Part 2: An Implementation Guide for Behavioral Health Program Administers
Chapter 1 – Trauma-Informed Organizations
IN THIS CHAPTER
- Show Organizational and Administrative Commitment to TIC
- Use Trauma-Informed Principles in Strategic Planning
- Review and Update Vision, Mission, and Value Statements
- Assign a Key Staff Member To Facilitate Change
- Create a Trauma-Informed Oversight Committee
- Conduct an Organizational Self-Assessment of Trauma-Informed Services
- Develop an Implementation Plan
- Develop Policies and Procedures To Ensure Trauma-Informed Practices and To Prevent Retraumatization
- Develop a Disaster Plan
- Incorporate Universal Routine Screenings
- Apply Culturally Responsive Principles
- Use Science-Based Knowledge
- Create a Peer-Support Environment
- Obtain Ongoing Feedback and Evaluations
- Change the Environment To Increase Safety
- Develop Trauma-Informed Collaborations
Part 2 provides a broad overview of how to create and implement an institutional framework for trauma-informed services in program delivery and staff development, policies and procedures, administrative practices, and organizational infrastructure in behavioral health services. Chapter 1, “Trauma-Informed Organizations,” focuses on specific organizational strategies that will help develop a trauma-informed culture in behavioral health settings. Numerous strategies are presented, including organizational commitment to trauma-informed care (TIC), trauma-informed organizational assessment, implementation of universal screening for trauma, and creation of a peer support environment.
Chapter 2, “Building a Trauma-Informed Workforce,” focuses on organizational activities that foster the development of a trauma-informed workforce, including recruiting, hiring, and retaining trauma-informed staff; providing training on evidence-based and emerging trauma-informed best practices; developing competencies specific to TIC; addressing ethical considerations; providing trauma-informed supervision; and preventing and treating secondary trauma in behavioral health service providers.
The strategies described in the following sections can help supervisors and other administrative staff members create a trauma-informed behavioral health environment. As a starting point, the administration should identify key personnel and consumers to guide the organizational change process and the organizational assessment. Administrators and supervisors need to plan for and demonstrate an ongoing commitment to these strategies, or staff may perceive development activities as comprising yet another idea or demand from the agency that is short-lived beyond the initial thrust of training.
Creating a trauma-informed organization is a fluid, ongoing process; it has no completion date. Consumer demographics change across time, exposure to specific types of trauma may become more prevalent, and knowledge of best and evidence-based practices (EBPs) will continue to advance. A trauma-informed organization continues to demonstrate a commitment to compassionate and effective practices and organizational reassessments, and it changes to meet the needs of consumers with histories of trauma. It is encouraging that recent Substance Abuse and Mental Health Services Administration (SAMHSA) data indicates that the majority of over 10,000 programs they surveyed state that they provide trauma-related care (Capezza & Najavits, 2012). However, there remains a major need to make TIC consistently high-quality, routine, and pervasive across treatment systems.
The following stages form the basis of creating a trauma-informed organization:
Commit to creating a trauma-informed agency.
Create an initial infrastructure to initiate, support, and guide changes.
Involve key stakeholders, including consumers who have histories of trauma.
Assess whether and to what extent the organization’s current policies, procedures, and operations either support TIC or interfere with the development of a trauma-informed approach.
Develop an organizational plan to implement and support the delivery of TIC within the agency.
Create collaborations between providers and consumers and among service providers and various community agencies.
Put the organizational plan into action.
Reassess the implementation of the plan and its ability to meet the needs of consumers and to provide consistent TIC on an ongoing basis.
Implement quality improvement measures as needs and problem areas are identified.
Institute practices that support sustainability, such as ongoing training, clinical supervision, consumer participation and feedback, and resource allocation.
