Healthcare and social service providers who aim to promote optimal health and wellness among the populations they serve cannot achieve their objectives unless they address the impact of traumatic life events (both past and recurring) on vulnerable individuals. The landmark Adverse Childhood Experiences (ACE) study offered compelling evidence of this (Menschner & Maul, 2016), and it is consistent with other research findings that suggest Social Determinants of Health (SDoH), the conditions in which we live, learn, work, grow, and affiliate with others, are more determinative of health outcomes than traditional healthcare services (Bernazzani, 2016). Although the research literature treats trauma and SDoH separately for conceptual purposes their interrelationship is indisputable. That is, certain life conditions, such as poverty and economic distress, physical and emotional abuse or neglect, racism and other structural inequities, among many others, are inherently traumatizing for many and can produce or perpetuate behavioral health disturbances. Thus, providers must mitigate the effects of trauma on those entrusted to their care. Perhaps more importantly, they must avoid practices that are retraumatizing for service recipients or inflict vicarious trauma on their personnel.
Ashley Brody, MPA, CPRP
These are seemingly Herculean tasks for providers who face other significant obstacles to the fulfillment of their missions. Chronic underfunding and enduring human resource constraints (specifically related to the recruitment and retention of qualified personnel) have afflicted healthcare and social service providers long before the COVID-19 pandemic exacerbated these trends. Furthermore, the pandemic constitutes a collective trauma, the sequelae of which have yet to be fully reconciled, especially for individuals with preexisting histories of trauma for whom the pandemic poses unique challenges. In order for providers and the organizations in which they operate to optimize their service environments and to facilitate the recovery of vulnerable individuals, service interventions must not be limited to specific “treatments” or evidenced-based practices. Organizational structures, practices, physical configurations, and guiding missions and philosophies must be aligned in furtherance of trauma-informed principles (Substance Abuse and Mental Health Services Administration, 2014).
The development of a “trauma-informed” organization is an iterative process that is never fully completed. It requires sustained leadership, allocation of sufficient resources, and the “buy in” of all organizational personnel – not merely those charged with clinical tasks or the delivery of clinical or rehabilitative services (Bryson et al., 2017). These are important considerations for organizations whose representatives encounter current or prospective clients at various “touch points.” Providers must consider how certain elements of the intake and assessment process, such as the physical configuration of its waiting areas, comportment of reception and front desk personnel, and the nature of questions posed during the assessment process might inadvertently undermine clients’ feelings of safety or evoke associations with past traumatic events. Providers must similarly acknowledge attributes of their environments or service settings that would reinforce or perpetuate trauma, modifications of which might be beyond their control. For instance, operators of residential congregate care programs in which recipients must share living accommodations and cohabitate with individuals whose behaviors might be viewed as hostile or aggressive must consider how these environments could compromise the impact of trauma-informed interventions, however effective they might be if applied under more propitious circumstances. Notwithstanding such limitations, attention to key ingredients of trauma-informed practice can enable organizations to achieve considerable progress in creating and sustaining environments conducive to recovery in all its forms.
Organizational leadership must play an integral role in the pursuit of trauma-informed practice (Menschner & Maul, 2016). Unlike other interventions whose impacts might unfold within a clinician’s office, classroom, or similarly circumscribed setting, trauma-informed care is all-encompassing and requires nothing less than a comprehensive review of the full environment and context in which care is delivered. This necessitates consistent commitment from organizational leadership and a commensurate allocation of resources. For example, the reconfiguration of a waiting area to reduce excessive noise and to enhance privacy and confidentiality necessitates the involvement of persons operating within different departments and at various levels of an organization’s hierarchy whose efforts cannot be successful without the endorsement of its senior leadership. In addition, engaging service recipients in organizational planning and service delivery processes can prove especially beneficial to an organization’s implementation of trauma-informed practices. Eliciting recipients’ expressed needs, preferences, and concerns is inherently empowering, and it can alert providers to organizational practices that must be modified in order to align with guiding principles (Isobel & Edwards, 2016). Training all personnel in trauma-informed practice ensures its organizational activities are aligned with and reinforce critical policies and procedures (Bryson et al., 2017). Inasmuch as such training educates and alerts personnel to the potentially deleterious effects of trauma it can also mitigate the effects of secondary trauma, thereby enhancing the overall health and wellbeing of an organization’s workforce (Substance Abuse and Mental Health Services Administration, 2014).
The foregoing practices, when implemented in an iterative and synergistic manner, enable organizations to become more “trauma-sensitive” in their orientation and to ameliorate the enduring effects of trauma and adverse life events on both individuals served and those charged to deliver services. These are seemingly lofty goals for organizations with limited resources, and partnerships that span organizational boundaries and service domains can provide essential support in the pursuit of common objectives (Keesler, Green, & Nochajski, 2017). For example, Coordinated Behavioral Health Services (CBHS), a prominent Independent Practice Association (IPA) comprised of health, behavioral health, and social welfare organizations operating throughout the Hudson Valley Region, has embarked on a Trauma-Informed Care initiative through which common standards and practices will be developed and disseminated to its participating providers. The IPA will also employ a Performance Enhancement Process to promote participants’ fidelity to established standards and practices. This model is poised to enable implementation of trauma-informed care on a scale that exceeds the scope of an individual provider or service organization. In doing so, it promises to deliver this proven practice throughout our region and to promote the overall health and wellbeing of a sizable cohort of its population.