Peer Support: The Three “E’s” and Four “R’s” of TIC

Trauma-Informed Care (TIC) requires for staff at all levels of trauma-informed services to recognize the presence of trauma symptoms and acknowledge the role that trauma plays in the lives of survivors. “SAMHSA’s Concept of Trauma and Guidance for a Trauma-Informed Approach,”1 has coined two mnemonic devices as part of a framework to aid in administering trauma informed care.

The first device is called “The Three E’s of Trauma.” This device is a simple method for diagnosing trauma. The method is used and extensively studied by all professionals in mental healthcare.

The Three E’s of Trauma

Events: Traumatizing events or circumstances may occur once or repeatedly over time. Such events may include actual occurrences or extreme threats of physical or psychological harm, or severe neglect that imperils a child’s healthy development.

Experience: The person’s perceived experience of the event or circumstance is what determines whether it is considered trauma. Two people may experience the same event, yet one may perceive it as traumatic and not the other. How the person assigns meaning to and is physically and psychologically disrupted by the event or circumstance is what makes it traumatic. Traumatic events and circumstances typically elicit a profound sense of powerlessness that leads to intense feelings of anger, humiliation, guilt, shame, blame, or betrayal.

Effects: The adverse effects of the event are a critical component of trauma. Adverse effects may occur immediately or may have a delayed onset. The duration of the effects can be short to long term. Sometimes the individual may not recognize the connection between the traumatic events and the effects. Examples of adverse effects include the inability to cope with the normal stresses of daily living; distrust in relationships; disruption in memory, attention, thinking; erratic behavior; uncontrollable emotions; hypervigilance; constant state of arousal; numbing; avoidance of certain stimuli; and physical, mental, and emotional breakdown.

Being traumatized means continuing to organize your life as if the
trauma were still going on unchanged.
~ Bessel van derKolk, M.D.

The Four “R’s”

The second mnemonic device is called, “The Four R’s,” which recommends four key assumptions in a trauma informed approach. TIC requires staff to be able to recognize, anticipate and respond to the issues, expectations, and needs of people who may have experienced trauma. The goal is to do no harm, ensure that staff and the people they serve feel physically and emotionally safe, and avoid retraumatization. Trauma-informed programs, organizations, or systems must respond by adopting a universal precautions approach in which one expects the presence of trauma in the lives of individuals being served, ensuring not to replicate it.

Universal Precautions of Trauma Informed Care2

  1. Assume that all people and connected persons with whom you are working are coping with the effects of trauma and modify your practice accordingly.
  2. Recognizing how your organization, your program, your environment, and your practice could potentially act as a trauma trigger.
  3. Recognize that you may also have experienced trauma and may be triggered by various circumstances and behaviors; and that you are susceptible to secondary trauma and must be aware of the warning signs.

The Four “R’s”

  1. SAMHSA’s Concept of Trauma and Guidance for a Trauma-Informed Approach. (2014, July). SAMHSA’s Trauma and Justice Strategic Initiative.
  2. Cestaro-Seifer. (n.d.). There is No Time Like Now to Build a Trauma Informed Workforce. The Southeast AIDS Education and Training Center.

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