Trauma-informed care

1. Introduction

Version followed: SAMHSA's Concept of Trauma and Guidance for a Trauma-Informed Approach (HHS Pub. SMA 14-4884, 2014) for the definition, four assumptions, six principles and ten domains; SAMHSA TIP 57 Trauma-Informed Care in Behavioral Health Services (SMA 14-4816, 2014) and its Quick Guide for Clinicians for clinician-level procedures; Fallot & Harris, Trauma-Informed Services: A Self-Assessment and Planning Protocol v1.4 (Community Connections, 2006) for the five core values; SAMHSA Practical Guide for Implementing a Trauma-Informed Approach (PEP23-06-05-005, 2023) for implementation phases. Where these differ, the difference is named.

Trauma-informed care (TIC) is not a single therapy. It is an organisational and practice framework that any service (mental health, substance use, primary care, child welfare, justice, housing, schools) adopts so that everything it does takes account of how common trauma is and avoids repeating its dynamics. SAMHSA and TIP 57 explicitly separate it from trauma-specific services (e.g. CPT, PE, EMDR, NET, Seeking Safety, TF-CBT), which are delivered by trained specialists; a trauma-informed service may or may not offer these itself, but must screen for need and refer [source: SAMHSA 2014; TIP 57 ch. 1; SAMHSA 2023]. There is no licence, certification or fidelity requirement to use the term; organisations instead self-assess with tools such as the CCTIC/Fallot-Harris protocol, the ARTIC scale or TICOMETER [source: SAMHSA 2023]. The framework grew from Harris and Fallot's work at Community Connections, Washington DC (Harris & Fallot 2001, Using Trauma Theory to Design Service Systems [uncertain]) and from the women's services sites described by Elliott et al. (2005).

How change happens. SAMHSA defines individual trauma by the "three E's": an event or circumstances, the person's experience of it, and lasting adverse effects on functioning [source: SAMHSA 2014]. Traumatic events involve a power imbalance and leave shame, self-blame and mistrust; services that are unpredictable, coercive or shaming can reactivate these and cause dropout, escalation and misdiagnosis. Change happens when the whole service realises the impact of trauma, recognises its signs in clients and staff, responds by building that knowledge into policy and practice, and resists re-traumatisation (the four R's) [source: SAMHSA 2014]. At the individual level, the mechanism is relational: consistent, transparent, collaborative contact that restores safety, choice and control, reframes symptoms as adaptations, builds coping skills, and connects the client to trauma-specific treatment when indicated [source: TIP 57 ch. 1; Elliott et al. 2005]. The shift is often summarised as moving from "What's wrong with you?" to "What happened to you?" [source: Menschner & Maul 2016].

2. Framework

TIC has no fixed session count or protocol. It runs on two levels at once. [source: SAMHSA 2014; SAMHSA 2023; TIP 57 Quick Guide]

A. Organisational level (what the service does)

SAMHSA 2023 describes three phases; the CCTIC protocol gives a compatible planning sequence.

The CCTIC protocol is organised as Part A, service level (procedures and settings reviewed against each core value; formal service policies such as coercion, crisis and grievance; trauma screening, assessment and service planning) and Part B, system level (administrative support; staff training; human resources) [source: Fallot & Harris 2006].

B. Client level (what the clinician does with each person)

The sources give components, not numbered phases; the sequence below is my ordering of them [synthesis]. TIP 57 treats safety as the initial objective and a need that recurs (e.g. after staff changes) [source: TIP 57 Quick Guide].

1. First contact and orientation (session 1): explain how the service works, what will happen and why, rights and choices; offer contact and naming preferences [source: TIP 57 ch. 1].
2. Universal screening (at intake, every client, early; do not wait for abstinence or stabilisation) [source: TIP 57 ch. 4]. Criterion to move on: screen positive for trauma history or symptoms → assessment; also screen for suicidality.
3. Assessment (may take several sessions; uses self-report, records, structured interview, collateral; focuses on current functioning, not on detailed retelling) [source: TIP 57 ch. 4].
4. Collaborative planning: treatment goals, the client's own definition of safety, preferred crisis responses [source: SAMHSA 2014; Elliott et al. 2005].
5. Stabilisation and skills within ordinary care: psychoeducation, normalising, grounding, trigger work, pacing, strengths [source: TIP 57 Quick Guide].
6. Referral to or integration of trauma-specific treatment when referral indicators are present (severe symptoms at screening; persistent negative beliefs about the trauma; intrusive memories; avoidance, dissociation or substance use blocking resolution; physical consequences; new traumas; comorbid mood disorder or serious mental illness) [source: TIP 57 Quick Guide]. Elliott et al. stress integrating trauma work with substance use and mental health treatment rather than sequencing it [source: Elliott et al. 2005].
7. Ongoing reassessment: clients often disclose more as trust grows, so reassess throughout [source: TIP 57 ch. 4].

Format: applies to individual, group, family, inpatient, residential and outreach contacts, and to non-clinical staff (reception, security, drivers) [source: SAMHSA 2014; Menschner & Maul 2016].

