1. Trauma-Informed Care: What We Have Learned
Image: Eight left hands encircling the words “Trauma-Informed Care.”
Trauma-Informed Care: What We Have Learned
The views, opinions, and content of this presentation are those of the presenters and do not necessarily reflect the views, opinions, or policies of SAMHSA or the U.S. Department of Health and Human Services.
Charles E. Lewis, Jr., Moderator
Minority Fellowship Program Coordinating Center

2. Trauma-Informed Care
Individuals who need behavioral health services often have been exposed to a wide range of traumas, including domestic violence, emotional abuse, neglect, physical abuse, sexual trauma, incarceration of a parent, violence in unsafe communities, and lack of permanency because of multiple moves or placements within the child welfare system. Without trauma-informed care, they are at risk of being “retraumatized” by the system.
Trauma-informed care shifts from asking “What is wrong with a person?” and begins asking “What has happened to this person?” Trauma-informed care is rooted in understanding and considering the pervasive nature of trauma and the need for environments of healing and recovery rather than practices and services that may inadvertently retraumatize.

3. Presenters
Images: Photos of presenters.
Rebecca Flatow Zornick, MSSW, J.D., is a lead public health analyst in SAMHSA’s Office of Policy, Planning, and Innovation. She is the team lead for the Division of Policy Coordination and serves as the staff lead to the senior advisor for children, youth, and family policy and SAMHSA’s Trauma and Justice Strategic Initiative.
Elicia McIntyre, MSW, LCSW–C, is a Public Health Advisor/Grant Project Officer for the Child Trauma Team, Emergency Mental Health and Traumatic Stress Services Branch, Division of Traumatic Stress, Prevention, and Special Programs, within SAMHSA’s Center for Mental Health Services.
Cheryl Sharp, MSW, MWT, CPSST, is a Master Wellness Recovery Action Plan (WRAP) trainer, Mental Health First Aid USA instructor, and trainer of Intentional Peer Support. She is an Exclusive Consultant for Trauma-Informed Services for the National Council for Behavioral Health.

4. SAMHSA’S Comprehensive Public Health Approach to Addressing Trauma
Rebecca Flatow Zornick, J.D, MSSW
Team Lead, Division of Policy Coordination
Office of Policy, Planning, and Innovation
Minority Fellowship Program Webinar
March 29, 2017

5. SAMHSA’s Trauma and Justice
Strategic Initiative
Integrate a trauma-informed approach throughout health, behavioral health, and related systems to reduce the harmful effects of trauma and violence on individuals, families, and communities. 
Use innovative strategies to reduce the involvement of individuals with trauma and behavioral health issues in the criminal and juvenile justice systems.
Reduce the impact of disasters on the behavioral health of individuals, families, and communities. 5

6. SI Goal: Implement and study a trauma-informed approach throughout health, behavioral health, and related systems.
Integrate an understanding of trauma and strategies for implementing a trauma-informed approach across SAMHSA, interested federal agencies, and other public service sectors.
SAMHSA’S Comprehensive Public Health Approach to Trauma
Coordinate and align SAMHSA’s trauma technical assistance and training activities.
SAMHSA’s Approach to Community and Historical Trauma
Develop and implement measures for population surveillance, client level data, facilities surveys, and quality measures.
SAMHSA’s Trauma Technical Assistance Coordination Strategy
Develop SAMHSA’s framework for community and historical trauma and a trauma-informed approach for communities.
SAMHSA’s Trauma Measurement Strategy

7. The Central Role of Trauma
School Problems, Incarceration
Homelessness, Relationship & Job Problems
Violence & Potential
Traumatic Events
Substance Abuse, Parenting Problems
Mental Health Problems
Suicide
PTSD
Depression
Schizophrenia
Image: Arrows connecting the events to one another.

8. Reported Prevalence of Trauma and Behavioral Health
43 percent to 80 percent of individuals in psychiatric hospitals have experienced physical or sexual abuse.
51 percent to 90 percent public mental health clients exposed to trauma (Goodman et al., 1997; Mueser et al., 2004).
Two out of three adults in SUD treatment report child abuse and neglect (SAMHSA, CSAT, 2000).
Survey of adolescents in SU treatment > 70 percent had history of trauma exposure (Suarez, 2008).
Juvenile justice involved youth, esp. females, report more exposure to trauma than the general population; one study reported over 60 percent juvenile detainees experience trauma (Ford et al., 2008; Kretschmar et al., 2014).

