Paving the Way for
Trauma-Informed
Organizations
Nancy J. Udolph, LISW-S, ACSW
Associate Professor of Social Work
Ashland University
What is Trauma?
• Trauma refers to intense and overwhelming experiences
that involve serious loss, threat or harm to a person’s
physical and/or emotional well being.
• These experiences may occur at any time in a person’s
life. They may involve a single traumatic event or may
be repeated over many years.
• These trauma experiences often overwhelm the persons
coping resources. This often leads the person to find a
way of coping that may work in the short run but may
cause serious harm in the long run. -SAMHSA
Examples of Traumatic Life Experiences
• Physical, emotional and/or sexual abuse in childhood or adulthood
• In Childhood
neglect or abandonment (food insufficiency, lack of money to met basic
needs, homelessness)
• death of a parent
• divorce
• family life that includes drug addiction, alcoholism, parental
incarceration, violence
•
• Rape
• Serious medical illness or disease (disabling conditions, loss of
function, invasive and distressing procedures)
Trauma can also occur from:
• Being in a car accident or other serious incident
• Having a serious health concern or hospitalization
• Sudden job loss
• Losing a loved one
• Being in a fire, hurricane, flood or other natural
disaster
• Witnessing violence
Trauma experienced in adulthood may also affect a
persons emotional and physical well-being
• Examples:
• Combat related trauma
• Refugee/torture/civil unrest
• Witnessing or experiencing violence
• Catastrophic loss (natural disasters)
• Terrorism
• Bottom line findings: These experiences raise the
individuals risk for severe emotional distress, suicide,
physical illness, substance abuse and a host of other life
difficulties
What the research tells us: The Adverse
Childhood Experiences (ACE) Study?
• Center for Disease Control and Kaiser
Permanente (an HMO) Collaboration
• Over a ten year study involving 17,000
people
• Looked at effects of adverse childhood
experiences (trauma)over the lifespan
• Largest study ever done on this subject
Impact of Trauma Over the Lifespan
• Increases the risk of neurological, biological,
psychological and/or social difficulties such as:
• Changes in brain neurobiology;
• Social, emotional & cognitive impairment;
• Adoption of health risk behaviors as coping
mechanisms (eating disorders, smoking, substance
abuse, self harm, sexual promiscuity, violence); and
• Severe and persistent behavioral health, physical
health and social problems, early death. (Felitti et al, 1998)
Healthcare conditions often associated with a
history of adverse childhood experiences:
• Diabetes
• COPD
• Heart Disease
• High Blood Pressure
• Obesity
• Cancer
• Liver Disease
• Gynecologic Disorders
• Sexually Transmitted
Diseases
• Unintended
Pregnancies
Why is Understanding Trauma Important?
• To provide effective services we need to understand the life
situations that may be contributing to the persons current
problems
• Many current problems faced by the people we serve may be
related to traumatic life experiences
• People who have experienced traumatic life events are often very
sensitive to situations that remind them of the people, places or
things involved in their traumatic event
• These reminders, also known as triggers, may cause a person to
relive the trauma and view our setting/organization as a source of
distress rather than a place of healing and wellness (SAMHSA)
“Trauma-informed” refers to all of the ways in which a
service system is influenced by having an understanding
of trauma, and the ways in which it is modified to be
responsive to the impact of traumatic stress. A
program that is “trauma-informed” operates within a
model or framework that incorporates an understanding
of the ways in which trauma impacts an individual’s
socio-emotional health. This framework should,
theoretically, decrease the risk of retraumatization,
as well as contribute more generally to recovery from
traumatic stress. (Harris & Fallot, 2001)
Trauma may negatively influence access to
and engagement in care:
1. Avoidance of social services
2. Non-adherence to treatment
3. Postponing services until things get very
bad
4. Misuse of services – ex. over use of ER
Services and misuse of pain meds
Why trauma is not routinely addressed:
Lack of time
Lack of awareness
Lack of tools
Lack of training
Misconceptions/discomfort
Benefits of trauma-informed services
• Evidence-based and effective
• Cost-effective
• Humane and responsive to real needs
• Aligned with over-arching goals
• Highlights glitches in the systems and offers
solutions
• Works with other best practices
What Can We Do to Provide Trauma Sensitive
Care and Practices?
A. Screen and assess for trauma
B. Communicate a sensitivity to trauma issues
C. Train “all” staff about trauma, sensitive practice and sharing
critical information
D. Create a safe and comfortable environment
E. Provide services in a trauma informed manner – some practical
tips
F. Policy analysis and development
Principles of Sensitive Practice
1.
2.
3.
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5.
6.
7.
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Respect
Taking Time
Rapport
Sharing Information
Sharing Control
Respecting Boundaries
Fostering Mutual Learning
Understanding Non-linear Healing
Demonstrating Awareness and Knowledge of Trauma
Handbook on Sensitive Practice for Health Care Practitioners: Lessons from Adult Survivors of Childhood Sexual Abuse was
researched and written by Candice L. Schachter, Carol A. Stalker, Eli Teram, Gerri C. Lasiuk and Alanna Danilkewich
Trauma-Informed Care (TIC) provides a new model under
which the basic premise for organizing services is transformed
from:
“What’s wrong with
you?”
to:
What has happened to
you?”
