Trauma-Informed Design as a Practice of Care

In the Australian context, 55-75% of Australians will experience a potentially traumatic event at some point in their lives (Mills et al. 2011; Rosenman 2002). Our individual and collective experiences of trauma influence how we relate, think, and act. Given the prevalence of trauma, human centred design could be considered the process of designing for and with bodies and minds impacted by trauma, by bodies and minds impacted by trauma. However, this acknowledgement and responsiveness to trauma in design is not our reality. As it stands most designers do not have the capacity to practice trauma-informed design in a skilful or useful manner.

In this piece, I discuss trauma-informed design as an emerging practice within human centred-design. I begin by positioning myself within this work, and then exploring what trauma is and the history of trauma-informed practices within health and human services. I then discuss trauma-informed design practice (TIDP), drawing on research and professional insight, and then attempt to situate this emerging practice within care ethics and cultures and practices of care. I conclude by reflecting on the concept of ‘practice’ and noting areas for further research.

My Interest Trauma-Informed Design Practice

I feel it is important to position and contextualise myself within this work – acknowledging my interest and motivation in enabling trauma-informed design practice is in part driven by my own trauma recovery and an attempt to support others’ recovery – having experienced “person-centred” systems, services and cultures which harm and re-traumatise rather than heal.

It is personal due to my lived experience of vicarious trauma and connection to people exposed to various forms of trauma (sexual violence, child abuse, medical etc.). It is personal due to supporting loved ones navigate systems and services which speak of “human-centredness” in some shape or form, yet disempower, transact rather than relate, and lack both safety and transparency. I consider this a failure of design. You cannot truly design for humans at the centre, without acknowledging and responding to trauma.

It is professional due to my previous work in sexual violence prevention where I led the co-design of a violence prevention strategy. This work involved survivors, activists, scholars, administrators and more – all working to change a system which had enabled sexual violence to occur and had failed to acknowledge, respond and support the healing of individuals and communities. Knowing what I do now, I recognise that while I was guided by ‘good intentions’, I was ill prepared for this work, that as a designer and professional I lacked awareness and support for vicarious trauma, and that there were significant potential harms that may have been caused to those I worked and designed with (noting, I am grateful that to my knowledge, no harm was caused).

As I’ve reflected on this experience over the years, I can see how my being new to ‘design’, my desire to do ‘good’, and my ego and my interest in ‘doing’ design and ‘being’ a designer – took priority more so than what I now see as a designer’s primary responsibility – the care of those I worked and designed with.

What is trauma?

The US Substance Abuse and Mental Health Administration (2014) defines trauma as:

“An event, a series of events or a set of circumstances experienced by an individual as physically or emotionally harmful or life threatening that has lasting adverse effects on the individual’s functioning and mental, physical, social, emotional, or spiritual well-being.” (SAMSHA 2014)

While trauma does not discriminate, trauma exposure is more common among specific groups such as people who experience homelessness, young people in out-of-home care, refugees, women and children experiencing family and domestic violence, LGBTIQ people, First Nations people, and certain occupation groups (for example emergency services, armed forces and veterans) (Bendall et al. 2018, AIHW 2018, AIHW 2020).

While trauma is experienced individually, collective and intergenerational experiences of trauma (e.g., racism, natural disasters, COVID-19) shape our societies and cultures. Resmaa Menakem (2021), in his book, My Grandmother’s Hands, beautifully illustrates this through the following quote:

“Trauma decontextualized in a person looks like personality. Trauma decontextualized in a family looks like family traits. Trauma decontextualized in a people looks like culture." – (Menakem 2021)

People exposed to trauma can experience a range of responses, both to varying extents and at different stages post exposure. Figure 1 below illustrates some of the common responses to trauma exposure. It is likely a participant or designer experiencing such responses during a design project will have difficultly meaningfully engaging unless there is awareness of trauma and sensitivity to its dynamics, in all aspects of the project.