3. Guiding principles

SAMHSA four assumptions ("four R's") [source: SAMHSA 2014]

• Realise the widespread impact of trauma and paths to recovery: assume any client, family member or colleague may be affected.
• Recognise signs and symptoms: read hypervigilance, numbing, avoidance, mistrust and dysregulation as possible trauma effects before labelling them non-compliance.
• Respond by building trauma knowledge into policy, procedure and practice: change the written procedure, not just your personal style.
• Resist re-traumatisation: identify routine practices (restraint, seclusion, invasive procedures, intimidating settings) that echo past harm and replace them.

SAMHSA six key principles [source: SAMHSA 2014; SAMHSA 2023]

• Safety: physical and psychological safety for clients and staff, defined partly by the client; ask what makes them feel safe.
• Trustworthiness and transparency: explain decisions and procedures openly and do what you said you would.
• Peer support: involve people with lived experience as core staff and as a route to hope; offer peer contact, not only professional contact.
• Collaboration and mutuality: flatten power differences between staff and clients and among staff; plan with, not for.
• Empowerment, voice and choice: build on strengths and self-advocacy; offer real options at every decision point.
• Cultural, historical and gender issues: address bias, offer gender-responsive services, use cultural strengths, recognise historical trauma; ask how culture shapes the client's experience. SAMHSA 2023 extends this to structural racism, cultural humility, LGBTQI+ people and disability.

Fallot & Harris five core values (overlap with SAMHSA; the practical translations differ) [source: Fallot & Harris 2006]

• Safety: welcoming waiting areas, explanation before every procedure, attention to discomfort, visible exits, adequate personal space, awareness of domestic violence risk.
• Trustworthiness: clear tasks, consistent practice, firm professional boundaries, realistic expectations, informed consent that allows consenting to part of what is offered.
• Choice: let clients influence timing, place, provider and method of contact; never make one service contingent on "earning" another.
• Collaboration: weight client preferences heavily in planning and evaluation; treat them as experts on their own lives.
• Empowerment: name existing strengths, express realistic optimism, aim each contact at both the task and a skill.

TIP 57 intervention and treatment principles (those not already covered above) [source: TIP 57 ch. 1]

• Promote trauma awareness: expect trauma from first contact without assuming it; train everyone who meets clients.
• Symptoms are adaptations: ask what a symptom has done for the client before trying to remove it.
• View trauma in context: assess individual, family, community and societal factors (social-ecological model).
• Minimise retraumatisation: learn each client's cues; offer alternatives when an element of treatment distresses them; keep asking rather than assuming.
• Safe environment includes reliability: follow through, be consistent, and be honest when things go wrong.
• Recovery from trauma is a primary goal: help the client link trauma to current problems and make trauma services available early.
• Support control, choice and autonomy: include everyday decisions (how to be addressed, how to be contacted).
• Collaborative relationships and participation: clients, families and peers help plan, deliver and evaluate services.
• Familiarise the client with services: assume they are new to treatment; explain each process and why trauma questions are asked.
• Universal routine screening: screen everyone at intake with a consistent procedure and a protocol for positives.
• Sociocultural lens: culture shapes what is traumatic, how distress shows and how help is sought.
• Strengths focus and resilience: identify the coping that got the client this far.
• Foster trauma-resistant skills: build new skills without dismissing old adaptations; explore where old coping no longer works.
• Organisational and administrative commitment: support screening, referral networks and anti-retraumatisation policy; join trauma committees.
• Address secondary trauma and promote self-care: monitor your own avoidance, numbing, insomnia and withdrawal; use supervision.
• Provide hope: define recovery with the client; frame recovery as managing trigger responses rather than never having them.

Elliott et al. (2005) additions for women's services [source: Elliott et al. 2005]

• Empowerment model: aim to reduce long-term dependence on professionals.
• Maximise choice even when you disagree: if a choice seems unwise, first understand her reasoning.
• Relational collaboration: be consistent, predictable, non-shaming and non-blaming; say openly that she may refuse questions or treatment, ask for alternatives or another worker.
• No confrontational tactics: do not attack "resistance" or dismiss trauma history as a distraction; do not push memory uncovering.
• Consumer involvement in design and evaluation: advisory boards, paid peer roles, focus groups.
• Universal precautions: because many survivors do not disclose, treat every client as possibly a survivor.

4. Intervention inventory

TIC procedures are mostly practice routines woven into ordinary care, plus a few named techniques from the TIP 57 Quick Guide. Groups: A. engagement, screening and planning; B. stabilisation and coping skills; C. relationship, culture and crisis; D. service- and staff-level procedures. Example language is my own wording unless quoted and cited.

A1. Orienting the client to the service

• Purpose / when: First contact and any new procedure. Clients new to services, or harmed by earlier ones, need predictability [source: TIP 57 ch. 1, "familiarise the client"].
• Steps: (1) Say who you are, what this contact is for and how long it lasts. (2) Describe what will happen today and over the next few sessions, including that you will ask about stressful experiences and why. (3) State rights: they may skip any question, pause, or ask for something different; where staffing allows, they can choose the worker's gender or reschedule [source: TIP 57 ch. 4; Elliott et al. 2005]. (4) Ask preferences: name, pronouns, how and when to be contacted, whether a support person may attend [source: TIP 57 ch. 1; Elliott et al. 2005]. (5) Explain confidentiality and its limits, including mandatory reporting, before any disclosure [source: TIP 57 ch. 4]. (6) Before any physical or procedural step, explain each part beforehand and as it happens [source: Elliott et al. 2005; Fallot & Harris 2006].
• Example language (illustrative): "Today is mostly about getting to know what you need. Part of it is a short set of questions about difficult things that may have happened, because they often affect health. You can skip anything, and you don't need to give details."
• Watch for: Shrinking, freezing or checking the door; repeated questions about what happens next. Working: the client asks questions, states preferences, returns.