Trauma-Informed Services and Service Systems
“A trauma-informed service system and/or organization is one in which all components of the system have been reconsidered and evaluated in the light of a basic understanding of the role that violence and trauma play in the lives of people seeking mental health and addiction services. A ‘trauma-informed’ organizational environment is capable of supporting and sustaining ‘trauma-specific’ services as they develop. A trauma-informed system recognizes that trauma results in multiple vulnerabilities and affects many aspects of a survivor’s life over the lifespan, and therefore coordinates and integrates trauma-related activities and training with other systems of care serving trauma survivors. A basic understanding of trauma and trauma dynamics…should be held by all staff and should be used to design systems of services in a manner that accommodates the vulnerabilities of trauma survivors and allows services to be delivered in a way that will avoid retraumatization and facilitate consumer participation in treatment. A trauma-informed service system is knowledgeable and competent to recognize and respond effectively to adults and children traumatically impacted by any of a range of overwhelming adverse experiences, both interpersonal in nature and caused by natural events and disasters. There should be written plans and procedures to develop a trauma-informed service system and/or trauma-informed organizations and facilities with methods to identify and monitor progress. Training programs for this purpose should be implemented.” Source: Jennings, 2009, pp. 111–112.
Strategy #1: Show Organizational and Administrative Commitment to TIC
Foremost, administrators need to understand the impact that trauma can have on people’s lives. The consistent delivery of TIC is only as effective as the organization’s commitment, which must extend to administrative practices with staff members, program policies and procedures, program design, staffing patterns, use of peer support, staff and peer training and supervision, organizational assessment and consumer feedback, and resources to uphold trauma-informed principles and practices. Even short-term change is not sustainable without the agency’s continual commitment.
Typically, desirable organizational change doesn’t occur by accident. It comes from steadfast leadership, a convincing message that change is necessary and beneficial for staff and consumers, and resources that support change. Many people naturally resist change; thus, an organization’s commitment includes a willingness to discuss with staff members the impact and role of trauma in their service setting, patience in planning and implementation, and the ability to tolerate the uncertainty that naturally accompanies transitions.
Seminal Resource for Administrators
As you investigate how best to implement or improve trauma-informed services within your organization or across systems, review the influential work, Using Trauma Theory to Design Service Systems: New Directions for Mental Health Services.
Advice to Administrators: Managing Staff Reactions to Implementation of New Processes or Ideas
A common hurdle for administrators after introducing a new process or idea is the staff assumption that it will require more work. Frontline staff members are often inundated with many responsibilities beyond face-to-face time with clients. In addition, a common misperception is that if you begin to address trauma, you will have difficulty containing it.
In addition to administrative buy-in, administrators must promote rather than simply announce the implementation of trauma-informed services. Promotion includes educating staff about the rationale for trauma-informed services, offering opportunities for discussion and input from staff and consumers, providing training focused on trauma-informed skills, and so forth. For example, the San Diego Trauma-Informed Guide Team (2012) created a promotional brochure on how TIC can make staff jobs easier:
Focuses on root problem
Increases support system
Provides consistency in agencies/systems
Uses evidence-based best practices
TIC may be cost-effective, lead to less intensive services and less use of services, prevent undue stress for staff members and clients, and prevent client crises caused by old policies that could retraumatize trauma survivors.
Strategy #2: Use Trauma-Informed Principles in Strategic Planning
Strategic planning provides an opportunity to explore and develop short- and long-term goals. The planning process often begins with reevaluating the organizations’ values, mission, and vision, yet agencies cannot adequately develop a trauma-informed strategic plan without obtaining specific information about internal (staff, resources, processes) and external environmental (referral constellation, changes in health care, funding sources, State and Federal standards, community needs, consumer demographics, etc.) factors and influences. Data gathered through staff, consumer, organizational, and community assessments shapes the direction of the plan, including projected demands, challenges, obstacles, strengths, weaknesses, and resources. At the conclusion of this planning process, the organization will have specific goals, objectives, and tasks to meet the needs of their stakeholders and to address any anticipated challenges. Ideally, strategic planning should define key steps in developing or refining trauma-informed services within the organization.
