Trauma-informed practice: toolkit

Appendices

Appendix 1

How to use the toolkit for Scotland

To assist in guiding implementation, a full list of the sample questions included in this toolkit is provided below. The questions are adapted from SAMHSA's "Concept of Trauma and Guidance for a Trauma-Informed Approach" document (2014), with supplementary items added as a result of the findings from our qualitative fieldwork conducted in Scotland.

Organisations across systems and sectors are encouraged to adapt the sample questions to fit the specific needs of their organisation, staff and service users. Once an organisation has decided on relevant questions and areas of focus, relevant outcome measures should be identified (Appendix 7) and an appropriate evaluation framework should be adopted.

Safety	Trust	Choice	Collaboration	Empowerment
10 Implementation Domains
Governance, management and leadership	How does organisation leadership show and communicate its support for implementing a trauma-informed approach? How do the organisation's mission statement and/or written policies and procedures include a commitment to providing trauma-informed services and supports? How do leadership and governance structures demonstrate support for including survivors with experience of using their service in this process (from start to finish)? How will a Service Walkthrough be completed, and how will the findings from this be built into the plan to help the service become trauma responsive? What is the plan for training provision in TIP to be provided to senior management? This should include examples on how to be a trauma-informed leader – including role modelling. What plan does organisation leadership have to amend the language used in relation to survivors and trauma among staff in their organisation? For example, to reduce power differentials. What systems are in place to encourage innovation in the workplace in relation to Trauma-Informed practice?
Policy	How do the organisation's written policies and procedures include a focus on trauma and issues of safety and confidentiality? How do the organisation's written policies and procedures recognise the pervasiveness of trauma in the lives of people (using the services and working with them), and express a commitment to the reducing retraumatisation, and promoting well-being and recovery? Has the organisation a specific health and wellbeing plan in place for staff, which recognises the pervasiveness of trauma and helps supervisors and workers support staff who have experienced trauma? If not, why not? How do the organisation's staffing policies demonstrate a commitment to staff training on providing services and supports that are culturally relevant and trauma-informed? How beneficial would it be to have an organisational policy on how screening should be completed and/or how service users should be asked about trauma? Would creating a specific policy in accessing supervision in your service create more service congruency? How do human resources policies attend to the impact of working with people who have experienced trauma? What policies and procedures are in place for including trauma survivors/ people receiving services and peer supports in meaningful and significant roles in organisation planning, governance, policy-making, services and evaluation? Does the language used in these policies position trauma as a natural reaction to traumatic events? Does it normalise trauma? And behaviours and coping strategies related to trauma?
Engagement and involvement of survivors	Does your organisation have a survivor involvement policy, outlining your mission and what you want to achieve by involving survivors? Have staff been involved in discussions on how this will work/ barriers to implementation? How can staff and clients be involved with developing a plan for improving engagement and involvement of survivors in service planning and delivery? Has budget been considered to support this? How does your organisation specifically take into account the experiences, and needs of Black and Minority Ethnic people? What can be done to improve trust and transparency in staff, for survivors who do become involved in service planning and delivery? How has their role been collaboratively identified and clearly outlined to avoid any confusion? What strategies are used to reduce the sense of power differentials among staff and clients? How do staff members help people to identify strategies that contribute to feeling comforted and empowered?
Workforce development and support	How does the agency help staff deal with the emotional stress that can arise when working with individuals who have had traumatic experiences? How does the agency support training and workforce development for staff to understand and increase their trauma knowledge and interventions? How does the organisation ensure that all staff (direct care, supervisors, front desk and reception, support staff, housekeeping and maintenance) receive basic training on trauma, its impact, and strategies for trauma-informed approaches across the agency and across personnel functions? How does workforce development/staff training address the ways identity, race, ethnicity, culture, community, and oppression can affect a person's experience of trauma, access to supports and resources, and opportunities for safety? How does on-going workforce development/staff training provide staff supports in developing the knowledge and skills to work sensitively and effectively with trauma survivors? What types of training and resources are provided to staff and supervisors on incorporating trauma-informed practice and supervision in their work? What workforce development strategies are in place to assist staff in working with peer supports and recognising the value of peer support as integral to the organisation's workforce?
Physical & Emotional Environment	How does the physical environment promote a sense of safety, calming, and de-escalation for clients and staff? How is a gender differential taken into account in site selection (if possible) and recruitment? How is a race and ethnicity differential taken into account in recruitment? In what ways do staff members recognise and address aspects of the physical environment that may be retraumatising, and work with either a) improving the environment and/ or b) with people on developing strategies to deal with this? How has the organisation provided space that both staff and people receiving services can use to practice selfcare? How has the organisation developed mechanisms to address gender-related physical and emotional safety concerns (e.g., gender-specific spaces and activities)? How has the organisation specifically recruited for individuals who have the skills and qualities necessary to be trauma-informed, e.g. empathetic, welcoming, caring? How will the organisation ensure all workers respond to survivors in a way which is emotionally safe? For example, providing training to staff at all levels. How is the emotional safety of staff considered by the organisation? Promoting self care, ensuring staff are adequately supported, staff are involved in feeding into the organisation how this should happen.
Cross Sector Collaboration	Have suitable collaborations been identified? How? Is this process sufficient/does it cover all bases? Is there a system of communication in place with other partner agencies working with the individual receiving services for making trauma-informed decisions? Are collaborative partners trauma-informed? How does the organisation identify community providers and referral agencies that have experience delivering evidence-based trauma services? What mechanisms are in place to promote crosssector training on trauma and trauma-informed approaches?
Screening, Assessment and Treatment	Is an individual's own definition of emotional safety included in treatment plans? Is timely trauma-informed screening and assessment suitable for your service? If so, is it available and accessible to individuals receiving services? If it is not suitable, how do staff still ask the difficult questions which need to be asked to identify trauma and how are they supported to do this? How confident are they in doing this? Do they need further training? How is this recorded and how is information passed on, respecting the collaborative and trusting relationship which has been built between staff/ survivor? Does the organisation have the capacity to provide trauma treatment or refer to appropriate trauma treatment services? Is there a wait for these? If so, is there an alternative service where the wait is less? How are peer supports integrated into the service delivery approach? How does the organisation address gender-based needs in the context of trauma screening, assessment, and treatment? For instance, do they offer any gender specific services? If not are there any they can be referred to which are? Do staff members talk with people about the range of trauma reactions and work to minimise feelings of fear or shame and to increase self-understanding? Can/should they be completing safety and stabilisation work with the client? How are these trauma-specific practices incorporated into the organisation's ongoing operations?
Finance	How does the organisation's budget include funding support for ongoing training on trauma and trauma-informed approaches for leadership and staff development? What funding exists for cross-sector training on trauma and trauma-informed approaches? What funding exists for peer specialists? How does the budget support provision of a safe physical environment?
Progress Monitoring and Quality Assurance	Does the organisation gather feedback from both staff and individuals receiving services? What strategies and processes does the organisation use to evaluate whether staff members feel safe and valued at the organisation? How does the organisation include cultural factors in monitoring and quality assurance? What mechanisms are in place for information collected to be incorporated into the organisation's quality assurance processes and how well do those mechanisms address creating accessible, culturally relevant, trauma-informed services and supports?
Evaluation	How does the agency conduct a trauma-informed organisational assessment or have measures or indicators that show their level of trauma-informed approach? How does the perspective of people who have experienced trauma inform the agency performance beyond consumer satisfaction survey? What processes are in place to gather feedback from people who use services and ensure anonymity and confidentiality? What measures or indicators are used to assess the organisation's progress in becoming trauma-informed?

