Trauma-Informed Social Work PracticeJill Levenson
Social workers frequently encounter clients with a history of trauma. Trauma-informedcare is a way of providing services by which social workers recognize the prevalence of earlyadversity in the lives of clients, view presenting problems as symptoms of maladaptive cop-ing, and understand how early trauma shapes a client’s fundamental beliefs about the worldand affects his or her psychosocial functioning across the life span. Trauma-informed socialwork incorporates core principles of safety, trust, collaboration, choice, and empowermentand delivers services in a manner that avoids inadvertently repeating unhealthy interpersonaldynamics in the helping relationship. Trauma-informed social work can be integrated intoall sorts of existing models of evidence-based services across populations and agency settings,can strengthen the therapeutic alliance, and facilitates posttraumatic growth.
KEY WORDS: adverse childhood experiences; adversity; trauma; trauma-informed care
Social workers frequently encounter clientswith a history of trauma, which is defined asan exposure to an extraordinary experiencethat presents a physical or psychological threat tooneself or others and generates a reaction of help-lessness and fear (American Psychiatric Association[APA], 2013). The exposure may have occurred inthe distant or recent past, and pervasive symptomssuch as intrusive thoughts of the event, hyperarousalto stimuli in the environment, negative moods, andavoidance of cues related to the trauma are charac-teristic of both acute and chronic posttraumatic stressdisorders (APA, 2013). Traumatic experiences takemany forms, but they typically involve an unexpectedevent outside of a person’s control such as criminalvictimization, accident, natural disaster, war, or expo-sure to community or family violence.
An abundance of research has revealed that trau-mas involving early child mistreatment and familydysfunction are especially prevalent and impactful(Centers for Disease Control and Prevention [CDC],2013). Children may experience other events thatalso result in trauma, such as bullying, death of afamily member, illness, out-of-home placement,and poverty; historical traumas like systemic oppres-sion or discrimination are also prevalent for minorityand other marginalized groups. Some traumas arequite overt, like physical and sexual abuse or wit-nessing domestic violence, whereas chronic experi-ences like emotional neglect, an absent parent, or asubstance-abusing caretaker may be more subtle
but can leave insidious effects. Individuals are oftenexposed to multiple related traumas and polyvicti-mization, leading to toxic stress and complex traumareactions (Cloitre et al., 2009; Finkelhor, Turner,Hamby, & Ormrod, 2011; Maschi, Baer, Morrissey, &Moreno, 2013).
Trauma-informed care (TIC) incorporates anunderstanding of the frequency and effects of earlyadversity on psychosocial functioning across thelife span (Substance Abuse and Mental Health Ser-vices Administration [SAMHSA], 2014a). TIC isdifferent from trauma-focused therapy, as its primarygoal is not to directly address past trauma, but to viewpresenting problems in the context of a client’s trau-matic experiences (Brown, Baker, & Wilcox, 2012).Trauma-informed social workers rely on their knowl-edge about trauma to respond to clients in waysthat convey respect and compassion, honor self-determination, and enable the rebuilding of healthyinterpersonal skills and coping strategies. The person-in-environment perspective held by social workershelps us recognize the role that adversity mightplay in the formation of maladaptive coping pat-terns. Social workers are trained to avoid over-pathologizing behavior and to appreciate the complexnexus between poverty, oppression, and trauma.As well, the core values and mission of social workinclude promoting social justice for oppressed andvulnerable populations (National Association ofSocial Workers, 2015). Trauma-informed practiceis consistent with these goals.
doi: 10.1093/sw/swx001 © 2017 National Association of Social Workers 105
DEVELOPMENTAL TRAUMA AND ITS EFFECTSThe largest study of the scope of adverse childhoodexperiences (ACEs) surveyed over 17,000 adultpatients of the Kaiser Permanente Health Systemand found that 64 percent of them reported at leastone type of childhood maltreatment or householddysfunction, and nearly 13 percent reported four ormore (CDC, 2013). Although these numbers dem-onstrate the high prevalence of ACEs, the ratesof early trauma among poor, disadvantaged, clinical,and criminal populations are even higher (Christensenet al., 2005; Eckenrode, Smith, McCarthy, & Dineen,2014; Larkin, Felitti, & Anda, 2014; Levenson, Willis,& Prescott, 2016; Wallace, Conner, & Dass-Brailsford,2011). As ACEs accumulate, the risk increases forcountless medical, mental health, and behavioralproblems later in life, including chemical depen-dency, smoking, depression, suicidality, fetal mor-tality, obesity, heart and liver diseases, intimatepartner violence, sexually transmitted diseases, andunintended pregnancies (Felitti et al., 1998). Thecombined effects of early adversity on health andpsychosocial well-being are profound and bringwith them grave implications for public health andsocial justice (Anda, Butchart, Felitti, & Brown,2010; Larkin et al., 2014).