A. Provide a Health Appraisal Questionnaire Examples of Questions with Yes/No Responses
(completed in private)
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•
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I have been physically abused as a child
I have been verbally abused as a child
I was sexually molested as a child or adolescent
I have been raped
I have been threatened or abused as an adult by a sexual partner
My partner has threatened, pushed, shoved me
My partner has threatened or abused my children
An empathic, validating response by a provider to
someone who discloses a trauma history may be:
“I’m sorry that that happened to you; no one has the right
to hit another person/force another person to have sex”
“Growing up in an environment of violence is so difficult
for a child – no one should have to face such upsetting
and scary situations”
“We know that there is a direct relationship between
these experiences and a person’s physical health; have
you ever had a chance to explore these?”
B. Communicating a Sensitivity to Trauma
Issues
• Trauma related materials in waiting areas
• Posters inviting individuals to talk about trauma and/or needs
located in offices
• Asking questions about trauma and/or needs during assessments
C. Train Staff about Trauma, Sensitive
Practices and Sharing Critical Information
• Increase awareness and importance of trauma as a factor
in health and mental health outcomes
• Primary and behavioral health have communication
channels to inform each other about a person’s trauma
and its affect on…
• mental health, substance use and physical wellbeing
• the person’s comfort with and use of medical and mental
health services
Tips for Sustaining Trauma Education and
Awareness
• One-time trainings are insufficient to
support organizational change.
Organizational change is a continuous
process, and new approaches take time to
be reinforced and deepened. Additionally,
high turnover rates necessitate repeated
training to provide knowledge and skills to
new staff. (Family Homelessness)
To be trauma informed, programs can build an
infrastructure for sustaining trauma-awareness and
growth in the following ways:
• Creation of a “trauma workgroup”: core group of staff
members from all levels of the organization, sanctioned
by management, who come together to take what they
have learned about trauma and strategize about how to
apply this knowledge to daily program practices, and
facilitate continued education about trauma for all staff.
• Incorporating trauma language— Using the term
“trauma” in program mission statement, handbooks, etc.
• Establishing external networks of support—
Programs can sustain trauma awareness by
establishing regular contact with outside agencies
with expertise in trauma, including the use of
outside consultants with expertise in trauma to
provide on-going education and case consultation
D. Creating a Safe and Secure Environment
• Survey service recipients to gain feedback about their
experiences, including the physical environment
• Solicit staff to suggest improvements to care and the
environment
• Insure individuals feel welcome and comfortable from
reception through exiting
• Do no harm – prevent re-traumatization
• Provide trauma sensitive practices and care
Establishing a Safe Physical Environment
• The building is well maintained and clean.
• Things are fixed when they are broken.
• The building is swept/dusted/mopped, sprayed for bugs,
etc.
• The building is locked.
• Transportation is provided or accessible for consumers to
get to and from the program.
• The building is accessible for people with hearing, visual,
and mobility impairments.
Staff supervision, support and
self-care are crucial to
maintaining a Traumainformed safe and secure
environment.
Trauma Informed Care: Practical Tips
• Ask if person is ready to begin and inform them that they can
pause or stop the session at anytime
• Encourage questions and ask about any worries or concerns and
how you can help (ex. leaving door ajar)
• Maintain a personable, respectful, kind and honest manner
• Encourage person to do what feels most comfortable (ex. keeping
coat on, listening to music)
• Place a high priority on culture; including ethnicity, race, religion,
sexual orientation, historical and social trauma such as
homelessness and poverty
E. Policy Analysis and Development
a. establish policies to eliminate practices which traumatize or
retraumatize persons with histories of abuse trauma, as well as
other consumers
b. create policy to ensure provision of trauma services and
professional education and training, i.e.. standards of care
c. ensure provider participation in trauma-based training and
education
d. create policy to increase detection and prevention of sexual,
physical and psychological abuse in institutional settings
Tips and Strategies for Reviewing Policies
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Is this policy or rule necessary?
What purpose does it serve?
Who does it help? Who does it hurt?
Does the policy facilitate/hinder consumer inclusion and control?
Were consumers included in its development?
Could this policy or rule re-traumatize the consumer (e.g., limit
consumer control and power, lead to fear and confusion, etc.).
Creating and sustaining organizational change is a
long and challenging process. Some initial changes
may be relatively easy to make, while long-term
goals require continued time and attention.
Sustaining organizational change requires programs
to be both thoughtful and creative about how to
thoroughly integrate trauma informed principles and
practices into the culture and practice of an
organization.
(Family Homelessness)
Agency Assessment Tools
• Agency Self-Assessment-Trauma-Informed Care Project
• Trauma-Informed Program Self-Assessment Scale
• Trauma-Informed Organizational Toolkit