O R I G I N A L P A P E R

Trauma-Informed Social Work Practice: Practice Considerations and Challenges

Carolyn Knight

Published online: 19 February 2014

� Springer Science+Business Media New York 2014

Abstract Adult survivors of childhood trauma are an

especially challenging group of clients, given the long-term

effects of the victimization and the present day difficulties

these individuals face. In this article, trauma-informed

practice is explained, incorporating the most recent theo-

retical and empirical literature. The purpose is to educate

and provide support to clinicians who encounter survivors

of childhood trauma in a range of settings that are partic-

ularly likely to serve this population like addictions, mental

health, forensics/corrections, and child welfare. The social

worker neither ignores nor dwells exclusively on the past

trauma. Rather, trauma-informed practitioners are sensitive

to the ways in which the client’s current difficulties can be

understood in the context of the past trauma. Further, they

validate and normalize the client’s experiences. Trauma-

informed practice requires the practitioner to understand

how the working alliance, itself, can be used to address the

long-term effects of the trauma. Emphasis is placed on

helping survivors understand how their past influences the

present and on empowering them to manage their present

lives more effectively, using core skills of social work

practice.

Keywords Childhood trauma � Sexual abuse � Clinical intervention � Indirect trauma � Child maltreatment � Adult survivors

Introduction

Adult survivors of childhood trauma account for a majority

of individuals seeking or required to seek clinical services

(Bride 2004; Harper et al. 2008; Probst et al. 2011). Much

has been written about working with this population, but

most of this literature assumes that the past trauma will be

the primary focus of the professional intervention. How-

ever, many practitioners encounter trauma survivors in

settings like addictions, mental health, child welfare, and

corrections/forensics, where these individuals are particu-

larly likely to require or seek out services (Macy 2007;

Pence 2011). The focus in these practice contexts typically

is on the present-day difficulties with which the survivor is

struggling, rather than the underlying past trauma.

Clinicians in these settings often feel ill-equipped to be

helpful to survivors, mistakenly assuming they lack the

required knowledge and expertise (Binder and McNeil

2007; Fusco and Platania 2011). Survivors’ sense of

urgency regarding their current problems-in-living, cou-

pled with the limited role that many practitioners play in

meeting their clients’ needs, often results in the history of

past trauma being overlooked, along with the impact that

this may have on current functioning (Chemtob et al. 2011;

Pence 2011; McGowan 2013). This is frustrating to clini-

cians and survivors alike. In fact, practitioners who do not

attend to survivors’ past, and the relationship it plays in the

present, undermine their ability to deal with the underlying

trauma and the present-day challenges that brought them

into treatment in the first place (Harper et al. 2008; Twaite

and Rodriguez-Srednicki 2004).

This article addresses a gap in the trauma literature by

focusing on the many instances in which a survivor of

trauma seeks out or is required to seek out treatment, not

for the past trauma, but for current problems in living. It

C. Knight (&) School of Social Work, University of Maryland Baltimore

County, 1000 Hilltop Circle, Baltimore, MD 21250, USA

e-mail: knight@umbc.edu

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Clin Soc Work J (2015) 43:25–37

DOI 10.1007/s10615-014-0481-6

 

 

begins with an overview of current theory and research

regarding the nature and long-term consequences of

childhood trauma. This is followed by an examination and

discussion of what is referred to as trauma-informed

practice (Brown et al. 2012; Layne et al. 2011), incorpo-

rating the most recent theoretical and empirical literature.

Case examples illustrate core concepts. The case material

reflects composites of actual client situations; all identify-

ing information has been changed to protect clients and

practitioners.

Nature of Childhood Trauma

The earliest definitions of childhood trauma emphasized the

event, itself and the traumatizing effects it had on its victims.

More recent conceptualizations recognize that the same

event will be experienced differently, based upon a range of

variables including cultural context and social and psycho-

logical factors unique to the individual (Elliott and Urquiza

2006). Williams and Sommer (2002) argue that, ‘‘Trauma is

in the eyes of the beholder…’’ (p. xix). More recent con- ceptualizations of trauma also have moved away from a sole

focus on pathology and dysfunction. Researchers point to the

existence of ‘‘adversarial’’ or ‘‘posttraumatic growth’’

(Bonnanno 2004; Linley and Joseph 2004); survivors’ sense

of self-efficacy, their ability to cope with challenging events

in the future, and their spirituality can be enhanced as a result

of exposure to trauma.

Childhood trauma, particularly in the form of interper-

sonal victimization like sexual and physical abuse, has

been found to be associated with a host of difficulties

ranging from emotional and psychological reactions such

as depression, low self-esteem, and suicidal ideation;

physical problems like chronic pain; psychiatric problems

such as anxiety/panic, borderline, post-traumatic stress, and

dissociative identity disorders; and behavioral problems

including substance abuse, eating disorders, domestic vio-

lence, and self-injury (Farrugia et al. 2011; Kuo et al. 2011;

Shafer and Fisher 2011; Spitzer et al. 2006).

