Trauma-Informed Practices Help Deliver Better Care to Clients and Staff

Poverty, violence, and racism can fuel toxic stress. It's critical that organizations respond with trauma-informed care. Here's how.

Close-up photo of a badly frayed rope made up of blue, white, and red strands, accompanying article on toxic stress and trauma-informed practices
Photo by Flickr user Alan Levine, CC BY 2.0

Bill McKinney, executive director of the New Kensington Community Development Corporation (NKCDC) in Philadelphia, is keenly aware that the neighborhood his nonprofit serves lies in one of the poorest parts of one of the nation’s poorest large cities, and is rife with trauma.

“The Kensington area is a very underserved, divested part of the city. It’s the epicenter of the opioid epidemic, we have a housing crisis, violence is off the charts, our health indicators are in a bad place. So there’s never any single issue here. All these determinants are racked up together, and each creates a baseline of trauma that everyone here is going through,” he says.

“You have long-term residents living life with little money and all the challenges connected to poverty,” McKinney continues. “And then layered on top of that you have another really large population of folks who are unhoused, suffering from addiction. So that’s another set of trauma folks are going through. And their experience, their expression of untreated trauma, creates trauma for other residents, both adults and children. It’s a constant cycle.”

“It was comfortable for me to say, ‘I am not well. This is what I just witnessed.’ And it clicked for me that the way we operate allowed me to function.”

A Kensington resident himself, earlier this summer McKinney stepped out his door to go to work and came across two people who had been shot. He stayed with them and assisted until police arrived. Then he regrouped briefly and went to work.

“It was a traumatic event. I was in shock, overwhelmed,” he recalls. “And if I were working at another organization, I would have stayed home. But I actually went to work, because I knew I would receive the support I needed to help process what was going on.”

At NKCDC, the staff has been trained in trauma-informed practices and has developed a toolkit for trauma-informed community engagement. McKinney’s first meeting of the morning began with a four-point check-in—“How are you feeling? What are your goals for today? Who’s got your back? And what are you doing for self-care?”

“It was comfortable for me to say, ‘I am not well. This is what I just witnessed,’” he says. “And it clicked for me that the way we operate allowed me to function. People around me were doing the things needed to help me get sorted out and do my job as executive director.”

Toxic Stress, Trauma, and Adverse Childhood Experiences

McKinney’s descriptions of the neighborhood and his experience touch on the chronic stress of day-to-day conditions and the immediate trauma of encountering a scene of violence, but also the kind of counterbalance an attentive, supportive environment can bring.

Jeanne Felter co-directs the Trauma Education Network at Thomas Jefferson University and was the founding director of the community and trauma counseling program there, where she teaches graduate students about the impact of early and chronic stress and trauma.

In her teaching, Felter talks about a stress continuum from healthy to toxic. “We all encounter stress, from minor challenges to a threat to our lives,” she says. “Each time we experience a stressor, our bodies exhibit a stress response. Stress is a normal and even vital part of healthy development. Our brains and bodies are programmed to survive, and that’s why we respond that way.”

It’s when stress is prolonged, severe, or chronic that it causes significant vulnerability, Felter says. Traumatic events that can set off toxic stress reactions include exposure to violence or threats of violence at home or in neighborhoods, war, terrorism, prolonged separation from caregivers, natural disasters, and even poverty and racism. Experiences like these can “trigger an excessive and long-lasting stress response, which can have a wear-and-tear effect on the body, like revving a car engine for days or weeks at a time,” according to Harvard’s Center on the Developing Child. That can harm mental and physical health, even to the point of eroding the protective caps on the ends of our chromosomes, known as telomeres.

“Toxic stress is just that—a toxic level of stress in the body,” Felter says. “Normal stress ebbs and flows. We have peaks, we regulate, it winds down. When it’s toxic, it’s like the switch is turned on and constantly operating at this high level, and the stress hormones flood our system.”

She lists some of the consequences of toxic stress: “heart disease, high blood pressure, a range of mental illnesses like depression and anxiety, and we also see cognitive impairment and impairment of immune functioning.”

