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Trauma-Informed Care

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Sarah Anderson

on 24 April 2015

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Transcript of Trauma-Informed Care

4. Collaboration & Mutuality
Importance is placed on partnering and the leveling of power differences between staff and clients and among organizational staff (from clerical to housekeeping personnel, to professional staff).
Demonstrating that healing happens in relationships and in the meaningful sharing of power and decision-making.
6. Cultural, Historical, and Gender Issues
The organization actively moves past cultural stereotypes and biases (e.g. based on race, ethnicity, sexual orientation, age, religion, gender-identity, etc.); offers, access to gender responsive services, recognizes the healing value of traditional cultural connections: incorporates policies, and processes that are responsive to the racial, ethnic and cultural needs of individuals served; and recognizes and addresses historical trauma.
The 6 Key Principles
1. Safety
2. Trustworthiness
3. Peer Support
4. Collaboration
5. Empowerment, Voice, & Choice
6. Cultural, Historical, and Gender Issues
The organization fosters a belief in the primacy of the people served, in resilience, and in the ability of individuals, organizations, and communities to heal and promote recovery from trauma.
Understand that the experience of trauma may be a unifying aspect in the lives of those who run the organization, provide services and/or who come to the organization for assistance and support.
Understand the importance of power differentials and ways in which clients, historically, have been diminished in voice and choice and are often recipients of coercive treatment.
Clients are supported in shared decision-making, choice, and goal setting to determine the plan of action they need to heal and move forward.
Supported in cultivating self-advocacy skills.
Staff are empowered to do their work as well as possible by adequate organizational support. This is a parallel process as staff need to feel safe, as much as people receiving services.
1. Safety
Staff & all clients feel physically & psychologically safe.
Interpersonal interactions promote a sense of safety.
High priority to understand safety.
2. Trustworthiness and Transparency
Operations within organizations are conducted with transparency with the goal of building and maintaining trust with clients and family members, staff and all others involved in the organization.

3. Peer Support
Peer support and mutual self-help are vital for establishing safety and hope, building trust, enhancing collaboration, and utilizing their stories and lived experience to promote recovery and healing.

5. Empowerment, Voice and Choice

Definition (NASMHPD, 2006) - The experience of violence and victimization including sexual abuse, physical abuse, severe neglect, loss, domestic violence and/or the witnessing of violence, terrorism or disasters

DSM IV-TR (APA, 2000) - Person’s response involves intense fear, horror and helplessness • Extreme stress that overwhelms the person’s capacity to cope

• Over a ten year study involving 17,000 people
• Looked at effects of adverse childhood experiences (trauma) over the lifespan
• Largest study ever done on this subject

ACE Study Findings

• 1 in 6 men have experienced emotional trauma
• 80% of people in psychiatric hospitals have experienced physical or sexual abuse
• 66% of people in substance abuse treatment report childhood abuse or neglect
• 90% of women with alcoholism were sexually abused or suffered severe violence from parents
• 2/3rd (67%) of all suicide attempts
• 64% of adult suicide attempts
• 80% of child/adolescent suicide attempts Are Attributable to Childhood Adverse Experiences
• Women are 3 times as likely as men to attempt suicide over the lifespan.

The Adverse Childhood Experiences (ACE) Study
Why is it important?
We might unintentionally cause harm by practices, policies and activities that are insensitive to the needs of our clients
Re-traumatizing someone unintentionally is a real possibility

Understanding trauma also means recognizing that our personal traumatic experiences or the stress associated with working in human services may impact our emotional and physical well being as well as our work success and satisfaction


Interactions that are humiliating, harsh, impersonal, disrespectful critical, demanding, judgmental

Interactions that express kindness, patience, reassurance, calm and acceptance and listening
Frequent use of words like PLEASE and THANK YOU

Congested areas that are noisy
Poor signage that is confusing
Uncomfortable furniture
Separate bathrooms
Cold non-inviting colors and paintings/posters on the wall

