Asking: “What’s Happened to You?” A Focus on Trauma-informed Care

Photograph of a young woman with her hand on her forehead.

Research suggests that most homeless youth have experienced multiple traumatic events both before becoming homeless and once on the street. This issue of the Exchange provides an introduction to trauma-informed care, an approach that asks, "What’s happened to you?" rather than, "What's wrong with you?"

We talk to one organization that has undergone a trauma-informed transformation in recognizing the symptoms and acknowledging the impact of trauma. We provide practical tips for youth workers on helping youth who have experienced trauma feel safe and open to accepting needed resources. And we talk to Tonier “Neen” Cain, a trauma survivor, about the trauma-informed treatment that helped her turn her life around.

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The Case of Youth on Fire: A Trauma-Informed Transformation

Youth on Fire Logo, showing a hand outstretched with flames in the background.To Ayala Livny, it just didn’t feel right.

When she was first hired as a front-line case manager at Youth on Fire, a Cambridge, Mass., drop-in center for homeless and street youth, members would confide horrifying stories of violence and loss. And they would look to her for some sort of meaningful response, a connection.

Her typical reply: “You should talk to a therapist.”

“For all of our members, trauma was so front and center in their lived experience, both past and present,” Livny says. “But, not being a social worker, I felt really limited in how I could respond.”

Now Livny knows that she can provide a different answer.  As Youth on Fire’s current Program Manager, she has overseen a trauma-informed transformation at the center, overhauling the space, rethinking policies and procedures, and training all staff to recognize trauma responses and triggers. The result is a place where the staff feel more effective and the young people are more comfortable, creating a space for true healing to begin.

Youth on Fire’s transformation was funded in large part by a 2005 grant from the Substance Abuse and Mental Health Services Administration to design a trauma-informed intervention to reduce the progression of substance abuse, HIV and hepatitis infections among homeless young adults. The grant helped pay for invaluable partnerships with experts at the Trauma Center and the Institute for Community Health.

Part of their transformation was an evaluation of the physical space. After talking to experts, they made a number of changes. For example, they repainted the walls a calming blue. They turned the television toward the wall, so the youth couldn’t inadvertently be triggered by something they happened to see on the screen. They added curtains to the cubicle doors of case workers to provide members a greater sense of privacy. And, at the request of the youth, they put a lock on the shower door.  

“None of us ever took a shower there, so it never occurred to us that that was a problem,” Livny says.  “Often there are really small things we can do that make spaces feel significantly different.”

Photograph of a young woman talking with a smiling older woman.They also reviewed policies and procedures to make sure each gave the members the greatest amount of choice and control, which is key to reducing retraumatization. For example, she said they now begin their intake process by telling new members that they don’t have to answer any question they don’t want to.  They have found that adding that small element of control makes young people more open and willing to talk.

Member input was key to the transformation process. Young people provided their suggestions through a few initial paid focus groups and then through their regular monthly advisory board meetings. Plus, conversations in the hall. Anywhere, really. “We find that young people love to have their voices heard,” Livny says. “It’s their experience. They want to tell us about it.”

The final component was staff training. Back when they were undergoing their transformation, Livny said it was harder to come by training materials written for front-line staff. Now, she’s says, those materials are all over the Internet, and it’s fairly easy to put together a training on your own.

“Trauma is pretty intuitive,” Livny says. “All of us as individuals have our traumas with big T’s and little t’s. We understand that things happen that affect the rest of our lives.”

A training around trauma triggers and responses can go a long way to giving front line workers the tools they need to understand and respond to the reactions they see.  For example, Livny said that they had a member who was storing some of his belongings in a staff member’s office. When he didn’t come back for a while, the staff person moved his stuff into a storage closet. When the member came back, Livny said he “freaked out.” But the staff person knew that what appeared to be a serious overreaction was a result of his feelings of loss of control over his belongings based on his past history of trauma.  

Now, trauma is part of the everyday language of the staff. A member’s trauma history is discussed at all case reviews and day-to-day interactions are approached with a trauma lens.

While Livny says that a grant like the one they got from SAMHSA was a wonderful opportunity, a transformation like theirs doesn’t have to be expensive or complicated. For example, there are a number of self-assessments now available online. The Hollywood Homeless Youth Project has e-learning courses and other resources on its website. And the Homelessness Resource Center has trainings and webinars available, as well.   

The impact on the staff alone was well worth the effort, she says. They are less burned out, less frustrated. They take things less personally. They don’t feel like their hands are tied or they are helpless.

”In those moments of vulnerability and connection, to be able to say ‘I can handle anything you tell me’ is really profound and really helps us build those safe and permanent connections that young people need,” she says. 