Strategy #3: Review and Update Vision, Mission, and Value Statements
Vision, mission, and value statements provide a conceptual framework for TIC development and delivery. They should not be created in isolation; they should reflect voices from the community, populations, and other stakeholders that the organization serves. These statements develop through input, discussion, and assessment. They are not static; they evolve as needs, populations, or environments change.
As behavioral health service providers, we strive to be trauma aware—to understand the dynamics and impact of trauma on the lives of individuals, families, and communities. We strive to create a trauma-sensitive culture by demonstrating, through consumer empowerment, program design, and direct care, an understanding of the relationships among trauma, substance abuse, and mental illness.
Advice to Administrators: How To Create Vision, Value, and Mission Statements
Define the organization’s vision, values, and mission to be compatible with TIC. Emphasize the organizational culture needed to provide TIC. An outgrowth of that cultural shift may include an enhanced working environment for employees and consumers that is noncoercive and reduces conflicts, restraint, and seclusion. Even if the current mission statement is appropriate, change it anyway to symbolize intended change within the organization. To define or redefine the vision, values, and mission:
- Involve consumers, all levels of staff, and leadership, including the director/CEO.
- Organizational priorities to identify and manage conflicting priorities.
- Resources to assess whether reallocation is necessary for change (e.g., to hire peer support specialists, to furnish comfort rooms).
- Operationalize the vision, values, and mission at the level of individual departments
- Evaluate progress at regular staff meetings to ensure that changing the culture of care stays on the agenda.
Strategy #4: Assign a Key Staff Member To Facilitate Change
Prior to the development of an oversight committee, a senior staff member with the authority to initiate and implement changes should be assigned to oversee the developmental process. By assigning a trauma-aware senior staff member who is committed to trauma-informed services, it is more likely that the organization’s and committee’s goals, objectives, and plans will remain in focus. This senior staff member is responsible for ongoing development and facilitation of the oversight committee; management of the initial organizational assessment, reassessments, and other evaluative and feedback processes; and facilitation and oversight of the implementation plan and subsequent changes, including policies and procedures to ensure delivery of TIC.
Strategy #5: Create a Trauma-Informed Oversight Committee
The role of the oversight committee includes providing ongoing input and direction in the initial organizational assessment, strategic plan, plan implementation, reevaluation and development of trauma-informed policies and procedures, and future reassessments. The committee monitors progress and uses real-time data to forge a clear pathway to new processes that support TIC. The committee should involve stakeholders from the community, consumers, specialists, staff members, and administrators. Leadership involvement is necessary. Stakeholders may be alumni, family members, community-based organizations, and other institutions that interact with the agency or would benefit from trauma-informed services.
Initially, the agency must educate the committee on the organization’s mission, values, and vision as well as the task at hand—developing trauma-informed services. To ease potential conflicts or confusion about the organization’s structure, the guidelines, expectations, and roles of the committee need to be communicated directly to committee members as well as the organization as a whole, including board members, support and professional staff, supervisors, and so forth. The committee also needs to know the extent of their power and the necessary lines of communication before, during, and after evaluating and implementing changes in the organization.
Including consumers and/or those who have lived through trauma is vital. They have unique knowledge, experiences, and perspectives on the impact of treatment design, delivery, policies, and procedures. They offer firsthand information on practices that can potentially retraumatize clients in behavioral health settings and can suggest preventive, alternative practices and solutions. Consumer committee members keep staff and administrators aware of the goal of achieving TIC.
Strategy #6: Conduct an Organizational Self-Assessment of Trauma-Informed Services
An organizational self-assessment evaluates the presence and/or the effectiveness of current trauma-informed practices across each service and level of the organization. This assessment allows an organization to see how it functions within the context of trauma-informed principles and provides feedback to inform the development or revision of the implementation plan for TIC. In essence, this assessment process can serve as a blueprint for change and as a benchmark of compliance with and progress in implementing trauma-informed practices across time. Overall, it is a process of identifying organizational strengths, weaknesses, opportunities, and threats related to the implementation and maintenance of TIC. Refer to Appendix F for sample organizational assessment tools for the organization and the consumer.