Treatment and waiting rooms that are comfortable, calming and offers privacy
Furniture is clean and comfortable
No wrong door philosophy: we are all here to help
Integrated bathrooms (clients and staff)
Wall coverings, posters/pictures are pleasant and coveys a hopeful positive message
The Importance of the Physical environment
The Importance of Policies & Procedures

Rules that always seem to be broken
Policies and Procedures that focus on organizational needs rather than on client needs
Documentation with minimal involvement of clients
Many hoops to go through before a client's needs are met
Language & cultural barriers


Sensible and fair rules that are clearly explained (focus more on what you CAN DO rather than what you CAN'T DO)
Transparency in documentation & service planning
Materials and communication in the person's language
Continually seeking feedback from clients about their experience in the program
A trauma-informed organization:

Increases safety for everyone
Improves the social environment in a way that improves all relationships
Reduces negative encounters and events
Creates a community of hope, wellness and recovery
Increases success and satisfaction at work
Promotes organizational wellness
Improves the bottom line
Principles of a Trauma-Informed Care Organization Include:
Safe, Calm, and Secure environment with supportive care
System wide understanding of trauma prevalence, impact and trauma-informed care
Culturally Competence
Consumer voice, choice and advocacy
Recovery, consumer-driven and trauma specific services
Healing, hopeful, honest and trusting relationships
A closer look
TIC is not an additional practice.
TIC is an approach, a philosophy, and a cultural change in the way current practices are delivered.

The Four R's: Key Assumptions in a Trauma-Informed Approach
A program, organization, or system
that is trauma-informed
the widespread impact of trauma
and understands potential paths
for recovery;
the signs
and symptoms of trauma in clients,
families, staff, and others involved
with the system; and
fully integrating knowledge about
trauma into policies, procedures,
and practices, and seeks to actively
resist re-traumatization

Guidance for Implementing a Trauma-Informed Approach
Developing a trauma-informed approach requires change at multiple levels of an organization and systematic alignment with the six key principles described before.

Domain 1. Early Screening and Comprehensive Assessment of Trauma
Developing respectful screening and assessment process that is routine, competently done, culturally relevant and sensitive and revisited over time.
Access to Recovery: From Principles to Action
1. Establish a safe environment.
Physical safety:
From abuse/stalking by partners, family, other consumers, visitors, staff

Emotional safety: Address and validate clients’ lived
Minimize re-victimization. Avoid strategies such as:
• Shaming
• Moral inventories in isolation
• Hard-core confrontation
• Intrusive monitoring
• Trigger situations

Organizational Self Assessment

What common trauma triggers might a participant
encounter in your program?

• Interacting with authority figures, in general
• Lack of privacy
• Removal of clothing (e.g., strip searches, medical
• Being touched (e.g., pat downs)
• Being watched (e.g., suicide watch)
• Loud noises
• Fear based on lack of information
• Darkness
• Intrusive or personal questions
• Lack of control and/or powerlessness
• Threat or use of physical force
• Observing threats, assaults, others engaged in self
• Isolation
• Being in a locked room or space
• Physical restraints (e.g., handcuffs, shackles)

The Institute for Health and Recovery outlines the following
steps to making trauma-informed changes

2. Use an empowerment model.
Always respect a client’s right to choose
Focus on client strengths
Build client skills

3. Support the development of healthy relationships
healing occurs by changing relationship context
from abusive to nurturing, unresponsive to empathic, lies
and denial to authenticity, and controlling to empowering.

4. Build healthy coping skills.
Emotional self-awareness
Making safe choices

5. Provide access to trauma-specific services. ATR
providers need to either give trauma-specific treatment
to clients who need it or make treatment available
through referrals to trauma-specific services.