Figure 1 'When Experiencing Overwhelm & Trauma' from (TSI 2021)

Trauma-Informed Care and Practice

Trauma-informed care and practice emerged as an approach to the delivery of health and human services in the 1990s based on work from the mental health and substance abuse sector. This approach recognised and acknowledged trauma and its prevalence, alongside awareness and sensitivity to its dynamics, in all aspects of service delivery. It also acknowledged that as the services were currently delivered, rather than "healing", many people were experiencing trauma in the service context itself (i.e., re-traumatisation)(Benjamin, Haliburn & King 2019).

Over the three decades since trauma-informed care has emerged, the breadth and depth of trauma-informed practices has continued to evolve and expand – moving into spaces and contexts outside of health and human services (classrooms, design studios, research, and more). With broader application, several principles of trauma-informed practice have begun to emerge. One example in the Australian context includes the NSW Agency for Clinical Innovation outlines 5 principles of Trauma-Informed Care (see Figure 2 below).

Figure 2 Trauma-informed care principles, NSW Agency for Clinical Innovation (2019)

Trauma-Informed Design Practice

In applying the tenets of trauma-informed care practice to design, a definition of TIDP could be:

A trauma-informed approach to design practice recognises and acknowledges trauma and its prevalence, alongside awareness and sensitivity to its dynamics, in all stages of the design process. It engages participants as partners in design and emphasises safety, choice, empowerment, trust and collaboration. It acknowledges the potential of design itself to harm and re-traumatise, not only participants, but designers themselves. It acknowledges the power of design to heal, connect and restore.

TIDP began to be adopted in the early 2000s in relation to the design of the built environment – mostly schools, hospitals or prisons (Elliott et al. 2005; Jewkes et al. 2019). These practices were focused on designing welcoming environments for people with experience of trauma by removing or reducing known adverse stimuli. This approach has matured within architecture and urban planning and has expanded into social issues such as homelessness and the design of temporary shelters (TID 2021).

While there is rich literature and experience of TIDP in relation to the built environment, TIDP within Human Centred Design (HCD) is a more recent discussion which began to emerge ca. 2018. These discussions have been led primarily by design practioners and have focused both on mitigating the risk of re-traumatising design participants and managing the risk of secondary trauma to designers (Deitkus, 2021; Fatllah 2021; Hussain 2021; McKercher 2020; Wechsler 2021). Further, they have also begun to critique common design practices through a trauma-informed lens - acknowledging that the ambiguity, lack of control and power sharing, and the extractive nature of many design practices can in themselves cause harm and re-traumatising. McKercher (2021) offers these examples from the field of good intentions, gone bad:

• Do not use autobiographical journey mapping with trauma survivor - Asking people to step through what happened in painful, sequential detail unnecessarily forces people to re-live their trauma in painful detail.
• Letting people with lived experience think their only value is in sharing their story. It can trigger panic and stress thinking about whether we will be asked to re-live our trauma in front of strangers during co-design.
• Focusing on issues and adversity without balancing resilience and strength.
• Challenging, minimising and comparing experiences.

In building a case for the adoption of TIPD, emerging research has shown that as design has embraced approaches and methods that bring designers and participants closer together, the potential for participants to experience qualitative research as therapy exists. This introduces complicated ethical considerations and may pose unanticipated risks (Hirsch 2020)– particularly in considering re-traumatisation. Further, research has also begun to explore the "emotion work" performed by design researchers: how researchers may experience emotional distress during research activity and how this experience may impact their work (Balaam et al. 2019). This will become increasingly important in conversations about managing secondary trauma among designers. Further research is needed to understand TIDP within the context of HCD – not only to influence current design practice, though to inform design education and the future of design.

Design as a Practice of Care

Much of the discussion thus far has focused on the “what” of TIDP and operates on the presumption that if design as currently practiced can and does cause harm, then, preventing and or mitigating that harm, through TIDP or otherwise, is the rational or logical choice. It then becomes about managing risk. While I believe this is part of a reason for adopting TIDP, on its own, I believe it is limited. Design which prevents and mitigates harm does not necessarily equate to design that heals and restores. And if design neither harms nor heals, what does it do? Perhaps, it cares.  

