Is Your Agency Trauma-Informed? Utilizing the SAMHSA Self-Assessment Tool for Excellence in Care

It’s widely recognized within behavioral health services that a significant portion of individuals seeking support have experienced trauma. However, the profound impact of these experiences often goes unacknowledged, both by the individuals themselves and by service providers. Clients may not connect their past traumas to their current challenges, or they might actively avoid discussing these painful experiences. Simultaneously, professionals might hesitate to delve into trauma histories, feeling ill-equipped to address trauma-related issues or to effectively manage traumatic stress within the constraints of their programs or agency guidelines.

To truly meet the needs of those seeking behavioral health services, it’s crucial to adopt a trauma-informed approach throughout the continuum of care. This involves creating an environment that prioritizes safety, collaboration, and compassion. It means actively preventing practices that could retraumatize individuals with trauma histories, building upon their inherent strengths and resilience, and embedding trauma-informed principles within the very fabric of an agency. A vital step in this journey is agency self-assessment. Tools like the Samhsa Trauma Informed Care Agency Self-assessment Tool are invaluable resources for organizations committed to enhancing their services and ensuring they are truly trauma-informed. This article will explore the critical aspects of trauma-informed care and how your agency can utilize self-assessment to elevate its practices and better serve those impacted by trauma.

Understanding the Scope of Trauma and Its Impact

Trauma is a pervasive issue, affecting individuals across all demographics and walks of life. While some individuals exposed to traumatic events may demonstrate remarkable resilience, many others, particularly those who have experienced repeated, chronic, or multiple traumas, are more likely to face significant and lasting consequences. These consequences can manifest as substance abuse, mental health disorders, and various physical health problems. Ultimately, trauma can deeply impact an individual’s ability to engage in essential life domains and their journey through treatment and recovery.

This understanding underscores the necessity for behavioral health service providers and administrators to be equipped with evidence-based practices and knowledge to effectively support individuals who have endured acute and chronic traumas, or who are at risk of developing traumatic stress reactions. A trauma-informed approach, guided by key principles, is essential for addressing prevention, intervention, and treatment strategies within behavioral health services. This approach must be adaptable across diverse settings, catering to individuals, families, and communities, and emphasizing the importance of integrated and coordinated service delivery.

Who Should Be Trauma-Informed? Your Intended Audience

This information is vital for a broad spectrum of professionals. It is directly relevant to behavioral health service providers, prevention specialists, and program administrators – those on the front lines of care for trauma survivors in substance abuse and mental health settings. However, the principles of trauma-informed care extend beyond these roles. Primary care professionals, including physicians, teams working with trauma-impacted clients and communities, service providers within the criminal justice system, and researchers in this field will also find this guidance invaluable. Essentially, anyone who interacts with individuals who may have experienced trauma can benefit from understanding and implementing trauma-informed practices.

Becoming Trauma-Informed: A Foundational Shift

Embracing a trauma-informed model of care represents a fundamental shift in perspective. It necessitates that behavioral health practitioners and organizations acknowledge the widespread prevalence and profound impact of trauma on the lives of those they serve. This recognition must translate into the development of trauma-sensitive and trauma-responsive services. Becoming trauma-informed is a journey that involves several key steps:

• Trauma Awareness and Knowledge: Understanding the nature of trauma and its potential effects is the first critical step. This includes recognizing the signs and symptoms of trauma and how they can manifest in diverse ways.
• Improved Screening and Assessment: Agencies need to refine their screening and assessment processes to effectively identify individuals with trauma histories. This ensures that trauma is recognized and addressed from the outset.
• Science-Informed Intervention Strategies: Implementing intervention strategies that are grounded in research and best practices is crucial. This includes both trauma-informed approaches applicable across various settings and modalities, as well as trauma-specific interventions when needed.

It’s important to note that trauma-informed services don’t necessarily equate to trauma-specific services. Trauma-informed care is a broader approach that permeates all aspects of service delivery, while trauma-specific services are specialized treatments for addressing traumatic stress reactions. Regardless of whether trauma-specific services are offered, a trauma-informed approach ensures that the potential role of trauma is considered throughout the entire continuum of care. This proactive approach fosters integrated and collaborative processes to effectively meet the needs of traumatized individuals and communities.

Individuals with trauma histories are at a significantly elevated risk for a range of co-occurring challenges. These include substance use disorders, mental health problems such as depression and anxiety, relationship difficulties, and physical health conditions like sleep disorders. Trauma-informed care recognizes these interconnected issues and aims to address them holistically. This approach emphasizes prevention, particularly selective prevention for those at risk due to trauma exposure or behavioral health conditions, and indicated prevention for individuals displaying early trauma-related symptoms. Treatment, within a trauma-informed framework, is viewed as a form of prevention, focused on building resilience, fostering safety and coping skills, and addressing co-occurring mental health and substance use disorders to promote comprehensive recovery.

Defining Trauma: A Foundational Understanding

To effectively implement trauma-informed care, it’s essential to have a clear understanding of what constitutes trauma. SAMHSA’s Trauma and Justice Strategic Initiative defines trauma as:

“…resulting from an event, series of events, or set of circumstances that is experienced by an individual as physically or emotionally harmful or threatening and that has lasting adverse effects on the individual’s functioning and physical, social, emotional, or spiritual well-being.” (SAMHSA, 2012, p. 2)

This definition highlights several key aspects of trauma:

• Wide Reach: Trauma affects people of all backgrounds – race, ethnicity, age, sexual orientation, gender, and socioeconomic status.
• Varied Forms: Traumatic experiences can range from single events to a series of events or chronic conditions like childhood neglect or domestic violence.
• Multi-Level Impact: Trauma can impact individuals, families, groups, communities, cultures, and even generations.
• Overwhelming Nature: Trauma often overwhelms an individual’s or community’s ability to cope and triggers the “fight, flight, or freeze” response.
• Emotional Aftermath: It frequently leads to feelings of fear, vulnerability, and helplessness.

