What is trauma-informed care?

Trauma-Informed Care is a way of providing services that takes into account the impact and pervasiveness of trauma. While employment social enterprises are designed to be supportive, providing trauma-informed care requires a transformational shift in mindset in order to effectively adopt trauma-informed practices in a genuine and effective way. Trauma-informed care cannot be provided without first understanding the impact of trauma and the ways in which individuals experience retraumatization when receiving services. Implementation of trauma-informed practices is not just about being a nice person; it is about making an intentional effort to reduce harm in all interactions. This cannot be done on an individual scale; it requires a commitment from leadership to cultivate a trauma-informed environment that supports the health and wellbeing of both staff and clients. A program cannot be trauma-informed without being a trauma-informed workplace.

Why is it important?

• Implementation of trauma-informed practices supports employment social enterprises with:
  • Accurately identifying the skills, goals, and needs of participants.
  • Communicating effectively with participant workers to build strong working relationships.
  • Supporting participant workers with building resilience and confidence.
  • Improving outcomes for participant workers and the organization.

What is trauma?

Becoming trauma-informed begins with an awareness of the significance of trauma. Trying to adopt trauma-informed practices without an understanding of trauma, results in services that feel insincere.

The Adverse Childhood Experiences Study was pivotal for understanding the impact of trauma and promoting trauma-informed care. The study was a collaborative research project between the Centers for Disease Control and the California-based healthcare organization, Kaiser Permanente. This study investigated the links between adverse childhood experiences and long-term wellness. Adverse childhood experiences were categorized into abuse, neglect, and household dysfunction.

Participants were scored from 1 to 10, with higher scores indicating more instances of adverse childhood experiences. Roughly two-thirds had a score of 1, while over 12% had a score of 4 or more. ACE scores were found to correlate to negative outcomes in adulthood. The higher the score, the more likely someone was to experience:

• Heart disease
• Lung disease
• Traumatic brain injuries
• Drug and alcohol addiction
• Mental illness
• Unplanned pregnancies
• Poverty
• Cancer
• Infectious diseases
• Early death

The original study explored the relationship between childhood trauma and health outcomes. The CDC conducted another study in 2009 that looked at the relationship between childhood trauma and socioeconomic outcomes. Yet again, roughly two-thirds of participants had at least one adverse childhood experience. 15.1% of men and 19.3% of women had a score of 4 or more. As ACE scores increased, so did the proportion of unemployed participants. 5.8% of the unemployed participants had no ACEs, while 13.2% had a score of 4 or more.

Despite these bleak statistics, it is important to note that no ACE score carries a 100% guarantee of significant health and/or socioeconomic burden. Adverse childhood experiences are risk factors for these outcomes, not a direct causal link. There are multiple opportunities for intervention; just as there are risk factors that contribute to these outcomes, there are also protective factors that counteract those risk factors.

Even if nothing changes about the frequency of that child’s trauma and the effect on their neurodevelopment, there are multiple opportunities to intervene to reduce the risk of future harm. Getting support with emotional regulation as a child can resolve excessive stress responses and prevent problematic behavior. Getting support as an adult to help maintain employment can help them afford healthier coping strategies and break cycles of intergenerational trauma.

Best practices for adopting trauma-informed care

Trauma-informed care isn’t about a specific list of practices. Adopting trauma-informed care means understanding the needs of the population you’re working with and the impact your work can have on them.

