trauma-informed services: a protocol for change roger d. fallot, ph.d. community connections...

Trauma-Informed Services: A Protocol for Change

Roger D. Fallot, Ph.D.Roger D. Fallot, Ph.D.

Community ConnectionsCommunity Connections

Conference on Co-Occurring DisordersConference on Co-Occurring Disorders

Long Beach, CaliforniaLong Beach, California

February 8, 2008February 8, 2008

What are Trauma-Informed Services?

Trauma-informed vs. trauma-specificTrauma-informed vs. trauma-specific Characteristics of trauma-informed servicesCharacteristics of trauma-informed services

Incorporate knowledge about trauma—Incorporate knowledge about trauma—prevalence, impact, and recovery—in all prevalence, impact, and recovery—in all aspects of service deliveryaspects of service delivery

Hospitable and engaging for survivorsHospitable and engaging for survivors Minimize revictimizationMinimize revictimization Facilitate recovery and empowermentFacilitate recovery and empowerment

Why Trauma-Informed Services?

Trauma is pervasiveTrauma is pervasive Trauma’s impact is broad and diverseTrauma’s impact is broad and diverse Trauma’s impact is deep and life-shapingTrauma’s impact is deep and life-shaping Trauma, especially interpersonal violence, is often Trauma, especially interpersonal violence, is often

self-perpetuatingself-perpetuating Trauma is insidious and differentially affects the Trauma is insidious and differentially affects the

more vulnerablemore vulnerable Trauma affects how people approach servicesTrauma affects how people approach services The service system has often been retraumatizing The service system has often been retraumatizing

A Repetitive Cycle of Risk

HomelessnessIncarceration

Substance Abuse

Mental Health Problems

Violence andTrauma

Comparing Traditional and Trauma-Informed Paradigms

Understanding of TraumaUnderstanding of Trauma Understanding of the Consumer/SurvivorUnderstanding of the Consumer/Survivor Understanding of ServicesUnderstanding of Services Understanding of the Service RelationshipUnderstanding of the Service Relationship

Traditional Human Services Paradigm

Understanding of TraumaUnderstanding of Trauma PTSD as organizing modelPTSD as organizing model The impact of trauma is seen in The impact of trauma is seen in

predictable and obviously related predictable and obviously related domains of functioningdomains of functioning

Trauma is viewed as a discrete event Trauma is viewed as a discrete event The impact of trauma follows a definable The impact of trauma follows a definable

course with specifiable time limitscourse with specifiable time limits

Trauma-Informed Human Services Paradigm

Understanding of TraumaUnderstanding of Trauma Traumatic events are not rare; experiences of life Traumatic events are not rare; experiences of life

disruption are pervasive and commondisruption are pervasive and common The impact of trauma is seen in multiple, The impact of trauma is seen in multiple,

apparently unrelated life domainsapparently unrelated life domains Repeated trauma is viewed as a core life event Repeated trauma is viewed as a core life event

around which subsequent development organizesaround which subsequent development organizes Trauma begins a complex pattern of actions and Trauma begins a complex pattern of actions and

reactions which have a continuing impact over the reactions which have a continuing impact over the course of one’s lifecourse of one’s life


Understanding of the Consumer/SurvivorUnderstanding of the Consumer/Survivor Each separate service system has its own view Each separate service system has its own view

of the consumer and her or his problemsof the consumer and her or his problems The consumer’s problem is understood as an The consumer’s problem is understood as an

individual problem independent of contextindividual problem independent of context The problem and the symptom are synonymousThe problem and the symptom are synonymous The consumer is often attributed either too little The consumer is often attributed either too little

or too much responsibilityor too much responsibility


Understanding of the Consumer/SurvivorUnderstanding of the Consumer/Survivor An integrated, whole person view of An integrated, whole person view of

individuals and their problems and resourcesindividuals and their problems and resources ““Symptoms” are understood not as pathology Symptoms” are understood not as pathology

but primarily as attempts to cope and survive; but primarily as attempts to cope and survive; what seem to be symptoms may more what seem to be symptoms may more accurately be solutionsaccurately be solutions

A contextual, relational view of both problems A contextual, relational view of both problems and solutionsand solutions

