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square bulletImplementation Updates January/February 2020

From Stephanie Sundborg, PhD, Research and Evaluation Coordinator, Trauma Informed Oregon

Over the next year you will notice that Trauma Informed Oregon is centering our newsletters around the principles of trauma informed care (TIC). These principles were first offered by Harris & Fallot (2001) and expanded by Substance Abuse and Mental Health Administration (2014) to include:  safety (physical and emotional); trust and transparency; empowerment, voice, and choice; collaboration and mutuality; responsiveness to cultural, historical, and gender issues; and use of peer support. As individuals and organizations work toward TIC (remember, it’s an ongoing effort that won’t be “finished”), the principles can guide the work. Maybe your organization uses the principles to identify opportunities for TIC (aka hotspots). Maybe your organization uses the principles as a way to educate the staff about the impact of trauma and the benefits of TIC. Or, maybe the principles are used as a way to measure progress and outcomes. Using the principles to measure the effect, consequence, or experience of TIC is what I’ll discuss in this blog.

Understanding the experience of TIC

On the TIC logic model, we suggest that the principles can help define the consequence or experience of TIC. Specifically, we propose that when programs, organizations and systems are trauma informed, service users and staff will feel safe, feel empowered (with voice and choice), feel valued and cared for, believe the organization has their interests in mind, and they will trust the organization, staff, and leadership.

Measuring the Principles of TIC

The principles of TIC are not unique concepts; therefore, many fields of study (such as psychology and sociology) have contributed to our understanding of these constructs. Additionally, service sectors such as healthcare have used many of these constructs to understand service quality and patient experience. To name a few examples, The Trust in Physician Scale and The Health Care Relationship (HCR) Trust Scale have been used to measure interpersonal trust and collaborative trust (emotional connection, honesty, and respectful communication), and the Consultation and Relational Empathy (CARE) has been used to measure relational empathy. Although these tools were not customized for trauma, they tap into similar concepts and could be useful. All of these measures have been tested for validity (the idea that an instrument/scale is measuring what you think it is measuring) and reliability (the idea that the results will stay consistent).

Within the field of trauma and TIC, there are only a few instruments that I am aware of that include items that reflect the experience of TIC (and map onto the principles of TIC). That’s to say, instruments that focus on the felt experience (e.g., I feel respected by the staff) as opposed to instruments that measure what people are doing (e.g., staff treat clients with respect) or what people believe (e.g., I believe clients should be treated with respect). I know this might seem like splitting hairs, but I believe the felt experience is one of the more valid indicators of whether individuals, organizations, or systems are trauma informed. The following are the instruments that I have found that include these types of items.

  • Creating Cultures of Trauma Informed Care (Fallot & Harris, 2009)
  • Developing Trauma Informed Organizations (Institute for Health and Recovery, 2012)
  • The Trauma Informed Practices Scale (Sullivan and Goodman, 2016)
  • The Trauma Informed Climate Scale (Hales, Kusmaul & Nochajaski, 2017)

To the best of my knowledge, only two of these (The Trauma Informed Practices Scale, and the Trauma Informed Climate Scale) have been tested for validity and/or reliability.

The Trauma Informed Practices Scale

The TIP measures service user experience and was created for use in domestic violence work (Goodman et al., 2016, guide for the tip scales, as well as the article). The exploratory factor analysis (the statistical process used to see if items cluster together to form distinct constructs) revealed one main scale and two supplementary scales. The main scale includes 20 items that reflect four domains: Agency environment including mutual respect, access to information about trauma, connection with others, and focus on strength. Example items include: “Staff respect the strengths I have gained through my life experiences” (focus on strength) and “Staff understand that I know what is best for me” (agency environment/respect). There are two supplementary scales identified in the analysis that reflect inclusivity, and parenting.

The Trauma Informed Climate Scale (TICS)

The TICS is a 34-item instrument measuring staff experience of their work environments in terms of the TIC principles safety, trustworthiness, choice, collaboration, and empowerment. The validation of the TICS was the result of two studies. The first study involved the initial creation of the instrument and the exploratory factor analysis (Kusmaul, Wilson & Nochajski, 2015). The second study used confirmatory factor analysis (the statistical process used to confirm the structure) to test the scale and its validity and reliability (Hales, Kusmaul & Nochajski, 2017). One of the most interesting findings from this work is that the dimensions (e.g., safety, trust, empowerment) are interrelated meaning they share a common dimension. As an example of this interconnectedness, the authors point out that a strategy aimed at increasing one dimension (e.g., safety) will affect other dimensions (e.g., trust or choice) as well. One of the benefits of this interconnection is that organizations can start their TIC efforts wherever most needed. All of the dimensions are important.

In 2019, the research team determined that a short form of this instrument would be beneficial to the field. Through another rigorous statistical process, they were able to create a 10-item version of the TICS (the TICS-10). The TICS long form (34 questions) and TICS-10 are available for use.

Disclosure: I collaborated with this research team to write the manuscript for the TICS-10; but I was not involved in creating or validating this tool.

Next Steps for Research and Practice

There is a need for rigorously tested measures of TIC and these instruments offer good options for the field.  As the work continues, look for measures that apply these concepts in different service sectors or across multiple sectors. As well, look for measures that reflect both the service user’s perspective and the workforce.

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References:

Fallot, R. D., & Harris, M. (2009). Creating cultures of trauma-informed care (CCTIC): A self-assessment and planning protocol. Washington, DC: Community Connections.

Goodman, L. A., Sullivan, C. M., Serrata, J., Perilla, J., Wilson, J. M., Fauci, J. E., & DiGiovanni, C. D. (2016). development and validation of the trauma‐informed practice scales. Journal of Community Psychology, 44(6), 747-764.

Hales, T., Kusmaul, N., & Nochajski, T. (2017). Exploring the dimensionality of trauma-informed care:

Implications for theory and practice. Human Service Organizations: Management, Leadership & Governance, 41(3), 317–325.

Hales, T., Kusmaul, N., Sundborg, S., & Nochajski, T. (2019). The Trauma-Informed Climate Scale-10 (TICS-10): A reduced measure of staff perceptions of the service environment. Human Service Organizations: Management, Leadership & Governance, 43(5), 443-453.

Harris, M., & Fallot, R. (Eds.). (2001). New directions for mental health services: Using trauma theory to design service systems. San Francisco, CA: Jossey-Bass.

Institute for Health and Recovery. (2012). Developing trauma-informed organizations: A tool kit. Retrieved from http://healthrecovery.org/images/products/30_inside.pdf

Kusmaul, N., Wilson, B., & Nochajski, T. (2015). The infusion of trauma-informed care in organizations: Experience of agency staff. Human Service Organizations: Management, Leadership, and Governance, 39, 25–37.

Substance Abuse and Mental Health Services Administration (SAMHSA). 2014. Trauma-informed care in behavioral health services (Treatment Improvement Protocol (TIP) Series 57. HHS Publication No. (SMA) 13-4801). Rockville, MD: Substance Abuse and Mental Health Services Administration.