Appendix 2: The tools

Toolbox 1: Background materials for explaining effects of trauma

Understanding the impact of stress on the brain, Blue Knot Foundation - Link to Appendix 3 Understanding the stress response, Blue Knot Foundation - Link to Appendix 3 The window of tolerance Blue Knot Foundation and locally developed tool - Link to Appendix 3 A useful film on neuropsychology and trauma ( NHS Lanarkshire) - https://vimeo.com/325875547 National wellbeing hub - is it normal to feel like this? - https://www.promis.scot/resource/common-reactions/

Toolbox 2: Staff wellbeing

Staff wellbeing - NES - https://sway.office.com/p3QWjY4altHviB6o?ref=Link Mind - wellness action plans - https://www.mind.org.uk/media-a/5760/mind-guide-for-employees-wellness-action-plans_final.pdf National Trauma Training Programme Online Resources - Link to Appendix 4 National wellbeing hub - coping and self-care - https://www.promis.scot/resource/coping-and-self-care Emergency service staff wellbeing - https://www.lifelines.scot/

Toolbox 3: Trauma-informed leadership

National Trauma Training Programme Online Resources - Link to Appendix 4 National wellbeing hub resources for leaders - https://www.promis.scot/resource/leadership/ Trauma-informed leadership for Organisational Change: A framework ( MHCC) - https://www.mhcc.org.au/resource/trauma-informed-leadership-for-organisational-change-a-framework/

Toolbox 4: Getting Lived Experience on Board

Good starting points for lived experience involvement (adapted from Harris & Fallot) - Link to Appendix 5 Inclusive Justice: Co-producing Change - https://www.cycj.org.uk/resource/inclusive-justice-co-producing-change/ Scottish independent advocacy alliance - https://www.siaa.org.uk/ Health Improvement Scotland - Participation toolkit - https://www.hisengage.scot/equipping-professionals/participation-toolkit/

Toolbox 5: Trauma Training

National Trauma Training Programme Online Resources - Link to Appendix 4

Toolbox 6: Evaluation

Outcome measures table - from scoping phase - Link to Appendix 6 Outcome measures used in case studies - Link to Appendix 7 Evaluation Scotland resources - logic models - https://evaluationsupportscotland.org.uk Better evaluation - https://www.betterevaluation.org/en/what-evaluation

Toolbox 7: Progress monitoring and Quality Assurance

Data collection - Link to Appendix 7 The Participation Toolkit (Scottish Healthcare Improvement Scotland) - https://www.hisengage.scot/equipping-professionals/participation-toolkit/ Inclusive Justice: Co-Producing Change - https://www.cycj.org.uk/resource/inclusive-justice-co-producing-change/

