1 Introducing a trauma-informed approach in non-clinical work settings

Trauma is more prevalent in individuals than initially thought [4, 15]. The Coronavirus (COVID-19) that shut the world down in 2014 and took the lives of 6,947,192 individuals worldwide is an example of the prevalence of trauma [19]. Before COVID-19, the Substance Abuse and Mental Health Service Administration (SAMHSA) labeled trauma as a “costly public health problem” ([17], p. 2). More recently, Ranjbar et al. [15] concluded that trauma could be considered a public health crisis because of the frequency and effect trauma has on society. How trauma is defined has changed over the years, with clinicians learning traumatic events affect individuals uniquely [4, 8, 15]. An event that seems traumatic to one individual may not have the same adverse effects on others who experienced the same incident. Isobel et al. [8] noted that the event itself and the amount of time the results of the event last are two key variables that depict how an individual will be affected and whether the event is construed as traumatic.

This researcher believes that trauma-informed care principles should not be confined to a clinical setting. The popular press called for a more trauma-informed workplace in a March 2022 publication of the Harvard Business Review [12]. From a scholarly standpoint, it would be hard to disagree with this recommendation. The purpose of this qualitative conceptual review was to introduce how trauma-informed care principles could be applied to the standard work setting. This paper begins by reviewing the term trauma, then transitioning to trauma-informed care with a discussion of using trauma-informed care principles in the workplace. The article closes with the discussion, limitations, future research recommendations, and conclusion sections.

2 Trauma

Trauma and how it is defined has changed over the years, with the definitions varying slightly. SAMHSA [17], the leading authority in substance use and behavioral health, noted this inconsistency and used its resources to garner the following definition:

Individual trauma results from an event, series of events, or set of circumstances that is experienced by an individual as physically or emotionally harmful or life-threatening and that has lasting adverse effects on the individual’s functioning and mental, physical, social, emotional, or spiritual well-being. (p. 7)

Researchers agree that three factors, also known as the three Es of trauma, are present when trauma occurs: (1) Event: the objective, undesirable occurrence that produces toxic stress; (2) Experience: portrays an individual’s subjective response to the adverse event; and (3) Effect: the duration (long-term vs. short-term) of the affliction [5, 17]

The prevalence of trauma is more common than one would think. Six out of ten men and five out of ten women will experience a traumatic event at some point in their lives [18]. However, Fallot and Harris [4] report that this percentage can be as high as 90%, with some individuals saying they have suffered five traumatic events. The Kaiser Family Foundation published that 11.00% of adults developed feelings of depression and or anxiety from January 2019 to June 2019, soaring to 41.10% in January 2021 [14]. In the workplace, post-traumatic stress disorder (PTSD) can have a costly effect. Individuals who have PTSD miss, on average, 3.6 days of work per month, which equates to $3 billion of lost revenue in the United States [11].

3 Trauma-informed care

Trauma-informed care is “a strength-based approach to caring for individuals mindfully, with compassion and clarity regarding boundaries and expectations” ([15], p. 9). Providers need to alter their attention from pathologizing to contextualizing when treating an individual who has experienced a traumatic event [6]. Practitioners can accomplish this by placing the presenting symptoms within the larger context of the individual’s past [7]. An essential part of providing trauma-informed care services is not retraumatizing the individual by unconsciously making them relive the event(s) that caused the trauma [9]. There are five guiding principles for supporting a trauma-informed environment in a clinical setting: (1) Safety: physical and emotional; (2) Trustworthiness: open and honest communication; (3) Choice: the client is their own expert; (4) Collaboration: strengthens the provider and client relationship with an emphasis on client choice; and (5) Empowerment: giving the client as much control as possible over their care and outcomes [7, 10]. Trauma-informed care includes being compassionate while establishing healthy cultures, policies, and practices that recognize and respond to the prevalence and persistent impact of trauma [3, 15]. Applying trauma-informed care principles across all healthcare settings was recommended by Ranjbar et al. [15], even when treating individuals who have not reported past trauma.

3.1 The sanctuary model

Bloom [1] explains the Sanctuary Model as a trauma-informed approach for constructing or transforming an organizational culture. Initially, this model was developed in the early 1980s at an acute care, short-term inpatient psychiatric facility serving adults who experienced childhood trauma. Since then, the model has become an evidence-supported standard of care, where staff and clients are vested as crucial decision-makers to help create a more emotionally intelligent environment that promotes growth and change [1]. The Sanctuary Model has been successfully implemented in clinical (residential treatment and substance use centers) and community (public and private schools) settings.

