Trauma Informed Care – Toolkit
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Introduction
Empowering Service Providers to Support Refugee Mental Health with Trauma-Informed Care
This toolkit is designed for service providers who work with refugees and refugee claimants, offering a practical guide to providing trauma-informed care and settlement support. The toolkit is rooted in principles of human rights, social justice, and Canada’s commitments under International Humanitarian Law, and focuses on supporting the mental health and resilience of forced migrants.This toolkit provides a structured framework to better understand the refugee experience, apply trauma-informed care principles, and incorporate self-care strategies for both service providers and clients. It also contains essential tools, resources, and strategies to improve your work and foster a compassionate,effective response to refugee needs.
The BC Refugee Hub has developed this Toolkit in partnership with VAST as part of the BC Safe Haven Resource Network, led by AMSSA, funded by the Province of British Columbia.
PART 1: Support Refugee Mental Health & Trauma-Informed Practice with refugees
Trauma is any event(s) that overwhelms an individual’s ability to cope. Trauma can be:
- Vicarious: Experienced through others.
- Intergenerational: Passed through generations.
- Non-linear: Trauma’s impact can be unpredictable and vary over time.
Post-Traumatic Stress (PTS) is often a short-term response that is a normal and healthy reaction to abnormal circumstances, while Post-Traumatic Stress Disorder (PTSD) is a pervasive condition that affects an individual’s ability to proceed with their day-to-day activities or goals, and is diagnosed under DSM-5 criteria. Survivors of trauma demonstrate incredible resilience, and their experiences can teach and inspire others.
Refugees face unique challenges across three stages:
- Pre-Migration: Exposure to violence, persecution, and instability.
- Migration: Journey marked by danger, uncertainty, and loss.
- Resettlement: Adjusting to a new environment while processing trauma.
Important Considerations:
- Stress vs. Distress: Recognizing the difference between normal stress and harmful, pervasive distress is crucial in supporting refugees.
- Pre-existing Resources: Building on survivors’ strengths, skills, and resilience developed from their past experiences is key to effective support.
Additional resources:
Manual: International Rehabilitation Council for Torture Victims (IRCT) – Global Standards on Rehabilitation of Torture Victims https://irct.org/wp-content/uploads/2022/05/IRCT_Global_Standards_on_Rehabilitation_of_torture_victims_2020.pdf
Training: The Centre for Addiction and Mental Health (CAMH) – Immigrant and Refugee Mental Health Main Course https://www.camh.ca/en/professionals/professionals–projects/immigrant-and-refugee-mental-health-project/courses
Training: Canadian Centre for Victims of Torture (CCVT) – National Trauma-Informed Care Training Project https://ccvt.org/coming-to-terms-with-torture/
Research Article: Compassion fatigue: Coping with secondary traumatic stress disorder in those who treat the traumatized. https://psycnet.apa.org/record/1995-97891-000
Research Article: Moving from compassion fatigue to compassion resilience Part 4: Signs and consequences of compassion fatigue https://pmc.ncbi.nlm.nih.gov/articles/PMC7560777/
Quick Read: Compassion fatigue: Signs, symptoms, and how to cope https://www.cma.ca/physician-wellness-hub/content/compassion-fatigue-signs-symptoms-and-how-cope#:~:text=What%20is%20compassion%20fatigue%3F,trauma%20can%20become%20their%20own.
Quick Read: The Zone of Fabulousness: Resisting vicarious trauma with justice doing https://vikkireynolds.ca/wp-content/uploads/2019/09/2019-context-uk-zone-of-fabulousness-reynolds.pdf
Video: Alternative ways to look at Vicarious Trauma & Worker Burnout: The Zone of Fabulousness https://www.youtube.com/watch?v=XLmxb2sc_Nc
Quick Read: Understanding Refugee Trauma and Recovery: A Guide https://www.startts.org.au/blog/understanding-refugee-trauma-and-recovery-a-guide/
Quick Read: The National Child Traumatic Stress Network https://www.nctsn.org/
Quick Read: Refugee Mental Health: What You Need To Know https://www.mcleanhospital.org/essential/refugee-mental-health
Research Article: Recognizing and Breaking the Cycle of Trauma and Violence Among Resettled Refugees https://pmc.ncbi.nlm.nih.gov/articles/PMC8590436/
Manual: Fraser Valley Refugee Response Team (RRT) Information Sheet: Supporting Refugee Clients Who Have Experienced Trauma https://www.dcrs.ca/assets/media/2019/01/RRT-FV_Information_Sheet_Supporting_Refugee_Clients_Who_Have_Experienced_Trauma.pdf
Research Article: Applying Trauma-Informed Practices to the Care of Refugee and Immigrant Youth: 10 Clinical Pearls https://pmc.ncbi.nlm.nih.gov/articles/PMC6721394/
Manual: Pacific Immigrant Resource Society – Community Based Training Guide: A Trauma-Informed Approach https://pirs.bc.ca/wp-content/uploads/2023/02/Trauma-Informed-Community-Based-Training-Guide.pdf
The Hakomi Principles guide VAST’s trauma-informed care approach:
Mindfulness: Using present-moment awareness to explore and transform core beliefs.