Besides the stresses and trauma of one’s current environment, it’s now well-known that long-ago experiences can have lifelong ramifications. The seminal 1990s Adverse Childhood Experiences (ACE) Study conducted by the Centers for Disease Control and Kaiser Permanente showed that even in a population of mostly middle-class and employed respondents, it was common to have experienced ACEs such as physical and emotional abuse, neglect, and household dysfunction, including witnessing domestic violence. What’s more, the study showed that the higher the number of ACEs experienced, the greater the likelihood of troubles later in life. These include poor academic achievement and dramatically higher risk of heart disease, diabetes, depression, substance abuse, and early death.

And toxic stress is the link that causes multiple trauma experiences over time in childhood to “get under the skin” and have such lasting negative impacts, according to the Harvard University Center on the Developing Child.

In the years since the original ACE study, Felter notes, subsequent studies have included more diverse populations and identified additional outside-of-the-home stress factors such as witnessing violence, experiencing racism and discrimination, and feeling unsafe in your neighborhood. A Philadelphia ACE Survey in 2012-13 revealed that nearly 40 percent of Philadelphians had experienced four or more community-level ACEs.

‘Normal stress ebbs and flows. We have peaks, we regulate, it winds down. When it’s toxic, it’s like the switch is turned on and constantly operating at this high level.’

The good news is that this new understanding of trauma and toxic stress comes also with an understanding of protective factors and trauma-informed approaches to medical care and services that can help mitigate the negative impacts of ACEs and later experiences that add to toxic stress. These approaches emphasize safety, choice, collaboration, trustworthiness, and empowerment. Of course, lowering the amount of ongoing stress being added to someone who has experienced or is experiencing toxic stress is crucial, something important when working with people still experiencing poverty, housing instability, racism, and related problems. So is avoiding things that may trigger a release of stress hormones for those in constant fight-or-flight mode, even if they would not be dangerously stressful for others. Positive relationships and support have also been shown to make a significant difference in increasing resilience to toxic stress, as have access to self-care practices including mindfulness, exercise, and sufficient sleep.

In fact, the American Association of Pediatrics’ definition of toxic stress is “the excessive or prolonged activation of the physiologic stress response systems in the absence of the buffering protection afforded by stable, responsive relationships” (emphasis added).

Taking these things into account, community-serving organizations, schools, and local governments across the country have begun implementing trauma-informed practices. These practices aim to provide more compassionate and effective service delivery, help bolster community resilience—and often, crucially, craft a healing environment for their own staff in the process.

Shelterforce spoke with some of the leaders across the U.S. whose organizations are working to implement trauma-informed practices.

Transforming Affordable Housing Resident Services

In 2020, Preservation of Affordable Housing (POAH) received a $2.5 million Housing Affordability Breakthrough Challenge grant for its project to design trauma-resilient communities. With the grant, the national nonprofit affordable housing developer and operator aims to tweak the built environment, improve resident services, and adjust property management rules, all with trauma in mind.

“What’s interesting is, here we are with a project that’s about stress and well-being, and now it’s under the housing affordability umbrella,” says Julianna Stuart, vice president of community impact for POAH. “There’s a growing awareness that recognizing the impact of trauma and toxic stress is important to housing affordability. What our project is really about is reimagining our affordable rental housing through this lens of trauma-informed care.”

Yet, she acknowledges, POAH leaders and resident services staff are not medical practitioners or experts, but housing experts. “So how do we recognize the way trauma and toxic stress impacts our residents?”

To gather information, staff at four of POAH’s housing developments underwent training on trauma-informed care and then interviewed fellow staff members, residents, and community partners. “Now we have hundreds of insights in how we can become more trauma-informed,” Stuart says.

Ripe for change are policies around property rules, lease renewal, and income verification that are often needlessly arduous or negative.

“For most affordable housing, you move in with a lease and a long list of rules, mostly what you can’t do: ‘Don’t use a grill here, don’t park there,’” she says. “How can we flip that typical landlord-tenant communication? Can we focus on where you do have a choice? Revising house rules is one example.”

Other problem areas include lease renewal, or recertification, which Stuart calls a “cumbersome, invasive, intimidating, difficult to navigate, time-intensive, and labor-intensive” process, and income verification deadlines.