Administrative Commitment

• Leadership supports long-term commitment to
trauma-informed services and approaches.
• Policy statement and/or amendment to organization’s
mission statement on trauma.
• Form a “change team” of staff and participants
to develop a plan to move toward being

• Identify or develop basic training around trauma
and trauma-informed services.
• Train all staff.
• Include clients willing to talk about their trauma
histories in the training.
• Incorporate training into new staff orientation.
Hiring and Human Resources Practice
• Identify or hire new staff with knowledge of trauma.
• Hire peers with trauma histories for peer-support
• Recognize and address the impact of secondary
trauma on staff.
What Is Trauma?
Why be Trauma-Informed?
Having a trained trauma-informed staff not only reduces the potential
for re-traumatizing clients' and families, but also helps make their entire service experience less overwhelming and more effective, and
potentially cost less in the long run.

Organizations also benefit internally from learning how trauma affects staff.

Trauma-informed workplaces have the resources to reduce “burnout” and mitigate “vicarious trauma.” Such support for employee well-being helps morale, retention and productivity, and strengthens the organization’s reputation as a respectful workplace.

The result hopefully will be an increased ability of the agency to attract high
quality staff.
Domain 2: Consumer Driven Care & Services

0= we don't meet this standard at all
1= we minimally meet this standard
2= we partially meet this standard
3= we mostly meet this standard
4= we are exemplary in meeting this standard (we have much to offer other grantees)
* A score of 4 means you met this standard very well and have expertise in this area that may be of help to other grantees interested in improving their performance around this standard

Domain 3. Trauma-Informed, Educated and Responsive Workforce
Increasing the awareness, knowledge and skills of the entire workforce to deliver services that are effective, efficient, timely, respectful and person centered taking into consideration that service providers also have histories of trauma.
Involving and engaging people who are or have been recipients of our services to play numerous roles (e.g., paid employee, volunteer, members of decision making committees, peer specialists) and meaningfully participate in planning, implementing and evaluating our improvement efforts
Domain 4. Provision of Trauma-informed, Evidence Based and Emerging Best Practices
Increase the awareness, knowledge and skills of the clinical workforce in delivering research informed treatment services designed to address the cognitive, emotional, behavioral, substance use and physical problems associated with trauma
Domain 5. Create a Safe and Secure Environment
Increase the awareness, knowledge and skills of the workforce to create a safe, trusting and healing environment as well as examining the changing policies, procedures and practices that may unintentionally cause distress and may re-traumatize those we serve.
Victim Witness Services
There are 6 Domains. Each domain has a specific topic and an average score based on the surveyed questions.
Domain 6. Engage in Community Outreach and Partnership Building
Recognize that the people we serve may be part of and affected by a larger service system including housing, corrections, courts, primary health, emergency care, social services, education and treatment environments such as substance use programs. We have an opportunity to engage and increase the awareness of these other service providers to the principles and practices of trauma-informed care. In this way, our efforts are less likely to be undermined by other parts of the system.
What can we do to Promote a Trauma-Informed Organization?
What is Trauma-Informed Practice?
Trauma-informed practice is grounded in specific education and training supported
by policies, included in, but not limited to the areas of: human resources,
supervision and crisis management. Other components include:
• Integrated universal trauma screening, assessments and service
• A strengths-based focus on resiliency, recovery and skills building;
• Continuous quality improvement
New clients screened for trauma receive an accompanying explanation as to what
trauma is and why it matters.
Paying attention to physical surroundings–such as
well-lit parking lots, sufficient signage in waiting rooms, and secure, well-marked
bathrooms–fosters a consistent sense of security.

Instead of asking “What is wrong with this child and family?” trauma-informed
practitioners ask “What has happened to this child and family?” Trained to this
simple shift in perspective, direct care staff recognize a “problem” behavior as a way
of coping with painful circumstances or as a stress response related to past trauma.

