Enablers and barriers to trauma-informed systems, organisations and workforces: evidence review

Section 5: Key findings – Impact

This section provides a summary of the evidence of the short- and medium-term positive impact of trauma-informed approaches on workforces, and people with experience of trauma.

1 – Outcomes of trauma-informed approaches for the workforce include:

• Improved wellbeing and satisfaction
• Improved communication and collaboration
• Increased confidence, skills and knowledge in relation to responding to psychological trauma.

2 – Outcomes of trauma-informed approaches for people with experience of trauma include:

• Improved wellbeing
• Reduce emotional difficulties for children and young people
• A positive impact on families and caregivers
• Increased knowledge and skills
• Improved access to specialist treatment or services where required
• Increased completion rates of treatment
• Reduction in experiences of seclusion and physical restraint

5.1 Outcomes of trauma-informed approaches for the workforce

Improved wellbeing and satisfaction:

Community-based interventions

Hales et al. (2019) reported an increase in staff levels of safety, trustworthiness, choice, collaboration, and empowerment after the implementation of a TIC intervention within a residential agency focused on treating addictions, mental health difficulties and homelessness. Hales et al. (2019) reported an increase in domains of staff satisfaction, including trusting each other, ability to work collaboratively, influencing their workplace, being encouraged to innovate, or feeling fulfilled. The most significant increases were observed in the areas of choice and emotional safety. In this case, the TIC intervention was based on the use of mentors and trauma champions, changes in policy and practice, the provision of staff training ad coaching and sharing trauma-relevant information with clients.

Schools

In Perry and Daniels' (2016) study, 97% of staff were satisfied with the trauma-informed approach training they received, reporting that it was useful and that they learnt about implementing self-care initiatives, identifying signs of trauma, and new techniques to reduce stress in the classroom. Staff in the school where this strategy was implemented also reported positive changes in attitudes toward students who experienced trauma.

Multi-agency

After a nine-months city-wide TIC implementation based on training delivered to government and non-profit organisations professionals, Damian et al. (2017) observed that professional satisfaction among staff improved significantly. Staff reported significant improvements in their perception of the quality of the work environment and increased agreement with managerial efforts to promote safety. The participants in this study, who worked across different sectors, including health and education, social services and law enforcement, reported significant changes in their knowledge and practice. The results showed that participants found the TIC training intervention to be beneficial for them, as it was linked to increased professional satisfaction. Moreover, it was also related to cultural changes and organisational benefits such as improved collaboration, morale, safety, or a better workplace climate. A rarely described impact of TIC training, was the changes it brought to the physical environment where some institutions restructured their offices and buildings to promote a safe space for staff and service users, which also promoted positive relationships between workers and clients. The intervention also increased staff awareness of their own stress and trauma-related symptoms, which highlighted their own needs for support and self-care. This increased awareness also helped improve the identification of their colleagues' symptoms of trauma and enhanced their empathy and understanding toward each other.

Improved communication and collaboration between services and systems:

Child welfare

The objective of the TILTS, the Trauma Informed Leadership Teams in the Massachusetts Child Trauma Project (MCTP) was to align the different trauma-informed services with a focus on treatment, to ensure families could access them. It promoted collaboration and coordination of services and families, with the aim of promoting effective partnerships at community and individual level (Bartlett et al., 2016). This led to the creation of a shared language between the different services involved, facilitating the understanding of each other's role and the development of resources that could be used to engage with community stakeholders and improved the referral process for evidence-based treatments. According to the results obtained by Bartlett et al. (2016), TILTs seemed to have a positive impact on the overall system due to the improved connections and communication between external services/systems (mental health services, schools, justice) and the child welfare system. This positive effect was particularly evident in the relationships between mental health services and the child welfare system because it helped creating a shared language between them. An additional benefit of TILTs is their capacity to address secondary traumatic stress, which has a positive impact on clinicians and child welfare staff.

Increased confidence, skills and knowledge in relation to responding to psychological trauma.

