An Overview of Trauma-Informed Care: Interview with Nancy J. Smyth, Ph.D.

Today's episode of the Social Work Podcast looks at Trauma Informed Care, one of the most promising approaches to working with people without causing additional trauma. And I had the honor of talking about Trauma-informed care with Nancy Smyth, professor and Dean of the School of Social Work at the University at Buffalo. There are three reasons why Nancy was the perfect guest for today's topic. First, she understands what it means to address trauma at the micro, mezzo, and macro level. She has worked in both mental health and addiction treatment settings for over 35 years as a clinician, manager, educator, researcher, and program developer. Second, she's what we like to call a “content” expert. She is a Board Certified Expert in Traumatic Stress.  Her research, teaching, and practice focuses on trauma, substance abuse, and on working with people recovering from those experiences, including the use of innovative treatment approaches like EMDR and mindfulness meditation. In today's episode, we talked about Nancy's interest in Trauma-Informed Care. She identified the basic assumptions behind Trauma-Informed Care. She clarified the relationship between a trauma-informed approach to working with clients and specific empirically supported treatments for people with trauma histories, and treatment for people with PTSD. She talked about some of the ways that she has translated trauma-informed principles into micro-level treatment practices. We ended with resources for people who are interested in learning more about Trauma-Informed Care, including a bunch of episodes on the inSocialWork podcast series.



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Bio

Nancy J. Smyth, PhD, LCSW is Professor and Dean at the University at Buffalo (UB) School of Social Work. Dr. Smyth has been on the UB faculty since 1991 and has served as dean since 2004.  She has worked in both mental health and addiction treatment settings for over 35 years as a clinician, manager, educator, researcher, and program developer. She also is a Board Certified Expert in Traumatic Stress.  Her research, teaching, and practice focuses on trauma, substance abuse, and on working with people recovering from those experiences, including the use of innovative treatment approaches like EMDR and mindfulness meditation.

Transcript

Introduction

In the late-1990s, early 2000s I co-facilitated a group for parents who were trying to reunify with their children who had been removed from their care by the state. Nearly all of the parents who were signed up for my group were women who had confirmed cases of neglect against them, primarily for failing to protect their children against abusive partners. As you can imagine, this was an intense group. As facilitators we always listened for moments when parents expressed genuine empathy towards their child's experience, took responsibility for their actions or inactions, and demonstrated steadfast dedication to protecting their children. I felt proud of this group, for the most part. There were times, though, that I had the unsettling thought that I was part of a system that did not practice what it preached. I remember this one mom who had suffered severe physical and sexual abuse at the hands of her husband for years, in part to protect the kids. In the end, it didn't stop him. Her reuinification plan included attending AA, job training, keeping a part-time job three bus rides away from her home, participating in individual therapy, this group, keeping her house spotless, and a couple other things that I can't recall. What I do recall is her saying that she felt like the system was setting her up to fail. If her house, attendance, or job performance was anything less than perfect, she would be punished in the worst way possible - never seeing her kids again. I'll never forget when she said “My husband was the same way – there was no room for error. Anything less than perfect and I'd get a beating. But there was only one of him. There are like 6 of y'all. I've felt more abused by this system than I ever did with my husband. It feels more like gang rape, which I know about.” I didn't have words for it at the time, but today I'd say that the system was retraumatizing this mom by taking away all of her power and sense of control over both her own life and that of her children. Now, does this mean that the system should ignore the fact that she did not protect her children from horrendous abuse? No. Of course not. But it does beg the question, how effective could the system be at helping her become a better, more protective parent, if she likened her experience in the system to gang rape?

So, what's the alternative? I'm glad you asked. Today's episode of the Social Work Podcast looks at Trauma Informed Care, one of the most promising approaches to working with people without causing additional trauma. And I had the honor of talking about Trauma-informed care with Nancy Smyth, professor and dean of the school of social work at the University at Buffalo. There are three reasons why Nancy was the perfect guest for today's topic. First, she understands what it means to address trauma at the micro, mezzo, and macro level. She has worked in both mental health and addiction treatment settings for over 35 years as a clinician, manager, educator, researcher, and program developer. Second, she's what we like to call a “content” expert. She is a Board Certified Expert in Traumatic Stress.  Her research, teaching, and practice focuses on trauma, substance abuse, and on working with people recovering from those experiences, including the use of innovative treatment approaches like EMDR and mindfulness meditation. In today's episode, we talked about Nancy's interest in TIC. She identified the basic assumptions behind Trauma-informed care. She clarified the relationship between a trauma-informed approach to working with clients and specific empirically supported treatments for people with trauma histories, and treatment for people with PTSD. She talked about some of the ways that she has translated trauma-informed principles into micro-level treatment practices. We ended with resources for people who are interested in learning more about Trauma-Informed Care, including a bunch of episodes on the inSocialWork podcast series.