The self-assessment should obtain feedback from key stakeholders, particularly consumers, family members, referral sources, community organizations, and all levels of the organization’s staff, including nonclinical and clinical staff, supervisors, and administrative personnel. Similar to the universal screening process, an organizational self-assessment is only as effective as the steps taken after data are gathered and analyzed. From this assessment, an implementation plan should be established that highlights the goals, objectives, steps, timeframe, and personnel responsible in overseeing the specific objective. Assessment shouldn’t be a once -and-done project. Timely and regularly scheduled organizational assessments should follow to assist in quality improvement. For an explanation of more detailed steps to take in conducting an organizational self-assessment, see Chapter 4 of the planned Treatment Improvement Protocol (TIP), Improving Cultural Competence.
Advice to Administrators: Ten Steps to Quality Improvement
Identify new goals or problems.
Gather input from each level of the organization, including consumers and other key stakeholders.
Analyze the feedback.
Explore improvement options and the potential barriers associated with each.
Select the overall approach and specific strategies to address barriers (anticipate barriers, and try to address them before they occur).
Develop an implementation plan, and then present the plan to staff members and other key stakeholders not directly involved in the quality improvement process.
Implement the plan.
Reassess the new plan.
Evaluate the results and determine if new goals or additional problems or issues need to be addressed.
Repeat the first nine steps.
Strategy #7: Develop an Implementation Plan
Implementation plans should evolve from consumer participation, demographic profiles of populations served, data from organizational self-assessment, and research on promising and evidence-based trauma-informed practices.
Advice to Administrators: Implementation Plan Content
- Introduction and overview: This includes the organization’s history, the demographics that characterize its client base, the rationale for the implementation plan, and the incorporation of TIC. Focus on identification of strengths, weaknesses, opportunities, and threats. Provide an overview of goals and objectives.
- Specific goals and objectives: Goals and objectives should address:
- Workforce development strategies for recruiting, hiring, retaining, training, supervising, and promoting wellness of clinical and nonclinical staff members to support TIC.
- Consumer participation and peer support development and implementation strategies.
- Policies, procedures, and practices to support TIC and culturally responsive services, to promote safety, and to prevent retraumatization.
- Specific evidence-based or best practice adoptions to support TIC.
- Strategies to amend facility design or environment (plant) operations to reinforce safety.
- Fiscal planning to ensure sustainability of the steps initiated in the organization.
- Guidelines for implementation: Guidelines should highlight the specific steps, roles, responsibilities, and timeframes for each activity to meet TIC objectives.
Using the framework proposed in this TIP, the oversight committee is responsible for designing a plan that outlines the purpose, goals, objectives, timeframes, and personnel responsible for each objective.
Exhibit 2.1-1 TIC Planning Guidelines
The following publications provide samples of organizational guidelines for implementing TIC.
Fallot, R. D. & Harris, M. (2009). Creating cultures of trauma-informed care (CCTIC): A self-assessment and planning protocol. Washington, DC: Community Connections, 2009.
Guarino, K., Soares, P., Konnath, K., Clervil, R., & Bassuk, E. (2009). Trauma-informed organizational toolkit. Rockville, MD: Center for Mental Health Services, Substance Abuse and Mental Health Services Administration; the Daniels Fund; the National Child Traumatic Stress Network; and the W. K. Kellogg Foundation.
Huckshorn, K. (2009). Transforming cultures of care toward recovery oriented services: Guidelines toward creating a trauma informed system of care. In Trauma informed care (TIC) planning guidelines for use in developing an organizational action plan. Alexandria, VA: National Association of State Mental Health Program Directors.
Jennings, A. (2009). Criteria for building a trauma-informed mental health service system. Retrieved on May 21, 2013, from http://www.theannainstitute.org/CBTIMHSS.pdf
Ohio Legal Rights Service (2007). Trauma-informed treatment in behavioral health settings. Columbus, OH: Ohio Legal Rights Service.