Traumatic events are often unexpected and can be experienced directly, witnessed, felt as a threat, or even learned about through the experiences of others. These events can be human-made, such as violence, abuse, or disasters, or they can be natural disasters. Trauma can occur at any age, and events that deviate from expected life stages can be particularly traumatic.

Crucially, the determination of whether an event is traumatic is not solely based on the event itself, but also on the individual’s experience of the event. The same event can be experienced and interpreted very differently by different people. Biopsychosocial and cultural factors play a significant role in shaping both immediate and long-term reactions to trauma. Resilience, the ability to overcome adversity and challenges, is a vital factor in navigating the effects of trauma.

Reactions to trauma can be temporary for some, while others experience prolonged reactions that can evolve into more severe mental health consequences like PTSD, anxiety disorders, substance use disorders, and physical health problems. Even when individuals don’t meet the diagnostic criteria for trauma-related disorders, trauma can still significantly impact their lives. Recognizing the diverse ways trauma can manifest and affect individuals is paramount in providing effective behavioral health services.

Why Trauma Matters in Behavioral Health Services

Over the past decade, there has been a growing awareness of the profound links between trauma, psychological distress, quality of life, health, mental illness, and substance abuse. Events like the September 11th attacks, wars, natural disasters, and abuse scandals have brought trauma into the public consciousness. No longer considered an abnormal experience, trauma is now recognized as a prevalent reality in many lives.

Studies, such as the National Comorbidity Study, have revealed the widespread nature of trauma. This study found that a significant majority of adults have experienced at least one traumatic event in their lifetime. Subsequent research, like the National Epidemiologic Survey on Alcohol and Related Conditions, further emphasizes these findings, highlighting the prevalence of witnessed trauma, physical injury trauma, and psychological trauma.

The Rationale for Trauma-Informed Care (TIC)

Integrating TIC into behavioral health services offers substantial benefits for clients, their families, communities, organizations, and staff. Trauma-informed services are rooted in the understanding that trauma can have a pervasive impact on an individual’s overall well-being, including both physical and mental health.

For behavioral health providers, TIC offers numerous advantages:

• Emphasis on Specialized Knowledge and Skills: TIC underscores the importance of acquiring trauma-specific knowledge and skills to effectively meet the unique needs of clients with trauma histories.
• Universal Trauma Awareness: It promotes the recognition that individuals may be affected by trauma, regardless of whether it has been explicitly disclosed or acknowledged.
• Prevalence Recognition: TIC highlights the likelihood that a significant portion of clients seeking behavioral health services have experienced trauma.
• Prevention of Retraumatization: It acknowledges that organizational policies and practices can inadvertently retraumatize clients, and emphasizes the need to proactively prevent this.
• Individualized Approach: TIC stresses the importance of tailoring services to the individual client, rather than applying generic treatment approaches.

For clients, TIC provides a more compassionate and understanding service experience. It can foster a greater sense of safety for those with trauma histories and create a foundation for preventing more severe consequences of traumatic stress. Even for clients who may not initially recognize the connection to their trauma history, trauma-informed services offer an opportunity to explore the impact of trauma, acknowledge their strengths and adaptive coping mechanisms, build resilience, and understand the complex relationships between trauma, substance use, and psychological symptoms.

Groundbreaking Studies Shaping TIC Development

Two landmark studies have been particularly influential in shaping the development and understanding of trauma-informed care:

• The Adverse Childhood Experiences (ACE) Study: This large-scale epidemiological study involving over 17,000 individuals analyzed the long-term impact of childhood and adolescent traumatic experiences on adult health risks, mental health, healthcare costs, and life expectancy. The ACE study provided compelling evidence of the profound and lasting effects of childhood trauma.
• The Women, Co-Occurring Disorders and Violence Study: This multisite study focused on women and explored the interconnectedness of trauma, violence, and co-occurring substance use and mental disorders. It emphasized the importance of incorporating trauma-informed and trauma-specific principles, models, and services in addressing the needs of women with these complex challenges.

These studies, along with extensive clinical experience and ongoing research, have solidified the rationale for and principles of trauma-informed care.

Enhancing Services Through Trauma-Informed Implementation

Implementing trauma-informed services offers a multitude of improvements across various aspects of behavioral health care. It can lead to enhanced screening and assessment processes, more effective treatment planning, and more appropriate service placement. Crucially, it significantly reduces the risk of retraumatization within the service environment.

Trauma-informed care fosters improved communication between clients and providers, minimizing misunderstandings of client reactions and presenting problems, and ensuring appropriate referrals for specialized evaluation or trauma-specific treatment when needed. Organizational investment in developing trauma-informed services can also translate to cost-effectiveness by ensuring that clients receive services that are better matched to their needs from the outset.

TIC is also a critical component of organizational risk management. It ensures that decisions are made with the goal of optimizing therapeutic outcomes while minimizing potential harm to clients and the organization. A core principle of TIC is the active engagement of the community, clients, and staff in the development and delivery of services. When clients and staff are empowered and involved in the process, they are more likely to be invested in and satisfied with the services provided.

Organizations that prioritize trauma-informed care also benefit from improved workforce development. By attracting and retaining a diverse workforce knowledgeable about trauma and its impact, agencies can build a stronger and more capable team. Trauma-informed organizations invest in their staff, adopting similar trauma-informed principles internally, providing ongoing support to promote TIC in practice, addressing secondary trauma, and fostering a safe environment for staff well-being. While investing in a trauma-informed workforce doesn’t guarantee perfect trauma-informed practices, it significantly increases the likelihood that services will evolve to effectively meet the needs of clients, staff, and the community.

