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Creating Cultures of Trauma-Informed Care: A Self-Assessment and Planning Protocol

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Abstract

This document outlines the fundamentals of the Creating Cultures of Trauma-Informed Care approach to organizational change. Buyilidng on core vales of safety, trustworthiness, choice, collaboration, and empowerment, this framework includes equal attention to the experiences of those receiving and those providing services. Though built on a foundation of behavioral health (mental health and substance abuse) agencies, this approach has been adapted to schools, to general medical settings, and to a variety of correctional settings, including juvenile justice.
Creating Cultures of Trauma-Informed Care (CCTIC):
A Self-Assessment and Planning Protocol
Roger D. Fallot, Ph.D. and Maxine Harris, Ph.D.
November, 2011
Over the past fifteen years, there has been growing acknowledgement of several
interrelated facts concerning the prevalence and impact of trauma in the lives of people in
contact with various human service systems. We advocate for trauma-informed service
approaches for a number of reasons.
Trauma is pervasive. National community-based surveys find that between 55 and
90% of us have experienced at least one traumatic event. And individuals report, on average,
that they have experienced nearly five traumatic events in their lifetimes. The experience of
trauma is not the rare exception we once considered it. It is part and parcel of our social reality.
The impact of trauma is very broad and touches many life domains. Trauma
exposure increases the risk of a tremendous range of vulnerabilities: mental health problems like
posttraumatic stress disorder, depression, excessive hostility, and generalized anxiety; substance
abuse; physical health problems; interpersonal struggles; eating disorders; and suicidality, among
many others. Trauma thus touches many areas of life not obviously or readily connected with
the experience of trauma itself. This broad impact makes it particularly important to understand
the less evident links between trauma and its sequelae.
The impact of trauma is often deep and life-shaping. Trauma can be fundamentally
life-altering, especially for those individuals who have faced repeated and prolonged abuse and
especially when the violence is perpetrated by those who were supposed to be caretakers.
Physical, sexual, and emotional violence become central realities around which profound
neurobiological and psychosocial adaptations occur. Survivors may come to see themselves as
fundamentally flawed and to perceive the world as a pervasively dangerous place. Trauma may
shape a person’s way of being in the world; it can deflate the spirit and trample the soul.
Violent trauma is often self-perpetuating. Individuals who are victims of violence are
at increased risk of becoming perpetrators themselves. The intergenerational transmission of
violence is well documented. Community violence is often built around cycles of retaliation.
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Many of our institutionscriminal justice settings, certainly, but also schools and churches and
hospitalsare too frequently places where violent trauma is perpetuated rather than eliminated.
Trauma is insidious and preys particularly on the more vulnerable among us.
People who are poor, who are homeless, who have been diagnosed with severe mental health
problems, who are addicted to drugs, or who have developmental disabilitiesall of these
groups are at increased risk of violent victimization.
Trauma affects the way people approach potentially helpful relationships. Not
surprisingly, those individuals with histories of abuse are often reluctant to engage in, or quickly
drop out of, many human services. Being vigilant and suspicious are often important and
thoroughly understandable self-protective mechanisms in coping with trauma exposure. But
these same ways of coping may make it more difficult for survivors to feel the safety and trust
necessary to helpful relationships.
Trauma has often occurred in the service context itself. Involuntary and physically
coercive practices, as well as other activities that trigger trauma-related reactions, are still too
common in our centers of help and care.
Trauma affects staff members as well as consumers in human services programs.
Stressors deeply affect administrators, clinicians, and support staff working in human services.
Not only is “secondary” or “vicarious” traumatization common but direct threats to physical and
emotional safety are also frequent concerns. Being asked to do “more and more with less and
less” becomes a pervasive theme underlying work experiences that may threaten to overwhelm
coping abilities.
Growing awareness of these facts regarding trauma has led to calls for the development
of both trauma-informed and trauma-specific services. Human service systems become trauma-
informed by thoroughly incorporating, in all aspects of service delivery, an understanding of the
prevalence and impact of trauma and the complex paths to healing and recovery. Trauma-
informed services are designed specifically to avoid retraumatizing those who come seeking
assistance as well as staff working in service settings. These services seek “safety first” and
commit themselves to “do no harm.” The SAMHSA-funded Women, Co-Occurring Disorders,
and Violence Study (1998-2003) has provided evidence that trauma-informed approaches can
enhance the effectiveness of mental health and substance abuse services. By contrast, trauma-
specific services have a more focused primary task: to directly address trauma and its impact
and to facilitate trauma recovery. An increasing number of promising and evidence-based
practices address PTSD and other consequences of trauma, especially for people who often bring
other complicating vulnerabilities (e.g., substance use, severe mental health problems,
homelessness, contact with the criminal justice system) to the service setting.
This Self-Assessment and Planning Protocol and its accompanying CCTIC Program Self-
Assessment Scale attempt to provide clear, consistent guidelines for agencies or programs
interested in facilitating trauma-informed modifications in their service systems. It is a tool for
administrators, providers, and survivor-consumers to use in the development, implementation,
evaluation, and ongoing monitoring of trauma-informed programs.
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Overview of the Change Process, Protocol, and Scale
Culture Change in Human Service Programs
The Creating Cultures of Trauma-Informed Care approach to organizational change is built on
five core values of safety, trustworthiness, choice, collaboration, and empowerment. If a
program can say that its culture reflects each of these values in each contact, physical setting,
relationship, and activity and that this culture is evident in the experiences of staff as well as
consumers, then the program’s culture is trauma-informed.
