Implementing Trauma-Informed Care in Victim Services Settings
Vivian Brown, Amy Fleischauer  -  2012/8/29
http://ovc.ncjrs.gov/ovcproviderforum
 
 
Are there federal and/or state regulations governing faith-based communities (churches) who are NOT running domestic abuse shelters, but are providing CISM / NOVA / NVAA model trauma care, short term para-counseling, and long-term counseling to victims of domestic abuse/sexual assault in the faith-based setting? --- Barbara Daugherty Crisis Responce Missionary Chaplain under training CISM / N[O]VAA
 
1.  Amy Fleischauer
 Every state has different regulatons and each funding source (ie: state or federal) may have their own regulations. That being said, Trauma Informed Care can easily fit into any agency as long as they are willing to adgere to the principals of TIC, conduct an honest evaluation of current service delivery using a trauma-informed lens, and consistently solicit survivor feedback in a manner that is safe for the survivor to speak honestly.
 
 
How can the faith-community, who’s providing acute trauma care and post trauma recovery, build collaborative relationships with governmental and NGO secular service providers who might be resistant to working with faith-based providers?
 
1.  V Brown
 Look for a trauma coalition in your community and attend. If there's none, begin by contacting 1-2 providers and meet with them to explain your services, and ask what role they could see you playing.
 
 
How does one overcome an organizational culture that might be resistant to implementing a system of trauma-informed care?
 
1.  Vicki
 Thank you for your reply. Would this be sufficient for a culture, such as law enforcement, that might have cultural elements that might constrain its acceptance? Are there examples of trauma-informed systems in law enforcement organizations?
 
2.  V Brown
 I would invite a trauma champion in your community to present a briefing on trauma-informed care. Make the briefing inviting; e.g. a breakfast meeting for executives.
 
3.  Amy Fleischauer
 The goal of TIC - and literature supports its effectivenees - is to make your work safer, more efficient and easier. It's hard to argue with that? However, many organizations are resistent to major change....so, begin small. You might begin by inviting someone in to provide training.
 
4.  Amy Fleischauer
 Remember that the goal of implementing TIC is to make work more efficient, safer and easier. Literature supports these findings! It's hard to argue with that!
 
 
Issue- a victim who repeatedly is re-traumatized by “system” Problems: a.) No Trained Victim Service Provider (Victim does not receive attorney for Order of Protection etc.); Victim not notified for Court b.) Multi-jurisdictional c.) Disparity in mental health system between jurisdictions (victim does not receive abuse counseling) One State utilizes community based alternatives Other State does not utilize CB options d.) Other Agency involvement-no communication and no Advocate or Service Provider This occurs in urban areas as well as rural areas. What would be your suggestion as a First Step to close this “gap” that may occur when more than one discipline is at hand?
 
1.  V Brown
 Here is where a conference, with all the system players invited, can help begin the discussion of a trauma-informed system. Invite a great trauma-informed speaker.
 
 
Can you suggest or provide us a specific guidelines designed solely for trauma survivors?
 
1.  V Brown
 The guidelines include: Safety first; collaboration between provider and client and between providers; control and choice; empowerment
 
2.  Amy Fleischauer
 If you begin to ask that question - "What happened to this person?", guidelines will begin to change.
 
3.  Amy Fleischauer
 The unerlying message of TIC work is to change the question from "What's wrong with you?" to "What happened to you?"
 
 
What is trauma?
 
1.  Amy Fleischauer
 Trauma is an individual response to a sudden or unexpected life event. An experience is traumatic if it’s out of the norm (unexpected), exceeds an individual’s perceived ability to meet its demands, and disrupts the individual’s frame of reference and other central psychological needs. Trauma can occur when our basic life assumptions are shattered. (ie: The world is generally a safe place, people are generally good, I am generally in control of my life)
 
2.  V Brown
 Trauma means experiencing, witnessing, or being threatened with an event or events that involve serious injury, a threat to the physical integrity of one’s self or others, or possible death. The responses to these events include intense fear, helplessness, and/or horror. (Definition used for the SAMHSA-funded Women with Co-Occurring Disorders and Violence Study). Trauma also can be defined as experiences involving disruption in relationships as the result of violence, abuse, war, or other forms of political oppression, or forced uprooting and dislocation from one’s family, community, heritage, and/or culture (Berman, Mason, et al., 2010).
 
 
Why is understanding trauma important to service provision?
 
1.  Amanda
 The best services can be provided by "starting where the client is." For many individuals, trauma is the foundation of many physical, mental health, and social issues. Therefore, in order to address these issues, the practitioner should be well-versed in understanding trauma.
 
