Trauma-Informed Care and Planning an Evaluation

Reactions to traumatic life events can have detrimental effects on mental health, physical functioning, spiritual health, and overall quality of life (Helms, Nicolas, & Green, 2012; Foa, 1997). This includes an increased risk of substance abuse (e.g., Breslau, 2002; Breslau et al., 2003), adrenal dysregulation, cardiovascular irregularity (Steptoe & Kivimäki, 2012), chronic depression, and suicide (http://www.ptsd.va.gov/professional/newsletters/research-quarterly/V19N4.pdf). Studies have shown that a range of different types of stressors can yield trauma reactions: for example, exposure to combat, natural disasters and catastrophes, sexual abuse, interpersonal violence, and terminal illness (Alonzo, 2000). While the manifestation of trauma and the corresponding health consequences are often discussed at the individual level, it is important to note that trauma can adversely affect entire communities and cultural groups (SAMHSA, 2012), as can be seen by the long-term effects of historical and intergenerational trauma. 

Some individuals exposed to traumatic stressors are able to effectively cope with the psychological and emotional effects of trauma and, subsequently become more resilient, but others experience significant impairment in their developmental and functional abilities.

To address the notable prevalence of trauma-related conditions in the US and the impact of traumatic stress on behavioral health [nearly 10% of the general population as defined by the DSM-V, and 16% as defined by the DSM-IV (Miller et al., 2012)], various organizations, including the US Department of Health and Human Services (HHS) and the Substance Abuse and Mental Health Services Administration (SAMHSA), have developed initiatives to support resilience and recovery for individuals, families, and communities impacted by trauma. Such initiatives (e.g., SAMHSA's Trauma and Justice Initiative) are targeted towards developing and implementing interventions and behavioral health systems of care specific to the trauma experienced by people within the community, and work to avoid re-traumatizing people through their experiences within healthcare and other public service systems (SAMHSA, 2012). Trauma-informed models have several characteristic features. They are:

  • Consistent with conceptual approaches to understanding optimal health and well-being (SAMHSA, NIMH, APA);
  • Based on principles of safety, respect, collaboration, empowerment, dignity, resilience, and change;
  • Designed to address the nature and function of symptoms and behaviors;
  • Addressing cultural, social, and historical issues.

Implemented effectively, trauma-informed models lead to improved assessment and mental/physical health treatment, enhanced recovery, reductions in recidivism, and prevention in the over-diagnosis of mental health disorders, including Bipolar Disorder and Borderline Personality Disorder. As noted by SAMHSA (2012): 

“A trauma-informed approach "realizes the widespread impact of trauma and understands potential paths for healing; recognizes the signs and symptoms of trauma in staff, clients, and others involved with the system; and responds by fully integrating knowledge about trauma into policies, procedures, practices, and settings." 

 

Evaluating Trauma-Informed Programs

In conducting program evaluation (process and treatment/service outcome evaluations), it is necessary to utilize measurement instruments and procedures that reflect an understanding of trauma (SAMHSA, 2012). The first step in this process should involve conducting an organizational self-assessment to examine the effectiveness of trauma-informed care at each   level of the organization (previously described) and to assess for policies and procedures that might be re-traumatizing. This evaluation provides an indication of how the organization or system is operating in the context of trauma by identifying both strengths and weaknesses related to the integration of trauma principles and implementation of trauma-informed care (SAMHSA, 2012). Organizational self-assessment will help to inform needed change at each level of a system (e.g., screening, referrals, discharge, etc.) and should be a continuous process that includes feedback from consumers and family members, program staff and personnel, referral sources, and community organizations and resources. SAMHSA offers a list of detailed steps and has identified useful measures in conducting culturally competent organizational self-assessment of trauma-informed care (see SAMHSA's Treatment Improvement Protocol - Improving Cultural Competence).

To evaluate the effectiveness of trauma-specific interventions, measurement instruments should be selected that are consistent with the operationalization of the specific trauma variables of interest. While research designs can vary (e.g. pre- and post-test designs, predictive analyses, repeated measures at various time points, etc.), evaluation procedures should capture changes in trauma-related physical and mental health symptoms, as well as behavioral factors such as substance use, that can be attributed to trauma-informed interventions and care.

At present, the evaluation of trauma-specific interventions and programming have become increasingly more prevalent, however, evaluation remains mainly confined to the programmatic level. Few behavioral health agencies conduct assessment of trauma-informed approaches at the organizational level, but this would be a valuable step to take, since national initiatives recommend that trauma principles become embedded in all domains of an organization or system.

 

Stay tuned for our upcoming Webinar: SAE's approach to Evaluation Design, Research and Implementation!

Next Issue Brief: Trauma Informed Care and Tools in Evaluation