Trauma Informed Practice

Q1: What is trauma? What are its causes?

Trauma is “a process that involves the interaction between an event or series of events and the individual and community’s vulnerability, protective and resiliency factors. If an event or series of events overwhelms the person or community’s capacity to adapt in a positive manner and instead lead them to suffer adverse consequences, then the event is considered traumatic.” [1].

 

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 threatening and that has lasting adverse effects on the individual’s functioning and physical, social, emotional, or spiritual well-being.” [2].

 

Examples of individual traumas could include an accident, living or witnessing abuse, or living through an unexpected environmental disaster, whereby the affected person is unprepared for the event [1].

Complex trauma “results from exposure to severe stressors that (1) are repetitive or prolonged, (2) involve harm or abandonment by caregivers or other ostensibly responsible adults, and (3) occur at developmentally vulnerable times in the victims’ life, such as early childhood … but, can also occur later in life.” [3].

 

Examples of complex trauma include, but are not limited to, experiences in the residential school system, war, terrorism, genocide, torture, discrimination, human trafficking, or forced migration [1]. It can include any negative long-lasting life event that erodes a sense of trust and safety [4].

 

Trauma occurs long-term when the affected person behaves as though the traumatic circumstances, such as abuse, neglect, or threatening condition, continue to exist [5]. Trauma affects the most vulnerable populations disproportionately and is the leading cause of morbidity and mortality globally [1].

 

The results of trauma in one generation, or in one individual, is likely to be passed to following generations. Yehuda and Bierer (2009) describe the ‘epigenetic contribution’, a change in DNA caused by an environmental disturbance (trauma) and resulting in a change in function, but not of structure, of a gene, the result of which can be passed from one generation to the next [6,7].

[1] Kimberg, L. and Wheeler, M. (2019). Trauma and Trauma-Informed Care. In Trauma-Informed Healthcare Approaches (pp 25-56). From https://www.researchgate.net/publication/332392165_Trauma_and_Trauma-Informed_Care , on June 20, 2022.

[2] Substance Abuse and Mental Health Services Administration (SAMHSA). From https://www.samhsa.gov/trauma-violence#:~:text=SAMHSA%20describes%20individual%20trauma%20as%20resulting%20from%20%22an,and%20mental%2C%20physical%2C%20social%2C%20emotional%2C%20or%20spiritual%20well-being.%22  on June 20, 2022.

[3] Courtois, C.A. and Fords, J.D. (Eds.) (2009). Treating Complex Traumatic Stress Disorders: An Evidence-Based Guide (pp. 448). New York. The Guilford Press.

[4] McFarlane, A. C., & de Girolamo, G. (1996). The nature of traumatic stressors and the epidemiology of posttraumatic reactions. In B. A. van der Kolk, A. C. McFarlane, & L. Weisaeth (Eds.), Traumatic stress: The effects of overwhelming experience on mind, body, and society (pp. 129–154). The Guilford Press.

[5] van der Kolk, B.A., A. C. McFarlane, A.C., & L. Weisaeth, L.(Eds.), Traumatic stress: The effects of overwhelming experience on mind, body, and society (pp. 129–154). The Guilford Press.

[6] Yehuda, R. and Beirer, L. (2009). The Relevance of Epigenetics to PTSD: Implications for the DSM-V. Journal of Traumatic Stress, Vol. 22, No. 5, pp. 427–434. From https://pzacad.pitzer.edu/~dmoore/psych155-2019/12_2009_yehuda–bierer_epig.pdf , on June 21, 2022.

[7] Mosby, I. and Galloway, T. (2017). “Hunger was never absent”: How residential school diets shaped current patterns of diabetes among Indigenous peoples in Canada. CMAJ, vol. 189, no. 32, pp. 1043-1045.

Q2: What is Trauma Informed Practice (TIP)? Why does it matter in the context of dietetics? When should I practice TIP?

Trauma-Informed Practice (TIP) is “a strengths-based framework grounded in an understanding of and responsiveness to the impact of trauma. It emphasises physical, psychological, and emotional safety for everyone, and creates opportunities for survivors to rebuild a sense of control and empowerment.” [1]. The principles of trauma-informed practice are consistent with patient-centred care [2].