Childhood trauma also distorts survivors’ thinking about

their social world and leads to social isolation and prob-

lems with attachment (Waldinger et al. 2006). Survivors

are likely to develop core beliefs about self and others that

are characterized by low self-esteem and feelings of

worthlessness, powerlessness, and vulnerability, as well as

mistrust of others (McCann and Pearlman 1990). Child-

hood trauma robs its victims of a stable sense of self. This

results in a lack of the ‘‘self-capacities’’ (McCann and

Pearlman 1990), that allow individuals to ‘‘maintain a

consistent sense of identity and positive self-esteem’’ (p.

21). These self-capacities reflect basic coping mechanisms

like the ability to: soothe and comfort oneself when

distressed; be alone and comfortable with oneself; experi-

ence a full range of affective reactions without being

overwhelmed by or denying them; regulate emotions; and

accept criticism and negative feedback.

There also is increasing evidence to suggest that expo-

sure to trauma in childhood leads to neurobiological

changes in the developing brain. These changes appear to

be more or less permanent and reinforce the previously

identified social, emotional, and behavioral consequences

of the abuse (Coates 2010; Delima and Vimpani 2011;

Rothschild 2003; Teicher et al. 2003).

Trauma-Informed Practice: Definition

When clinicians work in settings that are likely to serve

adults with histories of childhood trauma, it is important

that they entertain the possibility that the client could have

such a history, regardless of whether or not the client

presents her or himself as a survivor. Trauma informed

practice doesn’t mean that the practitioner assumes the

client is a survivor. It also doesn’t mean that the focus of

the intervention will be on the past trauma.

Rather, the practitioner is sensitive to this possibility and to

the ways in which the client’s current problems can be

understood in the context of past victimization. The worker

also recognizes the potential implications that being a survivor

have for the client’s willingness and ability to enter into a

working alliance; evidence suggests this may be especially

challenging for survivors, given core beliefs characterized by

hostility towards others, and their difficulties forming positive

attachments (Monahan and Forgash 2000; Stovall-McClough

and Cloitre 2006). ‘‘The development of the therapeutic alli-

ance…is often a daunting challenge with an interpersonally victimized [client]. The [worker] may be perceived as a stand-

in for other untrustworthy and abusive authority figures to be

feared, challenged, tested, distanced from, raged against,

sexualized, etc.’’ (Courtois 2001, p. 481).

Unlike trauma-centered intervention, where the under-

lying trauma is the primary focus of the intervention,

trauma informed practice helps survivors ‘‘develop their

capacities for managing distress and for engaging in more

effective daily functioning’’ (Gold 2001, p. 60). The effects

of the past childhood trauma aren’t ignored, but ‘‘extensive

and detailed immersion in [traumatic] material itself is not

encouraged, because…this tactic is…destabilizing and counter-productive’’ (Gold 2001, p. 60).

Importance of the Professional Relationship

Trauma-informed practice recognizes that the working

alliance can provide a corrective emotional experience for

26 Clin Soc Work J (2015) 43:25–37

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survivors (Banks 2006). The relationship can challenge

distortions in thinking about self and others, and it can be a

means through which self-capacities can be developed

(McCann and Pearlman 1990). For example, when practi-

tioners understand and anticipate ‘‘traumatic transference’’

(Spiegel 1986), whereby they represent those who have

exploited the survivor, they can assist the client in con-

fronting directly fear and mistrust of others (Dalenberg

2004; Horvath 2000). Further, the worker’s affective

reactions to the survivor and her or his story affirm and

give voice to the client’s own reactions (Courtois 2001).

The therapeutic potential of the relationship depends

upon workers being knowledgeable about childhood

trauma and its relationship to the client’s current difficul-

ties. The worker acknowledges the trauma directly and

responds empathically, but does so in a way that is con-

sistent with her or his professional role (Glover et al. 2010;

Karatzias et al. 2012). The results of several studies reveal

that survivors of trauma are likely to have been in treat-

ment multiple times and to report having experiences with

professionals that were not helpful and often counterpro-

ductive (Beutler and Hill 1992; Palmer et al. 2001;

Schachter et al. 2003). Specifically, survivors reported as

unhelpful clinicians who: avoided addressing the trauma at

all, asked for too much detail and encouraged expression of

feelings when it wasn’t appropriate, and minimized the

significance of the trauma in the client’s current life.

The therapeutic potential of the working alliance also

depends upon the worker adhering to professional bound-

aries to enhance survivors’ self-capacities. Survivors’ sense

of urgency can lead the worker to engage in practice

activities that are inconsistent with her or his role in

agency-based or private practice. It also can lead the

worker to extend her or himself in ways that move the

relationship away from a professional one into a realm that

is more personal in nature. The following case example

reveals how easily boundaries can be violated.

Margaret was a twenty year old college student in her

sophomore year. She was sexually and physically

abused over a ten year period by her stepfather. She

began to have problems managing the stress associ-

ated with her school work. She also began to have

flashbacks and nightmares. One of her instructors

referred her to the school’s counseling center, where

she began to see a professional clinician.

