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Chapter 37 - Trauma-Informed Care

Part 3

Page Section
Introduction 3-37.1
Purpose 3-37.1A
Background 3-37.1B
Authorities 3-37.1C
Policy 3-37.1D
Definitions 3-37.1E
Responsibilities 3-37.2
Chief Medical Officer, IHS 3-37.2A
Director, Division of Behavioral Health, IHS 3-37.2B
Mental Health Lead, IHS 3-37.2C
Area Chief Medical Officer 3-37.2D
Area Behavioral Health Consultant 3-37.2E
Chief Executive Office 3-37.2F
Trauma-Informed Care Processes 3-37.3
Creating Trauma-Informed Organizations 3-37.3A
Evaluating Polices, Procedures, Rules, and Practices 3-37.3B
Trauma-Informed Care Systems 3-37.3C
Early Screening and Assessment 3-37.4
Screening and Assessing for Trauma 3-37.4A
Screening using Trauma-Informed Approaches 3-37.4B


  1. Purpose. The purpose of this chapter is to provide guidance to Indian Health Service (IHS) hospitals, health centers, clinics, and health stations (hereafter referred to as facilities) in delivering trauma-informed care services. Simultaneously preparing our workforce to be trauma informed, and promoting self-care to prevent and treat secondary traumatic stress, also known as vicarious trauma, which can lead to compassion fatigue and staff burnout.
  2. Background. The IHS acknowledges the role that trauma, resulting from violence, victimization, colonization, and systemic racism plays in the lives of American Indian and Alaska Native (AI/AN) populations, specifically AI/AN youth who are 2.5 times more likely to experience trauma compared to their non-Native peers. Delivering trauma-informed services requires an understanding of the profound neurological, biological, psychological, spiritual, and social effects trauma and violence can have on individuals, families, and communities. The IHS workforce must be aware of the high prevalence of trauma in AI/AN populations, and trained to respond effectively to this trauma, which affects many individuals who seek services in IHS facilities. It is also important to recognize, and build on the resiliency of AI/AN people, which comes, at least in part, from their cultures and spirituality.

    Creating policy and services that support a trauma-informed perspective which appreciates the frequency of trauma, understands the impact at the individual and community level, and supports appropriate response is critical for improving the many health conditions experienced by the AI/AN population. Through the use of trauma-informed policies, practices and interventions, IHS can enhance its capacity for promoting relational well-being and improve patient outcomes by increasing understanding of the direct impact traumatic experiences have on a patient’s health and how the patient engages in healthcare.

  3. Authorities.
    1. Indian Health Care Improvement Act, 25 U.S.C., §§ 1601 et seq., as amended
    2. Snyder Act, 25 U.S.C. §13
  4. Policy. It is the policy of the IHS that:
    1. Each facility will examine the health care environment and current policies and practices to incorporate trauma-informed care approaches throughout all programs and services, to ensure safe, supportive, welcoming, non-punitive, respectful, healthy and healing environments for patients and staff.
    2. Staff at all levels will receive one hour of the appropriate level training annually on the impact of trauma, including Historical Trauma, on AI/AN. The training will address the impact of traumatic stress on the brain and body; the implications for mental and physical health; how to promote protective factors to increase resiliency; how to interact with people who are in distress in a positive manner; how to listen and validate a wide range of emotions; how working with trauma survivors can impact staff (vicarious traumatization, secondary traumatic stress or "compassion fatigue") and why self-awareness, support, and self-care are important to prevent compassion fatigue and "burnout". Training resources are available at
  5. Definitons.
    1. Historical Trauma. Refers to the cumulative emotional and psychological wounding across generations, including the lifespan, which emanates from massive group trauma.
    2. Protective Factors. Refers to conditions and attributes in individuals, families, communities, or the larger society that, when present, lower or eliminate risk and increase the health and well-being of children, families and communities.
    3. Re-traumatization. Refers to any situation or environment that resembles an individual’s trauma literally or symbolically, which could then trigger difficult feelings and reactions associated with the original trauma.
    4. Secondary Traumatic Stress. Refers to the emotional duress which results when an individual hears about the first-hand trauma experiences of another.
    5. Trauma. Refers to experiences that can cause intense physical and psychological stress reactions. It can refer to a single event, multiple events, or a set of circumstances experienced by an individual as physically and emotionally harmful or threatening and that can have lasting adverse effects on the individual’s physical, social, emotional, or spiritual well-being.
    6. Trauma-Informed Care. Trauma-informed care is an evidence-based service-delivery model that ensures dignity, peer support, and cultural competency and which promotes safety, collaboration, trust and empowerment to individuals. Trauma-informed care is a strengths-based service delivery approach that is grounded in an understanding of and responsiveness to the impact of trauma, that emphasizes physical, psychological, and emotional safety for both providers and survivors, and that creates opportunities for survivors to rebuild a sense of control and empowerment by:
      1. using Universal Precautions by treating all individuals as if they have trauma;
      2. realizing the prevalence of trauma;
      3. recognizing how trauma affects all individuals involved with the program, organization, or system, including its own workforce;
      4. responding by putting this knowledge into practice; and
      5. minimizing any re-traumatization.
    7. Trauma Symptoms. Trauma symptoms can include both emotional and physical symptoms and can occur over a short period of time or over the course of weeks or even years. Emotional symptoms may include denial, anger, sadness, fearfulness, problems focusing, and emotional outbursts. Physical symptoms may include increased startle reflex, lethargy, fatigue, poor sleep, racing heartbeat, and anxiety or panic attacks.
    8. Treatment Advocate. For the purposes of this chapter is used to denote others involved in the care of patients (e.g., significant others, persons of support chosen by the patient, caregivers, family, friends, advocates, etc.).
    9. Resilience. Resilience is the process of adapting well in the face of adversity, trauma, tragedy, threats or significant sources of stress — such as family and relationship problems, serious health problems or workplace and financial stressors. It means "bouncing back" from difficult experiences. Research has shown that resilience is ordinary, not extraordinary. Being resilient does not mean that a person doesn't experience difficulty or distress. Emotional pain and sadness are common in people who have suffered major adversity or trauma in their lives. In fact, the road to resilience is likely to involve considerable emotional distress. Resilience is not a trait that people either have or do not have. It involves behaviors, thoughts and actions that can be learned and developed in anyone.


