Victims of Crime Research Digest No. 9
Trauma- (and Violence-) Informed Approaches to Supporting Victims of Violence: Policy and Practice Considerations
By Pamela Ponic, Colleen Varcoe and Tania Smutylo
Dr. Pamela Ponic is a senior policy analyst in family violence prevention at the Public Health Agency of Canada.
Dr. Colleen Varcoe is a professor in the University of British Columbia School of Nursing with a program of research in violence and inequities.
Tania Smutylo, MSW, is a policy analyst with the Public Health Agency of Canada working on family violence prevention.
The traumatic impacts of violence have long-term effects on victims, whether the violence is ongoing or in the past. When systems and the service providers who work with victims of violence lack an understanding of the complex and lasting impacts of violence and trauma, they risk causing further harm. For example, each time an adult or child re-tells their story of abuse to seek help across multiple service systems, there is a risk of re-traumatization (Herman 2003; Valpied et al. 2014). Trauma-informed approaches are policies and practices regarding the provision of services and programming that—particularly when they are also violence-informed—work to minimize harm to victims of violence, and aid healing and justice.
During the last 10–15 years, there has been a movement to develop and implement policies and practices that are trauma-informed in sectors working directly with people impacted by violence, including in health, particularly in relation to mental health and substance use (Covington 2008; Savage et al. 2007), justice, housing, anti-violence, and social work sectors (Strand et al. 2015; Hopper, Bassuk, and Oliver 2010; Herman 2003; Dechief and Abbott 2012). This movement developed largely in response to a growing understanding of the connections among violence, trauma, negative outcomes in physical and mental health, and substance-use problems, as well as to the need to make systems more responsive to the needs of people who face these challenges (Poole and Greaves 2012). Implementing trauma-informed approaches across sectors provides a common conceptual framework that enhances efforts to develop integrated multi-sectoral responses for children and adults. These approaches also create opportunities for systems, and those who work within them, to improve the services they provide to people impacted by violence.
Trauma-informed approaches are built upon a foundational understanding of the impact of violence and trauma on people’s lives, health and behaviours (Covington 2008; Elliot et al. 2005). Such approaches require fundamental shifts in how systems are designed, how organizations function, and how service providers engage with victims. Trauma-informed approaches are relational; they recognize that individuals’ experiences of violence relate to how systems respond to them. For example, a person’s circumstances (including income, housing, and access to safe transportation and child care) influence both their exposure to violence and their ability and willingness to access supportive services. Services that are approachable and trauma-informed can mitigate these influences. Trauma-informed approaches also recognize that individual behaviours often associated with victimization—such as substance-use problems or future perpetration of abuse—relate to trauma (Watt and Scrandis 2013; Danielson et al. 2009; Hedtke et al. 2008). By integrating understandings of trauma into all elements of policy and practice, trauma-informed approaches prioritize victims’ emotional and physical safety, as well as facilitate victim control over and responses to violence. This integration also builds on their strengths and aids in recovery (Provincial Health Services Authority of BC 2013).
Trauma is both the experience of, and a response to, an overwhelmingly negative event or series of events, such as interpersonal violence, personal loss, war or natural disaster. In the context of violence, trauma can be acute (resulting from a single event) or complex (resulting from repeated experiences of interpersonal and/or systemic violence). Trauma can alter human neurobiology: brain and nervous-system function change. While neurobiological changes are not necessarily permanent, they can be long-lasting if not addressed appropriately. Neurobiological changes resulting from trauma can alter behaviour in both children and adults (Green et al. 2015). For example, adverse events in childhood, such as various forms of maltreatment, along with exposure to intimate-partner violence or alcoholism, can have long-term neurobiological effects and are associated with a wide range of negative outcomes, including stress, anxiety, depression and substance use (Anda et al. 2006; Felitti and Anda 2010; Cloitre et al. 2009). Complex trauma can also impact children’s development; it can foster an inability to manage difficult emotions (e.g. anger) or form appropriate attachments with those close to them (Haskell 2012). These negative outcomes can last into adulthood. Similarly, across the life span, experiencing interpersonal and systemic racism (for example, patterns of discrimination that limit education, employment, access to housing) can also change neurobiological patterns, which can have profound impacts on mental and physical health and wellbeing (Krieger et al. 2011).
Neurobiological changes in people who experience complex trauma include responding to potential threats to safety as if they are real, whether they are real or not (Van der Kolk 2000). Such responses can create enduring associations between the traumatic event(s) and particular sensations, emotions or thought processes. Triggers are external events that recreate these traumatic associations; in some instances, situations that seem innocuous and unrelated can activate triggers, creating an overwhelming sense of threat related to past experiences of violence. Even well intentioned services, practices and policies can activate triggers that re-traumatize (Harris and Fallot 2001). For example, touching a person without warning or permission can trigger a neurophysiological flight-or-fight response.