A2. Universal trauma screening

• Purpose / when: Every client at intake, with a consistent procedure, to find out (a) whether trauma has occurred and (b) whether symptoms warrant assessment. A positive screen means "assess", not a diagnosis [source: TIP 57 ch. 4].
• Steps: (1) Agree in advance, as a team, which validated tool you use, how it is scored, what counts as positive and what follows; only screen if referral routes exist [source: TIP 57 ch. 4; Menschner & Maul 2016]. (2) Introduce it as routine for everyone, matter-of-fact and supportive. (3) Prefer brief self-report checklists, which let the client choose how much to reveal, followed by a short interview [source: TIP 57 ch. 4; Menschner & Maul 2016]. (4) Begin with general questions and move gradually; do not ask for detailed accounts. (5) Keep a calm, even tone; avoid exclamations or reactions that could sound like judgement. (6) Respect personal space; use a trained interpreter, never a family member or friend. (7) Collect only what you need and avoid re-screening clients already screened elsewhere [source: TIP 57 ch. 4; Fallot & Harris 2006]. (8) If positive, also screen for suicidality (TIP 57 refers to TIP 50).
• Tools named by TIP 57 (names only; use licensed versions, do not improvise items): Trauma History Questionnaire, Life Stressor Checklist-Revised, Stressful Life Experiences screen, PC-PTSD, PTSD Checklist, SPAN, ACE score, STaT for intimate-partner violence, Combat Exposure Scale, and depression/anxiety/resilience measures [source: TIP 57 ch. 4]. TIP 57 describes the older 4-item PC-PTSD; a 5-item revision (PC-PTSD-5) is now widely used [uncertain].
• Timing debate: CHCS notes disagreement between screening at first contact and screening later once trust exists (suggested as possibly better in behavioural health); TIP 57 says screen early [source: Menschner & Maul 2016; TIP 57 ch. 4]. Version followed here: TIP 57 (early, universal).
• Example language (illustrative): "We ask everyone these questions, because many people have been through things that still affect them. Tick only what you're comfortable with; you don't have to say more than yes or no."
• Watch for: Denial is common, for example from people who see trauma as weakness [source: SAMHSA 2023]; many clients do not link past trauma to present problems [source: TIP 57 Quick Guide]. A negative screen does not close the question; revisit later.

A3. Responding to a disclosure

• Purpose / when: Any point at which a client mentions trauma, in screening or spontaneously.
• Steps: (1) Acknowledge it plainly and thank them, without asking for detail. (2) Do not challenge, minimise or express shock. (3) If distress rises, stop content, give time to settle, reorient to the present (see B3 grounding). (4) Briefly name common trauma reactions, even if they report no symptoms (see B1). (5) Clarify any reporting duty that applies and what you will do next. (6) Close only once they are grounded and you have asked about safety and plans for the rest of the day [source: TIP 57 Quick Guide; TIP 57 ch. 4].
• Example language (illustrative): "Thank you for telling me. You don't need to go into it now. Lots of people who've been through something like that notice effects later, and they make sense."
• Watch for: Dissociation, flat affect (numbing can make severity look lower than it is [source: TIP 57 Quick Guide]), apology or shame. Working: client stays oriented and is willing to come back.

A4. Feeding back results and moving to assessment

• Purpose / when: After every screen.
• Steps: (1) Give results in plain language and allow time for reaction. (2) Explain how they will shape the plan. (3) For positives, arrange fuller assessment: self-report tools, records, structured interview, collateral, possibly over several sessions, focused on how symptoms affect current functioning. (4) Record strengths, support network and cultural context alongside symptoms. (5) Reassess during treatment as trust and disclosure grow [source: TIP 57 ch. 4; TIP 57 Quick Guide].
• Example language (illustrative): "Your answers suggest some of what you're dealing with may be linked to what happened. That's useful: it tells us which kind of help fits. Next time I'd like to understand how it shows up day to day."
• Watch for: Assessment drifting into a full trauma narrative before a relationship exists; TIP 57 asks the counsellor to act as gatekeeper here [source: TIP 57 ch. 4].

A5. Collaborative treatment planning

• Purpose / when: After assessment; review regularly.
• Steps: (1) Start from the client's goals and reasons for seeking help [source: TIP 57 Quick Guide]. (2) Ask how they define emotional safety and write that into the plan [source: SAMHSA 2014]. (3) Ask what recovery would look like for them and how they will know they are progressing [source: TIP 57 ch. 1]. (4) Offer real options for timing, location, provider, modality and contact; do not make access to one service contingent on another [source: Fallot & Harris 2006]. (5) Allow partial consent (agreeing to some elements and not others) [source: Fallot & Harris 2006]. (6) If you think a choice is unwise, explore their reasoning first [source: Elliott et al. 2005]. (7) Involve family when the client wants it; update the plan together and ask for feedback [source: TIP 57 ch. 1; TIP 57 Quick Guide].
• Example language: "What does recovery look like for you?" [source: TIP 57 ch. 1]. Illustrative: "Here are three ways we could start. Which feels most doable?"
• Watch for: Passive agreement ("whatever you think") can be a trauma-linked pattern; keep offering small, concrete choices [synthesis].