Exposure to trauma is very common and such exposure in early childhood results in disease progression and poor health outcomes as adults [2,3]. In dietetics, trauma-informed care is important to understand why and how the behavior towards food, eating, drinking, and exercise can become coping mechanisms that have the potential to become problematic when restricted or used in excess. Recognizing these coping mechanisms and their source can make collaborative care more effective and empower clients to take control and make healthy choices [4].

As one of many behavioural approaches, trauma-informed care can also help dietitians minimize triggers and create a safe environment for their clients. It places the onus on the dietitian to practice self-regulation and recognize when a client is stressed and having difficulty coping, and how this may be expressed differently [4].

Given that there is a lack of validated and reliable tools to screen asymptomatic children and adults for experiences resulting in trauma, there is a push to “advise a universal education approach (rather than routine screening) as a safer option, due to concerns over the potential adverse effects of screening for lifetime trauma including stigmatizing patients and focusing on pathology rather than resilience.” [5]. Furthermore, as stated above in Q1, results of trauma can be passed from generation to generation, which can impact the ability to screen adequately. A trauma-informed approach to care can be, and should be, effectively employed for and benefit all clients, in all areas, such as mental health and addictions, acute care, home and community care, public health, and primary care [1,4].

 

[1] Government of BC. Trauma-Informed Practice Resources. From https://www2.gov.bc.ca/gov/content/health/managing-your-health/mental-health-substance-use/child-teen-mental-health/trauma-informed-practice-resources, on June 20, 2022.

[2] Kimberg, L. and Wheeler, M. (2019). Trauma and Trauma-Informed Care. In Trauma-Informed Healthcare Approaches (pp 25-56). From https://www.researchgate.net/publication/332392165_Trauma_and_Trauma-Informed_Care , on June 20, 2022.

[3] CDBC. Indigenous-specific racism and colonialism in dietetics. From https://collegeofdietitiansofbc.org/wp-content/uploads/2022/02/3_5_220223_Indigenous-specific-racism-and-colonialism-in-dietetics-FINAL.pdf

[4] O’Neill, L (Oct 8, 2020). Trauma Informed Practice Webinar for Registered Dietitians. Department of Psychology UNBC. https://www.bcdietitians.ca/digitaldownloads/recording-trauma-informed-practice-webinar-for-registered-dietitians  [paid webinar]

[5] Van Niel C, Pachter LM, Wade R, Jr., Felitti VJ, Stein MT. (2014). Adverse events in children: Predictors of adult physical and mental conditions. J Dev Behav Pediatr pp.35.

Q3: How do I know to use TIP approach in my practice?

As mentioned in Q2, a trauma-informed approach can benefit all clients. It is important to understand that people historically discriminated against based on personal characteristics such as culture, race/ethnicity, religion, sexual orientation, gender identity, are at risk of experiencing trauma [1].

In your nutrition assessment, you can screen for the following risk factors [1] and refer to Q8:

  • Lack of safe, stable, nurturing relationships
  • Young age
  • Family history of violence:
    • Female sex (at higher risk for sexual violence)
    • Male sex (at higher risk for community violence)
  • Minority status (race, ethnicity, religion, sexual orientation, gender identity, other)
  • Psychological instability
  • Substance use
  • Disability (physical and intellectual)
  • Homelessness, poverty

During your screening process, you may identify specific behaviours, warranting a need to use TIP [1,2]:

  • frequently missing appointments
  • lack of follow through with nutrition care plans, tests or referrals
  • unable to give consistent chronological history
  • lack of engagement
  • lack of ability to manage health information

[1] Kimberg, L. and Wheeler, M. (2019). Trauma and Trauma-Informed Care. In Trauma-Informed Healthcare Approaches (pp 25-56). From https://www.researchgate.net/publication/332392165_Trauma_and_Trauma-Informed_Care , on June 20, 2022.

