Trauma Matters - August 2007

Necessary Steps in the Transformation to Trauma-Informed Care
Trauma-Informed Care: What Mental Health Consumers Have Sought All Along
Trauma-Informed Care Improves Efficacy of Crime Victim Services
SAMHSA Convenes Experts to Assess Impact of Historical Trauma on Behavioral Health Care and Research
Ohio: Trauma-Informed Care ‘Crucial’ to Effective Child Behavioral Healthcare

Susan Salasin, CMHS Federal Project Officer
National Center for Trauma-Informed Care

In the early 1990s public mental health and substance abuse service providers began to recognize the magnitude of the sheer numbers of people coming in to their programs who had abuse experiences, giving rise to the “trauma syndrome.” Initially, much attention was focused on the pervasiveness of trauma (prevalence and frequency), the medical and physical health consequences, the precipitous spiritual questioning engendered, and the inter-relationship of trauma with commonly labeled psychiatric and substance abuse disorders.

What followed from the recognition of the presence of trauma, however, was a related realization that existing providers lacked the capacity to effectively assist people with histories of abuse and trauma. A number of deeply troubling service delivery failures related to this incapacity to treat trauma within public mental health and substance abuse systems were identified—including widespread lack of screening and assessment for trauma, lack of training in trauma treatment approaches, and mis-diagnosis or under-diagnosis of trauma followed by a standard regimen of inappropriately targeted services-as-usual, which often led to the revolving door of treatment and discharge. Even when correctly diagnosed, trauma was typically viewed as a “one-shot event” in the lives of consumer/survivors, rather than an ongoing series of events woven throughout the life cycle. And even less attention was paid to the inter-generational cycle of trauma that kept recurring in each new generation of children within a trauma-impacted families.

These concerns all helped to illustrate that mental health and substance abuse systems of care had long been serving consumer/survivors with little or no awareness of trauma and its impacts. A guiding precept for providers—as well as consumers/survivors—had seemed to be, Don’t ask [about trauma], don’t tell [about trauma].

What we have learned is that it is necessary to serve trauma survivors in an environment that is immediately and directly supportive, comprehensively integrated, and that strives to be empowering for consumers/survivors. We now know that our service systems must be designed, from the first contact, to respond proactively to the special vulnerabilities and “triggers” of past trauma for consumers/survivors. They must also support an active leadership role for consumers/survivors in developing and implementing their personal goals and life development strategies.

Providers must come to see themselves as supporters of the recovery process rather than controllers of the recovery process. This shift in roles has profound implications for the way business is done under this new treatment paradigm. The goal under this new treatment paradigm is “trauma-informed care”(TIC) which is designed not to treat the symptoms related to traumatic impacts, but to organize and deliver services in a manner that meets the unique trauma-related needs of consumers/survivors. Following are steps that a program, agency, or institution can take to begin the transformation to a trauma-informed environment. These steps may occur in various sequences, but all are critical to the development of TIC.

Facilitate Consumer/Survivor Empowerment
Consumers/survivors must have a leadership role in the development of a recovery plan They need to be supported in cultivating self-advocacy skills and in developing self-empowerment. Staff needs to be trained to facilitate the recovery process. When we consider that many providers are themselves trauma survivors, agency planning needs to create separate provisions for staff to address and work through their own trauma experiences in a context outside of the provider-consumer/survivor relationship.

Commit to New TIC Organizational Mission and Dedicated Resources
Build support and buy-in from those who control the resources in a given program, hopefully resulting in a new organizational mission statement and related operating procedures that reflect a commitment to develop staff understanding and capacity to respond to and support those they serve.

Conduct Universal Screening for Trauma
Ask each consumer/survivor questions, early in the first contact, to determine whether he or she has experienced violence, abuse, neglect, disaster, terrorism, or war. These questions not only help to obtain the information needed to plan an appropriate safety and recovery plan, but they also confirm to consumers/survivors that their trauma histories matter.

Establish “Safety” for Consumers/Survivors
Measures must be taken, from the time of initial contact, to ensure the physical, psychological, social and moral safety of consumers/survivors. Safety is defined by each consumer/survivor’s personal needs and boundaries. Safety is the “without which not” for recovery to begin and proceed.