In trauma-informed approaches, those who provide support services understand that any person they encounter may have experienced violence with traumatic effects. They understand that emotional states (such as depression, anxiety, anger, dissociation, difficulty concentrating, fear and distractedness) and behaviours (such as substance use, compulsive and obsessive behaviours, disordered eating, self-harm, high-risk sexual behaviours, suicidal behaviours or isolation) may arise, at least in part, from those experiences (Gutierres and Van Puymbroeck 2006; Schäfer 2009; Nadew 2012). Shifting the fundamental question from "what’s wrong with this person?" to "what happened to this person?" is important. It considers what might have happened and what might be happening to the person, and can result in a profound difference in how people are viewed and treated, and how they will respond (Williams and Paul 2008). Importantly, such approaches take into account that people can also experience growth in the aftermath of traumatic experiences (Shakespeare-Finch and de Dassel 2009; Glad et al. 2013; Birkeland et al. 2015; Katz and Gurtovenko 2015).
Service providers working directly with victims are often and repeatedly exposed to stories of terrifying and inhumane experiences with violence. These experiences can result in vicarious (or secondary) trauma with negative health impacts similar to those experienced by victims (Bartoskova 2015; Hensel et al. 2015; Middleton and Potter 2015; Raunick et al. 2015; van Mol et al. 2015). For example, service providers with vicarious trauma can experience depression, emotional exhaustion, anxiety and sleep disturbances (Cohen and Collens 2013). The negative impacts of vicarious trauma are associated with employment issues such as high turnover rates (Cieslak et al. 2014; Middleton and Potter 2015). Vicarious trauma can also manifest the trigger responses described earlier. Trauma-informed approaches take vicarious trauma into account by actively and intentionally supporting the wellbeing and self-care practices of service providers who are repeatedly exposed to stories of violence and trauma. Importantly, when well supported, service providers can also experience compassion, satisfaction and growth when working with people who have been victimized (Cohen and Collens 2013; Abel et al. 2014; Hyatt-Burkhart 2014).
From Trauma-informed to Trauma- and violence-informed
Recently, scholars have been calling for an important shift in language by referring to this policy and practice as trauma- and violence-informed, rather than only trauma-informed (Browne et al. 2015). This shift in language brings into focus acts of violence and their traumatic impact on victims (and distinguishes violence from other sources of trauma, such as natural disasters). It helps to put the emphasis on a person’s various experiences of past and ongoing violence as the cause of the trauma, and avoids seeing the problem as residing only in an individual’s psychological state. Because this view emphasizes making practices and policies safe, it fosters opportunities for service providers to prevent and limit harm, and to take actions at all levels: in their own practices, within their organizations and more widely in society. Although service providers cannot influence past events and the impact these events have on victims, providers can work to limit exposure to ongoing violence, and to reduce triggering and the potentially traumatizing effects of services.
This shift in language also allows for a more expansive understanding of people’s experiences of violence and trauma. Particularly in cases of complex trauma, histories of violence typically include interconnected experiences of interpersonal and systemic violence. For many victims, interpersonal violence is ongoing; it can be intergenerational and linked to broader historical contexts. For example, family violence and other forms of interpersonal violence in Indigenous communities have been linked to histories of colonization, including residential schools, the reserve system and ongoing child-welfare practices (Brownridge 2008; Daoud et al. 2013; Pedersen, Malcoe, and Pulkingham 2013). The enduring and ongoing effects of residential schools illustrate how systems can perpetuate violence and trauma, for example, through higher rates of incarceration for Indigenous versus non-Indigenous people (Narine 2012). While modern systems may be less blatant in their perpetuation of violence, policies and practices can continue to re-traumatize and harm victims, sometimes subtly and inadvertently. Discrimination, marginalization, and stigma remain an ongoing experience for many people within systems such as child protection, health care and criminal justice.
Considerations of gender and culture
Experiences and effects of violence are highly gendered. Although men are the most common victims of violence, including armed violence (World Health Organization 2011), women bear the greatest burden of family violence and men are the most common perpetrators of violence (Statistics Canada 2013). In 2013, 80% of reported cases of spousal violence were against women (Statistics Canada 2015). The rates of most forms of child abuse (i.e., physical, psychological, exposure to intimate partner violence) are similar for boys and girls, except for sexual abuse where rates are higher for girls (18%) than boys (7.6%) (Stoltenborgh et al. 2011). Girls are also at heightened risk of harmful practices, such as child, early and forced marriage and so-called honour-based violence, as well as female-genital cutting (Garcia-Moreno, Guedes, and Knerr 2012; Maryum Anis, Shalini Konanur, and Mattoo 2013; Muhammad 2010). Transgendered people experience alarming rates of violence; a recent Canadian survey showed that 65% of those who identified as transgendered had experienced domestic violence (Wathen, MacGregor, and MacQuarrie 2015).
Victims also experience gendered barriers to disclosure and accessing support, with men and boys being more strongly socialized away from help-seeking and disclosure (Vogel et al. 2011; Sierra Hernandez et al. 2014), and transgendered people facing multiple concomitant forms of discrimination (Logie et al. 2012; Bauer et al. 2015). People who experience child abuse face heightened risks of interpersonal violence in adulthood, with boys being more likely to become perpetrators and girls more likely to become victims (Abramsky et al. 2011; Radford et al. 2013; Sigurdardottir, Halldorsdottir, and Bender 2014). Given these differences, a gender lens is required to make trauma- and violence-informed responses to violence gender inclusive and appropriate.