Schools

Approaches such as TIES (Trauma-Informed Elementary Schools) aim to provide early intervention strategies for children in primary education who experience chronic stress or trauma (Tabone et al., 2020). The results obtained by Tabone et al. (2020) show that implementing TIES led to a significant improvement in children's emotional support, instructional support (teacher's ability to promote higher-order thinking and skills, to give meaningful feedback, and to use language stimulation and facilitation techniques) and classroom organisation (the teacher's ability to prevent/address challenging behaviours, manage instructional time, promote student engagement) across a school year. Non-TIES classrooms experienced a decrease or no changes in those areas at the end of the same academic year. Therefore, this study provides evidence of the benefits of these types of intervention when it comes to nurturing trauma-informed school environments and culture, highlighting that trauma-informed early intervention is critical for the prevention of re-traumatisation of children who have experienced trauma. Additionally, classroom level strategies like TIES, have the potential to benefit staff, pupils and their families, regardless of their trauma history (ibid).

According to Avery et al. (2021), teacher coaching, including group sessions, supervision, or workshops, was essential when it came to translating knowledge into practice. Therefore, coaching and supervision seem to enhance and strengthen the change and new practices linked to TIC adoption.

Child welfare

Understanding trauma and its impact was recognised as a key element of the Sanctuary Model's implementation. Participants Galvin et al's (2021) study recognised that most of the work they do relates to being trauma informed. Having a shared language, knowledge, and understanding of trauma and its long-lasting and negative effect had a positive and transformative impact on the organisation, where staff changed the way in which they addressed times of crisis and provided help and support young people. Part of this change came from having a greater understanding of the trauma young people in the organisation might face and its impact on their behaviour, as well as supporting these young people understand their own trauma and its overall influence.

Similarly, Jankowski et al. (2019) observed that the implementation of a comprehensive TIC intervention led to significant increases in the frequency in which trauma screening was used, and in the skills reported by part of the staff in this area. It also led to improvements in attitudes and behaviours regarding trauma screening and other areas such as case planning. The implementation of programmes such as the Massachusetts Child Trauma Project (MCTP) might lead to an increase in the use of trauma screening during the referral process (Bartlett et al., 2016). More specifically, after six months of the implementation of the MCTP, 6% more mental health agencies started using trauma screening at the start of the referral process (ibid). According to Bunting et al. (2019), projects reported that their efforts in training mental health services providers across their state, helped maximise capacity for assessment and treatment referrals after these professionals had better information regarding the effects of childhood trauma.

Bunting et al. (2019) observed how all of the studies reviewed reported increases in the confidence, responsiveness and awareness of staff in relation to trauma-informed approaches to practice after receiving trauma-focused training. These changes were maintained over time. This positive impact was reflected at individual and institutional level through staff's positive attitudes and commitment toward evidence-based and trauma-informed practice and their increased ability to deliver trauma-informed care.

Community-based interventions

Staff from an addiction treatment residential agency expressed how areas of supervision, support, self-care, training, education, assessments and involving former clients presented significant improvements after implementing TIC (Hales et al., 2019).

The findings described by Singh et al. (2020) include positive (self-reported) changes in practice, particularly in the areas of awareness (trauma recognition), competency (changing behaviour, knowledge application), collaboration (community engagement) and safety (environmental changes to become more welcoming, consistent, reliable). After being involved in Building Connections – the initiative designed to increase staff capacity in community-based projects supporting mothers and children who experiences interpersonal violence - participants reported increased capability to build positive relationships with the families in their organisation. Moreover, they discussed their increased confidence when working with women who might be facing interpersonal violence by building relationships that were based on safety, trustworthiness, and support. The participants stressed the key role that adopting critical trauma-informed (consideration of previous trauma, efforts to avoid re-traumatisation, etc.) and relational approaches had in that increased confidence and competence. This has relevance in this specific context as women who are facing interpersonal violence often struggle to disclose their circumstances, meaning that it is essential staff staff being able to recognise these situations and provide effective supportare essential (see Singh et al., 2020). Facilitators also mentioned the positive organisational impact of the intervention since they could observe positive changes on attitudes and practices, for instance, concerning referral procedures or the promotion of co-facilitation. A key finding from Singh et al's (2020) study was to demonstrate how trauma-informed approaches can be effectively implemented in non-clinical and community-based initiatives.

