Trauma-Informed Services:
A Protocol for Change
Roger D. Fallot, Ph.D.
Community Connections
Conference on Co-Occurring Disorders
Long Beach, California
February 8, 2008
What are Trauma-Informed
Services?
Trauma-informed vs. trauma-specific
 Characteristics of trauma-informed services
 Incorporate knowledge about trauma—
prevalence, impact, and recovery—in all
aspects of service delivery
 Hospitable and engaging for survivors
 Minimize revictimization
 Facilitate recovery and empowerment
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Why Trauma-Informed Services?
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Trauma is pervasive
Trauma’s impact is broad and diverse
Trauma’s impact is deep and life-shaping
Trauma, especially interpersonal violence, is often
self-perpetuating
Trauma is insidious and differentially affects the
more vulnerable
Trauma affects how people approach services
The service system has often been retraumatizing
A Repetitive Cycle of Risk
Incarceration
Homelessness
Violence and
Trauma
Substance
Abuse
Mental Health
Problems
Comparing Traditional and
Trauma-Informed Paradigms
Understanding of Trauma
 Understanding of the Consumer/Survivor
 Understanding of Services
 Understanding of the Service Relationship
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Traditional Human Services
Paradigm
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Understanding of Trauma
 PTSD as organizing model
 The impact of trauma is seen in
predictable and obviously related
domains of functioning
 Trauma is viewed as a discrete event
 The impact of trauma follows a definable
course with specifiable time limits
Trauma-Informed
Human Services Paradigm
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Understanding of Trauma
 Traumatic events are not rare; experiences of
life disruption are pervasive and common
 The impact of trauma is seen in multiple,
apparently unrelated life domains
 Repeated trauma is viewed as a core life event
around which subsequent development
organizes
 Trauma begins a complex pattern of actions and
reactions which have a continuing impact over
the course of one’s life
Traditional Human Services
Paradigm
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Understanding of the Consumer/Survivor
 Each separate service system has its own view
of the consumer and her or his problems
 The consumer’s problem is understood as an
individual problem independent of context
 The problem and the symptom are synonymous
 The consumer is often attributed either too little
or too much responsibility
Trauma-Informed
Human Services Paradigm

Understanding of the Consumer/Survivor
 An integrated, whole person view of
individuals and their problems and resources
 “Symptoms” are understood not as pathology
but primarily as attempts to cope and survive;
what seem to be symptoms may more
accurately be solutions
 A contextual, relational view of both problems
and solutions
 Appropriate and collaborative responsibility
allocation
Traditional Human Services
Paradigm
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Understanding of Services
 The primary goals of services are stability and
the absence of symptoms
 Services are often crisis driven
 Service time limits are economically and
administratively driven
 Services are chosen in order to minimize risk
and provider liability
Trauma-Informed
Human Services Paradigm
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Understanding of Services
 Primary goals are empowerment and recovery
 Survivors are survivors; their strengths need to
be recognized
 Service priorities are prevention driven
 Service time limits are determined by survivor
self-assessment and recovery/healing needs
 Risk to the consumer is considered along with
risk to the system and the provider
Traditional Human Services
Paradigm
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Understanding of the Service Relationship
 Hierarchical provider/consumer relationship
 Provider is presumed to have a superior
knowledge base
 The consumer is seen as a passive recipient of
services
 The consumer’s safety and trust are taken for
granted
Trauma-Informed
Human Services Paradigm
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Understanding of the Service Relationship
 A collaborative relationship between the
consumer and the provider of her or his choice
 Both the consumer and the provider are
assumed to have valid and valuable knowledge
bases
 The consumer is an active planner and
participant in services
 The consumer’s safety must be guaranteed and
trust must be developed over time
A Culture Shift: The Core
Principles of a Trauma-Informed
System of Care
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Safety: Ensuring physical and emotional safety
Trustworthiness: Maximizing trustworthiness,
making tasks clear, and maintaining appropriate
boundaries
Choice: Prioritizing consumer choice and control
Collaboration: Maximizing collaboration and
sharing of power with consumers
Empowerment: Prioritizing consumer
empowerment and skill-building
A Culture Shift: Scope of Change
in a Distressed System
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Involves all aspects of program activities, setting,
and atmosphere (more than implementing new
services)
Involves all groups: administrators, supervisors,
line staff, consumers, families (more than direct
service providers)
Involves making change into a new routine, a new
way of thinking and acting (more than new
information)
Protocol for Developing a TraumaInformed Service System
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Services-level changes
 Service procedures and settings
 Formal service policies
 Trauma screening, assessment, and service
planning
Systems-level/administrative changes
 Administrative support for program-wide
trauma-informed services
 Trauma training and education
 Human resources practices
Review of Service Procedures and
Settings
1) Identify formal and informal activities
and settings; specify sequence of events
 2) Ask key questions about each activity
and setting
 3) Prioritize goals for change
 4) Identify specific objectives and
responsible person(s)
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The Core Principles Revisited:
Key Questions in Reviewing
Service Procedures
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Safety: How can we ensure physical and emotional safety
for consumers? For staff?
Trustworthiness: How can we maximize trustworthiness?
Make tasks clear? Maintain appropriate boundaries?
Choice: How can we enhance consumer choice and
control?
Collaboration: How can we maximize collaboration and
sharing of power with consumers?