The pathways from early adversity to psychosocialproblems are complex, but early toxic environmentsstimulate hyperarousal and overproduction of neu-rochemicals that activate automated fight-flight-freeze responses and inhibit the natural developmentand connection of neurons (Anda et al., 2006;van der Kolk, 2006). These changes in the brainover time can destabilize emotional regulation, socialattachment, impulse control, and cognitive proces-sing (Anda et al., 2010; Anda et al., 2006; Whitfield,1998). This is especially true when children areexposed to chronic and persistent adverse condi-tions, enabling maladaptive responses to becomeextremely well rehearsed. Developmental psy-chopathologists propose that emotional and socialadaptations to environmental conditions arise froma reciprocal intersection of thoughts and emotions;we “establish a coherence of functioning as a thinking,feeling human being” through the meaning we affixto our experiences (Rutter & Sroufe, 2000, p. 265).When previously traumatized clients encountercurrent stress, they may feel intense and intolera-ble emotions, and cope with them through nega-tive behaviors (Brown et al., 2012). Social workerstaking psychosocial histories should consider the
damaging effects of child maltreatment and chaoticfamily environments and their contribution to theexacerbation of presenting problems.
Attachment theory illustrates the linkage betweenearly adversity and adult psychosocial troubles.Attachment theorists argue that children must experi-ence nurturing, consistent, and responsive interactionswith primary caretakers to perceive the world as a safeplace (Bowlby, 1988). Children who are exposed tomaltreatment and family dysfunction suffer inconsis-tent parenting patterns that impair the developmentof secure attachments to caretakers, and chaotichouseholds often lack good role models for healthyinterpersonal functioning across the life span (Carlson& Sroufe, 1995; Cicchetti & Banny, 2014). Earlyabusive and neglectful relationships are characterizedby betrayal and invalidation, which can then manifestin disorganized attachment patterns, distorted cog-nitive schema, boundary violations, and emotionaldysregulation (Young, Klosko, & Weishaar, 2003).Early attachment disruptions have been correlatedwith deleterious long-term impacts including com-promised relational skills, self-regulation difficulties,and mental disorders (Jovev & Jackson, 2004; Loper,Mahmoodzadegan, & Warren, 2008).
TRAUMA-INFORMED PRINCIPLESTIC differs from trauma resolution therapy, althoughtrauma work may be a treatment goal for manyclients. Trauma-focused cognitive–behavioral inter-ventions help clients to discuss painful memoriesand reduce anxiety to a more tolerable level, andto increase their ability to modulate emotion andbehavior (Cohen, Mannarino, Kliethermes, & Murray,2012). Rather than focusing on specific interven-tions, TIC seeks to create a safe environment forclients that enables trust, choice, collaboration, andempowerment across treatment modalities so thatclients can experience healthy relationships withothers (Elliott, Bjelajac, Fallot, Markoff, & Reed,2005; Harris & Fallot, 2001). Trauma-informedsocial workers appreciate how common trauma is,and that violence and victimization can affect psy-chosocial development and lifelong coping strategies;they emphasize client strengths instead of focusingon pathology, and they work on building healthyskills rather than simply addressing symptoms. TICdelivers services in a manner that recognizes theemotional vulnerability of trauma survivors, and mostimportant, the worker avoids inadvertently repeatingdynamics of abusive interactions in the helping
106 Social Work Volume 62, Number 2 April 2017
relationship (Elliott et al., 2005; Harris & Fallot,2001; Knight, 2015; Morrison et al., 2015).
Trauma-specific interventions are aimed at re-ducing symptoms resulting from the negativesequelae of trauma in the life of the individual.TIC models of service delivery, on the other hand,reflect the needs of survivors to connect with others,to be respected, and to become hopeful regardingtheir own recovery (Bloom & Farragher, 2013;Harris & Fallot, 2001; SAMHSA, 2013). Recog-nizing that presenting problems, in actuality, oftenare indicators of trauma and interrelated emotionalwounds, trauma-informed social workers developpartnerships with consumers in a way that empowersthem. Social services can be oppressive, and margin-alized clients often approach services with a mistrustof authority figures and a wariness of professionalhelpers. Instead of interpreting this response as hos-tility, lack of motivation, or resistance to services,social workers should view it as a normal protectivereaction when an individual feels vulnerable. Socialworkers recognize that the burden is on us to facili-tate trust and that this requires a compassionate andrespectful way of engaging with clients.
A trauma-informed approach views presentingproblems as maladaptive coping and regards traumanot as a distinct event but as a framework forunderstanding experiences that can define anddeeply affect the core of a person’s identity (Harris& Fallot, 2001; SAMHSA, 2014a). By understand-ing how early adversity shapes a client’s fundamen-tal beliefs about the world, the trauma-informedsocial worker helps the client to construct newways to organize feelings, coping skills, behaviors,and relationships (Knight, 2015; Morrison et al.,2015). The social worker can conceptualize nega-tive behaviors as coping strategies that were onceadaptive in the traumagenic environment butwhich have become self-destructive or harmfulacross different domains of human functioning. Byviewing the collective experiences of the individ-ual in this holistic way, client behaviors that seemirrational, self-destructive, or even abusive are re-conceptualized as survival skills that once helpedthe individual respond to threatening encountersbut which now impede the ability to toleratedistress and set boundaries (Levenson, 2014). Con-sistent with a strengths-based approach to posttrau-matic growth, trauma-informed workers can helpclients change problematic behavior, manage crisesmore successfully, and parent their own children in
a more nurturing and responsive fashion (Levenson,2014; SAMHSA, 2014a). These strategies are es-sential to interrupting the intergenerational cycleof victimization (Harris & Fallot, 2001; Larkin et al.,2014).
