3. Response

3.1. A Trauma Informed Approach to Supporting Survivors of Community Violence in a Hospital Setting

Matthew Krock, MSSA, LISW-S

Objectives

  1. Identify and apply the six principles of trauma-informed care at the bedside when responding to community violence.
  2. Identify the four stages of escalation and the appropriate staff responses in the Crisis Development Model.

Introduction

The following guide presents a hospital bedside approach for patients, families, and hospital visitors affected by community violence, including gun violence, assault, and domestic violence. The guide incorporates a trauma-informed approach, Psychological First Aid (PFA), and Nonviolent Crisis Intervention strategies.

This article explains how a trauma-informed approach can serve as an overarching guide and describes the four stages of escalation and corresponding staff responses in the Crisis Development Model.

Key Content

Surviving trauma, particularly community violence, places intense strain on the individuals, families, and staff involved. People who receive appropriate support are less likely to experience retraumatization.

According to the Substance Abuse and Mental Health Services Administration (SAMHSA), a trauma-informed organization understands the widespread effects of trauma and possible paths to recovery. It recognizes signs and symptoms of trauma, integrates trauma knowledge into policies and practices, and actively works to prevent retraumatization.

Six principles guide a trauma-informed approach:

  1. Safety
  2. Trustworthiness and Transparency
  3. Peer Support
  4. Collaboration and Mutuality
  5. Empowerment, Voice, and Choice
  6. Cultural, Historical, and Gender Issues

1. Safety

Establishing and communicating safety to patients and their families must be the first priority. Although physical and perceived safety are related, they are distinct. Providers must address immediate safety concerns while also considering the survivor’s perceived sense of safety and their own safety.

Trauma survivors often experience a heightened sense of danger. Perceived threats can produce fight, flight, or freeze responses that may appear as:

  • Aggressive behavior: Yelling, threatening, intimidating, or engaging in violence.
  • Avoidant behavior: Rushing through interactions or appearing jumpy, nervous, or fidgety.
  • Shutting down: Not engaging with others or appearing numb, distracted, or “spaced out.”

A provider who feels unsafe may unintentionally respond in ways that elicit a trauma reaction and escalate the situation. Staff should understand these behaviors in the context of acute stress, avoid overreacting, recognize how their actions may escalate or de-escalate a crisis, and use adaptive coping strategies to manage their own responses to stress.

2. Trustworthiness and Transparency

In support of safety, providers must build rapport through trustworthiness and transparency. Offer as much privacy as possible to increase comfort and protect sensitive information.

  • Introduce yourself and explain your role.
  • Summarize what you already know and state your purpose.
  • Use clear, concise language and avoid jargon.
  • Adapt communication to the developmental level of the audience, particularly when speaking with children.
  • Observe signs of emotional or physical discomfort and address them before proceeding.
  • Ask about and respond to immediate needs.

Do not come empty-handed. Small gestures, such as offering a blanket, water, or useful information, can help build trust and rapport.

3. Peer Support

Reuniting patients with family members and loved ones is an important source of comfort and support. A patient experiencing acute trauma may arrive unidentified, be placed under an alias, or be too ill to communicate. Patients also frequently arrive directly from the scene without family or friends.

Separation from a loved one and limited access to information can be distressing for visitors. For an injured patient, separation may add to feelings of panic and isolation. Hospital staff also have an interest in connecting with relatives who may have critical information about allergies, medical history, and current medications.

Staff should identify the patient’s trusted family members or loved ones and appropriately manage visitation and access to patient information. Patients with intentional injuries may require additional safety and security precautions.

Large groups may gather following serious or violent injuries. Although their intent is generally to support the patient, managing the group can be challenging. Staff should:

  • Identify the patient.
  • Identify and contact the next of kin or primary decision-maker.
  • When a large group is present, designate one primary contact through whom information and instructions can flow.
  • Select a contact who is reasonably calm, communicates effectively, and is respected by the other group members.

4. Collaboration and Mutuality

Collaboration and mutuality are essential to maintaining a successful patient-provider relationship. Staff should emphasize shared interests and avoid power struggles. Health and safety provide a common foundation on which patients, loved ones, and staff can develop more specific goals.

Continuous communication and partnership are important when navigating a crisis. Providers may encounter patients and family members experiencing varying levels of anxiety and dysregulation. The Crisis Development Model can help providers identify crisis behaviors and choose a response that supports de-escalation.

