JEA Q2 2020
Trauma-Informed Care: Best Practices for EAPs

By Leah Szemborski

The National Council of Behavioral Health calls trauma from adverse childhood experiences the “hidden epidemic” (2020). “Trauma-Informed Care [TIC] is an organizational structure and treatment framework that involves understanding, recognizing, and responding to the effects of all types of trauma” (Trauma Informed Care Project, 2018).
TIC isn’t a clinical intervention, although it certainly helps to inform clinical intervention. Rather, TIC is a way of seeing and responding to people who have likely been impacted by trauma by providing safety, compassion, and mindfully avoiding re-traumatization. If unaware of the presence and impact of traumatic experiences, EA professionals will miss opportunities to support employees and employers in recognizing and responding to the trauma epidemic.

Background: ACEs
Many helping professionals have heard of the ACEs (Adverse Childhood Experiences) study. The original study investigated childhood abuse and neglect and the correlation to health and well-being later in life. Nearly 66% of participants had at least one ACE, and more than 20% of participants had three or more.
In addition, researchers found that as the number of ACEs went up, so did the risk for many types of health problems including: alcoholism, depression, drug use, poor work performance, financial stress, domestic violence, smoking, suicide attempts, and more (Center for Disease Control and Prevention, 2016).
An employee who presents with chronic anxiety, depression, high reactivity, or other maladaptive behaviors might be expressing symptoms of past trauma. For example, an employee who is overly sensitive and tearful over constructive criticism, or a person who becomes patronizing and derogatory toward co-workers may both be indicating past trauma experiences.
An EA professional may employ well-meaning interventions that have little to no effect if underlying trauma is not addressed or acknowledged. Trauma manifests in many ways, and unless a person is intentionally looking for the signs, it may be missed completely. Trauma-informed helpers are trained to see trauma where others just see chaos. 

Developing the TIC Model
Trauma-Informed Care has been a work in progress for over 40 years. It began with research on war veterans and post-traumatic stress, and expanded to include individuals who had experienced other major life trauma within the mental health community.
In the 1990s SAMHSA began to look at trauma in the context of women and gender, and in 1994 convened the Dare to Vision conference to look at and address issues of trauma, especially as it related to female abuse victims and the re-victimization from well-meaning service institutions.
From there the idea of “Trauma-Informed Care” began to increase momentum, and in 2001 the National Center for Child Traumatic Stress was born. This organization began to steer evidence-based interventions to inform clinical practice and organizational structures that supported, empowered, and assisted recovery in individuals who have experienced trauma. These initiatives were integrated in many service systems including schools, juvenile justice, child welfare, and health care systems.
In 2012 the US Department of Health and Human Services, along with SAMHSA created a trauma-informed approach guided by 10 principles (Encyclopedia of Social Work, 2013). Over time these 10 principles have been whittled down to six, which are described in detail later in this article.

Introducing TIC to a Workplace
In the workplace, many managers often feel ill-equipped or frustrated at their inability to “manage” difficult employees. Well-meaning leaders may try walking on eggshells so as not to upset the person, come down hard with punitive measures, or simply throw their hands up in exasperation. EA professionals are in a position to coach managers on the idea of trauma-informed care by helping them to see their employee’s behaviors through a trauma-informed lens.
This strategy not only helps the manager be better equipped to deal with chaotic or upsetting behaviors in a calm, compassionate way, but may also help the manager not to take negative interactions personally, or blame themselves for problems the employee may cause.
When employees and leaders begin to understand trauma, its impacts, and best ways to respond, there is often a sense of relief and higher sense of control in managing difficult interactions and behaviors in the workplace.

Pushback to TIC is Lessening
In some instances managers may feel like trauma-informed care is “coddling” a person who just needs to learn how to behave. Unfortunately this attitude still persists in the workplace, and in society at large, but the good news is that with the great work and education being done through organizations like SAMHSA and the National Child Traumatic Stress Network, attitudes are changing and stigma is breaking around trauma, and mental illness as a whole. More and more organizations, leaders, managers, and employees alike are eager to adopt trauma-informed care practices in their personal and professional lives.

Foundation of TIC
As mentioned, Trauma-Informed Care (TIC) is based on six key principles (SAMHSA, 2014).
EA professionals can advocate for a trauma-informed approach in multiple ways; first, by integrating the six foundational principles (explained below) within their own EAP work.
Second, by educating client organizations about trauma-informed approaches when appropriate. Finally, EA professionals can adopt trauma-informed interventions with their clients.

Case Study
Consider one team of nurses in a small primary care clinic. The manager called EAP because the team culture was very unhealthy—negativity, mistrust, and sometimes outright aggression towards one another.
The manager had tried everything he knew—talking to each person individually, team building activities, and finally threats of corrective action. His efforts resulted in minimal improvements at best. The responding EA professional utilized the six principles of TIC to intervene in effective and empowering ways that made a lasting impact on the team.