TIC prescribes a set of basic principles: safety,trust, choice, collaboration, and empowerment (Elliottet al., 2005; Fallot & Harris, 2009; Harris & Fallot,2001; SAMHSA, 2014a). These concepts are consis-tently interwoven and applied throughout the intake,assessment, engagement, treatment, and terminationphases of social work services. The principles, wheninfused into practice, minimize the likelihood ofrepeating dysfunctional dynamics in the helping rela-tionship and capitalize on the opportunity to create acorrective experience for consumers of services.
The next sections describe the components ofTIC. At the micro level, social workers can beginto engage in TIC by treating everyone withkindness and respect, and listening with curiosityand compassion. At the systems or macro level,implementation of TIC requires a paradigm shiftwithin the organizational culture of an agency. Itis beyond the scope of this article to addresssystemic application of TIC principles, but thereader can refer to other resources. For instance,SAMHSA has published guidelines for TIC imple-mentation including TIP 57, which offers strategiesfor incorporating TIC in behavioral health settings(SAMHSA, 2014b). There are also several tools avail-able to measure TIC attitudes, readiness for change,and operational barriers. The new ARTIC scale(Baker, Brown, Wilcox, Overstreet, & Arora, 2016)can be used to assess employees’ perspectives through-out the process of adopting TIC protocols. The scalecomprises seven domains including attributions ofcauses for underlying problematic client behavior,preferred ways of responding to client symptoms,and systemwide support for TIC. Readers mayeven use the ARTIC tool as a self-assessment.Another instrument, the TICOMETER (Bassuk,Unick, Paquette, & Richard, 2016), can measureTIC in organizations at different points in time,making it useful for monitoring changes in servicedelivery, determining training needs, and refiningagency policies and procedures.
SafetyRecognizing the likely existence of a traumatichistory in the lives of social services consumers isthe first step in facilitating safety in the physical
107Levenson / Trauma-Informed Social Work Practice
environment and in relationships between clientsand providers (including staff). Warm and welcom-ing surroundings will create a sense of serenity forclients (Elliott et al., 2005; Fallot & Harris, 2009).Just the experience of a smiling receptionist can becalming and comforting for some clients. Physicalsafety can be ensured through facilitating protectionfrom hazards or dangers that might emerge withinthe physical space. For instance, good lighting,disability accommodations, and maintenance ofthe property can reduce the risk of physical injury.Security precautions can prevent threats from indi-viduals both within and outside the office. Respect-ful language, boundaries, and use of power canestablish and model safe and appropriate limits with-out recreating the oppressive dynamics of authorityfigures in the lives of many clients (Harris & Fallot,2001). In essence, safe relationships are consistent,predictable, and nonshaming (Elliott et al., 2005).
TrustErikson (1993) proposed that trust in our earliestrelationships with caretakers is foundational forestablishing a healthy personality, and that with-out the successful acquisition of trust, subsequentdevelopmental tasks of autonomy, initiative, compe-tence, and intimacy will likely be compromised.According to Maslow’s hierarchy, all humans havethe same basic needs including survival, physicaland psychological safety, social connection, self-esteem, and actualization (Maslow, 1943). When aclient’s basic needs for safety, respect, and accep-tance in the helping relationship are understood,an atmosphere of trust can be established (Elliottet al., 2005). Trust is earned and demonstrated overtime. By eliminating ambiguity and vagueness, thesocial worker can assist clients to clearly anticipatewhat is expected of them and what they can expectfrom their worker, diminishing the anxiety thatcomes with uncertainty and unpredictability (Harris& Fallot, 2001). For instance, workers can clearlyexplain the eligibility criteria, the process of receiv-ing services, and the expectations for successfulprogram completion, as well as information aboutconfidentiality, sharing of information, attendance,and fees. The style of interaction should be genuineand authentic, and in initial sessions, pressure shouldnot be put on clients to disclose information theyare not ready to share. There are stages of intimacythat all relationships go through, and by allowingthe consumer’s risk-taking and disclosure to proceed
at his or her own pace, the worker actually models ahealthy process of establishing trust based on deter-mining whether another individual is listening,hearing, and responding in a truly reliable and con-sistent fashion.
