help you and your organisations embed trauma informed practice in your A Best Fit Model of Trauma Informed Care for Young People in Residential and.

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2AcknowledgementsThe information in this document was developed in collaboration with people with lived experience. With thanks to: Tavoy, Abdi and Peter for their contributions as members of the Bristol Belonging Strategy Youth Consultation Team, to Mallika and Tom from Independent Futures (IF Group), and to Sam and Justine from the Independent Mental Health Network (IMHN). We would also like to thank staff, managers, clinicians and academics from a variety of organisations who were also involved. We are very grateful for their time, input and feedback. Living document This is designed to be a living document and we welcome any feedback. We have also developed a Knowledge and Skills Framework and an Implementation Toolkit to help you and your organisations embed trauma informed practice in your daily work. All of these documents are available to download here: adverse-childhood-experiences-and-trauma-informed-practice-in-bristol/ Our collective understanding of adversity and trauma, including ACEs, is constantly evolving, and this document is designed to be developed alongside this ever-growing body of evidence. If you have any feedback on either this document, the Knowledge & Skills Framework or the accompanying Implementation Toolkit, please email us at: This document is version 1, published March 2021

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3 Trauma Informed approaches recognise the prevalence of trauma in people™s lives and acknowledge the potential effects that this can have on individuals and their families, networks and communities. They are non-labelling, respectful and hopeful approaches that recognise people™s strengths and resilience and their potential for healing. They also recognise how service responses can be helpful for people, while also having the potential to be re-traumatising. Trauma Informed approaches are increasingly being used across a variety of organisations, including hospitals, schools and residential settings, and in health, primary care, disability, homelessness, mental health and young people™s services. These may be Trauma Informed approaches (focuses on whole workforce development) and/or Trauma Specific, where the service provides therapeutic clinical support to support the healing of trauma. Although much of this work originates from America, Australia, Canada and New Zealand, interest and practice in this area is growing at a steady rate within the UK, with NHS Scotland and Youth Justice services in Wales at the forefront. In addition, high profile situations, the work of campaigners, and the current Covid-19 pandemic, has also meant that trauma-related topics are beginning to be talked about in the media more frequently. There are currently several descriptions of ‚trauma™ and for the purposes of the information here, the following definition is used: ‚Individual trauma results from an event, series of events, or set of circumstances that is experienced by an individual as physically of emotionally harmful or life threatening and that has lasting adverse effects of the individual™s functioning and mental, physical, social, emotional, or spiritual wellbeing.™ Substance Abuse and Mental Health Services (SAMHSA, 2014a) Adversity is also included as an important aspect of the work being developed locally, as people with lived experience described how some people may not recognise their experiences as being linked to trauma. They also felt that some people might not have heard of the term ‚trauma™, that this word may hold no meaning for them, or that linking their situations to trauma could result in their experiences feeling more real and difficult to overcome. Language is seen as being really important by everyone involved in this project and the importance of any terms used being inclusive. Including ‚adversity™ is also a reminder that adverse experiences can be stressful and potentially traumatic, as can the absence of appropriate care (i.e. neglect). It also relates to the origin of much of this work, which is based on previous research on Adverse Childhood Experiences (ACEs).

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4Adversity & Trauma Informed Organisations 4 key assumptions For services to experience whole system and cultural change, the Substance Abuse and Mental Health Services Administration (SAMHSA, 2014a) proposes that 4 key assumptions are needed in addition to having a set of principles to work towards. The local working group felt that that whole system change was really important for Adversity and Trauma Informed approaches to be embedded in a meaningful way and so wanted to subscribe to the following assumptions as a result. According to SAMHSA (2014a) ‚a programme, organisation or system that is trauma informed™: Ł Realises the widespread impact of trauma & understands potential paths for recovery Ł Recognises the signs & symptoms of trauma in the people that they serve & in their families, staff & others involved with the system Ł Resists re-traumatisation (actively seeks to resist this) Ł Responds by fully integrating knowledge about trauma into policies, procedures & practices.These assumptions relate to all visitors, peers, volunteers and staff involved with the organisation regardless of role and to all areas of the organisation™s work. They also require agreement and sign up at all levels of staffing in order to be effective.

