BY , MSW, CSW, LMSW, AND , LMSW, MBA
It seems like every article you read lately starts with “The past year and a half…” as it references the hardships and struggles our nation and the world faced as a result of the pandemic. Just when we think that things are looking up, new issues arise that make it feel like we are taking two steps backward. This is why, now more than ever, we need to understand and embrace the concept of trauma-informed care (TIC) and trauma-informed leadership (TIL) to help people process and work through the stressors of this pandemic (Bhattacharya, 2020, Haseltine, n.d.).
Now, if we are being honest, long before COVID-19, healthcare workers, particularly case managers, have been facing the possibility of burnout due to work-related stress in conjunction with personal stressors. This has been identified in case managers regardless of how they deliver services, i.e., in-person or telephonic. Given the impact of TIC and TIL in the case manager role, it is important that we genuinely lean into the concepts of TIC and TIL by first understanding what “trauma” is. The information regarding the concept of trauma can be found in countless academic and medical journals, research and papers. Many times what we see as part of those narratives is one’s own working definition of trauma. Each definition is a little different or utilizes a slightly different set of criteria. This article focuses on the idea that trauma is an event that an individual sees as deeply distressing or disturbing. In adopting this definition, bear in mind that it does not specify the nature of the event. There is no mention of “an act of war” or any requirement of fear of “impending doom”; the event is simply perceived as distressing to the individual.
An excerpt from Trauma Redefined in the DSM-5: Rationale and Implications for Counseling Practice, (Jones & Cureton, 2014) provides us a summary of trauma: “Derived from the Greek word ‘wound;’ the tales of trauma and its profound consequences date back to the start of written history… Eventually, contemporary theories and definitions of trauma became largely fashioned from studies of male soldiers’ reactions to the horrors of war. (Herman, 1992a).
“The publications of the DSM-IV and DSM-IV-TR brought a considerably more inclusive definition of trauma (APA, 1994, 2000) with numerous events of differing severity considered variations of traumatic experience…Modern trauma theory conceptualizes trauma and traumatic responses as occurring along a continuum (Breslau & Kessler, 2001).”
This means, we can think of trauma as being anything we perceive as harmful, impacting the person in individual ways along the continuum of their lives.
As the medical community continued to see that the impacts from smaller events had the same effect on people as the obvious significant events (war, witnessing death, etc.), the question came to be, where do the trauma impacts start for an individual? When do we start feeling and seeing impacts of trauma? How do we prevent, heal or support individuals experiencing trauma? In the latter half of the 1990s, the CDC sought to answer some of these questions through the Adverse Childhood Event (ACE) study. The original study was conducted at Kaiser Permanente from 1995 to 1997 with over 17,000 members completing confidential surveys regarding their childhood experiences and current health status and behaviors (National Center for Injury Prevention and Control, Division of Violence Prevention, 2021).
The major findings from this study highlighted that ACEs are common across all populations. Almost two-thirds of study participants reported at least one ACE, and more than 20% reported three or more ACEs. Some populations are more vulnerable to experiencing ACEs due to the social and economic conditions in which they live, learn, work and play. Our vulnerability to, and ability to cope with, adverse events throughout our lives is something to keep in mind when interacting with peers and colleagues. The intersectionality of each of these adverse/traumatic streets and how we choose to navigate them ultimately determines who we are and who we will be (National Center for Injury Prevention and Control, Division of Violence Prevention, 2021).
The impacts of adverse childhood experiences on our development and interactions with the world around us cannot be overlooked. The impact spans the gamut of our personal and professional identities as well as how we portray ourselves within the healthcare system. To assist our clients, patients, team members and fellow humans in navigating their own traumatic streets with as much ease and efficacy as possible, we can turn to the trauma-informed care (TIC) and trauma-informed leadership (TIL) framework (Burke & Cooper, 2016).
There are 5 domains of TIC and TIL (Tubridy, 2021):
- Safety and Predictability
- Ensuring physical and emotional safety
- Trustworthiness and Transparency
- Maximizing trust through task clarity, consistency, and interpersonal boundaries
- Choice
- Maximizing client experiences of choice and control
- Collaboration and Empowerment
- Sharing of power
- Prioritizing empowerment and skill-building
- Empathy
- Staying curious
- Listening to understand
For case managers, these concepts in action could be:
- Engagement Phase
- Paying attention to tone of voice
- Providing expectations for yourself
- Assessment Phase
- Using motivational interviewing skills
- Explain the why behind surveys
- Develop a shared understanding of the problem
- Planning Phase
- Ensure the plan reflects what the client said they wanted to work on
- Planning PhasePrioritize the problems and solutions
- Planning PhaseWhat does the client think will work (what are they willing to commit to)
- Implementation Phase
- Respond to requests for additional help/information
- Monitor progress together
- The client is the expert – help them realize and capitalize on it!