9. The Impact of Trauma Trauma is cumulative.
Trauma affects the developing neurophysiological system.
Trauma increases likelihood of health risk behaviors (smoking, drinking, overeating) as means of coping.
Trauma is directly related to mental health symptoms, substance abuse, chronic physical illness, early mortality.
Has impact at the molecular, clinical, and population levels.
The ACE study and other research has given us a pretty clear picture of the impact of trauma and toxic stress. Go over slide.

10. Trauma and Co-Occurring Disorders
Now understood to be an almost universal experience of people in the public mental health, substance abuse, and social service systems.
Trauma survivors are at a much higher risk for co-occurring mental and substance use disorders, violence victimization and perpetration, self-injury, and a host of other risks/coping mechanisms that have devastating human, social, and economic costs.
Characteristics of Individuals with Traumatic Stress and Substance Abuse
Emotional and behavioral dysregulation
Coping deficits
Family strain
Environmental stress
Academic & vocational difficulties
Health problems
Involvement with multiple service systems (legal system, social services, mental health, substance abuse, special education)

11. Effects of Traumatic Experiences
Biology: Increased levels of stress hormones (e.g., akin to combat veterans) altered sleep patterns
Disrupted attachment; social isolation
Mood dysregulation and irritability
Cognitive problems (e.g., completing tasks, or planning for and anticipating future events/Learning problems)
Behavior control (e.g., poor impulse control, aggression, self-destructive behavior)
Dissociation: Detachment or depersonalization, as if they are “observing”/reality is unreal
Self-concept: Disturbed self image, low self-esteem, shame, and guilt
Sense of grief and loss

12. Lessons Learned from Grantees
Challenges
Increasing access to trauma interventions, knowledge, and practice
Workforce development and training
Expansion/inclusion of underserved, diverse racial and ethnic populations
Changing organizational structures to support a trauma-informed approach to operations
Multiple focus on individuals, communities, and populations
Lessons Learned from Grantees
The behavioral health impacts of trauma are a key focus in the national discourse about youth and adults behavioral health services
Growing evidence of effective trauma-focused services (e.g. TF-CBT)
Lack of sufficient training for practitioners on trauma screening and interventions
Need broader response to trauma
Even if excellent treatment provided others in setting close to child can negate good work of therapy

13. SAMHSA Concept of Trauma and Guidance for a Trauma-Informed Approach

14. SAMHSA Concept of Trauma Released 2014
Trauma and Trauma-Informed Care Experts Panel (May, 2012)
Leading experts included: Raul Almazar, Rene Anderson, Andy Blanch, Robyn Boustead, Roger Fallot, Norma Finkelstein, Julian Ford, Joan Gillece, Dan Griffin, Gene Griffin, Maxine Harris, Jacki McKinney, Cheryl Sharp, John Rich, Hank Steadman, Charles Wilson and facilitated by Barbara Bazron and Larke Huang
Concept/Framework:
Experts’ Working Definitions of Individual Trauma and Trauma-Informed Approach
Core Values and Principles of Trauma-Informed Approach
Guidelines for Developing a Trauma-Informed Approach
Preliminary discussion on the definition of community trauma
Public Comment (December, 2012) Online posting; >2,000 respondents; 20,000 comments or endorsements

15. SAMHSA Concept of Trauma and Guidance for a Trauma-Informed Approach
Gain shared understanding of what we mean by trauma and a trauma-informed approach (TIA).
Get agreement to enable discussions of trauma/TIA across different service sectors.
Provide the basis for measurement.
Provide the basis for training and technical assistance.

