Psychotherapy Bulletin

Psychotherapy Bulletin

Considerations in Trauma-Informed Training

In this article, we propose a trauma-informed lens as an essential ingredient of clinical competency. We draw from established trauma theory and research (e.g., Levine, 2010; Mate & Mate, 2022; Menakem, 2017; van der Kolk, 2014), including that specific to graduate and postgraduate supervision (e.g., Courtois, 2018; Knight & Borders, 2018; McChesney, 2022) to explore systems-level issues in establishing such a model within the university setting.  

While there are diverse perspectives on trauma, we gravitate towards those viewing trauma as embodied and involving not only the big T events (as in PTSD mapped out in the DSM) but the “small T” (often harder to identify) and complex traumas (e.g., racialized, attachment, and developmental trauma). Clinical therapist Resmaa Menakem conceptualizes trauma – including its racialized forms – as the body’s reflexive response to a shocking event, with individuals’ trauma responses unique. Bessel van der Kolk, author of The Body Keeps the Score, notes that trauma – an experience overwhelming the central nervous system – is marked by internal suffering rather than defined by the narrative of the event. Gabor Maté adds that trauma “is not the sexual abuse… not the war…not the abandonment…not the inability of your parents to see you for who you were. Trauma is the wound that you sustained as a result” (Maté & Maté, 2022, p. 20). Psychotherapist Peter Levine similarly emphasizes that trauma is held in and can be healed through the body. His somatic experiencing therapy frames trauma as the body’s inability to complete the fight, flight, or freeze response, and it uses bottom-up (versus top-down cognitive) processing to direct the client’s attention to and learn to regulate internal sensations linked with the traumatic event.  

Given that 70.4% of individuals will experience trauma at some point in their lives (Kessler et al., 2017), statistically speaking, a significant proportion of our counseling trainees will not only work with clients experiencing trauma but also themselves had or will have their own lived experience of it. Trauma is relevant and upfront for our trainees. 

In 2013, the Substance Use and Mental Health Services Administration (SAMHSA) joined a task force offering recommendations for best practices in working with individuals and families experiencing trauma. This working group developed an outline of trauma-informed care and specific guiding principles. According to SAMHSA (2014): 

“Trauma-informed care (TIC) views trauma through an ecological and cultural lens and recognizes that context plays a significant role in how individuals perceive and process traumatic events, whether acute or chronic. TIC involves vigilance in anticipating and avoiding institutional processes and individual practices that are likely to retraumatize individuals who already have histories of trauma. TIC upholds the importance of consumer participation in the development, delivery, and evaluation of services.” 

Trauma-informed care (TIC) involves best practices across sectors (e.g., healthcare, emergency services, social work, education), and their integration offers a proactive approach to attenuate the impact of trauma. In this article, we discuss SAMHSA’s six guiding principles: safety, trustworthiness, peer support, collaboration, empowerment, cultural, historical and, gender issues (SAMHSA, 2014; 2023), and we identify three areas relevant to delivering TIC in graduate training: A) faculty level; B) departmental /university level; and C) licensing bodies.  

A) Faculty Level

Given the prevalence and impact of trauma, there is a great need to provide content information to trainees who will later serve this population (and who may have or will experience trauma themselves). A content course may define and describe trauma (types, signs, symptoms, prevalence), provide information about trauma-informed care (e.g., SAMHSA’s six guiding principles), and introduce trauma interventions.  

An academic course on trauma may or may not be trauma-informed depending not only on whether trauma-informed care is covered but also on whether the faculty holding the classroom environment is conveying the SAMHSA principles of TIC (e.g., safety, trustworthiness, etc.). Just as it is important that clinicians be well-versed in both case conceptualization and technique, it is critical that we go beyond an intellectual understanding of trauma to model trauma-responsive practices. Without fully understanding what it means – and feels in their bones – to be trauma-informed, graduate students may bypass the important lived experience of co-creating a space marked by safety, trustworthiness, peer support, collaboration, empowerment, and attention to cultural, historical, and gender issues (SAMHSA, 2014; 2023). We can help trainees create a holding environment by guiding them to identify their own barriers to compassionate and culturally responsive care.  

Graduate students’ own trauma may be activated by course material, class discussions, and/or interactions with clients. Yet, we cannot avoid difficult topics; it is not only unrealistic given the content of courses, but it also does not prepare trainees to effectively (and ethically) work with clients. It risks their misunderstanding, bypassing, and/or shutting down clients’ thoughts, feelings, and experiences. We seek to invite students into a process - showing what it means to be trauma-informed in an experiential manner. 

