SAMHSA's Concept of Trauma and Guidance for a Trauma-Informed Approach in Youth Settings

SAMHSA’s Concept of Trauma and Guidance for a Trauma-Informed Approach in Youth Settings
Download the article in PDF

Abstract: This article clarifies SAMHSA’s approach to trauma-informed care and offers guidance for implementing a trauma-informed approach through key principles, philosophies, and procedures.

"SAMHSA's Concept of Trauma and Guidance for a Trauma-Informed Approach in Youth Settings" (2015)

By Rebecca B. Flatow, Mary Blake, & Larke N. Huang

Unaddressed trauma and violence against children, youth, and adults affects all of us. Violence occurs at all ages and in all settings, and its consequences affect all of our communities and social institutions. Youth with significant traumatic experiences are found in every community and youth-serving system. The impact of this violence over the lifespan is profound. Epidemiological research shows strongly proportional and significant relationships between trauma in childhood (adverse childhood experiences) and a variety of health, behavioral health, and social problems – even decades after the trauma. Depression; hallucinations; suicide; substance abuse; multiple sex partners, and heart, lung, and autoimmune disease1 2 are but a few of the consequences of early traumatic experiences. This is why it is critical for all youth-serving systems to recognize the importance of addressing trauma in our prevention, treatment and recovery interventions.

SAMHSA's Comprehensive Public Health Approach to Trauma

Over the last 20 years, the Substance Abuse and Mental Health Services Administration (SAMHSA) has been a leader in recognizing the need to address trauma as a fundamental obligation for public mental health and substance abuse service delivery. Consequently, SAMHSA has supported the development and promulgation of trauma-informed systems of care. SAMHSA's Trauma and Justice Strategic Initiative focuses on integrating a trauma-informed approach throughout health, behavioral health, and related systems to reduce the harmful effects of trauma and violence on individuals, families, and communities. The initiative also focuses on using innovative strategies to reduce the involvement of individuals with trauma and behavioral health issues in the criminal and juvenile justice systems.

SAMHSA's comprehensive public health approach to addressing trauma includes a framework that describes: trauma, a trauma-informed approach, key principles, and guidance for implementation of a trauma-informed approach. This framework builds from the work of key thought leaders3 4 in the field and is designed to be used across service systems that interface with youth – whether juvenile justice, child welfare, primary care, education, housing, and/or community support.

Trauma: The Three Es

The experience of trauma is complex and particular to each individual's life circumstances. Traumatic events and circumstances may happen as a single occurrence or repeatedly over time. Youth may experience multiple categories of traumatic events and circumstances – sexual abuse, bullying, and witnessing violence in the home or community, to name a few.

PBuilding on input from researchers, practitioners, and people with lived experience, SAMHSA developed the following definition of trauma: "Individual trauma results from an event, series of events, or set of circumstances that is experienced by an individual as physically or emotionally harmful or life threatening and that has lasting adverse effects on the individual's functioning and mental, physical, social, emotional, or spiritual well-being."5

Inherent in the definition are the "Three Es" an Event, an Experience of the event and the Effects. The Threes Es describe how an event, and the experiences or perception of an event, can have unique effects on a particular individual's well-being. Events and circumstances may include the actual or extreme threat of physical or psychological harm (i.e. natural disasters, abuse, physical or sexual violence, etc.) or severe, life-threatening neglect that imperils a child's healthy development.

The individual's Experience of these events or circumstances and the way in which it shapes the individual's worldview helps to determine whether the events were traumatic. A particular event may be experienced as traumatic for one individual and not for another. How the individual labels, assigns meaning to, and is disrupted physically and psychologically by an event will contribute to whether or not it is experienced as traumatic. Traumatic events by their very nature set up a power differential where one entity (whether an individual, an event, or a force of nature) has power over another. They elicit a profound question of "Why me?" The individual's experience of these events or circumstances is shaped in the context of this powerlessness and questioning.