A6. Linking trauma to presenting problems

• Purpose / when: When the client does not see a connection between trauma and substance use, mood or behaviour; TIP 57 treats this as central to making recovery from trauma a goal [source: TIP 57 ch. 1].
• Steps: (1) Ask when the problem started and what was happening then. (2) Ask what the behaviour does for them now (numbs, protects, helps sleep). (3) Offer the link as a hypothesis, not a verdict. (4) Pair with strengths questions (A7) [source: TIP 57 Quick Guide; synthesis for the ordering].
• Example language (illustrative): "I wonder whether drinking started doing a job for you after that year, like making the nights bearable. Does that fit?"
• Watch for: Rejection of the link; do not insist. Working: the client starts noticing connections themselves.

A7. Strengths-oriented questioning

• Purpose / when: Throughout; especially early, and when shame is high.
• Steps: Ask about what has helped them survive, creative ways they handle pain, coping learned from their culture, valued roles (parent, worker, community member), and earlier hardships they got through. Reflect these back explicitly [source: TIP 57 ch. 1; TIP 57 Quick Guide; Elliott et al. 2005].
• Example language: "What has worked for you?" [source: TIP 57 ch. 1]. Illustrative: "How did you manage to keep going through that time?"
• Watch for: Hope, small increases in self-efficacy statements. If the client hears it as dismissing their pain, acknowledge the pain first [synthesis].

B1. Psychoeducation about trauma reactions

• Purpose / when: After any disclosure, and when screening or symptoms raise trauma; reduces fear, shame and the sense of "going crazy" [source: SAMHSA 2014; TIP 57 Quick Guide].
• Steps: (1) Briefly describe common reactions (intrusions, avoidance, hyperarousal, numbing, sleep problems, mistrust, substance use as self-medication) even if the client reports none. (2) Explain that reactions can be delayed. (3) Offer printed or multimedia materials from a "resource box"; services can run a rotating, drop-in education group [source: TIP 57 Quick Guide]. (4) Check what the client took from it.
• Example language (illustrative): "After something like this, the body often stays on alert. Jumpiness, bad sleep or feeling numb are common ways the system tries to protect you."
• Watch for: Information overload; keep it short and repeat later, since fear impairs memory [source: Elliott et al. 2005].

B2. Normalising symptoms as adaptations

• Purpose / when: When the client describes symptoms with shame or self-criticism.
• Steps: (1) List each symptom with the client. (2) For each, note its positive and its negative consequences. (3) Emphasise how each helped them survive. (4) Then ask where it now costs more than it gives, which leads into skill-building [source: TIP 57 Quick Guide; TIP 57 ch. 1].
• Example language (illustrative): "Staying watchful kept you safe in that house. Now it's exhausting you at work. Both are true."
• Watch for: Normalising must not sound like minimising; acknowledge severity [synthesis].

B3. Grounding

• Purpose / when: When a client is triggered, flashing back, dissociating, overwhelmed, or has trauma-linked perceptions (e.g. mistaking a stranger for the abuser) [source: TIP 57 Quick Guide; TIP 57 ch. 4].
• Steps: TIP 57 tells clinicians to bring attention to the here and now and then normalise the reaction; its grounding exhibit is [uncertain]. Concrete steps below are general practice [synthesis]: (1) Speak calmly, use their name, say where they are and the date. (2) Invite them to notice things they can see, hear and touch, feet on the floor, temperature of a held object. (3) Slow, ordinary breathing, without forcing. (4) Once present, name what happened as a trauma reaction. (5) Teach the method in a calm session first so it is available when needed [source for teaching in advance: TIP 57 Quick Guide].
• Example language (illustrative): "You're here with me in the clinic, it's Tuesday afternoon. Can you feel the chair under you? Tell me three things you can see."
• Watch for: Eyes refocusing, answering questions, breathing slowing. Some clients find closed eyes or body-focused attention destabilising; keep eyes open and use external cues [synthesis].

B4. Ending each session grounded and safe

• Purpose / when: End of every session in which trauma content or distress arose [source: TIP 57 ch. 4; TIP 57 Quick Guide; Elliott et al. 2005].
• Steps: (1) Leave time before the end. (2) Check SUDS or ask how present they feel. (3) If needed, ground (B3). (4) Ask about their personal safety and what they will do for the rest of the day. (5) Allow time to settle before they travel home.
• Example language (illustrative): "Before you go, where's your distress out of 10? What's the plan for this evening?"
• Watch for: A client who says "fine" while visibly dissociated; check with a concrete question.

B5. Establishing safety: routines and a safe/unsafe list

• Purpose / when: Early phase, and again when safety is disrupted (e.g. staff changes) [source: TIP 57 Quick Guide].
• Steps: (1) Establish a predictable structure for individual, group or family sessions (same opening, agenda, closing). (2) Ask the client to write two lists: behaviours that feel safe for them today and behaviours that feel unsafe. (3) Use the lists to set immediate goals. (4) Teach grounding for moments of feeling unsafe [source: TIP 57 Quick Guide].
• Example language (illustrative): "Let's write down what keeps you safe right now and what puts you at risk, as you see it today."
• Watch for: Lists that change; update them. Working: more safe and fewer unsafe behaviours over weeks.