Graduate students lacking this trauma-informed and process framework may have insufficient understanding of and tools to support clients who exhibit signs of trauma. Without such a process lens, providing treatment can be overwhelming for the graduate student and/or be [re]traumatizing for the client. For example, trainees may unknowingly opt for brief therapies, lacking the safety of the therapeutic relationship as a vehicle for establishing trust (see Norcross & Lambert, 2019). Furthermore, their countertransference may become evident (via ostensible irritation or confusion, pathologizing or assigning responsibility to the client for “slow progress,” victim blaming, and/or through projections). Many years ago, one of our supervisees expressed frustration at his client’s avoidance of emotions, insisting he was unable to help her (thus risking abandonment, which not ironically was one of her trauma symptoms). It became evident that the trainee changed the subject when his client got close to expressing sadness. In this way, the graduate student’s own barriers around vulnerable emotions not only invalidated his client’s experience but also risked re-traumatization by his distancing and blaming her for that which was his unexplored wound.   

What does it actually mean to be trauma-informed? Many of our graduate students have not heard of this term and those who have to find it abstract, ill-defined, and difficult to operationalize. We relate. For years, we saw signs and posters (“We are trauma-informed”) peppering our clinical offices, and we heard only vague references to trauma-informed care before we understood what it meant and how to apply it. We need to be well-informed, to be explicit, and intentional about teaching, modeling, and practicing TIC. Here are some concrete strategies we have used to translate the SAMHSA trauma-informed guidelines into our graduate courses:  

1) Safety: These practices contribute to a sense of well-being in the physical and interpersonal environment. To foster this, we sit in a circle which develops community and connection. We offer an introduction survey, inviting students to privately share their preferred name, gender pronouns, instructional needs, and any concerns about the course. In addition, we co-create community agreements – guidelines (reviewed in each class) to facilitate trust and safety in sharing. These agreements include confidentiality (to allow for authentic and vulnerable sharing), speaking from our own experience, avoiding advice or crosstalk, and holding space for others’ feelings without trying to fix them. Students may pause the class to request a grounding exercise if they are activated. We utilize “oops/ouch” to encourage a safe, collaborative, and process-oriented space, inviting students’ reactions (“ouch”) to cue a peer’s repair (“oops”), genuinely apologizing for the ways that their intention did not match the impact. The Move Up, Move Up tool, an anti-ableist alternative to “Step Up, Step Up,” involves sharing the floor; it emphasizes that all voices are valued and contributes to building group knowledge. 

2) Trustworthiness and Transparency: We do this through modeling authenticity, providing a clear and transparent rationale for course requirements, and recognizing the humanity of students and clients alike (e.g., taking a non-pathologizing lens). Given the interpersonal breach of trust experienced by trauma survivors (i.e., no safe person with whom to share their experience, Levine, 2010), we are especially invested in timely repairs (Tatkin, 2012) in the event of a rupture. We model this by checking in, inviting a process, honoring trainees’ feelings, and making needed corrections. 

3) Peer Support: This may involve classroom (or supervision) activities to support students’ awareness of and ability to sit with their own and their classmate’s feelings. Regardless of the graduate course or training site, the holding space in the group shows trainees how to stay with what is hard. In addition, classroom agreements, making space for students’ feelings and reactions, and the “ouch/oops” process engage peer support. We also use a variety of arrival and grounding exercises (e.g., mindfulness). This assists with – and models – noticing and naming thoughts, feelings, and sensations (which they may opt to share with peers) and facilitates emotional awareness and distress tolerance, which trainees can carry into their own sessions (Harris, 2019). This empowers graduate students to identify and take ownership of their internal states (reducing the likelihood of projection onto peers or clients).  

4) Collaboration: This is evident in many of the aforementioned areas, including our co-creating class agreements at the start of the semester. In addition, we regularly engage students in dyadic exercises to practice skills experientially as well as support one another in processing reactions to the material.  

5) Empowerment, Voice, and Choice: We help trainees connect with their resiliency by highlighting their strengths and abilities (this is particularly supportive for those lacking confidence) and by creating opportunities to reflect on their growth. We engage in “checking in/checking out,” taking the temperature of the class before moving into course content. Students are invited to share feelings and experiences they are bringing into the space from their “outside” lives. Checking out, we can explore shifts in their acceptance and ability to stay with difficult feelings – in line with their value of learning (Harris, 2019). We recognize the diverse ways that students learn best and participate in class discussions, and we offer opportunities to convey understanding via various channels (e.g., dyadic and small group work, individual reflections and exercises, eye contact, and nodding). The choice may involve options for assignments and a choice of grounding exercises. Finally, we invite trainees to develop an individual care plan, identifying three actionable steps to take over the semester (e.g., seeking therapy, time with friends, mindfulness practices, and exercise). We check in with each student over the semester to support their progress towards these goals.  

