Trauma-informed practice: toolkit

Introduction

Evidence of the full impact of trauma has been emerging now for several decades, establishing beyond doubt that its effects can be wide-ranging, substantial, long-lasting and costly. Resulting from harmful experiences such as violence, neglect, war and abuse, trauma has no boundaries with regard to age, gender, socio-economic status or ethnicity, and represents an almost universal experience across the countries of the world. The seminal Adverse Childhood Experiences (ACE) study (Felitti, et al., 1998) suggests that childhood trauma is common: 30 per cent of the sample of over 17,000 people reported substance use in their household; 27 per cent reported physical abuse; 25 per cent reported sexual abuse; 13 per cent reported emotional abuse; 17 per cent reported emotional neglect; 9 per cent reported physical neglect; and 14 per cent reported seeing their mother treated violently.

Research exploring the distribution of traumatic events based on gender, age, ethnic background and socio-economic status has shown that traumatic events are more frequently experienced by people in low socio-economic groups and from black and minority ethnic communities (Hatch & Dohrenwend, 2007). In Scotland, one in seven adults reported four or more ACEs, with those in the most deprived areas twice as likely than those in the least to experience this quantity of ACEs. ACEs have also been shown to be highly correlated with socio-economic disadvantage in the first year of life (Marryat & Frank, 2019). Those who reported four or more ACEs were significantly more likely to have lower mental wellbeing scores, be obese, have cardio-vascular disease and/or limited long term physical or mental health conditions (Scottish Health Survey, 2019). A study involving a systematic review of the international literature estimated that half of the people in contact with mental health services had experienced physical abuse and more than one-third had experienced sexual abuse in childhood or adulthood, indicating rates that were significantly higher than the general population (Mauritz, Goossens, Draijer, & van Achterberg, 2015). Other surveys have found that people using mental health services are substantially more likely to have experienced domestic and sexual violence in the previous year compared to the general population (Khalifeh, et al., 2015).

These prevalence rates have driven a stream of research studies that have explored the ways trauma can lead to mental health problems (Cooke, 2016; Harper, Stalker, & Gadbois, 2008; Karatzias, Ferguson, Gullone, & Cosgrove, 2016; Kucharska, 2018; Mueser & Rosenberg, 2003; Salter & Richters, 2012; Xie, Jiuping, & Zhibin, 2017). The impact of trauma on behaviour has also been demonstrated in terms of contact with Social Work or the Criminal Justice System (CJS), or difficulties in education, employment or the primary care system (Substance Abuse and Mental Health Services Administration (SAMHSA), 2014).These studies have all added to a growing evidence base demonstrating that large numbers of people in contact with public services have experienced traumatic events (Greenwald, et al., 2012); that these experiences are causal in the development of mental distress (Morrison, Frame, & Larkin, 2003; Dillon, Johnstone, & Longden, 2012) and that there is a relationship between the severity, frequency and range of traumatic experiences, and the subsequent impact on mental health.

In the wake of the COVID-19 global pandemic the impact of trauma has seldom been more evident, with many organisations increasingly seeing the need to address trauma as an essential component of service delivery. Addressing trauma, however, requires a multifaceted, multi-agency approach that includes awareness-raising and education, upstream working, and effective trauma focused assessment and treatment. To maximise impact, all of these efforts will need to be made in a context that is trauma-informed, based on a sound understanding of trauma and its far reaching implications.

The journey towards becoming a trauma-informed organisation will require organisations to move beyond their traditional models of service delivery and to re-evaluate their entire organisational practices and policies through a trauma-focused lens. As part of this reconceptualisation of services, organisations will need to reframe complex behaviours as potential responses to trauma related triggers and will be required to prioritise the building of trusting, mutual relationships above all else. A rich body of work on trauma-informed practice points the way in this respect (Harris & Fallot, 2001; Azeem, Aujla, Rammerth, Binsfeld, & Jones, 2011; Chandler, 2008; Domino, Morrissey, Chung, & Nadlicki, 2006; Gatz, et al., 2007; Greenwald, et al., 2012; Messina, Calhoun, & Braithwaite, 2014; Morrissey, et al., 2005; Weissbecker & Clark, 2007; Bloom S., 2013), identifying the direction of travel for new models of service delivery: "from fear to safety, from control to empowerment, and from abuse of power to accountability and transparency" (Concetta, 2018). Scotland became the first country to recognise and respond to this need by implementing a National Trauma Training Programme (NTTP), led by NHS Education for Scotland. It provides evidence-based training resources which can help raise awareness, knowledge and confidence among the Scottish workforce, so people are equipped to embed trauma-informed practice throughout services.