The center has a twelve session limit, and once

Margaret and her counselor reached the limit, Mar-

garet pleaded with the counselor to continue to see

her, since she believed the counselor was the ‘‘only

one’’ who could help her. The counselor agreed to see

Margaret ‘‘on the side’’, for free, in her home. Mar-

garet began to have thoughts of suicide and the

counselor invited her to spend the night with her each

time these thoughts surfaced.

This practitioner’s desire to help Margaret was under-

standable but misguided and ultimately undermined the

client’s self-capacities. The professional’s sense of urgency

could have been constructively channeled into advocating

for a more trauma-informed approach to treatment in her

agency, such as a change in policy regarding session limits

for clients like Margaret. Survivors already struggle with

entering into a therapeutic alliance; therefore, they benefit

greatly from an ongoing, stable relationship with the

clinician.

Instead, the clinician disregarded agency policy, which

ultimately undermined Margaret’s growth. What this

practitioner failed to appreciate was that terminating with

Margaret and referring her to another agency, though

painful, would have provided Margaret with an opportunity

to further develop self-capacities associated with beginning

and ending relationships and managing the difficult feel-

ings associated with these transitions. Unfortunately, the

clinician was significantly impacted by Margaret’s pain

and abandonment issues, suggesting an enactment of

countertransference, discussed later. Inviting Margaret to

stay with her further compromised Margaret’s ability to

manage her feelings on her own. The clinician also left

herself vulnerable to liability issues, because she no longer

was operating under the auspices of her employing orga-

nization. This situation did not end well. The practitioner

was forced to have Margaret hospitalized. Her involvement

with Margaret became known to the school, and she was

fired from her position.

Boundaries between workers and any client population

should remain fluid and open to adjustment, in response to

changing circumstances and contexts (Gabbard 1996;

Lazarus 1994; Reamer 2003). With survivors, the worker

may need to loosen boundaries to be more available in

times of crisis without losing sight of professional role and

responsibilities (Harper 2006). In the previous case, had the

clinician not had to terminate with Margaret, she might

have needed to be more available to the client to deal with

the suicidal thoughts. This doesn’t mean taking Margaret

home. However, it could mean establishing a safety con-

tract that required more frequent meetings with Margaret

and/or keeping in daily contact via phone or email.

In contrast to the last example, this next case illustration

demonstrates how the worker can empathize with a survi-

vor but still set limits and maintain boundaries that promote

empowerment. 1

The worker was a foster care worker and

was providing ongoing case management to Ms. Davies,

who lost custody of her young children after leaving them

1 Adapted from Knight (2009).

Clin Soc Work J (2015) 43:25–37 27

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unsupervised for long periods of time. The worker, Anna,

visited Ms. Davies monthly to assess her progress on her

contract with the agency, the goal of which was re-unifi-

cation with the children. The following exchange took

place as their meeting was ending.

Anna: Well, I guess that’s it for today, Ms. Davies.

You’re doing very well, making a lot of progress. If

things continue on like this, I think you’ll be able to

have [her children] for an overnight visit very soon. Is

there anything else for today?

Ms. Davies: There’s just this one thing. Maybe I

actually already told you this. Did I ever tell you that

when I was a kid, my father pimped me out? He was

a drug addict, like me. He didn’t have no job or

nothing, so he used me to buy his drugs. He’d sell me

to his friends. Let them do what they want to me, and

then take money. Can you believe that? He sold his

own daughter, just to support his drug habit. That

son-of-a-bitch.

Anna: Oh, my, what a terrible story! I had no idea. It

took a lot of courage for you to tell me this. You must

have so many feelings about what your dad did to

you: anger, sadness, confusion. I guess maybe some

of the reason why you were using drugs yourself was

so you didn’t have to feel all this stuff?

Ms. Davies: Yeah, it hurts real bad. It got so, though,

that even when I was using, I would still be thinking

about what he done to me. It’s like I just keep seeing

what happened in my head over and over again.

Anna: I’m sure that this must be so difficult. [Pats

client on the shoulder.] What happened when you

were so little, and then not being able to stop thinking

about it now. You know that my job is to help you do

what it takes for you to get your kids back, right? I

am so glad that you have told me what you did,

because now I can be even more helpful to you. I’m

thinking that the fact that you have shared this with

me means that maybe you are ready to talk about it

with someone. What I’d like to do is refer you to

someone who can help you to do that.

This exchange exemplifies trauma-informed practice in

several ways. Most important, the worker responded

directly to the client’s disclosures of childhood trauma,

conveying her appreciation of the importance of what had

been shared. Anna empathized with Ms. Davies, which in

turn normalized and validated the client’s feelings. Yet,

Anna didn’t lose sight of her role. Anna didn’t offer ser-

vices she couldn’t provide, nor did she delve deeply into

Ms. Davies’s past. Asking Ms. Davies for more informa-

tion about her abuse could have been re-traumatizing and

undermined her self-capacities; it also was inconsistent

with Anna’s role as a foster care worker.