16. SAMHSA’s Concept of Trauma: ‘The 3 E’s’
“Individual trauma results from an event, series of events, or set of circumstances that is experienced by an individual as physically or emotionally harmful or life threatening and that has lasting adverse effects on the individual’s functioning and mental, physical, social, emotional, or spiritual well-being.”
From SAMHSA’s Concept Paper

17. A Trauma-Informed Approach (Four R’s)
A trauma-informed program, organization, or system
Realizes widespread impact of trauma and understands potential paths for recovery
Realizes
Recognizes signs and symptoms of trauma in clients, families, staff, and others involved with the system
Recognizes
Responds by fully integrating knowledge about trauma into policies, procedures, and practices
Responds
Seeks to actively resist retraumatization
Resists
Definition of Trauma: “Individual trauma results from an event, series of events, or set of circumstances that is experienced by an individual as physically or emotionally harmful or life threatening and that has lasting adverse effects on the individual’s functioning and mental, physical, social, emotional, or spiritual well-being.”
Safety
Trustworthiness and Transparency
Peer Support
Collaboration and Mutuality
Empowerment, Voice, and Choice
Cultural, Historical, and Gender Issues
From SAMHSA’s Concept Paper

18. Key Principles of a Trauma-Informed Approach
Safety
Trustworthiness and Transparency
Peer Support
Collaboration and Mutuality
Empowerment, Voice, and Choice
Cultural, Historical, and Gender Issues

19. Guidance Domains for a Trauma-Informed Approach
Governance and leadership
Policy
Physical environment of the organization
Engagement and involvement
Cross-sector collaboration
Screening, assessment, and interventions
Training and workforce development
Progress monitoring and quality assurance
Financing
Evaluation

20. Policy Example: Seminole County, Fla.
Community-Based Care of Central Florida Holdings has modified its policies to reflect trauma-informed care (TIC) principles and amended the language in its contracts with providers to relay the expectation that trauma-informed care be provided to children, youth, and families. It has also provided opportunities to educate staff and agencies on what TIC means.

21. Physical Environment Example: Raleigh, N.C.
The SOC Expansion coordinates closely with Project Broadcast, another grant funded project in North Carolina. Project Broadcast focuses on developing a trauma-informed workforce and ensures that its state and local policies are trauma informed.
Example: Florida Department of Children and Families, Fla.
Training is being provided to staff on TIC.

22. Screening, Assessment, Treatment Services
Example: Durham, N.C.
Provision of Traumatic Events Screening Inventory (TESI). TESI is typically completed by a clinician within 30 days of intake and is intended to inform and shape a youth’s plan of care as well as measure the level and scope of trauma experienced by the youth.
Example: Florida Healthy Transitions, Fla.
It uses the 2–1–1 Crisis Center as a central point of access for young adults and their families. A care coordinator assesses its needs and makes a referral to community programs or screens the individual for mental health services (using the Adverse Childhood Experiences, ACE, tool) and speaks to that person about Wraparound services and the Healthy Transitions program.

23. SAMHSA’s Comprehensive Public Health Approach to Trauma: A National Strategy

24. Substance Use and Mental Health Community-Based Services
VISION
A national comprehensive public health approach to addressing individual and community trauma.
MISSION
Set a strategic direction for behavioral health to advance policy, training, practice, research, evaluation, and coordination across various service sectors to mobilize and encourage organizations, systems, and communities to implement a trauma-informed approach.
Strategy 1
Increase efforts and opportunities that support a trauma-informed approach.
Strategy 2
Support communities to implement trauma-informed approaches and initiatives.
Strategy 3
Increase knowledge and awareness of a trauma-informed approach through TA, training, peer-to-peer sharing and resources.
Strategy 4
Build and foster effective partnerships across the private and public sectors.
Children and Families
Criminal/ Juvenile Justice
Disparities
Disasters
Homelessness
Primary Care
Substance Use and Mental Health
Suicide Prevention
Community-Based Services
Tribal

26. Community and Historical Trauma

27. Social Determinants of Trauma
Community Trauma:
Social Determinants of Trauma
Communities affected by trauma from adverse community conditions (e.g., interpersonal violence, structural violence)
Trauma-specific clinical interventions + trauma-informed care > standard practice in healthcare, MH care, and education
Attention and focus beyond individuals and solely on treatment after exposure
Addressing community trauma  attention and focus at a population level

28. Community Strategies
Kaiser Permanente & Prevention Institute, 2015

30. Resiliency in Communities After Stress and Trauma (ReCAST) Grant Program
Purpose: To assist high-risk youth and families and promote resilience and equity in communities that have recently faced civil unrest through implementation of evidence-based violence prevention and community youth engagement programs, as well as linkages to trauma-informed behavioral health services.
Goal: For local communities to work together in ways that lead to improved behavioral health, empowered community residents, and reductions in trauma and sustained community change.