Now, the third reason why Nancy was the perfect guest for today's episode (don't worry – I didn't forget) is that she is one of social work's technology visionaries. She was the driving force behind the University at Buffalo's award podcast series, inSocialWork. When UB's podcast series started in 2008, some of the most vocal fans of the Social Work Podcast expressed disdain that someone would produce a competing social work podcast series.  I've always been grateful to Nancy and her colleagues for the excellent work they do. Honestly, even if there were 10 podcast series on social work, we probably wouldn't even begin to scratch the surface of all of the content that needs to be covered. So, I've never thought of the inSocialWork podcast series as competition. And, truth be told, if I had to compete against their every-two-week production schedule I would lose. So in the spirit of non-competition and collegiality, today, April 29, 2013, the two podcast series are having a cross-promotion. I'm publishing my interview with Nancy Smyth, and the inSocialWork podcast series is publishing an interview with… me. inSocialWork's Laura Lewis interviewed me about my work on the nation's first public arts suicide prevention project - the City of Philadelphia's “Finding the Light Within” suicide prevention mural and storytelling website. After listening to my interview with Nancy, head on over to insocialwork.org.

And now, without further ado. On to episode 80 of the Social Work Podcast. Trauma-informed Care: Interview with Nancy Smyth, Ph.D., LCSW.

Interview

Jonathan Singer: Nancy, thanks so much for being here on the Social Work Podcast and talking to us today about trauma-informed care. And my first question is why are you interested in trauma-informed care?

Nancy Smyth: Well, personally my interest probably started way back in my early days in practice and I'll date myself here, but in the late 70s where I was working with people with serious mental health problems and it became very evident to me the extensive trauma histories these clients had, from sexual abuse, physical abuse, a lot of childhood issues and as a field we were starting to talk about this and a lot of these folks also had substance use problems and we're trying to figure out what you do about all that and I was fortunate in I think ‘89 to go to Cape Cod Institute with Judith Herman presenting on her book Trauma and Recovery. Actually, she had – I think she had just been publishing it at that point or it's about to come out the whole trauma and recovery model trauma theory and it really seemed to me like it was a missing piece for me and my work with clients. And so over the years I've really worked hard to try to get people to see some of those connections not so much in terms of a diagnosis like PTSD, but understanding how these events in people’s lives contribute to a lot of the things that we label as you know problems or diagnoses and that really start to affect how we go about providing care. And I think trauma-informed care, people get very confused about it and it's interesting if you go and look in the field of trauma and traumatology, which is you know the study of trauma a lot of the trauma people will not even know what trauma-informed care is. It's a movement that started politically from survivors of trauma who are in the mental health system, really based on a lot of research about how trauma affects people, but really starting to say, you know, our systems are hurting people. They're actually inadvertently retraumatizing people in the way things are done. And I certainly witnessed that first hand. I thought there's something wrong with us treating a trauma survivor in these ways, but it – you know, it didn’t start to become something defined as trauma-informed care until much later when people started thinking about the principles. For me, it became a way to really think about the work we were doing in a context that often made the difference for people that were not getting better, people that were staying stuck, that were challenging, that were getting labeled as untreatable in you know whatever sort of words, mental health professionals used for that or substance abuse professionals use and I think were then often clients that became very frustrating and demoralizing for the staff.

Jonathan Singer: You know the way that you're describing it, it sounds like this model or this philosophy trauma-informed care is really a great fit with social work because it acknowledges the individual experience, right so maybe a childhood trauma or maybe some sort of traumatic event, but then it also says this is not something that occurs in isolation. It occurs in a context and one of the contexts in which we interact most with people is service providers and so if the organization or the agency is doing something that is retraumatizing or contributes to the pain and suffering associated with the trauma or triggers it then we're not actually helping. And so it's a real nice integration between it's kind of the micro and the mezzo or the macro.

Nancy Smyth: Exactly. And I think that’s one of the things that’s really appealed to me about the model is it really does fit well with our profession in the sense of person and environment and looking at our systems of care. The core assumption of a trauma-informed care model is that it's not about what's wrong with you, it's about what happened to you and so it's actually a strength perspective in the sense that many of the things that we define as problem behaviors or symptoms particularly symptoms when it comes to people who’ve acquired a diagnosis of personality disorder actually make perfect sense when you start to understand what happened to people and you actually start to see that some of these things were coping strategies that came out of what happened. So those things are kind of congruent with I think the way social work at its core tries to view people. What's different about trauma-informed care is it incorporates the newer information about the impact of trauma, trauma and the brain, understanding issues of triggering and you know things like that which we didn’t have a strong an understanding of 20 years ago even.

Jonathan Singer: Can you give an example of something that might be seen in terms of a deficit or a problem that is reframed or reconceptualized as a strength?

Nancy Smyth: Yeah. Well, a really popular one that I think most professionals have a really tough time with is cutting.

Jonathan Singer: The self-injurious behavior that kids or adults have been engaging in more and more these days?

Nancy Smyth: Yeah, exactly and I'm not going to comment that it's always about this, but what I can tell you is that at least in many of the people that I've worked with I can talk about a case situation where the client gave me permission to talk about as long as I don’t identify who she was, but where she would listen to parents with horrific fights that would really scare her and she would hide in the bathroom and be terrified and then discovered that if she put her hands like the wrists up against the hot water pipes and hurt herself, that the feelings got better. They went away.

And what she said is that this was one thing that she could control and she also had a history in her family of when she really liked things they were often taken away from her. So this was something she could control and that was hers alone. And so understanding that, you know really being able to say to her I get it, you know, that it made perfect sense given what options she had to deal with at the time. That response to her was a huge huge change from how every mental health professional had dealt with her up to that point, which was you can't do this, you have to stop, it's bad.