For example, a social worker noticed that soapand toilet paper were missing from the restroomafter a criminal offender rehabilitation group meet-ing. Instead of confronting the group about theincident and reminding them of the consequencesfor stealing, she asked herself, “Who steals soap andtoilet paper?” and remembered that some clients inthe group are homeless. She got permission to usesome petty cash to buy a basket and filled it withsoap, toothpaste, toilet paper, and small bottles oflaundry detergent. She placed it in the group roomand said nonchalantly to all of them at the nextmeeting: “Here are some hygiene items, feel freeto take a few if you need them.” The worker’simplicit message was clear: I hear you, I understandwhat you need, and I won’t shame you, so next time youneed help you can ask me.
ChoiceTrauma-informed services attempt to emboldenclient decision making and a sense of control overone’s recovery (Fallot & Harris, 2009). All clientsprogress at their own pace as they explore theirunique experiences and realize how those en-counters primed them to respond in a certain fash-ion to environmental stressors. As clients developan expanded repertoire of coping strategies, theybegin to recognize that they cannot always controlothers or the environment, but they can controltheir own responses. As a result, clients gain a newsense of control in the service delivery environment,while workers promote and reinforce autonomyand self-determination, which can transform a clientfrom a powerless, overwhelmed victim to a survivorwho directs and owns his or her life decisions andthe associated outcomes (Elliott et al., 2005). Emo-tional and behavioral dysregulation can reinforcenegative beliefs about oneself (“I’m a failure”), so itis important to help clients to improve impulse con-trol and problem solving by reframing their trig-gered fight-flight-freeze responses to environmentalstress as only one of several alternatives available tothem. As they learn and practice new skills, theyincrease their repertoire of available choices.
Facilitating choice can include asking clientsabout their preferences in service delivery, helping
108 Social Work Volume 62, Number 2 April 2017
clients to identify options and ponder alternativesfor themselves, and guiding clients in their owninformed decision making. For instance, instead ofshaming or punitive responses to resistance behav-ior, workers can help clients to assess their readinessfor change; in doing so, we enable them to owntheir lifestyle choices and to explore obstacles totheir goals. Sometimes, clients express preferencesabout their practitioners (for example, race, gen-der, ethnicity), and these requests should be dis-cussed and processed with clients in a way thatgives voice to their underlying comfort level. Forinstance, a client may ask, “Do you have children?You look young. I want a worker who has kids.”The worker might respond, “I think you are won-dering if I can understand what it is like for you asa parent. Either way, my parenting experiencewould be different from yours; I really want tounderstand your situation, so that together we canwork on finding solutions that are right for yourfamily. Would you be willing to try that?”
CollaborationTrauma-informed programming is based on sharedpower between worker and client so the relation-ship offers a true alliance in healing (Elliott et al.,2005; Fallot & Harris, 2009; Morrison et al., 2015).The inherent power imbalance in the helping rela-tionship requires constant attention to the many(often subtle and insidious) ways that feelings ofvulnerability and subsequent resistance can be gen-erated for clients. Because many ACE survivorswere betrayed by those who were supposed to pro-tect and care for them, the helping relationship isfraught with potential for retraumatization whenreminders of the capricious nature of past authorityfigures are activated. Most of us are motivated toplease others, to conform to authority, and to seekacceptance and attention, generating opportunitiesfor some people in a position of authority to exploitthose in subordinate positions. Abuse survivors areparticularly vulnerable to instinctive compliance andmay need to be reminded that they have the right toask questions, decline services, or make requests. Atruly collaborative worker–client relationship is onein which the worker’s professional knowledge iscombined with the client’s expertise about his or herown life narrative and scope of coping responses. Byunderstanding each client’s life history and culturalbackground, and by allowing clients to participate indetermining the course of the intervention, social
workers can engage clients and dislodge barriers tochange. Using the helping relationship as a thera-peutic tool, the collaborative partnership facili-tates connection to others and thus exposure to anemotionally corrective experience.
EmpowermentTrue empowerment occurs with a strengths-basedapproach that reframes symptoms as adaptationand highlights resilience instead of pathology. Toooften, an intense focus on fixing problematic beha-viors neglects the importance of acknowledgingand reinforcing strengths. Instead of asking “What’swrong with you?” we should get in the habit of ask-ing, “What happened to you?” (SAMHSA, 2014a).Survivors of childhood trauma experience a pro-found sense of powerlessness when choice andpredictability are absent from their daily existence.In fact, the very term “survivor” was designed tooffset the helplessness implied by the word “victim”(Harris & Fallot, 2001). Bandura (1977) describedthe crucial role of self-efficacy, defined as belief inone’s own capacity to achieve goals, accomplishtasks, and respond competently to challenges. Byreframing trauma responses as normal reactions tothreatening encounters, social workers can cele-brate survival strategies, channel those instinctsinto healthier relationship skills, and help clientsto achieve a sense of control in one’s daily life. Inthis way, we can fertilize the seeds of self-efficacyto assist the survivor to embrace hope and beliefthat change is possible.
