Introduction
Traumatic life experiences play an important role in the etiology of such severe and persistent mental illnesses (SPMI) as schizophrenia, bipolar, and major depression.1 Posttraumatic stress disorder (PTSD) and other trauma-related conditions are known to be highly prevalent among individuals diagnosed with SPMI. Moreover, traumatic life events have been consistently shown to worsen an individual's prognosis with respect to the severity and treatment of SPMI symptoms. At the national level, epidemiological studies have estimated that between 70% and 98% of adults presenting SPMI also present a co-occurring history of trauma.2 In Hawai‘i, a 2009 survey of 175 consumers of state adult mental health services in Honolulu County found that 89% of the sample reported at least one traumatic life event and 32% screened positive for a history of PTSD.3 Aside from the prevalence data, there is substantial clinical evidence linking PTSD and trauma histories with higher rates of SPMI symptom relapse, comorbid substance use disorder symptomatology, and utilization of more costly mental health treatment services, such as inpatient care and emergency hospitalization.4,5 Studies also have noted those with SPMI are at a greater risk to experience traumatic life events and become more debilitated by their effects.6,7
When taken together, research on the prevalence of traumatic life experiences among individuals with SPMI has prompted several states to secure federal planning and implementation grant awards that aid mental health services transformation toward a trauma-informed system of care. In particular, the Substance Abuse and Mental Health Services Administration (SAMHSA) has funded separate Hawai‘i State Department of Health (DOH) initiatives to address the impact of traumatic life experiences on the child and adult populations DOH serves. As described in a previous article published in the Hawai‘i Journal of Medicine and Public Health,8 Project Kealahou began in 2010 in an effort to establish a trauma-informed system of care within DOH's Child and Adolescent Mental Health Division. In 2011, the Adult Mental Health Division's (AMHD) Trauma-Informed Care Initiative (TIC-IT) began, and AMHD has since made significant progress toward establishing itself as a trauma-informed system of care. This article provides a brief overview of AMHD's TIC-IT.
What is a Trauma-Informed System of Care?
According to Harris & Fallot (2001), a trauma-informed system of care comprises six domains: (a) trauma-sensitive service settings and environments; (b) formal trauma-informed policies and procedures; (c) trauma screening, assessment, and planning of trauma-specific services; (d) system-wide support for trauma-informed services; (e) provider education and training; and (f) human resources practices.9 The first domain reflects an agency's alignment with the guiding principles and core values of trauma-informed care, including: (1) establishing a physically and emotionally safe service environment; (2) creating a service climate of trustworthiness; (3) maximizing consumer choice and control in services planning; (4) maximizing collaboration between provider and consumer; and (5) promoting consumer empowerment and skill-building. The second domain describes organizational policies and procedures that reflect an understanding and sensitivity to the needs of trauma survivors, such as protecting the confidentiality of information, avoiding involuntary or coercive treatment strategies, using crisis de-escalation practices, and having clearly defined processes for filing grievances. The third domain reflects routine screening for traumatic life experiences and the incorporation of such results into the process of planning treatment services that are both trauma-specific and gender-specific. The fourth domain refers to providing trauma-informed resources and support to the whole system, including community stakeholders, organizational administrators, agency staff, service providers, and consumers. The fifth domain reflects the extent to which agency staff members have received appropriate education and training in trauma-informed care best-practices. The sixth and final domain reflects whether staff recruitment and hiring efforts take into account a candidate's knowledge of trauma-informed care policies, procedures, and practices.
Why Should a Trauma-Informed System of Care be Established?
Establishing a trauma-informed system of care holds the promise of improving efforts to prevent and intervene on the effects of trauma on consumer recovery. While creating a trauma-informed services environment reduces the likelihood of re-traumatizing consumers, providing trauma-specific policies, procedures, and practices improves consumer recovery and outcome. The literature suggests trauma-informed environments improve consumer engagement, retention, and outcomes, as well as reduce provider fatigue and burnout related to secondary trauma.10,11 Outcomes data also show integrating mental health, substance abuse, and trauma treatments decreases mental health symptomatology relative to standard treatments.12,13 Although the extant data provide strong support for the effectiveness of trauma-informed systems of care, it has yet to be established whether such positive outcomes can be replicated in geographic regions with high racial and ethnic diversity, like the State of Hawai‘i. Therefore, an important feature of AMHD's TIC-IT is the application and evaluation of trauma-informed care services, delivery principles, and consumer recovery outcomes, and the determination about whether program outcomes are equitable across gender, race, and ethnic lines.
What are TIC-IT's Overall Goal and Related Strategic Objectives?