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Watch a Webinar with Ayala Livny about trauma-informed care at Youth on Fire.

Trauma-Informed Care: Tips for Youth Workers

When Ryan* walked into a local shelter with all of his possessions in a trash bag, staff offered him—along with support and other services—a sturdy, new duffle. But Ryan refused. He didn’t want to give up his trash bag. Even though it was dirty and ripped and awkward to carry, it was his. The staff finally convinced him that his things would be safer in the new one, so Ryan reluctantly placed all of his things, still in the trash bag, inside the duffle.

While Ryan’s reaction may seem strange to some, young people who have lived through trauma exhibit lots of behaviors that seem out of place, says Vicki Lawton, who directs youth programs at the Community Action Partnership of Western Nebraska, which has adopted a trauma-informed care approach to serving all young people.

“Our assumption is that we’re seeing survivors of trauma,” says Lawton. Some have parents in prison, some are kicked out of their home because of their sexual orientation or because the family simply can’t afford to keep them, some leave because of physical or sexual abuse, or a parent’s drug or alcohol use.

“That kind of trauma is horrible,” says Stacey Doerr, Executive Director of Fremont County Group Homes in Wyoming. “But we tell youth: ‘That doesn’t define you, and it doesn’t excuse your behavior now’… Our role is to make sure young people are not victims and don’t see themselves that way.”

While each young person’s response to trauma is unique, youth workers who take a trauma-informed approach try to understand each young person’s emotional triggers, build supportive relationships, and give youth opportunities to rebuild control in their lives.

Understanding Triggers

In typical youth work, Lawton says, “good” behavior is rewarded and “bad” behavior has consequences. Trauma-informed youth work, on the other hand, views all behaviors, good and bad, as information. There’s always a reason for a particular behavior, Lawton says, and the youth worker’s job is to figure out what people, events, or things consistently trigger, or set off, particular reactions.

“It takes a lot of detective work,” Lawton says, “because it often feels like there’s no precipitating factor.”

It might be something seemingly benign, like a song or a carton of milk left out on the counter. “In the beginning,” Lawton says, “We don’t know what the triggers might be, and one young person could trigger another’s trauma.” So Community Action Partnership provides youth with individual apartments, to avoid roommates. Sometimes, young people have to deal with loneliness—and it’s more expensive than having young people share space—but Lawton thinks it works better in the long run.

“With some kids you can say, ‘What the heck was going on there?’ or ‘What were you thinking?’ But not kids who have been through trauma,” Doerr says. “Because they’re really not thinking.” Trauma impacts brain development in such a way that young people often can’t make complex—or even sometimes simple—decisions. When something has triggered an intense reaction, youth workers need to let young people calm down, and talk only when young people are really ready to listen.

Young woman looking uncomfortable while talking with an adult.Lawton agrees. “Young people can go from 0 to 60 in their emotions and even act out physically,” she says. “For kids who have experienced trauma, these are survival mechanisms.” Young people need help to get out of survival mode and feel safe accepting support.

Building Relationships

Building trusting relationships is key to helping young people feel safe and open to accepting needed resources. Lawton says, “You really have to be less rule-oriented and more relationship-oriented.”

For example, on intake, instead of making demands up front and asking young people to fill out forms, just have a conversation and let youth know you’re interested in getting to know them, Lawton says.

“If they were taken out of their home at an early age, and someone sat there at a table with a pile of paperwork, those forms might trigger bad memories. So we work to establish a caring relationship first and then take care of the legalities and all the things we have to do as an agency.”

Youth only stay in a Basic Center Program for 21 days at most, but if a young person has connected with a particular staff person, Lawton says, the Community Action Partnership makes every effort to continue that relationship after the young person leaves the shelter.

“We had one young man in our TLP who was using substances and becoming violent. In the old days, we would have kicked him out of the program,” Lawton says. “But with trauma-informed care, as long as the safety and well-being of the other residents isn’t threatened, we could work to meet that young man where he was. We were able to build a relationship. Now, that young man is asking for drug and alcohol treatment, and the treatment has a much better chance of being successful than if the agency demanded it.”

Giving Youth a Sense of Control

Because control is often taken away in traumatic situations, trauma-informed care also emphasizes the importance of choice, allowing young people to re-build a sense of efficacy and personal control over their lives.

When young people come to Community Action Partnership, staff ask them, “What do you need in order to feel safe here?” Together, youth and staff make a list, and staff will tell youth, “This is what we need for you to stay here.” They both sign it, and Lawton says the process of creating the agreement empowers youth because they can have some control over their environment, and because it instills a sense of personal responsibility.

