Trying to change systems is never an easy task. Efforts to encourage, argue, incentivize, and mandate change, are often met with piecemeal results, only to revert back to business as usual. On rare occasions however, profound change can happen quickly and even effortlessly. These changes often unfold in unplanned, unexpected and novel ways, and they typically accompany substantive shifts in underlying core values, assumptions and world-views.
The System-of-Care (SOC) movement marks one such shift in our recent history. In the 1980s, family members and youth felt that child-serving systems stigmatized and blamed parents, pathologized children, operated in compartmentalized silos, and devalued community and culture as driving forces of recovery and growth. The movement was a response to an implicit bias in traditional child-serving systems, which favored the perspective of providers and institutions over the lived experience of parents and children.
The SOC approach delineated “core values” that emphasized the importance of being family-driven and youth-guided, leveraging strengths rather than focusing on deficits, and providing individualized care through collaboration among providers, natural supports and community resources. These values were readily embraced by many providers who intuitively understood their importance, and catalyzed a sea change that rippled to local, State and Federal levels. To this day, SOC values and practices occupy an important place in policy, grant funding, and best practices. These values offer a lens that informs many non-traditional community-based interventions such as wraparound care, respite, family support, and youth-peer support.
Despite these gains, the SOC movement still operates largely within a service delivery environment that is often at odds with these values. Remnants of a disease model pervade much of our child serving systems, and medical necessity, levels of care, severity of illness, stabilization, and functional deficits can obfuscate the fact that symptoms and behaviors are almost always embedded in a situational and interpersonal context within which issues of survival and adaptation play a silent but important role. Providers can easily find themselves occupying two incompatible worlds, and often seek to split the difference by combining services based on system-of-care values, with those based on a disease model.
An encouraging recent movement, often referred to as “trauma-informed care,” offers an alternative to the more traditional medical model approach, and fits quite well with the SOC perspective. An important contribution of a trauma lens is that it offers a neurobiological basis for understanding why and how SOC values and practices are important. It essentially offers a new “medical model” that counterbalances lingering biases of the disease model. Rather than viewing symptoms and behaviors as evidence of an underlying pathological process, a trauma-informed approach views them as potentially adaptive efforts to survive.
Over the course of evolution, our brains and bodies have developed at least three distinct survival strategies, each of which has its own way of perceiving, feeling, reacting, remembering, and learning. The fight/flight response prepares us for explosive instrumental action when our lives are in danger; the freeze response shuts us down when the threat seems inescapable; and our most sophisticated survival strategy, the “social engagement system” comes online only when we feel relatively safe. Traumatic stress occurs when the more primitive fight/flight and freeze responses are activated too easily, too often or in the wrong situation; or when people get stuck in these states. And recovery, growth and resilience occur when people learn to recruit their more evolutionarily advanced social engagement systems to circumvent, traverse and get out of primitive survival states.
The social engagement system is optimally activated and becomes strengthened over time in response to experiences of positive attachment characterized by safety, trust, predictability, transparency, mutuality and empowerment. For this reason, trauma-informed treatment is guided by the client, strengths are emphasized, and traditional power differentials are leveled in favor of recognizing the respective expertise of both client and provider in a mutually collaborative effort. Trauma-informed perspectives also emphasize the key role of mind-body integration in recruiting and strengthening the social engagement system, and they embrace the value of community, cultural and spiritual traditions.
Such an approach aligns closely with SOC values and practices. Wraparound practices emphasize the voice and choice of families and youth in determining strengths and challenges, choosing services and interventions, and deciding whom to invite to meetings. Attachment and mutuality lie at the core of system-of-care values, as does collaboration, and connection to community and culture. In many ways, it could be argued that SOC values and practices were trauma-informed before the term ever existed. They evolved out of common sense, local knowledge, and the timeless wisdom of cultures and communities, rather than MRI scans and psychophysiological studies of trauma survivors; yet, both movements converge on the same values, principles and approaches.
In Westchester County, the synergy between these two movements promises to be a powerful catalyst toward systems and culture change. Westchester’s system of care is relatively unique in that it is built on a community-organizing model, which makes it one of the oldest and most enduring in the country. There is a vibrant infrastructure involving several local Community Networks (CNs), each of which meets monthly and comprises stakeholders from diverse systems. Volunteers facilitate wraparound meetings for families. The CNs communicate closely with a cross-systems oversight and planning body run jointly by the County’s Department of Social Services (DSS) and the Department of Community Mental Health (DCMH). This planning body in turn creates and supports various subcommittees, such as the Committee on Trauma-Informed Care, which meets monthly, and which also consists of a diverse group of engaged stakeholders. Each year, DCMH hosts a four-session “System-of-Care Orientation” for new employees. As a result, nearly every child-serving professional in the county is familiar and conversant in SOC values, and most have participated in wraparound meetings with families.
Westchester’s SOC culture provides a valuable platform for discussing and implementing trauma-informed ideas, practices, and initiatives. Perhaps because of the philosophical alignment between both movements, buy-in across disciplines and stakeholders has been surprisingly easy. Multiple stakeholders have readily joined the Trauma Committee, which now comprises representatives from mental health agencies, child welfare, probation, universities, schools, family support, youth-peer support, and recreation centers, as well as yoga- and mindfulness practitioners, first responders, and others. Such balanced diversity has been instrumental in ensuring that trauma-informed ideas are not relegated to proprietary clinical treatment models, but embrace a “common factors” approach that is relevant across disciplines. This diversity has also encouraged creative discussions about how various tools and practices can be adapted to other service settings.