Advice to Counselors: The Foundational Importance of TIC

The pervasive nature of trauma raises critical clinical considerations. Many counselors may lack extensive training in trauma-informed care or trauma-specific treatments, leading to uncertainty about how to respond to clients’ trauma-related reactions or symptoms. Some counselors may have personal trauma histories that could be triggered by clients’ narratives. Others, while eager to help, may inadvertently cause harm by delving too quickly into trauma material or by dismissing or minimizing a client’s trauma experiences. It is essential for counselors to be well-versed in trauma-related symptoms and disorders and their impact on clients in behavioral health treatment.

Counselors with direct treatment responsibilities should develop skills in:

• Recognizing Trauma-Related Reactions: Identifying the signs and symptoms of traumatic stress in clients.
• Integrating Trauma-Informed Interventions: Incorporating strategies to address trauma-related symptoms into client treatment plans.
• Building Client Safety Nets: Assisting clients in developing safety plans to prevent further trauma exposure.
• Conducting Psychoeducational Interventions: Providing clients with information and education about trauma and its effects.
• Making Appropriate Referrals: Knowing when and how to refer clients for further evaluation or trauma-specific treatment services.

All treatment staff must understand that trauma-related symptoms or disorders should not be a barrier to accessing mental health or substance abuse treatment. Co-occurring disorders must be addressed comprehensively within the treatment plan and setting. For instance, helping a client in substance abuse treatment manage trauma-related symptoms can significantly improve their chances of recovery and reduce the risk of relapse. Conversely, achieving abstinence in substance use provides a stable foundation for addressing and recovering from traumatic stress.

Trauma and Substance Use Disorders: An Intertwined Reality

A significant number of individuals with substance use disorders have experienced trauma in childhood or adulthood. Substance abuse itself can increase the risk of trauma exposure due to dangerous situations, accidents while under the influence, and lifestyle factors associated with substance abuse. Furthermore, individuals with co-occurring substance abuse and trauma histories often experience poorer treatment outcomes compared to those without trauma histories. This makes the recovery process more challenging and underscores the crucial role of counselors in addressing both issues concurrently.

Individuals presenting with both trauma and substance use disorders may face a complex array of challenges, including co-occurring mental health symptoms or disorders, poverty, homelessness, increased risk of HIV and other infections, and limited social support. Many seeking substance use treatment have experienced one or more traumas, with a significant proportion of women in substance abuse treatment reporting lifetime trauma exposure. Inpatient treatment settings also often see a high prevalence of clients with subclinical traumatic stress symptoms or PTSD.

Trauma and Mental Disorders: A Significant Comorbidity

Individuals receiving treatment for severe mental disorders are also significantly more likely to have histories of trauma. This can include childhood physical and sexual abuse, serious accidents, homelessness, involuntary psychiatric hospitalizations, interpersonal violence, and other forms of violence. Many clients with severe mental disorders meet criteria for PTSD, while others may present with psychological symptoms or mental disorders commonly associated with trauma, such as anxiety disorders, mood disorders (depression, bipolar disorder), impulse control disorders, and substance use disorders.

Traumatic stress is a significant risk factor for mental illness, and research suggests it can also exacerbate the severity of mental illness symptoms. This highlights the crucial role of trauma in the development and perpetuation of mental disorders. Similar to the relationship between trauma and substance use disorders, there is a bidirectional link: mental illness can increase the risk of experiencing trauma, and trauma significantly increases the risk of developing psychological symptoms and mental disorders. Recognizing these complex interconnections is vital for effective and holistic behavioral health care.

Trauma-Informed Intervention and Treatment Principles: A Practical Framework

Trauma-informed care is not just a set of techniques; it’s a fundamental intervention and organizational approach that centers on understanding how trauma impacts an individual’s life and their engagement with behavioral health services, from prevention to treatment. While definitions of TIC and models for implementation may vary, a core set of elements remains consistent. A trauma-informed approach fundamentally involves:

1. Realizing the Prevalence of Trauma: Acknowledging the widespread occurrence of trauma and its potential impact on individuals and communities.
2. Recognizing Trauma’s Impact: Understanding how trauma affects all individuals involved in a program, organization, or system, including staff.
3. Responding by Putting Knowledge into Practice: Actively integrating this knowledge into policies, procedures, practices, and settings to create a trauma-sensitive environment. (SAMHSA, 2012, p. 4)

TIC begins with the very first contact a person has with an agency. It requires all staff, from receptionists to administrators and board members, to recognize that a client’s trauma experience can profoundly influence their receptivity to services, interactions with staff and clients, and adherence to program guidelines. TIC necessitates program policies, procedures, and practices that safeguard the vulnerabilities of both clients and staff who have experienced trauma or provide trauma-related services. A supportive environment, designed with consumer participation, is essential to prevent retraumatizing practices. The ethical principle of “first, do no harm” is paramount in TIC.

“A program, organization, or system that is trauma-informed 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.” (SAMHSA, 2012, p. 4)

TIC involves a continuous commitment to staff competence and the establishment of programmatic standards and clinical guidelines that support trauma-sensitive service delivery. This includes:

• Competent Staff Recruitment and Retention: Hiring and retaining staff who are knowledgeable and trained in trauma-informed practices at all levels of the organization.
• Consumer and Survivor Involvement: Actively involving consumers, trauma survivors, and peer support specialists in the planning, implementation, and evaluation of trauma-informed services.
• Cross-System Collaboration: Developing collaborations across service systems to streamline referrals and ensure access to trauma-specific services when needed.
• Continuity of Care: Building a system that ensures continuity of trauma-informed care as clients transition between different services or systems.
• Re-evaluation of Service Delivery: Routinely re-evaluating each component of service delivery through a trauma-aware lens.