Best practices for trauma-informed care should consider the following guiding principles:

Guiding Principles of Trauma-Informed Care
When there is an absence of consideration for these principles, retraumatization can occur. Retraumatization is the activation of the stress response system that occurs when an individual faces a situation that parallels their trauma history.
Safety	Trauma occurs in the absence of safety. When we feel unsafe, our stress response system activates to protect us from harm. Physical, emotional, psychological, and moral/ethical situations can disrupt our ability to feel safe.
Trust	Trust must be mutual. The organization must cultivate an environment that allows participants to trust staff. Staff must also be able to trust participants as well as each other.
Collaboration	Everyone should be collaborating to ensure the best possible outcomes for all involved. Staff should be collaborating with each other and with participants. Effort should also be made to collaborate with the support systems of participants when possible and necessary to reduce unnecessary inconvenience.
Peer Support	Your participants are the experts when it comes to their own experiences. Encouraging peer support among participants allows them to build self-efficacy. It also reinforces the belief that people are willing to help them.
Cultural, Historical and Gender Issues	Regardless of how unbiased we may think we are, if we don’t consider the way culture, history, and gender impact the way we perceive others and the way we are perceived, we can unknowingly cause significant harm. Being educated and mindful of these issues ensure that our words and actions have the intended effect.
Empowerment and Choice	Trauma makes many people feel that they have lost control of their own lives. Providing opportunities to make real decisions about things that are important to them, allows them to feel empowered enough to take that control back.

Retraumatization isn’t always a conscious experience; many have a hard time identifying and sourcing triggers. Retraumatization doesn’t just happen to participants. Staff are also likely to have experienced trauma and  may experience retraumatization doing their work. Whether it’s an uncomfortable interaction with another staff member or a situation with a participant that calls to mind their own experiences, staff are just as susceptible to retraumatization as participants. Providing trauma-informed care can make staff even more susceptible to retraumatization if the organization doesn’t consider the needs of staff.

Some common responses to retraumatization for both staff and participants include:

• Disengagement
• Reduced performance
• Reduced communication
• Avoidance of specific people or situations
• Increased/unusual substance use, both on and off-site
• Violence/aggression

These behaviors can be best understood through the lens of the following stress responses:

• Fight – Facing a problem head-on
• Flight – Avoiding the problem
• Freeze – An decreased ability to have an active response
• Fawn – Surrendering to the problem to minimize harm

When you contextualize behaviors as stress responses, it becomes easier to understand how to manage them. For example, if someone stops showing up to the program and you make the assumption that they just don’t care anymore, you could be missing a major opportunity for intervention. When you contextualize it as a trauma response, you can begin to think about possible triggers that could have contributed to disengagement. You are then more able to be compassionate and more likely to get a response.

Trauma-informed practices need to be embedded in every part of the experience.

Best practices for developing a trauma-informed organization don’t just apply to the work being done with participants. Processes put in place to support participants should apply to staff as well. Every part of the organization should be utilizing trauma-informed practices.