“Somewhere in your 30-page lease is ‘If your income changes, you have a small window of time to inform us.’ But we’ve heard that people with temporary or seasonal employment find it hard to keep up with the reporting. Or maybe they lost a job and now have to refigure their child care and apply for jobs and just don’t have time,” she says. “So we want to ask, is this really necessary or just what’s always been done? Can we make it easier?”

In this process, POAH aims to engage housing residents as “co-designers” of any solutions and to work with partners to document the project and identify ways to make successful efforts replicable.

Summing up POAH’s shift, Stuart says, “For years, we’ve emphasized compliance and risk management. Now we’re trying to shift toward ‘How can we better support your resilience?’ as our guiding principle. It’s an idea whose time has come, and time for housing organizations to see the importance of designing a more person-centered housing system.”

‘Showing Up Differently for Young People’

In Asbury Park, New Jersey, the Boys & Girls Clubs of Monmouth County has been working for the past year to become a trauma-informed space where the 5- to 18-year-olds they serve can thrive. The effort extends to “everything from the moment a kid walks in the door, little things peppered throughout the club experience that create a level of connectedness, belonging, safety, and trust,” says Executive Director Douglas Eagles. “We’re working on ways we can rethink and restructure what we do as an organization to show up differently for young people who have been exposed to chronic stress.”

He notes that while trauma-informed care was naturally baked into what Boys & Girls Clubs were doing already—fostering healthy relationships, modeling good behavior, learning emotional regulation—in the past, these weren’t connected in a coherent way that would allow staff to target trauma intentionally.

To make the shift, the Boys & Girls Clubs partnered with another Asbury Park organization, KYDS, who delivered an eight-week training to staff—an introduction to trauma-informed practices with a heavy emphasis on mindfulness. Then they hired a director of programming and wellness integration, whose primary role is to champion the culture shift that needs to occur, Eagles says.

The process has been eye-opening.

“A lot of staff were surprised at understanding that some of the long-term health issues that they’ve been dealing with are tied to undealt-with trauma they experienced when they were younger,” Eagles says. “It was shocking, but also hopeful. It helped them understand their own lives and gave them a new sense of coherency. It also strengthened our will to recognize that this trauma journey we’re on is critically important to make sure children we’re serving today don’t develop those long-term health outcomes that come from not addressing the trauma they’re facing today.”

Even with the new understanding, it takes time to change habits.

“When you’re in an after-school environment and you’re trying to manage 20 kids in a group and they’re rambunctious, bouncing off the walls, the default response is to start yelling at them to gain control of the room,” Eagles says. “We’ve been trying to help our staff understand that act of yelling can be a trigger for kids to respond negatively. We’re working to develop different tools to manage the room without yelling. That’s been hard.”

On the other hand, when a new procedure visibly succeeds, it motivates staff and accelerates the shift.

“Early on, we had an 8-year-old kid exhibiting some troubling behavior, really challenging our staff. In the past, the staff would have focused on managing the behavior, stopping it, even taking a punitive approach,” Eagles says. “Now the overarching question is not ‘Why are you doing this?’ but ‘What happened to you? What’s led to you acting out in this way?’ The new approach allowed this child to open up and relate that his uncle had just died, and there was other trouble in the home with alcohol and an incarcerated parent. It was a really toxic environment, and he was acting out.

“Our staff member was able to give this child space and confidence that this was a safe environment in which to open up.” Eagles says. “This was an important win for our staff to hear about.”

Felter, whose work also involves consulting with school leaders on trauma-informed practices, echoes the emphasis on safety. “A phrase we use often is ‘Safety precedes learning,’” she says. “If children don’t feel safe, their brains are not prepared to receive new information.”

Caring For Clients Means Caring for Staff

At the Chinatown Community Development Corporation (CCDC) in San Francisco, licensed clinical social worker Melissa Hensel came on board this year as the organization’s first clinical director of resident services. She trains resident services program staff on trauma-informed approaches to residents of CCDC’s housing. The organization’s 3,500 affordable units across the city span supportive housing, senior buildings, single-room occupancy (SRO) hotels, and intergenerational housing for families.

While anti-Asian sentiments and hate crimes have certainly risen during the COVID-19 pandemic, Hensel says most of the stressors CCDC residents are facing were there already, especially the challenges of being low-income immigrants without English language skills.

