House—
in South Surrey in 1987, staff routinely screened prospective clients for alcohol
and other drug use and for mental health issues, as was and continues to be
the practice at many transition houses. If women admitted to either, they were
refused space.
1. For more information about Atira Women’s Resource Society, visit www.atira.bc.ca.
After Janice Abbott took on the position of administrative co-ordinator in

1992, Atira’s screening processes began to change. Abbott remarks that, based
on her lived experience and “the lies we were telling each other about women’s
use of substances and the lies we were forcing them to tell us, we just stopped
screening for struggles with mental wellness and substance use.”
Abbott admits they didn’t really know what they were doing, but they knew
women were using substances and hiding it or struggling with their use of
prescription or “legal” drugs, which were “allowed,” and no one was talking
with the women or supporting them around these struggles. Although most
of the prescription medication women were taking was to deal with problems
such as anxiety and depression, “we were screening for struggles with mental
wellness and, in theory, not doing admissions based on women having a
diagnosis. It just made no sense and we were missing a golden opportunity to
explore options and alternatives with women and unintentionally shaming
them with our silence or rather, our requirement they be silent.”
Despite the decision to stop screening for mental health, substance use or
anything other than an experience with violence/abuse, Abbott still believed
Atira needed to provide specialized resources for women struggling with
substance use. She started working with other women in the community to
establish a case for a new house and funding. By the time Shimai Transition
House opened in 1997, Atira was already firmly operating within a harm
reduction framework. And although they didn’t know the name of it then, they
were employing aspects of trauma-informed care in their daily practice. They
were focusing on what was wrong with the system and what had happened to
the women, rather than on what was “wrong” with the women themselves.
I spoke with Janice Abbott, now chief executive officer of Atira, about the
distinctive ways in which Atira is putting trauma-informed care principles
into practice today.
Lynda: Janice, one of the key characteristics of trauma-informed services is

that they focus on what has happened to the person rather than what is wrong
with the person. From this perspective, the use of alcohol or other drugs and
the development of mental health issues “are understood not as pathology but
primarily as attempts to cope and survive; what seem to be symptoms may
Chapter 27 Breaking Out of the Mould 331
more accurately be solutions” (Peck, 2009, p. 6). Tell me how Atira has
created services based on this view.
Janice: We recognized long ago that substance use and struggles with mental
wellness are often effects of trauma and that women who use alcohol or other
drugs and/or have mental health struggles are more vulnerable to ongoing
violence and abuse. So we not only don’t ban women from services for telling
us they struggle with either or both; we actually assume women struggle and
our services are informed by that understanding. We then create safety, under-
standing, acceptance, empathy and space for talking about and exploring
options and alternatives to substance use. We offer options for recovery and
empowerment and/or for using substances safely. And we are available if and
when women want support to stop using, no matter what time of day or night.
Lynda: Isn’t it true that you also work with other sectors, like the health care
system, to help them to understand and address the links between violence/
abuse, substance use and mental health issues?
Janice: Yes. In 2002, we contacted a kindred spirit in the local health authority
and started working with a group of community agencies to develop a health
centre, day care and housing for pregnant women struggling with their use
of alcohol and other drugs. We worked with the community and local and
provincial authorities to increase understanding of the relationship between
women’s experience of violence/abuse and substance use. When the Maxxine
Wright Community Health Centre opened in November 2005, it was for
women affected by their struggles with substance use and/or violence/abuse.
Services are provided from an understanding that, even if women don’t

disclose violence or abuse, we have to make every aspect of the program safe
for them. Every detail, from the intake form to how we share information
among the partners, is scrutinized for how it could potentially retraumatize
women affected by abuse or violence.
We recognize that even if women don’t disclose violence in their current

relationships, many have herstories of violence and abuse. These may be
from within their family of origin or within the foster care system, at school,
especially if they are not Caucasian, not heterosexual or are differently abled;
working in the sex trade (paid or unpaid); or just trying to make ends meet
and living in poverty. Our services are designed to assume the possibility that
women have been affected by violence/abuse/powerlessness and therefore
support women to live as valuable and valued and fully participating members
of their communities.
Statistics from 2009 show that 35 per cent of the women accessing
services at the Maxxine Wright Community Health Centre report
using alcohol or other drugs (but not experiencing violence), 14 per
cent report being affected by violence (but not using substances) and
51 per cent report being affected by both issues (Penaloza et al., 2009).
Lynda: Not requiring women to disclose violence and minimizing

retraumatization are key to providing trauma-informed care. Another
characteristic of being trauma informed is as Fallot (2008) states, taking
“an integrated, whole person view of individuals and their problems and
resources” (p. 9). Would you say that also happens at the Maxxine Wright
Community Health Centre?
Janice: Maxx Wright was developed because pregnant and early parenting
women facing these struggles were running all over Surrey to access services.
They were going to one doctor for their methadone and another for their
prenatal care. They were going to one program for a hot meal and yet another
one for free diapers. They were going to mental health services and being told
that they needed to get their addiction under control first, then going for
addiction counselling and being told that they needed to first deal with the
violence in their relationship. They were going to a transition house and
being told they weren’t allowed to stay if they had recently used alcohol or
other drugs. And that’s if they had enough bus money and energy to get to
all those places.
Maxx Wright recognizes the complexity of women’s lives and provides all
those services, and more, under one roof. Last year, we opened 12 units of
short-term/shelter housing for women on the same site, and this year, we
opened 24 units of longer-term housing. It’s hard for women to deal with
everything they’ve experienced and are experiencing if they don’t have a safe
place to live.
Lynda: According to Peck (2009), another tenet of trauma-informed care is

that service time limits are determined by survivor self-assessment and
recovery and healing needs. How is that enacted in Atira’s residential programs?
Janice: Until recently, funding for first-stage transition houses and shelters
stipulated that women could only stay for 30 days, so that was the policy at
several of our programs. However, instead of asking a woman/family to leave
after 30 days, we stretched the rules until the woman had safe, affordable
housing. We also created other housing programs that are longer term. For
example, at Koomseh, our second-stage transition house, women and their
children can stay up to 18 months. However, because we were finding that
that still wasn’t enough time for some women, we also created housing
without time limits, including housing with limited as well as with significant
supports. We call it indefinite housing. Finally, a year ago, our funders revised
our contracts so we can now work with individual women and families to
determine the best length of stay for them based on their circumstances. This
is one of the most important changes to our services in years, as every woman
has different needs and varying access to community and personal resources.
Lynda: I recently did a workshop with the staff at the Rice Block, one example
of “indefinite housing” for women, and when I entered the building for the
first time, it wasn’t immediately obvious to me who was working there and
who was living there. Is that related to the trauma-informed principle of
having a “non-authoritarian approach” and “seeing the clients as equals”?
Janice: Yes, it’s one of our policies at Atira to compel staff not to dress in ways
that create a separation between them and the women accessing our services.
And we don’t call the women “clients” or “patients”: we refer to them as
“tenants” or “residents,” but only when it’s absolutely necessary to make a
distinction; mostly we just call them “women.” It’s more accurate and we
don’t find that using a language of professionals is helpful in our work,
especially if it means diagnosing or labelling women. That can be part of
exerting power and control over women, which can be retraumatizing. It’s
what they are fleeing in their everyday lives, so we work hard not to recreate
that dynamic.
We also hire women with lived experience, which means we are the women
we work with. And while we encourage our staff to remember where we came
from, which creates a place of connection, we also encourage ourselves to
remember where we are. We do have jobs and homes and often stability, so we
need to acknowledge our points of privilege as well as our points of oppression.
Treating women with respect is key to our work. We do sometimes need to

involve the Ministry of Children and Family Development when we see issues
with the kids, but we do it in a very transparent way. We explain to women
why we think a call to the ministry is important and we encourage women to
make the call themselves with our support. Most women will do that. If they
don’t, we let them know that we need to make that call, and invite them to sit
with us while we call. As much as possible, we don’t have conversations about
women behind their backs, and we don’t share information about them
without their permission, not even among our own programs. Building trust
is very important for women who have been violated by the people in their
lives they trusted most.
Lynda: A focus on relationships, or a “relational approach,” is important in

trauma-informed work. It sounds like aspects of that approach—being
“strengths-based,” “prioritizing choice and control” and “focusing on
empowerment”—are pretty fundamental to Atira’s work.
Janice: Absolutely. A good example of that is Wraparound. Most of the women

we see are accessing a number of services and the Wraparound model helps
to “wrap” a range of services “around” a woman and her child by co-ordinating
the support network in her life. But it’s different than integrated case
management in some fundamental ways. To begin with, the woman herself
decides who is her network; networks often include “informal” supports like
family and friends, who are going to be there for the long haul when services
providers have closed her file or moved on to other jobs. The very first
meeting focuses on identifying the woman’s strengths. Some women struggle
to identify their own strengths and are amazed at what their network members
say. For example, a woman may have been accused by other service providers
of being conniving or of manipulating the system because she is accessing
a number of services for free items, whereas her network will identify her
resourcefulness at trying to make ends meet and provide for the needs of her
children.
Over several meetings, the support network together comes up with a realistic
action plan, with the Wraparound facilitator ensuring that the woman’s safety,
support needs and voice are central to the process. Again, the network doesn’t
talk about her or share information between meetings without her knowledge
and consent.
Preliminary evaluation of the Wraparound program revealed the

principles and processes to be very successful in working with
women and their children. In addition to being effective in engaging
“hard to reach” families, Wraparound resulted in significant
improvements in access to health care, birth outcomes, families’
health and well-being, housing and nutritional status of women and
their children, reduced risk from the use of substances, improved
parenting outcomes, fewer removals of children and an increasing
move toward family reunification. For more information and
quantitative and qualitative findings, see Cailleaux & Dechief (2007).
Lynda: How do you find staff with the necessary skills to provide trauma-
informed services to women and their children?
Janice: As noted earlier, we have a policy of hiring women with lived experience.
Some of our staff members have been to college or university, but we see real-
life experience as just as valuable, if not more so. We also provide paid training
for staff to support them in their work. In addition to undergoing eight hours of
basic orientation to Atira’s beliefs and practice with respect to supporting women
who have experienced violence, staff has over the years been offered training
in harm reduction, trauma-informed care, non-violent communication, anti-
oppression work, pregnancy-related integrated management of addictions, the
16-step empowerment model, motivational interviewing, relapse prevention
and cultural safety. And we are constantly reviewing and embracing best practices
based on our own experiences and those of others doing similar work.
We also have a policy to hire staff that reflects the makeup of the women we
provide services to, so we actively encourage applications from under-represented
groups, such as women of colour, Aboriginal women, women with disabilities,

lesbians and women whose sexual orientation is fluid. And more than
28 languages are spoken by Atira’s staff; we have Aboriginal women’s outreach
workers; and women of colour and Aboriginal women are well represented in
Atira’s management.
Lynda: Peer support and cultural safety/competency are key aspects of trauma-
informed care. How do you ensure that staff members themselves are
supported around the trauma they may have experienced and don’t burn out
doing this work?
Janice: We actively encourage women on staff to take care of themselves.