Now, we worked towards stopping, but you have to start with acknowledging the function, what was working about it and that it was so important to her and for me to sit and tell her she has to, you know, get rid of it is a repetition of what happened to her growing up whenever she had something that was valuable to her, people try to take it away. So that would be a really good example of “you know we say this is a maladaptive behavior”, but certainly it is now, okay, although it serves a function now, but the reality is she has different choices in her life now and she can learn some other skills now. She didn’t have that at age 4 or5.

Jonathan Singer: And as you were saying that, I thought about you know maladaptive for whom? I mean certainly, certainly there's this idea that you don’t want people to engage in self-injurious behavior frequently and with increasing intensity because then – and we know from the research that it can move into thoughts of suicide and self-harm and sort of this acquired capacity for hurt, but it's certainly maladaptive for a therapist or provider who’s worried about liability, who feels out of control, who doesn’t know–

Nancy Smyth: Yes. We were able to – you know, even in the 80s and early 90s and I did it again recently in my private practice. I was able to convince service providers to work with me with clients who self-harmed to not automatically demand that they be rushed to an emergency room for a full-pledged evaluation because once the self-harm had occurred most of the time the crisis was over and to then demand that you go up and see so and so and spend five hours in the emergency room isn't going to make a great deal of sense and then to throw someone out of treatment, which has often been the response because they’ve repeated the behavior a few times.

So, I was able to get systems to change those behaviors while I worked with the person on developing some other coping skills, but what was important was doing just the assessment that you said, which is not writing the behavior off either, every time doing a careful look and saying okay, you know, when you gave yourself harm, we have to check in, we have to talk, we have to see where you're at and make an assessment about whether there is additional risk at this point and then take action.

Jonathan Singer: So this all sounds like good sort of client-centered or client respectful practice, do you see the work that you did in changing systems as trauma-informed care? Is that how you conceptualize it?

Nancy Smyth: I didn’t conceptualize it that way the first time that I was doing it because we weren't even using those words at that time. The second time which was in you know within the last eight years, pieces of that were, yes, absolutely. It's about trying to get everyone to both understand the behavior – I mean, you know, that the research also says about self-harm that when someone shows up in an emergency room without behavior that they actually get high levels of hostility from ER staff and mental health staff because people get angry at this behavior and so then helping people see the behavior differently and understand that in context understand what it's done for someone even where it's come from, if the client is comfortable with people knowing that, can really change some of the responses of the system.

Of course, you're also working therapeutically to develop other coping skills. You have to work with a client on changing those things. So that would be a piece of trauma-informed care, but trauma-informed care is probably best thought of as not – it's not a method, it's a more framework and a context for which you do your work and it certainly, it has to work at a system level. You can't do it just in your office as a private practice therapist and not look at the system outside of that.

Jonathan Singer: That’s really interesting. So if I saw a private practitioner advertise I practice trauma-informed care then you would suggest well, maybe I should ask a couple of questions. Maybe I should find out what exactly they're talking about because trauma-informed care is not a practice model like say cognitive behavioral therapy or motivational interviewing or something of that nature.

Nancy Smyth: No, it really isn't. I mean it's guided by fundamental principles, but the methods you use for treatment couldn’t be all of the things you just mentioned. If I say I practice trauma-informed care, it tells you something about my practice in the sense that I'm working on principles of collaboration with a client as opposed to compliance. I'm working with principles of safety, of understanding safety, of understanding the need for client choice whenever possible and I – you know, there are occasionally times that that can't be brought into the place, but those are actually pretty infrequent and empowerment of a client.

So that might tell you, you know, that those are principles that I use, but the ways in which I use those and the treatment methods aren't going to be clear so from that. I would certainly expect to see someone who does trauma-informed care to use something like motivation interviewing because it's very compatible with that. But I also will need to intervene in systems if that’s appropriate.

Now, you know there may be clients that don’t need that level of intervention, but certainly when you're talking about people who’ve been really affected by repeated long-term trauma, which are mostly the clients that I work with, they're interfacing with many systems and you really do as best as you can to get those systems on board and sometimes you can't and then you're working with a client and helping them not internalize system reactions and understanding that it's a system issue. It's not about them.

Jonathan Singer: So there's this idea that trauma-informed care is a framework and that you can use different treatment approaches within that using – and still being guided by the principles that you just mentioned. You’ve also mentioned trauma theory and I'm wondering if you could talk a little bit about what trauma theory is and then I'm wondering if trauma theory is compatible with some of these other practice frameworks like CBT or behavior therapy and is it really possible to integrate it with these?

Nancy Smyth: Yeah. I mean trauma theory and actually it's probably more accurately described as trauma theories because there's multiple theories now in terms of how trauma affects people, but it basically looks at the role of these, you know, sort of horrific experiences in people’s development of self in the way people relate to the world and of the need for us to incorporate those understandings into our treatment. A really radical position of trauma theory might even say that most of what we think of as mental health problems need to be reconsidered in light of the research that’s now emerging, which is that regardless even things like schizophrenia that, you know, we can say how strong biological components that the history of trauma is often the thing that is part of the picture that may turn something from just biological predispositions into an actual full blown mental health problem.

Jonathan Singer: This gene environment interaction?

Nancy Smyth: Exactly. And you know it may express itself in one way or in another depending on someone’s genetics, but trauma theory will also truly recognize that one of the things we know very solidly from the research now about childhood trauma especially is that the way in which people manage emotion is what's affected by trauma, so you get emotional dysregulation and that emotional dysregulation, the inability to manage feelings can show up in a whole variety of mental health related problems and that that’s really what need to go after and to address.