Toolbox 8: Other Toolkits for Organisational Change

Trauma-informed Oregan Roadmap - https://traumainformedoregon.org/roadmap-trauma-informed-care/screening-tool/ Trauma-informed Practice Guide (British Columbia) - https://bccewh.bc.ca/wp-content/uploads/2012/05/2013_TIP-Guide.pdf CCTIC (Fallot & Harris, 2009) - https://www.theannainstitute.org/CCTICSELFASSPP.pdf Becoming Trauma-informed Tool Kit for Women's Community Service Providers (Stephanie Covington, 2016) - https://www.mappingthemaze.org.uk/wp/wp-content/uploads/2017/08/Covington-Trauma-toolkit.pdf TICPOT - https://mhcc.org.au/resource/ticpot-stage-1-2-3/ Useful reading and toolkits by sector - Link to Appendix 8

Toolbox 9: Hiring a Trauma-Informed Workforce

https://www.chcs.org/resource/laying-groundwork-trauma-informed-care/

Toolbox 10: Trauma-specific models and therapeutic modalities

Post traumatic Stress Disorder NICE guideline - https://www.nice.org.uk/guidance/ng116 What is complex PTSD", the Psychologist - https://thepsychologist.bps.org.uk/what-complex-ptsd Example of treatment approaches (Prolonged Exposure, EMDR, Seeking Safety, etc) - https://www.samhsa.gov/sites/default/files/programs_campaigns/childrens_mental_health/atc-whitepaper-040616.pdf Trauma-informed Care in Behavioural Services - https://www.ncbi.nlm.nih.gov/books/NBK207201/ EMDR - https://emdr-europe.org/

Toolbox 11: Trauma-informed lens tools

NES Trauma-informed Lens workshop - Link to Appendix 4 Sowing Seeds animation - Link to Appendix 4 Opening Doors Animation - Link to Appendix 4

Toolbox 12: Advice on how to use trauma-sensitive language

Recovery Orientated Language Guide ( MHCC, 2019) - https://mhcc.org.au/wp-content/uploads/2019/08/Recovery-Oriented-Language-Guide_2019ed_v1_20190809-Web.pdf Example of a Shared Language document (Lancashire Police, 2019) - https://www.lancashiresafeguarding.org.uk/media/1406/A-Shared-Language-for-ACEs-and-TIP.pdf

Toolbox 13: Asking about trauma

How to ask about trauma - Link to Appendix 9

Toolbox 14: Setting up/running a Trauma-Informed event

https://mhcc.org.au/wp-content/uploads/2018/05/ticp_checklist_v4_20180222.pdf

Toolbox 15: Policy and Procedures review

Link to Appendix 10

Appendix 3 – Background materials for explaining trauma

(adapted from Blue Knot guidance for Primary Care staff).

(1) understand the impacts of stress on the brain

Under stress, we can all lose the ability to be calm, reflect and respond flexibly

(See `Effects of stress on the brain')

(2) signs of trauma can take different forms

Trauma responses include both:

Hyperarousal (obvious agitation; e.g. shaking, sweating, raised voice)

And

Hypoarousal (e.g. glazed eyes; `zoning out'; `shut down'; can be harder to detect)

(3) simple ways to lower arousal can restore safety

We can all learn to do this for ourselves and others.

Lowering arousal allows the person to return to a place where they can tolerate their feelings (`the window of tolerance'; example used in case study area) and avoid being overwhelmed from hyper- and hypoarousal.

(4) challenging responses and behaviours can be defences against stress

Traumatised people develop coping strategies to protect them from being overwhelmed.

Understanding this allows us to consider what may have `happened to' a person rather than what is `wrong' with a person.

(5) the `way in which' we interact with a traumatised person (not just `what' we say and do) is important

It can also either increase or decrease a person's stress levels. This underlines the importance of knowing how to interact in a trauma-informed way, not make things worse, and `do no harm'.

Effects of stress on the brain

Brain Stem: Basic survival response, states or arousal; Automatic

Limbic: Emotion (fear), evaluation; Unconscious

Cerebral Cortex: Thinking, concepts, reflection; Conscious

Under conditions of stress, our 'lower' brain stem responses become dominant (`bottom up') and we are less able to be calm, reflect and respond flexibly. Trauma activates the `lower' brain stem region (the area below the cortex)

Conditions of stress affect our `higher' brain functioning (cortical; our ability to think). This is especially during times of overwhelming stress such as trauma. `When we are calm it is easy to live in our cortex, using the highest capacities of our brains [to reflect] But if something...intrudes on our thoughts...we become more vigilant and concrete, shifting the balance of our brain activity to subcortical areas...., '(Perry, 2006:49)

`As we move up the arousal continuum towards fear... we necessarily rely on lower and faster brain regions. In complete panic...our responses are reflexive and under virtually no conscious control' (ibid)