Staff also encourage youth to take walks outside or spend one hour every day doing something they want to do. Lawton says that every young person needs some time during the day that’s just theirs, and she’s found that youth value that time.

Young people won’t always make the choices you’d like them to make, but Doerr says the most important thing is to offer acceptance and let them know, ‘We’re here to help.’”

*Names have been changed.

A Client’s Perspective on Trauma-informed Care

Tonier “Neen” Cain was 37 years old when she first heard the words that changed her life: “We’re glad you’re here.”

Photograph of Tonier Cain.They were spoken by a member of Tamar’s Children, a Maryland-based nonprofit that counsels female inmates. Cain had met innumerable such social workers before, during a two-decade spiral of drug addiction, prison stays, and unsuccessful rehabilitations that had been ongoing since she was 19. Her childhood, too, was marked by parental neglect and routine sexual abuse. And like many others who spend their lives in perpetual conflict with the criminal justice system, Cain had begun to doubt her own worth as a person. She was resigned to moving from one agency and jail to another, essentially a spectator as different public officials decided her fate.

But those four simple words—“We’re glad you’re here”—offered Cain a glimpse of what life might be like if somebody valued her. “After years of living under a bridge and on the streets, in institutions or with people spitting on me, someone told me they were glad to see me,” she says. It was her introduction to trauma-informed care, a treatment method that assumed she had something to offer the world.

She now travels the country giving speeches on the power of trauma-informed care, and providing technical assistance to programs, cities, and counties that want to implement it. In her own words, Cain went from eating out of a trashcan and assuming she’d be homeless forever, to dining with politicians and guiding youth workers to help young people who have suffered unbelievably. Her experience with Tamar’s Children is a model of how trauma-informed care can positively affect former victims.

“There Were No Expectations on Me”

When Cain talks to program directors who are looking to implement a trauma-informed approach, she first tells them to expect skepticism from their traumatized clients. She speaks from experience: “We’ve been beaten and hurt all our lives by authority figures, so why would we come in to your program and feel safe?”Group hug.

Cain credits Tamar’s Children for their undemanding attitude. “I didn’t even want to live anymore, so when I came to the table… I didn’t have any hope. But there were no expectations on me,” she says. Having come to expect that social workers would simply view her as another irremediable repeat offender, she was surprised to instead find that the entire staff had prepared for her arrival. They’d had meetings to discuss her history, and each staff member was familiar with her past abuse and her emotional triggers.

So their first responsibility, Cain says, was to help her feel empowered instead of helpless. “People weren’t looking at me like I was a piece of gum on their shoe. So often the only thing we have to do with our own treatment plan is to sign it. But I was called to the table and asked what was the best way to help me. They wanted to help me help myself so I could become independent.”

“I Can Be Whoever I Want in this World”

Cain literally first learned about the concept of “trauma” at Tamar’s Children. She was so used to a life of abuse and neglect that she couldn’t imagine an alternative. But then, she says, “My counselor said, ‘Tonier, everything that happened to you as a child happened to you, you didn’t do it to yourself.’” This idea was revelatory. With her counselor, Cain addressed her abandonment by her mother, and began a process of actual recovery, not just damage control.

Photograph of Tonier Cain speaking with a photograph of her as a child in the background.Comparing it to the treatment she’d received before, Cain says, “[Trauma-informed care helped] my belief system change from ‘I am nothing’ to ‘I am somebody, and I can be whoever I want in this world.’ Once that changed I could start making good decisions in my life.”

Seeing Past “Behavior Problems"

In her current capacity providing training and technical assistance, Cain explains to youth workers that what might seem like “behavior problems” are often a traumatized youth’s way of coping with memories of abuse.

Cain remembers visiting a youth-care program to help implement a trauma-informed approach. One young woman had been deemed a racist by her adult supervisors. “I asked to have her in my focus group and they said, ‘You don’t want her, she’s racist.’ And the first thing she said in the group was, ‘I don’t like black people.’ But there’s always a reason, and she tells me she was gang-raped by six black men, and that she was homeless in an African-American community where girls were beating her up.”

Recognizing a person’s unique trauma is the first step in trauma-informed care, and that can only be done with a thorough intake process that is shared with every member of the staff. In Cain’s words, the intake form needs to be referred back to throughout treatment, “not just stapled to the front of a file, never to be seen again.”

From her own experience as a client, Tonier Cain knows that the best way to address trauma is through nonjudgmental, personalized care with an emphasis on an individual’s emotional triggers. And while this approach saved her life when she was well into adulthood, she advocates its use with young people so that they might avoid her struggles.

Reflecting on the help these young people might receive, Cain wonders, “If only someone asked me the same questions at age 9 that they asked me six years ago, and were prepared to hear the answers.”