And that’s not to say that the biological issues are not important, but that if you just are treating somebody with medication without dealing with those other issues, you're probably not going to get a lot of real stability for them.

Jonathan Singer: So you just mentioned emotional dysregulation and this is one of the sequelae of traumatic events. It changes the way people are able to manage their emotions and I can imagine somebody with an eating disorder or somebody with depressive symptoms or a variety of – or even acting out, oppositional defiant disorder, any of these sort of diagnostic labels that we give people as being associated with difficulties regulating emotions.

Nancy Smyth: Yes, absolutely. And that’s part of what trauma theory would say is you know the core here is trauma and its impact and then the way it gets expressed partly is influenced by biology. Part of it maybe also by other environmental influences in terms of you know whether I turn to substances or if I'm growing up in a family where substances are present and I'm exposed to them, you know, and I in fact can start to use them at an early age because of that environment, that may be one way it plays out versus something else.

Jonathan Singer: So would say that this understanding of where problematic behaviors, this assumption that this is where this comes from, is this compatible with practice theories – I'll just throw out, and so there's cognitive behavioral therapy, there can be solution-focused therapy, narrative, all these different treatment approaches that we use that we talk about.

Nancy Smyth: I think it can be. Most – I'm not going to say all approaches because you know there's probably something out there that maybe it wouldn’t fit with, but I think most people find that that approach can inform and work well with a variety of treatment approaches. Now, some people see this trauma theory perspective as psychodynamic. I don’t actually see it as psychodynamic because I think the difference between trauma theory and psychodynamic practice is trauma theory focuses a lot also on the issues of biology and the lack of emotional processing of trauma and that you get fragmentation of traumatic memory that happens and that that’s again biological and needs to be addressed through various treatment methods.

But certainly it wouldn’t be incompatible with psychodynamic and I think that certainly cognitive behavior, social learning theories recognize the role of learning and coping and of thoughts in that process. Solution-focused will obviously worry less about what happened to you, but it's still very strength-based and focused on solutions and most often see what you’ve been doing as an attempt at a solution. You just need to be working on some other solutions. So, I don’t think it's incompatible with that either.

What we talk about though in trauma-informed care is that in addition to taking the approach to the client, which really emphasizes choice and I think choice and collaboration empowerment maybe where you run into trouble with some of the traditional theories and I think this is not so much the problem with the theory as it is with its implementation because I see huge variation in practitioners, but if you're going to involve – give clients some choice in how treatments provided, you know, there are some traditions that are based more in the authority of the therapist and in the sort of blank slate that the therapist should be presenting and not a lot of self-disclosure.

Now, that’s more classic psychoanalysis than it would be the way psychodynamic theory gets implemented now, but a blank slate – a therapist who wasn’t very human and really just try to leave things sort of neutral would probably be very activating and triggering for most really severely traumatized clients because the lack of emotional queues and of responding would just there be so much transference that people might not engage in a therapy enough to get past it and I think that’s partly why you could get a lot of dropouts.

So, I think it really is partly about how the therapist implements the treatment and titrates it. What is recognized in trauma theory especially in trauma-informed care is that the relationship is critical and of course that’s not new to social work, but it puts an added understanding about here we have people by and large and you know, trauma-informed care becomes especially important for people who’ve lived through repeated traumas, childhood trauma as opposed to something like 911 where that was the only traumatic event they had.

That people were hurt within the context of trusted relationships and that here we ask them to come in and trust us and we ask them to come in and we're in an authority sort of caregiving role so the recognition that the therapist’s relationship is going to be triggering from the beginning and that what you really need to work slowly with that certainly isn't a unique thing to trauma-informed care, but it's one of the central pieces that you really pay attention to.

The other element of trauma-informed care that I haven’t mentioned and I think is important to mention is the emphasis on self-care for the therapist and for the staff. This is an approach that’s especially important and designed for systems like child welfare system, you know, group homes, juvenile justice, inpatient units as well as for people who are working independently in practice, but it's especially essential in those settings that everybody in the setting be part of understanding what these treatments are about and that we're paying attention to how the staff are doing and the impact of the work on the staff.

Jonathan Singer: And so self-care and workforce retention, burnout prevention, all of these concepts have been around for a long time. Why is this particular or central in trauma-informed care?

Nancy Smyth: Most of the models of trauma-informed care, and there's a bunch of them out there, but if you look at something like the sanctuary model–

Jonathan Singer: Sandra Blooms.

Nancy Smyth: Yeah, Sandra Blooms sanctuary model, that actively works at the level of staff – in other words, the same principles you would be applying to clients have to be applied to the staff in the organizations. So, it's a much more active organizational intervention and not just let's be worried about staff retention. So, we look at collaboration, choice, empowerment, safety as it relates to staff in addition to as how it relates to clients.

And in fact there are assessment instruments to measure the organization on those variables. We've been doing some research on that in our institute for trauma and trauma-informed care to look at some of those instruments and see how they hold up and what we found are that some of the organizations we've been looking at who say they're doing trauma-informed care don’t do a great job on that other piece of the staff element and yet we know from some research that Brian Bride did in Georgia, he looked at social work workforce and child welfare workforce in that State and I'm sure Georgia is not unique this way, 50% of the workforce qualified for diagnosis of Posttraumatic Stress Disorder related to their work.

