An Extension Educator Perspective on Trauma-Informed Care

Trauma-informed care (TIC) has become a major priority in recent efforts to address trauma and stress in the lives of children, adults, and families. The concept of TIC is fairly broad but typically involves acknowledging the prevalence of trauma, reducing its occurrence, treating those who have been affected by it, and using practices that are sensitive to an individual's history of trauma. Interest in TIC among Extension professionals has grown over the past several years as child- and family-serving organizations initiate TIC-related programs, trainings, and community initiatives and as Extension has taken an increasingly prominent role in working with distressed and vulnerable populations (Dworkin & Karahan, 2005; Kazura, Temke, Toth, & Hunter, 2002). In this article we provide a literature review–based overview of TIC and critical examination of TIC principles and assumptions, and we consider implications for Extension professionals.

Defining Trauma

Interest in the topic of trauma has been growing over the past two decades, especially as new research has documented the effects of trauma on long-term physical and mental health (Shonkoff & Garner, 2012). According to the Substance Abuse and Mental Health Services Administration (SAMHSA) (2018), 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 ("Working Definition of Trauma," para. 2).

The kinds of experiences that can cause trauma include physical and emotional abuse, child neglect, sexual assault, loss of a loved one, exposure to violence, disaster, war, and other emotionally harmful experiences. Findings from studies of adverse childhood experiences (ACEs) (e.g., Felitti et al., 1998; Mersky, Janczewski, & Topitzes, 2017) have raised awareness of the frequency and scope of adverse experiences and their contribution to trauma. Because of the potentially traumatic nature of many of the events identified in the study of ACEs, TIC is often linked to ACEs and has gained popularity as an approach for responding to them.

Defining TIC

SAMHSA's National Center for Trauma-Informed Care (2014b) has defined TIC as an approach for engaging people with histories of trauma that recognizes the symptoms and the role that trauma has played in their lives. It can be implemented in nearly any type of service or educational setting, organization, or system and is not limited to organizations and professionals who primarily work with high-risk populations (Center for Substance Abuse Treatment, 2014). Because many people have experienced adverse events, using practices that are sensitive to these potentially traumatic experiences, regardless of whether clients or practitioners are aware of them or their consequences, can reduce potential distress for individuals, help them feel safe, and reduce the chances that they will be retraumatized. Such measures contribute to the quality of the program or service being provided.

A TIC approach typically involves a number of essential principles and practices (Center for Substance Abuse Treatment, 2014; Klain & White, 2013). These include

• creating an environment where those being served feel physically and psychologically safe;
• recognizing the signs and symptoms of trauma and building on the strengths of clients;
• using practices that do not retraumatize individuals;
• working with clients in a compassionate, collaborative, and respectful manner; and
• sharing resources and practices that can help people on their paths to recovery.

Clarifying Terms

As interest in TIC has grown, the term trauma-informed has increasingly been used in a variety of different ways. A perusal of online resources related to the topic "trauma-informed" yields such related terms as trauma-informed culture (Holmes, Levy, Smith, Pinne, & Neese, 2015), trauma-informed practice (Klain & White, 2013), trauma-informed systems (Ko et al., 2008), trauma-informed policy (Bowen & Murshid, 2016), trauma-informed principles (SAMHSA, 2014a), and trauma-informed services (Butler, Critelli, & Rinfrette, 2011). Many of the terms are used interchangeably although they sometimes refer to different concepts. The current language surrounding trauma-informed work lacks precision and can lead to confusion.

One distinction that has been made involves the difference between the terms trauma-informed care and trauma-specific services (Butler et al., 2011). Trauma-specific services are particular clinical interventions or treatments designed to address the consequences of trauma. In contrast, TIC is the more general service delivery approach "that is grounded in an understanding of and responsiveness to the impact of trauma, that emphasizes physical, psychological, and emotional safety for both providers and survivors, and that creates opportunities for survivors to rebuild a sense of control and empowerment" (Hopper, Bassuk, & Olivet, 2010, p. 82).

Implications for Extension Educators

Given Extension's role in community education, it seems appropriate for Extension professionals to cultivate their understanding of TIC and how it might guide programmatic, organizational, policy, and community responses. Building awareness of the widespread occurrence of ACEs and encouraging the use of trauma-informed principles is important both internally, within Extension, and externally, with community partner organizations.

Building Extension Educator and System Capacity

Because trauma and adverse events are experienced by people across a wide spectrum of life stages and circumstances, undergoing training in trauma-informed practices may be beneficial to all Extension professionals. A better understanding of the nuances inherent in the concepts of ACEs and TIC becomes even more important for Extension educators who work with higher risk, underserved audiences and communities. Training goals may include fostering educators' understanding of ACEs and trauma, building skills to create physically and psychologically safe program environments, and making appropriate referrals for learners who may need care and assistance.

The following educational resources can be useful to those interested in obtaining trauma-related information and tools:

• National Association of State Mental Health Program Directors' webinars and trainings (https://www.nasmhpd.org/content/meetings-and-webinars),
• National Child Traumatic Stress Network's TIC resources (https://www.nctsn.org/trauma-informed-care),
• SAMHSA's National Center for Trauma-Informed Care training and technical assistance offerings (https://www.samhsa.gov/nctic/training-technical-assistance), and
• SaintA's community training and train-the-trainer programs (https://sainta.org/trauma-informed-care/trainings/).

A search for TIC articles in scholarly journals results in a plethora of study reports and reviews that can provide helpful empirical and theoretical insights. A good recent resource is the September–October 2017 special issue of the journal Academic Pediatrics (https://www.academicpedsjnl.net/issue/S1876-2859(17)X0002-8).

