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Trauma Matters – December 2008

The e-Newsletter from CMHS' National Center for Trauma-Informed Care

Statewide Consumer Networks: Strategic Allies in Building Trauma- Informed Systems and Services

By: Mary Blake, Public Health Advisor, CMHS

With many states in our nation showing tremendous interest and activity in developing trauma-informed systems of care, the role of consumers/survivors in systems change is more important than ever. Experts in the field of trauma-informed care have written extensively on the central role the consumer/survivor voice plays in designing, implementing, and evaluating trauma-informed systems across the spectrum of health, mental health, and human services[1].

Statewide Consumer Networks (SCNs) are perfectly positioned to collaborate with states in achieving their goals of building trauma-informed systems that provide the necessary environments in which healing and recovery can take place.

SCNs can serve as catalysts for change by strengthening coalitions among consumers, policymakers, and service providers to bring about this cultural shift. Historically, they have leveraged their expertise with other state and local initiatives by engaging in activities like:

• improving community services to include creating individualized plans of care, developing anti-stigma initiatives, interacting with the criminal justice system, through forensic peer support and other programs, supporting employment programs, and developing supports for returning veterans;
• improving cultural competence and civil rights (including rights protection), responding to the diverse needs of racial and ethnic minorities, and reaching out to rural, minority, transition age youth and young adults, and older adult populations;
• developing policy that improves and supports the establishment of standards of care, alternatives to seclusion and restraint, and the development/revision of credentialing, licensure, or accreditation requirements; and
• developing peer support via tele-health and other on-line supports, including the creation of personal recovery pages.

In some states, such as Wisconsin and Massachusetts, SCNs have taken a leading role as trauma champions. For instance, SCNs have promoted the urgent need to address trauma in mental health systems and programs and have formed alliances and participated in the development of state position papers and other initiatives to bring trauma-informed care to the forefront of policy discussions in the state. They have also begun implementing strategic plans for building trauma-sensitivity within consumerrun organizations.

Increasingly, consumer/survivor leaders are championing change within systems by building an understanding on the prevalence of trauma and its impact on people receiving services in hospitals, community mental health programs, vocational rehabilitation, criminal justice settings, and more. More importantly, consumers/ survivors are calling for the development of systems that provide safe, non-coercive, integrated services that focus on "what happened to you?" rather than "what is wrong with you?" by promoting strength-based, peer-led healing strategies rather than "illnessor deficit-based treatment."

As peer-run organizations, SCNs bring the "shared lived experience" - and since many staff have "been there" and can model the healing process, this brings great added value to those seeking services, the organization, and the greater community as well. Consumers /survivors, intuitively and at their core, respect voice and choice, meet survivors where they are, build on strengths, work toward the goals of healing and empowerment rather than symptom management, and work with peers in a collaborative way with mutual goals - and this exemplifies the essence of being traumainformed. SCNs have the unique capacity to educate providers, policy makers, and state authorities on how consumers, survivors, their families, and the communities in which they live experience, talk about, address, and heal from traumatic experiences. Not only are SCNs transforming systems, they also build bridges for communication, understanding, and meaningful partnership.

The depth and breadth of opportunities for SCNs to collaborate with states and state systems in reforming mental health and other social services is vast. In developing trauma-informed care initiatives, consumers/survivors are uniquely qualified to participate as change agents in multiple ways and not simply as leaders in their own treatment design. According to a paper developed for the National Association of State Mental Health Program Directors, "The voice and participation of consumers who have lived experiences of trauma should be actively involved in all aspects of .systems planning, oversight, and evaluation[2]." The time for leveraging the expertise of consumers/survivors in statewide trauma-informed systems change is here, and SCNs are potent potential partners for that change.

SCNs are uniquely positioned to address the impact of violence and trauma when the experience:

• Re-frames or adversely shapes a person's understanding or view of self, of self in relation to others, and of world view;
• Produces a feeling of isolation and disconnection from others or environment... often including a sense of betrayal;
• Creates power differentials in relationships and a resulting sense of powerlessness;
• Creates a lack of safety, trust, and feeling of connection (i.e. related to environments, interpersonal interactions, treatment practices); and
• Develops shame, blame, guilt, and stigma, whether by others or internalized by the survivor.

