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ResilienceThe process of adapting to trauma and adversity; the ability to bounce back, or return to the level offunctioning before the trauma/adversity occurred.Re-TraumatizationWhen a policy, procedure, interaction, or the physical environment replicates someone’s original traumaliterally or symbolically—triggering the emotions and thoughts associated with the original experience.Sanctuary ModelAn evidence-based approach for changing organizational culture to be more trauma-informed andresponsive that was created by Dr. Sandra Bloom and her colleagues.Secondary Traumatic Stress (STS)The onset of trauma-related symptoms in a worker as a result of witnessing the trauma/adversity ofanother.StagesThe first component of the trauma-informed organizational model that defines the things to consider,needs and resources for trauma-informed organizational change. Includes Pre-Implementation,Implementation and Sustainability.Trauma-InformedOne of the three levels of a trauma-informed approach; the overarching umbrella that provides the filterfor everything we do in a way that ensures universal precaution.Trauma-SensitiveOne of the three levels of a trauma-informed approach; the way that an organization/system/individualresponds to trauma and adversity in a sensitive manner.Trauma-SpecificOne of the three levels of a trauma-informed approach; the trauma-specific treatment interventions.Universal PrecautionSimilar to how health care professionals put on gloves to prevent the spread of blood borne pathogens, atrauma-informed approach involves putting on metaphorical gloves (changing our interactions, policies,etc.) to prevent the possibility of re-traumatization. 2019 The Institute on Trauma and Trauma-Informed Care10

Vicarious Post-Traumatic Growth (VPTG)Development of positive changes and growth in a worker’s world view as a result of witnessing the posttraumatic growth of others.Vicarious Resilience (VR)Positive meaning-making and shift of a worker’s experience as a result of witnessing the resilience ofothers.Vicarious Trauma (VT)The development of negative changes in world view of a worker as a result of the cumulative impact ofwitnessing the trauma/adversity of others over time. 2019 The Institute on Trauma and Trauma-Informed Care11

IntroductionForewordThe purpose of the Trauma-Informed Care Implementation Manual is to helporganizations and systems plan for, implement and sustain Trauma-Informed Care(TIC). The manual is separated into three main sections that will deliberately walkyou through the stages of trauma-informed organizational change and the keydevelopment areas in each stage, and provide resources and examples that canbe used for action planning. This manual serves as both a guide and a workbookby providing opportunities for you to utilize specific tools and worksheets in order toassess your organization/system’s current state and plan for next steps.Our best hope is that this manual will:1Be a means of acknowledging the work your organization/system is engagingin already in response to trauma, and2Provide a framework with guidance for moving forward.The Trauma-Informed Care Implementation Manual is intended for: organizations,systems of care, hospitals, schools and businesses that are considering and/orinterested in implementing a trauma-informed approach.The manual is separated into three main sectionsthat will deliberately walk you through the stagesof trauma-informed organizational change andthe key development areas in each stage. 2019 The Institute on Trauma and Trauma-Informed Care12

TRAUMA-INFORMED ORGANIZATIONAL YKey Development Areas:Key Development Areas:Key Development Areas:#1: Leading andCommunicating#1: Leading andCommunicating#1: Leading andCommunicating#2: Hiring and OrientationPractices#2: Hiring and OrientationPractices#2: Hiring and OrientationPractices#5: Establishing a SafeEnvironment#3: Training the Workforce(Clinical and Non-Clinical)#3: Training the Workforce(Clinical and Non-Clinical)#8: Collaborating with Others(Partners and Referrals)#4: Addressing the Impact ofthe Work#4: Addressing the Impact ofthe Work#9: Reviewing Policies andProcedures#5: Establishing a SafeEnvironment#5: Establishing a SafeEnvironment#6: Screening for Trauma#6: Screening for Trauma#7: Treating Trauma#7: Treating Trauma#8: Collaborating with Others(Partners and Referrals)#8: Collaborating with Others(Partners and Referrals)#9: Reviewing Policies andProcedures#9: Reviewing Policies andProcedures#10: Evaluation and ProgressDomains of Consideration (SAMHSA, 2014a): Governance and Leadership, Policy, Physical Environment, Engagement andInvolvement, Cross Sector Collaboration, Screening Assessment Treatment Services, Training and Workforce Development,Progress Monitoring and Quality Assurance, Financing, Evaluation 2019 The Institute on Trauma and Trauma-Informed Care13