Fundamental to this direction of travel has been the development of a working concept of trauma and a shared understanding of the steps organisations can take in their journey towards trauma-informed practice. Although decades of work have generated multiple concepts and a range of terminology, however, there has been substantial consensus concerning a definition of trauma (Substance Abuse and Mental Health Services Administration (SAMHSA), 2014) and the following working definition will be used for the purposes of this document:

Trauma

Individual trauma results from an event, series of events, or set or circumstances that is 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.

What is Trauma-informed Practice?

The development of Trauma-informed Practice (TIP) can be traced to the USA and to the ground breaking work of Maxine Harris and Roger Fallot (Harris & Fallot, 2001), and Sandra Bloom (Bloom S., 2013). Based on the models they developed, TIP is now widely understood as follows (Paterson, 2014):

Trauma-informed Practice

A model that is grounded in and directed by a complete understanding of how trauma exposure affects service user's neurological, biological, psychological and social development.

As such, TIP is informed by neuroscience, psychology and social science as well as attachment and trauma theories, and gives a central role to the complex and pervasive impact trauma has on a person's world view and relationships. It is applicable across all sectors of public service, including social care, physical health, housing, education, and the criminal justice system (Schachter, Stalker, Teram, Lasiuk, & Danilkewich, 2008; Havig, 2008; Cole, Eisner, Gregory, & Ristuccia, 2013). Trauma-informed organisations assume that people have had traumatic experiences, and as a result may find it difficult to feel safe within services and to develop trusting relationships with service providers. Consequently, services are structured, organised and delivered in ways that promote safety and trust and aim to prevent retraumatisation. Thus, trauma-informed services can be distinguished from trauma-specific services which are designed to treat the impact of trauma using specific therapies and other approaches.

Adapting an analogy used by Harris & Fallot (Harris & Fallot, 2001), the development of organisations that are trauma-informed is akin to the development of organisations that are disability-informed. The Disability Discrimination Act of 2005 states that organisations must make reasonable adjustments to their services and premises to ensure that disabled people can access them. As a result, buildings must provide access for people in a wheelchair, services need to provide written information in a variety of formats, and convenient parking must be provided for people with a disability. In this context, organisations were not required to deliver specific services to people with disabilities, but instead were required to make their services more accessible.

Why is it important to be trauma-informed?

A review of the literature provides evidence that trauma-informed practice is effective and can benefit both trauma survivors and staff. For trauma survivors, trauma-informed services can bring hope, empowerment and support that is not re-traumatising. Moreover, such services can help close the gap between the people who use services and the people who provide them (Filson & Mead, 2016).

"I think one of the key benefits is about creating more empathy within staff. For some reason it just really hits a note with people and behaviours which they had… You know, they've been given some of this information before but it just draws it together, and it seems like quite a powerful way to help staff make sense of people's presentation." (Mental Health)

For trauma survivors involved with the Criminal Justice System, evidence has suggested that trauma-informed practice can reduce the time to discharge for youth in secure care (Greenwald, et al., 2012). Another study found evidence of increased offender responsivity to evidence-based cognitive behavioural programmes that reduce criminal risk factors (Miller & Najavits, 2012). Trauma-focused alternatives to seclusion in an in-patient ward were also found to reduce restraints and seclusions for youth in secure psychiatric care (Azeem, Aujla, Rammerth, Binsfeld, & Jones, 2011). Furthermore, trauma-informed interventions for 'hard-to-reach' populations were found to increase engagement with treatment, reduce substance misuse, and reduce trauma-related symptoms (Cocozza, et al., 2005; Chung, Domino, & Morrissey, 2009; Gatz, et al., 2007).