We offer semi-annual workshops on collective care and ethics. We value
the women who work here and the work they do.
Atira staff are some of the highest paid in the province; they have good
benefits, including an employee assistance program where they can access
counselling; and they work a nine-day fortnight, which means they work
a short four-day week every second week. Having days off in order to have
a good work-life balance is important. In addition to the usual statutory
holidays, women also get International Women’s Day and their birthday off,
with pay. And we allow for a week of “special days,” so women don’t have
to lie to us about being sick if they need to stay home for the furnace repair
person or because they want to attend their child’s school play.
And we look for opportunities to do more. In 2009–2010, we received grants

from Worksafe BC and the Women’s Health Research Network to conduct
a research project that implemented mindfulness-based stress reduction
groups for the staff, based on gentle yoga stretching and movement, body
awareness and relaxation and understanding the stress-response cycle. The
mindfulness-based stress reduction group we implemented was found to
significantly improve staff’s ratings of their physical health, decrease their
emotional exhaustion and symptoms of depression and increase their sense
of professional efficacy (Dechief & Pomaki, 2010).
We’re not saying we’re perfect, far from it in fact, but we’re trying hard
to provide principled services and to keep evolving as we learn.
Lynda: It certainly sounds as though rather than making women fit into your
mould, you’re constantly working to expand the mould to include all women
who have been affected by violence, abuse and trauma.
HOUSING SERVICES OFFERED BY ATIRA
Housing services offered by Atira are unique in the range of supportive housing
models available—and the innovative services provided—to women of all ages,
and sometimes their children, many in Vancouver’s Downtown Eastside.
Some highlights:
Ama House, a transition house for women aged 55+, is the first of its kind
in Canada.
Kye7e House provides housing for 11 women over age 45 in the Downtown
Eastside. The women have a communal kitchen and sitting area with
a phone, and hot meals are delivered to them once a day.
The Rice Block is a 46-unit, single-room accommodation hotel. It has an

industrial on-site community kitchen, where women cook for themselves
and one another. The Rice Block has a drug and alcohol counsellor on site
and offers 16-step and Re-discover Parenting groups. Each resident works
one-to-one with a designated staff member. The Rice Block is also home to
the Enterprising Women Making Art storefront, a social-purpose business
that provides women with an alternative form of employment. A community
garden has been created in the abandoned lot adjacent to the building.
Shimai Transition House is a first-stage transition house for women and

their children escaping abuse, which is staffed 24 hours a day, seven days
a week. Length of stay ranges from a few hours to six months or longer,
depending on a woman’s self-identified needs. Like all of Atira’s programs,
Shimai operates within a harm reduction model.
Bridge Women’s Emergency Shelter in the Downtown Eastside is staffed

24 hours a day, with employees offering women emotional support,
referrals, resource information and advocacy. There is no maximum length
of stay and women work actively with a housing outreach worker to find,
secure and maintain long-term, safe, affordable housing.
References
Cailleaux, M. & Dechief, L. (2007). “I’ve found my voice”: Wraparound as a promising strength-
based team process for high-risk pregnant and early parenting women. UCFV Research Review,
1(2), 16–38. Retrieved from http://journals.ufv.ca/rr/RR12/article-PDFs/found.voice.pdf
Dechief, L. & Pomaki, G. (November 2010). Taking Care of Those Who Care: Assessing
Organizational and Individual Stress Management Interventions for Anti-violence Workers.
Richmond, BC: WorkSafe BC. Retrieved from www.worksafebc.com
Fallot, R. (2008, February). Trauma-informed services: A protocol for change. [PowerPoint slides].
Paper presented at the Conference of Co-occurring Disorders, Long Beach, CA.
Peck, J.A. (2009, May). Trauma-informed treatment: Best practices. [PowerPoint slides]. Paper
presented at the Los Angeles County Annual Drug Court Conference, Los Angeles, CA.
Penaloza, D. Stafford, V. & Soberano, L. (2009). Measuring success at Maxxine Wright CHC.
[PowerPoint slides]. Report prepared for the Fraser Health Authority, Surrey, BC.
339
Chapter 28
Integrating Treatment of
Tobacco with Other Substances
in a Trauma-Informed Way
Nancy Poole and Judy Lyon
In mental health and substance use services, we are moving slowly but surely
toward the implementation of tobacco-free policies. In the process, we are
noticing how critical it is to implement these policies in a trauma-informed
way, given how common it is for tobacco to be used by smokers to mediate
symptoms of stress and anxiety. This chapter uses the example of one substance
use treatment program that has implemented tobacco-free policies to illustrate
how the challenges of integrating work on tobacco can be addressed when
trauma is taken into account.
In 1998, staff at the Aurora Centre, a women’s substance use treatment

centre based in Vancouver, on the site of BC Women’s Hospital, began to
proactively track tobacco use among its clients. Clients were encouraged to
consider tobacco as a “drug of problem” alongside other mood-altering drugs
commonly used by women, such as alcohol, cocaine, marijuana and benzo-
diazepines. They were also asked to rate tobacco’s importance as a drug of
problem for them. The results were compelling—not only did approximately
two-thirds of the women in treatment indicate that smoking was a problem
for them, but in each year since this shift to inquire about tobacco, they have
rated tobacco as one of their “top three” drugs of problem.
These findings sparked an eight-year process of gradually integrating tobacco

treatment into substance use programs at Aurora. In May 2006, Aurora
became the first residential treatment centre in Canada to formally treat

tobacco along with other substances, and the centre officially became
“smoke free.” Other programs have begun to examine how they might
integrate treatment for tobacco dependence within treatment for other
substances (Bobo & Davis, 1993; Orleans & Hutchinson, 1993). In the course
of this work, programs have recognized how deeply entrenched is the
resistance to this integration, and how important it is to address the many
reasons for client and service provider resistance to integration, including
the perception that tobacco helps to cope with trauma and related stressors
(Hammond & Gregoire, 2011; Ker et al., 1996; Teater & Hammond, 2010).
This chapter examines how Aurora addressed the link between smoking,
alcohol and other substance use and the experience of trauma in this
groundbreaking programming. We describe the challenges of integrating
treatment for tobacco with treatment for other substances and how our
commitment to trauma-informed practice supported the process.
The Context: A Mystifying Lack of Recognition

of Tobacco and Trauma in Addiction Treatment
It is not easy to explain how support for tobacco cessation evolved separately
from treatment for other addictions, particularly given the high rates of
overlap between the two. Studies have found that 79 to 82 per cent of women
in substance use treatment smoke (Bobo, 2002; Teater & Hammond, 2010)
and that there are gender differences in smoking. Women with addiction to
other substances are significantly more likely to be smokers than their male
counterparts (Husky et al., 2007). Moreover, addiction treatment clients
smoke more (Perine & Schare, 1999), start earlier and have more difficulty
quitting (Asher et al., 2003). There are also serious interconnected health
impacts: smoking-related diseases are the leading cause of death for people
previously treated for alcohol and other substance use problems (Hurt et al.,
1996). In addition, tobacco use can be a relapse trigger for other substances
(Gulliver et al., 2006).
The health risks of smoking are particularly serious for women. Female
smokers are twice as likely to develop lung cancer as male smokers of similar
Chapter 28 Integrating Treatment of Tobacco with Other Substances 341
age and smoking history (Henschke, 2006). According to the Office of the
Surgeon General in the United States (2001), tobacco-related sex-specific and
gender-specific risks for women include reproductive health problems, cancers
and heart disease. These health risks alone are a compelling rationale for
expanded treatment options for women who smoke.
Treatment providers at Aurora were well aware of how the experience of

violence and trauma is linked to substance use problems in general. Yet only
recently have researchers specifically identified how smoking is more prevalent
in women who have a history of violence and trauma than for those in the
general population. For example, the smoking rates for women with post-
traumatic stress disorder range from 39 to 45 per cent (Fu et al., 2007;
Helstrom et al., 2009), to 54 per cent for survivors of sexual assault (Amstadter
et al., 2009) and 58 per cent for severely battered women (Weaver & Etzel,
2003). In one study (Lipschitz et al., 2003), 86 per cent of girls of low socio-
economic status with posttraumatic stress disorder smoked. In addition to the
high prevalence of tobacco use, women smokers with experience of trauma
are frequently heavy smokers. Loxton et al. (2006) found that women with a
history of intimate partner violence were almost four times more likely than
women smokers without trauma to consume a pack or more of cigarettes a day
(see also Lemon et al., 2002; Weaver & Etzel, 2003), and 29 per cent of women
smokers in trauma treatment have reported smoking a pack or more daily
(Helstrom et al., 2009).
Challenges Posed by Integration

While there were many compelling reasons for integrating treatment for
tobacco with the treatment for alcohol and other drug addiction, Aurora staff
faced a number of challenges. Three of these challenges are of relevance to
this chapter.
The first challenge was to enlist the support of referral agents to continue to
refer women smokers for treatment, which proved difficult, in part because
many continued to operate from the misconception that it is too much to ask
clients to stop all addictive substances at once. Referral agents play a critical role
in helping women prepare for treatment, including understanding women’s
readiness and capacity to heal within a group treatment environment. But
when Aurora began integrated treatment, surveys showed that only 37 per
cent of referral agents strongly supported the change in policy and practice,
whereas 65 per cent of clients strongly supported it.
A second challenge was to determine how to approach the use of tobacco

within what was traditionally an abstinence-based program. Aurora had
typically asked women who relapsed to return to outpatient treatment until
they were ready to commit to the abstinence approach of the residential
treatment context. But the nature of tobacco addiction, the high likelihood
of relapse and use of nicotine replacement therapy provoked the centre to
re-examine its policies related to eligibility for treatment, relapse and harm
reduction. We decided that clients would not be required to abstain from
tobacco for two weeks prior to admission, as they were with other mood-
altering substances. And staff realized that its approach to relapse had to be
more nuanced for tobacco. It became evident that when a woman relapsed to
tobacco use, there were often other treatment issues present that also needed
to be addressed, and these were fully explored. All in all, a paradigm shift was
required by staff members to factor in the significant change that was being
asked of clients in the implementation of the tobacco policy. This shift in
paradigm had benefits for increasing flexibility and commitment to trauma-
informed and harm reduction practice overall.
Aurora’s third challenge was in partnering with clients to increase their