Understanding the stress response

Hyperarousal

• Increased heart rate
• Increased rate of breathing
• Blood flows from the arms and legs to organs and major muscle groups
• Tension in the person's muscles
• Hypervigilance i.e. being on guard (for threat)
• Problems with the digestive system
• Disturbance of sleep and energy levels

Hypoarousal

• Having feeling of being 'shut down' or 'cut off'
• Avoidant – avoiding places, events, feelings
• Withdrawn
• Loss of humour, motivation, pleasure and connection with others
• Disturbance of sleep and energy levels

Tips to reduce stress

Hyperarousal

• Recognise being hyper-aroused is a distress/fear response
• Validate their response ('I can see you are...')
• Support the person to feel safe
• Turn the person's focus to their current need/task
• Support gentle ways for the person to release some energy
• Help the person to feel grounded, and feel settled in their body (e.g. feet firmly on the floor; some stretches)

Hypoarousal

• Recognise being hypo-aroused is a distress/fear response
• Support the person to feel safe
• Provide an opportunity for the person to express their current needs without pressuring them to do so
• Pay attention to the physical space (more or less proximity to others?)
• Help the person to become aware of their current surroundings and to tune into their senses
• Encourage the person to move a little, change their posture/position or practice a familiar ritual or rhythm. Emphasis should be on movement rather than sensations for hypo-aroused states.
• Direct attention outward (e.g. noticing objects in the room) rather than inward

Hand model of the brain

(Daniel J. Siegel, 2009) Demonstration at
https://www.youtube.com/watch?v=gm9CIJ74Oxw

The `hand model' of the brain is a simple and effective way of introducing the three basic areas of the brain (i.e. brain stem, limbic system and prefrontal cortex). It is also helpful to understanding of what happens in and to the brain under stress. As such, it provides a valuable illustration of information of which all primary care practice staff should be aware.

In the `hand model', the different parts of the human hand represent each of the above three brain regions. The brain develops with the bottom region forming first and the top region last. Hold hand upright with palm facing outward. The wrist represents the brain stem (the part which controls level of arousal and which developed first).The palm with thumb folded over it represents the limbic system (the `emotional' part of the brain which developed next). The fingers (folded down to cover the thumb and palm) represent the cortex or cognitive (`thinking/reflective') part of the brain which evolved last.

The simple shift of moving your fingers upright and away from your palm (so that thumb and palm are exposed) represents how severe stress can cause us to `flip our lid'. Stress activates our arousal (`survival') responses – represented by the upright wrist - and 'knocks out' our capacity to think and reflect:

The window of tolerance

(Siegel, 1999; Ogden et al, 2006) The `window of tolerance' is the state in which we can tolerate our feelings without becoming stressed, distressed, and overwhelmed. We all need to be in this state (also called the `optimal arousal zone') to maintain our well-being. If we stray outside of this zone and become hyper- or hypoaroused, we have exceeded our level tolerance and need to return to the `window of tolerance' state.

1. We can monitor our own stress levels if we consider `what part of the brain' we are in at any particular time.

If distressed and/or fearful, we will be in the `lower' (subcortical, represented by the wrist) part of the brain. We need to return to the `higher' functioning part (cortical, represented by the folded fingers) to be calm and to be able to respond flexibly.* *

See tips to reduce stress

2. People who experience the impacts of interpersonal trauma can be easily `triggered' by stress and can find themselves outside the window of tolerance.
Interacting in a trauma-informed way can assist them – and ourselves - to stay within `the window of tolerance'.

3. We also need to know how to assist people to RETURN to the window of tolerance if they stray outside it (i.e. if they become either hyper- or hypoaroused).

Appendix 4: Transforming Psychological Trauma

Appendix 4 is available in PDF format under Supporting Files.

Appendix 5 - Good starting points for lived experience involvement

Generally the following are good starting points for service user involvement (adapted from Harris & Fallot, 2001):

Clearly identify the strengths expected from achieving this organisational shift and promote this change among staff using this information. Potentially create a survivor involvement policy, outlining the mission and what you want to achieve

Be proactive in getting buy in/laying the groundwork – get stakeholders on board early, encouraging an open dialogue about their concerns already creates buy in and identifies barriers. Groups could be organised by the allocated trauma representative, with attendance from management as well to highlight the importance being placed on this culture change.

Create a plan – this needs to include concrete terms that are measurable

a. Define terms – what is meant by involvement; survivor; representation; advocate

b. Identify the goal – for example, to gain funding for a lived experience worker; to set up a panel of survivor service users; to gather information to quality assure services and feed it back into development.

c. Measure and monitor progress – how are you going to monitor the progress of each?

d. Outline how this is going to be maintained/become sustainable? Survivor leads? How will they be reimbursed to facilitate input?

Review policies – this links to the prior section, but some of the barriers listed above will need to be addressed in policies, particularly those that focus on benefits, contracts, budget and hiring. Adapting leave policies to reflect the sensitivity to the fluctuating needs of survivors in extreme conditions, unanticipated leave may be needed for substance abuse relapse, mental health and wellbeing days, as well as flexible working policies. Although, in a TI organisation, this would be the same for all staff.