We emphasize organizational culture because it represents the most inclusive and general level
of an agency or program’s fundamental approach to its work. Organizational culture reflects
what a program considers important and unimportant, what warrants attention, how it
understands the people it serves and the people who serve them, and how it puts these
understandings into daily practice. In short, culture expresses the basic values of a program.
Culture thus extends well beyond the introduction of new services or the training of a particular
subset of staff members; it is pervasive, including all aspects of an agency’s functioning.
In order to accomplish this culture change, we strongly recommend several steps:
1) Initial Planning. In this phase, the program considers the importance of, and weighs its
commitment to, a trauma-informed change process. The following elements are key to the
successful planning of organizational trauma-informed change: a) administrative commitment to
and support of the initiative (see Domain 4 below); b) the formation of a trauma initiative
workgroup to lead and oversee the change process; c) the full representation of each significant
stakeholder group on the workgroupadministrators, supervisors, direct service staff, support
staff, and consumers; d) identification of trauma “champions” to keep the initiative alive and “on
the front burner;” e) programmatic awareness of the scope (the entire agency and its culture) and
timeline (usually up to two years) of the culture shift.
Discussions of trauma-informed program modifications constitute an opportunity to involve all
key groups in the review and planning process. In our experience, the more inclusive and fully
representative these discussions are, the more effective and substantial the resulting changes.
2) A Kickoff Training Event. Usually two days long, the kickoff training is attended by as
many of the staff as practical and includes significant consumer representation; it certainly
includes all members of the trauma initiative workgroup. During this event, there are at least
three presentations. In the first, central ideas of trauma-informed cultures are presented,
emphasizing shifts in both understanding and in practice. Second, the importance of staff
support and care is emphasized, ensuring that staff members experience the same values in the
organizational culture that consumers need to experience. Finally, a third presentation addresses
the importance of trauma in the work of the specific agency (e.g., trauma and substance use,
trauma and children or youth, trauma and mental health problems). There is also a great deal of
time for the workgroup members and other attendees to discuss the planning process in more
detail and to conduct preliminary conversations that will mirror those to be held in the larger
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agency after the kickoff. The goal of the kickoff is to motivate and energize the change process
while simultaneously providing a beginning sense of direction. The kickoff ends with discussion
of next steps in the implementation of this change initiative.
3) Short-term Follow-up. Over the next several months, the agency takes the ideas from the
training and applies them in more detail, using this Self-Assessment and Planning Protocol.
First, the workgroup develops an Implementation Plan for review by the rest of the
administration, staff, and consumers, as well as by outside consultants with experience in
facilitating agency change. Community Connections consultants, for example, provide detailed
feedback on Implementation Plans; discuss any barriers as they arise; and assist in developing
strategies to overcome these obstacles. Community Connections staff offer this consultation on
site or by written or telephone discussions.
Simultaneously, two educational events are scheduled for all staff. The first is on
Understanding Trauma or Trauma 101. This training is designed to discuss the prevalence
and impact of trauma as well as some of the multiple paths to recovery, emphasizing the ways in
which trauma may be seen in the lives of consumers and in the work experience of staff. The
second training focuses more directly on Staff Support and Care, emphasizing that a culture
shift toward a trauma-informed system of care rests on staff members’ experiences of safety,
trustworthiness, choice, collaboration, and empowerment. Ideally, these training events are
offered by experienced trainers who are also able and willing to encourage and teach staff
members to become trainers themselves. In this way, as the program is able, its own trainers
become equipped to pass along the important information about trauma to newer or untrained
staff.
4) Longer-term Follow-up. After about six-nine months, Community Connections consultants
revisit the program site to meet with the workgroup and selected others, in order to review and
discuss progress to date. At that time, ongoing processes may be put in place to sustain the
initiative to its conclusion. Depending on the programs needs and interests, consultants may
return for additional site visits until the trauma-informed care initiative is firmly established in
the agency culture. Sustainability is obviously a key factor in this transformation and programs
have a range of choices about the best ways to maintain a trauma-informed culture. For
example, many agencies build trauma-informed questions into their Consumer Satisfaction
Survey (or use a specially developed survey to capture the five core values for consumers and
staff). Many add the Implementation Plans to the quality assurance or improvement process.
Still others, in larger systems, discuss ways to build in consultation to their own and other
agencies through a “train the consultant” approach. The most important goal in this phase is to
maintain the momentum established after the kickoff training until the culture change is
thoroughgoing. In our experience, this process may take from two to five years.
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The CCTIC Self-Assessment and Planning Protocol
The Self-Assessment and Planning Protocol is divided into six domains; they address
both services-level and administrative or systems-level changes. In each domain, there are
guiding questions for a collaborative discussion by a comprehensive workgroup of a program’s
activities and physical settings, followed by a list of more specific questions and/or possible
indicators of a trauma-informed approach. Many of these questions and indicators are drawn
from the experiences of human service agencies that have previously engaged in this self-
assessment.
Part A: Services-level Changes
Domain 1. Program Procedures and Settings: “To what extent are program activities and
settings consistent with five guiding principles of trauma-informed practice: safety,
trustworthiness, choice, collaboration, and empowerment?”
This section of the protocol can be used to assess the extent to which formal and informal
procedures and the physical environment in a human services program are trauma-informed and
to plan corresponding modifications in service delivery practices. Consumer-survivors should be
actively involved in the review process as should support staff, direct service staff, supervisors,
and administrators.
