Editorial Introduction to Special Issue on Trauma Karen M. Allen Virginia C. Strand Social work has always served society’s most vulnerable individuals and groups and it is difficult to think of an area of practice where one could avoid working with clients who have not been traumatized in some way. Although the field of traumatology initially evolved in response to soldiers and veterans who were shell-shocked in the World Wars, it has progressed beyond reductionist thinking that post-traumatic stress disorder is a pathology to an understanding of the significance and impact of trauma experiences in our lives. We now know that over one-third of adults are exposed to significant trauma as children and that the effects of these experiences are cumulative, complex, and often lifelong. Repeated exposure significantly increases the potential for negative outcomes including depression, alcohol and drug use, obesity, sexually transmitted diseases, smoking, cancer, chronic heart and lung disease, and early mortality (Centers for Disease Control, 2014). Even before we are born, in utero exposure to maternal stress can cause epigenetic changes that negatively affect development and contribute to poor health by compromising the immune system and reducing the capacity to stave off disease (Teicher, Andersen, Polcari, Anderson, & Navalta, 2002). Contextual factors such as age, gender, ethnicity, and socioeconomic status including historical and cultural trauma exacerbate the negative outcomes associated with trauma exposure and further increase the risk of retraumatization; creating a vicious cycle that can persist through generations. Over the past 35 years, our courage, compassion and skill in listening to the stories of our clients, bearing witness to unspeakable cruelties, assuring safety, restoring hope and demanding justice has begun to coalesce into a cohesive body of knowledge and empirically-tested interventions that promote healing (Allen & Wozniak, 2014; Najavits, 2002). Further, recognizing that to work effectively with traumatized clients practitioners must “face human vulnerability in the natural world and …the capacity for evil in human nature in order to bear witness to horrible events” (Herman, 1999, p. 7). We have pioneered new understandings in compassion fatigue, vicarious trauma and secondary stress (Figley, 2002). We have developed prevention and early intervention strategies such as stress inoculation and self-care techniques to help mediate negative outcomes and to promote the well-being of providers. Moreover, as new models of care, best practices, assessment tools and empirical studies emerge, we have adapted trauma-informed treatments for traumatized individuals to whole communities and most recently to agencies and institutions in order to develop trauma-informed systems of care (Strand, Popescu, Abramovitz, & Richards, 2015). Many agencies now recognize and promote trauma-based principles as a key component of interventions for complex psychological and social problems. SAMHSA (2015) has funded the National Child Traumatic Stress Network (NCTSN, n.d.) for almost 20 years and recently endorsed principles and practices for trauma-informed systems. ____ Karen Allen, Ph.D., is a Professor and Director, School of Social Work, Indiana University Bloomington, Bloomington, IN 47401. Dr. Virginia C. Strand is a Professor, Fordham University Graduate School of Social Service, West Harrison, NY 10604 and Co-Director, National Center for Social Work Trauma Education and Workforce Development. Copyright © 2017 Authors, Vol. 18 No. 1 (Spring 2017), i-iii, DOI: 10.18060/21630 This work is licensed under a Creative Commons Attribution 4.0 International License. ADVANCES IN SOCIAL WORK, Spring 2017, 18(1) ii Beginning with early work in child welfare, the Children’s Bureau initiated a focus on trauma-responsive child welfare systems (2017). Twelve schools of social work receiving traineeships through the National Child Welfare Workforce Institute (NCWWI, n.d.) now include a trauma lens in their child welfare courses. In 2012, CSWE released its standards for advanced social work practice in trauma and many schools of social work now offer concentrations, specializations, or certificates in trauma-based care. A joint initiative between CSWE and the National Center for Social Work Trauma Education is scheduled to publish a curriculum guide for Specialized Practice in Trauma by the end of 2017. This special issue of Advances in Social Work recognizes the increasing role and importance of integrating trauma-informed care into our practices and into our educational programs. The issue presents 25 trauma related articles starting with conceptual and foundational articles, followed by empirical studies suggesting best practices, and culminating with articles describing emerging approaches in integrative and holistic care. Beginning with two articles that explore integrating trauma-related content into