Appropriate and collaborative responsibility Appropriate and collaborative responsibility allocationallocation


Understanding of ServicesUnderstanding of Services The primary goals of services are stability and The primary goals of services are stability and

the absence of symptomsthe absence of symptoms Services are often crisis drivenServices are often crisis driven Service time limits are economically and Service time limits are economically and

administratively drivenadministratively driven Services are chosen in order to minimize risk Services are chosen in order to minimize risk

and provider liabilityand provider liability


Understanding of ServicesUnderstanding of Services Primary goals are empowerment and recoveryPrimary goals are empowerment and recovery Survivors are survivors; their strengths need to Survivors are survivors; their strengths need to

be recognizedbe recognized Service priorities are prevention drivenService priorities are prevention driven Service time limits are determined by survivor Service time limits are determined by survivor

self-assessment and recovery/healing needs self-assessment and recovery/healing needs Risk to the consumer is considered along with Risk to the consumer is considered along with

risk to the system and the providerrisk to the system and the provider


Understanding of the Service RelationshipUnderstanding of the Service Relationship Hierarchical provider/consumer relationshipHierarchical provider/consumer relationship Provider is presumed to have a superior Provider is presumed to have a superior

knowledge baseknowledge base The consumer is seen as a passive recipient of The consumer is seen as a passive recipient of

servicesservices The consumer’s safety and trust are taken for The consumer’s safety and trust are taken for

grantedgranted


Understanding of the Service RelationshipUnderstanding of the Service Relationship A collaborative relationship between the A collaborative relationship between the

consumer and the provider of her or his choiceconsumer and the provider of her or his choice Both the consumer and the provider are Both the consumer and the provider are

assumed to have valid and valuable knowledge assumed to have valid and valuable knowledge basesbases

The consumer is an active planner and The consumer is an active planner and participant in servicesparticipant in services

The consumer’s safety must be guaranteed and The consumer’s safety must be guaranteed and trust must be developed over timetrust must be developed over time

A Culture Shift: The Core Principles of a Trauma-Informed

System of Care

Safety:Safety: Ensuring physical and emotional safety Ensuring physical and emotional safety TrustworthinessTrustworthiness: Maximizing trustworthiness, : Maximizing trustworthiness,

making tasks clear, and maintaining appropriate making tasks clear, and maintaining appropriate boundariesboundaries

Choice:Choice: Prioritizing consumer choice and control Prioritizing consumer choice and control Collaboration:Collaboration: Maximizing collaboration and Maximizing collaboration and

sharing of power with consumerssharing of power with consumers Empowerment:Empowerment: Prioritizing consumer Prioritizing consumer

empowerment and skill-buildingempowerment and skill-building

A Culture Shift: Scope of Change in a Distressed System

Involves all aspects of program activities, setting, Involves all aspects of program activities, setting, and atmosphere (more than implementing new and atmosphere (more than implementing new services)services)

Involves all groups: administrators, supervisors, Involves all groups: administrators, supervisors, line staff, consumers, families (more than direct line staff, consumers, families (more than direct service providers)service providers)

Involves making change into a new routine, a new Involves making change into a new routine, a new way of thinking and acting (more than new way of thinking and acting (more than new information)information)

Protocol for Developing a Trauma-Informed Service System Services-level changesServices-level changes

Service procedures and settingsService procedures and settings Formal service policiesFormal service policies Trauma screening, assessment, and service Trauma screening, assessment, and service

planningplanning Systems-level/administrative changesSystems-level/administrative changes

Administrative support for program-wide trauma-Administrative support for program-wide trauma-informed servicesinformed services

Trauma training and educationTrauma training and education Human resources practicesHuman resources practices

Review of Service Procedures and Settings

1) Identify formal and informal activities 1) Identify formal and informal activities and settings; specify sequence of eventsand settings; specify sequence of events

2) Ask key questions about each activity 2) Ask key questions about each activity and settingand setting

3) Prioritize goals for change3) Prioritize goals for change 4) Identify specific objectives and 4) Identify specific objectives and

responsible person(s)responsible person(s)

The Core Principles Revisited:Key Questions in Reviewing

Service Procedures

Safety:Safety: How can we ensure physical and emotional safety How can we ensure physical and emotional safety for consumers? For staff?for consumers? For staff?