Allocating money for survivor involvement – expenses including recruitment, training, travel, interpreters where necessary.

Appendix 6 – Table showing outcome measures adopted by studies across sectors (from literature review)

TI Practice Sectors	Outcomes and measures adopted	Study
Mental Health (including inpatient adult and youth)	Seclusion and restraint events measured by admin data Time to discharge, Improvement in presenting symptoms (using e.g. Trauma-informed System Change Instrument) Trauma sensitivity ratings among patients and staff, measure via quality of care measure; Favourable beliefs about TIC (Trauma-informed Beliefs Measurement) Pre and post staff feedback (specifically designed questionnaire for service) Treatment retention Staff injuries and staff perception of safety (developed internally) Reactivity, measured via single item Subjective Units of Distress (SUDS) and "compassion towards clients" (internally developed measure)	Azeem, Auja, Rammerth, Binsfield and Jones (2011), Azeem et al. (2015), Blair et al. (2017); Borckardt et al. (2011) Bartlett et al (2016); Greenwald (2012); Messina (2014); Bockardt et al. (2011); Brown et al., 2012; Hall et al. (2016); Candler et al. (2008); Hortensia et al. (2007) Goetz & Taylor-Trujillo (2012) Greenwald et al. (2012)
Crime and Justice	MH symptoms Injuries to staff, assaults on staff, staff fear for safety, staff grievances (admin data)	King (2015) Elwyn, Esaki and Smith (2015)
Medical (Primary Care, Dental)	Knowledge of health related manifestations of trauma Confidence in treating survivors of trauma Knowledge, skills and attitudes related to TIP (questionnaire developed by developers) Patient/provider rapport (measured via patient report); perception of clarity of information from providers (patient report); perceptions of shared decision making between patient and providers) Patient-centeredness score (Roter Interactional Analysis System rating of taped visits between primary care providers and users) Integration of trauma-informed practice and confidence in delivering TIC (via Trauma-Informed Medical Care Questionnaire)	Raja et al. (2014); Raja et al. (2015); Hall et al. (2016); Strait and Bolman (2017) Raja et al. (2014); Raja et al. (2015); Hall et al. (2016); Strait and Bolman (2017) Choi & Seng (2015) Green et al. (2016) Green et al. (2015) Weiss et al. (2017)
Residential Care	Satisfaction with training and knowledge.	Crable et al. (2013);
Substance misuse	Alcohol use Drug use MH symptoms Admin data (length of time using drugs, court ordered treatment, exposure to interpersonal abuse; other stressful events. Knowledge of traumatic stress Frequency of asking patients about trauma exposure, attitudes towards trauma inquiry and response, confidence in trauma inquiry (all internally designed)	Morrissey et al. (2014); Cocozza et al. (2005); Gatz et al. (2007); Lotzin et al. (2007)
Social Work (C&F)	TIC knowledge and Self reported use of TI Practices (developed internally Perceptions of individual and agency capacity to provide TIC, measured via Trauma System Readiness Tool	Connors- Burrow et al (2016); Kenny et al. (2017)
Education	Disciplinary office referrals and suspensions, via admin data	Dorado et al. (2016)

Appendix 7 – Table showing data collected in case study areas for audit and evaluation purposes

Case study area	Data collected
CJSW	Psychometric Data ACE (Adverse Childhood Experiences) BCE (Benevolent Childhood Experiences) CORE 10 (General mental well being) ITQ: International Trauma Questionnaire (measure of trauma related symptoms including PTSD and Complex PTSD) PHQ9 - measure of level of low mood/depression GAD7 – measure of level of anxiety Staff Questionnaires Focus groups (externally facilitated separately for workers and leaders) Training Evaluation Forms (pre and post measures completed by participants)
Mental Health 1	Psychometric Data ACE (Adverse Childhood Experiences) BCE (Benevolent Childhood Experiences) ITQ: International Trauma Questionnaire (measure of trauma related symptoms including PTSD and Complex PTSD) Life events checklist – measure of exposure to potentially traumatic events Childhood Trauma Questionnaire Cognitive Emotion Regulation Questionnaire – measuring cognitive coping strategies WSAS – measures work and social functioning IROC – measures recovery HADS - measure of anxiety and depression ADMN20 – assessment of Adjustment Disorder a bespoke measure on behaviour following life events
Mental Health 2	Bespoke pre and post training measures
Residential	ARTIC measure – Attitudes Related to Trauma-informed Care
GP	CARE questionnaire scores (from 20+ patient consults every 5 years for GP appraisal)
Police	Bespoke pre and post training measures
Addictions	Psychometric Data CORE-10 Service user questionnaires

Glossary of measures:

International Trauma Questionnaire (ITQ) (Cloitre, M., Shevlin, M., Brewin, C. R., Bisson, J. I., Roberts, N. P., Maercker, A., ... & Hyland, P. (2018). The International Trauma Questionnaire: development of a self-report measure of ICD-11 PTSD and complex PTSD. Acta Psychiatrica Scandinavica, 138(6), 536-546.)

