Hodas & Rosser-Morris | 42-50



Positive Approaches Journal - Volume 2 Title

Volume 13 ► Issue 1 ► June 2024



Key Elements of Trauma-Informed Care and Potential Misconceptions

Gordon R. Hodas, MD and Cären L. Rosser-Morris, PhD


Introduction

This article, intended for agencies and organizations seeking to implement trauma-informed care (TIC) and for others seeking to learn more about it, identifies key elements of TIC and potential misconceptions related to TIC.

What Trauma-Informed Care Involves

Trauma-informed care is a universal public health principle that recognizes the prevalence and potential consequences of trauma and adverse childhood experiences in the population, and it seeks to address these. In mental health and other human services, TIC involves intentional efforts on the part of systems, agencies, and their staff to mitigate the impact of trauma and to prevent re-traumatization. TIC is a growing priority in children’s services, and it is relevant to mental health and other human services across the lifespan. The principles of TIC are also relevant in other systems and social contexts.

In 2014, the federal Substance Abuse and Human Services Administration (SAMHSA) identified 6 guiding principles for a trauma-informed approach to care.1 These principles have been widely adopted and involve the following:

Safety.

- Trustworthiness and transparency.

- Peer support.

- Collaboration and mutuality.

- Empowerment and choice.

- Cultural, historical, and gender issues.

A central theme is that the above interpersonal elements need to be present in relationships between individuals served and staff providing services. Of equal importance is that these same elements apply to the relationships between agency staff and their organization.

The Growth and Evolution of Trauma-Informed Care

For many reasons, awareness of the pervasiveness and consequences of trauma has increased over the past 35 years, along with greater interest in addressing trauma and preventing it in service settings. Contributing elements included increasing awareness of the potential negative effects of restrictive procedures in mental health, outcomes from the landmark Adverse Childhood Experiences (ACE) Study,2 and strong advocacy on the part of trauma survivors in support of what came to be known as trauma-informed care.3

In 2001, Harris and Fallot identified trauma-informed care, a concept distinct from trauma-specific treatment, as an orientation and commitment to all individuals irrespective of the type of service they might be receiving. 4 In 2009, these individuals highlighted the benefits of an intentional organizational commitment to TIC, which when implemented systematically can lead to a self-sustaining trauma-informed culture. 5

While the prevention of potential harm in care remains a TIC priority, TIC now also involves efforts to promote positive practices in treatment and care, which include supporting the autonomy and empowerment of individuals receiving services. In this way, TIC can help mitigate the negative impact of past trauma and also promote growth, resilience, and healing among individuals receiving care.

Key trauma-informed practices include the following:

- Partnering with individuals receiving treatment or services.

- Engaging individuals and encouraging their active participation in care by identifying their concerns, needs, and priorities.

- Identifying and promoting the strengths and capabilities of the individual and the family.

Using the trauma lens to better understand the individual’s experience of trauma and adversity, and also learning to recognize the adaptive nature of coping behaviors previously developed in response to unsafe circumstances, even though these behaviors might be viewed as maladaptive in a safer context.

- Promoting skill-building, including self-advocacy, self-care, and pursuit of wellness.

At a policy level, the Commonwealth of Pennsylvania, which has been promoting trauma-informed interventions in behavioral health for many years, made a formal commitment to become a trauma-informed state in 2019.6 This entails the envisioned attainment of TIC in public institutions and in communities. Within the Office of Mental Health and Substance Abuse Services (OMHSAS), the authors have developed specific tools to help agencies assess and promote a range of trauma-informed practices. These tools are available for use within Pennsylvania at no charge.7 In addition, OMHSAS has been pursuing a partnership around TIC implementation in Pennsylvania with the five behavioral health managed care organizations that serve Medicaid-enrolled individuals.

Trauma-Informed Care Implementation

The implementation of TIC is not easily achieved and requires an explicit agency commitment, an intentional approach, and persistence. Other important TIC facilitators, as described by Huo and colleagues (2023)8 include strong agency leadership, staff engagement, training, allocation of human and financial resources, service-user involvement in design and quality improvement, and collection and use of data. The absence of any of the above elements could undermine an agency’s efforts to implement TIC.  Effective TIC implementation also involves recognition of common misconceptions related to TIC. Below we identify and consider some of these. 

