Beyond a trauma-informed approach and towards shame-sensitive practice

Trauma is a significant public health issue, with evidence correlating it to various negative social and health outcomes. The trauma-informed approach (TIA) aims to integrate an understanding of trauma's effects into services. However, this paper argues that TIA fails to adequately address shame, a core emotional aftereffect of trauma. The authors contend that shame-sensitive practice is essential, providing a more effective way to address many post-traumatic issues. They aim to define shame-sensitivity and outline principles for its implementation in health, care, and social services. The introduction uses quotes from trauma survivors to emphasize the lived experience of shame in relation to trauma.

The paper reviews the existing literature on trauma, its long-term effects, and the development of the trauma-informed approach (TIA). It highlights the Adverse Childhood Experiences (ACE) study's impact on the understanding of trauma's link to health and social outcomes. The review then delves into the existing literature on shame, its various forms (acute and chronic), and its connection to trauma. Key aspects of this literature include shame's role as a world-organising affect for trauma survivors, its contribution to PTSD symptom severity, and its manifestation in various defensive behaviors like withdrawal, avoidance, and aggression. The review also explores how shame acts as a barrier to accessing and engaging with services, often leading to avoidance and attrition.

This is a conceptual paper; therefore, it does not employ traditional research methodologies. The authors use a literature review to establish the prevalence and impact of trauma and shame. They analyze existing literature on trauma-informed approaches and their limitations concerning shame. They synthesize this information to develop the concept of shame-sensitive practice. The methodology is based on examining published work, identifying gaps in current understanding and practice, and using this analysis to propose a new approach. There is no original data collection or empirical testing of the proposed model.

The key finding is the articulation of shame-sensitivity as a necessary addition to or even a foundational element of trauma-informed practice. The authors argue that shame is a pervasive and often overlooked consequence of trauma, acting as a significant barrier to service engagement and recovery. They present evidence demonstrating the interconnectedness of trauma and shame, emphasizing how shame manifests chronically in avoidance behaviors mimicking PTSD symptoms. Key components of shame-sensitive practice are presented as the 3As: acknowledging shame (on individual and organizational levels, including appreciating the differential experience of shame and recognizing shame and shaming behaviors), avoiding shaming (on individual and collective levels, including evaluating the impact of practice for shaming), and addressing shame (individually and by supporting shame resilience). These are elaborated on, with suggestions for practice changes.

The findings address the research question by demonstrating the gap in current trauma-informed approaches and proposing a novel framework—shame-sensitive practice. The significance of the results lies in the potential to improve service engagement and outcomes for trauma survivors by directly addressing the often-unacknowledged role of shame. The relevance to the field is in providing a practical, implementable framework for healthcare and social service providers, promoting more humane and effective support. The authors emphasize that shame-sensitivity is not just a supplement to TIA but has wider applicability, as everyone experiences shame, making it relevant to all populations.

This paper's main contribution is the conceptualization and operationalization of shame-sensitive practice as a crucial element of working with trauma survivors and individuals facing the impact of shame more broadly. Future research should focus on empirical testing of the proposed 3A model in various settings, investigating its effectiveness in different populations, and developing practical tools and training programs to facilitate the adoption of shame-sensitive practice. Furthermore, research should explore the interplay between shame-sensitive practice and other approaches to working with trauma and adversity.

As a conceptual paper, this work lacks empirical evidence validating the effectiveness of shame-sensitive practice. The framework is presented as a theoretical model, and its application across various contexts and populations requires further investigation. The authors acknowledge the complexity of addressing shame, especially chronic shame, and the potential for challenges in its implementation within existing service systems.