Trauma-informed work
in the room.
I want therapy that won’t make me go over everything.
A fictional teaching case across several sessions: safety before history, past sorted from present, a grounding instruction that doesn’t fit, and preparing for a necessary hospital stay.
What this is: a worked case with the therapist’s decisions made visible.
Why it matters: trauma-informed practice is easier to judge when you can see what it involves.
The sharpest moment: “I can’t feel my feet.”
One thing to take away: sort what is past, what is ongoing and what is necessary.
The short version
A fictional teaching case across several sessions. Oonagh has a spinal cord injury and a history of harm, some past and some recent. The case shows trauma-informed practice as a series of decisions: agreeing safety and the frame before any history, sorting what is past from what is ongoing, a grounding instruction that doesn’t fit her body and a repair, preparing for a necessary hospital stay, and distinguishing exposure to reminders from tolerating actual neglect, and leaving the choice about trauma-focused work to her.
The process in outline
Our framework- Agree safety and the frame first. Room, pace, information, how to stop, what happens if distress rises.
- Sort past from present. Which threats are over, which are ongoing, which situations are necessary and still coming.
- Address present threats. Practical safety, advocacy, preparation.
- Offer choices about trauma-focused work, including not doing it.
- Check every technique against this person’s body and experience.
- Review together, including what the therapist got wrong.
This sequence is this site’s way of applying SAMHSA’s principles in individual therapy. It is not a manualised protocol.
Oonagh is 39. Five years ago she fell from a horse and has used a wheelchair since; she has no sensation below her waist. Years earlier she left a controlling partner. Last spring, after surgery, she was left for hours in a soiled bed on a hospital ward, and nobody answered her bell. She now has panic attacks thinking about a planned operation in four months. She asks for therapy “that won’t make me go over everything”.
Oonagh is a fictional teaching example, not a real person.
Across several sessions
Illustrative sequenceSafety and the frame, before any history
They agree: online sessions on low-pain days, door visible, a stop word, no requirement to tell her history, a written summary afterwards. The therapist asks what helps when panic rises. Oonagh says: “Talk to me. Tell me where I am. Don’t tell me to breathe.”
Therapist’s decision: put the frame in place before any content. Asking what helps, rather than offering a standard technique, comes first.
Past, present and coming
Past
The controlling relationship. She has dealt with it, she says, and doesn’t want to revisit it now.
Recent, and repeatable
Being left in a soiled bed. It could happen again.
Coming, and necessary
An operation in four months, on a similar ward.
Therapist’s decision: respect Oonagh’s decision not to revisit the relationship. The work focuses on what is recent and coming, because those are what she is afraid of.
What the therapist is considering: whether the recent hospital neglect, rather than older memories, is driving the panic.
What remains uncertain: whether the relationship history is also part of it, and whether Oonagh will want to return to it.
What would change direction: Oonagh raising the relationship herself, or panic appearing in situations unrelated to hospitals.
A technique that doesn’t fit, and a repair
When panic starts, some people find it helps to notice their feet on the floor…
I can’t feel my feet.
I’m sorry. That was careless of me, and it’s exactly the kind of instruction that ignores your body. What do you notice that does feel steady?
My hands on the wheels. And my dog’s head on my knee, even if I can only see it.
Therapist’s decision: stop, apologise and ask. Why did this happen, when Oonagh had said in Session 1 “don’t tell me to breathe”? The therapist had heard that as a dislike of breathing exercises specifically, and reached for another standard script without checking whether it fit her body. The error wasn’t only the instruction; it was not checking. The new grounding uses what Oonagh can feel and see, and the therapist now checks every planned technique with her first. See Grounding Without Standing.
Preparing for a necessary hospital stay
Rather than trying to make the ward feel safe, they work on making the stay more controllable. With Oonagh’s consent, the therapist helps her write a one-page care plan covering continence care, call-bell response and what happened last time. They ask the hospital for a pre-admission meeting, and Oonagh’s sister agrees to visit at set times. Oonagh practises what she will say if her bell isn’t answered, and who she will call.
Therapist’s decision: preparation and advocacy for this admission. The distinction that matters is between working with reminders, or avoided situations that are safe enough, and asking someone to tolerate actual neglect. Exposure-based work is about the first; the bell going unanswered last time was the second, and the responsibility for preventing it lies with the hospital. Preparation and trauma-focused work may both have a place, depending on assessment and on what Oonagh wants.
What the therapist is considering: whether Oonagh also wants help with intrusive memories of the last admission; whether the hospital has actually agreed to the plan, or only received it.
What remains uncertain: whether involving her sister adds support or costs her privacy; whether practising what to say puts too much responsibility on Oonagh to prevent the next failure.
What would change direction: the hospital not engaging with the plan (then the focus shifts to complaint and advocacy); Oonagh finding the practice burdensome (then they drop it).
After the operation
The pre-admission meeting happened, and the care plan was in her notes. On the second night, her bell went unanswered for forty minutes. She rang her sister, who phoned the ward. Oonagh says: “It wasn’t okay. But I wasn’t helpless this time.” Her panic attacks have reduced. She says she might, one day, want to talk about the relationship. Not yet.
The formulation changes again: the plan helped her act, but it didn’t make the ward reliable, and that failure belongs to the ward. With her agreement, the therapist supports a written complaint about the unanswered bell. Oonagh’s nightmares about the first admission continue; she asks whether trauma-focused work could help with those, and they start planning it.
Several sessions is an illustrative sequence. Trauma work is often longer, and preparation doesn’t guarantee safety.
What the case shows
- What makes this trauma-informed: safety, information and choice before content; the person’s control over what is discussed; attention to the service’s own risks, not only to her reactions.
- A clear distinction between past, ongoing and necessary situations.
- A technique that assumed a body she doesn’t have, and a repair.
- Trauma-focused work offered, and declined for now, without that being a failure.
What needs attention here?
The person doesn’t want to revisit the past
Possible focus: respecting that, and working on the present
Watch for: insisting on processing
A necessary situation is frightening
Possible focus: preparation, advocacy and control
Watch for: exposure aimed at feeling safe there
A technique assumes a particular body
Possible focus: checking every technique against this person
Watch for: standard instructions
Possible starting points, agreed with the person, not rules.
Questions worth carrying, as a therapist
Therapist Reflection- Did I put the frame in place before asking for content?
- Have I sorted what is past, ongoing and necessary?
- Which of my techniques assume a body this person doesn’t have?
Evidence & sources
Sources checked in October 2026, using targeted searches rather than a systematic review. “We have not located” means our searches did not find it.
Safety; trustworthiness and transparency; collaboration; empowerment, voice and choice: SAMHSA (2014), SAMHSA’s Concept of Trauma and Guidance for a Trauma-Informed Approach.
The process outline, the therapist’s decisions and the reading of the case are this site’s synthesis.
Oonagh and the sessions are constructed for learning. She is not a real person, and these are not real sessions.
We have not located published case studies of trauma-informed therapy for adults with spinal cord injury preparing for further hospital treatment.
Last reviewed: October 2026.
How to cite this page: Donaghey, C. (2026). Trauma-Informed Work in the Room. Disability in Psychotherapy. Available at: https://disabilityinpsychotherapy.online/what-is-psychotherapy/trauma-informed-approaches/trauma-informed-work-in-the-room/ (Accessed: [date]).