Non-Violence: Creating a respectful, compassionate environment.
Mind-Body Integration: Understanding the deep connection between physical sensations, emotions, and unconscious patterns.
Unity: Emphasizing the interconnectedness of the human experience.
Organicity: Trusting in the innate wisdom and self-healing capacity within each person.
Judith Herman’s Stages of Trauma Recovery are crucial for understanding refugee healing:
- Safety and Stabilization: Ensuring safety and stabilizing the emotional state.
- Remembrance and Mourning: Processing traumatic memories and grief.
- Reconnection: Rebuilding relationships and understanding of self in a new context.
Additional resources:
Research Article: The Stages of Change: When are Trauma Patients Truly Ready to Change? https://www.utep.edu/lahdr/_files/research/document.pdf
Research Article: Recovery from psychological trauma https://onlinelibrary.wiley.com/doi/full/10.1046/j.1440-1819.1998.0520s5S145.x
Quick Read: 3 Stages of Recovery from Trauma & PTSD in Therapy https://healingmatters.ca/3-stages-of-recovery-from-trauma-ptsd-in-therapy/
VAST utilizes and shares its Vulnerability Assessment Tool to identify the urgent needs of refugees and prioritize their care. The tool involves a semi-structured interview and can be a good precursor to later using such standardized psychological measurements tools such as:
Harvard Trauma Questionnaire (HTQ)
Hopkins Symptom Checklist (HSCL)
PART 2: Trauma Informed Group Model
Trauma-informed group support recognizes the profound impact of trauma on individuals. It creates a space where survivors can safely process their emotions and experiences. The core principles of trauma-informed group support include:
- Safety: Ensuring a predictable and non-judgmental environment where participants feel secure.
- Empowerment: Allowing participants to have control over their healing journey by making choices about their participation.
- Collaboration: Building trust through shared experiences and mutual support.
This approach reduces isolation, enhances emotional regulation, and fosters collective healing.
Additional resources:
Manual: VAST Landing and Settling: A Group Therapy Program for Refugees in British Columbia https://drive.google.com/drive/u/0/search?q=landing%20and%20settling
Research Article: Inclusion, exclusion, and group psychotherapy: The importance of a trauma-informed approach https://psycnet.apa.org/record/2020-56134-003
Research Article: Trauma-Informed Groups: Recommendations for Group Work Practice https://link.springer.com/article/10.1007/s10615-019-00739-7
Quick Read: Group Therapy for Trauma: Is It Effective? https://www.charliehealth.com/post/group-therapy-for-trauma-is-it-effective#:~:text=Group%20therapy%20provides%20a%20space,in%20their%20emotions%20and%20reactions
Group development tends to follow five key stages:
- Forming: Initial planning and structuring of the group.
- Storming: Conflicts and challenges arise as group members test roles and boundaries.
- Norming: Trust is established, and group roles become clear.
- Performing: Group members actively work toward their goals.
- Adjourning: The group ends, with participants reflecting on the experience.
Each stage is crucial for building a safe, cohesive, and effective group dynamic.
Additional Resources:
Quick Read: Tuckman’s Stages of Group Development https://www.wcupa.edu/coral/tuckmanStagesGroupDelvelopment.aspx
Academic Article: Leading Teams #2: Stages of Group Development https://www.researchgate.net/profile/Sarah-Bush-9/publication/373727215_Leading_Teams_2_Stages_of_Group_Development/links/65a4257eaf617b0d8744e085/Leading-Teams-2-Stages-of-Group-Development.pdf
Trauma-informed groups must adhere to specific principles:
- Choice and Autonomy: Participants decide their level of involvement.
- Inclusivity and Accessibility: Practices that honor diverse cultural and individual needs.
- Invitational Language: Avoiding pressure and allowing participants to engage at their own pace.
- Collaboration: Groups are co-created spaces where participants feel valued and heard.