awareness that while they may perceive smoking as a beneficial coping
mechanism to deal with feelings of fear and anxiety, the actual harms
outweigh the perceived benefits. With that in mind, women were encouraged
to use the treatment experience as an opportunity to explore ways other than
smoking to self-soothe or relax. In order to overcome this challenge, staff
required education to allow them to factually respond to women’s queries
about the health, social and financial impacts of tobacco use. Staff members
were also required to support women’s stated post-treatment goals for tobacco
abstinence, regardless of the women’s level of awareness of these impacts.
To address these challenges, Aurora has incorporated the following core
aspects of trauma-informed care in the process of integrating tobacco
treatment into the treatment of other addictions:
1. Clients are encouraged to exercise choice within the treatment context

wherever possible.
2. A joint learning environment is created, where connections are made

between violence against women in general, trauma specifically and the
experiences of mental health problems and addictions. Clients learn
alternative coping strategies that increase safety and promote health.
3. In their work with women with substance use problems, treatment

providers assume a stance based on respect, rapport and relational collaboration,
rather than exercising their expertise and authority over the treatment
process.
4. Treatment providers educate and work with referral agents and others in
the addiction field from this respectful and rapport-fostering stance.
These four aspects of trauma-informed practice in the context of integrated

addiction treatment for women are described here in more detail. Responding
to the needs of women who are addicted to tobacco has served to reinforce,
clarify and improve the overall trauma-informed practice at Aurora.
Consumer Choice
Abstinence-oriented addiction treatment has often been experienced by
clients as rule bound and full of advice from treatment providers who claim
to “know best” about recovery because they have often had years of personal
recovery experience and/or experience guiding women through the process.
Gradually, provider-determined approaches have been supplanted by recovery/
discovery processes and client-directed (Miller et al., 2005) and women-centred
approaches, which make women with the substance use problems the experts
in their own lives (Payne, 2007).
The first choice that clients at Aurora had to make after tobacco treatment was
integrated into the addiction program occurred at intake, when they had to
decide what type or level of nicotine replacement they wanted to use—if they
wanted to use it at all. Working through this choice with women, especially
women who were new to cessation and had quit only to have access to
treatment, created an immediate shift toward a more sensitive and client-
driven intake process. All Aurora staff were keenly aware of the discomfort
and anxiety created by smoking cessation and the need for women to find
strategies to relieve these immediate symptoms, as well as longer-term
strategies for meeting the functions that tobacco had provided for them, such
as mediating trauma symptoms (Greaves, 1996).
The Aurora counsellors facilitate this process by framing tobacco cessation as

each woman’s commitment to her health and recovery, with staff providing
support to help women honour this commitment to themselves. In this way,
the overall trauma-informed principle of eliciting compassion and respect for self,
others and place is realized. Women are asked about their preferences for how
counsellors might support them when they experience fear and anxiety and may
be at risk of relapse. Should relapse occur, women are supported to reassess their
stage of readiness to abstain, and if they are interested, they are supported in
recommitting to tobacco abstinence and continued participation in the treatment
program. Choice and self-determination are maximized, and the potential
negative experience of authority, domination or traumatization is avoided.
Learning about the Connections

Learning about the impact of smoking on women’s health and its relationship
to other addictions and trauma is also a key aspect of trauma-informed care
at Aurora. Various group educational series have been offered by the centre,
each one designed and redesigned, based on input from clients. Over the
years, clients have indicated as useful three educational components that are
relevant to trauma-informed practice:
1. Naming the negative physical effects of smoking on women’s health

and the potential for health improvement with quitting. The immediate
physical health benefits of quitting smoking had been described in
Deborah Holmberg Schwartz’s Catching Our Breath (1997) as “Your body
will forgive you.” This linking of the health benefits of quitting with
forgiveness and compassion for self is very much aligned with trauma-
informed practice and was often cited in program evaluations by clients as
a particularly helpful framing of the uncomfortable quitting process. In
addition, the focus on positive health improvement was directly linked to
and reinforced by other treatment components that support physical
health recovery, such as yoga, morning walks and good nutrition.
2. Naming the links between smoking and victimization, coping and

healing. The educational programming covers the high levels of smoking
and experiences of trauma and violence among women in addiction
treatment. The programming also offers opportunities for women to
discuss how tobacco, similar to other substances, is used to cope with
stress, numb feelings and increase energy—thus acknowledging its
benefits, while also exploring the serious health risks of smoking. Women
often reported seeing tobacco as a reward after a stressful time: instead of
shutting down that conversation, the educational programming helps women
explore other self-care options they could use to address the perceived
benefits and needs that smoking has provided. Again, the focus is brought
to the positive—to women’s coping mechanisms, resilience and strengths.
3. Promoting “consciousness raising.” This has been done by addressing

how the tobacco industry has targeted and manipulated women by playing
on their vulnerabilities, promoting smoking as a way to feel liberated and
stay slim. The programming has used media resources to promote and
support women’s understanding and resistance to these messages,
drawing on, for example, Dr. Jean Kilbourne’s “Deadly Persuasion” media
presentation (1999). As such, the individual experience of tobacco use is
linked to structural influences on women’s smoking, much in the way that
service providers in women-centred treatment programs attempt to help
women understand the structural nature of violence against women, to
know that it is “not their fault” that they experienced violence.
Collaborative Provider Stance with Clients

The third aspect of trauma-informed practice facilitated by integration of
tobacco into addiction programming was a shift in the stance of treatment
providers. Counsellors were less confrontational and more collaborative and

had greater recognition of women’s need for safety and healing. In the process
of making the programming change, the counsellors undertook extensive
training to learn more about tobacco’s effect on women’s health, its link to
other addictions and the positive impact of smoking cessation on recovery
from other substances. In this process, some staff members were provided
with support to stop smoking. In becoming learners about nicotine addiction
themselves, and in recognizing first-hand how uncomfortable quitting smoking
can be, staff members were assisted in developing a less directive treatment
stance. The goal was to create a gentler, more supportive atmosphere, where
shame about smoking was reduced, and anxiety about relapsing and being
asked to leave treatment lessened. The treatment atmosphere shifted toward one
that fosters acceptance, reflection and community building.
Collaborative Provider Stance with Referral Agents

This tobacco-related work also afforded treatment providers an opportunity to
share their learning about tobacco with the external referral agents to help
other treatment providers engage with the importance of integrating tobacco
cessation into addiction treatment. This outward-focused, co-learning reduced
Aurora’s separation from other tiers of care, and helped outpatient counsellors
effectively prepare women for integrated treatment. It also prompted these
agencies to consider and revise their own practice of providing tobacco
cessation support within their services.
Conclusion
The Aurora Centre has courageously undertaken an extended effort to
integrate tobacco treatment with the treatment of other addictions. The
decision was made based on the high prevalence of smoking among women
in treatment for alcohol and other drug addiction, the very serious impact
of smoking on women’s health, the evidence for an increase in sustained
recovery for women when all substances are treated at once, as well as clients’
interest in getting enhanced support for smoking cessation. Recognition of
how tobacco and other substances are used to mediate the all too common
effects of violence and trauma for women was central to the enhanced
program design.
Working from a trauma-informed stance in the integration and delivery of

tobacco cessation programming had many benefits: clients had more choice
in the treatment process; Aurora created a less directive learning environment
and considered new approaches to relapse, and retraumatization was
minimized through a more collaborative treatment provider approach. In this
way the Aurora Centre serves as an exemplar of trauma-informed practice in
its work to integrate treatment for tobacco addiction into the treatment of
alcohol and other drug addictions.
References
Amstadter, A.B., Resnick, H.S., Nugent, N.R., Acierno, R., Rheingold, A.A., Minhinnett, R. et al. (2009).
Longitudinal trajectories of cigarette smoking following rape. Journal of Traumatic Stress, 22,
113–121.
Asher, M.K., Martin, R.A., Rohsenow, D.J., MacKinnon, S.V., Traficante, R. & Monti, P.M.
(2003). Perceived barriers to quitting smoking among alcohol dependent patients in
treatment. Journal of Substance Abuse Treatment, 24, 169–174.
Bobo, J.K. (2002). Tobacco use, problem drinking, and alcoholism. Clinical Obstetrics and
Gynecology, 45, 1169–1180.
Bobo, J.K. & Davis, C.M. (1993). Cigarette smoking cessation and alcohol treatment. Addiction,
88, 405–412.
Fu, S.S., McFall, M., Saxon, A.J., Beckham, J.C., Carmody, T.P., Baker, D.G. et al. (2007). Post-
traumatic stress disorder and smoking: A systematic review. Nicotine and Tobacco Research,
9, 1071–1084.
Greaves, L. (1996). Smoke Screen: Women’s Smoking and Social Control. Halifax, NS: Fernwood.
Gulliver, S.B., Kamholz, B.W. & Helstrom, A.W. (2006). Smoking Cessation and Alcohol
Abstinence: What Do the Data Tell Us? Bethesda, MD: National Institute on Alcohol Abuse
and Alcoholism.
Hammond, G.C. & Gregoire, T.K. (2011). Breaking ground in treating tobacco dependence at a
women’s treatment center. Journal of Social Work Practice in the Addictions, 11, 1–16.
Helstrom, A.W., Bell, M.E. & Pineles, S.L. (2009). Feeling better and smoking less: The
relationship between trauma symptoms and smoking over time. Cognitive Therapy and
Research, 33, 235–240.
Henschke, C.I. (2006). Women’s susceptibility to tobacco carcinogens and survival after
diagnosis of lung cancer. JAMA, 296, 180–184.
Holmberg-Schwartz, D. (1997). Catching Our Breath: A Journal about Change for Women
Who Smoke (2nd ed.). Winnipeg, MB: Women’s Health Clinic.
Hurt, R.D., Offord, K.P., Croghan, I.T., Gomez-Dahl, L., Kottke, T.E., Morse, R.M. et al. (1996).
Mortality following inpatient addictions treatment: Role of tobacco use in a community-
based cohort. JAMA, 275, 1097–1103.
Husky, M.M., Paliwal, P., Mazure, C.M. & McKee, S.A. (2007). Gender differences in association
with substance use diagnoses and smoking. Journal of Addiction Medicine, 1, 161–164.
Ker, M., Leischow, S., Markowitz, I.B. & Merikle, E. (1996). Involuntary smoking cessation:
A treatment option in chemical dependency programs for women and children. Journal of
Psychoactive Drugs, 28, 47–60.
Kilbourne, J. (1999). Deadly Persuasion: Why Women and Girls Must Fight the Addictive Power
of Advertising. New York: Simon & Schuster.
Lemon, S.C., Verhoek-Oftedahl, W. & Donnelly, E. (2002). Preventative healthcare use, smoking,
and alcohol use among Rhode Island women experiencing intimate partner violence.
Journal of Women’s Health and Gender-Based Medicine, 11, 555–562.
Lipschitz, D.S., Rasmusson, A.M., Anyan, W., Gueorguieva, R., Billingslea, E.M., Cromwell, P.F.
et al. (2003). Posttraumatic stress disorder and substance use in inner-city adolescent girls.
Journal of Nervous and Mental Disease, 191, 714–721.
Loxton, D., Schofield, M., Hussain, R. & Mishra, G. (2006). History of domestic violence and
physical health in midlife. Violence against Women, 12, 715–731.
Miller, S.D., Mee-Lee, D., Plum, B. & Hubble, M.A. (2005). Making treatment count: Client-
directed, outcome-informed clinical work with problem drinkers. Psychotherapy in Australia,
11, 42–56.
Office of the Surgeon General. (2001). Women and Smoking: A Report of the Surgeon General.
Atlanta, GA: Centers for Disease Control and Prevention.
Orleans, C.T. & Hutchinson, D. (1993). Tailoring nicotine addiction treatments for chemical
dependency patients. Journal of Substance Abuse Treatment, 10, 197–208.
Payne, S. (2007). In-hospital stabilization of pregnant women who use drugs. In N. Poole &
L. Greaves (Eds.), Highs and Lows: Canadian Perspectives on Women and Substance Use
(pp. 249–255). Toronto: Centre for Addiction and Mental Health.
Perine, J.L. & Schare, M.L. (1999). Effect of counselor and client education in nicotine addiction
on smoking in substance abusers. Addictive Behaviors, 24, 443–447.
Teater, B. & Hammond, G.C. (2010). Exploring smoking prevalence, quit attempts, and
readiness to quit cigarette use among women in substance abuse treatment. Social Work in
Health Care, 49, 176–192.
Weaver, T.L. & Etzel, J.C. (2003). Smoking patterns, symptoms of PTSD and depression:
Preliminary findings from a sample of severely battered women. Addictive Behaviors,
28, 1665–1679.
351
Chapter 29
Responding to the Women