Prescott, L., Soares, P., Konnath, K., & Bassuk, E. (2008). A long journey home: A guide for creating trauma-informed services for mothers and children experiencing homelessness [draft]. Rockville, MD: Center for Mental Health Services, Substance Abuse and Mental Health Services Administration; the Daniels Fund; the National Child Traumatic Stress Network; and the W.K. Kellogg Foundation.
The following resource is a system wide set of guidelines for implementing TIC.
U.S. Department of Health and Human Services, Health Resources and Services Administration (2006). Model trauma system: Planning and evaluation. Rockville, MD: Health Resources and Services Administration.
Strategy #8: Develop Policies and Procedures To Ensure Trauma-Informed Practices and To Prevent Retraumatization
In the early stage of evaluating current services and planning for TIC, the committee needs to assess practices, procedures, and policies that may have been or could be retraumatizing to any individual, at any level of the organization, from consumers to administrators. Programs that are not trauma informed are as likely to be unaware of the impact of trauma on staff as they are to be unaware of its influence on consumers. In the initial review, careful scrutiny should be used to eliminate any practice that is potentially harmful, including seclusion and restraint practices, therapeutic activities that are shaming, treatment planning without collaboration, any medical inquiry without privacy, and so forth.
Program Curriculum: Roadmap to Seclusion-Free and Restraint-Free Mental Health Services
This curriculum, written from consumer perspectives, provides behavioral health staff with education, strategies, and hands-on tools to prevent and ultimately eliminate the use of seclusion and restraint. It includes many handouts for participants and consumers. This training package, available online, is divided into seven modules plus a resources section:
Module 1: The Personal Experience of Seclusion and Restraint
Module 2: Understanding the Impact of Trauma
Module 3: Creating Cultural Change
Module 4: Understanding Resilience and Recovery from the Consumer Perspective
Module 5: Strategies to Prevent Seclusion and Restraint
Module 6: Sustaining Change Through Consumer and Staff Involvement
Module 7: Review and Action Plan
Source: Center for Mental Health Services (CMHS), SAMHSA, 2005.
Policies and procedures are the building blocks of each agency. They guide the service process and, if followed, they provide an opportunity for the agency to deliver consistent responses and care. Policies and procedures must incorporate trauma-informed practices across all domains and standards, such as admissions, plant/environmental standards, screening and assessment processes, referrals (to other services, including hospitalization, or for further evaluations), treatment planning, confidentiality, discharge, and more. They also need to be updated periodically to incorporate new science and to meet the changing needs of consumers. By regularly reviewing and adapting administrative and clinical policies and procedures in response to ever-changing needs and evidence, the agency can provide staff members with good guidelines for providing trauma-informed services that are consistent yet flexible.
Strategy #9: Develop a Disaster Plan
Facilities are often required to develop disaster plans, but specific requirements vary from State to State. From the outset, developing a disaster plan in behavioral health services is essential. Many clients in behavioral health services have lived with trauma, so proactive steps that reduce the impact of a new trauma may prevent worsening of symptoms and decrease the risk for more pervasive effects. (See also Technical Assistance Publication 34, Disaster Planning Handbook for Behavioral Health Treatment Programs [SAMHSA, 2013].)
Most disaster events cannot be accurately anticipated. Even so, behavioral health organizations can take steps to reduce the impact of a disaster event on program functioning and on the lives of clients. Each service or program should develop a disaster response committee that meets regularly to develop, maintain, and adapt policies and procedures to respond to disasters affecting the program. Committee planning efforts may include:
Creating a disaster response team of program staff members tasked with coordinating program administration and services in a disaster event.
Establishing a communication process for informing staff and clients of the status of program functioning and for coordinating staff assignments during and shortly after the disaster event.
Outlining a process to inform clients and their families of available services, their location, and contact information for accessing services to meet clients’ critical needs.
Developing plans for service provision during a disaster event and service implementation after the event.
Creating special plans for high-risk or special needs clients who need services during and shortly after the disaster. Examples of this are clients who are homeless, in detoxification services or methadone programs, on prescribed psychopharmaceuticals, or at risk for suicide.
