The Center for Rehabilitation and Recovery provides assistance to the New York City mental health provider community through expert trainings, focused technical assistance, evaluation, information dissemination and special projects.

The new paradigm in trauma healing and recovery is trauma-informed care. In this issue and the next, we will explore trauma, and ways organizations and clinicians can become more trauma-informed.

Five Simple Ways to Make Your Organization Trauma-Informed

Maxine Harris, PhD

Interpersonal trauma is an experience that violates and rips open what we come to expect in a relationship: a parent who is supposed to protect you turns violent; a brother who is supposed to guide you, and comfort you, becomes sexual; a partner who is supposed to love you slams you up against the wall. In each of these situations, “normal” behavior is turned upside down, and we are left struggling to make sense of a new reality. 

A treatment system needs to work hard not to inadvertently replicate the dynamics of trauma. Here are some simple ways to do that:

• Safety. Survivors experienced danger in places that were supposed to offer safety: at home, at school, in the neighborhood. Consequently the treatment environment needs to feel safe and this can be accomplished quite easily. Make sure people have easy access to exits and doorways. Ensure that seating is arranged so that there is adequate space between people. Make sure that parking lots are well lit and whenever possible that appointments are scheduled during daylight hours.     

• Respect. In situations of abuse, the wishes of the victim are never respected. In the treatment environment, ask people what they want, what makes them comfortable. You may be an expert in your field, but each individual knows her/his experience best. Respect the value of lived experience.

• Collaboration. Abuse is never collaborative. One person imposes his or her will on another. Collaboration in treatment means more than setting goals together. It may also mean that all documentation is done collaboratively. The individual has a chance to see what is being written, and to work together with the clinician to make sure the note accurately reflects the experience and the wishes of the individual receiving services.

• Trust. Trauma is a fundamental violation of interpersonal trust. You expect someone to keep a promise, and they fail to do so over and over again. You expect that someone will never willingly harm you, and they violate that trust again and again. As practitioners, we must be careful not to make promises we can’t keep. Appointments should be scheduled with the assurance the time will be predictable and honored. If we promise to assist the individual with a practical task, we should not stop in mid-stream and reverse that promise. If the consumer cannot trust us, then we are just like all the past people who they feel have betrayed them.

• Empowerment. When trauma occurs, the victim is left feeling disempowered in the face of an overwhelming force. Treatment cannot begin with one person feeling that all the power lies with the other, and the only power left is to walk out. Anything that can be done to lessen the power differential should be tried, and this might be as simple as thinking about how you address someone. Calling a 50-year old woman by her first name, while introducing yourself with your full title, sets up a dynamic of disempowerment right from the start.

Making a system trauma-informed does not treat trauma; what it does do, however, is create a climate in which treatment can occur.

Maxine Harris is CEO and Co-founder of Community Connections, a non-profit mental health agency in Washington, DC. She is also the author of several books, including Trauma Recovery and Empowerment and The Loss That Is Forever: The Early Death of a Mother or Father.

Trauma, Relationships, and Recovery

Elizabeth Breier, MAHAP

It is well documented that individuals who have experienced trauma in their lives, especially during childhood, have difficulty developing and maintaining relationships. My life has been no exception. My worldview has been shaped by fear of abandonment, fear of closeness, and an inability to trust. How do you form meaningful relationships with others when your expectation is that you will be hurt? Trauma can create a sense of isolation and loneliness that is difficult to overcome. Ironically, one way to handle this is by taking the plunge and attempting to forge relationships with others despite past failed attempts.

As the majority of my trauma was sustained within my given family, I have worked diligently to create a family of choice. This alternate family is comprised of friends who have weathered the aftermath of trauma with me. It is not an easy task. It is not as simple as expecting those in my life to carry this weight with no accountability on my part. Having relationships support my recovery requires me to constantly examine myself and my thinking, and take ownership of the way my brain has been altered by the sustained trauma. It requires me to be honest with myself, and think that sometimes my perceptions of interactions may not be accurate. Most importantly, it requires me to be honest and transparent about the damage so I can heal. This is my recovery.

The Need to Screen for Trauma History

Elizabeth Saenger, PhD

People with severe mental illness are far more likely than the average person to have experienced interpersonal trauma. For example, in one large study, 47% of the sample with mental illness (vs 21% of the general population) experienced physical abuse. For sexual abuse, these figures were 37% and 23% respectively.

Physical and sexual abuse in childhood and adulthood are major risk factors for psychosis in adulthood. As one study found, the greater the extent of such abuse in childhood, the greater the risk of psychotic symptoms later on. Using different methods, another study discovered that among people with schizophrenia, those with more severe cases had more serious abuse histories. Thus the amount of trauma appears to correspond to the amount of subsequent harm.

Just as trauma increases the risk of mental illness, mental illness can exacerbate the effects of trauma. In addition, substance abuse can complicate the picture, and lead to poorer treatment outcomes.

Because trauma is so common, and critical to recovery, experts recommend screening all clients for a history of trauma. There are many tools available – some focus primarily on exposure to traumatic events.  Others concentrate more on symptoms related to trauma exposure. 

Either way, having information about a person’s trauma history can:

• prevent misdiagnosis related to symptoms, such as dissociation, which may result from trauma, but also appear in conditions unrelated to trauma
• increase engagement in therapy
• decrease the risk of relapse
• forestall premature termination
• improve patient outcomes

For additional information on the need to screen for trauma, instruments to do so, and more, download Trauma-Informed Care in Behavioral Health Services – TIP 57. This 342-page publication from the Substance Abuse and Mental Health Administration Services Administration (SAMHSA), justifiably rated five out of five stars by readers, has easy-to-use sections for clinicians and administrators, as well as a research review.

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The opinions expressed in RECOVERe-works do not necessarily reflect the views of the Coalition of Behavioral Health Agencies.

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