YWCA Toronto Moves Its Practice to
a Trauma-Informed Approach
Lorraine Greaves in conversation with Jennie McKnight, Ruth Crammond

and Heather McGregor
The YWCA in Canada has a long and rich history of responding to women’s
social and housing needs in safe and compassionate ways. This article describes
the initiation and ongoing evolution of a trauma-informed approach at the
YWCA Toronto in response to women’s evolving needs. The following captures
Lorraine Greaves in conversation with YWCA Toronto staff: Jennie McKnight,
clinical director; Ruth Crammond, director of shelter and housing; and Heather
McGregor, CEO.
Lorraine: What provoked the transition from a feminist anti-oppression

approach to the development of a specific trauma-informed approach?
Jennie: The trauma-informed approach was intended to augment the existing

approach, which, among other things, included a commitment to working from
an anti-oppression framework. The historical context involves YWCA Toronto
being awarded a contract in the early 2000s to re-open a shelter for women and
children fleeing violence, which became known as ARISE. In planning for the
shelter’s opening, the YWCA sought to identify best practices for violence
against women (VAW) services and took steps to identify and implement a
model that reflected the state of knowledge and practice in the field.
Heather: We were seeing women with more and more complex mental
health issues. Providing appropriate services for them increasingly created
significant issues for our staff teams and our organization. We wanted
to assist women to prepare better for independence and autonomy by
enhancing their skills and abilities to support themselves in the community.
At the same time, we were being challenged to deal directly and more
effectively with the effects of their trauma and violence histories.
Jennie: Research into existing best practice approaches led to a team of

YWCA management and staff visiting a VAW shelter in Chicago that had
implemented a service model that incorporated elements of a trauma-
informed approach. In addition, YWCA Toronto conducted needs
assessments in which service recipients and staff of our existing shelters
commented on how to improve service delivery. The findings revealed that
women with mental health issues were not being well served (they were
either being discharged because of disruptive behaviour or self-selecting out
of the VAW system), and staff did not feel they were skilled in addressing
some of the behaviour related to the impact of trauma. A few years after the
new model was implemented at ARISE, the YWCA began to roll the model
out to other programs, including our previously existing VAW shelter (the
Women’s Shelter) and our homeless women’s shelter (First Stop, Woodlawn),
where we had more mental health and addiction issues among the women.
We spent a great deal of effort adapting the model to the unique service
mandates, client populations and physical layout of each program site.
Lorraine: How do you define “trauma informed”?
Ruth: We view it as a way of talking about the range of violent and intrusive
experiences that women can experience in their lives. This continuum can
include histories of chronic or episodic interpersonal violence, like partner
abuse, and it also can include the pervasive effects of experiences of social
violence, like poverty and racism. Our approach sees these experiences as
having an impact on women (and their families and communities), and a
critical aspect of our ability to be effective service providers is to see the
dynamics of our relationships in service settings through this lens.
An example we often use to describe how we apply a trauma-informed

approach has to do with “chores” in our shelters for women fleeing violence.
Chapter 29 Responding to the Women 353
Part of the communal living context in these settings requires that women
participate in some activities that support the maintenance of a clean and
healthy environment. Some women struggle with us around this issue for
different reasons. In our previous way of working, if a woman consistently did
not fulfil her community responsibility by doing her chore, she would be given
a series of warnings that could lead to her ultimate discharge. With the focus
on trauma, there is a greater effort to understand what might be happening
for this woman, both in terms of her relationship to the task itself and to us as
the people assigning it to her. Maybe her abuser criticized her housekeeping,
which led to violence. Or maybe she has experienced abuse and rejection
from parents or others in positions of power. We try to engage with her in
ways that might give some clues for everyone involved about how the actions
of workers and clients alike are being understood and responded to.
Lorraine: What were some of the operational issues in pushing this

philosophy forward?
Jennie: A big focus in the model’s development was identifying the staffing
resources (skills and capacities) to deliver it. New job descriptions were
developed that required knowledge and experience that had a more clinical
dimension. Considerable effort also went into operationalizing the model
by having subspecialties within the multidisciplinary team approach. For
example, case managers handling day-to-day operations were also required
to act as a resource to clients and the team in specific areas of practice, such
as addiction, mental health or immigration/legal information. The idea was
to create a multidisciplinary team that could attend to the range of service
needs we were seeing. Since we were operating from the assumption that
trauma and oppression can affect all aspects of experience, we wanted to
create a staffing model that could identify and meet the broadest range of
service needs in an integrated and timely way.
Lorraine: What specific practices did you change in the shelters?
Ruth: We tried not to replicate abusive systems, so we have minimized rules

and regulations. We do not control food and always have an open kitchen.
There is a natural tendency to revert to rules when things get tricky and to
impose structures, which we try to avoid by developing insight in both our
workers and clients to understand the impacts of trauma and oppression. Our
model did away with a formal warning system in our VAW shelters that would
caution women about the consequences of their behaviour. We refused to
institutionalize the homes, so there are not a lot of signs and warnings on the
walls. We also work with women to make the home seem like a community.
Jennie: It has been a great challenge to create the conditions where women
who have experienced trauma can see clear, transparent practice in how the
shelter runs, which can reduce their anxiety about staff having power over
them, without being either overly rigid or too loose. Either of those conditions
can be triggering, so we focus a lot on how our actions affect individuals and
the larger community.
Lorraine: How would you describe the decision-making process to make this
shift? Were there philosophical and political considerations?
Heather: From a management standpoint, we were certain this model would

be an improvement in shelter services for women, but we have a union and
we had to take careful steps as we introduced and expanded our new approach.
Shelter workers have traditionally been highly skillful in case management

areas—helping women who are in crisis or great danger to navigate complex,
multiple systems, such as housing, family and criminal and immigration law,
education, health and economics. With the trauma-informed approach, we
formally introduced more clinical elements, such as the demonstrated
capacity to understand how trauma plays out in women’s lives and to respond
appropriately. For example, if a woman who has been traumatized seems to
be avoiding contact with her worker, what might that say about her experience
of vulnerability and her strategies for safety? In the new model, we sought
workers who had training and experience in the kinds of reflective and
relational practices that render visible the ways trauma is present in the here
and now, not just as a historic event. Both case management skills and clinical
skills are important; we needed to be more rigorous in our recruitment and
retention efforts in making sure we hired for each. This continues to be quite
challenging, because these skills are not necessarily taught or acquired in the
same ways.
Jennie: At the sites where programs were already running, we had to negotiate
new job descriptions that included new qualifications with some existing
unionized staff. This was not easy. However, at all the sites, we invested
significant resources in training and capacity-building using a trauma-
informed model. For some existing staff, we offered additional training
opportunities, paid for some professional education and held jobs for those
going back to school.
Lorraine: What have been some issues in establishing the new model? Were
there any conflicts in practice?
Jennie: We endured some criticisms from the community for professionalizing

our staff this way, and there were worries about medicalization and elitism
from some of our partners and academic colleagues.
There has also been some tension in our efforts to integrate and apply
the analytical frameworks of trauma and anti-oppression. For example,
some social workers in residential settings tend to understand systemic issues
and power dynamics, whereas other workers coming to us sometimes take
a more traditional clinical approach emphasizing individualized behaviour.
As we try to incorporate the insights and knowledge of both of these
paradigms, we have had to overcome a tendency to polarize them as either
social or psychological. In daily practice, where women with complex histories
and ways of navigating in the world are sharing space and resources, it is
challenging to work in ways that acknowledge the effects of a range of
harmful experiences and also promote a climate of mutual respect, safety
and responsibility.
We have had some scope of practice issues and still need to work on clarifying
the differences between trauma-specific counselling and trauma-informed
services. We continue to work to bring team awareness to the dynamics
among and between clients and workers, needing to attend to issues of
structure, predictability and transparency, so that triggers related to trauma
are understood by all. Trauma has an impact on all of us. We strive for
a holistic approach that engages mind, body and spirit and creates an
environment where people can have experiences of self-efficacy, safety and
connection to others, which we believe are essential to recovering from many
of the harmful effects of trauma.
Lorraine: How do you see trauma-informed practice/philosophy being

integrated into your new 300-unit supportive housing unit at the Elm Centre
in downtown Toronto?
Heather and Jennie: The multidisciplinary element was already present in

our shelter service model, but Elm will include intensive multidisciplinary
supports for the 100 women (one-third of the residents) living with mental
health and addiction issues: this will include access to social work, addiction
support, nursing, psychiatry, occupational therapy and vocational support.
We also plan to integrate some on-site access to primary health care. Adding
these elements presents new logistical challenges, but is not a big leap
philosophically, since experience with our homeless shelter has indicated
that access to both mental health care and primary care is a barrier for
homeless women who are also struggling with addiction, mental health
issues and trauma-related sequelae. We will have a psychiatrist and a nurse
on the staff team.
Another way a trauma-informed approach is evidenced in the service model