Step One: Identify Key Formal and Informal Activities and Settings
The goal of Step One is to gain a comprehensive sense of the experiences of both consumers and
staff members as they come to the setting and participate in its activities, relationships, and
physical settings. The goal of this review is to capture for each of these groupsconsumer and
stafftheir experiences in detail from their very first to their very last contact with the program
or agency. Though some programs accomplish this effectively by forming a representative
workgroup to review the full range of contacts, others have found it very helpful to engage in a
“walk-through.” A walk-through is a process in which staff members come to the setting “as if”
they are new consumers and thus enter the setting with a consumer-oriented perspective. For
more details about one way to conduct such a walk-through, see the NIATx website:
www.niatx.net. Sites routinely begin by focusing on the experiences of consumers and then
repeat the process for staff members.
A. List the sequence of service activities in which new consumers are usually involved (e.g.,
outreach, intake, assessment, service planning). Think broadly to include informal as
well as formal contacts. For example, consumers may be greeted and given directions by
a number of people prior to formal service delivery.
B. Identify the staff members (positions and individuals) who have contact with consumers
at each point in this process.
C. Identify the settings in which the various activities are likely to take place (e.g., home,
waiting room, telephone, office, institution).
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Step Two: Ask Key Questions about Each of the Activities and Settings
(See list of questions for Domains 1A-1J following Step Four)
Step Three: Prioritize Goals for Change
After the workgroup has reviewed services and has developed a list of possible trauma-informed
changes in service delivery procedures, these goals for change should be prioritized. Among the
factors to consider in this prioritizing are the following: (1) feasibility (which goals are most
likely to be accomplished because of their scale and the kind of change involved?); (2) resources
(which goals are most consistent with the financial, personal, and other resources available?); (3)
system support (which goals have the most influential and widespread support?); (4) breadth of
impact (which goals are most likely to have a broad impact on services?); (5) quality of impact
(which goals will make the most difference in the lives of consumers?); (6) risks and costs of not
changing (which practices, if not changed, will have the most negative impact?).
Step Four: Identify Specific Objectives and Responsible Persons
After goals have been prioritized, specific objectives (measurable outcomes with timelines for
achievement) can be stated and persons responsible for implementing and monitoring the
corresponding tasks can be named. These objectives are incorporated into the program’s
Implementation Plan.
Domain 1A. SafetyEnsuring Physical and Emotional Safety
Key Questions: “To what extent do the program’s activities and settings ensure the
physical and emotional safety of consumers? How can services be modified to ensure
this safety more effectively and consistently?”
Sample Specific Questions:
How safe is the area around the program’s building? Are sidewalks and parking areas
well-lit? How far do consumers need to walk to get to the building or program entrance?
Is this walk a safe one?
Are directions to the program’s location readily available? Are they clear?
Once a consumer arrives, are directions to the receptionist or other offices clear?
Where are services delivered? In the office, institution, home, or community? What
safety considerations are important in the location of various services?
When are they delivered? Are there services available in addition to usual office hours?
If so, what safety considerations are important in the timing of various services?
Who is present (other consumers, etc.)? Are security personnel present? What impact
do these others have?
What signs and other visual materials are there? Are they welcoming? Clear? Legible?
Are doors locked or open? Are there easily accessible exits?
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How would you describe the reception and waiting areas, interview rooms, etc.? Are
they comfortable and inviting?
Are restrooms easily accessible? Are there signs indicating their location?
Are the first contacts with consumers welcoming, respectful, and engaging?
Do consumers receive clear explanations and information about each task and
procedure? Are the rationales made explicit? Is the program mission explained? Are
specific goals and objectives made clear? Does each contact conclude with information
about what comes next?
Are staff attentive to signs of consumer discomfort or unease? Do they understand these
signs in a trauma-informed way?
What events have occurred that indicate a lack of safetyphysically or emotionally
(e.g., arguments, conflicts, assaults)? What triggered these incidents? What alternatives
could be put in place to minimize the likelihood of their recurrence?
Is there adequate personal space for individual consumers?
In making contact with consumers, is there sensitivity to potentially unsafe situations
(e.g., domestic violence)?
Domain 1B. TrustworthinessMaximizing Trustworthiness through Task Clarity,
Consistency, and Interpersonal Boundaries
Key Questions: “To what extent do the program’s activities and settings maximize
trustworthiness by making the tasks involved in service delivery clear, by ensuring
consistency in practice, and by maintaining boundaries that are appropriate to the
program? How can services be modified to ensure that tasks and boundaries are
established and maintained clearly and appropriately? How can the program maximize
honesty and transparency?
Sample Specific Questions:
Does the program provide clear information about what will be done, by whom, when,
why, under what circumstances, at what cost, with what goals?
When, if at all, do boundaries veer from those of the respectful professional? Are there
pulls toward more friendly (personal information sharing, touching, exchanging home
phone numbers, contacts outside professional appointments, loaning money, etc.) and less
professional contacts in this setting?
How does the program handle dilemmas between role clarity and accomplishing
multiple tasks (e.g., especially in residential work and counseling or case management,
there are significant possibilities for more personal and less professional relationships)?
How does the program communicate reasonable expectations regarding the completion
of particular tasks or the receipt of services? Is the information realistic about the
program’s lack of control in certain circumstances (e.g., in housing renovation or time to
receive entitlements)? Is unnecessary consumer disappointment avoided?
What is involved in the informed consent process? Is both the information provided and
the consent obtained taken seriously? That is, are the goals, risks, and benefits clearly
outlined and does the consumer have a genuine choice to withhold consent or give partial
consent?
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Domain 1C. ChoiceMaximizing Consumer Choice and Control.
Key Questions: “To what extent do the program’s activities and settings maximize
consumer experiences of choice and control? How can services be modified to ensure
that consumer experiences of choice and control are maximized?”
Sample Specific Questions:
How much choice does each consumer have over what services he or she receives?
