ACES Are High: Transforming Systems of Care from Within

The concept of system transformation in behavioral health is one that has garnered much attention in recent years. In New York State, this often refers to the evolving iterations of Medicaid managed care and value-based payment. This transformation is focused on the “triple aim” of better care, improved outcomes, and contained cost. At the same time, however, another transformation is taking place – the increased recognition of the impact of trauma on the lives of people with behavioral health needs, and its impact on those who serve them. If we are truly to achieve improved clinical and psychosocial outcomes through system transformation, increasing the efficiencies of program implementation and payment is not enough. Our goal as service providers, and as advocates who shape the system in which we work, should be to ensure that trauma-informed practices are central to program and policy development in New York State and beyond.

Wherever you are in the behavioral health system, you likely know something about the groundbreaking research on adverse childhood events (ACEs) that began in the 1990s and is ongoing. Because of this research, we know that traumatic childhood experiences are extremely common and that they are strongly associated with negative health and behavioral health outcomes. As the ACEs research demonstrates, trauma takes many forms. Domestic violence, sexual assault and child abuse and neglect are just a few kinds of experiences that are all too common in our society. It is also clear that environmental, as well as interpersonal, factors can be traumatic and that interpersonal traumas may be exacerbated under particularly difficult environmental circumstances. For example, poverty, homelessness, and community violence are all sources of trauma and are all social determinants associated with poor health and behavioral health outcomes.

The implications of this research are staggering. The ubiquity of trauma and its deleterious effects require us to design and deliver our programs in a manner that, if not directly treating the symptoms of trauma, recognizes its impact and, at minimum, does not exacerbate traumatic reactions or inadvertently re-traumatize the people we serve. Fortunately, it is becoming a widely-embraced standard for human service organizations and systems of care to embed a trauma-informed approach into their work in recognition of trauma’s impact on outcomes.

But we have to do more. The results of the largest study to date on adverse childhood events reveals significant disparities in traumatic experience across populations. People of color, disproportionately bear the burden of personal, historical and environmental trauma. This is reinforced and exacerbated by government reimbursement structures that engender deficit-based, reactive operations in the nonprofit organizations providing essential human services. It is a vicious cycle.

Therefore, understanding the structural and environmental contributors to trauma does not end with understanding our clients’ experiences. While “trauma-informed practice” is an increasingly well-known service approach, we must also focus on the inevitable impacts of vicarious trauma on our sector. Yet mere recognition of our own trauma experiences is not enough – we also need to reflect on how our experiences influence our interactions with clients. How do we ensure that direct service, administrative staff, and others working within our sector are managing their own trauma reminders and are using strategies that minimize the re-traumatization of others during interactions? How do we ensure that individual employees, their families, and their communities have access to the same basic rights and healing opportunities that they work to provide for those designated as behavioral health consumers?

The answers to these questions are not simple, and not found in the mastery of a single technique or practice. And the responsibility for answering these questions cannot solely rest in the hands of individual practitioners. The ability to transform our system of care starts with shaping the culture of our organizations to support practitioners. True transformation requires awareness of the systems of oppression underlying intergenerational and environmental trauma, reflection on the power dynamics between staff and clients that may be unconsciously perpetuated as a result of trauma, and organizational structures that transparently address these dynamics by providing the training, skills, and safe space for staff to reflect. Examples of concrete practices at an organizational level that evidence the attention to these areas may include: an emphasis on regularly-scheduled reflective supervision; explicit skills training focused implicit bias, internalized oppression, vicarious trauma, and institutionalized racism; authentic feedback expected and modeled at all levels of the organization; and transparent leadership that intentionally addresses staff’s mental and emotional well-being.

On an organizational level, the recognition and response to trauma must be woven into the fabric of the culture in order to support staff reflection, healthy responses, and resilience. This approach must exist throughout the organization, as transformation on this level requires a willingness to challenge the existing paradigms and shift practices to ensure that the principles of trauma-informed care exist throughout the organization’s infrastructure. These guiding principles include: 1) safety, 2) trustworthiness and transparency, 3) peer support and mutual self-help, 4) collaboration and mutuality, 5) empowerment, voice and choice, and 6) cultural, historical and gender considerations. These guiding principles must be integrated into hiring practices, supervision structures, design of physical space, and leadership practices, making them the lifeblood of the organization.

Recently, we were involved in an initiative that sought to exemplify programs and practices that can help advance organizations’ ability to meaningfully address trauma. During the fall and winter of 2017 and 2018, The Nonprofit Coordinating Committee of New York (NPCC), in partnership with Vibrant Emotional Health, and with generous support from The New York Community Trust, provided a series of workshops called Addressing Trauma: Self-Care Strategies for You and the Communities You Serve. Based on attendance numbers and feedback from direct service and management staff, the demand for such forums is great. To help nonprofit organizations weave the trauma-informed concepts from the training series into the daily fabric of organization life, Vibrant Emotional Health created a corresponding toolkit called Staying in Balance: Healthy Solutions for Managing Workplace Stress. This toolkit can be a helpful place for organizations to start to identify and address issues related to stress, self-care, and organizational practices; it is easily accessed on the NPCC website:

Organizations are leaning into dismantling the roots of structural racism, violence, and stigma, but it can almost feel like a game of whack-a-mole: new payment structures vs. trauma-informed evidence-based practices vs. diversity equity and inclusion initiatives. Without adherence to a guiding principle of equitable access to behavioral health for all—inclusive of living wage and job satisfaction for the workforce—organizational life will continue to mirror the lack of control and safety that come with trauma exposure.

As champions of behavioral health, we need to ask ourselves, can we in good conscience continue along a status quo path?  As service providers, we are committed to shifting the paradigm of care and transforming from within. As a system, we value reflective practice in our clinical work and take this value and apply it to our organizational culture. We recognize what needs to be done and are increasingly taking steps, albeit sometimes slowly, to integrate trauma-informed practices throughout everything we do. This work is daunting. It is challenging. It isn’t easy – but nothing truly transformational ever is. We know that people heal from trauma within the context of relationships. So, too, we should realize that our individual organizations cannot reshape the system alone. We must collectively create the trauma-informed transformation that we want to see. We are all in this together.

About the authors. Lisa Furst, LMSW, MPH, is Assistant Vice President, Center for Policy, Advocacy and Education, Vibrant Emotional Health; Cristina Harris, MSW, is Program and Training Manager, Center for Policy, Advocacy and Education, Vibrant Emotional Health; and Elizabeth Speck, PhD, Principal, MindOpen Learning Strategies, LLC.


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