TrustworthinessTrustworthiness: How can we maximize trustworthiness? : How can we maximize trustworthiness? Make tasks clear? Maintain appropriate boundaries?Make tasks clear? Maintain appropriate boundaries?

Choice:Choice: How can we enhance consumer choice and How can we enhance consumer choice and control?control?

Collaboration:Collaboration: How can we maximize collaboration and How can we maximize collaboration and sharing of power with consumers?sharing of power with consumers?

Empowerment:Empowerment: How can we prioritize consumer How can we prioritize consumer empowerment and skill-building at every opportunity?empowerment and skill-building at every opportunity?

Safety: Physical and Emotional Safety

To what extent do service delivery practices To what extent do service delivery practices and settings ensure the physical and and settings ensure the physical and emotional safety of consumers? of staff emotional safety of consumers? of staff members?members?

How can services and settings be modified How can services and settings be modified to ensure this safety more effectively and to ensure this safety more effectively and consistently?consistently?

Trustworthiness:Clarity, Consistency,

and Boundaries To what extent do current service delivery To what extent do current service delivery

practices make the tasks involved in service practices make the tasks involved in service delivery clear? Ensure consistency in practice? delivery clear? Ensure consistency in practice? Maintain boundaries, especially interpersonal Maintain boundaries, especially interpersonal ones, appropriate for the program?ones, appropriate for the program?

How can services be modified to ensure that tasks How can services be modified to ensure that tasks and boundaries are established and maintained and boundaries are established and maintained clearly, consistently, and appropriately?clearly, consistently, and appropriately?

Choice: Consumer Choice and Control

To what extent do current service delivery To what extent do current service delivery practices prioritize consumer experiences of practices prioritize consumer experiences of choice and control?choice and control?

How can services be modified to ensure that How can services be modified to ensure that consumer experiences of choice and control consumer experiences of choice and control are maximized?are maximized?

Collaboration:Collaborating and Sharing Power To what extent do current service delivery To what extent do current service delivery

practices maximize collaboration and the practices maximize collaboration and the sharing of power between providers and sharing of power between providers and consumers?consumers?

How can services be modified to ensure that How can services be modified to ensure that collaboration and power-sharing are collaboration and power-sharing are maximized?maximized?

Empowerment: Recognizing Strengths and

Building Skills To what extent do current service delivery To what extent do current service delivery

practices prioritize consumer practices prioritize consumer empowerment, recognizing strengths and empowerment, recognizing strengths and building skills?building skills?

How can services be modified to ensure that How can services be modified to ensure that experiences of empowerment and the experiences of empowerment and the development or enhancement of consumer development or enhancement of consumer skills are maximized?skills are maximized?

Review of Formal Policies

Confidentiality policies are clear and shared with Confidentiality policies are clear and shared with consumersconsumers

Policies avoid involuntary or coercive elements of Policies avoid involuntary or coercive elements of treatmenttreatment

De-escalation policy is formalized and minimizes De-escalation policy is formalized and minimizes possibility of retraumatizationpossibility of retraumatization

Program prioritizes consumer preferences in Program prioritizes consumer preferences in responding to crises (e.g., use of preference forms)responding to crises (e.g., use of preference forms)

Program has clearly written, accessible statement Program has clearly written, accessible statement regarding consumer rights and grievancesregarding consumer rights and grievances

Trauma Screening, Assessment, and Service Planning

Universal trauma screening that is Universal trauma screening that is appropriate to the settingappropriate to the setting

Follow-up with appropriate assessment of Follow-up with appropriate assessment of trauma exposure history and impacttrauma exposure history and impact

Including trauma-based information in Including trauma-based information in collaborative planning for servicescollaborative planning for services

Offering, or linking to, trauma-specific Offering, or linking to, trauma-specific servicesservices

Administrative Support for Program-Wide Trauma-Informed

Services Support for the integration of knowledge Support for the integration of knowledge

about trauma and violence into all aspects about trauma and violence into all aspects of agency functioningof agency functioning

Possible indicators:Possible indicators: Formal policy or mission statementsFormal policy or mission statements Developing a “trauma initiative”Developing a “trauma initiative” Making resources availableMaking resources available Active administrator participationActive administrator participation