Specific TIC Misconceptions

1.     TIC is incorrectly perceived as applicable only to individuals with a known trauma history.

- As a universal public health principle, TIC is applicable to everyone.  Universal practices in medicine dictate the use of gloves for medical personnel treating an individual who is bleeding, predicated on the presumption that the individual in question is infectious. Similarly, universal practices in human services presumes that each individual receiving services has had exposure to trauma and adversities, and that this individual will therefore benefit from the provision of TIC. There are many individuals in communities who have been significantly impacted by trauma and adversity, whose trauma history has not been identified or disclosed. In addition, the ongoing risk of traumatization and re-traumatization in care settings further reinforces the need for the provision of TIC for everyone.

2.     TIC is incorrectly equated with the provision of trauma-specific treatment.

- As previously discussed, TIC is an intentional approach to treatment and care that is distinct from the provision of trauma-specific interventions, such as Trauma-Focused Cognitive Behavior Therapy (TF-CBT). While clinically based trauma treatment is indicated for some trauma survivors, TIC constitutes a set of interpersonal principles that is applicable to everyone. For example, all individuals receiving services require safety, and all can benefit from transparency and collaboration.   

3.     TIC is incorrectly perceived as an intervention that only trained mental health clinicians can provide.

- TIC involves a set of humane and respectful interventions that any committed and properly trained individual can provide. It is not necessary to be a mental health clinician in order to provide care that is trauma-informed. Further, while some individuals might be intuitively trauma-informed in their interactions with others, training, mentoring, and ongoing support in the provision of TIC remain important.

4.     Workforce well-being is inappropriately viewed as primarily the responsibility of individual agency staff members.

- TIC principles are applicable to staff both individually and as a workforce.  Staff working with trauma survivors are at risk of vicarious trauma and secondary stress. While staff self-care is an important part of staff well-being, agencies also have a responsibility to help maintain well-being within their workforce. Agencies need to demonstrate that they value and appreciate their staff and provide them with appropriate support and training. Agencies also need to actively address issues of staff’s well-being and wellness with staff directly, rather than simply providing information about wellness apps and/or the Employee Assistance Program (EAP). Supervisors in particular can help staff address work-related challenges and the maintenance of appropriate work-life balance. 

5.     TIC is incorrectly perceived as being unconcerned with individual responsibility and accountability for trauma survivors.

- TIC actively uses a trauma lens and considers the question of what happened to you rather than what is wrong with you. However, this focus in no way diminishes the importance of individual responsibility and accountability on the part of the individual. Skill-building and empowerment are key elements of TIC. In fact, by experiencing a greater sense of personal agency resulting from the provision of a trauma-informed approach that places value on personal voice and choice, the individual becomes better able to be responsible and accountable and to identify personally meaningful, prosocial goals. 

6.     TIC is incorrectly seen as being achievable through discrete trainings alone, rather than through an ongoing organizational commitment and the maintenance of a trauma-informed culture.

- There are no shortcuts for an agency seeking to provide TIC. Trainings are essential, but they need to be ongoing rather than once-and-done.  The agency’s commitment to TIC needs to be formal and explicit. Agency policies and procedures are reviewed and modified as indicated, so that they are consistent with trauma-informed practice. A trauma-informed culture is supported through respectful interactions, trauma-informed supervision, meetings that support safe and open discussion, and regular review of progress and ongoing challenges related to the effective provision of TIC. 

Conclusion

Current efforts to provide TIC and to create TIC systems build on decades of advocacy and the efforts of trauma-survivors, community advocates, and professionals concerned with the well-being of those impacted by trauma. Trauma-informed care involves an intentional effort on the part of health and human service agencies, public institutions, and their staff to recognize and address the widespread impact of trauma in the population, while also working to prevent trauma and re-traumatization in care provision. 