Jonathan Singer: Wow.

Nancy Smyth: This is an issue for our profession, you know, this issue of exposure vicarious traumatization and I think yeah, I think we come into this field with our own histories and those can be (assets) and they can also leave us vulnerable. And so I don’t think we're dealing well with this as a profession. Trauma-informed care would be casting a special spotlight on that and on what are the practices in an organization that are consistent with collaboration, choice, empowerment, all of those things which you're absolutely right, they all contribute to things like workforce, you know, retaining workers and to issues of burnout.

But I think because the model has been elaborated more specifically to look and measure the workforce that way if not just lip service about being concerned about those, it actually makes suggestions for intervention. And you know an example here in the school since we've implemented these principles into our MSW curriculum, in addition to some human rights content, but the trauma-informed care piece have us examining our implicit culture in the school and that is a struggle because I will – higher education institutions are hierarchical.

They're not necessarily empowering at all for faculty even and so we say well, how can we as a system implement as many of these principles as possible here and a simple decision like, you know, we have a student who’s getting some bad news from us related to maybe their status in the school, how are we approaching and dealing with that? How are we taking care of the staff in the process as well? I mean it focuses our attention on multiple layers where we would not be necessarily doing that except in maybe extreme situations.

Jonathan Singer: This idea of changing the culture in the graduate education program I think is such an interesting idea because I know that one of the ways that faculty have described or kind of reframed the frustration that students often feel in schools is this is just good preparation for what it's going to be like when you're out in the agencies in the organizations. That the feedback you give about good professors or bad professors or the assignments that seem like busy work, the you know wasting your time and money, this is what happens in your agencies and so I think that there's maybe a tongue in cheek, maybe sort of a way of explaining it away of this is – school is like this and we're not going to change it because this is how it is out there and what you're saying is that if we want our students who are going to become the providers to think differently about working in an organization or a system that is actually caring and understanding of things that might trigger someone that it would be important to make that change in the graduate education not just content, but the way that the education is provided, the way that the school is organized.

Nancy Smyth: Absolutely. And at the same time recognizing that there are competing things that the school is expected to do for instance gate keeping for the profession, right because these are not our clients. These are our students, so you know where do you draw some of those lines? But how do you do it still in a humane way, in a way that really takes full sort of responsibility and care and whenever possible transparency. And I say whenever possible because obviously you have to respect issues of people’s confidentiality and things like that in terms of their educational process, so it's not a – I don’t think anybody could create a perfect system, but it is more of a process and a struggle I guess and people come down in some different places with it.

But it's certainly – it's an effort you have to make and it's absolutely true. People are going to come up against barriers out there and they need to learn how to work with them, but I don’t think learning how to work with them is the same as just submitting to them. I think it's, you know, how do you work with them? How do you challenge them in ways that are going to be effective? You know, sometimes you do have to pick and choose your battles, but to just decide I need to become – to get used to what are in essence unworkable, unlivable work conditions whether it be in school or in the workforce.

I don’t think we're doing ourselves or our profession any favors because I think, you know, I see people leave the profession. I see people end up on disability. I think that there's reasons for that and when I look at research like Brian Bride, like oh my God, you know, we aren't talking about this, 50% I mean that’s–

Jonathan Singer: Yeah, that’s huge.

Nancy Smyth: It's huge. And we've emphasized a lot of self-care in our curriculum pieces for our students and what we find is that students will say okay, all right, but they rarely implement it and I think that what draws us to this field sometimes gets in the way of us taking care of ourselves first and trying to help people put those pieces together. So, I don’t want to make it sound like we haven’t figured out, boy we don’t. We're really struggling with it, but we're at least asking the questions and you know when we look at a process even like tenure and putting people through that process, we try to do that again in as transparent and humane way as possible understanding that it's an archaic process and you know higher ed institutions had their start in the middle ages and there's lots of pieces of them that still date back to that.

So, yeah, we try to model as much as we can and we do – some of us do better than others I'm sure and then the agencies would be trying to do the same and the whole point of the sanctuary model is to actively work with the entire agency from the janitor, the receptionist, all of the staff understanding trauma and understanding the principles of trauma-informed care and applying that to everybody, so you really need leadership on board to really fully implement this model in an agency and a program.

Jonathan Singer: So, you’ve mentioned so many important components to this idea of trauma-informed care and the more that we talk about it, the more that I understand why it's not something that I understood very well because it's multi-faceted, you know, just from the piece that you said that as an individual provider, you can have a trauma-informed framework and still do CBT as long as you are making every effort to apply these principles, you talked about choice and collaboration, empowerment, but also if you're – you could be a great CBT therapist and you could be great at working with people with PTSD in terms of reducing those symptoms associated with PTSD, but not be doing trauma-informed care if you don’t think outside of just that individual relationship.

Nancy Smyth: Absolutely, yeah.

Jonathan Singer: That there has to be this conceptualization of my individual practice is actually a systemic practice.

Nancy Smyth: Precisely.

Jonathan Singer: And I think that that – I think that’s a perpetual challenge in social work education and certainly it's a real challenge when you're out there in the field and you do have a large caseload. You don’t have the time and energy or support to think beyond, you know, improving that functioning score or reducing those symptoms or you’ve got 10 sessions that have been authorized. And so there are all of these barriers and it really sounds like taking a trauma-informed approach is both consistent with social work practice and also could result in better outcomes for clients. Is there a research to suggest that that is the case?