curricula and pedagogy, the issue then provides an overview of the literature related to creating trauma-informed communities. We then present research that explores trauma- informed interventions with specific populations including infants and toddlers, refugees, survivors of interpersonal violence, and male survivors of sexual abuse. The next section presents program and agency-based case studies that describe various strategies for implementing trauma-informed care such as staff training, learning collaboratives, interprofessional teams, and infrastructure development. Empirical studies testing the effects of trauma-based care or curriculums follow and include one study evaluating outcomes for the Core Concepts in Child Trauma for Child Welfare curriculum utilized in a Title IV-E university partnership, and another that assesses the effectiveness of a multiphase intervention with Latino youth. Additional studies describe the role that child attributes play in mediating the effects of trauma exposure and the relationship between Adverse Childhood Experiences (ACE) and youth arrested for sexual offenses. The issue concludes with articles describing innovative approaches in trauma therapy including work with children in a bereavement camp and an overview of equine-assisted psychotherapy for trauma survivors. We received a generous response to the initial call for papers for this special issue, which extended the anticipated timeframe for publication. We thank all of the authors and reviewers for their patience in working with us throughout the publication process. We would also like to thank Margaret Adamek, Kadie Booth, Valerie Decker, and Michael Hernandez for their help in bringing this issue to press. Although we were unable to include all of the submissions in this issue, we were impressed with the scope of work being done in this field as well as the compassion, creativity and dedication of individuals working in this area. We look forward to the continuing evolution of our understanding of trauma and effective ways of addressing trauma and hope that this issue contributes to that process. Respectfully, Karen Allen and Virginia Strand References Allen & Strand/TIC EDITORIAL iii Allen, K. & Wozniak, D. (2014). The integration of healing rituals in-group treatment for survivors of domestic violence. Social Work in Mental Health, 12(1), 52-68. doi: https://doi.org/10.1080/15332985.2013.817369 Centers for Disease Control and Prevention, National Center for Injury Prevention and Control, Division of Violence Prevention. (2014, May 13). Prevalence of individual adverse childhood experiences. Retrieved from: https://web.archive.org/web/20160404140139/http://www.cdc.gov/violencepreventio n/acestudy/prevalence.html/ Children's Bureau. (2017). Children's Bureau discretionary grant awards. Retrieved from https://www.acf.hhs.gov/cb/resource/cb-discretionary-grant-awards Council on Social Work Education. (2012). Advanced social work practice in trauma. Retrieved from: https://www.cswe.org/getattachment/Publications-and- multimedia/CSWE-Full-Circle-(1)/Newsletters-Archive/CSWE-Full-Circle- November-2012/Resources-for-Members/TraumabrochurefinalforWeb.pdf.aspx/ Figley, C. (Ed.). (2002). Treating compassion fatigue. Sussex, U.K.: Brunner-Routledge. Herman, J. (1999). Trauma and recovery: The aftermath of violence from domestic abuse to political terror. New York: Basic Books. Najavits, L. M. (2002). Seeking safety: A treatment manual for PTSD and substance abuse. New York: The Guilford Press. National Child Traumatic Stress Network. (n.d.). Home. Retrieved from http://www.nctsn.org/ National Child Welfare Workforce Institute. (n.d.). What’s new. Retrieved from www.NCWWI.org SAMHSA. (2015). Trauma-informed approach and trauma-specific interventions. Retrieved from https://www.samhsa.gov/nctic/trauma-interventions Strand, V., Popescu, M., Abramovitz, R., & Richards, S. (2015). Building agency capacity for trauma-informed evidence-based practice and field instruction. Journal of Evidence-Informed Social Work, 13(2), 1-19. Teicher, M. H., Andersen, S. L., Polcari, A., Anderson, C. M., & Navalta, C. P. (2002). Developmental neurobiology of childhood stress and trauma. Psychiatric Clinics of North America, 25(2), 397-426. doi: https://doi.org/10.1016/S0193-953X(01)00003- X Integrating a Trauma-informed Care Perspective in Baccalaureate Social Work Education: Guiding Principles Matthew Lorenzo Vasquez Shamra Boel-Studt Abstract: Over the past decade, there has been substantial growth in empirical evidence supporting that proper assessment and treatment of trauma using evidence-based practices can effectively reduce a wide range of symptoms in both children and adults. Given the complex nature of trauma treatment, trauma-based educational programming in social work is most commonly found at the graduate level. Yet, to date, there has been little discussion calling for the inclusion of trauma content in BSW education. In