2.  V Brown
 A great majority of our clients have a history of physical and/or sexual abuse (and other traumas) as children, adolescents, and adults. Traumatic experiences have a profound impact on women’s lives. Trauma can impact physiology (“flight-fight” responses), cognitive functioning, emotional responses, and behaviors. Many of the behaviors and symptoms that service providers find problematic or difficult to deal with are behaviors that women have developed as attempts to cope with trauma. In addition, many of our procedures and practices in service settings can be “re-traumatizing” for survivors, and we need to understand this and change some of our practices.
 
3.  Amy Fleischauer
 In short, becoming trauma-informed will make your job safer and easier thereby creating an atmosphere in which survivors can also work with you more efficiently and feel safer. Trauma Informed Care (TIC) will also assist your agency in avoiding inadvertent re-traumatization and will facilitate survivor participation. TIC may not be specifically designed to treat the actual trauma, but will provide services which allow clients to feel safe, to feel accepted, and to be understood.
 
 
Is it common for service providers themselves to re-traumatize survivors?
 
1.  Amy Fleischauer
 While wholly unintentional, systems of care are often created in a way that leaves survivors vulnerable to re-traumatization. Some common examples include: Using restraints, or conducting a restraint while others watch, night bed checks, boundary violations such as walking into rooms without knocking (even your own office!), a strong emphasis on compliance, mandating programmatic rules especially within shelters (curfew), an expectation of gratitude, or utilizing a typical meeting format.
 
2.  V Brown
 It is common, but unintentional. Many procedures and practices can be experienced by survivors as “re-traumatizing”, and can trigger women’s trauma responses, which may lead to withdrawal from services, outbursts of anger, increases of symptoms, and relapses.
 
 
What are the guiding principles of Trauma Informed Care?
 
1.  Amy Fleischauer
 Generally, the literature sites the five guiding principals of TIC as (1) Safety, (2) Trustworthiness, (3) Choice, (4) Collaboration, and (5) Empowerment. I would add Language Access and Cultural Competency to that list.
 
2.  V Brown
 The overall goal of trauma-informed care is to restore a sense of safety, autonomy, and control to the survivor. The guiding principles are: safety first (both physically and emotionally); respecting boundaries; sharing control and ensuring that the survivor has choices; collaboration; empowerment; and minimizing re-traumatization.
 
 
What are some practical steps in beginning the process of evaluating an organization’s policies and services through a TIC lens?
 
1.  Amy Fleischauer
 At the International Institute of Buffalo (IIB), an organization that daily interacts with possible trauma survivors through its domestic violence, human trafficking, and refugee resettlement programs, we began with a general training on trauma – the ‘why’ and ‘what’ of trauma, its impact on survivors’ behavior and the benefits of becoming trauma-informed. The team then creates a list of “what we know works” with this population and then identified where there was disconnect between what we KNOW and what we DO (this is the potential re-traumatization).
 
2.  V Brown
 There are a number of trauma-informed assessments that can be utilized to begin the process. Harris and Fallot developed Creating Cultures of Trauma-Informed Care (CCTIC), an assessment tool for organizations. Dr. Brown has adapted their assessment tool so that it can be used a “Walk-Through” of an agency. The National Center on Homelessness has also developed an assessment tool. In addition to these tools, it is important that there is administrative support from people in leadership positions; sensitive screening for trauma included in initial assessments; training for all employees, as well as specialized trainings for clinicians and supervisors; and that policies and procedures reflect trauma-informed services as a priority.
 
 
What are some practical changes/improvements that IIB made while going through this process on a micro, mezzo, and macro level?
 
1.  Amy Fleischauer
 The staff brainstormed ways to align more closely with what we know works by looking more closely at caseloads, meeting less often in person but allowing for more time during each meeting, and after the program director spoke to the executive director about changing an agency policy to be more flexible for “flex time”, allowed the client to choose the day of the week and time of day to meet based on their schedule, not the worker’s.
 
2.  Amy Fleischauer
 Here is one example: What we KNOW works is scheduling a full two hours to meet with any client who needs an interpreter (on average). What we DO due to time constraints, case load, or other factors is schedule clients back-to-back, often for less time then they need, often solely based on the convenience of our schedule. This has the potential to be re-traumatizing for survivors who may feel rushed (and therefore unimportant), not receive the information they need (information = safety, empowerment), and upset because they need to change their schedule to accommodate ours (lack of choice).
 
3.  Amy Fleischauer
 It is important to note that IIB underwent this evaluation in three areas: formal and informal practices/procedures when interacting with clients, procedures within individual departments, and finally, at the larger agency level. Many practical improvements were made to our procedures.
 
