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By Sarah C. Threnhauser, MPA

In recent years, the impact of trauma to health and well-being is certainly and appropriately getting a lot of attention from the health care and social services provider community. For example, six states (Colorado, Massachusetts, North Carolina, Ohio, Washington, and Wisconsin) reported implementing a mix of training, screening, and support systems for children affected by trauma and adverse childhood experiences (ACEs) (see States Using Approach With Mix Of Training, Screening & Support Services To Address Childhood Trauma).

There is a growing number of programs focused on incorporating trauma-informed principles. One example we covered in the last couple of years came from Grafton Integrated Health Network, a multi-state behavioral health care organization, that adopted a trauma-informed approach as part of its efforts to reduce the use of restraints and eliminate seclusion—an initiative that led to fewer staff injuries and lowered lost-time expenses, turnover cost, and workers compensation policy costs (see What Is The Alternative To Restraint?). Another example is the advent of “trauma informed courts,” which provide a new opportunity for provider organizations to connect consumers with the supports they need and to build partnerships with other organizations and agencies to improve both individual and community health outcomes (see Judging, Not Judging: Trauma-Informed Courts). And most recently, a study just reported that a trauma-informed approach to children’s residential services implemented in 13 residential programs in North Carolina reduced the number of behavioral incidents by 3% to 5% per month (see Trauma-Informed Residential Treatment Model Reduces Behavioral Incidents By Up To 5% Per Month).

Richard Knecht

But I continue to ask the question—how would one know if an organization is using a trauma-informed approach or not? We spoke with OPEN MINDS Advisory Board Member Richard Knecht, about the latest thinking in organizational trauma-informed care. According to Knecht:

The most universal challenge, organizationally, is to design, launch, and sustain a trauma-informed culture within a highly prescriptive and compliance-driven service landscape. Payers, licensing, and other oversight entities appropriately require a host of administrative actions from provider organizations, and often these obligations distract the agency from the principle role of healing the patient or client.

Mr. Knecht noted that while the health care field is just now truly exploring what it means to organizations to deliver trauma-based care, there are some emerging constructs to be aware of. Among others, he noted the work of Harris and Fallot (see Creating Cultures of Trauma-Informed Care (CCTIC): A Self-Assessment and Planning Protocol), who suggest that there are five primary elements or organizational characteristics which require leadership attention.

The first is to assure that universal screening for trauma is available—Traumatic experiences are present in the lives of most patients, and while it may or may not be the focus of the clinical interventions or care, trauma’s effects are prevalent for most patients and awareness of its potential role for the practitioner is critical. That screening does not have to be based in the use of the Adverse Childhood Experiences tool, but delivery systems should assess for the impact of trauma and perhaps more importantly, for some determination of the patient’s awareness of how that trauma is affecting their life and well-being.

High functioning organizations also invest in training—Just because an organization has clinical professionals trained in evidenced based trauma models, does not mean the healing environment of the organization is conducive to trauma impacted patients. Mr. Knecht noted how important it is to start by raising awareness about trauma; and training is certainly a first step. But simply training isn’t enough. Skilled coaching is the overarching component that will drive change.

The most effective didactic training rarely supports the depth and breadth of organizational change needed to be truly trauma-based. Field-based, “in vivo” management and observation are critical. And perhaps the unspoken, missing piece for health care providers is that supervisory processes do not support those charged with the role and opportunity to actually heal.

Often, supervisors and managers begin supervision and feedback opportunities by asking the wrong first questions of staff. Instead of first asking, “did you get those progress notes done yet?,” or “did you submit that clinical summary on time?”, the first question in supervision must be an authentic inquiry of the clinician, such as “How are you doing?” The most important job of the organization and its managers is to help healers be in a place where they can actually heal. This is what gives organizations long-standing sustainability—where the necessary organizational culture shift is both changed and sustained.

Easy steps can be taken to support the clinical professionals who are providing the interventions—For example, allow them to debrief with a supervisor or other trauma-informed professionals before their next session. This will help them to stay mindful and present during each therapeutic session. By supporting the clinical professional staff who are providing the care, we are contributing to better care for the consumers who need it the most.