  1. Chief Medical Officer, IHS. The IHS Chief Medical Officer is administratively responsible for the implementation of this policy
  2. Director, Division of Behavioral Health, IHS. The IHS Director, Division of Behavioral Health, Office of Clinical and Preventive Services, is responsible for ensuring that resources on training, organizational assessments, toolkits, and other tools are available for IHS facilities to implement trauma-informed care approaches.
  3. Mental Health Lead, IHS. The IHS Mental Health Lead assists in the implementation of this policy by providing training and technical assistance resources.
  4. Area Chief Medical Officer. The Area Chief Medical Officer or his/her designee collects copies of IHS policies in his/her respective area, reviews those policies for the compliance with this chapter, and submits findings and/or recommendations to the IHS Mental Health Lead.
  5. Area Behavioral Health Consultant. The Area Behavioral Health Consultant or his/her designee is responsible for providing technical assistance and resources related to trauma-informed care.
  6. Chief Executive Officer. The Chief Executive Officer or his/her designee develops local policy to reflect trauma-informed practices outlined in this chapter, leads the multi-disciplinary workgroup tasks, and monitors local implementation and employee training requirements. The Chief Executive Officer will identify a lead when relevant.


  1. Creating Trauma-Informed Organizations. Creating a trauma-informed organization requires system-wide implementation at the direct care level and in the administrative arena. This type of change can be difficult and will require a trained multi-disciplinary workgroup. The following guidelines are steps that IHS facilities will take to implement trauma-informed care services and approaches.
    1. Create a multi-disciplinary trauma workgroup consisting of a core group of staff representing all roles in the organization.
    2. Incorporate the goal of becoming trauma-informed in staff meetings and/or other settings that work best for the facility.
    3. Incorporate organization-wide trauma training to increase individual trauma knowledge and set the stage for organization-wide change.
    4. Provide training on trauma, secondary traumatic stress and trauma-informed care.
    5. Conduct an initial trauma-informed organizational self-assessment and reassess every three years.
    6. Compile organizational self-assessment results and review results in five domains annually:
      1. Supporting Staff Development
      2. Creating Safe and Supportive Environments;
      3. Assessing and Planning Services;
      4. Involving Patients and Treatment Advocates; and
      5. Creating and adapting local Policies.
    7. Incorporate trauma-informed approaches that include:
      1. Identified and agreed upon goals;
      2. Specific steps to reach each goal;
      3. Resources needed to achieve each goal; and
      4. Realistic timeframe for the achievement of each goal.
    8. Create safe, supportive environments by improving physical spaces with comfortable seating, quiet spaces, culturally appropriate artwork, clean and updated facilities, and ensuring facility security.
    9. Ongoing review of short-term and long-term goals is necessary and will occur annually to identify changes for sustainability. Other assessment tools include staff and patient and treatment advocate surveys, focus groups, and individual interviews.
    10. Provide trauma training to all new hires and annual refresher training for all staff, including non-clinical staff, on trauma and trauma-related topics to sustain trauma-informed change.
  2. Evaluating Policies, Procedures, Rules, and Practices. All IHS facilities’ multi-disciplinary trauma workgroups will identify and evaluate policies, procedures, rules, and practices, where trauma-informed care should be considered for staff and patients, with the following criteria:
    1. Is this policy, procedure, rule, or practice necessary?
    2. What purpose does it serve?
    3. Who does it help? Who does it hurt?
    4. Does the policy facilitate or hinder patient and treatment advocate empowerment?
    5. Were patients and treatment advocates included in its development?
    6. Could this policy, procedure, rule, or practice re-traumatize the patient or treatment advocates? (e.g., limit patient or treatment advocate control and power, lead to fear and confusion, etc.).
  3. Trauma-Informed Care Systems. IHS program staff are encouraged to bring their understanding of trauma and trauma-informed care to the broader service system outside of the health care discipline, educate other service systems and providers, and network with other programs to integrate trauma-informed organizational models and find ways to share information and experiences.


  1. Screening and Assessing for Trauma. All IHS facilities are to be trained to implement screening, assessment, and referrals for trauma to a behavioral health provider, when appropriate using culturally-competent, standardized and validated screening tools.
  2. Screening Using Trauma-Informed Approaches. All IHS providers are encouraged to use a trauma-informed approach when screening for:
    1. Depression, including maternal depression
    2. Suicide
    3. Sexual Assault
    4. Intimate Partner Violence
    5. Early Childhood Development, including social-emotional well-being
    6. Child Maltreatment
    7. Alcohol
    8. Substance Use