There are seven main characteristics related to the culture of an organization wishing to implement the Sanctuary Model:

  • Culture of nonviolence: building, and modeling safety skills and a commitment to higher goals.

  • Culture of emotional intelligence: teaching and modeling emotional management skills and the integration of thoughts and feelings.

  • Culture of social learning: building and modeling cognitive skills in an environment that promotes conflict resolution and transformation.

  • Culture of shared governance: creating and modeling civic skills of self-control, self-discipline, and administration of healthy authority.

  • Culture of open communication: overcoming barriers to healthy communication, reducing acting out, enhancing self-protective and self-correcting skills, and teaching healthy boundaries.

  • Culture of social responsibility: rebuilding social connection skills and establishing healthy attachment relationships.

  • Culture of growth and change: working through loss; restoring hope, meaning, and purpose ([1], p. 14)

The Safety, Emotions, Loss, and Future (S.E.L.F.) tool is essential when implementing the Sanctuary Model. Bloom [1] explains this tool is not a staged treatment model but a technique for treating complicated challenges by directing the assessments, treatment planning, and team/individual dialogues. Each of the four components of S.E.L.F. signifies an area of disruption that can transpire in somebody’s life. Trauma survivors typically have a tough time staying safe, have difficulty managing their emotions, have experienced several losses, and struggle with imaging a future. Using this tool can categorize any issue, with categorizing and naming being the first steps in managing a difficult situation [1]. When applying this model, organizational leaders attend an intense, five-day training and then are expected to return to their organizations and create an implementation team. Implementing the Sanctuary Model can take an organization three years. In their study, Middleton et al. [13] found that leaders used a transformational leadership style when committing to a more trauma-informed organization and applying the Sanctuary Model.

3.2 SAMHSA’s trauma-informed approach

For over 25 years, SAMHSA has been the leader in advocating the need for trauma-informed services in the public mental health and substance use delivery models. When addressing trauma and being trauma-informed, SAMHSA [17] suggests focusing on the four “Rs”:

  • Realization: staff members at all levels have a fundamental realization of what trauma is and how trauma can affect individuals, groups, communities, and families.

  • Recognize: employees can recognize the symptoms of trauma.

  • Respond: the organization responds by implementing a trauma-informed approach company-wide.

  • Resist re-traumatization: understanding that past procedures may be trauma-inducing and how toxic and stressful environments can interfere with the healing process.

Six fundamental principles are recommended by SAMHSA [17] versus a standard set of practices or procedures: (1) Safety: the people receiving services feel psychologically and physically safe; (2) Trustworthiness and transparency: decisions are made with full transparency to help induce trust with clients, families, and staff; (3) Peer support: using past trauma survivors in the delivery model to help build trust and offer hope; (4) Collaboration and mutuality: recognizing all levels within an organization plays a role in being trauma-informed; (5) Empowerment, voice and choice: providing the client the power to help make decisions about their plan of care; and (6) Cultural, historical and gender issues: looking past cultural and gender stereotypes while recognizing the value of traditional cultural healing practices and understanding historical trauma.

Like the Sanctuary Model, SAMHSA’s trauma-informed care approach starts at the top, with leadership and the governing body acting upon SAMHSA’s ten implementation domains. An organization must have leadership’s physical and financial backing to implement a trauma-informed care approach. SAMHSA [17] recommends designating a trauma-informed champion within the leadership team to help push the initiative forward. SAMHSA has designed a chart with sample questions centered around the key principles and implementation domains to help guide organizational discussions.

4 Being trauma-informed in the workplace

As with individuals, organizations are susceptible to the effects of chronic stress and are vulnerable to the traumatic events that happen to and within institutions [2]. Employees subjected to a toxic work environment, many of them who have been exposed to past trauma, will begin to develop trust issues with their leaders and co-workers [2]. In a trauma-informed care clinical setting, clients need to trust their providers. Clinicians must communicate openly and honestly while staying true to their commitments [15]. In the workplace, these same values hold true with the employee-employer relationship. Staff need to trust their leaders, meaning leaders must communicate openly while staying committed to their employees. Organizations must provide their team with a safe place to work through their emotions, or they could be exposing staff to vicarious trauma, secondary traumatic stress, and burnout [16].