- Evaluation Phase
- Intentional conversations on progress
- Reevaluating goals based on progress
- Termination Phase
- Explain criteria for termination up front
- Monitor and appropriately respond to emotional reactions to termination
- Offer choices for continued success
Just as we encourage our case managers to employ these skills with the populations they serve, we must ensure that leaders are equipped with these tools as well. At first glance, when we take a look at trauma-informed leadership skills, they may seem obvious. Yet, when we look for examples of how these skills are utilized, they are missed quite frequently. As professionals, we have to make a concerted, conscious effort to practice every day with each person we connect with and serve regularly (Nealy-Oparah & Scruggs-Hussein, 2018).
- Routines – Link to predictability and transparency
- Rituals – Link to respect
- Relationships – Link to empathy
- Regulation – Assists with creating psychological safety and is interconnected with the other 3 R’s.
TIC and TIL give us a pathway to create a trauma-sensitive environment (TSE). As we walk this pathway, we may find our thoughts shifting from “What were they thinking?” and “Why would they do something like that?” to “I wonder what happened to them?” and “How I can help them move to a place of growth?” This allows us to be person- and solution-focused, regardless of the situation. Perhaps most importantly, maintaining such a working definition of trauma and adhering to TIC/TIL principles allows us to avoid re-traumatizing the individual with our responses. By utilizing the shared strategies, leaders are equipped to support those who support so many: The true heroes and heroines of the front lines of healthcare.
, MSW, CSW, LMSW, MBA candidate, is an associate director for Humana’s SNP Medicare line of business. She oversees teams of nurses, social workers, and nonclinical case managers. She is a strategic and thought leader who has experience in mentorship, change leadership, program development, strategic planning, therapy services, community outreach, and advocacy. She is impassioned to amplify the voice of social work and build our next generation of effective and informed leaders and case managers.
, LMSW, MBA, is a clinical strategy and practice lead within Humana’s Medicaid Line of Business building out care management programs per state contract requirements and ensuring successful implementation. She is an influencer who leads through mentorship, promoting positive change through cross-functional projects within Humana. Her experience lies in leading care management teams, program development and behavioral health. She truly believes that success is not what you accomplish, but more about what you inspire others to do.
REFERENCES
Bhattacharya, K. (2020). Surgeon’s covid-19 traumatic stress disorder. Indian Journal of Surgery, 83(1), 382–382. https://doi.org/10.1007/s12262-020-02504-4
Breslau, N., & Kessler, R. C. (2001). The stressor criterion in DSM-IV posttraumatic stress disorder: An empirical investigation. Biological Psychiatry, 50, 699–704. doi:10.1016/s0006-3223(01)01167-2
Burke, R. J., & Cooper, C. L. (2016). The fulfilling workplace: The organization’s role in achieving individual and organizational health. Gower.
Haseltine, W. (n.d.). Covid-19 traumatic stress disorder. https://www.psychologytoday.com/us/blog/best-practices-in-health/202010/covid-19-traumatic-stress-disorder
Herman, J. L. (1992a). Trauma and recovery: The aftermath of violence—from domestic abuse to political terror. New York, NY: Basic Books.
Jones, L. K., & Cureton, J. L. (2014). Trauma redefined in the dsm-5: Rationale and implications for counseling practice. The Professional Counselor, 4(3), 257–271. https://doi.org/10.15241/lkj.4.3.257
National Center for Injury Prevention and Control, Division of Violence Prevention. (2021, April 6). About the CDC-Kaiser ACE study. Centers for Disease Control and Prevention. https://www.cdc.gov/violenceprevention/aces/about.html.
Nealy-Oparah, S., & Scruggs-Hussein, T. C. (2018). Trauma-informed leadership in schools: From the inside-out.
Tubridy, C. (2021, September). Trauma-Informed Case Management. West Central Wisconsin Community Action Agency Training. Wisconsin.