Additional Resources:
Research Article: Trauma-informed or trauma-denied: Principles and implementation of trauma-informed services for women https://onlinelibrary.wiley.com/doi/abs/10.1002/jcop.20063
Book: Trauma-Informed Principles in Group Therapy, Psychodrama, and Organizations https://www.taylorfrancis.com/books/mono/10.4324/9781003277859/trauma-informed-principles-group-therapy-psychodrama-organizations-scott-giacomucci
Quick Read: Understanding Trauma-Informed Facilitation https://www.nonprofitlearninglab.org/post-1/understanding-trauma-informed-facilitation-community-conversations-as-nonprofit-leaders#:~:text=Prioritizing%20physical%20and%20emotional%20safety,share%20or%20engage%20in%20conversation.
Manual: BC Ministry of Education – Compassionate Learning Communities, Supporting a Trauma Informed Practice – Facilitator Guide https://mytrainingbc.ca/traumainformedpractice/pdf/TIP_Understanding_FacGuide.pdf
Quick Read: Guidelines for Planning and Facilitating Trauma- and Violence-Informed Meetings https://www.kh-cdc.ca/en/resources/guides/guide3/index.html
Quick Read: Toolkit for Trauma- Informed Training Facilitation https://ofs.nashville.gov/wp-content/uploads/Trauma-Informed-Training-Toolkit-Final.pdf
Key techniques used in trauma-informed group support include:
- Grounding Exercises: Focus on physical sensations, such as the “5-4-3-2-1” exercise, which helps bring participants into the present moment.
- Mindfulness and Breathing: Techniques like box breathing to calm the nervous system and foster presence.
- Movement: Gentle yoga or body awareness activities to release tension and improve self-regulation.
Additional resources:
Quick Read: Practicing Mindfulness in Groups: 8 Activities and Exercises https://positivepsychology.com/group-mindfulness-activities/
Quick Read: Trauma-Informed Mindfulness: A Guide https://psychcentral.com/health/trauma-informed-mindfulness#can-mindfulness-cause-harm
Research Article: Single vs. Group Mindfulness Meditation: Effects on Personality, Religiousness/Spirituality, and Mindfulness Skills https://link.springer.com/article/10.1007/s12671-017-0865-0
Research Article: Mindfulness-based treatments for posttraumatic stress disorder: a review of the treatment literature and neurobiological evidence https://pmc.ncbi.nlm.nih.gov/articles/PMC5747539/
Research Article: The Role of Mindfulness and Embodiment in Group-Based Trauma Treatment https://pacja.org.au/article/94979-the-role-of-mindfulness-and-embodiment-in-group-based-trauma-treatment
The trauma-focused group model offers several benefits:
- Emotional Regulation: Techniques such as breathing exercises help stabilize emotions.
- Community Building: Group support fosters connections with others who understand shared experiences.
- Empowerment: Focuses on participants’ strengths and resilience, helping them regain a sense of control.
- Accessibility: Groups offer a welcoming entry point for those hesitant about one-on-one counseling, and for organizations who may not have the funding resources to be able to offer individual supports
- Mutuality: Being able to see ourselves in and through others is very helpful, and being able to see others at a different stage of the spectrum of healing, recovery, and progress, is beneficial to all, including to those who are able to shift to being in a position of helping others
Additional resources:
Book: Theory and Practice of Group Counseling, 8th Ed. https://students.aiu.edu/submissions/profiles/resources/onlineBook/y3b6k9_Theory_and_Practice_of_Group_Counseling-_8th_edition.pdf
Book Chapter: Group Work With Immigrants and Refugees https://books.google.ca/books?hl=en&lr=&id=c28RDgAAQBAJ&oi=fnd&pg=PA360&dq=benefits+of+group+model+support+for+refugees+academic+article&ots=oDCiEakcCT&sig=m7wXizFyXGVwSTT5yucsx4wiv9Y#v=onepage&q&f=false
Quick Read: Group therapy is as effective as individual therapy, and more efficient. Here’s how to do it successfully https://www.apa.org/monitor/2023/03/continuing-education-group-therapy
Quick Read: The Value of Support Groups https://www.psychologytoday.com/ca/blog/things-to-consider/202309/the-value-of-support-groups
Quick Read: What is the impact of peer support groups on refugees’ mental health? https://www.switchboardta.org/resource/what-is-the-impact-of-peer-support-groups-on-refugees-mental-health/
Research Article: Peer Support Groups: Evaluating a Culturally Grounded, Strengths-Based Approach for Work With Refugees https://advancesinsocialwork.indianapolis.iu.edu/index.php/advancesinsocialwork/article/view/21634
Research Article: Group Therapy for Refugees and Torture Survivors: Treatment Model Innovations https://guilfordjournals.com/doi/abs/10.1521/ijgp.2012.62.1.69
Powerpoint: Group Work: A Social Work Approach with Refugees https://www.iaswg.org/assets/FriendsofKisoro-Group-Work-A-Social-Work-Approach-with-Refugees.pdf
PART 3: Expressive Arts Therapy
Expressive Arts Therapy integrates creative methods (art, music, dance, writing, etc.) to help individuals process trauma. It provides a non-verbal outlet for expressing emotions and thoughts, especially for those who find it difficult to articulate their feelings through words. This therapy is particularly useful in trauma recovery as it allows for emotional release and healing in a safe, creative space.