Health services

Gundacker et al. (2021) conducted a literature review of the trauma-informed curricula for Primary Care Providers (PCPs), considering their effectiveness and research gaps. They concluded that trauma-informed training for PCPs lead to positive improvements, increased knowledge, screening, communication, and patient satisfaction. However, changes in referrals or health outcomes could not be reported.

Justice system

In the Promise Initiative (Lathan et al., 2019), police officers that had received trauma-informed interviewing training were more sensitive to the way other officers treated people who had experienced sexual assault and seemed to have better knowledge of trauma-informed approaches and dealt with more sexual assault cases. Receiving trauma-informed training was also associated with increased disposition to learn about sexual assault, how it impacted victims and how to conduct trauma-informed investigations, in comparison with officers who did not receive this training. However, the need to ensure the training provided to these officers also tackles rape myths was identified.

Incorporating trauma-informed principles into decision-making processes in areas such as the court system, led to an increased consideration of trauma-informed principles throughout Family Court processes. In the context of the Michigan Children's Trauma Assessment Centre, a Court Report Checklist (CRC) was developed to support Family Court judges understand childhood trauma and its impact on children, and on the services provided to them. Consequently, in the span of two years, 100% of the cases submitted a CRC to the judge before seeing the case in court. The Michigan Children's Trauma Assessment Centre also developed a Trauma-Informed Therapist Report to register the progress of trauma-informed provision and shared it with the relevant stakeholders.

Secure care

Barnett et al. (2018) maintain that the success of their TIC intervention within a youth residential treatment centre and accompanying special needs school was due to delivering a tailored intervention, leadership support, and incentivising the participation of staff via pay increases, certificates and continuous education credits. Finally, although not evaluated, thes authors reported a positive effect of their initiative on staff trauma and stress symptoms. Although not intended to be a part of the intervention, a high rate of staff disclosed their own trauma history and mentioned that this initiative was helping them gain knowledge about the impact of trauma on their personal lives and work performance. Staff mentioned feeling empowered by these training opportunities and reported increased effectiveness in their roles thanks to having the opportunity of processing these experiences within a safe context.

Multi-agency level

Frequency of participation in staff training was significantly correlated with self-reported trauma-informed skills (Barnett et al., 2018).

Purtle (2020) conducted a literature review to study the impact of trauma-informed interventions at the organisational level focusing on staff training. They concluded that staff trauma-related practice outcomes such as knowledge, attitudes, and behaviours improved after being involved in trauma-focused training.

5.2 Outcomes of trauma-informed approaches for people with experience of trauma

Improved wellbeing:

Child welfare

Murphy et al. (2017) concluded that that integrating trauma-informed care increased the wellbeing of children in care, as well as their placement stability a further finding of this study was that not all areas of children's wellbeing are linked with TIC implementation in the same way. This means that some improvements, for instance, those relating to functioning and behavioural regulation, were gained over time. However, improvements around emotional regulation took place after children were exposed to trauma-informed care in the first three months in the system. This reflects the principle of the "trauma systems therapy" that states that changes in emotional wellbeing can appear relatively early in the process, whereas changing behavioural patterns takes more time (ibid).

According to Zhang et al. (2021), TIC interventions have a moderate effect on the wellbeing of children involved in the child welfare system. However, this effect is stronger in the case of the reduction of problematic behaviour, particularly when compared to areas like post-traumatic symptomatology or psychological wellbeing improvement.

Health services

Implementing TIC in a residential addiction agency was linked to a positive increase in client satisfaction at discharge. Clients also reported an increase in staff being able to solve their difficulties (Hales et al., 2019).