Hospital Anxiety and Depression Scale (HADS) (Spinhoven, P. H., Ormel, J., Sloekers, P. P. A., Kempen, G. I. J. M., Speckens, A. E. M., & Van Hemert, A. M. (1997). A validation study of the Hospital Anxiety and Depression Scale (HADS) in different groups of Dutch subjects. Psychological medicine, 27(2), 363-370.)

I-ROC (Monger, B., Hardie, S. M., Ion, R., Cumming, J., & Henderson, N. (2013). The individual recovery outcomes counter: preliminary validation of a personal recovery measure. The Psychiatrist, 37(7), 221-227.)

Work and Social Adjustment Scale (WSAS) (Mundt, J. C., Marks, I. M., Shear, M. K., & Greist, J. M. (2002). The Work and Social Adjustment Scale: a simple measure of impairment in functioning. The British Journal of Psychiatry, 180(5), 461-464.)

ADMN-20 (Kazlauskas, E., Gegieckaite, G., Eimontas, J., Zelviene, P., & Maercker, A. (2018). A brief measure of the international classification of diseases-11 adjustment disorder: investigation of psychometric properties in an adult help-seeking sample. Psychopathology, 51(1), 10-15.)

Childhood Trauma Questionnaire (Bernstein, D. P., Fink, L., Handelsman, L., Foote, J., Lovejoy, M., Wenzel, K., ... & Ruggiero, J. (1994). Initial reliability and validity of a new retrospective measure of child abuse and neglect. The American journal of psychiatry.)

ACEs (Felitti, V. J. (1998). The relationship of adult health status to childhood abuse and household dysfunction. American Journal of Preventive Medicine, 14, 245-258.)

Life Events Checklist (Gray, M. J., Litz, B. T., Hsu, J. L., & Lombardo, T. W. (2004). Psychometric properties of the life events checklist. Assessment, 11(4), 330-341. )

Relationship Questionnaire (Bartholomew, K., & Horowitz, L. M. (1991). Attachment styles among young adults: a test of a four-category model. Journal of personality and social psychology, 61(2), 226.)

Cognitive Emotion Regulation Questionnaire (Garnefski, N., & Kraaij, V. (2006). Cognitive emotion regulation questionnaire–development of a short 18-item version (CERQ-short). Personality and individual differences, 41(6), 1045-1053.

Benevolent Childhood Experiences scale (Narayan, A. J., Rivera, L. M., Bernstein, R. E., Harris, W. W., & Lieberman, A. F. (2018). Positive childhood experiences predict less psychopathology and stress in pregnant women with childhood adversity: A pilot study of the benevolent childhood experiences (BCEs) scale. Child abuse & neglect, 78, 19-30.)

Attitudes Related to Trauma-informed Care. (ARTIC). Baker, C. Traumatic Stress Institute. USA.

Barkham, M., Bewick, B., Mullin, T., Gilbody, S., Connell, J., Cahill, J., Mellor-Clark, J., Richards, D., Unsworth, G. & Evans, C. (2012). The CORE-10: A short measure of psychological distress for routine use in the psychological therapies. Counselling and Psychotherapy Research, 1–11. http://doi.org/10.1080/14733145.2012.729069.

Kroenke K, Spitzer RL, Williams JB. The PHQ-9: validity of a brief depression severity measure. J Gen Intern Med. 2001;16(9):606-613. doi:10.1046/j.1525-1497.2001.016009606.x

Spitzer RL, Kroenke K, Williams JB, Löwe B. A brief measure for assessing generalized anxiety disorder: the GAD-7. Arch Intern Med. 2006 May 22;166(10):1092-7. doi: 10.1001/archinte.166.10.1092. PMID: 16717171.

Appendix 8: Useful reading and toolkits (sector specific) from the literature review

Mental Health

• Sweeney, A., Clement, S., Filson, B. & Kennedy, A. (2016). Trauma-informed mental healthcare in the UK: what is it and how can we further its development? (2016). Mental Health Review Journal. ISSN: 1361-9322
• Sweeney, A. & Taggart, D. (2018). (Mis)understanding trauma-informed approaches in mental health, Journal of Mental Health, 27:5, 383- 387, DOI: 10.1080/09638237.2018.1520973
• Wilton, J. & Williams, A. (2019) Engaging with Complexity. Providing effective trauma-informed care for women. https://www.mentalhealth.org.uk/sites/default/files/Engaging-WithComplexityTraum-Informed_0.pdf
• Practice Guidelines for Treatment of Complex Trauma and Trauma-informed Care and Service Delivery. (2012). Blue Knot foundation. https://doi.org/10.1111/inm.12012
• Muskett, C. (2014) Trauma-informed care in inpatient mental health settings: A review of the literature. https://doi.org/10.1111/inm.12012
• Wilson, A., Hutchinson, M. & Hurley, J. (2017) Literature Review of Trauma-informed Care: Implications for mental health nurses working in acute inpatient settings in Australia. https://doi.org/10.1111/inm.12344

CJSW

• Covington, S. (2016). Becoming Trauma-informed: toolkit for women's community service providers. Part of the One Small Thing Initiative www.onesmallthing.org.uk
• Levenson, J. Trauma-Informed Social Work Practice, Social Work, Volume 62, Issue 2, April 2017, Pages 105–113, https://doi.org/10.1093/sw/swx001
• Levenson, Jill. (2017). Trauma-Informed Social Work Practice. Social Work. 62. 10.1093/sw/swx001.
• Knight, Carolyn. (2015). Trauma-Informed Social Work Practice: Practice Considerations and Challenges. Clinical Social Work Journal. 43. 10.1007/s10615-014-0481-6.