I believe design as a practice of care and care ethics provide an interesting and alternative frame from which to consider TIDP. Design as a practice of care is a disposition of practice that utilizes a design mindset within a framework of care ethics and that is practiced in all design contexts, not just explicit “care” contexts (Vaughan 2018). Care ethics is a feminist approach to ethics that emphasises connection to others and defends some emotions, such as care or compassion, as moral. This approach also recognises that rules must be applied in a context (Ethics Centre 2021).

Vaughan (2018) proposes that a practice of care, design or otherwise, is grounded in the following:

• Connection to the subject of care— either through relationship or empathy;
• Expectation that the actions of care will have an impact or meaning for those being cared for; and,
• Capacity to perform the actions of care in a skilful and useful manner.

Care, in this context, is active, and may be based on empathy, but empathy may or may not result in acts of care. Vaughan (2018) further notes that although care can be used in everyday vernacular to articulate emotional connection to a person, place, or thing, it is the actions of care— the things that we do— that are the true articulation of care in practice.

It is this act of ‘caring’ that I believe holds promise in situating TIDP within design as a practice of care. TIDP is relational and involves acts of care for participants and designers – from considering safety in the physical environment, building relationships between designers and participants, partnering with participants as ‘co-designers’, selecting appropriate tools and methods, to including regular debriefs for the design team. Designers adopting TIDP do so out of an expectation that the acts of care involved will have an impact – though, whether they have meaning from the participants’ perspective will prove an interesting area of future research. However, as it stands, most designers do not have the capacity to perform TIDP in a skilful and useful manner. While there are numerous paths to building capacity in trauma-informed care, few exist that are tailored to HCD. This is an issue requiring urgent attention as Vaughan (2018) notes “just any old action undertaken with good intention will not do”.

While TIDP may have greater relevance in explicit “trauma” contexts, such as design in health and human services, I believe it has relevance as an approach in all design contexts. This is supported by Vaughan (2018) and their proposal that if we look through a framework of culture we can envision and realize a more expansive interrogation of care as both an approach and a context for design practices. As such, I believe we find further support for TIDP in all contexts through considering its principles applied at different scales.

• At the micro level, TIDP is about care in the design process itself, and largely the primary focus of this piece. At this level, it is about tools, methods, relationships between designers and participants, environment, time, and speed.
• At the meso level, TIDP then becomes about cultures of care in which design itself takes place. At this level, it is about support in place for designers and participants, ethical guidelines to selecting design projects, having the right designers with the right skills, for the right projects, compensating participants for their time/contributions.
• At the macro level, TIDP evolves more broadly into a design ethic and intersects with emergent design practices and approaches such as restorative design, decolonising design, transition design, design justice and more. At this level, it is about design that heals (or restores), that acknowledges the depth of the human experience, that distributes power and embraces lived experience, and that guides rather than directs.

Conclusion

In this piece, I have explored TIDP and sought to situate it within design as practices and cultures of care. In so doing, I have attempted to engage more theoretically, and not so on specific and actionable practices. This being said, I wish to conclude with a focus on term ‘practice’. A practice is ongoing, deliberative, and dynamic. A practice is not, or never will be, perfect. A practice evolves over time through reflection. A practice is not a guarantee, and in the context of TIDP, it is not a way of avoiding all harm and risk. Things can and will go wrong. Design will trigger and re-traumatise. Avoidance is not the goal. Design’s value is in its ability to engage and grapple with the heavy and complex aspects of the human experience. Though, we can and must do so with care. We as designers must learn about and become responsive to trauma. We must shape our practices and change our cultures to become trauma informed. The journey, as with the practice, is ongoing – though there is no time like the present to get started.

Questions, Curiosities and Future Research

The following are but a few of the questions which arose through the research I hope to explore in future:  

• When might design care “too much”? – Are there limits on the role of care in design? What about care burden on designers?
• When and where should design practice be trauma-informed?
• How might design education be trauma-informed to educate trauma-informed designers?
• How might we get current designers to “care” about trauma-informed practice?
• How will we know if our practices are perceived as trauma-informed? What tools exist to measure the intent and reality of care?

References

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