Over when, where, and by whom the service is provided (e.g., time of day or week, office
vs. home vs. other locale, gender of provider)?
Does the consumer choose how contact is made (e.g., by phone, mail, to home or other
address)?
Does the program build in small choices that make a difference to consumer-survivors
(e.g., When would you like me to call? Is this the best number for you? Is there some
other way you would like me to reach you or would you prefer to get in touch with me?)
How much control does the consumer have over starting and stopping services (both
overall service involvement and specific service times and dates)?
Is each consumer informed about the choices and options available?
To what extent are the individual consumer’s priorities given weight in terms of services
received and goals established?
How many services are contingent on participating in other services? Do consumers get
the message that they have to “prove” themselves in order to “earn” other services?
Do consumers get a clear and appropriate message about their rights and
responsibilities? Does the program communicate that its services are a privilege over
which the consumer has little control?
Are there negative consequences for exercising particular choices? Are these necessary
or arbitrary consequences?
Does the consumer have choices about who attends various meetings? Are support
persons permitted to join planning and other appropriate meetings?
Domain 1D. CollaborationMaximizing Collaboration and Sharing Power
Key Questions: “To what extent do the program’s activities and settings maximize
collaboration and sharing of power between staff and consumers? How can services
be modified to ensure that collaboration and power-sharing are maximized?”
Sample Specific Questions:
Do consumers have a significant role in planning and evaluating the agency’s services?
How is this “built in” to the agency’s activities? Is there a Consumer Advisory Board?
Are there members who identify themselves as trauma survivors? Do these individuals
understand part of their role to serve as consumer advocates? As trauma educators?
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Do providers communicate respect for the consumer’s life experiences and history,
allowing the consumer to place them in context (recognizing consumer strengths and
skills)?
In service planning, goal setting, and the development of priorities, are consumer
preferences given substantial weight?
Are consumers involved as frequently as feasible in service planning meetings? Are
their priorities elicited and then validated in formulating the plan?
Does the program cultivate a model of doing “with” rather than “to” or “for”
consumers?
Does the program and its providers communicate a conviction that the consumer is the
ultimate expert on her or his own experience?
Do providers identify tasks on which both they and consumers can work simultaneously
(e.g., information-gathering)?
Domain 1E. EmpowermentPrioritizing Empowerment and Skill-Building
Key Questions: “To what extent do the program’s activities and settings prioritize
consumer empowerment and skill-building? How can services be modified to ensure
that experiences of empowerment and the development or enhancement of consumer
skills are maximized?”
Sample Specific Questions:
Do consumer-survivor advocates have significant advisory voice in the planning and
evaluation of services?
In routine service provision, how are each consumer’s strengths and skills recognized?
Does the program communicate a sense of realistic optimism about the capacity of
consumers to reach their goals?
Does the program emphasize consumer growth more than maintenance or stability?
Does the program foster the involvement of consumers in key roles wherever possible
(e.g., in planning, implementation, or evaluation of services)?
For each contact, how can the consumer feel validated and affirmed?
How can each contact or service be focused on skill-development or enhancement?
Does each contact aim at two endpoints whenever possible: (1) accomplishing the given
task and (2) skill-building on the part of the consumer?
Domain 1F. Safety for StaffEnsuring Physical and Emotional Safety
Key Questions: “To what extent do the program’s activities and settings ensure the
physical and emotional safety of staff members? How can services be modified to
ensure this safety more effectively and consistently?”
Sample Specific Questions:
Do staff members feel physically safe? Do staff members provide services in areas
other than the office? If so, what safety considerations are important?
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Do staff members feel emotionally safe? In relationships with administrators and
supervisors, do staff members feel supported?
Is the physical environment safe--with accessible exits, readily contacted assistance if
it is needed, enough space for people to be comfortable, and adequate privacy?
Do staff members feel comfortable bringing their clinical concerns, vulnerabilities,
and emotional responses to client care to team meetings, supervision sessions or a
supervisor?
Does the program attend to the emotional safety needs of support staff as well as
those of clinicians?
Domain 1G. Trustworthiness for StaffMaximizing Trustworthiness through Task
Clarity, Consistency, and Interpersonal Boundaries
Key Questions: “To what extent do the program’s activities and settings maximize
trustworthiness by making the tasks involved in service delivery clear, by ensuring
consistency in practice, and by maintaining boundaries that are appropriate to the
program? How can services and work tasks be modified to ensure that tasks and
boundaries are established and maintained clearly and appropriately? How can the
program maximize honesty and transparency?”
Sample Specific Questions:
Do program directors and clinical supervisors have an understanding of the work of
direct care staff? Is there an understanding of the emotional impact (burnout,
vicarious trauma, compassion fatigue) of direct care? How is this understanding
communicated?
Is self-care encouraged and supported with policy and practice?
Do all staff members receive clinical supervision that attends to both consumer and
clinician concerns in the context of the clinical relationship? Is this supervision
clearly separated from administrative supervision that focuses on such issues as
paperwork and billing?
Do program directors and supervisors make their expectations of staff clear? Are
these consistent and fair for all staff positions, including support staff?
Do program directors and supervisors make the program’s mission, goals, and
objectives clear?
Do program directors and supervisors make specific plans for program
implementation and changes clear? Is there consistent follow through on announced
plans? Or, in the event of changed plans, are these announced and reasons for
changes explained?
Can supervisors and administrators be trusted to listen respectfully to supervisees’
concerns—even if they don’t agree with some of the possible implications?
Domain 1H. Choice for StaffMaximizing Staff Choice and Control.
Key Questions: “To what extent do the program’s activities and settings maximize
staff experiences of choice and control? How can services and work tasks be modified
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to ensure that staff experiences of choice and control are maximized, especially in the
way that staff members’ work goals are met?”