Trauma Training and Education

General trauma education for all staff (including General trauma education for all staff (including administrators and support staff)administrators and support staff) Recognize trauma dynamics; avoid Recognize trauma dynamics; avoid

retraumatization; understand range of coping retraumatization; understand range of coping behaviors; boundariesbehaviors; boundaries

Clinical trauma education for direct service staffClinical trauma education for direct service staff Modifications for their specific areas; trauma-Modifications for their specific areas; trauma-

specific interventions; staff self-carespecific interventions; staff self-care

Human Resources Practices

Hiring or identifying “trauma champions”Hiring or identifying “trauma champions” Knowledgeable about trauma; prioritize trauma Knowledgeable about trauma; prioritize trauma

sensitivity in service provision; communicate sensitivity in service provision; communicate importance of traumaimportance of trauma

Including trauma content in interviews of Including trauma content in interviews of prospective staffprospective staff Knowledge about trauma, trauma sequelae, and Knowledge about trauma, trauma sequelae, and

recoveryrecovery Including trauma-related activities in performance Including trauma-related activities in performance

reviewsreviews

Conclusion

What we know about trauma, its impact, and the What we know about trauma, its impact, and the process of recovery calls for trauma-informed process of recovery calls for trauma-informed service approachesservice approaches

A trauma-informed approach involves A trauma-informed approach involves fundamental shifts in thinking and practice at all fundamental shifts in thinking and practice at all programmatic levelsprogrammatic levels

Trauma-informed services offer the possibility of Trauma-informed services offer the possibility of enhanced collaboration for all participants in the enhanced collaboration for all participants in the human service systemhuman service system

Institute for Health and Recovery

Trauma-Informed Systems Change:Trauma-Informed Systems Change:Examples from MassachusettsExamples from Massachusetts

Norma Finkelstein, PhDExecutive Director,


Sixth Annual Conference on Co-Occurring Disorders: One Person, One Team, One Plan for Recovery

February 8, 2008Long Beach, CA


• IHR works across state systems in Massachusetts to integrate trauma-informed and trauma specific practices

• The 3 main systems IHR currently works with are:– Department of Public Health (DPH) /

Bureau of Substance Abuse Services (BSAS)– Department of Mental Health (DMH)– Department of Corrections (DOC)


Women, Co-Occurring Disorders and Women, Co-Occurring Disorders and Violence Study (WCDVS)Violence Study (WCDVS)

• Three grants in Massachusetts

• IHR put considerable focus on state-level systems change– State Leadership Council– Local Leadership Councils– Organizational Assessment – Trauma Tool-Kit


• IHR participates in several state-wide commissions and policy committees– Governor’s Commission on Correction Reform– Governor’s Commission on Sexual and Domestic

Violence– DPH/DMH Emergency Room Access for People

with Behavior Health Needs Work Group– DMH Restraint and Seclusion Advisory

Committee


• Goal: All substance abuse treatment programs in MA will provide trauma-informed care

• 2002: Provision of trauma-informed care included in terms and conditions of all contracts

• 2003: Presented results of WCDVS in multiple venues across state

• Conducted regional SA/DV summit meetings across state– Training in trauma-informed services– Needs assessment of what providers needed to work

together more effectively

Department of Public Health / Department of Public Health / Bureau of Substance Abuse Services Bureau of Substance Abuse Services

(DPH / BSAS)(DPH / BSAS)


2004-20062004-2006

• Provided trainings on trauma-informed care twice a year – opened to state-wide audiences

• Northeast Regional Conference on Integrating Substance Abuse, Domestic Violence, and Mental Health (funded by SAMHSA)

• Trauma training needs assessment with representative sample of SUD programs – all modalities across state

• Offered training on trauma-informed care and trauma-specific interventions to SUD programs upon request


• Revised strategy

• Goal: ensure that training and TA resulted in practice changes

• BSAS: two other successful system change projects – emphasized importance of working with agency teams over a sustained period of time

20072007


• Applied organizational change strategies learned from these projects to trauma initiative. Included:– Identifying champion for change– Forming change team– Team identifies targets for change– Gathering data before and after change is

implemented


BSAS – Current Revised Strategy:BSAS – Current Revised Strategy:Trauma-InformedTrauma-Informed

