Chapter 37 - Trauma-Informed Care

3-37.1  INTRODUCTION

1. Purpose. The purpose of this chapter is to provide guidance to Indian Health Service (IHS) hospitals, health centers, clinics, and health stations (hereafter referred to as facilities) in delivering Trauma-Informed Care services. This chapter will also prepare our workforce to be trauma-informed and promote self-care to prevent and treat secondary traumatic stress, also known as vicarious trauma, which can lead to compassion fatigue and staff burnout.
2. Background. The IHS acknowledges the role that trauma resulting from violence, victimization, colonization, and systemic racism plays in the lives of American Indian and Alaska Native (AI/AN) populations, specifically AI/AN youth who are two and a half times more likely to experience trauma compared to their non-Native peers. Delivering trauma-informed services requires an understanding of the profound neurological, biological, psychological, spiritual, and social effects trauma and violence can have on individuals, families, and communities. The IHS workforce must be aware of the high prevalence of trauma in AI/AN populations, and prepared to respond effectively to this trauma, which affects many individuals who seek services in IHS facilities. It is also important to recognize and build on the resiliency of AI/AN people, which comes, at least in part, from their cultures and spirituality.

   Creating policy and services that support a trauma-informed perspective which appreciates the frequency of trauma, understands the impact at the individual and community level, and supports appropriate response is critical for improving the many health conditions experienced by the AI/AN population. Using trauma-informed policies, practices, and interventions, IHS can enhance its capacity for promoting relational well-being and improving patient outcomes by increasing understanding of the direct and transgenerational impacts traumatic experiences have on a patient’s health and how the patient engages in healthcare.

3. Authorities.
   1. Indian Health Care Improvement Act, 25 U.S.C., §§ 1601 et seq., as amended
   2. Snyder Act, 25 U.S.C. §13
4. Policy. It is the policy of the IHS that:

   Each facility will examine the health care environment and current policies and practices to incorporate Trauma-Informed Care approaches throughout all programs and services, to ensure safe, supportive, welcoming, non-punitive, respectful, healthy, and healing environments for patients and staff.

5. Definitions.
   1. Historical Trauma. Refers to the cumulative emotional and psychological wounding across generations, including the lifespan, which emanates from massive group trauma.
   2. Protective Factors. Refers to conditions and attributes in individuals, families, communities, or the larger society that, when present, lower or eliminate risk and increase the health and well-being of children, families, and communities.
   3. Re-traumatization. Refers to any situation or environment that resembles an individual’s trauma literally or symbolically, which could then trigger difficult feelings and reactions associated with the original trauma.
   4. Secondary Traumatic Stress. Refers to the emotional duress which results when an individual hears about the first-hand trauma experiences of another.
   5. Trauma. Refers to experiences that can cause intense physical and psychological stress reactions. It can refer to a single event, multiple events, or a set of circumstances experienced by an individual as physically and emotionally harmful or threatening. It can also have lasting adverse effects on the individual’s physical, social, emotional, or spiritual well-being.
   6. Trauma-Informed Care. Trauma-Informed Care is an evidence-based service-delivery model that ensures dignity, peer support, and cultural competency and promotes safety, collaboration, trust, and empowerment to individuals. Trauma-Informed Care is a strengths-based service delivery approach grounded in an understanding of and responsiveness to the impact of trauma that emphasizes physical, psychological, and emotional safety for both providers and patients. It creates opportunities for patients to rebuild a sense of control and empowerment by:
      1. using universal precautions by treating all individuals as if they may have experienced trauma;
      2. realizing the prevalence of trauma;
      3. recognizing how trauma affects all individuals involved with the program, organization, or system, including its own workforce;
      4. responding by putting this knowledge into practice; and
      5. minimizing any re-traumatization.
   7. Trauma Symptoms. Trauma symptoms can include both emotional and physical symptoms and can occur over a short period of time or over the course of weeks or even years. Emotional symptoms may include, but are not limited to, denial, anger, sadness, fearfulness, problems focusing, and emotional outbursts. Physical symptoms may include, but are not limited to, increased startle reflex, lethargy, fatigue, poor sleep, racing heartbeat, and anxiety or panic attacks.
   8. Treatment Advocate. For the purposes of this chapter, treatment advocate is used to denote others involved in the care of patients (e.g., significant others, persons of support chosen by the patient, caregivers, family, friends, advocates, etc.).
   9. Resilience. Resilience is the process of adapting well in the face of adversity, trauma, tragedy, threats, or significant sources of stress, such as family and relationship problems, serious health problems, or workplace and financial stressors. It means "bouncing back" from difficult experiences. Research has shown that resilience is ordinary, not extraordinary. Being resilient does not mean that a person does not experience difficulty or distress. Emotional pain and sadness are common in people who have suffered major adversity or trauma in their lives. In fact, the road to resilience is likely to involve considerable emotional distress. Resilience is not a trait people either have or do not have. It involves behaviors, thoughts, and actions that can be learned and developed in anyone.
   10. Universal precautions. This is the practice, in medicine, of avoiding contact with patients' bodily fluids, by means of wearing personal protective equipment. Every patient is treated as if infected and therefore precautions are taken with every patient to minimize risk.
   11. Compassion fatigue. Compassion fatigue is a condition characterized by emotional and physical exhaustion leading to a diminished ability to empathize or feel compassion for others, often described as the negative cost of caring. It is sometimes referred to as secondary traumatic stress.
   12. Burnout. Burnout is a state of emotional, physical, and mental exhaustion caused by excessive and prolonged stress. It occurs when you feel overwhelmed, emotionally drained, and unable to meet constant demands.
6. Training.
   1. Annual Training. Employees at all levels will complete training annually on the impact of trauma, including Historical Trauma on AI/AN people. The training will address the impact of traumatic stress on the brain and body; the implications for mental and physical health; how to promote protective factors to increase resiliency; how to interact with people who are in distress in a positive manner; how to listen and validate a wide range of emotions; how working with trauma survivors can impact staff (vicarious traumatization, secondary traumatic stress or “compassion fatigue”); and why self-awareness, support, and self-care are important to prevent compassion fatigue and burnout. Training resources are available on the IHS Teleeducation website.
   2. New Employee Training. New employees must complete Trauma-Informed Care training within their first 30 days at IHS.