“We work with such a vulnerable population—predominantly low-income immigrants, seniors, families with children, people coming out of homelessness, and representing a diverse range of languages and cultures. Over 80 percent of our residents have limited English proficiency,” she says. “Our staff is really managing a lot of complex, intense social issues.”

[RELATED: Why We Must First Be Well Before We Can Do the Work of the People]

Part of Hensel’s work is helping staff to feel safe, empowered, and confident in their interactions with residents and to adopt a more collaborative approach. She likens resident concerns to an onion, with the core housing stabilization need often surrounded by layers of other stressors that need to be peeled back.

“A resident may come in with an initial need for interpretation of a letter for rental assistance. However, looking through a trauma-informed lens, our staff will be more thoughtful in assessing the person’s other needs,” she says. “Instead of saying ‘OK, give me the letter, I’ll read it to you,’ there’s a more compassionate approach. It’s building relationships, understanding the fuller picture of their vulnerability and history. My job involves helping our staff realize that their role can be a healing piece for residents.”

Trauma-informed approaches, Hensel says, create and reinforce resiliency in organization staff.

“It helps prevent burnout. It really reinforces protective factors, from confidence in their capacity to provide services to emotional regulation support,” she says. “From that, there’s a ripple effect, resulting in fuller delivery of service to residents. When we’re leading by example, we’re providing better services to the residents.”

Words of Wisdom: Implementing Trauma-Informed Practices

From their experience implementing trauma-informed training and practices, organization leaders have some wisdom to share.

Cultivate internal champions

“Any organizational change needs to be championed by influencers within the organization,” says Eagles. “If you don’t have those people championing it consistently over time, it becomes another fad that fades.”

It’s a long haul

“Don’t underestimate how long this is going to take to really get where you want to go,” says NKCDC’s McKinney. “To do it correctly, you have to cook it into everything. And that takes a long time. This isn’t a quick fix; it’s not just a workshop for a day.”

Several leaders stressed the importance of onboarding new staff and continually reviewing practices.

“What happens oftentimes is, you start a job, you get a manual, and maybe you scan it,” says Hensel. “We are really going to go through and help our staff see, ‘This is how the trauma-informed approach is aligned into policies and procedures that affect you and the services we’re providing.’ There wasn’t an intentional effort on that until I came on board.”

You have to educate (and possibly reject) funders

McKinney says, “You have to be willing to say, ‘If we don’t do it this way, it won’t be successful.’ We believe this trauma lens, along with our diversity, equity, and inclusion lens, is what leads to our success. It’s part of our theory of change. If someone doesn’t want to support us to do the work we know we need to do, that’s not a grant we want. We have to seek out the right partners that understand this is how we do our work.”

Don’t go overboard caring for your staff

“As you’re entering into this space and thinking about it for your own staff, you have to also walk a line,” McKinney cautions. “We exist to achieve the mission of the organization for a larger community. It’s very nuanced, but you can get to a point where you look up and realize you’re not doing your work anymore. You can’t work on your staff to the point where you stop serving your clients. It’s a balancing act.”

Feel the urgency

“As we’ve gone down this trauma journey, it’s been a subtle shift for our staff to draw a connection between what kids are going through at home or on the street and how we show up for them,” says Eagles. “That’s been a powerful learning experience. We are literally helping prevent long-term negative health outcomes. For me, it increases the level of urgency: Every minute we have with these kids, if we’re not doing it in a way that aligns with trauma-informed practices, we’re missing opportunities to be the best we can for these kids.”

Resources for Trauma-Informed Care Principles and Training

Myriad options exist to educate yourself or obtain training for your organization on ACEs and trauma-informed practices. Here are some of the resources mentioned by the leaders Shelterforce spoke with:

The Missouri Model for Trauma-Informed Schools

An oft-cited nationally recognized guide that lays out a phased learning process from trauma-aware to trauma-informed and defines the core principles of safety, trustworthiness, choice, collaboration and empowerment that underly most trauma-informed models.

The National Child Traumatic Stress Network

A rich source of education and resources for those providing services for traumatized children and families.

Center for Trauma Informed Innovation

This organization Truman Medical Center played a role in developing the Missouri Model and offers training, coaching and consulting on organizational culture change.

Trauma-informed community engagement toolkit

 

Sandra Larson is Shelterforce's health fellow.

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