Provide Ongoing TIC Staff Training and Education
Provide mandatory TIC training to all agency staff—from custodial workers and receptionists to managerial and treatment personnel—on the nature and impact of trauma, and how to better understand and respond to people with trauma histories. Central to each training session should be the active integration of consumers/survivors.

Improve Staff Hiring Practices
Screen job applicants to assess their trauma-informed values and beliefs and job competencies, with special emphasis on relationship building and de-escalation skills. The screening process should help to foster greater professional and personal self-awareness (including the impact of applicant’s own trauma histories on his or her capacity to provide trauma services).

Update Policies and Procedures
Identify and replace policies and procedures that serve as damaging replications or triggers of consumer/survivor past traumatic experiences, with special attention to replacing highly destructive “treatment” procedures such as seclusion and restraint with psychiatric advance directives and individually developed crisis stabilization plans.

We are finding that the challenge of trauma-informed care is being welcomed and proactively pursued by many different health and human service organizations and systems, at multiple levels of care, across the nation. Providers are beginning to see the benefits of trauma-informed care—not just for consumers/survivors, but also for the effectiveness of their overall programs and services.

NCTIC will continue to help nurture new and developing trauma-informed care programs so that we can identify and share best practices and lessons learned with others who are making the transformation to trauma-informed care. We will focus on building relationships with people and organizations from various health and human service areas in order to distill their wisdom into practical fact sheets and policy guidelines for moving forward with the transformation to trauma-informed care. We will also bring together potential and actual adopters of trauma-informed care in various types of meetings so that they can share their experiences and concerns with each other. NCTIC welcomes your ideas, comments, case studies, and other information you may want to contribute to this learning process.

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Mary Blake, Public Health Advisor
SAMHSA/CMHS/DSSI/Community Support Programs Branch

For over 35 years—from the early days of the mental health consumer/survivor movement to the groundswell of consumer advocacy today—we have sought to be treated with dignity and respect by those around us. Trauma-informed care provides the framework for a respectful approach that seeks first to understand consumer/survivor experiences and our lives rather than resorting directly and exclusively to diagnostic judgment. Consistent with consumers’ rallying cry, Nothing about us without us, the trauma-informed approach acknowledges the consumer’s lived experience as the bedrock of decision-making and promotes consumer choice and empowerment as integral to recovery.

Trauma is a fact in most of our lives—it’s that simple.. Trauma affects how we see the world and how we view ourselves in relation to the world—and to others. The effects of trauma can be profound and disabling. Yet talking about “trauma” is not easy for many of us. According to consumers interviewed as part of NCTIC’s ongoing consumer outreach, a strong and recurring sentiment is that “the process of accessing [mental health] services and benefits [itself] can be traumatic.”

Consider the real life experience of “Jane”…

Jane was diagnosed with bi-polar disorder and psychosis in her early twenties. She spent two years in a state mental health facility and then found herself cycling in and out of hospitals over the next ten years. Jane was considered “treatment resistant” and “incapable” of participating in her treatment due to “lack of insight.” It was not unusual for Jane to become “agitated,” voicing worries that people were “after her” and that she was being “invaded.”

Not equipped with an understanding of trauma-informed care, treatment professionals attempted to force medications to “calm her down.” The result often was an escalation that led to a “take down” or shackling to a bed in four-point (or more) restraints.

Eventually Jane met a young doctor who happened to ask her some intuitive (yet revolutionary) questions: What would help you when you feel scared or threatened? What happens when you feel invaded? Have you felt invaded before? By seeking to understand Jane’s experiences, this doctor validated Jane as a human being and gave her a voice. Both came to understand that Jane’s sexual abuse as a child had had a profound impact on her, and that “take-downs” and seclusion/restraint practices triggered this prior trauma and represented a traumatic experience in-and-of itself. Jane’s reactions became better understood by both her and the doctor as a triggering event rather than a “psychotic episode.”