The long-lasting adverse Effects of the event(s) and how they are experienced are a critical component of trauma. These adverse effects may occur immediately or may have a delayed onset. The duration of the effects can be short to long term. In some situations, the individual may not recognize the connection between the effects and the events. Examples of adverse effects include an individual's inability to cope with the normal stresses and strains of daily living; to trust and benefit from relationships; and to manage cognitive processes, such as emotions, memory, attention, thinking, and behavior. In addition to these more visible effects, there may be an altering of one's neuro-physiological make-up and ongoing health and well-being.

Trauma-Informed Approach: The Four Rs

The high prevalence of trauma and violence in the lives of young people across the developmental spectrum make it imperative that organizations and systems serving and supporting youth understand the importance of a trauma-informed approach. SAMHSA's framework describes the four elements of a trauma-informed approach through the "Four Rs:" "A program, organization, or system that is trauma-informed: realizes the widespread impact of trauma and understands potential paths for recovery; recognizes the signs and symptoms of trauma in clients, families, staff, and others involved with the system; responds by fully integrating knowledge about trauma into policies, procedures, and practices; and seeks to actively resist re-traumatization."5

In a trauma-informed approach, everyone at all levels of the organization or system has a basic Realization about trauma and understands how trauma can affect families, groups, organizations, and communities as well as individuals. People in the organization or system are also able to Recognize the signs of trauma, which may be gender-, age-, or setting-specific and may appear in those individuals seeking or providing services in these settings. The program, organization, or system Responds by applying the principles of a trauma-informed approach to all areas of functioning. Staff in every part of the organization, from the person who greets clients at the door to the executives and the governance board, have changed their language, behaviors, and policies to take into consideration the experiences of those who have trauma histories (including the staff members themselves). Ultimately, a trauma-informed approach seeks to Resist traumatizing or Re-traumatizing clients and staff. Staff are taught to recognize how organizational practices may trigger painful memories for clients with trauma histories.

A trauma-informed approach does not simply raise awareness of the issue of trauma, but fundamentally changes an organization or system's culture, behavior, actions, and responses. All components of the organization incorporate a thorough understanding of the prevalence and impact of trauma, the role that trauma plays, and the complex and varied paths in which people recover and heal from trauma. A trauma-informed approach can be implemented in any type of service setting or organization and is distinct from trauma-specific clinical interventions, such as trauma-informed cognitive behavioral therapy.

Six Key Principles of a Trauma-Informed Approach

  • Safety: Throughout the organization, the staff and the people they serve feel physically and psychologically safe; the physical setting is safe and interpersonal interactions promote a sense of safety.
  • Trustworthiness and transparency: Organizational operations and decisions are conducted with transparency and with the goal of building and maintaining trust among clients, family members, staff, and others involved with the organization.
  • Collaboration and mutuality: There is true partnering and leveling of power differences between staff and clients and among organizational staff, from direct care staff to administrators; they recognize that healing happens in relationships and in the meaningful sharing of power and decision-making.
  • Empowerment: Throughout the organization and among the clients served, individuals' strengths are recognized, built on, and validated. New skills are developed as needed.
  • Voice and choice: The organization aims to strengthen the experience of choice for clients, family members, and staff. It recognizes that every person's experience is unique and requires an individualized approach.
  • Culture, historical and gender issues: The organization incorporates policies, protocols, and processes that are responsive to the racial, ethnic, and cultural needs of individuals served, that are gender-responsive, and that incorporate a focus on historical trauma.

Guidance for Implementing a Trauma-Informed Approach

Developing a trauma-informed approach requires change at multiple levels of an organization and systematic alignment with the key principles described above. SAMHSA's suggested framework can provide a roadmap to help individuals and agencies get started.

