What does it mean to be trauma-informed or to use a trauma lens?

Understanding Trauma-Informed Care and the Trauma Lens

Being trauma-informed means fundamentally shifting from asking "What is wrong with you?" to "What happened to you?" while recognizing that current problematic behaviors often served protective functions in the past. 1, 2

Core Definition and Framework

Trauma-informed care (TIC) is a public health approach involving specific beliefs and practices centered on safety, trust, and empowerment that are intended to prevent and mitigate the impact of trauma. 1 The American Academy of Pediatrics defines TIC as medical care in which all parties assess, recognize, and respond to the effects of traumatic stress on children, caregivers, and healthcare providers. 1

The Trauma Lens: A Critical Perspective Shift

Using a trauma lens means understanding that problematic behaviors in the present, when viewed through this perspective, are often seen to have served a protective function in the past. 1 Without this lens, individuals with trauma histories continue to feel misunderstood and isolated, with their behavioral health and well-being seriously jeopardized. 1

The trauma lens requires clinicians to understand the role trauma plays in development and to recognize the pervasiveness of trauma across populations. 1 This perspective acknowledges that trauma has effects at the molecular, cellular, and organ level, with consequences on physical, emotional, developmental, and behavioral health across the lifespan. 1

Five Core Interpersonal Principles

A trauma-informed approach requires provision of these five essential elements in every interaction: 1

• Safety: Creating both physical and emotional environments characterized by compassion, cultural humility, equity, and collaboration 1
• Trustworthiness: Building dependable relationships through transparency and consistency 3
• Choice: Providing options whenever possible (e.g., which arm for blood pressure measurement) to restore a sense of control 1
• Collaboration: Involving patients and families as key decision-makers, including through Family Advisory Councils and family-centered rounds 1
• Empowerment: Supporting patient self-efficacy and partnership in the treatment process 4

Additional Critical Elements

Beyond the five core principles, trauma-informed care requires cultural, linguistic, and gender competence, plus availability of peer support. 1 This includes particular attention to racial and gender discrimination, implicit bias in care delivery, and workplace human relations. 1

Why Trauma-Informed Care Matters Clinically

If trauma is not recognized and addressed, other interventions—regardless of how well-intentioned—may be less effective. 1 Youth involved in systems of care have disproportionately high rates of trauma exposure and greater impairments at baseline compared to those without such history. 1

The approach recognizes that trauma is ubiquitous, affecting nearly half of American children (34 million under age 18) who have faced at least one potentially traumatic early childhood experience. 1 These experiences include community violence, natural disasters, medical procedures, intimate partner violence, parental substance use, parental mental illness, caregiver death, separation, neglect, or abuse. 1

Practical Implementation in Clinical Settings

TIC entails ongoing efforts to avoid retraumatization and promote recovery by understanding symptoms and manifestations of trauma exposure and the connection between past trauma and current behaviors. 1

In practice, this means:

• Monitoring your own response when difficult situations arise and resisting the urge to be angry or retaliate 1
• Focusing on the emotion rather than the behavior: "I can see that you are angry, worried, sad, upset" rather than criticizing actions 1
• Creating warm, welcoming environments with clear communication of expectations and procedures 1
• Empowering all staff members to emphasize safety and patient self-efficacy 1

Distinguishing TIC from Trauma-Specific Treatment

Trauma-informed care is the universal approach for all patients, while trauma-specific services are intensive clinical interventions for those with severe trauma exposure. 1 Examples of trauma-specific treatments include Trauma-Focused Cognitive Behavioral Therapy (TF-CBT), Child and Family Traumatic Stress Intervention (CFTSI), Child Parent Psychotherapy (CPP), and Parent Child Interaction Therapy (PCIT). 1

Common Pitfalls to Avoid

The most critical error is viewing trauma as solely an individual or interpersonal issue rather than recognizing collective and structural elements that impact health and well-being. 5 Organizations themselves can experience trauma and embed it within their culture, which inhibits staff from confronting problems, communicating effectively, and generating solutions. 3

Other pitfalls include:

• Triggering retraumatization through "trauma-uninformed" practices, staff interactions, or healthcare settings themselves 2
• Inadequate training and organizational support: Resource constraints, provider stress, and limited TIC emphasis in medical education remain significant barriers 4
• Failing to address secondary traumatic stress in healthcare providers who hear about firsthand trauma experiences of patients 1

The Relational Foundation

Trauma-informed systems are uniquely connected to relationships, as trauma both impairs relationships and is heightened in the absence of quality relationships. 3 The most fundamental mechanism for any child is a secure relationship with a safe, stable, nurturing adult who is continuous over time. 1 This protective relationship helps develop resilience skills that prevent or ameliorate the effects of cumulative adversities. 1