The Crisis Development Model

The Crisis Prevention Institute identifies four levels of crisis behavior, each with a corresponding staff response:

Crisis Behavior Level Staff Approach
1. Anxiety Supportive
2. Defensive Directive
3. Risk Behavior Safety Interventions
4. Tension Reduction Therapeutic Rapport

Anxiety: Use a Supportive Approach

When a person shows signs of anxiety, use a supportive approach. Acknowledge that the person appears uncomfortable and offer assistance.

Defensive Behavior: Be Directive and Set Limits

Defensive behavior may include refusing requests, questioning staff authority, or using intimidation. The appropriate response is to be directive and establish limits. Strategies may include:

  • Use “when/then” statements.
  • Provide two appropriate options.
  • Establish clear and realistic boundaries.
  • Follow through when boundary violations occur.
  • Ignore inappropriate questions and answer appropriate questions.

Risk Behavior: Use Approved Safety Interventions

When a person engages in behavior that presents an immediate safety risk, nonviolent physical interventions may be required. These interventions should only be used according to organizational safety and security protocols and by staff who have the required training and authorization.

Staff should remain current on organizational workplace-violence policies and complete crisis prevention and intervention training at regular intervals.

Many violent incidents are preventable. Consistent use of evidence-based violence prevention and intervention models can help minimize risk.

Tension Reduction: Re-establish Therapeutic Rapport

Tension reduction typically follows an expenditure of emotional or physical energy, such as yelling, venting, or physical aggression. The individual may be emotionally and physically exhausted and beginning to regain rational control.

Providers can use this recovery period to re-establish communication through therapeutic rapport. Approach the person without judgment, use a nonthreatening manner, and provide support while the person recovers and regains control.

Providers seeking more detailed instruction in the Crisis Development Model and crisis intervention techniques should complete Nonviolent Crisis Intervention training from the Crisis Prevention Institute.

5. Empowerment, Voice, and Choice

The fifth principle of a trauma-informed approach is empowerment, voice, and choice. This principle is closely connected to collaboration and mutuality.

Loss of control and feelings of helplessness are inherent in crisis and trauma. The hospital setting may unintentionally add to these feelings. Survivors are suddenly placed in an unfamiliar system over which they may have little control. Family members must entrust the patient’s health and welfare to providers who, despite being trained and compassionate, are likely strangers.

Providers should empower patients and loved ones as much as is reasonably and safely possible. Create opportunities for their voices to be heard and their concerns to be addressed. Recognizing the inherent power imbalance between patients and providers can help prevent power struggles and escalation.

6. Cultural, Historical, and Gender Issues

Providers must understand how cultural, historical, gender, and other perceived differences can affect the quality of care. Health care disparities have been documented among populations based on race, gender, income, and other factors.

Health care systems and providers committed to high-quality care have a responsibility to address these disparities. Organizations should maintain nondiscrimination policies and actively promote diversity, equity, and inclusion.

Individual providers should:

  • Avoid stereotyping patients and visitors.
  • Participate regularly in anti-bias education from reputable sources.
  • Provide culturally affirming rather than alienating services.
  • Consider accommodations such as lactation rooms and developmentally appropriate environments and activities for children.
  • Recognize how religious beliefs may affect medical decision-making.
  • Become familiar with the population served and the surrounding community.

The places where people live, work, and play contribute substantially to overall health and wellness. These factors are known as the social determinants of health. Historical trauma also has real and lasting effects on current and future generations. Understanding and acknowledging these effects can help providers and organizations avoid perpetuating harm.

Takeaway Points

Patients seeking medical treatment immediately after community violence require specialized care and attention to prevent retraumatization.

  • Trauma-informed care provides an overarching framework that systems, organizations, and providers can use to support survivors of community violence, their loved ones, and hospital staff.
  • The Crisis Development Model provides specific tools clinicians can use to maximize safety by recognizing, preventing, and responding to a crisis.

Action Item

What barriers could prevent you from using these trauma-informed strategies in your interactions with patients and families? What could be done to address those barriers?

Additional Information

Training and Webinars

Books and Guides

  • Practical Guide for Implementing a Trauma-Informed Approach , Substance Abuse and Mental Health Services Administration.
  • Psychological First Aid: Field Operations Guide, Second Edition, National Child Traumatic Stress Network.
  • Skills for Psychological Recovery: Field Operations Guide, National Child Traumatic Stress Network.
  • Learner’s Guide: Nonviolent Crisis Intervention Foundation Course, Crisis Prevention Institute.

Journal Article