Making plans for maintaining the security of client records, program records, and facilities during and shortly after the event.
Coordinating ahead with other community resources and services to ensure that clients at high risk or with special needs get the services they require as soon as possible.
Prioritizing how services will start back up after a disaster event.
Providing special services after the event to clients at high risk for trauma reactions and symptoms.
Establishing a postdisaster debriefing process to review disaster responses, services, and outcomes.
Some specific disaster events, such as hurricanes, may sometimes offer opportunities for planning and preparation in advance of the disaster event. This preparation time is usually just a few days, but it allows programs to make advance preparations and take advance action to establish lines of communication, stockpile resources, prepare for evacuation of clients, and protect client and program records.
Strategy #10: Incorporate Universal Routine Screenings
A key element of trauma-informed services is the institution of universal routine screening across all services, regardless of the individual’s path in accessing services (e.g., primary care, hospitalization, outpatient). Considering the prevalence of trauma among individuals who seek services for mental and substance use disorders, the implementation of screening is paramount. Without screening, clients are not identified as trauma survivors. Subsequently, they miss recovery opportunities and treatment services that would be more likely to meet their needs, while also running a higher risk of being retraumatized by unexamined organizational policies, procedures, and practices. For more information on the rationale, processes, and instruments of universal screening for trauma, refer to Part 1, Chapter 4.
Strategy #11: Apply Culturally Responsive Principles
Providers must be culturally competent when incorporating evidence-based and best practices as well as trauma-informed treatment models within the organization. Clients’ views of behavioral health differ according to race, ethnicity, and culture (refer to the planned Treatment Improvement Protocol [TIP], Improving Cultural Competence [SAMHSA, planned c]). Likewise, cultures attach different meanings to trauma, and responses to trauma will vary considerable across cultures (see Part 3, the online literature review, for more information). For example, trauma survivors who come from a collective society or culture, in which the goals of the group take precedence over the goals of the individual, may be more focused on the well-being of their family or the family’s response to the trauma survivors’ experience. Often, this view runs in opposition to the individualistic perspective of many behavioral health services. Subsequently, treatment providers who are not culturally competent may interpret collective values as a sign of resistance or avoidance in dealing with traumatic stress. CMHS (2003) outlines principles of cultural competence in disaster work applicable across all forms of trauma:
Recognize the importance of culture and respect diversity. Those who value culture and diversity understand their own cultures, attitudes, values, and beliefs, and they work to understand the cultures of others. This includes being able to communicate effectively with those from other cultures, respecting others’ feelings about personal space, knowing about others’ social organization, understanding how time is viewed, and being aware of others’ beliefs about the effects of their behaviors.
Maintain a current profile of the cultural composition of the community. This includes describing the community’s population in terms of race and ethnicity, age, gender, religion, refugee and immigrant status, housing status, income levels, rural/urban balance, unemployment, languages spoken, literacy, schools, and businesses.
Recruit workers who are representative of the community or service area. If the workers who are available do not match the community, they should have the personal attributes, knowledge, and skills to develop cultural competence.
Provide ongoing cultural competence training to staff. Topics should include cultural values and traditions, family values, linguistics and literacy, immigration experiences and status, help-seeking behaviors, techniques and strategies for cross-cultural outreach, and the avoidance of stereotypes and labels (DeWolfe & Nordboe, 2000b).
Ensure that services are accessible, appropriate, and equitable. In planning disaster work or TIC, community associations and organizations are invaluable. Gaining their acceptance requires time and energy.
Recognize the role of help-seeking behaviors, traditions, and natural support networks. Culture includes traditions that dictate whom, or which groups, to seek in times of need; how to handle suffering and loss; and how healing takes place. These customs and traditions are respected by a culturally responsive disaster relief program.
Involve community leaders and organizations representing diverse cultural groups as “cultural brokers.” Collaborating with community leaders is an effective means of learning about the community, establishing program credibility, and ensuring that services are culturally responsive.