 
How might an agency continue to evaluate itself for adherence to TIC principals?
 
1.  Amy Fleischauer
 Including client feedback in any and all policy and procedure decisions will ensure that agencies continue to align themselves with the principals of TIC. At our agency, we have an informal policy that all significant decisions are run by survivors before their implementation. Even brochures are approved by survivors before publication.
 
2.  V Brown
 Once an initial assessment is made, a Plan of Action should be developed to change whatever is found not to be trauma-informed. As part of the Action Plan, there should be timelines for accomplishing the steps developed. In this way, the agency continues to evaluate its movement toward TIC. In addition, it is important for agencies to have “Trauma Champions”, i.e., at least one staff member who updates the agency as new research and practices develop.
 
 
what is the min. training that staff should have (i.e. training on PTSD, burnout, crisis intervention, etc...) in order to provide trauma-informed care to victims? Is there specialized training that should be obtained?
 
1.  Amy Fleischauer
 I second Dr. Brown's words - In fact, here at IIB, we all agree that the MOST IMPORTANT employee to receive TIC training is our receptionist, as they have the initial (and sometimes the greatest influence) encounter with a client.
 
2.  Amy Fleischauer
 It is important to recognize that there is a significant difference in utilizing a trauma-informed lens within the organization and treating trauma. The goal of the first is to minimize re-traumatizaton and create trauma-informed policies and procedures that make the work safer and easier for all. Treating trauma is a very different arena and one that involves significant clinical training.
 
3.  V Brown
 We recommend that all staff (everyone) be trained in what is Trauma and how it impacts our clients and others. Then specialized training for the clinicians, group facilitators, supervisors. In addition, in the specialized training include "self-care" for the providers.
 
 
How can one be an effective helper when a victim has past trauma and Boderline personality disorder mixed with substance abuse issues, and domestic violence?
 
1.  V Brown
 It is important that you participate in specialized trainings, and if you can find a well-trained and sensitive clinician in your community have them work with you. Many of our survivors fit your description.
 
 
What kind of trauma based approach is believed to work best or is there a combination of approaches in Victim Service Settings?
 
1.  V Brown
 We usually start with a group that is based upon Stage 1 (Judith Herman's work);Seeking Safety by Lisa Najavits or Trauma Recovery and Empowerment (TREM)by Maxine Harris & Roger Fallot. They have excellent results. When the survivor wants to delve deeper, individual treatment is best.
 
2.  Amy Fleischauer
 I apologize for a re-post, but I believe that this answer will also address this question: Generally, the literature sites the five guiding principals of TIC as (1) Safety, (2) Trustworthiness, (3) Choice, (4) Collaboration, and (5) Empowerment. I would add Language Access and Cultural Competency to that list.
 
 
Thanks for moderating this important discussion. It is a positive indicator that OVC is facilitating the dialog regarding trauma-informed service provision. Do you know if this is part of a national agenda of any kind?
 
1.  Vicki
 Is there information available on this?
 
2.  Amy Fleischauer
 Yes! In fact, I was just part of a small group last week to be certified as a SAMHSA trainer on "How being Trama Informed Improves the Criminal Justice System"
 
3.  V Brown
 I do know that SAMHSA (Substance Abuse and Mental Health Services Administration)has taken this on as a national agenda.
 
 
How does TIC apply to working with young children, five and under, who have experienced and/or witnessed trauma in victim services settings, for those providing services (directly and indirectly) and regarding interactions with caregivers?
 
1.  V Brown
 TIC is extremely important for working with young children. The best resource for this is the Child Traumatic Stress Network (CTSN). They have many resources for you.
 
 
What are examples of TIC for survivors of homicide victims?
 
1.  Amy Fleischauer
 Again, I will point to the five guiding principals of TIC as (1) Safety, (2) Trustworthiness, (3) Choice, (4) Collaboration, and (5) Empowerment. Work through your policies and procedures to evaluate (with feedback from your team and clients, if possible) whether or not they support these principals.
 
2.  Amy Fleischauer
 I am not familiar with this group specifically, but currently work with survivors of domestic violence, many of whom have survived countless attempts on their lives.
 
 
How can agencies safely include children of victims into trama treatment and care?
 
1.  V Brown
 If the service site is a confidential site, and there is safety and security in the site, then it is important to include the children. Depending on the age of the children, there are a number of effective evidence-based interventions for them Check out the Child Traumatic Stress Network site (CTSN).
 
 
What are some strategies organizations working with victims of domestic violence can use to identify triggers in individual clients?
 