• Adopt a “No Wrong Door” policy (Principles: Safety & Collaboration)
  • A “No Wrong Door Policy” means that anyone seeking help can receive support regardless of who they approach first.
  • All staff should be proactive about making sure people are getting the support they need, such as greeting guests and making sure they have been seen.
  • Instead of redirecting them and sending them to the “right person” that staff person should initiate a warm transfer to ensure they get the support they need. A warm transfer means walking them to the appropriate department when possible or notifying the appropriate contact person and giving the individual an estimate of when they should be seen. If the individual is reaching out via email, CC the appropriate contact person in your reply.
  • Follow up after a warm transfer to ensure the individual received the support they needed.
• Develop a transparent application. (Principles: Safety, Trust, & Cultural, Historical and Gender Issues)
  • Your application should be clear about what is being asked and why. Participants will try to give you the information they think you want. This can lead to inaccurate responses.
  • Be explicit about gender affirmation: collect their name and pronouns on the application so they can be accurately identified in future communications without deadnaming and misgendering.
  • When collecting demographic information, be clear about what is and isn’t exclusionary criteria. Participants that are in need may misrepresent themselves if they think their reality may make them ineligible for services. This can cause them to not receive support for things they actually need.
    • For example: if you are asking about education level, someone without a high school diploma may assume that it is a requirement and say that they have one. As a result, this person would not be considered for GED services.
    • Hopeworks doesn’t collect this information in the application because the only criteria is age and availability. This information is collected during the intake session, which occurs once the individual is officially enrolled. By this point the individual is already informed of the additional resources we provide.
• Develop a structured system for engaging new participants during the recruitment phase. (Principles: Trust)
  • Contact should be made via call, text, and email to ensure the messages are received. Everyone uses a different primary mode of communication. This trifecta reduces the chances of missed communication.
  • Provide new participants with two additional reminders of their tours and start dates.
  • Respond to all open applications within 24hrs.
  • Keep in touch via weekly engagement emails so participants stay connected to what is happening and don’t feel ignored or forgotten.
  • Everyone gets a trifecta touch point every five days, at 50 days with no response we close the lead.
• Use a trauma-informed approach when communicating for recruitment. (Principles: Safety, Trust, & Empowerment and Choice)
  • Start recruitment calls by asking “How are you feeling?” Expressing a genuine interest in the emotional wellbeing of your participants helps them to feel comfortable sharing when they have needs.
  • Ask about their needs and potential barriers to identify ways you might be able to offer support. If your program has a waitlist or there is any delay before they can get started, asking “Is there something we can do to support you in the meantime?” is a great way of showing care and making sure they can get their needs met in order to be able to participate in the program.
  • Asking “Are we a good fit for you?” allows them to consider whether or not you are able to meet their needs, as opposed to thinking of whether or not they’re “good enough” for the program.
  • “How were your experiences with other programs, and how can we do better?” shows that you care about their previous experiences and are willing to make an effort to improve their experience.
  • Involving current participants in the recruitment process empowers current participants to talk about their experiences while also allowing new participants to hear about the program from the perspective of someone who has gone through it.
    • Hopeworks participants speak about their experiences at local recruitment events. This way people are able to ask questions about the program and receive firsthand accounts from our participants.
    • Before officially enrolling in the program, everyone is required to take a tour of Hopeworks.All tours are conducted by our participants. This process is embedded in our training to ensure our participants feel confident giving tours.
• Stop thinking “What’s wrong with you?” and think “What happened to you? (Principles: Safety, Trust, Collaboration, Peer Support, & Cultural, Historical and Gender Issues)
  • Working under the universal assumption that every participant is committed to doing the best they can to achieve success allows you to have a more positive concept of your participants.
    • Putting in the effort to understand the perspectives of your participants allows you to better understand their barriers and challenges, which are often at the root of the behaviors that lead to negative perceptions in the first place.
    • Your participants can tell when you have an unfavorable opinion of them, regardless of how well you think you’re hiding it. At best, participants will ignore you. At worst, they may be hostile or disengage from the program entirely.
    • When participants notice that they are being treated differently from other participants, this can also lead to conflict among participants.
  • Personally acknowledge any negative feelings you may have towards participants. Whether you do this with your supervisor or on your own, it’s important to admit when there is tension so you can address it and move forward appropriately.
    • Being frustrated by a participant doesn’t make you bad at your job. In fact, feelings of frustration are often associated with a desire to see participants succeed. It’s important for you to understand why you’re having these feelings.
    • It’s important to recognize any patterns or reenactments that might be present. Sometimes our feelings about participants are less about their behaviors and more about our own past experiences resurfacing.
    • For example: if a participant has qualities that remind you of someone that caused you or another person harm, you may avoid them or have difficulty identifying positive qualities about them. Acknowledging this allows you to separate the person in front of you from the person from your past and provide support.
