By Madalyn Vanarthos, MusicWorx Intern

When you search “Trauma-Informed Care” on the internet, this screen will pop up under images…

Though infographics are helpful, I find the collage of colors, ideas, key ingredients and alliterative terms daunting. The image epitomizes the chaos in my attempt to understand Trauma-Informed Care during my studies and as I emerge as a professional. I nod in agreement when colleagues or presenters touch on Trauma-Informed Care, but I did not know where to begin in my own practice. This outstanding approach to music therapy is blossoming in our field, but lacks clear, universal tenets – which I will suggest below.

What is Trauma?

The American Psychological Association’s definition of trauma states:

• “Any disturbing experience that results in significant fear, helplessness, dissociation, confusion, or other disruptive feelings intense enough to have a long-lasting negative effect on a person’s attitudes, behavior, and other aspects of functioning. Traumatic events include those caused by human behavior (e.g., rape, war, industrial accidents) as well as by nature (e.g., earthquakes) and often challenge an individual’s view of the world as a just, safe, and predictable place.”

The Substance Abuse and Mental Health Services Administration (SAMHSA) crafted a definition after consulting survivors, service systems, practitioners, researchers and policymakers, which states:

• “Individual trauma results from an event, series of events, or set of circumstances that is experienced by an individual as physically or emotionally harmful or life threatening and that has lasting adverse effects on the individual’s functioning and mental, physical, social, emotional, or spiritual well-being” (2014).

Takeaway: No definition will ever cover the full scope and experience of trauma. Trauma is an individual experience, and is even occasionally invisible to a seasoned professional. Check your assumptions at the door when it comes to understanding trauma.

What is Trauma-Informed Care?

Trauma-Informed Care (TIC) stems from Trauma Theory, which acknowledges that traumatic experiences or memories could present in physiological reactions (aka trauma symptoms) if the individual is unable to process the trauma verbally or mentally (Reeves, 2015). TIC was born out of the idea that we, as health care professionals, need to be aware of the signs and symptoms of trauma, recognize the pervasiveness of trauma, and consequently change our clinical practice, educate our employees, and create a healthy environment for our patients in response. TIC is not a series of interventions, a treatment protocol, nor a change in vocabulary, but a shift in practice that enhances growth and recovery for individuals who have experienced trauma.

What “R” You Talking About?

SAMHSA established the four R’s of TIC. These R’s are the Key Assumptions of Trauma-Informed Care. I like to think of the R’s as the Mission Statement of TIC. SAMHSA states,

“A program, organization, or system that is trauma-informed realizes the widespread impact of trauma and understands potential paths for recovery; recognizes the signs and symptoms of trauma in clients, families, staff, and others involved with the system; and responds by fully integrating knowledge about trauma into policies, procedures, and practice; and seeks to actively resist re-traumatization.” (2014)

Break It Down

Realize: Understand that…

• Trauma can affect ANYONE whether that is your patient, your colleague, an entire family, or even a whole community.
• Trauma has no expiration date. Past trauma that is left untouched, current somaticized trauma, or secondary trauma are all REAL experiences.
• Trauma is not exclusive. Yes, trauma is pervasive in behavioral health facilities, criminal justice systems, homeless shelters, health care facilities, etc. BUT, never assume that a client you have is immune just because they do not fall into one of those categories. Assume the presence of trauma.

Recognize:

• Recognize the signs of trauma. These are often organization, gender, age and population specific.
• Educate yourself, your employees and colleagues how to properly assess and handle trauma.

Respond:

• Staff training, budget creation for trauma workshops/seminars
• Hiring new professionals who have specialized training in trauma care
• Changing a mission statement to reflect TIC language

Resist Re-traumatization:

• Create safe spaces: Know your client’s trauma history and avoid any triggers within the therapeutic environment (i.e. smells, sounds, types of interactions, spaces, types of music, etc.)
  • Avoid a dark room without windows if you know your client lived in a basement while in foster care and rarely had access to the outdoors.

SAMHSA summarizes, “Staff in every part of the organization, from the person who greets clients at the door to the executives and the governance board, have changed their language, behaviors and policies to take into consideration the experiences of trauma among children and adult users of the services and among staff providing the services” (2014).

Time Is “TIC-ing”…That’s It Right?

Not quite. Remember that the four R’s are the assumptions behind TIC. The following lists are the PRINCIPLES of TIC. Throughout the years, the principles have been modified or expanded, but I will stick to the most widespread iteration.

Safety: SAMHSA emphasizes the need to “understand safety as defined by those served” (2014). We need to ensure the client feels physically, emotional, and psychologically safe to express themselves and grow.

Trustworthiness/Transparency: Be authentic as a clinician, be honest with your clients and be transparent as an organization. Trustworthiness and transparency will lead to building and maintaining trust with staff and clients.

Peer Support and Mutual Self-Help: “Peer” refers to individuals and potentially family members who have experienced primary or secondary trauma. Peer support/community groups, safe places to tell your story, online platforms, etc. promote trust, stimulate growth and ignite hope for recovery. When I say recovery, I do not mean an individual “gets over” their trauma. I would argue that recovery means restoring any form of normalcy, or part of themselves that might have been lost or altered due to the trauma, or learning to integrate their trauma into their story.

Collaboration and Mutuality: “Healing happens in relationships” (SAMHSA, 2014). The goal is to eliminate power differentials, and recognize that everyone has a role to play in TIC.

Empowerment, Voice & Choice: Clients have a say in their treatment plan, and staff help facilitate recovery but are not the primary means of recovery. Everyone in the organization is united in their awareness of trauma and aim to empower each other to contribute. Power differentials are negligible within this model.