Ensure that services and information are culturally and linguistically responsive. Communication with individuals who do not speak English, who are illiterate in all languages or have limited literacy, and who are deaf or hard of hearing is essential to service provision. Local radio stations, television outlets, and newspapers that are multicultural are an excellent venue for educational information after a disaster. Using survivors’ friends or relatives as interpreters is not recommended, as survivors may be uncomfortable discussing personal matters with family members or friends. Asking children to interpret can place too heavy a responsibility on them and reverses parents’ and children’s roles.
Assess and evaluate the program’s level of cultural responsiveness. Self-assessment and process evaluation can help keep a program on track. A variety of strategies can be used for collecting data and communicating findings to stakeholders.
Strategy #12: Use Science-Based Knowledge
Along with culturally responsive services, trauma-informed organizations must use science-based knowledge to guide program development and the implementation of services, policies, procedures, and practices. This includes the adoption of EBPs (see Part 1, Chapter 6, and Part 3, Section 1, to review definition, treatments, and resources for EBPs). TIC research is quite new; interpret these limited studies and information cautiously. Chambless and Hollon’s (1998) criteria, which are still the benchmark for EBPs, are valuable resources for administrators. Look closely at who was included—and excluded—from treatment studies. Often, the types of severe, chronic, and unstable cases seen in community settings are excluded from treatment studies. Evidence-based interventions should be a primary consideration in selecting appropriate treatment models for people with mental illness, substance use disorders, and co-occurring psychological trauma. Nonetheless, other variables must also be contemplated before adopting EBPs in an organization, including the cultural appropriateness of the practice; the strength of its clinical focus on strengths-based strategies; training and competence of clinical staff; the cost of training, materials, and implementation; and the ease of maintaining EBP fidelity amidst staff turnover.
For more detailed information on EBPs, visit the National Registry of Evidence-Based Programs and Practices (NREPP) Web site. For more specific research-oriented information on trauma and trauma-specific treatments, refer to the literature review in Part 3 of this TIP, available online.
Strategy #13: Create a Peer-Support Environment
The main purpose of peer support services is to provide consumer mentoring, support, and care coordination for clients with histories of mental illness or substance abuse. The goals are to help others deal with personal and environmental barriers that impede recovery and achieve wellness. Peer support accomplishes this through many activities, including advocacy, support during crises and recovery activities, modeling, education, and assistance in accessing available resources. Peer support programs send a powerful message to staff members, consumers, and the community—that recovery is possible through support, collaboration, and empowerment. These programs reinforce the trauma-informed premise that organizations need to reflect the populations that they serve and involve consumers in planning, implementing, monitoring, and delivering recovery services.
For an introduction to peer support services, see What Are Peer Recovery Support Services? (Center for Substance Abuse Treatment, 2009e).
Notably, peer support services have the potential to be considerably flexible to meet client needs at each stage of recovery. Specifically, peer support services can be incorporated across the continuum of care, starting with outreach services and extending into long-term recovery services. Peer support specialists can enhance consumer motivation to change, to initiate services, and/or to engage in recovery activities. They can play powerful liaison roles by supporting clients entering treatment and explaining what to expect from services. They can ease the transition into treatment, from one service to the next, from one modality to another (e.g., inpatient group to out-patient group), and beyond formal treatment. Moreover, peer support services create an atmosphere focused on mutuality rather than pathology. They provide living models of resilience and promote hope—that recovery is possible and attainable.
Administrators should familiarize themselves with how other organizations have implemented peer support programs, current curricula, certifications and training processes, competencies and ethics, and peer support service State standards or recommendations, if applicable. The Carter Center’s Summit in 2009, The Pillars of Peer Support Services, supported in part by SAMHSA and CMHS, highlighted the numerous elements necessary to develop a strong, vital peer workforce (Daniels et al., 2010). These elements include:
Clear job and service descriptions.
Job-related competencies and competence-based testing processes.
Peer support certifications.
Ongoing continuing education.
Media and technology access for peer specialists.
Research and evaluation components.
Code of ethics and conduct.
Competence-based training for supervisors.