When implementing a trauma-informed care approach in a clinical setting, Hales et al. [6] contend staff benefit through the importance of self-care and the concept of a healthier work environment. Specifically, Hales et al. noted an increase in staff trust and confidence towards each other, the ability to work towards agency goals more collaboratively, being influential in their respective work areas, being encouraged to be inventive, and a feeling of accomplishment. Comparable results were reported in an earlier paper by Harris and Fallot [7], where they observed an increase in staff satisfaction related to the five principles of being trauma-informed discussed earlier, when implemented in a clinical setting.

4.1 Implementing trauma-informed care principles into the work setting

The recommendations presented earlier in this paper introducing a trauma-informed care approach in a clinical setting could be manipulated and taught in a non-clinical work setting (e.g., retail, manufacturing, finance, etc.). For example, the S.E.L.F. (Safety, Emotions, Loss, and Future) tool created by Bloom [1]. In the workplace, it is vital for all staff to feel Safe in their work environment, where they can express their Emotions (or ideas) without fear of Losing their job (or other repercussions), which would have a significant negative impact on their Future, personally and professionally. Likewise, the four “Rs” (Realize, Recognize, Respond, and Resist Re-traumatization) recommended by SAMHSA [17], could be implemented in the workplace. It would be beneficial for all employees to Realize trauma is more prevalent than we initially thought, Recognizing that people come from all walks of life and have different stories of how they got to where they are, Respond by being more empathetic, understanding, and applying the trauma-informed principles, and removing toxicity and undue stress in the workplace to help not Retraumatize our co-workers.

In conjunction, SAMHSA’s [17] six fundamental principles (safety, trustworthiness/transparency, peer support, collaboration/mutuality, empowerment/voice/choice, and culture/historical/gender issues) could be applied to any organization. All employees should feel psychologically and physically safe in the workplace; leaders, and staff need to trust each other, which can be accomplished through transparency; pairing new employees with an experienced coworker (peer) to aid in the onboarding process, and to help ease any anxiety/nervousness; seeking collaboration from all levels, and allowing openness in the decision-making process; helping all employees feel empowered by allowing them to voice ideas/concerns in a safe and inclusive environment; and embracing cultural, and gender differences knowing that everyone has a past that has allowed them to become the person they are.

Consider the following mock scenario. A manager has an employee who is continuously late returning to work from their lunch break. Instead of reprimanding this individual, the manager could have a conversation with their employee in hopes of better understanding what might be causing their delay. The employee may have personal obligations that the manager can help navigate. For example, the employee is the sole caretaker for their ailing parent, who must take medication at a specific time, and the parent’s home is on the opposite side of town. To help accommodate this stressful and trauma-inducing situation, the manager could allow the employee to come to work early or stay late at the end of the workday, so the employee can have a more extended lunch break to care for their sick parent. Organizations must be adequately staffed throughout the business day to meet customer demands; however, organizations need to be understanding of their employees’ needs to help promote a more positive, trauma-informed care work environment.

5 Discussion

The ideas generated by this paper are a starting point, to help create conversations across all work settings at all levels. In addition to the tools and guidelines presented, other trauma-informed care resources are available that practitioners and business leaders could manipulate for use in non-clinical settings. For instance, Fallot and Harris [4] developed the Creating Cultures of Trauma-Informed Care (CCTIC) Self-Assessment and Planning Protocol to help clinics implement trauma-informed care revisions in their service delivery model. This researcher chose to review the Sanctuary Model as it has been in practice since the 1980 s. At the same time, SAMHSA’s approach was examined because SAMHSA has been the leader in advocating the need for trauma-informed services in the public mental health and substance use delivery models for the past 25 years.

6 Limitations and recommendations for future research

While this paper provides a starting point for introducing trauma-informed care principles into the workplace, the ideas presented are high-level and need more detail. Additional research needs to be performed to help move this idea forward. One recommendation would be to conduct a qualitative study utilizing working adults as participants. The study could survey employees across various industries to understand what elements are needed for a workplace to be considered trauma-informed.

7 Conclusion

The information presented in this qualitative conceptual paper could apply to various business settings. In a clinic environment, implementing trauma-informed care is a marathon, not a sprint. As previously discussed, the implementation period for Bloom’s Sanctuary Model is three years. Clinic leadership and their employees must be dedicated to this new way of thinking for the implementation to be successful. The same applies for introducing this idea into the workplace. Staff deserve to work in a positive environment that does not induce trauma, where employees feel safe sharing their ideas. Additional research is needed to understand how the trauma-informed care concept could be used in a non-clinical setting.