• Held initial state-wide meeting to familiarize SUD programs with trauma initiative

• Prioritized women’s and co-ed residential treatment programs


• Implementation of Revised Strategy – Agency submits letter indicating interest– Completes Trauma-Integration self-assessment– Chooses champion – individual at supervisory level responsible

for implementing change– Staff, including supervisors, attend four hours of trauma training

on site– Champion meets with staff (team) to begin trauma-informed

planning– Consultation provided for plan development as necessary– After plan, may request additional training and/or TA– Support provided for plan implementation over following six

months– Program repeats assessment at end of consultation period.


Trauma-Specific Group ImplementationTrauma-Specific Group Implementation

• Training on various trauma-specific group models (overview)

• Team chooses and purchases curriculum; clinicians assigned to lead groups read curriculum

• Introductory training on specific group curriculum provided


• Program commits to implementing groups ASAP. No more training provided until at least one group conducted

• Options:1. IHR facilitator co-leads group with two program

clinicians for one full cycle

2. IHR provides one-hour group supervision every two weeks for six weeks; then monthly.

Trauma-Specific Group ImplementationTrauma-Specific Group Implementation


Expected OutcomesExpected Outcomes

Program: • Improvement in trauma self-assessment• Increased provision of trauma-specific services• Decrease in client management problemsClient:• Increased program retention• Lower relapse rates• Decrease in self-harming behaviors


UpdateUpdate

• Still doing yearly state-wide trauma-informed training

• Working with four large, umbrella SA/MH programs, agency-wide

• Implementing Seeking Safety in multiple sites of three of these organizations

• Requests from two other umbrella agencies in discussion phase


Department of Mental Health (DMH)Department of Mental Health (DMH)

• SAMHSA state incentive grant to eliminate use of restraint and seclusion in state-operated adult inpatient system

• One strategy for DMH was workforce development, mainly training around trauma

• As grant ended, it was clear hospital staff needed ongoing support for continuing culture change required to institute trauma-informed care


• IHR providing consultation and TA to a number of state hospitals’ trauma integration teams– Includes managers of all departments– Human Rights Officers– Peer liaisons (consumers)

• IHR working to draft a Trauma Integration Plan– Goals– Objectives– Tasks– Responsibilities

• Then work with hospital to implement plan– Develop capacity and structures so that, when TA and training are no

longer available, hospital staff can do them on their own


• Plan includes specific feedback form for consumers.– What do you think staff at ___ Hospital need to

know in order to provide better care?– In addition to goals and steps, what do you think a

trauma consultant can do to help improve care?– What procedures should be changed to improve

care?

• Meetings held with willing consumers to discuss changes in hospital procedures


Department of Corrections (DOC)Department of Corrections (DOC)

• Governor’s Commission on Corrections Reform– Suggestions made around trauma

• New procurement for SA services in state prisons – Specified care must be trauma-informed


• IHR works with Spectrum Health Services at MCI Framingham and South Middlesex Correctional Center (state women’s prisons)– Staff training on trauma-informed

– Trauma consultation to all SA services in prison

– Training designated clinicians to run trauma recovery groups

– Wrote intro violence orientation group for trauma survivors and/or perpetrators

– Co-facilitating first round of Seeking Safety groups at both sites

– Providing group supervision at both sites

– Revising other program curricula within prison to make them more trauma-informed

– Beginning work at integrating SA services with mental health services provided by UMass


• In-depth, two-day training for managers and key staff members responsible for implementing trauma-informed practices within their areas

• Develop curriculum that can be used by individuals who attended two-day training to train others at their respective sites

DOC Training for Correctional StaffDOC Training for Correctional Staff


• Several three-hour trainings for all correctional officers, delivered during training of all new recruits

• Training of all officers working with female offenders

• All trainings also offered in DOC catalogue of voluntary trainings for correctional officers.

trauma-informed services: a protocol for change roger d. fallot, ph.d. community connections...

Documents

services trauma

traumaspecific trauma

impact of trauma

trauma slide

traumainformed services

selfperpetuating trauma

vulnerable trauma

trauma prevalence