[2] O’Neill, L (Oct 8, 2020). Trauma Informed Practice Webinar for Registered Dietitians. Department of Psychology UNBC. https://www.bcdietitians.ca/digitaldownloads/recording-trauma-informed-practice-webinar-for-registered-dietitians  [paid webinar]

Q4: If a key to TIP is to practice self-regulation, what does this mean and how can I ensure I am self-regulating?

Self-regulation or self-control refers to the “ability to regulate one’s emotions and behavior as a key aspect of executive function, the suite of skills that allow an individual to plan, monitor, and attain goals.” [1]

 

Behaviorally, self-regulation is the ability to act in your long-term best interest, consistent with your deepest values. Violation of one’s deepest values causes guilt, shame, and anxiety, which undermine well being. Emotionally, self-regulation is the ability to calm yourself down when you’re upset and cheer yourself up when you’re down.” [2]

 

In people who have experienced trauma, self-regulation is not well-maintained and potentially never achieved. The repeated reliving of traumatic events is associated with a heightened fight or flight response, resulting in high levels of glucocorticosteroids, damaging tissues at the cellular level, and an inability to stop the stress response [3]. This can result in adaptive behaviours, sometimes manifesting in unhealthy relationships [4].

 

Self-regulation on your part, during a nutrition care session, can promote a safe environment, avoiding re-traumatization of your client and promotion of healing [5]. Self-regulation includes respecting those around you (clients and colleagues alike) for their strength and spirit in the face of hardships [4]. It can also mean to look inwards, regulating your tone and affect when communicating, being aware of potential for burnout, compassion fatigue, your own stress levels, all while being aware of your surroundings [3].

[1] Psychology Today (2022). Self control. https://www.psychologytoday.com/us/basics/self-control

[2] Psychology Today (2022). Self regulation. https://www.psychologytoday.com/us/blog/anger-in-the-age-entitlement/201110/self-regulation

[3] O’Neill, L (Oct 8, 2020). Trauma Informed Practice Webinar for Registered Dietitians. Department of Psychology UNBC. https://www.bcdietitians.ca/digitaldownloads/recording-trauma-informed-practice-webinar-for-registered-dietitians [paid webinar]

[4] Kimberg, L. and Wheeler, M. (2019). Trauma and Trauma-Informed Care. In Trauma-Informed Healthcare Approaches (pp 25-56). From https://www.researchgate.net/publication/332392165_Trauma_and_Trauma-Informed_Care , on June 20, 2022.

[5] Government of BC. Trauma-Informed Practice Resources. From https://www2.gov.bc.ca/gov/content/health/managing-your-health/mental-health-substance-use/child-teen-mental-health/trauma-informed-practice-resources, on June 20, 2022.

Q5: How can using TIP influence the outcome of my dietetic care?

The burden of overall trauma in urban underserved communities is thought to approach that of conflict-ridden developing countries” [1].

 

Using principles of TIP can [2,3]:

  • Improve
    • Quality of care
    • Health outcome
    • Mental health
  • Reduce
    • Post-traumatic stress
    • Substance abuse
  • Promote health equity

[1] Kelly,V.G. VG, Merrill GS, Shumway, M., Alvidrez, J., Boccellari, A. (2010). Outreach, engagement, and practical assistance: Essential aspects of PTSD care for urban victims of violent crime. Trauma Violence Abuse (pp.144–156).

[2] O’Neill, L (Oct 8, 2020). Trauma Informed Practice Webinar for Registered Dietitians. Department of Psychology UNBC. https://www.bcdietitians.ca/digitaldownloads/recording-trauma-informed-practice-webinar-for-registered-dietitians  [paid webinar]

[3] Kimberg, L. and Wheeler, M. (2019). Trauma and Trauma-Informed Care. In Trauma-Informed Healthcare Approaches (pp 25-56). From https://www.researchgate.net/publication/332392165_Trauma_and_Trauma-Informed_Care , on June 20, 2022.

Q6: What are the risks to me in providing TIP? What are barriers to creating a safe space in which to provide TIP?

