The need for trauma-informed integrative care

Photo Cred: Polina Zimmerman/Pexels

By Erin Archer

Trauma-informed care (TIC) is not trauma therapy. Rather, TIC models recognize the high prevalence of trauma in our society, attempting to create healing, non-triggering environments for all patients, clients, and staff.

In the last few decades, there has been more awareness regarding the impacts of untreated trauma upon health outcomes, and more sensitivity to recognizing trauma in patients. In the mid-1990s, the Centers for Disease Control and Prevention (CDC) and Kaiser Healthcare teamed up to do the first of the Adverse Childhood Experiences (ACEs) studies, providing some of the first data showing direct correlations between the cumulative childhood traumas suffered by a person and their risk of chronic disease and early death. 

According to the CDC, research conducted between 2015 to 2017 showed that 60.9 percent of adults had at least one ACE. Nearly one in six adults (15.6 percent) had more than four ACEs. This data reflected a history of childhood exposure to abuse (physical, emotional, and sexual) and household challenges (household member substance misuse, incarceration, mental illness, parental divorce, or witnessing intimate partner violence) before the age of 18.

It is worth noting for diagnostic purposes, the American Psychiatric Association’s (APA) Diagnostic and Statistical Manual of Mental Disorders (DSM-5) has a much stricter definition of trauma than ACEs. For traumatic disorders, the DSM-5 requires “actual or threatened death, serious injury, or sexual violence.”

Discussion of the embodied nature of trauma has become more common, with “The Body Keeps the Score: Brain, Mind, and Body in the Healing of Trauma” by Bessel Van Der Kolk, MD being a near-constant feature on the New York Times’ Best Seller List for the last few years. In Van Der Kolk’s framework, the body needs to be involved in healing the trauma done to the mind. Because of this, certain integrative modalities can be particularly helpful for trauma survivors, including yoga, massage, and dance.

Bodyworkers and other healthcare practitioners need to be sensitive to the fact that their practice may bring about a range of physical, psychological, and emotional issues they may not be trained to handle. Professional trauma therapy is a specialty, and these specialists should be utilized. This is part of what it means to be “trauma-informed.”

A 2021 paper from the Osher Collaborative for Integrative Medicine recommends that anyone practicing complementary and integrative health and medicine be able to recognize symptoms of trauma, provide a safe environment for patients and clients, know how to communicate therapeutically about trauma, and know when to refer to trauma specialists.

Mark Olson, PhD, LMT, director of the Pacific Center for Awareness and Bodywork, agreed. He said he incorporates being trauma-informed into the curriculum of his school and recommends that his students maintain a current list of therapists who specialize in trauma, for patients who may need a referral.  “Many people will seek out a massage therapist but not a psychotherapist, not realizing that massage may very likely stir the psyche,” he said. “One might think that being a psychotherapist makes one inherently trauma-informed, but this is by no means the case.”

Much of the content on trauma-informed care has been based on research and guidance published by the Substance Abuse and Mental Health Services Administration (SAMHSA). SAMHSA’s Concept of Trauma and Guidance for a Trauma-Informed Approach is their manual that offers four key assumptions, six key principles, and 10 implementation domains to begin implementing a trauma-informed approach.

The Trauma-Informed Care Implementation Resource Center extrapolates on these principles, advising that practitioners meet the potentially “difficult” behaviors of patients and staff from an approach of “What happened to you?” rather than “What’s wrong with you?” Their implementation plans and stories illustrate that patients with trauma sometimes don’t respond well to rigid social structures and that they may not return to care if triggered. To be effective, a trauma-informed approach must be implemented throughout the organization.

Living Yoga has operated as a trauma-informed yoga outreach in Portland, Oregon for over 20 years, sending trained volunteers to work with the vulnerable populations in corrections and re-entry, substance use and recovery, and community and mental health. The paper “Program evaluation of trauma-informed yoga for vulnerable populations” showed significant benefits of Living Yoga’s program after just one trauma-informed yoga class. There were double-digit increases in the percentage of people who felt good about themselves after class, and there were double-digit reductions in people who reported stress or pain in their body.

The Living Yoga website explains that trauma-informed yoga is designed to down-regulate the nervous system to assist with healing the negative impacts of trauma. They explain that, for this reason, “a trauma-informed yoga practice is typically on the more gentle side, mindfulness based, and includes many options for modifying poses to fit the practitioner’s unique needs.” Unfortunately, Living Yoga closed its doors for live classes and live streaming classes on December 31, 2021, but it has online trauma-informed yoga classes on-demand through November 2022.

Liz Eisman, LMT, e-RYT, somatic coach, and certified tension and trauma releasing exercises (TRE) provider, was involved with Living Yoga for two decades and helped to design the study.

“In Living Yoga classes, we noticed that many participants were able to reclaim autonomy over their bodies, to feel their bodies as allies or assets rather than as a battleground or place to be avoided,” she said. “True safety can only come from inside. If we desire for people to find a home of safety inside themselves, a place of belonging and deep healing, we need an integrative approach.”

“Being trauma-informed is like being ADA-compliant at a psychosocial level,” Olson said.

Erin Archer is a Registered Nurse and freelance writer who lives in Tucson, Arizona. For over a decade, she has worked in communicable disease and also written about all manner of health topics.  She has written for Institut Pasteur, everydayhealth.com, the Catholic Health Association, and others and performed original research published in the Journal of Holistic Nursing. She is passionate about writing about mental and physical health and looks forward to writing more content regarding her long-time passion of integrative medicine. When not working as a public health nurse or writing, she can be found in her garden with her two rescue dogs.