With a new and deeper understanding of her lived experience, the hospital and treatment team were able to provide Jane the safety to stabilize and discover alternative ways to calm herself down when distressed. Jane and her treatment team re-designed her services to:

• Enhance Jane’s ability to control and choose interventions by utilizing community-based crisis/respite beds instead of hospitals, wherever possible;
• Ensure Jane’s emotional and physical safety in the context of her childhood experiences by eliminating seclusion and restraints; and
• Promote strength-based, self-directed care through safety planning, psychiatric advance directives, exercise, etc.

Jane’s experience is not unique. With growing awareness of trauma-informed approaches, more and more state mental health hospitals and systems are learning from the experiences of consumers like Jane who have begun to heal.

According to consumers interviewed by NCTIC,” [We] don't want to be shamed or ignored for bringing trauma up….” We want providers to “consider the possibility that what we say is true rather than a delusion.” Trauma-informed approaches matter. They provide opportunities to remove barriers caused by stigma, to validate our experiences and our voices, to foster respect and safety, and to promote collaboration, self-determination, and recovery. This is what consumers have wanted all along.

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Helga West, President and CEO
Witness Justice

Victims of violent crime are often severely impacted by trauma in the aftermath, particularly given the destructive nature of person-to-person violence. Yet most victim assistance and service programs have not incorporated a trauma-informed approach to supporting crime victims and their families. A trauma-informed approach creates safety, long-term support, and understanding, without pressuring or steering a survivor to take any particular action.

In addition, for survivors of violent crime who agree to work with the criminal justice system, it is not difficult to identify circumstances that can “trigger” emotional reactions associated with prior traumas, and also serve as a traumatic experiences in-and-of themselves. From “ victim-blaming” questions asked unknowingly by many in law enforcement (i.e. “Why did you walk down that dark street late at night?,” “What were you wearing?,” or “You should have fought back more.”), to making a child victim witness testify in front of an offender who stares fear (at her) across the courtroom – the system is riddled with painful hurdles. Even the most routine criminal justice procedures (e.g. reviewing mug shots, being asked repeatedly to detail the violent trauma, having to justify the need for victim assistance and compensation, recurrent offender parole hearings, etc.) can deepen traumatic wounds.

While many professionals in criminal justice and victim service understand that violence is traumatizing, few take the measures necessary to provide an environment that is considerate of circumstances that may trigger or exacerbate prior traumas, and engage in collaborative decision-making on matters affecting the victim’s welfare.

Lack of attention to these issues may be due to a lack of appropriate training, overworked staff, or a felt need to establish “appropriate” professional boundaries through detachment/distance. The reality is that while creating a trauma-informed environment or approach is a significant management commitment and does require a new orientation and different training, the expense is not great and, in the long run, this institutional/cultural shift benefits providers by:

• Increasing the likelihood that survivors will report the crime and work with and through the criminal justice process
• Improving the overall provision of service to survivors by making it “victim-centered”
• Improving sensitive and important communication with the survivor
• Making the provider’s work itself more successful and satisfying

The changes that take place can be subtle, but very meaningful. For instance, for a child victim, behavioral signals are the most common means of communication. The trauma response may be for the child to become detached or incommunicative, or it may result in physical or verbal outbursts. Providing a trauma-informed approach for a child receiving victim services means offering a place of safety and options where he or she has a voice.

A trauma-informed approach for a domestic violence survivor may require looking at how the center operates, how various protocols may be triggering, and how some current operating procedures (like not permitting male teenagers to reside with their mothers in shelters) may make it difficult for the survivor to find safety.

By integrating trauma-informed practices into victim services, there is greater potential for healing by the victim and justice.

The National Center for Trauma-Informed Care and Witness Justice are currently developing a trauma training model specifically for professionals in criminal justice and crime victim service. To learn more email feedback@witnessjustice.org.

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Early Intervention Models Show Great Promise

Dozens of government officials, service providers, survivors, advocates and others came together on July 26 to begin to explore ways to address the profound impacts of cultural, historical, and intergenerational trauma.