32. Tribal Behavioral Health Agenda (OTAP)
Developing a
Tribal Behavioral Health Agenda (OTAP)
Tribal Behavioral Health Grants
Preventing/reducing suicidal behavior, substance misuse, and the impact of trauma on tribal communities
Circles of Care
Community-based systems of care for children and families and
A public health approach to the impact of historical trauma
National Child Traumatic Stress Initiative
National Native Children’s Trauma Center supports TI interventions for AIAN children & families

33. Trauma Technical Assistance Coordination

34. Trauma and TA Centers Trauma & Clinical Practice
SAMHSA strives to support a better understanding of trauma in the many areas where trauma makes an impact. Trauma-specific resources can be found throughout SAMHSA’s Training and Technical Assistance, including the following:
Trauma & Clinical Practice
Trauma & Recovery from Addiction
Trauma & Violence
Trauma & Families
Trauma & Children
Trauma & Justice
Trauma & Disasters
SAMHSA’s National Center for Trauma-Informed Care (NCTIC, is a comprehensive introduction to trauma-informed care.
SAMHSA’s Center for Integrated Health Solutions ( provides a variety of resources on how primary care and behavioral healthcare practitioners can consider trauma in their practice.
The Great Lakes Region of SAMHSA’s Addiction Technology Transfer Center (ATTC, has several publications on the impact of trauma in recovery from addiction.
SAMHSA’s National Network to Eliminate Disparities in Behavioral Health (NNED, offers resources on violence, and its corresponding traumatic after-effects.
The National Center on Substance Abuse and Child Welfare ( offers resources on trauma among families affected by substance use disorder.
The National Center for Child Traumatic Stress Learning Center ( has abundant resources on the many forms of trauma that affect children.
The National Technical Assistance Center for Children’s Mental Health ( offers a comprehensive resource on trauma-informed care.
The work on SAMHSA’s Strategic Initiative on Trauma and Justice has generated a variety of resources.
The Trauma and Justice page is in the old website format, and only available through Google, not through direct navigation. Here is the current link:
SAMHSA’s Disaster Technical Assistance Center (DTAC, ) is a full-scope resource on behavioral health responses to disasters, including retraumatization and youth issues.

35. Resources and Information on Trauma-Related Initiatives by SAMHSA
Additional initiatives and resources: Safeguarding Children of Arrested Parents
Developed by the International Association of Chiefs of Police (IACP), in collaboration with the Bureau of Justice Assistance (BJA), Office of Justice Programs, U.S. Department of Justice
Child Trauma Collaborations (ACYF, CMS, SAMHSA)- increase number of trauma-exposed children in child welfare who receive the right services at the right time to improve social-emotional well-being.
State Directors’ Letters: State Children’s Mental Health, Child Welfare Administrators, Medicaid Directors on Child Trauma//

36. Contact Information
Rebecca B. Flatow Lead Policy Analyst Office of Policy, Planning, and Innovation Substance Abuse and Mental Health Services Administration

38. SAMHSA’s National Child Traumatic Stress Initiative (NCTSI)
March 29, 2017
Elicia McIntyre, MSW, LCSW–C
Center for Mental Health Services, SAMHSA

39. Poll
What is the track/area of concentration of your graduate degree program?
Children and Families
Child Welfare
Other
Ask webinar moderator in advance if there are poll capabilities on the platform. If so – incorporate poll to ask how many of the Fellows are pursuing child focused behavioral health tracks in their field of study, and which schools. (show percentages on screen after poll is closed?)

40. Understanding Child Trauma
I’ll begin this portion of the webinar by sharing a few data points surrounding child trauma in the U.S.
The “Understanding Child Trauma” Infographic pictured here is available for download at
Image: SAMHSA’s Understanding Child Trauma PDF.

41. Understanding Child Trauma
More than two out of three children reported at least 1 traumatic event by age 16.
The national average of child abuse and neglect victims in 2013 was 679,000 or 9.1 victims per 1,000 children.

42. Types of Trauma
The various trauma types that can lead to child traumatic stress are listed again here in an easier-to-read graphic here.

43. Key Facts About Child Traumatic Stress
Child traumatic stress is common.
More than 25 percent of American youth have experienced a serious traumatic event by the age of 16, and many children suffer multiple and repeated traumas.
Common sources of trauma include abuse and neglect; serious accidental injury; disasters and terrorism; experiencing or witnessing violence in neighborhoods, schools, and homes; and treatment for life-threatening illness.