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Adversity & Trauma Informed Principles The following principles were developed through discussions with people with lived experience, with input from staff and clinicians and through drawing on Adversity and Trauma Informed literature (SAMHSA, 2014a, & Chart by the Institute on Trauma and Trauma-Informed Care (ITTIC), 2015) to create the current version of the principles below. SafetyOrganisations provide a supportive, safe & nurturing environment for everyone that accesses it & promotes physical, emotional & psychological safety. All areas are welcoming, privacy is respected & there is a focus on every interaction creating a sense of safety. Choice & ClarityPeople have choice & control. Individuals, families, friends, carers & staff are given clear & appropriate messages about their rights & responsibilities. Collaboration Decisions are made with people & not for them & power is shared wherever possible. Individuals are invited to help design, develop, deliver & evaluate services in a meaningful way. Trustworthiness Staff seek to build trust through being consistent & reliable & through healthy & respectful interpersonal boundaries. Empowerment Individuals™ strengths, skills & resilience are recognised & organisations believe in & cultivate people™s empowerment & resilience . There is a culture of acknowledging people™s efforts & worth at each & every contact. InclusivityOrganisations actively seek to recognise & address inequalities, oppression & exclusion. People™s diverse needs are identified (e.g. gender, age, ability, sexuality, ethnicity, cultural) & responded to sensitively & with humility. Organisations understand the influence & impact of wider contexts in society & of historical trauma.5

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6Experiences & Practice The information below is based mainly on discussions with people with lived experience (where their words have been used as much as possible) together with relevant literature and clinical knowledge and experience. Safety Physically, emotionally and psychologically safe environments are a priority for trauma informed organisations, as without this it can be hard for individuals to seek support or to feel comfortable talking to staff. People need a supportive and nurturing environment that feels welcoming for everyone, including for those who visit services, their families, carers, friends and for staff. Individuals may react very differently to the same environment, as what feels safe for one person may not feel safe for another. Some people may have never had an experience of feeling safe in their lives and might need support to work out what they need, so it can be helpful to talk with people about what safety means to them and what needs to be in place for some sense of safety to be created. Physical safety starts from the approach to the building, do people know how they will get there and back? Will it be dark when they attend their appointment? Do they know what the building looks like? Are the outside areas well lit? Are there hidden areas or people standing around the entrance that might feel intimidating? If it is appropriate to use signs, are they easy to see and in an accessible language? Is the building welcoming? Safety also extends to the inside of the building too, such as the waiting area, meeting rooms, toilets and any other spaces that people might use. It is also important to consider whether the environment is colourful and inviting, and how the seating is arranged. Can people sit in a place that feels safe for them? Are the exits clear and accessible? Is the space busy and noisy or quiet and calm? Are there any activities that people can do that might help them to feel present and grounded or provide a needed distraction? It can be challenging for organisations to make changes to physical spaces, but there are many things that can be done with limited time and cost, some creative thinking and with the involvement of staff and people who access the service.Interactions with people are also key in creating emotional and psychological safety. Individuals described wanting to feel respected, for staff to acknowledge them when they enter a building and to let them know what will happen next. Consistent approaches are important and while this isn™t always possible, the efforts that staff make to act and communicate in a predictable and transparent way, can make the difference between someone feeling able to sit in a waiting area, or through an appointment and feeling too anxious to stay in the building for any length of time. Privacy is also important to consider. Are there confidential spaces where people can talk privately and if not, can they choose not to talk about more personal information until they are somewhere more private? Working with people to help them to have choice and control over their interactions with the environment and the people in it can make a big difference to their sense of safety.