Nancy Smyth: You know, there is some research that’s very preliminary and it's not certainly like randomized clinical trial. It's research at the evaluation level. The sanctuary model has been designated as a promising practice in some evidence-based approaches. It's certainly not the kind of standard you would look for, you know, when you talk about prolonged exposure or EMDR of both level A, you know, evidence in terms of lots of randomized clinical trials.

But there have been studies that have found reduced restraints, you know, some better child outcomes in like say child welfare programs, but the research don’t really need to be ___. And I think of this as being an evidence-informed approach meaning we have strong evidence about a variety of things, about how trauma affects people. It also is about giving people access to trauma-specific treatments, things like EMDR, prolonged exposure, seeking safety things that actually address the symptoms because that to me is a human rights issue and it is also trauma-informed care.

Make sure that people have access to those treatments as well as the whole framework of how you're doing treatment, but the, you know really solid evaluation data is not there at the level that scientifically we would want it. It would be a little harder to do it with a real experiment because you are talking systems here. What I will say is that I think our whole reason in moving to implementing this approach in our curriculum had to do with feedback from the community.

We had had a trauma counseling certificate program here in our continuing ed from about just before 911 actually and we started getting responses from agencies like, you know, about a women’s program that says I want my entire staff trained in this because it's making such a huge difference in their morale and their ability to work with a full range of what we're getting. And so when we got positive feedback from our stakeholders as we were trying to decide on focus in the curriculum, those were some of the things that made us say hmm, maybe we need to look at this, but I still think of it very much as a value-based approach partly and evidence-informed and promising practice by sort of SAMHSA guidelines.

I don’t think SAMHSA has classified it that way, but I do know that I think California had classified sanctuary model as a promising practice, you know, suggest the emerging evidence, but it's interesting it hasn’t stopped most of the country to moving to this approach in their systems and you know like child welfare systems around the country seem to be adopting this. Mental health systems in some places say they're adopting this. Now, I say “say” because, you know, it can all look good on paper.

I want to know what the experience of the recipients are in that process because that’s really what keeps us honest and I think the fact that we do bed checks in a mental health unit in the middle of the night and what that would do to trigger a sexual abuse survivor, what being put into restraints does to trigger people who are – have been through physical abuse. Those are things that have been re-thought as these approaches become more prolific and I do think that people find that when you start to individualize and change those practices based on someone’s trauma history and involving them in what's an advance directive.

When you lose control, how should we intervene with you as opposed to a global practice that people do find things like reduced restraints, but you know a full blown scientific study of all of this is still yet to be done.

Jonathan Singer: Do you think that some of the move to adopting a trauma-informed approach is in part response to our involvement in Iraq, in Afghanistan and the fact that we're just coming out of the longest military engagement in our country’s history.

Nancy Smyth: Yeah. You know, I don’t think it's responsible for the initiation of this approach because honestly – and you know this approach sort of got its start across the country before these conflicts. But I do think that these conflicts and understanding trauma and the impact on folks coming back as well as you know the other major mass disasters certainly has raised the interest level for trauma itself and you know are driving people to pay more attention to trauma models. I suspect it's accelerated it.

However that said, I am not aware and you know there may be some VA systems out there that are doing a trauma-informed model, but by and large I'm not aware that say for instance the VA is using trauma-informed care as a model of treatment. It seems to have caught hold more in the child welfare system nationally and that’s partly because instead of the centers on child abuse and neglect, there was a movement at a policy level to the child traumatic stress networks around the country taking this approach.

I've seen it more in addiction treatment in mental health care and I haven’t heard people much talking about it in treatment of veterans which is fascinating. I mean certainly it fits and when you look at how veterans have felt about, you know, in the past anyway about the VA system, it makes perfect sense. I mean you could watch an old movie like Article 99 which are Vietnam era vets dealing with the VA and see how not to deal with trauma-informed care, you know.

Jonathan Singer: It's like a negative example.

Nancy Smyth: Exactly. And I'm sure the VA is not like that now, but I also don’t know that the VA has actively taken this approach. And I'm really serious when I say, you know, we hired an extreme events faculty member a few years ago, a psychologist who has done a lot of work in research in PTSD and she’d never heard of trauma-informed model and she actually wrote it up for the psychological division that deals with traumatic stress in a magazine that’s published as part of that division because she said researchers don’t know about this and a lot of the standard trauma treatment people don’t know about it either.

It really is this sort of parallel perspective that’s developed mostly I think started by recipients themselves and addressing care systems and not by researchers working on PTSD and working on PTSD treatments. And so they’ve sort of come together a little bit. There is a national center for trauma-informed care that SAMHSA runs and if you do a search on trauma-informed care, it's usually one of the first things to come up and they have listed there trauma-specific interventions that fit well within a trauma-informed care model.

You know, the sanctuary model is one, risking connections another. They talk about seeking safety. They have a variety of things. The fact that it's at SAMHSA tells us that this is really something that’s moved in the services and not so much from the formal knowledge base of academe and from research. Policy makers are paying huge attention to it I think because systems have struggled with some of the issues and they're looking at the research.

When you're talking about 90% of a mental health population in some places and certainly substance abuse that have significant trauma histories, you’ve got to start paying attention to that. And then you’ve got this whole veterans thing, which I haven’t heard people intersect them much, so it's kind of interesting what you said. I think it's the veteran issue and the war have contributed more to this zeitgeist of awareness about trauma that’s probably fed it, but I haven’t seen it feed it directly.