APPLYING TRAUMA-INFORMED PRINCIPLESTO SOCIAL WORK PRACTICEBy recognizing the possible existence of a trau-matic history, we can make it a priority to establishphysically and psychologically safe therapeutic en-vironments. Early trauma (especially familial abuse)often breeds a sense of wariness and a mistrust ofcaregivers and authority figures. A salient need forclients, therefore, is to encounter environmentsand relationships that challenge their expectationsof the world as an unsafe place in which relation-ships are fraught with danger and disappointment.Safe relationships are consistent, predictable, andnonshaming. Social workers should model respectfulinterpersonal boundaries, language, and use ofpower so that safe and appropriate limits can be setwithout recreating the oppressive actions of others
109Levenson / Trauma-Informed Social Work Practice
that featured prominently in the lives of many clients(Bloom & Farragher, 2013; Harris & Fallot, 2001).
For example, when a client did not like ananswer he was given, he became combative andthen stood up to storm out the door, saying, “Ineed to leave before I do something I regret.”Instead of confronting or chastising the client, thesocial worker responded, “I can see that you areupset, and I appreciate that you want to controlyour temper. Let’s take some deep breaths together,and talk about what’s making you so mad rightnow.” After he calmed down, the social workerkindly observed, “I bet I’m not the first person to tellyou that you can be a little scary when you’re mad.”The client laughed and agreed that his mother andgirlfriend tell him that all the time. This opened aconversation about how his anger can sometimes beused to intimidate others into acquiescing to hisdesires, that this was similar to what he observedin his father growing up, and how better conflictresolution skills might reduce his tendency to violatethe boundaries of others in this way.
Motivational interviewing (Miller & Rollnick,2012) is commonly used with a variety of at-riskpopulations by infusing cognitive–behavioral ther-apies with humanistic principles to adopt a moreclient-centered approach. People who engage inaddictive, self-destructive, or victimizing behaviorsmay be judged by social workers as disturbed orunstable; with these clients it can be easy to over-look a history of trauma and attribute their be-havior to an unrelated cause, such as bad moralcharacter or lack of motivation for change. Whensocial workers view clients as being defective, wetend to intervene paternalistically and exacerbatethe very problems that would be better addressedthrough TIC (Levenson, 2014). Instead, we shouldvalidate the mixed feelings and inner conflictsabout change that naturally emerge in counseling,emphasize strengths, and help clients identify andreduce barriers to personal growth.
When practitioners fail to respond in a validatingor empathic manner to resistant, antagonistic, orhostile clients, a negative interaction occurs, ob-structing client engagement and producing a rup-ture in the therapeutic alliance (Binder & Strupp,1997; Teyber & McClure, 2000). When clientsdisplay resistance, clinicians in all disciplines some-times respond in ways that seem rejecting, judg-mental, or disapproving (Binder & Strupp, 1997).Social workers may be especially susceptible to
this detrimental process with nonvoluntary clients,because these individuals may enter mandated in-tervention programs with defensiveness or denial.Binder and Strupp (1997) cautioned that negativeprocess is a contributor to treatment failures in allpsychotherapy modalities serving a range of clientpopulations. Indeed, those with the most off-puttingbehavior may be most in need of trauma-informedresponses. Social workers should reflect on the waysthat their own beliefs, values, attitudes, and experi-ences might hamper their engagement style andunwittingly reproduce disempowering dynamics inthe helping relationship (Levenson, 2014).
Gender-specific services are also important, aswomen have specific empowerment needs thatreflect the link between poverty, violence, and mentalhealth symptoms (Covington & Bloom, 2007; East &Roll, 2015; Elliott et al., 2005; Topitzes, Mersky, &Reynolds, 2011). Men with childhood abuse historiesalso require relevant interventions (Easton, Coohey,Rhodes, & Moorthy, 2013; Levenson et al., 2016).For instance, responses to family dysfunction maymanifest in different ways: Teenage boys may gravi-tate toward gangs or delinquency for a sense of con-nection and inclusion, and teenage girls may beprone to early pregnancy if they long for someoneto love them. These problems are better viewed assymptoms of underlying trauma, and TIC interven-tions include simply interacting with clients in waysthat convey that they are special, important, andvaluable.
It is not uncommon for social services clients topresent with a history of poor self-regulatory capaci-ties. Households that lacked modeling of effectiveemotional and behavioral management often rein-force maladaptive coping methods that provided anantidote to anxiety or internal distress. When emo-tional dysregulation and flawed cognitive schemaare well rehearsed in the context of coping withchronic toxic stress, they can become deeply en-trenched in personality traits (Bloom & Farragher,2013). Traumatic reenactment occurs in the socialservices setting when negative clinician responsescontribute to self-fulfilling prophecies of failure,which in turn fortify anxiety and reinforce inflexiblecoping, thus dissuading clients from help seeking.For example, responding to a client who is consis-tently late to group therapy sessions with a criticalreminder about rules and consequences for tardinesscan reproduce shame and fear. Instead, the socialworker might remember that this client grew up in
110 Social Work Volume 62, Number 2 April 2017
a home with parents who were hoarders and whoprovided no modeling of routine, structure, order,or scheduling; the client had learned that disengage-ment from peers was a way to avoid the embarrass-ment of her household. The social worker mightacknowledge the client’s discomfort of being in agroup of people and can then help the client processher avoidant tendencies, check the bus schedule,plan what time to leave the house, and furtherdevelop and refine skills of time management.Some clients need social workers to provide amentoring role that their parents lacked, and toalter expectations accordingly.