The principles outlined below serve as a practical framework for implementing TIC. They are drawn from research, theoretical frameworks, clinical experience, and lessons learned from treatment facilities. While these principles are broadly applicable, they are especially critical when working with individuals who have experienced trauma.

Advice to Counselors: Implementing Trauma-Informed Services Practically

Recognizing the widespread impact of trauma, the National Center for Trauma-Informed Care (NCTIC) has developed a comprehensive framework to guide systems of care in establishing trauma-informed services. A system or program committed to supporting trauma survivors must take a systematic approach that encompasses trauma-specific diagnostic and treatment services, as well as a trauma-informed environment to sustain these services and foster positive client outcomes. NCTIC offers valuable technical assistance in implementing trauma-informed services. For detailed administrative guidance on TIC implementation, refer to Part 2, Chapters 1 and 2 of the original TIP document.

Key Principles of Trauma-Informed Care: A Detailed Exploration

The following principles provide a roadmap for agencies seeking to become truly trauma-informed. These principles can also serve as a framework for self-assessment, helping agencies identify areas of strength and areas for improvement. The SAMHSA trauma informed care agency self-assessment tool likely aligns with and assesses these core principles.

1. Promote Trauma Awareness and Understanding

The cornerstone of trauma-informed care is recognizing the prevalence of trauma and its potential impact on every facet of an individual’s well-being – emotional, behavioral, cognitive, spiritual, and physical. Being trauma-aware means being vigilant about the potential for past trauma to influence a client’s presentation and engagement with services. While not every client will have a trauma history, statistically, individuals with substance use and mental disorders are more likely to have experienced trauma. Trauma awareness is not about assuming everyone is traumatized, but rather, approaching every interaction with an understanding of this possibility, from initial contact through intake and assessment.

Even standard behavioral health practices can inadvertently retraumatize someone with a trauma history if implemented without trauma awareness. For example, recommending group therapy for a female client with a rape history without considering the group’s composition and dynamics could be retraumatizing. Trauma awareness is crucial for preventing such unintentional harm and prompts providers to critically re-evaluate their routine practices.

“Trauma-informed care embraces a perspective that highlights adaptation over symptoms and resilience over pathology.” (Elliot, Bjelajac, Fallot, Markoff, & Reed, 2005, p. 467)

Trauma awareness extends beyond recognizing trauma’s impact on clients. It encompasses a broader understanding that trauma’s effects can ripple outwards to significant others, family members, first responders, behavioral health workers, and even entire communities. Family members of traumatized individuals frequently experience secondary traumatic stress reactions. These vicarious experiences can increase the risk of secondary trauma and mental illness within the family and impact children’s development and future trauma risk. Prevention and intervention services can play a vital role in providing education and age-appropriate programs to build coping skills and support systems within families and communities.

Behavioral health providers themselves can be impacted by exposure to trauma-related content when working with clients. A trauma-aware workplace supports supervision and program practices that educate staff about secondary trauma, encourages processing trauma-related content through peer support and clinical supervision, and provides professional development opportunities in effective coping strategies. Creating trauma awareness within agencies requires ongoing staff training, sustained supervisory and administrative support, collaborative program design and implementation (involving consumer participation), and organizational policies that are flexible and responsive to the needs of trauma-impacted clients.

Self-Assessment Questions for Agencies:

• Does your agency provide regular training to all staff on trauma awareness and the impact of trauma?
• Are trauma statistics and prevalence data incorporated into staff education and program materials?
• Do your intake and initial contact procedures reflect trauma awareness and sensitivity?
• Does your agency have mechanisms to assess and address secondary trauma among staff?

2. Recognize That Trauma-Related Symptoms and Behaviors Originate From Adapting to Traumatic Experiences

A core principle of trauma-informed care is understanding that trauma-related symptoms and behaviors are not signs of pathology or weakness, but rather, an individual’s most resilient attempts to manage, cope with, and survive traumatic experiences. These are adaptive responses developed in the face of overwhelming adversity. While some coping strategies may be more effective than others in the long term, they all represent an effort to survive.

Individuals who have experienced trauma exhibit a wide range of traumatic stress reactions that vary in severity depending on factors such as the nature of the trauma, individual history, developmental stage, sociocultural context, and available resources. These reactions can profoundly influence how individuals respond to their environment, relationships, interventions, and treatment services. They can also shape fundamental assumptions about the world, others, their future, and themselves. These effects can be readily apparent or more subtle.

Shifting from a “pathology” mindset to a “resilience” mindset is transformative. Instead of labeling clients solely by diagnostic categories, a trauma-informed perspective views their presenting difficulties as understandable responses to surviving trauma. Traumatic stress reactions are seen as normal responses to abnormal situations. This understanding fosters a hopeful, strengths-based approach that recognizes clients’ inherent resilience, creativity, self-preservation, and determination.

This perspective is crucial for building collaborative therapeutic relationships. It allows providers to engage with clients in a non-judgmental way, exploring what coping mechanisms have and haven’t worked, and collaboratively developing intervention strategies that align with their strengths and resources. This resilience-focused approach prevents retraumatization by reframing traumatic stress reactions not as pathology, but as adaptive responses to adversity.

Self-Assessment Questions for Agencies:

• Does your agency’s philosophy and training emphasize viewing client symptoms as adaptive responses to trauma?
• Are staff trained to identify and understand the underlying reasons for trauma-related behaviors?
• Are treatment plans developed with a focus on client strengths and adaptive capacities?
• Does your agency actively challenge pathologizing language and approaches in client care?

3. View Trauma in the Context of Individuals’ Environments

Understanding trauma requires considering the broader context in which it occurs. Trauma is not solely an individual experience; it is shaped by a complex interplay of factors including individual attributes, developmental stage, life history, type of trauma, sociocultural context, available resources, and community responses. A narrow focus on individual characteristics alone is insufficient.