Jonathan Singer: And so it's so interesting.

Nancy Smyth: And that’s just my own opinion and I'm somebody like Charles Figley might tell me I'm crazy and he sees the connections.

Jonathan Singer: So, we've touched on a whole bunch of things here and I really really appreciate you providing this overview of trauma-informed care. I was wondering, could you just once again summarize what the principles of trauma-informed care are?

Nancy Smyth: Sure. I mean I think if you're talking principles, it partly depends on who’s model you're talking about, but essentially you first see a principle of it's not what's wrong with you, it's what happened to you and that treatment needs to be guided by a commitment to safety and collaboration, choice, empowerment and trustworthiness and really understanding how that trauma history is going to play out within the context of treatment so that trust and safety become paramount, you know, to getting treatment started and that trust will be key in the process. And paradoxically for me that will start with my clients by telling them they shouldn’t trust me until they’ve tested whether I'm trustworthy.

Jonathan Singer: That’s interesting. So when you first meet a client, or maybe not first, but in the beginning of your treatment you say hey, there's no reason why you should trust me, I have to earn your trust or something like that?

Nancy Smyth: Yes. I mean I basically – and it's often in the first session. I mean it depends on obviously what the client is coming from with the history, but if they have any kind of a history of significant trauma, what I'll say is listen you have more than enough experience in your life to indicate that people cannot be trustworthy. You don’t know me. There's no reason you should just automatically trust me. You are free to test your trust with me.

I want you to do that and let's talk a little bit about how you test trust with people. So, you know strangely enough when you leave with that, you engender some trust right at that moment–

Jonathan Singer: Yes.

Nancy Smyth: – because you're acknowledging their experience and you know acknowledging what they're probably feeling already which is, you know apprehensive about who is this person and can I trust them. And then in normalizing testing trust, all of those behaviors that we like to label as manipulative or whatever, you know, many of those fall into that category.

Jonathan Singer: Yes.

Nancy Smyth: So now we've talked about how can you test it and how can you test it in a way that might be more adaptive, but also one of the some of the ways that you’ve tested trust with people and you start to get that on the table, so that’s sort of taking a collaborative approach to understanding that issue of trust and how will we work on this together. Those would be examples of those principles sort of an action, but yes those are the principles that would really guide treatment and that’s why I think even if you're doing this within your office and your client population may not require huge levels of system of level intervention because maybe they're of higher functioning, but it will affect things like what's my availability to my clients and I'm not suggesting that we should all be available all the time, but I wrote a blogpost about a client that I had finished with and I’s shut down my private practice finally with this dean’s job just got too much and I gave her some referrals and she commented about how difficult it was dealing with a therapist who had very restricted ways of accessing them meaning you leave a voicemail message and they call you back and you get in this back and forth piece and what she said is that it felt very withholding and she realized it was triggering, that it felt a lot like her parents and her insight about that, I thought wow.

And she said, you know, you felt more accessible than that. Now, accessible, I allowed her to send me email not about crisis things but you know we talked about email and about the fact I wouldn’t respond instantly. She also was allowed to text me to change appointments and things and I set lots of boundaries around you do not tell me you're suicidal through text message or through email, you know, those types of things, but because I was accessible in the ways that she was accustomed to relating to the world, it didn’t feel so triggering.

So, you know that might be true for her and not true for somebody else, but I mean looking at the ways in which I'm connecting with my clients and asking that and looking to adjust them a little bit because yeah, you want to trigger a little bit in the sense that it gives you something to work on, but if someone is so overwhelmed initially that they can't cope because everything I'm doing is difficult for them to manage then we're never going to be able to get a relationship started and work together. So, I do think that those principles sound very clean and simple and it's more about using them to examine what you're doing and really working hard to solicit what your client’s reactions are and that’s not easy to do because people have been taught that they can't be honest with people or they're going to be beat up or you know whatever else, so you're really working to get honest opinions from people about what's working and what's not is an ongoing process.

Jonathan Singer: The examples that you just gave about how to turn these principles into practice are really interesting and I think it's exactly the kind of thing that folks listening to the podcast would love to learn more about. Are there resources? Are there either other podcasts or books or articles that you would recommend around the application of these trauma-informed principles and then are there other resources for the broader understanding of trauma-informed care as really as systems intervention?

Nancy Smyth: Mm-hmm. Let's see, well let me start with the systems of intervention ones because those are probably easier to find. There's a couple of podcasts in our School of Social Work Podcast Series, used to be called Living Proof, now it's In Social Work, that I think are especially helpful and that’s two interviews that I did with Brian Farragher of Andrus Children’s Center on the sanctuary model and how they implemented it at Andrus.

You know, he’s the executive director there and he really talks frankly about you know what putting that model into practice means and their struggles with it and I know that was very helpful to me in understanding. People search for that SAMHSA Center on Trauma-informed care and trauma services and you look under the option that says what is trauma-informed care. They have some interventions listed there. The risk and connection curriculum is mentioned there.