B6. OBSERVATIONS coping strategy

• Purpose / when: In-the-moment coping when triggered, once basic grounding is learned [source: TIP 57 Quick Guide].
• Steps (paraphrased components of the TIP's mnemonic): focus on the breath; name the current situation and how it resembles and differs from the past; name and validate the feeling; remind oneself the feeling will pass; ask for help; recall past strengths; stay open to new solutions; recognise having survived. Teach it in session, practise it on a mild trigger, give a written card [source: TIP 57 Quick Guide; teaching steps synthesis].
• Example language (illustrative): "When it hits, start with one slow breath, then ask yourself: what's happening right now, and how is it different from back then?"
• Watch for: Too many steps when highly aroused; start with the first two or three.

B7. Cognitive realignment for triggers

• Purpose / when: To link a specific trigger response to the past and generate new choices; one trigger at a time [source: TIP 57 Quick Guide].
• Steps: Take one recent trigger and ask in turn: when did this reaction begin; how does the current situation resemble the past; how is the reaction similar to then; how is the situation different; how did you respond then versus now; how are you different today; what choices do you have now. Then plan a response and coping strategy. Expect responses to be delayed at first and to speed with practice [source: TIP 57 Quick Guide].
• Example language (illustrative): "When he raised his voice in the meeting, what did your body remember? What's different about you now compared with then?"
• Watch for: Rising SUDS; this is not exposure work. Stop and ground if the client starts reliving rather than reflecting.

B8. Trigger self-monitoring log

• Purpose / when: Between sessions, to identify patterns.
• Steps: Client records each trigger, a brief description, and intensity on a 1 to 10 scale; review together, then pick one for B7 [source: TIP 57 Quick Guide].
• Example language (illustrative): "Just a line each time: what happened and how strong, 1 to 10. No need to write about the past."
• Watch for: Logging that becomes rumination; keep entries brief.

B9. SUDS for pacing

• Purpose / when: Throughout; gives a shared language, paces sessions and tracks progress [source: TIP 57 Quick Guide].
• Steps: Introduce a 0 to 10 distress scale with personal anchors; check at start, during difficult content and at the end; agree in advance a level at which you will slow down or switch to grounding [threshold choice: synthesis].
• Example language (illustrative): "If 0 is completely calm and 10 is the worst you've felt, where are you now?"
• Watch for: Balance: TIP 57 notes that too much trauma focus can cause dissociation or overwhelm and too little can reinforce avoidance; not every event must be retold [source: TIP 57 Quick Guide].

B10. Present-focused journaling and feelings journal

• Purpose / when: Between-session self-monitoring and strengths recognition.
• Steps: Keep writing on the present (coping used, strengths noticed), not on intense trauma content. A feelings journal logs the feeling, its intensity 1 to 10 and the situation [source: TIP 57 Quick Guide].
• Watch for: Entries drifting into trauma detail; redirect.

B11. Emotion regulation and distress tolerance

• Purpose / when: For too much emotion (dysregulation) or too little (numbing); goal is regulating without substances or unsafe behaviour [source: TIP 57 Quick Guide].
• Steps: Teach new coping and distress-tolerance skills; TIP 57 names mindfulness and cognitive-behavioural strategies as options without specifying a protocol [source: TIP 57 Quick Guide]. Choose from an established skills manual and name it in the record [synthesis].
• Watch for: Numbing leading family and staff to underrate severity [source: TIP 57 Quick Guide].

B12. Sleep

• Purpose / when: Sleep disturbance and nightmares, very common after trauma.
• Steps: Take a sleep history; screen sleep habits; educate on sleep hygiene; teach relaxation; consider nightmare cognitive rehearsal; reassess regularly [source: TIP 57 Quick Guide]. Persistent nightmares are a reason to refer for trauma-specific or sleep treatment [synthesis].

B13. Self-harm and suicidality

• Purpose / when: After any positive trauma screen and whenever self-harm appears.
• Steps: (1) Screen for suicidal thoughts and behaviour following current standard practice (TIP 57 points to TIP 50) [source: TIP 57 ch. 4]. (2) Distinguish suicidal from non-suicidal self-harm and assess both. (3) Explore what the self-harm does (managing overwhelming distress, dissociation, feeling trapped). (4) Teach safer ways to manage distress in tolerable amounts and address the underlying reasons. (5) Treat it as able to escalate; do not dismiss it as attention-seeking [source: TIP 57 Quick Guide]. (6) Collaborative safety planning and lethal-means counselling (safe storage or removal) per your service's protocol [synthesis].
• Example language (illustrative): "When you cut, what does it do for you in that moment? Let's find something that does part of that job with less cost."
• Watch for: Shifts from non-suicidal to suicidal intent; increased risk after new trauma.

B14. Integrating substance use

• Purpose / when: Co-occurring substance use, often self-medication of trauma symptoms.
• Steps: Screen substance use alongside trauma and do not wait for abstinence to screen or address trauma; build alternative self-soothing as use reduces; plan for heightened relapse risk after new trauma, especially in early recovery with PTSD [source: TIP 57 Quick Guide; TIP 57 ch. 4]. Treat trauma and substance use together rather than in sequence [source: Elliott et al. 2005].
• Watch for: Symptom rebound when substances stop; prepare the client for it.

