Trauma-informed care: A public health approach 

By Ann Berry-Gallegos
Center of Family Strengthening

Gabriella Grant.

–On April 18, at Cuesta College, Gabriella Grant, director of the California Center of Excellence for Trauma Informed Care and an innovative reformer of publicly provided services, presented Trauma-Informed Care (TIC) to nearly 300 professionals from SLO County’s public health and correctional agencies. She described a powerful, low-cost, effective transformation of our services to provide a dramatic solution to thousands of people who struggle with mental health problems, drug abuse, domestic abuse or trapped in low-level crime.

Public Health of San Luis Obispo, Center for Family Strengthening, Cuesta College and Community Action Partnership of San Luis Obispo County sponsored the event to reach a large core group of professionals representing all publicly funded social service organizations, including local behavioral and mental health organizations, criminal justice agencies, and public health departments in standing-room-only Cuesta auditorium.

Grant expressively used research and neuroscience to speak to an audience whose excitement built as we saw that we have the ability to provide high-quality treatment and services that facilitate healing from a wide range of mental health problems, drug abuse, domestic abuse and low-level crime as well as other, less intensive but still struggling people. The day allowed attendees to see the possibility of creating a cost-effective, on-demand treatment system that can be available to all.

Trauma-Informed Care (TIC) has quickly become the gold standard care in behavioral health. However, the pace of the growing acceptance of trauma-Informed care has not been matched by a redesign of the publicly funded system, including policies and practices.

In this intensive all-day seminar, Grant dynamically and convincingly described Trauma-Informed Care as based on the fundamental acknowledgment that early life traumatic experiences and the adaptations made to survive are overwhelmingly central to recognizing and treating “unsafe behaviors.” Drug addiction, violence, criminal activity, PTSD, mental illness, unsafe relationships, physical pain, homelessness and suicide are all “unsafe,” or more broadly identified as unsafe behaviors, thoughts, and relationships. By focusing on safety in the present, agencies can treat trauma through the treatment of unsafe behaviors, thoughts or relationships.

What is trauma?

In a nutshell, trauma is a loss or lack of safety. Physical safety and emotional safety are biological needs that have to be met before we can have relationships, go to school, become parents and succeed in life. Substance Abuse and Mental Health Services Administration (SAMHSA) defines trauma as “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 function and physical, social, emotional, or spiritual well-being.”

If we don’t have the foundational element of safety, some of the things we have as goals can end up crumbling around us at the moment when we should be enjoying ourselves, our relationships and the well-deserved successes in our lives.

Our current treatment system

There is a growing body of research showing that people with a range of adverse childhood experiences often experience a range of later-in-life negative health outcomes, including violence, drug addiction, and mental illness (See the ACEs Study by Kaiser Permanente). One way to understand these challenging social conditions is a public-health problem that is teetering on becoming epidemic-level. According to the Centers for Medicare and Medicaid, 1-percent of all patients—the super-utilizer of our healthcare systems—are responsible for 22-percent of all health spending. Trauma is one of the most salient contributors to become a healthcare super-utilizer. Our payer health systems and incarceration rates are at all-time highs and too few interventions are achieving lasting and tangible results. The public and private costs of this current treatment system have ballooned to unaffordable levels.

Grant postulated that, through no fault of their own, most service provider agencies work in conflict with each other and create barriers to treatment through required use of rules, regulations and compliance to policies. The rules have become the programs, and costs just continue to skyrocket with little or no impact on helping these patients.

For example, a patient in dire need of care will typically find that he first must be screened for eligibility for treatment, must meet medical diagnostic criteria and only then he can find a provider that will help him only to find that he ends up on a waiting list and is often soon forgotten, if he hasn’t already dropped out along the way.

A real life example is homeless shelters. Shelters require that you be free of alcohol and drug addiction to be admitted into the homeless facility and services. As a result, patients are driven to lie and cheat to gain entry to the shelters for a meal and a bed. They do not receive treatment for behaviors, which they are now forced to hide, to survive. It is these bad behaviors that put them in a homeless situation to begin with. A vicious cycle makes effective intervention and treatment impossible. And, unfortunately, processes and policies tend to drive punitive and shaming interventions that in turn result in more unproductive behaviors that end up even more unsafe, and at the same time alienating the victims from helpers and help. It is a self-perpetuating cycle of failure, costing us astronomical sums of money that we can scarcely afford.

In contrast, Trauma-Informed Care is a treatment framework that invites all of our SLO County’s public health and correctional organizations to re-design treatment through an examination of rules, regulations and compliance orientation to policies that focus on safety and building safety, self-regulation and self-protection skills. At its core, TIC requires a revamp of our public service organizations to help people who are struggling to feel and be safe, including acceptance, understanding, identifying and taking the action necessary to reverse the effects of traumas in a person’s life. All behavioral and physical healthcare providers and staff can balance compassion and accountability as this balance is critical for recovery from trauma. We can now build and support trauma-informed community services that focus efforts on meaningfully increasing physical and emotional safety in people’s lives.
Grant described the three stages in TIC that must be adopted. Simply put, it’s moving away from seeing the patient as “What’s wrong with you” to “What happened to you” then “How it is affecting you now.” She cited Dr. Judith Herman’s three stages of trauma recovery:

• Stage One is first to create a safe environment for the person, educating the person about safe coping skills, self-regulation, and self-care by focusing on the now.
• Stage Two is relational, remembrance and mourning—honoring the past, mourning the losses with a focus on the past.
• Stage Three is the future—reconnecting to one’s future, investing in future goals, and seeing relationships as enduring.