To truly understand trauma, it must be viewed through a contextual lens that integrates biopsychosocial, interpersonal, community, and societal characteristics. This includes factors present before, during, and after the trauma, as well as the short- and long-term effects, such as housing stability, community support, and family dynamics.

A social-ecological framework is particularly helpful in understanding trauma. This framework emphasizes:

• Environmental Influence: Environmental factors significantly impact emotional, physical, and social well-being.
• Person-Environment Fit: Health and illness are determined by the degree of fit between an individual’s needs and available resources.
• Multi-Level Interventions: Effective approaches integrate strategies targeting individual, interpersonal, and community systems. (Stokols, 1996)

This social-ecological model considers multiple levels of influence:

• Individual: Biopsychosocial characteristics.
• Interpersonal: Immediate relationships (family, friends, peers).
• Community/Organizational: Social support networks, workplaces, neighborhoods, institutions.
• Societal: State and federal policies, laws, social norms, governmental systems.
• Period of Time in History: The historical context in which the trauma occurs.

This model highlights the bidirectional influence of these levels on behavioral health service delivery. It emphasizes the importance of considering both risk factors and protective factors at each level. Culture, developmental stage, and the specific historical era also significantly shape trauma perception, help-seeking behaviors, and resource availability.

Self-Assessment Questions for Agencies:

• Does your agency’s assessment process consider the individual’s social-ecological context?
• Are staff trained to understand the impact of cultural, community, and societal factors on trauma responses?
• Do treatment plans address environmental factors that may contribute to or mitigate trauma’s impact?
• Does your agency collaborate with community resources and systems to provide comprehensive support?

4. Minimize the Risk of Retraumatization or Replicating Prior Trauma Dynamics

Trauma-informed providers are acutely aware that treatment procedures and practices can inadvertently trigger past trauma experiences and be perceived as retraumatizing. Clients may experience feelings of powerlessness, being trapped, or unsafety if treatment processes or provider behaviors mirror aspects of their past trauma. Potentially retraumatizing elements can include seclusion, mislabeling symptoms as personality disorders, authoritarian interactions, humiliating assignments, confrontational approaches, or conditional treatment based on provider beliefs.

Even seemingly safe and standard policies and procedures, including physical plant operations, can be retraumatizing if they resonate with a client’s trauma history. Examples include limited privacy, isolating interview rooms, physical examinations by someone resembling a perpetrator, group sessions with triggering content, or being discouraged from discussing distressing experiences.

While some practices are more obviously triggering, all standard practices should be evaluated for their potential to retraumatize. This requires understanding the specifics of each client’s trauma history. Consider a client who refuses to eat program meals and expresses anger toward dietary staff. Initially, this might be interpreted as an eating disorder or behavioral problem. However, a trauma-aware perspective might reveal a history of childhood neglect and abuse related to food, where meals were prepared haphazardly and forced upon him.

Self-Assessment Questions for Agencies:

• Does your agency have a process for identifying and evaluating potentially retraumatizing practices?
• Are staff trained to recognize signs of retraumatization in clients?
• Are clients actively involved in treatment planning and decision-making to maximize their sense of control?
• Does your agency regularly solicit client feedback on the safety and comfort of the treatment environment and procedures?

5. Create a Safe Environment

Creating a safe environment is paramount in trauma-informed care, extending beyond basic physical safety. It involves an agency-wide effort supported by effective policies and procedures. Safety within a trauma-informed framework encompasses:

• Physical Plant Safety: Addressing facility, environmental, and space-related concerns.
• Security: Ensuring the security of staff, clients, and personal property.
• Policies and Procedures: Including those specific to seclusion, restraint, emergency management, disaster planning, and client rights.
• Emotional Safety: Adapting the environment to foster a sense of emotional safety and responsiveness to clients’ needs.

Creating emotional safety involves anticipating potential triggers within the program environment (lighting, exits, seating, emotionality in groups, visual or auditory stimuli) and implementing strategies to help clients cope with these triggers. Consistency in client interactions and treatment processes, following through on agreements, and dependability are also crucial for building safety.

When inconsistencies or errors occur (as they inevitably will), honest and compassionate communication that conveys a sense of working through the situation together is essential for maintaining safety. Safety must extend to staff as well. Counselors and behavioral health staff need to feel safe and supported within the agency environment and be able to rely on the agency to maintain their safety. An organizational ethos that prioritizes both physical and emotional well-being for clients and staff is essential. This culture encourages staff to seek support and supervision when needed and to adhere to clinical and programmatic practices that minimize risks for everyone.

Self-Assessment Questions for Agencies:

• Does your agency prioritize creating both physical and emotional safety for clients and staff?
• Are staff trained to identify and respond to client triggers and emotional distress?
• Are agency policies and procedures consistently implemented and communicated to clients and staff?
• Does your agency have mechanisms for staff to access support and supervision to process challenging situations and maintain their well-being?

6. Identify Recovery From Trauma as a Primary Goal

Individuals entering behavioral health services may not always recognize their trauma experiences as a significant factor in their current challenges. This can be due to reluctance to revisit painful memories, a belief that trauma is in the past and no longer relevant, or a lack of awareness of the connection between trauma and their presenting problems. Even those who are aware of trauma’s impact may struggle to connect past events to their current choices, behaviors, and emotions. This makes it challenging for some clients to see the value of trauma-informed or trauma-specific interventions.

As a trauma-informed provider, it is vital to help clients bridge the gap between their mental health and substance use issues and their potential trauma histories. Trauma often precedes substance use and mental disorders, and these disorders can create further opportunities for traumatic events. If trauma is not addressed within mental health and substance abuse treatment, long-term recovery is less likely. Collaboration within and between agencies is crucial to provide integrated, timely, and trauma-specific interventions from the outset for clients engaged in behavioral health services.