  • Take a moment to think about frustrating behaviors/situations from the perspective of the participant. Their experiences may be very different from yours; if you only view them through the lens of your own experience, you can make unhelpful assumptions and contribute to more harm.
    • Even when a participant hasn’t directly asked for support, it’s important to consider the barriers they might be experiencing. When you take into account the things that you do know about a person, it becomes easier to identify their barriers.
    • Example: Someone without a supportive family might have difficulty with transportation, which can lead to issues with attendance and punctuality. Assuming they just don’t care and disciplining them without discussing the issue does nothing to prevent the issue going forward.
    • If you don’t have enough information about a participant to speculate about potential barriers they may be facing, you also don’t have enough information to judge their intentions as malicious.
• Develop a system for weekly supervision. (Principles: Trust, Collaboration, & Empowerment and Choice)
  • Trauma can have a significant impact on a person’s self-esteem. Meeting one-on-one with their supervisors on a weekly basis can help them to develop a more accurate view of their job performance.
    • People pleasing is a common trauma response, one that can very quickly lead to burnout in the workplace. Weekly supervision is an opportunity to validate efforts and successes and address any instances of overwork. This allows them to build confidence.
    • When an individual is not performing according to expectations, receiving weekly support allows for more efficient improvement. Being told to fix a problem without consistent guidance can lead to confusion and may potentially even decrease performance.
    • Weekly supervision also allows an opportunity to build rapport through open dialogue. One-on-one sessions can be a more comfortable environment to discuss things that would otherwise not come up in an informal setting. This can lead to more effective problem solving.
  • Maintain a strengths-based framework.
    • Always begin with positive affirmations and successes, and highlight what the individual is doing well. This allows them to focus and process more critical feedback more effectively when you deliver it.
    • Each session should be an open dialogue to allow both parties an opportunity to process feedback.
    • Critical feedback should be provided with clear expectations and suggestions for improvement.
• Develop key performance indicators (KPIs) for all staff and participants. (Principles: Trust, Collaboration, & Empowerment and Choice)
  • KPIs are the metric by which job performance is measured. Assigning KPIs ensures that everyone has a concrete way to track their job performance, rather than basing it on their supervisor’s opinion of them.
    • KPIs must be relevant to the individual’s role. Irrelevant KPIs don’t accurately portray the individual’s job performance and do not help them achieve success long-term.
      • In addition to role-specific KPIs, Hopeworks uses REDF’s Job Readiness Assessment as a KPI for all participants as a way to track their progress with soft skill development.
    • KPIs must be objective. KPIs that are open to interpretation make it easier to paint a picture of one’s performance that is based on opinion, not fact. This can lead to a low-performing individual receiving undue praise and a high-performing individual being discredited and undervalued.
    • KPIs must be consistent to properly track performance. It is difficult to identify long-term growth if the standards for success are constantly shifting.
    • KPIs should always be accessible and discussed during weekly supervision so individuals are able to see their progress and advocate for themselves. Having access to KPIs allows them to evaluate their performance on their own and adjust accordingly.
    • KPIs help build confidence by showing progression. Verbal affirmation can feel patronizing when it is the only confirmation of performance. When KPIs are properly tracked, changes in performance can be viewed in a timeline, which makes it easier to identify contributing factors.
• Address vicarious trauma and organizational trauma among staff. (Principles: Safety, Trust, Peer Support, & Empowerment and Choice)
  Vicarious trauma is a secondary form of trauma that occurs from exposure to narratives of trauma. These experiences can wear on the mental health of an individual. Providing trauma-informed care increases the likelihood of vicarious trauma because it creates a safe environment for participants to share their traumatic experiences. When staff are left unsupported, vicarious trauma can contribute to organizational trauma — a collective traumatic experience that occurs in organizations. While vicarious trauma can lead to burnout and decreased performance for an individual, organizational trauma affects the entire organization and can cause decreased communication, low morale, and high turnover. Worst of all, traumatized organizations are ineffective, which means the people they are serving cannot get their needs met.
  • Prioritize self-care and emotional wellness as an organization.
    • Openly supporting the mental health of staff and participants helps to cultivate an environment where people feel comfortable sharing when they’re overwhelmed. Putting forth the effort to make sure everyone is comfortable talking about their mental health ensures that people will speak up when they’re in need.
    • It’s important not to force people to talk about their feelings because it just reinforces the belief that sharing feelings leads to negative consequences. Providing them with the option to share allows them to speak up when they feel comfortable and share as much as they need to. This respects their autonomy and right to privacy.
  • Discuss wellness and self-care during supervision.
    • If an organization takes a stand in support of mental health but does nothing to practically support the mental health of its participants and staff, it’s meaningless. Supervisors should be regularly talking about self-care and emotional wellness during supervision to create an open dialogue.
    • If these discussions only come up when something is clearly wrong, it’s already too late!
    • Vicarious trauma and retraumatization aren’t the only sources of burnout. It’s important that everyone is having these discussions, not just those who work directly with participants.
    • Encourage the use of mental health days. It’s important for people to know they can take time for themselves when they need it. Being able to take time off without needing to jump through hoops to prove they “deserve it” is important.