As a result of early experiences of oppression,marginalization, discrimination, or child mistreat-ment, social services clients often display an as-sortment of relational problems that stem fromlong-standing core schema about themselves andothers (Teyber & McClure, 2011; Young et al.,2003). These thematic beliefs underlie interper-sonal skill deficits and associated behaviors, andcan generate a repetitive cycle of maladaptivedistress-relieving strategies and problematic rela-tional patterns. The helping relationship offers anopportunity for intervention when the professionalresponds to the vulnerability activating the negativeinteraction instead of directly challenging the behav-ior itself (Teyber & McClure, 2011; Young et al.,2003). For instance, a client became angry whenasked to change to a different group session. “I likethis group! I don’t want to start over with others!”Instead of pulling rank and forcing the switch, thesocial worker responded, “You make a good point.You are reminding me that your feeling of connec-tion with members in this group is more importantthan my need to assign you elsewhere.” When theclient continued the rant, the social worker observed,“Your expectation that others won’t respect yourwishes seems to be causing you to talk louder, whichmeans that you haven’t been able to hear me agreewith you.” This led to a great conversation about theanxiety and escalating agitation that are triggeredwhen feeling disrespected by others.
SUMMARY AND CONCLUSIONSTrauma-informed social work can be integratedinto all sorts of existing models of evidence-basedservices, but TIC can strengthen the therapeuticalliance and facilitate posttraumatic growth. In allsettings, engaging clients with compassion and
respect is the crucial factor in enabling change,regardless of the intervention, but practices mustalso be culturally relevant and consider the socialcontext of racial, economic, and gender disparities(East & Roll, 2015). Engagement difficulties canbe mitigated by recognizing and addressing thelegacy of complex trauma, and this is likely toenrich intervention effects.
Social workers who are familiar with the perva-siveness of early adversity and the damaging impactof these experiences on presenting problems acrossthe life span will be able to deliver services in amore trauma-informed fashion. The research liter-ature indicates that a warm, interested, and vali-dating therapeutic alliance is more influential infacilitating positive therapy outcomes than theoret-ical framework, professional discipline, or specificcounseling techniques (Duncan, Miller, Wampold, &Hubble, 2010; Thomlison, 1984; Wampold, 2001).A nonthreatening service delivery environment willfacilitate trust, emotional safety, and intimacy.
TIC should be conspicuously embedded in allsocial work settings, from a public or nonprofitagency to a private practice. Social workers in clin-ical, case management, or advocacy roles can allinfuse TIC principles into their understanding of,and interactions with, clients by conceptualizingproblematic behavior as a by-product of posttrau-matic stress (Levenson, 2014). The accumulationof negative experiences in childhood can triggerenduring neurodevelopmental changes, but neu-roplasticity allows the brain to integrate new ex-periences that pave the way for emotional healingand develop new neural pathways to behavioraland cognitive change (Anda et al., 2006; van derKolk, 2006; Weiss & Wagner, 1998). When socialworkers incorporate trauma-informed practices,they enable emotionally curative experiences thatpermit new skills to be cultivated, rehearsed, andreinforced. SW
REFERENCESAmerican Psychiatric Association. (2013). Diagnostic and sta-
tistical manual of mental disorders (5th ed.). Arlington,VA: Author.
Anda, R. F., Butchart, A., Felitti, V. J., & Brown, D. W.(2010). Building a framework for global surveillanceof the public health implications of adverse childhoodexperiences. American Journal of Preventive Medicine,39(1), 93–98.
Anda, R. F., Felitti, V. J., Bremner, J. D., Walker, J. D.,Whitfield, C., Perry, B. D., et al. (2006). The endur-ing effects of abuse and related adverse experiences in
111Levenson / Trauma-Informed Social Work Practice
childhood. European Archives of Psychiatry and ClinicalNeuroscience, 256, 174–186.
Baker, C. N., Brown, S. M., Wilcox, P. D., Overstreet, S., &Arora, P. (2016). Development and psychometricevaluation of the Attitudes Related to Trauma-Informed Care (ARTIC) scale. School Mental Health,8, 61–76. doi:10.1007/s12310-015-9161-0
Bandura, A. (1977). Self-efficacy: Toward a unifying theoryof behavioral change. Psychological Review, 84,191–215.