Self-Assessment Questions for Agencies:

• Does your agency explicitly state recovery from trauma as a primary goal within its mission and values?
• Are staff trained to help clients understand the connection between trauma and their presenting problems?
• Do treatment plans routinely incorporate trauma-informed goals and interventions?
• Does your agency have referral pathways and collaborations to ensure access to trauma-specific services when needed?

7. Support Control, Choice, and Autonomy

Not all clients with trauma histories will immediately embrace trauma-informed or trauma-specific treatment. They may believe they have already dealt with their trauma, minimize its current impact, or fear revisiting painful experiences. Others may be eager to disclose trauma experiences prematurely before establishing safety or developing coping skills. Clients present with diverse reactions, levels of trauma awareness, and urgency in addressing trauma.

It is essential to respect clients’ perceptions of their problems and view their responses to trauma’s impact as adaptive, even when those methods may seem detrimental. Engaging with clients to understand their experiences and adaptations conveys the message that they are experts in their own lives. This shifts the dynamic from “providers know best” to a collaborative “together, we can find solutions” approach.

Traumatic experiences often involve feelings of intense fear, helplessness, horror, and loss of control. Behavioral health services should not replicate these dynamics. Working collaboratively to maximize clients’ sense of control, autonomy, and choice throughout the treatment process, including treatment planning, is crucial in trauma-informed care. For some, regaining a sense of control and empowerment, alongside understanding traumatic stress reactions, can be pivotal for recovery.

Creating opportunities for empowerment reinforces clients’ sense of competence, often eroded by trauma. Prioritizing client choice and control applies not only to major treatment decisions but also to everyday interactions. Simple questions can empower clients:

• “What information would be helpful for us to know about what happened to you?”
• “Where/when would you like us to call you?”
• “How would you like to be addressed?”
• “Of the services I’ve described, which seem to match your needs?”
• “From your experience, what responses from others work best when you feel overwhelmed?”

Organizations must also foster staff autonomy, choice, and control. Staff should have access to resources and choices in processing emotionally charged content or events. Administrators and supervisors should solicit feedback on handling challenging situations. A parallel exists between administration-staff interactions and staff-client interactions: empowered staff are better equipped to value client empowerment.

Self-Assessment Questions for Agencies:

• Does your agency’s philosophy and practice emphasize client choice, control, and autonomy?
• Are clients actively involved in treatment planning and goal setting?
• Are staff trained to empower clients and promote their sense of agency?
• Does your agency also prioritize staff autonomy and empowerment in decision-making and service delivery?

8. Create Collaborative Relationships and Participation Opportunities

This principle has three key components:

• Collaborative Provider-Client Relationships: Ensure that the provider-client relationship is collaborative, regardless of setting or service. Care plans and treatment plans should be developed collaboratively with the client and, when appropriate, with family and caregivers. TIC views clients as experts in their own lives, emphasizing mutual learning between clients and providers.
• Collaboration Beyond the Client Relationship: Build ongoing relationships across service systems, provider networks, and the local community. This enhances TIC continuity as clients move between services and facilitates access to resources and trauma-specific expertise.
• Client/Consumer Participation in Program Development: Ensure client/consumer representation and participation in program development, planning, evaluation, and staff professional development. Clients must play an active role in achieving trauma-informed competence, starting with providing program feedback and extending to involvement in planning and improving trauma-informed services, policies, and procedures.

Trauma-informed principles and practices developed without input from those affected by trauma are less likely to be effective. Staff trainings should include individuals with lived experience of trauma. Their participation provides a personal perspective on resilience and strengths, moving beyond purely cognitive learning. Consumer participation also means offering opportunities for clients to become certified and employed as peer specialists in behavioral health settings.

Programs incorporating peer support services reinforce the importance of provider-consumer partnership and value consumers’ contributions. Peer support specialists, individuals with lived recovery experience, assist others with similar challenges, leading peer support groups, modeling coping skills, promoting self-care, and offering hope for recovery.

Self-Assessment Questions for Agencies:

• Does your agency actively promote collaborative relationships between staff and clients?
• Are clients and consumers involved in program planning, development, and evaluation?
• Does your agency have partnerships and collaborations with other service providers and community organizations?
• Does your agency utilize peer support specialists and value their lived experience?

9. Familiarize the Client With Trauma-Informed Services

It’s easy for providers to forget that many aspects of behavioral health services are unfamiliar to clients and their families. Introducing clients to program services, activities, and interventions with the assumption of unfamiliarity is essential. Educating clients about each process, from initial contact to recovery services, empowers them to actively participate and make informed decisions throughout their care journey.

Familiarizing clients with trauma-informed services goes beyond explaining program logistics. It includes explaining the value of trauma-related questions during intake, providing psychoeducation about trauma to normalize traumatic stress reactions, and discussing trauma-specific interventions and available services (including treatment methodologies and rationales). Developmentally appropriate psychoeducation ensures clients are informed participants in their care.

Self-Assessment Questions for Agencies:

• Does your agency have clear and accessible materials that explain trauma-informed care to clients?
• Are staff trained to explain program processes and interventions in a client-friendly manner?
• Is psychoeducation about trauma routinely offered to clients to normalize their experiences and reactions?
• Does your agency provide information to clients about available trauma-specific services and resources?

10. Incorporate Universal Routine Screenings for Trauma

Universal routine screening for trauma histories, experiences, and symptoms at intake benefits both clients and providers. It serves as a consistent reminder of trauma’s prevalence and potential influence, prompting providers to be vigilant for past trauma and its impact on client engagement across the continuum of care. Screening should inform treatment planning, alert staff to potential issues, and increase clients’ awareness of trauma’s possible effects and the importance of addressing related issues in treatment.

