2022 California Council of Community Behavioral Health Agencies (CBHA) Conference

Why Trauma Informed Care with Vulnerable Populations?

A vulnerable population can be described as a group of persons whose range of options is severely limited, who are frequently subjected to coercion in decision making, or who may be compromised in their ability to give informed consent (U.S. National Library of Medicine). There are many populations that fit this definition of a vulnerable population including: those with disabilities (both physical and mental), children, the elderly, individuals with substance abuse problems, those living in poverty and many other groups.

One experience common to all these populations, in fact to human beings in general is trauma. Trauma refers to experiences that cause intense physical and psychological stress reactions. It can refer to a single event, multiple events, or a set of circumstances that is experienced by an individual as physically and emotionally harmful or threatening and that has lasting adverse effects on the individual’s physical, social, emotional, or spiritual wellbeing (Substance Abuse and Mental Health Services Administration-SAMHSA Working definition of trauma and principles and guidance for a trauma-informed approach, 2012). As you’ll see, going through trauma is not rare.

Let’s look at some statistics on trauma. The following are taken from the U.S. Department of Veteran’s Affairs National Center for PTSD, 2017 Online: Approximately 6 of every 10 men (or 60%) and 5 of every 10 women (or 50%) experience at least one trauma in their lives. Women are more likely to experience sexual assault and child sexual abuse. Men are more likely to experience accidents, physical assault, combat, disaster, or to witness death or injury.

Here are other facts about trauma and PTSD based on the U.S. population –VA National Center for PTSD, 2017:

  • About 7 or 8 out of every 100 people (or 7-8% of the United States population) will have PTSD at some point in their lives. So, the same number of people who have PTSD in a given year is approximately the same as the number of people who reside in the state of New Jersey. A staggering number when you think about it.
  • Although about 8 million adults have PTSD during a given year this is only a small portion of those who have gone through a trauma.
  • About 10 of every 100 women (or 10%) develop PTSD sometime in their lives compared with about 4 of every 100 men (or 4%).

Here are additional facts about trauma to demonstrate its impact on vulnerable populations. Many people who have substance use disorders have experienced trauma as children or adults (Koenen, Stellman, Sommer, &Stellman, 2008; Ompad et al., 2005) and more than half of women seeking substance abuse treatment report one or more lifetime traumas (Farley, Golding, Young ,Mulligan, & Minkoff, 2004; Najavits et al.,1997).

In the Adverse Childhood Experience Study, Anda and Felitti (2003) found that 21% of a 17,000-person sample drawn from mostly middle class educated adults reported being sexually abused; 26% were physically abused; and 13% lived in a home with domestic violence as a child. 50% to 70% of women in psychiatric hospitals, 40% to 60% of women receiving outpatient mental health services, and 55% to 90% of women with substance abuse disorders report being physically or sexually abused, or both, in their lives (SAMHSA, 2007). In 2011, there were approximately 3.4 million reports of abuse or neglect that covered 6.2 million children (U.S. Department of Health and Human Services, 2011).

When we look at individuals with behavioral health disorders many clients with severe mental disorders meet the criteria for PTSD. Traumatic stress increases the risk for mental illness, and findings suggest that traumatic stress increases the symptom severity of mental illness (Spitzer, Vogel, Barnow, Freyberger& Grabe, 2007).

Without effective intervention, there is evidence of long-term adverse consequences of untreated trauma lasting into adulthood including substance abuse, suicidality, serious mental illness, and long-term physical health factors associated with early death (Felitti, Anda, Nordenberg, Williamson, et al., 1998; Anda, Dong, Brown, et al, 2009).

This evidence clearly demonstrates the need to create trauma informed systems of care and use trauma informed intervention strategies with vulnerable populations that we serve.

To address this problem, in May 2012, SAMHSA convened a group of national experts who identified three key elements of a trauma-informed approach: (1) realizing the prevalence of trauma; (2) recognizing how trauma affects all individuals involved with the program, organization, or system, including its own workforce; and (3) responding by putting this knowledge into practice (SAMHSA, 2012).

In a working paper SAMHSA (2012) suggests that a trauma-informed approach is guided by 10 principles:

  1. Safety: throughout the organization, staff and the people they serve feel physically and psychologically safe; the physical setting is safe and interpersonal interactions promote a sense of safety.
  2. Trustworthiness and transparency:

organizational operations and decisions are conducted with transparency and the goal of building and maintaining trust among staff, clients, and family members of people being served by the organization.

  1. Collaboration and mutuality: there is true partnering and leveling of power differences between staff and clients and among organizational staff from direct care staff to administrators; there is recognition that healing happens in relationships and in the meaningful sharing of power and decision-making.
  2. Empowerment: throughout the organization and among the clients served, individuals’ strengths are recognized, built on, and validated and new skills developed as necessary.
  3. Voice and choice: the organization aims to strengthen the staff’s, clients’, and family members’ experience of choice and recognize that every person’s experience is unique and requires an individualized approach.
  4. Peer support and mutual self-help: are integral to the organizational and service delivery approach and are understood as a key vehicle for building trust, establishing safety, and empowerment.
  5. Resilience and strengths based: a belief in resilience and in the ability of individuals, organizations, and communities to heal and promote recovery from trauma; builds on what clients, staff and communities have to offer rather than responding to their perceived deficits.
  6. Inclusiveness and shared purpose: the organization recognizes that everyone has a role to play in a trauma-informed approach; one does not have to be a therapist to be therapeutic.
  7. Cultural, historical, and gender issues: the organization addresses cultural, historical, and gender issues; the organization actively moves past cultural stereotypes and biases (e.g. based on race, ethnicity, sexual orientation, age, geography, etc.), offers gender responsive services, leverages the healing value of traditional cultural connections, and recognizes and addresses historical trauma.
  8. Change process: is conscious, intentional and ongoing; the organization strives to become a learning community, constantly responding to new knowledge and developments

Based on the evidence, trauma informed care should be the universal approach in the human services arena; shifting the conversation from, “What’s wrong with you?” to “What happened to you?”

This paradigm shift in understanding the impact of trauma is especially important in our work with vulnerable populations. These are the individuals and groups least likely to have a voice and at the same time most likely to have been or be at risk of being impacted by trauma. It is important that we adopt trauma informed principles throughout all aspects of our systems and organizations.

Trauma-informed care engages customers and clients as partners, empowering them and helping to reclaim the voice that they may have lost. It provides safety and fosters resilience to increase the capacity to face and overcome adversities now and in the future.

Darin Samaha can be reached at darinjsamaha@gmail.com and by phone at (518) 210-9529.

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