Organizations seeking to provide effective trauma-informed care need to recognize the long-term nature of this commitment in order to build on current resources and address potential barriers. One kind of barrier discussed in this article involves potential misconceptions related to TIC.  Building on a genuine understanding of what TIC is and what it can offer, we encourage human service agencies and other organizations to engage in self-assessment in order to identify both their strengths and their opportunities for improvement. These efforts can facilitate effective TIC implementation and the desired attainment of a trauma-informed culture.




References

1.     Substance Abuse and Mental Health Services Administration. SAMHSA’s Concept of Trauma and Guidance for a Trauma-Informed Approach. HHS Publication No. (SMA) 14-4884. Rockville, MD: Substance Abuse and Mental Health Services Administration; 2014.

2.     Felitti VJ, Anda RF, Nordenberg D, Williamson DF, Spitz AM, Edwards V, Koss MP, Marks JS. Relationship of childhood abuse and household dysfunction to many of the leading causes of death in adults: The Adverse Childhood Experiences (ACE) Study. Am J Prev Med. 1998;14(4):245-258.

3.     Jennings A, Ralph RO. In Their Own Words: Trauma Survivors and Professionals They Trust Tell What Hurts, What Helps, and What Is Needed for Trauma Services. Augusta, Maine: Department of Mental Health, Mental Retardation and Substance Abuse Services; 1997.

4.     Harris M, Fallot R, eds. Using Trauma Theory to Design Service Systems. New Directions for Mental Health Services. San Francisco, CA: Jossey-Bass; 2001.

5.     Fallot R, Harris M. Creating Cultures of Trauma-Informed Care (CCTIC): A Self-Assessment and Planning Protocol Community Connections.; 2009. A Self-Assessment and Planning Protocol.

6.     Jurman D. Trauma-Informed PA: A Plan to Make Pennsylvania a Trauma-Informed, Healing-Centered State.; 2020. Accessed April 13, 2024. Trauma Informed PA.

7.     Trauma-Informed Care in PA Mental Health and Substance Abuse Services. Department of Human Services. Accessed April 13, 2024. https://www.dhs.pa.gov/providers/Trauma-Informed-Care/Pages/OMHSAS-TIC.aspx.

8.   Huo Y, Couzner L, Windsor T, Laver K, Dissanayaka NN, Cations M. Barriers and enablers for the implementation of trauma-informed care in healthcare settings: a systematic review. Implementation Science Communications. 2023;4(1). doi: Implementation Science Communications.



Biographies

Gordon R. Hodas, MD: A Board-Certified Adult and Child Psychiatrist, who has been a policy consultant for the PA Children’s Bureau and the PA Office of Mental Health and Substance Abuse Services (OMHSAS) since 1992. He received his medical degree from the Pearlman School of Medicine at the University of Pennsylvania. His residency in Adult and Child Psychiatry was at Boston University Medical Center, and his Child and Adolescent Fellowship at the Philadelphia Child Guidance Clinic. Dr. Hodas is a Distinguished Life Fellow of both the American Psychiatric Association and the American Academy of Child and Adolescent Psychiatry. In his role with the Children’s Bureau, Dr. Hodas has advocated for trauma-informed care since approximately 1999. In 2006, Dr. Hodas’ paper, “Responding to Childhood Trauma: The Promise and Practice of Trauma Informed Care,” was published by the National Association of State Mental Health Program Directors (NASMHPD). Currently, Dr. Hodas is helping OMHSAS and the Department of Human Services in its efforts to implement trauma-informed care and related trauma-informed practices. 

PA/Train/Interagency Conference/2024 Conference-GRH Short Bio-1-24-24 

Cären L. Rosser-Morris, PhD: A licensed psychologist and consultant for the Pennsylvania Office of Mental Health and Substance Abuse Services since 2016.  She earned her doctorate in clinical psychology from Vanderbilt University under the mentorship of Dr. Hans Strupp in 1993 and has since become a subject matter expert on trauma-informed care. For over 30 years, she has provided psychological services to adults, children, youth and families struggling with the impact of trauma on mental and behavioral health in a variety of outpatient, inpatient, residential treatment, and educational settings.

 

Contact Information

Gordon R. Hodas

Email: gordonhodas@hotmail.com

Cären L. Rosser-Morris, PhD

Email: c-crosserm@pa.gov

Phone: 717-772-7639