44. Key Facts About Child Traumatic Stress (cont’d)
A child exposed to a traumatic event is at risk of developing traumatic stress. Children are more vulnerable to trauma because of their size, age, and dependence.

45. Key Facts About Child Traumatic Stress (cont’d)
Caring adults can help.
Not all children exposed to traumatic events develop a traumatic stress reaction. Many children, especially those supported by caring adults, and other support systems can be very resilient.
Parents and caregivers who take care of themselves are able to take better care of their children.
Not all children exposed to traumatic events develop a traumatic stress reaction. It’s important to maintain a developmental lens when working with children and adolescents who have experienced trauma.

46. Key Facts About Child Traumatic Stress (cont’d)
Treatments work
Treatment from a mental health professional who has training and experience working with traumatized children can reduce child traumatic stress and minimize physical, emotional, and social problems.
Trauma treatments for children may include psychotherapy and medications, and may involve families, schools, and other systems of care.

47. National Child Traumatic Stress Initiative (NCTSI)
The NCTSI’s goal is to transform mental health care for children and adolescents affected by trauma throughout the country, by improving the quality of community-based trauma treatment and services and increasing access to effective trauma-focused interventions.
The National Child Traumatic Stress Initiative (NCTSI) raises awareness about the impact of trauma on children and adolescents as a behavioral health concern. Congress, recognizing the serious mental health impact of traumatic events on children, adolescents, and families, authorized in 2000 the National Child Traumatic Stress Initiative (NCTSI), as part of the Children’s Health Act.

48. About NCTSI https://www.samhsa.gov/child-trauma
Image: Screenshot of SAMSHA’s National Child Traumatic Stress Initiative Web page.

49. About NCTSI NCTSI develops and implements
Evidence-based interventions to reduce the debilitating mental health impact of traumatic experiences on children and adolescents
Collaborations with all systems of care where children and adolescents who have experienced trauma receive services
Data collection and evaluation activities
Education and awareness raising with policymakers regarding trauma, resilience, and recovery
Product development for professionals, policymakers, families, youth, and the public
Partnerships with youth, families, and other consumers

50. The National Child Traumatic Stress Network (NCTSN)
The National Center for Child Traumatic Stress
Treatment and Service Adaption Centers
Community Treatment and Services Centers
Affiliate members
Through this initiative, a collaborative network of experts was created to further the development and dissemination of evidence-based clinical interventions for systems that serve children, adolescents, and families. The National Child Traumatic Stress Network (NCTSN) is made up of SAMHSA representatives, in cooperation with four distinct groups of grantees and stakeholders:
*The National Center for Child Traumatic Stress (NCCTS) works to promote leadership and collaboration across NCTSN and serves as a national resource center to disseminate NCTSN program and intervention products.
*Treatment and Service Adaptation centers identify, develop, support, and improve treatment approaches for different types of trauma that children and adolescents experience.
*Community Treatment and Services centers provide services to children who have experienced traumatic events by implementing and evaluating the effectiveness of trauma treatment and services in community and service system settings.
*Affiliate members, made up of 160 formerly funded NCTSN members, continue to contribute to the national mission and ongoing work in their states and local communities.

51. SAMHSA NCTSI–Funded Grants
Category 1. National Center for Child Traumatic Stress—1 site (Duke/UCLA)
Category 2. Treatment and Service Adaptation Centers—25 sites
Category 3. Community Treatment and Services Centers—56 sites
Currently, the SAMHSA NCTSI supports 82 funded grantees across the nation.
The National Center Shared is a cooperative agreement between Duke and UCLA.
The National Center develops and maintains Network structure, coordinates collaborative activity, oversees resource development, and coordinates national training and education.

