Creating Organizations that Address the Needs of Youth, Families, and Staff Who Have Experienced Trauma
Abstract: Focal Point’s final article in this issue provides an overview of trauma-informed methodologies and addresses the multiple domains, systematic approaches, and potential problems new organizations are advised to consider.
"Creating Organizations that Address the Needs of Youth, Families, and Staff Who Have Experienced Trauma" (2015)
The task of creating an organization that can adequately address the needs of youth, families and staff who have experienced trauma is daunting and ambiguous. There are multiple definitions of what being "trauma-informed" entails, and few sources offer suggestions for where to start and what to do. One obstacle is that no two human service organizations are alike – offering the same types of services to the same age groups who have experienced the same adversities and who are interacting with the same service systems in the same type of setting. There is no one-size-fits-all approach, and it is never a linear process. However, the National Child Traumatic Stress Network (NCTSN), a unique group made up of researchers, family members, front line providers, and national partners, has identified domains, resources, and practices that help create trauma-informed organizations.
An Overview of Implementing Trauma-Informed Organizational Change
In addition to the tools and practices needed to address trauma, a process of implementing organizational changes is essential to successfully establish and sustain trauma-informed practices. The four-phase EPIS (Exploration, Preparation, Implementation and Sustainment) model1 has been used successfully to implement evidence-based practices that address child maltreatment within child and family serving agencies. A similar system can be helpful with trauma-informed organizational change.
The exploration phase begins with an assessment of the degree to which the organization is currently recognizing and responding to trauma. The assessment should identify the areas that need to be addressed, and provide information for choosing the tools, resources or practices that will be a good fit for the organization. The preparation phase involves securing buy-in from key constituents, working with them to determine what tools and practices will be implemented, and developing a plan for implementation. The plan is carried out and monitored in the implementation phase. Finally, in the sustainment phase, financial and practical considerations inform long-term plans for continuing trauma-informed practices. In reality, this process is never linear and involves much going back and forth between phases as obstacles and opportunities impact the process.
Trauma-Informed Organizational Assessment
As is true with any change process, an organization needs to know where it currently stands in order to determine where it needs to go and how it should get there. This can be determined through a trauma-informed assessment of the organization. There are existing tools for this purpose created with different populations in mind.2 3 Most are based on the work of Harris and Fallot,4 who first laid out the parameters for a trauma-informed system. The NCTSN has combined many of these parameters with experience gleaned from its diverse group of member organizations to develop a definition of a trauma-informed service system.5 The current article uses that definition to identify the domains of a trauma-informed program. These domains create a structure for assessing an organization's strengths and gaps related to trauma-informed practices.
In addition to determining an organization's starting point, an organizational assessment is key to implementing trauma-informed practices. Key steps in the assessment process lay the groundwork for engaging leadership, staff and families in the process of creating trauma-informed organizational change. Assessment offers opportunities to describe what a trauma-informed organization may look like, identify ways that staff are already doing work that helps to address trauma, and draw a clear picture of how this work might impact each member of the organization. Additionally, an assessment can identify people who might become "trauma champions" – staff and consumers who exhibit an understanding of the potential impact of addressing trauma in their organization, and who will sustain and spread new practices.
The domains identified below can be assessed in a number of ways. In fact, applying different methodological approaches will strengthen the quality and reliability of the information collected. Interviews with administrators and key program leaders, a review of organizational materials, staff surveys, follow-up focus groups with staff, and interviews and focus groups with consumers will together uncover the strengths and challenges of trauma work in an organization.
Assessing the Domains of a Trauma-Informed Organization
Screening, assessment, and intervention. In order to better treat a young person who has experienced trauma, traumatic exposure and the resulting symptoms must be identified, explored and treated. This requires an examination of the process and tools used to identify whether a youth has experienced trauma (screening); the ways a mental health and trauma assessment are conducted (assessment); and how treatment plans are developed and executed (intervention). These tasks should be strongly connected to each other and incorporate a deep understanding of trauma and the impact of the traumatic event(s) (including trauma reminders, changes to the youth's family and caregiving system and environment following a trauma; and appropriate, trauma-informed treatments). The goals of assessing organizational processes are to:
- identify methods of screening that will most accurately identify youth and families who could benefit from trauma-informed services;
- create a complete picture of the youth, his or her trauma history profile, an understanding of current reminders of past traumatic experiences and how they influence current functioning, and the impact of the traumatic event(s) on caregiving and family systems;
- identify the most culturally and developmentally appropriate trauma-informed services and interventions; and
- form the foundation for case-planning.