Cultural, Historical & Gender Issues: TIC recognizes community and historical trauma and actively advocates for those who have been discriminated against.

If TIC is something you would like to implement within your practice, or workplace, I encourage you to review SAMHSA’s Ten Implementation Domains. A detailed article is cited below in the references section.

Food For Thought

With every approach, we need to understand the stereotypes and misconceptions to avoid potential pitfalls and incorrect implementation. Below are some thoughts that are springboards for discussion within your organization as you consider implementing TIC.

• The word “trauma” should not be overused or overemphasized. For some, acknowledging trauma is freeing and the first step to healing, but for others, talking about trauma makes them feel like they are solely defined by their experience. Each client’s response to the word and concept will be different. TIC should be implemented in practice, but do not hand out flyers about trauma at the door.
• Positive psychology emphasizes using the language of “enhancing well-being”, rather than “overcoming trauma.” I will note once again that TIC is a framework, not a type of treatment. As a clinician, you can still practice with a TIC lens while using language like “healing-centered” if that more closely aligns with your mission/approach.
• TIC is not a fad, or a fun catchphrase to tag on to the end of a mission statement. TIC is incredibly beneficial if implemented correctly, but before claiming it as your approach, really understand the underlying assumptions and principles.
• TIC is one of numerous frameworks available to us as clinicians. TIC is not the only approach worth considering. TIC can go hand in hand with music therapy approaches such as culture-centered, aesthetic, behavioral or feminists to list a few.
• Avoid the “Oh, if only this hadn’t happened to them, then they would have been fine” mentality. Trauma is multi-dimensional and exists in degrees. Do not get stuck on unpacking and processing one traumatic event to promote healing. Focus on general well-being and growth and let the clients guide their processing.
• TIC does not victimize the client, or negate personal responsibility.

Music Therapy Specific Takeaways

I have kept this post generic so that any professional has the opportunity to apply TIC to their practice, but I want to close with a few music therapy specific takeaways. Beck, et al., studied how trauma-focused Guided Imagery and Music (GIM) would impact adult refugees diagnosed with post-traumatic stress disorder (PTSD). A few of their suggestions specific to GIM, are applicable in all realms of practice. I will list a few below from the study and some generic recommendations.

1. Always be mindful of all sensory stimuli in your office space (smells, sights, sounds, textures of instruments, lighting, windows, placement of client in relationship to the door, proximity to the client, etc.).
2. Use short music listening periods (Beck, et al., 2018).
3. Use supportive music that is not overly abrasive musically or lyrically unless requested by the client (Beck, et al., 2018).
4. Always give the client options so they do not feel cornered (Beck, et al., 2018).
5. Consider replacing relaxation exercises with mindfulness or breathing exercises (Beck, et al., 2018).
6. If performing GIM, keep the client upright (avoid lying down) (Beck, et al., 2018).
7. Allow the client to choose if they would like to leave their eyes open or closed. (Beck, et al., 2018)
8. Always give the client full autonomy in the session. They have the power to stop and start the music, change the volume, alter the song choice, or even cut the session short if it is overwhelming (Beck, et al., 2018).
9. Be aware of the participant’s cultural background and music preferences (Beck, et al., 2018).
10. It could be beneficial to walk through the session plan at the beginning of the session so there are no surprises, or allow the client to listen to the song on their own time and come back with thoughts.
11. Do not be afraid to improvise. Yes, some clients will need structure, but improvisation is a great way to allow the client to translate their internal struggles, emotions and thoughts into music.

Resources

Conclusion

My goal in writing this blog post was to introduce people to TIC (if it was unfamiliar), clarify TIC for people like me who were intrigued by it but had no catalyst for understanding it, or reignite the TIC flame for professionals who have drifted away from its core principles. I challenge those who do not see this as applicable to their life or practice to reevaluate. Trauma exists everywhere, and I would argue that donning the TIC glasses could not only enhance your practice, but your relationships and your community. I will leave you with one final thought: Trauma cannot and should not be put in a box. We still have so much to research and discover in terms of best practices with trauma populations. All we can do is take the next best step in our practice. That may be as simple as reading this article and becoming more self-aware, starting conversations with your peers about TIC, or knocking on the CEO’s office to have a conversation about systemic changes. All of the above are steps in the right direction.

References:

APA Dictionary of Psychology. (n.d.). Trauma. In APA Dictionary of Psychology. Retrieved January 5, 2020, from https://dictionary.apa.org/trauma

Beck, B. D., Messel, C., Meyer, S. L., Codtz, T. O., Søgaard, U., Simonsen, & Moe, T. (2018). Feasibility of trauma-focused Guided Imagery and Music with adult refugees diagnosed with PTSD: A pilot study. Nordic Journal of Music Therapy, 27(1), 67-86. https://doi.org/10/1080/08098131.2017.1286368

Merriam-Webster. (n.d.). Trauma. In Merriam-Webster.com dictionary. Retrieved January 5, 2020, from https://www.merriam-webster.com/dictionary/trauma

Reeves, E. (2015). A Synthesis of the Literature on Trauma-Informed Care. Issues in Mental Health Nursing, 36(9), 698–709.

SAMHSA’s Trauma and Justice Strategic Initiative. (2014). SAMHSA’s concept of trauma and guidance for a trauma-informed approach. The Substance Abuse and Mental Health Services Administration. https://ncsacw.samhsa.gov/userfiles/files/SAMHSA_Trauma.pdf