Trauma- and violence-informed approaches are compatible with, and supported by, efforts to make policies and practices culturally safer. Cultural safety is an approach to working across multiple differences (including, but not limited to, ethnic differences) that shifts attention away from service providers learning about others, to making practices, policies and service environments safer for all regardless of expressed or assumed culture (Varcoe and Browne 2015; Kirmayer 2013). Importantly, the shift to trauma- and violence-informed approaches parallels the shift toward cultural safety; both put the onus on systems to change policy and practice, creating opportunities for policy makers and service providers to optimize support for victims.
Using the idea of cultural safety, service providers consider how power relations and the social, economic, political and historical realities of peoples’ lives shape their behaviors. This is especially imperative in the Canadian context. In Canada, Indigenous peoples experience multiple forms of disadvantage and marginalization, including disproportionately high rates of victimization and pervasive systemic racism, which can deter accessing services. Indigenous women are three times more likely than non-Indigenous women to experience family violence (Statistics Canada 2011), and four times more likely to be murdered or go missing (Royal Mounted Canadian Police 2014). The ongoing legacy of abuse in residential schools, and in foster and adoptive care, also contributes to intergenerational violence (McKenzie et al. 2016) and is an example of how systems of colonization have perpetuated violence against Indigenous peoples.
Cultural safety is also important to consider when supporting newcomers and others from non-Western cultures. Members of these populations may face assumptions about how their culture contributes to acts and experiences of violence, and these assumptions create barriers to effective services and supports. For example, service providers may assume that women who are identified with particular ethnic communities and experience intimate partner violence are well supported by their communities, whereas in reality they may fear and face ostracism for seeking help and disclosing abuse (Roger, Brownridge, and Ursel 2015; Thurston et al. 2013). Refugees are likely to have been exposed to various forms of violence (Guruge, Roche, and Catallo 2012; Bogic, Njoku, and Priebe 2015; Kirmayer et al. 2011). As noted by Pottie et al, "refugees, who are by definition forcefully displaced, are at highest risk for past exposure to harmful living conditions, violence and trauma" (Pottie et al. 2011, E827); this places them in great need of culturally safe and trauma- and violence-informed services.
Trauma- and violence-informed approaches: Principles and strategies
Trauma- and violence-informed approaches aim to transform policies and practices based on an understanding of the impact of trauma and violence on victims’ lives and behaviours. Table 1 outlines key principles and sample implementation strategies at organizational and service-provider levels that can be used in many different sectors, including justice, health, anti-violence, social work and housing.
In public-health and other social-service contexts, we argue that disclosure of an individual’s violence and trauma history is not necessary for the provision of excellent services. Although disclosure is oftentimes necessary in the justice context, the goals of the trauma- and violence-informed approaches are to provide emotional, physical and cultural safety for all, regardless of whether or not a particular history of victimization is known. Embedding these principles and strategies into systems creates "universal trauma precautions" that reduce harm and provide positive supports for all people (Raja et al. 2015). It is important to think about trauma and violence responses on a continuum. At one end of the continuum, trauma- and violence-informed approaches focus on minimizing the potential for service systems to cause harm by triggering and re-traumatizing, and on creating supportive environments that provide universal benefit to both victims and service providers. At the other end of the continuum, trauma-specific approaches strive purposefully to treat trauma and related health outcomes through specific healthcare modalities, such as psychotherapy or chronic-pain interventions (Poole and Greaves 2012). In many instances, specificapproaches require some understanding of an individual’s history of trauma and violence, so that treatment can be tailored to these experiences. Trauma-informed approaches can be implemented widely, but should be complemented by a multi-sectoral approach in which referrals can be made to forensic services, for example, or to specific forms of healthcare or housing services.
|Principles||Organizational/Policy Strategies||Individual/Service Provider Strategies|
|1. Understand trauma and violence, and its impacts on peoples’ lives and behaviours.||
|2. Create emotionally and physically safe environments for clients and service providers.||
|3. Foster opportunities for choice, collaboration, and connection.||
|4. Provide strengths-based and capacity-building approach to support client coping and resilience.||
Moving systems toward new paradigms of policy and practice such as trauma- and violence-informed approaches, cultural safety and gender inclusivity takes time and incremental change. For this shift to be effective, it requires patience and a strategic approach to system-wide change. But doing so can have multiple benefits. First, it provides both systems and service providers with the opportunity to create a support system that responds to victims in safe, compassionate and respectful ways, and thus have a more positive impact on the lives of clients and staff. Second, it provides a common and consistent platform of support across multiple service systems (i.e. health, justice, housing, etc.) that provide support to people who have experienced violence. Third, since past experiences of violence and trauma feed into cycles of abuse, including intergenerational cycles as noted above, a strong multi-sectoral response system can help break these cycles and prevent continued and future violence. Finally, and most importantly, trauma- and violence-informed approaches will better serve everyone by reducing harm and creating better opportunities for recovery and justice.
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