Additionally, organizational process issues are also examined. Who in the agency is administering the screening, assessment, and treatment? Are they receiving proper training and meaningful supervision? When are these tasks performed? Each step should inform the next so that the most appropriate services or treatment can be provided by the most appropriate service provider.
Strengthening the resilience and protective factors of youth and families. A trauma-informed organization builds the capacity of youth and families to heal by strengthening factors and characteristics associated with resiliency.6 Key questions include: How do programs, clinicians and staff support or provide opportunities for peer support with families? Do they outreach to fathers and other caregiving adults? Do they utilize family strengthening tools? Are they advocates for families in other systems (such as juvenile justice, child welfare, healthcare, and schools)? What type of work is done at the agency around strengthening the parent/child bond, parenting skills, connecting families to community resources, identifying family stress, addressing concrete needs, teaching skills related to social/emotional competence, and strengthening sibling relationships?
Trauma competence and awareness. Staff at all levels and in all programs need to have an understanding of trauma and how it impacts youth and families. Mimicking a client's experience of a program by walking through it and noting who and what they see will provide additional opportunities to help a family feel physically and psychologically safe. This can be followed up by asking clients and family members about their experience at each point of their visit and about how they feel in the physical spaces they occupy when they are on site.
Staff should have training opportunities related to trauma and trauma-informed practices. When trainings are implemented, pre- and post- tests of knowledge, beliefs, attitudes and behavior change related to trauma can help ascertain whether and how the training was effective.
Parent and caregiver trauma. Organizations often face obstacles related to providing trauma-focused treatment to adult caregivers when their mission and resources are aimed at youth. However, this creates a great opportunity for trauma-informed change. Key questions in assessing this domain include: Are staff at all levels aware of the impact of trauma on parents, and its potential impact on parenting? Do the agency's assessments include measures of parent trauma? What does the treatment of parents with trauma histories look like, and how is it accessed? What skills and knowledge do staff who work with parents have to help guide parents to appropriate treatments? What resources are available in the community to treat adult trauma, and how collaborative are those providers with the agency being assessed? The greatest level of coordinated care occurs when caregivers are treated within the same agency as young people. When that is not possible, developing collaborative relationships with providers of adult services can be a good alternative.
Continuity of care and collaboration across systems. Organizations should establish strong collaborations to promote a continuous system of services for youth and families. This helps prevent retraumatization by coordinating services to achieve shared goals. This domain is assessed on two levels: (a) the individual/family and (b) the organization/system.
A trauma-informed agency would work with others providing services in a family's life to coordinate care, work towards shared goals, and minimize further traumatization of the family. Collaboration might occur through family team meetings, co-located services, technology or tools which allow for easier and better communication between systems, or multi-disciplinary approaches to treatment. An agency can increase opportunities for collaboration with other systems by providing or attending cross-trainings, co-locating services, jointly developing protocols for collaborative services, and developing technologies or tools for more effective communication between systems.
Secondary traumatic stress (STS). An organization cannot be trauma-informed if its staff are experiencing STS, compassion fatigue, or burnout. One of the most essential components of a trauma-informed organization is that it creates an environment for staff that recognizes the impact of working with trauma survivors. It considers how STS can impede staff's ability to do their job effectively, how the work may remind staff of their own trauma histories, and how to minimize the STS risk factors through its training and supervision practices.
Staff at all levels should receive training on healthy boundaries between professional and personal life, self-care, and managing difficult feelings and reactions. An agency should provide supervision to all direct-care staff by a supervisor trained to understand trauma. Supervision time should be spent helping staff understand their own stress reactions and how they impact their work. Team and administrative meetings should address STS topics. In addition to asking administrators and staff about organizational practices that promote staff resiliency, an assessment can include instruments that measure STS in individuals, such as the Professional Quality of Life Scale (Pro-QOL.)7 This can be re-administered when policies to address STS have been implemented to determine their effectiveness.