In a surprisingly quick timeframe, the attendees were able to shift away from thinking rules and compliance are both treatment and recovery while ignoring the current impact of trauma on the individual toward a model that focuses on creating measurable, tangible safety in people’s lives leading to stable healing and recovery.

Trauma is neurobiological

Grant provided an intensive overview of the technical impact of trauma on three areas of the brain and described the functions, challenges, feelings and strategies to begin to heal the trauma. She based her presentation on the Neurosequential Model, developed by Dr. Bruce Perry, senior fellow of the Child Trauma Academy. Dr. Perry’s model of therapeutics to trauma recovery is a neurobiological approach which starts – in the brain – with the brainstem, which regulates core body functions and, when chronically dysregulated through lack of safety, results in unsafe behaviors, relationships, and thoughts. Key to treatment is developing self-regulatory, self-protection and safety skills so that these core body functions signal safety so that then the social engagement system can come online and be available to the person, leading as a result of changes in the thought process and ability to shift focus toward the plans and goals.

• Function: Symbolic Abstraction and Cognition (Pre-frontal Cortex)
o Challenges: Decision-making, planning, insight, and future orientation
o Feelings: indecisiveness, fear of the future, poor self-awareness
o Strategies: group goals, abstract thinking, design with purpose, context

• Function: Empathy: (Limbic Structure)
o Challenges: Attachment issues and interpersonal conflict
o Feelings: Trust, shame, loyalty, jealousy, betrayal, flirtation, loss, hatred
o Strategies: Pair work, scripts, play, art projects, theater, games

• Function: Self-Perseveration: (Brainstem)
o Challenges: Self-regulation, attention, arousal and impulsivity problems
o Feelings: Anger, aggression, fear, disgust, hunger, fatigue
o Strategies: any patterned, repetitive somatosensory activity to reorganize like dancing, playing with fidget toys, music.

How do we go about creating this trauma-informed transformation across all of our existing public service organizations? Grant proposed that we can start by creating and launching a public health campaign, which clearly and accurately describes the current crisis both regarding human life and personal pain as well as the ballooning costs that we can no longer afford.

Her vision showed how the leaders of our SLO County’s public health and correctional services can lead this public health campaign. Through this campaign, she said, “We will send a strong message to our citizens that we now have the ability to provide high-quality, low-cost treatment and services that facilitate healing to the super-utilizers of publicly funded health systems, including people struggling and suffering from mental health problems, drug abuse, criminal activity, and domestic abuse. The shift in message is that this treatment can be cost-effective, available on demand, and available to all who need it when they need it.”

In the end, most everyone was convinced that we can implement TIC as the cost effective, patient-effective gold standard care in Behavioral Health in San Luis Obispo County. The 300 professionals from SLO County’s Public Health and Correctional organization responded with applause, excitement, and enthusiasm, concluding that SLO County can become among the first California counties in to adopt a public health approach to TIC.

About Gabriella Grant

Gabriella Grant is the director of the California Center of Excellence for Trauma Informed Care, overseeing the center’s research, program, and professional development as well as policy analysis activities. Her background includes heading the nation’s first community corrections-based victim advocacy program and running a three-year project funded by the California Department of Public Health to increase access to domestic violence shelters by women with mental health and/or substance abuse issues. The domestic violence shelter project showed that it is possible to increase capacity to serve women with co-occurring disorders by understanding trauma and developing programs that respond to people’s need for safety. Grant brings to the center a long history of professional experience developing innovative programs for female offenders, crime victims, and domestic violence survivors. Through this work, she has also gained an understanding of how program design, policies and procedures can positively affect the people being served. She earned her undergraduate degree from Amherst College, a Latin teaching certificate from the Pontifical Gregorian University in Rome, Italy and a Masters in Public Policy from Johns Hopkins University. She has taught at the primary, secondary and university levels and has trained professionals, advocates, and consumers in a wide variety of settings.

About Center for Family Strengthening

In 1988, the San Luis Obispo County Board of Supervisors designated Center for Family Strengthening as the self-governing entity responsible for local efforts to prevent and respond to child abuse and neglect. Center for Family Strengthening is dedicated to strengthening families through education and advocacy. Center for Family Strengthening partners with family support organizations in SLO County to provide resources to families in need, protect children from abuse and neglect, and ensure that strong families are a community priority. To donate or learn more about Center for Family Strengthening go to www.cfsslo.org or call (805) 543-6216.