this paper, we examine the current state of trauma-content inclusion in social work education, and offer a guiding framework for integrating core trauma content into the BSW curriculum that is based on the core principles of trauma-informed care. Keywords: Trauma; trauma-informed care; baccalaureate social work Over the past decade, there has been mounting evidence for assessment and treatment methods capable of effectively identifying and reducing a wide range of trauma symptoms in pediatric (de Arellano et al., 2014; Schneider, Grilli, & Schneider, 2013) and adult samples (Ehlers et al., 2010; Rubin & Springer, 2009). Subsequently, trauma-focused interventions have grown in popularity and are increasingly being recognized as a standard form of treatment for trauma-affected individuals. Given the complex nature of trauma treatment and the numerous issues that can arise concerning client-safety, trauma-based educational programming is most commonly found at the graduate level (Courtois & Gold, 2009). Indeed, a growing number of MSW programs have begun integrating trauma content into their curriculum (Abrams & Shapiro, 2014; Bussey, 2008; Strand, Abramovitz, Layne, Robinson, & Way, 2014). Yet, to date, there has been little discussion calling for the inclusion of trauma content in BSW education (McKenzie-Mohr, 2004). With BSWs often having “first contact” with various client populations, including those who have been chronically maltreated and traumatized, it is necessary for BSW programs to include content into their curriculum that provides students with an understanding of trauma, its treatment, and the ways in which service organizations can best serve traumatized individuals. In this paper, we examine the current state of trauma-content inclusion in social work education, and offer guiding principles for integrating core trauma content into the BSW curriculum that is based on the principles of trauma-informed care. Definition and Prevalence of Trauma A variety of definitions of trauma have been presented in the literature. In an effort to develop a common conceptualization that is applicable to both practitioners and researchers, the Substance Abuse and Mental Health Services Administration (SAMHSA; ______________________ Matthew L. Vasquez, PhD, LMSW is Assistant Professor, Department of Social Work, University of Northern Iowa, Cedar Falls, IA 50614, Shamra Boel-Studt, PhD, is Assistant Professor, College of Social Work, Florida State University, Tallahassee, FL 32306. Copyright © 2017 Authors, Vol. 18 No. 1 (Spring 2017), 1-24, DOI: 10.18060/21243 This work is licensed under a Creative Commons Attribution 4.0 International License. Vasquez & Boel-Studt/INTEGRATING TIC 2 2014) conducted an extensive review of existing definitions followed by a review from an expert panel to propose the following definition: Individual trauma results from an event, series of events, or set of circumstances that is experienced by an individual as physically or emotionally harmful or life- threatening and that has lasting adverse effects on the individual’s functioning and mental, physical, social, emotional, or spiritual well-being. (p.7) Prevalence of exposure to traumatic events is high among children and adults in the United States. Studies have shown that approximately 70-80% of children and adolescents (ages 2-17) were exposed to at least one type of victimization in their lifetime and 66% had been exposed to multiple types of victimization including child maltreatment, attempted kidnapping, peer/sibling victimization, domestic violence and crime in their communities (Copeland, Keeler, Angold, & Costello, 2007; Turner, Finkelhor, & Ormrod, 2010). In a nationally representative survey of adults, 89.7% reported having been exposed to at least one traumatic event with an average exposure to 3.30 different types of events (Kilpatrick et al., 2013). Similar rates of traumatization have been found in other studies using national and internationally representative samples (see Breslau et al., 1998; Frans, Rimmö, Åberg & Fredrickson, 2005; Stein, Walker, Hazen, & Forde, 1997; Vrana & Lauterbach, 1994). Trauma Studies in Social Work Education Numerous studies highlight the impact of trauma on long-term health and mental health functioning (Dong et al., 2004; Felitti el al., 1998), including the high rates of social service use among these populations (Elhai, North, & Frueh, 2005; Jennings, 2008; Solomon & Davidson, 1997). Consequently, there is a growing sentiment that the inclusion of trauma- focused content should be presented in helping professional degree programs (Courtois & Gold, 2009; Marlowe & Adamson, 2011; Strand et al., 2014). Yet, Courtois (2002) notes that the specialized study of traumatic stress has yet to be fully included in social science educational programs. Courtois (2002) cautions: This lack of inclusion has the effect of preventing traumatized individuals from getting needed services from