This guidance can also assist in developing a change strategy, help identify organizational strengths and weaknesses, provide milestones to measure progress, and prevent re-traumatization. While the list of domains is similar to those in any basic organization change model, it is the infusion of the six key principles that makes it trauma-informed. The following guidance can be a useful starting point:

  • Governance and leadership: The leadership and governance of the organization support and invest in implementing and sustaining a trauma-informed approach. There is an identified point of responsibility within the organization to lead and oversee this work and peer voices are included.
  • Policy: There are written policies and protocols establishing a trauma-informed approach as an essential part of the organizational mission. Organizational procedures and cross-agency protocols reflect trauma-informed principles.
  • Physical environment of the organization: The organization ensures that the physical environment promotes a sense of safety.
  • Engagement and involvement of people in recovery, trauma survivors, consumers, and family members receiving services: These individuals have significant involvement, voice, and meaningful choice at all levels and in all areas of organizational functioning (e.g., program design, implementation, service delivery, quality assurance, cultural competence, access to trauma-informed peer support, workforce development, and evaluation).
  • Cross-sector collaboration: Collaboration across sectors is built on a shared understanding of trauma and principles of a trauma-informed approach. While a trauma focus is not the stated mission of different service sectors, understanding how trauma impacts those served and integrating this knowledge across service sectors is critical.
  • Screening, assessment, and treatment services: Interventions are based on the best available empirical evidence and science, are culturally appropriate, and reflect principles of a trauma-informed approach. Trauma screening and assessment are an essential part of the work. Trauma-specific interventions are acceptable, effective, and available for individuals and families seeking services. When trauma-specific services are not available within the organization, there is a trusted, effective referral system in place that facilitates connecting individuals with appropriate trauma treatment.
  • Training and workforce development: Continuous training on trauma, peer support, and how to respond to trauma is available for all staff. A human resource system incorporates trauma-informed principles in hiring, supervision, and staff evaluation; procedures are in place to support staff with trauma histories and/or those experiencing significant secondary traumatic stress from exposure to highly stressful material.
  • Progress monitoring and quality assurance: There is ongoing assessment, tracking, and monitoring of trauma-informed principles and effective use of evidence-based and trauma-specific screening, assessments, and treatment.
  • Financing: Financing structures are designed to support a trauma-informed approach which includes resources for staff training, development of appropriate facilities, establishment of peer support, and evidence-supported trauma screening, assessment, services, and interventions.
  • Evaluation: Measures and evaluation designs used to evaluate service or program implementation and effectiveness reflect an understanding of trauma and appropriate trauma-research instruments.

Moving Forward

SAMHSA continues to carry out this framework through its policies, initiatives, grant programs, and technical assistance to the field, as well as via collaborations with federal partners and experts in the field. As more federal, state, and local agencies embrace an understanding of trauma and implementation of a trauma-informed approach, SAMHSA will continue to promote a shared understanding of this conceptual framework. A unified working concept will serve to advance the understanding of trauma and a trauma-informed approach and to develop measurement strategies for successful implementation that will lead to better outcomes for children, youth, families, and communities.

References

  1. Felitti, V. J., Anda, R. F., Nordenberg, D., Williamson, D. F., Spitz, A. M., Edwards, V., . . . Marks, J. S. (1998). Relationship of childhood abuse and household dysfunction to many of the leading causes of death in adults: The Adverse Childhood Experiences (ACE) study. American Journal of Preventive Medicine, 14, 245–258.
  2. Anda, R. F., Brown, D. W., Dube, S. R., Bremner, J. D., Felitti, V. J., & Giles, W. G. (2008). Adverse childhood experiences and chronic obstructive pulmonary disease in adults. American Journal of Preventive Medicine, 34(5), 396-403.
  3. Harris, M., & Fallot, R. (2001). Using trauma theory to design service systems. New directions for mental health services. San Francisco, CA: Jossey Bass.
  4. Fallot, R., & Harris, M. (2006). Trauma-informed services: A self-assessment and planning protocol, Version 1.4. Washington, DC: Community Connections.
  5. Substance Abuse and Mental Health Services Administration. (2014). SAMHSA's concept of trauma and guidance for a trauma-informed approach. HHS Publication No. (SMA) 14-4884. Rockville, MD: Author.

Suggested Citation

Flatow, R. B., Blake, M., & Huang, L. N. (2015). SAMHSA's Concept of Trauma and Guidance for a Trauma-Informed Approach in Youth Settings. Focal Point: Youth, Young Adults, and Mental Health, 29, 32-35. Portland, OR: Research and Training Center for Pathways to Positive Futures, Portland State University.

More Focal Point Issues