"Understanding distressing behaviour amongst pupils means a calmer school. More compassionate staff. Better-behaved children. More emotionally stable children. You can see their self-esteem begin to build ... Attendance improved and exclusions dropped. Improved behaviour overall. Wellbeing language improved. Children's confidence and self-esteem improves." Education

"If you're going to work in a trauma-informed practice approach, that actually benefits everybody because it actually then means that the people who are keeping all of that buried, who may be…you know, repeatedly presenting as physical complaints, that actually that then enables them. And actually, in the longer term, it actually means you provide better care........ What I try and get across to people though is that if you do…if you apply trauma-informed practice approaches, then actually what that means is that over serial consultations,… you save time, people seem to feel better. And you get to where you need to with healthcare concerns." General Practice (GP)

With regard to the benefits of trauma-informed practice for staff, evidence is emerging that people who work in human services have a high prevalence of ACE scores themselves (Esaki & Larkin, 2013). Healing thus becomes just as relevant to staff as it is to service users, making the provision of staff training, supervision and support of utmost importance (Menschner & Maul, 2016b). Indeed, organisations that do not support their staff to take care of themselves run the risk of exposing them to secondary traumatic stress, vicarious trauma and burnout, all of which will inhibit their ability to provide high quality care (National Child Traumatic Stress Network (NCTSN), 2011).

"You're coming from a very kind of trauma-informed place with the knowledge of why somebody might be acting in a certain way. I think you can feel more confident about the action that you're taking and not over-react or be overly kind of punitive.... It reduces staff burnout and it also kind of is good to think about the impact of trauma on staff and that you feel kind of more confident to talk about how you might be feeling when things are difficult." (Police)

The importance of staff support in the context of a global pandemic has been particularly evident recently, with studies demonstrating that levels of stress and burnout are reduced among frontline workers when they feel well prepared for their role as a result of specialised training, or when they feel confident in their own knowledge and understanding of the situation (Lai, et al., 2020; Brooks, Rubin, & Greenberg, 2019; Wong, Wong, Lee, & Goggins, 2007; Maunder, et al., 2006). The importance of leaders that convey compassion and sensitivity has also been underlined (Trauma-informed Oregon, 2020; Shanafelt, Ripp, & Trockel, 2020), and evidence is growing that the nurturing of self-compassion among healthcare staff can enhance staff wellbeing (Cole, et al., 2020; Flowers, et al., 2018). Recent studies have also suggested that the building of support mechanisms into daily work routines can provide space for staff to look out for each other and reflect on shared experiences, with reports that time spent on such exercises can result in significant improvements in staff wellbeing (Bailey & West, 2020).

Key principles

The key principles underlying TIP are listed below, adapted from Fallot and Harris (Fallot & Harris, 2006).

Key principles of trauma-informed practice

1. Safety

Efforts are made by an organisation to ensure the physical and emotional safety of clients and staff. This includes reasonable freedom from threat or harm, and attempts to prevent further retraumatisation.

2. Trustworthiness

Transparency exists in an organisation's policies and procedures, with the objective of building trust among staff, clients and the wider community.

3. Choice

Clients and staff have meaningful choice and a voice in the decision-making process of the organisation and its services.

4. Collaboration

The organisation recognises the value of staff and clients' experience in overcoming challenges and improving the system as a whole. This is often operationalised through the formal or informal use of peer support and mutual self-help.

5. Empowerment

Efforts are made by the organisation to share power and give clients and staff a strong voice in decision-making, at both individual and organisational levels.

Although there may be differences in terms of their application, it is widely acknowledged that these principles are relevant across the public sector and its range of services. It is also recognised that the development of trauma-informed practice requires systematic alignment with these five principles, along with change at every level of an organisation. For this reason, the implementation of TIP is often described as an ongoing process of organisational change, requiring a profound paradigm shift in knowledge, perspective, attitudes and skills that continues to deepen and unfold over time (Alive and Well Communities Educational Leader's Workgroup, 2014). Thus the literature increasingly refers to a 'continuum' of implementation, where TIP is a journey, not a destination.