52. NCTSI–Funded Grants

53. Program Reach Since inception, NCTSN has provided
Trauma treatment and services to hundreds of thousands of children, adolescents, and their families
Training in the assessment and treatment of traumatic stress to more than 250,000 people, including mental health professionals, primary care providers, and other professionals in child-serving systems, consumers, and the public

54. Success Story
There is hope. Children can and do recover from traumatic events. Treatment works!
As part of SAMHSA’s monitoring of our NCTSI grants, I conducted a site visit to one of our Category III Community Treatment and Services Centers in After reviewing meeting with key staff, and reviewing the project’s achievements and outcomes over the past grant cycle, I had the opportunity to meet with an adoptive parent whose nephew had completed treatment at the center. I asked her what she wanted other parents/caregivers to know about treatment. She shared that she learned so much about her son’s behaviors as a result of attending Child-Parent Psychotherapy (CPP), which is one of the available evidence-based treatments. She said one of the biggest takeaways from the treatment was learning not to personalize her son’s problematic behaviors, and learned to make the connection to his past trauma. Together, they learned new ways of coping with challenges and helping him succeed at school and home. You can read about CPP and many other treatments at under the “Treatments That Work” tab. You’ll see a screen shot of the NCTSN web page on the next slide.

55.
You can explore the public section of the site which includes helpful resources for professionals, caregivers, and the public. You can learn about the evidence-based treatments our TSA centers have developed and disseminated, which are being implemented by our Community Treatment and Service Centers. The Learning Center provides continuous learning opportunities for members of the Network. Since 2010, over 1.4 million product files have been downloaded from NCTSN.org with 488,754 occurring in fiscal year
Image: Screenshot of the National Traumatic Stress Network Web page.

56. Raising Public Awareness
“Bounce” (SAMHSA PSA) “News Feed” (SAMHSA-Campaign to Change Direction PSA)
“Bounce” is a brief, 30-second PSA that SAMHSA developed in It is also available in Spanish. Both versions are available for viewing at
In 2016, SAMHSA partnered with Campaign to Change Direction to create a set of PSAs to educate the public and raise awareness re: mental health issues. This youth PSA, entitled, “News Feed,” focuses on youth learning to recognize signs that their peer might be struggling and need help.

57. Resources

58. SAMHSA TIP 57
SAMHSA creates a series of Treatment Improvement Protocols, or TIPs, which are briefs useful to behavioral health professionals seeking information on best practices. This is one such tip, on Trauma-Informed Care in Behavioral Health Services. You can order it from the SAMHSA store at
Image: Screenshot of SAMSHA’s TIP 57 Web page.

59. NCTSN Products
Think Trauma
Child Welfare Trauma Toolkit
Child Sexual Abuse Fact Sheet
Cops, Kids, and Domestic Violence
The NCTSN has developed numerous products to train and inform clinicians, parents/caregivers, and systems addressing each trauma type - these are just a few.
Think Trauma: This training provides an overview for juvenile justice staff of how to work towards creating a trauma-informed juvenile justice residential setting
Child Welfare Toolkit: Target audience is Child welfare professionals
Child Sexual Abuse Fact Sheet: Provides parents and caregivers with tools to help them support children who have been victims of sexual abuse, information on the importance of talking to children and youth about body safety, and guidance on how to respond when children disclose sexual abuse.
Cops, Kids, and Domestic Violence: Provides law enforcement officers with concrete information about what they can do when responding to the scene of a domestic violence call where children are present.
Overall, the resources on children and domestic violence are among the top 10 most frequently downloaded from the site.
There are a variety of tools, including fact sheets, toolkits and other products available for ordering at

60. Contact Information
Elicia McIntyre, MSW, LCSW–C Public Health Advisor/Government Project Officer Emergency Mental Health & Traumatic Stress Services Branch Division of Prevention, Traumatic Stress, & Special Programs Center for Mental Health Services SAMSHA

61. Exclusive Consultant for Trauma-Informed Services
National Council for Behavioral Health Implementing Trauma-Informed Approaches
Cheryl S. Sharp, MSW, ALWF
Exclusive Consultant for Trauma-Informed Services
March 29, 2017

62. Overview National Council’s Trauma-Informed Services
Organizational Self-Assessment
Implementation of Trauma-Informed Care
Becoming Trauma-Informed Using Implementation Science

63. Cheryl S. Sharp, MSW, ALWF Exclusive Consultant for Trauma-Informed Services
Cheryl Sharp holds the unique perspective of a person who has recovered from significant mental health challenges, a trauma survivor, a family member of a loved one who died as a result of mental health challenges, and a provider of substance misuse and mental health services. Ms. Sharp has worked with adult trauma survivors for more than 30 years and trains and speaks nationally on trauma-informed care. She received a SAMHSA Voice Award (2015) for her advocacy. She is an exclusive consultant for trauma-informed services at the National Council for Behavioral Health.
Image: Photograph of Cheryl Sharp.