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8Building trust also involves being consistent and reliable, and people spoke about the importance of staff doing what they said they would or if they are unable to do this or are unsure of what is possible, communicating this honestly instead. People described it being particularly upsetting when staff make promises that they then do not keep. They prefer professionals to say that they will try their best rather than making promises, as this helps them to avoid the experience of their hopes being raised, only to feel disappointed later. People described reliability as also being important, which involved professionals keeping the appointments that they made. While this is sometimes unavoidable due to a variety of reasons, individuals shared their experiences of appointments being regularly changed or double booked and how this can leave them feeling as though they are unimportant and being reluctant to go back. They also said that it was important to refer individuals to appropriate services. They described common experiences of finally having the confidence to ask for help, only to be signposted elsewhere to an inappropriate organisation who were unable to provide them with support. While it is not always possible to control the outcome of a referral, this highlights how the level of knowledge that staff hold about other agencies work, can help to build or negatively affect individuals™ trust. Empowerment This involves focusing on individuals™ and communities™ strengths and supporting them to claim/re-claim the power to take control over their lives, which may have been taken from them through their experiences of adversity and trauma or through contact with services. People spoke about wanting their voices to be heard and young people in particular, felt that their voices are often missing in services. The ability to have a voice applies to everyone working with the organisation, so that people accessing services, family members, carers, staff and other people involved with the system have a sense of feeling heard too (SAMHSA, 2014a). Individuals wanted services to ask them ‚what does ‚empower™ mean to you? How can we help to empower you?™. The pressures of working in a busy environment and society™s expectations of who should be helping who, can sometimes mean that staff can inadvertently disempower people by stepping into an expert role or taking on the responsibility of trying to make people™s situations better. These intentions understandably come from a compassionate place but can have the effect of disconnecting the people that they work with from their own skills and resources (British Columbia Centre of Excellence for Women™s Health and Ministry of Health (2013), Klinic Community Health Centre, 2013). Trauma Informed organisations seek to identify what people can do and take non-expert approaches in their work, looking to find solutions to challenges alongside visitors to their service. It involves recognising what everyone can do instead of a focus of what they are unable to, while also allowing a space for difficulties to be heard and support put in place as needed. It also includes viewing people as people and not as problems or as the difficulties or challenges that they might face.

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9InclusivityThis was seen as a really important principle and was particularly highlighted by young people. For them, being inclusive means that services need to be accessible in terms of geography, cost and in how they communicate with the people that they work with. They want professionals to recognise and understand the differences in individuals™ personal experiences and to accept them for who they are, and for services to feel non-judgmental and to communicate and respond to different groups of people sensitively. This could include staff adapting their communication (including body language) and approaches according to individuals™ age gender, geography, religion, ability, appearance, class, culture, ethnicity, education, employment, sexuality, sexual orientation and spirituality and the interactions between these, as needed. People spoke about the importance of staff having some knowledge of these areas, but also of professionals understanding the uniqueness or ‚novelty of different people™ and how the person in front of them might not be who they expect to see (not making assumptions). This can involve asking people about their cultural values, beliefs and experiences and how they might influence their understanding of their situation and/or experiences of contact with services (SAMHSA, 2014b). It is important for organisations that aim to be non-judgmental and inclusive, to think about how they demonstrate this to people. This could be through the discussions that they have, the ways that information is provided, where they meet with people, or how their environments are organised. It is also important for professionals to be aware of their own diversity and how the lenses that they view the world through (e.g. age, appearance, ethnicity, gender, sexuality etc) can influence their interactions with others and vice versa. Inclusivity includes paying good attention to inequalities, people™s experiences of oppression and understanding the impact of wider contexts in society on how individuals see themselves and how they are viewed by other people (e.g. messages in society about people who are homeless or use substances, who have particular political views, ‚norms™ or romantic relationships, or how parents or people of a particular age, gender or role ‚should™ act) (British Columbia Centre of Excellence for Women™s Health and Ministry of Health (2013), Klinic Community Health Centre, 2013). Historical trauma and how intergenerational events and experiences may have an impact on subsequent generations and communities. Are also important to consider. Recent examples of this could include understanding and responding to people™s experiences of living through the Covid-19 pandemic and how it has impacted individuals, their networks, families and communities and may affect younger generations as they grow older either as sources of distress and/or resilience. Other areas relevant here might relate to political conflicts, migration, people who have lived through natural disasters, families where there have been intergenerational losses (e.g. people who experienced a parent™s death or separation at a young age and are now parents themselves), and communities that have been and/or continue to be oppressed.