Sample Specific Questions:
Is there a balance of autonomy and clear guidelines in performing job duties? Is there
attention paid to ways in which staff members can make choices in how they meet job
requirements?
When possible, are staff members given the opportunity to have meaningful input
into factors affecting their work: size and diversity of caseload, hours and flex-time,
when to take vacation or other leave, kinds of training that are offered, approaches to
clinical care, location and décor of office space?
Domain 1I. Collaboration for StaffMaximizing Collaboration and Sharing Power
Key Questions: “To what extent do the program’s activities and settings maximize
collaboration and sharing of power among staff, supervisors, and administrators (as
well as consumers)? How can services be modified to ensure that collaboration and
power-sharing are maximized?”
Sample Specific Questions:
Does the agency have a thoughtful and planned response to implementing change that
encourages collaboration among staff at all levels, including support staff?
Are staff members encouraged to provide suggestions, feedback, and ideas to their
team and the larger agency? Is there a formal and structured way that program
administrators solicit staff members’ input?
Do program directors and supervisors communicate that staff members’ opinions are
valued even if they are not always implemented?
Domain 1J. Empowerment for StaffPrioritizing Empowerment and Skill-
Building
Key Questions: “To what extent do the program’s activities and settings prioritize
staff empowerment and skill-building? How can services be modified to ensure that
experiences of empowerment and the development or enhancement of staff skills are
maximized? How can the program ensure that staff members have the resources
necessary to do their jobs well?”
Sample Specific Questions:
Are each staff member’s strengths and skills utilized to provide the best quality care
to consumers/clients and a high degree of job satisfaction to that staff member?
Are staff members offered development, training, or other support opportunities to
assist with work-related challenges and difficulties? To build on staff skills and
abilities? To further their career goals?
Do all staff members receive annual training in areas related to trauma, including the
impact of workplace stressors?
Do program directors and supervisors adopt a positive, affirming attitude in
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encouraging staff, both clinicians and support staff, to fulfill work tasks?
Is there appropriate attention to staff accountability and shared responsibility or is
there a “blame the person with the least power” approach? Is supervisory feedback
constructive, even when critical?
Domain 2. Formal Services Policies
Key Questions: “To what extent do the formal policies of the program reflect an
understanding of trauma survivors’ needs, strengths, and challenges? Of staff needs? Are
these policies monitored and implemented consistently?”
Some Possible Indicators:
Policies regarding confidentiality and access to information are clear; provide adequate
protection for the privacy of both consumers and staff members; and are communicated to the
consumer and staff in an appropriate way.
The program avoids involuntary or potentially coercive aspects of treatmentinvoluntary
hospitalization or medication, representative payeeship, outpatient commitmentwhenever
possible.
The program has developed a de-escalation or “code blue” policy that minimizes the possibility
of retraumatization.
The program has developed ways to respect consumer preferences in responding to crisesvia
“advance directives” or formal statements of consumer choice.
The program has a clearly written, easily accessible statement of consumers’ and staff
members’ rights and responsibilities as well as a grievance policy.
The program’s policies address issues related to staff safety. For example:
Policies address if and when a staff member may be alone in the building or on duty.
Policies govern specific ways for staff to offer home or community based services.
Incident reviews follow verbal or physical confrontations and lead to effective plans
to reduce staff vulnerability.
Domain 3. Trauma Screening, Assessment, Service Planning and Trauma-Specific Services
Key Question: “To what extent does the program have a consistent way to identify individuals
who have been exposed to trauma, to conduct appropriate follow-up assessments, to include
trauma-related information in planning services with the consumer, and to provide access to
effective and affordable trauma-specific services?”
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Some Possible Indicators:
Staff members have reviewed existing instruments to see the range of possible screening tools.
At least minimal questions addressing physical and sexual abuse are included in trauma
screening.
Screening avoids overcomplication and unnecessary detail so as to minimize stress for
consumers.
The program recognizes that the process of trauma screening is usually much more important
than the content of the questions. The following have been considered:
What will it mean to ask these questions?
How can they be addressed most appropriatelyfor the likely consumers, for the
service context, time available, prior relationship, possible future relationship, at various
points in the intake/assessment process?
The need for standardization of screening across sites is balanced with the unique needs of
each program or setting.
The screening process avoids unnecessary repetition. While there is no need to ask the same
questions at multiple points in the intake or assessment process, there is often a good rationale
for returning to the questions after some appropriate time interval.
Screening is followed as appropriate (given the nature and goals of the program, the length of
time consumers are involved, and the specific relationships established with staff members) by a
more extensive assessment of trauma history (type, duration, and timing of trauma) and of
trauma-related sequelae (addressing resilience-related strengths and coping skills as well as
vulnerabilities and problems).
In service planning, clinicians and consumers discuss ways in which trauma may be taken into
account in clinicians’ work with the consumer to achieve the consumer’s goals (e.g., the place of
trauma and trauma-related strengths and problems in giving shape to the recovery plan, its
priorities, and the services and other supports that may be useful).
The program either offers or makes referrals to accessible, affordable, and effective trauma-
specific services. Group and individual approaches to trauma recovery and healing are both
available.
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Part B: Systems-level/Administrative Changes
Domain 4. Administrative Support for Program-Wide Trauma-Informed Services
Key Question: “ To what extent do program or agency administrators support the integration
of knowledge about violence and abuse into all program practices?”
Some Possible Indicators:
The existence of a policy statement or the adoption of general policy statement from other
organizations that refers to the importance of trauma and the need to account for consumer
experiences of trauma in service delivery.