In their study based at a maternity clinic, Racine et al. (2021) report modest benefits for new-born outcomes, and no improvements for maternal health during pregnancy. Specifically, they found that exploring ACEs history within the parental care setting as part of a TIC initiative showed no association with differences in the health of pregnant women when compared with standard (non-TIC) care. The association with better outcomes for children at birth was moderate. Additionally, there was no association between implementing a TIC initiative and the increase of mother or child health risks.

Increased rate of treatment completion:

Health Services

Hales et al. (2019) reported a significant increase of planned discharges within a residential addiction agency in relation to a trauma-informed approach. Planned discharges are an indicator of successful treatment completion.

Reduced emotional difficulties for children and young people:

Schools

A TIC intervention in a specialist school (Diggins, 2021) led to a reduction in difficult behaviours, problems with peers and overall difficulties. Total difficulties and emotional symptoms decreased significantly during the 12-month implementation period. Externalising problems such as hyperactivity and peer problems also diminished, the former in a consistent way during the 12 months period, and the latter during the first 6 months. A factor that might explain this difference is the complexity of the interactions amongst the students. Behavioural problems also showed a significant reduction during the 12 months period of the intervention, which might be linked to the proactive approach and focus on problem-solving skills adopted as part of the trauma-informed intervention. Finally, Diggins reported that the intervention had a more significant effect on new than existing students. This could perhaps be because existing students had been part of the initiative for two years and were showing fewer behavioural and emotional difficulties. However, new students who were joining a specialist school were likely to be showing particularly high levels of behavioural and emotional difficulties at the beginning of the intervention..

According to Fondren et al. (2020) tier 1 interventions, based on prevention strategies, the promoting of positive behaviours and increasing socioemotional learning (SEL), were linked to increased positive behaviour and SEL skills. Tier 2 initiatives, targeting groups of children at higher risk of having experienced trauma, without having to meet strict criteria regarding the type of trauma, helped increase prosocial behaviours and measures of children's outlook on the future. These interventions were also linked to the decrease of children's post-traumatic stress disorder (PTSD) symptomatology and negative behaviours (internalising and externalising). Tier 3 interventions, delivered to students reporting having experienced significant trauma and PTSD symptoms, are linked to reduced children's PTSD symptomatology and psychopathology and improved school functioning.

In their literature review, Avery et al. (2021), found that studies that implemented trauma assessment and intervention strategies reported improvements in trauma symptoms in students. The implementation of TIC led to an increase in the number of children reported as having symptoms of trauma, either at all open cases or for children going into the welfare system.

Child welfare

Bartlett et al. (2016) and Barto et al. (2018) studied the effectiveness of the Massachusetts Child Trauma Project (MCTP), a state-wide intervention based on providing trauma-focused training to mental health staff and promoting trauma-informed practices within child welfare systems. These authors observed that children supported by staff who had participated in the MCTP had increased levels of functioning and were less likely to suffer maltreatment, including physical abuse and neglect, than children who were not part of the intervention.

Bartlett et al. (2016) assessed the effect of EBT. They reported that children showed fewer trauma-related symptoms and behavioural difficulties, six months (or less) after treatment. More specifically, they showed that, overall, children displayed fewer internalising and externalising negative behaviours. Furthermore, post-traumatic symptomatology decreased significantly, particularly amongst older children, who also showed fewer avoidant, numbing, and re-experiencing symptoms, as well as weakened arousal symptoms. Substantial reductions in functional impairment and of indicators of reduced arousal symptomatology were observed for young children who also were exposed to the EBTs known as Child-Parent Psychotherapy (CPP), Trauma-Focused Cognitive Behavioural Therapy (TF-CBT) or Attachment, Self-regulation, and Competency (ARC). Contrastingly, caregivers did not observe improvements for these children displaying re-experiencing, avoidant or numbing symptoms, or of their severity. The reason behind these inconsistencies might be due to caregivers' biases or methodological limitations since the reliability of the instrument employed (the Young Child PTSD Checklist (YCPC)) is unclear. Bartlett et al. (2016) concluded that research is still needed to clarify the role of EBT fidelity in achieving TIC system objectives. Additionally, the findings suggest that more solid outcomes might emerge in the future, after staff (clinicians, supervisors, etc.) and agencies had received full training, acquired additional experience and knowledge of the treatment models and after TIC has been developed and implemented across child welfare systems more consistently.

