Trauma Informed Care or Trauma Therapist: The Key Difference and How to Practice Effectively Within Your Scope

If you are a therapist, you have worked with clients whose presenting problems are related to or exacerbated by trauma. This post will define psychological trauma, review the principles of trauma informed care and identify evidence-based practices for treating trauma. A  trauma-informed practice means being informed and mindful of race-, culture-, intergenerational, and identity-based traumas. It also means being aware of presentations of trauma, mental wellness, and mental dis-ease and wellness that may differ across cultures.

What is Psychological Trauma?

The most recent research shows that there is a wide range of what is considered traumatic. Historically, the mental health field focused on acute, “Big T” traumatic events. However, more recent findings indicate chronic, “little t” traumas result from ongoing relational, community, or cultural/systemic occurrences that erode one’s sense of self, safety, and wellbeing over time. 

Big T Trauma: the acute events that most people are going to identify as being traumatic: Witnessing or experiencing a life-threatening event, physical injury, or violence. In contrast, the DSM-5 criteria for post-traumatic stress disorder (PTSD), and traumas most recognizable to patients, are outlined as: 

• Physical attacks
• Sexual assault
• War or combat

Often overlooked Big T Traumas include:

• Arrest
• Incarceration
• Loved ones taken by force or unexpected death

Little t trauma: The often chronic traumas. DSM-5 notes “repeated exposure to aversive details of traumatic events,” often referred to as  “vicarious trauma” in your practice. However, other types of chronic traumas may be overlooked:

• Race-based trauma, such as experiencing micro-aggressions or other racist or biased statements, actions, policies, and/or systems
• Emotional or other neglect by a parent or other attachment figure/caregiver
• Violence in your community
• Being the victim of bullying or cyberbullying
• Being consistently “othered” in your family, community, or by society
• Intergenerational trauma

The Neuroscience and Physiology of Psychological Trauma

I’ll preface this section by saying I’m a neuroscience nerd. I found my way into social work and public health by way of behavioral neuroscience. While it may be tempting to skip this section, having a basic understanding of what someone could be experiencing in their body lends itself to better supporting them. This supports being transparent and thorough about your assessment and treatment options. 

The professor I first studied neuroscience under was most interested in studying our stress responses and the amygdala. In addition to some primal functions, the limbic system, which houses the amygdala, is responsible for emotional processing. The amygdala specifically responds to stressful stimuli. The amygdala lives next to the hippocampus, which is involved in memory consolidation. This location is important when we consider the effects of trauma on memory.

Stress (whether this is a big T trauma, little t trauma, or a licensing exam) activates our amygdala and sympathetic nervous system. The sympathetic nervous system is our “fight or flight” response. When our sympathetic nervous system is activated, other functions shut off so that we can focus on staying safe. Importantly for therapists: This means that we are not consolidating memories effectively. This is going to impact memories of traumatic events, and for those who have consistent, ongoing, or chronic traumas, this can impact their ability to recall events over time. These effects on the brain and memory have been demonstrated in MRI brain studies in humans.

I recommend the following books if you want a deeper dive into these concepts:

*Note: recommendations below are Amazon affiliate links, meaning if you click and purchase Stress Less Enterprises LLC may receive a small commission.

• The Body Keeps the Score, Bessel van der Kolk*
• Waking the Tiger, Peter Levine*
• The Polyvagal Theory: Neurophysiological Foundations of Emotions, Attachment, Communication, and Self-Regulation, Stephen W. Porges*

The Principles of Trauma Informed Care

1. Establish and Maintain Safety: As a therapist, it is your job to maintain safety in the room. This means pausing someone who is becoming flooded and can’t stop telling you about their traumatic experience/s, and having tools to support a regulated nervous system.  It is paramount to stay regulated with someone who is becoming dysregulated.
2. Establish Trust and Transparency: Be open about your assessment and approach to treating the person in front of you. Share your understanding of their experiences and your treatment recommendation. Be transparent about your scope of practice. 
3. Collaboration, Empowerment, and Choice: Treatment planning is a collaborative process. You want to make sure that the assessment and plan align with the client’s presenting problem and goals. Even when treatment is mandated, our job is to offer clients a choice in the care they receive.
4. Recognize Strengths and Resilience: Every client who comes to see you has demonstrated strength and resilience. Pay attention to the strengths they name and that you observe. Your clients may have difficulty identifying these positive attributes if they are feeling despair, hopelessness, or numbness. Identifying their resilience and the positive impacts of their cultural values on their ability to navigate hardship is empowering and a trauma-informed practice.

My #1 Rule of Trauma Informed Care Practice: Know Your Scope

As a trauma-informed therapist, your goal is to practice with the above principles in mind. You should be able to name trauma, impacts of trauma, and the ways that trauma shows up for the people you serve. You will want to be able to discuss the concepts of how bodies hold onto trauma and even bring in some psychoeducation around the neuroscience and physiology of trauma. You’ll need to understand the importance of and be able to implement pausing the session. In practice, kindly hold space and name the reason you’re pausing the person in front of you so that they feel heard, validated, and safe to continue.