Empowerment: How can we prioritize consumer
empowerment and skill-building at every opportunity?
Safety:
Physical and Emotional Safety
To what extent do service delivery practices
and settings ensure the physical and
emotional safety of consumers? of staff
members?
 How can services and settings be modified
to ensure this safety more effectively and
consistently?
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Trustworthiness:
Clarity, Consistency,
and Boundaries
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To what extent do current service delivery
practices make the tasks involved in service
delivery clear? Ensure consistency in practice?
Maintain boundaries, especially interpersonal
ones, appropriate for the program?
How can services be modified to ensure that tasks
and boundaries are established and maintained
clearly, consistently, and appropriately?
Choice:
Consumer Choice and Control
To what extent do current service delivery
practices prioritize consumer experiences of
choice and control?
 How can services be modified to ensure that
consumer experiences of choice and control
are maximized?
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Collaboration:
Collaborating and Sharing Power
To what extent do current service delivery
practices maximize collaboration and the
sharing of power between providers and
consumers?
 How can services be modified to ensure that
collaboration and power-sharing are
maximized?
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Empowerment:
Recognizing Strengths and
Building Skills
To what extent do current service delivery
practices prioritize consumer
empowerment, recognizing strengths and
building skills?
 How can services be modified to ensure that
experiences of empowerment and the
development or enhancement of consumer
skills are maximized?
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Review of Formal Policies
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Confidentiality policies are clear and shared with
consumers
Policies avoid involuntary or coercive elements of
treatment
De-escalation policy is formalized and minimizes
possibility of retraumatization
Program prioritizes consumer preferences in
responding to crises (e.g., use of preference forms)
Program has clearly written, accessible statement
regarding consumer rights and grievances
Trauma Screening, Assessment,
and Service Planning
Universal trauma screening that is
appropriate to the setting
 Follow-up with appropriate assessment of
trauma exposure history and impact
 Including trauma-based information in
collaborative planning for services
 Offering, or linking to, trauma-specific
services
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Administrative Support for
Program-Wide Trauma-Informed
Services
Support for the integration of knowledge
about trauma and violence into all aspects
of agency functioning
 Possible indicators:
 Formal policy or mission statements
 Developing a “trauma initiative”
 Making resources available
 Active administrator participation
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Trauma Training and Education
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General trauma education for all staff (including
administrators and support staff)
 Recognize trauma dynamics; avoid
retraumatization; understand range of coping
behaviors; boundaries
Clinical trauma education for direct service staff
 Modifications for their specific areas; traumaspecific interventions; staff self-care
Human Resources Practices
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Hiring or identifying “trauma champions”
 Knowledgeable about trauma; prioritize trauma
sensitivity in service provision; communicate
importance of trauma
Including trauma content in interviews of
prospective staff
 Knowledge about trauma, trauma sequelae, and
recovery
Including trauma-related activities in performance
reviews
Conclusion
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What we know about trauma, its impact, and the
process of recovery calls for trauma-informed
service approaches
A trauma-informed approach involves
fundamental shifts in thinking and practice at all
programmatic levels
Trauma-informed services offer the possibility of
enhanced collaboration for all participants in the
human service system
Trauma-Informed Systems Change:
Examples from Massachusetts
Norma Finkelstein, PhD
Executive Director,
Institute for Health and Recovery
Sixth Annual Conference on Co-Occurring Disorders:
One Person, One Team, One Plan for Recovery
February 8, 2008
Long Beach, CA
Institute for Health and Recovery
• 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)
Institute for Health and Recovery
Women, Co-Occurring Disorders and
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
Institute for Health and Recovery
• 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
Institute for Health and Recovery
Department of Public Health /
Bureau of Substance Abuse Services
(DPH / BSAS)
• 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
Institute for Health and Recovery
2004-2006
• 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
Institute for Health and Recovery
2007
• 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
Institute for Health and Recovery
• Applied organizational change strategies
learned from these projects to trauma
initiative. Included:
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Identifying champion for change
Forming change team
Team identifies targets for change
Gathering data before and after change is
implemented
Institute for Health and Recovery
BSAS – Current Revised Strategy:
Trauma-Informed
• Held initial state-wide meeting to familiarize
SUD programs with trauma initiative
• Prioritized women’s and co-ed residential
treatment programs
Institute for Health and Recovery
• 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.
Institute for Health and Recovery
Trauma-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
Institute for Health and Recovery
Trauma-Specific Group Implementation
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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.
Institute for Health and Recovery
Expected Outcomes
Program:
• Improvement in trauma self-assessment
• Increased provision of trauma-specific services
• Decrease in client management problems
Client:
• Increased program retention
• Lower relapse rates
• Decrease in self-harming behaviors
Institute for Health and Recovery
Update
• 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
Institute for Health and Recovery
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
Institute for Health and Recovery
• 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
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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
Institute for Health and Recovery
• 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
Institute for Health and Recovery
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
Institute for Health and Recovery
• IHR works with Spectrum Health Services at MCI
Framingham and South Middlesex Correctional Center
(state women’s prisons)
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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 traumainformed
– Beginning work at integrating SA services with mental health services
provided by UMass
Institute for Health and Recovery
DOC Training for Correctional Staff
• 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
Institute for Health and Recovery
• 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.
Institute for Health and Recovery