Prisons

• Allcock, A. (2016). Developing a TI approach to rehabilitative groupwork in prisons. Winston Churchill Trust.
• Miller, N.A, Najavits, L.M. Creating trauma-informed correctional care: a balance of goals and environment. Eur J Psychotraumatol. 2012;3:10.3402/ejpt.v3i0.17246. doi:10.3402/ejpt.v3i0.17246
• Vaswani, N & Paul. S (2019). It's knowing the right things to say and do - challenges and opportunities for trauma-informed practice in the prison context.The Howard Journal of Criminal Justice. https://doi.org/10.1111/hojo.12344

Education

• Missouri model for Trauma-informed Schools
• Child Trauma Toolkit for Educators, NCTSN (2008)
• The Compassionate and Connected Classroom curricular resource

Homelessness

• DeCandida, Beach & Clervil. (2013). Closing the gap: Integrating services for survivors of domestic violence experiencing homelessness. A toolkit for transitional housing programs.
• Trauma-informed care for women veterans experiencing homelessness: a guide for service providers (Women's Bureau US Department of Labour)
• Trauma-informed Organisational Toolkit for Homeless services – the National Center on Family Homelessness.

Social Work

• NCTSN Child welfare Trauma Training Toolkit
• What is a trauma-informed child and family service system, NCTSN Factsheet (2016)
• A Social Worker's tool kit for working with immigrant families. Healing the damage (Sept, 2010). https://bettercarenetwork.org/sites/default/files/A%20Social%20Worker%27s %20Toolkit%20for%20Working%20with%20Immigrant%20Families.pdf

Judiciary

• Primer for juvenile court judges: A trauma-informed approach to judicial decision making for newcomer immigrant youth in juvenile justice proceedings (NCTSN)
• Juvenile court assessment (NCTSN)
• NCTSN Benchcard for the trauma-informed judge

Residential Care

• Johnson, D. (2017). Scottish Journal of Residential Child Care 2017 – Vol.16, No.1
• Hanson, R. F. and Lang, J. (2016) 'A Critical Look At Trauma-Informed Care Among Agencies and Systems Serving Maltreated Youth and Their Families', Child Maltreatment, 21(2), pp. 95–100. doi: 10.1177/1077559516635274.
• Bath, H. (2008). The Three Pillars of Trauma-Informed Care. Reclaiming Children and Youth, v17 n3 p17-21 Fall 2008

GPs

• Raja, S., Hasnain, M., Hoersch, M., Gove-Yin, S., Rajagopalan, C. Trauma-informed Care in Medicine, Family & Community Health. July/September 2015. Volume 38. Issue 3. P216-226
• Blue Knot guidelines for those working in primary care
• Brennan, R., Bush, M. & Trickey, D. (2019). Adversity and Trauma-informed Practice: A short guide for professionals working on the frontline. Young Minds.
• RACGP. Abuse and violence. Working with our patients in General Practice. 4th edition.
• Trauma-informed Practice Guide. (2013). BC Provincial Mental Health and Substance Use Planning Council

Older adults

• Ganzel, B. (2018) Trauma-informed Hospice and Palliative Care. The Gerontologist, Volume 58, Issue 3, June 2018, Pages 409– 419, https://doi.org/10.1093/geront/gnw146
• Hey (2018). Foundations of Trauma-informed Care: An introductory primer. Resilience For All Ages.
• Implementing TIC: A guidebook.
  https://www.leadingage.org/sites/default/files/RFA%20Guidebook.pdf

Appendix 9: Asking about Trauma

Before asking, it is important the questions have a preface, which normalises the question and explains that they do not have to answer it if they do not want to. For example,

"We know that difficult experiences people have been through, maybe linked to the mental health difficulties they are experiencing. I am going to ask you some questions we always ask people, we know they can be difficult questions for some, and you do not have to answer them if you don't want to."

The actual question needs to be specific and clear. When Sweeney et al. (2016) implemented TIC in Newcastle and Tyne NHS, a specific policy was created on how people should ask about trauma and how to respond/next steps to take. If an individual does not want to answer the question, that needs to be understood by staff as disclosure needs to go at the pace of the individual. The box below provides recommendations on how a practitioner should respond to trauma and abuse disclosures. Where a person discloses trauma and abuse, Read and colleagues (2007) recommend the practitioner responds in the following way:

• reassure the person that disclosure is a good thing
• do not try to ascertain the details of the trauma or abuse
• ask if anyone has been told previously and how that went
• offer trauma-specific support and know how to refer people to it
• ask whether the trauma is related to their current difficulties
• check their current safety (freedom from abuse)
• check the person's emotional state after the conversation
• get in touch to follow up with them.