B15. Building resilience and trauma-resistant skills

• Purpose / when: Throughout; to strengthen everyday buffers.
• Steps: Reconnect personal and social supports; encourage action; keep a stable routine (sleep, meals, work, chores, hobbies); recall hardships handled successfully; keep perspective and hope; encourage peer support or mutual-help groups [source: TIP 57 Quick Guide]. Give the client chances to practise handling difficult situations and frame discomfort as manageable [source: TIP 57 ch. 1].
• Example language (illustrative): "What's one part of your day we could make predictable this week?"

B16. Grief and loss

• Purpose / when: When trauma involved losses: people, health, faith, identity, sense of safety.
• Steps: Be present; normalise grief; assess supports; name losses including internal ones; use a feelings journal; consider rituals or contributions that honour the loss [source: TIP 57 Quick Guide].
• Watch for: Complicated grief needing specialist referral [synthesis].

C1. Consistency, boundaries and repair

• Purpose / when: Throughout; trust is built by reliability more than by words [source: TIP 57 ch. 1; TIP 57 Quick Guide].
• Steps: (1) Be consistent and dependable; start on time; if you are late or make a small error, name it promptly. (2) Set clear boundaries and explicit goals; avoid drift into personal relationships [source: Fallot & Harris 2006]. (3) Prepare clients well ahead for your leave or staff changes. (4) When conflict arises, use it to show that relationships can be repaired respectfully. (5) Consider referring to trauma survivor support groups [source: TIP 57 Quick Guide].
• Example language (illustrative): "I was ten minutes late today and I know reliability matters to you. I'm sorry; we'll still have the full time."
• Watch for: Testing behaviour after a lapse; respond with the same steadiness.

C2. Culturally responsive practice

• Purpose / when: Every client; especially with experiences of collective or historical trauma.
• Steps: (1) Ask whether the client has experienced cultural trauma such as war, genocide, oppression, torture or terrorism. (2) Ask how their family and community view trauma and how distress is expressed in their culture. (3) Use cultural brokers to interpret patterns and liaise. (4) Use trained interpreters and culturally adapted instruments. (5) Treat somatic complaints as a possible idiom of distress but still refer for medical evaluation. (6) Ask about coping drawn from cultural history [source: TIP 57 Quick Guide; TIP 57 ch. 4]. (7) Consider sexual orientation, religion, age, class, disability and race/ethnicity; ask and stay open to learning [source: Elliott et al. 2005]. (8) Recognise structural racism and historical trauma, with cultural humility rather than claimed competence [source: SAMHSA 2023].
• Example language (illustrative): "In your family or community, how do people usually talk about, or not talk about, hard things like this?"
• Watch for: Imposing your own value judgements on the client's beliefs [source: TIP 57 Quick Guide].

C3. Crisis planning and advance preferences

• Purpose / when: Before any crisis; essential where restraint, seclusion or involuntary care are possible.
• Steps: (1) Together, write down the client's triggers, early warning signs, what calms them, which services and people they want involved, and their preferred alternatives [source: Elliott et al. 2005; Te Pou 2013]. (2) Tell them in advance in what circumstances restraint might be used and what options they have [source: Elliott et al. 2005]. (3) Keep the plan current, easy to find in a crisis, with a copy held by the client [source: Te Pou 2013]. (4) Honour stated crisis preferences in policy [source: Fallot & Harris 2006]. (5) Avoid physical or chemical restraint and involuntary hospitalisation wherever possible [source: Elliott et al. 2005].
• Example language (illustrative): "If things got very bad, what would help you, and what has made it worse in the past?"
• Watch for: Plans written once and never used; review after every crisis.

C4. Referral to trauma-specific treatment

• Purpose / when: When referral indicators are present (see section 2B step 6) [source: TIP 57 Quick Guide].
• Steps: (1) Discuss with the client what trauma-specific treatment involves and their choice of option. (2) Refer to a provider trained in an evidence-based model: SAMHSA 2023 names CPT, EMDR, NET, PE, CBT for acute stress and Seeking Safety; CHCS adds ARC, CPP and TF-CBT for children [source: SAMHSA 2023; Menschner & Maul 2016]. (3) Use a trusted referral network; invite partners to your training [source: SAMHSA 2014; Menschner & Maul 2016]. (4) Keep the client engaged in current care while waiting, and avoid repeat screening by sharing results with consent [source: Menschner & Maul 2016].
• Watch for: Drop-off at hand-over; a warm introduction helps [synthesis].

C5. Connecting with peer support

• Purpose / when: To build hope, reduce isolation and model recovery [source: SAMHSA 2014; TIP 57 ch. 1].
• Steps: Introduce clients to peer support staff or survivors further along in recovery; orient them to self-help groups so they feel safe attending; invite clients into peer roles or advisory boards when ready [source: TIP 57 ch. 1; Elliott et al. 2005; TIP 57 Quick Guide]. SAMHSA 2023 describes peer support as voluntary, non-judgemental, honest, reciprocal and power-sharing.