Example: Hopeworks

Hopeworks is an employment social enterprise that offers paid technical training to young professionals and supports them with developing soft skills to transition them into sustainable employment. Hopeworks was founded in 2000 to address the alarming rate of poverty in Camden, NJ. Hopeworks was an organization that was founded out of love for the community and a desire to see the community prosper. That love presented itself as a tough love approach and a rigid structure to prepare young people for the harsh realities of the workforce. Hopeworks grew to serve over 200 people in 2008. Unfortunately, that tough love progressively got tougher and for many young people was all tough and no love. Hopeworks saw significant decreases in enrollment from 2008 to 2012. Even before this decline, Hopeworks was ineffective at serving the young people that were coming in. Only 5-10% of the young people coming in finished the program and left with a job. Staff retention also suffered as the program became less and less impactful.

In 2012, Hopeworks started a Mental Health Commission as a way of addressing the significant challenges the youth were facing. As a result, Hopeworks adopted the Sanctuary Model. The Sanctuary Model is a vigorous process for building a trauma-informed organization. It involves significant training and consultation and includes a certification process for ongoing evaluation and fidelity to the model.

The transition to the Sanctuary Model was very difficult. It required a lot of internal reflection about policies and practices that weren’t just ineffective but actively harming the wellbeing of staff and participants. There was already conflict within the organization; this was a big shift that many staff were not comfortable making. Hopeworks lost a lot of staff in the transition, but it ultimately proved to be worth it. It was not an immediate improvement by any means. The transition was long and difficult, but each year after implementing the Sanctuary Model saw an increase in enrollment, retention, and jobs earned.

Over 200 youth enrolled during FY2016, which hadn’t been achieved in 5 years. More importantly, we had an 87% completion rate that year and got 50 young people jobs. This level of success was new to Hopeworks. Even when our enrollment was high, few youth stuck around and even fewer left with jobs. Before Sanctuary, we were doing a great job of talking about our mission, but a poor job of actively living it.

The Sanctuary Model helped us to decrease conflict and tension between staff and participants and provide actual support. As our outcomes improved, staff recognized the impact of a trauma-informed approach and were able to embrace it more authentically. When our outcomes matched the hard work our team was doing, people were happier doing their jobs. Our staff retention improved significantly. People want to work for effective organizations, and happy employees are more effective.

The Sanctuary Model was developed with clinical services in mind. While it was an incredibly helpful step in the right direction, ultimately Hopeworks did not maintain Sanctuary Certification. We did, however, maintain the trauma-informed practices we learned and continue to modify our organizational practices. Our Learning and Development team provides training in trauma-informed care at onboarding and continues to build on those lessons in workshops during our monthly staff meetings.

Additional Resources

• https://www.scientificamerican.com/article/childhood-adverse-event-life-expectancy-abuse-mortality
• https://www.ajpmonline.org/article/S0749-3797(98)00017-8/fulltext
• https://www.cdc.gov/violenceprevention/aces/about.html
• https://store.samhsa.gov/product/practical-guide-implementing-trauma-informed-approach/pep23-06-05-005
• https://www.thesanctuaryinstitute.org/about-us/the-sanctuary-model/