The existence of a “trauma initiative” (e.g., workgroup, trauma specialist).
Designation of a competent person with administrative skills and organizational
credibility for this task.
Chief administrator meets periodically with trauma workgroup or specialist.
Administrator supports the recommendations of the trauma workgroup or specialist and
follows through on these plans.
Administrators work closely with a Consumer Advisory group that includes significant trauma
survivor membership. Consumer-survivor members of this group identify themselves as trauma
survivors and understand a part of their role as consumer advocacy. They.play an active role in
all aspects of service planning, implementation, and evaluation.
Administrators are creative in finding ways to elicit consumer suggestions and feedback on the
process of becoming trauma-informed. These mechanisms may include focus groups; suggestion
boxes; walk-throughs by senior administrators to check in with consumers (and staff); brief
feedback sessions or surveys following groups or other interventions; special events to highlight
the initiative; among others.
Administrators actively support the trauma-informed culture change initiative by marketing it
throughout the agency, raising its profile and making it a central part of the programs agenda
and mission. Administrators recognize the value of everyones enthusiastic participation in the
initiative and facilitate broad-based buy-in from all groups.
Administrators make collaboration and shared decision-making a key part of their leadership
style. When working with staff members and consumer advisors, they listen respectfully and
solicit ideas for project development. Whenever possible and practical, they involve both staff
and consumers in planning, implementing, and evaluating program changes.
Administrators make basic resources available in support of trauma-informed service
modifications (e.g., time, space, training money).
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Administrators support the availability and accessibility of trauma-specific services where
appropriate; they are willing to be creative about finding alternative reimbursement strategies for
trauma services.
Administrators find necessary sources of funding for trauma training and education (this
sometimes requires going outside the usual funding mechanisms in a creative way).
Administrators are willing to release both direct service and support staff from their usual
duties so that they may attend trainings, plan trauma-informed changes, and deliver trauma-
specific services. Funding is sought in support of these activities.
Administrators are willing to attend trauma training themselves (vs. sending designees in their
places); they allocate some of their own time to trauma-focused work (e.g., meeting with trauma
initiative representatives, keeping abreast of trauma initiatives in similar program areas).
Administrators participate actively in identifying objectives for systems change.
Administrators monitor the program’s progress by identifying and tracking core objectives of
the trauma-informed change process
Administrators may arrange pilot projects for trauma-informed parts of the system.
Domain 5. Staff Trauma Training and Education
Key Question: “To what extent have all staff members received appropriate training in
trauma and its implications for their work?”
Some Possible Indicators:
General education (including basic information about trauma and its impact) has been offered
for all employees in the program with a primary goal of sensitization to trauma-related dynamics
and the avoidance of retraumatization.
Staff members have received education in a trauma-informed understanding of unusual or
difficult behaviors. (One of the emphases in such training is on respect for people’s coping
attempts and avoiding a rush to negative judgments.)
Staff members have received basic education in the maintenance of personal and professional
boundaries (e.g., confidentiality, dual relationships, sexual harassment).
Clinical staff members have received trauma education involving specific modifications of
services in their content area: clinical, residential, case management, substance use, for example.
Staff members have received training in basic coping skills for trauma survivors, including
psychoeducational framing of trauma-related experiences and coping responses, grounding and
emotional modulation techniques, and safety planning,
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Trauma clinicians have received training in additional skills-based and other trauma-specific
approaches.
Staff members offering trauma-specific services are provided adequate support via supervision
and/or consultation (including the topics of vicarious traumatization and clinician self-care).
Domain 6. Human Resources Practices: “To what extent are trauma-related concerns
part of the hiring and performance review process?”
Key Question: “To what extent are trauma-related concerns part of the hiring and
performance review process?”
Some Possible Indicators:
The program seeks to hire (or identify among current staff) trauma “champions,” individuals
who are knowledgeable about trauma and its effects; who prioritize trauma sensitivity in service
provision; who communicate the importance of trauma to others in their work groups; and who
support trauma-informed changes in service delivery.
Prospective staff interviews include trauma content (What do applicants know about trauma?
about domestic violence? about the impact of childhood sexual abuse? Do they understand the
long-term consequences of abuse? What are applicants’ initial responses to questions about
abuse and violence?)
Incentives, bonuses, and promotions for line staff and supervisors take into account the staff
member’s role in trauma-related activities (specialized training, program development, etc.).
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Addendum A: Possible Items for Consumer Satisfaction Surveys
(Items are worded to be consistent with a Likert response scale from “strongly disagree” to
“strongly agree;” specific items and wording should be tailored to the program’s goals and
services)
Safety
When I come to [program], I feel physically safe.
When I come to [program], I feel emotionally safe.
Trustworthiness
I trust the people who work here at [program].
[Program] provides me good information about what to expect from its staff and services.
I trust that people here at [program] will do what they say they are going to do, when they say
they are going to do it.
The people who work here at [program] act in a respectful and professional way toward me.
Choice
[Program] offers me a lot of choices about the services I receive.
I have a great deal of control over the kinds of services I receive, including when, where, and by
whom the services are offered.
People here at [program] really listen to what I have to say about things.
Collaboration
At [program], the staff is willing to work with me (rather than doing things for me or to me).
When decisions about my services or recovery plan are made, I feel like I am a partner with the
staff, that they really listen to what I want to accomplish.
Consumers play a big role in deciding how things are done here at [program].
Empowerment
[Program] recognizes that I have strengths and skills as well as challenges and difficulties.
The staff here at [program] are very good at letting me know that they value me as a person.
The staff here at [program] help me learn new skills that are helpful in reaching my goals.
I feel stronger as a person because I have been coming to [program].
