It was a warm spring day and the sun was shining brightly. A woman walked into the lobby of a mental health agency visibly shaken. She had taken advantage of the nice weather to exercise with a brisk walk in her neighborhood. Trembling, she went to the receptionist’s desk and her case manager soon appeared through an open door.

“Karen? What’s wrong?” the clinician asked.

“I was walking and I heard a dog bark,” she said in a whisper.

“So?”

“It sounded like a big dog,” Karen said even more softly as she turned her gaze to the floor.

“Come back when you have a real problem,” the clinician said loudly enough so others in the lobby could hear.

Slowly, the woman looked up, and then around her, and made her exit from the agency.

Unfortunately, this is a true story. What is so unfortunate? The woman was in crisis because she heard a dog bark and she wasn’t taken seriously by her clinician. But why would a dog’s bark be worthy of concern? It was later discovered by the peer specialist serving this woman, that she had been severely bitten by a dog as a child. Scars on her arms were constant reminders of the trauma. The clinician missed it. Karen left the agency distraught and in tears; obviously feeling worse than when she arrived. The message Karen received: “My problem isn’t important.” She may have also left thinking she was not important.

Trauma. It can have different meanings for different people. What one person may see as a minor event may be a major trigger for another. Or, there may be no event at all and a sudden, unexpected memory may enter one’s head to create a serious crisis. A growing body of literature suggests that trauma has a pervasive impact on the lives of recipients of services in public health and human systems, in particular mental health. Further exploration with trauma survivors indicate that exposure to potentially traumatic events alters the world view across the lifespan and ultimately impacts the social, emotional and spiritual aspects of their existence. The systems designed to provide the necessary support and services to trauma survivors further complicate services delivery when they fail to promote recovery, prevent retraumatization and remain unresponsive to the unique needs of diverse survivors. Central to systems change is integrating values and principles of a trauma informed approach. Some enhancements are underway with the development of peer leadership and consumer empowerment initiatives but these activities can not function in a vacuum. A universal approach to incorporating trauma informed standards into systems change can further promote culture shifts that value the voice of survivors, embraces hope and promotes connection with others using a public health approach.

Trauma has a pervasive impact on the lives of service recipients in public health and human service systems and congers different meanings for different people. Sources on multiple service settings indicate that the incidence of exposure to a traumatic event in one’s history across is over 90%; this number includes reports on criminal justice, mental health and substance abuse settings. Survivors endure a variety of social, emotional and spiritual challenges that are not addressed and impact survivors across the lifespan.

Some enhancements are underway with the development of peer leadership and consumer empowerment initiatives to counter the challenges faced by survivors. These activities have made extraordinary milestones to create systems change and begun to establish pathways to integrating a trauma informed approach. These activities alone can not fully effect systems change but promote values and principles that should be inherent in every culture aspiring to be trauma informed. This culture shift can be further supported with the application of a universal approach to incorporating trauma informed standards into systems change. Using a public health approach, the process can further promote culture shifts that value the voice of survivors, embraces hope and promotes connection with others.


Considerations to Promote Hope and Connection

Since the emerging focus on survivors of domestic violence in the 1970’s, work remains on the integration of trauma informed approach in systems of care. The facts are well established that early encounters with abuse and violence can impact the course of one’s lifespan; integrated behavioral health care can address key issues of recovery; costs of untreated trauma are enormous; state leadership is needed to effect systems change; and the voice of the survivor as the expert on the lived experience, supports and services to effectively facilitate trauma recovery.

Despite these accomplishments, challenges remain on the implementation of trauma informed approach across systems. The systems designed to provide the necessary support and services to trauma survivors further complicate service delivery when they fail to promote recovery, prevent retraumatization and remain unresponsive to the unique needs of diverse survivors. To further the accomplishments, a systemic standard of expectations provide value to creating a culture of practice committed to change. Ethical standards would promote self-determination, hope and commitment to change that can be applied to any setting, system and level of practice.