The goal of TIC-IT is to establish a sustainable trauma-informed system of care within AMHD. To achieve this goal, AMHD set out to accomplish three broad and interconnected strategic objectives:
Objective 1: | Develop a workforce of trained trauma-informed providers of care. |
Objective 2: | Establish universal trauma screening and assessment across provider agencies. |
Objective 3: | Implement trauma-specific evidence-based practices within provider agencies. |
Figure 1 summarizes key elements of TIC-IT, including its basic assumptions, goals, objectives, and populations of focus. Figure 1 also summarizes TIC-IT grant activities at administrative, provider, and consumer levels that are geared toward establishing a trauma-informed system of care.
Figure 1.
What are TIC-IT Populations of Focus?
TIC-IT targets all those who either provide or receive case management services from a community mental health center or contracted provider. The TIC-IT transforms AMHD's system of care by achieving its strategic objectives to implement trauma-informed care best-practices at administrative, provider, and consumer levels.
At the administrative level, TIC-IT focuses on involving AMHD stakeholders in the development and implementation of formalized trauma-informed policies and procedures. At the provider level, TIC-IT focuses on creating trauma-informed environments and infrastructures within AMHD's 8 community mental health centers (CMHC) and 12 contracted providers of case management services. At the consumer level, TIC-IT focuses on building AMHD's capacity to provide trauma-informed care to the over 10,000 individuals it serves each year.
What TIC-IT Activities are Related to Workforce Development?
Workforce development activities represent the foundation for TIC-IT and are geared toward sustainability. At the administrative level, workforce development activities include organizing peer stakeholders and supporting the formation of a Peer Advisory Board (PAB). The PAB consults with AMHD administration on (a) the development of trauma-informed policies procedures and practices, as well as (b) the implementation of new trauma-informed curriculum for training Hawai‘i Certified Peer Specialists (HCPS). Workforce development activities also are targeted toward AMHD's CMHC and contracted provider agencies, such as conducting system-wide self-assessments on trauma-informed care readiness, and offering trainings on trauma screening, assessment, and treatment methodology. Based on Harris & Fallot's (2001) model, AMHD's CMHCs are examining their readiness to implement trauma-informed care services, and receiving one-on-one consultation with Dr. Fallot on agency specific trauma-informed care practices. Results and progress from these self-assessments and consultations also are being shared with AMHD administration so as to translate CMHC best-practices into new trauma-informed policies and procedures. Workforce development activities also are continuing to educate providers on the core elements of trauma-informed care and methods to reduce the impact of vicarious trauma on providers. Additionally, providers are receiving ongoing training on methods to screen consumers for a history of trauma, and assess whether such histories meet criteria for PTSD. Finally, TIC-IT includes several workforce development activities targeted toward expanding and enhancing its HCPS program. Most critical has been working with Hawai‘i's Department of Human Services to establish Medicaid billing codes and rates in its state plan amendment for peer support services provided by HCPS. Other workforce development activities targeted towards HCPS providers include formalizing the Peer Specialist's role in CMHC reorganization, and integrating Supported Employment,14 Wellness Recovery Action Planning (WRAP),15 and Forensic Peer Support into the training curricula and certification process.
What TIC-IT Activities are Related to Universal Screening and Assessment?
Administrative policies and procedures are being modified to institute protocols for (a) consistently screening AMHD's consumers for a history of traumatic life experiences, and (b) assessing whether such experiences meet diagnostic criteria for PTSD. In general, these protocols standardize methodology and recommend specific psychometric tools that aid in ascertaining which consumers may benefit from trauma-specific treatments for PTSD and co-occurring substance use problems. Efforts are ongoing to train AMHD's providers in administering and scoring of the Trauma Assessment for Adults scale (TAA-R)17 and the PTSD Check List for Civilians (PCL-C).18 Both tools were developed by the US Veterans Administration, and have shown high reliability, validity, specificity, and sensitivity in previous research.19 Providers also are trained on the use of decision rules for TAA-R screening and PCL-C assessment, such that only those who screen positive on the TAA-R are assessed for PTSD with the PCL-C. Consumers are expected to benefit from this method because it minimizes the likelihood of false negatives and false positives, while maximizing the likelihood that those who are in need of trauma-specific services receive referral in a manner that is timely and least intrusive.
What TIC-IT Activities are Related to Implementation of Evidence-based Practices?