professional and lay personnel who are knowledgeable about trauma, trauma response, and their particular role. In turn, it has also had the potential for creating more distress in traumatized individuals, in their loved ones, and in even those charged with providing help. Thus, the need for this information and its inclusion in professional curricula, is not casual and is, in fact urgent. (p. 53) This sense of urgency has not gone unnoticed within the field of social work. In 2012, the Task Force on Advanced Social Work Practice in Trauma published guidelines on how to integrate trauma-focused content into social work programming (CSWE, 2012, Advanced Social Work Practice in Trauma). These guidelines are based on the 10 Education and Policy Accreditation Standards (EPAS) core competencies that were set forth by CSWE in 2008, and include individual, family, organizational, and community-based recommendations for advanced social work practice in trauma. The authors are clear that these guidelines are meant for integration in MSW-level programming. As such, there is ample discussion of activities that concern assessment, diagnosis and clinical intervention, ADVANCES IN SOCIAL WORK, Spring 2017, 18(1) 3 which are practice behaviors often associated with advanced social work practice. Thus, it could be argued that the current state of social work education views the inclusion of trauma-related content as best-suited for the graduate level. Graduate Social Work Education in Trauma Currently, there are several graduate-level trauma certificate programs offered at schools of social work throughout the nation. Many of these programs have a clinical emphasis, and include specific training in interventions like trauma-focused cognitive behavioral therapy (TF-CBT), crisis/disaster intervention models, and trauma-informed care (see Bussey, 2008). These programs may be included as part of the graduate curriculum, or housed within continuing education programs, with graduate students and practicing social workers being able to participate. Many of these programs are relatively new and, therefore, have yet to be evaluated. One recent approach to integrating trauma-related content into graduate social work education has come from the National Child and Traumatic Stress Network’s (NCTSN) Core Curriculum on Childhood Trauma (CCCT; Layne et al., 2011). The CCCT’s aim is to advance the knowledge of graduate students and current working professionals on the core concepts of psychological trauma, which can then prepare them for more advanced training in evidence-based trauma treatment (EBTT). The CCCT consists of a five-tier conceptual framework, and uses problem-based learning (such as the use of real case vignettes) along with the use of facilitators who hold extensive clinical experience in trauma-related practice. In a large-scale evaluation of a modified version of the CCCT, the Core Concepts in Child and Adolescent Trauma, in graduate schools of social work researchers found that students experienced significant pre-posttest increases in self- reported confidence in applying the core concepts of trauma (Layne et al., 2014). The researchers also found that other students who participated in the “gold standard plus” educational model, which included the CCCT course, training in EBTT, and implementation of the EBTT in field placement, experienced significant pre-posttest increases in self-reported conceptual and field readiness. The CCCT constitutes one of the first comprehensive initiatives to promote trauma training for MSW students, and may reflect a growing trend for schools of social work to implement more structured approaches to offering trauma-based programming. There is also a growing discussion of how to safely and effectively present trauma content to graduate social work students. Students with trauma histories who are exposed to trauma-related content, whether in the classroom or during field placement, have the potential to experience vicarious trauma, or to be re-traumatized by material that reflects past experiences (Carello & Butler 2014, 2015; Didham, Dromgole, Csiernik, Karley, & Hurley, 2011; Knight, 2010). This can be highly disruptive to student learning (Miller, 2001), as those who lack awareness of the severity of their past trauma can draw upon intense, maladaptive patterns of coping when exposed to course content that triggers prior traumas (Etherington, 2000). In response to this issue, recommendations have been offered on how to make the classroom environment a safe place for graduate students by presenting content that aids in the reduction of secondary traumatic stress (O’Halloran & O’Halloran, Vasquez & Boel-Studt/INTEGRATING TIC 4 2001; Shannon, Simmelink, Im, Becher, & Crook-Lyon, 2014) and vicarious trauma (Dane, 2002). Baccalaureate Social Work Education in Trauma Although the inclusion of trauma-related content in graduate level curricula has grown in popularity, the literature on