[1] See for example, Using Trauma Theory to Design Service Systems. Fallot, R. and Harris, M. (2001); Creating Trauma Services for Women with Co-occurring Disorders. Moses, D. J., Reed, B. G., Mazelis, R., and D'Ambrosio, B. (August 2003), SAMHSA, CMHS; "Improving the Quality of Demonstration Research: Integrating Those with Personal Experience." Mazelis, R. (March 2005). Journal of Substance Abuse Treatment, Volume 28, Issue 2, Pages 147-148; and "Blueprint for Action: Building Trauma-Informed Mental Health Systems, State Activities, Accomplishments and Resources." Jennings, A. (2007 in draft), prepared for Abt Associates, Inc. under contract with the Center for Mental Health Services (CMHS), the Substance Abuse and Mental Health Services Administration (SAMHSA), U.S. Department of Health and Human Services (HHS).

[2] Jennings, A., Description of Criteria for Building a Trauma-Informed Mental Health Service System. Adapted from Developing Trauma-Informed Behavioral Health Systems: Report from NTAC National Experts Meeting on Trauma and Violence, by Andrea Blanch, Ph. D. 2003

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Consumer Networks at Work!

Ways in which Statewide Consumer Networks can leverage their expertise and ongoing work with their peers, states, and others in designing trauma-informed systems:

• Work with consumers/survivors to enhance understanding of trauma impacts and healing approaches.
• Provide for formal consumer/survivor support mechanisms, such as peerdeveloped/ led support groups, training curricula and training programs, newsletters, conferences, warm lines, diverse community outreach teams, and "bridgers" activities to help people through transition periods.
• Encourage the development and use of informal peer support opportunities.
• Develop and provide peer-run crisis or respite services.
• Create wellness centers.
• Establish recovery education and evaluation tools for peers and traditional service providers.
• Train consumers/survivors to coordinate peer support services.[1]
• Work with consumers/survivors to scan the environments in which services are delivered to see if they are trauma-informed and develop recommendations for improvement.
• Train consumers/survivors in research design, implementation, and evaluation through participatory action research and other research efforts to ensure peer collaboration in performance improvement/outcomes measurement.
• Initiate advocacy and education for state and other leaders.
• Integrate consumer/survivor-developed and delivered workforce development curricula. (Possible topics include stigma, engagement strategies, crisis planning/de-escalation, employment, housing, cultural relevance, addressing family needs, etc.)
• Incorporate consumers/survivors in the development of organizational "self-care" strategies, whether for staff (including peers) or for those accessing services.
• Ensure that recruitment and hiring practices prioritize integration of consumers/survivors at all levels and in all roles within the workplace.
• Incorporate consumers/survivors in review of human resources policies, supervision policies, and case reviews.
• Utilize peers in cross agency planning and service integration efforts.
• Include consumers/survivors on organizations' Board of Directors, Advisory Boards, and in other planning or oversight efforts.
• Develop internal "life coaches" to assist peers/staff with workforce stress, self-care, goal setting, etc.
• Create internal/external, peer-run ombuds offices to facilitate mediation/ conflict resolution where necessary.
• Develop cost-effective, comprehensive peer-professional alliances in support of a trauma-preparedness support system. Such alliances provide a "surge buffer" to prevent relapse/crises among vulnerable people in the event of redeployment, job loss, subsequent local traumas, natural disasters, or otherwise triggering and re-traumatizing events.[2]

[1] The Damaging Consequences of Violence and Trauma: Facts, Discussion Points, and Recommendations for Behavioral Health Systems, Peer Support and Self-Help, see http://www. annafoundation.org/D-PSS.html

[2] Ibid.

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The Unspoken Story

The depth of pain and loss felt after violence and trauma is intense. It's what leads some to drink, some to anger, and some to silence.

Along the path to healing over time, many come to a place in their personal growth where telling the story provides a freeing nature and new connection and understanding for what has taken place. Traditionally, telling the story has been spoken or written, but from a trauma-informed perspective, survivors should be supported in any number of ways they might express that story.

In the new film "Call + Response," music is used to speak for victims of human trafficking who are forced into the modern day slavery of prostitution and unpaid labor. One line from the movie explains "music can get into your heart and mind without asking permission." The healing attributes of music are well known, but it also has the quality of giving voice to what cannot be said.

Other forms of art and expression such as painting, photography, poetry, dance, and various sports can be a means of sharing the story. In working with survivors and consumers, thinking about alternative means of expression and communication is part of what being trauma-informed is. And in finding paths to healing, opening to the possibilities of telling stories in unspoken ways not only meets the survivor where they are, but gives potential to share in deep and different ways.

