1. 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

2. What are Trauma-Informed Services? Trauma-informed vs. trauma-specific Trauma-informed vs. trauma-specific Characteristics of trauma-informed services 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

3. Why Trauma-Informed Services? Trauma is pervasive Trauma is pervasive Trauma’s impact is broad and diverse Trauma’s impact is broad and diverse Trauma’s impact is deep and life-shaping Trauma’s impact is deep and life-shaping Trauma, especially interpersonal violence, is often self-perpetuating Trauma, especially interpersonal violence, is often self-perpetuating Trauma is insidious and differentially affects the more vulnerable Trauma is insidious and differentially affects the more vulnerable Trauma affects how people approach services Trauma affects how people approach services The service system has often been retraumatizing The service system has often been retraumatizing

4. A Repetitive Cycle of Risk HomelessnessIncarceration Substance Abuse Mental Health Problems Violence and Trauma

5. Comparing Traditional and Trauma-Informed Paradigms Understanding of Trauma Understanding of Trauma Understanding of the Consumer/Survivor Understanding of the Consumer/Survivor Understanding of Services Understanding of Services Understanding of the Service Relationship Understanding of the Service Relationship

6. Traditional Human Services Paradigm Understanding of Trauma 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

7. Trauma-Informed Human Services Paradigm Understanding of Trauma 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

8. Traditional Human Services Paradigm Understanding of the Consumer/Survivor 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

9. Trauma-Informed Human Services Paradigm Understanding of the Consumer/Survivor 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

10. Traditional Human Services Paradigm Understanding of Services 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

11. Trauma-Informed Human Services Paradigm Understanding of Services 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

12. Traditional Human Services Paradigm Understanding of the Service Relationship 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

13. Trauma-Informed Human Services Paradigm Understanding of the Service Relationship 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

14. A Culture Shift: The Core Principles of a Trauma-Informed System of Care Safety: Ensuring physical and emotional safety Safety: Ensuring physical and emotional safety Trustworthiness: Maximizing trustworthiness, making tasks clear, and maintaining appropriate boundaries Trustworthiness: Maximizing trustworthiness, making tasks clear, and maintaining appropriate boundaries Choice: Prioritizing consumer choice and control Choice: Prioritizing consumer choice and control Collaboration: Maximizing collaboration and sharing of power with consumers Collaboration: Maximizing collaboration and sharing of power with consumers Empowerment: Prioritizing consumer empowerment and skill-building Empowerment: Prioritizing consumer empowerment and skill-building

15. A Culture Shift: Scope of Change in a Distressed System Involves all aspects of program activities, setting, and atmosphere (more than implementing new services) 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 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) Involves making change into a new routine, a new way of thinking and acting (more than new information)

16. Protocol for Developing a Trauma-Informed Service System Services-level changes Services-level changes  Service procedures and settings  Formal service policies  Trauma screening, assessment, and service planning Systems-level/administrative changes Systems-level/administrative changes  Administrative support for program-wide trauma-informed services  Trauma training and education  Human resources practices

17. Review of Service Procedures and Settings 1) Identify formal and informal activities and settings; specify sequence of events 1) Identify formal and informal activities and settings; specify sequence of events 2) Ask key questions about each activity and setting 2) Ask key questions about each activity and setting 3) Prioritize goals for change 3) Prioritize goals for change 4) Identify specific objectives and responsible person(s) 4) Identify specific objectives and responsible person(s)

18. The Core Principles Revisited: Key Questions in Reviewing Service Procedures Safety: How can we ensure physical and emotional safety for consumers? For staff? 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? Trustworthiness: How can we maximize trustworthiness? Make tasks clear? Maintain appropriate boundaries? Choice: How can we enhance consumer choice and control? Choice: How can we enhance consumer choice and control? Collaboration: How can we maximize collaboration and sharing of power with consumers? 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? Empowerment: How can we prioritize consumer empowerment and skill-building at every opportunity?

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

20. Trustworthiness: Clarity, Consistency, and Boundaries 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? 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? How can services be modified to ensure that tasks and boundaries are established and maintained clearly, consistently, and appropriately?

21. Choice: Consumer Choice and Control To what extent do current service delivery practices prioritize consumer experiences of 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? How can services be modified to ensure that consumer experiences of choice and control are maximized?

22. Collaboration: Collaborating and Sharing Power To what extent do current service delivery practices maximize collaboration and the sharing of power between providers and consumers? 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? How can services be modified to ensure that collaboration and power-sharing are maximized?

23. Empowerment: Recognizing Strengths and Building Skills To what extent do current service delivery practices prioritize consumer 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? How can services be modified to ensure that experiences of empowerment and the development or enhancement of consumer skills are maximized?

24. Review of Formal Policies Confidentiality policies are clear and shared with consumers Confidentiality policies are clear and shared with consumers Policies avoid involuntary or coercive elements of treatment Policies avoid involuntary or coercive elements of treatment De-escalation policy is formalized and minimizes possibility of retraumatization 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 prioritizes consumer preferences in responding to crises (e.g., use of preference forms) Program has clearly written, accessible statement regarding consumer rights and grievances Program has clearly written, accessible statement regarding consumer rights and grievances

25. Trauma Screening, Assessment, and Service Planning Universal trauma screening that is appropriate to the setting Universal trauma screening that is appropriate to the setting Follow-up with appropriate assessment of trauma exposure history and impact Follow-up with appropriate assessment of trauma exposure history and impact Including trauma-based information in collaborative planning for services Including trauma-based information in collaborative planning for services Offering, or linking to, trauma-specific services Offering, or linking to, trauma-specific services

26. Administrative Support for Program-Wide Trauma-Informed Services Support for the integration of knowledge about trauma and violence into all aspects of agency functioning Support for the integration of knowledge about trauma and violence into all aspects of agency functioning Possible indicators: Possible indicators:  Formal policy or mission statements  Developing a “trauma initiative”  Making resources available  Active administrator participation

27. Trauma Training and Education General trauma education for all staff (including administrators and support staff) 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 Clinical trauma education for direct service staff  Modifications for their specific areas; trauma- specific interventions; staff self-care

28. Human Resources Practices Hiring or identifying “trauma champions” 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 Including trauma content in interviews of prospective staff  Knowledge about trauma, trauma sequelae, and recovery Including trauma-related activities in performance reviews Including trauma-related activities in performance reviews

29. Conclusion What we know about trauma, its impact, and the process of recovery calls for trauma-informed service approaches 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 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 services offer the possibility of enhanced collaboration for all participants in the human service system

30. Institute for Health and Recovery 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

31. 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)

32. 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

33. 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

34. Institute for Health and Recovery 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 / Bureau of Substance Abuse Services (DPH / BSAS)

35. 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

36. Institute for Health and Recovery 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 2007

37. Institute for Health and Recovery 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

38. 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

39. 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.

40. 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

41. Institute for Health and Recovery 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 Implementation

42. 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

43. 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

44. 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

45. 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 –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

46. 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

47. 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

48. Institute for Health and Recovery 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

49. Institute for Health and Recovery 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 Staff

50. 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.