Trauma-informed staff gain trust by establishing and maintaining appropriate
boundaries and communicating clearly. Trustworthy organizations demonstrate
consistent policies and reasonable expectations.
They share power with consumersand value all perspectives. Collaboration with family and youth lets their insights as to individual and family history, culture and needs inform all phases of service planning and delivery such as where, how and when services are provided
First & Foremost - Agency Self-Assessment
Roles of people Surveyed: Staff (8), Volunteers (2), Interns (2), and Board Members (5)
VW score 3.01 Average

Staff: On initial intakes, in depth exploration is not always practical or (time) possible. Advocates can be experienced to be in 4 range, but we will always need volunteers which will make it more difficult to maintain optimal services.

- I feel this agency does a good job at meeting these standards.
- On initial intake forms, questions relating to previous trauma are not available.

- I view 'intake' from a volunteers standpoint. Our duties are to ensure the safety and needs of the victim, not explore their past. While a '1' looks negative, past trauma is simply and rightfully not the concern during a crisis intake.

"There is an increasing focus on the impact of trauma and how service systems may help to resolve or exacerbate trauma-related issues. These systems are beginning to revisit how they conduct their business under the framework of a trauma-informed approach."

-SAMHSA's Trauma and Justice Strategic Initiative
Therefore... We need to presume the clients we serve have a history of traumatic stress and exercise “universal precautions” by creating systems of care that are trauma-informed. (Hodas, 2005).
VW score 2.62
- I think of consumers as our clients and that they drive the process and their own outcomes but do not participate in our office policies and procedures.

- I think that we have recently become more interested in opening up a dialogue with employees regarding their ideas and thoughts about current standards/practices within VWS.

- This agency is great when it comes to the aspects of training as well as victim rights and program opportunities.

- From what I've seen, the organization allows the public to participate, but the public often does not participate in large numbers. Perhaps the opportunity to participate are not well known to the community.

VW Score 3.10
- I think we are moving in the right direction with regard to providing staff with trauma informed care practices for which they can rely on.

- VWS takes self-care very seriously, but are still learning to manage what triggers our stress and when to recognize it and approach it.

- This agency really recognizes the importance of how the staff feels and if they need any kind of support.

VWS Score 2.69
Again, we are only as good as our weakest link and our volunteers still need more training and experience re: trauma informed care and evidence based practices.

- This agency is good with providing services and follow ups.

Board Members:
- I don't know enough to comment.

VWS Score 2.86
- I don't think there are set 'systems' in place even though we seem to follow these type of guidelines.

- This agency is good at approaching physical and emotional incidences.

Board Members:
Given the success of VWS I am certain that these systems are in place.

VWS Score 2.96
- Still in progress - will be "4" exemplary within the year.
- We have community partnerships that have been developed but could expand on our reach to include new audiences.

- This agency is very good at putting themselves/services out to the public and other agencies and/or facilities.
- This organization has very good relationships with local agencies around town that help assist in crisis.

VWS Strengths
VWS Need Improvement
Domain 3 - Trauma-Informed, Educated & Responsive Workforce (3.10)
Domain 6 - Engage in Community Outreach and Partnership Building (2.96)
Domain 5 - Create a Safe and Secure Environment (2.86)
Domain 1 - Early Screening and comprehensive Assessment of Trauma (3.01)
Domain 2 - Consumer Driven care and services (2.62)
Domain 4 - Provision of Trauma-Informed, Evidence Based & Emerging Best Practices (2.69)
Based on the scores from each Domain:
Where does
10 Implementation Domains
Governance and Leadership

• How does agency leadership communicate its support and guidance for implementing a trauma-informed approach?
• How do the agency’s mission statement and/or written policies and procedures include a commitment to providing trauma-informed services and supports?

• How do leadership and governance structures demonstrate support for the voice and participation of people using their services who have trauma histories?

•How do the agency’s written policies and procedures include a focus on trauma and issues of safety and confidentiality?

How do the agency’s written policies and procedures recognize the pervasiveness of trauma in the lives of people using services, and express a commitment to reducing re-traumatization and promoting well-being and recovery?

How do the agency’s staffing policies demonstrate a commitment to staff training on providing services and supports that are culturally relevant and trauma-informed as part of staff orientation and in-service training?