For me, this is implicit in creating safety and being transparent, but it is worth stating explicitly. Your scope of practice as a trauma-informed practitioner is going to be more limited. Being trauma-informed means not diving into trauma healing without specialized training. There is evidence suggesting that retelling trauma stories in detail can actually lead to memory distortions that reinforce the negative beliefs, emotions, and physical sensations associated with the event and even amplify the perceived severity or proximity of the traumatic event. This is one of the reasons why I urge therapists against trying to facilitate healing psychological trauma without the proper training.

Scripts for Pausing a Flooded Client

Below is an example of what I include in my mandatory disclosure and consent to services. This reinforces being transparent and establishing safety.

There may be times I interrupt you to help you slow down. I want to prepare you for that now so that it is not unexpected. When I do this, it is usually because it is unsafe for us to go too deep into our trauma histories or the retelling of stressful events, and I want to help you maintain safety in this space.

As needed, I will revisit this practice later in treatment. I may do this by pausing the client and offering some choices on how to proceed. This reestablishes safety, confines the session to the scope, and offers an opportunity for collaboration. I might say something like:

I’m going to pause you here. I’m noticing you start to talk faster, and it looks like you might be feeling agitated. Just a reminder that part of my role as your therapist is to maintain safety in this space. How do you feel about trying some breathing, grounding, or other resources?

During this pause, I like to integrate grounding and mindfulness exercises. This is two-fold: 

1. It helps reestablish a sense of safety in my client’s body and 
2. They recognize that they can go in and out of their stress response. I name both of these explicitly in the room when they have restored to a more relaxed state (parasympathetic nervous system/ventral vagal). 

On the flip side, if someone is in a freeze response (dorsal vagal/parasympathetic activation), I don’t want to further relax them; I want to support them with becoming more activated and embodied. I might have them stand up, rub their arms and legs, clasp their hands together, or offer another option to bring them back into a ventral vagal state. 

If these practices are interesting to you, I recommend the following somatic and polyvagal workbooks:

*Note: recommendations below are Amazon affiliate links, meaning if you click and purchase Stress Less Enterprises LLC may receive a small commission.

• Somatic Therapy Toolbox: 125 Exercises and Worksheets to Treat Trauma & Stress, Manuela Mischke-Reeds*
• Polyvagal Card Deck, Deb Dana*
• Polyvagal Practices: Anchoring the Self in Safety, Deb Dana*

Trauma Therapy Practice

To practice as a trauma therapist, you will need advanced training to safely support your clients with healing their trauma. You can do excellent work to help clients achieve wellbeing with other modalities. CBT, DBT, and attachment-focused modalities can help clients identify and challenge negative core beliefs that were borne out of their traumatic experiences to find a positive view of themselves, the world, and develop secure attachments.

However, unless you are trained in a modality to reprocess and integrate traumatic events, the client will continue to experience instances where they are triggered and respond from their trauma. A few evidence-based modalities for treating trauma include: Eye Movement Desensitization and Reprocessing (EMDR), Acceptance and Commitment Therapy (ACT), Internal Family Systems (IFS), and Somatic Experiencing.

As an EMDRIA-certified therapist and consultant-in-training, I am partial to using EMDR. My training in Cognitive Behavioral Therapy made integrating EMDR into my practice feel more seamless since it specifically targets negative core beliefs and facilitates the integration of a positive self-concept. EMDR is an 8-phase therapy that was developed to treat PTSD. There is substantial evidence demonstrating EMDR’s efficacy in alleviating symptoms of anxiety, depression, and treating substance use disorders.

Integrating somatic practices and IFS into my practice, whether or not I’m using EMDR. Somatic and polyvagal practices help establish safety and help clients reconnect with their bodies in a way that enables them to move through the world more healthfully and intentionally. I often use these practices right from the start of my therapeutic work with someone, including during intake. 

Because EMDR is an 8-phase therapy, it is not as fast as many people expect. While healing trauma is faster with EMDR than with other modalities, the process of getting there intentionally takes time because trauma processing shouldn’t be rushed. The first two phases are history taking and preparing your client for EMDR.

The bulk of the second phase (“preparation”) is dedicated to developing skills and other resources that can be utilized to restore safety and calm in the room. Spending this time to build rapport, learn about your client’s history and strengths, and develop resources is integral to practicing within the principles of trauma-informed care.

Opportunities for training (I am an EMDRIA-certified therapist, but do not receive any compensation for posting this information):

• EMDR Training and consultation: https://www.emdria.org/emdr-training/
• IFS Training and Consultation: https://ifs-institute.com/trainings 
• Somatic Experiencing: https://traumahealing.org/
• Trauma Therapist Institute (variety of trainings in trauma treatment): https://www.traumatherapistinstitute.com/ 
• PESI Trainings (many modalities and certifications offered): www.PESI.com 

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