There's a model called the atrium model and all of them sort of something called the TREM Trauma Recovery and Empowerment. They all do provide some trauma-specific intervention, but they were all sort of grounded within some principles of trauma-informed care. I have a chapter out in a Wiley book which just came out which talks more about trauma-informed social work practice and I think one of my criticisms of this approach is it doesn’t get specific enough for practitioners. I haven’t seen a huge number of things that translate that in very many specific ways. I could give you a million different examples, but–

Jonathan Singer: Maybe we'll have to do a part 2 where you do that. Yeah.

Nancy Smyth: Yeah, yeah, you know because I really think that it comes down to – it does come down to very specific interactions with people, but I haven’t seen anybody pull the wrong one together in one way to really guide what I would call more than micro principles. I would say that I think motivational interviewing at its core is what I would ask tell people to learn if they really want to understand trauma-informed care.

And it doesn’t talk about trauma at all, but the principles and what drives that are so congruent with the core principles. Then you just have to take that to the next level and you have to ask the question of how am I operating my practice? You know, how are those things – how do I make those decisions? How am I involving people in those – you know, in what I do? Things like my policies around how to contact me. Things like how my office is set up.

I mean I will always ask my clients looking around my office, is there anything here right now that is difficult for you to sort of tolerate and you'll find out about things that are triggers that never in a million years would have occurred to you. And so learning just to ask those questions, so you have to sort of apply some of those principles in what you do, but I haven’t seen anyone put all of that in writing and you know maybe that’s just like a book or a chapter or something I need to write in a more micro level.

Jonathan Singer: Well, that’s good to know, too. I think it's good to know what resources are out there. I also think it's I fully know what's not out there because if you can't find something, is it because you don’t know how to look for it or because it's not there? And so I appreciate you saying that, that from your understanding and what you’ve looked for you haven’t been able to find something that really brings it down to a practice, a micro level in the sense that we're talking about.

Nancy Smyth: Yeah. And I do think that those links on the National Center for Trauma-Informed Care, those particular models will talk about it at a micro level within their approaches. They just won't do it at the sort of global. This is trauma-informed care and generally they’ll do it within the context of the Trauma Recovery and Empowerment model and those – so those are what I think be good starting resources for people.

Jonathan Singer: That’s great. Well, Nancy I really appreciate you taking all of this time to provide us this overview of trauma-informed care. Is there anything else that you wanted to add that we didn’t cover before we end this?

Nancy Smyth: You know, the only other thing I would add about a resource is and it's kind of buried in our website which is a problem, but I just actually sent it out. I think it will go out over Twitter at some point today on our School of Social Work account is that we have a resource center on our website at University of Buffalo School of Social Work that Trauma and Human Rights Resource Center and in there there's a link for conference resources and if you click through that, you'll find some videos of Sandra Bloom describing sort of a Trauma 101 model, you know. In other words, how does trauma affect people? And another of video of her talking about sanctuary model and then as well as Dr. Andrus who’s talking about the ACES study which is Adverse Childhood Experiences and research that’s come out of making us understand that the number of adverse childhood experiences people live through predicts a whole range of health problems, mental health problems in adulthood. So, those are great free video resources for folks and I think I like her description of sanctuary model there better than our podcast on it, which you know we do have a podcast on the sanctuary model with her, but she more talks about how she discovered and came to the sanctuary model in the podcast and it's not so much great overview of the sanctuary model.

Jonathan Singer: Oh, that’s really interesting. Okay. Well, we'll make sure that we put that up there as well.

Nancy Smyth: Okay. And now I thank you for having me here. I could talk about trauma and trauma-informed care forever, so I appreciate your interest and patience.

Jonathan Singer: Absolutely. Well, I think you know if we were having coffee we could probably talk about all afternoon, but knowing full well that people are listening to this in the car and on the bus and perhaps even on the treadmill, probably a good time for us to end our conversation. So, Nancy thank you so much. I really appreciate it.

Nancy Smyth: Thanks Jonathan.
[End of Audio]
(0:58:51)

References and Resources

• inSocialWork podcast: Implementing Sanctuary Model in an organization http://www.socialwork.buffalo.edu/podcast/episode_multipart.asp?mp=farragher_sanctuary
• 10 Dr. Sandra Bloom Sanctuary Model (describes how she realized the need for it): http://www.socialwork.buffalo.edu/community/trauma-conference.asp
• National Center on Trauma and Trauma-Informed Care: http://www.samhsa.gov/nctic/trauma.asp
• Videos: Sandra Bloom, Trauma 101 and the Sanctuary Model: http://www.socialwork.buffalo.edu/community/trauma-conference.asp
• Bloom, S. L., & Farragher, B. (2013). Destroying sanctuary: the crisis in human services delivery systems. New York: Oxford University Press.
• Smyth, N.J. blog post; Trauma-informed social work practice: What is it and why should we care? http://njsmyth.wordpress.com/2013/04/19/trauma-informed-social-work-practice/
• National Child Traumatic Stress Network (n.d.). Birth Parents with Trauma Histories and the Child Welfare System: A Guide for Child Welfare Staff. Retrieved from http://nctsn.org/sites/default/files/assets/pdfs/birth_parents_trauma_history_fact_sheet_final.pdf

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APA (6th ed) citation for this podcast:

Singer, J. B. (Producer). (2013, April 29). An Overview of Trauma-Informed Care: Interview with Nancy J. Smyth, Ph.D. [Episode 80]. Social Work Podcast [Audio Podcast]. Retrieved from http://www.socialworkpodcast.com/2013/04/an-overview-of-trauma-informed-care.html