How do human resources policies attend to the impact of working with people who have
experienced trauma?

What policies and procedures are in place for including trauma survivors/people receiving services and peer supports in meaningful and significant roles in agency planning, governance, policy-making, services, and evaluation?

• How does the physical environment promote a sense of safety, calming, and de-escalation for clients and staff?

• In what ways do staff members recognize and address aspects of the physical environment that may be re-traumatizing, and work with people on developing strategies to deal with this?

• How has the agency provided space that both staff and people receiving services can use to practice self-care?

• How has the agency developed mechanisms to address gender-related physical and emotional safety concerns (e.g., gender-specific spaces and activities).

Cross Sector Collaboration

• Is there a system of communication in place with other partner agencies working with the individual receiving services for making trauma-informed decisions?

Are collaborative partners trauma-informed?

How does the organization identify community providers and referral agencies that have experience delivering evidence-based trauma services?

What mechanisms are in place to promote cross-sector training on trauma and trauma-informed approaches?

Training and Workforce Development

• How does the agency address the emotional stress that can arise when working with
individuals who have had traumatic experiences?

• How does the agency support training and workforce development for staff to understand and
increase their trauma knowledge and interventions?

• How does the organization ensure that ALL staff receive basic training on trauma,
its impact, and strategies for trauma-informed approaches across the agency and across
personnel functions?

• How does workforce development/staff training address the ways identity, culture, community,
and oppression can affect a person’s experience of trauma, access to supports and
resources, and opportunities for safety?

• How does on-going workforce development/staff training provide staff supports in developing
the knowledge and skills to work sensitively and effectively with trauma survivors?

• What types of training and resources are provided to staff and supervisors on incorporating
trauma-informed practice and supervision in their work?

• What workforce development strategies are in place to assist staff in working with peer
supports and recognizing the value of peer support as integral to the organization’s
Progress, Monitoring and Quality Assurance

• Is there a system in place that monitors the agency’s progress in being trauma-informed?

• Does the agency solicit feedback from both staff and individuals receiving services?

• What strategies and processes does the agency use to evaluate whether staff members feel safe and valued at the agency?

• How does the agency incorporate attention to culture and trauma in agency operations and quality improvement processes?

• What mechanisms are in place for information collected to be incorporated into the agency’s quality assurance processes and how well do those mechanisms address creating accessible,
culturally relevant, trauma-informed services and supports?

• How does the agency conduct a trauma-informed organizational assessment or have measures or indicators that show their level of trauma-informed approach?

• How does the perspective of people who have experienced trauma inform the agency performance beyond consumer satisfaction survey?

• What processes are in place to solicit feedback from people who use services and ensure anonymity and confidentiality?

• What measures or indicators are used to assess the organizational progress in becoming
- Developed by SAMHSA
Screening, Assessment, Treatment Services

Is an individual’s own definition of emotional safety included in treatment plans?

Is timely trauma-informed screening and assessment available and accessible to individuals receiving services?

Does the organization have the capacity to provide trauma-specific treatment or refer to appropriate trauma-specific services?

How are peer supports integrated into the service delivery approach?

How does the agency address gender-based needs in the context of trauma screening, assessment, and treatment? For instance, are gender-specific trauma services and supports available for both men and women?

Do staff members talk with people about the range of trauma reactions and work to minimize feelings of fear or shame and to increase self-understanding?

How are these trauma-specific practices incorporated into the organization’s ongoing operations?
Created for Victim Witness Services
Engagement and Involvement

• How do people with lived experience have the opportunity to provide feedback to the organization on quality improvement processes for better engagement and services?

How do staff members keep people fully informed of rules, procedures, activities, and schedules, while being mindful that people who are frightened or overwhelmed may have a difficulty processing information?

How is transparency and trust among staff and clients promoted?

What strategies are used to reduce the sense of power differentials among staff and clients?

How do staff members help people to identify strategies that contribute to feeling comforted and empowered?
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