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104 Key elements – areas that underpin & run through everything 1. Building bridges through good communication Individuals said that how professionals communicate has to be appropriate and that good communication underpins all of the principles. They described the importance of professionals being able to relate to them well, in order for the service to be accessible and so that people are more likely to accept support and engage with staff. This was seen as something that needed to happen from the very first contact and was viewed as especially relevant for people where English is not their first language, as they believe that ‚you can build bridges through good communication™. Good communication was important for everyone that contributed to the principles, but stood out as particularly important for young people. They suggested that services should ask people ‚what is their mode of communication and adapt to fit™ that. Individuals also spoke about self-awareness being important. They wanted staff to pay particular attention to their body language, tone of voice and how they show people that they are listening well. Keeping things simple and not giving people too much information at once was viewed as helpful too. This is especially important if people are feeling anxious, as this can make it difficult to concentrate on what is being said, make it hard to read information and to challenging to remember what they have been told. 2. Relationships & connection Trauma often occurs in the context of relationships and traumatic events can impact not only the person affected but also their families and wider networks. On the other hand, relationships, a sense of belonging and a connection to others can also be incredibly healing. For example, people sometimes find that their sense of who they are is affected by trauma and healthy relationships and connections with others can be key in helping to rebuild this (Herman, 2001). People spoke about how having supportive relationships with staff and peers is central to services being helpful. They felt that the area of relationships needed to be emphasised in the principles and that this should run through all other areas. 3. Being human People said that they need the service offer and relationships to feel genuine, to believe that staff are interested in them and that they care. They talked about knowing when staff responses feel scripted and how this can deter them from feeling able to engage. They described not wanting staff to imitate (mirror) them, and instead wanting them to understand them and the importance of professionals getting to know each person as a unique individual, understanding their individual needs and next steps and working in a person-centred way. Feeling that staff were reading from scripts came up several times in discussions and people asked that if staff need to use scripts, for them to be transparent and ask permission about this first (e.g. if it™s something new and useful that they and

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11individuals might want to try, or if they are students or new to the role and need to use structured or written information to support them). A further area highlighted was the importance of professionals and individuals getting to know each other as people and wanting staff to show an interest in them as ‚human beings and not just clients™, while also keeping to healthy and safe interpersonal boundaries. This included wanting staff to engage in ‚small talk™, using humour (as and when appropriate) and finding out about each other™s personal interests. In relation to their experiences and backgrounds, individuals spoke about wanting staff to understand their real story. This means staff putting aside any professional lens that they may view individuals™ situations through and really listening to what people™s own perspectives are. It was also important to people that staff did not present themselves as experts and that instead they would prefer to work with a ‚fallible™ person who can be honest about not having all of the answers, who is willing to learn and to own their mistakes. 4. Being flexible Individuals suggested that staff need to understand where they are at any particular moment in their lives and that services need to be flexible to fit that. They spoke about the importance of finding out what people might need at different steps and at different times, and adapting how they work as appropriate. Young people described how it may take some time for people to feel safe enough to talk about their story so it is important for staff to work at a pace that feels ok for each person. They spoke about how it is sometimes hard to talk, that everyone will reach out in their own time and that services need to be flexible for that. Young people in particular described how they did not like the feeling of professionals ‚prying™ or ‚trying to get too much information™ from them. Some people may never want to share their story and services need to allow for this, while at the same time giving individuals the opportunity to speak about their histories if they wish to. A helpful goal here is for staff to find a balance between asking too much information about distressing events (as this can be re-traumatising through disempowering people and crossing personal boundaries) and not asking about their situation when they might really want to talk about difficult events, but feel unable to unless someone asks them directly. It can be helpful to let people know that they can say as much or as little as they want to and on a need-to-know basis, to help identify what support they might need. This can allow people to have a greater sense of control and to share information that feels safe for them to talk about. Flexible approaches can also help create a greater sense of physical, emotional and psychological safety. For example, if someone feels unsafe sitting in a group in a waiting room, if staff are able to be flexible enough to allow them to wait outside and be called in for their appointment from there, it may be much easier for them to access support.

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