C6. Trauma-informed group work

• Purpose / when: Any group in a trauma-informed service.
• Steps: Use a predictable structure; review group assignment for retraumatisation risk; avoid confrontational tactics and attacks on "resistance"; stop abusive behaviour between clients when it occurs; do not require members to disclose trauma details [source: TIP 57 ch. 1; Elliott et al. 2005; TIP 57 Quick Guide]. Ground and check the room before ending [synthesis].

C7. Handling mandatory reporting

• Purpose / when: Disclosures that may trigger a reporting duty.
• Steps: Explain limits of confidentiality before asking about trauma; know your jurisdiction's requirements; use supervision; when a report is needed, tell the client what you must do and why, and involve them as far as possible [source: TIP 57 ch. 4; client-involvement steps synthesis].

D1. Physical and procedural environment check

• Purpose / when: Before and during implementation; any clinician can do it for their own setting.
• Steps: Walk the client's route from arrival to session. Check lighting, noise, monitored entrances, welcoming signs, easy exits from rooms, private space, adequate personal space, waiting-room material free of violent or sexual content [source: Menschner & Maul 2016; Elliott et al. 2005; Fallot & Harris 2006]. Check social safety: respectful greeting, predictable schedules, advance notice of changes, open doors where preferred, quiet or calming spaces [source: SAMHSA 2023]. Fix what you can and log the rest for the service plan.

D2. Service self-assessment and planning (CCTIC process)

• Purpose / when: Phase 1 of organisational change.
• Steps: Form a representative workgroup (administrators, supervisors, direct and support staff, consumer-survivors); map the sequence of contacts for a new client; review each domain against the five values; prioritise; set measurable objectives with owners and timelines; re-rate at milestones, optionally with outside raters [source: Fallot & Harris 2006]. Pay people with lived experience for their time [source: Menschner & Maul 2016; SAMHSA 2023]. Do not reproduce the protocol's items; obtain it from Community Connections.

D3. Seclusion and restraint reduction (Six Core Strategies)

• Purpose / when: Inpatient, residential and crisis settings. Developed by NASMHPD in the US; the version used is Te Pou's New Zealand adaptation (2013) [source: Te Pou 2013].
• Steps (six strategies): (1) Leadership: senior commitment, a reduction plan with owners and targets, every event visible to management. (2) Data: baseline and ongoing tracking of events, hours and injuries by unit and shift; share graphs; record near misses. (3) Workforce development: training in trauma-informed care, de-escalation and safe practice; review whether unit rules are necessary. (4) Prevention tools: trauma history and trigger assessment at admission, medical risk screening for restraint, individual safety/crisis plans, an agreed behaviour scale, sensory or quiet rooms and activities. (5) Service-user roles: paid peer roles and inclusion in incident reviews. (6) Debriefing: an immediate on-site debrief to confirm safety and restore the unit, then a formal debrief within days facilitated by someone uninvolved, using root-cause analysis, with the service user's input at a time they choose; feed learning back into the person's plan [source: Te Pou 2013].
• Watch for: Side effects such as more property damage or longer de-escalations; monitor them [source: Te Pou 2013].

D4. Workforce: hiring, training, supervision

• Steps: Use behavioural interview questions about relationship-building, responding to stress, self-care, non-judgement and collaboration; train all staff including reception, security and drivers from onboarding (trauma theory, principles, equity, secondary traumatic stress); provide reflective supervision, manageable caseloads, short breaks after intense encounters, employee assistance and mental-health days [source: SAMHSA 2023; Menschner & Maul 2016].

D5. Clinician self-monitoring for secondary traumatic stress

• Purpose / when: Ongoing, for yourself.
• Steps: Watch for intrusive reactions to client material, avoidance, numbness, somatic complaints, insomnia, negative thinking, low mood, withdrawal, and do not explain them away as other stress. Bring reactions to supervision, keep peer contact, consider personal therapy, keep a balanced life, and hold clear work and client boundaries [source: TIP 57 ch. 1; TIP 57 Quick Guide].

5. Handling problems

Overwhelm or dissociation in session. Stop content, ground (B3), normalise, and close only once oriented and safe (B4) [source: TIP 57 ch. 4; TIP 57 Quick Guide]. Next time, lower the intensity: use SUDS check-ins, agree a stop signal, work on present-day triggers rather than past detail, and confirm that retelling is not required [source: TIP 57 Quick Guide; stop signal synthesis]. If dissociation is frequent or severe, it is a referral indicator; dissociation may need clinical interview rather than checklists [source: TIP 57 ch. 4; TIP 57 Quick Guide].

Client denies trauma or rejects the link to current problems. Expected; do not push. Keep universal routines, return to the question as trust grows, and frame links as hypotheses (A6). Denial can stem from seeing trauma as weakness or from cultural norms [source: SAMHSA 2023; TIP 57 Quick Guide; TIP 57 ch. 4].

"Resistance", missed sessions, non-adherence. Read them first as possible adaptations (avoidance, mistrust, fear of loss of control) rather than defiance; avoid confrontation and criticism of resistance [source: TIP 57 ch. 1; Elliott et al. 2005]. Concretely: ask what got in the way; review whether any element is distressing and offer an alternative; give more choice over timing, location and method of contact; check that no service is contingent on compliance [source: TIP 57 ch. 1; Fallot & Harris 2006]. Shorten or simplify homework (e.g. one-line trigger log) [synthesis].

