square bulletDestination TIC: Using the TIO Road Map and Standards of Practice to Guide Implementation

August 7, 2018

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

Ok, so we know the Road Map to Trauma Informed Care is not new. In fact, it’s the most downloaded resource on the website. TIO frequently incorporates the Road Map during forums, trainings, and consultations. So, many of you have probably seen it as a handout as you pondered what step along the way best reflects your organization’s work with trauma informed care (TIC).

I thought, with this newsletter’s focus on measurement, this would be a good time to bring up some ways to think about the Road Map, introduce some improvements we’re working on (that will roll out soon), and talk about how the Road Map works in coordination with the Standards of Practice for Trauma Informed Care.

Reminders about the Road Map to Trauma Informed Care – Challenging the Metaphor

The Road Map lays out areas of focus along the journey toward TIC. From left to right (or west to east for any of you on the metaphor band wagon) we go from Recognition and Awareness to Foundational Knowledge to Agency Readiness to Process and Infrastructure to Gather Information on to Implement and Monitor. It’s portrayed as a very linear and sequential path to implementation. In fact, so linear that we might be tempted to refer to these as mile markers (ok, I hear the groaning now). This is where the image (and corresponding metaphor) needs explanation. The metaphor (road to trauma informed care) is great as a high level way to think about the journey. It is generally true that you need awareness before you gain knowledge and before you start a process for implementation. That said, there are a few things to remember as you use this tool.

First reminder, as the focus areas are portrayed on the map, they seem equally important. However, some of these focus areas may be more important to some organizations than for others. For instance, in some organizations, TIC may be really new information and they will spend more time acquiring foundational knowledge. For other organizations, their culture may require that they stay in the readiness phase for longer. Even recognition and awareness can vary across disciplines. It’s important to remember that this journey looks different for each organization.

Second reminder, the image conveys a sequence when moving along the road. While this is true, for the most part, we need to remember that often we will be working in several areas of focus somewhat simultaneously. An organization may be forming a workgroup and starting to implement some trauma informed strategies at the same time others in the organization are acquiring the skills and knowledge they need for TIC. I guess what I’m saying is that if we want to characterize this as a journey to trauma informed care, we need to acknowledge that sometimes it will feel like we are driving in reverse and other times we might notice we’ve been circling the block. Which brings me to my final reminder. As much as I’m a fan of the metaphor, portraying TIC as the final destination ignores the fact that TIC is happening throughout the journey.

Improvements to the Road Map (Road Map 2.0)

Whaaat?? After you just reminded us how to think about the road map you are going to tell us you changed it? I can hear it now. Not to worry, the icons aren’t changing nor is the layout. You will still move west to east from recognition to implementation. What is changing, or shall we say improving, is how we think about the focus areas. We’ve learned some things since originally introducing the Road Map. One of the things we’ve learned is that it’s helpful to think about groups of focus areas as representing developmental phases. We first heard about this way of conceptualizing implementation from work done by the Missouri State Trauma Roundtable. They talked about four developmental phases of implementation: trauma aware, trauma sensitive, trauma responsive, and trauma informed (see The Missouri Model: A Developmental Framework for Trauma Informed Care for information about the Missouri Model). And, we noticed this language really resonated with people, as it seemed easier to talk about what phase of implementation their organization was in.

So, one of the improvements we’ve made to the Road Map is that we’ve aligned focus areas with these four developmental phases. Phase I (trauma aware) aligns with recognition and awareness, Phase II (trauma sensitive) captures foundational knowledge, agency readiness, and process and infrastructure, Phase III (trauma responsive) aligns with gather information and create a work plan, and Phase IV (trauma informed) aligns with implement and monitor and adopt policy and practice. We added the phase information with sign icons as well as grouping the other icons together by color. The other improvement we made was adding a road sign that represents our intended destination. This icon is accompanied with the action word, “assess,” as a reminder that we need to see what changes as a result of TIC. What are the outcomes?

These changes are part of our collective learning about TIC implementation. It continues to be our goal to translate lessons learned on the ground into helpful resources.

Using the Road Map in Coordination with the Standards of Practice for Trauma Informed Care

In our effort to create useful resources for folks who are working to implement TIC, it’s possible that we’ve confused some people by offering multiple tools that have a similar focus. This is particularly true with the Road Map to Trauma Informed Care and the Standards of Practice for Trauma Informed Care. I thought this might be a good opportunity to explain the difference and similarities between these tools and ways to think about their use. Before getting into that, however, I’d like to note that we’ve updated the Standards of Practice, changing or eliminating some of the items, and clarifying some of the language.

Both the Standards and the Road Map offer ways to think about implementation. There isn’t anything contradictory between these two tools, but they do vary in terms of conceptualization and detail. The Road Map is fairly high level without many details. As an example, agency readiness is suggested but the details of what and how are not specified. While we do provide consideration pages for all of these focus areas, the recommendations are merely that—recommendations. The Standards of Practice, on the other hand, are a bit more prescribed and specific, outlining the standards needed when becoming trauma informed.

The Road Map conveys a stronger sense of order and movement compared to the Standards. This is due, in part, to our desire to convey the organizational change process on the Road Map. While we might argue the Standards should be thought of in terms of sequence, it is less obvious in this document. The Standards are listed numerically, but organizations usually don’t tackle the focus areas in order, sequence is not as important for the Standards.

The final notable difference is that the Standards are grouped in terms of domain, e.g., environment and safety, whereas the steps in organizational change, e.g., agency readiness, organize the Road Map. Both documents are based on the Substance Abuse Mental Health Services Administration (SAMHSA) principles of trauma informed care, but this alignment is probably more evident in the Standards.

Our recommendation is that the Road Map and Standards be used together. The Road map will help an organization think about the work in terms of sequence and the organizational change process, while the Standards will provide more detail about the what, how, and why.

As always, if you are using these tools and you have words of advice or wisdom, we’d love to hear from you.