However, screenings are only effective with clear guidelines and processes for responding to positive screens. Staff must be trained to use screening tools consistently, ensuring uniform application across all clients. They also need to understand scoring, and how factors like race/ethnicity, language, gender, and culture can influence results. For instance, a female sexual assault survivor may be hesitant to answer questions if a male staff member or interpreter administers the screening. Individuals in abusive relationships may not disclose interpersonal violence due to fear or denial.

Staff training on trauma screening tools must include guidance on gathering relevant information after a positive screen. Organizational policies should guide staff responses to positive screens, such as referrals for in-depth trauma assessments, psychoeducational sessions on trauma’s effects, and care coordination for access to trauma-specific services. Screening tool selection is crucial. Tools vary in format and question presentation. Selection should consider sound test properties, breadth of traumatic experiences covered, and flexibility for individual interpretation of traumatic events.

Self-Assessment Questions for Agencies:

• Does your agency have a policy of universal routine trauma screening at intake?
• Are staff trained on how to administer, score, and interpret trauma screening tools?
• Are there clear protocols for responding to positive trauma screens, including referral pathways and follow-up procedures?
• Are screening tools regularly reviewed and updated to ensure cultural sensitivity and appropriateness?

11. View Trauma Through a Sociocultural Lens

Understanding trauma’s impact on an individual, family, or community requires recognizing life experiences and cultural background as key contextual elements. Culture significantly shapes the interpretation and meaning of traumatic events, beliefs about personal responsibility, and the acceptability of symptoms, support, and help-seeking behaviors.

Some populations and cultures are more likely to experience certain types of trauma. Culture influences whether events are perceived as traumatic and how individuals interpret and assign meaning to trauma. Certain traumas may have a greater impact on specific cultures if they disrupt cultural practices or ways of life. Culture dictates acceptable responses to trauma and shapes the expression of distress, influencing behavior, emotions, and thinking both immediately and long after the event. Traumatic stress symptoms can vary based on trauma type within a culture. Culture defines what constitutes a legitimate health concern and which symptoms warrant help, shaping beliefs about acceptable help-seeking behaviors and healing practices. Culture can also be a source of strength, providing unique coping strategies and resources.

Culturally responsive practices must be integrated into behavioral health systems, service provider training, licensing agencies, and accreditation bodies. This includes incorporating cultural responsiveness into curricula, standards, policies, procedures, and credentialing processes. Culturally responsive practices guide treatment planning to ensure trauma-informed services are appropriate and effective across diverse populations.

Self-Assessment Questions for Agencies:

• Does your agency prioritize cultural competency and cultural responsiveness in trauma-informed care?
• Are staff trained to understand the influence of culture on trauma experiences, responses, and help-seeking behaviors?
• Are services adapted to be culturally appropriate and accessible to diverse communities?
• Does your agency actively seek to understand and address cultural factors in treatment planning and service delivery?

12. Use a Strengths-Focused Perspective: Promote Resilience

Fostering individual strengths is essential in trauma prevention and intervention. It builds upon existing resources and views individuals as resourceful and resilient survivors. Trauma survivors develop diverse strategies and behaviors to adapt to trauma’s consequences. While some are effective long-term, others may create difficulties.

Traditional behavioral health services often focus on problems, risk factors, and symptoms. While important, overemphasizing these areas can undermine clients’ sense of competence and hope. Focusing only on problems misses the opportunity to recognize clients’ resourcefulness in managing stressful experiences. A balanced approach targets both problems and strengths, acknowledging clients’ resilience and adaptive behaviors. A strengths-based, resilience-minded approach allows survivors to recognize and appreciate their fortitude and survival strategies.

“Trauma-informed care recognizes symptoms as originating from adaptations to the traumatic event(s) or context. Validating resilience is important even when past coping behaviors are now causing problems. Understanding a symptom as an adaptation reduces a survivor’s guilt and shame, increases their self-esteem and provides a guideline for developing new skills and resources to allow new and better adaptation to the current situation.” (Elliot et al., 2005, p. 467)

Self-Assessment Questions for Agencies:

• Does your agency’s approach emphasize a strengths-based perspective and promote client resilience?
• Are staff trained to identify and build upon client strengths in assessment and treatment planning?
• Are strengths-based questions routinely incorporated into client interactions and sessions?
• Does your agency culture celebrate client resilience and adaptive capacities?

13. Foster Trauma-Resistant Skills

Trauma-informed services build a foundation for clients to explore trauma’s role in their lives and tailor interventions to their needs. Prevention, mental health, and substance abuse services should educate clients about trauma’s effects and focus on developing self-care skills, coping strategies, support networks, and a sense of competence. Building trauma-resistant skills begins with normalizing traumatic stress symptoms and helping clients connect current problems with past trauma.

However, skill-building in TIC should not overshadow acknowledging individual strengths, adaptive creativity, and inherent resources. Some skill-building models are deficit-based, assuming individuals lack necessary tools and must learn new skills to recover. TIC, conversely, assumes clients are experts in their lives, have already adapted, and acquired survival skills. TIC honors these adaptations and helps clients explore if these strategies are still effective and if other, more helpful strategies might be beneficial.

Self-Assessment Questions for Agencies:

• Does your agency integrate skill-building interventions that promote trauma-resistant skills?
• Are staff trained to teach clients self-care, coping strategies, and build support networks?
• Is psychoeducation about trauma and its effects a routine component of your services?
• Does your agency balance skill-building with recognition of client strengths and adaptive capacities?