Bassuk, E. L., Unick, G. J., Paquette, K., & Richard, M. K.(2016). Developing an instrument to measure organi-zational trauma-informed care in human services: TheTICOMETER. Psychology of Violence. Advance accesspublication. doi:10.1037/vio0000030
Binder, J., & Strupp, H. (1997). “Negative process”: Arecurrently discovered and underestimated facet oftherapeutic process and outcome in the individual psy-chotherapy of adults. Clinical Psychology: Science andPractice, 4, 121–139.
Bloom, S., & Farragher, B. (2013). Restoring sanctuary: A newoperating system for trauma-informed systems of care. NewYork: Oxford University Press.
Bowlby, J. (1988). A secure base: Clinical applications of attach-ment theory. London: Routledge.
Brown, S. M., Baker, C. N., & Wilcox, P. (2012). Riskingconnection trauma training: A pathway towardtrauma-informed care in child congregate care set-tings. Psychological Trauma: Theory, Research, Practice,and Policy, 4, 507–515.
Carlson, E. A., & Sroufe, L. A. (1995). Contribution ofattachment theory to developmental psychopathol-ogy. In D. Cicchetti & D. J. Cohen (Eds.), Developmen-tal psychopathology, Vol. 1: Theory and methods(pp. 581–617). Oxford, England: John Wiley & Sons.
Centers for Disease Control and Prevention. (2013). AdverseChildhood Experiences Study: Prevalence of individualadverse childhood experiences. Retrieved from http://www.cdc.gov/ace/prevalence.htm
Christensen, R. C., Hodgkins, C. C., Garces, L., Estlund,K. L., Miller, M. D., & Touchton, R. (2005). Home-less, mentally ill and addicted: The need for abuse andtrauma services. Journal of Health Care for the Poor andUnderserved, 16, 615–622.
Cicchetti, D., & Banny, A. (2014). A developmental psy-chopathology perspective on child maltreatment. InM. Lewis & K. Rudolph (Eds.), Handbook of develop-mental psychopathology (pp. 723–741). New York:Springer.
Cloitre, M., Stolbach, B. C., Herman, J. L., van der Kolk, B.,Pynoos, R., Wang, J., & Petkova, E. (2009). A devel-opmental approach to complex PTSD: Childhoodand adult cumulative trauma as predictors of symp-tom complexity. Journal of Traumatic Stress, 22,399–408.
Cohen, J. A., Mannarino, A. P., Kliethermes, M., & Murray,L. A. (2012). Trauma-focused CBT for youthwith complex trauma. Child Abuse & Neglect, 36,528–541.
Covington, S., & Bloom, B. (2007). Gender responsivetreatment and services in correctional settings. Women& Therapy, 29(3–4), 9–33.
Duncan, B. L., Miller, S. D., Wampold, B. E., & Hubble,M. A. (2010). The heart and soul of change: Deliveringwhat works in therapy. Washington, DC: American Psy-chological Association.
East, J. F., & Roll, S. J. (2015). Women, poverty, andtrauma: An empowerment practice approach. SocialWork, 60, 279–286. doi:10.1093/sw/swv030
Easton, S. D., Coohey, C., Rhodes, A. M., & Moorthy, M.(2013). Posttraumatic growth among men with
histories of child sexual abuse. Child Maltreatment, 18(4), 211–220.
Eckenrode, J., Smith, E. G., McCarthy, M. E., & Dineen,M. (2014). Income inequality and child maltreatmentin the United States. Pediatrics, 133, 454–461.
Elliott, D. E., Bjelajac, P., Fallot, R. D., Markoff, L. S., &Reed, B. G. (2005). Trauma-informed or trauma-denied: Principles and implementation of trauma-informed services for women. Journal of CommunityPsychology, 33, 461–477.
Erikson, E. H. (1993). Childhood and society. New York:W. W. Norton.
Fallot, R., & Harris, M. (2009). Creating cultures of trauma-informed care (CCTIC): A self-assessment and planningprotocol. Retrieved from https://www.healthcare.uiowa.edu/icmh/documents/CCTICSelf-AssessmentandPlanningProtocol0709.pdf
Felitti, V. J., Anda, R. F., Nordenberg, D., Williamson, D. F.,Spitz, A. M., Edwards, V., et al. (1998). Relationshipof childhood abuse and household dysfunction tomany of the leading causes of death in adults: TheAdverse Childhood Experiences (ACE) study. AmericanJournal of Preventive Medicine, 14, 245–258.
Finkelhor, D., Turner, H. A., Hamby, S. L., & Ormrod,R. (2011). Polyvictimization: Children’s exposure to multipletypes of violence, crime, and abuse. Washington, DC:U.S. Department of Justice, Office of Justice Programs,Office of Juvenile Justice and Deliquency Prevention.
Harris, M. E., & Fallot, R. D. (2001). Using trauma theory todesign service systems. San Fransisco: Jossey-Bass.
Jovev, M., & Jackson, H. J. (2004). Early maladaptive sche-mas in personality disordered individuals. Journal of Per-sonality Disorders, 18, 467–478.
Knight, C. (2015). Trauma-informed social work practice:Practice considerations and challenges. Clinical SocialWork Journal, 43(1), 25–37.