3-37.2  RESPONSIBILITIES

1. Chief Medical Officer, IHS. The IHS Chief Medical Officer is administratively responsible for the implementation of this policy.
2. Director, Division of Behavioral Health, IHS. The IHS Director, Division of Behavioral Health, Office of Clinical and Preventive Services, is responsible for ensuring that resources on training, organizational assessments, toolkits, and other tools are available for IHS facilities to implement Trauma-Informed Care approaches.
3. Mental Health Lead, IHS. The IHS Mental Health Lead assists in the implementation of this policy by providing training and technical assistance resources.
4. Area Chief Medical Officer. The Area Chief Medical Officer or designee collects copies of IHS policies from their respective area, reviews those policies for the compliance with this chapter, and submits findings and/or recommendations to the IHS Mental Health Lead.
5. Area Behavioral Health Consultant. The Area Behavioral Health Consultant or designee is responsible for providing technical assistance and resources related to Trauma-Informed Care.
6. Area Chief Executive Offices. The Area Chief Executive Officer or designee develops local policy to reflect trauma-informed practices outlined in this chapter, leads the multi-disciplinary workgroup tasks, and monitors local implementation and employee training requirements. The Chief Executive Officer will identify a lead when relevant.
7. Area Directors. The Area Directors are administratively responsible for the implementation of this policy across their respective Area.
8. Headquarters Office Directors. The Headquarters Office Directors are administratively responsible for the implementation of this policy within their respective Office.

3-37.3  TRAUMA-INFORMED CARE PROCESSES

1. Creating Trauma-Informed Organizations. Creating a trauma-informed organization requires system-wide implementation at the direct care level and in the administrative arena. This type of change can be difficult and will require a trained multi-disciplinary workgroup. The following guidelines are steps that IHS facilities will take to implement Trauma-Informed Care services and approaches.
   1. Create a multi-disciplinary trauma workgroup consisting of a core group of staff representing all roles in the organization.
   2. Incorporate the goal of becoming trauma-informed in staff meetings and/or other settings that work best for the facility.
   3. Incorporate organization-wide trauma training to increase individual trauma knowledge and set the stage for organization-wide change.
   4. Provide training on trauma, secondary traumatic stress and trauma-informed care.
   5. Conduct an initial trauma-informed organizational self-assessment and reassess every three years.
   6. Compile organizational self-assessment results and review results in five domains annually:
      1. Supporting Staff Development
      2. Creating Safe and Supportive Environments;
      3. Assessing and Planning Services;
      4. Involving Patients and Treatment Advocates; and
      5. Creating and adapting local Policies.
   7. Incorporate trauma-informed approaches that include:
      1. Identified and agreed upon goals;
      2. Specific steps to reach each goal;
      3. Resources needed to achieve each goal; and
      4. Realistic timeframe for the achievement of each goal.
   8. Create safe, supportive environments by improving physical spaces with comfortable seating, quiet spaces, culturally appropriate artwork, clean and updated facilities, and ensuring facility security.
   9. Ongoing review of short-term and long-term goals is necessary and will occur annually to identify changes for sustainability. Other assessment tools include staff, patient, and treatment advocate surveys, focus groups, and individual interviews.
   10. Provide Trauma-Informed Care training to all new hires within their first 30 days at IHS and annual refresher training for all staff, including non-clinical staff, on trauma and trauma-related topics to sustain trauma-informed change.
2. Evaluating Policies, Procedures, Rules, and Practices. All IHS direct patient care facilities’ multi-disciplinary trauma workgroups will identify and evaluate policies, procedures, rules, and practices, where Trauma-Informed Care should be considered for staff and patients with the following criteria:
   1. Is this policy, procedure, rule, or practice necessary?
   2. How does this policy support Trauma-Informed Care delivery?
   3. Who does it help? Who does it hurt?
   4. Does the policy facilitate or hinder patient and treatment advocate empowerment?
   5. Were patients and treatment advocates included in its development?
   6. Could this policy, procedure, rule, or practice re-traumatize the patient or treatment advocates? (e.g., limit patient or treatment advocate control and power, lead to fear and confusion, etc.).
3. Trauma-Informed Care Systems. IHS program staff are encouraged to bring their understanding of trauma and Trauma-Informed Care to the broader service system outside of the health care discipline, educate other service systems and providers, and network with other programs to integrate trauma-informed organizational models and find ways to share information and experiences.