for Elm is the commitment to a subteam within the larger staff that is
specifically focused on community development across the entire community
of 300 units. This shift reflects both the specificity of working in a mixed
residential setting as well as an acknowledgment that many of the long-term
effects of trauma include social and relational challenges. Along with the
intensive individual case management services, community developers with
subspecialties will support active participation in the community, which we
hope will have a beneficial impact on overall well-being, especially as it relates
to trauma.
As well, trauma-informed practice has been integrated into our Elm model
through our intake process, which is informed by an understanding of
trauma. We include trauma screening in our intake process and ensure that
our intake workers are flexible and skillful in helping women through those
difficult portions of the conversation. We haven’t required that applicants have
pre-existing formal mental health diagnoses, and in fact have broadened the
types of formal mental health diagnoses beyond what would ordinarily have
been prioritized for assertive community treatment team (ACTT) support.
In practice, the impact of the trauma these women experience gets codified
under a wide variety of diagnostic categories, and we wanted to be sure we
were responding to how trauma and mental health actually affect women’s
homelessness.
Lorraine: How do you measure the success or impact of this new model?
Heather: Evaluation is one dimension of our practice that requires more effort
and resources. The reality of operating 24-hour crisis services for clients and
families with complex service needs often makes it difficult for us to allocate
organizational resources (time, funds, etc.) to identifying goals and outcomes
and then measuring and analyzing results. We need more sponsored research
and profiling of the work in the YWCA on our program innovations such as
this. As the funding climate for some services tightens and mandated
accountability functions move toward more evidence-based measures of
quality, we need to focus our organization and program efforts to make
improvements in this area.
Jennie: At the moment, success and impact are most often identified
anecdotally (with the resolution of a particular case being assessed in a team
activity that includes reflection and application of trauma-informed principles)
or as part of other, often informal, evaluation processes. For example,
individual staff may report that they feel more competent as a result of ongoing
trauma-related training or the availability of clinical supervision. Teams
problem solve issues applying trauma-informed principles and reflection,
which often increases compassion in our workers. We have found that by
analyzing difficult issues or clients, service providers more readily see women’s
strengths and focus on shifting their energies in a more effective direction.
Lorraine: How do you transmit this approach to the women and to new (and
experienced) staff?
Jennie: The staff members are keen to learn about trauma and trauma-
informed work, but women, especially in our VAW shelters, generally are not
asking for the kind of support that directly touches the trauma content. We
focus on how to connect with women where they are, and we are less didactic
than we used to be, preferring instead to create community and connect with
the women through the incremental steps involved in building safety and
stability, whether this is by securing housing or finding other resources for
them and their children.
Trauma creates disconnections, and we try to ameliorate that. In our teams,

we may still encounter the idea that the “real” work involves a woman disclosing
details of her abuse and having the attending emotional experiences that go
with that. However, we try to encourage growth and healing without going to
the content of the trauma. In the VAW shelters, this is tricky, because to get
emergency housing or other supports, women are often asked to document
their trauma, so the discussion happens. This is an example of how the larger
system can create conditions that make it difficult to practise strictly within
a trauma-informed framework. But we continue to maintain there is no
obligation to hear the details or to tell the details. That said, we also want to be
responsive in a way that can take advantage of moments with women where
aspects of the trauma are present and there might be an opportunity for insight
or a more informed choice. We try to bring awareness and compassion to these
encounters, neither probing for disclosure nor avoiding the source of the
discomfort or distress.
Our homeless shelter is a much larger, busier environment than our VAW
shelters. Residents often find it challenging and sometimes triggering to live
with so many others. The need continually to problem solve around co-operative
living strategies has meant that in that setting we often end up working with
women to navigate how their past and current traumas are affecting their
here-and-now interactions with others. Here we have tended toward a hybrid
between trauma-informed and trauma-specific work. We don’t attempt to
deconstruct the content of a woman’s actual trauma. We have found that the
accessibility of the service includes paying attention to the structure of the
program and the stance of the staff, but also working with women to widen
their own strategies to include ones less defined by trauma. There is a certain
amount of trauma recovery work that is useful in such dynamic environments.
We are reluctant (and unable) to rely on power-over techniques as the main
way of creating safety in such an interactional setting.
There have been significant organizational resources invested in communicating

the approach to staff. It has been interesting to observe that although many
women who are practising in settings where our trauma-informed model is in
place have engaged in extensive team training and group discussion, there is
still an elusive quality to the approach. This may be related to the lack of clearly
articulated goals and outcomes. It may also be related to the difficulty social
workers who are either new to the field or new to traumatology may have in
identifying clinical contexts where an analysis of trauma would be useful, and

then applying the knowledge in skillful intervention.
Lorraine: Do you transmit these ideas to the women you serve?
Jennie: With the women, yes, we do explicitly communicate—in individual

and group programming—about the effects of different forms of trauma
(for women and their kids) and we try to support women to build and share a
range of skills for mitigating those impacts. Doing this can help lessen shame
and anxiety. For example, framing parenting challenges in relation to trauma
can ease the extreme fear women in VAW shelters have about being judged for
the ways their kids are behaving and their own responses to that behaviour.
Lorraine: Have you let other agencies and services know about your approach?
Jennie: The YWCA has communicated this approach reasonably well to other
service providers in our sector in informal settings and to funders (public and
private). As public awareness of mental health issues has grown, the ability
to frame the work we do with women in terms of trauma can be helpful in
mobilizing support and understanding. We have not, however, engaged in much
formal knowledge-sharing through conference presentations or publications.
Lorraine: Do you have an example of success with this approach?
Jennie: Yes, we had a client who had come to Canada several years earlier
fleeing an extremely violent abuser and an unresponsive police system. She was
told by those close to her not to make a refugee claim, and her undocumented
status added to her vulnerability, which led to a sequence of abusive relationships
here. She and her three children faced a number of issues, the most urgent
being that she was in danger of being deported to the unsafe situation in her
country of origin. We connected her to a lawyer and worked with them to make
a refugee claim using a trauma-informed approach; arguing that her decisions
had been survival decisions, and that inconsistencies in her story were related
to trauma-related injuries. We identified aspects of her current behaviour that
reflected mental health issues and were clearly trauma related. She won her
refugee status based on these trauma-related examples. We felt that was a
successful application of our philosophy.
361
Conclusion
What lies ahead? Becoming trauma informed requires a range of adjustments

in practice and system designs, supported by research, innovative change
and inspired leadership. This is a tall order, and requires complex thinking.
Becoming trauma informed benefits from collaboration and co-operation
between all levels of service delivery. For the survivor, the support milieu
becomes a web of relationships rather than another experience of being
overwhelmed. Becoming trauma informed for systems and services is an
ongoing process of system change and quality improvement, requiring
constant adaptations and ongoing monitoring.
The contributors to this book offer hope and direction for this complex
undertaking. Their many approaches and philosophies of practice offer rich
ideas for practitioners, policy-makers and program and system developers alike.
The challenging theoretical dilemmas posed offer all sectors rich food for
thought. Innovative practices in a range of settings offer inspiration. Illustrations
of agencies or institutions engaging with the challenges and moving past
resistance are reassuring. Issues in improving our collective responses to a range
of diverse populations offer clear challenges to “mainstream” practices and
policies. And integrating gender and equity lenses into our planning and change
processes remains underdeveloped, but critically important.
Across Canada, individuals, agencies and institutions are taking up these

challenges. Ultimately, people with lived experiences of trauma can take credit
for this shift in thought and practice, by providing their own challenges and
teachings to our systems of care. It is those with lived experiences of trauma,
as well as service providers, who will benefit. Through trauma-informed
services, survivors can feel safe enough to access the help they need, stay with
treatment and improve their health: this includes cutting back on problematic
substance use; experiencing fewer symptoms of trauma; and gaining a greater
sense of agency, self-esteem and capacity for mutuality and authenticity in
relationships. This book is a contribution to that change. Becoming trauma
informed is indeed a big challenge, but one that is increasingly being
embraced by trauma survivors, service providers, substance use and mental
health services and other health and social services and systems.
Becoming trauma informed is a process. This process is built on knowledge

and a wide range of types of evidence, and requires innovative thinking,
leadership, compassion and understanding. Fortunately, interest in becoming
trauma informed in both practice and system design is flourishing in Canada.
This interest has given us an opportunity to gather and showcase a range of
theoretical, clinical and systemic perspectives on trauma-informed work, and
to showcase these efforts in this book.
Undoubtedly, there are many other examples of trauma-informed practice

in various settings and with more and more diverse groups developing in
Canada and beyond. In this book, the contributors provide examples of work at
the individual, group, agency and intersectoral levels. These examples are part
of a “joined-up” service system approach to becoming trauma informed: the
examples are distinct from trauma-specific or integrated system designs, and
reinforce the centrality of trauma for people accessing help from various service
systems. This increased interest in becoming trauma informed reflects
significant efforts in practice and health system design to function as whole
systems and to engage meaningfully with transdisciplinarity. The non-linear
nature of complex service interventions, the influence of specific contexts and
the constant evolution of evidence and practice will continue to make the path
to becoming trauma informed a complicated one. As such, there is much more
to be done to implement and evaluate “what works” in trauma-informed
interventions, across multiple settings and with different populations.
To move forward, there is a dire need to integrate knowledge, practice and

experiences in creating trauma-informed responses. Current practitioners and
system designers consider how to integrate theories or parts of theories on
trauma, anti-oppression, feminist and other approaches into their current
practice. Conscious consideration of the theoretical material presented here,
along with other current thinking, is a foundation for better practices in this area.
Practices can then be modified or introduced. For example, trauma-informed

and harm reduction–oriented screening and intake processes in addiction and
mental health services can be developed. In this context, trauma-informed
intake and screening processes are important in creating a culture of safety
within our interactions and our agencies to more effectively and consciously
engage people who have difficulty seeking help and navigating relationships
with service providers and with processes.
Conclusion 363
Creating linkages between trauma-informed and trauma-specific approaches

across service tiers is also crucial. For example, trauma-informed work in
prevention and outreach-oriented services needs to be, and can be, effectively
linked with services that offer trauma-specific treatment in hospitals and other
intensive treatment settings for those who want this approach. The roles of
practitioners who provide trauma-informed support in community-based
programs serving specific populations and those who work in intensive mental
health services can be clarified. Such linkages address the recommendations
for a tiered system of care as defined in A Systems Approach to Substance Use in
Canada (National Treatment Strategy Working Group, 2008), where each tier
of care understands and is respected for its role in providing support.
Many more services have yet to consider how to integrate trauma-informed

practice within intensive treatment settings. In addition to agency-wide
policies, narrower examples exist of how to embed trauma-informed practice
and system change in intake processes, and treatment planning in mental
health services.
An area of integration less often addressed is the physical health impacts of