14. Demonstrate Organizational and Administrative Commitment to TIC

Becoming a trauma-informed organization requires administrative leadership and support at all levels. Staff are unlikely to sustain TIC practices without ongoing organizational commitment to professional development and resource allocation. Agencies committed to TIC benefit from assessing how staff identify and manage trauma and trauma-related reactions. Are staff trauma-aware, recognizing trauma’s significant impact on client functioning and service engagement?

Agencies need to implement specific strategies at every organizational level to create trauma-informed services. This begins with staff education on trauma’s impact. Other strategies include:

• Universal trauma screening and assessment procedures.
• Interagency and intra-agency collaboration for trauma-specific services.
• Referral agreements and networks to match client needs.
• Mission and value statements endorsing trauma recognition.
• Consumer- and community-supported committees and trauma response teams.
• Workforce development strategies, including hiring practices.
• Professional development plans, including TIC-focused staff training and supervision.
• Program policies and procedures ensuring trauma recognition, trauma-informed practices, trauma-specific services, and prevention of retraumatization.

TIC requires organizational commitment and often, cultural change.

Self-Assessment Questions for Agencies:

• Does your agency leadership demonstrate a clear and visible commitment to trauma-informed care?
• Is TIC integrated into your agency’s mission, values, and strategic plan?
• Are resources allocated to support trauma-informed training, implementation, and ongoing quality improvement?
• Does your agency have a designated TIC champion or committee to guide and oversee implementation efforts?

15. Develop Strategies To Address Secondary Trauma and Promote Self-Care

Secondary trauma is a recognized occupational hazard for behavioral health professionals, especially those working with trauma survivors. Staff members experiencing secondary trauma can exhibit a range of traumatic stress reactions from providing trauma-focused services or listening to trauma narratives. Counselors with personal trauma histories may be particularly vulnerable to secondary traumatization when working with trauma survivors.

Secondary trauma symptoms can be similar to primary trauma symptoms, causing varying levels of distress and impairment. Symptoms may include physical or psychological reactions to client trauma memories, avoidance, emotional numbing, somatic complaints, heightened arousal, negative thinking, and detachment from supports.

Working daily with traumatized individuals can be burdensome, and staff may attribute secondary trauma symptoms to other stressors. Despite growing awareness of secondary trauma and compassion fatigue, agencies often lack routine prevention practices. Staff may struggle to prioritize self-care due to workload, time constraints, lack of resources, or an organizational culture that discourages help-seeking. However, neglecting secondary trauma can impair provider effectiveness and potentially harm clients through boundary violations, missed appointments, or client abandonment.

TIC must include organizational and individual strategies to address secondary trauma and its consequences. Agencies need to foster a culture that promotes acceptability, accessibility, and accountability in seeking help, accessing supervision, and engaging in self-care. Agencies should involve staff working with trauma in developing formal and informal practices to prevent and address secondary trauma. Prevention strategies can be integrated into existing agency structures like staff meetings, case consultations, and supervision.

Self-Assessment Questions for Agencies:

• Does your agency recognize and address secondary trauma as an occupational hazard for staff?
• Are staff trained to recognize and respond to secondary trauma symptoms in themselves and colleagues?
• Does your agency have policies and procedures that promote staff self-care and well-being?
• Are resources available for staff to access support, supervision, and professional development related to secondary trauma prevention and management?

Utilizing the SAMHSA Trauma Informed Care Agency Self-Assessment Tool

The principles outlined above provide a strong foundation for understanding trauma-informed care. To effectively translate these principles into practice and ensure your agency is truly trauma-informed, utilizing a self-assessment tool is invaluable. The SAMHSA trauma informed care agency self-assessment tool is a resource designed to help organizations like yours evaluate their current practices and identify areas for growth.

While the specific content of the SAMHSA tool would need to be reviewed directly, it likely incorporates elements that align with the principles discussed. Such a tool would likely guide your agency through a systematic process of examining:

• Policies and Procedures: Do your agency’s written policies and procedures reflect trauma-informed principles across all departments and services?
• Staff Training and Development: Is trauma-informed care a core component of staff training at all levels? Is there ongoing professional development to enhance staff knowledge and skills in this area?
• Screening and Assessment Practices: Are your screening and assessment processes trauma-informed, universal, and effective in identifying clients with trauma histories?
• Treatment Planning and Service Delivery: Are treatment plans individualized, collaborative, strengths-based, and trauma-sensitive? Are services delivered in a way that minimizes retraumatization and promotes safety, choice, and control?
• Organizational Culture and Environment: Does your agency culture promote trauma awareness, staff well-being, and a commitment to continuous quality improvement in trauma-informed care?
• Consumer and Community Involvement: Are consumers and community members actively engaged in the planning, implementation, and evaluation of services?
• Data Collection and Quality Improvement: Does your agency collect data to monitor the effectiveness of trauma-informed practices and use this data for ongoing improvement?

By utilizing the SAMHSA trauma informed care agency self-assessment tool, your agency can gain a clearer picture of its strengths and areas for improvement in becoming truly trauma-informed. This process can guide quality improvement efforts, inform strategic planning, and ultimately enhance the services you provide to individuals and communities impacted by trauma.

Conclusion: Embracing a Trauma-Informed Future

Trauma-informed care is not simply a trend; it is a fundamental shift in how behavioral health services should be delivered. It is an ethical imperative to recognize the prevalence and impact of trauma and to create systems of care that are truly responsive to the needs of trauma survivors. By embracing the principles of trauma-informed care and utilizing tools like the SAMHSA trauma informed care agency self-assessment tool, your agency can embark on a journey of continuous improvement, ensuring that you are providing the most effective, compassionate, and healing services possible. Committing to trauma-informed care is an investment in your clients, your staff, and the future of your organization, leading to better outcomes, increased client engagement, and a more resilient and supportive environment for all. Take the vital step of self-assessment and begin your agency’s journey towards trauma-informed excellence today.

[