At the core of AMHD's TIC-IT is the implementation of two inter-related evidence-based practices: (a) Seeking Safety treatment and (b) Supported Employment. The Seeking Safety treatment is a standardized group intervention for consumers who present PTSD symptomatology with or without co-occurring substance use problems. Evidence has shown Seeking Safety is an effective and efficacious treatment for PTSD symptomatology across a number of different target populations,20 and is consistent with the philosophy of trauma-informed care. The incorporation of Seeking Safety treatments into AMHD's services array is connected to TIC-IT's universal screening and assessment objective and related administrative, provider, and consumer level actives. Specifically, it is expected that policies and procedures instituting universal trauma screening and assessment among provider agencies will lead to increases in Seeking Safety referrals, which in turn, will lead to increases in the number of consumers benefiting from trauma-specific services. The TIC-IT project supports the development of an AMHD administrative infrastructure for Seeking Safety program evaluation, fidelity monitoring, outcome analysis and dissemination. The TIC-IT project also supports provider training in Seeking Safety treatment delivery, which also is aligned with workforce development activities. These efforts include training both qualified mental health professionals and peer-support staff on Seeking Safety group facilitation, which is expected to enhance these providers' capacity to collaborate while working at AMHD's CMHCs and contracted case management agencies.
The second evidence-based practice implemented through AMHD's TIC-IT is the Supported Employment of candidates for the HCPS program. The HCPS training has been offered to consumers in Hawai‘i since 1992, and AMHD's TIC-IT enhances and expands this program by integrating basic concepts of the trauma-informed care and Supported Employment models. Through AMHD's TIC-IT, the HCPS training curriculum was revised, with the consultation of administrative, provider, and consumer (peer) stakeholders, to include modules on trauma-informed care and WRAP.15 These trauma-specific practices are now integrated into the HCPS training, accompanying the nationally established core curriculum (ie, The Georgia Model),21 and Hawai‘i-specific cultural adaptations. The key adaptation of the HCPS program to come about through AMHD's TIC-IT is the inclusion of the Supported Employment component, permitting HCPS candidates the opportunity to complete a 13-week paid internship (195 hours total) at an AMHD service provider agency or CMHC. The HCPS internship is entered into after successful completion of coursework and prior to receiving certification. During the HCPS internship, consumers receive structured supervision by agency staff and participate in regular peer support meetings sponsored by AMHD administrative staff. At the administrative level, this Supported Employment track is monitored for fidelity and evaluated for outcomes, while developing an HCPS workforce capable of providing trauma-specific services in the form of co-facilitating Seeking Safety groups and working with consumers to develop WRAP documents. This expansion of the HCPS program also adds to the array of billable services that can be provided by HCPS in the workforce. For consumers, becoming an HCPS can be viewed as an integral step toward recovery and individual empowerment, while those receiving HCPS services benefit from working with para-professionals trained in both peer support and trauma-informed care.
Conclusion
Considerable research has shown traumatic life experiences play a key role in the development, maintenance, and treatment of SPMI. Acknowledging this evidence, the AMHD is taking the initiative to transform its system of care in ways that are trauma-informed. Like other initiatives across the nation and in Hawai‘i, AMHD's TIC-IT is implementing several strategic objectives that target sustainable organizational change at the administrative, provider, and consumer levels. Implemented in 2011, AMHD's TIC-IT is continuing to make significant progress towards achieving its overarching goal, establishing a sustainable trauma-informed workforce, instituting universal trauma screening and assessment within provider agencies, and offering integrated trauma-specific services that reduce the impact of trauma on consumer recovery. To date, TIC-IT project has trained 1,209 members of AMHD's staff and contracted providers in trauma-informed care, completed 2,053 trauma screening and assessments with AMHD consumers, with 111 of them offered the Seeking Safety treatment, and matriculated 55 HCPS candidates and supported employment interns. These achievements are in spite of several changes in leadership and TIC-IT staff, as well as prolonged difficulties with contracting of trauma-specific services. Nevertheless, TIC-IT is establishing several key infrastructures for the sustainability of AMHD's trauma-informed care approach, and analyses are underway to evaluate the impact that this project is having on AMHD's services delivery processes and consumer recovery outcomes. Results of this program evaluation will be the subject of a forthcoming final report and peer-reviewed publication at the conclusion of AMHD's TIC-IT grant funding period.
Acknowledgement
The Trauma-Informed Care Initiative is supported by a grant from the Substance Abuse and Mental Health Services Administration (SM060159). The authors would like to thank TIC-IT team members: Dr. Mark Fridovich, Dr. James Westphal, Kathleen Merriamm Randy Hack, and Sunny Algoso for their tireless efforts to help this project achieve its goals, specific aims, and intended purposes.
Contributor Information
Tetine L Sentell, Office of Public Health Studies at John A. Burns School of Medicine.
Donald Hayes, Hawai‘i Department of Health.
Conflict of Interest
None of the Authors report a conflict of interest.
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