- Holistic Engagement: Involves the mind, body, and emotions in the healing process.
- Non-Judgmental Environment: Encourages self-expression without the need for artistic skill or judgment.
- Process Over Product: The focus is on the experience of creating, not the final product.
- Mindfulness: The act of creation helps individuals be present in the moment, reducing distress.
- Empowerment: Participants have control over their creative choices, fostering a sense of autonomy.
Additional resources:
Video: What is Expressive Arts Therapy? An Introduction by Cathy A. Malchiodi, PhD https://www.youtube.com/watch?v=o2UVJ-ng9MA
Research Article: Introduction to the Use of Expressive Arts in Counseling https://connect.springerpub.com/content/book/978-0-8261-7702-5/chapter/ch01
Quick Read: 6 Benefits of Expressive Arts Therapy https://ctrinstitute.com/blog/6-benefits-of-expressive-arts-therapy/
- Emotional Expression: Helps individuals express feelings that are too difficult to verbalize.
- Healing Through Creation: Art offers a safe space for exploring trauma and healing without revisiting painful memories verbally.
- Restoration of Control: Provides individuals with the tools to reconnect with their sense of self and regain control over their healing process.
- Cultural Sensitivity: Creative expression is adaptable to diverse cultural contexts and can honor individuals’ backgrounds.
Additional resources:
Video: Four Functions of Expressive Arts Therapy in Trauma Recovery by Cathy A. Malchiodi, PhD https://www.youtube.com/watch?v=81RBSAPWI0k
Research Article: Effectiveness of trauma-focused art therapy (TFAT) for psychological trauma https://pmc.ncbi.nlm.nih.gov/articles/PMC10826536/
Quick Read: What Is Trauma-Informed Expressive Arts Therapy? https://www.psychologytoday.com/ca/blog/arts-and-health/202005/what-is-trauma-informed-expressive-arts-therapy
Quick Read: Expressive Arts Therapy Is a Culturally Relevant Practice https://www.psychologytoday.com/ca/blog/arts-and-health/201909/expressive-arts-therapy-is-culturally-relevant-practice
- Visual Art: Drawing, painting, and sculpting are common methods to represent emotions and release tension.
- Music and Sound: Playing instruments or listening to music helps facilitate emotional regulation and expression.
- Dance and Movement: Expressive movement allows the body to release stored trauma, promoting relaxation and healing.
- Writing: Journaling or creative writing provides a channel for reflecting on and processing trauma.
Additional resources:
Research Article: The Connection Between Art, Healing, and Public Health: A Review of Current Literature https://ajph.aphapublications.org/doi/full/10.2105/AJPH.2008.156497
Video: Expressive Arts Therapy and Trauma: Movement, Sound, Image, Performance with Cathy Malchiodi, PhD https://www.youtube.com/watch?v=SutB72QBvZs
Quick Read: Expressive Arts Therapy: 15 Creative Activities and Techniques https://positivepsychology.com/expressive-arts-therapy/#courses
PART 4: Organizational Assessment
Organizational assessments for trauma-informed and culturally appropriate practices are critical for ensuring that service providers are meeting the needs of refugees and other vulnerable populations. These assessments evaluate various components of an organization’s operations, from policies and practices to staff training and cultural competency. By conducting these assessments, organizations can identify areas for improvement, implement necessary changes, and create an environment that fosters healing, trust, and empowerment for those affected by trauma. Contact VAST if you are interested in obtaining support to conduct any of the below assessments.
● Self-Assessment: Evaluates the organization’s readiness to implement trauma-informed practices, focusing on staff awareness, safety policies, and the physical environment’s support for healing.
● Reception/Frontline Service Assessment: Assesses how well frontline services, such as intake and initial contact with clients, incorporate trauma-informed and culturally sensitive practices.