Another way state Extension systems can incorporate TIC into their outreach is by establishing learning communities of interested educators. We are part of a group of Extension family educators in Wisconsin who meet regularly to communicate about ongoing ACEs and TIC work. Our group has presented webinars for colleagues and written an impact report for state and local administrators, and our plan is for continued internal capacity building with educators across program areas.

Building Individual and Family Capacity

Providing programs directly to individuals and families has long been a strength of Extension family outreach, and that tradition lends itself well to TIC. As more curricula become available that center on a TIC approach, family-focused educators are well positioned to become trained on and then teach these programs. In Wisconsin, Extension educators have taught trauma-informed parenting using a national curriculum from the National Child Traumatic Stress Network that teaches caregivers how to recognize trauma symptoms and triggers and adjust their caregiving to best support and protect their children (see https://www.nctsn.org/resources/resource-parent-curriculum-rpc-training-modules). Extension educators also can integrate TIC principles into existing curricula and program efforts. Moreover, when audiences are likely to include individuals who experienced multiple ACEs, educators can make simple changes to help create safer learning environments, such as limiting or eliminating questions that ask learners about their childhood experiences.

Building Community Capacity

Working with coalitions that are directed at reducing the incidence of trauma and ACEs seems appropriate for and consistent with Extension efforts. Extension professionals' contributions might include developing system-level plans based on sound theories of change, sharing research and recommendations about effective interventions and practices, and providing leadership and guidance on developing and facilitating effective coalitions, as well as assistance on evaluating such activities. In Wisconsin, Extension educators have trained professionals from youth- and family-serving agencies, child care providers, educators, and local government leaders on childhood trauma, TIC, and methods for integrating a strengths-based approach into their professional practices.

Extension also can bring a model of empowerment to coalition efforts that involves assisting learners in identifying and nurturing their strengths and working with these individuals in collaborative and respectful partnerships (Collazo et al., 1993). In addition, there is value in communicating to partners and stakeholders how Extension's traditional youth- and family-focused efforts contribute to the prevention of ACEs and the reduction of childhood trauma. A growing number of online resources support TIC work within community settings. Two particularly helpful inventories of such offerings are

• ACEs Connection's set of TIC tool kits (https://www.acesconnection.com/blog/trauma-informed-care-toolkits-1) and
• ACEs Too High's "Resources" list (https://acestoohigh.com/resources/).

Advancing public understanding about how early childhood experiences can have long-term consequences complements recent recommendations from professional organizations such as the American Psychological Association Working Group on Stress and Health Disparities (2017). However, even though raising awareness through education is important, it is not enough. There is also a need to increase understanding of and support for the importance of childhood experiences that promote well-being and protect against harm. Addressing this need is consistent with Extension's traditional focus on prevention, early intervention, and promotion of positive behaviors. Extension educators also can be helpful in framing issues, identifying common language and definitions, and sharing current research findings on child development, family strengthening, and community support for families. Along these lines, Extension educators in Wisconsin have organized community screenings of relevant movies (e.g., The Raising of America, Paper Tigers) to foster public dialogue on childhood trauma and encourage local action.

Pitfalls to Avoid

TIC can be an important area of focus for Extension educators, but it is not without its risks. When working in this area, we in Extension need to be aware of the boundaries of our organizational mandate and the limits of our expertise and professional training. Direct involvement in programs and interventions targeted at high-risk audiences who have been affected by traumatic events, or who are currently coping with them, moves us into a grayer area. Whether or not to become involved should probably be considered on a case-by-case basis depending on one's professional training, experience, and organizational support and the expertise of one's professional partners. For example, providing parent training to foster parents or kinship caregivers who are caring for children with a history of trauma may be appropriate for educators with training and experience in family therapy, counseling, or social work and/or who are coteaching with a licensed therapist or counselor.

When working in this area, we should be careful that we do not inadvertently cause harm. For individuals who are suffering from trauma, educational programs may not be sufficient for addressing their problems. We need to be cautious that our efforts are not substituted for needed therapy or treatment. We also should avoid administering clinical screening tools that assess possible traumatic or adverse events. Without proper interpretation and follow-up, individuals may draw inappropriate conclusions that can lead to unnecessary distress. Similarly, presentations of ACEs findings may lead some people who have experienced one or more adverse events but who are not themselves traumatized to think otherwise. On the other hand, when providing presentations about ACEs or TIC to general audiences, we have a responsibility to make available information on resources and referrals to qualified professionals to increase the chances that people will get the support or treatment they might need.

Overuse of the words trauma and survivor can inadvertently promote a victim mentality and be self-fulfilling. There is also concern that if we use the term trauma too generally, it becomes impossible to distinguish serious trauma from other less challenging experiences. For instance, we know that similar adverse events may be experienced very differently on the basis of such factors as the duration, severity, and timing of the event; the protective factors surrounding the individual; and the context within which the event occurred (Shonkoff & Garner, 2012). Assuming that most individuals who have experienced an ACE also have been traumatized may undermine the support that is vital to those who have experienced prolonged, recurring, and severe adversity.

Conclusion

As with other important issues, Extension professionals are likely to be drawn to efforts related to TIC. Whether or not one becomes involved should be based on a variety of factors, including how such involvement advances major program efforts, the value one can bring to the issue, organizational priorities and support, opportunity costs, and an individual's professional readiness to address the issue.

Acknowledgments

We would like to thank the other members of the University of Wisconsin Cooperative Extension Workgroup on ACEs and Trauma-Informed Care for their insights and feedback: Brook Berg, Anne Clarkson, Mandi Dornfeld, Rene Koenig, Liz Lexau, and Lori Zierl.

References

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