Adapting to your SystemDifferent systems adapt TIC as an approach to the work they do—which may or may not involve care. Forexample, we have adopted the title of Trauma-Informed Educational Practices (TI-EP) in our work withschools and Trauma-Informed Medicine (TIM) in our work with health care settings. It is important to notethat similarly to how we worked with systems to adapt TIC to TI-EP or TIM, the language in this manual canalways be adapted to your specific system. For the sake of consistency throughout this manual, TI-EP andTIM will be used when discussing examples related to those settings, but otherwise we will use the termtrauma-informed approach.NOTE: Look for the icons below throughout the manual, as they indicate real-life implementation examplesfrom our work in different organizations/systems.UniversalAny organization, system or business, regardless of itsrole/functionTrauma-Informed Educational Practices (TI-EP)Specific to education/schoolsTrauma-Informed Medicine (TIM)Specific to hospitals, primary care and other healthcare systemsFor more details regarding how to use this manual, please read the section on page 32. 2019 The Institute on Trauma and Trauma-Informed Care14

LegacyBeing trauma-informed and providing Trauma-Informed Care (TIC) have their origins in Dr. SandraBloom’s work of creating sanctuary (The Sanctuary Model). Others—notably Dr. Roger Fallot and Dr.Maxine Harris (2001) in their Using Trauma Theory to Design Service Systems: New Directions for MentalHealth Services and Dr. Ann Jennings (The Anna Institute, formally the Anna Foundation)—have contributeda substantial platform for the world to understand, accept and respond effectively to the impacts traumaand adversity have.The comprehensive trauma-informed treatment approaches introduced by Dr. Ricky Greenwald (2005)and Dr. Lisa Najavits (2002) profoundly influence how we treat trauma. The Substance Abuse and MentalHealth Services Administration (SAMHSA)’s (2014) Trauma-Informed Care in Behavioral Health Services(TIP-57) has provided a practical tool for us all.BackgroundTrauma-Informed Care (TIC) is an organizational culture change process that requires the traditionalpower hierarchy to be a more flattened, collaborative environment, while reflecting the paradigm shiftfrom “What is wrong with you?” to “What has happened to you?” in all that we do (Bloom, 1994; Bloom,2013; Harris & Fallot, 2001).Trauma and adversity are growing public health concerns that impact all. Using a trauma-informedapproach in organizations, systems of care, schools, hospitals and businesses is critical to the persistenceof a movement—one of universal precaution, which involves all of us (Bloom & Farragher, 2013, p.29; BurkeHarris, 2014).Universal precaution is often used within the medical field todenote preventative measures of containment of potentiallyhazardous or infectious materials/fluids.When taking universal precaution, a professional approachesall fluid in the same manner without first determining the levelof hazard—generally this is done by putting on gloves or glovingup to protect against exposure.Trauma-Informed Care is also universal precaution in that aprofessional is asked to just assume that all individuals have ahistory of trauma by gloving up metaphorically (i.e., changinginteraction style, policies, procedures, etc.) in order to reducethe possibility of triggering or re-traumatizing others. 2019 The Institute on Trauma and Trauma-Informed Care15

Post-traumatic stress disorder (PTSD)and acute stress disorder (ASD) are thetwo diagnoses related to traumaTrauma and Adversity: What Do I Need to Know?Trauma is conceptualized by considering the events/circumstances that occur, the characteristics ofthose events/circumstances and the negative effect(s) they have on the individual’s well-being. Moreimportantly is the individual’s perception of the event/circumstances, which is ultimately what determinesif it is traumatic or not (SAMHSA, 2014a).Trauma overwhelms an individual’s ability to cope.Post-traumatic stress disorder (PTSD) and acute stress disorder (ASD) are the two diagnoses related totrauma.The Adverse Childhood Experiences (ACE) Study found a relationship between childhood adversity andnegative health outcomes in adulthood (Felitti et al., 1998).The 10 types of childhood adversity (referred to as ACEs) included in the study were: physical, emotionaland sexual abuse, physical and emotional neglect, and growing up in a household with a caretakerwho had a mental illness, abused substances, was incarcerated, was a victim of domestic violence orwas divorced.While ACEs can be considered traumatic, experiencing adversity does not necessarily equal trauma.WORLDVIEWEXPERIENCEPERCEPTIONTRAUMAFigure 1 – What Shapes Trauma 2019 The Institute on Trauma and Trauma-Informed Care16

