We are pleased to welcome Dr. Roger Fallot, a clinical psychologist, specializing in the development and evaluation of services for trauma survivors and the role of spirituality in recovery. He is also the director of research and evaluation for Community Connections, Inc. Dr. Fallot authored numerous clinical and research articles and was principal investigator on the District of Columbia Trauma Collaboration Study, a SAMHSA-funded research project examining the effectiveness of integrated services for women trauma survivors with mental health and substance abuse problems. He and a group of clinicians at Community Connections have developed a men's version of the Trauma Recovery and Empowerment Model, a manualized group intervention for working with survivors of physical and sexual abuse.

Question: Please explain trauma theory.

Answer: Trauma theory refers to the set of concepts and empirical findings that make trauma central to our understanding of human behavior. A “psychologically traumatic” experience overwhelms one’s internal and external resources for positive coping. Knowledge of the widespread prevalence of trauma, its broad-ranging and profound impacts, and the diverse paths people take as they move toward recovery and healing are key elements in this approach.

Question: Can you give the basic steps for a case manager to assess an individual’s level of trauma?

Answer: The most important stance for a case manager is to be empathically interested in what has happened in a person’s life (i.e., their history of trauma exposure) and how they have coped with those events. This means that everyone should be asked basic questions about trauma history at some point fairly early on in their engagement with a clinician. Asking directly about physical, sexual, and emotional abuse using concrete and specific language is also important (for examples, see the Adverse Childhood Experiences questionnaire at www.ACEStudy.org). Then the case manager may follow up by asking the person about ways in which their experiences can be taken into account in their recovery plan and life goals, including possible referral to trauma-specific interventions that facilitate trauma recovery and empowerment.

Question: Is there a difference in how a clinician would approach trauma in a man versus a woman?

Answer: Trauma frequently carries with it a great deal of shame and stigma for both sexes. However, men’s gender role expectations in most cultures require that they remain (or appear to be) invulnerable and strong in the face of whatever has happened in their lives. Men are more therefore more likely to appear angry than women and are more likely to be withdrawn and isolated. Women, by contrast, are more likely to develop PTSD and other anxiety-related difficulties and to be depressed. Clinicians attuned to these broad gender differences can be more responsive in engaging both sexes in a discussion of their trauma histories.

Question: Is there a rating scale to assess the different levels of trauma?

Answer: In addition to the ACE Study questionnaire noted earlier, there are a large number of formal inventories that assess both trauma exposure (e.g., the Life Stressors Checklist) and posttraumatic symptoms, including PTSD (e.g., the Posttraumatic Stress Symptom Scale) and depression (e.g., the PHQ-9). We have also developed a scale, the Trauma Recovery and Empowerment Profile, designed to assess the person’s skills in several domains of trauma recovery, like self-soothing, emotional modulation, and self-protection.

Question: How does spirituality play a role in recovery?

Answer: Spirituality has many functions for individuals and is frequently cited as a major source of support in personal recovery stories. Most basically, trauma can challenge one’s assumptions about oneself, other people, the world in general, and even the nature of the transcendent, sacred, or divine. In the face of such challenges, people often find spirituality a key to making sense of their experiences, to providing meaning, and to restoring purpose in their lives. It is important for clinicians to note that, for some people, spirituality is deeply embedded in a specific religious tradition whereas for others it is not associated with organized religion. A culturally competent clinician will explore the roles of spirituality and religion for each individual in relation to trauma and recovery or healing.

Question: How do faith-based organizations handle trauma and recovery differently than lay organizations?

Answer: I don’t think one can make a general statement about faith-based communities’ responses to trauma and recovery. Faith-based organizations tend to reflect the religious communities that sponsor them and these religious groups are, in turn, extremely diverse in their understanding of, and the supportiveness of their responses to, trauma. At their best, faith communities provide contexts of compassion and care for trauma survivors, embracing them in a set of relationships that are grounded in ultimate reality as the person understands it. At their worst, as we have seen in numerous reports in recent years, faith communities can be the source of abuse and violence and can serve to justify and protect perpetrators. A sensitive clinician can help a survivor sort through their actual or potential involvement in a specific faith community in order to discern the extent to which that community is supportive of the individual’s growth and healing.

Question: How should wraparound services for a trauma survivor differ from someone without the traumatic background?

Answer: Wraparound services, like the entire service system, should reflect fundamental trauma-informed values: safety, trustworthiness, choice, collaboration, and empowerment. They should have the universal expectation that everyone who is receiving services is a trauma survivor. In doing so, they will be right far more frequently than they will be wrong. And, for the relatively rare individual who has not experienced trauma, the system will be providing services that are welcoming, hospitable, accepting, and respectful; they thus maximize the possibility of a person’s fuller engagement in their own recovery planning and achieving their life goals.

Question: Anything else you’d like to discuss?

Answer: One element of a trauma-informed culture of care that is frequently overlooked is the importance of staff support and care. When we first began working with agencies who wanted to be “trauma-informed,” we focused almost exclusively on the experiences of people receiving services. We soon saw, however, that staff members often feel extraordinary amounts of stress in their daily work. We learned a basic lesson: it is impossible for staff to create a culture of safety, trustworthiness, choice, collaboration, and empowerment unless they also experience these same factors in their work setting and relationships with colleagues, supervisors, and administrators. So we now emphasize this “parallel process” much more fully, reminding agencies that providing staff support and care is a requirement, not an option or a luxury. When staff experience the possibility, for example, of truly collaborating in building a program that is meaningful for them as well as for the people they serve, trauma-informed cultures may flourish.