64. What Is Trauma? Definition (SAMHSA Experts 2012) includes
three key elements:
Individual trauma results from an series of events, or set of circumstances that is by an individual as overwhelming or life-changing and that has profound on the individual’s psychological development or well-being, often involving a physiological, social, and/or spiritual impact.
event,
experienced
effects
The experience of violence and victimization including sexual abuse, physical abuse, severe neglect, loss, domestic violence and/or the witnessing of violence, terrorism or disasters
DSM IV-TR (APA, 2000)
Person’s response involves intense fear, horror and helplessness
Extreme stress that overwhelms the person’s capacity to cope.
The experience of interpersonal violence including sexual abuse, physical abuse, severe neglect, loss, and/or the witnessing of violence, terrorism, urban violence, war/combat, motor vehicles accidents and disasters
Events that are shocking, terrifying and/or overwhelming to the individual
Results in feelings of horror, fear, helplessness
Trauma occurs when an external threat overwhelms a person’s internal and external positive coping resources

65. Child maltreatment and complex trauma
Image: Cluster of images depicting tragic events.
Child maltreatment and complex trauma
Serious accident or illness
Victim/witness to domestic, community and school violence
Natural disaster, war, terrorism, political violence
Traumatic grief/separation, significant loss
Historical and generational trauma

66. The ACEs Study
Image: Multicolored pyramid depicting flow of ACE mechanisms that influence health. 66

67. Life-Long Physical, Mental, and Behavioral Health Outcomes Linked to ACEs
Alcohol, tobacco, and other drug addiction
Auto-immune disease
Chronic obstructive pulmonary disease and ischemic heart disease
Depression, anxiety, and other mental illness
Diabetes
Multiple divorces
Fetal death
High-risk sexual activity, STDs, and unintended pregnancy
Intimate partner violence— perpetration and victimization
Liver disease
Lung cancer
Obesity
Self-regulation and anger management problems
Skeletal fractures
Suicide attempts
Work problems—including absenteeism, productivity, and on-the-job injury

68. ACEs Are Not Destiny
Image: Three different-colored notes, each fastened to a line with a clothespin.

69. Paradigm Shift We begin to ask, “What happened to you?” rather than
“What is wrong with you?”
We have to ask,
“What’s strong?”
“What’s wrong?”
Image: A red-tinted circular lens, framed by the word “lens.” At the center reads: “Whose lens do you look through?”

70. Trauma-Informed Care

71. Defining a Trauma-Informed Approach
Realizes
Recognizes
Resists
retraumatization
Responds
A program, organization or system that is trauma-informed -
realizes the widespread impact of trauma and understands potential paths for recovery;
recognizes the signs and symptoms of trauma in clients, families, staff, and others involved with the system;
resists re-traumatization, and
responds by fully integrating knowledge about trauma into policies, procedures, practices, and settings.

72. What Does a Trauma-Informed Organization Include?
Safe, calm, and secure environment with supportive care
System-wide understanding of trauma prevalence, impact, and trauma-informed care
Cultural competence and humility
Consumer voice, choice, and advocacy
Recovery, consumer-driven, and trauma-specific services
Healing, hopeful, honest, and trusting relationships

73. Seven Domains of Trauma-Informed Care (TIC)
Domain 1 Early Screening and Assessment of Trauma
Domain 2 Consumer-Driven Care and Services
Domain 3 Trauma-Informed, Educated, and Responsive Workforce
Domain 4 Trauma-Informed, Evidence-Based Best Practices
Domain 5 Safe and Secure Environment
Domain 6 Community Outreach and Partnership Building
Domain 7 Ongoing Performance Improvement
Domain 1 - Developing a respectful screening and assessment process that is routine, competently done and culturally relevant and sensitive and revisited over time
Domain 2 - Involving and engaging people who are or have been recipients of our services to play numerous roles (e.g., paid employee, volunteer, members of decision making committees, peer specialists) and meaningfully participate in planning, implementing and evaluating our improvement efforts
Domain 3 - Increasing the awareness, knowledge and skills of the entire workforce to deliver services that are effective, efficient, timely, respectful and person centered taking into consideration that service providers also have histories of trauma
Domain 4 - Increase the awareness, knowledge and skills of the clinical workforce in delivering research informed treatment services designed to address the cognitive, emotional, behavioral, substance use and physical problems associated with trauma
Domain 5 - Increase the awareness, knowledge and skills of the workforce to create a safe, trusting and healing environment as well as examining and changing policies, procedures and practices that may unintentionally cause distress and may re-traumatize (cause harm) those we serve.
Domain 6 - Recognize that the people we serve may be part of and affected by a larger service system including housing, corrections, courts, primary health, emergency care, social services, education and treatment environments such as substance use programs. We have an opportunity to engage and increase the awareness of these other service providers to the principles and practices of trauma-informed care. In this way, our efforts are less likely to be undermined by other parts of the system.
Domain 7 - The organization values a systematic approach to measuring performance on each of the core trauma-informed domains. Data is used to track, measure and analyze performance improvement in order to inform leadership and its core implementation team on areas needing improvement as well as guiding the process of sustainable change.