Ensuring self care and self-regulation to provide the safest care possible is paramount to your effective TIP. Recognize the following in yourself, as a trauma informed care practitioner [1]:

  • Feeling emotionally exhausted, which could include an impaired ability to feel empathy or sympathy
  • Cynicism, contempt, or resentment towards your client, resulting in a feeling of hopelessness in your ability to provide care to your client.
  • Anxiety, depression, fearfulness, vulnerability
  • Hopelessness, burnout
  • Dissatisfaction with career focus
  • Secondary PTSD/Vicarious trauma

Using effective TIP and care means having a supportive work environment [1]. Do you work with compassionate, collaborative staff? Do they understand Trauma-Informed Practice? Are there underlying stereotypical assumptions made about your clients by your or any workplace colleagues? Is your workplace physically and visually safe and supportive? Do you have the ability to refer to a colleague whose scope of practice includes screening for trauma risk factors or addressing trauma with a client?

[1] O’Neill, L (Oct 8, 2020). Trauma Informed Practice Webinar for Registered Dietitians. Department of Psychology UNBC. https://www.bcdietitians.ca/digitaldownloads/recording-trauma-informed-practice-webinar-for-registered-dietitians  [paid webinar]

Q7: What CDBC Standards of Practice apply to Trauma Informed Care?

Standard 3. A Dietitian maintains competence in their practice area. Indicators 2, 3.

Standard 4. A Dietitian acts ethically in their professional interactions and while providing professional services. Indicator 3. This standard pairs with the CDBC Code of Ethics.

Standard 6. A Dietitian provides information and obtains informed consent prior to the provision of professional services. Indicators 3, 6.

Standard 9. A Dietitian communicates in a clear, concise and respectful manner. Indicators 1-6, 8, 9.

Standard 10. A Dietitian contributes to the provision of quality professional services as a member of the clients’ interprofessional team. Indicators 3, 4.

Standard 12. A Dietitian provides quality professional services that reflect the unique needs, goals, values and circumstances of the client. Indicators 1-6.

Standard 13. A Dietitian seeks information and incorporates an evidence-informed approach to their practice. Indicators 1-6.

Standard 14. A Dietitian uses critical thinking to obtain assessment data, determine practice problems, plan, implement and evaluate professional services. Indicators 1-10.

Standard 16. A Dietitian leads and organizes effective and timely delivery of services. Indicator 5.

Q8: TIP seems to use principles and skills that cross scope into social work, medical, and psychological care. Can the CDBC speak to my role for assessing risk of PTSD or the use Cognitive Behaviour Therapy (CBT) as an approach for TIP?

You are right to recognize that TIP involves many aspects of care that overlap with other professions. For example, it is not within dietitians’ scope to be able to diagnose conditions such as PTSD. However, it is helpful, in the context of providing TIP, that you understand the potential symptoms of psychological instability, such that you can learn to recognize client behaviors that stem from trauma and refer to appropriate healthcare professionals on your team. These signs may include any combination of [1]:

  • Flat or labile affect
  • Dissociation, lack of connection
  • History of anxiety, depression, aggression
  • History of identity disturbances, personality disorders
  • Suicidal ideation, self harm
  • Substance abuse
  • Disordered eating
  • Recurrent and multiple medical symptoms with no organic cause

You are encouraged to have a look at the CDBC resource: Cognitive Behaviour Therapy (CBT) Q&A.

[1] O’Neill, L (Oct 8, 2020). Trauma Informed Practice Webinar for Registered Dietitians. Department of Psychology UNBC. https://www.bcdietitians.ca/digitaldownloads/recording-trauma-informed-practice-webinar-for-registered-dietitians  [paid webinar]

Q9: Where can I learn more about TIP?
  • How childhood physical abuse, sexual abuse and neglect are associated with a wide range of physical illnesses in adulthood:

 

  • A good review for the history and potential for future use of TIP:
    • Raja, S., Hasnain, M., Hoersch, M., Gove-Yin, S., & Rajagopalan, C. (2015). Trauma informed care in medicine: current knowledge and future research directions. Family & community health38(3), 216–226. https://doi.org/10.1097/FCH.0000000000000071

 

 

 

 

 

 

 

 

 

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