The CMHS National Center for Trauma Informed Care launches an effort to develop ethical standards for engaging trauma informed approach across systems of care. These standards will promote self-determination, hope and commitment to change that can be applied to any setting, system and level of practice. Trauma informed ethics will further the course of peer leadership and empowerment while creating a culture of practice committed to change. Ethical standards yield opportunities for improvement and establish new ways of thinking that moves beyond complacency with the status quo. Using a public health approach, these standards would operationalize prevention and support the healing process in the lives of trauma survivors and communities.

This forum is designed as an interactive way to learn, share feedback and discuss topics related to trauma survivors via a virtual community. The opportunity to develop trauma informed ethics provides a vehicle for hope, empowerment and change in the lives of survivors across systems. We welcome your thoughts, comments and suggestions for the development of a vital element to creating trauma informed systems.

The forum experts have provided resources available to the public. These resources reflect values and principles that are consistent with creating trauma informed systems of care and offer insight to the development of trauma informed ethics. The resources are not exhaustive list and suggestions for additional references are welcomed. As you prepare to join the forum, review the reading material to establish your views on the meaning of trauma informed ethics, the impact of development of such standards and next steps in the evolution of systems change. Ethics Matters…and so do the lives of every survivor of a traumatic event.

How's it going?
Wan

I just finished reading 2 of the articles posted here on trauma ethics amd recovery culture by Steve Harrington. As the newly appointed director of Comunity Mental Health Program here in Rochester NY (18 mos) I am inspired and renergized. The culture you described fits perfectly in my organization: we espouse recovery orientation and "person centered care" principles but often don't even involve clients in the devlopment of their own treatment/care plans. We all too often focus on Government Centered and/or Financial Centered Care at the expense of trauma informed, recovery orientated models of service delivery. I am a 100% supporter of system change that would transform the system from Government/Professional Driven Care to Consumer based - Person Centered Care and I am increasingly convinced that this is a culture shift that parallels other social change models (such as racism or sexism). I have been shocked and amazed at the resistance to examine or even discuss new ways to deliver services within my own agency. I have quickly learned that the attitude of; "But, this is the way we've always done it", or "But, this is they way "they" (meaning the Gov't agency) told us to do it" means that change will take a great deal of time, years or even decades, of continuous effort and energy for the winds of change to resculpture the landscape of "Government Centered Care" to systems of care that truly embrace Habilitation, Rehabilitation, Recovery and Independence. Trauma informed care really means care that is delivered by people who really "care" about the people who they want to help!
I applaud the people who have put the effort into this project. Change will and does happen!

We have a very long row to hoe - it will take a long time, so we must start early. Like right now. I am an advocate for people with mental illness and am employed by the state's protection and advocacy agency. Most of my work time is spent with patients at our state hospital. Of more importance is the 40+ years experience as a family member of a person diagnosed with mental illness. I say "diagnosed" with MI because dissociation and PTSD might more appropriately be labeled "survival skill" than diagnosed as a MI.
Your website is a great resource. I've printed the articles and shared liberally. Many providers, family members, patients, and advocates are familiar with the term "trauma-informed", but few of us have integrated it. Because "trauma-informed care" is about relationships, values, and ethics, I believe it is hard to learn from reading books or articles. It must be modeled and experienced. It is easier to hire someone who has it, than to train someone into it. The persons who "get it" and "use it" come from a variety of backgrounds, education and experiences, but they all like and enjoy other people. An important attribute I've notice in the trauma-informed people I've met is we believe we have learned and gained more from working and living our lives with survivors than otherwise would have been possible.
Thank you for what you have done and continue to do and for providing this opportunity for discussion. I hope there will be active dialogue here.

Charlie: Thanks for your insights and, especially, your advocacy work. I gleaned from your comments that trauma-informed care is strongly related to values, which begs the question: Can you really teach values? I believe it is possible but extremely difficult and it takes a long time. Persons who have experienced adversity in their lives--and have learned from that experience--often seem to be more understanding and compassionate. Robert Thomas' book, Crucibles of Leadership, is a valuable resource for more on this issue. Thanks, again, for your comments and advocacy! Steve