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A Trauma-Informed Approach to Building New Lives for Refugees

From countries or localities in the throes of repression, war and violence, and torture and death threats, many refugees find their way to the United States seeking to establish peaceful and productive life. Given the level of threat and violence and trauma that may have been experienced during this process of resettlement, a peaceful life can be very difficult to attain. Along with the challenges of resettlement and personal healing, refugees have a whole host of other issues like, language and cultural barriers, finding employment, loss of at least some family and friends not able to accompany them on the journey to resettlement, and all of the challenges inherent in building a new way of living.

For anyone who has a professional or personal interest in a trauma-informed public mental health system, and for everyone working with refugees, the new NCTIC supported monograph and related PowerPoint Transcending Violence: Emerging Models for Trauma Healing in Refugee Communities (Andrea Blanch, PhD) provides a thorough and thought provoking view of refugees and their inspiring resilience - often based in philosophical or religious beliefs that serve to buffer and enhance their capacity for healing. This insightful paper looks at possible approaches the public health system, using with a trauma-informed care approach, can not only "do no harm" but also play a role in healing and recovery from trauma and its impacts by refugees and refugee families.

Refugees differ significantly from all other groups of people who migrate from one place to another. While what brings a refugee to the United States may or may not be voluntary, it is frequently rooted in fear and strained by some of the impacts of trauma. In this monograph Blanch provides a thorough review and understanding of the international situation of refugees, the U.S. system for refugee services, and refugee migration and resettlement. It serves as a primer for an in-depth discussion regarding our system of public health as it applies to refugee trauma, the issues surrounding the use of this framework when working with refugees, and the cultural complexity involved in refugee readjustment.

Using this background along with an understanding of the demonstrated capacity refugees (as a group) have to survive, Blanch makes a strong argument for becoming trauma-informed as a path to understanding the myriad of ways trauma can affect mental health. Furthermore, the complex nature of refugee circumstances, needs, and available resources lend itself to the application of unique trauma-informed systems and partnerships to address refugee needs.

Trauma informed care recognizes this individual and complex nature of the trauma experience as well as the inner strength and capacity people have to thrive when empowered to do so. The nature and circumstance of refugees creates a need to develop and adapt trauma informed support systems (programs, partnerships, and services) which recognize the complex array of issues surrounding these refugees.

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New on "Ning"

NCTIC's social network site Dare to Transform, a place to connect with colleagues, consumers, and others interested in trauma informed discourse and learning, continues to grow with hundreds of members from more than 33 states and Canada, and numerous forum discussions spanning a wide array of topics.

Forum posts range from discussion topics to professionals looking for input and answers. Topics are as varied as the members who post them and prove to be thought provoking and informative. Some notable threads include:

"Creating Trauma Informed Environments in Juvenile Services" - a forum looking for information and started by Dare To Transform member Kathy Seifert, has resulted in a number of interesting suggestions on materials relevant to this topic including the Sanctuary Model and the Positive Youth Development Resource Manual.

"The I-TEAM Approach: Helping Homeless Women Recovering from Addictions and Trauma" - provides a presentation for download, created by Amy Price and Gretchen Clark Hammond of Amethyst, Inc. at the 2008 Dare to Transform Conference The ITEAM Approach Presentation.ppt

"Richard Mollica, MD: author of Healing Invisible Wounds and Plenary Speaker at Dare to Transform" - asks members to weigh in on questions posed by Dr. Mollica as he formulates his theories about the role empathy and the divine play in healing and the impact memories and lessons taught by significant others have on the recovery process. Clearly this postulate diverges from traditional thinking, embracing a trauma-informed perspective recognizing the importance of individual perspective and experience - and it seems to resonate. As one member puts it: "Tell Mollica he's on to something!"

"Trauma, Healing and Media Arts in Therapy" - directs members to www.mediaartstherapy.ning.com/, created by member Basia Mosinski, who is looking to engage "in dialog and possible partnership with individuals interested in researching the use of media arts as a therapeutic device in unraveling the effects of imagery and sound linked in trauma memory."

These forums and others are still active and can be found on www.daretotransform.ning. com. If you haven't already, sign up, login, and join the dialog and start new forum topics of discussion!

Calendar of Events

01/15/2009 - NY Trauma, PTSD & Grief Seminar, White Plains, NY

01/16 - 01/17/2009 - Children in Trauma, Chico, CA

01/22/2009 - Regional Community Support Center at Northern Virginia Mental Health Institute conference on Trauma and Trauma Informed Care (12:30 pm - 4:00 pm), Falls Church, VA 22042
For more information contact: Amy Rushton at 703-645-3129

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NEW Contact Info!

p: 866-254-4819
NCTIC@NASMHPD.org