COGNITIVE FUNCTIONINGTrauma/adversity affects one’sability to:Form memoriesLearn and concentrateMake decisionsEMOTION REGULATIONProcess and express languageTrauma/adversity affects one’sability to:Control impulsesInterpret emotional cuesTrust in the reliability of othersWHATHAPPENS?Establish a predictable senseof selfPHYSICAL & MENTAL HEALTHTrauma/adversity affects one’sability of:Developing diabetes, heart disease,cancer and other ailmentsEngaging in substance abuseAttempting suicideDeveloping a sexually transmitteddiseaseRELATIONSHIPSTrauma/adversity affects one’sability to:Identify and form healthyrelationshipsTrust othersExpress needs and wants to othersPERCEPTIONS & BELIEFSSet boundariesTrauma/adversity affects one’s:Core beliefs about self, othersand the worldAbility to hopeFigure 2 – The Imoact of Trauma and Adversity 2019 The Institute on Trauma and Trauma-Informed Care17

Resilience and Post-TraumaticGrowthADVERSEEVENTGROWTHLEVEL OF FUNCTIONINGAs noted in Figure 2, experiencingtrauma/adversity can lead to varyingRESILIENCElevels of impairment and distress. Thereaction could illicit several differentoutcomes:resilience, growth andIMPAIRMENTimpairment. Resilience is the process ofadapting to trauma and adversity—theability to bounce back, or return to thelevel of functioning prior to the trauma/TIMEadversity occurring. When individuals areable to derive meaning from the event orFigure 3 – Trajectories Following Traumacircumstances and experience a positive(Butler, 2010; O’Leary & Ickovics, 1995)change as a result, they undergo whatis called (Tedeschi & Calhoun, 2004). Anexample of PTG is a mother who lost herchild to an accident caused by an intoxicated driver joining Mothers Against Drunk Driving in order toadvocate for and support others.RESILIENCE is the process of adapting to trauma and adversity—the ability tobounce back, or return to the level of functioning prior to the trauma/adversityoccurring.POST-TRAUMATIC GROWTH [PTG] occurs when individuals are able to derivemeaning from the event or circumstances and experience a positive change asa resultExperiencing trauma/adversitycan lead to varying levels of impairmentand distress. The reaction could illicitseveral different outcomes: resilience,growth and impairment. 2019 The Institute on Trauma and Trauma-Informed Care18

Impact of the Work: Considering the WorkforceA trauma-informed entity not only recognizes the effect of trauma on clients/patients/students/consumers,but also the impact on the workforce based on their own and others’ experiences of trauma and/oradversity. Figure 4 below describes those impacts:IMPACTDEFINITIONSecondary Traumatic Stress (STS)Experience of trauma-related symptoms in a worker as a result of witnessingthe trauma/adversity of another; typically quick in onsetVicarious Trauma (VT)Development of negative changes in work world view as a result of thecumulative impact of witnessing trauma/adversity over timeCompassion Fatigue (CF)Experiencing the combination of STS, VT and/or burnoutVicarious Resilience (VR)Positive meaning-making and shift of the worker’s experience as a result ofwitnessing the resilience of othersVicarious Post-Traumatic Growth (VPTG)Development of positive changes and growth in worker’s world view as aresult of witnessing the post-traumatic growth of othersFigure 4 – The Impact of the Work, Adapted from Krause & Green (2015) and Tedeschi & Calhoun (2004)Examples to operationalize some of the concepts above are indicated in Figure 5 below. The impact ofthe work may look different depending on the profession—consider how your organization/system may beimpacted as you read the examples below.SECONDARY TRAUMATIC STRESS: Shortly after interviewing a victim of physical abuse, anurse begins to have a headache and is unable to concentrate, which results in her leavingher shift early.VICARIOUS TRAUMA: A child welfare worker finds herself not wanting to let her daughterout of her sight after taking the position six-months prior because she feels the world is notsafe for children.VICARIOUS RESILIENCE: A teacher reaffirms the reason he decided to go into educationafter witnessing one of his students excel in his classroom despite the struggles she had atthe beginning of the year due to family adversity.VICARIOUS POST-TRAUMATIC GROWTH: A counselor reflects on how he has become morecompassionate and self-aware over the years as a result of witnessing the growth of his clients.Figure 5 – Examples of STS, VT, VR & VPTG 2019 The Institute on Trauma and Trauma-Informed Care19