Cross-domain themes. Throughout this organizational assessment, there are two additional factors that should be examined within each of these domains. First, to what extent does the organization partner with its youth and families, both in its clinical engagement and treatment, as well as in making programmatic and agency-wide decisions? Research supports that family involvement in clinical services promotes positive changes in a youth's care and improves outcomes.8 The NCTSN offers two assessment tools for examining how an organization is partnering with youth and families, and suggests changes to clinician and organizational practice to improve those partnerships.9
The second cross-domain theme is cultural competence. Culture is inherently tied to both trauma and resilience. In the development of a trauma-informed organization, cultural competence promotes empowerment, a sense of belonging, and opportunities to incorporate cultural healing practices. It also reduces instances of retraumatization due to cultural insensitivity. The National Center for Cultural Competence has developed the Cultural and Linguistic Competence Family Organization Assessment Instrument (CLCFOA) for organizations that serve youth and families with behavioral health needs.10 Incorporating questions from the CLCFOA into a trauma-informed organizational assessment can show how a culturally competent organization will be better able to address the needs of diverse youth, families, and staff who have experienced trauma.
Creating trauma-informed organizations is meaningful work that can be accomplished through the systematic process of exploring, preparing, implementing, and sustaining practices that address the domains discussed above. Variability of youth-serving organizations prevents a one-size-fits-all approach. However, with careful assessment of an organization's existing resources and needs, the selection and implementation of the right evidence-informed strategies is a less overwhelming and more worthwhile task.
- Aarons, G. A., Green A. E., Palinkas, L. A., Self-Brown, S., Whitaker, D. J., Lutzker, J. R., . . . Chaffin, M. J. (2012). Dynamic adaptation process to implement an evidence-based child maltreatment intervention. Implementation Science, 7(32). Retrieved from http://www.implementationscience.com/content/7/1/32
- Chadwick Trauma-Informed Systems Project. (2013). Creating trauma-informed child welfare systems: A guide for administrators (2nd ed.). San Diego, CA: Author.
- Guarino, K., Soares, P., Konnath, K., Clervil, R., & Bassuk, E. (2009). Trauma-informed organizational toolkit. Rockville, MD: Center for Mental Health Services, Substance Abuse and Mental Health Services Administration, and the Daniels Fund, the National Child Traumatic Stress Network, and the W. K. Kellogg Foundation.
- Harris, M., & Fallot, R. D. (Eds.). (2001). Using trauma theory to design service systems. San Francisco, CA: Jossey-Bass.
- National Child Traumatic Stress Network. (n. d.). Creating trauma-informed systems. Retrieved from the National Center for Child Traumatic Stress Network Web site: http://www.nctsn.org/resources/topics/creating-trauma-informed-systems
- Development Services Group. (2013). Protective factors for populations served by the Administration on Children, Youth, and Families: A literature review and theoretical framework. The Child Trauma Academy. Bethesda, MD: Author. Retrieved from http://www.dsgonline.com/acyf/DSG%20Protective%20Factors%20Literature%20Review%202013.pdf
- Stamm, B. H. (2010). The concise ProQOL manual (2nd ed.). Pocatello, ID: ProQOL.org. Retrieved from http://proqol.org/uploads/ProQOL_Concise_2ndEd_12-2010.pdf
- Koren, P. E., Paulson, R., Kinney, R., Yatchmenoff, D., Gordon, L., & DeChillo, N. (1997). Service coordination in children's mental health: An empirical study from the caregiver's perspective. Journal of Emotional and Behavioral Disorders, 5, 162-172.
- National Child Traumatic Stress Network. (2008). Pathways to partnerships with youth and families in the National Child Traumatic Stress Network. Los Angeles, CA and Durham, NC: National Center for Child Traumatic Stress. Retrieved from http://www.nctsn.org/sites/default/files/assets/pdfs/Pathways_ver_finished.pdf
- Goode, T., Jones, W., Jackson, V., Bronheim, S., Dunne, C., & Lorenzo-Hubert, I. (2010). Cultural and Linguistic Competence Family Organization Assessment Instrument. Washington, DC: National Center for Cultural Competence, Georgetown University Center for Child and Human Development.
Goldman, J. H. (2015). Creating Organizations that Address the Needs of Youth, Families, and Staff Who Have Experienced Trauma. Focal Point: Youth, Young Adults, and Mental Health, 29, 36-39. Portland, OR: Research and Training Center for Pathways to Positive Futures, Portland State University.