Abuse. Bullying. Climate change. Combat. COVID-19. Death of a relative. Discrimination. Divorce. Floods. Homelessness. Mass shootings. Opioids. Poverty. Social media. War. Trauma is a widespread public health issue, and the sources of trauma for individuals and communities are endless.
In 2014, the Substance Abuse and Mental Health Services Administration (SAMHSA) issued a concept paper that explained trauma and a trauma-informed approach (TIA) framework for consideration by a wide variety of human service organizations. They included systems such as child welfare, law enforcement, criminal and juvenile justice, education, victim services, physical health care, services for housing insecurity, veterans affairs, and the military. Eight years later, trauma continues to be a cross-cutting topic, given its significant role in prevention, treatment, and recovery of mental health and substance use disorders.
Given this, SAMHSA’s Policy Lab, which runs the Evidence-Based Resource Center (EBRC), asked Abt Associates to create a document that would “update” the trauma discussion. We looked at two approaches. One was a literature review to see if organizations had used TIA since 2014 and if so, whether it was effective. The other option was to develop practical guidelines and instructions for implementing a TIA approach that could be applied across the board by any organization that touches a human life, not just behavioral health practices.
Abt Senior Director for Equity Dr. Rucha Londhe, who served as team lead on the EBRC's Practical Guide on Implementing a Trauma-informed Approach, talks about how Abt handled the task and the guide that emerged.
Which path did you take?
We did both. The literature review we conducted on the practice of TIA informed the guide we created, which SAMHSA published in June. We provide strategies and tips across various human service sectors for the implementation of TIA. For example, understanding underlying trauma enables police to de-escalate 911 incidents, gives teachers ways to work with students experiencing emotional or physical distress, and offers health care professionals ways to treat patients more effectively. Growing demand for behavioral health services increases the urgency of disseminating these practical tips for TIA, training personnel in their use, and expanding their implementation.
How does a TIA work?
The first step in implementation of a TIA is one that is required for any change management initiative: assessing the capacity and readiness of an organization or system. Organizational assessments and monitoring also should be built into the change process while implementing a TIA. These assessments should cover all aspects of organizational functions—from governance to finance to physical environment. The ultimate goal of the organization should be to integrate TIA into its structure, service delivery, and culture.
Are there common tasks that every organization needs to perform?
Yes. After an organization completes the assessment of its readiness and capacity to implement a TIA, the organization needs to implement TIA ideally in each of the following 10 domains:
- Training and workforce development
- Governance and leadership
- Cross sector collaboration
- Physical environment
- Engagement and involvement
- Screening, assessment, and treatment services
- Progress monitoring and quality assurance
To maximize the likelihood of success, organizational leadership must buy in to the approach, adopt appropriate policies, and collaborate with other agencies that work with their clients. An organization also must provide the finances for training, changes to the physical environment, new services, and monitoring and evaluation to gauge TIA’s effectiveness and determine any modifications that may be needed. And most importantly, people with lived experience of trauma have to inform the approach and its implementation.
Do different types of service providers—police, teachers, health professionals—need to do things differently?
Yes, absolutely. There is not a cookie-cutter approach to making changes. The details of implementation depend on the type of organization and services provided. The new SAMHSA practical guide provides three case studies to show how TIA works in practice across different human service sectors.
For example, the Cambridge, MA, Police Department redesigned interview rooms to be more comfortable spaces for individuals who have experienced trauma. The department also adopted a new policy that requires detectives to use a trauma-informed interview procedure when interviewing individuals.
The second case study is that of Fall-Hamilton Elementary School in Nashville. The school moved away from a focus on student discipline and instead emphasizes a safe, nurturing, and supportive environment for students. Each classroom has a “peace corner” where students can go to calm down and reflect. The corner has a timer, comfortable seat, and a worksheet for students to document and monitor their feelings and reactions. The school also initiated a Check in-Check out system in which an adult—not the student’s teacher—checks in with the student at the start of the day by asking a question about something that interests the student and then they set a small, attainable goal for the day (social, academic, or executive). They check out at the end of the day to evaluate the goal, creating a mentor-mentee relationship that shows the student someone is excited to see them at the start and end of the day.
The results of these and other TIA strategies are impressive: a 96 percent reduction in office referrals, no suspensions between 2018 and 2022, and a 90-95 percent teacher retention rate. And the school ranked in the top five percent in the state for academic growth in 2012-2022.
The third example in the guide is that of the Center to Advance Trauma Informed Health Care in San Francisco. The University of California-San Francisco-based center redesigned the clinic to make it feel safe, calm, and inviting. The clinic provides chair massages, food, acupuncture, and a therapy dog in the waiting room. It also adopted a hub-and-spoke model in which a family care manager ensures collaboration and coordination between its flagship Women’s HIV Program and outside agencies such as community-based social services agencies, adult physical and behavioral health services, and housing, legal, and other social supports.
Is there a central common thread for these efforts?
There is a critical commonality. It’s the desire to detect and understand devastating life experiences and to apply a TIA across the system, which includes physical settings, interventions, policies, training, monitoring, financing, and interpersonal relationships. It is this comprehensive approach that is vital for the success of any TIA initiative.
Do we know if TIA is effective?
We need more evaluations to bolster the limited data available to date. But anecdotal evidence suggests that TIA works. The Fall-Hamilton Elementary School results show the potential that, we hope, other kinds of service providers can realize.