Hire the right people—Organizations must invest in recruitment, screening, orientation and on-boarding of team members who are prepared for the unique opportunities that trauma-aware healing invites. This can be a major challenge, of course, particularly in the competitive employment market of 2019. But making thoughtful decisions about the personnel who form the teams, assures that the organization won’t spend inordinate time and resources in correcting the performance issues which can be present when unprepared staff members are unsuccessful. Knecht elaborated:

Ultimately, as an organization supporting the healing needs of consumers, you must bring in people who are able to work with individuals who have experienced trauma. Working in this field can be psychologically distressing. Trauma often manifests itself behaviorally as anger or fear. When clients or patients manifest dis-regulated behavior, for professionals, this can set off our own triggers, making it hard to stay present, balanced and accessible during the intervention.

Embrace the culture change—Becoming a trauma-informed organization often means that a significant cultural shift needs to occur within the organization. The shift in culture can be one of the most challenging aspects of implementing a trauma-informed approach. Ultimately, the focus needs to be on the consumer, and the goal needs to be delivering the most effective, efficient, and consumer-centered services. Mr. Knecht noted:

The barriers to implementing trauma-informed care are not always about heavy caseloads or the lack of resources within an organization. Often, it is about presence and empathy. Being present and empathic requires an investment in time and emotional energy from the clinician. Some might say, ‘I can’t do that with my large caseload’. I encourage managers to ask staff, “are there some cases where you can implement the approach…start with two clients and then coach and support their progress to see if the staff can extend that healing energy for other children and families on their caseload.”

Additionally, supporting a culture change also invites measuring your efforts. There is a need for measurement-based care across all areas of behavioral health, but particularly in trauma-informed care, to continuously monitor outcomes and use the results to further inform decisions regarding the consumer’s care and treatment. It is also just as important to measure the efficacy and outcomes of the training programs for trauma-informed approaches among staff and leadership, including measuring staff knowledge and the organizational outcomes post-implementation. Mr. Knecht noted that when measuring the efficacy of the training programs for staff and organizations, there is only an early developing body of knowledge:

One tool that shows promise is the Attitudes Related to Trauma-Informed Care (ARTIC) scale—a research-informed and validated tool to measure readiness and eventual progress at the organizational level. With the evidence-based models and frameworks for trauma-informed care, it’s important to start asking what is working in our field, and if we are really trauma-informed.”

Review policy and procedures—At the administration level within a provider organization, it is also necessary to understand how your organization’s policies and procedures align with a trauma-informed approach to care. To further support the shift in the organization’s readiness and culture, the trauma-informed approach must be embraced at all levels, and this must be reflected in the organization’s policy and procedures, governance documents, and mission and vision statements.

For more on trauma-informed care, check out these resources from the OPEN MINDS Industry Library:

  1. Making Trauma-Informed Care An Operational Reality
  2. Trauma-Informed Care In Action
  3. Care Delivery In A Value-Based Era – Evidence-Based, Practice-Based, Standardized & Measurement-Based
  4. Making The Link – Trauma & High-Needs Consumers
  5. The Trauma Quandary
  6. Traumatic Consequences
  7. Judging, Not Judging: Trauma-Informed Courts
  8. What Is The Alternative To Restraint?
  9. ‘Person-Centered’ Health Care Records Take Center Stage
  10. Would This List Bend The Cost Curve?

The transition to a true, trauma-informed approach to care is a complex endeavor. It is also one that needs to be implemented across all levels of leadership within an organization and across all models of care. Most importantly, a trauma-informed system is one that considers the consumer first. To support consumers in this context, as a leader of an organization, it’s necessary to support those who are providing the healing and intervention, and to foster an environment where trauma-informed knowledge can be better translated into trauma-informed practice.

For more, join me on September 10 at The 2019 OPEN MINDS Executive Leadership Retreat in Gettysburg, Pennsylvania for the keynote, “Building A Trauma-Informed Provider Network: The Aetna Experience,” featuring Robert M. Atkins, M.D., MPH, Senior Medical Director, Aetna Medicaid.

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