The 5 key drivers for organisational change recognised by NES include: 1) Leadership and Management; 2) Workforce Wellbeing; 3) Workforce knowledge and skills; 4) Experts by Experience; and 5) Data and information. For the purposes of developing a toolkit, we have used SAMHSA's published guidance (Substance Abuse and Mental Health Services Administration (SAMHSA), 2014) which adopt more detailed implementation domains, drawn both from the organisational change management literature and from models of trauma-informed practice (Farragher & Yanosy, 2005; Elliot, Bjelajac, Fallot, Markoff, & Reed, 2005; Huang, et al., 2012; Fallot & Harris, 2006). Not all implementation domains will be directly attributable to every organisation, however they have provided the necessary detail needed to ensure the toolkit is detailed enough to be actionable across organisations.

Ten implementation domains

1. Governance and leadership

The leadership and governance of the organisation support and invest in implementing and sustaining trauma-informed practice. There is an identified point of responsibility within the organisation to lead and oversee this work. There is inclusion of the peer voice.

2. Policy

There are written policies and protocols establishing trauma-informed practice as an essential part of the organisational mission. Organisational procedures and cross-agency protocols reflect trauma-informed principles.

3. Physical environment

The organisation ensures that the physical environment promotes a sense of safety and collaboration. Staff and clients must experience the setting as safe, inviting, and not a risk to their physical or psychological safety.

4. Engagement and involvement

Staff, clients and their family members have significant involvement, voice, and meaningful choice at all levels and in all areas of organisational functioning.

5. Cross sector collaboration

Collaboration across sectors is built on a shared understanding of trauma and the principles of trauma-informed practice.

6. Screening, assessment and treatment services (Direct service provision)

Practitioners use and are trained in interventions that are based on the best available empirical evidence and science, are culturally appropriate, and reflect the principles of trauma-informed practice. Trauma screening and assessment are an essential part of the work (where relevant). Where interventions are not being delivered in organisations, direct services are provided which are culturally appropriate and reflect trauma-informed practice principles.

7. Training and workforce development

There is ongoing training in trauma and peer support. The organisation's human resource system incorporates trauma-informed principles in hiring, supervision and staff evaluation. Procedures are in place to support staff with trauma histories and/or those experiencing secondary traumatic stress or vicarious trauma, resulting from exposure to and working with individuals affected by trauma.

8 Progress monitoring and quality assurance

There is ongoing assessment, tracking and monitoring of trauma-informed principles and effective use of evidence-based trauma-specific screening, assessments and treatment.

9 Financing

Financing structures are designed to support trauma-informed practice which includes resources for: staff training on trauma; key principles of trauma-informed practice; development of safe and appropriate facilities; establishment of peer support; provision of evidence-based trauma screening, assessment, treatment and recovery supports; and development of trauma-informed cross-agency collaborations.

10 Evaluation

Measures and evaluation designs used to evaluate service or programme implementation and effectiveness reflect an understanding of trauma and appropriate trauma-oriented research instruments.

To guide the implementation further, SAMHSA also provided sample questions for each of the ten domains to help stimulate discussion within organisations (Henry, Black-Pond, Richardson, & Vandervort, 2010; Hummer & Dollard, 2010; Penney & Cave, 2013; Fallot & Harris, 2006).

The development of a toolkit for Scotland

In recent years the field of trauma has generated multiple toolkits aimed at helping organisations become more trauma-informed. Relatively few, however, have been based on trauma survivors' and staff views of what trauma-informed practice looks like in a real-world setting. Moreover, none of the toolkits has been based on real-world settings in Scotland.

This guidance document aims to fill this gap, using the unifying framework of trauma-informed principles and implementation domains described above. It reports the findings of a two-year piece of translational research, giving a strong voice to both service users and staff, identifying concrete examples of TIP across a wide variety of settings. These findings are translated into a set of questions (Appendix A) and associated tools to help organisations on their trauma-informed journey.

"I think there's a lot of misunderstanding about exactly what that phrase is and exactly what true trauma-informed care is. And hopefully by painting a very good picture across sectors in something that's easy for people to read, they'll start realising that actually…a lot of people are not doing trauma…you know, they haven't started their trauma-informed care journey." (GP)