Multilevel support and program support teams.
Advice to Administrators: Sample Peer Support Staff Tasks
Use active listening skills help peers identify areas of dissatisfaction and benefits of changing beliefs, thoughts, and behavior.
Use problem-solving skills to help peers identify barriers to recovery and develop plans to meet peer-determined goals.
Facilitate recovery support groups.
Link clients with community resources.
Work with the treatment team to advocate for clients and to remove recovery barriers.
Participate in consumer panels to educate staff about the consumer perspective and about peer support.
Participate in hospital-wide committees and workgroups
“Peer recovery support services are evidence based and have been demonstrated to promote positive health outcomes and control the cost of healthcare. These services are offered by a trained individual with lived experience and recovery from a mental illness, substance use and/or chronic health conditions. Peer recovery support services minimally include chronic illness self-management, whole health and wellness promotion and engagement, relapse prevention, life skill coaching, and insurance and health systems navigation.”
(Daniels et al., 2012, p. 22)
Strategy #14: Obtain Ongoing Feedback and Evaluations
Obtain feedback on and evaluations of organizational performance on a regular basis. Give consumers a clear avenue for offering feedback at any time, and make evaluations assessing the organization’s progress toward providing trauma-informed services standard practice. Without feedback and further evaluation, organizations cannot assess whether they are meeting trauma-informed objectives. A routine monitoring process for TIC implementation gives the organization additional information necessary to combat new obstacles and threats and to understand what works. Regular monitoring equips organizations with the ability to formulate different strategies to meet objectives as well as to respond to the changing needs of the population. Ongoing evaluation and consumer feedback are essential in improving the quality of services.
Strategy #15: Change the Environment To Increase Safety
Practices that generate emotional and physical safety are necessary. Another aspect of creating safety is reevaluating the physical facilities and environment to enhance safety and to circumvent preventable retraumatization. Think how traumatizing it would be if you were a female rape survivor and a night counselor was conducting a room check at 2:00 a.m., or a male security guard was walking the women’s residential wing. What would it be like if you were sitting with your back to the door in a small office during an intake interview, if your history included a physical assault and robbery? For most, it would at least increase anxiety; for others it would be retraumatizing. Trauma-informed providers must carefully assess environmental safety. Although you are likely to identify some facility issues that could erode safety for trauma survivors, a safe environment will only be established if regular feedback is obtained from consumers about their experiences with the program.
Strategy #16: Develop Trauma-Informed Collaborations
TIC is about collaboration with consumers, staff members, key stakeholders, and other agencies. Collaborative relationships provide opportunities for consumers to access the most appropriate services as needs arise. Rather than waiting for a crisis or a dire need for a service to investigate available resources, it is far more efficient and compassionate to establish relationships within the agency and with other community resources before these needs arise. No agency can meet the needs of every client; referral agreements and/or collaborative arrangements that integrate the delivery of TIC, including support services (e.g., housing, legal, medical), are important.
The sanctuary model is a trauma-based therapeutic approach that has been used in inpatient, residential, therapeutic community, and outpatient settings with children, adolescents, and adults. It provides a template for changing social service delivery systems so that they are better equipped to respond to the complex needs of trauma survivors. Sanctuary is informed by four knowledge areas: “the psychobiology of trauma, the active creation of nonviolent environments, principles of social learning, and an understanding of the ways in which complex adaptive systems grow, change, and alter their course” (Bloom et al., 2003, p. 174).
The sanctuary model describes a stage-based approach to healing that is referred to as SAGE: safety, affect modulation, grieving, and emancipation. This model is nonlinear; an individual does not necessarily move from one stage to another in a straight path, but progress in one area does affect progress in other areas (Bloom, 1997; Bloom et al., 2003). SAGE is a cognitive–behavioral translation of the sanctuary model (Bills, 2003). Early in treatment, the focuses are typically on safety and affect management. Safety encompasses four domains: physical, psychological, social, and moral (Bloom, 1997; see http://www.sanctuaryweb.com for further details and a curriculum).