Larkin, H., Felitti, V. J., & Anda, R. F. (2014). Social workand adverse childhood experiences research: Implica-tions for practice and health policy. Social Work in Pub-lic Health, 29(1), 1–16.
Levenson, J. S. (2014). Incorporating trauma-informed careinto sex offender treatment. Journal of Sexual Aggres-sion, 20(1), 9–22.
Levenson, J. S., Willis, G. M., & Prescott, D. (2016). Adversechildhood experiences in the lives of male sex offendersand implications for trauma-informed care. SexualAbuse: A Journal of Research and Treatment, 28, 340–359.doi:10.1177/1079063214535819
Loper, A. B., Mahmoodzadegan, N., & Warren, J. I. (2008).Childhood maltreatment and Cluster B personalitypathology in female serious offenders. Sexual Abuse:A Journal of Research and Treatment, 20, 139–160.
Maschi, T., Baer, J., Morrissey, M. B., & Moreno, C.(2013). The aftermath of childhood trauma on late lifemental and physical health: A review of the literature.Traumatology, 19(1), 49–64.
Maslow, A. H. (1943). A theory of human motivation. Psy-chological Review, 50, 370–396.
Miller, W. R., & Rollnick, S. (2012). Motivational interview-ing: Helping people change. New York: Guilford Press.
Morrison, L., Alcantara, A., Conver, K., Salerno, A., Cleek, A.,Parker, G., et al. (2015). Harnessing the learning communitymodel to integrate trauma-informed care principles in service orga-nizations. Retrieved from http://mcsilver.nyu.edu/sites/default/files/reports/TIC-Implementation-Report.pdf
National Association of Social Workers. (2015). Code ofethics of the National Association of Social Workers.Washington, DC: Author.
Rutter, M., & Sroufe, L. (2000). Developmental psychopa-thology: Concepts and challenges. Development andPsychopathology, 12, 265–296.
112 Social Work Volume 62, Number 2 April 2017
Substance Abuse and Mental Health Services Administra-tion. (2013). Trauma-informed care and trauma services.Retrieved from http://www.samhsa.gov/nctic/trauma.asp
Substance Abuse and Mental Health Services Administra-tion. (2014a). SAMHSA’s concept of trauma and guidancefor a trauma-informed approach. Retrieved from http://store.samhsa.gov/shin/content//SMA14-4884/SMA14-4884.pdf
Substance Abuse and Mental Health Services Administra-tion. (2014b). TIP 57: Trauma-informed care in behavioralhealth services. Retrieved from http://store.samhsa.gov/shin/content//SMA14-4816/SMA14-4816.pdf
Teyber, E., & McClure, F. (2000). Therapist variables. InC. Snyder & R. Ingram (Eds.), Handbook of psychologicalchange: Psychotherapy process and practices for the 21st cen-tury (pp. 62–87). New York: Wiley.
Teyber, E., & McClure, F. (2011). Interpersonal process in ther-apy: An integrative model (6th ed.). Florence, KY:Brooks/Cole.
Thomlison, R. J. (1984). Something works: Evidence frompractice effectiveness studies. Social Work, 29, 51–56.
Topitzes, J., Mersky, J. P., & Reynolds, A. J. (2011). Childmaltreatment and offending behavior: Gender-specificeffects and pathways. Criminal Justice and Behavior, 38,492–510.
van der Kolk, B. (2006). Clinical implications of neurosci-ence research in PTSD. Annals of the New York Acad-emy of Sciences, 1071(1), 277–293.
Wallace, B., Conner, L., & Dass-Brailsford, P. (2011). Inte-grated trauma treatment in correctional health careand community-based treatment upon reentry. Journalof Correctional Health Care, 17, 329–343.
Wampold, B. E. (2001). The great psychotherapy debate: Mod-els, methods, and findings. Mahwah, NJ: Lawrence Erl-baum Associates.
Weiss, M.J.S., & Wagner, S. H. (1998). What explains thenegative consequences of adverse childhood experi-ences on adult health. American Journal of PreventiveMedicine, 14, 356–360.
Whitfield, C. L. (1998). Adverse childhood experiences andtrauma. American Journal of Preventive Medicine, 14,361–364.
Young, J. E., Klosko, J. S., & Weishaar, M. E. (2003).Schema therapy: A practitioner’s guide. New York:Guilford Press.
Jill Levenson, PhD, MSW, is associate professor of social work,Barry University, 11300 NE 2nd Avenue, Miami Shores,FL 33161; e-mail: email@example.com.
Original manuscript received November 16, 2015Final revision received March 17, 2016Editorial decision March 29, 2016Accepted March 29, 2016Advance Access Publication January 23, 2017
113Levenson / Trauma-Informed Social Work Practice
Copyright of Social Work is the property of Oxford University Press / USA and its contentmay not be copied or emailed to multiple sites or posted to a listserv without the copyrightholder’s express written permission. However, users may print, download, or email articles forindividual use.