A number of models have been developed to guide organisations and individual workers in incorporating trauma-informed care into their policies, programs, procedures and practices. Links to some of these are available at the end of this chapter. Common to all of them are six guiding principles [385]:
- Safety: Ensuring clients and staff feel physically and psychologically safe with respect to the physical setting and interpersonal interactions.
- Trustworthiness and transparency: Making decisions with transparency to build and maintain trust.
- Peer support: Promoting mutual support to aid in healing and recovery.
- Collaboration and mutuality: Leveling power differentials and recognising that everyone plays a role in recovery and care.
- Empowerment, voice, and choice: Recognising and building upon individuals’ experiences and strengths (including their strength in coming through their traumatic experiences and seeking help), and helping clients to establish a sense of control.
- Cultural, historical, and gender issues: Acknowledging and addressing the impact of historical trauma, overt discrimination, and implicit biases.
At the organisational level, creating a trauma-informed approach requires continual review of policies, procedures, and programs to identify possible areas of re-traumatisation [386]. AOD workers should similarly regularly undertake a review of their own individual practices to identify areas for potential improvement. Many common procedures and practices used in AOD services may potentially re-traumatise. For example, aggressive or confrontational group techniques can trigger memories of past abuse, are counterproductive, and may lead clients who have been exposed to trauma to revert to previous coping strategies, for example dissociating or shutting down, and further AOD use. This may then lead to the client being labelled as ‘treatment-resistant’, with consequent feelings of failure and self-blame [136].
A focus on building trust is essential in AOD worker-client interactions. Many clients’ traumas have occurred in the context of interpersonal relationships in which their trust, safety and boundaries have been violated. They may also have had personal information used against them in the past, making it difficult for them to trust others [390, 391]. Attention to boundaries, and the use of language that communicates the values of empowerment and recovery is important [392]. Clients of AOD treatment services with severe co-occurring mental health conditions may also have experienced traumatic events within the context of receiving health care (e.g., if they have been forcibly restrained or secluded in the context of receiving involuntary mental health treatment) [393]. These experiences can be deeply traumatic, trigger memories and feelings of past trauma, and have an ongoing impact on the person and their ability to trust healthcare providers.
For those who have experienced interpersonal trauma in particular, healthcare providers may also be seen as authority figures and some interactions may imitate the interpersonal dynamics that were evident in an abusive relationship. There is an inherent power imbalance in the helper–helped relationship and AOD workers must do their best to reduce this inequity [390, 394, 395]. Many clients also fear judgement on the part of their healthcare providers, so it is important that AOD workers adopt a non-judgemental attitude. People who have experienced trauma often feel a great deal of shame and guilt either in relation to the trauma itself or how they reacted to the trauma. Sometimes clients may have experienced stigmatisation from others due to their trauma experiences, mental health, and/or AOD use. Recognising clients for their resilience in the face of adversity is important, even if past adaptations and ways of coping, such as AOD use, are now causing problems. Understanding AOD use as an adaptive response can help to reduce a client’s guilt and shame, and provides a framework for developing new skills to better cope with symptoms [384].
An additional part of the process of building a sense of trust and safety is helping clients to regain a sense of control, as both trauma and AOD use disorders are characterised by feeling out of control. For example, rather than telling a client that, ‘It’s time for your doctor’s appointment’, providing clients with choice and control by saying, ‘It’s time for your doctor’s appointment, are you still ok to meet with them now?’.
Stability is also key to establishing a sense of safety [396]. A structured program in which clients know what to expect and have clear transparent expectations can be helpful. Sometimes clients who have experienced trauma may be physically and mentally ‘on guard’, so it can be helpful to avoid surprises, use slow, calm movements, a gentle tone of voice, and not encroach on their personal space. It can also be helpful to advise clients what to expect in terms of their progress through treatment. As mentioned in Chapter B7, some clients experience an increase in trauma-related symptoms when AOD use is reduced or ceased. Preparing the client to expect that their trauma-related symptoms may increase, and normalising these reactions, may make it easier for clients to manage their symptoms.