6) Cultural, Historical, and Gender Issues: This involves actively moving past cultural stereotypes and offering gender-responsive services, leveraging the healing value of traditional cultural connections, and recognizing and addressing historical trauma. We invite students to engage in self-reflection (whether private journaling, dyadic work, and/or classroom discussion) related to their social identities. When and how did they develop and/or become aware of these identities? How have they benefited from or been disadvantaged by them?  In what ways do these social identities offer power and privilege? How does this affect who they are as a therapist? In addition, students reflect on their family history: How were emotions handled? What was welcomed/tolerated/forbidden? What have they learned about communication and emotional responsibility? Such reflective and experiential activities build students’ awareness of and care for the diversity of human experience and foster their holding space for their classmates and clients. 

B) University/Departmental Level

Changing the culture in an individual course is foundational, though these classrooms risk becoming silos unless there is departmental and university reinforcement. Academic freedom allows faculty to teach in a trauma-informed manner – or choose not to do so; there is no mandate to teach in a trauma-informed way or to gain continuing education in this area. So, in addition to implementing a trauma-informed framework in individual academic classes and supervision, we advocate for programmatic change. A trauma-informed lens (across courses) does no harm yet helps many – by providing brave and inclusive learning environments marked by nurturance, respect, and support from educators and peers. Moving towards this framework does not place an undue burden on universities or compete for the resources within higher education. Because trauma-informed training is culturally responsive, inclusive, fosters students’ well-being, and is equitable, its adoption at the university level – beginning with the admissions process and later matriculation - supports diverse graduate student cohorts as they arrive in our programs and throughout their training. Trauma-informed care recognizes the prevalence of trauma, honors diverse identities by deepening awareness of issues of power and privilege, and prepares trainees to respond respectfully and appropriately to people of all cultures and other diverse backgrounds in a way that acknowledges, affirms, and values their client’s worth – all of which benefit graduate students and their clients. 

We are grateful for the departmental and university support of a trauma-informed lens in our own teaching and supervision, as well as for the rich discussions about the benefits of graduate requirements to include such a framework (which can be implemented across courses and supervision). And, for the university to additionally require a trauma content class (with an explicit focus on trauma signs, symptoms, prevalence, impact, and interventions) presents some practical problems (i.e., more requirements translating into higher tuition, increased time in the program and longer to enter the workforce, with delays in attending to the mental health needs of the public). To offer trauma coursework as an elective fosters students’ choice and empowerment, but it neither establishes it as a priority nor reaches each and every student (can a program say they are trauma-informed if they do not require a trauma course?). Although there are certificate programs focused on trauma, we believe that each and every counseling/clinical program should include a trauma-informed lens and trauma coursework (process and content, respectively). Trauma is ubiquitous. As such, there is a need for all graduate trainees in counseling/clinical programs to engage in this important work rather than certificate programs offering it post hoc.  

C) Licensing Bodies

At the broader level are the licensing bodies which determine content areas required for credentialing. These areas may differ depending on the state (and country) and the type of program (MA, LSW, Ph.D., Psy.D., Ed.D). We encourage these boards to require coursework in trauma-informed practice (including information about trauma, how it resides in the body and affects the individual, as well as trauma-responsive care and a process orientation). Without such a mandate, it is left to the individual university, which may be already struggling to balance the financial and time needs of its consumers (e.g., calling for shorter graduate programming) with the ethical issue of providing such training.  

In this article, we have presented the need for trauma-informed graduate training and supervision, and we have discussed several systems-level issues involved. We are left with some questions: How can we add trauma course requirements to graduate training without creating undue burdens (e.g., financial) for our students? What are we willing to give up (e.g., elective courses) or revamp (e.g., the current core curriculum) in order to make this happen? While it may be that graduate programs address this on an ideographic basis, we hope that this article inspires conversations across training sites and licensing bodies to best support our trainees and the clients they serve. 

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Rebecca brings a trauma-informed lens to her teaching and supervision, research, and clinical work. She is a Professor of Psychology at Westfield State University and a licensed clinical psychologist and health care provider. She received her M.Phil in Social and Developmental Psychology from the University of Cambridge and her Ph.D. in Child Clinical Psychology from the University of Denver, with a focus on adolescent depression. She is passionate about teaching counseling and developmental courses and supervising graduate trainees. Clinically, Rebecca specializes in treating internalizing symptomatology, particularly among individuals who have experienced developmental and interpersonal trauma. Her research examines self-worth contingencies, emotion processes, and rumination in the development of depression, as well as risk and resilience in relational trauma.

Cite This Article

Burwell, R. (2023). Considerations in Trauma-Informed Training. Psychotherapy Bulletin, 58(4), 45-50.

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