Finally, and perhaps most importantly, the evolution of the committee itself over the past five years has engendered a sense of safety, trust and respect among members, which allow for rich, well-balanced discussions. There is also a great deal of informal collaboration and partnerships. Members share their own and their agencies’ struggles and successes; trainings are developed and delivered for various audiences on a wide range of topics and practices; and initiatives and conferences are combined to leverage synergy. Currently, the committee is assisting DSS and DCMH in a joint initiative to encourage a trauma lens among supervisors in foster-care, preventive-services, and mental-health agencies. Thus, Westchester’s SOC provides an infrastructure and values-based culture that supports the trauma committee’s spirit of inclusiveness, diversity and shared purpose, which in turn enriches the SOC in a variety of ways.
A more specific example of how Westchester’s SOC encourages trauma-informed systems transformation is illustrated in the role that young adults have played in identifying and prioritizing policy issues. With the help and guidance of Westchester’s family support organization, Family Ties of Westchester, a youth movement called the Bravehearts emerged. The founding members of the Bravehearts started as a small group of foster care alumni, who organized large weekly meetings, advised county government, and mentored individual youth. Family Ties initially helped them organize and receive a two-week curriculum on a variety of issues, including trauma and resilience.
Once engaged in this curriculum, the Braveheart leadership was quick to grasp how trauma and resilience related to their own lives, their friends and families, and even those who had cared for them in residential facilities. Many referred to this knowledge as “liberating,” “empowering,” and a way to understand, accept and have more compassion for themselves. They also generalized this understanding to a systems level in their recommendations to the county DSS. One was to have an ombudsman for foster care youth; another was to have every foster care youth learn about trauma, noting that it would have been immeasurably helpful for them to have this knowledge while they were in care. Looking back, the Bravehearts’ enthusiasm and advocacy may have done more to build momentum for trauma-informed systems change than any other single group. The Braveheart leadership has continued to pursue their interest in trauma-informed care by attending trainings in Trauma Systems therapy as well as a mini course at Fordham University designed for social work graduate students. Most recently, they organized a panel on trauma-informed care for a Juvenile Justice Re-entry Summit. Family Ties went on to adapt the trauma curriculum to wider range of at risk younger teenagers. As this example illustrates, Westchester’s System-of-Care values, practices and infrastructure created conditions for youth voice to be heard and respected, which in turn helped catalyze efforts toward trauma-informed systems change.
Another example of the synergy between Westchester’s system of care and trauma informed care is illustrated in the evolution of Trauma Systems Therapy (TST) within the county. In 2010, a meeting between the developers of TST and DCMH Children’s Mental Health generated some intriguing possibilities for a novel application of TST within a System-of-Care context. Many elements of the TST model corresponded closely to those of the wraparound process, and Westchester’s SOC infrastructure offered some interesting opportunities for multiple stakeholders to become conversant in TST practices across systems.
Shortly thereafter, DCMH and the Trauma Committee hosted a TST conference for a large diverse audience. With a small amount of seed money, along with considerable generosity from NYU Child Study Center and three separate agencies, four home-based programs engaged in TST training and ongoing consultation. Although two programs eventually dropped out, two remained actively involved and a third joined in. The enthusiasm generated from this small project led to an unprecedented partnership between Fordham University’s National Center for Social Work Trauma Education and Workforce Development, NYU’s Child Study Center and the entire agency of Family Services of Westchester (FSW) to bring TST to all its programs including mental health clinics, therapeutic foster care, group homes, a community residence, respite, and others. This agency-wide implementation crosses both mental health and child welfare systems, and has allowed for better communication and more integrated treatment for children and families.
FSW’s implementation of TST within a system-of-care context enriched their agency-wide initiative while also benefiting the system of care itself. For the past three years, the first day of the annual TST training for FSW employees has been open to outside stakeholders, including child welfare workers, supervisors and managers, therapists, family support advocates, the Bravehearts, school representatives and others. Last year, NYU facilitated an additional day of training to an even wider range of community stakeholders to discuss novel ways TST principles could be applied to systems outside of an individual treatment context. This year, an entire DSS unit of preventive services workers, supervisors, and managers will be receiving advanced TST training through the FSW project. In addition, a large school district will be providing TST to homeless students who have also experienced trauma.
As these examples suggest, systems transformation does not appear to be a linear process that can be boiled down to a series of cause-effect relationships, or a single top-down strategy. Rather it seems that SOC values, practices and infrastructure create conditions that allow trauma-informed ideas, innovations, and opportunities to unfold in novel and unexpected ways. A SOC culture places family- and youth voice front and center, and it values inclusiveness and collaboration across systems, silos and disciplines. A trauma-informed perspective offers a neurobiological basis for SOC values and practices, and is helpful in counteracting biases of a disease model and bridging conceptual gaps between clinicians and community providers. Together, they make for more productive discussions, better integration across disciplines, expanded partnerships, and a stronger shared purpose. Westchester County has by no means accomplished the goal of becoming trauma informed or fully embodying our system-of-care aspirations. However, we are hopeful that combining and integrating these approaches will continue to help us enhance collaborations, generate constructive solutions, and anticipate responses to future opportunities and challenges in a way that moves us ever closer to this goal.
The author wishes to thank Danielle Weisberg, Dr. Liane Nelson, Dr. Adam Brown, Polly Kerrigan, Dr. Virginia Strand, Michael Orth, and Carol Hardesty for their feedback and suggestions.