After being involved in the Fostering Connections initiative, Lotty et al. (2020) observed significant improvement in the emotional and behavioural difficulties of children in foster care, fifteen months post intervention, with a small effect size. In this case, these changes could be related to the intervention focussing on child regulatory strategies, which could have helped improve children's behaviour. They concluded that Fostering Connections could potentially be an effective programme to help increase the capacity of foster parents to provide trauma-informed care.

Secure care

After implementing an educational-based intervention in two youth juvenile detention facilities, Baetz et al. (2021) observed a reduction in violent incidents at both facilities. However, significant effects were found only in one facility. The authors concluded that various elements led to this positive change, including delivering staff training and a skills development programme for the youth in the facility, as well as having a larger proportion of young people take part in the intervention for a sustained period of time.

Positive impact on families and caregivers:

Schools

In Perry and Daniels(2016) families reported improved communication with the school. The implementation of the trauma-informed model also led to the creation of a support network as the families involved decided to keep supporting each other after the end of the intervention. They also reached out to those in their communities who could be experiencing stress to help them get support. Diggins' study (2021) was based on the perspective of the students' families which allowed for an exploration of the impact of school-based trauma-informed practices on life beyond school.

Perry and Daniels (2016) also reported improvements in children's social and family life, as well as in their learning. Although some programmes focused on strengthening the communication between families and institutions (schools in the case of Perry and Daniels, 2016), it was easy for families to remain out of the loop. Unreliable communication can negatively impact the level of trust families have in schools. The Care Coordination strategy discussed above also focused on addressing this difficulty by promoting trauma-informed engagement, education, and empowerment in all contacts with the family, the student, and the school.

Child welfare

Amongst the benefits associated with trauma screening, Bunting et al. (2019) reported improved family engagement and reduced caregiver stress. Additionally, Murphy et al., (2017) report that children who worked with staff with higher levels of trauma-related training (Trauma Systems Therapy dosage) experienced greater placement stability (i.e. their total number of placements significantly decreased). Bunting et al. (2019) also reported increased placement stability linked to being in contact with trauma-informed interventions.

Care-givers

After being involved in the Fostering Connections intervention, significant improvements were found in the knowledge of foster parents regarding trauma-informed fostering, tolerance to children's challenging behaviours and fostering efficacy, which was maintained 15 months after intervention (Lotty et al., 2020).. The potential reasons forsupporting these changes include the role of increased trauma-focused knowledge on facilitating behavioural change, how increased understanding of the impact of trauma could increase tolerance toward challenging behaviour, or that foster parents with increased confidence when supporting children who have experienced trauma has a positive impact on their wellbeing potentially due to increased feelings of safety and security in the foster parent-child relationship.

Increased knowledge and skills:

Schools

Providing psychoeducation to school children and adolescents helped them acquire skills to identify signs of stress in themselves and other people, relax, worry less, recognise who are the members of their community that can act as their support network and trust others (Perry and Daniels, 2016). Students in this intervention also had the opportunity to learn skills to react to future traumatic events and help with ongoing symptoms.

Improved access to specialist treatment or services where required:

Health services

The use of ACEs screening in the low-risk maternity clinic where Racine et al. (2021) implemented a TIC strategy led to the referral of some patients to access mental health support. Following completion of a modified version of the ACEs questionnaire and assessment of their needs, 18 women (5.3% of the patients) were referred to access mental health treatment.

Reduction in experiences of seclusion and physical restraint:

Health services

Azeem et al. (2017) demonstrated a significant reduction in the number of seclusions and restraints used within a child and adolescent psychiatric hospital after implementing six trauma-informed care strategies. The significant decrease in the number of restrictive practices was maintained for most of the intervention. Azeem et al. (2017) concluded that their study strengthens the evidence about the benefits of using trauma-informed prevention strategies, inclusive treatment plans, monitoring and appropriate training for staff.