Holes in "Traditional" Trauma-informed Practice Teaching -- Is Choice Always Trauma-Informed?


13 Oct

Trauma-Informed Practice In Healthcare -- Falling through holes in TIP Education

Written by Erika Cheng, MD, CCFP, FCFP

Have you ever given a patient or a client the opportunity to choose if they wanted a medication or not, in a compassionate, respectful and empathic way, only to have them suddenly yell at you? If you have, you are not alone.  Although offering choices is often necessary, and usually best practices, it can be triggering, and sometimes even reproduce abuse dynamics -- in other words, reproduce aspects of abuse interactions that someone had to endure  in the past.

But wait a sec! Isn't the offering of choice one of the pillars of Trauma-Informed Practice? So how can this be?

Trauma-Informed Practice education is fast becoming unofficially standardized with curriculum that was "first on the market" -- published with information that was known at the time when the topic was first being recognized by pioneers in the field.  However, much progress has been made in the understanding of the neuroscience of trauma, trauma therapy, dissociation, and dynamics of healing in the last ten to fifteen years . What is now clear is that some of the "standard TIP" curriculum is sturdy, while other aspects of it is only applicable in certain circumstances. In fact,  some of the standard recommendations frequently promoted as pillars of Trauma-Informed Practice is not always trauma-informed when applied universally, and indeed, can trigger survivors into anger against us, numbing against our input, or excessive anxiety over their situation.

One such area involves offering choices. Offering structured, safe choices in correct situations can be an extremely helpful aspect of providing safety.  However, unstructured choices, or choices carrying some degree of unpredictability or risk, can be extremely triggering or even reproduce abuse dynamics in other circumstances.  For example, adults who were "parentified" in their childhood -- forced to make too many decisions or carry out too many parental responsibilities for siblings because adult caregivers were preoccupied, abusive,  or neglectful -- can be easily triggered when we ask them to make too many choices, particularly when those choices carry inherent risks, such as happens often in healthcare when we ask patients to make choices involving risky medical decisions for themselves or their loved ones.

Offering certain types of seemingly benign choices can also trigger when we unknowingly reproduce abuse dynamics through the context in which the choice is offered. Remember that many survivors of childhood abuse were forced to make 'no-win' choices by perpetrators who covered up their coercion with the guise of choice in order to make the child feel as they 'asked for' the abuse.  No-win choices are frequent in healthcare if we seek, as we should, informed consent from patients and clients.  Medications carry risk, treatment choices carry risk, and so do the diseases and illnesses that we are hoping to treat with the treatment choices.

How, then, can we tell when it is trauma-informed to present choices, and how do we present risky choices in a truly trauma-informed way?

Understanding the "Trauma-in-a-Nutshell" (Cheng 2017) and "Triple S Goals" (in print, Cheng 2019) of TIP will help you have an easy to remember framework for making choices truly trauma-informed.  For details, see "The Handbook of Trauma-Informed Practice Essentials & Study Guide" (in print, will be available in the STORE in 2020) or sign up for our Banff 2021 workshop (see EVENTS page).  To find out more sooner, consider requesting a workshop for your team through info@beyond-the-cycle-of-trauma.org.  Workshops are held at reduced rates, and all proceeds are used to support  affordable education provided through the Beyond the Cycle of Trauma Institute (Beytcot).