the inclusion of trauma content in BSW education is limited. McKenzie-Mohr (2004) calls for the inclusion of trauma-focused content in the BSW curriculum due to the high likelihood that most graduates will obtain employment in organizations that provide services to traumatized and/or oppressed individuals. Breckenridge and James (2010) discuss the rationale for their development of a BSW course that emphasized multifaceted approaches to addressing trauma that encourages students to view treatment as including individual, group, community, and policy-based interventions. Finally, Farchi, Cohen, and Mosek (2014) describe their development of an Israeli stress and trauma studies (STS) program. The STS was a supplementary curriculum to an undergraduate social work program in which students were trained to act as psychological first responders to those who had just experienced traumatic events with the aim of preventing the development of trauma symptoms. Currently, there is no recommended model for infusing trauma-related content across the BSW curriculum like the one provided by the Task Force on Advanced Social Work Practice in Trauma (CSWE, 2012) for MSW programming. The reasons behind this lack of emphasis are not entirely clear. One reason could be, as previously discussed, the potential for students to experience duress when exposed to trauma content. MSW students may be viewed as having more life and/or work experience than BSW students, and therefore, perceived as mature enough to manage the sensitive nature of the content (Bell, Kulkarni, & Dalton, 2003; Neumann & Gamble, 1995). Another reason may be the perception that the study of trauma is inherently complex and clinical in nature (see CSWE, 2012), and therefore best suited for graduate-level social work programming. The CSWE Educational Policy and Accreditation Standards (EPAS; 2015) state that MSW programs help students to “identify the specialized knowledge, values, skills, cognitive and affective processes, and behaviors that extend and enhance the nine Social Work Competencies and prepare students for practice in the area of specialization” (p.12). Although there is no discussion of what constitutes specialized practice, the study of trauma and its treatment may be viewed as a primarily clinical endeavor, which is often synonymous with advanced or specialized practice. Thus, the structure of graduate social work education, with its strong emphasis on field education, may be deemed as best-suited to help students learn the theoretical concepts related to trauma and then to apply them during field placements. Due to BSW education being rooted in generalist practice, which does not typically include content on clinical or other specialized forms of practice, there may be a perceived difficulty in connecting trauma- related content with the BSW curriculum. With the high likelihood of BSW students finding employment with organizations that serve traumatized individuals, we advocate for the inclusion of trauma-related content in the BSW curriculum. Such content should provide students with an understanding of the ADVANCES IN SOCIAL WORK, Spring 2017, 18(1) 5 ways in which trauma affects individuals, families, and communities, along with an understanding of how social service organizations’ practices and policies can impact service delivery and their clients who have experienced trauma. One practice model that may offer an effective way to integrate a broad spectrum of trauma content into a generalist model of social work practice is trauma-informed care. Trauma-Informed Care In recent years, there has been a growing movement for trauma-informed practices to be implemented across a broad spectrum of service settings and client populations, such as in child welfare (Ko. et al., 2008), in-patient psychiatric settings (Azeem, Aujla, Rammerth, Binsfeld, & Jones, 2011; Huckshorn, 2004; Regan, 2010), with inmates (Levenson, Willis, & Prescott, 2014), and the homeless (Hopper, Bassuk, & Olivet, 2009; McKenzie-Mohr, Coates, & McLeod, 2012). Generally, in trauma-informed care settings, staff a) assess for and understand the impact of trauma on their clients, b) provide clients the knowledge and skills needed for recovery, and c) actively address treatment barriers and service delivery practices that may lead to potential re-traumatization (Elliott, Bjelajac, Fallot, Markoff, & Reed, 2005; Gatz et al., 2007). Depending on the specific needs of the client population, staff may be trained in how to establish and maintain safety and therapeutic relationships, de-escalation techniques, and strengths and empowerment models of client-care and case management (Azeem et al., 2011; Borckardt et al., 2011; Elliott et al., 2005). A trauma-informed care system also serves to support and maintain trauma-specific treatment approaches, which are “designed to treat the actual sequelae of sexual or physical abuse trauma” (Jennings, 2008, p. 10). These approaches can