1.  Maria Hammond
 I was following this topic on the 29th of August and have tried to get a copy of the Well Being Safety Plan through the email address you posted and by contacting the agency directly, but have not yet received it. Where would I find it?
 
2.  DV Advocates
 Can you please email us the resources you mentioned?
 
3.  Amy Fleischauer
 Feel free to contact me directly at afleischauer@iibuff.org
 
4.  DV Advocates
 Please do share those resources. Where can we access the de-escalation form?
 
5.  Amy Fleischauer
 Our agency has developed a "Well-Being Safety Plan" that we conduct with survivors along with the typical safety plan. This allows survivors to have a thought-out written plan to access when they begin to feel anxious or have been triggered unexpectedly. I'd be happy to share that resource following this webinar.
 
6.  Ashia Alexander
 The agency I work for uses safety planning as a way to identify triggers and premeditated responses and actions to those triggers.
 
7.  DV Advocates
 How do we use identification of triggers as a preventative measure against retraumatization?
 
8.  DV Advocates
 How would you recommend we approach the discussion and exploration of triggers with clients in a residential setting?
 
9.  V Brown
 There is a De-Escalation Form developed by the Mass. Trauma Coalition that asks survivors "What events/situations upset you?" and "What Helps you calm down when you feel you are losing control?" This definitely helps identify triggers. However, remember that sometimes something can trigger survivors and they may not be able to predict that. That is why training in helping survivors learn grounding techniques is also important.
 
10.  Ashia Alexander
 Safety Planning is one way my agency helps victims identify triggers and safe responses and actions to deal with them. A safety plan is simply premeditated responses/actions to identified situations.
 
11.  Amy Fleischauer
 The client wasn't sleeping at night, even though she had left the situation. We asked the client what might be a better time for her and she chose the later afternoon. She was not late again. Simple question. Sad, but simply trauma explanation. Simple answer. Notice that she was not considered non-compliant or resistant to treatment. Rather, we asked "What happened to her?"
 
12.  Amy Fleischauer
 I think it's important to assist clients in being able to identify them within themselves. Our clients usually have all of the answers! For example, we recently were working with a client who was consistently (and significantly) late for appointments. When we asked about this, we found that the client had been forced to stay awake all night by her abuser.
 
 
Our client services staff is interested in adopting a Trauma Informed Model of care, they suggested that the whole agency become trauma informed. Does anybody have experience with transforming an agency to a trauma informed model?
 
1.  Amy Fleischauer
 Yes. This what we've started to do here at IIB. I began by going through extensive training myself. Then, we conducted a department evaluation, out of which came identified needs for changes on the management and agency level. It has been a slow process, but very effective!
 
2.  V Brown
 Yes, I and 8 other agencies in the country did that under the SAMHSA-funded Women with Co-Occurring Disorders and Violence Study. The sites are named on the SAMHSA website under the WCDVS Study.
 
 
What would you suggest as an appropriate response to a client who presents as a domestic violence victim, but then severe mental health issues surface and the mental health issues are only presented to immediate service providers, but not to outside agencies?
 
1.  Amy Fleischauer
 A mental health provider who is trained to treat trauma should be helpful to you and your staff in these situations, either through technical assistance or direct mental health services. I will say that this is not unusual and that often mental health issues begin to surface where a client feels the most safe. So, it sounds like you are already on the right track!
 
2.  V Brown
 I would explain to the client that it is important that her mental health issues are addressed. If you do not have the mh capability in your agency, then I would explain that you know and trust another agency that has staff who can also help, and that if she gives permission (consent) you will introduce them to her.
 
 
What is an appropriate method to use when assisting a client who is suffering from PTS and substance abuse?
 
1.  V Brown
 Seeking Safety is an excellent group intervention for PTSD/trauma and substance abuse. Dr. Najavits has written an excellent manual (published by Guilford Press) and it is designed for all levels of facilitators.
 
 
Is there a national or state (Indiana)listing on Trauma-Informed Care service providers? How do we know if a provider utilizes Trauma-Informed Care and what should we look for or ask about?
 
1.  V Brown
 I would ask any provider that you know and trust whether they consider themselves "Trauma-Informed". If they ask you what that is, they are NOT. If they say yes, then ask them what trainings they have had, and what interventions they use for survivors. Then I would have a number of your staff meet with them and go through their program procedures with them.
 
2.  Amy Fleischauer
 SAMHSA is a good place to begin. Also, some communities are beginning to conduct research in this area. Because it remains a small (but growing field), it may be helpful to reach out to an organization outside of your area and ask for a referral. The Institute on Trauma and Trauma-Informed Care at the University of Buffalo is an excellent resource.
 
Return to Discussion