74. Our Learning Community Model

75. More Than 20 Learning Communities
Blue Sky, Ohio
Texas TICTOC
Alaska Resilience Initiative
Texas DHS
Providence Services Corp.
Baltimore, Md. (3)
Tristate Trauma Network
Trauma Sensitive Schools (3)
DOJ Initiative
National Learning Communities (6)
Kaiser Permanente
Trenton Health Team, Trenton, N.J.
Fostering Futures
Ardmore, Okla., WOTIC
Hancock County, Ohio
Stark County, Ohio

76. Our Learning Community Is About
Group of organizations committed to improving services related to a specific area of quality
Members communicate regularly to share their experiences and to learn from each other
A Learning Community (LC) Faculty under the National Council for Behavioral Health Trauma-Informed Team provides guidance and support to members of the learning community
Builds on the collective knowledge and real world experiences of teams
Promotes social networking and shared learning
Advances widespread practice improvement
Addresses common and unique concerns, challenges and needs
Addresses needs related to specific areas of work
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77. Core Implementation Team
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78. The Trauma-Informed Core Implementation Team (CIT) Includes
Leadership/Program Director
Clinical Director
Consumer/Peer/Family Leaders (2)
Quality Improvement Staff

79. Role of the Learning Community CIT Members
Drive the TIC work in your organization.
Serve as the bridge between your organization and the NC faculty and Learning Community.
Share with fellow Learning Community teams through listservs, small-group calls, special-interest calls, and Webinars.
Attend and participate in Webinars.
Meet regularly.
Develop a system to collect data.
Consider organizing a larger oversight group in your respective organization or create smaller sub-groups to address various domains

80. Role of the Learning Community Faculty
Provide educational and logistical support.
Respond to specific needs of LC members.
Facilitate
Coaching calls
Webinars
Listserv
Access to resources and TIC expertise

81. Now You Want Me to Do What?
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82. John Kotter’s Eight Stages of Change
The Heart of Change
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83. Communicate for Buy-In
Influence attitudes, beliefs, expectations.
How?
When?
What is it?
Influencing attitudes, beliefs, expectations, perceptions and worries to support the adoption of trauma informed care
Increasing positive feelings in a way that overcomes the “negative” feelings that is often associated with change:
Control
Meaning
Status
Communicate frequently and in a heartfelt manner
Emphasize the benefits to ALL stakeholders
Include stakeholders in the change process
Ensure that leadership “walks the talk”
Acknowledge common workforce concerns:
Personal meaning associated with current practices
Fear of loss of control
Change in perceived professional and personal status
Assist staff to regain control, status and personal meaning
Shareholder (the makeup of the audience)
Message, content and modalities employed
Messengers
Venue (time, place, duration)
Expected outcome and how is it measured
Follow up Activities
Image: “Communicate” spelled out in alphabet blocks on a grid.
Who?
What?

84. Organizational Self-Assessment (OSA)
OSA helps
Assess baseline
Develop implementation plan
Measure progress
Answer the questions:
What do I/we need to
Stop doing
Start doing
Do more of

85. Contact Information
Cheryl S. Sharp, MSW, ALWF National Council phone number:

86. Contact DSG If you have questions or need additional information
about this Webinar, contact Charles E. Lewis, Jr.
Minority Fellowship Program Coordinating Center
Development Services Group, Inc.

87. Archived Webinar
Today’s Webinar will be archived for future viewing within a week. You can access the archived Webinar at: