Organizational Guidelines for Trauma Informed Care
Dr. Dawn-Elise Snipes, PhD, LPC-MHSP, LMHC
Objectives
~ What do we mean by trauma?
~ What do we mean by a trauma-informed approach?
~ What are the key principles of a trauma-informed approach?
~ What is the suggested guidance for implementing a trauma-informed approach?
~ What are the core training elements in developing a trauma informed system?
What Is Meant By Trauma?
~ An event, series of events, or set of circumstances that:
~ Is experienced by an individual as physically or emotionally harmful or life threatening
~ Has lasting adverse effects on the individual’s functioning and mental, physical, social, emotional, or spiritual well-being.
What Is Meant By Trauma?
~ 3 Es of Trauma
~ Event: Actual or threat of physical or psychological harm or significant neglect that disrupts healthy development and/or the individual’s ability to integrate his/her emotional experience is overwhelmed. Circumstances of the event commonly include abuse of power, betrayal of trust, entrapment, helplessness, pain, confusion, and/or loss.
~ Experience: How the individual labels, assigns meaning to the event. “Why me?” “How could this happen?”
~ Effects: Physical & neurological, emotional, interpersonal, cognitive, spiritual
What Is A Trauma-informed Approach?
~ Realizes the widespread impact of trauma and understands potential paths for recovery
~ People’s experience and behavior are understood in the context of coping strategies designed to survive adversity and overwhelming circumstances, whether these occurred in the past or present, or whether they are primary or secondary experiences
~ Recognizes the signs and symptoms of trauma in clients, families, staff, and community
~ Responds by fully integrating knowledge about trauma into policies, procedures, and practices
~ Resist re-traumatization
6 Key Principles of TIC
~ Safety
~ Trustworthiness and transparency
~ Peer support
~ Collaboration and mutuality
~ Empowerment, voice and choice
~ Respect for cultural, historical, and gender issues
Implementation Guidelines
~ IMPLEMENTATION DOMAINS
Governance and Leadership
Policy: Mission, “hard-wired” policy and cross-agency protocols
Physical Environment
Engagement and Involvement at all levels and in all areas of organizational functioning
Cross Sector Collaboration (LEO, Schools, Medical, Child Welfare)
Screening, Assessment, Treatment Services
Governance and Leadership
~ Agency leadership communicates its support and guidance for implementing a trauma-informed approach
~ The agency’s mission statement and/or written policies and procedures include a commitment to providing trauma-informed services and supports.
~ Leadership and governance structures demonstrate support for the voice and participation of people using their services who have trauma histories.
~ There is a TIC champion or committee responsible for assessing needs & developing an action plan. (Culture Warrior, Safety Liaison)
~ There is a TIC steering committee that moves the process forward, including people from all levels of the organization: Administrators, clinicians, medical assistants, clerical staff, families/youth, etc.
Policy
~ 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.
~ The agency’s written policies and procedures include a focus on trauma and issues of safety, avoiding re-traumitization and confidentiality.
~ 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.
Policy–Organizational
~ The organization makes decisions with transparency by documenting the values and rationale behind decisions that impact clients & staff
~ The organization has the capacity to provide trauma-specific treatment or refer to appropriate trauma-specific services.
~ Trauma informed continuous quality improvement activities are part of the organization’s culture and all staff and clients participate in them. (Including annual reviews, discharge evals, MIT surveys)
~ Goals for enhancing TIC in the program and providing TIC services on an individual level are incorporated into individual performance plans as well as program evaluations.
~ The agency has a policy that states the confidentiality and legally mandated reporting policies are reviewed with families at the beginning of service delivery and each time a request to share confidential information is requested.
Policy–Organizational
~ The TIC Team meets at least monthly
~ There are TIC subcommitties/domain specific workgroups
~ Trauma informed care outcomes are clearly identified including:
~ Safety: Ensuring physical and emotional safety for clients and staff
~ Trustworthiness: Making tasks clear, ensuring consistency within practice and maintaining appropriate boundaries
~ Choice: Maximizing choice and control
~ Collaboration: Maximizing collaboration and sharing of power
~ Empowerment: Building capacities and encourage having a voice and mastery of life and prioritizing the individual’s power and growth
~ Education about the impact of trauma
Policy–Organizational
~ There is a procedure for developing specific strategies for addressing disparities in targeted outcomes.
~ Number of clients screened for trauma
~ Number of clients with positive screen for trauma
~ Number of clients with a positive screen that receive a comprehensive trauma assessment
~ Number of clients referred to on-site trauma-specific services
~ Number of clients referred to off-site trauma specific services
~ Number of clients who accept referral and attend trauma specific services
~ Pre-and post survey of clients experience of onsite trauma-specific services (satisfaction, education, suggestions)
~ Client trauma-related health outcomes
Policy–Organizational
~ Staff members are trained in methods for keeping people who are frightened or overwhelmed fully informed of rules, procedures, activities, and schedules, even though they may have a difficulty processing information.
~ Transparency and trust among staff and clients promoted.
~ Identified strategies are used to reduce the sense of power differentials among staff and clients.
~ Growth and change is achieved through inquiry, self-reflection or assessment, and the acquisition of knowledge.
~ Staff members believe that healing and recovery is possible.
~ Staff members believe that the agency can improve and grow.
~ Positive risk taking is seen as an essential part of the process of change for staff and clients.
Policy– Organizational
~ All policies are designed to further the principles of
~ Nonviolence and trust by helping to build safety skills and a commitment to higher goals
~ Refusal to retaliate with physical or psychological violence
~ Emotional Intelligence by using emotional information to guide thinking
~ Capability of individuals to
~ Recognize their own emotions and those of others
~ Discern between different feelings and label them(and their causes) appropriately
Policy– Organizational
~ Social Learning (Constantly learning, problem solving)
~ Learn from one another, via observation, imitation, and modeling healthy interactions
~ Become aware of, articulate, and unlearn established patterns and routines (What are some toxic routines at your agency? That you have?)
~ Open Communication (Maintaining a flow of ideas)
~ Social Responsibility (Common goals and focus) Helping to rebuild social connection skills, establish healthy attachment relationships
~ Democracy creating civic skills of self-control, self discipline, and administration of healthy authority Communicating that everyone’s participation as a personal responsibility
~ Growth and change to restore hope, meaning, purpose and empower positive change
Policy—HR and Training
~ Job descriptions include an accurate description of skills and attributes that support a trauma informed organization
~ Recruitment material clearly describes the job duties and application process in a way that promotes TIC Principles
~ Policies exist that ensure interviews with prospective employees assess knowledge of trauma & its impact and self-care practices.
~ Agency staffing policies demonstrate a commitment to staff training on providing services and supports that are culturally relevant and trauma-informed. (When and what)
Policy—HR and Training
~ Onboarding information include resources for staff self-care, work life balance
~ All staff participate in an initial TIC training that includes trauma and its impact, resilience building, TIC principles and application to your setting, the Sanctuary Model and secondary traumatic stress prevention/intervention.
~ There is a policy to identify TIC training needs and develop annual training to review and/or enhance TIC practices in the organization.
Policy—HR and Training
~ Staff receives training to recognize individuals in crisis and provide calming/de-escalation strategies and techniques
~ Supportive measures are in place in the event there is a personal or workplace traumatic event
~ The organization supports ongoing self-care, wellness and work-life balance.
~ There is a constant flow of communication throughout the organization
~ When a layoff occurs, there is a procedure to support remaining employees, such as addressing the loss of coworkers, shifts in job responsibilities and load, goals of organization to maintain the current staff, or remaining employees’ concerns over their own job security
Policy—HR and Training
~ The agency has a “buddy system” to orient/support new staff and to encourage self-care activities for all staff
~ Resources are available to prepare supervisory staff with knowledge about TIC so they can guide staff in implementation.
~ Staff receives regular trauma-informed supervision
Core Curricular Elements
~ Training ensures establishment of an ongoing trauma informed structure
~ Feasibility of implementation
~ Procedures for continued training and maintenance
~ Procedures to monitor fidelity and effectiveness
~ Training includes
~ Information about the physical & neurological, emotional, interpersonal, cognitive, spiritual effects of trauma
~ Assessment, and culturally sensitive and trauma informed differential diagnosic practices for mental health and somatic complaints
~ Strategies for problem prevention and resolution on an individual, family and community level
Core Curricular Elements
~ Training includes established interventions to diminish distress such as:
~ Sanctuary Model
~ Seeking Safety
~ ACT
~ ARC
~ CPT
~ DBT
~ Compassion Focused Therapy for Trauma
Core Curricular Elements
~ Training ensures a full understanding of the local context/culture
~ Help-seeking expectations
~ Duration of treatment and obstacles to treatment
~ Preferences for type of intervention (medication, family-focused, cognitive, spiritual etc.)
~ Family and cultural attitudes and involvement in the recovery process
Policy—HR and Supervision
~ Human Resource policies & practices address the impact of working with people who have experienced trauma/toxic stress
~ Staff & supervisors are encouraged to monitor traumatic stress symptoms & initiate plans to reduce symptoms.
~ Resources such as Employee Assistance Programs and wellness activities are available to all staff and their use is encouraged and confidential
~ Policies exist for FMLA and bereavement leave
Policy—HR and Supervision
~ Staff has adequate access to timely supervision to address clinical, programmatic and stress-related issues
~ Members share responsibility for doing good work, adhering to the rules of the community, and being accountable for their behaviors and decisions
~ There is a procedure for the prevention and review of allegations of boundary violations, including sexual harassment and inappropriate social contacts.
Policy—Treatment and Crisis Management
~ The agency has TIC policies & practices regarding handling program emergencies, crisis situations and legal reporting requirements (reviewed at least annually with all staff.)
~ There a system in place to immediately respond to reports of current and harmful adverse life experiences such as domestic violence, community violence or natural disasters
~ Debriefing sessions are held following crisis situations & critical incidents to encourage healing and learning
~ Conversations in incident debriefs include use of reenactment terminology, including the three roles
~ Responses to disruptive or challenging incidents are used as opportunities for social learning through the use of red flag reviews, incident deconstruction and post-crisis analysis.
Physical Environment and Safety
~ Physical, psychological, social and moral safety for all members of the community is a primary value for the organization which guides all policies, practices and treatment
~ The milieu supports safety and treatment with posted schedules private meeting spaces and comfortable areas for learning and relaxing.
~ The physical environment is monitored for
~ Safety issues, including parking lots, entrances, etc.
~ Aspects that might be frightening or uncomfortable for those with a history of various types of trauma. (DV, kidnapping, fire, hurricane, abuse, hate crimes, car accidents)
~ Ways to promote a sense of safety, calming, and de-escalation for clients and staff
Physical Environment and Safety
~ 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.
~ Ethical issues or conflicts of interest are exposed and resolved.
~ Conflict in the community is raised and resolved in a safe way.
~ There are protocols in place for preventing and responding to violence.
~ Staff members use nonviolent techniques when dealing with difficult issues
Physical Environment and Safety
~ Community members are able to question or dissent from decisions made by those in authority and do not experience retribution or negative consequences.
~ Incidents of violence are actively processed to discern root causes, re-enactment dynamics and parallel processes and prevent reoccurrences.
~ The program offers predictable structure including rules, consequences and responses for clients/students.
~ Point and level systems are individualized, flexible enough to allow for recognition of improved behavior despite continued disruptive behavior, and reviewed and revised when necessary
~ Input from youth/families about perceived safety in the physical environment is obtained.
Physical Environment and Safety
~ Safety guidelines exist for staff, e.g. home visiting safety measures, signals for help, notifications of threats, etc.
~ Receptionists, security guards and others at the “front door” are trained to interact in calm and supportive ways.
~ Nonconfining spaces are available for private conversations.
~ The organization’s mission & values are clearly displayed & available to all staff and families/youth
~ Principles of Trauma Informed Care are prominently displayed
~ Staff provides services in a timely and reliable fashion; changes/exceptions are clearly communicated.
~ Staff turnover is minimized
~ Policies for communicating staff departures
Physical Environment and Safety
~ There is space where both staff and people receiving services can use to practice self-care.
~ The agency has developed mechanisms to address gender, age and disability-related physical and emotional safety concerns (e.g., gender-specific spaces and activities).
~ The physical environment reflects/honors the diverse groups in the target community
~ Include images, symbols, etc. from diverse cultures in the design & décor of the physical environment. (e.g. pictures, posters)
~ Seek input from representatives of all groups when building or renovating the physical environment.
Physical Environment and Safety
~ Spaces/furniture are arranged in ways that address culturally significant practices.
~ Services/reading materials are available in the languages that families/youth prefer
~ Language interpreters are provided for all essential service delivery.
~ All staff and supervisors are conscious of posture, gestures, voice, volume/tone and position at all times.
~ Staff provides regular feedback to organizational leaders about the workplace environment and service delivery
Engagement
~ Administrators, supervisors and staff interact with each other and with those who seek services in a nonshaming and respectful manner
~ Staff members clearly communicate program services, expectations, and limitations to families/youth
~ People with lived experience have the opportunity to provide feedback to the and organization on quality improvement processes for better engagement and services.
~ Opportunities exist for peer to peer case consultation and/or mentoring, and informal peer to peer support, such as celebrations, wellness activities, etc.
Engagement
~ The organization engages in outreach, engagement and recruitment activities that invite/encourage participation by families/youth (ex. Trauma quilt)
~ The organization has strategies to maintain engagement with families/youth (School and community presentations)
~ Mechanisms to obtain feedback from staff, families and/or youth about the organization’s policies & practices are utilized
Involvement
~ Waiting rooms are set up to invite interaction among families/youth
~ Formerly served families/youth are available as resources for currently served families/youth.
~ Families/youth lead organization efforts in peer support.
~ Feedback about organizational services and approaches are sought from staff, and families/youth, including those who are not receiving services
~ Clients serve on the organization’s governing board and/or family and/or youth advisory committee.
~ When addressing treatment issues or making organizational or programmatic changes, multiple perspectives are included, and decisions are not made autocratically
Cross Sector Collaboration
~ There is a system of communication in place with other partner agencies working with the individual receiving services for making trauma-informed decisions.
~ The organization has procedures to identify community providers and referral agencies that have experience delivering evidence-based trauma services and trauma-informed care.
~ An inventory of trauma-Informed community agencies is developed and maintained which includes information about Trauma-specific treatment resources in the community.
~ The agency promotes and facilitates cross-sector training on trauma and trauma-informed approaches.
~ The organization provides or refers families to opportunities for peer support and mutual self-help
Cross Sector Collaboration
~ Opportunities exist to participate with other organizations to sponsor, provide, and/or facilitate trauma informed care and community resilience building activities such as recreation activities, community projects, mutual self-help activities, etc.
~ The agency incorporates community building/resilience activities into its service delivery.
~ How does the agency provide information to families/youth about community activities and scholarships, transportation or other help for families/youth to participate in community activities.
Screening, Assessment and Treatment
~ Trauma-specific practices are incorporated into ongoing operations.
~ Screening
~ There a system in place to periodically re-screen clients who were initially screened as having none to few adverse life events
~ The agency addresses individual (age, gender, sexual orientation, ethnicity, etc.) needs in the context of trauma screening, assessment, and treatment.
~ Evidenced-based methods/tools to screen, assess and treat individuals in need of trauma-specific services are utilized: http://www.nctsnet.org/, http://www.nrepp.samhsa.gov/, http://www.ptsd.va.gov/professional/assessment/child/index.asp
Screening, Assessment and Treatment
~ Screening
~ Screening for trauma/toxic stress and resilience is incorporated into service delivery so that youth/families can be screened and receive appropriate services/care.
~ Clients report participating in discussions about their histories
~ Screening activities include education for families/youth about trauma/toxic stress and its impact.
Screening, Assessment and Treatment
~ Screening
~ There is a clear process for responding to screens and/or disclosures of trauma/toxic stress which includes offering support/affirmation, exploring trauma related needs and referring for trauma-specific intervention as needed/desired.
~ All members of the treatment team are aware of trauma histories and triggers and this knowledge is incorporated into the intake and discharge summaries, treatment plans, progress notes.
~ Conversations in team meetings or other venues include use of parallel process and collective disturbance concepts
Screening, Assessment and Treatment
~ Treatment
~ Staff that provide clinical treatment are trained in and utilize evidenced based, trauma specific interventions.
~ Staff members report an understanding of trauma on individual, family, community and organizational functioning
~ Staff members are curious about what behavior “means” rather than assuming that they already know.
~ Staff report knowledge of client history and ways that information influences their work with the clients
~ Emotional Intelligence: Recognizing and anticipating the influence that emotions have on behavior and using that information to guide practice
Screening, Assessment and Treatment
~ Treatment
~ For group-based programs/interventions, families/youth are involved in developing group rules, topics, learning objectives, etc.
~ A Motivational Interviewing approach is used to determine family/youth readiness for change & actions they wish to take.
~ Specific resilience building activities are built into the service delivery approach that increase supports, connections and capacities.
~ 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.
Screening, Assessment and Treatment
~ Treatment
~ Communications from staff encourage self care among clients and everyone has a self-care plan
~ Staff members help people to identify strategies that contribute to feeling comforted and empowered.
Screening, Assessment and Treatment
~ Treatment Plan
~ Families/youth participate in development & implementation of individual goals and their service/treatment plan
~ An individual’s own definition of emotional safety included in treatment plans.
~ Families/youth exercise choice in the way services are provided within an evidence based model
~ Treatment plans are strengths based and include language that reflects a lens of injury rather than sickness
~ Education provided to clients to explain the impact of adverse life events on a person’s whole health
~ Clients, staff and family members develop and are aware of safety plans
Screening, Assessment and Treatment
~ Emotional and Behavioral Regulation
~ Clients, families and staff recognize and manage feelings in non-harmful ways.
~ Emotional vocabulary used in conversations
~ Behavior management practices are strength based.
~ Staff, clients and families are able to identify and participate in an analysis of trauma-related behaviors
~ Trauma related behaviors are reviewed with the community and the possible existence of reenactment or collective disturbance is always considered.
~ Staff and clients participate in community meetings
Screening, Assessment and Treatment
~ Emotional and Behavioral Regulation
~ Members appear to feel safe to share
~ Conflict is addressed openly and nonviolently
~ Differing opinions are accepted and respected
~ Clients, families and staff teach and practice self-regulation/ coping skills
~ There are posted community norms or rules
~ There is availability of space for taking time away
Screening, Assessment and Treatment
~ Emotional and Behavioral Regulation
~ Interpersonal activities are observed to be based upon the importance of managing and modeling safe and respectful expressions of affect, regardless of context.
~ Treatment and supervision practices include conversations about emotional management and ways that coercive practices are avoided or disrupted
~ There is a mechanism in place to identify, discuss and correct drift from these strength based practices towards coercive practices. (i.e. address physical, verbal and psychological coercion)
Screening, Assessment and Treatment
~ Resources are available to assist clients, families and staff in dealing with loss.
~ Artifacts of loss rituals may be present (plaques, tree plantings, memorials, etc.)
~ Procedures are in place for assisting staff, family and clients in dealing with losses in the community
~ Peer supports are integrated into the service delivery approach.
Summary
~ 1: Show Organizational and Administrative Commitment to TIC
~ 2: Use Trauma-Informed, Culturally Responsive Principles in Strategic Planning
~ 3: Assign a Key Staff Member To Facilitate Change
~ 4: Create a Trauma-Informed Oversight Committee
~ 5: Conduct an Organizational Self-Assessment of Trauma-Informed Services
~ 6: Develop an Implementation Plan
~ 7: Develop Policies and Procedures To Ensure Trauma-Informed Practices and To Prevent Retraumatization. Review and Update Vision, Mission, and Value Statements
~ 8: Develop a Disaster Plan
~ 9: Incorporate Universal Routine Screenings
~ 10: Create a Peer-Support Environment
~ 11: Obtain Ongoing Feedback and Evaluations
~ 12: Change the Environment To Increase Safety
~ 13: Develop Trauma-Informed Collaborations
Summary
~ Trauma Informed Care requires buy-in at the highest levels of the agency and community.
~ It is imperative to have trauma informed services throughout the continuum of care (mental health, law enforcement, child welfare, schools)
~ Involvement of people who have trauma histories as well as staff and leadership creates an empowering collaborative environment.
~ Trauma Informed care creates a respectful environment in which all people feel safe, respected and empowered to achieve their goals.
Ponder This
~ How does it impact people who grew up in chaotic environments when there is high staff turnover?
~ How does it impact people who are survivors of abuse when staff is visibly stressed and unhappy?
~ How does it impact people who were neglected when staff fails to keep promises or is dismissive?
~ How does it impact people who were abused or victims of crime to be physically restrained?
~ How does it impact people with a trauma history when treatment is dictated for them and done to them?
Ponder This
~ How does it impact people who have had to live in a shelter due to natural disaster or to escape abuse when they are crammed into bedrooms like sardines or in crowded areas?
~ How does it impact the trauma survivor when they enter a new program and are not properly oriented in a way that is meaningful for someone who is under stress?
~ How does it impact a trauma survivor who has experienced alterations in their sense of spirituality and meaning when they enter a clinic that displays décor with highly religious themes?