Adapted from Sweeney et al. (2018) A common misconception when a disclosure is made, is that the person receiving the disclosure needs to gather detailed information about the trauma. This is not the case, as long as enough information is gathered to ascertain if the person is still at risk, or others are could still be at risk. When safety and stabilisation work is not available within the organisation, there should be a clear referral system in place so workers know the correct next steps in helping someone in their recovery.

Appendix 10: Policies and procedures checklist

An important part of building a trauma-informed culture is including trauma-informed care in the organisations policies and procedures. This includes both how policies and procedures are developed, and how they are operationalised. In the journey of becoming trauma-informed, tending how trauma-informed principles and practices are threaded through policies and procedures will advance success. Leaders need to ensure that all relevant policies and procedures reflect the organisation's trauma-informed principles and practices. Pay particular attention to the following:

Human Resources

Background screening

New staff induction

Training – staff and supervisors

Support for supervisors to coach employee performance using a trauma-informed lens

Performance review documentation and process Employee development plans including progressive discipline grievance and other conflict resolutions models and practices

Employee Assistance Program

Temporary or agency staff

Contracted health professionals

Environmental Services

Safety, Privacy, Security

Abuse and Reporting

Quality Assurance and Performance Improvement

Financial and Budget Policies

Communications

With employees

With service users

With others – volunteers, stakeholders, vendors, and contractors

Adapted from Resilience for all ages, Leading Age Maryland, p27

Appendix 11: Database Searching

Databases were searched across the EBSCO and ProQuest hosted databases, as well as the Campbell Collaboration database. Databases were searched for literature review articles discussing trauma-informed care, published from 2001 onwards. 2001 was selected as the cut-off date due to the publication of Harris & Fallot's (2001) Using trauma theory to design service systems. We reviewed only literature review articles due to time resources available. An overview of the searches conducted and results retuned are presented in table 1. The final articles used to inform the current project are presented in table 2.

Databases	Search terms	Where in article	Limiters	Number of results	Full Text Reviewed
EBSCO; PsycInfo, Medline, CINAHL, ERIC	" Trauma informed OR trauma-informed OR trauma focused OR trauma-focused OR trauma responsive OR trauma-responsive" AND " Care OR approach OR system OR practice"	Abstract	2001-2019 Methodology= ' literature review' , ' systematic review'	114	39
Proquest: Criminology collection, education collection, social sciences database, sociology collection	" Trauma informed OR trauma-informed OR trauma focused OR trauma-focused OR trauma responsive OR trauma-responsive" AND " Care OR approach OR system OR practice"	Abstract	01/01/2001-present Full text available Peer reviewed ' literature review' ' review'	39	5
Campbell Collaboration	" Trauma"	Abstract	None	13	0

Author	Title	Area
Kulkarni (2018)	Intersectional Trauma-Informed Intimate Partner Violence (IPV Services: Narrowing the gap between service delivery and survivor needs	Domestic Violence
Ko et al. (2008)	Creating Trauma-Informed Systems: Child Welfare, Education, First Responders, Health Care, Juvenile Justice	Child Welfare; Education; Emergency Services; Criminal Justice
Reeves (2015)	A Synthesis of the literature on trauma-informed care	Healthcare
McDonnell & Garbers (2018)	Adverse Childhood Experiences and Obesity: Systematic review of behavioural interventions for women	Healthcare
Muraya & Fry (2015)	Aftercare services for child victims of sex trafficking: a review of policy and practice	Child Welfare
Lucio & Nelson (2016)	Effective practices in the treatment of trauma in children and adolescents: from guidelines to organisational practices	Mental Health
Hegarty et al. (2016)	Interventions to support recovery after domestic and sexual violence in primary care	Primary Care
Bryson et al. (2017)	What are effective strategies for implementing trauma-informed care in youth inpatient psychiatric and residential treatment settings? A realist systematic review	Residential Treatment
Krause et al. (2017)	Solution-Focused Trauma-informed Care (SF-TIC): An Integration of Models	Child Welfare
Branson et al. (2017)	Trauma-Informed juvenile systems: a systematic review of definitions and core components	Criminal Justice
Miller & Najavits (2012)	Creating trauma-informed correctional care: a balance of goals and environment	Criminal Justice
Rapp (2016)	Delinquent-victim youth – adapting a trauma-informed approach for the juvenile justice system	Criminal Justice
Le Brocque et al. (2017)	Schools and natural disaster recovery: the unique and vital role that teachers and education professionals play in ensuring the mental health of students following natural disasters	Education
Record-Lemon & Buchanan (2017)	Trauma-Informed practices in schools: a narrative literature review	Education
Raja et al. (2015)	Trauma-informed Care in Medicine – Current knowledge and future directions	Healthcare
Muskett (2014)	Trauma-informed care in inpatient mental health settings: a review of the literature	Mental Health
Wilson et al. (2017)	Literature review of trauma-informed care: Implications for mental health nurses working in acute inpatient settings in Australia	Mental Health
Ganzel (2018)	Trauma-Informed Hospice and Palliative Care	Healthcare