Stuck: stable but not improving. Revisit the client's own definition of recovery (A5) and check balance: too little trauma focus can reinforce avoidance [source: TIP 57 Quick Guide; TIP 57 ch. 1]. Check the referral indicators and offer trauma-specific treatment (C4). Review whether old coping still works or now costs more (B2) [synthesis on ordering].

Ruptures and trust lapses. Name your own lapse quickly, apologise plainly, and use the repair as evidence that relationships can recover [source: TIP 57 Quick Guide]. When something goes wrong in the service, communicate honestly about it [source: TIP 57 ch. 1]. If the client wants another worker, treat the request as legitimate where possible [source: Elliott et al. 2005].

Choices you think are unsafe. Explore the client's reasoning before advising [source: Elliott et al. 2005]. Where risk to life is present, standard risk procedures override preference; explain what you are doing and why, offer every choice that remains, and debrief afterwards [synthesis].

Self-harm or suicidal crisis. Follow standard risk assessment and safety planning; TIP 57 points to TIP 50 [source: TIP 57 ch. 4]. Address the function of self-harm and teach safer coping (B13) [source: TIP 57 Quick Guide]. In residential or inpatient care, use the client's crisis plan and the least restrictive response; if restraint or seclusion happens, run both debriefs (D3) [source: Te Pou 2013].

Agitation and threatened coercion. Use the agreed behaviour scale and calming spaces before any restrictive step; restraint or seclusion of survivors is a named route to re-traumatisation [source: SAMHSA 2014; Te Pou 2013].

New trauma during care. Re-establish safety first; safety needs recur [source: TIP 57 Quick Guide]. Expect a higher relapse risk in early substance-use recovery, especially with PTSD; increase contact and coping support [source: TIP 57 Quick Guide].

Disclosure that triggers a mandatory report. Follow C7; seek supervision [source: TIP 57 ch. 4]. Expect strain in the alliance; schedule a follow-up contact soon after [synthesis].

Modality-specific difficulties (these concern how TIC itself is implemented):

• Training without policy change. SAMHSA warns against relying on training alone; changes must be written into policy and procedure [source: SAMHSA 2014].
• Screening without somewhere to send people. Screen only if referral and follow-up exist [source: TIP 57 ch. 4; Menschner & Maul 2016].
• Repeat screening across agencies retraumatises and frustrates; share results with privacy protections [source: Menschner & Maul 2016; Fallot & Harris 2006].
• TIC used as a label without substance ("we're trauma-informed" with unchanged coercive practice). Use a self-assessment (D2) and client-perspective measures beyond satisfaction surveys [source: SAMHSA 2014; SAMHSA 2023].
• Confusing TIC with trauma processing. Generalist staff should not elicit detailed trauma narratives; that belongs in trauma-specific treatment with a trained clinician [source: TIP 57 ch. 1; TIP 57 ch. 4].
• Staff burnout and secondary traumatic stress undermine everything else; use D4 and D5 [source: SAMHSA 2023; Menschner & Maul 2016].
• System barriers (fee-for-service, short appointments, funding silos) limit what is possible; CHCS names these but does not give solutions; raise them in service planning [source: Menschner & Maul 2016; response synthesis].

Problems the sources do not address (all [synthesis]). (a) Telehealth: ask about privacy and who else is present, agree what to do if the connection drops mid-distress, and have the client's location and an emergency contact. (b) Clients who experience choice itself as overwhelming: offer two options instead of open questions, and increase choice gradually. (c) Your own trauma history being activated: take it to supervision or personal therapy before it shapes decisions. (d) Children and families: these sources are adult-focused; for child-serving work use child-specific guidance (e.g. NCTSN materials [uncertain]).

Sources

Sources:

• SAMHSA's Concept of Trauma and Guidance for a Trauma-Informed Approach (HHS Pub. SMA 14-4884, 2014)
• TIP 57: Trauma-Informed Care in Behavioral Health Services, Part 1 Ch. 1 (NCBI Bookshelf)
• TIP 57, Part 1 Ch. 4: Screening and Assessment (NCBI Bookshelf)
• Trauma-Informed Care in Behavioral Health Services: Quick Guide for Clinicians Based on TIP 57
• Fallot & Harris, Trauma-Informed Services: A Self-Assessment and Planning Protocol v1.4 (Community Connections, 2006)
• SAMHSA, Practical Guide for Implementing a Trauma-Informed Approach (PEP23-06-05-005, 2023) (case studies and references not read)
• Menschner & Maul, Key Ingredients for Successful Trauma-Informed Care Implementation (CHCS, 2016)
• Te Pou, Six Core Strategies for reducing seclusion and restraint, NZ adaptation (2013)
• Elliott, Bjelajac, Fallot, Markoff & Reed (2005), Trauma-informed or trauma-denied, Journal of Community Psychology 33(4)

Further reading (not drawn on) [uncertain]:

• Harris, M., & Fallot, R. D. (Eds.) (2001). Using Trauma Theory to Design Service Systems. New Directions for Mental Health Services, 89. Jossey-Bass.
• SAMHSA (2009). TIP 50: Addressing Suicidal Thoughts and Behaviors in Substance Abuse Treatment (referenced by TIP 57).
• Huckshorn, K. A. / NASMHPD, original US Six Core Strategies curriculum (only the NZ adaptation used).
• PC-PTSD-5 revision of the PC-PTSD screen.