trauma in primary care and mental health and substance use treatment
settings. This practice of addressing physical health impacts has often been
neglected, although practitioners are increasingly recognizing the links
between stress responses and substance use and mental health. Along with
these connections, practitioners and systems planners need to promote an
understanding of the role of sex and gender in the physical health impacts of
trauma, and to respond in gendered and trauma-informed ways in a range
of settings. This includes treating chronic pain, gastrointestinal problems,
asthma, musculoskeletal difficulties and other health problems that differ in
prevalence, expression, disease course and treatment for men and women.
Diversity and equity issues also need to be integrated into systems of care and
systems design. The needs of Aboriginal girls and women, for example, are
often not responded to adequately. Amnesty International’s Stolen Sisters
campaign and the Native Women’s Association of Canada’s Sisters in Spirit
initiative are revealing the alarmingly high levels of trauma among and
violence against Aboriginal women. Aboriginal women, men, their families
and communities have also suffered immeasurably due to historical and
ongoing colonization. Culturally safe, holistic support for Aboriginal people is

critically needed, with trauma-informed practice as a key component.
Finally, integrating practice with education is critical. Trauma awareness

always underpins trauma-informed practice. Given the scope of the
adaptations needed across settings and populations, the structures for
learning about trauma and its implications need to be innovative and
multiple. For example, multi-sectoral communities of practice could be
used to build consensus on system-level approaches. Blogs could provide
immediate updates on research findings. Websites could be used as a source
for collected evidence. Webcasts could broadcast oral presentation of new
findings and debate around new approaches. Researchers could use virtual
collaboratories (locations for social and other scientists to collaborate) to
engage in transdisciplinary research. Listservs could connect people to
updates on news, programming and research. And people could meet other
innovators at conferences. All of these mediums offer opportunities for
integrating new knowledge into training and education. They are tools to
accelerate the speed of uptake of trauma-informed knowledge and practice.
There are many reasons to be hopeful about becoming trauma informed.

Through mechanisms such as the Grounding Trauma conferences and the
Canadian Centre on Substance Abuse online SystemAction web workspace,
practitioners across Canada have indicated an overwhelming interest in
learning more about trauma, its centrality in the lives of people with
substance use and mental health disorders and the broad implications for
practice and policy. These efforts and interests underpin many emerging
examples of systems of care improvement, such as efforts to reduce
traumatization in collaborations between substance use and child welfare
systems. While being trauma informed may not be the sole purview of any
agent, service or location, it is clearly an important process to be embedded
in all systems that aim to serve and support people. We hope that others
interested in trauma-informed practice will be inspired by the work of the
contributors to this book.
Conclusion 365
References
National Treatment Strategy Working Group. (2008). A Systems Approach to Substance Use in
Canada: Recommendations for a National Treatment Strategy. Ottawa: National Framework for
Action to Reduce the Harms Associated with Alcohol and Other Drugs and Substances in
Canada. Retrieved from www.ccsa.ca
367
About the Editors
Nancy Poole, MA, PhD candidate, is the director of research and knowledge
translation for the British Columbia Centre of Excellence for Women’s
Health, and the provincial research consultant on women and substance use
issues for BC Women’s Hospital in Vancouver. Nancy is well known for her
collaborative work on research, training and policy initiatives on women’s
substance use issues with governments and organizations on local, provincial,
national and international levels. She is currently doing doctoral studies on
virtual knowledge translation, studying the role of virtual communities of
practice (vCoPs) to collaboratively examine evidence on women’s substance
use issues and generate consensus on avenues for improving our response.
Lorraine Greaves, PhD, is senior investigator at the British Columbia Centre

of Excellence for Women’s Health and its founding executive director. Prior to
that, she was the founding director of the Centre for Research on Violence
against Women and Children in Ontario. She is the lead mentor of IMPART,
a training program for researchers in gender and addiction and their
intersections with mental health, violence and trauma issues. As executive
director of the Health Systems Strategy Division at the Ministry of Health and
Long-Term Care in Ontario, she developed equity and intersectoral strategies
for policy development. She is internationally recognized as an expert in
women and tobacco use, gender-based analysis and integrating gender and
equity into policy and practice.
Nancy Poole and Lorraine Greaves co-edited the book Highs and Lows:
Canadian Perspectives on Women and Substance Use (2007), also published
by the Centre for Addiction and Mental Health.
369
About the Authors
Janice Abbott has been the CEO of Atira Women’s Resource Society since
1992 and of Atira Property Management Inc. since its launch in 2002.
In 1995, Janice spearheaded the opening of Shimai Transition House, a
specialized transition house for women affected by violence who were
struggling with substance use and mental wellness. Janice’s understanding
of and passion for supporting others to understand the complex relationship
between violence and substance use comes from her lived experience.
Throughout Atira’s herstory, Janice has championed barrier-free and low-
barrier access to programs and services for women, ensuring Atira’s programs
are accessible to all women and their children.
Branka Agic, PhD candidate, is the manager of health equity at the Centre
for Addiction and Mental Health and deputy director of the Collaborative
Program in Addiction Studies in the School of Graduate Studies at the
University of Toronto, where she received a master’s degree in health science
in health promotion. Branka has a medical degree from the University of
Sarajevo in Bosnia and Herzegovina. She is a doctoral candidate in the Dalla
Lana School of Public Health at the University of Toronto. Her primary
interests include mental health and substance use in immigrant, refugee,
ethnocultural and racialized groups.
Donna Akman, PhD, CPsych., is a psychologist with the Women’s Program

at the Centre for Addiction and Mental Health and an assistant professor in
the Department of Psychiatry at the University of Toronto. She has worked
extensively as a clinician and researcher in the area of women’s mental health.
Donna has a long-standing interest in developing, implementing and
evaluating feminist-informed approaches to women’s mental health care.
Sabrina Baker, MSW, RSW, has worked for more than 30 years in mental
health care in various settings, focusing on family-centred care and family
therapy. She currently works in private practice, specializing in promoting
recovery with families whose relatives have mental health issues by providing
support, education and counselling. She is passionate about teaching, training,
supervising and consulting students, workers and volunteers in promoting
and providing family-centred care. Sabrina co-wrote Promoting Recovery from

First Episode Psychosis: A Family Guide (Centre for Addiction and Mental Health,
2009) and has contributed chapters to other books on family-centred care.
Richard Bebout, PhD, is chief clinical officer at Community Connections in

Washington, D.C., and has been affiliated with the human services agency
since he earned his doctorate at the University of North Carolina at Chapel
Hill in 1987. Richard has contributed more than 20 articles and book chapters
on mental health services and frequently trains and consults in the areas of
supportive housing, trauma-informed care and M-TREM, a group approach
to addressing the impact of traumatic violence on men’s lives. Richard also
maintains a private therapy practice in Washington.
Julia Bloomenfeld, MSW, RSW, is the director of clinical services at the Jean
Tweed Centre, an agency for women with substance use and gambling
concerns in Toronto. Since graduating in 1991, Julia has spent most of her
career in women-centred services in the criminal justice and substance use
sectors, where she has delivered programs that respond to the distinct needs
of women, especially those with a history of trauma. Julia has actively
supported a shift toward providing care that is more trauma informed by
participating in various community of practice forums, including discussion
and trainings, and by writing in the substance use sector.
Vivian B. Brown, PhD, founder and former CEO of PROTOTYPES, a

California non-profit agency, has more than 40 years of experience developing
innovative mental health, substance use, trauma-informed, trauma-specific,
HIV/AIDS and co-occurring disorders services. She has conducted outcome
studies, including the Women, Co-occurring Disorders and Violence Study,
and has numerous publications. She has sat on many federal, state and local
advisory committees, including the Substance Abuse and Mental Health
Services Administration’s National Advisory Council and Women’s Advisory
Committee. Vivian provides consultations about integrating mental health,
substance use, health and trauma services to organizations and state and local
agencies throughout the United States.
Stephanie R. Capyk, M.Ed., RCC, CCC, was the clinical supervisor and
manager at the Victoria Women’s Sexual Assault Centre in British Columbia
until 2012. Since 1997, she has worked for women’s safety through doing
About the Authors 371
community-based research, counselling survivors of sexualized and domestic

violence and facilitating learning about trauma, healing and reconnecting
with one another and the natural world. In recent years, her practice has
shifted to supporting counsellors as a trainer and clinical supervisor.
Stephanie’s current projects include raising a baby and bees with her partner
on their farm in northern Alberta.
Gloria Chaim, MSW, RSW, is the deputy clinical director in the Child,
Youth and Family Program at the Centre for Addiction and Mental Health.
She is assistant professor in the Department of Psychiatry and an adjunct
lecturer in the Factor-Inwentash Faculty of Social Work at the University of
Toronto. Gloria’s main interest is in the development of service capacity for
under-served populations, particularly women, children, youth and families
where concurrent disorders are a concern. To foster opportunity for innovation,
her focus most recently has been on developing cross-sectoral networks and
collaborations that provide a forum for knowledge exchange and joint service
and research initiatives.
Jennifer Chambers is co-ordinator of the Empowerment Council, a voice for

clients at the Centre for Addiction and Mental Health (CAMH). On behalf of
the council and its predecessor, the Queen Street Patients Council, Jennifer
has worked to have the client voice heard where it was not heard: in
interventions in cases before the Supreme Court, through standing at
inquests and by training members of the Toronto Police Service. She spent
several years negotiating the CAMH Bill of Client Rights. She focuses on
connecting the client voice with evidence that supports it and exploding the
myth that the client voice (or advocacy) and good science are at odds.
Natalie Clark’s work is rooted in more than 15 years of experience with