Trauma Screening Process
The staff explained to me why they asked about difficult experiences in my life (like violence
or abuse).
The staff are as sensitive as possible when they ask me about difficult or frightening
experiences I may have had.
I feel safe talking with staff here about my experiences with violence or abuse.
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This document was prepared by: Roger D. Fallot, Ph.D. and Maxine Harris, Ph.D.
Community Connections
October, 2002; May, 2003; March, 2004; February, 2005;
March, 2006; April, 2009; July, 2009
For further information, please contact:
Roger D. Fallot, Ph.D.
Director of Research and Evaluation
202.608.4796 (voice)
202.608.4286 (fax)
rfallot@ccdc1.org
Rebecca Wolfson Berley, MSW
Director of Trauma Education
202.608.4735 (voice)
202.608.4286 (fax)
rwolfson@ccdc1.org
Community Connections
801 Pennsylvania Avenue, S.E.
Suite 201
Washington, DC 20003
Citation:
Harris, M. and Fallot, R. (Eds.) (2001). Using Trauma Theory to Design Service Systems. New
Directions for Mental Health Services. San Francisco: Jossey-Bass.
The developers of this approach would like to acknowledge the assistance in expanding and
enriching this protocol of the many individuals and programs that have participated in Creating
Cultures of Trauma-Informed Care trainings and consultations.
... To achieve this change, the entire system must learn how trauma can influence daily life (Australian Government, 2007;APS, 2010). With a strong program that utilised trauma-informed care, it is possible to minimise revictimisation, and increase wellness among all people (Davis-Salyer, 2015;Fallot & Harris, 2009;Krieg, 2009). ...
... Therefore, mental health practices are guided through philosophies to assist in eliminating these factors. Furthermore, research shows that the recovery-oriented approach requires a solid understanding of trauma (Fallot & Harris, 2009;Herman, 1997;Lawn & McMahon, 2015). ...
... Trauma, such as through lived experiences, must be recognized in order to develop effective trauma-informed care. It is also important to know that triggers may cause repeated issues related to the experience (Fallot & Harris, 2009;Fromene & Guerin, 2014). Therefore, those providers considering and/or using trauma-informed recovery-oriented services must consider the impact of trauma during recovery. ...
Thesis
Full-text available
The research seeks to identify the location, mode of therapeutic intervention and the type of clinician most effective in meeting the treatment needs of individuals diagnosed with Borderline Personality Disorder. It is anticipated that the research will offer a platform to inform further research to work towards evidence based approaches for the therapeutic management of Borderline Personality Disorder. The research adopts a three-phase approach identifying the location, mode of therapeutic intervention and type of clinician effective in meeting the treatment needs of individuals with BPD. The first phase is the establishment of a stakeholder advisory group comprising 6 to 12 participants. The second phase involved running focus groups comprising mental health professionals and consumer consultants. The third phase was an online survey of mental health professionals with expertise in working with people diagnosed with BPD.
... Trustworthiness is a core principle of trauma-informed care (Harris & Fallot, 2001;Battaglia et al., 2003;Elliot et al., 2005;Fallot & Harris, 2009;Hopper et al. 2014;SAMHSA, 2014;Wolf et al., 2014). Recognizing the impacts of historical trauma is fundamental to integrity of care with Indigenous people (Brave Heart, 2003;Brave Heart et al., 2011;Evans-Campbell, 2008;Goodkind et al., 2010;Goodkind et al., 2012;Mohatt et al., 2014;Kirmayer et al., 2014;Burnette, 2015;Burnette and Figley, 2017). ...
Article
Objective: Housing and Urban Development (HUD) Continuums of Care (COCs) are responsible for providing entry to integrated healthcare for unhoused people toward housing stability. A client’s safety is a crucial variable to receive services. A comprehensive safety strategy understands the importance of relationship quality for clients and their multidisciplinary healthcare teams (MHT) to prevent safety incidents. Greater depth of knowledge on participant experiences informs the development of a process model for implementing the Community Resiliency Model (CRM) for crisis prevention response to decrease health disparities among unhoused Indigenous peoples in Albuquerque. Methods: This qualitative key informant study applied an ecological lens on Relational-Cultural Theory (RCT) and 24 participant interview content analysis. Participants include unhoused people who self-identified with Native American, about accessing and receiving homeless services and members of their MHT across COC agencies. Findings: Participants shared a congruent understanding of the interpersonal, multidisciplinary, and organizational resilience factors for crisis stabilization and prevention. Integrated healthcare providers identified cohesion when an MHT has the organizational supports needed to consistently provided compassionate care and relevant recovery options. Interpersonal resilience emerged as the sense of belonging experienced in a compassionate and accepting relationship. Relational courage is a key facilitator of interpersonal resilience when an integrated healthcare provider can clarify with a client what is the most important and brings purpose or meaning. Participants emphasized multilevel factors for the cultivation of hope in recovery at the heart of crisis prevention. Discussion: The findings provide a rationale for a paradigm shift to resilience for housing stability. CRM wellness skills can enhance growth-fostering connection and cultural relevance for safety planning. Significantly, cohesion enhances the capacity of an MHT to support a client’s success in recovery. Cohesion correlates with integrated healthcare providers in their OK Zones. Ethical distress escalated crises and contributed to barriers preventing safety incidents. The implications for integrated healthcare and housing policy are to increase multilevel support for organizations to provide workforce training, implementation support, and solutions to sustain MHT cohesion and maintain intra-organizational systems. Cohesion is a key variable to enhance the capacity for a comprehensive safety strategy to be successful.