Our ApproachEvaluationEvaluation is a key component of the trauma-informed approach. It allows us totake a pulse and reassess how trauma-informed we are. Evaluating how traumainformed an organization/system is involves looking at the culture and climate, aswell as its policies and procedures, through a trauma-informed lens. Our evaluationprocess utilizes an organizational assessment tool which asks staff (and sometimesclient/patient/student/consumer) for their perceptions of the five guiding values andprinciples of a trauma-informed approach, and about specific policies/procedureswithin their work at their organization/system that are trauma-informed. There aremultiple trauma-informed organizational assessment tools to choose from, whichwe will discuss later in the manual within the key development areas.Taking a pulse refers to assessing wherean organization/system currently is in thetrauma-informed change process in orderto make informed decisions about next steps.Having a big picture evaluation plan is critical for measuring the progress andoverall success of trauma-informed organizational change. Part of the evaluationplan is taking a baseline, which means evaluating before any trauma-informedtraining or implementation steps occur. The organization/system can then use theresults of the evaluation to make deliberate decisions regarding trauma-informedchange—mainly what to focus energy and resources on first based on reportedstrengths and areas for improvement. In addition to identifying where to start, theorganization/system can also use the baseline evaluation as an anchoring pointto monitor progress moving forward. As can be seen in Figure 6 below, regularmonitoring of progress via evaluation of implementation steps (what is working,what needs to be tweaked, etc.) is the central component of sustaining traumainformed organizational change. Strategies and considerations for creating anoverall evaluation plan will be discussed later in the manual under the Evaluatingand Monitoring Progress section. 2019 The Institute on Trauma and Trauma-Informed Care20

TIONEVALUATIONSUSTAINABILITYFigure 6 – Trauma-Informed Evaluation PlanADJUST PLANAS NEEDEDFive Guiding Values and PrinciplesThe five guiding values and principles proposed by Harris and Fallot (2001) provide a generalframework that can be used in any organization/system with everyone, including at a worker-toclient/patient/student/consumer level, a worker-to-worker level and a leadership-to-worker level.While we strive to incorporate all five to the best of our ability, we may not be able to use all of themin every interaction. As can be seen in Figure 7, the values and principles are unique and stronglyrelated (Hales, Kusmaul & Nochajski, 2016). This means that the values and principles can be usedflexibly. For example, if we truly cannot provide any choice in a specific mandated situation, howcan we at least let the individual know what to expect (trustworthiness) and/or ensure emotionalsafety during the process? Having a good understanding of each of the values and principles iscritical for being able to be deliberate in their use.1. Safety5. Empowerment4. Collaboration2. Trustworthiness3. ChoiceFigure 7 – The Five Guiding Values and Principles Adapted from Harris & Fallot (2001) 2019 The Institute on Trauma and Trauma-Informed Care21

The five values and principles are listed below withdescriptions and examples of what they can looklike in different systems:Safety is broken down intoconsiderations of physical andemotional safety of all individuals inthe organization/system. Physicalsafety involves thinking aboutsecurity and the aesthetics of the bu

coach and/or advocate for a trauma-informed approach in order to ensure overall sustainability. Compassion Fatigue (CF) A combination of secondary traumatic stress, vicarious trauma and/or burnout that manifests in a worker. Domains of Consideration Domains of organizational change that the Substance Abuse a