“Historical trauma is cumulative emotional and psychological wounding over the lifespan and across generations, emanating from massive group trauma,” said Maria Yellow Horse Brave Heart, Ph.D., and Associate Professor at the Columbia University School of Social Work.

Traumatic intergenerational aftereffects can emerge in different ways across generations, at different stages of the lifespan, and are shaped by culture, gender, individual, family, community, and societal forces. The impact of historical traumatic group events can be subtle and embedded in the culture of a group as a survival strategy, and passed through generations without conscious awareness of its historical origin or utility.

“The historical trauma response is a constellation of features in reaction to massive group trauma,” Brave Heart added. Just a few of the groups observed to have this response are Native Americans, Jewish survivors of Nazi Germany, and Japanese-American internment camp survivors—and their descendents.

Historical trauma responses among individuals are much like those of survivors of “direct” psychological trauma—e.g. intense fear, survivor guilt, depression, anger, hypervigilance, dissociation, use of potentially destructive coping mechanisms such as substance abuse, etc.

However, historical trauma cannot be best understood within the current paradigm of post-traumatic stress disorder (which focuses on the lifetime events of an individual) or complex trauma (which does not account for the cumulative and multiple traumatic events over a lifespan). Historical trauma addresses both complex and intergenerational trauma.

For example, due to severe and chronic exposure to trauma, Native Americans may have a higher trauma threshold and therefore not meet the criteria for PTSD. In fact, two-thirds of Native American youth affirm multiple traumas but do not meet PTSD criteria, Brave Heart said.

Establishing these connections is a critical factor in designing and implementing trauma-informed and culturally competent care and behavioral health research for today's survivors. For these survivors, trauma-informed care begins with the recognition of the fact that trauma is an experience that helps shape both group and individual core identity in ways that may block or hinder growth and healing.

Major components of an historical trauma intervention strategy may include:

• Confronting historical trauma and embracing group history;
• Understanding trauma—including historical trauma;
• Releasing the Pain; and
• Transcending the trauma.

Key elements of successful interventions may include:

• Psychoeducation about the group’s historical and cultural trauma (e.g. in the case of Native Americans—education about genocide, boarding school losses, and oppression);
• Use of audio/visual materials to stimulate memories and educate participants about the traumatic historical context;
• Small and large group “processing” and exercises;
• Integration of an understanding of the individual lifespan trauma; and
• Traditional cultural experiences and activities, which can be very cathartic.

While only a relative few historical trauma interventions have been designed and implemented, some already have shown great potential. Positive outcomes have included:

• Reduced shame, stigma, anger, and guilt
• Increased joy and hope
• Improved self-evaluation and pride in group culture and heritage
• Increased use of native language
• Perceived improved parenting skills
• Perceived improved relationships with children, parents, and community

Experts also touched on the concept of “collective recovery” which is based on the assumption that social groups are collectives and that collectives can be injured just as individuals can. This injured collective can lose some ability to function, and individuals within this injured collective can endure further suffering as a result of the damage to the collective.

As a starting point in the journey toward self-healing for these persons, it is essential to recognize the link between intergenerational cultural and historical group trauma and an individual group member's current trauma-inducing life events.

For more information contact Dorothy Lewis at dorothy.lewis@samhsa.hhs.gov or 240.276.1619

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Children need trauma-informed treatment from Ohio’s behavioral health system, according to a new report from the Ohio Legal Rights Service.

“The majority of children [in Ohio] receiving behavioral health treatment or involved with the juvenile justice system have been traumatized,” OLRS concludes, noting that “children can be re-traumatized by current treatment settings” such as foster homes, inpatient psychiatric units, residential treatment facilities, and detention centers.

Among the report’s recommendations to the state are:

• create a standing, statewide Trauma Task Force that includes individuals with lived experience and family members;
• develop a written policy statement on trauma-informed care;
• review and modify current treatment systems to be more trauma-informed; and
• develop timeline for implementing trauma-informed treatment service systems.

“The behavioral health system must be sufficiently aware of the existence of trauma, and its effects, in the lives of children it serves,” the OLRS states.

Click here to download the full report, A Closer Look: Trauma-Informed Treatment in Behavioral Health Settings

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