● Program Evaluation: Reviews the effectiveness of specific programs in meeting client needs and implementing trauma-informed care principles, with a focus on program outcomes.
● Managerial Assessment: Evaluates the organization’s management structure and practices, including leadership’s commitment to trauma-informed care and organizational support for staff.
● Overall Organizational Assessment Focus: A comprehensive evaluation of all aspects of the organization, ensuring alignment with trauma-informed and culturally sensitive practices at all levels
Additional resources:
Manual: Trauma-Informed Practice Guide (Ministry of Children and Family Development) https://www2.gov.bc.ca/assets/gov/health/child-teen-mental-health/trauma-informed_practice_guide.pdf
Toolkit: Canadian Centre for Diversity and Inclusion: Creating a diversity, equity, and inclusion strategy https://lp.ccdi.ca/ccdi-dei-strategy-toolkit
Manual: National Association of Social Workers – Standards and Indicators for Cultural Competence in Social Work Practice https://www.socialworkers.org/Practice/NASW-Practice-Standards-Guidelines/Standards-and-Indicators-for-Cultural-Competence-in-Social-Work-Practice
Manual: National Culturally and Linguistically Appropriate Services (CLAS) Standards https://thinkculturalhealth.hhs.gov/clas/standards
Manual: National Center for Child Traumatic Stress – Trauma-Informed Organizational Assessment https://www.nctsn.org/trauma-informed-care/nctsn-trauma-informed-organizational-assessment
Quick Read: What is Culturally-Sensitive Trauma-Informed Care? https://www.healthcaretoolbox.org/culturally-sensitive-trauma-informed-care
Research Article: Trauma-Informed Organizations https://www.ncbi.nlm.nih.gov/books/NBK207204/
PART 5: De-escalation Techniques and Communication Strategies
De-escalation is a crucial process in conflict resolution, especially when working with individuals who may be experiencing trauma, stress, or emotional overwhelm. The goal is to reduce emotional intensity and regain control of the situation to prevent escalation into violence or further distress. A trauma-informed de-escalation approach involves understanding the person’s emotional state, maintaining calmness, and fostering a sense of safety.
Additional resources:
Toolkit: De-escalation and responding to challenging situations https://oacas.libguides.com/deescalation
Quick Read: Collaborative communication during escalated situations https://www.camh.ca/-/media/images/all-other-images/covid-19-professionals/tidesinfosheetcollabcomm-pdf.pdf?la=fr&hash=917A6EC4D8EE67E3DB9408076EC2BBDAB53F0FB5
Video: Calming & De-escalation Strategies https://www.youtube.com/watch?v=R2PSExM-NhU
Quick Read: The DBT STOP Skill https://cogbtherapy.com/mindfulness-meditation-blog/mindfulness-stop-skill#:~:text=During%20Conflict%3A%20Take%20a%20moment,prevent%20overwhelm%20and%20regain%20focus.
Course: Nonviolent Crisis Intervention Training https://www.crisisprevention.com/our-programs/nonviolent-crisis-intervention/
PART 6: Torture Definition and Prevalence
Canada signed and ratified the United Nations Convention Against Torture (UNCAT) in 1987, agreeing to prevent torture locally and globally, and support the rehabilitation of survivors. According to UNCAT, torture involves intentionally inflicting severe physical or psychological pain on someone for purposes such as punishment, intimidation, obtaining information, or discrimination. Necessarily, torture refers to violence done by an institution that should be supporting or protecting a person, including police, military, healthcare, and education systems; and the violence is done based on some aspect of the individual’s identity. Most people may not be aware, but local and global data indicate that approximately 35% of all refugees and refugee claimants are identifiable as survivors of torture.
VAST has received continuous support from the United Nations Voluntary Fund for Victims of Torture since 1993, longer than any other rehabilitation centre globally. We strongly believe in every survivor’s right to rehabilitation, as outlined in international standards, including the Istanbul Protocol which defines how we can document the physical and psychological impacts. VAST is also a member of the International Rehabilitation Council for Torture Victims (IRCT), a global network focused on survivor rehabilitation and the prevention of torture.
Additional resources:
Quick Read: The Centre for Victims of Torture – Effects of Torture https://www.cvt.org/resources/effects-of-torture/
Manual: The Centre for Victims of Torture Manual for Group Counseling https://www.cvt.org/restoring-hope-and-dignity-cvt-manual-for-group-counseling/
Policy: Convention against Torture and Other Cruel, Inhuman or Degrading Treatment or Punishment
Policy: Implementing The Right to Rehabilitation
Policy: Istanbul Protocol