Trauma-informed care in child/family welfare services

CFCA Paper No. 37 – February 2016

Challenges in implementing a trauma-informed approach to care

As noted previously, implementing trauma-informed care requires a paradigm shift in service delivery (Hopper et al., 2010; Jennings, 2004). The literature around trauma-informed care indicates that there are still some challenges to implementing this approach for systems and services, as well as the need for research to evaluate the approach's effect on client wellbeing and other service delivery outcomes (Ashmore, 2013; Australian Centre for Posttraumatic Mental Health & Parenting Research Centre, 2013; Hopper et al., 2010; Muskett, 2014). These challenges are discussed in the following sections.

Inconsistent understandings of what it means to be trauma-informed

The most identifiable challenges across the literature are in the need to create shared understandings, and current inconsistencies in education regarding trauma-informed care (Australian Centre for Posttraumatic Mental Health & Parenting Research Centre, 2013; Hopper et al., 2010). It is difficult to align organisational change to a specific practice without a shared understanding or vision of what trauma-informed care actually is. In a comparative study of trauma-informed care in acute mental health inpatient units, Ashmore (2013) identified this as an issue in the implementation of trauma-informed care in an acute patient environment. A lack of definition and of a shared framework, as well as a lack of information specific to an acute mental health inpatient setting, were associated with challenges and inconsistency in implementation.

In their review of the literature, the Parenting Research Centre and the Australian Centre for Post-traumatic Health (2013, now Phoenix Australia) found that although participants within the child and family services sector who worked with children exposed to trauma were familiar with terminology such as "trauma-informed care", they argued that:

  • the field still lacked clear definitions or understandings of concepts;
  • there were assumptions that children's social and behavioural difficulties were necessarily trauma-related without clear assessment; and
  • there was a lack of guidelines for assessment and treatment of trauma.

SAMHSA's (2014) recent guidance document is clearly aimed at addressing this lack of consistency in definitions and the 2012 document by Adults Surviving Child Abuse provides some practice guidelines (Kezelman & Stavropoulos, 2012). However, an aspect of trauma-informed care is that it must be culturally relevant to the populations it serves (Elliot et al., 2005; Jennings, 2004) and any broad level articulation of policy approaches or frameworks must be applicable in a range of systems and settings and for a variety of cohorts.

Translating trauma-informed care to specific practice and service settings

In addition to the array of terminology and concepts that are sometimes used interchangeably and inconsistently, there is a lack of evidence-based guidance for specific settings and systems to assist with coordinating how trauma-informed practice should be provided for particular service settings and specific populations of service users. This issue was identified by Muskett (2013) and Ashmore (2013) in relation to mental health nursing, where the need to remove the use of seclusion and restraint is emphasised but, beyond this, little has been articulated to support the use of specific practices for service settings to adopt to improve service delivery consistent with principles of trauma-informed care. Dealing with survivors of trauma, particularly in a mental health or child protection setting, may require individuals to use their prior experience to respond to specific situations. In such stressful and potentially dangerous settings, crisis management could lead to a de-prioritisation of trauma-informed responses (Conners-Burrow et al., 2013). Training and guidance for staff on how to respond to acute situations appropriately and feel confident that they are acting in accordance with the principles of trauma-informed care is recommended (Knight, 2015; Muskett, 2014).

Facilitating complex system change

As noted by the American Institute for Research, in order to build a trauma-informed system, commitment at all system levels is required. This includes a commitment to ongoing training and service transformation (DeCanandia et al., 2014). Australia is behind the USA and Canada in developing models and systemwide responses to children and other service users impacted by trauma (Bateman et al., 2013). For example, the USA has the National Child Traumatic Stress Network, funded by SAMHSA, which brings a singular and comprehensive focus to responding to childhood trauma. Australia is arguably still at the stage of requiring policy change to articulate a clear direction for moving towards systems of trauma-informed care in a range of different service delivery areas relating to child/family wellbeing (Bateman et al., 2013).

Systemic change is important because it enables people to receive services that are sensitive to the impact of trauma regardless of whether they enter through any particular service setting or intervention.

Large-scale systems change is also logistically difficult and time-consuming and requires commitment and resources (Hopper et al., 2010). Philosophical differences between sectors that need to work together to integrate care can also impede systemic change (Hopper et al., 2010). Ashmore (2013) identified particular features of systems change for systems such as mental health that are challenging. These challenges include that hierarchical systems such as health may encounter resistance and that there is an inherent power inequality between service users and professionals in such environments.

Creating change at a systemic level is more than providing practitioners and organisations with tools. It requires changes to funding models to support outcomes rather than outputs, and changes to education for mental health practitioners, social workers and other specialists. Essentially, this is about a move towards a more holistic understanding of the inter-related biological, psychological and social dimensions of trauma.

Evaluating a trauma-informed approach to care

Studies from the USA, particularly following the Women With Co-Occurring Disorders Study, have found that trauma-informed, integrated services are judged to be cost-effective when compared with treatment as usual in the comparison sites of that particular study (Domino, Morrisey, Chung, Huntington, & Larson, 2005). Although this study is regularly cited in the literature as evidence of the cost-effectiveness of trauma-informed care (DeCanandia et al., 2014, Hopper et al., 2010; Kezelman & Stavropoulos, 2012); in reality, there is a lack of evaluation about cost-effectiveness and other aspects of trauma-informed care approaches, including its effectiveness in improving outcomes for service users (Quadara, 2015). There is also a lack of evaluation tools to measure the extent to which an organisation is trauma-informed, and the lack of consistent definitions further translates into difficulties in identifying a clear method to indicate the degree to which a service or program is trauma-informed (Hopper et al., 2010).

Other challenges identified in evaluating trauma-informed care, highlighted by Hopper et al. (2010), include the difficulty in measuring cultural change and sustainability of change and whether changes in outcome are attributable to trauma-informed environments or trauma-specific interventions. In addition, the need for cross-system collaboration and assessing human service interactions to establish the extent of trauma-informed care practice implementation further complicates evaluation in this area (Kramer et al., 2015).