Principle 1: Safety. This refers to both physical safety as well as psychological safety. Trauma-informed care stresses the need for interactions that help others feel secure—all voices will be heard, respected and validated, and no one will suffer retaliation for unpopular ideas or mistakes.

In the case above the EA professional decided to meet with the entire nursing team in order to assess team dynamics, explore root issues, and prompt individuals to commit to positive change.
Prior to the meeting she initiated safety by coaching the manager on appropriate responses to negative or critical comments. The EA professional believed it was crucial that people be able to speak honestly without any retaliation or critical remarks from the leader.

Principle 2: Trustworthiness and transparency. Organizations that operate with transparency communicate openly and honestly. They help both employees and customers feel informed and confident about policies, procedures, services, and expectations.

After laying the ground rules for the meeting, the EA professional was transparent in explaining what precipitated EAP involvement and the purpose of the meeting – to assess and resolve root issues that perpetuate conflict and negativity, with the intention of creating a more cohesive, healthier team dynamic. She explained that the conflict resolution process can be uncomfortable—even tense at times, but tension is often a necessary part of the process.
She stated that she believed every person could tolerate and work through the discomfort, however, if the conversation turned unsafe (such as name calling, yelling, aggressive gestures, etc.) she would intervene immediately. 

As participants began to open up it wasn’t long before one gentleman, Tom, became upset. He pointed his finger at a co-worker, saying loudly, “You never listen! You act like you’re so much better than everyone with your holier-than-thou attitude!”
The EA professional was quick to put her hand up and say in a loud voice, “STOP!” All eyes turned to her and it got quiet immediately. The EA professional reiterated the ground rules and helped Tom voice his concerns in a more appropriate way.
 
The EA professional demonstrated trustworthiness in following through on her commitment to ensure safety in the meeting. Many people commented to the leader afterward how glad they were that Tom wasn’t allowed to berate others in the meeting, as this was a behavior that he exhibited frequently without repercussions.
In addition, by boldly enforcing limits on unacceptable behavior, the EA professional was modeling for the manager, who needed to improve his skills in this area to ensure psychological safety for the team.

Principle 3: Peer support and mutual self-help. Modern business is no longer a top-down world. Good ideas, strength, and support can come from anyone, in any position, as long as individuals are open to be both supporting and supported. EA professionals can help companies implement policies, procedures, and development opportunities that leverage peer support and mutuality.

Principle 4: Collaboration and mutuality. This principle implies that there are power differentials in basically every relationship. When possible, organizations can move beyond those dynamics in order to share power and make collaborative choices that encourage participation and ownership from everyone involved. 

During the nurse team meeting it became apparent that some of the frustrations were stemming from inadequate onboarding—individuals were “thrown” into job duties they weren’t certain they could perform, therefore making a lot of incorrect assumptions and mistakes. In turn, seasoned staff perceived that new staff just didn’t care or were not as invested in the work. 
The EA professional pointed out the contrasting perspectives, and the team was able to problem-solve the issue by suggesting an informal peer-support process: new staff would be paired up with seasoned staff members for weekly meetings to ask questions, problem solve issues, or discuss concerns.

The leader agreed to pilot this for three months. There were some snags in the execution, but the outcome was largely successful. Not only did new staff gain confidence in their skills, trust was built within the team, and experienced staff found that their mentees had insights and resources to offer as well. This process of peer support, collaboration, and mutuality proved to be a win for everybody.

Principle 5: Empowerment, voice, and choice. Those who survive trauma know the vulnerability and fear resulting from those experiences. Offering safe environments where individuals are encouraged to speak up and make meaningful decisions regarding their life, work, and leisure is integral to recovery. 

At the initial nurse meeting, the EA professional was careful to ensure everyone’s voice was heard within the context of a safe, supportive environment. Some great solutions were born from that meeting, but one meeting was not enough to resolve the deeply rooted issues.
In the second meeting the EA professional brought educational materials about personality differences and conflict styles. She was careful to use a strengths-based perspective, but was also direct and honest about problem areas. As the EA professional discussed the trait of sensitivity, Jennifer became very upset and tearful. She explained that she was offended, and felt like she was being targeted.

The EA professional thanked Jennifer for being honest, and silently assumed that this conversation had likely been a “trigger” for Jennifer who may have a history of trauma based on her highly reactive response to the conversation.
The EA professional gave Jennifer an option to either continue in the discussion, or take a break from the meeting and talk privately afterwards. Jennifer decided to abruptly pack up her things and walk into the hall, shutting the door loudly behind her. 

When the EA professional met with Jennifer afterwards, they were able to have a candid conversation about her reactions. Jennifer explained that when she was young her mom always made fun of her for being sensitive, and the group discussion made her very agitated. The EA professional validated Jennifer’s willingness to share this.
She also gently pointed out how Jennifer’s reactions affected the team and offered that she could make an appointment to talk more about her triggers and how she could better manage her reactions in the workplace.
The EA professional wanted to validate Jennifer and her experiences, but also empower her to make some positive changes—if she wanted to. Because Jennifer felt supported by the counselor, she was open to meeting again. 

