Trauma Informed Care: Clients' Perspectives on Agency Experiences

Background and Purpose: Trauma informed care (TIC) research has examined client outcomes based on observed behaviors and described organizational practices that increase the five domains of TIC (client safety, trustworthiness, choice, collaboration, and empowerment.)  While staff may believe they deliver trauma informed services, less is known about clients’ perceptions of services.  This study addresses this gap by examining client accounts of receiving services at social service agencies in a region in the Northeastern United States. 

Methods:  Twenty-six in depth, semi-structured interviews were conducted with adults who were currently receiving agency-based social services.  The agencies were a convenience sample selected from a larger group of agencies participating in a TIC research study. For the client interviews, the researcher contacted each agency’s administrator. If they agreed to participate, they posted recruitment flyers in their common areas/waiting rooms. Researchers met with client participants individually at their agency. Participants received a $5 gift card after the interview. Agency types included refugees (n=4), substance abuse (n=3), mental health (n=5), older adults (n=12), and maternal/child health (n=2).  Participants were asked about their experiences of safety, trustworthiness, choice, collaboration, and empowerment at the target agency.  Interviews were recorded and transcribed verbatim.  Guided by phenomenology, interviews were analyzed using a multi-step content analysis method to explore participants’ lived experience of receiving social services in their particular setting.

Findings: Data analysis revealed themes in each of the five TIC domains and two overall themes.

Safety: Staff made clients feel safe, but clients sometimes felt unsafe with other clients.

Trustworthiness: Trustworthiness included delivery of services as promised, openness, and follow through.  Not all staff was considered trustworthy.

Choice: Some settings offered more choice than others.

Collaboration: Client definitions of collaboration included both opportunities to work with staff on specific goals and to suggest future services. 

Empowerment: Empowerment included recognizing strengths, listening to clients, and offering opportunities for education and self-direction. 

Theme 1:  Clients across settings experienced differences between how staff treated them and how they were treated by other clients.  Example: a respondent said another client cheated during recreational activities, so while staff was trauma informed, he had to “look out” for other clients. 

Theme 2: Although research suggests that TIC is a single construct (Hales, Kusmaul, & Nochajski, 2016), simultaneously addressing all sub-constructs was a challenge.  Example: a policy intended to increase safety, curfew in a facility in a dangerous neighborhood, was perceived by clients as decreasing choice.  

Conclusions and Implications: The interconnected nature of TIC constructs creates implementation challenges. In addition, clients in multiple settings reported that the TIC environment was challenged by other agency clients. Agencies need to address the ways and places that clients interact with each other and establish ground rules that are clear, enforceable, and trauma informed.  All stakeholders should review agency policies to ensure that they are trauma informed (staff, client, management).  Future research needs to examine the effects of trauma-informed policies on client experiences of each TIC domain.