include psychoeducation, therapies designed to address trauma and its accompanying symptoms (e.g., cognitive therapies, desensitization therapies, prolonged exposure), emotional regulation and social skill-building, enhancing resiliency, and psychotropic medication management (Cohen, Mannarino, Berliner, & Deblinger, 2000; Jennings, 2008; NCTSN, 2007). This dual- approach to service delivery provides all those involved in client cases (e.g., case managers, clinicians, and administrators) with a common understanding and language surrounding the impact of trauma and its treatment. Such an environment allows clients to safely and confidently engage in trauma-based therapy without the fear of potential mismanagement of their care by those uninformed about their specific needs. At the crux of trauma-informed care is the understanding that service organizations need to be consistent in the ways that they engage clients who have experienced trauma, while being flexible in responding to their individual needs (Prescott, Soares, Konnath, & Bassuk, 2008). Striking this balance requires staff to continuously reflect upon and evaluate both personal and organizational forms of practice, and to make changes accordingly. We propose that the skills and competencies needed to effectively engage in this type of practice closely align with those found in generalist social work practice. Therefore, the BSW curriculum, which is based on a generalist model, serves as an ideal platform to present principles of trauma-informed care. In the following sections, we present a comprehensive trauma-informed care framework that educators can use to guide the infusion of trauma-related content into their BSW curriculum. Vasquez & Boel-Studt/INTEGRATING TIC 6 Method To identify core content areas that could be integrated into the BSW curriculum, we conducted a literature search to identify common principles found in trauma-informed care practice frameworks across a variety of professional disciplines. Focusing on frameworks that were published since 2000, we searched Google Scholar, Academic Search Complete and Elite, and PsychINFO. Additionally, we searched the internet using Google to identify frameworks published on organizational and government websites and other reputable non- academic literary sources (e.g., NCTSN, SAMHSA, National Center for Biotechnology Information). We used a combination of the search terms: trauma, trauma-informed care, approach, perspective, principles, and framework. To begin, each author conducted a separate literature search to identify trauma- informed frameworks. In total 13 frameworks were found using our search criteria. Each framework was then separately reviewed for common practice principles by both authors and compared for agreement. Initially, 19 common principles were identified. In a second review, we collapsed seven of the principles into broader categories in which they were closely aligned (e.g., empowerment, choice, autonomy). We further applied a selection criterion in which a principle had to have been present in at least four frameworks to be considered ‘common’. This was based on our finding that a principle appeared at least four times and below that range, the identified principles or guidelines were sporadic, appearing only once or twice. At that point, we reached 100% agreement on the remaining principles. This level of agreement was facilitated by the high level of consistency in the stated principles and the language used across frameworks. The remaining nine principles are summarized in Table 1, and represent the most commonly identified principles of trauma- informed care practice across the fields of mental health, social work, nursing, child welfare, and criminal justice. In the following section, we present these nine principles, along with recommendations for integration within a generalist BSW curriculum. Similar to the Task Force on Advanced Social Work Practice in Trauma (CSWE, 2012), our framework should serve as a guide for social work educators. ADVANCES IN SOCIAL WORK, Spring 2017, 18(1) 7 Table 1. Common Principles Identified Across Trauma-Informed Care Practice Frameworks 2 Trauma 3 Safety & 4 Empowerment 1 Trauma 5 Identifying 6 Cultural 7 Healthy 8 Emotion Screening & Minimize Re- & Self- 9 Self-Care Knowledge Strengths Competency Relationships Regulation Source Assessment victimizing Determination Bath (2008) X X X Bloom & Sreedhar (2008) X X X X X Covington et al. (2008) X X X X X X Elliot et al. (2005) X X X X X X X Guarino et al. (2009) X X X X X X X X Huckshorn (2004) X X X Huckshorn et al. (2005) Harris & Fallot (2001) X X X X Fallot & Harris (2001) Kinniburgh et al. (2005) X X X McManus & Thompson X X X X (2008) NCTSN (2007) X X X X X X X Prescott et al. (2008) X X X X X X X X Saakvitne et al. (2000) X X X X X SAMSHA (2014) X X X X Note. NCTSN = National Child Traumatic Stress Network; SAMSHA = Substance Abuse and Mental Health Service Administration.