... Safety: Safety refers to ensuring that people feel safe when using, designing, or otherwise interacting with technology. Traditionally, notions of safety in trauma-informed care [53,114,183] mean ensuring a physically safe environment (e.g., keeping noise levels low) [114] as well as psychological safety, which encompasses "a sense of safety, or the ability to feel safe, within one's self and safe from external harm" [26]. Safety in computing encompasses not only digital safety in the sense of protection against malicious websites and software [169], but also feeling psychologically safe in using a product or navigating a platform. ...
... Further, trauma-informed education encourages the use of trauma-informed interventions with service users, while also prioritizing self-care for the worker, regardless of profession. Fallot and Harris (2009) outline five components to facilitating a traumainformed environment: safety; trustworthiness; choice; collaboration; and empowerment. Adopting a trauma-informed stance is particularly important when discussing personal and intimate themes related to sexuality, as it recognizes that trauma is pervasive. ...
... Today there is a greater understanding of the dynamics of violence and trauma and the connection to coping abuse, such as substance abuse (Edmund & Bland, 2011;Chansonneuve, 2005). There is also a better appreciation of the strengths within Aboriginal communities and traditional knowledge and practice (Fallot & Harris, 2009). ...
Article
Within health care, trauma-informed care has become an embedded approach in caring for patients; however, nurse leaders are not always prepared to lead nurses with a background of trauma. Nurses’ past trauma, coupled with workplace stressors, may result in compassion fatigue, burnout, and secondary traumatic stress. Nurse leader engagement and trauma-informed leadership approaches are imperative to mitigate and mediate the effects of trauma in nurses as the COVID-19 pandemic recedes.
Chapter
Full-text available
Bu çalışmada; travmaya dair genel bir çerçeve sunulmuş, travma bilgisi içeren yaklaşım ve prensipleri açıklanmış, son olarak da travma bilgisi içeren yaklaşımın sosyal hizmet uygulamalarında nasıl bir enstrüman olabileceği ve hangi görünümlere sahip olacağı tartışılmıştır.
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This study explored the lived experience of Australian women affected by intimate partner violence (IPV) and determined whether and how recovery was part of that experience. An online survey of 665 Australian women in long-term recovery from IPV gathered qualitative information about their experiences and their definitions of recovery. The guiding methodology for data analysis was qualitative content analysis, as it provided a close analysis of the manifest meanings of the women’s responses and an interpretation of the latent themes within the data. Outcomes included a thematic analysis and the numbers of women referring to each theme. The women’s definitions focused on their lived experiences of recovery rather than on the psychological and academic constructs favoured by researchers. The five themes identified in the women’s definitions were safety and survival, gaining freedom, moving on, enjoying a better life, and issues with children and parenting. These themes did not represent sequential stages but generally occurred concurrently. Relapses, digressions, and highs and lows were also common aspects of recovery. Thus, these themes were more like threads woven together in a multi-axial continuum or recovery journey, rather than sequential phases. Although many women considered they had recovered from IPV, most women found recovery to be ongoing. Some women struggled to make any progress in recovery at all. Overall, recovery from IPV is multidimensional and individualistic in nature. It is an arduous journey that evolves over a long period of time and requires a great deal of support.
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Trauma-informed approaches may promote the well-being of CNAs and disrupt organizational practices that perpetuate inequities. There is a dearth of literature addressing evidence-based, trauma-informed training for direct care staff, yet CMS now requires trauma-informed care in nursing homes. Five focus groups exploring trauma and resilience-related concepts were conducted using an expressive-collaborative model with 18 CNAs at four nursing homes. A thematic analysis was conducted and themes were identified related to identity, relationships with residents, organizational values, and personal wellness. CNAs voiced frustration at limited time and support to implement well-being or stress management practices. Relationships with residents were sources of strength and, conversely, sources of emotional injury due to disrespect, disregard, and hostile behavior directed at CNAs. Central to health and well-being, CNAs called for change within facility cultures experienced as disrespectful, inequitable, and contrary to work-life balance. Trauma-informed training can be used to give particular attention to direct care staff. Administrators would benefit from learning about trauma and resilience among CNAs and precipitating organizational factors such as reasonable care ratios, equitable benefits, and peer support that impact CNA well-being, job satisfaction, and quality of care. The development and implementation of a trauma-informed training curriculum for CNAs are warranted.
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Mental health practitioners are becoming increasingly aware that they are encountering a large number of men and women who are survivors of sexual and physical abuse. An understanding of trauma, its sequelae, and the impact that it has in shaping a consumer's response to subsequent experience is essential for providers working in the human services field, regardless of whether they are asked to deliver specific services intended to address the effects of abuse. This book identifies the essential elements necessary for a system to begin to integrate an understanding about trauma into its core service programs. The basic philosophy of trauma-informed practice is examined across several specific service components: assessment and screening, inpatient treatment, residential services, addictions programming, and case management. The modifications necessary to transform a current system into a trauma-informed system and the approaches that may become contraindicated are identified. The changing roles of consumers and providers in a trauma-informed system are also discussed. (PsycINFO Database Record (c) 2012 APA, all rights reserved)
Community Connections
  • Roger D Fallot
  • Maxine Harris
Roger D. Fallot, Ph.D. and Maxine Harris, Ph.D. Community Connections October, 2002; May, 2003; March, 2004; February, 2005; March, 2006; April, 2009; July, 2009
MSW Director of Trauma Education 2024735 (voice) 202
  • Rebecca Wolfson Berley
Rebecca Wolfson Berley, MSW Director of Trauma Education 202.608.4735 (voice) 202.608.4286 (fax) rwolfson@ccdc1.org Community Connections 801 Pennsylvania Avenue, S.E. Suite 201