Transforming Organizations to Embrace Trauma-Informed Care

How do we know if we are on the right path to providing trauma-informed care? 

Research shows us that trauma is present in almost every age, race, ability, and socioeconomic group, and it has a ripple effect throughout communities. Unaddressed trauma increases the risk of mental health disorders, substance use, and chronic physical issues. 

However, with the right treatment and support, people can and do overcome trauma, which is why trauma-informed care is becoming a mainstay in behavioral health settings. 

It can be challenging to sort out the different methods and terminology surrounding trauma-informed care. Some clinicians are seeking better ways to implement trauma-informed care in their day-to-day practice, and organizations are searching for ways to measure and evaluate the effectiveness of treatment. And trauma-informed care is most effective when multiple agencies and organizations provide coordinated assessment and treatment.

What are some of the tenets of trauma-informed care? And what are the ways to evaluate efforts to determine if treatment is successful? 

Trauma Basics

Trauma is what happens when the extreme stress of an event or circumstance overwhelms someone’s ability to cope. It is caused by threats to physical or emotional health: violence, hate crimes, sexual abuse, or anything else that causes extreme stress.

The Substance Abuse and Mental Health Services Agency (SAMHSA) defines trauma as follows: “Individual trauma results from an event, series of events, or set of circumstances that are 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.”

Trauma is far too common. 

The ACEs

How do we know when someone has experienced trauma? The ACE Score Questionnaire is an assessment tool used by thousands of professional clinicians and researchers. It includes questions that help determine if someone was abused, witnessed abuse, felt deprived of food or care, or had parents who were too impaired to take care of them. 

According to the Centers for Disease Control (CDC), 61% of people report experiencing at least one type of adverse childhood experience (ACE) before age 18, with one in six experiencing four or more types of ACEs.

The negative outcomes of ACEs are numerous, including injury, mental health conditions, maternal health concerns, infectious and chronic disease, risky behaviors, and missed opportunities in school and life.

Because none of these things are the fault of the victim, trauma-informed care transforms the conversation in an important way.

The Need for Trauma-Informed Care

The Trauma-Informed Care Implementation Resource Center’s website provides a clear description of trauma-informed care: “Trauma-informed care shifts the focus from ‘What’s wrong with you?’ to ‘What happened to you?’”

A trauma-informed approach to care is based on an understanding of the experience and implications of trauma for individuals, families, and communities. Trauma is not just a health care issue. Multiple service sectors interact with people who have experienced trauma. 

The Difference Between Trauma-Informed and Trauma-Specific Treatments

We are learning more about how to address trauma to help people heal from the events of the past. There are two main types of trauma treatment.

Trauma-specific treatment is designed to address trauma. This includes a number of approaches such as Trauma Affect Regulation: Guide and Education Therapy (TARGET), Eye Movement Desensitization and Reprocessing Therapy (EMDR), Accelerated Resolution Therapy (ART), and group models like Seeking Safety, Trauma Recovery and Empowerment Model, and Healing Trauma. 

Trauma-informed treatment is a bit broader. It incorporates knowledge of trauma even when the treatment focuses on substance use, mental health disorders, or other issues.

Why Is Trauma-Informed Care Important?

A trauma-informed approach is important because it provides a holistic healing way of understanding the context of a person’s stressors and behaviors. 

Many people who have experienced trauma have challenges in maintaining healthy relationships, including with care providers. The positive, trusting relationships that are nurtured with a trauma-informed approach are not only better for clients, but they also help clinicians avoid burnout.

SAMHSA and many other respected authorities emphasize that a trauma-informed approach is essential because of the danger of re-traumatization. Some organizations unintentionally create stressful situations or environments that interfere with recovery from trauma. 

How do we measure the effectiveness of trauma-informed care?

The Challenge of Measuring Trauma-Informed Care

Some federal, state, and local governing bodies are requiring organizations, schools, and service systems to demonstrate that they are advancing trauma-informed care in their settings. But they don’t always provide guidance about how to do that.  

For example, the Family First Services Prevention Act requires Qualified Residential Treatment Programs (QRTPs) to demonstrate effective use of a trauma-informed care framework but leaves it to states and QRTPs to determine how to evaluate their efforts. Schools face similar pressures to show positive outcomes for their trauma-sensitive school initiatives.

It is more challenging to show progress in measuring trauma-informed care than in trauma-specific treatment. With trauma-specific treatments, one generally measures individual-level outcomes like depression, anxiety, or PTSD symptoms, and it is easier to show that treatment affects these outcomes. When changing systems to a trauma-informed model, there are many more possible outcomes to measure and factors that can have an impact on the change process.

For this reason, there are currently many recognized evidence-based, trauma-specific treatments and few, if any, evidence-based models of trauma-informed care. This makes working to measure trauma-informed care that much more important.

Why Do Organizations Want to Measure Trauma-Informed Care?

• To assess their readiness for a trauma-informed change process

• To know if their change efforts are showing progress

• To know if a particular intervention such as training or a new screening protocol had a positive impact

• To determine if organizations are truly trauma-informed compared with those using more traditional or universal approaches

• To assess whether TIC change in the organization has been sustained

• To demonstrate success to stakeholders such as boards of directors, referral sources, or governing bodies enacting trauma-informed care mandates

• To build the evidence base for the trauma-informed field

Tools to Measure Trauma-Informed Care

There is a reliable tool that is being used to measure the impact of trauma-informed care. It’s called the Attitudes Related to Trauma-Informed Care (ARTIC) Scale. The ARTIC Scale is a psychometrically validated instrument that is widely used. It measures the attitudes of professionals and paraprofessionals. It is the only measure of trauma-informed care listed on the California Evidence-Based Clearinghouse for Child Welfare. 

Many organizations that are committed to a trauma-informed approach are seeking ways to evaluate and measure their progress. 

The Purpose of Doing a Trauma-Informed Care Evaluation  

There are many possible purposes for trauma-informed care evaluations. Here are some of the most common for organizations.  

• To take a baseline measure of trauma-informed care to decide on a course of intervention

• To determine readiness for a trauma-informed initiative in order to create the conditions necessary for the initiative to succeed

• To learn about the impact of an intervention (trauma-informed training, policy revision, trauma screening, etc.) so they can fine-tune their actions

• To know if the initiative made the people they serve better off so they can determine if they are fulfilling their mission

• To assess how well providers in their system are doing with trauma-informed implementation so that they can determine how to help them become more trauma-informed

• To determine if the change efforts are sustained over time so they can decide if they need to recommit to trauma-informed care implementation

Using Data to Inform and Improve Practice

When organizations and systems don’t have much experience with program evaluation and data, they sometimes underestimate the skill needed to use the data effectively and the time it takes to do so.  

If an organization lacks data expertise or the human resources to do program evaluation, there are automated online TIC measures (ARTIC Scale, TICOMETER) that can help. Sometimes a research consultant, local doctoral student, or professor can help you plan the program evaluation and manage the data.

Of course, it is important for everyone in the organization to have a shared understanding of trauma-informed care and how to provide it.

A Trauma-Informed Lens

The Connecticut Women’s Consortium offers many trainings on creating trauma-informed spaces and nurturing trauma-informed cultures. These workshops take participants through a trauma-informed framework and apply it to the settings where behavioral health professionals work. They also provide opportunities to assess an agency’s culture and physical environment to determine if the spaces and systems are implementing the principles of trauma-informed care.

When we transform our clinical spaces in this way, we open up new possibilities for healing our clients and communities.