Aboriginal girls as an ally, auntie, sister and group facilitator, and through her
own journey. Her work is informed and mobilized through her interconnected
identities, including her English, Welsh and Aboriginal ancestry; as a solo
parent of three Aboriginal children; and as an academic and a community-
based researcher and counsellor. Natalie practises and provides training
on trauma-informed girls’ groups, including It’s a Girl Thang, which she
co-developed. Her recent work involves developing indigenous girls’ groups
in partnership with the Interior Indian Friendship Society and School District
73 Aboriginal Programs in Kamloops, B.C.
Stephanie S. Covington, PhD, LCSW, is a clinician, organizational consultant

and lecturer who for more than 25 years has focused on creating gender-
responsive and trauma-informed services. Her experience includes designing
women’s services at the Betty Ford Center, as well as developing programs
for women in criminal justice settings. She was a consultant to the United
Nations Office on Drugs and Crime in Vienna and was selected for the
U.S. federal Advisory Council on Women’s Services. Her publications include
six gender-responsive, trauma-informed treatment curricula. Stephanie is
based in La Jolla, California, where she is co-director of the Institute for
Relational Development and the Center for Gender and Justice.
Lynda Dechief, MSc., is a researcher and consultant in women’s health and

social issues, with a focus on the intersections of oppression, violence,
substance use and mental health issues. Her company, Equality Consulting,
collaborates with non-profit organizations, research centres and government
agencies to work toward making the world a safer, healthier place for those
most marginalized and stigmatized. This involves community-based research
and evaluation, program and policy development and management, workshop
creation and facilitation and writing. Lynda has a master’s degree in population
and public health and feels that she has learned the most important lessons
from the women she has directly supported and advocated for.
Colleen Anne Dell, PhD, is a professor at the University of Saskatchewan in

the Department of Sociology and the School of Public Health, where she
holds a Research Chair in Substance Abuse. She is also a senior research
associate with the Canadian Centre on Substance Abuse, Canada’s national
addictions agency. Colleen’s research is grounded in a community-based
participatory approach and focuses on Aboriginal populations, criminalized
women and substance-using populations. She has worked extensively at the
community and national levels, including with the Elizabeth Fry Society and
the Senate of Canada.
Amy Druker, BSW, MSW, works with young people and their families at
Oolagen Community Services as an individual and family therapist. She
values a narrative therapeutic philosophy in her conversations with young
people and families. Amy’s previous work with substance-using pregnant and
parenting women helped grow her understanding of the systemic injustices
women face as a result of the stigma against women who use substances,
particularly pregnant/parenting women. She remains involved with the Grief

and Loss Education and Action Group as a volunteer. She is excited about
the social change initiatives that have come from the group’s work around
systemic change in the child welfare system.
Roger D. Fallot, PhD, is director of research and evaluation at Community

Connections, a private, not-for-profit agency that provides a full range of
human services in Washington, D.C. He is a contributing author and
co-editor (with Maxine Harris) of Using Trauma Theory to Design Service
Systems (Jossey-Bass, 2001) and consults widely on the development of
trauma-informed cultures of care in human services. Roger and a group
of clinicians at Community Connections have developed a men’s version
(M-TREM) of the Trauma Recovery and Empowerment model (TREM), a
group intervention for working with survivors of physical and sexual abuse.
Maria Haarmans, MA, PhD candidate, has 20 years of experience in hospital

and community settings working with individuals with schizophrenia. She
has trained in cognitive-behavioural therapy for psychosis (CBTp) with leading
experts in Canada and the United Kingdom. Maria has published on CBTp
and gender issues and provides training and supervision/consultation for
mental health practitioners. She practises and promotes empowering and
depathologizing approaches to psychological distress. Maria has a master’s
degree in community psychology (feminist stream) from the University of
Toronto. She is completing a doctorate in clinical psychology, focusing on
gender role socialization and psychosis, at the University of Liverpool.
Mary Harber, MSW, PhD candidate, is an assistant professor in the School of

Social Work and Human Service at Thompson Rivers University in Kamloops,
British Columbia. She has been a social worker for 24 years and has practiced
in a variety of contexts, including child welfare, substance use, youth, sexuality
and disability. Her current research and community work focuses on supporting
individuals with fetal alcohol spectrum disorder using creative engagement to
help them develop social skills that facilitate community inclusion.
Lori Haskell, Ed.D., CPsych., is a clinical psychologist and author of First Stage
Trauma Treatment: A Guide for Mental Health Professionals Working with Women
(Centre for Addiction and Mental Health, 2003). She has a status appointment
as an assistant professor in psychiatry at the University of Toronto and is an
academic research associate with the Centre for Research on Violence against
Women and Children. Lori lectures and teaches on topics related to complex
trauma and its treatment, vicarious trauma and violence prevention.
Joanna Henderson, PhD, CPsych., is a clinician scientist with the Child,

Youth and Family Program at the Centre for Addiction and Mental Health
and an assistant professor in the Department of Psychiatry at the University
of Toronto. Joanna has worked extensively with children and youth with
complex behavioural and emotional needs and their families. Currently, she
is developing, implementing and evaluating evidence-based practices for
addressing the needs of youth, particularly youth with co-occurring mental
health and substance use concerns. Joanna’s other research interests include
trauma, trauma-informed care, youth risk-taking, improving access to care,
treatment engagement and collaborative models of service delivery.
Steven Hughes, M.Ed., is the manager of training and development for the
Canadian Training Institute in Toronto. He has worked in the social service
support system for more than 25 years. As a lifelong learner, Steven is
interested in adult education, accelerated learning, dialogue methods,
violence prevention in organizations, appreciative inquiry and practices that
help individuals cultivate self-awareness and unlock their full potential.
Steven is committed to bringing positive energy to organizations so that
individuals in the workplace can flourish and make their unique and valued
contributions to the world.
Paul Hyman is president of Brain Fitness International. He is an integrative

functional specialist combining mind/body approaches and brain research,
working in conjunction with other health care and education professionals.
During his 10 years as a therapist at the Centre for Addiction and Mental
Health (CAMH), he was a member of the design team responsible for
creating Ontario’s first problem gambling program and also developed a
stress management program. Paul is a licensed Brain Gym instructor/
consultant and pioneered the use of Brain Gym at CAMH.
Frances Jasiura, BPHE (Hons), BSW, RCC, co-founder of Change Talk

Associates, offers practice-based training and virtual coaching across Canada,
strengthening people’s capacity to guide change conversations and positively
influence health outcomes. Her work is informed by decades of experience in
motivational interviewing, training and counselling. Empowering women

in addiction day treatment programs has inspired her respect for groups as
a context for sustainable change. Frances is a member of the international
Motivational Interviewing Network of Trainers and a contributing author in
the book Motivational Interviewing in Groups (Guilford Press, in press). She is
also a certified spiritual director.
Yona Lunsky, PhD, CPsych., is an associate professor in the Department of

Psychiatry at the University of Toronto; the section head of research in the
Dual Diagnosis Program at the Centre for Addiction and Mental Health; and
an adjunct scientist at the Institute for Clinical Evaluative Sciences. She is also
a clinical psychologist who works primarily with adults with developmental
disabilities. Her research focuses on the mental health of adults with
developmental disabilities and their caregivers, and she has published more
than 100 research papers and book chapters on the topic.
Judy Lyon, MA, MPCP, SFTT, has more than 20 years of experience as an
addiction counsellor in health care and corrections settings. She most recently
was lead addiction counsellor at the Aurora Centre in Vancouver. Judy now
works as a counsellor, consultant and focusing-oriented therapy trainer in
private practice in Surrey, British Columbia. She specializes in working with
complex trauma and related issues, such as addictions and disordered eating,
and is an active advocate for trauma-informed, integrated care.
Tammy MacKenzie, M.Ed, is a manager within the Addictions Program at

the Centre for Addiction and Mental Health. Prior to this, she was manager of
the Pathways to Healthy Families Program at the Jean Tweed Centre. Given
her work with women who have children and substance use concerns, she
has taken a particular interest in the grief and loss of these mothers whose
children are not in their care.
Peter Menzies, PhD, is a member of Sagamok Anishnawbek First Nation in

northern Ontario. He has spent 10 years building culturally congruent mental
health and addiction programs in partnership with urban and First Nations
communities. Before joining the Centre for Addiction and Mental Health,
Peter held front-line and management positions at both Aboriginal and
mainstream agencies. He earned a doctorate from the University of Toronto
and received the Centre for Equity and Health in Society’s Entrepreneurial
Development and Integration of Services Award in 2005 and the Kaiser

Foundation’s Excellence in Indigenous Programming Award in 2011.
His research interests include Aboriginal homelessness, intergenerational
trauma, child welfare and suicide prevention.
Anna M. Palucka, PhD, is a clinical psychologist in the Dual Diagnosis

Program at the Centre for Addiction and Mental Health and an assistant
professor in the Department of Psychiatry at the University of Toronto.
Her clinical and research interests include mental health issues in develop-
mental disabilities, pathways to the use of emergency services by people with
autism spectrum disorders, the impact of life events and trauma, and forensic
issues. Currently, Anna is exploring applications of mindfulness-based
interventions in supporting and treating people with developmental
disabilities and their caregivers.
Barbara Peck, MA, MSW, works at the Victoria Women’s Sexual Assault
Centre as a counsellor and as the co-ordinator/trainer for the centre’s TIPS
(Trauma-Informed Practice and Support) program. She has been involved
in the anti-violence movement for many years, and sees both her counselling
practice and the TIPS program as a means of effecting social change. She
has a background in physiological psychology and social work, and has also
worked in the areas of head injury, women’s health and career counselling.
Currently, Barb is striving to ensure her work is more fully informed by an
understanding of anti-oppressive practices.
Athina Perivolaris, RN, MN, is an advanced practice nurse at the Centre for
Addiction and Mental Health (CAMH), specializing in mental health and
geriatrics. She obtained her degrees from the University of Toronto, where
she has a clinical appointment as adjunct lecturer with the Bloomberg Faculty
of Nursing. Athina co-led CAMH’s prevention of restraint and seclusion
initiative, working for three years with stakeholders to develop and implement
the restraint prevention strategic plan. She collaborated and consulted with
external organizations embarking on their own restraint prevention initiatives.
Athina is a team leader for the Registered Nurses’ Association of Ontario
best practice guideline Promoting Safety: Alternative Approaches to the Use of
Restraints.
Ann Pottinger, RN, MN, graduated from the University of Toronto, where
she has a clinical appointment as adjunct lecturer at the Bloomberg Faculty
of Nursing. She is an assistant lecturer at the School of Nursing at York
University and an advanced practice nurse at the Centre for Addiction and
Mental Health (CAMH). Her areas of focus include geriatrics, mental health
and health equity. She co-led the CAMH Restraint Minimization Taskforce
and partnered with stakeholders to help shape CAMH’s restraint prevention
journey. Ann is co-author of “The End of Life” and “Mental Health Practice”
in The Health Care Professional’s Guide to Clinical Cultural Competence
(Elsevier Canada, 2007).
Tammy Rasmussen, MSW, RSW, is a trauma therapist at the Jean Tweed