In addition, the EA professional followed up with the manager regarding Jennifer’s reaction in the group. Since this type of occurrence happened frequently among the team, the manager was open to suggestions on how to handle these kinds of situations.
Going forward he committed to accept and validate an employee’s feelings before asserting expectations, and then follow up with a “how can we solve this together?” type of response that invited dialogue and collaboration from the employee rather than defensiveness. 

Principle 6: Cultural, historical, and gender issues. Every person has a story—experiences, perceptions, and events that have shaped them to be who they are. Trauma-informed care sees every life within a broader context and acknowledges the impact these experiences have on the person today. 

Through her work with the nursing team, it became apparent to the EA professional that there were some in the group who had histories of trauma, and their current perceptions and reactions were shaped by those past experiences. In addition, the EA professional could see that there were some on the team who were perpetrating victimization by their aggressive reactions and controlling behavior.
By approaching this team with a trauma-informed lens, the EA professional was able to embrace the six principles of TIC to provide safe and effective interventions on the group level, as well as engage some individuals to do their own work privately.
In addition, she was able to coach the leader on how to utilize TIC principles in the workplace to enhance safety, teamwork, and collaboration, while still holding each person accountable to standard expectations.
Organizational leaders and EA professionals might be ready to embrace the six principles of TIC, but may not be sure how to begin. There are many training and consulting programs available online and in person to support EAPs on their trauma-informed journey.
A few organizations that can help include the Traumatic Stress Institute (https://traumaticstressinstitute.org/) and ACES Connection (https://www.acesconnection.com/). 

Manager Referrals and Consultation
EA professionals are in a position to provide basic education to organizations on TIC, as well as coach employers on ways they can put these principles into practice. In addition, EA professionals can also consult with leaders to work with “difficult,” or emotionally volatile employees who may have a history of trauma.
Instead of responding to emotional outbursts with punitive measures, managers might refer the employee to the EAP where they can be assessed and, if relevant coached on strategies to regulate emotions and calm the overactive fight or flight system.
These interventions don’t have to be limited to individuals with trauma histories – the great thing about TIC is that the principles are safe, effective, and empowering for any individual, regardless of their exposure to trauma.

Trauma Informed EA Counseling
Considering the pervasiveness of trauma, EA professionals might consider conducting a simple trauma screening as part of their standard assessment, especially if the client’s concerns are chronic or pervasive. Trauma screenings can provide valuable information to guide more targeted, short-term interventions as well as make better referrals to longer term care.
Short-term interventions may include grounding and emotion regulation strategies to improve coping, but long-term interventions are usually indicated for individuals with chronic or pervasive trauma histories. There are many free trauma assessments online, such as the Life Events Checklist recommended by SAMHSA and HRSA (2020).  

Summary
Trauma from childhood experiences has been called the hidden epidemic. When EA professionals look for signs of trauma and reliably practice the principles of TIC, short-term interventions can be more effective, both for individual recovery as well as workplace culture improvement.
On the other hand, if EA professionals are unaware of trauma and the principles of TIC, they may unwittingly cause more harm, or make recommendations that are not effective. EA professionals can use their knowledge of TIC to provide high quality client care, as well as coach, consult and support organizations in creating happy, healthy work cultures where employees can thrive.

Leah Szemborski, LPC, has over nine years of experience in EAP counseling. She takes special interest in issues of trauma and domestic violence, as well as providing education and consultation to businesses on these critical topics.


References
Center for Disease Control and Prevention (2016). Adverse Childhood Experiences (ACES). Retrieved November 28, 2018 from website: https://www.cdc.gov/violenceprevention/acestudy/index.html 

Encyclopedia of Social Work (2013). Trauma-Informed Care. Retrieved November 19, 2020 from website: https://oxfordre.com/socialwork/view/10.1093/acrefore/9780199975839.001.0001/acrefore-9780199975839-e-1063. DOI: 10.1093/acrefore/9780199975839.013.1063

National Counsel for Behavioral Health (2020). Trauma from Adverse Childhood Experiences: The Hidden Epidemic. Retrieved February 12, 2020 from website: https://www.thenationalcouncil.org/webinars/trauma-from-adverse-childhood-experiences-the-hidden-epidemic/. 

SAMHSA (2014). Guiding principles of trauma-informed care. Spring 2014, 22(2). Retrieved December 7th, 2018 from website: https://www.samhsa.gov/samhsaNewsLetter/Volume_22_Number_2/trauma_tip/guiding_principles.html 

SAMHSA & HRSA (2020). Life Events Checklist. Retrieved January 21, 2010 from website: https://www.integration.samhsa.gov/clinical-practice/screening-tools

Trauma Informed Care Project. (2018). What is TIC? Retrieved December 4th, 2018 from website: http://www.traumainformedcareproject.org/index.php