Centre in Toronto. With more than 15 years of clinical experience, Tammy
specializes in providing therapy to women whose lives have been affected by
trauma and substance use and/or gambling. Tammy offers individual and
group counselling to women, as well as consultation and training to service
providers working concurrently with trauma and substance use and gambling
issues. For the past four years, Tammy has been integrating sensorimotor
psychotherapy into her practice, in addition to using other approaches, such
as eye movement desensitization and reprocessing (EMDR), mindfulness,
cognitive-behavioural therapy and energy psychology.
Cheryl Rolin-Gilman, RN, MN, CPMHN(C), is the advanced practice nurse

with the Women’s Program at the Centre for Addiction and Mental Health
(CAMH). She is adjunct lecturer for the Lawrence S. Bloomberg Faculty
of Nursing and the Department of Psychiatry at the University of Toronto.
Her particular interest is in working with people with trauma histories.
She has specialized training in dialectical behaviour therapy. In 2008, Cheryl
co-authored Clinical Supervision Handbook: A Guide for Clinical Supervisors for
Addiction and Mental Health with members of the professional practice group
at CAMH and the Faculty of Social Work at the University of Toronto.
Susan Rosenkranz, MA, is a PhD candidate in the Department of Psychology

at York University in Toronto. Her primary clinical and research interests are
in the field of childhood traumatic stress. Her current research explores factors
accounting for the connection between exposure to potentially traumatic events in
childhood and the development of substance use problems during adolescence.
Diane Smylie, MSW, RSW, is working on the Connections Project (knowledge

exchange for agencies serving women with substance use problems) with
McMaster University in Hamilton, Ontario. She also works with the BC
Centre of Excellence for Women’s Health, supporting a provincial project
to strengthen trauma-informed care in mental health and substance use
services. Previously, Diane worked at the Jean Tweed Centre in Toronto,
which provides programming for women with substance use problems and
their families. She has more than 17 years of clinical and management
experience in substance use services, including methadone maintenance
and services for pregnant and parenting women.
Roberta K. Timothy, PhD, has used anti-oppression approaches for more

than 20 years as a therapist, trainer, group facilitator, researcher, community
organizer, professor and clinical supervisor in community and educational
settings and in private practice. Her interests include critical expressive arts
therapy, trauma and transgenerational violence, work culture and organizational
change, resistance education and creative resistance. Roberta holds a bachelor’s
degree in political sciences, sociology and international justice and human
rights, two master’s degrees in political sciences and counselling psychology
and a doctorate in adult education, community development and gender
studies. She is doing a Social Sciences and Humanities Research Council of
Canada post-doctoral fellowship in the Counselling Psychology Department at
the University of Toronto.
Brenda Toner, PhD, completed her degree at the University of Toronto,

followed by a post-doctoral fellowship in eating disorders. Brenda is a full
professor in the Department of Psychiatry at the University of Toronto and
graduate co-ordinator at the Institute of Medical Science in the university’s
Faculty of Medicine. She worked at CAMH for more than 25 years, more
recently as a senior scientist and head of Women’s Mental Health Research.
Brenda has expertise in eating disorders, anxiety, depression, chronic pelvic
pain, chronic fatigue, and irritable bowel syndrome, as well as psychosocial
factors that affect women, such as violence, body dissatisfaction, discrimination
and gender role socialization.
Mercedes Umaña, PhD candidate, has more than 20 years of experience

facilitating personal, community and organizational development and healing
processes locally and internationally as an educator, therapist, researcher and
consultant. Her areas of interest include anti-oppression practice, community

mental health, health psychology, trauma, post-traumatic growth, bereavement,
HIV, intersectional analysis and research methodologies and knowledge
translation. Mercedes holds a bachelor’s degree and a master’s degree in
psychology and is a doctoral student in the Counselling Psychology Program
at the University of Toronto. Mercedes has worked as a therapist at Women’s
Health and Women’s Hands Community Health Centre for more than 10 years.
Cristine Urquhart, MSW, RSW, co-founder of Change Talk Associates, offers

training and coaching across Canada in evidence-based communication
practices that increase engagement and build motivation for health-related
change. Passionate about improving the health of women, Cristine translates
research to practice, integrating women-centred, motivational interviewing
and trauma-informed approaches. She has worked with the BC Centre of
Excellence for Women’s Health as a trainer and program designer for various
projects since 2005. Cristine is a member of the international Motivational
Interviewing Network of Trainers, an instructor at the University of British
Columbia and a contributing author to Motivational Interviewing in Social
Work Practice (Guilford, 2011).
Carolyn Ussher, MSW, is the manager of client services at the Children’s

Aid Society of Toronto, where she has worked since 1994 in various roles,
including front-line intake worker and supervisor for both intake and ongoing
family services. Carolyn has a particular interest in improving child welfare
service provision and co-ordination for children and families where substance
use is a concern.
Linde Zingaro, PhD, completed her doctorate in educational studies at the

University of British Columbia, where she won the IIQR Dissertation Award.
Her thesis, “Speaking Out: Storytelling for Social Change,” was published
in 2008. Linde’s academic efforts reflect her lifelong work in activist and
advocacy roles: as administrator, educator and counsellor working with
individuals and groups struggling with trauma and marginalization. After
a decade of front-line work with street youth, she has maintained a private
counselling practice in Vancouver for 26 years. Since 1992, she travels every
year to Japan to work with women’s groups and service providers dealing with
child abuse and violence against women.
Growing evidence suggests that most people accessing mental health and addiction
services have experienced trauma at some point in their lives. Community services,
treatment agencies and hospitals are recognizing that they need to understand the
potential effects of trauma on all of their clients and create programs, spaces and
Becoming
policies that are trauma informed.
Becoming Trauma Informed

Becoming Trauma Informed describes trauma-informed practice at the individual,
organizational and systemic levels. The editors and authors bring unique
perspectives from various settings and from the diverse groups with which they
work, sharing how trauma-informed principles have been integrated into different
mental health and addiction treatment and social service environments. They
emphasize how trauma-informed services must take into account an understanding
Trauma
of trauma, and place priority on trauma survivors’ safety, choice and control. These
contributors offer hope and direction for becoming trauma informed, showcasing
their innovation, leadership, practices, ideas and compassion.
I found this book both exciting and inspiring. It should be read by practitioners,
administrators, researchers and educators who work in mental health, addictions,
child welfare, violence against women; in fact, by everyone who labours to improve
Informed
the lives of people who are hurting. The content provides state of the art knowledge
about the transformation in service delivery and improved outcomes that occur when
helping professionals and helping systems are trauma informed.
CAROL A. STALKER, PhD, RSW
professor and associate dean, phd program, faculty of social work,
wilfrid laurier university, waterloo, on
This is an ambitious and powerful book, whose editors and authors have more than risen
to meet the challenge of demonstrating to their colleagues creative ways to think about
delivering care through the lens of trauma. Every health and mental health practitioner
should read this book, whether they believe themselves to be working with trauma
survivors or not. The compassionate, thoughtful and evidence-based information in this
volume will improve quality of care for all patients and clients.
LAURA S. BROWN, PhD, ABPP
author of cultural competence in trauma therapy: beyond the flashback,
and director, fremont community therapy project, seattle, wa Edited by
Nancy Poole
This publication may be available in other formats. Lorraine Greaves
For information about alternative formats or other
CAMH publications, or to place an order, please
contact Sales and Distribution:
Toll-free: 1 800 661-1111
Toronto: 416 595-6059
4566 / 10-2012
Online store: http://store.camh.net
Website: www.camh.ca World Health Organization Collaborating Centre

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What is the book about?

What is the book about?

What perspectives are shared in the book?

What perspectives are shared in the book?

Growing evidence suggests that most people accessing mental health and addiction

Becoming Trauma Informed

A Pan American Health Organization /

Becoming trauma informed / edited by Nancy Poole and Lorraine Greaves.

ISBN: 978-1-77114-058-4 (PRINT)

1. Psychic trauma—Patients—Care. 2. Psychic trauma—Patients—Mental health services.

RC552.T7B42 2012 616.85’21 C2012-904264-1

Toll-free: 1 800 661-1111

This book was produced by CAMH Education.

4566 / 09-2017 / PG140

PART 1: WHAT IS “TRAUMA INFORMED”

37 3 Using a Feminist- and Trauma-Informed Approach in Therapy

47 4 Anti-oppression Psychotherapy as Trauma-Informed Practice

6 Cognitive-Behavioural Therapy for Psychosis: A Trauma-

89 7 Trauma-Informed Body-Centred Interventions

ECTION 1: DIVERSE GROUPS

121 9 Trauma-Informed Care for Refugees

135 10 The Evolution of Trauma-Informed Practice at the

145 11 Show Not Tell . . . Trauma-Informed Creative Engagement with

151 12 Girls’ Groups and Trauma-Informed Intersectional Practice

175 14 An Intergenerational Trauma-Informed Approach to Care

SECTION 2: DIVERSE SETTINGS

201 16 Using a Trauma-Informed Approach to Guide the Journey

225 18 Trauma-Informed Care on a Women’s Inpatient

235 19 Trauma-Informed Primary Care with Immigrant, Refugee and

PART 3: CHANGING THE SYSTEM THROUGH

263 21 Curricula to Support Trauma-Informed Practice with Women

275 22 Responding to Women’s Self-Harm: A 10-Year Reflection on the

289 23 A Mother’s Loss: The Unacknowledged Grief of Child

311 25 What Do Client Rights Have to Do with Trauma-Informed Care?

329 27 Breaking Out of the Mould: Creating Trauma-Informed Anti-

339 28 Integrating Treatment of Tobacco with Other Substances in

367 About the Editors

369 About the Authors

As with our previous collaboration on Highs and Lows: Canadian Perspectives on

We dedicate this book to the survivors of trauma who have experienced

Nancy Poole and Lorraine Greaves

Our experiences at the British Columbia Centre of Excellence for Women’s

In 2007/2008, BCCEWH was part of the Canadian National Treatment

Our connections with the leaders of the Women, Co-occurring Disorders

provoked us to think about how we might apply them to encourage similar

This guidebook is intended to support the work of practitioners in the

In Canadian mental health and addiction services, designing trauma-

Why Trauma-Informed Care?

Trauma describes experiences that may overwhelm a person’s capacity to cope.

The American Adverse Childhood Experiences study looked at the life

For Aboriginal people, experiences of trauma are compounded by the inter-

In short, there is compelling evidence that mental health and substance

linked to the experience of developmental trauma. She identifies how early

Situating Trauma in Substance Use and Mental Health

reduction–oriented practice has brought attention to how many people cannot

In the anti-violence field, a greater understanding of how violence, sexual

The Need for Systemic Responses

Despite their importance, however, trauma-informed service and system

Interestingly, a parallel shift in responding to homelessness illustrates a

Strategies for implementation are obscure, few program models exist,

37 3 Using a Feminist- and Trauma-Informed Approach in Therapy

135 10 The Evolution of Trauma-Informed Practice at the

145 11 Show Not Tell . . . Trauma-Informed Creative Engagement with

175 14 An Intergenerational Trauma-Informed Approach to Care

201 16 Using a Trauma-Informed Approach to Guide the Journey

225 18 Trauma-Informed Care on a Women’s Inpatient

235 19 Trauma-Informed Primary Care with Immigrant, Refugee and

275 22 Responding to Women’s Self-Harm: A 10-Year Reflection on the

289 23 A Mother’s Loss: The Unacknowledged Grief of Child

329 27 Breaking Out of the Mould: Creating Trauma-Informed Anti-

339 28 Integrating Treatment of Tobacco with Other Substances in

Trauma-informed services consider issues around client safety and empowerment